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Show DISEASES OF THE ORGANS OF RESI'IRATION. SECTION 111.] fibrinoiis bands. TABLE I X. FIG. l.-(Vm‘fl_7/ in HIP wp/m' lolw of tllci'igl/f lung. s/rc plea/ills. Arll/c- ,lnjilirm‘ioi/ (Ii/(l tubercles in. i‘lic [(77 lung. (,‘Asic l{.--\ man :50 years of age. Ili'slori/.--llzid a dry, harassing cough a number of years. Lately he presented the following symptoms: A cavity in the apex of the right lung. Percussion .' tyinpaiiitic sound over the region oftlic cavity. .\ singular vibrating murmur at the end of every expiration heard on ausculta- tion. Latent extensive pleiiritis on the same side: thorax distended over a large portion of the right lung, indicating exudation by dull sound over infiltrated part. No fever. llas an enormous appetite. Shortly before (l lath he could not be up, but had to lie on his right side. )Vas slightly anasarcous. \Vas suddenly seized with very severe pain in the right axilla. where enormous phlegmoiiousinfiamina- tion had set in. Tiiinefaction and pain extended forward beneath the pectoral muscles and backward beneath the serratus iiiagniis; also all along the whole arm. Died six days after this attack. - Pas-t fiIortcni.-The whole axillary cavity filled with pus, and extending forward and backward. The vascular and neii'al sheaths, the perivascular tissue, and the muscles were all infiltrated with pus. Large quantities of it were contained in the folds of the fascia. The right lung (Fig. 1) v 'as reduced in volume and col- lapsed. Was surrounded by a pseudo-memb mic and extensive exudation. The upper lobe of this lung was firmly attached to the costal pleura; the balance of the lung was separated from it by massive exudates; the base was enormously excavated. X0 part of the organ was permeable to air. The tissue was soft, infiltrated with a turbid liquid, and penetrated in every direction by gray colored The work of repair begins in the pleural and in the interlobiilar tissues in the tbllmving manner: Either a pyogenie membrane is formed by the interlobular connective tissue round a caseous lobiile, and thus cuts the eomniiiiiieatiiiii between the affected and the non-affected parts, the afferent bronchus and the blood vessels form- ing a sort of a scattoldiiig to support the cyst-like enlosure (Rim/- flaw/L), or, a granulating membrane. is formed by the iiiterlobiilar structures surrounding the caseous mass. Vascular spurs, ciiVeloped in great quantities of granulating tissue, filled with pus corpusclcs, enter the cavity, aiidfill it gradually up from all sides with a stiff ci :atricial tissue. The great vasciilarity of such tissue in its formative stage often gives rise to frequent, though small, lizeiiior- rhages. \Vlien the cavities are not large, or do not (‘Ullil‘nlllliczlie with other cavities; or, when the caseous formations are confined to few localities, the graiiulations produce contracted cieatriccs, the lung tissue shrinks and becomes harmless. Occasionally a whole series of partly obliterated cavities are found in a large portion of a lobc, the central portion taken up by the obsolete vessels and bronchi (Sec. III, Tab. 1X, Figs. 1, "2). \thii a reactive iiifiammatimi sets in, in a very early stage of the caseous process, by extensive liyperplasti * action, very voluminous and very dense bands of connective tissue of various colors are formed. They begin at the thickened pleural covering, and traverse the organ in every direction, and connect with the perivasciilar and peri- broiichial tissue, thus forming a. labyrinthine system of cavities and passages. Cach is invested with a pyogenic membrane, and is separated from the adjacent -avity by a. very thick membranous partition. The bronchi in such structures are in a high state of dilatation. The usual result of the softening of caseous matter, and con- comitant ulceration, is the formation of enormous numbers of abscesses, which follow each other in succession until the whole mass, when it becomes colliqiiated, is emptied into the pleural cavity, and produces piieuiiio-l»yo-thorax (Sec. III, Tab. VII, Figs. l) A few indurated tubercles were scattered through the tissues. The superior portion contained a ‘avity, which was partly filled up l)V two conical frag- ments of lung-tissue (M. l'. 1'.) They: were indurated. but the substance to which they were attached readilv broke down. The walls of the cavity were verv thin and coininuiii ‘ated with some bronchi, which were much corroded, and in the cavity of which extensive ulceration existed. The apex of the left lung showed a fine example of cicat- rization of caseous tissue. This was shrunk, wrinkled, and indurated. Between the dark-colored structure white bands extended in all directions, giving it a. striped ap- pca 'ance. A great many indurated tubercles, of various sizes, were disseminated throughout the whole mass. (F. M., mediastinal surface of the pleura.) Fig. 2 represents a vast. cicati‘ized cavity (C. P. C. P), occupying the superior lobe of the right lung of another individual. Great, numbers of bands and strings traversed it in all directions. They consisted of cicatricial tissue, and on their surfaces presented the appea 'aiice of mucous iiieinb'anc. Each band contained very numerous blood vessels. In the bronchial ‘avities, which communicated with the excavated lung, there was no miiciis. A few smaller cavities ((1. 1'. C. 1'.) partly closed by cicatrization existed in the lower portions ot'the lung. Fig. 5 shows an excavated upper portion of a lung by ulceration, and sinus opening externally at the left late a] portion of the larynx. (F. S., pulmonary sinus.) (L. 8., superior lobe.) Fig. 4. A highly thickened portion of the pleura. in the case described in Fig. 1. (A. A., external surface.) (15. 