reported the effect of its use in five cases, giving .1 to .3 grm. (1.5
to {229} 4.5 grs.) in pill with extract of lactucarium and cumarin, the
purpose of the latter being to disguise the odor. His formula was as
follows: Iodoform, 1 gram (15 grs.); ext. lactuc. sat., .1 gram (15
grs.); cumarin, .1 gram (1.5 grs.), to be made into twenty pills. In
one case the sugar disappeared in twelve days; in the second, at the
end of six months; in the third case it had diminished from 14.4 to 1.6
grams in three months; in the fourth, from 28 grams to 1.6 in four
months; and in the fifth case, from 9.2 to 6.1 grams.
[Footnote 60: _Wiener Med. Wochenschr._, Nos. 17, 18, 19.]
The use of the remedy in Moleschott's hands produced no unpleasant
results, but Drasch,[61] who used the same treatment after Moleschott's
method in three cases, with the effect of diminishing the thirst, the
quantity of urine, and the proportion of sugar, found excessive itching
of the skin, diminished appetite, and diarrhoea to result in such
degree as to demand its disuse in the majority of cases. Iodoform has
been used by the Italian physicians De Renzi,[62] Bozzolo,[63] and
Silvestrini,[64] and by Sara E. Post[65] of New York, with varying but
generally favorable results, except in Silvestrini's case. These
results included diminution in thirst, quantity of sugar and urea, with
increase in weight. The drug deserves a trial in doses of from 1 to 2
grams (15 to 30 grains) a day, but due regard should be had to possible
toxic effects; and to this end the administration should be interrupted
at the end of one or two weeks, and the interruption continued for a
like period. It may be given in pill or in capsule, and in divided
doses or in a single dose at bedtime. The latter course is recommended
by Post, and is said to avoid eructations and anorexia. Theories of its
action based upon experimental use of poisonous doses ascribe its
effect to a primary stimulating and ultimately fatally degenerative
effect upon the protoplasm of cells, and especially those of the liver
and nervous system.
[Footnote 61: _Wiener Med. Presse_, 1882, xxiii. 1487.]
[Footnote 62: "Tre Storie di Diabete." _Gior. internaz. d. sc. med._,
Nap., 1882, N. S. iv. 913-917.]
[Footnote 63: "Sur l'action du iodoforme dans la diabète sucre," _Arch.
ital. de biol._, Turin, Feb., 1883, iii. 317-321.]
[Footnote 64: "Iodoforme dans le diabète," _La France Méd._, October,
1883, ii. 567.]
[Footnote 65: _Archives of Medicine_, April, 1884, p. 116.]
Transfusion of blood has been recommended by Dieulafoy,[66] and is
approved of by Ralfe,[67] especially to combat the symptoms of
acetonæmia, which, if due to a toxic agent, as seems most likely,
should be met by altering the percentage composition of the blood with
relation to the toxic agent.
[Footnote 66: "Étude sur la Transfusion du Sang dans le diabète sucre,"
_Bullétin et Mém. Soc. Méd. de Hôp. de Paris_, 1884, 4, S. 1, 38, 41.]
[Footnote 67: "Discussion before the Path. Soc. of London," _Lancet_,
Apr. 7, 1883, p. 592.]
Diabetic neuralgia yields generally to the treatment of the disease in
general correspondingly to the reduction in the quantity of sugar, and
at times to salicylate of sodium, while it does not respond to morphia
or other remedies for ordinary neuralgia.
The alkalies, which attained some reputation after Mialhe claimed for
them the power of destroying sugar in the blood and of neutralizing the
fatty acids which were thought to accumulate there in consequence of
the deficient action of the skin, are not often used at the present
day. Potassium carbonate was the favorite preparation, and in the hands
of Pavy its use seems to have been followed by good results. He gave it
in 10, 15, and 20 grain doses in combination with aromatic spirit of
{230} ammonia. Sodium bicarbonate was less satisfactory, as were also
potassium acetate, potassium citrate, and Rochelle salts. These were
given in doses of from four drachms to an ounce daily. In Germany, too,
the alkaline treatment has been used to some extent.
