Complete Text (Part 21)

to suspect metastatic processes in the lungs, and should always induce us to institute careful search for such processes whenever its presence cannot be readily accounted for in any other way. As is always the case in septic suppuration, the cells become destroyed with great readiness, and the fluid when examined microscopically is found to contain little more than broken down pus cells, detritus, and often large masses of micro- cocci. 5. We have now reached the last class of the inflamma- tory affections of the pulmonary parenchyma, interstitial pneumonia, the primary seat of which is the interstitial or interlobular connective tissue. Acute suppurative interstitial pneumonia is rather rare ; one variety of it we have already mentioned as an unusual complication of some cases of fibrinous pneumonia. In cases of empyema we sometimes find yellow bands of sup- puration which start from the surface of the pleura, extend inwards along the septa, and in the interior may be connected with one another, and follow the course of the bronchi and vessels. There is generally no difficulty in ascertaining that the pus is contained in spaces with smooth walls, the course and distribution of which is such that they must be lymphatic vessels, and the process, therefore, is a suppurative lymphan- gitis. Chronic interstitial pneumonia., or cirrhosis of the lung., is a far more common affection, and results in fibrous thicken- ing of the septa. The pulmonary tissue, which may or may not be involved in the inflammation, is seen to be traversed by narrow bands of connective tissue, which may gradually compress it more and more, finally converting it into dense THE LUNGS. 151 fibrous masses. Large quantities of black pigment derived from the blood are always deposited in these places — slaty induration, — and show them to have been the seat of an acute process at one time. Chronic interstitial pneumonia, pure and simple, is always suggestive of syphilis, but is rather rare. It is far more apt to be associated with other chronic and sometimes cheesy conditions of the parenchyma and bronchi, and then represents a sort of cure of these processes. This form occurs chiefly in the apices, and may completely surround small cheesy or calcified nodules ; retraction of the upper part of the chest results, as is also evident from clini- cal experience. 6. Peribronchitis, inflammation of the connective tissue surrounding the bronchi, is sometimes an affection of great importance. In the form of acute suppurative peribronchitis, it is rather rare and occurs only in connection with very rapid phthisis. It is far more common in the chronic forms oi fibrous and cheesy peribroyichitis, and is then manifested on section by great numbers of small, round, and closely aggre- gated nodules which may easily be, and indeed often are, mis- taken for tubercles ; these really represent cross sections of clusters of minute bronchial tubes close to their junction with larger branches. On careful inspection a minute dark point may sometimes be seen at the centre of each of these nodules — the open end of the tube — but this is not always the case, since the tubes may be either obliterated or completely plugged with cheesy material. The lung substance which intervenes between these nodules of peribronchitis is very often the seat of slaty induration, and the lung then contains hard masses of the size of a walnut or larger, which can be felt from the outside, and consist of dense slate-colored fibrous tissue in which the gray or yellow peribronchitic nod- ules of the size of a pin's head or millet seed are imbedded. The affection does not remain stationary but continues to progress, and it is consequently at the edge of the slaty por- tions that we find the most typical peribronchitic nodules. 7. It is our purpose in this place to touch on inflammation 152 DIAGNOSIS IN PATHOLOGICAL ANATOMY. of the smaller broncbi, bronchitis, or better, bi'onchioUtis., only as far as it is directly connected with inflammation of the parenchyma. Thus limited it is always essentially a chronic process. In connection with peribronchitis it has al- ready been mentioned that fibrous bronchitis causes obliter- ation of the smaller tubes. Cheesy bronchitis is an affection of greater importance, the products of catarrhal inflamma- tion remaining within the tubes, and there undergoing case- ation. Cheesy inflammation of the larger bronchi is easily recognized, and can be demonstrated by cutting the tubes open with scissors ; when the same affection involves the smaller bronchi and, as happens so often, is associated with fibrous peribronchitis, it may easily be mistaken for tubercu- losis on account of the strong resemblance which the nodules with yellow, cheesy centres and gray, fibrous circumferences (encysted tubercle of the older authors) bear to old tuber- cular deposits which have become cheesy. They can always be recognized as belonging to the bronchi by their arrange- ment in clusters. (/.) Tubercles are found in the lungs in three forms which differ essentially from one another. 1. The simplest, and at the same time the rarest form is disseminated tuberculosis^ which is but part of a general or widely distributed process and is characterized by the presence of minute gray nodules which are scattered pretty uniformly through the tissue, but which, especially in the upper lobes, may be of large size, yellow at the centre, and gray and translucent at the periphery. The smaller miliary tubercles in particular often project like little spheres above the level of the cut surface and can be easily isolated from their con- nections. The diagnosis is decidedly strengthened when the nodules are found along the blood-vessels also, in the terri- tory of the lymphatic vessels which accompany them. The large nodules to which we have already referred are usually in part the result of a desquamative pneumonia which is set up by and surrounds the tubercles. 2. Localized tuberculosis may be further subdivided into THE LUNGS. 