SOME PROBLEMS IN PULMONARY DISEASE, WITH SPECIAL REFERENCE TO RADIOGRAPHY. BY

H. H. Carleton, M.A., M.D. Physician

Assistant

to

(Oxon.), M.R.C.P.,

the Bristol General

Hospital.

be derived from The extent of information which may radiography, also the limitations of this method,

pulmonary are worthy for

the

to be

nothing are

consideration. Assuming that the technique production of satisfactory radiographs leaves of

responsible

desired, difficulties of correct interpretation for a certain sense of disappointment, and

of tend to diminish the usefulness

pulmonary radiographs

Over-interpretation, i.e. the drawing from radiographs of deductions which are logically unsound, some of this disappointment and for alone is responsible

for many clinicians.

sceptics.

creates

hardly be necessary to emphasise that a method to be used in conjunction radiography of lungs is itself the method is with clinical signs and symptoms ; by should

It

seldom form the sole basis of

incomplete, and should it opinion. For instance,

is obvious that

showing well-marked can give no information

as to

shadows of

On

an

single skiagraph pulmonary tuberculosis, a

activity of the disease. taken at intervals the other hand, several skiagraphs in the alteration of shadows, that show, by virtue

may active

changes

One it is

the

in progress. the technical side of

are

point on

impossible

to

pulmonary radiography : get good pictures showing satisfactory

DR.

212

detail

in

It is not

to

see

practically instantaneous enough that a patient can hold his

In

Heart movements cannot be

they are considerable, and are sufficient picture. Personally, I have never seen a good

similarly

lung picture second.

with

few seconds.

a

to blur the

CARLETON

H.

lungs except

exposures. breath for inhibited

H.

;

in which the exposure exceeded about half a taking a chest for lung disease we do not want

the structure of the ribs.

blurred films

responsible

are

some as to

expressed by point

A second

insist that the

Over-exposed,

flat and

for much of the dissatisfaction

the value of

pulmonary radiography. : one should always the whole of the lungs. whole of the intercostal

the technical side

on

picture

shall include

Small films which do not show the

It is in the peripheral parts of the spaces are valueless. intercostal spaces that we look for the mottling characteristic of pulmonary tuberculosis. Thirdly : it is desirable to take all

skiagraphs

the tube is at to

in

a

varied,

standard

If the

position.

considerable alteration of

position of appearances

the

apices results and, further, it becomes impossible compare satisfactorily skiagraphs of the same patient

taken at intervals. It needs to be

emphasised

that there is

no

such

thing

normal chest ; in other words, appearances differ widely The difference is chiefly in in perfectly healthy people. as a

the amount of fibrous tissue. of the

detail,

will show

A

good radiograph, by

proportionately

shadows of the bronchial tree than will

conspicuous

more a

flat

reason

over-exposed

recognised we shall be confronted with the suggestion that every patient, who obtains a good skiagraph, is suffering from fibrosis, which is manifestly negative.

If this is not

absurd.

Pulmonary

fibrosis is

one

of the

problems

I wish

to

raise for discussion. I may say at the outset I

am

a

complete disbeliever

SOME

in the as

PROBLEMS IN

PULMONARY DISEASE.

213

interpretation of striation in pulmonary radiographs pathological fibrosis. Such a conclusion

indicative of

from

shadows is

radiographic

The clinical

signs

form of shrinkage

or

an

of fibrosis

falling

in of the chest

Shrinkage includes,

dyspnoea.

unjustifiable deduction. are chest deformity, in the of course,

wall, cough

and

displacement

of

internal viscera.

appreciate all that is involved one must turn to the essential significance of cough as a symptom. Why does anyone cough ? Fundamentally it would appear the cough is a physiological response to some degree of To

obstruction in

the air

anywhere

passages

between

and

air vesicles and

larynx. We may for the moment including neglect certain reflex causes of cough, e.g. wax in the ears. I believe that in every

cough

is

a

constant

and denied

inquired

by

the

case

of

pulmonary

tuberculosis

it may be insignificant unless the matter is carefully

symptom, though

patient

into.