As is the case with so many diseases which are incurable by any special
treatment, a large number of remedies have at different times been
suggested for diabetes, mostly on a foundation which does not admit of
close analysis. One of these was the nitrate of uranium, suggested by
Dale of Lemont, Pennsylvania, who gave it in doses of 1 grain three
times daily, increased to 3 if necessary, in pill, powder, or solution,
by aid of a few drops of nitric acid. He appears, however, to have used
it in connection with a selected diet. I have tried it both with and
without a selected diet; in the latter case there was no effect, and in
the former there was none which the diet alone would not have produced.
Sodium phosphate, salicylic acid, salicylate of sodium, have all been
used, it is claimed, with good results, and the late Dr. Dougherty of
Newark, New Jersey, used with apparent advantage a mixture into which
all of these, together with sodium carbonate, entered, made up with
glycerin, tincture of cardamom, and water, the doses being 2½, 2½, 4½,
and 8½ grains respectively. Moleschott has also obtained good results
with salicylic acid.
{231}
SCROFULA.
BY JOHN S. LYNCH, M.D.
SYNONYMS.--Scrophula, Scrofulosis, Morbus scrophulosus, Struma, King's
evil, The evil, Quince, Cruels and Crewels (Scotice).
DEFINITION.--A morbid condition of the system manifested by a peculiar
liability to certain forms of nutritive disorders of the skin, mucous
membranes, joints, bones, organs of special sense, and especially the
lymphatic glands.
There is probably no disease of which it is more difficult to give an
exact and satisfactory definition than scrofula. The general tendency
of medical opinion within the last few decades has been to narrow the
significance of the term, and even to restrict it to those slow and
indolent inflammations and over-growths of lymphatic tissue which end
in caseation and finally imperfect suppuration. Formerly almost every
deviation from healthy functional activity in the young, as well as
every disorder of nutrition which could not be assigned to any definite
cause, was called struma; and thus, as Heule well remarks,[1] "Scrofula
became the receptacle into which one vaguely casts all the ailments
which afflict children under fourteen years, and of which we do not
know the cause."
[Footnote 1: _Handbuch der Rationellen Pathologie_.]
Before hereditary syphilis was understood all its manifestations were
classed as scrofulous, and at least one eminent authority in the United
States[2] has expressed the opinion that scrofula is only a
manifestation of the syphilitic poison in the second or third
generation. Rickets, chronic hydrocephalus, favus, lice, and worms
(Lugol), diabetes (Carmichael), and even scirrhus and cancer (R.
Hamilton), have all been classed as scrofulous diseases. Then there is
a large class of unhealthy persons whose morbid state can be no more
definitely expressed than by saying that they are "delicate" or of
"feeble health" or of "frail constitution," and by some all these are
included under the term scrofulous. But as knowledge advances, and
pathological knowledge as well as diagnostic acumen becomes larger and
keener, many of these affections and morbid conditions can be
eliminated from scrofula and assigned their true pathological and
nosological position.
[Footnote 2: S. D. Gross, _Transactions American Medical Association_,
1878.]
To many who have been educated in the more modern schools of medical
thought, therefore, our definition will appear much too broad, while to
others it may appear too narrow.
Scrofula is essentially and purely a diathetic, not a cachectic,
disease. {232} It is true that what may be called the manifestations or
lesions of the disease are often excited by some preceding dyscrasia,
and also that the long persistence of these lesions may excite a
cachectic condition which we might call the scrofulous cachexia; still,
as many children suffer from the lesions of scrofula who have never
exhibited any evidence of a precedent dyscrasia, but on the contrary
appear to be in perfect health, and many others, on the other hand,
show unmistakable evidence of ill-health and are decidedly dyscrasic,
yet are never attacked by scrofula, it is believed that every subject
of scrofula becomes so not because of any pre-existing dyscrasia or
cachexia, but because of some peculiar condition of the system--innate
or acquired--which constitutes a diathesis.
