Part 12

John Overend was attacked with pain in the right thigh and loins, which were considered as rheumatic. Shortly after the thigh was observed to be elongated, and issues were applied over the hip joint, upon the supposition of its being a common case of morbus coxarius. But no considerable relief was obtained by this; on the contrary, the upper part of the thigh swelled, whilst the lower part wasted, his appetite diminished, his pulse was quickened, and he passed sleepless nights. The thigh was rubbed with anodyne balsam, and draughts with laudanum were given every night, but only with temporary benefit. For the course of some months these complaints continued, with occasional remission and aggravation. At last he began to complain of difficulty in making water; and this soon ended in a complete retention. The catheter was attempted to be passed; but although its point was bent, and directed so as to correspond to any deviation of the prostate gland from its right situation, it could not be introduced. By examining per anum, a large elastic tumor could be felt in the pelvis, which was considered as the bladder. A trocar was therefore passed up the rectum, and the bladder attempted to be tapped. A considerable quantity of bloody fluid came away; but he complained of no pain at the glans, which most patients do when the bladder is wounded; and a considerable quantity of high coloured fœtid urine was voided by the urethra, and continued even afterwards to be passed, although with some difficulty. Within a week after this the patient died.

On dissection, I found the hip joint to be completely surrounded with a soft matter, resembling the brain, inclosed in thin cells, and here and there cells full of thin bloody water; the head of the femoral bone was quite carious, as was also the acetabulum. The muscles were quite pale, and almost like boiled liver, having lost completely their fibrous appearance, and muscular properties. On opening the abdominal cavity, the same kind of substance was found within the pelvis; and the greatest part of the inside of the bones of the affected side were quite carious. Large cells were found in this diseased substance, containing bloody water; and it was into one of these that the trocar had entered when the bladder was attempted to be tapped.

CASE III.

James Walker received a stroke upon the outside of the foot, immediately below the ankle joint. A small tumor instantly formed, which continued stationary for several weeks, and gave him little uneasiness; but afterwards it began to increase, and was attended with a shooting pain. The tumor was elastic, pretty tense, and rather irregular in its appearance. I was anxious to operate, but the man would not give his consent. I therefore advised frictions with anodyne balsam, which at first gave him relief, but soon lost its effect. For several weeks I heard nothing of him; but, at the end of this time, he again applied to me. The irregularities of the tumor were much greater, more prominent, of a red colour, and one of them had burst: From this a soft half-organised fungus protruded, and a bloody fluid run out constantly. An operation was again urged, but the timidity of the patient made him again refuse. A month after this he came under the management of another surgeon. There were now three openings in the tumor, from each of which protruded a broad cauliflower-looking fungus, covered with thick fœtid matter; there was likewise a thin red serum discharged from the margins of the ulcers. The tumor was as large as a child’s head, and one of the inguinal glands was a little swelled. The man now consented to lose his limb, and amputation was accordingly performed. Whenever the turniquet was applied, a very copious stream of veinous blood issued from the tumor; but this ceased when the veins had emptied themselves. Unluckily it was considered as unnecessary to extirpate the diseased gland.

On examining the leg, all the bones of the ankle joint were found to be quite soft and carious; the tumor consisted of a soft substance, resembling the brain, with light membranous intersections. The cyst on the upper part was hard and thick, but beneath it was entirely wanting, having either never been formed betwixt the tumor and the tendons of the muscle, or having been destroyed. The former opinion is the most probable; for I have never in any stage found the cyst continued over the under or back part of the tumor, but it always terminated imperfectly in the part on which the tumor was seated.

The wound healed as well as could be desired, but the gland became rather larger, notwithstanding which no operation was urged. Two months after this I was requested to visit him. The gland was now as large as the head of a newborn child; it was soft and spongy, and had at one part an irregular prominence, but the skin was not coloured. The pulse was about one hundred and thirty, and the patient completely hectic. In this situation I proposed nothing excepting nourishment. He died in the course of a week after I saw him.