The invasion of the wall of tubercle results in

neighbouring

an

by

a

obstruction to the

vesicle,

air

bronchiole

spreading air-way from a resulting broncho-pneumonic a

with

catarrh and the formation of

yellow tubercle. This is The X-ray productive of a short spasmodic cough. in the is lung. stippling appearance But this stippling is not pathognomonic of tubercle, for it occurs just as obviously in pneumokoniosis and even a

simple bronchopneamonia. The actual truth seems to be that stippling is an index of terminal vesicular catarrh, ?bronchopneumonia, if you prefer the term?and this is the only deduction that may be drawn from X-ray appearances. in

In

chronic, that

of

pneumokoniosis

the process is

extremely X-ray appearances are characteristic, in wide-spreading lesions, originally bronchopneumonic cases

and the

areas, come to be

pervaded by

dense fibrous

plaques

which

DR.

214

H.

H.

CARLETON

are very obvious in skiagraphs. Such huge masses are seldom seen in pulmonary tubercle; because an extensive

invasion with

long

usually brings death

the tubercle bacillus

before the

protective

response in the form of fibrosis degree seen in pneumokoniosis.

appear to the high One is forced, then, to the conclusion that

can

tuberculosis and with

certainty

pulmonary

shadows that cannot

pneumokoniosis yield distinguished by X-ray appearances

be

alone.

peribronchial striation causes no deformity of chest wall, no displacement of viscera, no obstruction to the air-way, and therefore, per se, no cough. It is usually not a sign of pulmonary fibrosis in any pathological sense, but merely an index of increasing years, and comparable to the gradual development of arteriosclerosis. Radial

question were it not thai: the fallacy is costing the country thousands of pounds a year in pensions to ex-soldiers, in addition to One would not be

so

keen to raise this

which there is the serious mental effect been

taught

to consider themselves

on

men

invalids

on

who have no

evidence than the presence of striae in a radiographic The position of the tracheal shadow is always

better

picture. worthy

it should be visible in every skiagraph, and normally, of course, occupies the mid-line. Its upper part is occasionally displaced by a goitre to such an extent that of attention ;

the details of the

larynx

are

visible.

Deviation of the lower

of the tracheal shadow is often

sign of pulmonary Naturally asymmetrical fibrosis. It is a frequent accompaniment of pulmonary tuberculosis or pneumokoniosis, and is an index of chronicity. Sometimes a patient gives only a short history of failure of health, suggesting that the present illness is the first breakdown part

fibrosis.

from tuberculosis.

a

deviation indicates

However,

trachea indicates that

well-marked deviation of the

probably

he has been

the

subject

SOME PROBLEMS IN

of

a

PULMONARY DISEASE.

215

years before. This deduction also in prognosis, because it indicates

previous attack, possibly

will carry some weight that the patient possessed the past, and may well to treatment.

Incidentally useful check

relatively good resistance in reasonably be expected again to respond

the

on

degree

by

of tracheal

manometric

mechanical effects of treatment

a

artificial

the effects of pressure

displacement is a readings, judging the when

increasing intrathoracic pressure in pneumothorax. The trachea shows more readily than the mediastinum

generally, at any rate the displacement of the trachea can be more readily detected. It is possible to maintain good pulmonary collapse without displacing the trachea. If this rule is observed

of the difficulties and discomforts

some

associated with the maintenance of

particularly

thorax,

Gross

the left

on

displacements

usually opacity, associated with generally diagnostic of fluid.

mediastinal

displacement is malignant disease, uniform opacity on

produce a

a

condition does

are

uniform

Unilateral,

such

side,

of the mediastinum

obvious.

Sometimes

artificial pneumocan be avoided.

an

not

e.g. one

lymphosarcoma, may side of the chest, but

usually displace

the mediastinum.

The X-ray appearances of fluid in the chest deserve further mention. A simple effusion never presents a clearlydefined upper level. The appearance of fluid exhibiting a clear-cut, straight line is pathognomonic of gas plus fluid in the gas is

pleural cavity. present

Hydrothorax

The free

mobility

of the fluid when

is very characteristic in a screen examination. occurs rather frequently in cases of artificial for.

pneumothorax and should be looked fluid undergoes spontaneous absorption. I know of no X-ray appearances by

distinguish

between

is to be based

on

serous

effusion and pus.

other evidence.

Sometimes such which

we may The distinction

216

dr.

the

Perhaps mediastinum of

long

h.

h.

carleton

grossest displacements

are

duration.

with well-marked

associated with Such

of the heart and

chronic fibroid

phthisis

associated

displacements always falling in of the intercostal spaces are

on

the

affected side.

