No. 1405.

AUGUST 3, 1850.

A Course of LecturesIN

GENERAL PATHOLOGY;Delivered at St. Thomas’s Hospital,

BY JOHN SIMON, ESQ., F.R.S.,ONE OF THE SURGICAL STAFF OF THAT HOSPITAL.

LECTURE IX.

SCROFULA:—tubercle its essential and diagnostic product. Dis-tinction of scrofula from sub-inflammatory and atrophic pro-cesses occasioned by mere debility. Experiments on the artificialproducibility of tubercle. Hereditary transmission of scrofulousdiathesis, as a developmental peculiarity. Material of tuber-cular deposits. Its microscopical characters. Is it an inflam-matory product ? Organs preferentially invaded by tubercle.Its anatomical relations to the natural structures. Diseaseswith which tubercular deposition is incompatible. Diseaseswith which it has affinity: fatty degenerations. Pathologicalgeneralisations as to tubercle and the tubercular diathesis. Con-trast with cancer. Therapeutical influences against tubercle.

GENTLEMEN,—For the subject of to-day’s lecture I propose toconsider Tubercle,--meaning by this term that un-organizabledeposit which occurs in various organs of the body, under theinfluence of a peculiar constitutional state-marking such astate, and rendering it specific, by the name of the S’crofulous

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diathesis. In this country, at least, you can have no more in-teresting object of study. The frequency and the fatality ofthe disease constitute its importance. If you look at the

Registrar-General’s statistics of mortality in the metropolis,you will see that among the specified causes of death" tuber-cular diseases" hold the chief place. He assigns to themabout a fifth of the total mortality; and when you considerhow very many instances there must be of disease in internal

organs due to tubercular deposit, where the nature of themorbid process is unrecognised, and where consequently thecause of death is recorded by the mere mention of its site-as " disease of the brain," " disease of the kidney," " diseaseof the lung;’-when you consider, besides, how many otherfatal diseases may be derived, indirectly, from the same de-posit, or the same diathesis,-you will be able to measure foryourselves the vast importance of acquiring an accurate know-ledge of influences so hostile to life.

Already, in the first words of this lecture, I have spoken oftubercle as the specific product of a peculiar constitutionalact; and in order to ensure accuracy of phrase, no less thanfor the sake of pathological exactness, I would recommendyou to employ the adjective " scrofulous" only when you mean" essentially associated with tubercular deposit."

It may hereafter appear-at least I will not venture toassert the contrary-that other manifestations of disease mayadmit of being classed in an equally close relation of depend-ence on the same constitutional state; but at present there isno evidence to justify us in extending to other diseases theparticular formula which includes the pathology of tubercle :-this, namely, that under the influence of a constitutional bias,which is peculiarly susceptible of hereditary transmission, andpeculiarly difficult of artificial generation, there occur localdeposits of an organic material, which is insusceptible ofulterior development.In order to clear the ground, I shall begin by speaking of

some of those conditions to which the name has been-I willnot say wrongly, but incautiously and vaguely applied.

Manifestations of the scrofulous diathesis very frequentlyoccur in connexion with a state of general debility-with sucha state (I mean) as consists, not in evident failure of mus-cular strength, but in depression of the vital power, in imper-fection of the nutritive processes, in defective resistance toinjury and to disease; and, in respect of these conditions, weconstantly see tubercle associated with other phenomena,which belong to it merely by reason of that accompanyingweakness-belong to it accidentally, not essentially. Thesephenomena-the accidental associations of scrofula-admit ofready reproduction and imitation, by experiments which aremerely debilitating. They are essentially temporary, or ratherare essentially co-extensive in duration with whatever debili-tating causes may have produced them; and (so far as I

know) they do not evince the slightest tendency to hereditarytransmission.

Look, for instance, at Magendie’s well-known experiments,as to the influence of non-nitrogenised diet, and other insuffi-ciencies of nutriment. Ulcers of the cornea, leading to de-struction of the globe of the eye, were observed by him toarise uniformly in connexion with the emaciation and the im-poverishment of blood produced under these circumstances.From my own observations I can confirm the accuracy of

these statements. In animals exposed experimentally to suchcauses of disease, I have again and again seen various ulcera-tions arise in the cornea, the stomach, the intestines, &c.; andthe dietetic causes have seemed capable of acting with in-creased effect, when their debilitating influence has beenassisted by confinement in damp, dark, and ill-ventilatedplaces.Now, in the practice of medicine and surgery, these dis-

orders of defective nutrition play a very important part. Thevarious slighter forms of chronic inflammation with which weare familiar-the sore eyes, the sore ears, the sore noses, thesore legs, the whitlows, the congested and catarrhal mucousmembranes, which are so frequent among our hospitalpatients; all these, I repeat, may be readily produced underthe artificial influence of defective nourishment. True-thatthey may occur in connexion with tubercular disease; thesubjects of tubercular disease are, in fact, from the reasons Ihave mentioned, very liable to them; but, on the other hand,any amount of tubercle may exist without these accompani-ments ; or they may exist to an unlimited extent without theslightest trace of tubercular deposit in any part of the body;and experiment on the lower animals, which so easily producesthe one class of derangements, can hardly be made to producethe other. As it requires the passage of (at least) some gene-rations to form a variety of the human race, and to fix andrender hereditary the conformation of a Caucasian, or a Carib,or a Bushman; so it takes time to establish and render per-manent the scrofulous or tubercle-forming diathesis. WhileI entertain no doubt that it is artificially producible, yet I ampersuaded that its producibility by experiment has been im-mensely over-rated. The difficulty of producing it in any onegeneration, free from the taint, amounts almost to impossi-bility ; unless change of climate be added to the other condi-tions of the experiment. The influences, by which scrofulahas become a permanent element in human society, have pro-

bably affected several generations in succession; and are intheir nature such as, if concentrated on one generation, wouldnot produce tubercular deposits, but would rather destroy life

by the local inflammations above mentioned, or by certain.

other deposits or degenerations, which I shall presently men-tion as standing in very closer affinity to the tubercula.

