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THE RADIOGRAPHY 
 OF THE CHEST 
 
 Vol. I. 
 
 PULMONARY TUBERCULOSIS 
 
 With 9 Line Diagrams and 99 Radiograms 
 
 BY 
 
 WALKER OVEREND, M.A.,M.D.(Oxon).B.Sc.(Lond.) 
 
 Hon. Radiologist and Physician to the Electrotherapcntic Department, 
 East Sussex Hospital (Hastings) ; Radiologist to the City of London 
 Hospital for Diseases of the Chest (during the War) ; late Chief Assistant 
 in the X-Ray Department, St. Bartholomew's Hospital ; Physician to the 
 Prince of Wahs^ Hospital, London, and Radcliffe Travelling Fellow. 
 
 ST. LOUIS 
 
 C V. MOSBY COMPANY 
 
 1920 
 
'cL-t,<J.<^—^X^-' 
 
 d 
 
 Pi iiile<l in Grtal Britain 
 
 
To My Wife 
 
PREFACE 
 
 During the present decade, the manufacture of more powerful 
 installations, the improvement of special technique, and the gradual 
 accumulation of knowledge, have greatly enhanced the value of 
 X-ray examination in the diagnosis and prognosis of diseases 
 of the chest. Nevertheless, it is always expedient to check and 
 compare the results by means of the usual methods of investigation ; 
 although, on the other hand, in many instances radiography alone 
 has proved absolutely decisive. The real foci of disease may be 
 concealed by superimposed shadows, or by the persistent sequelae 
 of obsolete lesions. Consequently, the correct inierprelation of 
 pulmonary opacities may become a very difficult problem, and 
 necessitate the exercise of expert clinical skill as well as a wide 
 radiological experience. For this reason, the data of physical 
 examination have been summarised and included, whenever 
 possible, throughout the book. 
 
 I have attempted to describe the majority of the types of pul- 
 monary tuberculosis, with the commoner localities of incipient 
 disease, and have adopted, for this purpose, a radiological class- 
 ification which is personal and provisional. In order to anticipate 
 criticism, I may emphasise the great complexity of the subject and 
 the impossibility — in the absence of anatomical control — of placing 
 accurately many intermediate forms. For instance, examples of 
 perihilar nodal tubercle may assume a pseudolobar expression ; 
 cases of mild diffuse fibroid arc in reality attenuated, often 
 arrested ; whilst some of those depicted under the heading of 
 minor phthisis might have been included, with almost equal justice, 
 in the following chapter on iibroid affections of the lung. 
 
 The large number of radiograms — permitted by the generous 
 consideration of the publishers — has rendered it more convenient 
 to devote this volume to the description of pulmonary tubercle 
 alone; in the second, non-tuberculous diseases of the lung and 
 affections of the heart and aorta will be discussed. With the ex- 
 ception of a few woodcuts and radiograms — mentioned below — 
 the illustrations are original. Some have been taken at the City of 
 London Hospital for Diseases of the Chest, others at the East 
 
Sussex Hospital ; a few are selected from patients sent by medical 
 friends. Reproduction has been allowed by the medical staffs and 
 by local medical confreres. I seize this opportunity of recording 
 my very grateful thanks. Of the woodcuts, 2, 3, 4, 6, 9 are after 
 Rieder, Schut, Piery, and Besangon ; radiograms 4, 5, 65B, and 68 
 have been enlarged from Assmann. 
 
 A list containing standard text-books and periodicals of cognate 
 literature is given in the Appendix. Piery's "Manual," I may 
 mention, has been of great assistance, from the clinical point of 
 Tiew, in the preparation of Chapter VII. 
 
 WALKER OVEREND. 
 St. Leonards-on-Sea. 
 
CONTENTS 
 
 CHAP. PAGE 
 
 I, — The Normal Chest i 
 
 II. — Classification : Tuberculosis of Bronchial 
 
 Glands . . i8 
 
 III. — Bronchopneumonic Nodular and Nodal Types 33 
 
 IV. — Bronchopneumonic PsEUDOLOBAR Tubercle . . 41 
 
 V. — Minor Phthisis 48 
 
 VI. — Fibroid Phthisis 58 
 
 VII. — Pneumonic Phthisis: Miliary Tubercle . . 68 
 
 VIII. — The Complications of Pulmonary Tuberculosis . 78 
 
 IX. — The Radiological Diagnosis of Pulmonary 
 
 Phthisis 92 
 
RADIOGRAPHY OF THE CHEST. 
 
 CHAPTER I 
 
 The Normal Chest. 
 
 The general principles of X-ray technique are described 
 in British text-books of radiology; nevertheless, it may be 
 advantageous to make a few remarks referring exclusively 
 to the examination of the chest. For radioscopy, as well 
 as radiography, soft X-ray tubes with tungsten targets 
 should always be employed. The best degree of softness 
 is between 6 and 7 Bauer ; the milliamperage for the 
 radioscopy being about 2 to 3, the diaphragm of the tube- 
 box being contracted down for examination of the apices, 
 the hila or any abnormal opacity. For radiography the 
 milliamperage should be from 7 upwards. The exposure 
 is made in moderatel}'' deep inspiration, in a condition of 
 complete immobilit}', and should not last longer than from 
 5 to 10 seconds. It is possible, by means of intensifying 
 screens and massive amperage, to reduce this period to 
 the fraction of a second ; but such pictures may not be 
 entirely free from grain, and the finer details then become 
 invisible. The distance of the fluoroscopic screen from 
 the target should be from 20 to 24 inches, and for a 
 complete photograph plates of 15 in. by 12 in., or 12 in. by 
 lo in. are necessary. For the oblique diameters and the 
 apices plates of 10 in. by Sin. may be sufficiently large. 
 Stereoscopic pictures of the varied diameters maybe made 
 in the usual manner ; it is preferable, however, to remove 
 the target two inches towards the diaphragm and cardiac 
 apex for the second radiogram, and to view the plates 
 
2 Radiography of the Chest 
 
 laterally on the stereoscope. In this way the whole chest, 
 is more easily obtained on the radiogram. 
 
 When a complete radiological investigation of the chest 
 is made, several principal or cardinal positions are selected 
 but the one most generally useful is the anterior or dorso- 
 ventral; the rays entering the chest from the back, with 
 the anode at the level of the junction of the fourth costal 
 cartilage with the sternum, and the fluorescent screen 
 placed over the front of the chest. With feeble invalids 
 the recumbent posture is preferable, although the upright 
 or sitting position possesses several advantages and 
 sometimes is indispensable. The image on the screen 
 presents three distinct areas, one median and two lateral. 
 The median zone is dark, and increases in breadth towards 
 the left side of the patient from above downwards. It is 
 termed the median shadow, and is produced by the summa- 
 tion of opacities due to the greater densities of the vertebral 
 column, heart, great vessels, and the sternum. The lateral 
 areas are the 7'ight and left pulmonary fields. These are 
 bounded on each side by the ribs and below by the 
 diaphragm. The fields are roughly triangular in shape, 
 and are crossed by the shadows produced by the ribs, which 
 run obliquely from above downwards, so that the anterior 
 portions of the higher ribs intersect the posterior opacities 
 of the lower. Since the cartilages of the ribs are trans- 
 parent to the rays, there is a gap between the anterior 
 osseous extremity of each rib and the sternum. As age 
 advances calcification of the first rib cartilages is common; 
 also the same process is often seen in the form of linear 
 opacities running along the upper and lower borders of the 
 cartilages of the lower ribs. Each pulmonary field is 
 divided into two unequal parts by the horizontal opacity 
 due to the clavicle. The lower border or diaphragm 
 consists of two arches (with the convexities directed up- 
 wards) which rise and fall with the movements of 
 respiration. 
 
 The outlines of the heart are visible outside the shadow 
 
Radiography of the Chest 3 
 
 of the vertebral column, commencing about one inch below 
 the sternal ends of the clavicles. On the right the margin 
 is practically straight ; the upper two-thirds correspond to 
 the ascending aorta and the superior vena cava ; the lower 
 third to the right auricle. On the left three rounded 
 projections may be more or less in evidence. The upper 
 corresponds to the bend of the aortic arch as it passes 
 backwards to become the descending arch and descending 
 aorta. It has been termed the left aortic bulge. As age 
 advances it becomes more pronounced and tends to reach 
 the level of the sterno-clavicular joint. The middle 
 eminence denotes the position of the pulmonary artery, 
 and the lowest and largest is formed by the left ventricle. 
 In certain diseases, as in mitral stenosis, h3'pertrophy of 
 the left auricle is seen to produce an intermediate convexity 
 between the pulmonary artery and the left ventricle. 
 
 Closely connected with the median shadow is that of each 
 hilum or root of the lung, of which the right is the more 
 conspicuous, the lower part of the left being concealed by 
 the cardiac opacity. Between the right hilum and the 
 heart a clear space is occasionally seen, which corresponds 
 in position with the branch of the right main bronchus 
 running towards the diaphragm. Each hilum with its 
 upward and downward prolongations presents the form of 
 a crescent. By slight rotation of the patient to the right, 
 or by elevation of the screen a foot from the chest, a better 
 radioscopic picture of the right hilum is obtained. In good 
 radiograms the branches proceeding from the hilum may 
 be followed upwards, outwards and downwards, and it is 
 seen that they subdivide and finally produce a retiform 
 appearance towards the periphery, which has been termed 
 the radio-structure of the lung. 
 
 The shadow of the right dome of the diaphragm lies 
 higher than that of the left. In ordinary quiet respiration 
 the curve of the convexity remains the same both in descent 
 and ascent. At the inner e.xtremity between each cupola 
 and the heart lies the cardio-phrenic sulcus. In deep 
 
Radiography of the Chest 
 
 Diagram i. 
 
 Chest. — Anterior or dorso-ventral view. For the sake of clearness the 
 lower ribs on the right side are omitted. 
 
 Heart.— R.A., right auricle; R.V., right ventricle; L.V., left ventricle; 
 Aur.A., position of auricular appendix; Pul.C, pulmonary artery; A.B., 
 left aortic bulge; S.V.C. and A. A., superior vena cava and ascending 
 aorta. 
 
 R.A., L.A., right and left pulmonary apices; R.C1., L.Cl., right and left 
 clavicles; Cor., coracoid process of scapula; Ac, acromion; L.H., 
 humerus; L.N., left nipple; L.H., R.H., right and left hila; P.V., para- 
 vertebral; MC, mid-clavicular; Ax., axillary bronchi of upper lobe; 
 M.L.B., chief bronchus of right middle lobe; L.L.B., bronchi running to 
 lower lobes; V.C, vertebral column, the figures refer to the number of 
 rib, vertebral and sternal portion; R.D.M., L.D.M., right and left phrenic 
 leaflets; R.Car.P.S., right cardio-phrenic sulcus; R.Cos.Ps., right costo- 
 phrenic sulcus ; V. vertebral border of scapula. 
 

 
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Radiography of the Chest 5 
 
 inspiration, when the diaphragm descends, the sulcus 
 widens, and occasionally completely separates the shadows 
 of the heart and the central tendon. At times a fine 
 shadow is visible within the sulcus on either side of the 
 heart, which is the expression of the pericardial sac. At 
 the outer extremity of the diaphragm, between it and the 
 ribs, lies the costo-phreiiic sulcus, obliteration of which is 
 produced by adhesions and thickenings of the pleura, or 
 by the presence of small pleural effusions. To see the 
 latter the upright position is necessar}-. (Diagram i.) 
 
 The posterior or ventro-dorsal position is obtained by 
 arranging the tube in front and the screen on the back. 
 It is the reverse picture, the apex of the heart now lying 
 to the left side of the observer. The shadows of the 
 posterior divisions of the ribs stand out more prominently, 
 but they appear thinner and the interspaces narrower than 
 in the anterior position because they are nearer the screen. 
 The lower border of the rib presents an overhanging 
 margin, 3 to 4 inches long, best seen in the 7th to the 9th, 
 which corresponds to the costal groove, sulcus costalis, 
 and lodges the intercostal vessels and nerve. On the 
 other hand, the cardiac outlines are less sharp and the 
 opacity is larger. The vertebral border of the scapula is 
 more obvious (Radiogram i), and can easily be identified 
 by movement of the upper arm. The excursions of the 
 diaphragm and changes of the costophrenic sulci are easier 
 to follow. When a radiogram is taken it is preferable to 
 fix the target at the level of the fifth dorsal spine. 
 Although this view is not so generally used as the former, 
 it cannot be omitted, since many lesions, especially those 
 of tuberculosis, often lie nearer the posterior surface and 
 are therefore more accessible to the screen and plate in 
 this position. 
 
 The right antero-latcral or oblique posture is obtained when 
 a patient in the anterior or dorso-ventral position is slowly 
 rotated from the left to the right of the observer, until the 
 right mammary line comes into contact with the screen. 
 
6 Radiography of the Chest 
 
 The rays then penetrate the chest, from behind forward, 
 obHquely at an angle of about 45^^. If recumbent, the left 
 hand may be placed under the head and the right arm 
 drawn away from the side and supported by an air cushion. 
 A sand-bag applied below to the back will steady the chest. 
 In practice it is unnecessary to employ this angle exactly; 
 it is sufficient to move the patient gradually with the help 
 of the screen out of the anterior position, until the median 
 shadow, consisting of sternum, heart and vessels, is thrown 
 forward from the vertebral column, and the best picture 
 obtained. Three clear zones (Radiogram 2) are distin- 
 guishable ; the right is the left pulmonary field; the middle 
 small mediastinal area is limited by the heart and aorta in 
 front, the vertebral column behind, and is partially covered 
 by both pulmonary fields ; the third bright area on the left 
 is the right pulmonary field. The heart itself appears 
 triangular ; at the apex lies the arch of the aorta, the base 
 is formed by the right ventricle and diaphragm. The 
 vertebral border of the heart is constituted below by the 
 right auricle, above which a less definite middle portion 
 consists of left auricle, although the pulmonary vessels and 
 superior vena cava participate. Above this lies the ascend- 
 ing aorta. If the descending aorta is sclerosed, as is often 
 the case in hypertrophic emphysema, the continuation of 
 the arch may be followed over the vertebral column. In 
 deep inspiration the posterior mediastinal zone brightens, 
 the diaphragm descends, and the inferior vena cava may be 
 seen in the cardio-phrenic sulcus. The left side of the 
 cardiac triangle consists of ascending aorta, the conus 
 arteriosus of the pulmonary artery, and the left ventricle.. 
 Sometimes the left auricular appendix is visible. Between 
 the aorta and vertebral column is the retrocardiac space, 
 which is occupied by the trachea and oesophagus. The 
 former cuts the shadow of the arch and produces a sharp 
 contrast. The left bronchus and one or more of its 
 divisions may be followed through the shadow of the 
 ventricle ; the right bronchus towards the spine, and the 
 
Rad. 3'- Lett anterolateral racJiugram. A. A., aortic arch; L.B., 
 left bronchus; P.A., pulmonary artery; Tr., trachea. 
 
Radiography of the Chest 7 
 
 bifurcation space is defined. Occasionally the left carotid 
 in front, and the innominate artery behind may be recog- 
 nised. The right oblique diameter is useful for the 
 determination of dilatation of the aorta, aneurism of the 
 arch and descending aorta, and for the recognition of 
 dilatation of the left auricle. Also it is necessary for the 
 diagnosis of enlarged bifurcation glands, for mediastinal 
 growths, and for the determination of lesions of the 
 cEsophagus by the aid of bismuth paste. Above the 
 clavicle, in front of the dorsal vertebrae, opacities due to 
 the presence of endothoracic goitre may be visible. 
 
 In the left antero-lateral or oblique attitude the patient is 
 rotated in the opposite direction, that is from right to left, 
 (observer). The same three bright zones are obtained, 
 due to the right lung on the left and a median mediastinal 
 division. The heart is more rounded in outline ; its 
 vertebral border is made up of left ventricle and left auricle, 
 and on the sternal side the right auricle (Radiogram 3). 
 In the sclerosed aorta the arch curves like a broad hoop 
 over the dark cardiac opacity and the aorta descendens 
 disappears within the shadow of the spine. Small pulsat- 
 ing opacities above the arch, which occasionally materialize 
 on the plate, are the innominate, left carotid, and left 
 subclavian. A pulsating ductus Botalli should be visible 
 in this diameter below the arch and between it and the 
 pulmonary artery. 
 
 The left posterior oblique (postero-lateral) diameter is 
 obtained from the posterior or ventro-dorsal position by 
 rotating the patient until the left shoulder blade comes 
 into contact with the screen. The diameter is selected 
 which gives the greatest breadth of the posterior mediastinal 
 space. This position is also employed for the determination 
 of the calibre and integrity of the oesophagus by means of 
 bismuth and for the diagnosis of aneurism of the descending 
 aorta. 
 
 The left lateral examination is made by placing the screen 
 on the left lateral aspect of the patient. The best results. 
 
8 Radiography of the Chest 
 
 are obtained in thin individuals and in deep inspiration 
 The heart lies close to the screen, leaving a clear retrosternal 
 space above, and a retrocardiac space below. The cardiac 
 apex appears close to the thoracic wall. The descending 
 aorta in thin elderly individuals may be visible, particularly 
 if dilated or aneurismal. Small effusions of the pleura are 
 visible in the retrocardiac space. The retro sternal space 
 also widens during inspiration, the upper portion of the 
 heart moving slightly backwards, while the viscus, as a 
 whole, is drawn downwards by the crura of the diaphragm. 
 In this position the antero-posterior diameter of the heart 
 may be measured by orthodiagraph3^ 
 
 In the anterior and posterior positions a general idea is 
 obtained as to theincreaseof illumination during inspiration, 
 of the movements of the ribs and diaphragm, and the 
 existence of local abnormal opacities, which may or may 
 not become less opaque during the same phase of respira- 
 tion. Special attention must be directed towards certain 
 areas, as the apex, the hilum, the fissures, the diaphragm 
 and its sulci. The apex of the lung is bounded above and 
 laterally by the first and second ribs, internally by the 
 vertebral column, and below by the clavicle. Since the 
 latter, however, is not a fixed line, but moves with the 
 shoulders and during inspiration, it is preferable to select 
 as the lower boundary a line drawn horizontally at the 
 level of the junction of the fourth rib with the spine. In 
 anterior pictures the shadow of the apex is partially con- 
 cealed by the opacities of the first rib and clavicle. Well 
 developed muscles of the neck, as the sternomastoid and 
 sternothyroid, impair the illumination of the inner half. 
 The presence of indurated supra-clavicular glands and of 
 an endo-thoracic goitre may also produce a cloudy appear- 
 ance. It is well, therefore, to palpate carefully the supra- 
 clavicular triangle in every case before screening the area. 
 The apices are less clear than the rest of the lung, and 
 they exhibit only a very slight difference in inspiration and 
 expiration, since they are aerated only by the descent of 
 
Radiography of the Chest 9 
 
 the diaphragm and the pull of the crura upon the hilum of 
 the lung ; when the patient coughs, both apices should 
 expand and appear brighter. Some apices appear large ; 
 in these, as a rule, the ribs run steeply and possess larger 
 interspaces. The size is also dependent on the position of 
 the X-ray tube. They are smaller when the tube is exactly 
 beneath ; larger when the target is at the level of the tendon 
 of the diaphragm, or a few inches above the apex in the 
 
 Diagram 2. 
 
 Radiological Triangles.— S.T., Subclavicular; M.T,, Middle Triangles or the 
 Wings ; B.T., Basal Triangles. 
 
 cervical region. In both posterior and anterior radiograms 
 the first interspace is often invisible. If the upper border 
 of the lung on the radiogram falls within the shadow of 
 the rib it is not seen. Often it is visible, however, as a 
 faint narrow opacity running along the lower edge of the 
 second rib. According to some radiologists, when the 
 first interspace is visible the clear area is not due to lung, 
 but to the effect of contrast between soft muscular tissues 
 
lo Radiography of the Chest 
 
 and the shadows of the first and second ribs. That this is 
 not the case may be deduced from the following observa- 
 tions : in posterior radiograms, especially in women, with 
 some amount of emphysema of the upper lobe, plates may 
 be obtained in which the shadow above described runs 
 along the lower border of the first rib, and others in which 
 the shadows produced by the reticulum of the lung may be 
 followed into the first interspace, to become connected with 
 small round areas which are obviously peribronchial apical 
 foci. In children it is usual to see a fair-sized first space 
 in posterior radiograms taken during deep inspiration. 
 
 The fissures of the lung. (Diagram 3.) The great fissure 
 begins at the upper part of the hilum, ascends shghtly on 
 the vertebral surface of the lung, and reaches the posterior 
 border about three inches below the highest point of the 
 lung at the upper margin of the vertebral end of the fourth 
 rib. It runs spirally downwards and outwards, crosses 
 the fifth rib in the axillary line, then forwards to the base 
 of the lung, reaching it a short distance behind its anterior 
 end, where it turns up and ends in the hilum. The 
 secondary or horizontal fissure, only present in the right 
 lung, leaves the great fissure at the fourth rib in the 
 axillary line and runs horizontally along it towards the 
 sternum, where it turns back along the mediastinahsurface 
 of the lung to the hilum. It lies above the nipple, but it 
 may be absent, abnormal in position, or so adherent as to 
 be separated with difficulty. A shadow seen at^the level 
 of these fissures may indicate interlobar thickenings of 
 the pleura or an interlobar empyema. 
 
 The hilum lies opposite the vertebral ends of the 5th, 
 6th and 7th ribs, and is about i >^ inches broad. In the 
 anterior radiograms, its external border lies well within 
 the space left between the osseous extremities of the 2nd 
 and 4th ribs and the mediastinal shadow. The opacity 
 is a summation of shadows due to the pulmonary vessels 
 and lymphatics, with the bronchi and a certain amount of 
 connective tissue. It increases in extent and intensity of 
 
Radiography of the Chest 
 
 ir 
 
 opacity with age ; it is more conspicuous in town dwellers, 
 and those who work in a dust-laden atmosphere (pneumo- 
 coniosis). 
 
 Divisions of the lung. In order to facilitate the description 
 of the pulmonary field, it has been divided into areas by 
 selecting certain more or less fixed points and connecting 
 these by straight lines. By drawing a paravertebral line 
 (where the heads of the ribs join the vertebrae) from the 
 4th to the 8th, and another from the 8th to join the hori- 
 zontal line at the level of the head of the 4th in the axilla, 
 we obtain a sitbapical or subclavicular triangle within which 
 
 Diagram 3 (after Piery). 
 
 Showing the position of the interlobar fissures, and the limits of the pleura 
 in the right lateral and left lateral positions; R.L., right lung; L.L., loft, 
 
 lung; N., nipple. 
 
 lies the seat of election for adult pulmonary tubercle; the 
 great fissure traverses the outer and upper part. It also 
 contains the first and most of the second anterior inter- 
 costal spaces. Another line is drawn from the head of the 
 8th rib along its shaft to the outer margin of the chest, 
 producing a middle triangle or wing, within which are ta 
 be sought the foci of broncho-pneumonia in children, 
 changes due to gangrene of the lung, and the first signs 
 of miliary and perihilar tuberculosis. The basal part of 
 the lung, thus separated, is the diaphragmatic area in 
 which small pleural effusions and basal emphysemata are 
 
12 Radiography of the Chest 
 
 found and almost all adult bronchiectases. It corresponds 
 with the distribution of the lower bronchus (Diagram 3). 
 
 Injections of the arteries or of the bronchi may be made 
 separately with substances opaque to the rays ; the rami- 
 fications of each system will then appear as opaque 
 dendriform shadows on the fluoroscopic screen, and may 
 be radiographed. The trachea and the bronchial tree may 
 be injected in situ, or after removal with the lungs from 
 the cadaver. In order to control the flow it is necessary 
 that the injection should be semi-fluid ; since, as a rule, 
 only the larger branches of the chief bronchi are required. 
 For this purpose the author finds an emulsion consisting 
 of equal parts barium sulphate and vaselin the best. 
 Stereoscopic pictures are then combined and the distribu- 
 tion of each branch is readily recognisable. (Vide infra, 
 page 14.) 
 
 The pulmonary reticulum. On good radiograms, taken 
 with short exposures, a network of threads is visible in the 
 peripheral and lateral parts of the lung, which must either 
 be due to. structures containing a less amount of air, and 
 therefore interposing some resistance to the penetration 
 of the X ra3^s, such as blood and lymph, or the connective 
 tissue walls of the terminal and minute divisions of the 
 bronchi themselves. Passing centripetally, these linear 
 shadows become thicker and more obvious, and approach- 
 ing the hilum they become heavier trunks, assuming the 
 form of bronchial and vascular ramifications. The actual 
 anatomical substratum to which the above tracery is 
 attributable is still a matter of doubt and discussion. Is 
 it due to the arborisations of the bronchi, or of the blood 
 vessels, or both ? Attempts have been made to solve the 
 question by the injection into the bronchi or blood vessels 
 of substances, like emulsions of bismuth carbonate, which 
 absorb the rays, and by the subsequent comparison of the 
 pictures obtained with those of the normal. From these 
 •experiments the only conclusion to be drawn, with regard 
 to the course and pattern of the picture, is that either 
 
Radiography of the Chest 15 
 
 might have been responsible. In pulmonary radiograms, 
 of the cadaver the lung tracery is much less pronounced 
 than in the living subject, and must be attributed to the 
 deficient distension of the vessels, as well as to the absolute 
 stagnation of the fluid which may still remain within the 
 veins and l3''mphatics. In opposite conditions during life, 
 such as in the passively'' congested lung of mitral stenosis, 
 the arborisation is more obvious than usual. When we 
 consider the difference of structure between the two 
 systems of ramification, the vessels, being airless, should 
 show a compact solid shadow, whereas the bronchi, being 
 tubes filled with air, should appear, if cut longtitudinally, 
 as clear streaks with a double contour. In the diffuse 
 bronchiectasia of children, after pertussis, we meet with 
 such pictures in all parts of the lung, especially tow^ards 
 the base and costophrenic sulcus ; moreover, optical 
 transverse sections are visible as minute circles with clear 
 centres. This obscurit}' of the rim or circumference of 
 the tube is emphasised when the walls are thickened by 
 connective tissue proliferation, such as occurs in chronic 
 bronchitis with emphysema, in the earlier stages of pul- 
 monary tuberculosis, and in quiet extensive peribronchial 
 phthisis. The nearer the periphery is approached, the 
 more pronounced do the interweavings and intercrossings 
 of the two systems become, so that finally a confused 
 entanglement is produced which it is impossible to inter- 
 pret. Most radiologists are now of opinion that both 
 sets of arborisation play a part in the production of the 
 network, but that the influence of the bronchi is more 
 pronounced in the central parts of the lung; that of the 
 blood vessels is more apparent at the periphery. In good 
 soft radiograms of the lung, taken some days after a copious 
 haemoptysis, occasionally the seat of the haemorrhage may 
 be determined by the presence of an excessive number of 
 fine shadows, without central lumina, connected with a 
 caseous focus and situated often in the upper posterior 
 areas of the lung. The lines are not so finely cut as in the 
 
14 Radiography of the Chest 
 
 bronchi, since the column of blood is never still. The 
 solution of the problem, to some extent, possibly lies in 
 •the quality of the tube. Soft rays will portray the vessels 
 better, slightly harder the bronchi, whereas still harder rays 
 will delineate more exclusively the ribs and the spine. 
 
 The right bronchus gives off an apical or eparterial 
 branch, which divides into {a) anterior, {b) posterior, 
 and {c) ascending branches to supply the upper lobe. On 
 radiograms of emphysema with thickened bronchi, we can 
 easily make out three chief sets of branches ; paravertebral 
 to the apex, mid-clavicular, and axillary, the mid-clavicular 
 being supplied by posterior branches of {a) and {h), the 
 axillary by anterior branches of the same. The main 
 bronchus then gives off a ventral branch to the middle 
 lobe (which is often visible just beneath the anterior end 
 of the 4th rib), a dorsal to the apex of the lower lobe, then 
 ventral (one of which goes to the azygos lobe) and dorsal 
 branches to the rest of the lower lobe. (Rad. 3a.) 
 
 The diaphragm arises from the margin of the lower 
 thoracic aperture in two main divisions, {a) ihe sterno- 
 costal, from the inner surfaces of the costal cartilages of the 
 lower six ribs and the back of the ensiform process, the 
 fibres passing backwards as they ascend, and {b) the crural, 
 from the front of the bodies of the upper two or three 
 lumbar vertebrae and the arcuate ligaments, to the posterior 
 part of the central tendon. The right and left domes are 
 supported and their curvatures preserved by the elastic 
 traction of the lungs; the central tendon by means of its 
 connection with the pericardium, the latter being con- 
 tinuous above with the deep cervical fascia and also 
 attached by ligaments to the back of the sternum. To 
 measure the height of the diaphragm. Professor Keith 
 suggested a horizontal line drawn at the level of the 
 junction of the body of the sternum with the ensiform 
 cartilage (meso-metasternal line, Dally). In the normal 
 thorax this line crosses the 5th cartilage, in emphysema it 
 crosses below this cartilage ; if the ribs are depressed, as 
 
AX. BR. 
 
 R.XD 3^ (Ant.) - Main bronchus of left upper lobe nijectcd with an 
 emulsion consisting of carbonate of lead and vasehn; P.\ .. 
 paravertebral ascending branches; M.C.. ra.d-clav.cular 
 branches; Ax. Br., branches to axillary area and lateral wall. 
 
 Facing p. U- 
 
Radiography of the Chest 15 
 
 an the habitus phthisicus, it crosses above the cartilage 
 {Journal of Anatomy and Physiology, Vol. XLII). But since 
 the meso-metasternal junction is not a fixed point, it is 
 preferable to select the line drawn horizontally at the level 
 of the junction of the loth rib with the spine (Dickey). 
 
 In expiration the lateral muscular zone of the diaphragm 
 lies in contact with the thoracic wall. During inspiration 
 the enlargement of the lungs below is assisted by abduc- 
 tion of the floating ribs produced by the contraction of the 
 quadratus lumborum and deep costal muscles. The viscera 
 and intra-abdominal pressure play an important part in the 
 determination of the movement of the diaphragm, by 
 preserving the abduction of the lower ribs and furnishing 
 a fixed point for its sterno-costal fibres. When there is a 
 large gastric air sac, one may sometimes see, on the radio- 
 .§ram, the left crus passing to the tendon. 
 
 The intra-abdomihal pressure assists the elastic traction 
 of the lung in the recumbent, but is opposed to it in the 
 upright position, the weight of the abdominal viscera also 
 exercising a tug upon the diaphragm. The condition of 
 the abdominal muscles is also important, that is, whether 
 they are strong and capable of assuming a firm reflex tone 
 in the erect posture. As determined by orthodiagraphy, 
 in front, on standing the highest point of the dome lies at 
 the upper edge of the 5th right and lower edge of the 5th 
 left rib. In dorsal decubitus the dome may reach the lower 
 edge of the sth rib. Behind, on standing, the lower edge 
 of the 9th right and loth left; in the recumbent position, 
 the lower edge of the Sth right and 9th left rib. In children 
 the figures are somewhat lower; sometimes during deep 
 inspiration almost the whole extent of the pleural sinus is 
 •occupied by lung. 
 
 In the horizontal position the diaphragm ascends nearly 
 one inch, since the elastic traction of the lung is now 
 assisted by the abdominal viscera. In right lateral 
 decubitus, the right dome rises higher than in dorsal 
 decubitus, and the heart sinks a little to the right. In left 
 
1 6 Radiography of the Chest 
 
 lateral decubitus the left dome is less elevated than the 
 right in right lateral decubitus, but in this position the liver 
 produces considerable stretching and lowering of the right 
 dome, so that the complimentary space or pleural sinus is 
 almost entirely exposed on that side. In the lateral 
 decubitus, therefore, the inspiratory depression practically 
 only affects the dome of the side nearer the couch. The 
 free side shows little or no movement, since its compli- 
 mentary sinus is already laid bare, and the dome can 
 scarcely descend any farther. 
 
