scrofula and tubercles, and that its effects will which we have been considering, occasioned be imputed to the circumstance just mentioned. scrofula much more frequently than we believe 50. F. Climate, residence in large towns, occu- they do, the distinction is of great practical impations in factories, confinement in union-houses, portance, viz, that they do not act in virtue of in pauper institutions, in prisons, &c., and other a specific influence suited of itself to produce circumstances tending to prevent due exercise scrofula, but as general morbific agencies which in the open air, or sufficient ventilation, or to impair digestion, and thus indirectly contribute deprive persons in early life of the requisites to to the production of the disease. That food, inhealthy assimilation and nutrition, may be con- sufficient in quantity, or innutritious in quality, sidered as concurring agencies in the produc- stands in the relation of cause to the develoption of either external or internal scrofula. Mr. ment of scrofula, more directly than any other PHILLIPS has investigated these analytically, but morbific agent, is shown by this circumstance, with reference only to the production of external that whenever food is abundant in quantity, and scrofula, and has come to the conclusion that of a sufficiently generous character, scrofula is the development of scrofula is not shown to kept under, that is to say, it is less frequently be so influenced by climate or temperature as seen, although other noxious agents are perhaps to bear any definite relation to the warmth or rife, and the general mortality is great; and coldness of the country in which the disease is that in our rural districts, where the air is probfound. Neither the general mortality nor the ably pure and the occupation healthy, and where deaths from scrofulous diseases bear any defi- the general mortality is small, scrofula is largely nite relation to the closeness with which the pop- developed; because the food, even when abundulation is crowded together, whether the com- ant, does not contain sufficient stimulus to preparison is made between one town or district serve the frame in healthy vigour. Yet, aland another, or between different portions of the though we may have no satisfactory proof that same town or district. Particular occupations a contaminated atmosphere, or any one of the and social conditions exercise a greater influ- other indirect agencies to which we have reference on health and the duration of life than is red, will operate so injuriously on the digestive produced by impure air or insufficient ventila-functions as of itself to induce scrofula, I do not tion, but they do not operate in the production the less deplore the influence of those debilitaof scrofula in the sense of a specific agent or of ting agencies, which impair the healthy activity, a direct cause. The general mortality and the and lessen the proper vigour of large numbers deaths from particular diseases bear a close re- of our countrymen" (p. 241). But that the inlation to the poverty of the population, and to jurious or indirect agencies which Mr. PHILLIPS the vicissitudes, or alterations of prosperity or considers so little influential, are really of imadversity, to which they may be exposed; while portance as respects the development of externwealth and station, which insure to the more al and internal scrofula, both in early life and in elevated classes of the community abundant more advanced age, I am convinced, although food, ample clothing, convenient and well-ven- a sufficiency of wholesome food will counteract tilated dwellings, and pure air, are nevertheless them to a considerable extent, and especially unfavourable to longevity; and the industrious when an hereditary taint or predisposition is not labourer, whose toil insures steady remunera- present. tion, and whose temperate habits and provident character insure him the necessaries of life, good of their kind and ample in quantity, is in the condition the most favourable to long life and uninterrupted health. In the last result, then, it is to diseased nutrition, however brought about, that we refer the production of scrofula; an opinion in which there may be some novelty, inasmuch as many authors have assigned to perverted nutrition a powerful agency in develop ing the disease-especially CARMICHAEL in England, and LEPELLETIER and BAUDELOCQUE in France; yet my controversy with BAUDELOCQUE consists in a denial of the exclusive agency which he assigns to impure air in deranging nutrition" (p. 239). 