I do not hesitate to confess that knowledge on these sub-jects is far from perfect, and you will understand that futureobservation may correct what I have stated, and may givecertainty where hitherto we have but doubt; establishing,perhaps, a nearer connexion than is yet seen, between tubercleand the transitory effects of defective nutrition. I would,however, strongly recommend you, in the present state of ourinformation, to confine your use of the word "scrofulous" tosuch diseases only as are attended with those deposits mostcharacteristic of the diathesis.Having spoken of experiments performed on the lower

animals, I feel bound to caution you against a too implicitbelief of all you may read in books as to the experimentalproduction of tubercle. Statements on this subject have beenmade and disseminated too hastily. For instance, rabbits arecited by authors, as peculiarly prone to become subjects of thedisease. "A rabbit, fed in a damp, dark cellar, on wateryvegetable food, (says Mr. Phillips,) soon becomes the victimof tubercular deposits." There are certain influences (says Dr.Walshe) " which experience has proved to lead unfailingly tothe development of tubercle in the liver of rabbits." Fouror five years ago, when I was busy with experiments on thissubject, I received from a friend the so-called tubercular liverof a rabbit; the deposit was white, not very firm in any part,and in some spots diffluent; it extended in several directionsthroughout the thickness of the organ, reaching its surface,and bulging it at various points; but there was something inits appearance which struck me at first sight as unlike tuber-cular deposit; it appeared continuous in lines, rather than in

masses; it seemed to branch, too, in the direction of the ducts,! as though it were dependent on their anatomical arrangement.’ I proceeded to examine it with a high power of the microscope,- and found, to my astonishment, that the whole mass consistedof the minute oblong eggs of some entozoon. The fact seemed

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likely to be of importance, and consequently I followed up the sitions to disease does not belong to scrofula only; it forms aobservation by others. On inquiry of a candid poulterer (for very important problem in the pathogeny of cancer with itsthe sellers of eatable stock are naturallv reluctant to admit the allied disorders (for they are often hereditary) of gout andpossibility of disease in their animals) I found that these tuber- rheumatism (for they, too, are heirlooms in families); and itcular livers are common-very common; that they will be accordingly constitutes one of the most considerable questionsfound often in almost every tame rabbit cut open, and in litter in the study of General Pathology.after litter; and, strangely enough, that they do not appear Every one recognises in the process of generation a certainincompatible with good health, or at least with health suffi- amount of hereditariness-a certain amount of that influenceciently good for market purposes. Now, I examined dozens by which a parent becomes the pattern of formation for hisof these livers, always with the same result; and I may men- child. One allows for accidental deviations-for hare-lips,tion to you, as of some interest in relation to the habits of the for club-feet, even for an occasional acephalism; but, theseentozoon, that while engaged in these examinations, I found allowances being made, one prognosticates with great cer.the same ova in the gall-bladder and in the whole length of tainty as to the result of any particular sexual intercourse.the intestinal canal; in several parts of the latter (as e. g. in No man expects to become the father of an armadillo, of athe caecum) I observed them actually following the inflexions flying-fish, or a stag-beetle; nor (except in the Arabianof the mucous membrane, and lining its follicles almost like Nights) do royal husbands believe that their princesses can bean epithelium, accouched of logs of wood. But, more than this, it is ex-

In continuation I made various experiments, to see if I could pected, and, on the whole, very generally realized, that theproduce tubercle artificially, and various other examinations child shall be more like its father than its god-father. So farto see if I could find it in rabbits dying under other circum. the case is clear; but I wish you to observe the tendencystances. The result may be told in a word: I have never further. Follow the child in its ulterior development (forseen tubercle in a rabbit. I do not wish you to infer from that is the point) and mark how exactly, in various exteriorthis, that rabbits are insusceptible of the disease; my know- and noticeable signs, he repeats the development of his father;ledge by no means extends to this; there may have been some how, in arriving at the age when his father got corpulent, heshare of accident in my non-observation of tubercle among so acquires the same figure; how, at the age when his father be-many specimens; and other more fortunate observers may came grey, or bald, he, too, becomes grey or bald, and withhave witnessed the disease, perhaps frequently. But what I the same succession of parts-vertex first, or temples first, orwould insist on is, that the artificial producibility of tubercular forehead first, as the case may be; how his teeth decay, ordeposit is by no means the simple and straightforward pro- drop, or protrude, just as his father’s; how his pulse is of thecess it is supposed to be. So far as the belief in it depends same general character-even, as I have often noticed, to theon such statements as I have cited to you, I feel bound to degree of copying an intermittent rhythm (not accounted forcaution you against its reception; and I would even venture by organic heart-disease); and how his habits of sleeping andto say, that at the present moment the balance of evidence is waking follow the same direction.against the supposition that tubercle can be produced in Now observe, (for the distinction is of great importance) thatanimals by any of the means which I have specified. these things are not co2inate; the child is not born a copy ofFor I may inform you in addition, that, not only in rabbits, his father as he begat him; but he is born, having his father’s

but in sheep, and in cats or dogs which have been made the past development as a type for his own future development,subjects of experiment, a very large proportion (I refrain from so that he shall be developed as his father was developed, andsaying all) of the alleged tubercular deposits, artificially pro- shall hereafter become like him. In addition to that generalduced, prove, on careful examination, either to be instances of law of human development, by virtue of which he is destinedparasitic development in the substance of the lungs, or to to be a mammal rather than a bird; and a man rather thanconsist of some other morbid product utterly unlike human an ox; and to reach puberty, manhood, old age, and death in atubercle. certain defined succession; he is further possessed by an in-One sort of experiment does apparently tend to develop herited personal and particular law of development, which

