seldom occurs for in them cancer is comparatively rare in the parts in which scrofula is frequent. In the old, the lymph-glands and the bones are as frequently the seats of scrofula as of primary cancer. In the old, therefore, the difficulty of diagnosis between these two diseases may be greater and more frequent than in the young; but I think that the difficulty is commonly due, in some measure, to our expecting to find cancer rather than scrofula in old persons. The regularly increasing frequency of cancer as age advances, i.e. its increasing frequency in proportion to the number of persons living at each advancing age, is well known: and this knowledge gives some prejudice in favour of believing that a swelling in an old person is very likely to be cancerous. Scrofula, on the other hand, is often presumed to be very unlikely. I believe that if it were generally admitted to be not very unlikely, the difficulty or hesitation in making out its existence would nearly cease.

Some general rules for the diagnosis, however, may be kept in mind.

In the cases of doubtful diseases of the bones or of doubtful swellings not glandular, the scrofulous affections are generally inflamed, however lowly; the cancerous are not so. Tenderness and heat are indications of scrofula rather than of cancer, and are rarely absent at and about a scrofulous bone at whatever time of life; with cancer they are present only when the diseased part is casually inflamed.

Spontaneous pain-that is, pain independent of movement or pressure-indicates, if severe, cancer rather than

scrofula; but it is a very fallacious sign, especially in the early periods of either disease.

Redness over diseased bones tells of scrofula more than of cancer. When present with scrofulous disease in the old it is duskier and less ruddy than in the young; not only because of the less brightness and probably slower movement of the old blood, but because of the deeper colour of the epidermis, which, with its brown pigmental degeneration, partially veils and shades the colour of the blood beneath it.

In the diagnosis between scrofulous and primary cancerous lymph-glands in the old, the chief things indicative of cancer are hardness or at least great firmness of substance, close-clustering, deep-seated attachments, pain, and quick increase. The opposites of these conditions, especially when tenderness and external redness are added to them, commonly signify scrofula. In the cervical lymph-glands, which, in old persons, are the most frequent seats of both scrofula and cancer, the lower glands are most frequently scrofulous, the upper ones cancerous; the soft primary cancerous disease is very rare in the old, and not so rare in the young; the soft scrofulous disease or simple hypertrophy which is frequent in the young is very rare in the old; the cancerous disease in the old is often secondary to some comparatively trivial primary disease; the scrofulous is very rarely so.

Respecting the treatment of senile scrofula little need be said. I believe that whatever is useful for scrofula in the young is, not indeed useless, but less useful in the old. As age advances, all medicines that act by increasing the activity of organic processes become, as it seems, less

potent and so iron and cod-liver-oil and iodine have comparatively little influence. Even high mountain-air and sea-air become, as age advances, less invigorating, and the more so the more the old age is attended with infirmities that hinder active exercise.

SCARLET FEVER AFTER OPERATIONS.

THE boy lately operated-on for stone had scarlatina; at least, an eruption exactly like that of scarlatina appeared over nearly the whole surface on the day after operation with general febrile disturbance. Two days later it began to fade, and in a few days had disappeared, and left him in about the same state that we may suppose he would have been in if no such illness had occurred; all went on well for a month, the wound was nearly healed, and he was deemed convalescent, when perhaps in consequence of exposure to cold, he had severe pain in passing urine, and evacuated with it a considerable quantity of blood from the kidneys, and tenacious mucus. Two days after this he had sore-throat, then an eruption like scarlet fever again appeared: it continued for three days, and was succeeded by desquamation. The urine in about ten days had gradually regained its natural condition, and he again seemed well. But now whoopingcough set in, and again retarded, though it did not finally prevent, recovery.

If I had never seen a case similar to this I should have hesitated to call it scarlatina; for the symptoms of the first attack were very incomplete, and those of the

second were unusual and disorderly. But I believe the case was really one of scarlatina modified by the circumstances in which it occurred: and that it may be reckoned with other similar cases in illustration of some interesting general principles.

About this time last year, when scarlatina was very prevalent, I saw six cases after operations in private practice, I have notes of four more that occurred either before or since, and I have heard of many more. By some, these cases may be supposed to have been only casual coincidences of scarlatina with surgical diseases; but if they were so, we ought to find a proportionate number of cases among surgical cases not operated-on. But this does not happen. In private practice I do not remember to have seen scarlet fever supervene in any surgical cases, except those in which operations had been performed; and in Hospital-practice, I doubt whether it is much more frequent among all the other patients taken together than it is in those who have been operated-on. I cannot, therefore, doubt that there is something in the consequences of surgical operations which makes the patients peculiarly susceptible of the influence of the scarlatina-poison. And, together with this susceptibility, we may observe that the disease undergoes in them certain modifications, especially in the period of incubation, which is much shortened. In all the ten cases that I have noted, the eruption appeared within a week after the operation, and in eight of them within three days after it, namely in two cases on the first, in three in the second, and in three on the third day. Other deviations from

1 Note XVII.