Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 127

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

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The results obtained from our injection experiments of animal and human lungs were disappointing. Plates taken after injecting bismuth into the trachea and bronchi showed shadows apparently corresponding in position and size to the shadows normally seen at the hilum and in the lung fields. However, plates taken after similarly injecting the blood ves- sels disclosed shadows also apparently corresponding in posi- tion and size to the normal shadows. If both bronchi and blood vessels were injected the shadows appearing on the plates were too dense to allow of careful study. Hence as a means of settling the disputed question this method was valueless, as might have been inferred by the widely different conclusions reached by the earlier investigators using the method.

Our dissection work on animal lungs was more satisfactory, especially the series in which pigs' lungs were used. These gave very beautiful pictures showing the bronchi as areas of decreased density. Partial injections of pigs' lungs showed the artery to be directly in contact with one side of the bronchus, the vein in contact with the other side. An in- structive experiment consisted in carefully separating the lobules from over a bronchus, which was exposed throughout its course from hilum to periphery. A section of the bron- chus was now removed and placed on another portion of the lung. The plates taken showed first a definite shadow cast by the removed bronchus; second, definite shadows cast by the artery and the vein in the space from which the bronchus had been removed. These latter shadows were less dense than the shadows with which they were continuous above and below. In other words, the arteries and veins cast shadows in X-ray plates of pigs' lungs, but normally their shadows are aug- mented by the shadow of the bronchus. Thus the veins, the arteries and the walls of the bronchi cast shadows of great density in the pigs' lungs; the lumen of the bronchi appears as a shadow of slight density. It now became important to repeat this experiment on a human lung.

To this end a normal human lung was obtained as soon

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after death as possible, inflated to its natural degree and the first set of plates taken. In these, lines of increased density were readily seen, radiating from the root of the lung toward the periphery. The lung tissue in the region corresponding to one of the more definite lines was carefully separated until a vessel was exposed throughout its course. In the second set of plates the shadow cast by the exposed vessel, a vein, was seen to correspond in position to the shadow on the first plate. The vein was now carefully removed and placed across another portion of the lung, and a third set of plates taken. In these a definite shadow was cast by the removed vein and a shadow was still present in the original position but of lessened density. Beneath the vein lay the artery and this was now removed and placed parallel to the vein, and the course of the bronchus which was now exposed was mapped out with two pins. In the fourth set of plates the bronchial shadow was distinct, although faint, running between the pins, and a definite shadow was present corresponding to the removed artery. The bronchus was now removed and placed parallel to the vein and artery. The plates now showed an absence of any shadow in the original location and definite shadows cast by the vein, artery and bronchus. The proximal end of the bronchus in which cartilage was present cast a very marked shadow. A section of the primary bronchus and of the large thick walled pulmonary artery was now placed side by side on another portion of the lung, and X-ray plates were made. The plates showed a very definite shadow cast by the primary bronchus and a much less marked shadow cast by the walls of the pulmonary artery. Finally two other vessels were exposed and by means of syringes blood, to which a small amount of sodium citrate had been added to prevent coagulation, was injected directly into them. The plates of this last experiment showed slight but definite increase in the density of the shadow beyond the tip of the syringe needles, the site of the injected blood.

We believe that we have proved in this experiment beyond the question of a doubt that the walls of the arteries, the walls of the veins and the walls of the bronchi cast shadows in X-ray plates of normal lungs removed from the body and that these structures bound together as they are by a small amount of fibrous tisue and surrounded by the lymphatics, are collectively responsible for the shadows seen in the paren- chyma of the lungs. Furthermore, that the blood normally contained in the pulmonary vessels increases to some degree the density of the shadow cast, and finally, that the walls of the large bronchi are capable of casting very definite shadows which normally are heavier than the shadows cast by the walls of the large vessels. However, the large vessels, with their contained blood, cast a homogenous shadow, whereas the bronchi, with their contained air, cast a very different shadow, consisting of two parallel bands of great density separated by an area of slight density.

