ART. VIII.

Bidrag till den Tuberkulösa Lungsoten's Nosographi och Pathologi. Af. PEHR ERIK GELLERSTEDT, Med. Doctor, &c., och Sjukhus Läkare vid Kongl. Allm. Garnizons Sjukhuset i Stockholm.-Stockholm, 1844. Contributions to the Nosography and Pathology of Tubercular Phthisis. By PETER ERIK GELLERSTEDT, M.D., and Physician to the Royal Garrison Hospital in Stockholm.-Stockholm, 1844. 8vo, pp. 127.

WE have recently had the pleasure of introducing to the notice of our readers the writings of a Swedish physician, who, though as yet comparatively a young man, has obtained considerable eminence as an acute and diligent observer in his own country. In the Clinical Reports of Dr. Huss, to which we allude, we had occasion to regret that we could not present to our readers the opinions of that author upon many important diseases, from the circumstance of his having treated of them in other of his annual volumes, to which unfortunately we had not access. The present work, in a manner, supplies a part of this deficiency, by laying before us the opinions and experience of one placed in the most favorable position to observe, and who is, if we may judge from the work before us, fully competent to the task. Our knowledge of phthisis, as it appears in various countries of Europe, has of late years been very much extended, but we have not seen a single recent work, even from the laborious press of Germany, that gave any account of this disease as it exists in the Scandinavian peninsula. Nor must we look upon the present essay as completely filling up the hiatus we complain of; for it pretends only to be the result of observations made in the Military Hospital at Stockholm, where soldiers alone are admitted. The general results of Dr. Gellerstedt's researches cannot therefore be of much avail in the statistical history of phthisis. But our author, at the very beginning, expressly assures us that it is not the general history of phthisis which he pretends to write, but merely to illustrate certain symptoms and features of the disease as it has occurred in his own practice.

Dr. Gellerstedt believes that phthisis in Sweden is upon the increase. The fact, if a fact, may perhaps be accounted for on the supposition that more luxurious habits are beginning to invade the stern regions of the north; but it is more probable that, as the means of diagnosis are now so much improved, the disease is only more readily detected. In the garrison at Stockholm, consisting of about 3500 men, the average mortality is about 80 deaths per annum, and of these 28 die from phthisis, while many more, affected with the same malady, are dismissed as incurable from the regiment, and return to die in their own homes. This gives a per centage upon the total deaths from all diseases of 35 per cent. in favour of phthisis.

The researches of our author during his five years of service in the hospital, have been chiefly directed to the pathology of the disease, and especially to the earliest commencement of the organic changes in the lungs. This, it is acknowledged by all, is the most interesting and important point in its whole history, nor can we say, in spite of the elabo

rate researches of Louis, Fournet, and others, that the subject is in any way exhausted.

In a brief preface, our author gives us, as preliminary to the other matters, the result of his own researches on the intimate structure of the lungs. He differs from Reisseisen and others as to the mode of termination of the bronchi. That author believed that each ultimate division of a bronchus was terminated by a single cell; Dr. Gellerstedt, on the contrary, inclines to the opinion of Dr. Hodgkin, that the bronchi diminish till their diameter is equal to that of two air-cells, and then really terminate. For, on slicing dried portions of the pulmonary parenchyma, and placing them under the microscope, numerous air-cells may be seen opening directly into the parietes of the bronchial tube, which tube cannot be traced beyond that point. In a word, as our author vividly expresses it, these air-cells line the walls of the ultimate bronchial divisions (tapetsera dess väggar). After briefly analysing the rest of Reisseisen's well known descriptions, Dr. Gellerstedt states, that he has recently, for very fine microscopical injections, employed blood deprived of its fibrine:

"I inject this," says he, "through the pulmonary artery, till it pours out from the opening of the pulmonary veins; I then tie both vessels, and, inflating the lungs, place a ligature on the bronchi, to prevent the escape of the air. After this, the whole mass is sunk in a vessel containing dilute sulphuric acid, in which it is allowed to lie for one or two hours, until the colouring matter of the blood is entirely coagulated throughout the whole lung. It is then taken out and slowly dried, until it becomes sufficiently hard to allow of its being cut into very thin slices."

The lining membrane of the ultimate division of the bronchi scarcely, he thinks, can claim the appellation of a mucous membrane, as the muciparous glands are wholly wanting; nor is the fine villous coat, so characteristic of that tissue, any longer to be found.