51. While the disease is imputed chiefly by Mr. PHILLIPS to insufficient food, the other circumstances which I have viewed as concurring causes of no mean influence, especially a selfpolluted or otherwise contaminated air (938-42), are considered of little importance by him provided that the food is sufficient. It is manifest, however, that his investigation of external scrofula, chiefly with reference to an early age, has led him to overlook the more remote influences of certain causes, which he accounts of little importance. "But the cause of diseased nutrition," he remarks, "at that period of life when the seeds of scrofula are sown, is, in the vast majority of cases, insufficient food or improper feeding; and even if the less direct agencies, 52. The injurious influence of insufficient feeding in poor-houses, union-houses, in other pauper institutions, and in prisons, has been sufficiently demonstrated by CARMICHAEL, BALY, PHILLIPS, TYLER SMITH, and others. But it is not to the insufficiency of food alone that the production of scrofula should be imputed, although it may be admitted to be the chief agent. Crowding of the sleeping apartments, breathing an impure or contaminated atmosphere, insufficient ventilation, confinement or deprivation of exercise in the open air, and depression of spirits, co-operate more or less with this more efficient cause. But as in most of the union-houses the inmates have more food than the independent labourer can procure, even when fully employed, it cannot be a matter of surprise to find scrofula more prevalent in some country districts than it is even in some manufacturing towns. In connexion with this subject, Mr. PHILLIPS very justly remarks, that, believing the health of the child and the vigour of the man to depend upon the sufficiency and nutritious character of their food, a still more liberal diet for pauper children than is at present afforded would, at one and the same time, better the health of our population, and be consistent with a sound national economy. The reports of the Inspectors of Prisons furnish numerous instances where prisoners have manifested glandular tumours under the discipline to which they have been subjected, and have quickly rallied under an improved diet. Dr. BALY states, that a "marked difference, in respect of their general health and the number affected with scrofulous disease, is presented by the convicts sent to the central prison at Millbank from different parts of Great Britain, preparatory to their transportation. By far the thinnest convicts, and the largest proportion of unhealthy and scrofulous individuals, come from the Scotch prisons, in which the diet consists of a sparing allowance of vegetable and farinaceous food." not be overlooked, in our pathological speculations, that the cutaneous function is supplemental of other important functions-of the respiratory, of the renal, of the hepatic, and of the intestinal; and that, even when no supplemental or vicarious office may be traced to this func tion or to either of these other functions, a very intimate relation subsists between them, the due discharge of the one influencing the others more or less. The importance, therefore, of duly regulating this function, guarding against its excess as well as its suppression, by proper clothing and exercise, will be admitted. 56. Among the dark-skinned races, a free and even an abundant cutaneous perspiration is most necessary to the continuance of health; and when it is habitually diminished, especially by migrating to a colder climate, tubercles, especially in the lungs, supervene in very numerous instances. A diminution of the accustomed perspiration may not, however, be the sole cause of this liability of the Negro and other dark races to tubercles after migrating to temperate or cold climates. The sedative influence of cold upon the constitution of these races may have a considerable or chief share in the production of this effect, especially in connexion with the obvious want of adaptation of the constitution of these races to temperate and cold climates. Of the influence of climate generally upon the prevalence of scrofulous and tubercu 53. iii. OTHER CAUSES CONCURRING IN THE PRODUCTION OF THE SCROFULOUS TAINT, AND AIDING OR DETERMINING THE DEVELOPMENT OF TUBERCULAR FORMATIONS.-The causes which have been here insisted upon are certainly the most influential in the production of latent and developed scrofula and tubercles; but there are others which concur with the foregoing either in producing a scrofulous taint or external scrofula merely, or in developing internal tubercles, especially in the lungs, in persons who are already imbued with this taint, and which, when acting energetically, may produce this effect even on those who are not thus manifestly imbued. In this latter case, the causes in question, acting either independently of the foregoing causes, or conjointly with them, or aiding and determining their effects, impair not only the vital energy and vital functions throughout the frame, but also the nutrition of the several tissues, and the intimate condition of vital co-lar diseases no precise data exist. The subject, hesion and action. Many young persons possessed of a scrofulous diathesis, or who have been the subjects of external strumous disease in childhood, and even some who present no very marked sign of a scrofulous taint, become, as puberty, or early manhood, or more mature age, is arrived at, the victims of tubercular formations in some internal organ, especially in the lungs, owing to the operation of those causes which I am now about briefly to consider. however, will be adverted to in the sequel, and in the article on TUBERCULAR CONSUMPTION. 