Part 20

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, 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.

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, 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.

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, 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.

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.

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.” 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.

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.