From these short, but interesting, notices of the pulmonary parenchyma, our author passes to the more immediate subject of tubercular degeneration, and first discusses the interesting point of the nature of miliary tubercle. He admits with Laennec, that the gray semitransparent granulations are of tubercular origin, but he has not generally met with a yellowish softer point in the centre of these small bodies. Dr. Gellerstedt has, however, frequently found portions of the miliary tubercle to be of a different colour from the appearance it generally presents, but he considers this to result rather from engaged portions of the parenchyma of the lungs, than from any change operated in the granulations themselves. Andral and Lombard's opinion that these granulations are the result of a crouplike exudation into separate air-vesicles, he does not consider to be supported by microscopical examination, for the granulations are too large to be contained in single air-vesicles, and, besides, they are seen to contain numerous engaged fragments of the pulmonary parenchyma, which, were their theory correct, could not be the case.

Crude tubercle, properly so called, is distinguished from the gray granulations by its opacity and by its yellow colour. It has not, observes Dr. Gellerstedt, the well-rounded form that generally distinguishes the miliary variety. Our author describes also a round isolated tubercle of not very frequent occurrence, which is of a firm wax-like consistence, and often

attains, unaltered, the size of a hazel nut. It is surrounded with a firm cyst, and is generally found isolated in the lungs : it has been observed by Dr. Gellerstedt in 24 cases, in most of which the patients had died of tubercular phthisis.

Tubercular infiltration of the lungs is minutely described. Dr. Gellerstedt admits of two varieties of this alteration: the one he terms isolated tubercular infiltration (insulär tuberkel infiltration); the other is that general form, so well delineated by Rokitansky. We do not remember to have seen any better description of the former variety, and we therefore introduce it here from Dr. Gellerstedt's work:

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"Insular tubercular infiltration occurs in masses, from a pea to a walnut in size, and is of a blueish-gray colour, with a smooth and almost fatty aspect when The tissue of the lungs, when this occurs, has entirely lost its accustomed porous appearance, without assuming the character of hepatization, or that given by aggregated miliary tubercles. At the edge of these gray masses we observe many small yellowish-white points of a looser consistence, and which consist of softened tubercular matter. These points are sometimes so abundant that they surround the gray infiltrated masses as with a ring. It is rare that they are to be found within the mass itself."

Insular or isolated infiltration of the lung occurred in 17 cases out of 119, or in 14 per cent. of those who died of phthisis, and in 11 per cent. of those whose death was occasioned by other maladies.

Caverns or excavations in the lungs occurred, as might be expected, very frequently, but in only 4 instances out of 119 did they preponderate, or appear only in the lower lobes of the lungs. The larger bronchi are generally described as being abruptly cut off at their entrance into these excavations, but Dr. Gellerstedt states that a slightly swollen ring is usually formed around the orifice by the mucous membrane lining the air-passages. He has only once observed a single cavern in patients who died of phthisis, but he has met with single excavations seven times in those who had succumbed to other maladies. Dilatations of the bronchi were frequently observed, and in one instance, where the patient did not die of phthisis, so large a cavity had been formed in this way, that it abutted upon the pleura, which was adherent to the ribs, and threatened to form a communication with the external parietes. The bronchi, too, are frequently compressed in phthisis; Dr. Gellerstedt has traced a bronchus thus flattened, and forming a compact ligament of two lines in diameter, till it ended in a double-headed mass containing a calcareous concretion.

Ulcers in the larynx, &c. In speaking of ulcerations of the trachea, Dr. Gellerstedt observes, that the mucous membrane surrounding these ulcers is frequently covered with a white albuminous layer, similar to that described by Bretonneau under the name of diphtheritis. True tubercle or tubercular matter he has never met with in the trachea. These ulcerations appear to supervene at an advanced stage of the disease, for out of 45 cases in which they were observed, 42 were so far advanced, that caverns already existed in the lungs. The ulcerations in the larynx, so common in phthisis, are, however, believed by Dr. Gellerstedt to be truly of tubercular origin, while those of the trachea here described, he regards, with Louis, as of an aphthous nature, arising from the constant irritation of the cough.

In two instances the pericardium contained tubercular matter in the form of calcareous concretions. One of these was about the size of a walnut, and consisted of a cyst with thick walls, containing a substance in consistence and appearance exactly resembling whitewash.

The intestinal canal presented very frequent lesions, tubercular deposit having occurred there in 97 cases out of 119. It appeared in various forms: a. As granulations; in size and consistence resembling miliary tubercles, but differing from these in their colour, being whitish-yellow and opaque. They were not confined to the solitary or agminated glands, though they were rarely met with in the large intestines, their seat being almost always in the submucous cellular tissue of the ileum. b. As ulcerations; occurring in the usual form but we cannot think our author justified in separating these two varieties, as it is most probable that tubercles always form where ulcerations are found, but have subsequently softened and have been carried away.