57. C. Intimately connected with the foregoing is the influence of dress and of various phys ical conditions depending on occupations and habits of life. Exposure of parts of the frame requiring protection or uniformity of temperature, as the upper regions of the chest, and the hips and lower extremities, to vicissitudes of season and weather, and sleeping in too low a range 54. A. Neglect of exercise in the open air-of of temperature, are injurious, the effects being exposure to the light of day and to sunshine-more frequently manifested in the lungs than in is one of the causes which is most influential any other organ. To restrain habitually the in superinducing tubercular formations in the movements of the thoracic and abdominal pariscrofulous diathesis, and even in constitutions etes, by position, by occupation, or by dress, or which evince no evidence of this taint. The to otherwise embarrass the function of respirageneral neglect of the indications suggested by tion, is much more injurious than is generally the alternations of night and day; the neglect considered. The stooping position, particularly of repose during the hours of darkness, and of when long continued or frequent; stooping at a rising and of being employed during the hours low desk or table, especially if a part of the pariof day; the common practice of pursuing our etes of the chest is brought in contact with, or avocations and recreations during a large por- rests upon, the desk; and, above all, stiff and tion of the time intended by nature for our re-closely-laced stays or corsets, are among the pose, and of devoting a large portion of the day to sleep, is not without influence in impairing the constitutional powers, in weakening the assimilating and excreting functions, and in relaxing the mental vigour. An early departure to nocturnal repose, and the limitation of this repose to the hours of darkness-the trite maxim of "early to bed and early to rise," &c., is of much greater importance than is indicated by the practice of modern times. | most injurious agents to which youth or mature age can be subjected, and their effects are most frequently manifested by favouring the development of tubercles. 58. Stiff or unyielding stays prevent the due exercise of the muscles of the trunk, impair their development in early life, and weaken these muscles at later periods. If this article of dress be too closely applied or drawn around the waist, the movements of the ribs are re55. B. Inattention to a due preservation of the strained or even prevented; the liver is carcutaneous function is not without its influence.ried upward, and it invades the thoracic caviThe imperfect performance of this function, the ty, compressing the lungs and embarrassing the sudden arrest of it, or the entire suppression of circulation through the heart and large vesit, however well it may be vicariously discharged sels; and the colon is more or less displaced by the lungs, kidneys, or intestinal canal, endan- or pressed upon, with the rest of the abdomingers the healthy condition of the blood, and dis- al viscera. The undoubted consequences of orders the assimilating processes. It should these conditions-consequences which vary in amount and danger with the cause now as- | only in respect of the identity of these morbid signed-are an imperfect performance of the states, but also as regards the origin, modificarespiratory, of the digestive, of the assimila- tions, complications, and various other pathoting, and of the excreting functions; and ulti-logical relations of both. It will, therefore, be mately a morbid state of the blood, tubercular requisite to describe, 1st. The Structure of Scrofdepositions, especially in the lungs, hæmopty-ulous and Tubercular Matter-a. as anatomicalsis, anæmia, &c. 59. Not less injurious than tight lacing is the practice of wearing unyielding supports in the stays, especially steel supports, which, however well covered, tend to carry the electromotive influence from the frame, and to withdraw a salutary stimulus of nervous power from the system. The importance of attention to this matter is not hypothetical but real, as proved by long and frequent observation, and by the results following the removal of this evil. The more freely the movements of the trunk and spine are allowed to be performed, and the more efficiently the actions of the muscles concerned in these movements are accomplished, the more certainly and healthily will the functions of the several organs contained in the trunk be discharged. (See art. DISEASE, § 23, et seq.) ly displayed; b. as appearing under the microscope; and, c. as determined by chemical examination. 2d. To inquire into The Identity and Dissimilarity of Scrofula and Tubercles. 34. To consider The Pathological Relations, Origin, and Nature of these Maladies. 4th. Their Localization or Seats. 5th. Their Modifications and Complications. 6th. The Comparative Pathology of Scrofula and Tuberculosis. The discussion of these topics will prove the best introduction and guide to the consideration of the very important subjects of the prevention and cure of these very prevailing diseases. 64. i. THE STRUCTURE OF SCROFULOUS AND TUBERCULAR MATTER.