Scrofula: its nature, causes, and treatment; and on the prevention and eradication of the strumous diathesis

Front matter

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SCROFULA,

SfC. 8fC.

Chapter I. General View Of The Nature And Causes

OF SCROFULA.

Of all chronic diseases Scrofula, in its varied forms, may¬ be truly pronounced as that from which the inhabitants of the countries at present in a state of civilization, experience most suffering, and from which they incur the greatest danger of physical degeneration. Still it may be said of scrofula that no variety of climate, constitution, or physical condition, can ensure positive exemption from its ravages. The chief habitat of the disease is, however, in the tem¬ perate zones, it being comparatively rare both in cold and tropical climates. Writers on the natural history of man have shown that, from the adaptation of the human consti¬ tution to cold or temperate latitudes, a peculiar organiza¬ tion, the Xanthous, or fair-haired variety of our race has arisen. The healthiest type of this division is found in the sanguine temperament, an organization in which all the vital functions are performed with celerity and vigour, and which is eminently fitted to withstand the severity and thermal variations of the climates in which it is found. In very cold countries this temperament is in a great measure universal ; but in more temperate latitudes, other constitu¬ tions besides the sanguine are very common. Of these the most important to the present subject is the lymphatic temperament, a deviation, or it may perhaps be said, a de¬ generation from the sanguine, in which the vital cohesion

B seems to be diminished, the nutritive processes are slower, and the circulating fluids, together with the secretions and ex¬ cretions are less perfectly produced. Hence it is less capable than its more perfect prototype of resisting alow or change¬ able temperature. It is in a modification of this temperament, as I shall hereafter endeavour to show, that scrofula ap¬ pears with by far the greatest frequency.

In whatever light we examine the subject, there are strong reasons for considering climate as one of the great primary causes of the disease. Remotely, we may attribute to the long- continued influence of a cold and variable climate through successive generations, the power of de¬ veloping, with the assistance of accidental causes, the pe¬ culiar diathesis or temperament in which scrofula most commonly appears. And immediately, we may observe the effects of changes of weather and vicissitudes of tempera¬ ture in producing the disease in constitutions already pre¬ disposed, in exciting it in sound constitutions, and in the rapid development of scrofulous affections in the natives of warm climates on removing to such a temperature as our own. Next in order, the vices, wants, and diseases of civi¬ lization appear to be the most prominent causes of scrofula.

Though the subject fairly admits of this generalization, it is not meant to deny that scrofula is found in warm or mild climates, such for instance as those of Madeira or New Zealand ; or that it may and does make its appear¬ ance occasionally in the most opposite temperaments, wdien they are exposed to causes which lower the vital energies, and deteriorate the organic constitution of the body. Strumous maladies may be called, par excellence, the diseases of civilization. They are extremely rare among savage races, except when these are brought into contact with the vices of civilized life, or transplanted into an ungenial climate. With all civilized nations, on the contrary.

NATURE AND CAUSES OF SCROFULA.

they are well known to prevail to an immense extent, and in none perhaps more than our own. Tuberculous disorders affect, too, all the domestic animals which man has reclaimed from the savage state, and they are common among the species brought from tropical climates to our own country. Climate appears, in the first instance, to have given rise to the peculiarity of constitution most favourable to scrofula ; and the wants and vices incident to civilized life seem to be the agents which have produced the disease in the soil already fitted for its reception.

The chief element in the actual formation of the disease is the presence of tuberculous matter, which, in scrofula, is chiefly developed or deposited in the glands, in the cellular system, the bones, joints, nervous tissue, and in the serous and mucous membranes. This morbid product is composed, according to Dr. Carswell, in the human subject principally of albumen, with various proportions of gelatine and fibrine ; its chemical constitutions, in the opinion of this eminent pathologist, varying somewhat according to the period in which it is analysed, and probably in different organs and animals.