We therefore believe that the anatomical basis of the shadows seen in the lung fields and at the hilum in X-ray plates of normal chests is definitely settled. The hilus shadow is caused by the primary branches of the pulmonary

vessels with their contained blood and by the walls of the primary branches of the bronchi, together with the lymphati: glands and fibrous tissue which accompany these structures and bind them together. Remembering that the large bloed vessels cast a uniform shadow, the blood vessels probably af- count for a greater part of the hilus shadow than do the tr: parallel shadows cast by the branches of the bronchi; how ever, this bronchial shadow is a very definite part of tx general whole. The shadows seen in the lung fields are als due to the blood vessels with their contained blood and to the walls of the bronchi. The surrounding fibrous and lymphaty tissue is normally so slight that it probably plays little par. in the production of these shadows. Here again the blox! vessels, with their contained blood, must cast more shadow than do the walls of the smaller bronchi with their containe: air, but it is evident that this bronchial shadow cannot neglected as a factor in the production of the finer marking in the lung fields.

LITERATURE.

1. Hickey: Journal of the Michigan State Medical Society, 1904. III, 2.

2. Holzknecht: Die röntgenologische Diagnostik der Erkrankung- en der Brusteingeweide, 1901, 45.

3. De la Camp: Physikalische medizinische Monatschrift, 194 05, I, 223.

4. Holzknecht & Kienböck: Ibid, 305.

5. De la Camp, Ibid, 310.

6. Cowl: Lehrbuch der klinischen Untersuchungsmethoden voz Eulenburg, 1904, I, 506. Kolle, Weintraud, Berlin.

7 Rieder: Verhandlungen der deutschen Rontgengesellschaft 1907-08, III-IV, 25.

8. Cunnington: Practitioner, London, 1908, 86.

9. Fraenkel & Lorey: Archives of Röntgen Ray, 1910, No. 115.

PART III. By SAMUEL WOLMAN, M. D.

The purpose of this paper will be better accomplished if : confess to you that in the first few days of the work, I cor- ceived a profound distrust of diagnoses that had to be based or Dr. Dunham's peculiar stereoscopic markings. But now I can testify to my conversion to a belief in these same scorned markings. The original distrust was as natural as the conse- quent conversion, for the markings and interweavings declara! to be pathognomonic of tuberculous changes in the lung tissue. had no assignable anatomical or even clinical basıs. We had all read of tubercles large and small, of caseated areas, c: foci of softening, of thickening and congestion around all such areas, even of gross tuberculous fibrosis, yet nothing of all this was competent to explain why, for example, in the pres- ence of a small tuberculous focus at an apex, a peculiar char- acteristic, recognizable, and yet delicate tracery should develop- throughout a large surrounding area, and extend to the ver: periphery of the organ; and the more advanced the lesion the more extensive, the grosser this tracery. These markings bein: unexplained, mysterious, not attachable to our existing system of knowledge, had then for us no meaning. Nor even now d we know of any acceptable explanation. However, after sul-

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The clinical notes of all the cases reported in this paper, were made before the radiographs were taken. The radio- graphic study and diagnosis, on the other hand, were made without any knowledge of the history or clinical findings. Needless to say, the appearance of the patients themselves was not such that snap-shot diagnoses could be made by the radio- grapher, for we did not send Dr. Dunham emaciated and buxom patients alternately for examination. Indeed, in order to make the test severe, we sent comparatively few advanced cases, since the plates of these showed gross markings, such as are easily seen on single plates, and it was the stereographic markings that we were most curious to study. And then too, our study of the advanced cases soon convinced us that our clinical technique could be safely subjected to a more search- ing criticism, for there was an extremely gratifying coin- idence of the physical and radiographic findings. And here it may be well to emphasize that the stereographic plates show not less, but more, than the single plate readings, so that not only were we testing the radiograph, but the radiograph, in urn, was testing the clinical work.

In recording the clinical findings, our aim was first to note every abnormality of the physical signs; secondly, on the basis of history, symptoms, sputum examination, tuberculin tests, ind physical signs, to decide whether these signs should be attributed to tuberculosis or not. The radiographer, in his urn, noted all abnormal markings in the lungs, and would hen commit himself in writing as to their etiology.

This series embraces 92 cases, and in only seven of the 92 was there a disagreement between the clinical and the X-ray indings. However, in six of these seven, the disagreement ras only partial and comparatively slight, so that in only one f the 92 cases was there a definite clash.

