Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 126

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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BULLETIN

J1 25 19.1

RECEIVED

'HE JOHNS HOPKINS HOSPITAL

Entered as Second-Class Matter at the Baltimore, Maryland, Postoffice.

XXII .- No. 245.]

BALTIMORE, JULY, 1911.

[Price, 50 Cents

CONTENTS.

PAGE

;ereoscopic X-Ray Examination of the Chest with Especial eference to the Diagnosis of Pulmonary Tuberculosis. (Illus- ated.)

By H. KENNON DUNHAM, M. D., WALTER W. BOARDMAN, M. D., and SAMUEL WOLMAN, M. D.

Discussion by F. H. BAETJER, M. D., LOUIS V. HAMMAN, M. D., and W. S. THAYER, M. D. 229

ysmal Hemoglobinuria; Blood Studies in Three Cases. By W. L. Moss, M. D. 238

ilcification of the Costal Cartilages, the Cardio-Thoracic Index id Other Signs of Pulmonary Tuberculosis.

By W. W. BOARDMAN, M. D., and H. KENNON DUNHAM, M. D. 247

Experimental Studies on Tuberculo-Protein Hypersensitiveness and Their Possible Applications.

By ALLEN K. KRAUSE, M. D. . 250

Variations in the Leucocyte Count in Normal Rabbits, in Rabbits Following the Injection of Normal Horse Serum, and During

& Cutaneous Anaphylactic Reaction. (Illustrated.) By W. L. Moss, M. D., and G. L. BROWN, M. D. 258 The Use of Antiformin in the Examination of Sputum for the Tubercle Bacillus. By W. W. BOARDMAN, M. D. . 269 Serum Treatment of Hemorrhagic Diseases.

By W. L. Moss, M. D., and J. GELIEN, M. D. . 272 Concerning the Much-Holzmann Reaction. By W. L. Moss, M. D., and F. M. BARNES, JR., M. D. . 278

'HE STEREOSCOPIC X-RAY EXAMINATION OF THE CHEST WITH ESPECIAL REFERENCE TO THE DIAGNOSIS OF PULMONARY TUBERCULOSIS. BY H. KENNON DUNHAM, M. D., Cincinnati, WALTER W. BOARDMAN, M. D., Assistant Physician, The Phipps Tuberculosis Dispensary, The Johns Hopkins Hospital, and SAMUEL WOLMAN, M. D., Instructor in Medicine, The Johns Hopkins University.

DISCUSSION BY F. H. BAETJER, M. D., LOUIS V. HAMMAN, M. D., and W. S. THAYER, M. D.

PART I.

By H. KENNON DUNHAM, M. D.

object of this paper is to call attention to the principles chnique of stereoscopic X-ray examinations, and to e the alterations in the normal chest shadows, which ieve to be characteristic of pulmonary tuberculosis. X-ray, when properly applied, is an instrument of pre- for recording differences of density. On the single e we have of necessity various shadows superimposed. po-rentgenographs taken with mathematical precision

the chest is seen in true perspective, the shadows occupying the same relative position in the image, as the structures which cast the shadows occupy in the chest. This result is obtained by applying the principles of binocular vision. As you will recall " the retinal images of external objects, particularly near objects, are different in the two eyes. Whenever what we may call a right-eyed image of an object is thrown on the right eye and simultaneously, a left-eyed image is thrown on the left eye, whether in nature or by an artifice, we at once perceive depth or solidity in the object." The technical prob- iem then, in stereo-rontgenography was, first to obtain two

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negatives corresponding to the right-eyed and to the left- eyed image respectively, and second, to view simultaneously, by means of some suitable optical device, the right-eyed image with the right eye and the left-eyed image with the left eye

There are at present several types of apparatus which enable us to obtain the necessary negatives. The common principles in these are, first, a movable carrier for the X-ray tube, and second, a movable carrier for the X-ray plates.

In the movement of the tube there are four details requir- ing consideration. First, recalling that the X-rays originate at the so-called target of the tube, this target should be moved in a plane parallel to the X-ray plate, in order that the focal distance may be equal in both exposures. Second, between the first and second exposures the target should be moved a dis- tance slightly less than the inter-pupillary distance. Six centimeters has been found satisfactory. Thus every one who has good use of both eyes can see the stereo picture and per- sons with a greater pupillary distance can estimate, by means of their personal equation, the amount of fore-shortening and allow for it. Third, the target should be moved in a line parallel to rather than across the spine of the patient because this enables us to see around the ribs, thereby obtaining a less obstructed view of the lung fields. Fourth, the target should not be too near the plate. Twenty-five inches is a good working average.