In an analysis by M. Thenar d, it was found to be com¬ posed chiefly of animal matter, with a small quantity of muriate of soda, phosphate and carbonate of lime, and a faint trace of oxide of iron. Its physical characters are, that it is of a greyish white colour, and of the consistence of soft cheese or curd. In shape it differs much, according to the manner and the organs in which it is deposited ; and in size it varies from the point-like atoms found in myriads in tuberculated lungs, to the large masses which sometimes accumulate in the brain, or in the external lymphatic glands.

As regards the mode in which this morbid element, tuberele, is formed, pathological science can offer nothing that is conclusive. Dr. Carswell looks upon it as a morbid product of which the mucous membranes are the natural emunctories. Other pathologists are equally positive that the cellular tissue is the natural locality for its depositon. Dr. Todd has deduced the following theory of the formation of tubercle from his vivisections of the amphibia. From experi¬ ments “ on the reproduction of the amputated exremities of the salamander, he concludes that nutrition is composed of two processes, — the production of organizable lymph ; and the organization, or infusion of vitality into this organizable matrix.” He conceives that from a combination of causes this matrix, or coagulable fluid, may be deposited in a state below the natural and healthy standard ; which, instead of forming living, normal tissue, degenerates into an anormal, unorganized, and unorganizable product — tubercle. On the other hand, the great French pathologist, Andral, is of opinion, that “ in the present state of science, tubercle must be considered as a modification of secretion , which is often attended or preceded by an active sanguineous congestion. This is all we know for certain ; beyond this, everything is mere conjecture.” There are, however, good grounds for hoping that this uncertainty will not continue. The admirable researches, by means of the microscope, into the development of cells and the deposition of morbid products, render it probable that we are on the eve of dis¬ covering the true mode in which tubercle and other patho¬ logical elements are produced.

The points of identity and resemblance between scro¬ fulous matter of the lymphatic glands and tubercle in the lungs are so strong, that pathologists speak of the two productions in synonymous terms. Dr. Carswell may be said to have proved that tubercles of the lungs, and the

NATURE AND CAUSES OF SCROFULA.

scrofulous matter of enlarged glands, are one and the same thing. He states that he never found the lymphatic glands, when generally affected, exempt from the presence of tuberculous matter. Louis, who has given immense labour to the study of the subject, lays it down as a law of tubercle, that there never exists a deposition of this matter in the lymphatic glands, or in any other part of the body, in subjects above the age of fifteen, without its being also present in the lungs. It has, however, been shown by M. Lombard, of Geneva, that pathological sta¬ tistics reverse this law in the case of scrofulous children, in whom separate disease of the glands is even more fre¬ quent than separate disease of the lungs. In the ex¬ amination of 1 00 children by M. Lombard, — *

The bronchial glands were tuberculated in 87

The lungs . in 73

The mesenteric glands . in 31

Other tissues of the body were affected in smaller propor¬ tions. Thus it appears that in a given number of children dying of tubercular disease, there is a considerable nume¬ rical excess of glandular over pulmonary disease. Of the number given by M. Lombard, there must have been 14 per cent, in which the bronchial glands were diseased, while the lungs remained healthy. It must be remembered, too, as an important fact which pathologists seem to have over¬ looked, that tables of this kind are deceptive, inasmuch as they only take fatal cases into consideration ; whereas, it is well known that bronchial and cervical glandular diseases are, comparatively speaking, seldom fatal, while pulmonary tubercle is almost invariably so. Hence it follows as an inference, that as external scrofulous glandular disease is far more frequent than pulmonary disease of the same kind, there must be, in reality, a much larger number than such tables show, of cases in which the glandular affection exists without any sign of tubercles in the lungs. If the law of Louis be applied to fatal cases above the age of fifteen, there can be little doubt of its correctnes; but I believe I have seen many living cases of scrofulous, or tuberculous enlargement and ulceration of the glands, the cellular tissue, and the bones, in which the disease existed for many years, and then disappeared without the production of any gene¬ ral or local sign of pulmonary tubercle.

External scrofulous disease from enlarged glands and pulmonary tubercle can, it is plain, be shown to be of the same nature, by the analyzation of the essential morbid product of each, and by the exact physical resemblance between tubercles developed in different parts of the body, whether in the lungs or in the lymphatic glands. The identity in these cases can be further supported, if neces¬ sary, by the facts, that the internal and external disease frequently co-exist ; that often one member of a family may suffer from the first alone, and another from the second ; or again, that the two states of disease may be developed indiscriminately in similar organizations by the same ex¬ citing causes.