-Scrofulous and tubercular matters are peculiar morbid formations, the product of an altered secretion and nutrition of the parts containing them, arising independently of inflammation, although frequently associated with a modified state of inflammatory action, apparently induced by these morbid products. These morbid formations are different, 1st, from the products of ordinary inflammation, occurring in a previously healthy constitution; 2d, from other morbid growths, as shown in the article on Scirrhous and other Morbid Tumours. The scrofulous change, matter, or deposit present various appearances, superficially, according to its stage, its seat, and the alteration of the surrounding tissues; yet it is essentially the same at each of its stages, whether it is formed in a scrofulous external gland or in an internal organ. It varies chiefly in grade or stage, or in the successive changes which it undergoes, and in the form of its infiltration, especially at an early stage. Opinions, however, on these and other allied topics are extremely various, but I shall notice the chief of them. 60. D. Excessive secretion, and more especially an excess of the recrementitious secretions, or an undue discharge of the latter contrary to the intentions and indications of nature, and particularly the unnatural and debasing vice of manustupration-a vice most generally practiced by prudes, the unmarried, and the sanctimonious-have no mean influence in the production of tuberculosis, especially of the lungs, even independently of the pre-existence of a scrofulous diathesis. The vice now adverted to, and a premature or excessive sexual intercourse, are injurious both by the discharge from the economy of a secretion intended to aid the healthy development of the frame, and afterward to support and to promote the nervous and other functions, and by the frequent and excessive excitement by which this discharge is preceded, a consequent state of langour, depression, and vital exhaustion always resulting. 61. E. Prolonged mental application, or exertion, is more or less exhausting to both mind and body, as respects not only its direct operation, but also its indirect influence, especially in preventing a salutary recourse to hygeienic measures, and inducing a neglect of exercise in the open air, of change of air, and of the various recreations which tend no less to strength-er the tubercular deposit, which is undoubtedly en the body than to invigorate the mind. 62. F. An inordinate indulgence of the passions and affections; the various depressing moral emotions, anxiety of mind, hope deferred; frettings and disappointments, losses of fortune and friends, and all the sentiments which tend to weaken the organic nervous energy and lower the heart's action, more or less affect the digestive and assimilating as well as the excreting functions, lower the powers of life, vitiate the circulating fluids, impair or alter the nutrition of the structures, and thereby favour or develop tubercular formations. But it is unnecessary to pursue this topic any farther, as it is more fully considered in another part of this work (see art. DISEASE, the Causation of, § 22, et seq.) 65. A. The Physical or Anatomical Structure of Scrofulous and Tubercular Matter.—(a) As respects scrofulous or enlarged superficial lymphatic glands, the difficulty has been to demonstrate the changes which take place at the commencement, or at an early period of this disease. The question to be solved respecting them is wheth the chief change even in them, is the primary manifest lesion, or whether the increased vascularity often attending this deposit is the primary morbid alteration? This question will, however, be more fully considered in the sequel; but, before it can be entertained, the appearances presented by the scrofulous deposit, in various situations and seats, require to be noticed. The most obvious change in a scrofulous gland is its increased size. LLOYD and SOEMMERING ascribe this enlargement chiefly to thickening and increased vascularity; but it is more certainly owing to tubercular infiltration, in patches and rings, throughout the structure of the gland. The gland often remains in a stationary condition for a long time, presenting a granular yellow tuberculization, with little or 63. III. OF THE PATHOLOGY OF SCROFULA AND no increase of vascularity, and with a permeaTUBERCULOSIS.-Writers on scrofula and tu- ble state of the vessels. But as the morbid bercular deposits have differed remarkably not | deposits augment, the vascularity of the gland itself diminishes, or is gradually obliterated, owing to the pressure of the infiltrated matter, although the vascularity of the cellular tissue surrounding the gland is increased. BREDOW considers that the vessels found early in scrofulous glands belong to the tissue of the gland itself, and not to the scrofulous deposit in it. around the mass, or around the cavity left by into which the scrofulous or tubercular matter infiltrated matter in the surrounding tissues 69. Dr. GLOVER remarks on this topic, that these facts and observations, taken together, lead to the conclusion of the vascularity of tu66. Tuberculous matter, then, is infiltrated bercle being a non-essential phenomenon; and in the tissues of a gland, organ, or part. Some-that the obliteration of the vessels of the tissue times traces of those tissues may still be recognised in the tubercular mass. It is only in such cases that any appearance of blood-vessels can be traced, the