"The hypothesis," says Niemeyer,[3] "that scrofula depends upon a
faulty composition of the blood (dyscrasia), and that the lesions found
in scrofulous persons were due to a deposit in the tissues of a matter
circulated by the blood and called a scrofulous material, is almost
universally abandoned."
[Footnote 3: _Textbook of Practical Medicine_, vol. ii.]
But while insisting upon the peculiar and, so to say, specific origin
of the disease in some special condition of the system, without which
it will never exist, it is admitted that the lesions of scrofula do not
differ essentially from other similar lesions of the same tissues of a
non-scrofulous origin. They are mostly of an inflammatory nature, and
are only to be distinguished by the often trivial character of their
exciting causes--often, indeed, by the total absence of any known
exciting cause--and by their tediousness and intractability.
ETIOLOGY.--We believe, as already stated above, that the essential
cause of scrofula is some peculiarity in the constitution of the
tissues of the scrofulous subject; and we think it highly probable that
H. F. Formad of Philadelphia has pointed out what constitutes this
peculiarity. He declares--and the correctness of his observation has
been abundantly verified--that microscopic examination of the tissues
of certain animals characterized by their extreme aptness to be
affected by scrofula and tuberculosis, as well as of children known to
have been scrofulous or tuberculous, discloses the fact that the
lymph-spaces in these subjects are always more numerous, larger, and
more crowded with cells than in non-scrofulous subjects. The tissues of
the scrofulous are therefore coarser, less compact and solid, and there
is a greater tendency to undue cell-growth, than in the non-scrofulous.
And these are precisely the characteristics which they present
clinically, and such as we might have, a priori, expected to find.
This peculiarity of anatomical structure is in a large number of cases
undoubtedly inherited from the parents, but while heredity plays, as is
well known, an important part in the etiology of struma, it is not the
essential factor. Bad hygienic surroundings, overcrowding, and
consequent want of fresh air, improper food, consisting of a too great
proportion of starch, during the early months or years of life, will
cause the growing tissues to assume the peculiar anatomical arrangement
alluded to above. "A coarse diet, containing but little nourishment in
comparison with its bulk, is especially held in evil repute. The
earlier this injudicious feeding of an infant commences, so much the
greater danger that it will become scrofulous; hence the children fed
on pap furnish a very important contingent to the army of scrofulous
persons."[4] The {233} well-known fact that few children at the breast
suffer from scrofulous lesions, but that a large number do so within
the first two or three years after weaning, certainly tells in favor of
the belief that too much starch and an insufficiency of animal food
favor, if they do not actually produce, that faulty nutrition and
construction of tissues which we believe lies at the foundation of the
scrofulous diathesis. Independent, however, of improper food and the
other predisposing causes mentioned, it is quite probable that faulty
nutrition caused by accidental disease of the digestive or assimilative
organs during infancy may create a predisposition. How else can we
account for those not very rare cases in which from parents perfectly
free from any scrofulous taint a large family of children may be
reared, of which only one will suffer from any scrofulous lesions? Two
such instances have been brought to my notice, and as the children in
these cases lived upon a farm on the water-side, and enjoyed an
abundance of pure air and salt-water bathing, and were certainly not
stinted in food of proper quality, it is difficult to account for the
acquired diathesis except upon the hypothesis above. Among the general
predisposing causes of scrofula in addition to the special ones I have
mentioned may be added--
[Footnote 4: Niemeyer, _loc. cit._]
1. Locality and Climate.--It has long been believed that scrofula is
more common in the temperate zone than in the extreme north or in the
tropics. While this is probably true, it must be stated that a
sufficient amount of reliable statistics bearing upon this point have
not yet been collected to prove the fact beyond cavil. That we should
find that the disease prevails more extensively in cold and damp
situations than in warmer and drier ones is to be expected, since the
former conditions involve a greater confinement within dwellings, and
consequently a diminished supply of fresh air, which, as we have seen,
constitutes one of the predisposing causes of scrofula. Moreover, it is
in these situations we would encounter a greater number of catarrhs,
which, as we shall see, are known to be among the most active of the
exciting causes of the glandular affections of scrofula.