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Tubercular ulceration of the stomach is of rare occurrence; Dr. Gellerstedt has observed this alteration not less than five times in 119 cases of death from phthisis. It remains, we think, to be proved that these ulcerations were really tubercular.

The mesenteric glands presented no other form of disease than tubercular infiltration, and were less frequently affected than the intestines, in the proportion of 44 to 97. Our author met with but five cases out of 46 in which the mesenteric and the bronchial glands were simultaneously tuberculous. He rarely observed the fatty degeneration of the liver so accurately described by Louis.

It was only in two instances out of all his dissections that Dr. Gellerstedt found tubercular matter in other parts of the body when it did not exist in the lungs. In both these cases its site was the bronchial glands, and in one a cyst full of tubercular matter existed in the pericardium.

It will be thus seen that the proportion of cases of tubercular degeneration of the intestinal canal is much greater in Dr. Gellerstedt's reports than in those of Louis or of Lombard. Our author accounts for this, by supposing that the intestinal canal is more frequently affected in Stockholm than in Geneva or Paris, yet the statistics of typhoid fever give a contrary result.

Tubercles of the lungs accompanied Bright's disease of the kidney, in the proportion of 7 per cent.

From these minute but interesting results of his post-mortem examinations, Dr. Gellerstedt next passes to the obscure subject of the pathology of phthisis, and attempts to lay before us a full history of the origin and development of tubercle. With the physiologists of the present day our author believes tubercle to commence like other tissues, healthy or diseased, as a cytoblastema, yet with Vogel, he believes that something more is wanting to produce tubercular matter, some vitiation of that vital influence that develops the cytoblastema into healthy tissue, but which, when weakened in any way, causes the same cytoblast to pass into pseudoorganization, such as tubercle or schirrus. The germination (if we may use the term) of a cytoblast, is the same for all the tissues of the body, but the cells which are developed as nuclei in the original vesicle, first show the different tissues to which they are to be adapted, as a chemical [?]

change takes place in their parietes, and under a vitiated influence they are altered sometimes to tubercle, which in its highest stage of development consists of cells, with more or less of granular matter lying between them. This hypothesis will, of course, be well known to many of our readers, and we have therefore merely noticed it as the doctrine which is adopted by the writer of this essay. Dr. Gellerstedt believes that tubercle may appear under different forms, either as miliary tubercle (the gray semitransparent granulation of authors), or as crude tubercle, nearly, if not quite opaque, and of a yellowish white colour. He does not, however, seem to infer that from either of these two forms we can trace the peculiar appearance termed tubercular infiltration. It will be known to most of our readers, that of late the opinions of the best pathologists have tended to regard this alteration as of inflammatory origin, as being, in fact, the result of a species of scrofulous pneumonia. Dr. Gellerstedt allows that this may possibly be the case, in so far as that pneumonic hepatization may in scrofulous subjects be converted into tubercular hepatization, which in due time may soften, and leave excavations in the lungs.

"But," he adds, "I have never observed such a process to give rise to granular tubercle, except in those cases where the tubercular disease has advanced rapidly with symptoms of pneumonia; and I have then invariably found the tubercular deposit to be of a yellowish white colour, granular, and indistinctly circumscribed, and bearing a strong resemblance to the hepatization and abscesses occurring in the lung after phlebitis."

We have already seen that our author is opposed to the doctrine of the inflammatory origin of tubercle, but he acknowledges that the formation of tubercle and the process of inflammation present many points in common; though, if we trace them carefully, we always find that their mode of development is totally distinct and dissimilar.

The signs of inflammatory action discovered by the microscope in the form of exudation-corpuscles, are easily, he thinks, explained by the fact that tubercles act as a foreign body, and irritate the surrounding parenchyma. The condition of the blood, too, in phthisis, has been much insisted on by the advocates of the inflammation theory; but the cause of the increase of fibrine in that fluid is undoubtedly, he believes, the presence of the tubercular masses, which are already sufficiently far advanced to irritate and inflame the surrounding parenchyma. In fine, Dr. Gellerstedt candidly acknowledges that the influence determining the formation of tubercle in the body has as yet eluded observation; and with other pathologists, he takes refuge in the doctrine of a depression of nervous or vital influence to explain its origin.

In every instance he has found tubercle to occur only as infiltrated into the parenchyma of the various organs wherein it occurred, nor has he ever seen it lying loose in the bronchi, as described by Dr. Carswell.

As to its mode of increase, tubercle has been generally supposed to grow by juxtaposition, and not as in organized bodies by intussusception. Dr. Gellerstedt considers tubercle to be of a low standard of organization, and therefore to be incapable of developing a union between itself and other tissues. The further progress of tubercle from the original cell is produced, he thinks, by the neighbouring blood-vessels, from whence a