176 CHAPTER XIV. DISEASES USUALLY TERMED CONSTITUTIONAL, WHICH ARE Scrofula.-Phthisis and its connexion with Scrofula.-Pulmonary Consumption.-Relation of Consumption to Enteric Fever, Measles, and Scarlatina. Diminution of Phthisis by Improved Sanitary Conditions.Special localities favour Phthisis.—Relation of Phthisis to Impure Air.— Relation between Phthisis and Occupation.-Reduction of Phthisis in Army by Hygienic Measures.-Phthisis and Scrofula in Workhouses, Schools, and Public Institutions. SCROFULOUS AFFECTIONS.-These diseases may be included under the head of scrofula, for although it is possible that other diseases, now considered constitutional, may have local and preventable causes, yet scrofula and its allies, are the only so-called constitutional diseases which are at present known to be fairly within the control of sanitary measures. The diseases included under this head are-pulmonary consumption, tuberculosis, tabes, rickets, scrofulous glandular diseases, strumous or purulent ophthalmia, and the minor forms of strumous disease. It would not be advisable, in the present state of our pathological knowledge, to treat scrofula and tuberculosis as synonymous terms; but even admitting that in many cases the diseases may be far removed from one another, yet, from a sanitary point of view, they must be looked upon as having a close relationship. PHTHISIS.-By far the most important disease of this class is phthisis or pulmonary consumption, which is much more under the control of sanitary measures than is generally believed by the public. There are There are a great many varieties of pulmonary consumption, originating in various ways, but no small proportion of them take their origin in zymotic disease. The frequency with which phthisis follows enteric fever, measles, and scarlatina, is but too well known; and that a great many cases are also due to the prevalence of pythogenic pneumonia is pretty certain. Besides these modes of origin, the lowering of the general health of those living under insanitary conditions must tend to the development of consumption in those who have a hereditary predisposition to the disease. The general conditions which favour the spread of zymotic diseases also favour the spread of consumption, and any measures which diminish the one group of diseases also diminish the other. This is clearly shown by Table IX. already referred to, where the death-rate from phthisis has diminished, pari passu, with the other diseases. Besides the indirect effect of drainage works in diminishing phthisis, by the diminution of zymotics, they seem to act directly by drying the soil. This has been shown by many authorities, but especially by Dr. Buchanan, in his Report on the "Distribution of Phthisis as affected by Dampness of Soil." Dr. Buchanan concludes that "wetness of soil is a cause of phthisis to the population living upon it." "Phthisis has been greatly reduced in towns where the water of the soil has been artificially removed, and it has not been reduced in other towns where the soil had not been dried." There is less phthisis among populations living on pervious than on impervious soils, and less among those living on high-lying than on low-lying pervious soils, and less among those living on high-lying than on low-lying impervious soils. There is a general agreement with regard to the prevalence of phthisis in places of similar geological or topographical conditions. It may be safely affirmed that the prevalence of this disease in certain families, commonly attributed to hereditary predisposition, might more correctly have been attributed to the circumstance of those families living for many generations upon a damp and impervious soil. The 1 Privy Council Report. No. 10. P. 109. N removal of certain members of phthisical families to other localities, at no great distance, seems to have saved them from the disease, all other conditions, except the locality, being the same. Many cases of pulmonary consumption owe their origin to constant inhalation of impure air. Impurity of the air as a cause of pulmonary disease has been a subject of much discussion. It has not been shown, indeed, that any one particular atmospheric impurity is the cause of the pulmonary disease of those who constantly inhale impure air. One thing is certain, that persons following in-door occupations are more liable to the disease than those following out-door occupations. Thus, Dr. Cotton1 shows that, in 1,000 cases of phthisis, 841 were in persons following in-door occupations, and but 159 in those following out-door occupations. Dr. Pollock 2 says:"Confinement within doors seems to be in itself a predisposing cause of phthisis, which, judging by figures, is one of the most powerful." Among 3,214 men at the hospitals, more than one-half had followed in-door occupations; and the 2,413 women may be said to have been almost all so engaged. Dr. Pollock gives the following Table of occupations of phthisical patients, taken from the Report of the Hospital for Consumption and Diseases of the Chest, Brompton :— 1 On Consumption, its Nature, Symptoms, and Treatment. By R. P. Cotton, M.D. 1858. P. 69. 2 Elements of Prognosis in Consumption. By J. E. Pollock, M.D. London. 1865. P. 366. TABLE XXI.-Showing the Occupations of 5,627 Persons, of both Sexes, affected by Phthisis. From this Table it is apparent that phthisis prevails in exact proportion to the degree of confinement of the sufferers. The influence of closeness of air in the production of phthisis is so great that Dr. MacCormac, of Belfast, has supported the view that this is the cause of phthisis, and has further argued that the inhalation of air which has already been respired is the sole cause of the disease, and further, that the noxious element in the respired air is the carbon of the carbonic acid contained therein. While we do not go quite so far as Dr. MacCormac, we admit that the most potent single cause of phthisis is the constant inhalation of impure air. 1 Consumption and the Breath Rebreathed. By Henry MacCormac, M.D. London: Longmans. 1872. By sanitary measures, chiefly those of improved ventilation and increased cubic space, the mortality from this disease in the army has been reduced to one-half in all, and to onethird in some corps. In considering this question it is not fair to include as consumption those pulmonary diseases which are the result of special occupations, such as those arising from dust or particles of materials used in trades, as the so-called miners' and knife-grinders' diseases. SCROFULA. The prevalence of other forms of scrofulous disease can be easily shown to depend on insanitary conditions, especially impurity of air, unwholesomeness or insufficiency of food. The greater prevalence of scrofula among the children of the poor, as compared with those of the rich, can be explained only upon this supposition. The prevalence of scrofula in large establishments, especially workhouse and charity schools, was in former days so constant that it was looked upon as an almost inevitable disease in such institutions, and unfortunately was always attributed to the scrofulous diathesis of the person before admission. The improved sanitary conditions, now so generally enforced in public establishments, have shown that scrofulous disease in such communities is not only not an inevitable necessity, but that children admitted with scrofulous affections may have their unhealthiness removed by the mere transfer to well-regulated public establishments. A great deal of scrofulous disease among children in public institutions may be attributed to the rigidness of the rules. Thus children of varying ages and different degrees of mental and bodily vigour are constantly classed together with regard to diet, rest, exercise, or study. From some too much is expected, and from others possibly too little. As the majority of sanitary authorities in Ireland have to deal with the management of workhouses and workhouse schools, they, together with their officers, should be especially aware of the fact that improper classification in the above-mentioned important matters will almost certainly give rise to scrofulous diseases among the children under their charge, and |