The heart may be drawn over to such an extent that there is no heart shadow lying in front of the vertebral column. I wish the

region

now to pass to a discussion of appearances in of the hilum of the lung, together with the shadows

of scattered

present

in

intrapulmonary glands. Hilum shadows are early childhood and increase with age, as a

consequence of the relative increase in fibrous tissue. Even dense hilum shadows are without pathological significance

diagnosis of fibrosis. This has already been discussed in dealing with fibrosis ; but the presence of clearly-defined glands at the hilum and in the substance of the lung requires more consideration. Personally I regard the presence of opaque glands very much in the same light as I view the von Pirquet reaction. They represent in many cases old obsolete reactions to past infections. Everyone acquires infection se, and should never form the basis of

;per

the

with

reactions, part. The as

tubercle in which

bacillus

a

and

undergoes lymphatic glands play

immunising a

prominent

presence of opaque glands must not be interpreted evidence of broken-down resistance past or present.

Supposing the glandular barrier fails, infection is carried by lymphatics, interlobular, peribronchial or perivascular, to the peripheral parts of the lung distal to the intra-

the

pulmonary glands. and

are

seen

as

Here

bronchopneumonic

characteristic

stippling

lesions

in the

develop,

peripheral

of the intercostal spaces. We are led to the following position if my interpretation be correct, that opaque glands

parts per

se are not to

But if

be taken

as

peripheral stippling

evidence of clinical tuberculosis. is also

present

the

glandular

PLATE

?fntal ^?rtnal

lung

with

unusually well-marked

slriation.

l"'*cosis costs showing

plaques oj fibrous

XIII.

Pulmonary silicosis.

fibrosis Note

from a case of falling together of

intercostal spaces.

tissue. tissue.

Pneumothorax.

PLATE

Large effusion.

Note

displacement

mediastinum.

Acute tuberculosis. Acnle

of

XIV.

Note mediastinum mediasiin*1"1 Malignant disease. No!e not displaced, owing to adhesions

H^e ?i Note the ike clear line demarcation between gas and flu*' f'1'1''

Hydrothorax.

lS is

SOME PROBLEMS IN PULMONARY DISEASE.

barrier has broken down.

peripheral stippling

is

217

It should be

emphasised that radiographic sign of seen in cases of miliary

the earliest It is best

pulmonary tuberculosis. tuberculosis.

Turning

the appearances of cavities in the

now to

it is

in

lung

no means uncommon to see

reports by skiagraphs, are present in cases which exhibit no cavities that stating The truth seems to be that clinical signs of cavitation. good radiographs, there are a by their enclosed outline or roughly circular conformation may suggest cavities. The origin of these misleading shadows is quite uncertain. I think that some of them, at any rate, are formed by the

while all cavities

are

visible in

number of shadows which

churning

action of mixed cardiac and

respiratory

movements

thrown out on the surface of the lung. upon plastic lymph It will be a safe rule never to diagnose the presence of a Of course, thick-walled on X-ray appearances alone.

cavity

cavities may leave cases

no

other clinical

important

signs

as

will

to their

nature, but in such

correspond.

localisation

accurate

The

doubt

of

cavities

by X-rays

is

in relation to certain forms of treatment which

will be referred to later.

important point in diagnosis emerges from the consideration of radiographs, namely that pulmonary tuberis by no means always, I culosis even in its early stages the apical disease that we are might almost say usually, therefore, about alleged Discussions, taught to believe. matter much. mechanism of apical infections do not really One

to

say Perhaps it is true examination by physical in the

comparatively

logical process early lesions and the

more

is easier at the

No.

areas

158.

apices.

Further,

cramped space of the apices the pathoin the disease produces more crowded

therefore relatively

spacious

Vol. XL1I.

that the detection of the disease

of

lung 18

more

destruction

than

remote from the apex.

in

218

dr.

h.

h.

carleton

conditions other than those mentioned produce characteristic appearances. For instance, emphysema

Pulmonary thin

produces

pictures

with wide

latter

taking up a horizontal Bronchiectasis is not, as a

there is

spacing

position. rule, well

instillation of

seen

of the

the

ribs,

by X-rays

unless

preliminary radio-opaque lipiodol. I have no experience as to the effects of aspirating nebulised opaque fluids for this purpose. The practical point with reference to the radiography a

substance,

e.g.

of bronchiectasis is that unilateral

think, the

be treated

patient by

real. 6

oz.

to

some

cases

by artificial pneumothorax.

this method in unilateral

Sputum may be reduced from an entirely negligible quantity.

the treatment of bronchiectasis from risk.