 In quiet respiration both domes descend about half an 
 inch. During the descent the costophrenic sinus and the 
 convexity of the dome do not change in form. In forced 
 respiration the excursion may reach one inch or more,, 
 whilst the costophrenic angle may descend as much as 
 two inches. Deep inspiration is effected by increased 
 action of the inspiratory muscles. For increased activity 
 during expiration only relatively weaker muscular power 
 is available ; and the elastic force of the lung increases to 
 a slight degree only. The expiratory position of the 
 diaphragm is really not higher than in quiet respiration, 
 indeed, it may be lower. This fact explains the origin of 
 dilatation of the lung and emphysema as the result of 
 increased inspiratory activity {vide page 87). 
 
 In young muscular adults, when repeated and forced 
 inspirations are taken in the erect posture, the incipient 
 depression of the dome may be immediately followed by 
 a rise, which may assume a higher level than that of 
 expiration. This normal paradoxical effect is accompanied 
 by a depression of the epigastrium, and is explained by 
 examination in the lateral position The posterior part of 
 the diaphragm is depressed, as usual, by contraction of the 
 crura, but in the anterior and ventral parts the powerful 
 elevation of the thorax carries with it the costal and sternal 
 attachments of the diaphragm, "so that the parietal portions 
 of the latter appear even higher than the dome, even in the 
 expiratory position. 
 
Radiography of the Chest 17 
 
 When the diaphragm contracts, in the absence of activity 
 of the intercostal muscles, as in faradisation of th^ phrenic, 
 the pleural sinus is almost completely exposed. This is 
 best seen on the right side. A similar condition is seen 
 when the chest is held in a rigid position (rigid thorax) 
 when the pleural sinuses become almost completely filled 
 by the lung. This is accomplished by fixation of the costal 
 and sternal attachments ; the convexity of the domes 
 becomes entirely lost. 
 
 The outlines of the mammary glands in the female are 
 often visible on the radiogram ; on the screen they may 
 obscure the diaphragm and costophrenic sinus. They 
 should be drawn upwards. A fine line running above and 
 parallel to the clavicle is due to the fold of skin continued 
 over the clavicle from the neck. In strong, muscular men, 
 the lateral edge of the pectoralis major may often be 
 followed to the sixth rib. The diminished opacity of 
 cylindrical shape in the median upper part of the chest is 
 due to the trachea. It is continuous with that of the right 
 bronchus, and the latter may be followed as far as the 
 hilum. The left bronchus is not so readily traced, since 
 it passes in front of the descending arch of the aorta. 
 Occasionally the nipples appear as rounded opacities in the 
 middle of each field. (Radiogram 48.) 
 
l8 Radiography of the Chest 
 
 CHAPTER 11 
 
 The Classification of Pulmonary Tuberculosis : 
 Tuberculosis of the Bronchial Glands 
 
 A FEW introductory remarks concerning the varieties of 
 pulmonary tuberculosis are necessary before undertaking 
 a description of their prominent radiological features. On 
 account of the pol^-morphism of the disease ; of the 
 propensit};' of the bacillus to create a permanent nidus 
 within the pulmonary organs, and its disposition to invade 
 the surrounding healthy tissues, insidiously and slowly, 
 or widely and tempestuously, in accordance with the 
 alternating phases of individual resistance and susceptibility 
 — invasive attacks which are often followed by periods of 
 relative or even perfect calm, during which the defences 
 of the organism are remobilised, and the invalid, v/ithout 
 symptoms .and physical signs, may be apparently cured ; 
 on account of the variability in quality of the lesions, their 
 mode of onset, and evolution, with the individual diathesis 
 and period of life, and finally by reason of the possible 
 occurrence of separate types in the same patient, even in 
 the same lung, a satisfactory classification upon any 
 absolutely rational basis appears unattainable. Certain 
 interesting groupings of the disease may be mentioned, 
 e.g., that which records the method of onset (insidious, 
 pyrexial, catarrhal, haemoptoic, dyspeptic, enteritic, chlo- 
 rotic, neurasthenic, dyspnoeic, influenzal, bronchitic, bron- 
 chopneumonic, pneumonic, pleuritic). Again, Pegurier, of 
 Nice (1903), introduced the factor of resistance, and 
 classified phthisis into three principal groups : {a) with 
 active and adequate, ib) with inconstant resistance, and 
 (c) in which the resistance is nil. These classifications 
 may suggest to the clinician the presence of the disease 
 concealed under general manifestations, or may call atten- 
 
Radiography of the Chest 19 
 
 tion to the connection between it and certain abdominal 
 functional lesions, due apparently to reflex irritation of the 
 enteric vagus, — occasionally hypersecretion, may be pyloric 
 spasm from h^'peracidity ; in others rapid gastric evacua- 
 tion, appendicular pain, and tachykinesis of the small and 
 large bowel. Classifications based on (a) dyscrasias, such 
 as gout, rheumatism, alcoholism, syphilis, and diabetes ; 
 and (b) on the period of life, such as infancy, adolescence, 
 adult life, and old age, possess but a subsidiary utility ; 
 nevertheless, they may remind the clinician of the t3pe of 
 disease most frequently to be expected under the above 
 conditions : for instance, in alcoholism, disseminated nodal 
 disease with fibrosis ; in diabetes, a rapid disease with 
 large excavations, little pyrexia and expectoration, and 
 possibly no night sweating ; in gout, scrofula, and rheu- 
 matism, often a mild attenuated type. With regard to age, 
 during infancy it suggests the prevalence of tuberculous 
 bronchoadenitis, sometimes in the shape of large tumours; 
 of acute bronchopneumonic nodal tubercle, generally of 
 perihilar origin ; of generalised miliary tuberculosis, and 
 in the very young, of the acute caseating pneumonic 
 variety ; of apical disease, only after the second dentition 
 and the approach of puberty, as a general rule ; in adol- 
 escents, of galloping phthisis of different types ; in middle 
 life, of the various modalities of the fibroid lung; in old 
 age, of the very slowly progressive fibroid cavitary forms, 
 ending sometimes in subacute bronchopneumonic nodal, 
 in pneumonic lobar, or in miliary localised dissemination. 
 In the "Nomenclature of Disease" (Royal College of 
 Physicians, 19 18), pulmonary tuberculosis is divided into 
 (a) acute, and {/») chronic. The acute disease is further 
 subdivided into (i) miliary, (2) bronchopneumonic, and 
 (3) pneumonic ; the chronic into (i) caseous, (2) fibroid, 
 and (3) fibrocaseous; each of the latter three with or without 
 excavation. This clinico-pathological classification is 
 unsatisfactory, since miliary, bronchopneumonic, even 
 pneumonic, may become chronic ; moreover, many cases 
 
20 Radiography of the Chest 
 
 of caseous phthisis, included under the heading of chronic 
 disease, may become rapidly acute. 
 
 Bard bases his classification on the anatomical and 
 topographical distribution of the lesions, according to the 
 particular pulmonary entity chiefly involved, e.g., lobule, 
 connective tissue, bronchus, and subpleural tissue ; that is, 
 {a) parenchymatous, (b) interstitial, (c) bronchial, {d) post- 
 pleuritic. Among the parenchymatous forms he differ- 
 entiates : — 
 
 (a) Mild attenuated cases (apical cicatrices, etc.). 
 
 {b) Progressive forms. 
 
 1. Caseating types — 
 
 {a) Pneumonia caseosa. 
 
 {b) Pneumonia caseosa extensiva (phthisis 
 galoppans). 
 
 2. Fibrocaseating type, ordinary phthisis. 
 
 3. Fibroid forms (Chap. VI), 
 
 B. In the interstitial are included the miliary forms, viz., 
 
 {a) general (generalisata) ; (^) localised (discreta vel 
 benigna) ; (c) migratory (migrans), attacking several 
 organs in succession ; {d) suppurative ; and {e) the 
 typho-tuberculosis of Landouzy (" La Presse Medi- 
 cale," October, 1908 and November, 1909). 
 
 C. In the bronchial category are included, (a) tuberculous 
 
 capillary bronchitis ; {b) tuberculous broncho- 
 pneumonia ; (c) tuberculous bronchiectasis ; {d) 
 bronchitic or asthmatic phthisis, with emphysema. 
 
 D. In the post-pleuritic division are included fibroid as 
 
 well as fibrocaseating forms (Chapters VI and VIII). 
 In 1899, Turban introduced a classification based on (i) 
 the extent, and (2) the seriousness of the lesions, and dis- 
 tinguishes three stages, namely, (i) slight lesions reaching 
 the magnitude of one lobe only at the outside ; (2) lesions 
 more extensive but not exceeding that of two lobes, or 
 severe lesions affecting the extent of one lobe ; (3) all lesions 
 more extensive than 2. The area, corresponding to that 
 of the right upper lobe, is selected as defining the extent 
 
Radiography of the Chest 2r 
 
 of one lobe ; it may be represented by the halves of two 
 lobes, or the thirds of three lobes. By a mild affection is 
 understood disseminated foci, with slight impairment of 
 percussion note, weak breath sounds or harsh breathing, 
 fine or medium rales. Severe lesions are represented by 
 compact infiltrations containing excavations. At the Inter- 
 national Congress, at Washington (1908), a modification of 
 this classification was suggested. The stages again were 
 three in number, of which in the first there are lesions 
 limited to small areas of one lobe, for instance, not reach- 
 ing below the spine of the scapula and the clavicle, if 
 bilateral, bounded by the second rib in front if unilateral ; 
 (2) areas more extensive but not exceeding the magnitude 
 of one lobe, or a severe affection extending to half one 
 lobe ; (3) all lesions exceeding the second degree, or with 
 excavations. The difficulty of these classifications lies in 
 the delimitation of the magnitude of the lesion by means 
 of physical examination — this can only be done thoroughly 
 by stereo-radiography — also, the precise extent of a lesion 
 is no guide to its attributes, and the qualifications, slight 
 and severe, are inadequate. Finally, no attention is paid 
 to the perihilar lesions unmasked by radiography. 
 
 A further advance was made by Frankel (19 17), who 
 distinguished : — 
 
 {a) Indurative, fibroid healing examples. 
 {b) Nodal peribronchial progressive cases 
 {c) Caseative pneumonic or bronchopneumonia con- 
 ditions. 
 In each case prognosis is rendered unfavourable by the 
 presence of excavations. For the "closed " non-bacillary 
 types the "plate" alone is decisive for diagnosis (Frankel). 
 From a pathological standpoint Nicol describes (a) con- 
 glomerate, and {b) confluent forms. In the former are 
 included nodal and lobulo-bronchopncumonic, in the 
 latter lobar pneumonic and lobar fibroid manifestations. 
 
 For the purposes of radiography the types of phthisis 
 are now described in the following order : — 
 
22 
 
 Radiography of the Chest 
 
 I. Tuberculous disease of the bronchial glands. 
 II. Disseminated nodular phthisis. 
 
 III. Disseminated nodal phthisis. 
 
 IV. Bronchopneumonic pseudo-lobar tuberculosis. 
 V. Chronic attenuated phthisis. 
 
 VI. Fibroid phthisis. 
 VII. Pneumonic phthisis. 
 VIII. Miliary tuberculosis. 
 
 Diagram 4. 
 
 In Chapter VIII remarks will be found re post-pleuritic 
 as well as bronchitic phthisis ; and in Chapter IX on 
 diagnosis observations concerning quiescent, arrested and 
 quasi-arrested disease. 
 
 Tuberculous Disease oj the Bronchial Glands. 
 
 The bronchial glands form the principal anatomical 
 
 substratum of intrathoracic tuberculous infection in the 
 
 latter part of the first and the earlier 3-ears of the second 
 
 decade (5-15). Their general topography is indicated in 
 
^ 
 
 o 
 
Facing p. 23. 
 
Radiography of the Chest 23 
 
 Diagram 4. It is seen that three groups are distinguish- 
 able : (a) mediastinal, (b) hilar, and (c) perihilar. The 
 mediastinal group are again subdivisible into tracheo- 
 bronchial (a, Diag. 4), and the bifurcation glands, (d, Diag. 4). 
 The tracheobronchial, bifurcation, and hilar glands may be 
 affected singly or simultaneously ; lesions of the tracheo- 
 bronchial and bifurcation glands may lead finally to the 
 production of tuberculous mediastinitis. When hyper- 
 trophied and inflamed the glands become visible as faint 
 shadows outside their topographical loci-opacities which 
 become more intense when caseation or fibrosis subse- 
 quently occurs. The deepest contrast is exhibited when 
 calcification takes place. Intrathoracic caseating ; lands 
 form a continual menace to life ; they are generally present 
 in tuberculous meningitis, and in many instances they 
 constitute the primary focus of this disease. 
 
 Of the various groups the bifurcation glands appear to 
 be the most frequently affected. Their position behind 
 the cardiac base conceals them in the anterior and posterior 
 positions ; in order to visualise and radiograph them the 
 right anterior oblique diameter is necessary. On the 
 radiogram, for the purposes of diagnosis the divisions of 
 the trachea, that is the two chief bronchi, should be 
 discernible with the opacity between them. The glands 
 lie principally along the inferior border of the right 
 extra-pulmonary bronchus, and are only separated from 
 the right pulmonary artery b}' the pericardium. Posteriorly 
 they lie on a level with the fifth dorsal spine. The^' 
 receive lymphatics from the lower lobes and part of the 
 rii^ht middle lobe. The left tracheobronchial (intrathoracic 
 paratracheal) come into close contact with the left re- 
 current laryngeal nerve (d). They are separated, to some 
 extent, from the main bronchus running to the left lung 
 by the left branch of the pulmonary artery (e) ; on the 
 right side, consequently, there is a more direct communica- 
 tion between the right tracheobronchial group and the 
 right hilar glands and those situated along the bronchus 
 
24 Radiography of the Chest 
 
 of the right upper lobe and its ramifications (R.U.L. 
 
 Dig. 4). 
 
 Case i. — Radiogram 4 (posterior). On the right of the spine, 
 just beneath the sternal end of the clavicle, there is a dark shadow 
 with a well detined border. In the right hilum a deep opacity 
 containing a lighter area — the right bronchus. On the left, in 
 the fourth posterior interspace, a convex shadow between the 
 aorta and tlie left edge of the heart. Post-mortem examination : 
 in the right hilum a number of caseating glands aggregated 
 together ; above the right hilum, overhanging the superior vena 
 cava and the right innominate vein, a caseating gland — one of the 
 tracheobronchial group, about the size of a walnut. Above the 
 left hilum a gland about the size of a hazel nut, which surrounds 
 the back' of the left bronchus, and contains caseating and 
 calcareous debris. 
 
 Case 2. — Radiogram 5. Clinical: Percussion note slightly im- 
 paired at the right apex, otherwise clinical signs normal ; diarrhoea, 
 the stools containing tubercle bacilli. In the radiogram there 
 is an opacity within the fifth left interspace near the cardiac 
 shadow. Closely adjacent to it, within the fourth and sixth spaces, 
 small foci are present with defined contours. Diagnosis : circum- 
 scribed induration (glands ?) in the left hilum. Post-mortem : in 
 the neighbourhood of the left hilum, and corresponding in position 
 and extent to the shadows on the plate, indurated lung tissue is 
 found containing small calcareous foci. In both hila several 
 anthracotic and partially calcareous glands. The left hilar opacity 
 is due to induration of the pulmonary' tissue and not to diseased 
 glands. The opacities surrounding it are produced by small 
 indurated glands containing calcareous material. (Tuberculous 
 foci and induration in the left perihilum.) For a similar case, vide 
 Radiogram 44. 
 
 Case 3. — Radiogram 6. Florence T , a;t. 12. Clinical: was 
 
 in good health until three years ago, when the glands in the neck 
 began to swell : there is cough : occasional night-sweats : 
 hiemoptysis : physical signs withni the lungs indefinite : right 
 parasternal dulness (?). In the radiogram there are enlarged and 
 caseating glands in the right paratracheal group : some increased 
 shadowing within the right hilum, continued along the lower 
 bronchus : a slight paratracheal shadow on the left side, and a few 
 caseating glands in the left hilum. 
 
 Case 4. — Radiogram 7. Clara M , let. 21 : has suffered 
 
 from cough for some years : since influenza, live months ago, it 
 has been worse : expectoration scanty : wasting 4- '• night sweats + : 
 breath sounds harsh, right apex. Clinical diagnosis undetermined: 
 The Radiogram shows polyglandular caseation and calcitication. 
 Outside the right border of sternum a faint shadow with an 
 
o .z: 
 
 - a 
 -J o 
 
 '^ c 
 
 Facing p.'24. 
 
Radiography of the Chest 25 
 
 external limit running parallel with sternum, and containing within 
 it deeper opacities : one marked caseating gland with calcareous 
 spots (arrow) at lower part of right hilum : twin, calcareous 
 opacities in right middle lobe near axillary lines (Ghon's primary 
 focus ?) : some indurations along bronchi of right upper lobe : 
 calcareous and caseating opacities at the left hilum, and one long 
 cylindrical calcareous opacity at the level of left clavicle at its 
 junction with the sternum. Phrenic leaflets uneven — irregular 
 contraction of muscular fibres (?): some dilatation of the right 
 auricle. A small lead disc over left nipple. 
 
 Case 5. — Radiogram 8. Alice P , set. 16 : suffers from cough 
 
 and night sweats : is thin, anaemic : menstruation is delayed : there 
 is no clubbing. Physical si^ns : right paravertebral dulness (Ewart) 
 
 Diagram 5. 
 
 to percussion, and double parasternal (4 cm. on right, and 5 cm. 
 on left-normal 2 cm.): both apical areas (Kronig) narrow, at this 
 age normal is 4 cm. : breath sounds blowing at tlie right apex, in 
 the upper back and down the spines to the third dorsal, with 
 whispering pectoriloquy: breath sounds blowing at the left apex, 
 but less than on the right : a few " crackles," on deep breathing, 
 over the right base in front, and the left base behind : no other 
 adventitious sounds: reflex bands of impairment to percussion 
 (Riviere). Clinical diagnosis: tuberculous bronchoadenilis with 
 some hilar tubercle. The radiogram shows enlargement and 
 caseation of all the central groups of glands, right and left 
 paratracheal, hilar, and in the right oblique radiogram the bifurca- 
 tion glands. Some dissemination, and slight contraction of chest 
 along the axillary lines in right upper and middle lobes. Some 
 dilatation of the bronchi at the bases. Right supraclavicular apex 
 somewhat darker than the left. 
 
26 Radiography of the Chest 
 
 Case 6. — Radiogram 9. Joseph Y — — , let. 1 2 : cough, dyspnoea, 
 weakness : he has always been dehcate : complexion pale : palpable 
 glands are present in the axilke, in the anterior and posterior 
 triangles of the neck. These are firm and discrete : spleen just 
 palpable: blood-count, 4,200,000 red : 10,800 white: haemoglobin, 
 80 per cent : polymorphs, 53 per cent. : lymphocytes, 47 per cent. : 
 small, 36 per cent, (lymphocytosis) : (diminished polynucleosis and 
 increased lymphocytosis characteristic of abortiv^e, that is, attenuated 
 tuberculosis) : temperature, 97"6° to 98° : Physical signs : percussion 
 note over left upper lobe impaired in front and behind : breath 
 sounds harsh and expiration prolonged : vocal resonance increased : 
 over the rest of the lungs breath sounds diminished, as well as the 
 vocal resonance. The radiogram (anterior) shows massive hilar 
 shadows, some containing dark granules (calcitication) : calcified 
 glands in left axilla : convex paratracheal shadow below sternal 
 end of right clavicle : and a smaller opacity below the left clavicle 
 on the mediastinal border : glands obviously enlarged and fibro- 
 calcareous. In right oblique diameter bifurcation opacities and 
 glands along internal mammary also enlarged : tuberculous 
 mediastinitis : some basal emphysema. A small leaden square on 
 each nipple. 
 
 Case 7. — Radiogram 10. Ethel G , set. 19: cough, night 
 
 sweats, no hccmoptysis : Clinical : a few rales at right apex and 
 superior angle of right scapula : distended abdomen, fulness in 
 iliac fossa, and diarrhoea : stools not examined for bacilli. The 
 radiogram exhibits horizontal ribs and emphysema: a slight 
 costophrenic adhesion on the left (radioscope). The arrow points 
 to the inverted comma, the prolongation of which upwards marks 
 the right border of the trachea : the comma is evidently an en- 
 larged often fibrosed tuberculous gland: there are slight para- 
 tracheal shadows on each side of the upper sternum, and some 
 dissemination betraying itself by the presence of thin shadows in 
 the peripheral fields, especially in the right costophrenic angle, 
 and an opacity in the lower periphery of the right hilum. 
 
 Case 8. — 'Miriam F , aet. 28 : has been confined to bed in 
 
 hospital six months, with more or less continuous pyrexia, ranging 
 between 102° and 99°: family history is negative: the illness 
 commenced with rheumatic pains in the joints, which became 
 swollen, and with diarrhoea : chest signs practically nil, with the 
 exception of harsh breathing and prolonged expiration at the 
 apices, and granular breathing, almost inspiratory crepitations in 
 the right axilla, also marked basal annular emphysema. Emacia- 
 tion extreme. The Radiogram (11) shows massive hilar shadows 
 and fibroid infiltrations, especially on the left, and some pulmonary 
 dissemination on both sides : a patch of fibro-calcareous opacity in 
 the right axilla, not so well seen in print as in the plate : a few 
 
^ s 
 
 
 Facing p. 26, 
 
i 
 
 5 
 
 
 V3 
 
 
 "^ 
 
 -j 
 
 ^ 
 
 s 
 
 O 
 
 
 
 c 
 
 U 
 
 o 
 
 73 
 
 u 
 
 , . 
 
 
 C/) 
 
 
 
 o 
 
 O 
 
 
 ^ 
 
 •^ 
 
 o 
 
 5 
 
 J 
 
 -y; 
 
 
 
 
 & 
 
 >. 
 
 p 
 
 o 
 
 
 
 !~i 
 
 
 
 a 
 
 4-1 
 
 o 
 
 C/) 
 
 
 O 
 
 ,__, 
 
 ^ 
 
 .2 
 
 b£ 
 
 
 3 " >> 
 .'§'•" o 
 
Radiography of the Chest 27 
 
 glands outside chest in right upper axilla, also not seen in print : 
 and a few calcareous foci scattered irregularly in the apices and 
 right middle lobe. The chest tends to the thorax paralyticus. 
 The case raises the question of the relations between certain 
 forms of rheumatism and tubercle (Poncet and Leriche). The 
 association of granular breathing and hbro-calcareous deposits in 
 the right axilla suggests that rhe former is not always a sign of 
 incipient tubercle, but may really be an indication of arrested 
 disease. The radiogram represents chronic tuberculous media- 
 stinitis. 
 
 Case 9. — Mary F , ait. 25 : about six years ago suffered 
 
 from apical trouble which healed : about three years ago, after 
 measles, enlargement of the cervical glands began in the thyroidean 
 region, and extended to the posterior triangle : these are painful 
 and chiefly on the left side : the isthmus of the thyroid is en- 
 larged : the eyeballs are prominent : Graefe's sign absent : pupils 
 rather dilated and not very sensitive to light : double parasternal 
 and right paravertebral duluess (Ewart) is present : no added 
 sounds, except Heeting clicks at the right apex on deep breathing: 
 there is slight bronchial breathing and increased tactile fremitus 
 and vocal resonance at the axillary end of the right clavicle : a 
 faint systolic bruit over third left interspace (anaemic) : pulse, 76-90 : 
 blood pressure, 125 mm.: palpitation, flushes, and occasionally 
 frontal headaches. The Radiogram (12) shows tracheobronchial 
 opacities on each side: and iuliltration of each hilum, especially 
 the left, with some fibrosis of this side. The case is interesting, 
 since it shows the revival of central tubercle, and of the glands 
 in the neck, after an attack of measles, as a cervical and 
 endothoracic adenitis. In the blood there is increased poly- 
 nucleosis, and diminished lymphocytosis, indicating that tubercle 
 is still in play. The enlargement of the thyroid, the tachycardia, 
 the Hushing and prominence of the eyeball suggest Graves' disease 
 of a mild form. It is quite common to fuid an increased right 
 paratracheal opacity, or the remains of a massive, almost general 
 infection of the lung itself in subjects of this disease : occasionally 
 attacks of exoj")htlialmic goitre occiu- simultaneously with ex- 
 acerbations of pulmonary tubercle : also in soldiers exhibiting 
 the signs of hyperthyroidism, paratracheal shadows may be present. 
 The relations between the two diseases are still obscure, and 
 require further investigation. At least every case of exophthalmic 
 goitre should be radiographed, and if the glands or the Ihynnis 
 arc found enlarged. X-ray treatment should be at the same time 
 administered to these structures. 
 
 Case 10. — Robert P , x't. 21, suffers from enlargement of 
 
 cervical glands in both posterior triangles, especially on the left 
 side, and both axilke, and there is one large supraclavicular gland 
 
28 Radiography of the Chest 
 
 on the left. The glands are firm: there is pyrexia and some 
 wasting: Clinical signs : there is slight impairment of percussion 
 resonance over the right chest front and back, and a right 
 paravertebral dulness, with some line crepitations at the right 
 base. The posterior radiogram shows pleural thickenings at both 
 supraclavicular apices, especially the left : a faint paratracheal 
 shadow on the right side, otherwise the lungs are normal. In the 
 right oblique radiogram (Radiogram 13) the faint paratracheal 
 shadow is indicated by the middle arrow : the highest arrow points 
 to the tail of the comma, which is evidently a thickened lymphatic, 
 and here indicates the posterior margin of the trachea : the lowest 
 arrow indicates the bifurcation opacity between the limbs of the 
 main bronchi. 
 
 In very young children the central glands may become very 
 
 large. Grace B , :jet. 2^ years : family history is negative : 
 
 suffered from measles and bronchitis eight months ago, and has 
 never been well since : there is a paroxysmal cough without whoop : 
 no expectoration : loss of appetite : night sweating about the 
 head: no pyrexia: temperature generally subnormal. Clinical 
 iigns : right apex, impaired note : vocal vibrations and resonance 
 increased : bronchial breathing and crepitations : slight collapse 
 of the right chest : child was discharged in statu quo after six 
 weeks. Clinical remarks : " The diagnosis of collapsed upper lobe 
 due to tuberculous mass of glands pressing on right upper bronchus 
 unlikely owing to absence of stridor and the presence of added 
 sounds : the clinical diagnosis therefore remains doubtful." 
 Pirquet evidently not employed. Radiogram 14 (posterior) a 
 large wedge-shaped opacity, apex below, is present along the 
 right side of trachea and right bronchus (paratracheal), outside 
 which, in the right upper lobe, there are signs of dilated tubes and 
 slight infiltration. The left hilum shows an opacity of increased 
 magnitude and intensity. On the right the shadow is uniformly 
 opaque. Radiological diagnosis : caseating tracheobronchial glands 
 on the right producing an opaque mass in the radiogram, and 
 leading, by compression of right bronclius, to incipient fibrosis of 
 right upper lobe. Bifurcation glands in the right oblique position 
 unaffected. 
 
 Radiograms Nos. 15 and 16 are inserted in order to 
 show the softening and final irruption of hilar caseating 
 glands into the lung. This patient was kept under 
 observation for about one year. The final dispersal, which 
 produced an acute nodular bronchopneumonic tuberculosis, 
 occurred a few weeks before death. The differential 
 diagnosis of the various mediastinal and hilar opacities, 
 such as are produced by mediastinal tuberculous, sarco- 
 
Kau. 14 (Post.) Caseatiiig right iiaratraclical opacity. 
 
 Facing p. 28. 
 
o }i 
 
 o 5, 
 
 u O 
 
 o u 
 
 o c 
 
 r3 
 
 XI 
 
 L4 
 
 
 H 
 
 •a 
 
 1 
 
 
 1 
 
 rt 
 
 ^^ 
 
 c 
 
 
 
 c 
 
 a 
 
 < 
 
 =2 
 
 
 _(/} 
 
 
 
 
 
 *v3 
 
 _ 
 
 >. 
 
 ^ 
 
 X 
 
 
 
 ri 
 
 ■c 
 
 
 <u 
 
 LTl 
 
 ^ 
 
 
 
 
 r! 
 
 ~ 
 
 ^ 
 
 
 
 tti 
 
 Facing p. 28. 
 
Radiography of the Chest 29 
 
 matous and carcinomatous growths, b}'' enlargement of the 
 thymus, b}^ lymphadenoma, aneurysmal swellings, is 
 discussed in Vol. II, in the chapter devoted to tumours of 
 the lung and mediastinum. 
 
 Clinical and Radiological Remarks. — The above cases 
 render it obvious that there are no clinical criteria of any 
 value, and that the radiological examination is necessary 
 for the diagnosis of tuberculosis of the bronchial glands. 
 Difficult as it is, in the case of the child, in the adult it is 
 more perplexing still. The simultaneous occurrence of 
 several clinical symptoms may render the diagnosis 
 suspect. These are parti}' due to pressure on bronchi, 
 blood vessels, lymphatics, nerve trunks and plexuses, and 
 partly due to the absorption of toxins 'produced by the 
 virus. The glands, however, very rarely become tumours 
 of sufficient size to produce marked pressure S3'mptoms, 
 unless very favourably situated, and some of these effects 
 may in reality be due to reflex influences exercised on the 
 external inspiratory muscles and the diaphragm. Very 
 occasionally the bifurcation glands may become large 
 enough to compress the oesophagus and induce difficulty 
 of swallowing (one case — the author), or they may soften 
 and become evacuated by this channel. Occasionall}^ 
 enlarged paratracheal glands on the left compress the 
 recurrent nerve, producing hoarseness and sometimes loss 
 of voice; the paroxysmal cough may be due to compres- 
 sion of the vagus or to mechanical irritation of the lining 
 of the chief bronchi and trachea near its bifurcation. In 
 children it is usual to lay stress on the presence of whis- 
 pering pectoriloquy in the paravertebral regions of the 
 chest and dorsal spines ; to signs of pain on pressure upon 
 the spinal processes of the upper dorsal vertebrae, which 
 may be very occasionally met with ; to the presence of an 
 increased Ewart's area of paravertebral dulness, and harsh 
 blowing, or even weakened apical breath sounds, with 
 perhaps an occasional click (oedema?) at the end of a deep 
 inspiration. 
 
30 Radiography of the Chest 
 
 With the formation of small areas of perihilar infiltra- 
 tion, crepitations may be heard at the level of the nipple, 
 the hila behind, or these may be conducted to the axillae 
 and apices. In the majority of cases in children the dis- 
 semination is purely lymphatic, the lymph trunks become 
 thickened, and the pulmonary glands enlarge, but remain 
 follicular, and do not become infiltrative. It often corre- 
 sponds to a general hyperplasia of the lymphatic glands, 
 and is merely a passing phase of temporary loss of the 
 powers of resistance, which, under proper treatment, 
 rapidly disappears. Between the ages of 5 and 15 the 
 immunity is generally sufficient to prevent any serious 
 establishment of the disease. {Vide Lancet, Sept. 30th, 
 191 7, Overend and Riviere.) When the presence of 
 pulmonary tuberculo-adenitis in the adult is suspected, the 
 presence of faint bronchial breathing, of rales, or sibili in 
 the neighbourhood of the hilum, in front or behind, will 
 make the diagnosis more probable. Especially will this 
 be the case if the temperature is labile, with an increased 
 reaction 'after work and exercise ; if the pulse is of low 
 tension and unstable, becoming easily accelerated ; if there 
 is a paroxysmal cough, and if the patient shows signs of 
 anaemia, lassitude, or neurasthenia. The clinical signs 
 may be due to a localised congestive bronchopneumonia, 
 or actually to a hilar or perihilar tuberculosis. The pro- 
 bability, as in children, is in favour of the former. A good 
 radiogram may prove illuminative, and is the only certain 
 method of diagnosis. 
 