CASE IV.

The following case shows this disease in its most advanced stage. It is extracted from the fifth volume of the London Medical Journal, and is intituled, “An Account of the Fatal Effects produced by attempting to remove a Ganglion by Seton.” It was drawn up by Mr. W. Dease, surgeon in Dublin.

“In July 1781, a clergyman, aged thirty-seven, consulted me about a moveable ganglion, of the size of a small nutmeg, situated between the fore-finger and thumb of his right hand, near the wrist. He was eager to have it removed, and had been advised, for this purpose, to have a seton passed through it, as the best and most certain method; but, as he was apparently a robust healthy man, and the ganglion was attended with no pain, I advised him to consider it as a matter of no consequence, and not to meddle with it. Four months after this I was desired to visit him, and found him in a melancholy situation. A seton had been passed through the ganglion, and the consequences were, that the back of his hand had inflamed violently, that the ganglion had rapidly and amazingly increased, and that the openings made by the seton were filled with an ill-conditioned fungus, which sprung up as fast as it was removed, and was attended with frequent hemorrhage, and much pain. In consultation, it was agreed to remove this fungus by a free incision, which was done, and the metacarpal bones appeared bare and rough. Another opening was made through the thenar, and a seton passed through it, in order more effectually to prevent the growth of fungus. The bark was administered in large quantities, an opiate was given at night, and due attention was paid to the regimen of the patient. This method seemed to promise the most happy event. The fungus appeared to be entirely destroyed, a laudable suppuration took place, the swelling of the hand subsided, and the sores in a short time were so contracted as to indicate their speedy cicatrization. These favourable appearances, however, were not of long continuance; for, after some time, the fungus began gradually to rise again, and any mode of keeping it down, either by caustic, cutting, or pressure, seemed to produce no permanent good effect, as it increased rapidly, and at length degenerated into the most frightful cancerous fungus I have ever seen. Every local application that has been recommended in similar cases was tried in this, but without success; and internal remedies proved equally inefficacious. He took, for a considerable length of time, two ounces of bark in substance, in the course of twenty-four hours, so that he took, in the whole, twenty-eight pounds of that medicine. The extract of hemlock had also a fair trial, but produced no apparent effect.

“When he had laboured under this complaint fifteen months, he was advised to undergo the amputation of his hand; but before he would consent to submit to this operation, he chose to have an account of his case transmitted to the Royal Academy of Surgery at Paris, that he might have their opinion of it: The result of which was, that the members of the academy pronounced the fungus not cancerous, but merely scorbutic. This decision, by the bye, should make us extremely cautious in delivering our sentiments on similar occasions, without seeing the patient, as much depends on the general appearance of the sores in cases of this sort. The academy were of opinion, that the disease was entirely local, and required only local treatment. For this purpose, they advised that the fungus should be taken down by means of euphorbium, savine, &c. and afterwards washed with salt water. If this method proved ineffectual, recourse was to be had to the actual cautery, from the application of which they seemed to expect the most decisive advantages. To this mode of treatment the unhappy sufferer submitted; and, during the space of six weeks, the fungus was almost every day burnt down with the actual cautery; but his complaint all the while continued to gain ground apace; so that being now disappointed in all his expectations of relief from regular practitioners, he had recourse to quacks of every denomination. The arsenic plaster of Plunket was applied, and he was salivated for seven weeks. At length, after undergoing the operation of a variety of nostrums, he again placed himself under my care. In consultation, it was much doubted whether amputation should now be thought of, as the patient seemed to be in the last stage of a cancerous consumption. His limbs were swelled, and his whole habit was wasted by the repeated hemorrhage from the fungus, which was now so increased in bulk as to weigh down his arm, and entirely cover the back of his hand. In short, after every return of hemorrhage, it was apprehended that the next would put a period to his sufferings.

“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.