Part 13

This constitution is more easily acted on by certain agents, particularly such as tend to induce inflammation, than healthy constitutions in the same circumstances. It would likewise appear, that, on the contrary, there are other agents which operate with more difficulty. It is in general observable, that scrophulous people are less easily affected with mercury. On a few, indeed, it operates readily; but, when we attend to the general habitude of these people, we must consider the aptitude of some individuals to assume the mercurial action to depend on some peculiarity of constitution, unconnected with the scrophulous condition.

By the ancients, and many of the moderns, the pituita was considered as the cause of scrophula, producing tumefaction, by stagnating in the glands. When any of the bile became mixed with the pituita, then the inflammation was more violent, and the ulceration deeper. Some latter writers, convinced that a simple redundancy of any particular humour could not produce scrophula, had recourse to the supposition of an acrimony, which was productive of swelling and ulceration, and which might “taint the whole fluids of the body[85].”

[85] Cullen’s First Lines, Vol. IV.

Others attempted to explain this disease, upon the principle of debility existing in the whole body, but particularly in the lymphatic system[86]. This is an idea still more puerile than the doctrine of morbid humours, which, however unfounded, had several plausible arguments to support it, and which was incontrovertible until the laws of the animal economy were better understood. Simple debility never can give rise to the marks of the scrophulous constitution; it cannot produce ulcers of a nature and appearance so peculiar; neither can it explain why particular parts are more apt to be affected than others; because, if debility exist equally in every part of the absorbent system, then every part ought to be alike diseased; and if it exist only in particular parts, then it is necessary to point out some cause of this partial debility. We likewise frequently observe very great debility in this system, owing to general weakness, and yet no symptoms of scrophula appear in consequence.

[86] Bell’s Treatise on Ulcers, p. 424.

Scrophulous people possess a peculiar constitution, and may therefore be said to constitute, in one respect, a distinct variety of the human race. This state is produced by a peculiar condition of the semen (owing to the peculiarity of the system which forms it), or of the female organs of generation, which possess the same general nature with the body, of which they form a part. When the organs of generation in both sexes are healthy, that is to say, similar in nature to what may be considered as the proper nature of the human race, taken as a distinct class of animals, then the semen stimulates the ovarium to the formation of a healthy child, or one which possesses a constitution, or susceptibility of performing, and having actions induced in it, similar to that of the majority of mankind. In this process, the ovarium is to be considered as a gland, and the semen as its peculiar stimulus. If, however, either the nature of the gland, or of its stimulus be changed, it is evident that the action induced must be more or less modified, and the secretion or product changed to a greater or less degree in its nature and properties. Were it possible for a progeny to be produced by an intercourse betwixt the human and the brute creation, they would possess a nature different from both, or perform actions of a mixed kind. This may be observed with regard to mules amongst brutes. In the same way, a healthy and scrophulous person must produce a child which differs from a healthy one, in having a certain peculiarity of constitution.

Agents produce different effects in different animals; thus the matter of cow-pox applied to the cow and to man produce very different appearances. Agents likewise, in the same genus of animals, produce different effects, according to the peculiar constitution of the individual. Thus, the matter of small-pox in some men produces only a slight local sore, whilst in the generality it produces a general disease, and eruption. The same disease affords an instance of changes taking place in the constitution after birth, by the establishment of certain actions; for it is rendered unsusceptible of the same action being induced afterwards; and, in this respect, is brought to resemble the constitution of a different genus of animals, with regard to that disease. There are some constitutions, such as those called irritable, in which certain symptoms of febrile, and other actions, are much more violent than in people of a different description. In them, for instance, typhus fever is attended with a very frequent pulse, and yet the other effects of this action are not violent in the same proportion.

Peculiarity of constitution is often manifested by no evident sign, and the modifications of actions induced are often marked by no perceptible diseased phenomena, which may be considered as belonging exclusively to that constitution. But, in the scrophulous constitution, there are, in almost every instance, perceptible modifications of the formative action[87], producing a peculiar appearance of the eye, countenance, &c. as has already been mentioned; and although some diseased actions, which receive modifications from this peculiarity of constitution, may not be attended with obvious alterations, yet others, especially such as are attended with an inflammatory condition, are distinctly changed. It is these changes which constitute what in common language has been called scrophula, which is merely a peculiarity of a common action (namely, inflammation), which is dependent, not upon any particular nature of the agent or exciting cause, but upon the peculiarity of constitution, which is susceptible, by these agents, of such an action.