 Some of the cases in children of school age, as mentioned 
 above, exhibit on the radiogram the presence of a general 
 hypertrophy of the tracheo-broncho-pulmonary lymphatic 
 tract, and quite small nodules may even be seen just 
 beneath the pleura. There may be a fine narrow shadow 
 running parallel to the sternum on the right, and both 
 hilar areas assume a diffuse gray appearance. In addition, 
 the cervical axillary (and possibly the mesenteric glands) 
 
Radiography of the Chest 31 
 
 are enlarged and palpable. These are accompanied by 
 malaise, anaemia, and later by amenorrhoea. 
 
 Hyperplasia of the central lymphatic glands, both in 
 children and in adults, may be due to causes other than 
 tubercle. Enlargement may accompany simple chronic 
 bronchitis, lobular and lobar pneumonia, in particular that 
 which accompanies measles and pertussis, also the rare 
 adult form of fibrinous bronchitis, and certain neoplasms 
 of the mediastinum. In some instances, as well as in mild 
 tuberculous infections, the effects of forced inspiration 
 during cough, aided by a presumed deficiency of elasticity 
 in the pulmonary tissue, may be shown by the production 
 of a generalised cylindrical bronchiectasia and of emphy- 
 sema, with their proneness to attacks of recurrent bron- 
 chitis, and which, if the tuberculous contagion becomes 
 negligible, assume the predominant features. The pressure 
 of enlarged paratracheal and bifurcation glands on the 
 bronchi may lead, as in other forms of compression, as 
 those of neoplasm and aneurysmal swellings, to the pro- 
 duction of pulmonary fibrosis beyond the seat of compres- 
 sion, and conversion of the offending mass into innocuous 
 fibrous tissue will not necessarily restore the integrity of 
 the upper lobe, which in the meantime has become cirrhotic 
 and is occupied by dilated tubes. In other cases an un- 
 resolved basal lobular or lobar pneumonia may finally 
 become fibrosed, then bronchiectatic, and this may be 
 bilateral. A radioscopic examination at once demonstrates 
 the presence of a basal triangular opacity, with its apex at 
 the hilum and its base occupying all, or nearly all, one 
 moiety of the diaphragm. It may be termed the basal 
 bronchiectatic fold or triangle. 
 
 Cases of unresolved basal pneumonia, and of pure fibroid 
 lung in children, are often sent to the tuberculosis dis- 
 pensary to be treated as tubercle; they are, in reality, more 
 common than the genuine afiection. We return to this 
 subject in the chapter on " Bronchiectasis " (Vol. II). It is 
 obvious, however, that in patients suffering from general 
 
32 Radiography of the Chest 
 
 cyhndrical bronchiectasia the prescription of respiratory 
 exercises may do more harm than good, if undertaken 
 before the pulmonary elasticity has recovered. This type 
 of bronchiectasis is also readily diagnosed by radiography. 
 
Radiography of the Chest 33 
 
 CHAPTER III 
 Bronchopneumonic Phthisis 
 (Bronchopneumonia Tuberculosa) . 
 Bronchopneumonic phthisis, or caseating bronchopneu- 
 monia, may be described under three heads, {a) nodular, 
 (b) nodal, and (c) pseudolobar, according as the foci are 
 quite small and nodular, or larger and multilobular (nodal). 
 The latter may fuse and produce extensive tracts (pseudo- 
 lobar), which then approach in appearance the pneumonic 
 forms. For the sake of convenience this t3'pe is described 
 in Chapter IV. 
 
 Bronchopneumonic tubercle is the classical type in 
 children. Both in children and in adults it is secondary to 
 primary foci already present within caseating hilar glands, 
 or to infiltrations occurring in a state of softening or 
 excavation within the lung itself It may follow influenza, 
 one of the infectious fevers (measles, etc.), and diabetes; it 
 may occur in women exhausted by frequent pregnancies 
 and by the repeated nursing of children ; also it may 
 complicate the debilitated conditions produced by penury 
 and starvation. 
 
 I. Disseviinatcd nodular Phthisis. 
 When fragments of a softened caseous gland, or portions 
 of a caseating dissolving mass, lying in an apical or peri- 
 hilar cavity, become detached and obtain access to the 
 air passages in larger bulk than can be convenientl}' and 
 adequately expelled pari passu, bacilli may be scattered by 
 inspiratory efforts, either widely throughout both lungs 
 (general dissemination) or may affect certain areas of one 
 or both lungs alone (partial dissemination). This process 
 of dispersal, which may accompany the periodic exacerba- 
 tions of chronic cavitary pulmonary tubercle, and may be 
 attended by slight haemoptysis, increased cough and 
 
 D 
 
34 Radiography of the Chest 
 
 pyrexia, plays a much greater role in the evolution and 
 the radiographical topography of pulmonary phthisis than 
 clinical examination suspects or is able to reveal. No 
 period, not even old age, is exempt from its possible 
 occurrence, provided the necessary lesions exist within 
 the lung. As elucidated by radiograms, it appears to take 
 place in the adult, perhaps more frequently during the 
 third and fourth decades of life. Moreover, isolated 
 groupings of small rounded foci, often present in the 
 lateral areas of the chest, near the axillary lines, frequently 
 owe their origin to a similar cause ; in the process of time 
 these may become inofifensive fibroid specks, or may 
 vanish altogether from view. iGeneral and partial dissemin- 
 ation is consequently a secondary manifestation, due to 
 the persistent and fitful activity of primary foci, situated 
 either within caseating glands or among the debris of 
 imperfectly evacuated cavities. Such disseminated foci 
 appear as grayish white nodules, located, in recent cases, 
 at the extremities of the bronchioles. They are inde- 
 pendent of each other at first ; but are crowded and packed 
 together so as to give a granular appearance to the 
 fluoroscopic screen and to the lobules as seen post-mortem. 
 Primarily of the size of a grain of millet, or of a hemp 
 seed, they may rapidly increase in size and become as 
 large as a bean, or the nodules may aggregate to form 
 larger opacities, producing finally either bronchopneumonia 
 nodal or pseudolobar infiltrations {q.v.). Careful examin- 
 ation of a satisfactory radiogram will usually discover 
 the presence of a large or of several small cavities, with 
 surrounding infiltrations on one or both sides, about the 
 level of the anterior osseous extremity of the first rib, 
 within the axillary areas, or in the depth of the perihilum. 
 These cavities may not present the aspect of old thick- 
 walled extinct excavations, but their outlines may be less 
 definite, irregular, and obviously they still enclose caseating 
 material. There is often a tendency to general cylindrical 
 dilatation of the smaller bronchi (paresis of the muscular 
 
— -J 
 
 — (U 
 
 « 
 
 l-'aciriK p. 34. 
 

 Facing p. 34- 
 
Radiography of the Chest 35 
 
 wall) ; in some areas the foci are arranged around the 
 circular bronchial transparencies; in others they stud the 
 bronchial walls, fortuitously cut in their long axes, and 
 these foci may coalesce to form fibrocaseous, ultimately 
 fibroid sheaths. 
 
 The severity of the process varies within the widest 
 limits. Occasionally the condition may remain, in older 
 patients generally, for months in statu quo, and a second 
 radiogram may reveal minor changes only ; in others, 
 where the bronchi appear little affected, and no fibrosis 
 succeeds, the process of aggregation and infiltration 
 advances rapidl}'', leading to extensive confluent pseudo- 
 lobar infiltrations, and a fatal issue within a few months. 
 Even in the widely disseminated cases the physical signs 
 may be indefinite. The percussion note may be slightly, 
 if at all, impaired, or there may bean emphysematous note 
 (general dilatation of small bronchi ?) and an absence of 
 retraction of the chest. Auscultation may reveal a few 
 doubtful crepitations, perhaps at one apex or base, or 
 within the lateral axillary lines, and occasional sibilant 
 sounds. Haemoptysis is rarely profuse ; it may be a mere 
 staining or it may be absent altogether. Cough may be 
 persistent, expectoration trifling, pyrexia irregular but not 
 severe, and night sweats may cease. The expectoration 
 may contain bacilli, intermittently in accordance with the 
 repeated exacerbations. Emaciation in some instances is 
 pronounced. Very occasionally a local pleuritic effusion, 
 perhaps basal and axillary, may be present. 
 
 Case i. — Walter R , aet. 44 (2.7.18). Clinical : pain 
 
 in side and cough for ten weeks : wasting + : haemop- 
 tysis + : began in pleurisy three months ago : now unable 
 to follow his employment : right apex in front and behind 
 slight impairment of percussion note: crepitations 
 right apex : in left lung crepitations in mammary region : 
 dulness at bases behind. Clinical diagnosis: phthisis 
 and pleurisy. Radiogram 17: disseminated tubercle 
 showing patchy aggregations : enlarged hila : cavities at 
 
36 Radiography of the Chest 
 
 right apex (only visible on the plate) : slight emphysema 
 of both lungs and general cylindrical dilatation of the 
 bronchi. 
 
 Case 2. — George H , aet. 21 (9.4.18). Clinical: 
 
 cough and haemoptysis : emaciation, i stone : dyspnoea 
 + + : heart apex beat normal : movement diminished 
 and slight flattening at the right apex : crepitations both 
 apices. Clinical diagnosis: pulmonary phthisis — both 
 apices. Radiogram 18 : shows a general dissemination 
 of foci throughout both lungs : small excavations in the 
 right supraclavicular apex : irregularly located aggrega- 
 tions of foci in the right lung : an extensive broncho- 
 pneumonic infiltration in the left lung : enlarged para- 
 tracheal glands on each side of the central mediastinal 
 opacity. 
 
 Case 3. — William G. B , aet. 21 (9.4.18). Clinical : 
 
 cough + : haemoptysis — : emaciation, 2 stone: night 
 sweats — : movement diminished and flattening of right 
 chest : crepitations at both apices. Clinical diagnosis : 
 double apical phthisis. Radiogram 19, contraction left 
 chest, large cavity right apex with a central more 
 translucent area (bronchus ?): both lungs filled with 
 small nodular foci apparently becoming arrested on 
 right, rather sparing dispersal of foci throughout left 
 lung : both hilar opacities increased in area and density: 
 nodal opacities in left hilum : some emphysema of right 
 lung. 
 
 Case 4. —William V , aet. 28. Clinical: t° 97°-98°^ 
 
 Tbc. + : signs of infiltration at the right apex and of fluid 
 at the left base (where breath sounds, vocal fremitus and 
 vocal resonance are absent). Radiogram 20 : general 
 disseminated foci throughout both lungs : just beneath 
 the middle of right clavicle an infiltration containing less 
 opaque areas (cavities) : some of the foci in right lung 
 becoming calcareous or fibroid : left basal effusion, not 
 reaching as high as the nipple (metal square) : very 
 slight deviation of heart towards the right side. The 
 case aff'ords one of the numerous illustrations of the 
 contrast between the poverty of clinical and radio- 
 scopical and the wealth of radiographical signs. With 
 the fluorescent screen the opacity at the right apex and 
 
15 
 
 m 
 
 l-"acine p. 36. 
 
Radiography of the Chest 37 
 
 the small basal effusion on the left side alone were visible 
 thus demonstrating the absolute unreliability of radio- 
 scopy per se, except in gross lesions. 
 
 In the chronic or subacute cases, the fibrosis becomes 
 more pronounced, and the dissemination, if primarily more 
 or less general, becomes restricted to localised areas. 
 
 Case 5. — Frederick B , aet. 60, painter. Cluneal: 
 
 haemoptysis frequent and small in amount : cough + : 
 temperature 97°-98°: Tbc. + : clinical signs chiefly of 
 emphysema and bronchitis. Radiogram 21 : small cavi- 
 ties within the left supraclavicular, and apparently two 
 larger in the infraclavicular areas : disseminated small 
 foci in the lateral part of the left lung : calcified rib 
 cartilages. 
 
 Case 6. — Leonard S , aet. 23 : ex-soldier. Clinical : 
 
 percussion note impaired at both apices : weak breath 
 sounds left apex : crepitations in right lung : no pyrexia : 
 Tbc. + : Clinical diagnosis : pulmonary tuberculosis of 
 both lungs. Radiogram 22, a large cavity cut by 
 clavicle on right side : in left supraclavicular apex and 
 upper subclavicular triangle several lighter areas : fusi- 
 form fibroid bands of opacity running towards left hilum : 
 a cavity (pseudo?) between second and third ribs at the 
 left axillary border : disseminated foci in the right 
 middle lobe and in the axillary region of the left lung. 
 Radiological diagnosis: chronic fibroid disseminated 
 phthisis. 
 
 Disseminated Nodal Phthisis. 
 
 In some cases the nodal foci may be numerous, closely 
 packed together (Radiogram 23), and the disease is 
 subacute. One sees this form occasionally in middle-aged 
 men addicted to alcohol ; when well defined, it may be 
 termed the inebriate's lung. In others the nodal infiltra- 
 tions are few, the progress is slow and may become 
 actually arrested.* Chronic apical andperihilar infiltrative 
 
 • These nodal infiltrations, when radiographed later, often pass directly 
 into healed patches of fibrosis. This transformation is dependent upon the 
 nature of individual resistance, which may be inherent or acquired. 
 
38 Radiography of the Chest 
 
 types are described in Chapter iVI. The subacute and 
 chronic dissemination from the primary caseous focus may 
 be partial only, or advance may be made by mere con- 
 tiguity, that is, by the passage of bacillary sputum along- 
 the walls of the bronchi : or by way of the lymphatics. In 
 the acute types aspiration probably plays a more important 
 role by carrying the bacilli to distant parts of the lungs. 
 If the general dissemination occurs at a time when the 
 systemic resistance is low, the foci may rapidly enlarge 
 and produce pseudolobar infiltrations, which appear as 
 extensive opaque areas on the radioscopic screen, pro- 
 ducing an acute phthisis of short duration. 
 
 In bronchopneumonic nodal types the cough may be 
 frequent, it may be accompanied by a greyish-white 
 expectoration, and the dyspnoea may become far more 
 severe than is warranted by the meagre physical signs. 
 There may be small scattered areas, in some cases, of 
 sibilant or subcrepitant rales ; in others, localised regions 
 of bronchial breathing and bronchophony, not necessarily 
 more pronounced towards the apices : loss of weight and 
 strength, and obvious cyanosis. The diagnosis rests on 
 the examination of the sputum, and on the radiogram. In 
 some instances, where prolonged pyrexia occurs in cases 
 of creeping or wandering influenzal bronchopneumonia, 
 where cough is slight and expectoration is trivial or 
 unobtainable, but loss of strength and emaciation are 
 paramount, it is only when cavitation occurs, and this may 
 be delayed, or when caseating foci are found post-mortem 
 in the bronchial glands or elsewhere, that a diagnosis of 
 tubercle becomes justified. In protracted cases of delayed 
 resolution, after bronchopneumonia lasting several weeks, 
 even two or three months, the radiogram will show 
 unresolved and resolved patches of bronchopneumonia 
 side by side in one lung, or resolved areas in one, and 
 unresolved areas in the other lung. There may, however, 
 be signs of old apical tubercle, and the family history 
 may be suggestive. 
 
u 
 
 5 i^ 
 
 -^ 5 
 
 34 
 
 laciiiK 11. 38. 
 
Radiography of the Chest 39 
 
 Isaac L , aet. 59, complains of pains in the left 
 
 chest, with cough which has lasted for three months, 
 and of emaciation. Clinical diagnosis : emphysema, 
 bronchial catarrh, arterio-sclerosis. On account of 
 difficulty in swallowing, patient was sent to the X-ray 
 department for examination of the oesophagus by means 
 of the bismuth bolus. This showed spasmodic con- 
 traction at the level of bifurcation of the trachea, and 
 again lower down near the diaphragmatic opening 
 (tuberculous laryngitis ?). On account of suspicious 
 fluoroscopic appearances, observed during the progress 
 of deglutition, a radiogram of the chest was taken, in 
 which (Radiogram 23) there is an irregular cavitation 
 at each apex, and nodal consolidations are present 
 in the upper lobe of the right, and scattered throughout 
 the whole of the left lung, producing a characteristic 
 dappled appearance. 
 
 For comparison the following case of influenza-pneu- 
 monia is included : — 
 
 Eliza S , aet. 23, had a severe attack of influenza- 
 pneumonia, commencing nine weeks ago. There is a 
 family history of phthisis, and one sister is now in a 
 sanatorium. The pyrexia is still oscillatory, reaching 
 101° or 102'' of an evening, with morning remissions: 
 emaciation is severe, but cough and sputum are absent. 
 It was suggested that an encysted empyema might be 
 present, but the clinical signs and the radiogram nega- 
 tive this possibility. The latter (Radiogram 24, posterior) 
 reveals a bronchopneumonic irregular consolidation 
 affecting chiefly the area around the interlobe, and 
 showing transparencies due to dilated tubes, Crane's 
 inverted comma along the right side of the trachea, and 
 partial resolution of the left basal bronchopneumonia, 
 which was present three w-eeks ago in the first radio- 
 gram. There may have been an apical bronchopneu- 
 monia as well on the left side, as shown by the small 
 excavations, and a slight opacity above the left clavicle. 
 On the other hand, the lesion at the left apex may be 
 tuberculous : if this is the case the prognosis becomes 
 unfavourable. The left diaphragm was immobile. Pyrexia 
 gradually abated and strength returned slowly for a 
 
40 Radiography of the Chest 
 
 time. Subsequently an encysted empyema was found 
 
 radiologically, which was treated by resection and 
 
 drainage. The patient is still under treatment (22.7. 19).* 
 
 An example of chronic localised nodal disease is 
 
 shown by Hilda A , aet. 27 (Radiogram 25): she has 
 
 suffered from cough for a month, with small haemoptyses 
 on several occasions : wasting + : physical signs in- 
 definite. The radiogram shows several broncho- 
 pneumonic nodal opacities, in the right supraclavicular 
 apex, over the first right rib, and in the first right 
 anterior interspace, also several in the base of the right 
 upper lobe, a few in the left upper lobe, and a condition 
 of diffuse cylindrical bronchiectasia, especially in the 
 right lung. There are indistinct signs of a cavit}^ below 
 the middle of the right clavicle. Clinical examination is 
 inconclusive : there is no sputum and the physical signs 
 are ambiguous. 
 
 They are generally considered to be cases of chronic 
 bronchitis on account of the presence of rhonchi and 
 rubber ball sounds in certain areas, may be the apex, the 
 axilla, or the mammary region ; but the real diagnosis is 
 evidently chronic nodal pulmonary tubercle. 
 
 * Two months later the patient died. No examination was allowed. 
 
o 
 
 Facing p. 41. 
 
Radiography of the Chest 41 
 
 CHAPTER IV 
 
 Bronchopneumonic Pseudolobar Tuberculosis (Apical) 
 
 Apical bronchopneumonic phthisis may be acute, sub- 
 acute, or chronic. In the very chronic forms the area of 
 apex infiltrated is generally small, and situated usually at 
 the level of the anterior osseous extremity of the first rib. 
 Here a fibrocaseous patch may be found, with small 
 irregular cavitation within it, or a definite isolated cavity. 
 When the disease spreads downwards it may heal from 
 above, and exhibit a slowly advancing margin of consolida- 
 tion in the lower part of the upper, or within the middle 
 lobe. In some cases the initial focus may be in the 
 axillary region. , 
 
 In the more acute apical and perihilar forms, symptoms 
 such as cough, pyrexia, emaciation, and anorexia are often 
 prominent before the diagnostic signs appear. Such signs 
 as diminished or weak breath sounds, diminished supra- 
 clavicular isthmus, granular breathing, harsh breathing 
 with prolonged expiration, interrupted breathing, are not 
 pathognomic, since they may be merely the persistent 
 signs of an arrested tuberculosis. 
 
 In the ordinary apical phthisis, Fowler localises the 
 initial lesion about two inches below the right apex, and 
 nearer the posterior surface of the lung. Chauvet places 
 this primary focus in the middle of the line joining the 
 intervertebral space between the seventh cervical and first 
 dorsal with the tubercle of the spine of the scapula (which 
 is generally quite easily seen and felt). This corresponds 
 with the radiographic appearances, consequently early 
 cases are most profitably auscultated and radiographed in 
 the supraspinous fossa about the level of the third dorsal 
 spine. Before the complete invasion of the upper lobe is 
 accomplished, a second lesion may appear below the apex 
 of the right lower lobe at the level of the fifth spine, and 
 
42 Radiography of the Chest 
 
 about half way between it and the inner border of the 
 shoulder blade. It is said that an interval of quiescence 
 may now take place, after which the lesion commences to 
 spread in two directions, (i) along the right interlobe, 
 (2) towards the right base ; and a third lesion appears in 
 the upper lobe of the opposite lung. To follow the line of 
 march radiographically it is necessary to take stereo- 
 radiograms at frequent intervals in typical cases ; and the 
 results do not entirely coincide with those deduced from 
 percussion and stethoscop}^ In man}' cases the disease 
 starts almost simultaneously in both apices ; in others the 
 left apex only is attacked, and the disease may then remain 
 for a long time unilateral ; occasionally it seems to spread 
 downwards on the right (apical), and centrifugally from 
 the hilum on the left (perihilar). Furthermore, when cavita- 
 tion occurs in both acute and chronic cases, the line of march 
 may be obscured by the occurrence of showers of broncho- 
 genic foci affecting both lungs, and may subsequently 
 advance more quickly in certain unexpected situations. 
 
 1. Sidne}' S , ast. 16 (4.2.19): had an attack of 
 
 influenza, July, 191 8 : cough + : emaciation + : night 
 sweats + : hectic + . Clinical signs : crepitations both 
 apices, particularly on the right. Radiogram, posterior 
 (No. 26) : bronchopneumonic pseudolobar tubercle 
 spreading from right apex, with cavitation below the 
 clavicle, and a second beneath the axilla ; consolidation 
 in the middle lobe : and deposition in the right basal 
 lobe : on the left, cavitation commencing below sternal 
 end of left clavicle, and slight areas of infiltration in the 
 apex of the lower lobe of left lung (galloping phthisis). 
 
 2. Emma B , aet. 18 (12. 8. 18): suffered from pleu- 
 risy, Christmas, 1917. Clinical : movement of left chest 
 deficient : no crepitations : winter cough : wasting : 
 night sweats : anaemia. Radioscope : left diaphragm^ 
 inner half only mobile : heart apex not adherent : large 
 opacity in middle of left field. Radiogram No. 27A 
 (anterior) shows an advanced bronchopneumonic phthisis, 
 apparently commencing at right apex, where indurations, 
 and a number of small cavities are visible. It has spread 
 
u 
 
 J2 
 
 a 
 
 oi 
 
 KacinK p. 42. 
 
FacinK p. 42. 
 
Radiography of the Chest 45 
 
 throughout the right lung : subsequently it has settled 
 in the left hilar area, thence spreading outwards into the 
 left lung. The latter is riddled with small cavities as 
 far as the supraclavicular apex. Some of the opacities 
 in the right lung are very opaque, and probably cal- 
 careous. At present the disease appears to be quiescent 
 (bronchopneumonic pseudolobar). 
 
 3. Alice B , aet, 24 (at least seven years in duration)^ 
 
 was in sanatorium in 191 2 : complains now of frequent 
 cough : expectoration is scanty and white: weight 10.10 
 in sanatorium, now 8.6: was diagnosed in 191 2 double 
 apical phthisis. Clinical signs : crepitations at the left 
 apex and rhonchi in left upper lobe : no enlarged cer- 
 vical glands (Radiogram No. 27B). It is difficult now 
 to realise the line of march : there are sinuous small 
 excavations at right apex in the second anterior inter- 
 space : some thickened tubes in the middle lobe : both 
 hilar regions are cloudy : on left side dilatations of 
 tubes: sinuous cavitation: a pleural apical cap, and a 
 few small transparencies in the left supraclavicular apex: 
 bands of indurated fibrosis along the bronchi : heart 
 central, some dilatation of the right auricle, 
 
 Pcrihilar Broncliopncnmonic Pseudolobar Phthisis 
 (Subacute and Chronic). 
 It has been already stated that perihilar disease, whether 
 uni- or bilateral, may be secondary to an apical lesion ; very 
 often, however, both apices, so far as clinical and radio- 
 logical examination can determine, are normal. Five 
 examples of this type are now described : — 
 
 I. Amelia R , aet. 35. Clinical : in the right upper 
 
 lobe percussion note impaired, a few crepitations. In 
 the left upper lobe expansion diminished : there is 
 tubular breathing above, becoming amphoric near the 
 nipple: cardiac apex not found. Radiogram 28: on the 
 left side there are many rounded opacities (broncho- 
 pneumonic nodal), connected by less dense indurations: 
 an irregular cavitation extends as far as the supra- 
 clavicular apex. On the right side a narrow band of 
 disconnected induration from the hilum running out- 
 wards towards the axilla, and containing small cavities. 
 
44 Radiography of the Chest 
 
 and dilated tubes : the right phrenic leaflet is much 
 higher than the left. There are a few opacities in the 
 right middle lobe. The disease on the right is older 
 and becoming arrested. The right extreme apex is free. 
 This patient contracted influenza during the winter of 
 1 91 8, with a fatal result. 
 
 2. Regina R , aet 16. Clinical: has suffered from 
 
 cough for 1 8 months: expectoration + : tubercle bacilli 
 + : right lung, percussion note impaired : crepitations 
 right apex : harsh breath sounds behind with increased 
 whisper: temperature, g6°-g%°. Radiogram 2g: a uni- 
 lateral bronchopneumonic pseudolobar infiltration, 
 spreading along the right interlobe with irregular ex- 
 cavation (arrows) above and below it, near the hilum. 
 The lesion extends along the bronchi to the supracla- 
 vicular apex, where excavation also has ensued. The left 
 lung is practically free. The heart, aorta, and trachea 
 deviated slightly towards the right. 
 
 3. James S , a;t. 26 : family history + : cough + : 
 
 expectoration + : haemoptysis small, on several occa- 
 sions : night sweats — : 97'6°-gg'6° : Tbc. after several 
 examinations — . PJiysical signs : indefinite : a few doubt- 
 ful crepitations observed on two occasions between 
 vertebral border of scapula above the spine and the 
 vertebral column. Classed B, June, 1917. Radiogram 
 30A shows several round bronchopneumonic foci, nodal, 
 outside the right hilum in the interlobar region, with 
 some surrounding induration and thickened tubes or 
 congested vessels running fan-wise towards the axilla. 
 Radiological diagnosis : right interlobar phthisis. Ten 
 months subsequently re-examined. Clinical : cough + : 
 Tbc. now +: emaciation +: night sweats +: has had an 
 attack of pleurisy on right side. Radiogram 30B : there 
 is now a single perihilar cavity (arrows) in the right 
 interlobar region, which is "silent "to the stethoscope 
 and communicates with several bronchi: dilated tubes in 
 the middle lobe surrounded by bands of infiltration 
 apparently becoming fibroid : diminished interspaces 
 on the right, and enlargement of right paratracheal 
 glands. A thin infiltration towards the right base. 
 
 4. Robert C , set 40 (10.9. 17). Clinical : patient 
 
 had an attack of rheumatoid arthritis four years ago : 
 
I'aciiiK p. 44. 
 
o 
 
 Facing p. 44- 
 
Rad. 32 (Ant.) I\TiliiIar nodal tul)ori lo in places pseuilolobar. 
 Kii,'lit l)asal piicmnotliorax. 
 
 I'acinR p. 44. 
 
Radiography of the Chest 45 
 
 now complains of morning cough, with slight expectora- 
 tion : a small haemoptysis occurred for the first time 
 four days ago : a few scattered catarrhal sounds in the 
 right lung, but there are no definite physical signs. 
 Radiogram 31 a, posterior, shows a band of infiltration 
 containing small cavities in the right interlobar area : 
 involvement of the middle lobe : lateral scoliosis, convex 
 to the right. Diagnosis: right interlobar phthisis. 
 Second examination (12.3. 18). Clinical: crepitations (?) 
 both apices (crackles), distant tubular breathing over 
 right middle lobe : weight slightly increasing. Radio- 
 gram 3 IB. There has been a dissemination from the 
 interlobar cavities, which foci now appear to be under- 
 going fibroid metamorphosis. The disease has now 
 become unilateral disseminated fibroid. The old excava- 
 tion at left apex is visible. The patient is now following 
 his employment. Scoliosis appears to be frequent in 
 these unilateral forms. 
 
 5. Alice W. , aet 20. Clinical: anaemic : cough for 
 
 six weeks : expectoration scanty : haemoptysis — : emacia- 
 tion (?) : night sweats + : dyspnoea + . The chest is 
 long, emphysematous : crepitations (?) at apex : catarrhal 
 sounds behind : supraclavicular isthmus on each side- 
 equal (4)4) '■ Radiogram 32 shows a left perihilar tuber- 
 culosis extending to the summit of upper lobe : some 
 left hilar and perihilar excavation: right basal tubercle r 
 two large calcareous opacities (arrows) in right lung, 
 and a small basal pneumothorax (arrows). Partial 
 pneumothorax as visualised by radiology in quiet tubercle 
 often occurs in con?icction tvitli a subplcural calcareous focus, 
 and it is generally free from fluid. The condition in the 
 upper left reminds one of the Laennec's grey infiltration, 
 which is really a caseating lobular chronic broncho- 
 pneumonia. 
 
 General Remarks. — The above illustrations show that 
 perihilar fibrocaseous tubercle may be almost exclusively 
 unilateral. If bilateral the pulmonary lesions are not, as a 
 rule, cotemporaneous; one may be subacutely progressive,, 
 whilst the other is manifestly' quiescent, even retrogressive. 
 They arise in connection with hilar or perihilar glands on 
 the same side, and maj' produce either discrete discon- 
 
.46 Radiography of the Chest 
 
 nected nodes or broad homogeneous infiltrations. At 
 times the disease may arise from apical lesions — pre- 
 sumably, from their radiological aspect, semi-quiescent — 
 in the same or in the opposite lung, when bacilliferous 
 material, issuing from a cavity, is scattered broadcast 
 throughout the bronchi and fastens upon the perihilar area. 
 During its subsequent evolution, cavities may form in the 
 perihilum, and a second dispersal of aerial foci may pro- 
 ceed from them which may be partial — affecting the 
 -diseased side only — or it may be general. In Radiogram 
 30A the interlobar dissemination is discrete, and probably 
 has spread by way of the lymphatic tracts. The evacua- 
 tion of the deep perihilar cavity (Radiogram 50B) is not 
 yet complete ; but, in this case, there has been up to the 
 present little deposition of foci in adjacent parts of the 
 lung. 
 