As to the movement of the plates it is merely necessary that the second plate on exposure occupy the position held by the first plate during its exposure. Finally, the total time re- quired for the two exposures, and the movement of tube and plates must not exceed a period of easily sustained inspiration, a time well under ten seconds. For observing the finished plates, the stereoscope devised by Whetstone early in the last century, is most generally used.

Turning now to a study of the shadow pictures seen in stereo-rentgenographs of human chests, let us first consider the normal before attempting to describe the tuberculous.

On examining a stereo-rontgenograph of a normal thorax, one sees the shadow picture of the bony framework, with its covering of soft parts, enclosing the chest cavity, except be- low, where it is bounded by the shadow of the diaphragm. The shadows within the chest cavity, seen as we have stated, in their normal relations, are readily divided into three main groups : first, the " heavy central shadow," extending irreg- ularly from the upper boundary of the chest cavity to the diaphragm ; second, the " hilus shadow," radiating irregularly to a distance of four or five centimeters on either side of the fifth, sixth and seventh dorsal vertebra; and third, the " linear markings " seen in the lung fields.

The " heavy central shadow " need not here be described in detail. It is cast by the vertebra and the mediastinal con- tents ; the heart, aorta and other large vessels, trachea, oesoph- agus. lymphatics and connective tissue. The trachea can usually be distinguished as a band of less density bordered by parallel bands of great density, extending downward from the neck. Often it can be seen to divide in front of the fifth

dorsal vertebra, the shadow of one bronchus going to the ri. and the other to the left hilus. The right is the more to: seen as the left passes under the aortic arch and is genere. obscured for some distance. In good plates, these bronch. shadows may be seen to subdivide and extend into the Int: fields, as a part of the heavy trunks, to be described directi.

The hilus shadow, as has been stated, is cast by the prime- branches of the pulmonary vessels with their contained L'e . the walls of the primary bronchi, and the lymphatic : fibrous tissue surrounding these structures. Normally, hilus shadow is of moderate density, irregular in outline : of small extent, merging internally with the heavy cen. shadow. Externally the hilus has a sharp border which . made irregular by the heavy trunks emerging from it into E. lung fields.

The shadows in the lung fields may be subdivided into tr groups; the heavy trunks and the fine linear markings: T- heavy trunks appear as definite shadows radiating from :: hilus shadow toward the periphery. Three groups can usa." be seen on the right side, one group running upward and .c. ward, another outward and the third downward and outwe! These groups mark what we call divisions. They correspx roughly to the lobes of the lung. On the left side only IF such groups can be seen, one extending upward and outwar. the other downward and outward. Distally these heavy trun. divide and subdivide producing the radiating shadows des: nated as the fine linear markings. Examined more careful: these fine radiating shadows appear as fairly definite streit lines extending toward the periphery, but with our technic :. they are lost on the normal plate before they reach the peripc- ery of the lung. These shadows are the combined shadow cast by the blood vessels with their contained blood, the wal. of the bronchi, reinforced by the accompanying lymphar- and fibrous tissue. The heavy trunks are the shadows of large branches distributed to separate lobes of the long. "- linear markings are the shadows cast by the smaller brani- distributed to the various lobules of the separate lobes. T :- linear markings in the lower left division of the lung :" rarely distinct, owing to movement, during exposure, no. sioned by the cardiac contractions. Therefore alteration: : the character of the markings in this region cannot be dirt- rately determined.

Bearing in mind, then, this normal shadow picture, let ?: consider the stereo-rontgenographs of chests in which early but definite signs of pulmonary tuberculosis are found : physical examination. In such cases changes are noted in từ hilus shadow, the heavy trunks and especially in the lines" markings.

