Part 34

The teeth in scrofula show nothing that is distinctive, though there is undoubtedly a tendency to early decay. As this tendency to decay is, however, so common in many persons who have at least shown no other evidences of the scrofulous diathesis, no positive conclusions can be drawn from this fact.

Clubbed fingers, too, so common in persons who have become cachectic from the long persistence of scrofulous disorders, are not characteristic. Clubbed fingers and incurvated nails will generally be found in persons suffering from any disease characterized by slow wasting. They are seen in phthisis of all varieties, as well as in cancer, heart disease, aneurism, Bright's disease, empyema. They therefore have no significance as far as struma is concerned.

GENERAL MANIFESTATIONS OF SCROFULA.--As, according to our view, there is no such disease per se as scrofula, but simply a diathesis which impresses its own malign influence upon every other disease with which the strumous individual may happen to be afflicted, increasing perhaps the general predisposition to be injuriously affected by all morbific influences, or impairing the powers of resistance to these, and especially intensifying any special predisposition which age, sex, personal peculiarities, occupation, habits, mode of life, or heredity may have created, we cannot describe any morbid processes as specifically scrofulous. At most, we can only say that struma is more apt to impress its malign influence upon certain diseases or upon inflammations and injuries of certain tissues, that some diseases in the scrofulous are more apt to be {247} attended by certain complications and followed by certain sequelæ, and that all of these are characterized by chronicity and incurability, by slowness of evolution of pathological processes, and, in the case of inflammations, by a tendency to profuse cell-production and to rapid caseation. Thus, measles is apt to be complicated with or followed by otorrhoea, chronic bronchitis, caseation of bronchial glands, phthisis, and even tuberculosis; scarlatina by otitis, hyperplasia of the tonsils, caseation or suppuration of the submaxillary and other lymphatic glands about the neck, and by chronic catarrh of the renal mucous membranes, causing dropsy and finally death; eczemas about the face or catarrhs of the mouth and throat by hyperplasiæ and caseation of lymphatic glands in the neighborhood. Boils and other subcutaneous inflammations of the areolar tissue, so common in childhood and adolescence, do not run their usual rapid course, ending in suppurations and cicatrization, but become in the one case the scrofulous gumma, degenerating into the scrofulous ulcer, or if more deeply seated become a cold abscess. A single injury of a joint, whether mechanical or rheumatic, will "sometimes take the form of a simple hydrarthrosis, sometimes that of a so-called tumor albus, while at others it assumes the nature of a malignant arthrocace, accompanied by suppuration, caries of the articular surfaces, burrowing of pus, and the establishment of fistulæ." A slight injury inflicted in the sports of childhood and soon forgotten--the prick of a pin perhaps--is followed by a disease sometimes beginning in the periosteum, sometimes in the bone itself, and presenting at one time the character of periostitis and ostitis, and at another that of caries or necrosis, or of the two combined.

"As long as the existence of cheesy masses," says Niemeyer, "was regarded as characteristic of the tuberculous nature of a disease, it was of course necessary to ascribe many of the inflammations of the joints and bones of scrofulous persons to a complication of scrofulosis with tuberculosis."

A simple bronchitis, possessing nothing specific in its origin at least, will persist and extend to the lobuli of the lung and excite a catarrho-pneumonia which ends in consumption and death; a simple intestinal catarrh will result in inflammation and caseation of the mesenteric glands--a tabes mesenterica; or a simple dysentery, persisting in spite of the most {248} approved treatment, causes proliferation and caseation of the endothelial cells of the follicles, terminating in that obstinate and intractable follicular ulceration which wastes the strength and wears out the life of the little patient.

A simple conjunctivitis of the globe often will be followed by ulceration of the cornea, giving rise to intense photophobia, and leave behind it opacities of that organ which remain a perpetual evidence of the scrofulous diathesis, if they do not shut out for ever the light from the eye. Or if it is the palpebral conjunctiva that is affected, the meibomian glands and follicles of the ciliæ become involved, destroying the lashes and leaving the lids raw and everted or inverted--a perpetual deformity. In short, there is no conceivable disease or injury occurring in what we may call the intensely scrofulous that does not have impressed upon it some one or more of the malign characteristics which we have spoken of as indicative of the scrofulous diathesis. But it is not probable that there is ever any special disorder or lesion which can be said to be caused exclusively by scrofula; or, in other words, there is no such disease as a specifically scrofulous one. Lupus, cold abscess, and particularly caseous glands, are especially attributed to struma, because they are often thought to make their appearance independent of any assignable cause; but as boils, eczema, impetigo, and numerous other affections of the skin and areolar tissue affect children who are not scrofulous, and equally independent of any known causes, the argument is not conclusive. Besides, all these affections occur sometimes in the non-scrofulous; and even caseation of a single inflamed gland quite often occurs in children who are weak or in ill-health, but who show no other evidences at that or at any other time of the scrofulous habit.