 The disease advances in the upper lobe towards the 
 •axilla ; in the lower lobe towards the costophrenic sulcus, 
 finally, in each case, producing a cuneate tract of infiltra- 
 tion with its apex situated at the hilum. In the left upper 
 lobe, on account of the absence of the superior fissure, the 
 opacity may be fan-shaped (Radiogram 28). As the lesion 
 marches centrifugally it becomes more and more super- 
 ficial, until in certain areas the characteristic tuberculous 
 jrale becomes audible to the stethoscope. In the earlier 
 stages, when symptoms form the chief clinical feature, 
 post-tussive inspiratory crepitations may be detected (a) 
 €it the sides of the chest, between the axillary lines above 
 the level of the nipple ; {b) in front, on the left side in 
 particular, in the parasternal area within the second and 
 third interspaces, or (c) behind, at the level of the jiila or 
 a little higher, between the vertebral border of the scapula 
 -and the spine, also {d) along the interlobe on the right, 
 or {e) at the base of the lung. Mistakes ma}' be made by 
 the clinician, who thinks only of apical crepitations, and 
 <does not auscultate the fissures, the axilla, and the base. 
 When the disease progresses towards the summit, crepi- 
 
Radiography of the Chest 47 
 
 tations (cedema ?) are occasionally conducted towards the 
 apex, before any radiological evidence is forthcoming as to 
 the existence of disease in that area. Pleuritic pains in 
 the axillary regions, and right basal effusion, are not 
 infrequent. The latter is more likely to occur when the 
 middle and lower lobes are invaded. Basal effusions may 
 be met with in middle age, which recur several times after 
 tapping, and may conceal perihilar discrete foci in the 
 middle and lower lobes. At this period of life they may 
 be accompanied by serious cardiac embarrassment and 
 alarming dyspnoea, which necessitate a partial evacuation 
 of the fluid. 
 
 Perihilar bronchopneumonic infiltration, when bilateral, 
 may therefore occupy the wings of the chest, or it may 
 approach the apex in the one, and the base in the other 
 lung ; there may be an obvious protrusion of the middle 
 intermammary region of the chest, especially in women, 
 and the more marked the deformity the more likely is the 
 disease to be semiquiescent or arrested. Such disfigurement 
 may be termed aymiilar emphysema. There is a greater 
 tendency in this t3^pe to fibrosis and chronicity than in the 
 purely apical variety. The prognosis is more serious in 
 the cavitary forms, and, ccctcris paribus, the younger the age 
 of the patient ; when the foci are small and disconnected, 
 the prospect is brighter than when continuous tracts of 
 infiltration are visible on the radiogram. In the strictly 
 unilateral forms the outlook is also more favourable. 
 Finally, this essentially chronic type appears to be more 
 closely connected with the flat chest {thorax aplati, or 
 paralyticus), whether congenital or acquired, which, when 
 it becomes emphysematous, still remains practically flat, 
 merely bulging, if at all, in the lower middle and basal 
 parts of the lung. 
 
 Perihilar, attenuated or abortive tubercle {phthisis minor), 
 and perihilar fibroid are mentioned later (Chapters V 
 and VI). 
 
48 Radiography of the Chest 
 
 CHAPTER V 
 
 Chronic Attenuated or Minor Phthisis 
 
 To the radiologist a heterogeneous multiplicity of forms 
 is included in this category. The disease is generally 
 strictly localised ; it may become temporarily arrested, or 
 may possess a certain low activity which is more or less- 
 continuous. It may remain quiescent for many years, 
 occasionally altogether; and then approach the type 
 described by Bard under the title Abortive Phthisis. The 
 latter embraces cases where post-mortem examination 
 reveals a few apical scars containing caseous, calcareous, 
 or fibrous nodules. These nodules may also occur beneath 
 the pleura in other parts of the lung, or within its deeper 
 regions. At other times an area of fibro-pneumonic 
 infiltration is discovered, in the interior of which there 
 may be several calcareous foci, a dilated bronchial tube, or 
 one or more smooth cavities. The mediastinal lymphatic 
 glands may be enlarged, and fibroid or calcareous. The 
 physical signs are indefinite ; there may be an impaired 
 note at the apices, increased vocal vibration, harsh 
 inspiration, prolonged expiration, weak breath sounds, 
 and slight bronchophony, without crepitations. The 
 symptoms are equally inconclusive ; pyrexia is absent or 
 trivial, there is an occasional dry cough, absence of bacilli 
 in the sputum, and non-bacillary haemoptyses (due to 
 congested arterioles ?). During the period of haemoptysis 
 areas of small crepitant rales, and of slight tubular 
 breathing, may be perceived along the fissures, and 
 occasionally concomitant signs of pure mitral stenosis, 
 chlorosis, or thyroidean hypertrophy, may be present. 
 According to Piery, the so-called latent forms, which give 
 no clinical signs, and have no appreciable effect on the 
 organism at large, are more or less permanently arrested, 
 and are often due to affections involving the tracheo- 
 
< 
 
 U 
 
 < 
 
 Facing p. 40. 
 
Radiography of the Chest 49 
 
 bronchial, bifurcation, and hilar glands, as well as those 
 of certain extra-thoracic regions (axillary, cervical, mesen- 
 teric). The quiescence may be interrupted by the 
 occurrence of a haemoptysis, or of a pleurisy with or 
 without an effusion. These patients may therefore exhibit 
 periods of low-grade activity, in which there may be 
 slight evening pyrexia and moderate night sweating, 
 anaemia, loss of weight, fatigue, headache, and lassitude. 
 
 The disadvantage of Bard's classification lies in the fact 
 that it was made before the advent of reliable radiography, 
 and, as a consequence, it is to some extent one-sided, 
 unsatisfactory, and incomplete. This authority, moreover, 
 is apt to draw broad distinctions where radiography 
 demonstrates obvious connecting links. Clinical examina- 
 tion is notoriously unable to decipher correctly, if at all, 
 events occurring far beneath the surface, whilst it is 
 practically mute with regard to hilar and perihilar lesions. 
 In the absence of actual post-mortem investigation, which 
 in most of these cases is obviously unattainable, the 
 rays constitute its most reliable substitute; experience 
 diminishes year by year the objections and hostile 
 criticisms directed against it, and at the same time 
 emphasises its value and its necessity. 
 
 The radiographical manifestations exhibited by the mass 
 of minor pulmonary phthisis may be arranged in 
 the following manner : {a) apical nodular, {b) apical 
 infiltrative, (c) perihilar discrete and disseminated, {d) 
 perihilar infiltrative, {e) perihilar fibrotic, (J) lymphatic 
 disseminated, and {g) bronchitic. Examples of each will 
 now be described. 
 
 As a genera] rule these cases are closed, that is, the 
 sputum, if obtainable, is devoid of bacilli. The symptoms 
 are slight, and, except at certain times, may cause little or 
 no anxiety — malaise, slight loss of weight, tachycardia, 
 occasional niglit sweats. There may be a few indefinite 
 crepitations either at one apex, within the axillary lines, 
 along the interlobes, or at the base. 
 
 B 
 
50 Radiography of the Chest 
 
 (a) Apical nodular. George F , aet. 45 (8. 5. 19) : dull 
 
 to percussion at right base : weak breath sounds : TF — : 
 VR — : Diagnosis: thickened pleura + phthisis of the 
 right lung : had influenza with pneumonia in December, 
 191 8: cough since: does not improve: invalided from 
 Army, March, 191 9, with the diagnosis of chronic 
 bronchitis and emphysema. Radiogram 33, nodular 
 tubercle, affecting right apex especially : excavation right 
 supraclavicular apex near axilla : calcareous opacities, 
 one large opacity at the level of left clavicle near sternum: 
 dilated tubes left upper lobes : emphysema both lungs : 
 slight hypertrophy of left ventricle. A chronic case, 
 reactivated probably by influenzal attack. 
 
 {b) Apical infiltrative. Elizabeth L , aet. 38(3.3.17): 
 
 was in hospital for gastric ulcer in 1916: suffered from 
 an attack of pleurisy two months ago with cough and 
 haemoptysis (^IV) at commencement. Right apex, 
 percussion note impaired, air entry at both apices poor, a 
 few crepitations at the left apex : Tbc — . Radioscope : 
 diaphragmatic movements good: both supraclavicular 
 apices open on cough : pulmonary transparency generally 
 impaired. Radiogram 34, posterior, an area of infiltration 
 at left apex, containing small cavities : in right axilla an 
 opacity suggesting a fibroid patch, to which a thickened 
 bronchus runs : a few scattered old foci in right lung: 
 emphysema in right base : interspaces diminished above 
 on right side : mediastinum slightly deflected towards left: 
 slight scoliosis, convex to right. (In scoliosis the inter- 
 spaces on concave side are narrower.) Evidently an old 
 no n-progressive case.(A very co mmon type of minor 
 phthisis, but generally the right apex is involved instead 
 of left.) 
 
 3. Emma R , aet. 39 : had pleurisy on left side two 
 
 months ago with pain : cough + : yellow expectoration : 
 no haemoptysis : general weakness. Clinical : moist 
 sounds, emphysema : diagnosis, chronic bronchitis. 
 Radiogram, posterior, 35 : below apex of right axilla, an 
 area of induration, a few cavities with disseminated foci 
 within right upper lobe, especially between axilla and 
 hilum : emphysema : median heart, cardioptosis. 
 
 4. Ellen M , aet. 25 (5.3.19): influenza pneumonia 
 
 last November : cough — : expectoration — : haemop- 
 
H 
 
 l-'acing p. 50. 
 
c< 
 
 Facing p. 50. 
 
Radiography of the Chest 51 
 
 tysis — : emaciation — : dyspnoea + : pain occasionally 
 on left side. Right apex a few moist sounds, and 
 percussion note impaired : t° irregular, 97°-99° : 
 Radiogram 2,6 : slight deviation of mediastinum to left : 
 patch of infiltration in right axilla with a few small 
 cavities: thickened tubes and bands of cirrhosis in both 
 fields, especially at the right base and in the middle 
 lobe. Many sanatorium cases exhibit a similar appear- 
 ance. Occasionally the infiltration is in the left upper 
 lobe instead of the right. 
 
 Perihilar discrete. — Annie C (19. 3. 18), aet. 24: an 
 
 in-patient six years ago : remained well till January, 
 when she began to be hoarse (paralysis of left cord): 
 glands of neck on left side enlarged, but not caseating : 
 doubtful signs at both apices : mitral stenosis. Radiogram 
 37 : enlarged left auricle (mitral stenosis) : old caseating 
 nodal foci (some calcareous) in both lungs, especially 
 right middle lobe : left paratracheal glands not obviously 
 enlarged : paralysis of cord probably due to enlarged left 
 auricle compressing the recurrent nerve against aorta 
 (case of minor tubercle associated with mitral stenosis). 
 
 Nellie K , aet. 32 : husband suffers from pulmonary 
 
 phthisis, he has been in a sanatorium and is now at home. 
 She has complained of pain in the chest for five months : 
 cough + : expectoration slight : haemoptysis four months 
 ago : wasting + : night sweats — : Tbc. — . Clinical signs : 
 impaired resonance left apex, no adventitious sounds. 
 Radiogram 38 : thorax pareticus, increased area of both 
 hilar opacities : disseminated foci chiefiy in lower and 
 basal fields of lung : slight general cylindrical dilatation 
 of bronchi : small excavations (?) in both supraclavicular 
 apices, from which possibly showers of bacilli may have 
 escaped with the ha;mopt3'sis four months ago: disease 
 now becoming quiescent. Patient seen a year later, 
 practically in statu quo. 
 
 In thejlat or paralytic thorax {vide Diag. 6) the antero- 
 posterior diameter of the chest is reduced; the upper 
 anterior interspaces appear broader in front than usual ; 
 the lower ribs are deep, crowded, the lowest approximating 
 the iliac crest. There are often deep clavicular grooves 
 and wasted pectoral muscles. The descent of the clavicle 
 
52 
 
 Radiography of the Chest 
 
 brings the aortic bulge nearer to it. In many instances 
 it is a secondary manifestation, the outward sign of an 
 arrested tuberculous infection, in individuals with feeble 
 inspiratory energy and of an acquired immunisation. 
 Should tubercle become active again in adult life, it is 
 generally of a slow evolutionary type, liable to become 
 chronic, or entirely latent. 
 
 Diagram 6. 
 
 Maud W- 
 
 October, 191 8 
 
 , set. 20 (18. 3. 19): cough since "flu' 
 pain on left side: wasting +: sweats 
 
 m 
 
 97*2' 
 
 Tbc + : nasal obstruction: percussion note 
 
 diminished on left : crepitations at bases behind : m- 
 creased whisper both apices, vocal cords slightly injected. 
 Radiogram 39 : disseminated nodular phthisis affecting 
 middle lobe chiefly, and base of right upper lobe : the 
 condition at right hilum suggests an irruption into the 
 
< 
 
 Facing p. 52. 
 
— 
 
 ■^ 
 
 
 
 'J 
 
 M 
 
 
 'C 
 
 ^ 
 
 o 
 
 
 Lh 
 
 o 
 
 f3 
 
 ■^ 
 
 3 
 
 u.'^ 
 
 Facing p. 52. 
 
Radiography of the Chest 53 
 
 bronchi from caseating glands : in left hilum discrete 
 nodules, with some dilatation of tubes running to left 
 apex : both supraclavicular apices clear : slight paretic 
 thorax and basal emphysema, with some left axillary 
 pleuritic adhesion, 
 
 Albert W , aet. 29 (28.5.18): was in sanatorium 
 
 six years ago : rejected by the military tribunal one year 
 ago: cough ver}' little: sputum of a morning : haemoptysis 
 six years ago, streaks : no emaciation. Clinical signs : 
 right chest flat : percussion note impaired : vocal 
 resonance + : no definite physical signs : heart deviated 
 to right : bases clear : Radiogram 40 : on the right side 
 fibroid interlacing strands up to the first rib : a fibroid 
 mass in right hilum, thickened strands and dilated tubes 
 running to right base : on left side slightly increased 
 densit}^ of the hilum, small nodules in the external parts 
 of lung, and particularly towards and including the left 
 base (mottling). Cardiac outlines somewhat increased, 
 aortic arch apparently transposed to the right. A case 
 which will show periodic bursts- of minor activity. 
 
 Elizabeth M , aet. 8, always delicate : bronchitis for 
 
 18 months : now cough and pain in left side for six 
 months : t° 99°, evening : expectoration scanty : 
 bacilli +: night sweats — : clubbing — : family history — . 
 Clinical: heart apex beat normal: right chest flat, de- 
 ficient movement : dulness to percussion : crepitations : 
 posteriori}'' also crepitations in both lungs, and dulness 
 below angle of scapula: cavity (?) right axilla behind. 
 Clinical diagnosis : hilar phthisis, rather advanced. 
 Radiogram 41 : both hilar opacities increased : trachea 
 deviated to right, rather more than normal : an opacity 
 outside it on right, which may be an enlarged tracheo- 
 bronchial opacity : irregular cavitation right axilla : 
 small foci along bronchi running from right apex to 
 right hilum, and along the bronchi passing to the right 
 base: right phrenic adhesion (phenomdne du feston 
 diaphragmatique-Maingot). 
 
 Pcrihilar and hilar infdlration. — Ilenr}- L (20.6. 18), 
 
 act, 6 : pallor : dyspnoea : tubular breathing right base, 
 also some at left base (conducted?), and crepitations 
 with dulness to percussion. 22,7,18, dulness at right 
 base, no crepitations now : no tubular breathing. 
 
54 Radiography of the Chest 
 
 Radiogram 42 : a triangular opacity (infiltration) with 
 base at right hilum and apex near axillary bend of the 
 fifth rib (therefore in middle lobe with its superior edge 
 limited by small interlobar fissure) : caseating (?) tracheo- 
 bronchial opacity on the right : some nodules along 
 bronchi running to right apex and a few in left hilum : 
 Tbc. — : re-examined six months later : appearances 
 practically in statu quo. 
 
 Annie M (3.4.19), aet. 31 : suffers from bronchitis 
 
 every winter: influenza, December, 1918 : percussion 
 note impaired right lung : rhonchi over left lung : 
 crepitations left upper lobe. Radioscope : right diaphragm 
 immobile, left sluggish : cuneate interlobar shadow. 
 Radiogratn 43 : a cuneate infiltration with its apex 
 external, starting from the right hilum : fibrosis of middle 
 lobe : thickening of bronchi in right upper lobe, and 
 some fibrous nodules in left hilum. 
 
 Occasionally a similar hilar infiltration is found at the 
 base of the right upper lobe, the lower margin of which 
 runs along the interlobe. The real significance of opacities 
 of this kind, and in this region, is not clear. They may be 
 due to a direct tuberculous infection of the lung by way 
 of caseating hilar or bifurcation glands. If radiographed 
 again at the interval of some weeks the opacity may be 
 found to have disappeared, leaving behind merely an inter- 
 lobar stripe ; moreover, the opacity may reform (recurrent 
 hilar infiltration). It has been suggested that these relapses 
 may be due to the evanescent appearance of recurrent 
 interlobar effusions. In the case of the boy mentioned 
 above {Radiogram 42) it is possible that the opacity was 
 originally bronchopneumonic, and has now, six months 
 afterwards, become fibrotic. In other words, these opacities 
 are not always of a tuberculous nature, and the diagnosis 
 from bronchopneumonia must depend on subsequent 
 radiological examination, assisted by clinical and labora- 
 tory methods of investigation. 
 
 Lily M (i 1.3. 19), aet. 19: a mouth breather: 
 
 nutrition good : influenza and pneumonia, October, 191 8: 
 cough + : expectoration slight : haemoptysis in October. 
 
C s! 
 
 Facing p. 54. 
 
Radiography of the Chest 55 
 
 Clinical signs : percussion note impaired with crepitations 
 at both apices : Radiogram, posterior, No, 44 : both hilar 
 opacities prominent, especially the right : two small 
 infiltrations outside left hilum (arrows) : network of 
 thickened lymphatics (?) running to left apex : foci in 
 the left first posterior interspace, scarcely visible except 
 on plate : thickened bronchi or vessels in right lung : 
 apparently an infiltration at the level of the sternal 
 osseous extremity of first right rib : superior emphysema, 
 some homogeneous shadowing in the basal and axillary 
 areas on right side : a few foci brought into view through 
 the sternal end of right clavicle. 
 
 Examples of perihilar fibrosis are described in Chapter 
 VI. Two cases are here inserted of the disseminated type, 
 one chiefly affecting the right middle lobe, the other both 
 hila and their prolongations. 
 
 Ada F , aet. 23: (T.B. Dispensary): cough nearly 
 
 gone: sputum scanty : haemoptysis — : night sweats?: 
 emaciation ? : liable to catarrh : slight exophthalmos : 
 patient looks well and is not thin. Ph3'sical signs nil : 
 Radiogram 45, shows a disseminated old disease, 
 probably spreading from hilum, and producing some 
 fibrosis of the right middle lobe : a few old fibroid 
 specks in the lower part of right upper lobe : apices 
 clear, excepting an apical pleural cap on left. The 
 case may be entered among the latent forms — with 
 regard to tubercle it is now practically quiescent. 
 Generalised obsolete and fibroid disseminated lesions 
 of this type frequently accompany exophthalmic goitre. 
 
 Nettie L , ajt. 22 : has had a cough for two years : 
 
 haemoptysis eight months ago, small: clubbing: cough 
 tight: vomits with cough: appetite poor: air entry into 
 both lungs poor: at right base breath sounds practically 
 absent : wheezy rales over both lungs : dulness to 
 percussion over left. Clinical diagnosis : bronchitis. 
 Radiogram 46: chest flat and paretic: basal emphysema: 
 both hila fibrotic, prolonged upwards and downwards : 
 bronchus running to upper left lobe dilated, and thick- 
 ened : small nodules along bronchi : slight dissemination 
 in the wings of chest : heart cardioptosis, with hypoplasia 
 (narrow, long), aorta narrow : no infiltrations. Perihilar 
 
56 Radiography of the Chest 
 
 fibroid disease in which the signs of past tubercle are 
 fast disappearing. 
 
 Lymphatic dissemination. — Maud S , aet. 33 : suf- 
 fered from severe attack of pertussis over one year ago, 
 during which she had an attack of haemoptysis : never 
 well since : cough morning : expectoration small in 
 amount and dark : palpitation : giddiness. Clinical signs : 
 chest flat : weak breathing left upper lobe : slight 
 systolic murmur : t° normal. Radiogram 47 : linear 
 opacities, thickened lymph trunks following the course 
 of the bronchial tree : tubes cylindrically dilated in left 
 upper lobe and at bases : dilated tubes in right middle 
 lobe : commencing calcification of rib cartilages on both 
 sides : diminished transparency in right upper lobe : 
 right hilar shadow intense : enlargement of lymphatic 
 nodes (at bifurcation of bronchi) nearly to the periphery : 
 pleuritic thickening left apex. 
 
 Rosina W , aet. 51 : cough on and off since an 
 
 attack of pleurisy two years ago : no expectoration : 
 influenza nine months since : a few crepitations at right 
 apex which disappear on cough (pleuritic) : rough breath 
 sounds on right : crepitation and friction sounds at the 
 right base : dulness to percussion above left diaphragm. 
 Radioscope : diaphragmatic movements impaired : scle- 
 rosis of aorta : some diminished transparency in the right 
 lung. Radiogram 48 : perihilar disseminated tubercle 
 (peribronchial): dilatation of tubes generally with 
 thickened walls, especially in the left upper lobe : and 
 in certain localities, as in left mammary region, studded 
 with small nodules. Opacities due to nipples conspicuous 
 (arrows), both hilar opacities intense, and paravertebral 
 bronchus in right upper lobe much thickened : several 
 dense opacities in right hilum (anthracotic). Thorax 
 paralyticus. 
 
 Bronchitic{l). Mar3^J.B (5.3.18), ast. 19: injanuarj^ 
 
 191 7, had an attack of influenza with pleurisy, each side 
 in succession : in March the abdomen became distended, 
 but subsided after a few months' treatment : cough — : 
 expectoration — : bacilli — after many examinations: 
 emaciation + : night sweats + : a few crepitations 
 occasional!}'- audible in the right upper lobe with inter- 
 rupted sounds. Radiogram {anterior) 49 shows dilated 
 
Facing p. 56, 
 
Rad. 49 (AnL)— Chronic fibrocaseating broiichitic (?) phthisis. 
 
 Facing p. 50. 
 
Radiography of the Chest 57 
 
 and thickened bronchi throughout : dense right hilar 
 opacities reaching nearly to the base : the bronchi and 
 ramifications exceedingly well seen in certain localities, 
 suggesting a perihilar caseating bronchitis : * resembling, 
 in the right upper lobe, the stunted branches of a 
 leafless tree (upper arrow) : a small infiltration left 
 axilla: emphysema both lungs. {Vide Chapter IX.) 
 
 * Or a slowly advancing tuberculous lymphangitis. 
 
 Additional remarks concerning the relations between tubercle and 
 certain types of bronchitis will be found in Vol. II. 
 
58 Radiography of the Chest 
 
 CHAPTER VI 
 
 Pulmonary Fibroid Tuberculosis 
 {Phthisis Fibrosa) 
 
 The designation " fibroid pulmonary tubercle " may be 
 reserved for those cases in which the radiogram shows 
 numerous fibroid deposits, extensive areas of fibrosis, or 
 evidence of considerable displacement of internal organs, 
 and deformities of the chest wall with or without the 
 presence of cavities. In many cases the continuous 
 shrinking of the fibrous tissue is carried to an extreme, 
 and leads to massive distortion of the chest wall, intense 
 crowding of the ribs, marked deviation of the mediastinum, 
 and blurring of the aortic arch and cardiac outlines. The 
 degree of disfigurement of the chest depends on the 
 unilaterality of the disease, on the age of the individual, 
 and on the iproduction of thickened parietal adhesions of 
 the pleural wall. The aifection is often limited chiefly to 
 one lung, the other becoming hypertrophied and passing 
 beneath the sternum and in front of the spine into the 
 diseased side. In these unilateral cases of pulmonary 
 cirrhosis, whether tuberculous or purely fibroid, B^clere 
 has called attention to the displacement of the mediastinum^ 
 which occurs during deep inspiration^ towards the diseased 
 side. 
 
 The varieties of fibroid tubercle may be provisionally 
 grouped in the following manner : — 
 
 1. Fibroid disseminated nodular and nodal (P. fibro- 
 
 disseminata). 
 
 2. Fibroid infiltrative — pseudolobar and lobar, often 
 
 containing small cavities and dilated tubes (P. 
 fibro-densa). 
 
 3. Fibroid peribronchitic, in which the bands of 
 
 cirrhosis appear either as linear, often wavy 
 
Radiography of the Chest 59 
 
 opacities, or as shorter fusiform shadows along 
 the course of the bronchi. 
 
 4. Fibroid diffuse granular, with a ground-glass 
 
 appearance on the radiogram — chronic inter- 
 stitial tubercle (P. fibro-diffusa). 
 
 5. Fibroid cavitary forms par excellence (P. fibro- 
 
 cavernosa). 
 
 Of these types the nodular and nodal forms may become 
 arrested for years. The ground-glass forms, which are 
 uncommon, may be diagnosed chronic interstitial pneu- 
 monia by the clinician. These are practically permanently 
 arrested ; also the peribronchitic forms may settle down 
 and become quiescent ; in the cavitary forms, when the 
 excavation is complete, the prognosis becomes more 
 hopeful. The ultimate outcome is more dependent on 
 secondary conditions, such as the incidence of sclerosis in 
 the systemic vessels and viscera, the age of the patient, 
 and the nature of his environment. In middle life, and 
 beyond it, many of these cases masquerade as chronic 
 bronchitis and asthma ; the tuberculous character of the 
 disease may only be verified by the presence of the 
 so-called tuberculosis granules in the sputum, and its 
 tuberculogenic power after inoculation into the lower 
 mammals, as the guinea pig. Some more easil}^ applied 
 pathological test is an urgent desideratum. If incident 
 at an early age the displacement of the mediastinal 
 organs may become extreme ; nevertheless, life may be 
 prolonged, even under these conditions of severe cardio- 
 vascular strain, for several years {vide Radiograms 63A 
 and b). 
 
 I. Phthisis jxhro-disseminata is generally bilateral, and 
 often appears to be the direct result of fibrosis following 
 subacute types of the same name (Chap. III). When it is 
 bilateral, it is usually accompanied by double emphysema, 
 which throws into bold relief the opaque foci when viewed 
 on the fluoroscopic screen. The picture becomes even 
 more striking after an attack of asthma, a complication 
 
6o Radiography of the Chest 
 
 which is frequent in these individuals as they advance 
 in years. 
 
 (a) Archibald E , aet. 28 (26.2.18). Clinical: has 
 
 been in the army since boyhood : cough +: emaciation +: 
 night sweats — : heart apex beat normal : flattening and 
 diminished movement right apex : crepitations both 
 apices. Radiogram 50 : disseminated fibroid tubercle 
 with cylindrical dilatation of tubes throughout : some 
 cavitation at right apex : small bronchopneumonic nodes 
 and thickened bronchi : several patches of consolidation 
 below the left axilla, and some excavation in the lowest 
 (arrow) Radiological diagnosis : fibroid disseminated 
 tubercle. 
 
 Those cases in which the nodules become fibro- 
 calcareous may be included in this category. They are 
 often accompanied by calcareous metamorphosis of the 
 lymphatic glands in the neck, in the axilla, and of the 
 glands along the internal mammarj'' artery. In the 
 unilateral forms the diseased lung may be prevented 
 from becoming emphysematous by the presence of 
 thickened and adherent pleura at the base. In such 
 cases the comparatively healthy lung hypertrophies and 
 finally becomes emphysematous. 
 
 2. Fibroid infdtrative disease leads to the formation ot 
 large opaque areas, as seen on the screen. These may be 
 present in one or both upper lobes covering the supra- and 
 immediate infra-clavicular regions with a dense veil, or 
 they may be present in other parts of the field, as the base 
 of the right upper or in the middle lobe. Tvro cases are 
 described in Chapter VII. 
 
 (^b) Henry W , aet. 16(11.9.16). Clinical: family 
 
 history — : bronchitis as a child : cough now six weeks : 
 expectoration slight : Tbc. + : haemoptysis — : night 
 sweats — : movement of apices fair (?) : percussion note 
 impaired, crepitations and breath sounds harsh at both 
 apices : pyrexia irregular: temperature normal on leaving 
 for sanatorium (21.5. 17). Radiogram 51: dense in- 
 filtrations at both apices, with lighter areas, on the plate 
 at the level of the osseous end of the first right rib : 
 
»i 
 
 oi 
 
Oh 
 
 « 
 
 Facing p. 60. 
 
Radiography of the Chest 6i 
 
 disease more advanced in left upper lobe : long cirrhotic 
 streamers running downwards along the bronchi : 
 trachea deviated to right : some dilatation of bronchi at 
 the right hilum, and small disseminated nodules in the 
 rest of the right lung. Heart median, and narrow. 
 
 (r) Mrs. K , aet. 23. Clinical: in left upper lobe, 
 
 dulness to percussion, bronchial breathing, moist sounds : 
 sputum, Tbc. — . Clinical diagnosis : pulmonary tuber- 
 culosis in left lung. Radiogram 52 : both hilar opacities 
 increased in density and fibrotic : scattered nodules 
 throughout the right lung: a triangular area of fibrosis 
 extending from the left hilum towards the axilla with its 
 apex external, and containing a few transparencies 
 (cavities ?). Diagnosis, left perihilar fibroid. 
 
 3. In the peribronchial fibroid type (peribronchitis fibrosa) 
 the fibrosis often assumes the form of wavy bands of 
 opacity, which sometimes form thick sheaths around the 
 bronchi. They may, originally, be partial disseminated 
 nodular ; in other instances they may be due to gradual 
 spread along the peribronchial lymphatics from the hilum ; 
 occasionally they are the final residues of arrested 
 bronchopneumonic tubercle in which the lesion has 
 advanced per contiguitatem along the bronchial wall. 
 
 {d) Jane F , aet. 42 : examined as a contact case : 
 
 has been nursing a daughter who died of pulmonary 
 phthisis. Clinical: there are some distant sounds at 
 both roots, especially the left, a faint cardiac systolic 
 murmur not conducted outwards : oedema of the legs at 
 night. Clinical diagnosis as regards tubercle negative. 
 Radiogram 53 : old cavitary infiltrations at both apices, 
 with fibroid nodes and bands running towards the hila. 
 Both hilar opacities dense. Dilatation of ascending 
 aorta and slight cardiophrenic adhesion at the apex. 
 
 Such cases emphasise the advisability of the examina- 
 tion of contact individuals. Parents suffering from quasi- 
 arrested old disease may infect their children and outlive 
 them. 
 
 {e) Florence E , aet. 35. Clinical: caught cold 
 
 16 months ago: never well since: complains of pre- 
 cordial pain radiating down left arm after exertion : 
 
62 Radiography of the Chest 
 
 children seven — four dead : some had snuffles. Previous 
 history, bronchial catarrh. Physical signs, left upper lobe 
 dull to percussion, crepitations in front and behind left 
 apex, and physical signs of a cavity : Tbc. — : dyspnoea 
 + +. Clinical diagnosis, fibroid tubercle (?), media- 
 stinitis (?). Radiogram 54 : in the left upper lobe a 
 condition of fibrosis with small cavities : below these 
 again, dilated tubes : scattered patches in the right 
 lung : right phrenic leaflet irregular. X-ray diagnosis, 
 pulmonary fibrosis of left upper lobe with bronchiectasis : 
 possibly gummatous and non-tuberculous. Wassermann 
 not employed. 
 