There is one striking peculiarity connected with scrofula which, perhaps, draws a line of demarcation between it and tubercular phthisis more decidedly than any other ; namely, that the former disease may possibly be developed without the actual presence of tuberculous matter. Eor instance, any ulcer or wound, but particularly a sore of syphilitic origin, occurring in a constitution such as may be defined to be of the strumous diathesis, is capable of being converted into a genuine scrofulous wound, without any preceding or accompanying deposition of tubercle in the parts affected. I believe, also, that in these constitu¬ tions, common abscesses of the cellular tissue will degene-

NATURE AND CAUSES OF SCROFULA.

rate into scrofula in the same manner. Wounds produced by the suppuration of tuberculous glands have a substra¬ tum of tubercle which occasions the discharge of a curdy, flaky matter, mixed with thin pus. This same curdy matter, consisting of half-dissolved or half-formed tubercle, is sometimes secreted spontaneously with the pus produced from sores that have become scrofulous by metamorphosis ; but this is by no means constant, nor does it even occur in the majority of cases of this kind. In general, the discharge is little altered from that of ordinary suppuration, but the sores have the physical characters and indisposition to heal which indicate true scrofulous ulceration. In strumous disease of internal organs, tuberculous matter forms an integral part of the disorder. I know of no internal affec¬ tion in which other lesions degenerate into scrofulous ulcer¬ ation without the intervention of tubercle, though I would not be held to deny that such may occur. In the external disease in cases of this kind, it would appear that when the constitution arrives at that point where, on the applica¬ tion of an adequate exciting cause, tubercle would be de¬ posited, the same kind of ulcer which usually results from tubercle may be produced without the intermediate agency of that morbid product. When a certain constitutional status exists, scrofula appears spontaneously: sometimes the mucous membrane of the eye or ear, — at others, a com¬ mon incised wound, abscess, or syphilitic sore, — become metamorphosed into sores having all the chief characters of scrofulous disease.

Thus, in some respects, scrofula — though in the majority of cases it resembles consumption, in being caused by the same morbid element — would seem to hold an intermediate place between the softening of tubercle, as it occurs in the lungs, and common suppuration.

Scrofula, struma, and tubercular disease, liave been used almost indiscriminately in designating tubercle ; the two former terms, in particular, have been applied to the external form of the disease as meaning precisely the same thing. I would submit that struma can be more properly used as a generic term, which should include every variety of tuber¬ cular disease. The external form of strumous disease appears chiefly in the lymphatic glands, in the cellular tissue, the bones, and the joints ; the internal, in the lungs, intestines, serous membranes, nervous centres, secreting glands, and in the meseraic ganglia. The external does not appear till after birth, wdrile the internal is sometimes found in the foetus, or in the first few months of independent existence. Scrofula is far more common before puberty than after, and pulmo¬ nary tubercle after puberty than before. Altogether the symptoms, the lesions, and the results in the two classes of disease, though depending in the main on the same morbid product, are so essentially different, and affect such different kinds of organs, that for practical purposes it becomes ne¬ cessary to consider them as distinct diseases. The object of the present treatise is to attempt the elucidation of the nature, causes, and treatment of external tubercular disease, or, as it is termed, scrofula.

Though we cannot, in the present state of science, learn how it is that tubercle is formed from the other materials of the body, or separated, as it most probably is, from the circulating fluids, we can understand to a very great extent the condition of the system that gives rise to tubercle. It is to the increase and dissemination of this knowledge that we must at present look for the amelioration of tubercular disease ; as well as to improvements in the management of the disorder, when it has been fully developed in the constitution. Fortunately for those

NATURE AND CAUSES OF SCROFULA.

suffering from scrofulous disease, which is essentially humoral in its nature, the study of the fluids is rapidly regaining its old ascendancy.