tubercle. As we often stay the process of phthisis in the affixes a something peculiar and individual to his passagehuman subject by transferring our patient to a tropical climate; through each period of his existence.so, conversely, we can facilitate the development of the disease If my meaning in all this has been intelligible to you, youby importing the subject of our experiment from warmer to will readily conceive that diseases affecting the developmentcolder latitudes. It is said that, among the beasts in the of the body are peculiarly those which would transmit them ;Zoological Society’s gardens, tubercle is a frequent cause of selves in the line of hereditary succession; that the dispositiondeath; and especially among those which come to our climate to a disease would be hereditary, where the disease consistedfrom one of higher temperature. From my own knowledge, I in the results of a vicious type of development, affectingwill only venture to confirm this statement in regard of limb or viscus, solid or fluid in the body; and that no diseasemonkeys: as they have the dignity of standing next to man in would be hereditary except in so far as it might be develop-form, so they have the inconvenience of this very human lia- mental.bility: when transferred from the hotter climates to England, Practically, this is notorious. There used to be a comicaland when surrounded by the artificial circumstances of a print in the shop-windows, with the inscription " a chip of themenagerie, they are apt to die with tubercles in their lungs, old block;" it represented an old seaman having his infantmesentery, and spleen. son presented to him; and this new-born individual wasThe influence of temporary, or even habitual, deficiencies made to carry the family-likeness by having a wooden leg

in air, in exercise, in diet, though it be insufficient to ensure exactly like his father’s. Every one could smile at thisthe production of tubercle in those persons who are free from absurdity, because of the general recognition of what I haveinherited disposition to the deposit, is yet quite sufficient to just stated to you. Accidental mutilations do not becomearouse all the energy of that disposition, if it be latent; or, in hereditary; for many centuries the Jews and the Moham-any man (whether with or without scrofulous predisposition) medans have undergone circumcision of the prepuce; but theto excite an infinite number of those atrophic and inflamma- local deformity has never transmitted itself; the new-borntory lesions which I have already generalised as apt to occur Jew or Mussulman offers probably as much foreskin to thein depressed states of the system. And to the mention of shears, as the immediate successors of Abraham or Mohammed.these disorders I shall presently add that of another morbid If, on the contrary, one could so regulate the embryonic de-condition, which is of easier artificial production than tubercle, veloprnent of a human being, that it should be born havingand yet seems, in many respects, very nearly akin to it: I one leg, or no prepuce; and still more, if one could repeat thismean the fatty degeneration of certain tissues. modification of development for two or three generations;

Here, however, let me detain you on the subject of the he- then, I entertain no doubt that the peculiarity acquired inreditary transmission of scrofula, and explain to you what I these generations would transmit itself indefinitely in themean, when I speak of its being continued in this manner future productions of the race.from generation to generation. I do not mean that, in the And, if you transfer these arguments to the several varietiesprocess of procreation, actual tubercular matter passes from of disease, you will know, on the one hand, in what diseasesthe system of the scrofulous father into the germ of the infant, to anticipate hereditary transmission; and, on the other hand,to remain latent there, till circumstances call for its develop- what peculiar character of disease (to wit, its developmentalment ; nor, that during uterine life, the blood of the child is character) may be inferred from the fact of its hereditarypoisoned by its mother’s blood, as occurs in small-pox or succession. Of a disease like scorbutus, or ague, dependentsyphilis. What I mean is this:-that the scrofulous diathesis on the presence or absence of certain exterior accidental con-- that the disposition to form tubercles is transmitted; that the ditions, you would anticipate that it could not be hereditary,child inherits an imperfect pattern of development. any more than a wound or a dislocation. Of those accidentalI must explain this more fully, for the inheritance of dispo- accompaniments of scrofula-the morbid processes which arise

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in defective nutrition (the ulcerations of the cornea or intes- stance, of yellowish colour; sufficiently firm, vet friable; oftines for instance, which depend on insufficient or inappro- little tenacity, and resembling cheese very nearly in point ofpriate nourishment) and which, as I have said, are essentially consistence; inelastic; without particular smell; accumulatedco-extensive in their duration with the exterior causes which in small masses, varying in size from a pin’s head to a hen’sproduce them-you would know that they could have no egg; of homogeneous aspect all over their divided surface;natural tendency to perpetuate themselves in this way. Of exhibiting no vessels; insoluble in water, and, if mixed there-another disease, on the contrary-one like plethora, relating with, quickly subsiding to the bottom. And these are theessentially to the rate or degree of development in an element properties of a material which, in respect of its physiology, isof the body, you might predict that it would tend to become characterized by its tendency to become soft, after it hashereditary. And whereas it is in the blood, more strikingly existed for a variable period in the condition of firmness, andand more constantly than in any ingredient of the organism, to induce various changes in the natural textures with whichthat development is ever in progress; whereas, it is eminently it is connected-changes eventually effecting its own completein the blood, that we have at each moment an epitome of the disintegration and elimination. In the same natural texturewhole development of the body, and find the earliest rudiments with such tuberculous matter as we have now described areand the latest reliques of every organised tissue, nascent or in very frequently found certain small bodies, varying in sizedecay; so surely it would be in this fluid—the scene or the from that of a pin’s head to a very small pea, of greyish-whitesubject of so many developmental metamorphoses, that one or greyish tint, and glistening aspect. These bodies occur inwould expect to find the material explanation of many heredi- different organs and textures, in association with yellowtary diseases. One would expect that an inherited disposition tubercle; they are more or less transparent; and though into form, at various periods of life, and in a number of different their own substance of light-greyish colour, their translucencyorgans, certain special and characteristic materials, bearing sometimes gives them, in appearance, the tint of the circum-definite relation to the normal products of the body, would jacent structure; their section exhibits a smooth and closeindicate a peculiarity in the development of the blood, whereof surface; hard as cartilage, almost, in some instances, and in-those deposited materials would be the result and the expres- variably remarkable for firmness; in general outline seemingsion. roundish, yet in reality of somewhat angular form, and ad-Such is the state of the case in regard of scrofula; and there- hering so closely to the adjoining tissues, that they cannot be