15., mediastinal surfaces.) ((1., apex where the pleural sur- faces meet.) The membrane is covered with fibrinous ridges and other neoplastic formations. l5ayle extended the name tubercles to many other forms of pulmonary phthisis. and introduced thereby great confusion into the true nature of the disease. Afterward Laenec designated the caseous masses found in many diseased lungs as Tl‘UiiiiReiJis; larger infilt‘ates occupying a. great portion of, or a. whole lobe, he named Tuberculous Diff/fruits. and the true tubercle he called JI/l/urg/ Granular/012. With him, and for a long time afterward, a caseous condition of a tissue was considered tuberculous. Virchow has subsequently shown that caseous masses may form in 'arious \‘ays and have ditferent sigiiifi *ances. ()n aiiatoiiii 'al grounds he established the (lt'l/ill/li' Ti/lwrclr. At present a tubercle is defined as an avasculai‘ cellular nodule. which only reaches a certain size, and when arrived at the. height of its development remains for some time in that condition, and then becomes caseous, which then undergoes either softening, inortificatioii, or becomes calcareous. The most recent investigations of Lino/Imus, Scluippcl, Abcsl‘cr, Riml_l'l(l.~‘cli, C't!‘h/H'l)lf, and Zirr/lcr have added the facts that the tubercle has in many cases a peculiar histological structure; that the same kind of cells often recur in the tubercle and give it a specific character. The central portions of it contain giant cells, which are many- nuclear. Single nuclear cells resemble lymphoid elements. Sometimes they are of large size, and have an epithelioid form. The larger cells have a. largely granular protoplasm and small spheroid nuclei. They are usually imbedded in a sir/mm having a net-like arrangement. At one time it was thought that the cpithclioid and giant cells were peculiar to tubercular structure, and they were considered diagnostic of that morbid alteration; but it was found that every infianii'natory tissue-formation is preceded by a stage of development of large cells, and a. number of tubercular elements can readily be produced experimentally. T/uc w/lillm' clement» incl 'll‘lllt oi the tubercle ro'c lilo II‘ls't‘fb/l'm/ in ('L‘t‘l'j/.I/l‘lllilllI/llo/I,' and every- thing speaks iii favor of the idea that a tubercle is (I spu-{ficform of gruim/rllioiz, but new of [is rlruic/o‘s row special to it, for they, like all graiiiilatiiig elements. are derivatives of the emigrated colorless Such dangerous and usually fatal termination is some- corpuscles from the blood vessels; the fixed elements of the tissues times prevented by thickening of the walls of thc abscesses and contribute but few coiitingeiits to the make-up of the tubercle. llistologically they differ from ordinary graniilatioiis only in that they contain a greater number of large or epithelioid cells, assume. a nodular form, attain a. certain stage, and undergo retrogressive change. Tuberculous nodules are met in diseased tissues in all the stages of progressive and retrogrcssive development, and may contain either larger and smaller cells grouped together. large cells alone, or small cells only in one tuberculous group. 1, 2, 3). attachment to the pleural covering. Till/cm-alas/N. Considering the great frequency of tubercles in the tissues of man and animals, and the innumerable researches, both clinical and anatomical, made by very numerous of the most able pathologists and pathological aiiatoiiiists into this subject of Tuberculosis. one might expect that, by this time, a well-defined notion of its nature and morbid character, or at least a definite pathological anatomy of the lesion has been established. Yet such is not the case. It seems even as if the multiplicity of the labors of the investigators has rather tended to confuse than to solve the problem. The great reason of the vast diversity of opinions niiist undoubt- edly lie in the extremely 'ariable phenomena manifested under different conditions by the morbid processes peculiar to tuberculosis. In a. work like this, having a coiiipendioiis character, only what has been definitely established can find place on its pages, and only so much as is so far certain will be described. The main character of 'l‘uberculosis constitutes the presence of a greater or lesser number of various sized cellular nodules in any involved tissue. These nodules have been, and still are, called tubercles. Formerly all sorts of infiltrates and other morbid formation, having a knotty appearance, were designated as tubercles. Baillie (in 1794) and l5aylc (in 1810) first called attention to the gray nodules or congeries of cells. which we at present call tubercles. A tubercle, according to the latest investigations made by Robert Koch, of 5erliii, will have to be defined us It cellular iiorlulc, in 1/‘l1lc/i. Home is could/Iml l/«c spcclfic rim/s, I'UllNlNl/llt/ of Mr Bacillus Tuberculosis. Whether this will become the permanent definition or not the future will decide. Pi'oprlr/alio/i of 'l'ulirrc/rs. Tuberculosis coming within the category of infectious granulations, it partakes of the nature of these specific iiitiaiiiinations as liindficisch has properly characterized them. Clinically consul-I cred, they have the peculiarity of being infections in a variety of ways: 15y progressive extension, that is. by passing from a central point centrifugally into the adjacent tissues. Simultaneous With this extensioiirtlic central infectious portion undergoes a process of decav. The lymphatic system connected with it becomes involved, and within the lymph-glands similar infectious centers are formed. from which further extension into the different parts of the |