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490 Dr. SEMPLE considered that great praise was due to Dr. Smith for his elaborate and ingenious paper, and regretted that a very short time was left for the discussion of a subject of such great importance as the diagnosis and treatment of the pre- tubercular stage of phthisis. That such a stage existed was very probable, and it was of the deepest interest to all practitioners to be able to recognise it. At the same time he thought that Dr. Smith’s views were merely theoretical, but that they might be capable of practical demonstration at some future time. Suppose, for instance, that a person who was in the pre-tuber- cular stage of phthisis, and whose condition had been ascer- tained by competent physical examination, were to die of some ’,, other disease, or by an accident, it would then be possible to verify the diagnosis, and such a contingency might one day occur. At present, however, he (Dr. Semple) thought that the I existence of the pre-tubercular stage, although highly probable, was not proved; and if he found a patient presenting the phenomena described by Dr. Smith-namely, dulness on per- cussion, absence of respiratory murmur, and bronchial respira- tion, he should conclude that the deposition of tubercle had already commenced, not perhaps in the fully developed form, but in that semi-fluid state which is known to be the first form under which tuberculosis of the lung makes its appearance. With regard to the non-identity of phthisis with scrofula, this was so novel a doctrine that it required much deliberation be- fore it could be admitted. It was true that the external mani- festation of scrofulous tumours was not always or perhaps very generally associated with tubercular deposition in the lung; but still there was so complete a resemblance between the matter of scrofula and the deposit in phthisis, that he could not at present believe with Dr. Smith that they were distinct. Dr. ANDREW CLARK said he had listened with pleasure to Dr. Smith’s paper, because he had himself been engaged for some years in the study of’ phthisis, and because it must be a pleasure to every working man to hear what another had to say who came fresh from the interrogation of Nature at the bedside, and not merely from the study of books or the specu- lations based upon them. Dr. Clark would, in the first place, refer to the view of the origin of phthisis which ascribed it exclusively to that state of blood termed" fibrin crasis." The doctrine of " blood erases" developed by Rokitansky had been adopted almost without question, and upon mere authority, by the majority of English pathologists. He would not, then, stay to show how the doctrine was speculatively unsound, as every exclusive humoralism or solidism must necessarily be; but he would mention one illustration to prove that it was practically untrue. The doctrine of erases was based upon the assumed fact that the blood-clots corresponded in structural and chemical characters to the exudations found without the vessels. In a case of advanced phthisis, for example, the blood-clots present the characters of croupous fibrin: if the doctrine of erases be true, all the exudations in such a case must present the same characters; if they do not, the doctrine must fall to the ground, not merely because it is insufficient, but because it is untrue. Two bodies were lately examined at the London Hospital on one day. The first died from an in- jury to the chest, followed by pleuritis; the second died from phthisis, in which pleuritis had supervened shortly before death. In both cases a fibrinous exudation had occurred in the pulmonary pleura. In the first case the lymph was soft, yellow, diffluent, imperfectly fibrous, and studded with irre- gular cell particles; in the second, the lymph was greyish, semi-transparent, disposed in a nearly uniform layer, distinctly fibroid, and contained few cell particles of any kind. In the healthy man the lymph was croupous ; in the phthisical man it- was plastic. The contradiction here was obvious and fatal. Such illustrations could be multiplied. -Aiany surgeons knew well that healthy lymph could be exuded on fresh-cut surfaces in patients labouring under extensive cancerous deposits. There could be no doubt that the blood was diseased in tubercle and cancer; there could be no doubt, however, that there was also a preceding or coincident change in the solids; there could be no doubt that as yet the changes of the blood were incapable of distinction or definition, and none that the arbitrary and coarse classificatious of them into erases were not only inade- quate to the explanation of the nature of morbid products, but offered serious hindrances to the advancement of truth. Dr. Smith observed that there were no uniform structural or che- mical changes to be found in the blood of phthisis. Dr. CIa.rk would not then enter into the chemical details of the question, but he would