fore it is, that I have analysed this question of hereditary ten- removed without particles of these ; they have a strikingdencies to disease. Strict experiment would not, I think, jus- tendency to accumulate in groups."tify me in telling you as a certainty, that the scrofulous Such, then, gentlemen, are the two conditions in which thediathesis has its explanation in such ground as we have gone scrofulous product may show itself; either as the yellowover; but, though we are short of absolute demonstration on tubercle, or as the semi-transparent grey granulation; and asthe subject, I may tell you this with confidence: there exist regards the relations of these to each other, it appears thatmany facts rendering it highly probable that tubercle has its (in organs where both occur) the grey granulation is therise in disease of the blood; that this disease of the blood is one earlier deposit; that it may be seen alone; that the yellowaffecting its development; and that it is as a developmental dis material may be seen in its substance, and may gradually takeease of tlae blood that scrofula acquires its tendency to heredi- its place; that, in short, it may fairly be considered to consti-tary succession-its tendency to perpetuation as part of a tute a first stage of the local disease, and to be preparatory forfamily likeness. I shall presently give you other evidence in the more characteristic yellow deposit. This, however, mustsupport of the same view. not be understood, by any means, as of universal application;Meanwhile, to return for a moment to the narrower ground for there are many organs (as, for instance, the lymph-glands

from which we started, remember, that what is meant in call- and brain) in which the grey granulation has rarely or nevering scrofula an hereditary disease, is-not that the tubercular been seen, although the yellow tubercle is among their fre-material is to pass from parent to child--not that the child is to quent diseases; so that the former deposit cannot be consi-be born with tubercle already in its body, but that the dispo- dered necessary for the development of the latter. It is espe-sition to form blood in a manner which shall give tubercle as a cially in the lungs, that the grey granulation is habituallycollateral phenomenon, exists as a clause in the child’s charter encountered; and in these organs unquestionably it seems toof life, and forms a part of its type of development, as truly as form a point of attraction-a matrix or a nucleus-for theany exterior resemblance which he may bear to the configu- yellow deposit.rative growth of his parents. The material of tubercle habitually presents itself in the

I may illustrate to you the importance of these considera- shape from which its name is derived-namely, as tubera ortions, in quoting the result of some statistics collected at the rounded bodies, varying from the size of the smallest pin’sConsumption Hospital, by the officers of that institution, and head to that of an orange; evidently attaining their largerpublished by them in their last year’s Report. They find that development by means of exterior accretion; and tending,among their female phthisical patients (I dwell rather on the where numbers exist together, to coalesce into irregularfemale patients, because, as is well observed in the Report, (though still tuberiform) masses. Where the individualtheir closer domestication enables them usually to give better tubercles have reached the size of the smallest pea, their sub-information than males can afford regarding the histories of stance consists almost invariably of the yellow material. Intheir parents,) that thirty-six per cent. of such females report some organs, the structure which intervenes between separatetheir parents as having been consumptive. If you consider tubercular masses, will show to the naked eye no other thanthis statement simply, you will be struck with its importance, its normal characters; but in the lung it is frequent to findand with the magnitude of its consequences; and in order to considerable inflammatory condensation of this interveningdo full justice to it, you must further remember, that in the tissue. Sometimes, too, in this organ a large irregular extentremaining sixty-four per cent., there may have been another of structure will have lost its natural sponginess, will haveconsiderable proportion whose parents had not, indeed, suffered become dense and impervious to air, though still moist andfrom tubercular phthisis, but may have suffered from tuber- compressible, and will present, on section, a nearly homo-cular deposit predominantly in other organs than the lung-in geneous, glistening, semi-transparent section, at various pointsthe lymphatic system,perhaps, or elsewhere; and that there may of which one may perceive the deposit of yellow tubercularhave been a second considerable proportion, in whose family the material. It is this latter condition-one by no means frequentparents may, perhaps, have escaped tubercular disease in their in its occurrence-which is known by the name of tubercularown persons, but may yet have transmitted the predisposition infiltration; it apparently consists in the accidental presencefrom their own immediate predecessors to those later inhe- of true tubercle in the midst of common chronic hepatizationritors of the disease: for it is notorious, in many matters of of the lung from pneumonia, and may be supposed to dependfamily-likeness, that some very characteristic feature, healthy on a partial tubercular change of some prior inflammatoryor morbid, may develop itself only in alternate generations, or exudation.may at least remain latent during a single generation, unless Tubercular deposit in the lymphatic glands is in so far anmany circumstances conspire powerfully to favour its evolution. exception to the general description I have given, as not toWith respect to the material of tubercle, you so often have present itself at first in the spherical or tuberose form. Sec-

opportunities of seeing it, that I need hardly detain you with tions of a scrofulous lymph-gland, made when its mass is onlyany elaborate description of its characters. " When in that partially tubercular, show an irregular yellow blotting of thecondition that its properties are most clearly marked, and cut surface, not arranged in circles or segments of circles.when at that period of its development that no dissentient Masses of yellow material, like firm curd-cheese-existingopinions are held as to its nature, it presents (says Dr. either in a concreteness which allows it to be squeezed fromWalshe*) the following characters:-It is an opaque sub- the diseased organ as though from a follicle, or else diffused

in the substance of such an organ, and blended with its struc-

* Cyctopædia of Anatomy, vol. iv. ture, so as not to be isolable by pressure or dissection; and

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-smaller masses of semi-transparent grey material, extremely discharge and irritation. It is the same process, again, whichfirm, and presenting a close resemblance to certain forms of leads to the formation of scrofulous abscesses in the lymph.fibrinous concretion observed on the valves of the heart: glands of the neck or mesentery, and in other organs of thethese, then, are the two sorts of deposit habitually noticed in body; where we have opportunities of observing the curativethe tissues of scrofulous persons; and it will be obvious to you processes (identical with the healing of ordinary abscesses)that the first-mentioned is the characteristic and distinctive which ensue in parts not of vital importance, when the tuber-product. cular material has been enabled to discharge itself.