DIAGNOSIS.--The only affection likely to be mistaken for scrofula is congenital or acquired syphilis in its later manifestations. In this disease we see the same tendency to increased cell-production, the same tedious, slow, and intractable inflammations and ulcerations, which are characteristic of scrofula. And this apparent similarity has induced many persons to believe that scrofula is nothing else than syphilis in the second or third generations. But in congenital syphilis the lesions usually make their appearance soon after birth or are present at birth, and long before even hereditary scrofula begins to show its malign influence. In most cases, too, a history of syphilis can be obtained, and even when this is not obtainable a few inunctions or fumigations with mercury, in connection with a few large doses of iodide of potassium, will very quickly decide the question of diagnosis for us.

In the case of lupus, in which Erichsen admits there is no means of positively distinguishing the syphilitic from the so-called scrofulous varieties, the diagnosis is more difficult. But as this disease appears later in life than the more ordinary scrofulous manifestations--when, therefore, a history of syphilis can generally be obtained if there is one, and when there would almost certainly be also a history of scrofula if it existed--it would seem that the diagnosis even in this case cannot be so difficult. Diagnosis here, however, is of little consequence, since the treatment recommended for both forms is the same.

PROGNOSIS.--This of course depends upon the nature of the special lesion. The simpler lesions incident to childhood, such as glandular {249} hyperplasiæ, catarrhs, eczemas, impetigoes, etc., usually do well under appropriate treatment and proper hygienic conditions. Diseases of joints, bones, mesenteric glands, etc. often terminate fatally or result in serious deformities and permanent impairment of function. Not infrequently diseases of the bones and articulations, attended with profuse and protracted suppuration, cause amyloid degeneration of the liver, kidneys, spleen, or other glandular organs, and, as a consequence, death. Catarrho-pneumonia in a scrofulous subject almost invariably causes phthisis sooner or later. Occasionally the caseated cellular exudation in the air-sacs remains quiescent for months, and even years, the patient remaining quite well except for a harassing cough during the winter months; but sooner or later the caseous mass will soften, the symptoms of active consumption ensue, with fever and wasting, and death closes the scene. Far more frequently, however, softening and suppuration follow swiftly upon the caseous degeneration, and the whole process occupies a period of only a few months. Tuberculosis especially runs a rapid course in these subjects, and while a few perhaps only develop tuberculosis of the lungs--in which case the duration of the disease may be a little longer--in by far the larger number there is a generalization of the tubercular process which puts a speedy end to their existence.

TREATMENT.--This may be most profitably discussed under two heads--prophylactic and therapeutic.

Prophylactic.--Scrofulous persons who are closely related by blood should be earnestly advised not to intermarry. We have so often seen the deplorable results upon offspring of such marriages that we cannot too strongly urge this upon the profession. Such persons should be frankly and clearly told what are most likely to be the consequences of such marriage, and all possible moral influences should be exerted to prevent them. The canons of the Church wisely interdict such marriages, but, unfortunately, its ministers seldom attempt to enforce them, or if they do their efforts are made ineffectual by the facility with which the marriage-rite can be obtained from civil officers in most of the States of the American Union. The medical profession can do more than any other class to diffuse knowledge and create a correct public opinion upon this subject, but, unfortunately, it too often neglects this important mission.

