Clinical Roentgenology 
OF 
Diseases of the Chest 
BY 
H. WESSLER, M. D. 
Adjunct Physician and Associate Roentgenologist 
Mt. Sinai Hospital 
AND 
LEOPOLD JACHES, M. D. 
Roentgenologist 
Mt. Sinai Hospital 
NEW YORK CITY 
THE SOUTHWORTH COMPANY 
TROY, N. Y. COPYRIGHTED 1923 
BY THE SOUTHWORTH COMPANY DEDICATED 
TO THE MEMORY OF 
EUGENE WILSON CALDWELL, B. S. M. D. 
Pioneer American Roentgenologist 
and Martyr to the Science Preface 
In the preparation of this work, we have had two objects in mind, 
first, an exposition of the Roentgen features of thoracic diseases and 
secondly, their correlation with such clinical facts as are necessary to an 
intelligent Roentgen interpretation. It is therefore hoped that the fol- 
lowing pages will commend themselves no less to the clinician than to the 
Roentgenologist. We have been heartened to our task, in spite of the 
difficulties attending it, by the lack of any adequate treatise on this sub- 
ject in the English language. 
In no branch of medicine has the clinical application of the Roentgen 
ray yielded more gratifying results than in diseases of the chest. It has 
effected a revolution in thoracic diagnosis and, when properly employed, 
has eliminated much of the uncertainty inherent in the older methods 
of examination. 
It is not our purpose, however, in these prefatory remarks, unduly 
to glorify the Roentgen examination; we may safely leave its achieve- 
ments, illustrated in the following pages, to speak for themselves. Rather 
is it our wish, among other things, to emphasize the importance of a 
correlation of the Roentgen with the clinical examination, which is no- 
where more vital to correct diagnosis than in diseases of the chest. 
The question arises—To whom shall we look for such a correlation, 
to the clinician or to the Roentgenologist? Unfortunately, the latter is 
rarely a capable clinician and his medical inexperience is fraught with 
grave consequences in the diagnosis of thoracic disease. On the other 
hand, the clinician is, as a rule, poorly trained in the technique of Roent- 
genology and in the interpretation of its findings. Technical excellence 
is perhaps more essential in the examination of the chest than of any 
other part of the body. A slight fuzziness in outline or a distortion of 
the shadows is fatal in roentgenograms of the lungs, in which dependence 
is placed on the faintest of shadows and the sharpest of lines for the dif- 
ferentiation between normal and pathological conditions. 
For these reasons, the ideal of a clinician-roentgenologist can rarely 
be attained and the difficulties arising from the diversity of their train- 
ing, can, for the present, only be overcome by a close co-operation of the 
clinician and roentgenologist in arriving at a diagnosis. Such co-opera- 
tion is especially important in surgical diseases of the chest where an 
interpretation of the plates in the light of the clinical facts must often 
determine the judgment of the surgeon as to his procedures. 
It may not be amiss to insert here a few remarks on Roentgen tech- 
nique which have purposely been omitted from the text. In order to 
obtain on the plate a faithful reproduction of the fine linear markings 
of the lung, it is necessary that the patient be placed at a considerable 
distance from the tube. At lesser distances, especially at the conventional 
28 inches, these markings are apt to suffer enlargement and distortion 
which render accurate diagnosis difficult or impossible. For practical purposes, having due regard for the time of exposure, we have found that 
a distance of four feet will meet the requirements of the average case. 
Of no less importance is the position of the patient, which should be up- 
right whenever possible. The prone position, with the resultant upward 
displacement of the diaphragm, engorgement of the lungs and interfer- 
ence with breathing, causes such an exaggeration of the lung markings, 
that the plates are of little value for diagnosis. 
The use of intensifying screens, except with very sick patients who 
cannot control their breathing or for tele-roentgenograms, has seemed to 
us a distinct disadvantage in chest work. The lack of perfect contact 
and the defects which develop in the screens, result in a hazy picture 
which cannot compare with the clearness and definition of a good plate. 
To obtain the necessary penetration of the ray at the distance which 
we have adopted, it has been found advantageous to employ a spark gap 
of 7 to 81/2 inches at 40-50 milliamperes. This necessitates the use of 
gas tubes, as the type of Coolidge tube which can operate at this setting 
emits so many parasitic radiations from the anticathode stem, that the 
image loses its definition. The high spark gap is especially adapted to 
the Roentgen examination of the lungs, as the penetration of the ray is 
facilitated by their air content and contrast is afforded by the soft tissues 
of the thorax. 