Let us first study the six instances of only partial agree- ient :

CASE I .- Clinically, impairment at right apex. The stereoscope hows impairment at both apices, but much more marked at the ght. Both clinical and X-ray diagnoses are: not definitely tuber- ilous.

CASE II .- Age 5. Clinically, transient rales in the upper chest I each side, which we were not willing to diagnose as tubercu- 18. The X-ray suggests tuberculosis in both upper lobes. The per cent tuberculin eye test was positive.

CASE III .- A girl of 16 with mild mitral insufficiency. Clinic- y, fibrous changes in right upper and lower lobes, with a finite consolidation at the left base. This girl had but few mptoms, except some weakness, and a moderate cough. She 8 examined by Dr. W. S. Thayer. The question arose as to ether the insufficiency could explain the lung signs. The X-ray ›wed the changes discovered in the right chest to be of a tuber- ous nature. The consolidation at the left base was not shown, : Dr. Dunham admits difficulty in reading the left base, ecially where the heart is enlarged.

JASE IV .- Clinically diagnosed as tuberculous at the right apex. , X-ray diagnoses lesions at both apices, but more marked on right side.

crackles. The X-ray agrees as to the right lung, but shows also a large lesion in the left. (This may have been concealed, however, by the compensatory emphysema noted clinically).

CASE VI .- Colored woman. Wasserman test +, eye test ++ (5 per cent). Clinically, only an impaired note over both upper lobes, which we were chary of diagnosing as tuberculous on account of the lues. X-ray diagnosis, tuberculosis in both upper lobes.

CASE VII .- The one of disagreement-concerns a child of three years. The skin-test was positive; otherwise the examination was clinically negative, but the X-ray showed a small lesion in the left lung.

These seven cases comprise our entire list of differences, and we feel that neither the clinician nor the radiographer emerges badly wounded. Hereafter our talk is of harmony, and as follows.

The next group is of 38 cases, in which, clinically, the diagnosis of pulmonary tuberculosis was made definitely. Twelve of these are far advanced cases, and in 16 tubercle bacilli were found. In all these 38, there was agreement be- tween the clinical findings and the plates, as to the position, grade, and general extent of the lesions. (But it must be said that in every case, the pulmonary disturbance, as judged by the interweaving, is more extensive than the lesion, as judged by clinical means. Even a slight apical lesion appears as a long track from the root). Four of the cases were clinically stated to be fibroid. The same diagnosis was made by the X-ray. However, two cases which had at one time given definite physical signs, and had now been for some time with- out symptoms, and almost without signs, were reported by the radiographer as tuberculous, without any saving note. And here we must state that the X-ray, even with the stereoscope, does not seem to be able to differentiate active from healed lesions. However, neither do the physical signs.

We then have 24 cases in which definite physical signs were found. For these signs a tuberculous basis was suspected, but could not be definitely affirmed, clinically. In all these 24, the X-ray showed abnormalities corresponding to the physical signs, and in 12 of the 24, a diagnosis of tuberculosis was made. It is extremely interesting to find that in 12 of these cases, that is, in 50 per cent of those marked only probably tuberculous, clinically, the radiographer too, made a diagnosis of probable, rather than positive, tuberculosis. This conserva- tism on the part of the stereograph, was extremely reassuring to those of us who were timid about relying on the mysterious interweavings. Case VI of this series had a mitral lesion, which made us hesitate in diagnosing tuberculosis. The X-ray said tuberculosis, and the sputum showed tubercle bacilli. However, Case VIII, which the X-ray diagnosed as only prob- able, we fully believe is tuberculous, on the basis of later signs and symptoms.

Case XIV is one of general bronchitis, with indefinite signs at the apices, but severe constitutional symptoms. Although clinically, we were not ready to diagnose the case as tubercu- lous, yet we were strongly tempted to do so. However, the

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X-ray note made was "borderline case. Suggests thickened bronchi." Later events showed no ground to suspect tubercu- losis.

In Case XIX, the clinical diagnosis was, thickened pleura, bilateral. The X-ray note was, " Pleurisy at the apices. Prob- ably an old tuberculous lesion."