[87] The morbid condition of the formative action is very frequently manifested in the bones, which are less perfect, that is to say, softer, containing less calcareous earth, and later of being formed. Thus, the teeth are longer of appearing; the bones of the head are soft and yielding, and hence the head is large; the long bones bend and lose their shape, or their extremities swell, and, from being more vascular than their nature is fitted for, inflammation is very apt to be induced. The yielding and increasing of the bones of the cranium is likewise attended with a similar effect, for the brain becomes too large in proportion to the rest of the body, and is very apt to inflame, and have effusions formed into it. At other times, the diseased state of the formative action appears most distinctly at the surface, the skin being rough, and very apt to desquamate.

From what has been said, it will appear, that I consider the scrophulous inflammation, or what has in common language been called scrophula, merely as an accidental circumstance, occurring in a scrophulous constitution; but it is by much the most dangerous and troublesome effect of the peculiarity of constitution. It has likewise a very evident effect in increasing this condition of the system; for we find, that the probability of scrophula appearing in a child is, cæteris paribus, correspondent to the presence or absence of scrophulous inflammation in the parent; or, in other words, that those who have either at the time of marriage, or before it, had scrophulous inflammation, are more likely to have their children strongly scrophulous, than others of the same family, who have not had inflammation. It is likewise certain, that if, by any cure, we can, for one or two generations, prevent the appearance of scrophulous inflammation, the children will become less and less diseased, or have less peculiarity of constitution; but if, by any accident, scrophulous inflammation be in one of the descendents excited, even in a slight degree, his immediate progeny will be more diseased than he himself before the induction of the inflammation[88].

[88] Some gentlemen have denied that scrophula was a hereditary disease; but it is unnecessary to offer any argument on this subject.

With regard to the exciting causes of scrophulous inflammation, I may remark, that they are similar in kind to those capable of inducing simple inflammation; but they frequently operate more powerfully; that is to say, causes which would scarcely induce inflammation in a healthy person, may induce a local disease, and inflammation, in a scrophulous habit; because the different parts of the body perform their functions less healthily in a strongly scrophulous person, and are more easily deranged. In every system, those parts which are most delicate, or require the greatest perfection of action in order to keep them right, are most easily deranged. Now, in scrophulous people, the natural action being modified, the body becomes more delicate, and is more susceptible of derangement, especially those parts which naturally are delicate[89], or require a perfection of action. The glands seem to be amongst the most delicate organs; for they have not only to perform the formative, or nutritive function, in common with every other part, but they have also to perform a separate and distinct function, or change the nature of certain fluids which are brought to them. It is on account of the natural delicacy of the glandular system being increased by the diseased condition of the general system, and of the exposure of the lymphatic glands to the action of stimulating matter, taken up by the absorbents on the surface, as, for instance, matter from scabs on the head of children, that this species of inflammation most commonly appears in the lymphatic system; but this system does not seem to be the peculiar seat of the diseased condition, as some suppose, nor to be otherwise predisposed to scrophulous inflammation, except in so far as its natural delicacy is increased by the diseased condition which it possessed, ab initio, in common with the rest of the body; and consequently it is rendered less able to perform its functions properly, the effect of which is, the induction of a new local diseased action, or slow inflammatory action, by the slightest cause.

[89] This term is used here in a different sense from its common one, which signifies sensibility, or delicacy with regard to sensation, and capability of being acted on.

Besides the common exciting causes of inflammation, the particular formation of organs may induce this disease, or at least make very slight causes produce it. Thus, for instance, in people with a very small narrow chest, the circulation of the blood must be performed with greater action than in other circumstances, and thus may tend to induce an inflammatory state. When the bones are very vascular, and imperfectly formed, they are apt to have a morbid degree of action excited in them by very slight causes; and the same holds true with regard to any other part of the body which is imperfectly formed, or which is not exactly fitted for the support and performance of its requisite action[90].

[90] Parts which are improperly organised, or which are not in every respect similar, both in their structure and constitution (by which I mean, mode of acting in general), to what naturally they ought to be, are not only less capable of performing their actions aright, but likewise are to be considered as in some respect extraneous to the human body, or, as it were, insulated, and do not correspond exactly to other parts. They therefore receive less support from the neighbouring parts, and, consequently, have their power diminished. The imperfection of action consequent to these causes is proportioned to the morbid condition of the part.