Microscopical examination of tubercle shows the following In the progress of softening, the stroma of the tubercleprincipal ingredients: (1) a substance which constitutes dis- vanishes; the molecular oil and other molecular matters in-tinctively the bulk of the grey granulations, and which in its crease; the involved elements of natural tissue break up, andgeneral character is identical with the matter of condensed add the products of their dis-integration; serum and pus arefibrinous concretion; namely, a dense, transparent, and almost contributed by the surrounding structures; glomeruli arise;homogeneous stroma, soluble in acetic acid and in the alkalies: and the whole mass, becoming saturated with fluid, shows, on(2) granular material, often in overwhelming abundance, microscopical examination, a mixture of organic detritus withespecially in the yellow tubercle (where it is superadded to incidental inflammatory products.the former constituent) and consisting partly of fibriniform When this change has commenced, the circumjacent partsgranules, partly of molecular oil: (3) aborted cyto-blasts, dark, probably contribute to its completion, by furnishing an addi-Condensed, mis-shapen, angular, insoluble in acetic acid. tional fluid which favours the decomposition of the tubercle;

These, it appears to me, are the characteristic elements of but the change is originated, as an intrinsic and characteristictubercle; and, in addition to them, we habitually observe the one, in the tubercular material itself; commonly commencingadmixture of other and accidental products-viz., (4) cal- in the interior of its concretion, where the product is of oldestCareous granules, frequent in some forms of tubercle, repre- formation, and where the influence of neighbouring tissuessenting the material by which they are liable to cretaceous would of necessity be least. Its resemblance to the well-transformation, and consisting mainly of the phosphate and known softening of fibrinous coagula in veins is too remark-carbonate of lime; (5,) shapes evincing the various stages of able to be overlooked-a resemblance both in the steps of thepus-development, and derived from inflammatory changes in process and in its material results. This is rendered thethe adjoining non-tuberculized parenchyma of the organ- more interesting from the obvious similarity which existschanges due to the proximity of the tubercular concretion, between tubercular matter and fibrin, in respect of mostand manifested chiefly at the period of its softening; (6) chemical characters and of some general physical qualities.especially in the lung, a variety of cell-forms native to the There seems no reason to doubt that these processes areorgan; epithelium of larger and smaller bronchial tubes, essentially identical, and that the pathological gist of scrofulaciliated and non-ciliated, often presenting partial abnormalities consists in the deposition and ulterior deliquescence of aof growth due to chronic irritation of the mucous membrane; fibriniform material.(7) blackening carbonaceous deposit, which is especially The often-asked question-Is tubercle an inflammatorycommon about such grey granulations as are becoming obso- product ? seems to be answered in anticipation by the descrip-lete ; (8) plates of cholesterine and glomeruli of oil, mixed in tion I have already given you. In itself, it is clearly no pro-the detritus of softened tubercle; (9) remnants of the original duct of inflammation, but is apt, especially at the period of itstissues through which the tubercular deposit has been infil- softening, to act as an irritant of surrounding textures, and totrated; as, for instance, in the lung, fragments of elastic fibre. invite the addition of their inflammatory exudations. TheNo formation of new blood-vessels ever occurs in connexion evidence of its non-inflammatory origin--the evidence of its

with the processes of tubercular deposition. On the contrary, origin as a concretion-seems sufficiently furnished by theeach mass as it forms, effects a complete obliteration of all results of microscopical examination; and to this may bethe capillaries within its sphere of infiltration, so as to become added the testimony of all clinical observers, that tubercularutterly non-vascular. In the concrescence of several tuber- accumulations may advance latently, and may reach con-

cular masses, intermediate arteries and veins may remain siderable magnitude or extensive diffusion, without producingpervious, and continue to maintain the circulation of blood in in the patient any signs, local or general, of inflammatoryparts more distant; but the tubercle itself, however large, action. It is important, however, to know that its mechanicalhas no trace of capillary circulation in its interior; it is essen- interference with the circulation of blood is great. In thetially bloodless. lungs-for some reason hitherto unexplained-this obstructionYou will observe, in this enumeration of the elements of to the passage of blood acts peculiarly, and leads to the occur-

tubercle, that I make mention of no characteristic cells. I rence of hæmoptysis. We do not find hmmorrhage habituallyknow of none such. I believe, that so far as a given mass is associated with tubercle in other organs of the body; nor dotubercle, so far it is incapable of originating or maintaining we find that other than tubercular deposits in the lung readilyany process of cell-growth; and I suspect that some observers induce haemorrhage there; but this particular deposit in thathave fallen into the error of describing, as characteristic of particular organ produces the result with extreme frequency.tubercle, cells which have been derived from the inflammation In the first Report of the Consumption Hospital it is statedof adjoining textures. With exception of those large glomeruli that about two-thirds of their phthisical patients suffered fromor granuliferous cells, which are found in the fluid of softened haemoptysis; and in nearly three-fourths of this number thetubercle (just as in deliquescent venous coagula) appurtenant symptom in question arose before the occurrence of softening;to the disintegrating process, but neither characteristic of when namely it must have depended on the rupture of blood-tubercle nor habitual to it at other periods of its existence- vessels from their mechanical obstruction, and not on theirwith exception of these (which are probably of extrinsic being opened by any ulcerative process.origin) and of the undoubted products of inflammation fur- I have now to state to you the order of preference in whichnished by the vicinity, I am ignorant of any cell-growth asso- different organs are invaded by tubercular disease; and I mayciated with tubercle. take this opportunity of saying explicitly (if I have not alreadyThe aborted and stationary cyto-blasts which I have men- done so) that I look upon the scrofulous deposit, which we so