In Case XXII, the clinical finding was impairment at both apices, but more on the left. No râles. The X-ray reports both apices involved, but the older lesion on the left.

The next group comprises 14 cases. In these 14, neither the X-ray nor the physical examination noted any abnor- malities. It should be remembered that in the entire series of 92, there was only one other case in which the chest was physically negative, and in that case, as already stated, the X-ray showed a lesion. This accord as to absolutely negative findings on both sides of the investigation in 14 out of 15 cases, so reported clinically, is of considerable significance.

The last group comprises eight cases. In these eight, the diagnosis of "not tuberculous " was made by both methods, but in contrast to the preceding group, physical signs were present, and were similarly reported by the radiographer, and by the clinician. It should here be noted that evidently the stereograph does not report all abnormalities in the pulmonary parenchyma as tuberculous. ( This indeed appeared also in the group of probable cases, as noted above). Case I of this series had definite tertiary lues elsewhere in the body. Case II was one of bronchial asthma. The X-ray reports signs in all five lobes, but they suggest bronchial trouble, rather than tuberculosis. The patient, at the time the picture was taken, did not give evidence of having secretion in the bronchi. The lungs that day seemed clear. In this case, too, pleural thick- ening over the right upper lobe was diagnosed by both methods. In Case III, Dr. Dunham refused to make a diag- nosis, but said the plate showed what was perhaps a healed lesion. The clinical history, too, suggests an old infection, whatever the etiology.

We wish further to mention two cases. Both were young adults, both in apparently good health, but each had a history of chronic cough and expectoration. Physically, there were signs of severe general bronchitis. However, in each case the râles were more numerous on the right side, and there was moderate impairment over the upper lobe of the right lung. The stereograph diagnosed tuberculosis in both cases, more marked in the right lung. The patients, however, seemed in good health, and we might have been skeptical, had not one of them produced tubercle bacilli in the sputum. And we are inclined to believe the diagnosis in the other case, too, since the signs are more emphasized on one side.

To sum up: In only one of the 92 cases was there an entire disagreement; in only six, a partial disagreement. In 85, there was entire agreement. Of these, 39 are positive clinic- ally, 24 are probably clinically, and 12 of these 24 are diag- nosed as only probable by the X-ray. In eight cases, physical signs were found by both methods, but they were diagnosed as not tuberculous, and in 14 cases, there was an agreement as to the entire freedom of both lungs from abnormalities.

We think these figures rather convincing as to the ability of the stereograph to discover abnormalities and to diagnos them; and although in the great bulk of cases, it tells us 1: more than a careful clinical examination, yet in a fair number of cases, and these among the most interesting and puzzling it gives additional information. But we must add the cautic: that a careful history is indispensable, since not even ti: stereograph can tell an active from a healed lesion.

DISCUSSION.

DR. F. H. BAETJER .- I have listened with a great deal pleasure to these three papers and must congratulate the authors on the admirable work they have presented to us tr night.

Dr. Boardman's paper was of great interest to me as I thin; that he has definitely settled the question as to the meaning the linear radiation that we see in the X-ray plate of the lungs. As you have been told various theories were held as t the meaning of these lines, some looking upon them as simply being the small bronchi, others as being due to the veins an? still others as being due to the arteries. I think that he has shown positively that these lines are due to all three. Dr Dunham's paper was of special interest to me in that I do nr: agree with him absolutely as to the interpretation of the lines: markings. According to his classification the lung is divide! into three zones, first, the markings just outside of the sternum, and these he calls the hilum shadows; second, the prolongation of these shadows out a little beyond the middle of the lungs, and third, the zone that is made up of the line: markings extending to the periphery of the lungs. It is especially with the third zone that we have to deal as it is upor these markings that Dr. Dunham makes his diagnosis of early tuberculosis. These lines are not normally present and he has found that when they are present and extend to the peripher: it is due to a tuberculous change. As he himself says th: method of diagnosis is empirical and has no pathological bass but that his findings have also been substantiated by the clit- ical findings. Now it seems to me that this is the point where error could so easily creep in. In the first place the only checi upon X-ray findings is the clinical findings and it seems to : that this is not an absolute proof. Secondly, it seems to r .: that any chronic infection of the lungs could just as easily produce changes in the bands which carry the artery, vein an .: bronchus. In emphysema and chronic bronchitis we see ! marked thickening of these bands extending throughout the lungs. I agree with Dr. Dunham that the irregularities along these linear markings which he has termed "fuzzy" ar: collections of small tubercles but they are seen in a later stag: of the disease. Since the X-ray will give us the slightes: changes in density the X-ray plate will naturally record ver; fine and minute changes. In many of the plates these lines" markings are very fine and it seems to me that it is impossible for the clinician either by percussion or auscultation to detat: them. Our own experience here in the hospital has been ths: the radiograph will invariably show greater changes than the clinical findings. Consequently in these very early cases wher:

