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in tuberculosis and in syphilis there are certain more common sites of inoculation. In the case
of tubercle, the mucous surface is more frequently infected than the skin, although I am
inclined to think that the cutaneous structures are primarily affected oftener than is usually
supposed.
We may restrict ourselves for the moment to the mucous surface. Although the point of
inoculation may be anywhere, certain localities seem to be more readily invaded. While any
point, from the lips down to the anal orifice in the one tract, and from the nostril to the ultimate
alveolus in the other, is liable to attack, I would lay stress on the posterior nares, the faucial,
and the tonsillar region as being specially vulnerable.
Whether inoculation occurs in that region, or in intestine, or in the larynx,or in the bronchiole,
matters relatively little for our present purpose. The significant fact is that successful inoculation
may be accompanied by little, if any, local change. The surface of the mucous membrane
may appear intact even to the critical examination of the histologist. This is specially likely
when infection has taken place, as it frequently does, during the tender period of developing
childhood. At that date the muccus surfaces are more absorbent and succulent. This explains
the great frequency of infection, and likewise the limited evidence of surface lesion.
Tuberculosis has this, then, in common with syphilis, that there is a definite, if not always
traceable, point of entrance of the invading organism. It differs from syphilis in the fact that
the disturbance at the seat of inoculation is generally slight and more transient. When
inoculation takes place through the skin, the local manifestations are more evident and lasting.
In such cases the primary sore may be a conspicuous feature, as in syphilis.
At whatever point inoculation has occurred, whether through mucous membrane or
skin, the further course consists for the most part, in a gradual spread by way of the lymphatic
system. It is impossible to emphasise this too strongly. First, one or two glands in the neighbourhood
of the point of inoculation become enlarged, and then progressively others at a greater
distance, and so on. The extent of the spread depends on the degree of resistance which the
patient offers. There is evidence which suggests that the glands exert a definitely antagonistic
influence.
In speaking of enlargement of glands, I should like it to be clearly understood that I refer
not to the enlargement of glands which is characterised by gross deformity with associated
caseation, and, perhaps, softening, but rather to progressive infiltration in chain after chain of
lymphatic glands, so slight in degree that it is for the most part over.looked. I am satisfied
that, if the more hkely seats of such lymphatic infiltration were scrupulously supervised in
childhood and adolescence, the determination of tuberculosis at the lymphatic stage would
be a common event.
In respect of the progress of infection from the initial point of inoculation by way of the
lymphatic glands, the course of tuberculosis presents further resemblance to that of syphilis.
As stress is laid on the presence of glandular enlargement in relation to a possible syphilitic
infection, so we ought, I hold, to be similarly suspicious in view of a possible tuberculosis/
Persistent glandular enlargement in any area—however slight the degree of enlargement
—should not be passed over lightly. In the case of the child and adolescent, persistent enlargement
of glands, whether in the cervical, in the axillary, or in the abdominal regions, should
be regarded as clinical phenomena calling for definite explanation.
I press the view with all the force of which I am capable, being strongly convinced that it is
at the lymphatic stage that tuberculosis ought to be opposed, and that, when thus opposed, its
further spread within the system is readily prevented.
The later incidents in the progress of tuberculosis vary much—whether its spread takes
place by the lymph stream or the blood current. We are not concerned to.night with details.
For the present it matters little whether the infection is carried to bone, or lung, or kidney or
brain. It is to the infective process as a whole that I ask your attention, rather than to particular
local or visceral lesions.
It must be constantly in our minds that the chief danger in tuberculosis lies not in the
anatomical changes which are produced—whether in lung or in other organ. The significant
factor in the process resides rather in the systemic intoxication, which is the necessary outcome
of the bacillary invasion. The more important chnical features and the fatal termination,
when it occurs, are in greater part referable to such intoxication.
The tuberculous toxins would seem to act specially on neuro.muscular structures. The
dystrophic influence is seen in the progressive loss of sarcous substance, and associated
enfeeblement, and irritability of muscle. To this, I believe, are referable the early manifestations
of motor weakness, both of limbs and viscera—the feeling of tiredness, the disinclination
for effort, the softening pulse, and the gastro.intestinal sluggishness. These are
generally in evidence long before cough or expectoration or other indication of local lesion is
forthcoming."
It may be added that tuberculosis is also characterised by the fact that it may affect any portion
of the human body. It is most familiar to us as tuberculosis of the lungs (pulmonary tuberculosis,
" consumption ") but it is almost equally well.known as a disease of the glands of the neck, of the skin
(lupus), of the bones and joints, of the brain and its covering membranes (meningitis), of the abdomen,
etc., etc.
Equally important is its economic importance as a disease of the community. Tuberculosis,
unlike measles and whooping cough which kill most of their victims at a very early age, or again cancer