by

and should, I

can

The benefit to may be very

cases a

matter

At the

of, say,

same

time

this method is not free

I have had

a case in which, after Only recently an apparently quite successful induction of pneumothorax an empyema occurred, evidently from the breaking down of adhesions. As far as my own personal experience goes I have had no similar instance of infection following induction

of artificial

pneumothorax

Turning adjunct

to

more

in tuberculous

particularly

cases.

to the value of

X-rays

as an

treatment, the problem of artificial pneumothorax

calls for consideration. this method

The indications for treatment of

in unilateral

by

high degree activity X-rays in the selection of cases is quite obvious. However, cases in which the possibility of treatment by are a

cases.

The value of

pneumothorax arises are seldom truly unilateral. problem presents itself in the following light: Is the proportion of active disease so overwhelming in one lung that, if the said lung can be immobilised, a very high proportion of existing toxaemia can be cut out, thus enabling artificial

The

cope with any small residual amount of disease which may be present in the relatively sound lung ??

the

system

to

SOME PROBLEMS IN PULMONARY DISEASE.

In the selection of which

radiographs

cases

quite unsuitable, by disease or by showing up either

are

extent of

2ig

will indicate those

reason

of the bi-lateral

the signs which go to The latter may be presumed displacements of the mediastinal

indicate extensive adhesion. where

exist

to

gross

structures and the

Further, prior

present.

in of the intercostal spaces are to induction of artificial pneumo-

falling

thorax it is desirable to know whether with

an area

again,

of normal

the value of

pleura

X-rays

is

one

is

likely

free from adhesion.

perfectly

to meet

Here,

clear.

While for purposes of continuous treatment by artificial pneumothorax cases must be selected on the unilateral

basis,

the

same

the method

as

desideratum does not a

haemostatic.

of the most efficient

one

The

one

point

of

means

apply to the use pneumothorax

Artificial of

of is

controlling haemoptysis.

prime importance

is that

we

shall know

lung the hemorrhage is occurring. It matters little or nothing that the opposite lung be free from disease, because in the ordinary way the treatment will not be persevered in once the danger of further bleeding is past. The advantage of artificial pneumothorax as a mode of arresting hemorrhage is that in the first place it prevents the from which

spread of blood by means of the bronchial tree to parts of the lung hitherto not infected. The second great advantage is that nursing is greatly facilitated. The patient can be turned and moved about with safety, and food can be administered with much greater freedom than can be done in the case of treatment of haemoptysis by older methods. cavities in

radiographs appearance of pulmonary From the discussed. surgical standpoint already been localisation of cavities by X-rays is of considerable

The has the

importance. is

a

case

in

The successful

point.

drainage of pulmonary abscesses

220

DR.

On the Continent not

H.

H.

CARLETON

with well-marked cavities

cases

by local compression where lung by artificial pneumothorax

treated

infrequently

compression

of the

be achieved

owing

The

to adhesion.

surgical procedures

is

success

are

general cannot

of such local

largely governed by radiographic

records. THE PHTHINOID

All of

are

us

of

poor type chest: flat in and

familiar with individuals

presenting

that

phthinoid physique usually designated front, kyphotic behind, narrow transversely, the

from above downwards,

long

and cubic with

CHEST.

capacity.

consumption

This

type

possessing poor expansion of chest has been associated

in the minds of clinicians from the time

of Aretaeus. The

physical signs of the

appearance

examination

on

patient

are

so

and

the

suggestive

general

that

they

frequently lead, to say the least of it, to a premature diagnosis of pulmonary tuberculosis. In my opinion the genesis of the phthinoid chest is to be found in enteroptosis. The subjects of this type of deformity practically invariably suffer from enteroptosis and a narrow dropped heart well displayed in radiographs. I suggest that it is the general dropping of the abdominal contents which pulls down the lungs and diaphragm in their wake. In consequence expansion in the upper part of the chest can only occur by carrying and overcoming the "

"

overload of the abdominal contents. enfeebled frame is

fore,

become

take

on

poor

resonance

a

equal

to.

permanently

The

of

which is

quite

"

lungs

more

at the

than the

apices,

there-

deflated and the breath sounds

bronchial character.

diagnosis

This is

The

latter,

associated with

and poor expansion, leads to the frequent infiltration at both apices," a deduction

unsound.