 (/) Edward P , aet. 28 (4.4.17). Tea salesman: 
 
 invalided from Army, 191 5 : haemoptysis, two ounces on 
 three occasions ten years ago : cough slight : expect- 
 oration small in amount, yellow : Tbc. + : emaciation, 
 one stone : dorsal kyphosis : right lung bronchial 
 breathing and rhonchi locally : fine crepitations on deep 
 inspiration at both apices above clavicles : dulness to 
 percussion : crepitations cleared up after a few weeks. 
 Climcal diagnosis: pulmonary tubercle of both apices. 
 Radioscope, both diaphragmatic halves move well : apices 
 dull, not opening on cough : heart median, long, narrow. 
 Radiogram 55, fibroid nodules and fusiform bands of 
 fibrosis in both apices : small supraclavicular excava- 
 tions (?) : disease spreading downwards internally and 
 along axilla on right, more centrally on left side : a dense 
 fibrotic opacity between left aortic bulge and apex of 
 left lung ; basal emphysema. 
 
 (4). Diffuse granular forms (P. fibro-diffusa). This 
 type of fibroid disease of the lung may be overlooked by 
 the radiologist, especially when it presents no isolated 
 opacities, but is uniformly grey. It may be erroneously 
 considered to be a thin diffuse pleuritic th/ckening. 
 Careful examination of a good plate, however, may reveal 
 the signs of an old apical or perihilar excavation surrounded 
 by an opaque infiltration, or dilated perihilar tubes 
 encircled by what appear to be caseous shadows. It is 
 often diagnosed as chronic interstitial pneumonia, espe- 
 cially if the clinical history is suggestive, and the past 
 
i 
 
 Facing p. 62. 
 
a 
 
 X 
 
 a 
 ■5 
 
 u 
 
 ta ^ 
 
 racing p. 62. 
 
Radiography of the Chest 63 
 
 evidence of a tuberculous origin is ambiguous, uncon- 
 sidered, or ignored. 
 
 (g) Bessie C , aet. 29 (3.10. 18). Wasting + : 
 
 appetite poor : has had pneumonia several times. 
 Clinical signs : dulness at left base, heart slightly de- 
 viated to the left. Clinical diagnosis : fibrosis of the left 
 base. Radioscope, deviation of heart and mediastinum 
 to the left : adhesion of left phrenic leaflet to the costal 
 wall externally : outer half immobile. Radiogram 56 
 (anterior), apex of heart to the left : near left hilum at 
 level of sixth rib two small opacities surrounding a 
 dilated bronchus. Both lungs are emphysematous, and 
 the abrupt twist of the ribs on the left side just above 
 the diaphragm indicates old pleuritic adhesion. 
 
 Some of these cases are evidently arrested chronic 
 tubercle, since an apical cavitation is present. In the 
 posterior radiogram of this case there were a few small 
 excavations at the left apex. Others are of perihilar origin, 
 and the signs of tuberculosis are obscured by the homo- 
 geneous fibrosis, and become revealed only after the 
 employment of laboratory methods. The next radiogram 
 shows a transitional condition. 
 
 (h) Katherine W , aet. 34. Has suffered from a 
 
 winter cough for years : expectoration — : haemop- 
 tysis — : Tbc. — : breath sounds clear: crepitations 
 outside cardiac apex in front and over the left lung 
 behind, with dulness to percussion. Radiogram 57 
 (anterior), heart slightly pulled over towards the left : 
 metal square on left nipple : a lateral axillary pleuritic 
 thickening over left lung, ending abruptly just below 
 the nipple: acute bending of the ribs on left side: in 
 the right lung a granular appearance, showing a studding 
 of foci along the thickened bronchial tubes : en larged 
 right hilum, and an unevenly contracted right phrenic 
 leaflet. The crepitations were evidently of pleuritic 
 origin. 
 
 Chronic interstitial tuberculosis may occur in associa- 
 tion with pure mitral stenosis. 
 
 (i) Rosa M , aet. 35. Cough nocturnal + ; 
 
 wasting + ; percussion note impaired in the right upper 
 
64 Radiography of the Chest 
 
 lobe : sent to X-ray department as incipient tubercle (?). 
 Radiogram 58, cardiac outlines of mitral stenosis : both 
 pulmonary fields pervaded by the fine mottling of diffuse 
 fibrosis : emphysema in both lungs, with a tendency to 
 the paralytic thorax. On the right side of the intra- 
 thoracic trachea a thickened line, ending below in a 
 slight enlargement (Crane's inverted comma), which is 
 to be regarded as a fibroid metamorphosis of one of the 
 deeper tracheobronchial glands. The comma with its 
 prolongation (fibrosed lymphatic) is a guide to the 
 right border of the trachea. In Radiogram 37, Chapter V, 
 mitral stenosis is accompanied by a nodular arrested 
 tubercle. 
 
 For the sake of comparison two cases of pneumoconiosis, 
 due to the inhalation of organic dust, are depicted in 
 Radiograms 59 and 60. 
 
 {a) Henry T , aet. 48. French polisher : has 
 
 suffered from asthma for five months : heart apex beat 
 normal : chest emphysematous : rhonchi diffused through- 
 out both lungs. The Radiogram, No. 59, show^s emphy- 
 sema, phrenic leaflets flattened : heart vertical and 
 median : mediastinum slightly deviated to the left : a 
 fine network of fibrosed tubes most marked in the right 
 lung : slight general dilatation of the right bronchi : both 
 hilar opacities enlarged and fibrous. The resemblance, 
 and at the same time the distinction from interstitial 
 fibroid tubercle, are noticeable. 
 
 The affinity of this case with tubercle is exceedingly 
 remote. Occasionally in the elderly, tubercle becomes 
 grafted upon pneumoconiosis (fibro-tuberculous) ; when 
 this occurs the infection often occupies the right upper 
 lobe, or it may be interlobar. In the latter event the ap- 
 pearance of bacilli in the sputum may be considerably 
 delayed. 
 
 {b) Peter H , set. 21. Has worked in grain for four 
 
 years. Clinical : cough + : expectoration + : Tbc. 4- : 
 percussion dulness impaired on the right side in front 
 and behind : rhonchi right lung in front and both bases 
 behind: no clubbing. Radiogram 60, the right hilar 
 opacity is very large (a characteristic of dust disease), 
 
KaciriK p. 04. 
 
1 
 
 Facing p. 64. 
 
Radiography of the Chest 65 
 
 and contains dilated tubes : old infiltrations at the right 
 apex with excavations (only seen distinctly on the 
 plate) : a pronounced general striation — possibly disease 
 in this instance first tuberculous, then pneumoconioid. 
 
 In coal miners the inhalation of carbon dust is said to 
 play an important part in the production of dense fibroid 
 phthisis. On the other hand, the researches of Tripier 
 and others seem to establish the inverse relation^ namely, 
 that pulmonary tuberculosis induces the production of 
 pneumoconiosis in dust workers ; the presence of the dust 
 hinders the development of existing tubercle, and converts 
 what might become an ordinary common phthisis into a 
 mild, very slowly progressive fibroid form. In other 
 words, it is tuberculo-fibroid in character {vide Vol II); 
 and therefore only occurs in miners already aff"ected with 
 tuberculosis. A similar line of thought may be suggested 
 with regard to alcoholism and specific disease when asso- 
 ciated with tubercle. 
 
 (5) In the cavitary forms par excellence, the excavations, 
 when apical, may possess adequate drainage through the 
 bronchi, may become empty, dry, surrounded by a thick 
 capsule, and comparatively innocuous. Their outlines 
 may remain perfectly regular and oval for3'ears ; they may 
 contract, or may again become enlarged, eroded, and ragged 
 as the result of mixed infection. 
 
 {a) Henry H , aet. 34. His illness began with an 
 
 influenza cold two years ago : cough + : expectoration + : 
 Tbc. + : t° 97^-98 •4*'. Clinical signs, percussion note 
 impaired at both apices with crepitations. Clinical diag- 
 nosis : pulmonary tuberculosis of both apices, quiescent : 
 Radiogram 61, one large cavity in each axillary region, 
 •'silent" and unrecognised by stethoscope, with fibroid 
 induration surrounding each. Small nodes in each 
 supraclavicular apex. On each side the disease reaches 
 nearly to the level of the hilum. Heart median, narrow. 
 
 {b) Horace G , aet. 36.* Ex-soldier: Clinical: 
 
 influenza 1918, five weeks in bed : at end of second week 
 haemoptysis, half-a-pint ; in 1916 haemopt3'sis, i pint: 
 " In more advanced stages of this variety the greater part of one or both 
 fields may exhibit a similar radiographical appearance. 
 
 F 
 
66 Radiography of the Chest 
 
 cough + : wasting + : t^ 97 "4° : dulness both apices: 
 isthmus, right 3", left 2V : paravertebral dulness : no 
 adventitious sounds. Radiogram 62A, areas of nodular 
 fibrosis, small consolidations and small irregular exca- 
 vations at both apices : disease advancing towards the 
 base on the right : heart median : basal emphysema. 
 
 {c) Olivia B , 62B, aet. 13. An example of marked 
 
 bilateral fibroid, with cavitation in both upper lobes : 
 in the large cavity on left the openings of the bronchi 
 are visible, and it is crossed by the axillary border of 
 the scapula : there is increased deviation of the heart to 
 the left, and laevo- mediastinum. A few broncho- 
 pneumonic nodes are visible in the middle of the right 
 lung. The patient succumbed during the spring epi- 
 demic of influenza, 1919. 
 
 {d) Fred. B , aet. 13. An example of unilateral 
 
 fibroid phthisis (?) : wasting + : coarse features : 
 dyspnoea + : nails incurved : sputum copious : night 
 sweats — : apparent onset four years ago : heart beats 
 felt outside right nipple line : cavitary signs in front at 
 the base : over the back rales in right lung : bronchial 
 breathing and bronchophony at the left apex : crepita- 
 tions at the left base (consolidation?): moist crepitations 
 over the right side in front. Clinical diao;nosis: fibrosis 
 (tubercle ?) of right lung. Radiogram 63A, anterior : 
 right lung contracted : left hypertrophied, reaching 
 middle line at cardiac apex : dextro-cardia : dextro- 
 mediastinum : dextro-trachea : on right side upper arrow 
 points to the ascending aorta, which was seen beating in 
 the middle of the right pulmonary field : the lower, to 
 the bifurcation of the trachea : on the left side the arrows 
 indicate the aorta, and the scoliosis cardiac apex. 
 Posterior Radiogram, 63B, the middle of contracted 
 right chest is occupied again by ascending aorta : a large 
 apical cavity (arrows) : bifurcation of trachea on right 
 of spine (arrows) : several small cavities and dilated 
 tubes below : cardiac outlines blurred. Patient seen 
 again two years later ; he has put on weight, has now a 
 healthy complexion, and is in some light employment. 
 The radiographic appearances are unchanged. This 
 case may be one of pure fibroid lung : the apical cavity 
 has thin walls and may be bronchiectatic. Final diag- 
 nosis: Pure fibroid lung, bronchiectasis. 
 
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 ^ 
 
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 6 
 
Facing p. 66. 
 
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 bO 
 
 O 
 
 KacinK p. 66 
 
Radiography of the Chest 67 
 
 (e) Emma B- , aet. 55. Has complained of weak 
 
 chest for twenty years : had attack of pleurisy ten years 
 ago, and was tapped several times : cough + : expect- 
 oration + : Tbc. + (six years ago) : complexion good : 
 suffers from dyspnoea : does not appear tuberculous, 
 and has preserved weight. Posteriorly, dulness to per- 
 cussion throughout : on left side, commencing above, 
 increasing signs of cavity, very marked at base (broncho- 
 phony, whispering pectoriloquy, amphoric breathing) : 
 ■on right side expiration prolonged : no moist sounds. 
 Radiograyn 64, large cavity in left apex, laevo-trachea 
 and its bifurcation (arrows) : increased deviation of 
 heart to left : crossing of right lung to left of spine : 
 irregular cavity at right apex — perfectly- oval when 
 radiographed in 1913 — six years ago. The important 
 features are the marked cavitary physical signs at 
 base, instead of at the apex (acoustic anomal}-), and 
 its evolution which is not entirely stationary. Apart 
 from the ragged excavation at right apex, and the 
 entrance of the right lung into the left chest, the con- 
 dition is in statu quo. Prognosis is more favourable 
 when the right lung is intact. Lateral scoliosis is 
 present of the same degree as before, convex to the 
 right. There is still a liability to winter colds and 
 slight attacks of haemoptysis. As regards its precise 
 position, the case probably corresponds to the post- 
 pleuritic fibro-caseous (cavities) type of Bard, with a 
 supplementary slozvly progressive fibrosis and somewhat 
 favourable prognosis. Moreover, the patient's environ 
 ment is perfect. 
 
68 Radiograpky of the Chest 
 
 CHAPTER VII. 
 
 Pneumonic Phthisis : Miliary Phthisis. 
 I. Pneumonic Phthisis. 
 
 Pneumonic Phthisis {Pneumoriia caseosa), as in other types 
 of pulmonary tubercle, may be acute, subacute, or chronic 
 in its course. Although secondary, as a rule, to fibro- 
 caseating cavitary apical phthisis, it may occasionally 
 originate as hilar or perihilar disease ; in the latter case 
 evidence of old apical lesions may be found at the autopsy. 
 When a consolidation does not resolve in the usual manner, 
 after an attack of pneumonia, the possibility of a tuberculous 
 infection may be entertained, even if no bacilli are present 
 in the sputum : the explanation of a well marked radio- 
 logical opacity present in the lower part of the right upper, 
 in the middle, or in the basal lobe, which remains some 
 time after the clinical symptoms and signs have become 
 less severe or have disappeared altogether, is often a very 
 delicate problem. In some cases it is obviously a fibrotic 
 or chronic interstitial pneumonic shadow ; sometimes it 
 may be due to a collapse fibrosis after bronchopneumonia, 
 in which the bronchi will become dilated eventually ; in 
 others it may be either a pure pneumonic or broncho- 
 pneumonic residue in a tuberculous subject, or an actual 
 pneumonic caseation which has assumed a subacute or 
 chronic phase. It may be necessary to examine and re- 
 examine the patient at intervals of two or three months by 
 means of clinical, radiological, and laboratory methods 
 before arriving at a final and satisfactory solution. 
 
 Tuberculous pneumonia is characterised post-mortem 
 by the pres^ence of a massive lesion, occupying at least the 
 whole or the major part of one lobe of the lung. Death 
 may supervene in rapid cases in the stage of hepatisation 
 before any material_^solution has occurred ; or there may 
 
Radiography of the Chest 69 
 
 have been time, as generally happens, for the production 
 of diffuse or sinuous excavation of the caseating mass. As 
 regards the clinical features, the physician at first probably 
 considers that he has before him an ordinary lobar 
 pneumonia, until he finds that the crisis has not appeared 
 at the end of the second week, the temperature still 
 ranging between 103^ and loi^, while the weakness and 
 emaciation are becoming more manifest, if not accelerated, 
 and the physical signs of crepitant rales and cavernous 
 sounds still persist. The clinician may then suspect the 
 presence of an encysted empyema or of a massive 
 pneumonia, but the physical signs do not support either 
 impression ; during the course of epidemic influenza, 
 the possibility of a subacute migratory bronchopneumonia 
 may be suggested ; finally the sputum, which in the mean- 
 time may have become purulent, is examined, and a few 
 bacilli may be found, or, if possible, the patient is examined 
 by the rays, a radiogram is taken, and the problem is 
 solved. (Vol. II.) 
 
 A summary of the essential and distinctive features may 
 be useful. The commencement of the disease is rarely 
 acute, like that of ordinary lobar pneumonia, with its 
 rigor, pain in the side, and sudden rise of temperature to 
 104° ; on the contrary, there has usually been a pre- 
 liminary period of a few weeks or months during which 
 the patient has been " out of sorts," with a chronic cough, 
 headache, loss of weight and strength ; and he has become 
 increasingly dyspnceic. In some instances the disease is 
 ushered in by a severe haemoptysis, which renders the 
 diagnosis clear. The sputum may be stained, gelatinous, 
 viscid; it may be simply mucoid; when the lesion softens 
 it becomes mucopurulent, and finally purulent. Often the 
 sputum is non-bacillary ; in the case of Radiogram 65A the 
 bacilli were abundant on the first examination. The tem- 
 perature curve is rarely continuous, but intermittent from 
 the beginning. The physical signs are generally' on the 
 right side, in the region of the superior interlobc, above it, 
 
70 Radiography of the Chest 
 
 or at the bases behind ; occasionally they are limited to 
 the middle lobe in front. There is dulness and sub- 
 crepitant rales, and the breathing is more amphoric than 
 in common pneumonia. On the healthier side there may 
 be rhonchi, or the signs of a scattered bronchopneumonia^ 
 or those of a dry pleurisy. There may be auscultatory 
 evidence of the existence of arrested tuberculous fibrosis 
 of the right apex; sometimes the radiological evidence of 
 apical cavities, with or without stethoscopic confirmation ; 
 it is believed that these cavities act as resonators in the 
 production of the amphoric breath sounds. This concep- 
 tion may also serve to explain the acoustic anomalies in 
 Radiograms 64, 63A and 63B. Pneumonic phthisis is 
 prone to occur during indigence and after chronic neglect 
 of healthy conditions of living; its progress may be so 
 precipitate that death occurs within three weeks from 
 massive toxaemia ; more often it runs a course of two or 
 three months, with the formation of cavities and gradual 
 extension to the other lung ; exceptionally it assumes the 
 chronic form, and continues as an ordinary fibrocaseous 
 phthisis. 
 
 (a) Frederick O , aet. 24, by trade a fitter : two 
 
 months before had apparently been in good health: now 
 is suffering from post-influenzal pneumonia : cough + : 
 cyanosis + : dyspnoea +: pyrexia +: clubbing of fingers 
 + : Physical signs : crepitations at both apices : behind^ 
 dulness on both sides and crepitations : sputum muco- 
 purulent and contains numerous bacilli. Radiogram 65A : 
 at the lower part of right upper lobe a dense, practically 
 homogeneous infiltration, reaching nearly to clavicle, and 
 forming nodal opacities below in right middle lobe : 
 signs of old cavitation in the right infraclavicular 
 apex(?): disseminated bronchopneumonic patches ex- 
 tending from the left hilum towards the axilla : cardiac 
 apex slightly retracted towards the right, or possibly a 
 median heart. A large paratracheal opacity on right 
 border of the intrathoracic trachea, not clearly separable 
 from the pneumonic consolidation in the print, but easily 
 on the plate and lantern slide. 
 
u 
 
 u 
 
 Facing p. 71. 
 
Radiography of the Chest 71 
 
 (b) Radiogram 65B (posterior), was taken seven weeks 
 before death. In the right middle lobe there is a deep 
 shadow, with a definite line of demarcation above, which 
 is practically horizontal, with a curved outline extern- 
 ally : internally the opacity joins that of the heart. In 
 the remainder of the fields a few scattered nodules, left 
 supraclavicular excavations, thickened and dilated hilar 
 tubes. Post-mortem : the right middle lobe was almost 
 completely occupied by confluent caseating nodules : in 
 the h/t apex a cavity, about the size of a hen's Qgg, ivith- 
 out thickened walls, and somewhat obscurely seen on the 
 plate. Probably radiograms of the isolated left apex, 
 ventral and dorsal, would have brought the excavation 
 more clearly into view. 
 
 {c) Arthur B , aet. 49 (6.5.19). Family history 
 
 negative: had pneumonia in India in 1895: pleurisy in 
 1911: influenza in October, 1918: winter cough for 
 fifteen years: expectoration white and abundant: haemop- 
 tysis, streaks the week before admission : emaciation, 
 four stone : night sweats — : dyspnoea +. Clinical signs: 
 scattered sibilant sounds behind on right side : right base 
 dull to percussion, and no breath sounds : chest rigid : 
 crepitations in left lung: 96?-98'4* : Tbc. negative: 
 Radioscope : a dense opacity in the right middle lobe, 
 the right leaflet of the diaphragm almost immobile. 
 Radiogram 66, anterior : a dense shadow continuous 
 with the right border of the heart, mapping out the right 
 middle lobe, with a lighter streak between it and the 
 diaphragm corresponding to the right basal lobe. Dis- 
 semination spreading to the upper right lobe and to the 
 left lung, apparently lymphatic : spreading through left 
 hilum, many nodal shadows along bronchus running to 
 lower lobe, and also radiating lines running towards the 
 left apex. The posterior view showed that the margins 
 of the opacity were blurred. The diagnosis lies between 
 bronchial carcinoma and caseating pneumonia of the 
 right middle lobe. The absence of bacilli, the very 
 pronounced emaciation, the type of lymphatic carci- 
 nomatous dissemination, with very few nodular foci, the 
 absence of pyrexia, are in favour of neoplasm, which, 
 as a matter of fact, it proved to be. 
 
 It is convenient here to describe the somewhat infrequent 
 
72 Radiography of the Chest 
 
 condition of fibroid tuberculous pneumonia (phthisis hyper- 
 plastica tuberculosa) which, according to Tripier, follows 
 a prolonged red hepatisation. Generally, the patient is a 
 chronic or latent consumptive, who is attacked by a lobar- 
 pneumonia which does not resolve, but still shows the 
 clinical signs of a persistent fibrosis (dulness, bronchial 
 breathing, bronchophony). The disease is often fatal 
 within six months or a year ; although there is radiological 
 evidence that this period may be considerably prolonged, 
 and the consolidation, when it affects the base of the right 
 upper lobe, and, of a certainty, when it is also accom- 
 panied by interlobar adhesions, may shrink, producing a 
 marked diminution of the three upper interspaces. 
 
 {d) William R , aet, 46: boot maker. Clinical: 
 
 cough for years : now worse : dyspnoea + : Tbc. + : 
 wasting + : dulness to percussion in the right upper 
 lobe: crepitations and catarrhal sounds in the right 
 upper lobe : heart not displaced. Clinical diagnosis : 
 pleuritic phthisis. Radiogram 67, consolidation in the 
 lower part of right upper lobe, with a well defined lower 
 edge running horizontally : scattered foci present along 
 the bronchi of middle lobe : extreme apices free : signs of 
 excavation in middle of right upper lobe (arrows) : one 
 arrow points to a very large Crane's comma : calcifica- 
 tion of rib cartilages and emphysema. On examination 
 six and twelve months later, little, if any, change was 
 noticeable. 
 
 II. Miliary and Subtniliary Tubercle. 
 The differentiation of general miUary tuberculosis from 
 malignant endocarditis and lenteric fever — the two 
 diseases for which it is most likely to be mistaken — may 
 be at times very difficult, even after repeated clinical 
 examination, assisted by the most elaborate up-to-date 
 refinements of laboratory technique. Under these circum- 
 stances a fluoroscopic examination alone may be advisable, 
 and prove of valuable service ; whilst a satisfactory radio- 
 gram, if obtainable, may clinch the diagnosis. Before the 
 ophthalmoscope is able to demonstrate the occurrence of 
 
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 Facing p. 72. 
 
Radiography of the Chest 73 
 
 choroid tubercles, and examination of the urine and 
 cerebro-spinal fluid reveal the presence of the bacillus of 
 tubercle, the fluoroscope may already show cloudy 
 pulmonary fields, and the radiogram manifest the conclusive 
 signs of miliary tuberculosis. The chest may, at the same 
 lime, disclose very little information on physical exami- 
 nation : the lungs may even be quite resonant to percussion, 
 and a few scattered rales only may be audible on steth- 
 oscopy : whilst the incidence of functional symptoms, 
 such as extreme dyspnoea and obvious cyanosis, may 
 indicate, nevertheless, that a severe pulmonary lesion does 
 in reality exist. 
 
 The radiogram shows a more or less uniform permeation 
 of both lungs by innumerable small rounded foci, usually 
 about the size of a pin's head, sometimes a little larger, 
 ■even smaller; occasionally they may be almost concealed 
 by a thin diffuse opacity, due probably to a summation 
 •effect produced by the maculae situated in the layers of 
 lung lying more distant from the plate. A great deal of 
 discussion has taken place concerning the true interpre- 
 tation of these miliary haematogenous opacities ; also 
 concerning the differential diagnosis from peribronchial 
 disseminated nodules, miliary carcinomatosis, and pneu- 
 moconioid flecks. The consensus of opinion now appears 
 to be that the maculae seen on the radiogram actually 
 represent the size and topography of the respective 
 tubercles which lie in immediate proximity to the photo- 
 graphic plate. 
 
 The granules are situated for the most part in the walls 
 of the alveoli, in connection with minute vessels, and some 
 may develop within the vessels of the bronchial wall. 
 According to Bard 'there are cases where the latter 
 localisation is so pronounced as to merit the name of 
 bronchial granule (la granulie bronchique). It has been 
 stated by some authorities that peribronchitic foci may be 
 distinguished radiographically from pure miliary tubercles 
 by a greater tendency to aggregation and the consequent 
 
74 Radiography of the Chest 
 
 formation of larger opacities. Although this occurs 
 generally, it is not always the case. Recourse must then 
 be had to the clinical data {vide page 75). The difficulty 
 must be increased in the genuine broncho-vascular miliary 
 dissemination just mentioned. If the plate demonstrates 
 at one apex the existence of an imperfectly evacuated 
 cavity, the chances are that we are dealing with an 
 ordinary disseminated nodular type of disease. Both true 
 peribronchial and real miliary foci are best seen in the 
 middle parts of the chest and towards the scapular areas. 
 In the peribronchial there is, nevertheless, often a more 
 crowded appearance in the upper lobes, and the foci in 
 these situations are slightly larger in size and more 
 irregular in outline than those in the remainder of the 
 pulmonary fields. In pulmonary carcinomatosis the foci, 
 though small, are very irregular in size, and the age of the 
 patient and the presence of carcinoma elsewhere will settle 
 the diagnosis. (See Vol. II for radiogram of miliary 
 carcinomatosis of the lung.) A difficulty may arise from 
 the co-existence of the two diseases in the same lung. In 
 pneumoconiosis from the inhalation of inorganic dust the 
 separate foci are considerably larger, they are essentially 
 perihilar, and there are massive hilar shadows, particularly 
 in the right lung. 
 
 {a) Radiogram 68, posterior: the pulmonary fields are 
 filled by a number of foci of pin-head size. At the right 
 hilum there is an increased shadowing : on the right of 
 trachea, opposite the osseous end of first rib, a slightly 
 convex shadow (arrow). Post-mortem examination : 
 meningitis tuberculosa : the lungs permeated by 
 numerous miliary foci : a small gland the size of a bean 
 reaches about 1" outwards from the superior vena cava 
 (softened with caseating contents) : at the right hilum 
 several softened and one large caseating gland. The 
 small submiliary foci of the radiogram correspond to 
 the miliary tubercles of the lung as disclosed by the 
 post-mortem. The caseating gland in the right hilum 
 and that on the right side of the S.V.C. are also repre- 
 sented on the radiogram. 
 
Rad. 69 (Post.) -Miliary phtliisis. (Compare witli Rad. 68.) 
 
 Facing p. 75. 
 
Radiography of the Chest 75 
 
 Miliary tuberculous dissemination may be to some extent 
 localised in the lung, and two forms have been described, 
 (i) The asphyxial form of Graves, where there is a massive 
 miliary dissemination throughout the lungs, with extreme 
 dyspnoea, due to the mechanical embarrassment of pul- 
 monary oxidation, and negative clinical signs, and (2) the 
 catarrhal form, which, according to the intensity of the 
 disease, may appear {a) bronchitic with the signs of or- 
 dinary bronchitis, and eventually become acute local, or 
 generalised tubercle : {b) capillary, and (c) bronchopnen- 
 monic, in which the physical signs resemble those of 
 ordinary disseminated bronchopneumonic tubercle (Chap. 
 III). Possibly the more severe forms are sometimes due 
 to the irruption of a caseating bronchial gland at the hilum 
 into one of the tributaries of the bronchial vein; in these 
 cases there may be a more crowded dispersal through the 
 S.V.C., right ventricle and pulmonary circulation. Miliary 
 tuberculosis of the lung may occur after measles, pertussis, 
 and influenza, with which increased activity of tracheo- 
 bronchial and hilar glands maybe associated. After these 
 infectious fevers there may also be a more or less general 
 cylindrical bronchiectasia, with a somewhat copious ex- 
 pectoration. Pyrexia is irregular, and there may be 
 morning remissions, wasting, loss of strength, and enlarge- 
 ment of the spleen. 
 
 (b) Elizabeth F , aet. 15, is just recovering from 
 
 pertussis : there is a somewhat copious (one ounce or 
 more per diem) purulent expectoration, devoid of bacilli : 
 dyspnoea: an evening t** of 102° or 103°, with morning 
 remissions: anaemia : pallor: lossof weight and strength. 
 Physical signs insignificant and indefinite. The con- 
 dition became aggravated, and death occurred about 
 eight weeks after the radiogram was taken. The latter 
 (69) shows a slight diffuse cylindrical bronc^hicctasia, 
 and a wide distribution of small foci, particuhirly in the 
 wings, with no disposition to aggregation, and all 
 practically of the same size. 
 
 A mild curable type of pulmonary miliary tuberculosis 
 (tuberculosis miliaris benigna) was isolated by Pallard, in 
 
76 Radiography of the Chest 
 
 1901. He described 18 cases, the diagnosis of some being 
 confirmed by autopsy. The patient is often elderly, or at 
 least middle-aged, complains of headache, loss of appetite 
 and strength for perhaps a month after influenza, bronchitis 
 and the like. There may be a fafnily history of phthisis, 
 and the patient may be subject to winter cough, or may be 
 •actually suffering from mild attenuated or chronic fibroid 
 tubercle of the lung. The physical signs are indefinite, 
 perhaps, at one apex, usually the right, there is tubular 
 breathing and an absence of adventitious sounds (fibrosis). 
 Bacilli may not be present in the sputum. There may 
 occasionally be a small haemoptysis. The pyrexia, which 
 varies from 102° of an evening to 98^ of a morning, may 
 last for three weeks. In the aged the course is often 
 apyrexial. In one case, radiographed by the author, the 
 patient was over 60 years of age, was ordinarily thin, but 
 now had become emaciated. She complained of severe 
 headache, and, in fact, became somewhat peculiar in be- 
 haviour and disposition, suggesting a dissemination of 
 foci within the meninges, a possibility which does not 
 •appear to have been mentioned by alienists. The radio- 
 gram showed numerous very small foci, uniform in size, 
 in the right upper lobe, and particularly in the axillary 
 region. According to Pallard these foci may resolve 
 completely, or produce fibroid specks, which may unite to 
 form patches of fibrosis. 
 
 (c) Arthur H , ast. 47. Illness began nine years 
 
 ago with pleurisy. Physical signs : at the right apex 
 tubular breathing, increased vocal vibration, no added 
 sounds : Tbc. +. The Radiograms (70A and 70B) show 
 a dense infiltration at the right apex, with excavations 
 better seen on the posterior plate, and some indurated 
 patches reaching towards the hilum. On the posterior 
 radiogram there are numerous very small dark foci, 
 probably fibroid and miliary, which appear to be 
 ■coalescing to form a festoon below the dense induration. 
 It is possible that some of the foci are pleuritic. 
 :Stereo-radiograms might solve the question. 
 Partial miliary dissemination is by no means uncommon 
 
1 
 
 FaciiiK p. 76, 
 
Radiography of the Chest 77" 
 
 during the course of chronic phthisis, and may be recog- 
 nised on the radiogram. 
 
 (a) Radiogram 71 presents difficulties. James J ,. 
 
 aet. 65. His illness began three weeks before the 
 radiological examination was made, and on the day 
 following a severe physical and accidental strain, in 
 which the patient was compelled to sustain for a short 
 time a massive weight, fit only for four men to lift. 
 Next day he began to expectorate, and during the course 
 of the same day he had a haemoptysis of one ounce : 
 then slight night sweats and headache. Auscultation 
 was indefinite. The radiogram shows aortic sclerosis 
 with fusiform dilatation, a narrow heart, somewhat dense 
 hilar opacities with several calcareous nodes, and a dis- 
 tribution of fine foci at the sides of the chest. On 
 re-examination four weeks later these had disappeared,, 
 leaving slightly clouded areas. In the radiogram all 
 the foci are small, they show no tendency to aggregate : 
 a few run, possibly fortuitously, along the bronchi : are 
 they miliary or bronchogenic ? The rib cartilages are 
 calcified, and the chest tends to assume the paralytic 
 type. 
 