It is interesting to observe how nearly the opinions of the present day, on the nature of scrofula, approximate to the views of the older writers. Mead referred the disease to a “ lentor,” or to a corrosive condition of the blood. By Wiseman, who practised extensively in scrofulous disease, it was considered to be dependant on a peculiar acidity of the “ serum sanguinis.” Others called it “a dyscrasy of the fluids.” The idea of a mechanical lentor, or chemical acidity, has been quite disproved by modern investigators ; but the elder writers may be pardoned for using their terms awkwardly, on the score of their ignorance of the consti¬ tuents of the circulating fluid. Their obvious meaning is much the same as we now express by the phrase, “ morbid conditions of the blood.” At all events they agreed with us in considering the blood as chiefly in fault. Andral supposes tubercle, or scrofula, of the lymphatic ganglia to be chiefly caused by an alteration or stagnation of the circulating lymph. In our own country, the explanation by Dr. T. J. Todd, of the production of tubercle, is the best yet offered. He considers it, as already explained, to be formed in the processes of nutrition, by the degenera¬ tion of “ organizable lymph,” a term very nearly identical with the “ serum sanguinis” of Wiseman. Prof. Midler ap¬ proaches still nearer to the ancients, when he gives it as his opinion that in scrofula, the lymphatic vessels and glands suffer from the irritation of “ fluids morbidly formed,” in their passage through the absorbent glands ; the fluids re¬ ferred to being the liquor sanguinis, or lymph circulating in the lymphatic system.

The comparative pathology of strumous disease has re¬ ceived much attention. Tubercular disease is excessivelv frequent among the monkey tribes when brought to Europe : nearly all the Chimpansees that have of late years perished from the effects of climate are recorded to have had tuber¬ cles. In the horse, Dupuy found that tubercles and scrofu¬ lous swellings were very frequent in the pituitary membrane, and in the sublingual glands. Of forty-two horses with pulmonary tubercles, dissected by this anatomist, twentyseven had them also in the sublingual glands. Tubercles have been often found in birds (especially foreign birds in¬ troduced into this country), in the hog, the sheep, and the ox; and they are excessively common in the liver of rabbits. In rabbits they can be developed in this organ to almost any extent, by improper food, or exposure to damp, as shown experimentally by Jenner and Baron. They appear to be developed with little difference both in herbivorous and carnivorous animals ; though this is not at all in accord¬ ance with the general belief which obtains among medical authorities, that tubercle is rare among persons using a large quantity of animal diet, such as butchers and dealers in fish. No case of exemption from tubercle is known among any class of animals reclaimed by man from the savage state. At one time Andral was of opinion that dogs formed an exception ; and he explained this from the fact that dogs live in a climate natural to them, and more nearly in a state of nature than any other domesticated animal. Dupuy, however, has occasionally found tubercles even in the dog ; but there is no doubt that they are comparatively infrequent in the canine race. It would be an interesting subject of research to discover what animals are most exempt, and what class is most liable, to strumous disease. Such an investigation might afford some clue, leading to a greater control over the internal forms of tubercle than we at present possess.

Sir James Clark inclines to the opinion, that tubercular

NATURE AND CAUSES OF SCROFULA.

disease has increased among the upper classes of society during the last half century. There is every probability that this has been still more decidedly the case among the poorer population of this country. No external circum¬ stances are sufficient to ensure escape from its ravages : it affects the high and low, rich and poor ; the inhabitants of the most wholesome rural districts, and the dwellers in manufacturing towns ; those who reside on the seashore* and those who live inland ; — all suffer, though with varying degrees of frequency and severity. There is no doubt the disease is less common among the rich than the poor, in the country than in towns and cities, at the seaside than in inland places ; still it is so common that scarcely a family in any station or circumstance, from the throne to the poorhouse, can be found in which an observant physician can¬ not discover some trace of the scrofulous temperament.

