go so far as to deny the possibility of corrosion of an intact mucous membrane by the contents of the pulmonary caverns (Heinze). It seems to me that order may be restored to this conflict of opposite opinion, and reconciliation of these widely divergent views be accomplished, by referring to the corrosive action of the sputa those ulcerations alone which form the subject of this paper. In examining the problem from this standpoint the influence of the sputa is reduced to definite dimensions, and the error is avoided, on the one hand, of clinging to a doctrine which recent observation has shown to be false, and on the other hand, of overlooking a curious pathological fact which has never been satisfactorily explained. Passing then to a summary of the evidence upon which the corelationship between diphtheritic, as contradistinguished from tubercular, ulceration of the air-passages and the corrosive action of the sputa rests, the following facts present themselves in favor of the view expressed above: a. The predilection of the ulcers for those places which are in constant contact with the sputa, viz. the trachea and the bronchi, and especially the posterior wall of the former, and the laryngeal surface of the epiglottis. 3. The fact that they increase in number as the lungs are approached, and that they are much less common in the upper portion of the trachea and larynx. It was these familiar pathological facts that suggested to Louis the hypothesis which bears his name. 7. That they may be traced from the bifurcation of the trachea to the division of the bronchial tubes, where in all cases they become visible only in one tube, which is that leading to a cavity. This remarkable distribution of the ulceration in pulmonary phthisis, which I have repeatedly verified by dissection, did not escape the observation of Stokes,* who advanced it in support of Louis' hypothesis. 8. Their absence in the bronchi of lungs which are not the seat of cavities or advanced phthisical change. This at least has been my experience, and I am unaware that they have been observed by others where the lungs were not the seat of pronounced disorganization. e. Their occasional presence in the oesophagus, stomach and intestines, from swallowing the sputa. In one of my cases ulceration was found in the oesophagus and small intestine macro- and microsco *Diseases of the Chest. Vol. I, p. 62. Phila., 1837. pically identical with the diphtheritic ulcers in the larynx. Tubercle was present only in the lungs. 7. Finally, their occasional appearance in suppurative pneumonia (Wunderlich*) and gangrene of the lung. These lesions, therefore, may be regarded as the result of an inoculation, so to speak, of the mucous membrane with the detritus from the broken-down pulmonary tissue, leading to the formation of a loss of substance pathologically distinct from, but possessing some of the external characteristics of the tubercular ulcer. Notwithstanding, however, that these diphtheritic nodules owe their existence to the disintegration in the lung, it does not seem to me justifiable to look upon them, as Eppinger has done, as specific tubercular products, for the following reasons: First: That they differ histologically in no respect from the circumscribed diphtheritic ulceration of the mucous membranes of individuals in whom no evidence of tuberculosis exists; an important point in their differentiation from the well-defined and characteristic anatomical changes of tubercular infiltration and ulceration. In this connexion it may be added that the tubercular process, as shown by Heinze, commences under the epithelium, whereas in the ulcers under review that structure is always first affected. Secondly: That well-pronounced circumscribed inflammatory infiltration, resulting in necrobiosis and sloughing, and histologically identical with these diphtheritic lesions, is found, although not as frequently and abundantly, in the mucous membrane of the air-passages, and particularly in that of the trachea, as a secondary complication in diseases other than pulmonary phthisis. Thus, in circumscribed gangrene of the lung, or as the result of perforation into the trachea of broken-down, sloughing bronchial glands, small, round diphtheritic erosions may be detected in the mucous membrane of the trachea and bronchi, which are the histological analogues of those described above. Thirdly: That on other mucous membranes of the body, under similar conditions, namely, as the result of a neighboring, long-standing gangrenous process, or the constant passage over them of an ichorous discharge, ulceration is found, identical in every respect with that described above. This is true, for instance, of the mucous membrane of the vagina in gangrenous conditions of the uterus. In the anatomical museum of the Rudolfspital in Vienna is an instructive preparation of this kind, in which the vagina is studded with these small diph*Handbuch d. Pathol. u. Therap. III, 2. Stuttgart, 1856, p. 96. theritic erosions, the result of gangrene of the portio vaginalis uteri from an unknown cause. The great number of the ulcers, their absence in intense acute and chronic simple catarrh of the pharyngo-bronchial membrane, their characteristic macroscopical appearances, especially their often elevated, livid, irregular edges and sloughing base, and the picture which the microscope reveals, are sufficient to exclude the idea of their catarrhal nature, and strongly militate against the hypothesis which would relegate them to the simple inflammatory condition of the mucous membrane which often ushers in or accompanies the phthisical process in the air-passages. I think, therefore, in conclusion, that my observations go to show that diphtheritic ulceration of the larynx, trachea and bronchi occurring in the course of pulmonary phthisis is related to the affection in the lung in so far as it is produced by the corrosive action of the sputa; but that in the present state of our knowledge it it is impossible to affirm its specific tubercular nature. LIST OF PRESIDENTS-1799-1882. Upton Scott, 1799-1801. Philip Thomas, 1801-15. George C. M. Roberts, 1859-70. |