125 Scrofula (Scrophula)

Scrofula can be defined only historically. That is, scrofula is a term about which there was some mea­sure of consensus in the past, but one that has now been largely superseded by terms that indicate some form of tuberculosis.

The distribution of scrofula, as we shall see below, has much more to do with the religious and political convictions of those who saw it than with physical geography or economic conditions or other circum­stances normally considered conducive to diseases. Likewise in regard to its clinical manifestations, we may note, first, that this term itself implies an under­lying entity that becomes manifest. But, second, scrofula, historically, was its collection of symptoms and signs. What we need to understand is what went into that collection, and why.

History and Geography

“Scrophula,” like “scurvy” and “syphilis,” is not a term that was used by the ancients. Whereas there may be special reasons why the latter two were unknown (a distribution to the north of the ancient Mediterranean and a possible Columbian origin, re­spectively), there seems to be no reason to suspect that scrofula was a new disease. Or, at least, so it seemed to many of the humanist doctors of the Re­naissance, trying to reconstitute Greek medicine. In fact, the best they could do in the case of scrofula was to claim that one of its chief symptoms, tumors in the neck, was to be identified with the struma of the classical physicians.

The answer is that there were medieval descrip­tions of scrofula. Partly these came from a surgical tradition, which was less Hellenizing than the physi­cians’ medicine of the Renaissance. And in part they came from a popular tradition in which scrofula was identified as the “King’s Evil,” and it was believed curable by the touch of a king. The essence of the medieval ceremony of touching in order to dispel the evil was that it demonstrated the quasi-sacerdotal nature of the office of kingship. The political advan­tages were clear, for a king, in performing the cure, showed that he was king in accordance with God’s will. This was the important point in the seven­teenth and eighteenth centuries, when the nature of scrofula was most energetically explored: The power of curing by the Royal Touch was a power vouch­safed by God only to the true line of kings. It could therefore be used to legitimate claim and accession to the throne. The kings of France continued to touch until the Revolution, and were emulated by other monarchs. In France and pre-Reformation En­gland, the religious nature of the ceremony ce­mented the relationships and mutual stability of church and throne. It was a ceremony too miracu­lous for the taste of some Protestants, although the English Puritans at first tolerated it, and James I, although of a Calvinist background, found it increas­ingly expedient to use the Touch. But by the time of Charles I, his opponents saw it as a justification of absolute royal rule by a king who claimed to act as a representative of God. The Stuarts, whether on the throne or in temporary or permanent exile, contin­ued to touch for the King’s Evil, and their supporters continued to claim that their success in curing scrof­ula was a sure sign of their descent in the true line and thus the only legitimate monarchs.

The strongest passions were aroused in the con­flicts that surrounded the issue. Crowds pressing around the Stuart kings to receive the Touch con­tained thousands of individuals; and there is no need to emphasize that in the Civil War the questions that split families were ones of religion and personal salva­tion, and ofliberties and duties on Earth. Because the King’s Evil was intimately bound up with the person of the king, if we look for a “distribution” of scrofula - for example, by examining seventeenth-century medical works - we find abundant references to the disease in Britain and France. But elsewhere the texts may be completely silent about the disease. Thus in Holland, recently freed from the rule of an absolutist and Catholic monarch, and a republic of

sorts, scrofula had no place in the medical conscious­ness. Nor did Italian or German medical men, with no national attachment to a true line of kings, have much reason to emphasize scrofula as a disease en­tity, but rather viewed its separated symptoms as different entities. By the eighteenth century, some medical reference works betray an Enlightenment embarrassment in identifying scrofula as a disease that had a nonmedical cure, the Touch. In discussing the disease, British writers of the eighteenth century drew on a tradition of literature that rested on the works ofRichard Wiseman, surgeon to Charles II. In the earlier nineteenth century, with the disappear­ance of the French line of kings, scrofula continued to be identified, although perhaps more regularly in its adjectival form and applied to a symptom. The notion that lay behind the name did not long survive germ theory, when attention turned away from collections of symptoms to causative microorganisms.

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 - Hpitudo.

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 eighteenth­century 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 eighteenth­century 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.

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.

RogerK. French

Bibliography

Barlow, Frank. 1980. The King’s Evil. English Historical Review 95: 3—27.

Blancard, S. 1715. The physical dictionary, 6th edition. London.

1735. Lexicon medicum renovatum. Leyden. Bloch, M. 1973. The royal touch. London. Boerhaave₁ H. 1727. Institutiones medicae in usus annuae exercitationis domesticos. Leyden.

1738. Aphorismsi de cognoscendis et curandis morbis. Paris.

Dunglison, Robley 1833. Medical lexicon: A dictionary of medical science, ed. Richard Dunglison. Philadelphia, 1874.

Hooper, R. 1801. A compendious medical dictionary, 2d edition. London.

1831. Lexicon medicum; or medical dictionary, 6th edi­tion. London.

James, R. 1743-5. A medical dictionary, 3 vols. London.

Longmore, T. 1891. Richard Wiseman, sergeant surgeon to Charles II. London.

Nicholaus, E. 1747. Methodus concinnandi formulas medi­camentorum. Magdeburg.

Quincy, J. 1713. Lexicon physico medicum graeco-latinum. Leipzig.

Swieten₁ G. van. 1787-92. Commentaria in Hermanni Boerhaave aphorismos de cognoscendis et curandis morbis. Wurzburg.

Wiseman, R. 1705. Severall chirurgical treatises, 4th edi­tion. London.