353 two forms, the first of which may retain the term localized tuberculosis., though in a narrower sense, and bears a similar relation to the lungs as the disseminated form to the body in general. It is characterized by the development of single tu- bercles about a cheesy nodule or cheesy ulceration in the lung as well as about the bronchial glands. The tubercles are gen- erally surrounded by normal pulmonary tissue, are apt to be more closely aggregated, larger, and further advanced in caseation immediately about the cheesy centre, and to become more scattered, smaller, and younger as we recede from that point. This resembles the disseminated form also in being more commonly met with in children than in adults. The second subdivision of localized tuberculosis in its broader signification is characterized by the deposition of tu- bercles in inflamed pulmonary tissue, near and in the midst of the inflammatory products. The forms of inflammation which are thus complicated are cheesy pneumonia and peri- bronchitis, those forms which are especially prone to result in destruction of tissue. To adopt a nomenclature analogous to that which is employed with reference to serous mem- branes, this form may be termed tubercular infiammation of the lungs. Of all the forms it is the most difiicult of recog- nition ; it may, indeed, be said that it is generally impossi- ble to decide in any given case without the aid of the micro- scope, whether the pulmonary disorganization is of a purely inflammatory or of a tubercular inflammatory nature. As one would naturally expect, but little is to be gained by even microscopic examination of a fresh specimen, for a knotty point like this can be solved in only the thinnest and most delicate sections. It is pretty safe to assume, however, in most cases that the affection is not purely inflammatory, but of a mixed or tubercular and inflammatory character, even when the pathological changes must be ascribed in great measure to true inflammatory processes. 3. The third and last variety of pulmonary tuberculosis is tubercular inflammation of the bronchial tubes, particularly of the smaller ones — bronchitis tuberculosa. In very re- 154 DIAGNOSIS IN PATHOLOGICAL ANATOMY. cent cases, the tubercles usually appear to the naked eye as very minute dots or points in the bronchial mucous mem- brane and are more likely to occur in the upper lobes. They almost never attain considerable size, and least of all, become cheesy, for the reason that they are very prone to break down rapidly and to leave superficial ulcerations with everted edges and grayish-yellow bases. If the mucous membrane is in- flamed and reddened the ulcers are easily recognized ; but if, on the other hand, it is pale and ansemic, then recognition is often attended with great difficulty. In the latter case they can sometimes be brought to view by rubbing a little blood gently over the surface ; the blood adheres to their edges and thus renders them easier of recognition. The ulcers increase both in size and depth by tue constant forma- tion and breaking down of fresh tubercles, and may finally perforate the bronchial wall and involve the surrounding pulmonary tissue, which is generally more or less inflamed. (^.) To complete our sketch of these latter processes, all of which are very intimately connected with pulmonary con- sumption or phthisis, we will next take up the chronic for- mation of cavities in the lungs. 1. Dilatation of the bronchi or bronchiectasis may be either pretty widely distributed and uniform (^cylindrical ectasis^, or limited to small areas and without uniformity (^saccular ectasis^. It may again be vicarious or secondary, when for any reason contiguous bronchi have become imper- vious to air, or it may result simply from chronic bronchitis. The dilated tubes are everywhere lined with mucous mem- brane, which retains its ciliated epithelium unimpaired. In the saccular form, especially, the secretions are very often re- tained, become decomposed, and set up inflammation Qputrid bronchitis') ; or else inflammation follows inspissation and caseation of the secretion. These dilatations are also a favor- ite seat of the above described tubercular ulcers, which soon transform the dilated bronchi into ulcerating cavities. 2. Cavities or vomicae, may also be formed by the breaking down of pulmonary substance which has become the seat of TUE LUNGS. 155 the above mentionecl cheesy processes. Such cavities may be completely closed and contain a soft mixture of pus and cheesy material, or they may be in direct communication with a bronchus through which their secretion is emptied ; the fact that such a communication exists does not in itself prove that the cavity is the result of bronchiectasis, for the reason that a cavity which increases in size must sooner or later be- come connected with one or more of the larger bronchi. It is only by. the presence or absence of a mucous membrane that we can determine the nature of these cavities. If a com- municating bronchial tube can be followed up for some dis- tance along the inner wall of the cavity, or if traces of mu- cous membrane are found here and there within it, bronchial dilatation must have been present at this place at some time ; if such, however, is not the case, it is impossible to make a differential diagnosis from the local condition alone. Smooth- ness of the inner wall of the cavity proves nothing, of course, when taken alone, since a pulmonary cavity, the result of ulceration, may become perfectly smooth after the ulcerative process is arrested, but can still be distinguished from sim- ple bronchiectasis by the absence of a lining of ciliated epi- thelium. Several contiguous cavities may be gradually united into one, and thus form an irregularly scolloped cavity, the origin of which is betrayed by the persistence of portions of the septa. The only component parts of the lungs which show much resistance to destructive processes are the branches of the pulmonary artery, which often traverse cavities in