In regard to the purely clinical side of this work, no attempt has 
been made to present the clinical aspect of diseases of the chest in a com- 
plete or systematic manner. That would be foreign to its purpose. We 
have rather sought to emphasize those features of the clinical history, 
physical signs and pathology which are necessary to an intelligent inter- 
pretation of the plates. On the other hand, we have tried to present the 
facts of Roentgenology as completely as possible and in accordance with 
the most enlightened opinion in respect of interpretation. Some phases 
of the Roentgen diagnosis of chest disease, notably that of pulmonary 
tuberculosis, are still the subject of controversy. In regard to it, we have 
not hesitated to express our personal views, believing as we do, that they 
are in accord with the best thought and best harmonize with what we 
know of its pathology. 
Nor have we hesitated to point out, in numerous instances, the limi- 
tations of the Roentgen ray in respect of diagnosis. It must always be 
borne in mind that a Roentgen plate is, after all, only a conglomerate of 
shadows, the arrangement of which, though usually characteristic of defi- 
nite diseases, is occasionally susceptible of different interpretations. 
It is a pleasure to acknowledge the help of those who have co-oper- 
ated with us in the preparation of this work. We have been fortunate 
in securing the aid and advice of Mr. Walker of the Walker Engraving 
Company in the making of the half tones and of Mr. S. W. Nourse whose 
skillful photographic work helped materially in the reproduction of the 
original negatives. Finally, we are indebted to the publishers, The 
Southworth Co. without whose generous helpfulness this work would not 
have been possible. Contents 
SECTION I 
THE NORMAL LUNG 
Chapter 1 
The Normal Lung : 11 
Roentgen technique, 11; the lung fields, 13; the lung markings, 14; the 
lung roots, 14; aeration of the lungs, 16. 
SECTION II 
THE PULMONARY VESSELS AND CIRCULATION 
Chapter 2 
The Pulmonary Vessels and Circulation 21 
Passive congestion, 21; abnormalities of the pulmonary conus, 24; open 
ductus Botalli, 24; congenital enlargement of the pulmonary artery, 26; 
aneurysm of the pulmonary artery, 26; athero-sclerosis of the pulmonary 
artery, 27; infarct of the lung, 29. 
SECTION III 
THE TRACHEA AND BRONCHI 
Chapter 3 
The Trachea 35 
Normal position, 36; calcification of, 36; displacement of trachea, 36; 
compression of trachea, 38; tumors of trachea, 39; tracheo-oesophageal 
fistula, 41. 
Chapter 4 
The Bronchi 43 
Chronic bronchitis, 43; bronchiectases, 44; bronchostenosis, 48; tumors of 
the bronchi, 50. 
SECTION IV 
THE LUNGS 
Chapter 5 
Pulmonary Tuberculosis In Adults 55 
Methods of Roentgen examination, 55; stereoscopy, 56; incipient tubercu- 
losis, 57; earliest lesions of tuberculosis, 68; location of earliest lesions, 
69; distinctive appearance of early tuberculosis, 70; associated changes 
with incipient tuberculosis, 72; process of healing in early tuberculosis, 
73; evolution of the tuberculous process, 94; moderately advanced tubercu- 
losis, 95; advanced tuberculosis, 101; fibro-caseous and fibroid tuberculosis, 
109; acute tuberculosis, 116; acute general miliary tuberculosis, 116; mil- 
iary tuberculosis of the lungs, 119; acute pneumonic tuberculosis, 126; 
tuberculous cavities, 131; hilum tuberculosis, 141; lower lobe tuberculosis, 
146; solitary tuberculous cavities, 147; unilateral advanced tuberculosis, 
151; absorption of tuberculous infiltrations, 158; hemoptysis and the 
Roentgen examination, 160; the Roentgen findings in relation to activity, 
161; the Roentgen examination in relation to the pathology of tuberculosis, 
162; the Roentgen findings vs. physical signs, 167. II 
Contents 
Chapter 6 
Pulmonary Tuberculosis In Children 172 
Pathology, 172; primary lesion, 175; healed primary lesions, 176; caseous 
pneumonia, infantile phthisis, 180; tuberculosis of intrathoracic lymph 
nodes, 181; hilum tuberculosis, 191; recurrent hilum pneumonia, 192; 
basal tuberculosis, 193; miliary tuberculosis, 194; adult forms of tubercu- 
losis, 196. 
Chapter 7 
Pneumonia 201 
Lobar pneumonia, 201; upper lobe, 202; middle lobe, 203; lower lobe, 
204; multiple lobe, 208; resolution of pneumonia, 211; atypical resolution, 
212; pleuro-pneumonia, 218; central pneumonia, 221; broncho- and lobu- 
lar'pnepmonia, 223; influenzal pneumonia, 224. 
Chapter 8 
Pulmonary Suppuration. Abscess and Gangrene of the Lung. . . 227 
Etiology, 227; pathology, 228; aspiration abscess, 229; postpneumonic 
abscess, 231; clinical course, 236; healing of lung abscess, 240; residual 
abscess, 242; abscess cavities, 244; location of abscess, 249; complications, 
250; differential diagnosis, 256. 