vessels being merely those be-servations, that the irritation produced by the longing to the infiltrated tissues. In other cases, the tissues, being more and more compressed by the increase of the tubercular matter, almost or altogether cease to be distinguishable, and nothing is to be found but a homogeneous mass of this matter. In some instances, the mass is isolated by degrees from the surrounding living parts, and a cyst becomes formed around it, as is formed around pus or any foreign body. Here there is a close analogy between the formation of pus and tubercular matter, either of which being infiltrated into the tissues of the part in which they are found, and afterward becoming isolated by impacting the tissues around them into a cyst. According to MECKEL (Pathol. Anatomie, 2ter Bd., 2ter Th., s. 370) the encysted state of tubercles is more frequently met with in the low-is changed to this state, it generally gives rise er animals than in man. 67. KINGSTON, THOMPSON, and LUGOL, however, maintain that they have recognised bloodvessels in tubercles; but CANSTATT remarks, that SEBASTIAN explains this rightly in viewing it as a mistake, arising from the circumstance of tubercular matter being sometimes deposited on a small blood-vessel without giving off a branch to this deposit. ANDRAL, ROCHOUX, CARSWELL, CANSTATT, and others agree in asserting that lymph-vessels do not communicate with the scrofulous deposit. 70. The tubercular deposit, whatever may be to an ulcerous cavity, which extends more or 71. (b) Much discussion has arisen as to the earliest recognised form and appearance of the tubercular formation. M. LAENNEC conceived that the white opaque corpuscle, constituting tubercle, is preceded by a grayish, semi-transparent granule, in whose centre is developed a whitish point, which by degrees extends to 68. MM. BARTHEZ and RILLIET infer, 1st. the surface and involves the whole substance That, when a lung contains gray granulations of the granule, so that the granule is really the isolated from one another, an injection pene- first stage of tubercle. Dr. BARON and M. Dutrates easily by the bronchi and by the pulmo- PUY believed that tubercles originate in a transnary arteries and veins; 2d. That the vascular parent vesicle. M. ANDRAL has endeavoured to net-work which surrounds the granulations ascertain the accurary of this opinion, and he communicates very evidently with the pulmo- states that it is quite certain that, in some few nary artery, and probably not with the vein; 3d. cases, small, round, transparent vesicles, filled That the bronchial injection surrounds on all with a serous fluid, are found along with unsides the gray granulation, and conceals it in doubtedly genuine tubercles of various sizes in part only it is not disposed in very fine rami- the lungs of the horse; but that he has never fications similar to a vascular lace-work, but in been able to find this appearance in the human little grains united to one another; and, 4th. subject, excepting in one solitary case. He has That perhaps the bronchial injection can pene- sometimes seen the fluid contained in these trate the granulations. As respects the semi-vesicles in the horse lose its transparency and transparent, gray infiltration, they state that there the veins and pulmonary arteries are very penetrable by injections, while the small bronchi are obliterated, which latter fact is similar to what is observed in pneumonia. These observations, however, do not prove the vascularity of tubercular deposits, but rather that this deposit, as respects the lungs, often takes place in the vesicular structure or air-cells of the organ, as supposed by MAGENDIE, CRUVEILHIER, CARSWELL, ANDRAL, and KINGSTON. That the vessels become obliterated with the progress of tubercular infiltration, is contended for by GUILLOT and CANSTATT, according to whom the tubercle itself is always non-vascular, but become turbid, and the entire vesicle thus as- 72. M. ANDRAL farther contends that the orig- thologist respecting the origin of tubercles in | PAPAVOINE, NELATON, and others, that they are granulations has led to the notion that the small, found also in other organs. grayish, irregularly-rounded bodies sometimes found studding the free surface of serous membranes are incipient tubercles. M. ANDRAL, however, more correctly views them as the mere rudiments of false membranes; and a similar mistake has been made in considering as incipient tubercles those grayish granules sometimes found in mucous surfaces, which seem to be merely mucous follicles in a state of enlargement. The identity, therefore, of the granulations found in different organs and surfaces with tubercles is not proved, although those granulations are frequently complicated with tubercles, and may secrete tuberculous matter as they may secrete pus. 75. In scrofulous meningitis gray granulations and yellow particles are observed, as in the lungs. The former may also be detected in the glands, especially in the mesenteric glands, and between the coats of the intestinal canal. BARTHEZ and RILLIET, also, view the gray granulation as a form of incipient tubercle, not peculiar to the lungs, but existing occasionally in other organs, as under serous membranes, in the