the form of rounded cords, or project prominently from their inner walls and are still pervious to the blood-stream. The wall which lies toward the cavity is sometimes the seat of aneu- rismal dilatation, when it is greatly weakened, and may rup- ture and give rise to fatal hasmorrhage. The vessels which traverse cavities sometimes eventually break down after thrombosis has taken place within them, and leave only small, hard, grayish stumps or prominences projecting from 156 DIAGNOSIS IN PATHOLOGICAL ANATOMY. the wall. The presence of these prominences on the inner wall of a cavity may be regarded as proof positive that such a cavity — at all events in its present condition — is the result of ulceration. The appearance of the walls varies according to the condition which they may happen to be in. If the de- structive process has been progressing actively they seem to be formed of yellow, cheesy, and broken down masses, which often contain tubercles. We also meet with cases which have run a very rapid course where cavities are found filled with larger or smaller portions of lung tissue, which have been cut off from the circulation, have become cheesy, and are al- most completely detached from the wall ; if the process has become stationary, the walls are formed of dense fibrous tissue, the surface of which may be of a bluish-gray color or covered with granulations. Cavities occasionally become closed, contract, and heal completely, but this is by no means the rule. We have now described all the processes which are com- prised in what is generally known as pulmonary consumption^ or phthisis. It would be a great mistake to suppose that any one of these processes singly brings about all the changes which are found in a case of phthisis ; as a rule several or many processes are coexistent, and this accounts for the great variety of appearance in phthisical lungs, of which scarcely any two are to be found alike. For this reason we cannot undertake to describe the manifold appearances to which combinations of the processes may give rise, but hope that what has been already said will enable the reader to distin- guish the several processes from one another, and thus un- derstand their sum. We would only repeat that many cases which at first were of a purely inflammatory nature are sub- sequently complicated with tuberculosis, which also takes its part in the destruction of tissue. The condition receives its name from the process which may happen to be predominant, and we speak of inflammatory or pneumonic phthisis when inflammation and caseation are chiefly prominent, or of tuber- cular phthisis when the reverse of this is the case. THE LUNGS. 157 It should be mentioned, in conclusion, that cheesy masses, whether in the bronchi or in excavations of the pulmonary- tissue, may become in a measure harmless through calcifi- cation ; they become first thick and gritty, then grow gradu- ally harder and more stony until they form concretions known as pulmonary and bronchial calculi. On the other hand the destruction of tissue may be greatly hastened if putrefaction takes place in and about the collections of cheesy material — gangrenous phthisis. The cavity then contains dirty greenish-yellow necrotic material instead of cheesy pus, and its walls are ragged and gangrenous. (A.) Tumors are not uncommonly found in the lungs, and, although almost any form may be primary here, they are gen- erally the result of contiguity (as in cancer of the breast), or else of metastatis (mammary, gastric, oesophageal cancer, sarcoma of the neck or glands, etc.). We have already described the characteristics of the various forms of new growths, but one should take care not to mistake the normal pulmonary alveoli, which often persist toward the edges of the tumor, for the alveoli of cancer. By adding dilute caustic soda or potash to the microscopic specimen, the elastic fibres and their peculiar arrangement may be clearly brought out, and thus error avoided. There are a few manifestations to which tumors some- times give rise in the lungs, which are so peculiar as to de- serve special mention. All the forms of cancer are, in these organs, peculiarly prone to break down, and may form cavi- ties communicating with a bronchus or with each other, very similar to those which result from cheesy pneumonia. An ulcerative destruction of the lungs may be thus brought about, and has been justly termed cancerous phthisis. A second peculiar manifestation is that which is due to cancer- ous., sarcomatous., etc., lymphangitis. The tissue is traversed by narrow bands of the morbid growth, with dilatations or nodules at the points of anastomosis, very much as in super- ficial, or subpleural, and deep, or parenchymatous, purulent lymphangitis. This form is chiefly met with in connection 158 DIAGNOSIS IN PATHOLOGICAL ANATOMY. with cancer of the breast and stomach, lymphosarcoma of the cervical glands, etc. Careful examination of the contents of the lymphatic vessels with the microscope will generally throw light on the nature of the process, though the under- taking is not always an easy one. (z.) Echinococci are sometimes found, and may give rise to the formation of abscess and perforation : their characteris- tics were described in sufficient detail in connection with the brain. (ß.) Morbid Conditions of the Larger Bronchi. Although the bronchial affections, and tubercular bron- chitis in particular, of which we have already spoken on account of their intimate connection with parenchymatous changes, are also met with in the larger bronchi, these latter are more commonly the seat of independent processes, chiefly of an inflammatory nature — catarrhal and purulent bron- chitis. The catarrhal form is manifested by swelling and redness of the mucous membrane and increase in its secre- tion ; the purulent form by more intense redness and swell- ing, and gray or yellowish- white muco-purulent, or light yel- low purulent secretions, which may be poured out in such quantities as to completely fill the larger tubes. In