tioned, are very general in tubercle, and probably represent often find in the glands of the neck and in other lymphaticmodified natural elements df the lymph and blood. I should glands, as identical with the material of pulmonary and otherhesitate to speak of them as invariably and diagnostically visceral tubercles. Both chemical and anatomical examina-present, but I do not know that I have ever failed to see them. tions establish this view (in my opinion) so conclusively, thatThey are not particularly abundant in the grey granulation. I am quite unable to understand how it is that some patholo-The ulterior changes of tubercular matter, when once it has gists still hesitate to admit the fact. The description which

been deposited in mass, are almost invariably in the direction I have given of yellow tubercle, as it occurs in the lung, wouldof deliquescence. Exceptionally, the grey granulation may apply with equal accuracy to scrofulous deposit in any otherbecome horny, hard as a shot, and incapable of further in- organ of the body.trinsic change; or the yellow mass may lose its animal in- As respects the choice of organs for scrofulous deposit, Igredients, and become the seat of a permanent calcification; can give you infinitely better authority than my own, in quot-but, speaking generally, tubercle tends to soften by some ing the observations of Professor Rokitansky; his pathologicalchemical conversion of its material, and thus, in aliquified form, statistics-founded, as they are, on what he well calls" colossalto be discharged from the system by the ulceration of sur- materials", can be equalled from no other source. The annualrounding parts. It is this process, long confounded with sup- necropsies in the General Hospital at Vienna probably exceedpuration, with which you are familiar in the process of at least twenty-fold those which occur yearly in any one ofphthisis, as leading to the formation of vomicæ, and as con- our large London hospitals; and Rokitansky’s great name hastinuing, in an infinite majority of cases, to form cavity after been connected with this unique school of pathology, I believe,cavity in the lung, till the patient sinks, exhausted by their during twenty years. In summing up figures for such statis-

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tical deductions as I am about to give you, his materials must have caused the destruction of membranous septa. I am notconsist of more than tens of thousand.s of instances. The fol- able to tell you with certainty, whether the tubercular ele-lowing, then, on his authority, I give you as the order of fre- ment of the blood may coagulate within the capillary vesselsquency with which different organs are found tubercular in of the lung, and in their immediate proximity; but there arethe dead body:-Lung; intestinal canal; lymph-glands, espe- pathological reasons for considering this as not improbable,,cially the abdominal and bronchial; larynx; serous mem- and as helping perhaps to explain the extreme power ofbranes, especially peritonaeum and pleura; pia mater; brain; obstruction which tubercle exercises on those vessels, and thespleen; kidneys; liver; bone and periosteum; uterus and singular tendency which it possesses, beyond all morbid in-Fallopian tubes; testicle and its appendages; spinal marrow; terferences with the pulmonary circulation, to produce the-voluntary muscles: and, in children, this order of precedence symptom of haemoptysis.so far undergoes a modification, that the lymph-glands and Likewise, among anatomical peculiarities of this deposit maySpleen stand first in the list. be mentioned, that in almost every organ there is a favourite. But, in order to be rendered a true transcript of Nature, spot, where the masses of tubercle first appear. Thus, in thethis list requires a very important qualification. It confounds lungs, there is the well-known preference for the summit; intogether the primary tubercular deposits with those which the pia mater, for the region of the base, about the commence-have occurred as secondary formations, during the fatal pro- ment of the optic nerve and the fissure of Sylvius; in the braingress of the disease; counting (for instance) tubercular ulcera- itself, for the grey substance; in the osseous system, for thetion of the intestines as an unit for the statistical table, when- cancellated structure; in the bowels, for the lowest part of thesoever it is found in the dead body, although perhaps it may ileum; in the testicle, for the epididymis; in the female sexualnever have been discovered, except as a posterior complica- system, for the Fallopian tubes and fundus of the uterus.tion of other tubercular disease. The important question ob- Next we have to inquire-What are the pathological affi-viously is this,-by what organ does scrofula first possess itself nities of tubercle ? what diseases does it refuse to co-existof the system? not-what organs are oftenest found tubercular with ? with what diseases is it often associated ?in post-mortem examinations, where several organs are simul- First, for the negatives: Rokitansky, whose immense

taneously seen to be diseased? but-what organs are selected materials are again a sure resource, says: Tubercle hardlyby Nature for the first invasion of the disease ?-what organs ever occurs in those who are the subjects of cystic tumours,give the greatest facilities for its characteristic deposit ? Hear such as those of the ovary: Bronchocele seems incompatibleRokitansky again :-The lungs and the lymph-glands still with it, and ague is alleged to be so’ It is with the utmostmaintain, in a very high degree, their numerical superiority rarity that tubercular patients are attacked with typhus:to all other organs affected singly; while the intestines, Tubercle and cancer are incompatible.larynx, and trachea, serous membranes, spleen, and liver, fall Lastly, I told you in a former lecture, that Rokitanskyat once from the high level at which they stood in the less attaches great importance to an increased venosity of the blood,discriminative list; they fall so low as to indicate, conclusively, as an antagonistic condition to the formation of tubercle; andthat they are almost, or quite, insusceptible of the primary under this head he includes every influence which interferesinvasion of tubercular deposit—that they suffer only in a directly or indirectly with oxygenisation of the blood, either bysecondary way, and are visited (so to speak) only by the su- diminishing the capacity of the chest, or hindering the expan-perfluities of the disease. sion of the lungs, or by deranging the pulmonary circulation of

This is matter of immense importance. The organs, in blood, or by impeding the free access of air thereunto.which the disposition to primary deposit almost exclusively For example: a case of spinal deformity narrowing theprevails, are such as may, with equal exclusiveness, be called chest; a case of abdominal tumour encroaching upward, andthe organs of blood-development; and in this generalisation we causing dyspncaa; a case of cyanosis maintaining deficientpossess a clue, which it is impossible to over-estimate, for aeration of the blood; these would be cases in which, accordingarriving at a true interpretation of this fatal disease. to this observer of hundreds of thousands, the tubercular de-We have next to inquire, respecting the several organs in posit would not arise.