The children of scrofulous parents should be nursed (at the breast) longer than other children, so as to ensure an abundance of animal food during the first two years of life. Some advise scrofulous mothers not to nurse their children, lest they should imbibe the scrofulous taint through the milk. This fear is entirely groundless. We know of no reason why such a mother should not nurse her offspring, unless it be that it injures her. The child receives its scrofulous inheritance not through the mother's milk, but from the ovarian or spermatic cell. Milk can convey no disease or diathesis except on account of its deficiency in nutritive properties. If, therefore, there is any special reason why the mother should not nurse her infant on her own account, it may be well to turn it over to a healthy wet-nurse; but the temptation to give an infant raised on the bottle starchy foods prematurely is too strong generally to be resisted. The numerous infant foods advertised consist principally of starch, and young infants would infallibly starve on any or all of them {250} if their venders did not always direct that they should be taken with a large quantity of cow's milk. If the circumstances of the parents do not enable them to obtain a wet-nurse, then good cow's milk constitutes the best food for infants until they have cut their canine and anterior molar teeth. The custom of weaning infants at a certain age in every case is a pernicious one. Some infants are as well developed as to their digestive organs at fifteen months as others are at thirty, and the eruption of the teeth may generally be taken as a safe guide as to that question. A moderate amount of food containing starch after the period indicated may be allowed, but always with a preponderance of animal food. It is not so much the starch that acts injuriously upon the nutrition of children as the excess of that substance; and if the food contains but little nutrition in proportion to its bulk, it is so much the worse. Even milk containing too little casein and fat in proportion to the watery elements may be perhaps quite as injurious as potatoes. And hence if the mother's milk should be poor in these elements, it ought to be supplemented with cod-liver oil or other animal fat in small doses.

A practice existed among the Southern slaves (and to some extent also among the whites) before emancipation which at first I was inclined to condemn until I saw the excellent effects resulting from it. Within an hour or so after birth a piece of fat salt pork or bacon was placed between the child's lips, and it was permitted to suck this at all times when not nursing. Tied to its wrist by a short string, so as to prevent swallowing it, this piece of pork furnished both nutrition and amusement to the infant for many hours while the mother was at work in field or garden. The children throve well on it, and thus treated we found them to be as well developed at twelve months as most other children were at twenty. It was doubtless due in part to this practice that there was so little scrofula among them.

An abundance of pure air is also a valuable factor in preventing the establishment of the strumous diathesis. Strict regard, therefore, should be had to ventilation, and overcrowding should if possible be avoided. Children over twelve months of age should not even be permitted to sleep with their parents, but should have in cold weather a crib, cradle, or other bed to themselves; and in warm weather they should be put to sleep in a net hammock, which is now so cheap as to be within the means of almost everybody. This will not only secure to them a better supply of air, but it will also prevent them from suffering so much from the heat, which is so potent a factor in the production of cholera infantum.

Bathing in proper season is also useful as a prophylactic. Sea-bathing especially has long enjoyed great credit as a remedy for scrofula, but we think this is often resorted to too soon and practised at improper times. In warm countries a bath of cold water may be taken every day in the year, but it should be given at the warmest hour of the day, not early in the morning. In all climates due regard should be had to the powers of resistance to cold and the promptness of reaction after the bath. If children remain cold and pale for a long time after the cold bath, the practice should be discontinued and tepid water substituted. In colder climates tepid bathing should be practised once or twice a day during the winter, and in summer a little lower temperature may be used. Bathing children under three or four years in the sea at any time is pernicious, {251} both because the temperature is too low and on account of the fright which it always causes in these young children. After four years a child will take to the water almost as instinctively as a young duck.

Therapeutic.--Almost all of the so-called scrofulous manifestations belong to the surgeon, dermatologist, or oculist and aurist, and we shall therefore say nothing about the special and local treatment of these manifestations, but refer the reader to works upon these several departments of medicine. But as little success will be had in the treatment of these special disorders unless due regard is had to the general condition, and unless the local treatment is supplemented by constitutional measures, we shall briefly give some directions for this constitutional treatment of the scrofulous individual.

It is important in determining upon the proper treatment in any given case to bear in mind the division of the scrofulous into the two types of torpid or lymphatic and sanguine or erethistic already described. It is true that in many cases it is not easy to determine to which class a patient belongs, and many possessing some of the characteristics of both certainly cannot be referred to either. Still, in many cases the discrimination is easy, and then furnishes very clear and valuable indications as to treatment. Iodine (and its preparations) has since the time of Lugol, who first brought it into prominent notice, been regarded as a useful remedy in scrofula. But burnt sponge (spongia usta), which contained the iodides of sodium and potassium, had been used to dissipate goitrous and scrofulous swellings many hundreds of years before the time of Lugol. It is a valuable remedy in certain cases, and if it is falling into disuse it is probably for the want of proper discrimination in the selection of cases. In all cases in which there seems to be an abundant production of fat, and therefore in nearly all the cases of coarse struma where there is an indolent process of assimilation and disassimilation, iodine and its preparations will be found useful. Indeed, in the form of syrup of iodide of iron we have rarely failed with it to cause strumous enlargements of glands to disappear when the remedy was used soon after their first appearance. Of course, neither iodine nor any other medicine can have any effect in removing these enlargements after the glands have become caseous. While good results may be obtained with the syrup in all forms of scrofula, it is unquestionably in the sanguine and neutral types that it is most useful. It should be given in doses of 10 to 30 drops to children under five years of age, and to older ones ½ to 1 fluidrachm three or four times a day may be administered. We have given the latter dose to children four or five years of age for a long time, with the best effect upon their scrofulous manifestations, and without any injury whatever to their digestive organs.