The hilus shadow shows usually an irregular increase i: area and density with here and there small irregular shadow: of very marked density. These bright areas of great density st- due to the presence in the chest of calcified caseous or fibres glands, while the increased area and density of the hil- shadow is due to a general increase in the fibrous and lymphati tissue which accompanies a local or general mediastinici- Such changes alone are of very slight diagnostic value 3º Te-

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"y" jwowwczy of tuberculous origin, indicate an old pro- more or less healed. In fact the presence of calcified ds, the other conditions being favorable, may be taken as od prognostic sign.

he heavy trunks extending toward the involved area illy appear broader, denser and less regular in outline . in the normal. Here again this change in the heavy ks is not necessarily tuberculous in origin, so that too t importance must not be attached to this change alone. ccompanying this alteration in the heavy trunks we find ne diseased area a similar change affecting the fine linear kings. They appear broader, denser and less regular in ine, frequently their course is studded, sometimes almost bliteration of the lines. We can no longer trace them as ating but find them broken in continuity and reaching to ear the periphery. As a result of these changes the linear kings appear to cross and interweave, producing a delicate ork of varying sized mesh. In the uninvolved areas of lung the shadow picture may be normal or there may be a it alteration, such as thickening or increased density of the ks and linear markings. The anatomical explanation of altered shadow picture we are not at this time ready to iss, but we firmly believe that the increase in the hilus ow, the thickening of the trunks, together with the altera- 3 in the linear markings-increase in density and breadth, ding, interweaving and extension to the periphery-con- ite a shadow picture characteristic of early pulmonary rculosis. As the lesion progresses the alterations become e marked, the linear markings are more and more broken nd irregular, the studdings become larger and denser and interweaving closer, until eventually the whole area ap- s as a more or less homogenous shadow of increased den- due to the presence of gross areas of consolidation within lung. The more advanced change due to cavity forma- we need not discuss at this time.

e have now considered the appearance of the stereo-ront- graph of the normal chest and of the typically early tuber- Is chest. However, all cases do not fall into these two 's. In the clinical report by Dr. Wolman the cases were ed into five groups : (1) Normal; (2) Diseased but not rculosis; (3) Probably Tuberculosis; (4) Definitely rculosis; (5) Healed Tuberculosis. It must be clearly stood that the stereo-rontgenographic examination does raw a sharp line of differentiation between these various s any more than does the clinical examination. In ng the border line cases the personal attitude and ex- ce of the examiner is of great importance. We cannot, ore, set forth any absolute rules to be applied in the Ication of every case, but a brief description of the w pictures which we consider typical of the various I may be of some assistance.

normal picture has already been discussed. It might Itioned that with advancing age there is an increase in Asity of all the shadows, hilus, heavy trunks, and linear gs, for which due allowance must be made.

pearance of acute pneumonia, abscess, gangrene, cyst, etc., except to say that they should cause no diagnostic difficulty. There is, however, a large class of cases presenting indefinite clinical signs suggesting pulmonary tuberculosis, which upon examination disclose an interesting and sometimes puzzling appearance. The hilus shadow and heavy trunks are increased in area and density, but sharply defined, radiate, often reach- ing close to the periphery. These changes are usually diffuse rather than localized and there is also an absence of the inter- weaving and studding characteristic of the tuberculous cases.

In the probably tuberculous cases some of the characteristic alterations are seen but the picture is not complete. There may be the changes in the shadows cast by the hilus and heavy trunks and suggestive alterations in the linear mark- ings, or some other atypical alteration. These are the cases that require the most careful study and judgment in reaching a diagnosis. The history, symptoms and physical examina- tions are essential in these cases.

The moderately advanced and advanced cases of pulmonary tuberculosis are readily recognized. In the less advanced cases, careful study will disclose the alterations in the linear markings, heavy trunks and hilus shadow previously de- scribed. If in such cases the fine linear markings are fuzzy, or seem to merge to form a cloud effect, such as a film of tobacco smoke in a close room, an active tuberculosis would be suggested.

On the other hand if the linear markings in a limited area are sharply defined and dense and show heavy studdings be- vond the trunks, a healed lesion is suggested. This condition is emphasized if it is accompanied with heavy coarse inter- weavings which reach to or near the periphery. The heavy trunk leading to such an area is usually broad and dense as is the hilus on the same side. Numerous calcified areas would complete the picture, but such a diagnosis should not be made from the plates alone.

