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