spleen, kidneys, liver, lymphatic glands, &c. It is chiefly developed in the cellular tissue, especially that connecting serous or other membranes to adjoining parts, and is often produced by congestion or by a mechanical hyperæmia. It is not improbable that the gray and gelatiniform infiltrations of LAENNEC are early stages of tubercular formations. The gelatiniform infiltration may pass into a gray infiltration, and this latter into a gray granulation, which may or may not go on to the state of yellow tubercle. The tuberclegrains, whether yellow, miliary, or semi-transparent granulations, are most separated and scattered when small, or at an early stage of development. As they increase in size they often become confluent. In the lungs more especially, they present every grade or stage both of change and development. There are often found, even in the same subject, the gray or semi-transparent granulation, rarely alone, but usually accompanied with yellowish granulations; the same miliary tubercle, quite yellow and caseous; tubercles much larger; masses more or less softened, or even cretaceous cav 73. M. CRUVEILHIER has advanced another opinion, namely, that before the occurrence of tubercle as a hard body, and at an earlier period, it may be detected in a fluid puriform state. MM. TROUSSEAU and LEBLANC have, as well as CRUVEILHIER, found among well-formed tubercles clusters of points, in some of which was a purulent infiltration, in others very small ab. scess. M. ANDRAL has seen, in a few cases, a similar appearance; but although those facts seem to offer some confirmation to M. CRUVEILHIER'S Opinion, yet the same objection applies to it as I have already adduced. It is probable that tubercles are secreted in a fluid state, but the fact is not demonstrated; and, however small tubercles may be, they are always found in the solid state. I have observed these bodies in the lungs of very young infants, and of the fœtus at the full time-where they are extremely rare; but they have always pre-ities, &c. In many cases death supervenes sented the solid or consistent form. 74. It may be granted, as contended by M. ANDRAL, that tubercles are in their first stage when they appear as minute, opaque, friable, rounded bodies of a yellowish-white colour, and without any trace of organization or texture. But this is not the only form in which they may commence. Besides these yellowish miliary tubercles, there is another form, which, since the appearance of the writings of BAYLE, has been the subject of much discussion, namely, the gray, semi-transparent granulations, which, according to LAENNEC and Louis, are the first degree of development of tubercle, the miliary yellowish tubercle being only a transformation of the grayish granulation. This is, in fact, confirmed by microscopic observation by LEBERT (§ 85). The gray granulations, transparent towards their margins, and sometimes also at their centres, often show in this latter situation a point more opaque and yellower than the rest. They are not surrounded by any envelope. They do not constitute the necessary and constant origins of fully-developed tubercles, but are only one of two forms which these bodies assume at their commencement, the yellowish miliary tubercle often commencing as such, and sometimes being a transformation of the grayish granulations. Tubercle may, therefore, at its commencement, present either of these forms; or it may appear as a gray and yellow infiltration, as a gelatiniform infiltration, or as tuberculous dust, according to French pathologists. It was supposed that the gray granulations occurred only in the lungs; but it has been shown by MM. VALLEIX, before a large proportion of the minute grayish tubercles, or granulations, has reached more advanced phases of their growth or progress. In many instances, grayish granulations are found as the commencement of tubercular disease in one organ, and the yellowish miliary tubercle in another organ or part. It is not rare to find in young children the latter in the sub-arachnoid cellular tissue, and the former under the pia mater. Gray granulations are often found in the sub-pleural cellular tissue, and yellowish tubercles in the lungs. 76. (c) Gray granulations are found to possess the globules of tubercle from their earliest appearance (see the microscopic appearance of tubercles, 81), and may exist in every part in which tubercle has been detected.-b. They are not a product of inflammation, although they may be found in inflamed structures.-c. They are most abundant and most frequent in the lungs and in the pia mater.-d. They are sometimes accompanied in the lungs with a dark or melanotic secretion.-c. When death does not take place early, they generally pass into the form of yellowish tubercles, by the destruction of the fibrils which separated their constituent elements and by the progressive deposit of the tubercular matter.-f. Tubercles do not necessarily commence in the grayish semi-transparent granulations, but also as frequently commence as yellow and opaque miliary tubercles.-g. In the same body both these forms of commencing tubercle are not unfrequently found, not only in different organs but even in the same organ. 77. (d) Growth.-Besides the transformation |