There can be no question of the hereditary nature of the diathesis and the disease. Perhaps it is more truly so than in any other disease whatsoever. This was at one time de¬ nied ; but the fact that a scrofulous, or tuberculous mother may give birth to a child having tubercles existing in its constitution at the time of birth, proves beyond dispute that the parent may communicate the disease to the offspring. There can be no greater proof of hereditary disease than this. It is uncertain whether the father or mother has the greatest tendency to transmit hereditary faults of constitu¬ tion to their children ; but I believe the balance of evidence and observation to be in favour of considering the female, more likely than the male, to communicate mental and phy¬ sical organization, and of course with these the tendency to particular diseases.

There is one curious point connected with scrofula de¬ serving notice, and closely related to its hereditary nature, which I consider to be of much importance in a therapeutical point of view. I refer to the circumstance, that in a highly scrofulous family the scourge may pass over one generation without affecting it, but only to revisit the next. Thus, the grandparents may suffer from scrofula, and it will remain dormant in the children, but reappear among the grandchildren. This kind of Atavism, as it can be termed, may seem to border on the marvellous, but I be¬ lieve its truth to be thoroughly established. I have myself known many instances of the kind, and possess the records of scrofulous families in which alternate exemption and affliction have run through more than five generations. At the present time I am acquainted with some children among whom no decided sign of scrofula or the scrofulous diathesis has appeared, whose ancestors have alternately been afflicted with scrofula for five generations. More frequently it occurs in scrofulous families, that there are some affected in every generation, while others remain pure. The disease, or the tendency to disease, often de¬ scends indirectly and irregularly, occurring in uncles and aunts in one generation, and nephews and nieces in the suc¬ ceeding. I should observe that Sir James Clark believes that the occurrence of scrofula in alternate generations will admit of explanation, without supposing that the disease sleeps in one generation to reappear in the succeeding. I believe this eminent physician considers these cases are explainable by the actual eradication of the disease in the generation in which it is absent, and its re-development when it appears in the following generation, by the agency of new causes. I submit, however, that there are suf¬ ficient reasons for the rejection of this latter doctrine. Such a kind of pathological atavism, or irregular develop¬ ment of disease, has always been so frequent, and so much a matter of common observation, as to be very gene¬ rally believed. And farther, we see the same thing hap-

NATURE AND CAUSES OF SCROFULA.

pen with regard to physical organization. It frequently occurs that a child resembles one of its grandparents or an uncle or aunt, in growth, stature, temperament, and mental qualities, while it bears little likeness to its imme¬ diate progenitors.

Again, this is often still more remarkable in the trans¬ mission of striking physiognomical traits in families. Any one feature becomes prominently fixed of a certain stamp in a family ; and this feature or peculiarity appears, not con¬ stantly, but at intervals, in different generations, through a long series. This may be seen beautifully illustrated in the portrait galleries of many of our ancient families. One peculiar expression, or a distinctive mould of the eye, the mouth, or forehead, runs from the founders of the family through a long line of descendants. But it is not seen passing regularly from father to son : the intermittent like¬ ness, so to speak, appears now in a female face, then in a male ; sometimes passing off into collateral branches, and again returning capriciously to the main stock. In these kind of instances the likeness of feature, or organization, resembles the original, it may be twenty generations off, too closely to admit the possibility of its depending on any mere accidental development. This peculiarity has been recog¬ nised by Prichard, Blaine, Mason Good, Walker, and other physiologists. Moreover, it is not confined to the human race, but happens in the generation of the lower animals.

I have dilated thus far on this interesting topic, because, as I before remarked, it seems capable of being turned to account in our endeavours to eradicate the strumous ten¬ dency from individuals and families.

I conceive, that when the disease lapses in one generation of a scrofulous race, judicious management of the consti¬ tutions of the individuals, and healthy matrimonial alliances.

will so control the tendency which the dormant germs of scrofula have to re-appear, as in many cases to prevent their resuscitation in succeeding generations ; whereas, if it be allowed that in generations or individuals of scrofulous descent, presenting no overt appearances of scrofula, the disease is actually eradicated, there will be no need of en¬ joining more than common precautions as regards the future. Unless the return of the enemy be held in dread, families will make little, if any, exertion to prevent such a contin¬ gency.