In the torpid types preparations stronger in iodine should be used. Here Lugol's solution or iodide of potassium or sodium will be found very useful, either alone or in connection with the iron preparation above mentioned. Indeed, as in these cases it seems to be disassimilation that appears to be specially faulty, even very small doses of mercury in the form of bichloride or biniodide will be found useful. Donovan's solution may be prescribed in these cases along with the active preparations of iodine with good effect, or if the arsenic in that preparation is objectionable, one-fiftieth of a grain of bichloride or biniodide of {252} mercury may be substituted. The mercurial should not, however, be continued longer than one or at most two weeks at a time, after which it should be suspended and the iodine continued.

Cod-liver oil, which is too indiscriminately prescribed in all cases, will be found to be of little use in the lymphatic types, if indeed it is not actually injurious; but in those cases with pale, thin skin, with deficient development of fat, and with small muscles--in short, those in which emaciation or delicacy is prominent--it is a most valuable remedy. It is almost surprising to see how rapidly ulcerations, caries, eczemas, catarrhs, etc. occurring in this class of subjects will disappear under the use of this medicine alone.

The hypophosphites and lactophosphates are also useful in this class of cases, especially where there is disease of bone or joints, in connection with the cod-liver oil. We have long been in the habit of using the following formula, which we have found very useful:

Rx. Pulv. Acaciæ, drachm ij; Ol. Amygdal. amar., gtt. vj; Syr. Calcii hypophosphit., vel Syr. Calcii lactophos., fluidounce iv; Ol. Morrhuæ, fluidounce iv; Ft. mist.

S. Teaspoonful to tablespoonful three times a day according to age. Syrup of iodide of iron may be added if desirable, though we prefer to give this by itself.

Gentle exercise, passive or active, pure air, well-ventilated sleeping apartments, a generous diet--in which wholesome animal food should predominate--and bathing are of course as necessary and as useful in the treatment as in the prevention of the scrofulous diathesis.

Alkalies should be given in all cases in which we are trying to dissipate enlarged lymphatic glands, for the reason that caseation of these glands occurs because of insufficient alkalinity of the blood to effect reduction of fat, and because also the strumous almost always suffer from excessive acidity of the gastric and other secretions. When the iodides of potash or soda or the hypophosphites of lime and soda are given, the additional administration of alkalies may not be necessary; but if not, bicarbonate of sodium or potassium (which have long enjoyed a good reputation in the treatment of struma) should be added to the other remedies.

Since the appearance of Niemeyer's Handbook of Clinical Medicine the proper treatment of scrofulous glands that have undergone the caseous degeneration has been a moot question. Some recommend the ablation of these glands by the knife, some advise spooning out the caseous matter through a small opening, while others prefer to await the natural process of softening and the discharge of the caseous matter by suppuration. There can be no question that the removal of these glands by the knife, when this can be done without serious risk, will leave behind a less unsightly scar, and will be attended with less fever and consequent deterioration of the general health, than usually attends suppuration. Spooning out the caseous matter will perhaps leave no extensive cicatrix, but we can never be sure that by this operation we have removed all the caseous matter, and it must certainly be more painful than the knife. Mothers will generally object to either of these {253} operations, and as the risks of infection by absorption of the caseous pus during the suppurating process do not seem to be very great, it is perhaps best to leave these glands to nature, unless the vitality of the patient is so low as to give reasonable ground for fear that the child may succumb to the effects of the natural process. If any surgical interference is deemed necessary, we are decidedly in favor of removing the caseous gland entire by the knife.

{254}

HEREDITARY SYPHILIS.

BY J. WILLIAM WHITE, M.D.