One other change which is almost constant in pulmonary tuberculosis, but which is less often diagnosed, either clinically or radiographically, is pleurisy. Marked localized thickenings and interlobular pleurisies are recognizable, but the evenly distributed pleurisy which spreads uniformly over one or both pleural surfaces usually defies detection. On the other hand, pleurisy with effusion, even of moderate magnitude, is readily detected and presents a most interesting appearance in the stereo-rontgenograph. The fluid is seen to be pressed up around the periphery of the chest cavity. The line of contact between the shadow of the fluid and the shadow of the lung is not, however, a smooth rounded surface, but rather a series of cup-like depressions. Apparently the pressure of the lung upon the fluid is not uniform, there being bands between which the pressure upon the fluid is greater than at the bands. Emerson has compared the position of the pleural effusion pressed upon by the lung with the position of water in a bottle pressed upon by an inflated rubber bag. The simile would be more exact if the rubber bag were covered by a balloon .net. Regarding the oft repeated statement that in pleurisy with

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effusion the upper border of the fluid moves on change of posi- tion of the patient; the X-ray shows but slight if any change in the fluid level whether the patient be in the erect or re- cumbent position.

The report of Dr. Wolman clearly illustrates the value of this method of studying pulmonary lesions. So far as we know, this is the first report of any careful stereo-rentgeno- graphic study of the alterations in the fine linear markings occurring in pulmonary disease and the application of this knowledge to the diagnosis of pulmonary tuberculosis. We hope in the near future to be able to explain on anatomical grounds the alterations in the appearance of the linear mark- ings. However, although the method is still empirical and controlled only by careful clinical examinations, we are firmly convinced of its great worth and feel that its more general adoption would greatly increase the value and accuracy of the radiographic diagnosis of pulmonary conditions.

PART II. By WALTER W. BOARDMAN, M. D., and KENNON DUNHAM, M. D.

There is considerable diversity of opinion as to the value of Rontgen rays as an aid in the diagnosis of early pulmonary tuberculosis, some authorities placing them above ordinary physical examination, others on a par with physical examina- tion and still others denying to them any such position. To investigate this matter it was decided to install an X-ray apparatus in the laboratory of the Phipps Dispensary and to study an extensive series of cases, controlled by careful clinical examination, tuberculin tests, etc.

In reading an X-ray plate, as in the study of a pathological specimen, it is first necesary to become familiar with the nor- mal before trying to interpret the abnormal. Further, as in studying a pathological specimen it is important to know the structure and arrangement of the various units, so in an X-ray plate it is important to know the anatomical basis for the shadows seen. We therefore turned our attention to a consideration of this subject.

Remembering that in an X-ray plate we have merely a record of differences of density,-the tissues of greater density appearing as light areas, those of less density as dark areas,- we know that the shadows seen correspond to structures in the chest possessing greater density than the structures imme- diately surrounding them. On the single plate we have of necessity various shadows superimposed one upon the other. In stereoscopic plates, however, the chest is seen in perspective, the shadows occupying the same relative position in the image as the structures which cast these shadows occupy in the chest. The advantage of the stereo-rontgenogram for the careful study of the various shadows must therefore be self-evident.

Turning then to a consideration of a stereo-rentgenogram of a rormal chest we see the shadow picture of the bony frame- work, with its covering of soft parts enclosing the chest ex- cept inferiorly, where the shadow of the diaphragm is seen. The shadows within the chest cavity seen, as we have stated,

in their normal relations, may readily be divided into three main groups: first, the heavy central shadow extending from the upper boundary of the chest cavity to the diaphragm; ner: the hilus shadows, radiating irregularly to a distance of four or five centimeters on either side of the center of the pre- ceding shadow, and finally the finer markings seen in the lung fields.

Owing to imperfections of apparatus, the hilus shadows an the finer markings were rarely, if ever, seen upon the plate of the earlier workers and it was not until 1900 that they attracted any serious consideration. Thus Hickey ' states that we find various shadows constantly present which are inte; preted as shadows of the bronchi by some, shadows of th: pleura by others, and shadows of consolidation by still others However, he believed them to be perfectly normal, and basing his opinion on various injections, concluded that they wer the shadows of the larger pulmonary vesels.

Holzknecht' believed that the hilus shadows were due t pulmonary blood vessels; but to the smaller vessels situate. near the surface of the chest next the plate, rather than to ti. large centrally situated vessels.

De la Camp ' disproved Holzknecht's contention by X-raying serial frontal sections of a cadaver. By this means he det. nitely proved that the hilus shadows were due to organs which originate at the root of the lung and branch out toward the periphery and are not due to formations near the plate From various injection experiments he also concluded th .: the bronchi were responsible for these shadows and that to: vessels took practically no part in them.

Holzknecht and Kienbock * rejected the conclusions of E- la Camp and stated that they believed the pulmonary vese: were primarily responsible for the shadows and that t .: bronchi participated in them to but a slight extent.