•yS Radiography of the Chest 
 
 CHAPTER VIII 
 
 The Complications of Pulmonary Tuberculosis 
 Pleurisy 
 
 For many years clinicians and pathologists have dis- 
 cussed the question as to the existence of primary 
 tuberculous pleurisy, produced by the autonomous and 
 independent deposition of tubercles within this serous 
 membrane, and the manner in which the infection is 
 carried to it. The possibility of its occurrence may be 
 admitted, also the probability that the bacilli may be 
 conveyed in some manner via the lymphatic circulation. 
 Tuberculous pleurisies have consequently been divided 
 into (i) ^primary, and (2) secondary. The former have 
 again been subdivided into {a) the superficial and {b) the 
 deep, in the latter of which the subjacent pulmonary 
 tissue participates. The secondary pleurisies arise from 
 tuberculous lesions occurring in the neighbourhood — the 
 lung, the ribs, the dorsal vertebrae and the peritoneum, 
 or they are the result of a widespread infection like that 
 of generalised miliary tuberculosis. In the primary tuber- 
 culous pleurisies the effusion will constitute therefore the 
 first radiological manifestation of the disease. Radiological 
 examination made before, and subsequently to the 
 evacuation of the effusion, gives no support to the view — 
 either active tuberculous foci are present already 
 within the lung, or there is ample evidence of a latent 
 or quasi-latent tuberculous infection of the hilar or peri- 
 hilar areas. For these reasons the so-called post-pleuritic 
 types of pulmonary phthisis (Bard) are more accurately 
 described as varieties of tubercle in which pleuritic 
 effusions and adhesions impress a particular character 
 upon, and exercise a preponderating influence over, the 
 -evolution of the disease. The following case illustrates 
 

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Radiography of the Chest 79 
 
 some of the points at issue, and at the same time the utihty 
 of radiological examination for the purposes of diagnosis. 
 
 Case i. — John , aet. 50. Had pleurisy twenty years 
 
 before : haemoptysis six weeks ago with night sweats, 
 pain in the right side, dyspnoea and some loss of weight. 
 On the right side, in front and above, percussion note 
 impaired : vocal resonance diminished : breath sounds 
 weak : right side, behind and below, vocal resonance 
 increased and breath sounds loud. Clinical diagnosis : 
 unresolved pneumonia. Radiogram 72 shows a well 
 defined lower edge of the right upper lobe with an 
 interlobar pleuritic thickening and adhesion : tuberculous 
 infection in the shape of thickened dilated tubes and 
 small indurated foci in right upper lobe : " inverted 
 comma" conspicuous along the right border of the 
 trachea (arrow) : some general cylindrical bronchi- 
 ectasia and indurations along certain bronchi of the 
 right middle lobe. There is some contraction of the 
 right upper chest, slight deviation of the heart and 
 mediastinum towards the right side, and irregularity of 
 the outer half of the right phrenic leaflet : hilar fibrosis 
 on the left side, and dilatation of tubes : also dilatation 
 of the ascending aorta. 
 
 The case bears some resemblances to the benign type 
 isolated by Piery, and termed by him pleuritis tuberculosa 
 recidivans (pleurite tuberculeuse a repetition). It is 
 possible that a genuine bronchiectasis may ultimately be 
 produced beneath the interlobar opacity. 
 
 Secondary pleurisies, with or without effusion, occur so 
 frequently during the course of pulmonary tuberculosis 
 that they may be regarded, not so much as complications, 
 but as a natural consequence due to the pla}' of the 
 defensive powers of the organism. Beside the pleurisies 
 with large effusions, one often meets with pleurisies in 
 which the effusions are insignificant, commencing in- 
 sidiously, and at times overlooked. The radiographical 
 appearance is not always characteristic, since the effusion 
 may occur within a pleural cavity limited and deformed by 
 adhesions — moreover, the amount of fluid may not be 
 
8o Radiography of the Chest 
 
 sufficient to produce displacement of the heart and media- 
 stinum, or these organs may already be fixed by previous 
 disease. As a rule the fluid is serous, generally basal, and 
 it is more commonly found in men from 20 to 40 years of 
 age, and on the left side. 
 
 Case 2. — Richard F , aet. 28 years : suffered from 
 
 pleurisy ten months ago : cough + : expectoration + : 
 Tbc. + : dulness and loss of movement at the left base 
 extending above the left nipple : crepitations in both 
 upper lobes : heart apex beat not found. Diagnosis : 
 phthisis of both upper lobes, with effusion at the left base. 
 The Radiogram (No. 73) shows a disseminated tubercle 
 with dilated tubes in both lungs : irregular cavity at left 
 apex beneath middle of left clavicle : excavations (?) in 
 right apex : an effusion at left base, the upper edge of 
 which runs upwards and outwards : slight deviation of 
 right auricle to the right, and of upper mediastinum to 
 the left. A metal square on the left nipple (seen in plate, 
 not in print) appears in the middle of the opacity. On 
 standing, the distance of the upper line of the effusion 
 from the disc was one inch higher than in the recumbent 
 position. 
 
 Collections of encysted fluid may occur in any part of 
 the chest. They are commonest in connection with the 
 right upper and lower interlobar fissures. 
 
 Case 3. — Henry F , set. 30 years : suffers from 
 
 cough at night : expectorates about one ounce of sputum 
 per day : there are night sweats : a temperature 
 occasionally 100° of an evening : there is dulness at both 
 bases, crepitations in the right lower lobe : heart not 
 displaced. Clinical Diagnosis : chronic pleurisy with 
 effusion. Radioscopic examination : on the right the 
 diaphragm moves well : there is an area of dense opacity 
 at the right base, of the same appearance in front and 
 behind : Radiogram 74, a large encysted effusion at the 
 right base (connected with the lower fissure ?), thickened 
 pleura at the left base : slight deviation of the upper 
 mediastinum and trachea to the left : fibrosis or collapse 
 of the middle lobe : slight illumination at the base due 
 to basal lobe : some old nodules at right supraclavicular 
 
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 Facing p. 8o. 
 
Radiography of the Chest 8i 
 
 apex. On puncture a straw-coloured fluid was obtained 
 which contained tubercle bacilli. 
 
 Localised adhesions may remain after the absorption and 
 evacuation of effusions, or may be the result of a dry 
 pleurisy. Simple thickenings of the visceral pleura may 
 occur at the apices, interlobes, diaphragm, and in the 
 mediastinum. Over the apex they may form a thick cap, 
 concealing deeper lesions. This is often seen as an opacity 
 in the posterior radiogram, running parallel to the lower 
 border of the second rib. Pleuro-visceral adhesions at the 
 apex may lead to pain, diminished movement, weak breath 
 sounds, or interrupted breathing, with friction sounds and 
 retraction of the fossa. The opacity in the supraclavicular 
 region may be more obvious posteriorly, both sides 
 therefore should be examined by the rays. If basal, 
 the diaphragm may be rather sluggish, but on its descent 
 should show a narrow band of opacity parallel to its 
 upper margin. 
 
 Thickenings of the parietal pleura are commoner at the 
 base, and may produce adhesions between the diaphragm 
 and the ribs. Costophrenic adhesions are not uncommon 
 on the left side. Occasionally^ the whole of one half of 
 the diaphragm is immobile and fixed to the ribs, producing 
 dulness at the base, and leading to the clinical diagnosis 
 of basal effusion, unresolved basal pneumonia, or basal 
 fibrosis. If the adhesion is slightly yielding, there may be 
 an inspiratory tremor in the diaphragm without descent 
 (Radiogram 84). Adhesions of the diaphragm to the ribs, 
 the remains of old dry pleurisy, may retain the diaphragm 
 at one or more localities, which are best seen during 
 inspiration. A common situation is at the level of the 
 main basal bronchus (phenomene du feston diaphragm- 
 atique, Radiogram 41). Mediastinal adhesions are shown 
 by disfigurement or irregularities of the cardiac outline 
 on one or both sides, and by thin shadows below the 
 inner end of the right clavicle, running parallel to the 
 sternum. Thickenings limited to the axillary region 
 
 G 
 
82 Radiography of the Chest 
 
 may be present (Radiogram 57). Cardiophrenic adhesions 
 are common {vide Vol. II). 
 
 Diffuse pleural adhesions (concretio diffusa) may occur, 
 obliterating the pleural cavity, with or without thickening 
 of the membrane ; in the latter case there may be little or no 
 loss of transparency on the radiogram. The diagnosis then 
 depends on the position of the ribs, the narrowness of the 
 interspaces, a sudden bending of the ribs in the axillary line, 
 scoliosis of the spine, the convexity towards the healthy 
 side (Radiogram 64), abnormal respiratory movements, 
 such as the cradle or see-saw movement of the lower part 
 of the chest. In other cases diffuse thickenings (visceral?) 
 may occur without adhesion when the whole of one side of 
 the chest appears opaque ; occasionally more intense 
 patches of opacity may be seen through the shadow, due 
 to infiltrations of the lung. In some instances the opacity 
 is so thick that nothing can be ascertained as to the state 
 of the subjacent lung ; moreover, in the earlier stages 
 there may be little or no constriction of the chest. In- 
 formation as to the existence of tubercle may be gained by 
 contrasting anterior and posterior radiograms, and by 
 careful examination of the more transparent lung. Fail- 
 ing these, recourse must be had to laboratory methods 
 for diagnosis. 
 
 Case 4. — Mary W , aet. 39, has had a weak chest 
 
 from a child : pleurisy three 3Tars ago, ill then for two 
 months : pain in chest : cough 4- : expectoration — : 
 dyspnoea — : palpitations- : night sweating + : wasting + : 
 at left base dulness, and sinking in of lower ribs below 
 the seventh during inspiration and movement towards 
 the right side (see-saw movement). The radiogram, 
 No. 75, shows a pleural S3^mphysis on the left, in which 
 the pleural leaves are but slightl}^ thickened, and fibrosis 
 of the left upper lobe. Re-examination, after eighteen 
 months, showed an improvement and a diminution of 
 the cradle movement. Scaphoid scapula on left (arrow). 
 The right lung and hilum show changes due to obsolete 
 tubercle. 
 
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 Facing p. 83. 
 
Radiography of the Chest 83 
 
 Pneumothorax 
 
 Pneumothorax is one of the difficulties of physical 
 diagnosis, one of the easier problems for the radiologist. 
 The commonest seat of tuberculous pneumothorax is near 
 the diaphragm in the axillary line (Radiogram 32), and its 
 size ma}^ vary from that of a large cavity to that of half a 
 lobe of the lung: in certain cases, where adhesions are not 
 present, the whole lung may collapse and appear as a mere 
 stump at the hilum. In pulmonary tuberculosis this is rare, 
 since adhesions are practically always present either at 
 the base or at the apex of the lung. 
 
 Case i. — Thomas G , aet. 33. Had pleurisy on 
 
 the right side one year ago: has had pain between the 
 shoulders and on the right side of the chest : at the right 
 base the breath sounds are faint, vocal resonance is 
 absent : there are no crepitations, but there are crepita- 
 tions at the left apex : heart not displaced. Diagnosis : 
 undetermined (because pneumothorax was not sus- 
 pected). The diagnosis was made clear at once by the 
 radioscope, since there was a bright area of illumination 
 at the right base. Radiogram No. 76 confirms the diag- 
 nosis of pneumothorax, due chiefl}- to collapse of the 
 right middle lobe with a disseminated tuberculosis of 
 low-grade activity, and congestion in the left lung. 
 
 The progress of recovery of the lung should be ascertained 
 b}' repeated radioscopical examinations: six weeks' rest 
 may be necessar}' for complete re-expansion. The same 
 routine should be emplo3-ed in cases of operative pueumo- 
 thorax after emp3'ema. Very often patients are sent out of 
 hospital with one lung half collapsed, since the surgeon 
 does not think of its condition. Sometimes in cases of 
 spontaneous pneumothorax a posterior view will show 
 how the right middle and right upper lobes separate 
 during inspiration as the air enters the collapsed lung 
 {vide Vol. II, "Emp3'ema"). When the pneumothorax con- 
 tains fluid insufficient on the one hand, or in excess, so 
 that audible succussion is not obtained, the physical 
 diagnosis is still more difficult. It is often diagnosed by 
 
84 Radiography of the Chest 
 
 skilled clinicians as fibroid lung. The radioscope, the 
 patient being in the vertical position, shows a clean cut, 
 horizontal fluid line, an air space above it, and visible 
 succussion 
 
 Case 2. — Thomas N , aet. 32 years: cough for one 
 
 year: weakness: emaciation: tubular breathing at right 
 apex : crepitations both apices : and splashing. Radio- 
 gram No. 77 shows a right hydro-pneumothorax, about 
 two-thirds full, with excavations at the left apex. 
 
 These effusions are usually left alone, unless symptoms, 
 such as urgent dyspnoea and distressing cough are present. 
 The absorption of the fluid usually requires a considerable 
 time — maybe six months or more — and leaves behind it 
 a greatly thickened pleura, the horizontality of the upper 
 margin of the opacity becomes lost ; it may now run 
 obliquely upwards and outwards. 
 
 In pneumothorax there is generally a marked inspiratory 
 deviation of the mediastinum towards the diseased side, and 
 in the erect position, if fluid be present, and the cavity 
 not more than one-third full, the level of the effusion rises 
 during the same period of respiration. If empty, certain 
 curious paradoxical movements of the diaphragm are 
 observed (z/f^^ Vol. II, "Pneumothorax"). Metallic tinkling 
 is not frequent in pneumothorax — about 30 per cent. It has 
 been attributed to the dropping of fluid on the surface of the 
 effusion, or to the bubbling of air ascending through the 
 liquid during inspiration from a fistulous tract in the lung 
 situated beneath the level of the fluid (Norris and Landis, 
 p. 129). Since this tinkling — it has been compared to the 
 sound produced by the falling of grains of sand into a 
 wine glass — may be audible in a pneumothorax devoid of 
 fluid, and also in operative pneumothorax after empyema, 
 where there is no doubt as to the integrity of the visceral 
 pleura, the above explanation does not satisfy all cases. 
 Skoda and other authorities also have considered the 
 presence of fluid unnecessary for its production. They 
 thought it might be due to the propagation of mucous 
 rales through an air chamber acting as a resonator. It 
 
Rad. 77 (Ant.) RiKlit pncumothonix with ofTusion. Cavitation 
 left apex. 
 
 FacinK p. 84. 
 
Radiography of the Chest 85 
 
 is heard during inspiration, coughing, and change of 
 position. In one case, without fluid, auscultated by the 
 author, it was heard best just over the displaced and 
 mobile mediastinum, so that it is possibly due to the 
 stretching of adhesions produced by the inspiratory move- 
 ment of the mediastinum itself The heart and mediastinum, 
 unless fixed b}' adhesions, are pushed over towards the 
 healthy side ; this is more obvious when the pneumothorax 
 is on the left. In some instances, especially in artificial 
 pneumothorax, the mediastinum yields at one of its two 
 weak spots — one in front of the ascending aorta between 
 it and the sternum — a bulge appearing on the healthy 
 side: or just behind the heart about the level of the eighth 
 or ninth vertebra ; a protrusion then appears at the base. 
 These may be termed the superior and inferior ballooning 
 of the mediastinum. The complication ver}^ rarely happens 
 in spontaneous pneumothorax ; the author has seen one 
 case where superior ballooning occurred. 
 
 It has been already stated that the radiogram may 
 exhibit calcareous, obviously subpleural foci, in the near 
 vicinity of a spontaneous pneumothorax (R. 32 and R. y6)\ 
 at other times such foci are not obvious. In Rad. y6 
 there is a slight deviation of the heart, so that the vertebral 
 column is just visible. The absence of deviation to 
 palpation, in cases of right pneumothorax, may mislead 
 the clinician, since the heart may be originally median, 
 with little protrusion to the left, a circumstance which is 
 frequent in tubercle. 
 
 Emphysema 
 
 During the progress of pulmonary tuberculosis the 
 chest may assume an inspiratory emphysematous position, 
 or the ribs may sink and the interspaces become narrow, 
 producing the flat chest (thorax aplati or paral3'ticus). 
 Also partial, vicarious, or compensatory emphysema is 
 common. Compensatory emphysema is limited to par- 
 ticular areas ; for example, a single or double apical 
 tuberculosis may lead to dilatation of the bases, and 
 
86 Radiography of the Chest 
 
 finally to emphysema. In other cases there may be a 
 localised apical emphysema, especially in women, and par- 
 ticularly involving the second right interspace. Occasion- 
 ally the middle chest is expanded (annular). Localised 
 and diffuse emphysema may be associated with many non- 
 tuberculous affections, such as chronic bronchitis, atheroma, 
 and dilatation of the aorta, myocardiac degeneration, and 
 pressure on the main bronchi by neoplasms and aneurysms ; 
 but, as a general rule, double hypertrophic emphysema is 
 paratuberculous ; in other words, it is to be regarded as 
 the outward expression of a chronic pulmonary tuber- 
 culosis. The radioscopical and radiographical features are 
 given in greater detail in the second volume ; a few of the 
 salient characters are mentioned here. In all cases the 
 crural as well as the sternocostal halves of the diaphragm 
 must be examined ; in well marked cases of emphysema, 
 while the sternocostal or frontal diaphragm is flat, deep, 
 and practically immobile, the crural or posterior diaphragm 
 may be working well. In very severe cases of generalised 
 emph3'sema, occurring in old asthmatics, and after serious 
 gas attacks in young men, the crural diaphragm may also 
 lose its movement and may be pushed down. Under these 
 conditions there is a condition of complete diffuse hyper- 
 trophic emphysema ; a central or perihilar emphysema is 
 superadded, and the dyspnoea becomes extreme. As a 
 contrast to this condition, very occasionally one sees a case 
 of apparent emphysema where the sternocostal and costal 
 diaphragms show little or no abnormality either in move- 
 ment or position. They are difficult to explain ; possibly 
 they are due to a loss of elasticity in the bronchi alone, 
 which produces a general cylindrical bronchiectasia. 
 
 On the radiogram a variety of tuberculous conditions 
 are associated with well marked emphysema, {a) enlarged 
 hilar and paratracheal opacities, either with or without 
 cylindrical bronchiectasis ; {b) basal emphysema may 
 develop in the presence of ordinary apical fibrocaseous 
 disease, and in the absence of basal pleuritic adhesions ; 
 
Radiography of the Chest 87 
 
 (c) a chest originally flat — thorax paralyticus — scarcely, if 
 ever, assumes the expanded condition of emphysema, 
 except in its lower parts. The ribs do not run quite 
 horizontally as in the usual cases of emphysema. The 
 asthmatic chest is often a modification of this form — very 
 much hyper-inflated below, with enlarged hila, a con- 
 spicuous bronchial arborisation within the lung, perihilar 
 and other infiltrations possibly becoming arrested, or 
 liable to recurring attacks of perihilar congestion, with 
 some thickening of the bronchial walls, and a median 
 narrow cardiac opacity. (d) In other instances there 
 may be a bilateral disseminated nodular or nodal fibroid 
 phthisis, the small dark and irregular maculae and nodes 
 of which are connected by a fine reticulum, or by fibroid 
 strings, with enlarged hilar and fibrosed right para- 
 tracheals. Occasionally the disease is unilateral, dis- 
 seminated, or dense, and the healthy lung is hyper-inflated 
 only, passing across the spine into the diseased chest. 
 As the result of radiological observations it may be 
 suggested that (a) diffuse emphysema is primary and 
 inspiratory in origin ; that {b) calcification of the first costal 
 cartilages, instead of being an element in the aetiolog}'^ of 
 the disease, is an effect, and acts, along with later calci- 
 fication of the lower ribs, as a safeguard against excessive 
 expansion. In the gas poisoningof soldiers, where emphy- 
 sema may become extreme, the rib cartilages remain quite 
 soft and invisible to the rays, (c) Rigidity of the chest in 
 the mean respiratory, or in the expiratory position, in the 
 aged is due to the presence of many calcified cartilages ; 
 in the young adult it may be associated with an extensive 
 adherent pleurisy. 
 
 Haemoptysis 
 may be an early event in pulmonar^^ phthisis ; it may occur 
 on several occasions during the course of the disease, or it 
 may be copious and terminal. In the earlier and median 
 stages it may be a mere staining of the sputum, an insig- 
 nificant spot, a minute clot, or it may be abundant and 
 
88 Radiography of the Chest 
 
 amount to more than twenty ounces. Non-tuberculous 
 sources of haemorrhage, like mitral stenosis, aneurism, 
 bronchiectasis, the gums, retro -lingual varicosities, the 
 pharynx and fauces (and malingering), are usually excluded 
 by the ph3^sician. It is not considered expedient to bring 
 a patient to the X-ray department earlier than about ten 
 days after a severe attack of haemoptysis ; during this 
 interval any changes in the density of the fields may have 
 become less evident. Nevertheless, with a soft tube and a 
 short exposure it may even then be possible to verify the 
 stethoscopic localisation of its source. There may be one 
 or more caseating foci in one of the apices, surrounded 
 by a network of what appear to be not bronchi but enlarged 
 vessels — lymphatic or otherwise — there may be the remains 
 of an interlobar effusion concealing the right upper lobe, 
 which disappears after some few weeks, revealing nodular 
 foci or a pneumonic patch beneath ; or there may be an 
 irregular fluff}^ area of infiltration at the osseous extremity 
 of the first rib on the right, which suggests an active con- 
 dition. Such instances of earlier haemoptyses may there- 
 fore be termed (a) congestive, (b) pleuropneumonic, and 
 (c) pneumonic. In the early congestive forms it may be 
 the accompaniment of mild minor phthisis only, with no 
 pyrexia, no bacilli, and an appearance practically normal. 
 
 On reviewing a large number of radiograms of cases in 
 which haemoptysis — small, medium, and severe — has 
 occurred, one is struck (a) by the fact that very often 
 localisation of the bleeding point is a pure speculation ; 
 (b) by the not uncommon occurrence of cloudy irregular 
 hilar and perihilar or interlobar opacities without any 
 other changes ; (c) by the constant association of small or 
 medium, very occasionally severe, haemoptyses, with the 
 presence of disseminated nodular foci, and of cavities 
 within the apex or other parts of the lung; (d) and by 
 the frequency of small haemorrhages in the fibroid lung. 
 In the two latter the haemorrhage is probably due to 
 erosion of arterioles within existing cavities. Very often 
 
Radiography of the Chest 89 
 
 a copious haemorrhage in early tuberculosis connotes a 
 more favourable prognosis than frequent streaking of the 
 sputum and repeated small haemoptj'ses. A perusal of the 
 radiograms already given will illustrate these paragraphs. 
 
 Cavities 
 are recognisable on the radiogram by their thickened 
 edges, their oval shape, their central translucency, which 
 may approach that of normal lung, and even surpass it. 
 Excavations are sometimes found at the autopsy which 
 are invisible on the plate, because their edges are often 
 thin and indefinable ; they may be uneven and ragged ; 
 or the cavity may lie in the midst of healthy tissue. 
 Sometimes a cavity is visible in one radiogram, usually the 
 posterior, and is almost or quite invisible in the anterior ; 
 it is therefore missed if the anterior position alone is 
 photographed. In other cases the surrounding tissue is 
 infiltrated or fibroid, or a dense layer of thickened pleura 
 covers it. If the cavitj' is partially or completely full 
 of vascular and tissue debris, or if it is filled with 
 secretion, it is not clearly defined. An enclosed circular 
 s|)ace or loculus, clearer than the rest of the cavity itself, 
 may be due occasionally to a dilated bronchus. 
 
 Pleural stripes and thickenings, lung cicatrices, etc., may 
 be so arranged as to simulate a cavity with thickened 
 wall ; the presence of lung structure within the circle may 
 settle the question ; optical sections of dilated bronchi, 
 especially in the perihilar areas, often prove a difficulty. 
 Opaque infiltrations within the supraclavicular and 
 infraclavicular areas, containing oval, so-called clover- 
 leaf-shaped transparencies, are often due to the presence 
 of small, old, dry excavations ; sometimes they are dilated 
 tubes, at other times genuine cavities. In cases where 
 irregular masses of induration form, the excavations appear 
 as sinous and irregular transparencies ; in some instances 
 these are dilated and tortuous tubes. 
 
 In the very early stages of a cavity, where necrosis of 
 tissue has occurred, without solution of the contents, the 
 
90 Radiography of the Chest 
 
 presence of an opaque ring is characteristic. The interior 
 may appear normal. In other cases the annular opacity is 
 incomplete, and may remain unfinished. 
 
 Fred S , set 23, complains of cough, dysphagia, 
 
 wasting : no adventitious sounds : there is a small ulcer 
 on the free edge of the epiglottis. Radiogram 78 : dis- 
 seminated fibroid tubercle of both apices. One cavity in 
 each apex, probably not quite empty, and the commence- 
 ment of a second in right apex below the first (arrows). 
 There is no doubt that cavities are much more easily 
 diagnosed by radiography than by clinical methods. The 
 former shows cavities in situations where they may be 
 unexpected, and it gives precise information — especially if 
 stereoradiograms are taken — of their size, depth, and 
 contents. If quite empty the prognosis is more favourable 
 (Chapter III). As a rule no clean-cut fluid level is 
 obtainable, even in large cavities — either they are empt}', 
 the contents are semi-solid, or are so tenacious that they 
 stick to the wall. Cavities are not discernible by the 
 stethoscope unless they are fairly superficial, reach the 
 size of a walnut, and are surrounded by infiltrated tissue. 
 As long as they do not contain air they do not give the 
 usuah physical signs — only subcrepitant rales and seldom 
 bronchial breathing. Until they are thoroughly emptied, 
 there is always the danger of dispersal throughout the 
 lung, and the formation of new tuberculous foci and of 
 laryngeal and intestinal complications. 
 
 The thickness of the wall is a criterion of its age. A 
 thick-walled cavity may exist unchanged for years ; but if 
 subjected to the effect of mixed infections it may enlarge 
 and become irregular in shape. (Radiogram 64, right apex.) 
 When very large, a cavity may be mistaken for a small 
 pneumothorax. (Vide Wo], II.) 
 
 Bronchiectasis 
 In chronic pulmonary tuberculosis dilatation of the 
 bronchi is a common complication ; sometimes it is suffi- 
 ciently advanced to constitute a true bronchiectasis, and 
 
_ to 
 -r O 
 
 3 O 
 
 Ok 
 
 (z< 
 
 Facing p. 90. 
 
Radiography of the Chest 91 
 
 at first sight may mask the genuine disease. It may be 
 present as a general cylindrical dilatation throughout both 
 lungs ; as definite bronchiectatic cavities at the base, in 
 exceptional cases, large bronchiectatic cavities may even be 
 found in the upper lobe. A sputum examination may 
 reveal the presence of bacilli ; in other cases they are 
 continuously absent, when the suspicion of non-tuber- 
 culous lesions naturally arises. Clubbing of the fingers 
 accompanies bronchiectasis, whether it is primary or if it 
 is a complication of tubercle. 
 
 Mary G , aet. 32, has suffered from cough since 
 
 childhood : and now from a winter cough for years : the 
 sputum is scanty, bacilli are absent, the weight is 
 stationary. At present the chief complaints are cough 
 and great lassitude. Clitiical signs: creaking sounds 
 near left nipple, dulness, rhonchi in both lungs, crepita- 
 tions at the left base. Radiogram 79: several dilated 
 bronchi (left paracardiac) just outside cardiac apex : 
 thickened tubes, especially the right paravertebral, 
 throughout both lungs : emphysema, particularly of the 
 right side: a slight deviation of the mediastinum towards 
 the left : and the general appearances of old arrested 
 tubercle in both lungs. 
 
 It appears to be an old latent perihilar disease, probably 
 first occurring in childhood, in which the typical bronchi- 
 ectatic sputum has never developed, but the lesion has left 
 dilated bronchi as the clinical indication of its previous 
 existence. Several of the previous radiograms show the 
 presence of a cylindrical generalised bronchiectasia (Radio- 
 grams 17, 5o, 69, etc.) as a side-issue of the genuine tuber- 
 culous disease (Vol. II, "Bronchiectasis"). It has been 
 already stated that the co-existence of the two lesions, 
 especially if the bronchiectasis is local and conspicuous, 
 suggests the possibility of a specific infection. 
 
92 Radiography of the Chest 
 
 CHAPTER IX 
 
 The Radiological Diagnosis of Pulmonary Tubercle. 
 
 Preliminary Observations 
 
 Careful perusal of the foregoing chapters will convince 
 the reader that in several forms of pulmonary phthisis the 
 sputum may not, and probably tiever will, contain the bacilli 
 of tubercle. In other words, there are numerous cases in 
 which the lesions are permanently closed. 
 
 Secondly, that when the sputum, previously bacilliferous, 
 becomes free, the disease may be neither arrested nor 
 cured ; and thirdl}^ that if the diagnosis be confirmed by 
 the discovery of bacilli, the necessity of radiological exami- 
 nation still continues urgent. By means of the latter the 
 locality of the lesions, their extent, their attributes, and 
 the type of the disease are more accurately determined 
 and recorded. In many instances, unfortunately, when 
 the sputum is positive, no attempt to ascertain the essen- 
 tial quality of the lesions is made by the medical examiner; 
 at the same time, it cannot be too strongly emphasised that 
 delay in pronouncing a patient "tuberculous" merely 
 because the expectoration furnishes no proof is dangerous, 
 both to the individual himself and to the community at 
 large. 
 
 When properly conducted and the results logically 
 analysed, in so far as the peculiarities of acoustic con- 
 duction in the chest are understood, clinical examination 
 is of the greatest value ; but if the apices alone are 
 investigated, whilst the deep axillae, the interlobes, and 
 mammary regions, are neglected, mistakes are unavoidable. 
 For this reason alone X-ray examination is of service; 
 opacities of any size on the plate are at once recognised, 
 even by the less experienced, and a clinical re-examination 
 may confirm the X-ray observations. By the use of both 
 
Radiography of the Chest 93 
 
 methods a mutual control is provided, and difficult pro- 
 blems more readily solved. On the other hand, the 
 argument has been seriously advanced that radiological 
 examination leads both practitioner and student into 
 undesirable habits, so to speak ; tends, indeed, to make 
 them distrust the results of their own clinical examination — 
 in reality a spontaneous acknowledgment of the value of 
 the X rays. The two methods are dissimilar; each ap- 
 proaches the subject from a different point of view ; it is 
 imperative, therefore, that the diagnosis should depend, as 
 far as practicable, on the combined and corroborative 
 evidence of both. 
 
 The additional role assigned to the radiologist is the 
 determination of the character of the plate; whether it is 
 under, over, or accurately exposed, fully or incompletely 
 developed ; whether the X-ray tube was correct in qualit}', 
 too hard, or too soft. He must also decide what is normal 
 and what is pathological on the radiogram ; in the latter 
 event he must differentiate the sharp clean-cut outlines of 
 old arrested lesions from the cloudy definitions of active 
 disease. It has been asserted that one may be uncon- 
 sciously biassed in the interpretation of the radiogram by 
 a knowledge of the preceding clinical examination ; and 
 conversely, that it is easy to find dulness on percussing, 
 rales and crepitations on auscultating localities, where 
 obvious opacities are present on the plate ; a statement 
 tending to cast suspicion on the utility of physical examin- 
 ation of the chest in general. 
 