Chapter 9 
Non-tuberculous Chronic Infections of the Lungs 257 
Chronic indurative pneumonia, 257; chronic pneumonia with bronchi- 
ectases, 258; pleuro-pneumonic fibrosis, 260; differentiated from tubercu- 
losis, 263. 
Chapter 10 
Actinomycosis of the Lungs 264 
Chapter 11 
Echinococcus Cyst of the Lungs 266 
Chapter 12 . 
Syphilis of the Lungs 268 
Diagnostic criteria, 268; syphilitic infiltration at the root, 269; at the 
base, 271; gumma of lung, 273; syphilis with secondary suppuration of 
the lung, 274; syphilitic fibrosis, 276; mediastinitis 277. 
Chapter 13 
Tumors of the Lungs 278 
Primary tumors, 278; benign tumors, 278; malignant tumors, 279; lobar 
carcinoma, 280; bronchial carcinoma, 282; diffuse peribronchial carci- 
noma, 286; secondary changes with lung tumors, 288; necrosis of tumors, 
289; bronchostenosis, 289; Roentgen-clinical correlations, 291; sarcoma, 
295; clinically benign tumors, 296; differential diagnosis, 299. 
Chapter 14 
Metastatic Tumors of the Lungs 300 
Sarcoma, 300; carcinoma, 304; miliary carcinosis, 309; hypernephroma, 
310; complications, 311; Roentgen-clinical correlations, 312. Contents 
Ill 
SECTION V 
THE PLEURA 
Chapter 15 
The Pleura 319 
Dry pleurisy, 319; pleural effusions, 320; free effusions, 320; purulent 
effusions, 323; fibrino-plastic pleurisy, 324; early diagnosis of empyema, 
325; encapsulated effusions, 326; superficial encapsulated effusions, 328; 
axillary effusions, 329; basal effusions, 332; apical effusions, 333 ; mesial 
effusions, 339; multilocular effusions, 343; concealed effusions, 345; 
infrapulmonary effusions, 346; mediastinal effusions, 347; interlobar 
effusions, 351; encapsulated effusions wit! pneumothorax, 363; fluid 
levels in pleura, 366; secondary changes with pleural disease, 368. 
Chapter 16 
Pneumothorax 371 
Factors determining size of pneumothorax, 371; adhesions the lung, 
372; tension pneumothorax, 377; hernia of the mediastinum, 377; 
pneumopericardium, 380; pyopneumothorax, 380; diagnosis of small 
pneumothoraces, 381; differential from cavities, 382; artificial pneumo- 
thorax, 382. 
Chapter 17 
Tuberculosis of the Pleura 384 
Thickening of the pleura, 384; thickening of the interlobar fissure, 384; 
pleuro-phrenic adhesions, 384; calcification of the pleura, 384; miliary 
tuberculosis of the pleura, 388. 
Chapter 18 
Tumors of the Pleura 389 
Clinical features, 389; endothelioma, 391; early stage of pleural tumors, 
392; late stage, 392; secondary tumors of the pleura, 393; fissural carci- 
noma, 394. 
Chapter 19 
Chronic Pleurisy 396 
Pleural adhesions, 396; pleuro-phrenic adhesions, 397; thickening of the 
interlobar fissure, 397; secondary to empyema, 398. 
SECTION VI 
THE MEDIASTINUM 
Chapter 20 
The Mediastinum 401 
Acute mediastinitis, 401; mediastinal abscess, 401; chronic mediastinitis, 
402; tuberculous, 403; syphilitic, 404; actinomycosis of the mediastinum, 
404. 
Chapter 21 
Tumors of the Mediastinum 407 
Clinical features, 407; Roentgen features, 407; early diagnosis, 408; 
mediastinal sarcoma, 409; lympho-sarcoma, 410; infiltrating tumors, 414; 
carcinoma, 414; secondary tumors of the mediastinum, 415; complications, 
418; pulmonary metastases, 419; differential diagnosis, 420; artificial 
pneumothorax in diagnosis, 422; Roentgen-clinical correlations, 423; 
tumors of pericardium, 424. IV 
Contents 
Chapter 22 
The Thyroid Gland 426 
Hyperplasia of the thyroid, 427; intrathoracic goiter, 427; colloid goiter, 
428; malignant goiter, 429; pulmonary metastases, 430; bony metastases, 
430; pressure effects of goiters, 432; cardio-vascular symptoms of goiters, 
432; calcification of thyroid, 434. 
Chapter 23 
The Thymus 435 
Normal variation in size of thymus, 435; influence of respiration on 
width of mediastinum, 435; technical considerations, 436; enlargement 
of thymus in infants, with stridor, 436; without symptoms, 437; differentia- 
tion from tuberculous lymph nodes, 439; status thymo-lymphaticus, 441; 
thymus in exophthalmic goiter, 441; tumor of the thymus, 441; dermoid 
cyst of the mediastinum, 442. 