Scrophulous inflammation is in general dangerous and tedious, in a degree proportioned to the effects and duration of simple inflammation upon the same parts. Thus, simple inflammation of one of the conglobate glands of the neck, is tedious, but not dangerous; and the same holds true of scrophulous inflammation; but the duration of this is much longer. Simple inflammation of the lungs, again, is dangerous; and scrophulous inflammation is infinitely more so. Such parts as heal easiest, when affected with simple inflammation, or ulceration, recover soonest from scrophulous inflammation; and the same causes which retard the one will retard the other also. Thus, the same cause which renders a superficial simple ulcer unhealthy and chronic, will prevent a superficial scrophulous ulcer from healing: But, if none of these causes operate, then scrophulous inflammation, or ulceration, will heal pretty readily, provided that simple inflammation, or ulceration of the same parts, would do so; but, for this purpose, it must be quickly induced; for all inflammation, or ulceration, which is slowly induced, is slowly removed. As a confirmation of these positions, we find, that a blister on a scrophulous person will heal readily, because the inflammation is induced acutely, or with a certain degree of quickness, and has, when the affection is simple, a promptitude to heal, which manifests itself also in scrophulous people. In this instance, the difference in the time required to heal the inflammation in a sound and a scrophulous person is not perceptible; because the affection, if simple, has a tendency to heal immediately. But, in a deep wound, especially if contused, we find the difference more marked; because here, although the constitution be healthy, the duration of the disease is considerable; and, in a scrophulous person, the cure is protracted still longer, and the sore assumes a specific appearance. In diseases of the glands, the difference is still more perceptible; because the disease, although simple, is longer in duration. In affections of the bones and cartilages, the same is observed. When a bone is fractured in a healthy person, it unites without inflaming; and, in a scrophulous person, unless the diathesis be exceedingly strong, it likewise does so, but the union is longer of taking place; but, if a bone inflames in a sound person, the disease is very tedious; and, in a scrophulous habit, it is infinitely more so. The same holds true with regard to tendons and cartilages; and hence the greater danger of a sprain in a scrophulous than a healthy person. From these, and other facts, which it is altogether unnecessary to mention, it fully appears, that scrophulous inflammation is tedious and dangerous, in proportion to the progress and effects of simple inflammation and its consequences, when it attacks the same parts; but this proportion is not regular and uniform; but the duration increases, in a higher ratio, in proportion as the simple inflammation and ulceration of the same parts, and in the same circumstances, is tedious. Thus, a deep wound in a healthy person is pretty long of healing; but, in a scrophulous person, it is much more so. Simple inflammation of a gland is still more tedious than the same extent of inflammation in cellular substance; and scrophulous inflammation is still longer of running its progress; but the proportion betwixt the duration of the scrophulous inflammation, in these two cases, is not exactly as the duration of the simple inflammation of the two, compared with each other, but is in an increased ratio.

When scrophulous inflammation is excited in the vicinity of a part already possessing this action, it occasionally removes the action from that part, in the same way as inducing simple inflammation by a blister in one part cures the same disease in another part in the vicinity. It was an observation of this fact which made it be considered as part of the description of scrophulous tumors and ulcers, that they not unfrequently disappear in one place, whilst they show themselves in another; but, in every instance, this disappearance is an effect, and not a cause; for we uniformly observe, that, before it takes place, the new part has begun to inflame or swell.

With regard to the diagnosis of scrophula, it is impossible to say any thing satisfactory; because, as long as the inflammation remains trifling, and the skin sound, it is very difficult, if not impossible, to distinguish a scrophulous swelling from any other of a different kind. Much assistance has been supposed to be derived from the situation of the tumors, most of those which appear in the neck being considered as scrophulous; but this is certainly a false principle. From the same method of reasoning, most swellings in the groin have been considered as venereal, whilst many are of a very different nature, and not a few scrophulous. The best plan is to attend to the appearance of the body in general, and to the presence or absence of the sign of a scrophulous system; next, whether any ulceration be present, by the absorption of matter, from which these swellings may have been produced. If these be present in a system not possessing the marks of scrophula, the probability of the tumor being scrophulous is less; but, if the system be evidently scrophulous, then we must consider, whether the glands, originally swelled by the absorption of matter, have assumed the slow inflammation of a scrophulous nature, or have assumed a different species of inflammation, dependent upon the peculiarity of the matter; for they can scarcely be supposed to be simply inflamed. Scrophulous swellings of the lymphatic glands are generally soft and doughy, and frequently give the feel of containing a fluid long before suppuration has taken place. They are at first free from pain, and, in mild cases, even toward the end, the pain is inconsiderable. When matter is formed, the skin generally becomes purple, and then gives way in a small spot. Swellings of the secreting glands are to be distinguished from schiro-cancer, by the hardness being less, the pain very inconsiderable, the presence of a scrophulous habit, and by the feel of fluctuation much earlier than takes place in cancer. Upon the whole, the presumption of any affection being scrophulous, is to be formed by the presence of the marks of a scrophulous diathesis, and the absence of such symptoms and appearances, whether antecedent or present, which characterise inflammation of a different species, or make us suppose it to have taken place, whether this be simple or specific. Scrophulous ulceration is distinguished by its peculiar aspect, joined with the marks of a scrophulous habit.