2. Season.--For the same reason we find that a large number of cases of
scrofula make their appearance in the early spring months, the results
of catarrh contracted during the previous winter or of the sudden
changes of temperature which accompany the transition of winter to
summer.
3. Age.--Scrofula is essentially a disease of early life, but not
exclusively so. As the diathesis can only be acquired directly from the
parent, or fortuitously by malnutrition during the period of active
growth, it follows that it becomes established, if at all, before the
age of twenty years. And as the predisposition seems to be quite strong
in most cases, and as the exciting causes are more apt to be applied
during the earlier years of life, it is not surprising that a very
large majority of the cases occur between the ages of three and fifteen
years. A few, however, escape during childhood, and only suffer from it
between twenty and thirty, while a small number only develop the
disease in old age. Rindfleisch mentions the period between twenty and
thirty as a common one for the development of hereditary scrofula; and
senile scrofula was first pointed out by Sir James Paget.[5] In all
these cases of deferred {234} manifestation of the scrofulous
diathesis--and they are not very numerous--it is to be presumed that
they have escaped the most active of the exciting causes of the
disease. Indeed, it is natural that a person having inherited the
predisposition should be more sedulously guarded--at first by his
parents, and afterward by himself--against the exciting causes of
scrofula during infancy and adolescence.
[Footnote 5: _Clinical Lectures and Essays_, London, 1875.]
4. Sex.--There is no reason to believe that sex plays any part in the
predisposition to this disease. Both sexes seem to be affected in about
equal proportions, but from the statistics bearing upon this point it
does seem to have some influence in determining the variety of its
lesions. Thus, females seem to be more frequently affected with
glandular disease, while males suffer from diseases of the joints in
the form of coxalgia, white swelling of the knee, and Pott's disease.
5. Condition in Life: Social Position.--If what we have said about the
predisposing influence of improper or insufficient food, overcrowding,
etc. be true, it will naturally be inferred that a large proportion of
the cases of scrofula will be found in the lower strata of society; and
this is true. Especially in cities, where the disease prevails most
extensively, we always find that the denizens of narrow streets, lanes,
and alleys furnish the largest contingent to the deaths as well as the
deformities from scrofula. It is here that the poor congregate to avail
themselves of the cheaper rents, and here will be found combined all
those predisposing causes which may be briefly summed up in one
word--poverty. It is true that cases of scrofula are quite numerous in
the country, and in a note to Sir Thomas Watson's _Practice of Physic_
(1851) D. Francis Condie quotes from a work on _The Nature and Causes
of Scrofula_, by Phillips, statistics which showed a greater
preponderance of deaths from scrofula in a given number of the rural
population than a nearly equal urban one. But at the time these
statistics were gathered in England (and perhaps now) it is probable
that there was a comparatively greater number of abjectly poor people
among the rural population than in London, where was congregated such a
large number of small tradesmen, artisans, and laborers, who, though
not well-to-do, were better paid, and consequently lived better, than
the agricultural laborers. Of course, a certain number of cases of
scrofula are found in the United States, and perhaps in all other
countries, among the children of the wealthy. These, however, are
almost invariably caused either by direct transmission from parents or
by some accidental injury to the digestive and assimilative organs in
early childhood, as we have already pointed out. When it is remembered
that in the constantly changing fortunes which are so frequently
witnessed in this age of excessive activities, and that in the grand
opportunities for obtaining wealth furnished by the liberal
institutions and rapidly-growing industries of the United States the
descendant of the pauper of the last generation may be the millionaire
of the present, it is not surprising that so many who are now wealthy
may possess the strumous diathesis as an inheritance from their parents
or grandparents, and which they in turn transmit to their offspring.