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anges in the lung substance or that the auscultation and cussion have reached a degree of surprising accuracy. Dr. Dunham deserves a great deal of credit for this piece of rk but at the same time my feeling is that we must have thological instead of clinical substantiation before we can solutely accept this method for the determination of very ·ly tuberculosis.

DR. L. V. HAMMAN .- Dr. Baetjer has discussed these pers from the technical standpoint and perhaps it would well to say a few words about the early diagnosis of Imonary tuberculosis from a clinical standpoint. During : six years that the Phipps Dispensary has been in exist- 'e we have given more study to this particular question in to any other and the change that has gradually come out in our attitude towards it has been a matter of sur- se and of the keenest interest to us. When the dispensary s started those of us who worked there had the average ining and skill that comes from some years of medical vice in hospital and dispensary. This we considered ficient for our needs, but from constant and continuous plication to pulmonary diagnosis we soon developed a Il that made apparent abnormal physical signs that had :viously been overlooked. This was the period of greatest isfaction and confidence for the signs meant trouble in : lungs and trouble in the lungs spelt tuberculosis and Imonary tuberculosis needed energetic treatment and such atment was followed by improvement. We had innumer- e cases of early pulmonary trouble in those days, many re than you could find in our records now. We were ther intrenched in our confidence by the confirmatory dence lent by tuberculin. To give added assurance we ninistered tuberculin to these patients subcutaneously. about 36 patients so tested at Eudowood all but one re- ed. Slight physical signs and the tuberculin reaction ved so smoothly into one another's hands that we at last ime suspicious and began to give tuberculin indiscrimi- ely to as many patients as we could control and to our nay found that about 60 per cent of all individuals react, ther they are suspected of having tuberculosis or not. advent of the local tuberculin tests allowed us to apply rculin on a large scale and to verify our previous obser- ons by convincing numbers. This was the check that e us review more cautiously our previous conviction and `o a less ready and more difficult judgment of our cases. viduals that formerly would have been peremptorily emned were now kept under observation instead of being ed to a sanatorium, and somewhat to our disappoint- , they continued well under ordinary conditions of life ite of the persistence of the abnormal physical signs. is has brought us to the period where we now are in a the clinical symptoms play such an important role in guishing active from inactive lesions-of course I can- into details.

me weeks ago a prominent man from the medical clinic

remarked "of course the patient has tuberculosis." He was told no we really thought the man did not have tuberculosis, when with assumed surprise he replied " why I had no idea that you ever failed to find tuberculosis in a patient." This was to us a very painful display of lack of knowledge of our aims and methods. However, some days later, speaking to a physician extremely active in tuberculosis work, I men- tioned that we had grown more conservative in the diagnosis of early pulmonary tuberculosis and he rebuked me with " yes, I know you have, and even too conservative."

The dispensary then is in a not very enviable position- too hot for medical men and too cold for the specialists. In the predicament the X-ray comes in and offers a helping hand.

The result of the valuable work that Drs. Dunham, Wol- man and Boardman have done that interests me most, prob- ably because it brings a ray of comforting reassurance, is the remarkable correspondence between the results of the physical examination and the plate readings. Here is at least some-' thing definite that we can hang too. A skillful physical ex- amination-and I emphasize skillful-outlines for us with unexpected precision even slight changes in the lungs. The interpretation of these changes may be and indeed is an occa- sion of keen discussion. With the objective verification it can no longer be insinuated that the signs are the expression of an imagination stimulated to overwork by a prurient en- thusiasm, nor that even such minor changes come within the range of normal variation.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 127

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

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