 Method of Examination 
 Incidental remarks follow concerning the clinical signs 
 of the different forms of tubercle : these are appended 
 because the radiologist is often asked to examine and 
 report on patients in the absence of clinical data. He is 
 expected to diagnose the case just as if these had also 
 been supplied to him. The examination should be 
 systematic and orderly : (a) the history of the patient 
 carefully recorded, {b) the symptoms enumerated, (r) 
 
94 Radiography of the Chest 
 
 cHnical examination as to (i) type of chest, (a) expansion, 
 (3) percussion and auscultation of apices, axillae, interlobes, 
 interscapular areas, mammary regions, and the bases, (4) 
 radioscopy, (5) radiography, (6) a second physical examin- 
 ation of anomalous radiographical opacities, and of areas 
 to which abnormal intensities of striation are directed. 
 Since the plate is actuall}^ the sine qua non for the purposes 
 of diagnosis, it is unnecessary to spend much time on 
 radioscopy — after the outlines of the heart, the condition 
 of the hila, the extreme apices, the movements of the ribs 
 and diaphragm, any abnormal opacities have been observed 
 from different points of view, the radiogram should be taken 
 forthwith and any smaller plates, with the addition of 
 stereoscop}', of suspicious areas, if expedient. 
 
 Clifiical Comments. 
 It is said that (i) lessened expansion of one upper lobe, 
 (2) slight increase of apical tactile fremitus and vocal 
 resonance, (3) some impairment of percussion note of one 
 apex, (4) prolonged expiration, (5) post-tussive inspiratory 
 crepitations in the upper lobe, are the earliest signs of 
 tuberculous infiltration. Some authorities have mentioned 
 (i) grminlar breathing at the apex as the earliest sign, (2) 
 feeble breath sounds in the same area, or over the whole 
 of the affected side, (3) interrupted breath sounds, (4) 
 slight bronchial breathing and whispering pectoriloquy, 
 followed later by (5) more pronounced bronchial breathing, 
 (6) medium sized rales, or mucous clicks — the latter of which 
 are said by some physicians to be pathognomonic of 
 tuberculous infiltration— and (7) showers of fine inspira- 
 tory rales after cough. Difficulties arise in the clinical 
 diagnosis of the different types, whether incipient or- 
 advanced, e.g., of the fibrocaseating bronchopneumonic 
 cases, and in particular of the perihilar varieties of this 
 group ; of the different manifestations of minor and fibroid 
 phthisis, which per se may not reach alarming proportions, 
 but which, even when latent and obsolete, leave behind 
 clinical sequelae which subsequently may render diagnosis 
 
Radiography of the Chest 95 
 
 uncertain. Moreover, classification of such a protean 
 disease as phthisis is liable to become obscured by the 
 implantation of active progressive types upon ancient, 
 apparently obsolete lesions. In the fibroid nodal dis- 
 seminated forms, with emph3'sema, percussion is generally 
 resonant except possibly at the apex (areas of fibrosis or 
 pleural thickenings and adhesions) ; rhonchi, accompanied 
 by moist rales, are often heard during periods of temporary 
 bronchitis and pulmonary catarrh ; whilst in the dissemin- 
 ated nodular forms phj^sical signs are extremely feeble 
 and indefinite. Apical fixed rhonchi with some percussion 
 dulness are associated radiologicall}' with localised minor 
 fibroid infiltrations in the neighbourhood of dilated tubes. 
 Mucous rales are present also in caseating pneumonia; 
 and along the borders of consolidations, reactivated by 
 various circumstances, fine rales are to be perceived. The 
 so-called typical tuberculous rale, due to softening of a 
 caseous focus, is moist, generally inspirator}', increased by 
 cough, is localised and fixed ; whereas the mucous rales, 
 just mentioned, are heard over wider areas, are both, 
 inspiratory and expiratory, and disappear after a few weeks 
 medical care. Pleural crepitations are dry, superficial 
 sounding, present both during inspiration and expiration, 
 and disappear for one or two inspirations after cough. 
 These may be heard in many latent apical fibroid lesions 
 in middle-aged individuals who seek advice for extra- 
 pulmonary disorders. 
 
 The clinical signs of arrested and obsolete tubercle may 
 include flattening and diminished expansion of one or both 
 apices, diminished supraclavicular areas of percussion 
 dulness (Kronig), deficient apical respiratory murmur 
 harsh breath sounds with prolongation of expiration at the 
 apices, some definite bronchophony and whispering 
 pectoriloquy in the same areas, and in children, telengi- 
 ectases around the cervico-dorsal spines (C7. Dj.Dj.D,) and 
 elsewhere. Of these clinical signs some have been 
 regarded as indicative of incipient and active tubercle. 
 
96 Radiography of the Chest 
 
 Piery ascribes the idiminished respiratory murmur to 
 pleuritic adhesions ; interrupted breath sounds to roughen- 
 ings or irregular thickenings of the pleura ; but there are 
 other causes in addition. Harsh breath sounds are con- 
 sidered by the same authority to be due to disseminated 
 nodal fibrosis with emphysema. In any case, many of the 
 above signs are certainly inapplicable to the real beginning 
 of pulmonary phthisis, since they may be permanent and 
 not followed by rales and crepitations. The radiological 
 features observed under the above conditions also vary — 
 diminished transparency of one or both apices (pleural 
 thickenings or pulmonary infiltrations), weak apical breath 
 sounds (often increased hilar opacities), weak breath sounds 
 at base or generally (diminished traverse of one or both 
 halves of the diaphragm, with or without adhesions). 
 
 Granular breathing may be associated locally and radio- 
 logically with an aggregation of apparently caseous, fibro- 
 caseous, or fibroid opacities ; in many cases of slight 
 apical bronchophony and whispering pectoriloquy there is 
 no obvious radiological substratum ; apical mucous clicks 
 have been found in some cases of marked perihilar lesions 
 without apical changes on the plate (oedema ? from pressure 
 on perihilar veins and lymphatics) ; also adhesions at the 
 base have giyen rise occasionally to the clinical diagnosis 
 of basal fibrosis. Mere catarrhal sounds, rhonchi, and 
 sibili are not necessarily represented, since they may be 
 due to simple congestion of the bronchial mucous mem- 
 brane. The slow progressive dissemination of small 
 discrete foci from the hilum towards the periphery is not 
 likely to be accompanied by definite physical signs. 
 
 Pulmonary Tuberculosis in the Great War 
 Both the French and Italian authorities have attacked 
 the serious problem of the tuberculous soldier in a com- 
 prehensive and satisfactory manner. The latter — fortu- 
 nately able to take some time in preparation — installed 
 diagnostic centres {Reparti di accertamento diagiiostico) to 
 investigate all cases. Caccini {Medical Record, 191 8) 
 
Radiography of the Chest 97 
 
 describes that established at Rome. The Italian medical 
 boards employed rigorous methods for the purpose of 
 admitting men into the armies. They rightl}' rejected 
 those with a history of past pleurisy, including interlobitis, 
 with pleuritic thickenings and adhesions, the relics of past 
 disease. At first it was thought that such men might be 
 utilised in the auxiliary services ; but inasmuch as they 
 are only able to give a minimum of work, and are liable, 
 under the periods of excessive mental and bodily strain 
 imposed by military necessity, to recrudescence or to new 
 manifestations, it was considered advisable to reject them, 
 except under special conditions of urgency. The logical 
 deduction is that recruits after admission must be con- 
 sidered free from tubercle, and that all cases of tuberculosis 
 arising subsequently must be regarded as caused by the 
 vicissitudes and by the fatigue of warfare. The X rays 
 were preferred to tuberculin, and radiography fortunately 
 took precedence over radioscopy. Stereoscopic pictures 
 were taken in the sitting position, with the tube behind. 
 The data were divided into (a) positive, and (b) presump- 
 tive. Positive evidence w^as arranged in four categories, 
 viz., (i) tubercle bacilli +: (2) larynx +: (3) Tbc. — : signs 
 + : X-ray +: (4) Tbc. — : signs — : X-ray + . Examination 
 of the larynx is indispensable, since tuberculosis may be 
 active in this situation and clinically latent in the lung. 
 The radio-signs in the fourth category include broncho- 
 pneumonia and pleurisy, followed to their possible con- 
 sequences ; evidence, however, which should be considered 
 presumptive, or in which a final decision should be post- 
 poned (Author). The prcsinnptive evidence falls under three 
 sections, (i) Tbc. — : signs + : symptoms — : X-ray -f : (2) 
 Tbc. — : signs — : symptoms + : X-ray + : and (3) Tbc. — : 
 signs — : symptoms — : X-ray +. Under section 3 the X-ray 
 signs of peribronchitis and bronchoadenitis are included ; 
 signs which may be inconclusive and not necessarily tuber- 
 culous (Autlior). Soldiers exhibiting presumptive evidence 
 were given 4-12 months leave and then re-examined. 
 Those with minimal signs of presumptive proof were 
 
 H 
 
98 Radiography of the Chest 
 
 detached for sedentary service. The French Government 
 also estabHshed a probation centre for each army {centre 
 du triage), and certain of the results have already been 
 published. The examinees consisted of soldiers who had 
 undergone military service and had been subsequently sent 
 back on account of obvious or presumptive tuberculosis. 
 Emile Sergent and Delamore, of the Paris centre, reviewed 
 600 cases admitted into hospital for further observation 
 {Journal de Medecine, 1916). After complete examination 
 (repeated clinical, radioscopical and radiographical, in- 
 vestigation of sputum, and tuberculin reactions, tem- 
 perature charts, blood pressure and pulse), 14 per 
 cent, were found to be non-tuberculous. Among these 
 were cases of simple anaemia, emaciation, dyspepsia, 
 of mitral disease, bronchitis, and emphysema. About 
 5 per cent, exhibited nasal lesions, with emaciation, 
 anaemia, cough, the absence of pyrexia, of increased vocal 
 vibrations, and of fixed adventitious sounds, with the 
 possession of normal arterial tension. One had a foreign 
 body in the lung, another a hydatid cyst. Many cases 
 of nasal disease, including ethmoiditis, antral disease, 
 hypertrophy of turbinates, the presence of spurs and 
 deflections of the septum, are accompanied by a chronic 
 coryza which graduall}^ spreads downwards, leading to 
 granular pharyngitis and bronchitis. There was a bacillary 
 sputum in 15 per cent, which was confirmed by physical 
 and radioscopic examination. Occasionally the latter 
 showed intrapulmonary foci and cavities which the stetho- 
 scope was unable to disclose on account of their central 
 and deep situation, or on account of accompanying 
 bronchitis and thickened pleura. In 70 per cent, of the 
 suspects the changes were apical, and in about 50 per 
 cent, tuberculosis was active. The presence of paren- 
 chymatous apical changes was shown by dulness on 
 percussion, increased vocal vibrations, crepitations, haemo- 
 ptysis ; the apical opacity being unchanged by cough, and 
 being accompanied on the plate by the presence of striae 
 and small foci. Pleural adhesions were shown by dulness 
 
u 
 
 ^ 
 
 pL. 
 
 Facing p. 99. 
 
Radiography of the Chest 99 
 
 on percussion, diminished tactile fremitus, pleural friction 
 sounds, diffuse opacity with some illumination on cough. 
 Sergent also gives two signs in addition, viz., inequality of 
 pupils (affected side usually dilated) and supraclavicular 
 adenitis due to the pleural affection. The various items of 
 the pleural syndrome are far from being always contem- 
 poraneous, and their duration is as variable as their 
 frequency. " Les frottements sont tres precoses et tres 
 fugaces : ils traduisent la presence d' exsudats permeables 
 aux rayons X et caracterisent la periode- initiale, purement 
 stethacoustique de la pleurite apical e . . . les voiles qui 
 resultent del'organisation des adherences conjonctives sont 
 plus tardifs et plus persistants; ils caracterisent la phase 
 terminale, essentiellment radiologique, de la symphj'se du 
 sommet." These statements lack anatomical verification. 
 Delherm and Kindberg {Journal dc Radiologic ct d'Elcctro- 
 logie, 19 1 7), made observations on one thousand cases at a 
 probation centre in France, but their results are scarcely 
 reliable, since they considered that it is necessary in every 
 case to place in evidence the bacilli of tubercle, and by the 
 fact that radioscopy alone seems to have been employed. 
 
 REPORTS OF CASES ILLUSTRATIVE OF PRECEDING 
 STATEMENTS 
 
 A. — Hilar, Pcrihilar, and Interlobar Lesions 
 
 I. James S , aet. 22. Cough, haemoptysis, ,^ii fourteen days 
 
 ago: Tbc+: family history + . Signs: crepitations at both apices, 
 scattered rhonchi. Radioi^rani 80 : both hilar opacities increased 
 in size, and irregular in outhne: right paratracheal opacity: thick- 
 ening and dilatation of bronchi, especially in upper left lobe, some 
 diminished transparency along both axillary lines: inliltration of 
 left perihilum : small subclavicular foci on both sides, emphysema. 
 
 3. Caroline H , act. 20. Enlarged tonsils, especially right : 
 
 mouth breather : cough nine months : expectoration since inlluenza 
 six months ago: hx'inoptysis, an occasional staining: no night 
 sweats: Tbc. — : t° subnormal. Sii^ns: left isthmus diminished: 
 granular breath sounds, some rough breathing and diminished 
 expansion, and occasionally a few crepitations at left apex. Radio- 
 logical : diaphragm sluggish, left hilar opacity much enlarged, 
 diffuse grey, and branches running to left upper lobe thickened : 
 median microcardia. 
 
lOO Radiography of the Chest 
 
 3. Irene S , set. 30. Cough, night sweats, emaciation^ 
 
 marked anaemia. Clinical signs : fixed catarrhal sounds and sHght 
 cHcks at left apex : breath sounds weak at the right base. Radio- 
 gram : left hilar opacity increased in size, with a few suspicious 
 perihilar nodes between it and left apex. 
 
 4. John M , aet. 13. Expectoration — : wasting + : hccmo- 
 
 ptysis — : looks ill : left chest — , dulness to percussion: no other 
 physical signs. Radiogram : left hilum enlarged with an indefinite 
 periphery : thickened bronchi and congested vessels running to« 
 left apex : costophrenic adhesion at cardiac apex : right hilum 
 enlarged, bronchi running to left base thickened. 
 
 5. Nellie F , aet. 21. Cough three months, expectoration : 
 
 Tbc. + : night sweats: pain between shoulder blades (interlobar?): 
 t° 97-100°. Physical signs: indefinite. Radiogram: right upper 
 interlobar infiltration, which yields dulness to percussion: bronchial 
 breathing and inspiratory crepitations on auscultation — fissure not 
 examined until after the radioscopic examination. 
 
 6. Daisy D , ^et. 26. Cough and pain leftside for six weeks : 
 
 sputum +: Tbc. + : emaciation slight. Physical signs: movement 
 and percussion not diminished left: breath sounds feeble, no crepi- 
 tations : at left aj~ex breath sounds rough. Radiogram 81 : cavity 
 in subaxillary region on left : a few infiltrations between it and left 
 hilum. Cases like this are not uncommon. They may leave the 
 sanatorium improved and without bacilli in sputum : but when the 
 lobe containing the cavity, or one of the other lobes, exhibits what 
 is apparently a spray of congested vessels, small hasmoptyses (31) 
 occur with change of barometric pressure, slight unaccustomed 
 exertion, and in association with menstruation (P. congestiva). 
 The cavity is not usually visible on the anterior plate. 
 
 B. — Apical Infiltrations with or without Excavations {on Radiogram^ 
 
 1. Isabella , ret. 20. Cough, expectoration, no haemoptysis, 
 
 dyspnoea, wasting, night sweats, family history positive : Clinical 
 signs : at left apex diminished movement, feeble breath sounds, no 
 crepitations. Tbc. negative (9 times). Radiogram: left upper lobe 
 striated in appearance, a small caseating node in left supraclavicular 
 area : slight left lateral microcardia. 
 
 2. Elizabeth J , ret. 40. Cough, sputum staining: chronic 
 
 cough since attack of pleurisy and hremoptysis five years ago : f* 
 normal : Clinical : left lung, diminished expansion and crepitations 
 left apex. Radiogram : infiltrations in left upper lobe reaching as 
 low as second rib, containing small excavations. 
 
 3. Thomas D , ret. 37, ex-soldier. Gunshot wound left lung, 
 
 cough, expectoration, hremoptysis, wasting, dyspnoea. Clinical i 
 breath sounds feeble left base, no adventitious sounds, vocal fremi- 
 tus increased. Radiogram : fracture of left ninth rib : thickenings 
 
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Radiography of the Chest lor 
 
 of pleura and induration of lung in the vicinity : infiltration at left 
 apex, apparently old, at level of osseous extremity of first rib. The 
 symptoms seem due to the traumatism : the apical lesion has not 
 been roused into activity. 
 
 4. Morris L , ast. 46. Pleurisy eighteen months ago : cough 
 
 for years, sputum frothy, haemoptysis fortnight ago, emaciation : 
 family history — . Physical signs: slight and indecisive. Radiogram: 
 an infiltration in right first and second interspaces, outer half: no 
 excavations: right paratracheal opacity: microcardia, slight, lateral 
 and to right. 
 
 C. — Disseminated Lesions 
 
 1. Amy G , ast. 29. Began to be ill three months ago : flatten- 
 ing and diminished expansion left side: signs indefinite : Tbc. + : 
 Radiogram: disseminated nodular in both lungs, apparently mainly 
 fibrotic: tendency to aggregation at apices: dilated thickened tubes 
 at bases. 
 
 2. Albert J , oet. 18. Cough one year, recently left pleurisy. 
 
 Signs: crepitations behind at inferior angles of scapulae, dulness at 
 left base. Radiogram : disseminated nodal opacities in right middle 
 and basal lobe : thickenings of right upper interlobe : pleuritic 
 residues at left base and cardiophrenic adhesion. 
 
 3. Edward R , ret. 33. Cough for years, severe influenza 
 
 fifteen and again ten years ago : cough, h:emoptysis on three occa- 
 sions : crepitations and rhonchi in right lung. Clinical diagnosis : 
 bronchitis (?). Radiogram : disseminated nodular phthisis in both 
 lungs, becoming fibrotic: mediastinal deviation to the right: some 
 dilated tubes in right upper lobe. 
 
 4. Joseph P , ivL 44. Cough and expectoration for months: 
 
 no hx-moptysis: emaciation. Clinical signs: impaired resonance at 
 left apex, a few rhonchi, toneless heart sounds. Radiogram : dis- 
 .seminated foci and small cavities left upper lobe, nests of small 
 foci lower down: shrinking of left upper lobe: central micro- 
 cardia. 
 
 5. Solomon F , rtt. 46. Severe anorexia and emaciation 
 
 four years ago : occasional pyrexia 100°: no physical signs. Tlie 
 Radiogram shows a widely spread crowded distribution of very small 
 foci in both lungs: supraclavicular apices free: ossification of first 
 rib cartilages. 
 
 D. — Chronic Infillrativc Fibroid Lnng 
 
 I. Catherine E , a't. 33. Cough, dyspnoea, tachycardi:i, 
 
 dyspepsia. Signs : general dulness to percussion over left side, 
 breath sounds and tremitus diminished, in places breath sounds 
 tubular. Systolic bruit at cardiac apex. Radiogram 82 : left chest 
 homogeneously opaque, excepting a darker shadow, only seen in 
 
102 Radiography of the Chest 
 
 view box, at level of fifth interspace : laevo-trachea : mediastinum 
 and heart slightly to right : emphysema of right lung : nipple 
 shown — arrow: shrinking of interspaces on left, old foci in right 
 lung : diagnosis lies between pure pleuritic fibroid lung and post 
 pleuritic fibroid tubercle. Wassermann test not employed. 
 
 2. Albert C , set. 52, glass worker. Cough, expectoration, 
 
 dyspnoea. B.P. 180/95. Left side flat, tubular breath sounds,, 
 coarse crepitations and clicks. Clinical diagnosis: aneurism or 
 tubercle (?). Radiogram : opaque patch outside left hilum reach- 
 ing to axilla, and a thin opacity reaching as far as left diaphragm 
 from lower part of hilum. Rad. diagnosis: pure fibroid (dust ?). 
 
 3. Lily C , ast. 39. First husband and one daughter died of 
 
 phthisis: cough, Tbc. — : t° subnormal but variable. Signs: crepi- 
 tations both apices. Radiogram : fibrosis of lower right and middle 
 lobe: emphysema: dilated right auricle. (Conjugal tubercle is not 
 uncommon; it is often perihilar, of minimal activity, or arrested.) 
 
 4. Morris M , aet. 45, boot-laster. Movement on right side 
 
 impaired : harsh breath sounds: bronchial breathing : dull cracks 
 in front and back of upper right: Clinical diagnosis: fibroid con- 
 solidation right upper and lower lobes, and left upper. Radiogrant 
 83: consolidation reaching from mediastinum to right axilla at 
 level of second rib : right supraclavicular area opaque : micro- 
 cardia : dilatation of ascending aorta and sclerosis. 
 
 E. — Midlohar Fibrosis 
 
 1. Louisa W , ret. 30. Cough, expectoration slight, wasting, 
 
 flushed face. Signs: percussion impaired on right, especially middle 
 lobe : Tbc. — : Radioscopy : diaphragmatic movement on right 
 minimal, inspiratory tremor only : Radiogram 84 : disseminated 
 nodular fibroid, especially affecting right middle lobe. 
 
 2. Emily G , aet. 28. Cough, sputum, no haemoptysis r 
 
 t°97'6° : Clinical : diminished movement, breath sounds feeble, no- 
 crepitations on right side. Radiological : right hilum enlarged, 
 with infiltration extending into middle lobe : some deviation of 
 mediastinum to left. Tuberculosis or unresolved pneumonia? 
 
 3. A B., aet. 33. Cough one year, expectoration streaked : 
 
 Tbc. — : Clinical: movement and percussion note impaired right 
 apex : granular breath sounds in hilar region posteriorly. Radio- 
 gram: fibrosis middle lobe, and heavy hilar opacity. 
 
 F. — Pleuritic 
 
 I. Henry T , aet. 36. No cough, no haemoptysis, night 
 
 sweats + : dyspnoea + : Signs indefinite : Clinical diagnosis, 
 tubercle? : wife has pulmonary tubercle. Radiogram : slight 
 pleural adhesions in left axillary line : thickenings at left apex : 
 left chest contracted : no signs of pulmonary involvement. 
 
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 Facing p. 103. 
 
Radiography of the Chest 
 
 103 
 
 2. Sidney P , act. 29. Cough, dyspnoea, night sweats, haemo- 
 ptysis a staining : finger nails incurved : t° gy-gS'^^. Si^iis : in- 
 definite, no moist sounds. Radiological : right leaflet of diaphragm 
 sluggish : a visceral pleuritic shadow running parallel to diaphragm 
 is revealed in radiogram taken in deep inspiration : slight pleuritic 
 general thickening over right lung : a few scattered foci in pul- 
 monary fields : central microcardia. 
 
 I. Alfred W- 
 
 —Bronchitic and Bronchiedatic 
 
 , was in sanatorium, 1912, for fifteen weeks, 
 then said to have bacillary sputum : no haemoptysis. Signs : on 
 left, percussion note impaired at apex, a few moist sounds, heart 
 apex more to left than usual. Clinical diagnosis : fibrosis of left 
 hing. Radiogram : diffuse cylindrical bronchiectasis in both lungs 
 only : (non-tuberculous ?). 
 
 Diagram 7. 
 
 2. Edward W , a,"t. 45, carpenter. Bronchitis three years 
 
 :igo, never free since: cough, expectoration, no ha_-moptysis : night 
 sweating : effort dyspnoea : no emaciation : no clubbing : Tbc. — : 
 Clinical : percussion note impaired right apex, distant rhonchi.and 
 a few post-tussive crepitations right apex posteriorly (Diagram 7). 
 Rndiogrant 85 : patch of aggregated foci at right apex with an area 
 of dilated bronchi surrounding it : slight emphysema: microcardia 
 and cardioptosis. (Broncliitis tuberculosa.) 
 
 3. Elizabeth C , aet.38. Pleurisy as a child, bronchitis every 
 
 winter since : pneumonia eight years ago : dulness both apices and 
 crepitations (12.6.18) : moist sounds gone (30.7.18). Clinical 
 tliagnosis: plithisis Iioth :ipices. Radioi^rani: shows a saccular para- 
 cardiac broncliicctasis of leftside : streaky fields : calcification first 
 rib cartilages. (Non-tuberculous bronchiectasis.) 
 
104 Radiography of the Chest 
 
 4. Fanny S , cet. 26. Cough, sputum, emaciation, pyrexia, 
 
 lassitude, no hzemoptysis, family history — . Clinical (Diagram S) : 
 scattered rhonchi, granular breath sounds near right nipple. Radio- 
 gram 86 : small fibrocaseous consolidation near right nipple (arrows) : 
 scattered foci in right middle lobe and in left lung : some generalised 
 dilatation of bronchi : paralytic thorax, slight basal emphysema : 
 central microcardia slightly dilated : thin right paratracheal shadow 
 (B. tuberculosa). 
 
 Diagram 8. 
 
 Mrs. S — — . Diffuse rhonchi ; g.b., area of granular breath sounds 
 
 5. Henry H , vet. 24. Has complained of cough, with copious 
 
 expectoration and frequent hremoptyses since an attack of pneumonia 
 six years ago : no loss of weight : Tbc. — : is following the vocation 
 of milk carrier. Signs : no crepitations, diminished movement of 
 right side with emphysema. Radiological : diaphragmatic halves 
 almost immobile. Radiogram shows a condition of dilated cylin- 
 drical and saccular bronchiectasis : some tubes in upper left lobe 
 are partially filled with sputum : at the base of right hilum a 
 triangular patch of unresolved pneumonia ? Rad. diagnosis : non- 
 tuberculous diffuse bronchiectasis after bronchopneumonia. 
 (Radiogram 87.) 
 
 6. AdaR , ast. 41. Cough, expectoration somewhat excessive, 
 
 mucopurulent. Signs of tubercle inconclusive : Tbc. — . Radiogram 
 88 shows a condition of purulent bronchitis (chronic influenza) with 
 enlarged hila (sputum), distribution of larger tubes well seen : the 
 rounded foci in periphery are tubes cut transversely, filled with 
 secretion : note the bend of tube (arrow) just below sternal end of 
 first rib : cardiac opacity normal. No radiological signs of pul- 
 monary tuberculosis. (Bronchitis chronica mucopurulenta.) 
 
 7. John H , 3et. 27. Haemoptysis, twelve times in a month : 
 
 gassed three years ago (tear gas) : cough, sputum : Tbc. — : no 
 physical signs in lung. Radiogram : both fields filled with an in- 
 
cy 
 
 Facing p. 104. 
 
Radiography of the Chest 105 
 
 tense interlacing fibrosis, especially marked at both bases : a few 
 ■calcareous nodes in right hilum (non-tuberculous bronchial fibrosis). 
 
 A discussion of the relations between bronchial asthma 
 and tubercle must be relinquished for the present. 
 
 H. — Partial Miliary Dissemination 
 
 I. Eleanor O , aet. 22. In-patient, then in sanatorium five years 
 
 ago : no cough, no sputum, no haemoptysis. Signs : movement at 
 right apex diminished and expiration prolonged. Is at work, but 
 feels very tired and languid : t98'4°-99-6o. Radiogram shows old 
 healed (?) infiltration at right supraclavicular apex : and a shower of 
 very small foci in the right axilla, apparently more recent (minimal 
 activity with slight pyrexia and lassitude ?) : central microcardia : 
 emphysema. 
 
 K. — Exophthalmic Goitre 
 
 1. Sylvia E , xt. 20. Enlarged thyroid, cough night and 
 
 morning: expectoration: sweating sometimes: at right apex per- 
 cussion note impaired : expiration prolonged, rhonchi right base. 
 Radiogram: right paratracheal opacity: opacities outside right 
 hilum : irregular right phrenic leatlet, supraclavicular apices clear : 
 dilated right auricle. 
 
 2. Sarah M , aet. 23, cigarette maker. Cough three weeks, 
 
 expectoration copious : slight swelling of thyroid, slight exophthal- 
 mos and tremor of hands: crepitations at left hilum posteriorly: 
 systolic hoemic murmur. Radiogram : considerable perihilar dis- 
 semination, especially on left, and enlarged paratracheal glands. 
 
 The relations between tubercle and Graves' disease are 
 still obscure. Radiological examination in 191 5 and 1916 
 of twenty cases in young women sent up for X-ray treat- 
 ment showed paratracheal opacities as a general rule, 
 increased hilar opacities, and occasionally the signs of a 
 massive general infection. When the salient features of 
 the disease, as the exophthalmos, the tremor, and cervical 
 swelling are less obvious, certain symptoms, as the cough, 
 occasional bursts of perspiration (which are, however, 
 diurnal), the oscillations of temperature, the dyspnoea, 
 tachycardia, emaciation, may suggest incipient phthisis. 
 Moreover, in many cases of chronic phthisis, a recru- 
 descence of the disease may be accompanied by a fresh 
 outburst of adrenalism. Possibly certain facts to be 
 obtained from the radiogram may be useful in prognosis. 
 With regard to the opposite condition of myxoedema, in 
 
io6 « Radiography of the Chest 
 
 which it is said the resistance to tubercle is diminished^ 
 the author has little experience. In one case of chronic 
 myxcedema after middle age, the radiogram showed both 
 lungs filled with small disseminated fibroid foci, with a 
 hilar infiltration at junction of right interlobe with sternum, 
 and a cardiac ^opacity in which the pulmonary curve was 
 markedly enlarged. 
 
 L. — Nasal Lesions 
 
 I. Albert E , ast. 29. Cough, loss of voice, emaciation, 
 
 pharyngitis, deflected septum, chronic rhinitis, rhonchi in chest. 
 Radiogram ; right supraclavicular apex dull : in left chest a few 
 old opacities : no signs of active tuberculous disease. Obviously 
 the cause of the cough and slight emaciation is the chronic rhinitis 
 with pharyngitis, and the gradual downward involvement of the 
 larynx and larger bronchi. 
 
 hicipicjit Pulmonary Tuberculosis. — In cases which are 
 diagnosed clinically, incipient or early, radiological ex- 
 amination often reveals the existence of one or more 
 indurated) even calcareous arrested lesions either in the 
 apex, or in the hilum and its vicinity. The clinical signs 
 are really due to the resuscitation of a dormant lesion or 
 to the incidence of a new infection — usually the former. 
 On the other hand, when the disease is really incipient, 
 the radiological manifestations may be meagre and in- 
 different. But such an event is really unique ; as a rule a 
 lesion which is incipient to the clinician is already pro- 
 gressive to the radiologist. There are three principal 
 localities in which radiology may find the first signs of 
 pulmonary tubercle, viz., (i) the supraclavicular apex, 
 (2) the hilum, and (3) the paravertebral triangle. 
 
 (i) T/ie supraclavicular apex or apical triangle. In order 
 to delineate clearly doubtful lesions in this area, it is 
 advisable to take special plates of the posterior apices, 
 stereoscopic by preference. The X-ray tube should be 
 soft, and slightly elevated towards the head, so as to throw 
 the clavicles downwards, and to give an unobstructed 
 view of the second and third posterior interspaces. 
 Opacities present in this situation may be produced by 
 old arrested fibroid lesions, probably containing smal 
 
00 
 2ci 
 
 Tacing'p. I06. 
 