SOME

PROBLEMS IN

I should like to state in of

patient

a

with

a

PULMONARY DISEASE.

emphatic

phthinoid

chest

no

terms that in the case

of

diagnosis

tuberculosis should be made in the absence of

crepitations

of

or

unquestionable

tuberculosis from the sputum or This account of pulmonary reason

by

visible

on

221

pulmonary post-tussic

corroborative evidence of

X-rays. radiography

is

incomplete

of the omission of all reference to appearances the fluorescent screen. The omission is intentional,

not because the

subject is unimportant, by such examinations apart from the presence of

raised

problems

demonstrated

but because the well

be

patient,

the

cannot

the

and the apparatus at work. While the value of the screen examination is fully recognised, it may be well to mention certain possible sources of error. It is usual to dark

room

hear

great

stress laid

ments of the

of the

lungs

on

the

of deficient

significance

move-

diaphragm and poor illumination of the apices as an early sign of pulmonary tuberculosis.

It should be remembered that these two

degree present

in

practically

every

case

signs

of

are

in

some

phthinoid chest,

under what unfavourable conditions such The signs, therefore, do not in chest has to work.

simply showing a

themselves indicate the presence of

pulmonary tuberculosis.

DISCUSSION.

Dr. Bergin said that, while infiltrations believed

they

changes. in

a

are

chest

usually

were

often indicative of

as

that

not indications of

He did not agree

appeared

agreeing

a

peri-bronchial tuberculosis, he

early pathological

that, if the upper level line, gas was present ;

of fluid it

was

common to see the

upper level in this way. could sometimes definitely state after

exceedingly He thought that one seeing a skiagram that a cavity could be found clinically.

was

present, although

none

222

DR.

H.

H.

CARLETON

X-ray diagnosis of clinical signs enabled

Dr. Mayes maintained that often tubercle could be made this to be done.

He attached

diaphragmatic excursion ; the lung. He emphasised shadows in the medial

third shadows a

this the

of

gross lesion of to be given to

a

importance chest

in the

area;

The

uncommon.

more

shadow the less active the condition

it.

Dr. Edgeworth described was

meant

not

were

to diminution

importance

outer third of the

dense and definite

causing

before

long

interrupted by

appeared, except by skiagraphy. found.

a

loss of

haemoptysis. diaphragmatic movement, revealed

Three weeks later

thought

good health physical signs

in which No

Sanatorium treatment

Dr. Symes

a case

sudden

that

rather than too little."

was

an

apical

was

successful.

"skiagraphy

He had

friction

shows too much,

never seen a case

with

no

physical signs in which a skiagram helped diagnosis phthisis. He agreed that the diagnosis of cavities should not be made by skiagraphists, and thought they were inclined to see more on their films than existed in the patient. He was interested to learn of the tracheal deviation as a new and helpful sign, and asked whether there was any means of diagnosing adhesions by the X-ray. symptoms

or

of

a

Mr. Walters related level of fluid

operation Dr.

a

lung

Nixon

importance

a

case

in which

regarded

this

method

definite upper

of

as

great

in the routine examination of the chest, and

systematic procedure for Screening was important. He agreed necessarily indicate tubercle, and that

sketched

a

No empyasma was found, but at abscess was discovered.

was seen.

a

"

such examinations. that striae did not cavities

"

diagnosed

SOME PROBLEMS IN

PULMONARY DISEASE.

by skiagraphy

often did not

similar mistake

was

relied

exist

at

not unknown when

223

autopsy. But a physical signs were

on.

Dr. Carey Coombs thought that a linear upper border of fluid did appear when no physical signs indicated gas, and suggested that we might have to reconstruct our ideas on intra-thoracic

physics

value of

The

great position and

promised an interesting research. X-rays lay in their help in showing the

extent of lesions.

Dr. Carleton, in

sign area

of which the

cavity

said he believed there

reply,

which

of

a

; this

reliable, namely

was

straight

side

was

a

was one

semi-circular

influenced

by gravity, by coughing up the above fluid, he meant a

and which could be made circular contents.

In

regard

to the line

clear-cut definite line, about which there this

was

pathognomonic

of gas.

When

was no

screening

a

mistake, chest the

eyes should be fully accommodated to darkness, and minimal illumination was useful in bringing out slight differences in

transparence. Defective movement of the diaphragm was a sign of pleurisy, not of tubercle. He wished to mention that artificial

pneumothorax haemoptysis.

was

the best method of

arresting

Some Problems in Pulmonary Disease, with Special Reference to Radiography.

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