De la Camp," after further careful experimental work. acknowledged that the blood vessels might cast some shadow. but held that they were secondary in importance to bronchi as a source of the hilus shadows.

Cowl' very definitely states that the shadows normal. present in the fields of the lungs are due to the ray-like spreJi- ing lung vessels and bronchi, but he brings forth no proof då his statement.

Rieder' speaks of the irregular spotted markings seen ir the lung fields and states that they are caused more by ta pulmonary vessels, especially the arteries, than by the bronch. Later he states that the anatomical nature of the shad:» stripes and hilus shadows has not yet been determined, !: that most investigators believe both bronchi and blood vessel play a part in the production of these shadows.

Cunnington ' describes a " tree branch striation " which ? noted in only a few of his tuberculous cases and which he to lieves is due to the distended lymphatics draining the involve areas.

Many others have expressed opinions regarding the anat mical basis of these shadows, but have made no attempt prove their statements. As Rieder has said, the most gr erally accepted opinion regarding these shadows is that the

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conclude that " the anatomical sub-stratum of the hilus shadow consists entirely of the blood vessels of the lungs and that under normal conditions the bronchial arborization gives no shadow on the Röntgen plate. It is, however, quite possible that in abnormal conditions, dilated bronchus filled with pus, it may give a shadow."

From the foregoing references to the literature it is evident that the question as to the anatomical basis for many of the shadows seen in X-ray plates of the chest had not been settled. In our investigations upon this question the work falls into four divisions : first, studies of stereoscopic X-ray plates of normal and diseased chests before death; second, studies of stereoscopic plates taken shortly after death, the X-ray read- ing being carefully compared with the autopsy findings; hird, studies of stereoscopic X-ray plates of animal and human beings in which blood vessels and bronchi had been injected with bismuth or other similar materials; and fourth, studies of stereoscopic X-ray plates of the lungs of animals and human beings upon which more or less dissection had been lone. The use of the stereoscope and the dissection were of greatest value.

From our study of the stereoscopic X-rays of normal and diseased chests, several points were settled. First, the hilus shadow is due to structures originating at the root of the ung and radiating toward the periphery, as demonstrated by De la Camp, since with the stereoscope these shadows were seen in their normal relations to the other structures in the chest. Second we were able to divide these radiating shadows n the hilus region and also in the lung fields into groups corresponding to the anatomical division of the lung into obes; three on the right, two on the left. These subdivisions vere very beautifully seen in the stereoscopic plates of injected ungs.

The shadow cast by the heart, with its surrounding peri- ardium and by the aorta, is too well known to require com- hent. The tracheal shadow, in many plates, could be defi- itely traced from the larynx into the hilus shadow as a band f slight density lying between parallel bands of great ensity ; in several cases the divisions and subdivisions could be !early traced well out into the lung fields. Aneurisms and ilatations of the arch of the aorta were readily recognized and leir location determined.

From our autopsy work we satisfied ourselves that enlarged id calcified lymph glands may be easily recognized if occur- ng about the edge of or outside the heavy central shadow; if ley occur within the heavy central shadow it may be impos- ble to pick them out. Without doubt the heavy central adow is cast by structures in the mediastinum; the heart ith its pericardium and great vessels, the oesophagus, the ills of the trachea, the lymphatic glands and the mediastinal nnective tissue. But it is difficult or impossible to recog- ze the shadows corresponding to some of these different ructures.

One of our autopsy experiments gave interesting informa-

vertebral shadow and extending from the clavicle to the base of the heart. This shadow must be cast by structures on the right side of the superior mediastinum. Here we have the superior vena cava surounded by lymphatics and mediastinal tissue. In order to demonstrate what part, if any, this vessel played in the production of this shadow, a body was placed upon the table and a set of plates taken. The right internal jugular vein was then opened and a rubber tube filled with lead shot passed some distance into it and a second set of plates taken. In these the shadow of the tube and shot can be seen extending from the neck through the shadow under consideration and into the heart shadow. At autopsy the tube was found to have traversed the right internal jugular, the right innominate, the superior vena cava, the right auricle and to have entered the inferior vena cava. We therefore feel justified in stating that the superior vena cava, with its con- tained blood, is at least in part responsible for the shadow seen; the lymphatics and fibrous tissue, however, must play some part in its production.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 126

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189