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.
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.