mention two uniform structural changes which he had found in the blood of phthisical patients, and the truth of which anyone of moderate experience might test by personal observation. The first was the excessive number and altered 490 character of the colourless corpuscles; the second, the dimi- nished number, colour, anl elasticity of the discs, most of which were also increased in size. To these two he might add a third, the presence of numerous free molecules and granules. Dr. Smith’s idea of the nature of phthisis appeared to be that it was distinct from scrofula; that it was, in its outset at least, a local disease, and that it essentially consisted in deficient inspiratory action of the air vesicles leading to diminished che- mical changes in the residual air. Waiving the physiological part of this question, Dr. Clark could not for a moment agree in the opinion that tubercular scrofulous deposits were distinct local manifestations of distinct constitutional states. The deposits were identical in their structural and in their chemi- cal characters. The state of the fluids and solids during their production was in essentials the same. The deposits were fre- quently interchanged at different periods of life and under different conditions. The offspring of the phthisical parent exhibited scrofulous diseases; of the scrofulous parent, phthi- sical disease; and the healing of scrofulous glands was often the prelude to the induction of phthisis. In all respects, whether in relation to cause, to the constitution subject to them, or to their intimate nature, Dr. dark believed scrofu- lous and tubercular deposits to be identical-to require the same treatment. Dr. Clark could not agree with Dr. Smith. in viewing chronic phthisis to be, in any sense of the term, a local disease. Antecedent to all local deposit and to all changes of the blood, he believed there was a recognisable condition of the mental as well as the bodily parts which was characteristic of the phthisical or scrofulous tendency, and which would most certainly lead to their local development under unfavourable circumstances. The essential characteristics of the psychical as well as the physical constitution were weakness, heightened: susceptibility, and a deficient power of restraint in the mani- festation of the mental or bodily operations. Psychically, this constitution was manifested by precocity, undue excitability, rapid but unsustained response to ordinary causes of excite- ment, aptness for novelty, incapacity for regular and prolonged mental pursuit, great emotionalism, and alternating states of exaltation and depression. Physically, the characters were ana- logous : there was rapid development and growth, which fluc- tuate under the most trivial influences. In the elements of the tissues and organs, also, there was the same rapidity of growth with a proportionate rapidity of decay. The cell ele- ments of the textures grew very rapidly, and were thrown off before the end of their existence was fultilled. The epithelium of the lips was always desquamating, the hair and nails grow- ing with unwonted speed; the fæces were mixed with abun- dance of epithelium; wounds rapidly but feebly repaired. Such constitutions were capable of great temporary but little sustained muscular exertion; the circulation was feeble and small; and we wondered at the source of so much apparent animation and vigour. Dr. Clark could not consider dimi- nished capacity of inspiration as the cause of phthisis. It wag’ one of its concurrent phenomena, but did not necessarily in. duce phthisis, even under unfavourable circumstances. Dr. Clark believed, after numerous experiments, that the spiro- meter did not, in the majority of cases, give sound evidence as to the actual capacity of the lungs. Intelligent patients, after repeated practice, could be brought to yield uniform results; but in the conduct of numerous observations at an hospital the results were, on the whole, unsatisfactory. Dr. Clark also stated that patients with limited chronic phthisis often gave the full average results common to their height; whilst hyste- rical or nervous women, free from pulmonary lesion, did not. PATHOLOGICAL SOCIETY OF LONDON. TUESDAY, OCTOBER 21ST, 1856. MR. ARNOTT, PRESIDENT, IN THE CHAIR. MR. JONATHAN HUTCHINSON exhibited casts and specimens of DISEASE OF THE SHOULDER-JOINT. The case was before the Society last session. It did well for some time after the operation, but the disease soon reappeared in the bone and the glands in the axilla, and she died six months after its performance. The tumour was of six years’ growth. At one time it was diagnosed at the London Hospital as cancer, when it was proposed to resort to an operation; but this the patient refused. The case was under Mr. Hutchin- son’s care for three weeks before the operation. He did not wish to say much upon it until the reporters appointed to examine the specimens formerly presented had made their re-