which tubercle occurs-what anatomical relation is borne by With respect to those contrary classes of disease, with whichthe morbid deposit to the natural tissues of the organ. tubercle most readily associates itself; there stand, first of all,In the lymph-glands, I suspect that tubercle is in truth no those atrophic, ulcerative, and sub-inflammatory processes, to

deposit; that it is not derived from the blood in the vessels which I have already adverted as apt to occur in depressedthere ramifying, but is an accumulation in the tubes of the states of the system, and which -maintain (as I explained atgland of their own morbidly coagulable or inspissated lymph; the commencement of my lecture) only an accidental affinitythat it is therefore not, strictly speaking, a disease of the to tubercle. But there is one very important class of struc-lymph-gland, but of the lymph in the glands. tural changes, which the tubercular constitution so habituallyAs respects other organs, it seems that the readiness with associates with itself, that I can hardly refrain from con-

.which the tubercular material coagulates, prevents its passing side ring their mutual relations important or essential. I alludeto any distance from the vessels which have furnished it. to what is called the fatty degeneration of the liver, the kid-Accordingly, we do not find it occurring in tissues which ney, and the arteries; and I am disposed to believe that, whenderive their nourishment by imbibition through some length our knowledge of the subject has become more complete thanof extra-vascular structure, as cartilage. But in organs which it now is, we shall find proof that these fatty degenerationsconsist of involuted mucous membrane, with a more or less stand in some essential relation to the tubercle-forming-solid plexus of blood-vessels, we find that the deposit readily diathesis-stand perhaps in the relation of secondary depend-concretes on the free surface of the membrane; thus, in the ence on it. You will rarely make the post-mortem examina-lungs, it may be seen to lie as a secretion in the air-cells, till tion of a tubercular patient without finding an augmentedit has collected in sufficient quantities to obliterate their formation of fat in one, two, or all of the three situations Isepta, and microscopically to appear as what may be termed have mentioned; in the liver, constituting its well known fattytubercular infiltration. Among the observations which illus- enlargement; in the kidney, associated with those othertrate the first deposit of tubercle in the lung, I have much changes which concur with it to constitute the scrofulous formpleasure in citing those of my colleague, Mr. Rainey; and I of Bright’s disease; in the arteries effecting their atheroma-- recommend you to read attentively the paper on this subject tous degeneration, weakening their coats, and disposing themwhich he communicated to the Medico-Chirurgical Society in to aneurism or to rupture. In the liver, this fatty deposi-1845. In other compound mucous organs I have seen the tion occurs as a very simple change, merely increasing (though-same thing; for instance, in the follicles of the uterus, and in often to an immense extent) that molecular oily ingredient,those of the vermiform appendage; while a mash of softened which is native to the endothelium of the gland, and whichtubercle has been lying over the general surface of the mucous is visible microscopically in the form of minute globules ofmembrane, I have been able to isolate the subjacent follicles, oil within the limits of each nucleated cell. In the artery,to see them full of apparently tubercular matter, and yet with other changes are associated with the fatty accumulation-attheir definite limitary membrane quite uninjured. However, least, whenever it is extreme; changes which have suggestedwhile I entertain not the slightest doubt that tubercular to pathologists a suspicion that the atheromatous degenera-matter concretes readily within the air-cells, on the free sur- tion consists in the fatty conversion of some fibrinous orface of the limitary membrane (for on many occasions I have fibriniform material previously deposited there. In the kidney,seen it occupying this position) I should hesitate to admit likewise, at least in that of the human subject, the process ofthat this is its exclusive seat, even in the earliest commence- fatty accumulation (shown, as you look on the section of thement of the disease. In studying injected specimens of pul- gland, by a vast number of bran-like spots diffused usually overmonary tubercle, one sees many nebulae of deposit, which a pale and flabby surface) is far from being a simple one: youshow no trace of subdivision according to the arrangement of never see the kidney extensively affected in this way, withoutair-cells, and which, yet do not appear of sufficient density to observing simultaneously that there exists some considerable

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destruction of tubules, or some serous or fibrinous infiltration all surrounding textures by inflammatory and ulcerative pro.of the gland, for which the presence of fat in its endothelium cesses, are commonly defeated in this tendency when theywould be insufficient to account. That fatty accumulation in occur in vital organs (as the lung) or attain it by the completethe kidney, confined to its endothelium, and existing there as sacrifice of the invaded organ, as when present in lymph-a primary deposit, constitutes the proximate cause of the glands, testicle, or breast.scrofulous form of Bright’s disease, is a view which I cannot I have told you that cancer and tubercle are incom-consider supported by conclusive evidence. Many of the patible diseases-that the one excludes the other. Youmicroscopical forms (some derived from the tubules during cannot wonder at this. They are pathological antitheses inlife, others from sections of the organ after death) which have regard of the blood. In the one case, if I may use so strongbeen ascribed to fatty engorgement of the endothelium, are a phrase, the blood dies still-born; it never attains its maturityindistinguishable from the glonteruli which arise in fibrinous of growth or function; it stops short of the distributiveand bloody effusions, and which (as in the white substance of arteries of the body; it never reaches the aorta; it perishes-the brain) are often met with in parts not naturally possessing and decays on the threshold of the circulation. In the con-a nucleated cell-growth. trary case of cancer, there is an obstinate excess of vitality,