The power of a scrofulous individual to impart the disease to others, has long been considered limited to hereditary transmission. The French pathologists have made nume¬ rous experiments, both on the human subject, and on in¬ ferior animals, which show that the direct introduction of scrofulous matter into a healthy constitution by inoculation, produces no effect whatever. With respect to contagion, the opinion formerly prevailed, and in fact continues to the present day in some countries, that tubercular consumption occasionally attacks healthy persons in consequence of their sleeping and living with consumptive patients. Such an idea had been entirely discarded in this country ; but there seems to be of late a disposition to inquire, whether the emanations from the body of a person dying of consumption may not injure those exposed to such influences, and give them a tendency to tubercular disease. If there be any truth in such an opinion as regards pulmonary consumption, the same kind of danger would probably attend severe cases of scrofulous disease ; but I believe if any effect of this kind is produced it can only be to a limited extent.

With respect to the comparative liability of the two sexes to scrofula, little of a positive nature can be adduced. The majority of writers have leant to the opinion that it is most prevalent among females ; but this has been met by such

NATURE AND CAUSES OF SCROFULA.

conflicting testimony, as to render it doubtful whether the distribution of scrofula is not pretty nearly equal in either sex.

Pathologists are agreed that childhood is the era in which scrofula mostly makes its appearance. From extensive data, M. Lombard fixed from the fourth to the sixth year as the period most prolific in scrofulous disorders. I am con¬ vinced that at all events two-thirds of the cases of glandular scrofula date their commencement before the age of twelve. This circumstance, which I shall hereafter have to revert to, finds a ready explanation in the great activity of the glandular system which exists in childhood and youth.

The relation borne by scrofula to rickets, another import¬ ant disease of childhood, has never yet been clearly defined. Some have considered them nearly allied in their nature, while others have considered them entirely dissimilar ; from which it would seem evident that there must be many points of resemblance, and many particulars in which the two diseases are essentially different. They are alike in being dependant on debility of organization, the blood being in both deficient in its richest constituent, fibrin ; and the phy¬ siognomical signs, particularly of the face and head, bearing a decided resemblance. Moreover, the two disorders often co-exist ; but the age at which rickets makes its appearance is considerably earlier than the time at which struma pre¬ vails, rickets being much more common before the third year than afterwards. In scrofula there is a great tendency to suppuration, which is of rare occurrence in rachitis. In rickets there is the want of one of the constituents of the healthy body, namely, the earthy matter of the bones ; while in scrofula a morbid element, tubercle, is superadded to the natural organized elements. Thus it is evident that, though there may be a superficial resemblance between scrofula and rickets, yet the more minutely we examine their essential natures, the further do we remove the one from the other.

Scurvy is another disease which has been popularly asso¬ ciated with scrofula ; but this arises not so much from the actual relationship between the two disorders, as from the fact, that the state of the fluids and solids in scurvy tends powerfully to produce the irruption of scrofula in the scro¬ fulous constitution, while individuals of the scrofulous diathesis are those who become first attacked bv scurvy, when numbers are exposed to the exciting causes of the latter disease.

Our knowledge of scrofula is as great as of most other diseases, yet it is difficult if not altogether impossible to give a concise and direct theory of its nature and causes. It is not like a mere local affection, in which the cause and the effect stand in near and immediate relation one to the other, and in which any constitutional symptoms that may occur are referrible to a local origin ; but it is a constitutional malady in the most extended signification of the term. Its cause, wdiatever it be, may reveal itself palpably when the disease is fully developed, in its effects in some particular part ; but we have certain signs that the same cause affects every tissue, every organ, and, we may add, every molecule of the body. Hence we speak of the “ scrofulous constitution,” and of the “ strumous diathesis,” terms which evidently apply not to any particular localities or functions, but to the entire organization. If we attempt to narrow the definition of the disorder, and separate the scrofulous temperament from other constitutional states, wre shall probably come to the formation of tuberculous matter, as the most distinctive trait ; or to a vitiated condition of the lymph circulating through the absorbent glands ; or to some fault in the pro¬ cesses of nutrition and secretion : but all these are them¬ selves but signs or results of more remote deviations from