Radiography of the Chest 107 
 
 cavities, of the size of a pea and of the shape of a clover- 
 leaf; by calcareous, caseating or fibroid nodular lesions ;. 
 by diffuse or irregular pleuritic thickenings and small 
 calcareous pleural plates, often linear and 13'ing horizon- 
 tally. They may be due to opacities lying externally ta 
 the pleura, such as accumulations of adipose tissue, or 
 thickened subcutaneous or muscular tissue, to sclerodermia 
 or indurated and calcareous lymphatic glands lying in the 
 supraclavicular fossa. Stereoscopic radiograms place each 
 opacity at its proper level, and recognise the presence ot 
 slight scoliosis. In most cases the foci are arrested and 
 of no serious importance. 
 
 Recent apical lesions are seldom susceptible of verific- 
 ation by autopsy. Radiogram 89 shows several foci^ 
 about pin-head size, in each second interspace. The general 
 transparency is not affected. On the right they are rather 
 more numerous ; on the left they are somewhat larger and 
 more distinct. Post-mortem : in both spaces several 
 caseous foci were found, on the left some were indurated 
 and larger. Apical pleura on each side intact. 
 
 (2) The Jiiliim. — In the great majority of cases pulmonary 
 tubercle appears to take its origin from the central glands. 
 These have been described in Chapter II. Disease in this 
 situation leads to an irregular configuration of the hilar 
 opacities, often the right alone, and to an increase in 
 breadth. If merely hypertrophied there may be only a 
 faint gre3'ish increase of shadow; distinct rounded shadows 
 within the hilum may be caseating, fibroid (anthracotic)^ 
 or calcareous glands according to the degree of opacity. 
 Caseating paratracheal glands appear as convex opacities 
 in the two anterior interspaces, or as an opacity parallel to 
 the sternum. When the area between the right hilum 
 and cardiac opacit}', which is usually translucent, becomes 
 opaque, the latter is often due to caseating bifurcation 
 glands on the lower border of the right extrapulmonary 
 bronchus. With regard to the hilum itself, care must be 
 taken not to diagnose tubercle because of an increased 
 
To8 Radiography of the Chest 
 
 shadowing of the hilum only, since this may occur in 
 association with pneumonia, bronchopneumonia, influenza, 
 pertussis, and measles; also in simple chronic bronchitis, 
 aneurysm of the aorta, and in passive pulmonary congestion 
 from morbus cordis ; it may be due to the inhalation of 
 dust, so that oppidans do not exhibit normal hila, and par- 
 ticularly those who work habitually in a dust-laden 
 atmosphere (pneumoconiosis) ; in children under fifteen, 
 since anthracosis do not occur before that age, heavy hilar 
 opacities are to be viewed with suspicion unless there are 
 other positive circumstances to account for them. In the 
 description of certain radiograms already given the 
 diagnosis of hilar phthisis has been discussed, so that 
 further remarks are here superfluous. 
 
 (3) The Paravertebral Triangle [enclosed by 
 lines drawn {a) from the right hilum about the level 
 of the vertebral end of the seventh rib to a point 
 in the clavicle half way between its sternal end and 
 the axillary margin of the chest; {h) along the media- 
 stinum; and (c) along the inner clavicle] frequently 
 contains cord-like linear opacities which are often studded 
 with minute foci. Into the outer and upper part of the 
 triangle the anterior end of the first rib usually pro- 
 trudes ; and it is in this vicinity that actual consolidations 
 and aggregations of foci, in the first place, generally 
 materialise, that is, within the distribution of the para- 
 vertebral bronchus. In some instances autopsy has 
 shown that these paravertebral linear opacities are 
 produced by fibrotic thickening of the lymphatics ; in 
 •others the radiograms suggest bronchial dilatations with 
 thickened walls, which appear invested with small round 
 foci, generally considered peribronchial from their position ; 
 in some the leash of shadows suggests the presence of 
 congested vessels and lymphatics. The latter may be 
 found in congestive forms, and then often lie more external 
 between the right upper interlobe and the axilla, and are 
 accompanied by small frequent haemoptyses. When the 
 
Radiography of the Chest 109 
 
 disease slowly disseminates, in all directions along the 
 lymphatics it is usually benign, and the small foci become 
 in time fibroid and harmless (follicular). Nodal, even 
 larger infiltrations may be found in early cases in the para- 
 vertebral triangle, in the upper external part already men- 
 tioned, or at the periphery of the hilum and in the perihilum 
 just outside it. The diagnosis between the two forms, 
 follicular and infiltrative, may generall}^ be made from the 
 radiogram, particularly if assisted by a correct report of 
 clinical symptoms and signs. In man}- cases of early 
 tubercle apical and hilar disease are both present, but hilar 
 changes, without apical, are more common than the 
 converse. 
 
 Less favourite situations for the incipient development 
 of nodules and infiltrations are the deep axilla and the 
 vicinity of the interlobes. Considering the number of the 
 latter type the radiologist meets, so to speak, incidentally, 
 it is probably not at all infrequent. 
 
 To sum up. — The majority of incipient cases (60 per cent, 
 at least) exhibit either minute foci dVth in. in diameter, or 
 rather more) or minimal infiltrations, either in the upper 
 lobe (that is, within the supraclavicular triangle, or imme- 
 diately below the inner third of the clavicle), or just outside 
 the limits of the hilum — in some instances in both situations 
 simultaneously. These areas lie within the distribution of 
 the paravertebral bronchus.* 
 
 With regard to central lesions, a caseating right hilum, 
 apparently quiescent, may re-awaken, inducing cough, 
 wasting, and night sweats ; sometimes only emaciation 
 and a stained sputum. The author has met with cases 
 where a diagnosis of " tuberculosis of the roots " has been 
 made by the physician, where only cough and emaciation 
 
 • The foci may become aggregated and form small patches of broncho- 
 pneumonic infiltration. If the opacities are of feeble intensity, with 
 ill-defined and fluffy margins, they are iicUvc, with clinical symptoms and 
 physical signs; whereas darker shadows with sharper edges indicate 
 caseation, fibro-caseation, or fibrosis. 
 
no Radiography of the Chest 
 
 without any physical signs have been present, and in-which 
 radiology revealed increased hilar opacities merely. Hilar, 
 or perihilar, phthisis should not be diagnosed unless a 
 definite amount of pulmonary infiltration can be de- 
 monstrated by the radiologist, and then only in correlation 
 with the signs and symptoms. 
 
 In very young children (under one year) the researches of 
 Ribadeau-Dumas, Weil and Maingot (191 2) have shown 
 that tubercle usually begins as a small focus in the lower 
 lobe, from which it spreads centripetally to the hilum, and 
 then affects the paratracheal and bifurcation glands before 
 reaching the apices. These researches do not seem to 
 have been confirmed up to the present, although the patho- 
 logical observations of Ghon (191 3) prove that in children 
 such primary foci may occur in any part of the lung. In 
 /a/^r )'(?<7r5 (5-15) pulmonary tubercle is largely a question 
 of central glandular disease and its centrifugal diffusion 
 along the lymphatic tracts. At this period children 
 appear, however, to possess a remarkable power of control 
 over the further development of this disease, a fact pro- 
 bably due to the production of immunity by the primary 
 infection. Tuberculous infection may be slight, moderate, 
 or massive, and its degree is associated with altered 
 radiographical signs of lymphatic dissemination. The 
 types of tubercle in children are, (a) caseating lymphatic 
 intrathoracic glands ; ih) hilar infiltrations chiefly on right 
 and affecting one of the upper two lobes; (c) broncho- 
 pneumonic nodular disease due to irruption from the hilum 
 into the bronchial tree ; id) fibroid disease of axillary or 
 apical areas, sometimes associated with pressure on root 
 bronchi by enlarged packets of hilar glands ; {e) broncho- 
 pneumonic pseudo-lobar disease springing from the hilum ; 
 (/) very occasionally extensive fibroid cavitary lesions ; 
 (^) miliary and submiliary forms. Children are often 
 brought to the radiologist, or sent to the tuberculosis 
 dispensary, with the suspicion or the diagnosis of phthisis, 
 in which the lesion is either non-tuberculous or a non- 
 
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 Facing'p. ill. 
 
Radiography of the Chest iii 
 
 tuberculous sequel, as it were, of an arrested perihilar 
 tubercle. In the majority of cases it is either, (i) a central 
 glandular disease with peripheral dissemination, which is 
 gradually fading ; (2) one of the manifestations of un- 
 resolved bronchopneumonia (cirrhosis), in the latter case 
 often implicating the right base and right cardiophrenic 
 cul-de-sac, accompanied by cough, wasting, basal crepita- 
 tions and inferior emphysema ; (3) in other cases there is 
 a brcjic/iiecfasis, diffuse and cylindrical, or more or less local 
 and confined to the hilum and the base. This condition 
 requires a different form of treatment from that of hilar 
 tubercle ; if the affection does not clear the little patient 
 may become a chronic bronchitic, although the character- 
 istic sputum of bronchiectasis may never or may take years 
 to develop. {Vide Vol. II.) 
 
 The Radiological Signs of Arrested and Healed Phthisis 
 These may be seen as (i) isolated calcareous nodes, 
 which may be as dark as projectiles, generally rounded, 
 sometimes oblong, and present within the hilum, perihilum, 
 paravertebral triangle, or along the bronchi running towards 
 the right middle lobe and bases of both lungs ; (2) the 
 inverted comma (Crane) already mentioned ; (3) old fibroid 
 and anthracotic opacities of the paratracheal, and in the 
 right oblique position of the bifurcation glands ; (4) uni- 
 lateral fibroid infiltrations in the supraclavicular and upper 
 part of the subclavicular triangle, with lighter spaces in 
 their midst (old cavities); (5) scattered old nodal opacities 
 which have diminished in size, increased in densit}'', and 
 their cloudy irregular borders have become replaced by 
 sharp clean-cut edges ; (6) occasionally slight deviations 
 of the mediastinum towards old fibroid lesions; (7) old 
 costal adhesions of the diaphragm, or cardiophrenic resi- 
 dues, and pleuritic thickenings at apex, or at axillar\- lines, 
 with diminution of interspaces and dove-tailing of the ribs; 
 (8) a scattered diffuse dissemination of small foci in young 
 children and adults (tuberculous infection), due to 13'm- 
 phatic dissemination ; or a more uniform distribution of 
 
112 Radiography of the Chest 
 
 small rounded fibroid foci as the result of bronchogenic 
 diffusion from caseating cavities ; and (9) shrinking of chest 
 from pleuritic adhesions, and the production of a scoliosis 
 convex to the more healthy side. In the two latter 
 divisions some may be cases of feebly progressive fibroid 
 disease ; (10) occasionally in the adolescent one may localise, 
 in the external pulmonary fields, the primary focus of 
 Ghon. 
 
 Associated Disease 
 It has been stated that various types of pleurisy, with or 
 without effusion, of chronic bronchitis, asthma, cylindrical 
 and saccular dilatations of the bronchi may accompany 
 tuberculosis. Occasionally pronounced forms of morbus 
 cordis, prominent dilatations of the aorta, and conspicuous 
 aneurysms may be associated with it. 
 
 Arthur H , aet. 39, ex-marine policeman : washed 
 
 down hatchway in December, 191 5, kept on duty three 
 months, then entered hospital with pain in right chest 
 and dyspnoea. Cough commenced October, 1917, and 
 emaciation became severe (three stone in four months) : 
 Tbc. + : haemoptysis, occasional streaks. Clinical sigjis : 
 dulness right chest, bronchial breathing, short systolic 
 at base : dyspnoea extreme : pupils and radial pulses 
 equal: no tracheal tugging: liver enlarged, distended 
 veins over abdomen: fingers clubbed and cyanosed. 
 Radiogram 90 : cardiac opacity much enlarged towards 
 right, dulness in right upper lobe with small excavations. 
 The opacity was considered to be an aneurysm of the 
 first part of the aorta. It possessed no pulsation, and it 
 moved slightly with inspiration. The opacity became 
 larger very gradually, finally marked pulsation became 
 visible over the right mamma. The autopsy proved the 
 existence of an aneurysm of the ascending aorta which 
 had eroded several of the anterior ribs, with tuberculosis 
 of the right upper lobe. 
 
 So much time has been devoted to the different types of 
 phthisis that an account of the relations between this 
 disease and syphilis, malaria, traumatism, and carcinoma 
 must be unavoidably postponed. 
 
Radiography of the Chest 1 13 
 
 The Heart in Pulmonary Tuberculosis 
 This question in reality deserves a chapter to itself; we 
 must content ourselves with a few disjointed remarks on 
 the subject. Radiograms 17, 24, 25, 27A, 27B, 33, 35, 38, 
 46, 51, 55, 57, 61, 62A, 6-/, 70A, 71 and 91 will demonstrate 
 the prevalence of microcardia in pulmonary phthisis, and 
 also that this form of heart is not necessaril}' limited to 
 any one particular type of phthisis. No doubt its character 
 is one of the causes of the low arterial tension, of the 
 tachycardia, and of the proneness to dilate under conditions 
 of severe strain which is exhibited, among others, b}' 
 cases of disordered action of the heart in soldiers. It 
 is frequent!}^ placed centrally in the chest, occasionally 
 laterally (Radiogram 91). It is obvious that the prognosis 
 in tubercle, as regards length of life, is dependent, cceteris 
 paribus, on the degree of microcardia, the integrity of the 
 aorta, their dilatability, and the extent of the muscular 
 reserve. Moreover, cardiophrenic adhesions may be 
 present, which render the prospect still more unfavourable. 
 IVith regard to Diagnosis, the Association of Microcardia 
 iVith Haemoptysis is always Suspicious. Theorthodiagraphic 
 transverse measurement may be as low as three inches 
 but the chief point appears to be the differentiation 
 between a normal cardiac silhouette and one of micro- 
 cardia disfigured and magnified by dilatation. [The 
 author has met with several cases of centrally placed hearts 
 in late middle-aged men, who have exposed themselves 
 continuously to increased bodily and mental strain during 
 the war ; in such individuals there has been considerable 
 cardiac dilatation, fits of giddiness, sudden faints, slight 
 neurasthenia, and occasionally a low arterial tension. 
 Rest in bed for some weeks, the exhibition of digitalis, and 
 gentle massage are required.] 
 
 The relation of microcardia to general congenital 
 asthenia, including visceroptosis, and in particular to its 
 variety the habitus phthisicus, appears to be intimate. 
 Roughly, the types of microcardia may be grouped under 
 
114 
 
 Radiography of the Chest 
 
 three headings, (i) microcardia without cardioptosis ; 
 (2) with cardioptosis ; (3) the " hanging" heart. (Diagram 
 9.) In the last group there is a space on deep inspiration 
 between the heart and diaphragm, better seen in the 
 upright position, during which the right ventricle barely 
 touches the central tendon. In this case the suspensory 
 ligaments (vessels, upper pericardial and cervical fascia) 
 hold firm.* In some cases with marked ptosis of the 
 diaphragm (Radiogram 91) the cardiac apex is at the level 
 
 Diagram 9. 
 
 Hanging heart in woman aged 28 years.with bronchial asthma and tubercle 
 
 suspect; ptosis of diaphragm. Ao, left aortic bulge; P., pulmonary curve; 
 
 AS., left auricle; P.e., pericardium visible in left cardiophrenic sulcus. 
 
 Radiogram taken in deep inspiration. 
 
 of the eleventh rib in recumbency. In this radiogram 
 there is evidence of old arrested tubercle in the upper 
 lobes, and severe gastroptosis was shown by the bismuth 
 meal. On the screen the right ventricle may take part in 
 the right vertical border of the cardiac opacity, and the 
 right auricle may be above and behind it. Occasion- 
 
 * The three variations may be expressed thus: (I) M — C — V; (2) 
 M + C + V; (3) M + C< + V>; where M= microcardia; C= cardioptosis; 
 and V = visceroptosis. 
 
Radiography of the Chest 115 
 
 ally the hanging heart (cor pendulum) is said to produce 
 tracheal tugging by traction on its suspensory attachments. 
 The depth of the left ventricle, and the degree of its hyper- 
 trophy, if any, may be determined by Vaquez-Bordet's 
 method of procedure. 
 
 Concluding Remarks 
 
 The advantages of the X-ray investigation have been 
 amply demonstrated in the preceding pages. But it should 
 not be expected that the radiologist is able to determine 
 at one examination the diagnosis in cases which have 
 possibly puzzled one or more skilled clinicians. Two, even 
 more, examinations may be nece,ssary, and supplementary 
 plates, ordinary and stereoscopic, of suspicious areas may 
 be expedient. Progressive tendency and activity in the 
 absence of definite clinical symptoms may be ascertained 
 by observations at fortnightly intervals if required. 
 Certain signs are special to the radiologist: the progressive 
 studding of the bronchi in slow perihilar dissemination, 
 the hazy outlines of an apical active infiltration, the wedge 
 of dilated vessels or lymphatics, with its apex at the hilum, 
 inmanycongestivecases: thesmall nodular foci in the supra- 
 clavicular and paravertebral triangles, the unexpected diffu- 
 sion of nodular foci from half-emptied cavities, the fusiform 
 scraps and cylindrical fragments producing a broken chain 
 from the hilum to the clavicle and axilla in forms passing 
 into arrest and fibrosis, the circumscribed sharp edges of 
 calcareous foci and of healed arrested fibroid patches, and 
 the caseating opacities of the central lymphatic glands. 
 These are phenomena which the radiologist must learn to 
 recognise, and at the same time assign to each its proper 
 importance and interpretation. As regards the rest, the 
 mutual co-operation of clinician, pathologist, and radiologist 
 is requisite in order to increase our knowledge of the 
 disease in its incipient stages, its principal types, the life 
 history of each, and to mature the methods of treatment 
 and control. 
 
ii6 Radiography of the Chest 
 
 PERIODICALS AND BOOKS OF REFERENCE. 
 
 1. Norris and Landois. " Diseases of the Chest," 1917. 
 
 2. Walsham and Orton. " The Radiology of the Chest," 1906. 
 
 3. Greene. " Medical Diagnosis." IV. Edition, 1918. 
 
 4. Piery. " La Tuberculose Pulmonaire," igio. 
 
 5. Chantemesse et Courcoux. "Les Pleuresies Tuberculeuses," 1913. 
 
 6. Rieder. "Die Rontgendiagnostik der Lungen," 1912. 
 
 7. Letulle. "La Tuberculose Pleuropulmonaire," 1917. 
 
 8. Assmann. " Erfahrungen ii. d. Rontgenuntersuchungen der Lungen,'* 
 
 1914. 
 
 9. Dunham. "Stereorontgenography of the Chest," 1915. 
 
 10. Riviere. "The Diagnosis of Early Tubercle," 1919. 
 
 11. Barjon. " Radiodiagnostic des Affections Pleuropulmonaires," 1916. 
 
 12. Dickey. "Applied Anatomy of the Lungs and Pleura," 1911. 
 
 13. Fowler. "Chronic Arrested Tuberculosis," 1892. 
 
 14. Poncet et Leriche. "La Tuberculose Inflammatoire," 191 2. 
 15- Poncet et Leriche. " Le Rheumatisme Tuberculeux," 1909. 
 
 16. Bard. "Formes Cliniques de la Tuberculose Pulmonaire," 1901. 
 
 17. Ewart. British Medical Journal, October, 1912. 
 
 18. Pegurier. Congr. Internat., Madrid, 1903. 
 
 19. F. Bezanfon. Soc. Med. des Hop., 1907-1908. 
 
 20. Chauvet. La Presse Medicate, 1908. 
 
 21. Neumann and Matson. Beilr. z. Klitiik der Tub, 191 2. 
 
 22. Straub and Otten. Beitr z. Ktiuik der Tub, igii. 
 
 23. Groedel. " Rontgendiagnostik," 1909. 
 
 24. A. Bezangon. "Conformations thoraciques chez les Tuberculeux.'" 
 
 These. Paris, 1906. 
 
 25. Crane. American Journal of Rontgenology, I918. 
 
 26. Morton and Owen. Archives 0/ Radiology, igi^. 
 
 27. Schut. Beitr.z.Klitiik der Tub, igi^. 
 
 28. Jordan. Practitioner, 1912. 
 
 29. Heise and Sampson. American Journal 0/ Tuberculosis, 1917. 
 
 30. Frankel. Miinch Med. Woch, August, 1916. 
 
 31. Walsham and Overend. Archives of Radiology , August, I9I5- 
 
 32. Overend and Riviere. Archives of Radiology, August, 1916, and Lancel„ 
 
 September, 1916. 
 
 33. Beclere. "The Diagnosis of Tubercle," etc., 1904. 
 
 34. Riviere. " Hilus Tb. in the Adult," February, 1919. (Lavcet.) 
 
 35. Hulst. American Journal of Rontgenology, October, 1916. 
 
 36. Overend and Hebert. Atchives of Radiology, 'Dzcevaber, igij. 
 
 37. Caccini. Medical Record, 1918. 
 
 38. American Journal of Tuberculosis, 1917, 1918, 1919. (Various papers.> 
 
 39. Knox. Treatise on Radiography and Radio-therapeutics (1914). 
 
 40. Morriston Davies. Surgery of the Lung and Pleura C1919). 
 
INDEX 
 
 Abortive phthisis (Bard), 48 
 Adhesions, apical, 81 
 
 basal, 81 
 
 interlobar, 79 
 
 mediastinal, 81 
 
 phrenic, 81 
 Age, influence of, on tuberculosis, 19 
 Alcohol and tubercle, 37 
 Anasmia in tuberculosis, 30, 100 
 Aneurism and phthisis, 18, 30, 112 
 Anthracosis, 65 
 Aortic bulge, left, 3 
 Apical nodular phthisis, 49 
 
 infiltrative phthisis, 50 
 Appendix, left auricular, 6 
 Arrested tubercle, X-ray signs of. If I 
 Aspiration from cavities, 33, 35 
 Asthma, 59 
 
 B 
 
 Bard, classification of, 20 
 Becl^re, fibroid phthisis, 58 
 Bifurcation glands, 23, 28 
 Blood pressure in phthisis, 30 
 Botalli ductus, pulsation of, 7 
 Breath sounds, 94 
 Breathing, granular, 94, 96 
 Bronchial glands, anatomy and tuber- 
 culosis of, 21, tt »cq. 
 phthisis, 20 
 Bronchiectasia, cylindrical, 3 1 
 Bronchiectasis and tubercle, 65, 67, 
 
 90,91 
 Bronchiectatic fold or triangle, 3 1 
 Bronchitis and tubercle, 56, 103 
 fibrinous, 3r 
 muco-purulenta, 104 
 Broncho-pneumonia, influenzal, 39 
 tuberculosa, acute (galloping), 42 
 chronic, 43 
 
 nodal (disseminated), 37 
 nodular (disseminated), 33 
 pseudolobar, 41, 45 
 subacute, 44 
 
 Carcinoma of lung, 71 
 Carcinomatosis, 74 
 Cardioptosis, 55, II3 
 
 Cavities, 89, 100 
 
 and pneumothorax, 90 
 Chest, contracted, 47, 51 
 
 emphysematous, 16, 86 
 
 long, flat, 47, 51 
 
 normal, I 
 
 paralytic, 47, 51 
 Children, tuberculosis in, 22, no 
 Cirrhosis of lung, 58 
 Classification of pulmonary tubercle, 18 
 
 Bard, 20 
 
 Frankel, 21 
 
 Nicol, 21 
 
 Turban, 20 
 Closed cases, 21, 49, 92 
 Coal miner's phthisis, 65 
 Congestion, passive, of lung, 1 3 
 Conjugal phthisis, 5 1 
 Contact cases, 6 1 
 Cor pendulum, 1 1 3, 1 14 
 Crane's inverted comma, 36, 64, et scq. 
 Creeping pneumonia, 1 5 
 Crepitant rales, 94, 95 
 Cuneate interlobar shadows, 54 
 
 D 
 
 Dextro-cardia, 66 
 
 Diabetes and phthisis, 19, 33 
 
 Diaphragm, 14 
 
 crural, 14 
 
 dome of, 15 
 
 in decubitus, 15, 16 
 
 sterno-costal, 14 
 Diagnosis, X-ray, in phthisis, 92 
 Dilatation of aorta in chronic fibrosis, 
 
 76 
 Disseminated phthisis, 33, lOI 
 Dissemination, lymphatic, 30, 56 
 
 partial miliary, 105 
 Ductus Botalli, 7 
 Dulness, parasternal, 25 
 
 paravertebral, 25 
 Dyscrasias, [9 
 Dysphagia in phthisis, 38 
 
 Emphysema, 85 
 
 annular, 27, 47, 87 
 after gassing, 86 
 compensatory, 85 
 hypertrophic, 86 
 
ii8 
 
 Index 
 
 Emphysema, perihilar, 86 
 
 radiology of, 86 
 Evidence, positive, 97 
 
 presumptive, 97 
 Ewart, paravertebral dulness, 25 
 Exophthalmic goitre and tubercle, 27, 
 55, 105 
 
 Fibrinous bronchitis, 31 
 
 Fibrocaseous phthisis, 20 
 
 Fibroid induration, 102 
 phthisis, 58 
 
 cavitary, 58, 59. 67 
 diffuse granular, 58, 59 
 disseminated, 58, 59 
 infiltrative, 58, 59, 60 
 with bronchiectasis, 67 
 
 First rib cartilage, calcification of, 2 
 
 Fissures of lung, 10 
 
 Fowler's line of march, 41 
 
 Friction sounds, pleuritic, 95 
 
 Q 
 
 Galloping phthisis, 42 
 " Gassed " lung and bronchitic fibrosis, 
 104 
 
 and emphysema, 87 
 Glands, bifurcation, 22 
 
 hilar, 22 
 
 tracheo-bronchial, 22 
 Goitre, endothoracic, 8 
 
 exophthalmic and tubercle, 27, 55, 
 
 105 
 Granular breathing, 94, 96, 104 
 
 tuberculosis, 59 
 Graves' asphyxial type of miliary 
 
 phthisis, 75 
 Gummata of lung, 62 
 
 H 
 
 Haemoptysis, varieties of, 88 
 "Hanging" heart, 114 
 Healed phthisis, ill 
 Heart, outlines of, 3 
 
 hypoplasia of, 55 
 
 in tubercle, II3 
 
 soldier's, 113 
 Hilar glands, 23 
 
 lesions of, 99 
 
 irruption of, 28 
 
 radiography of, 24 
 
 phthisis, 51, 107, et scq. 
 Hilum of lung, 3, 10, 23, 107 
 
 I 
 
 Incipient phthisis, 1 06 
 
 Influenza and tubercle, 33, 50 
 
 and broncho-pneumonia, 39 
 Interlobar phthisis, 44, 45, lOO 
 
 Kronig's isthmus, 95 
 
 Laennec's grey infiltration, 45 
 Laryngeal nerve, recurrent, 51 
 Latent phthisis, 48 
 Lung, fibrosis of, 58 
 
 fissures of, 10 
 
 lobes of, 10 
 Lymphatic glands, bronchial, 23 
 
 in adults, 30 
 
 in children, 29 
 Lymphocytosis in active tubercle, 27 
 
 in arrested tubercle, 26 
 
 M 
 
 Mammary gland, 17 
 Mediastinitis, 26, 27 
 Mediastinum, displacement of, 58 
 
 glands of, 23 
 Meningitis tuberculosa, 74 
 Metallic tinkle in pneumothorax, 84 
 Microcardia in phthisis, 113 
 Midlobar phthisis, 53, 102 
 Miliary tubercle, 20, 72 
 Milliamperage, I 
 Miner's phthisis, 64, 65 
 Minor phthisis, 48 
 Mitral stenosis and tubercle, 51, 64 
 
 N 
 Nasal disease and tubercle, 98, 106 
 Neurasthenia and tubercle, 18 
 Nipple, 17, 56 
 Nodal chronic phthisis, 39 
 
 disseminated fibroid phthisis, 58 
 Nodular disseminated fibroid phthisis, 
 58 
 
 O 
 
 Orthodiagraphy, 1 13 
 
 Paralysis of recurrent nerve, 51 
 Paravertebral triangle, 1 08 
 Pectoriloquy over dorsal spines, 29 
 Perihilar tubercle, 43, 5 1 
 
 fibroid tubercle, 55 
 
 infiltration, 53 
 Pertussis, 56, 75 
 
 Phrenic nerve, faradisation of, 16 
 Phthisis fibrosa, 58 
 
 fibro-diffusa, 59 
 
Index 
 
 119 
 
 Pleural effusion, 36 
 encysted, 80 
 
 interlobar adhesions, 79 
 
 space, obliteration of (symphysis), 
 82 
 
 thickenings, 81, 82 
 Pleurisy and tubercle, 78, 102 
 
 diaphragmatic, 81 
 
 dry, 81 
 Pleuritis tuberculosa recidivans, 79 
 Pneumonia caseosa, 20, 71 
 
 extensiva, 20 
 Pneumoconiosis, 64, 65 
 Pneumothorax ballooning, 84 
 
 diaphragm in, 84 
 
 displacement in, 85 
 
 effusion in, 84 
 
 operative, 84 
 
 spontaneous, 45, 83 
 
 succussion in, 83 
 Polymorphonucleosis, 26, 27 
 Post-pleuritic phthisis, 20 
 Positions, cardinal, I 
 
 anterior or dorso-ventral, I 
 
 left antero-lateral or oblique, 6 
 
 right antero-lateral or oblique, 5 
 
 posterior or ventro-dorsal, 5 
 
 lateral, 7 
 Pulmonary artery, 6, 23 
 
 congestion, 1 3 
 
 fields, 2 
 
 fibrosis, 58 
 Pulse in phthisis, 30 
 
 Rales, medium, 94 
 tuberculous, 95 
 Recurrent laryngeal nerve, 23, 51 
 Red hepatisation, 70 
 Reflex bands of dulness, 25 
 Reticulum, pulmonary, 12 
 Resolution in pneumonia, 39 
 Rheumatism and tubercle, 27, 45 
 
 Screens, intensifying, I 
 Shadow, median, 2 
 
 paratracheal, 24 
 Space, retrocardiac, 67 
 Spine, scoliosis of, 45 
 Stereoscopy, I 
 Sulcus, cardiophrenic, 3 
 
 Sulcus, costalis, 5 
 
 costophrenic, 5 
 Succussion-splash, 84 
 Supraclavicular apex, 1 06 
 Syndrome, pleural, 99 
 Syphilis and phthisis, 62, 65 
 
 Tachycardia, 113 
 Telengiectases, spinal, 95 
 Temperature, labile in phthisis, 30 
 Thorax aplati, 47 
 
 rigidus, 16 
 
 paralyticus, 47 
 Thymus, 29 
 Thyroid, 8, 27, 55 
 Tracheal, tugging, 113 
 Tracheo-bronchial glands, 23 
 Triangles of chest, 9 
 
 paravertebral, 108 
 Tripier on miner's phthisis, 65 
 Tube, X-ray, quality of, i , 93 
 Tuberculosis of lungs, arrested. III 
 
 and pleurisy, 78, 102 
 
 bronchiectasis and, 66, 90 
 
 cavities of, 89, 100 
 
 conjugal, 51 
 
 fibroid, 58 
 
 heart in, 113 
 
 haemoptysis in, 88 
 
 in great war, 90 
 
 influence of age in, 19 
 of dyscrasias in, 19 
 
 malaria and, 112 
 
 miliary, 20, 72 
 
 mitral stenosis and, 5lf 64 
 
 neurasthenia and, 18 
 
 onset of, 18 
 
 pneumonic, 68 
 
 pneumothorax in, 83 
 
 primary foci of, 1 08, 1 09 
 
 rales in, 94, 95 
 
 reinfection in, 106 
 
 resistance in, 18 
 Turban, classification of, 20 
 
 U 
 
 Unilateral forms, 60 
 
 W 
 
 Wandering pneumonia, 39 
 Wounds of lung and tubercle, 100 
 
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