6. Consanguineous Marriage.--It has long been a popular belief that the
offspring of parents closely related by blood are more apt to be
scrofulous than when no such relation has existed. Indeed, not only
scrofula, but numerous other diseases, deformities, and imperfections
have been {235} ascribed to such unions. Idiocy or feeble-mindedness
has also been especially accredited to the production of such
marriages. But a thorough investigation of this point in England some
years ago demonstrated positively that no more idiotic, feeble-minded,
or insane children are born of such marriages than of an equal number
of marriages contracted between persons not related by blood to each
other. There is, however, this amount of truth in the popular belief:
if persons closely related to each other possess the scrofulous
diathesis, there will be a greater probability--almost certainty--that
the diathesis will be transmitted to their offspring. If one parent
only is tainted with scrofula, and the other is entirely free from it,
there is a possibility--even a probability--that some or all of the
children may escape.
7. Complexion and Temperament.--It has been stated by some observers
that scrofula occurred principally in the fair-haired, and with equal
positiveness by others that it was in the dark-haired that the disease
found the most of its victims. Such statistics as have been furnished,
however, upon this subject seem to show that there is no connection
whatever between scrofula and complexion. It will generally be found
that whenever in any country or locality more cases of scrofula occur
in persons of one or the other of the complexions, it is only because
that particular complexion is the predominant type among the
inhabitants of that locality.
8. Race and Nationality.--While it would seem that no race or nation is
entirely free from struma, yet there are certainly in the United States
two peoples who furnish an enormously disproportionate number of
scrofulous cases: these are the Irish and Jews. Among the first of
these both scrofula and tuberculosis abound with exceeding frequency,
while among the latter it is scrofula alone which seems to predominate.
The last, however, are not exempt from tuberculosis, but only exhibit
about an equal predisposition to it with their fellow-citizens. It is
not difficult to explain the special predisposition of these peoples to
scrofula when their past history is taken into account in connection
with what has been said about the bad influence of food and
surroundings in producing the scrofulous diathesis. The principal food
of the Irish peasantry--oppressed and ground into poverty by their
Anglo-Saxon conquerors for hundreds of years--have been bread and
potatoes, often potatoes alone. It cannot be surprising, therefore,
that Irish children fed upon this diet and reared in ill-ventilated
hovels should develop the scrofulous diathesis in legions. The Jews,
too, oppressed by all nations through ages, have been during many
generations reared in poverty and squalor. Even those of them who in
not very remote times had acquired by thrift the means of securing both
the comforts and luxuries of life dared not live according to their
means, lest a show of wealth should attract the unpleasant, often
fatal, attention of their rapacious and unscrupulous Christian or
Mohammedan neighbors. This condition, this mode of life, has existed
among them for many hundreds of years, and has so intensified the
strumous diathesis among them that almost the whole race may be said to
be patently or latently scrofulous. The negro or African race, however,
as observed by the writer in the Southern States of the American Union,
do not seem to have developed any special predisposition to struma,
notwithstanding their servile condition. This, at first sight, would
seem to {236} be contrary to our expectation based on what has been
said about Jews and Irishmen. But as my remark has been predicated only
on observation of the African in the Southern States, where the climate
is not favorable for the development of scrofula, the fact is not so
surprising. Besides, the food of these people consisted largely of
bacon or pork, fish, milk, and the succulent fruits and vegetables,
with a moderate quantity of corn bread, and very rarely potatoes. As
the rude cabins in which they dwelt were usually constructed of unhewn
logs and covered with rough boards, and cost almost nothing except
labor, overcrowding was unknown and ventilation always perfect. The
waiter practised medicine fourteen years in Wilcox county (S. W.),
Alabama, containing a population in 1870 of 28,377, of whom 21,610 were
colored, and during this time saw only two cases of genuine scrofula
and one of tuberculosis among the colored population.
Pork as an article of food has often been accused of producing a
tendency to scrofula, but evidently with great injustice, for we have
seen that the Jews, who never eat it, are almost universally
scrofulous, while the Southern negroes, whose staple animal food it
was, were conspicuously free from it.