_Of the Treatment of the Scrophulous Inflammation._

If the foregoing reasoning be just, it will appear, that, in scrophulous habits, our great attention ought to be directed to the prevention of the scrophulous inflammation, which is to be done by avoiding, as far as lies in our power, the operation of any agent tending to excite inflammation. It has been observed, that, in scrophulous systems, very slight causes were sufficient to produce disease; because the parts on which they act possess a peculiar constitution, and are less capable of performing their natural and healthy functions properly, and therefore are sooner rendered diseased. Inflammation may also be induced by the structure of the part being such as to prevent it from carrying on its functions properly, and therefore the same effect is produced as in the former case, where the constitution, or mode of action, and not the evident structure or mechanism of the part, was affected.

The lungs are to be prevented from assuming the scrophulous inflammation, by avoiding, in the first place, all the common exciting causes of pneumonia, such as cold, damp, &c. It is, in the next place, to be prevented, by avoiding such causes as tend to increase the circulation in the chest, or affect the function of respiration. Hence, violent exercise, climbing ascents, intoxication, thick hazy atmosphere, are to be guarded against.

The lymphatic glands are to be prevented from inflaming, by avoiding exposure to cold, and to the other common causes of inflammation, but especially by preventing the absorption of irritating matter, such as matter from sores, and the like. A neglect of this is perhaps one of the most frequent causes of scrophulous inflammation; for swellings of the glands of the neck can very often be distinctly traced to scald head, to ulcerations about the ears, little sores in the mouth, caries of the teeth, or to the absorption of particles of food allowed to remain and undergo fermentation in the mouth. The greatest attention ought therefore to be paid to cleanliness. The head ought, in scrophulous children, to be washed daily, and the sweat removed from behind the ears; vermin ought to be diligently removed; but mercurial, and acrid preparations, frequently used with that intention, ought to be avoided.

The mesenteric glands are to be prevented from inflaming, by supporting the action of the bowels, and preventing the formation of irritating matter, which, when absorbed, may swell these glands. Nourishing digestible diet, conjoined with rhubarb, and such remedies as act as tonics, at the same time that they keep the belly easy, are of use in this view; for the whole process of digestion is thus supported, and neither the feculent part of the food, nor the mucus of the intestines, become morbidly irritating.

The other parts of the body are to be prevented from inflaming, by avoiding the usual causes of inflammation, and the action of whatever may injure the healthy condition of the part, or impede the natural action. Thus, the knee and ankle joint occasionally become affected with scrophulous inflammation after fatigue, which injures the healthy condition of the parts.

Besides these precautions, which are necessary in those of an evidently scrophulous constitution, with regard to particular parts, it is likewise useful to preserve as vigorous and perfect a performance of the natural actions of the system, considered in the aggregate, as possible, by which we lessen the risk of any one part becoming diseased; for, whatever impedes or diminishes the performance of the natural and healthy action of a part (and, in this case, the whole body is to be considered as made up of parts), renders that part more susceptible of disease, or derangement of its actions. Cleanliness, pure air, warm and sufficient clothing, nourishing and digestible diet, invigorating exercise, and a due proportion of sleep, are therefore very powerful preventatives of this species of inflammation, insomuch, that Dionis remarks, that seventy-five out of the hundred, who came to be touched by the king, were children of the poor peasants.

When scrophulous inflammation does take place, then this invigorating plan is had recourse to as a cure, whilst, in truth, it is most useful as a prophylactic. The invigorating plan, which consists in the use of good diet, moderate exercise, sea bathing, &c. is indeed useful at this period, both because it tends to make the disease more easily overcome, and prevents other parts from being injured; but its utility is still greater as a prophylactic; and it does not appear to have any certain efficacy in promoting the resolution of scrophulous tumors, because these have naturally a strong disposition to advance slowly to suppuration, and therefore are not readily affected by such means as tend simply to strengthen the system, or support its actions, because these do not change its peculiarity, or morbid modification, which existed, ab origine. But, when the tumors have proceeded the length of ulceration, then they have gone a step farther to a natural termination; and, although the means which strengthen the system cannot remove the scrophulous diathesis of the system, they may nevertheless accelerate the cure of a chronic tedious ulcer, which is slowly tending of itself to a termination.