Clinical Manifestations Contemporaneous Observations

To this point we have seen something of the nature, geography, and history of scrofula. We should next examine what it was that contemporaneous observers saw when describing the disease. The classic description was that of Wiseman (1705), a passionate royalist, to whom the Restoration seemed an expression of God's will, which had placed the rightful line of kings back on the throne. The power of the king to cure by the Touch was triumphantly demonstrated again, and if it was good to show that the king cured, it was better to show that he cured a disease that medicine or surgery could not. Thus Wiseman selected only the most extensive and difficult cases to go forward to the king. He rejected the simple identification of scrofula and struma and said that "none of these definitions seem to describe sufficiently the Disease which we in England call the Kings-Evil." Scrofula, he insisted, included more than the tumors-in-their-own-membranes that was struma: There were the bifurcated swelling of the upper lip; the tumors of the muscles, ligaments, tendons, and bones; the fistulae of the tonsils and of the lachrymal region of the eyes; together with ophthalmia. The cases sent to the king had a characteristic tumor near the mastoid muscle, and protrusion of the eyes - lipitudo.

Wiseman, of course, was in a position to insist on his definition of scrofula in that he both chose who would receive the Royal Touch and published the most authoritative account of the condition. But he drew together his description of the disease partly from descriptions made by other practitioners, and there must have been something like a national consensus of what the disease consisted of. There would not otherwise have been any perception of the disease or the king's role in its cure among the thousands of ordinary people, or among their parsons or squires who, we may suppose, encouraged them to go to London for the Touch.

The term "scrofula" remained in use in mainly British and French medical texts through the eighteenth century, and we can gather more information from medical practice in hospitals about what physicians saw the disease to be. The voluntary hospitals of the eighteenth century were charitable institutions of one form or another. Demand for effective use of charitable funds (and the utility of recovered patients for advertising purposes) often led to pressure for a quick turnover of patients. This meant that chronic cases were generally not admitted, nor were infectious cases, on the grounds that they would endanger the other patients. So when we see scrofulous patients being admitted to an eighteenth-century hospital, we can assume that the physician or surgeon who made the admissions did not think that the disease was chronic or infectious. In practice, admissions to hospitals show the same ambivalence about the nature of scrofula as the eighteenth-century medical world at large. Sometimes the term simply did not exist in the language of the physician in charge or in his hospital, and at other times scrofulous men and women were refused admission as incurable or even infectious. Often a physician could not tell whether the patient's symptoms were scrofulous, and took in the patient for tests. Sometimes admittedly scrofulous patients were taken into hospitals in the belief that they were not infectious and that a course of mercury-sweats would cure them.

From the records we can see that the physician or surgeon was looking for a number of things to establish that his patient was scrofulous: an itch and tumors in the glands, joints, and other tissues. As the disease progressed, the physician saw these tumors change into ulcers, which became deep and ultimately produced caries in the bones. Exploratory surgery was used to discover whether the last stage of the disease had been reached and what, accordingly, the prognosis was. Sometimes patients were sent home as incurable, sometimes they were treated in a hot room with mercury-sweats to unblock their glands and vessels of the impediment that was held to cause scrofula. Which of these many alternatives was used probably depended on where the doctor had been trained.

The politics of early-nineteenth-century Europe no longer supported the idea of the "true line of kings." Without true kings, there was no King's Evil, and scrofula was seen as a disease entity less often than in the preceding century. It is true that a system so influential as that of William Cullen retained the disease entity, but in fact his subdivision of it helped to destroy the unit of scrofula as a term. He distinguished, first, "scrofula vulgaris" as the disease in its external form, without complications. This is probably the scrofulous itch of the hospitals. Cullen's second type was "scrofula mesenterica," the internal form of the disease, with swelling abdomen, pale countenance, and loss of appetite. The third type was "scrofula fugax," consisting of swelling about the neck and corresponding to the old struma. Cullen's fourth category was "scrofula americana," which by the 1830s was thought of as European scrofula combined with the yaws.

The term "scrofula" survived largely in the adjectival form, so that scrofulous tumors or ulcers could be seen and described on their own without a necessary connection to the other defining characteristics of the seventeenth-century disease. With the new emphasis on postmortem pathological anatomy of the first half of the nineteenth century, cases of internal scrofula were often found to be characterized by tubercles in the lungs. The discovery (by Robert Koch in 1882) of the bacillus responsible for these created an ontology of disease around tuberculosis, thus rendering scrofula peripheral to medicine and accessible only to the historian.

Roger K. French

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