Part 14

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.