In the domestic cat-at least in our metropolitan cats-the which will not be quenched. You remember how the blood’stubules of the kidney almost invariably (though I presume plasma, as though out of a luxuriance of life, contributed-notabnormally) contain a very large quantity of oil; and I think to perishable concretions, but to profuse living growths; youit probable that this quantity may artificially be increased by remember how these growths, tending to an effort of elimina-interference with the locomotion and respiration of the animal, tion, still maintained an uninterrupted dependence on theThis is a condition of simple fatty accumulation, analogous blood, constituting the strange paradox of an organised ex-probably to the fatty liver of the human subject. Though im- cretion; you remember how they evolved themselves withmeasurably greater in degree than any similar accumulation exhaustive rapidity out of a too fructifying blastema, vege-ever observed in the human kidney, it is attended by no tating without limit at the expense of other organs, till thedestruction of the tubules; nor does it often, if ever, interfere whole fluid of the circulation seems to devote itself, away fromwith the function of the organ or with the health of the its slower and legitimate uses, to this impetuous by-play ofanimal. Some years ago, too hastily, I believed that these organisation.kidneys were exquisite analogies of our scrofulous form of Our therapeutical knowledge of tubercle is scanty in theBright’s disease, and would explain its human pathology; but extreme. We are not sure that we possess a drug capable offurther investigation has convinced me of the inaccuracy of interfering with its deposit. Iron, which acts so powerfullythis first impression. on the corpuscular development of the blood, and which mustLet me now, gentlemen, in a few paragraphs, collect for you therefore, in some degree, affect its total progressive changes,

the total result of our present knowledge of tubercle, and state has acquired no reputation for the prevention of tubercularto you what inferences may be drawn as to its true pathology concretions. Cod-liver oil, which is said to influence materiallyfrom those extensive generalisations which I have set before you. the earlier stages of blood-development, has latterly beenThe material products of the scrofulous diathesis consist in much vaunted as a contra-scrofulous remedy; its credit, in many

some mis-developed proteinous ingredient of the lymph and cases, is well-deserved, and its alleged action on the bloodblood. The essence of this mis-development lies in the fibrini- would seem to bring its method of operation nearer to theform solidification and concretion of something which should root of the disease; but much in all this is conjectural, and Iremain fluid in the plasma of the blood. I call it fibriniform, dare only speak of it as a matter for continued observation,because-though it is not identical with fibrin, it probably whether the drug does really affect the initiative acts of blood-arises in some analogous method of formation, and undergoes development, and whether it does really counteract the ten-similar final metamorphoses. This solidification occurs in the dency to tubercular precipitation. Of the iodide of potassiumascensive development of the lymph and blood: it occurs with we know nothing at all; and we have only some very crudean infinite preference in the lymph-glands and in the lungs ;- and general analogies to guide us to an impression, that itsin the former, where lymph is brought into intimate rela- action would rather consist in disintegrating and removingtions with arterial blood; in the latter, where lymph (which the morbid product, than in hindering its first formation.is constantly accruing to the blood) first comes into immediate Climate, as I have already told you, is a most material in-relations with the atmosphere. It seems then to affect the fluence for and against the development of tubercle. A de-total blood, only by reason of the lymph which is contained in gree of scrofulous diathesis, which would tuberculise theit; in other words, not to be a disease of the total blood, but lungs of a patient in England, would leave him quite un-one of the lymph or nascent blood. Precipitability by the scathed in Cairo, or at the Cape; and, conversely, a minor deatmosphere is the characteristic of this morbid product; its gree of the diathesis, which would be harmless in a tropicalplaces of election are determined by this peculiarity: tubercles climate, would determine the development of phthisis, if itsform, where lymph and blood get their first opportunities of subject should be made an inmate of our colder atmosphere.increased oxidation. In accordance with this law, venosity of I cannot refrain from connecting these notorious facts withthe blood precludes the tendency to tubercular deposition. that which I have already told you, as to the anti-tubercularThe fibriniform product of scrofula is insusceptible of deve- power of an increased venosity of the blood. The first andlopment: it is a dead concretion. Like true fibrin, it may most essential change, wrought by the transference of anbecome the seat of calcareous deposit, and may thus form a animal from England to India, is in the respiratory function,permanent inorganic concretion. Like true fibrin, it chiefly and, consequently, in the oxidation of the blood. Where thetends to soften, and its softened substance is copiously infil- thermometer stands at 90°, the quantity of respiration (owingtrated with fat: probably it undergoes a fatty degeneration. to rarefaction of the air) must be very much less than whereThe diathesis in which tubercular deposits occur, is accom- the thermometer stands at 450; the blood will, con-panied by a remarkable tendency to the accumulation of fat sequently, be in a condition of relative venosity, and thein the liver, and to the fatty degeneration-either of the sub- disposition to tubercular precipitation will be pro tantostance of other organs, or of some previous infiltration in those diminished. This, I have no doubt, is the manner in

organs: possibly this tendency may indicate that the fibrini- which transference to a warmer climate acts beneficiallyform material of tubercle in its molecular state can un- in the prevention of tubercular disease. More than this,-dergo, either in the blood, or in those organs, the same where the deposits already exist, or where the ulteriordegenerative changes as affect it in its concrete condition. destructive changes have commenced in them, a warm andIn short, the scrofulous diathesis consists in an inherited equal atmosphere can exert a palliative tendency, in diminish-peculiarity of blood-development, under the influence of ing the liability to those catarrhal complications which are sowhich the nascent blood tends to a molecular death by super- frequent in our precarious climate. Do not believe, in regardoxidation; partly it may appear that these dead proteinous of your scrofulous patients, that climate will prevent theelements can undergo, within the stream of the circulation, softening of tubercular masses which already exist, or thatsuch degenerative changes as will qualify them for discharge it will ensure the cicatrisation of cavities already formed, orby excreting organs; partly it may appear that these changes about to be formed. Its power is much more limited thanlead to fatty accumulations in the endothelium or in the paren- this: it will counteract very powerfully the disposition to

chymatous blastema of such organs; but mainly and charac- further deposits; it will give Nature more chance of effectingteristically, it is the way of those dead proteinous elements to the discharge of softened tubercle in her own gradual manner,concrete in the organs where their precipitation has been than if the process were to be complicated with constant re-determined, and there to construct the fibriniform masses newals of catarrhal inflammation; and in both these respectscalled tubercle. These masses undergo changes of deliquescence -provided there be no large extent of vital organs diseased-and destruction, which tend to their ultimate expulsion from it will give powerful assistance towards the patient’s recovery.the system, but which, as they entail the disorganisation of More than this it will fail to accomplish.