Chapter 24 
Aneurysm of the Aorta 445 
Clinical latency of aneurysms, 446; fusiform aneurysms, 446; sacculated 
aneurysms, 448; of ascending aorta, 448; multiple sacculations, 450; 
aneurysm of the transverse arch, 455; aneurysm of the descending arch, 
455; periarteritis and calcification in aneurysms, 457; perforating 
aneurysm, 457; pressure effects of aneurysms, 458; pulmonary infection 
with aneurysms, 459; differential diagnosis, 460; pulsation of aneurysms, 
461; dynamic dilatation of the aorta, 462; the heart with aneurysms, 463; 
atherosclerosis of the aorta, 463; aneurysm of the innominate artery, 464. 
SECTION VII 
THE INTRATHORACIC LYMPH NODES 
Chapter 25 
The Intrathoracic Lymph Nodes 469 
Infectious adenopathies, 469; acute bronchial lymph-adenitis, 469; chronic 
hyperplasia and anthracosis, 470; tuberculosis of the bronchial lymph 
nodes, 471; syphilis of the bronchial lymph nodes, 473; non-infectious 
adenopathies, 474; glandular tumors, 474; lymphosarcoma, 474; metastas- 
tases in bronchial lymph nodes, 475; with cancer of the breast, 475; 
lymphomata, 475; lymphatic leukemia, 475; acute leukemia, 475; leukemic 
infiltration of lungs, 476; clinical application of the Roentgen examina- 
tion, 477. 
Chapter 26 
Hodgkin’s Disease 479 
Frequency of involvement of the intrathoracic lymph nodes in Hodgkin’s 
disease, 479; various types of Hodgkin’s disease, 480; pulmonary infiltra- 
tions, 483; characteristic enlargement of the lymph nodes, 487; enlarge- 
ment of the paratracheal nodes, 487; differentiation from tuberculosis of 
the lymph nodes, 488; combination of Hodgkin’s disease with other 
conditions, 489. Contents 
SECTION VIII 
THE DIAPHRAGM 
Chapter 27 
The Diaphragm 493 
Normal position and contour of diaphragm, 493; movement of the dia- 
phragm, 493; elevation of the diaphragm, 495; in pleurisy, 495; subphrenic 
abscess, 495; left sided subphrenic abscess, 498; subphrenic hematoma, 
498; liver abscess, 499; subphrenic gas abscess, 500; splenic cyst, elevat- 
ing diaphragm, 502; eventration of left half of diaphragm, 502; symptoms 
of, 503; right sided eventration, 504; differentiation from hernia of the 
diaphragm, 506; chronic atonic dilatation of the stomach, 507; phrenic 
paralysis, 507; depression of the diaphragm, 508; pneumoperitoneum, 
510; spontaneous, with perforated gastric ulcer, 510; induced, 511; ptosis 
of liver, 512; depression of diaphragm with broncho-stenosis, 512; dia- 
phragmatic adhesions, 513; abnormalities of diaphragmatic movement, 
517; paradoxical movement, 517; adherent pericardium, 518; diaphragm 
in pulmonary emphysema, 518; excessive contraction of diaphragm, 518. 
SECTION IX 
SURGICAL DISEASES OF THE CHEST 
Chapter 28 
Surgical Diseases of the Chest 521 
Residual empyema, 521; apical empyema, 512; mesial empyema, 521; 
persistent empyema sinus, 523; injection of sinus with bismuth, 526; col- 
lapse of the lung, in empyema, 527; thickening of the parietal pleura, 
after empyema, 528; decortication of the lung, 528; thoracoplastic opera- 
tions, 528; localization of lung abscess, 529; lobectomy and its complica- 
tions, 529; extrapleural compression of the lung, 530. 
SECTION X 
DISEASES AND ABNORMALITIES OF THE CHEST WALL 
Chapter 29 
Diseases and Abnormalities of the Chest Wall 535 
Cervical ribs, 536; fusion of ribs, 536; aplasia of the bony thorax, 536; 
sarcoma of ribs, 537; sarcoma of the chest wall, 539; osteoma of rib, 
541; multiple myeloma, 541; sarcoma of vertebrae, 542; tuberculous 
abscess of vertebrae, 545; kyphosis, 546; deformity with kyphoscoliosis, 
549; tumors of soft tissues of chest wall, 549; peripleuritis, 550; shadows 
of tuberculous cervical lymph nodes, 550; shadows of enlarged axillary 
lymph nodes, 552; shadows of nipples, 552. List of Illustrations 
1. Normal lung, adult female. 
2. Normal lung, adult male. 
3. Falciform shadow at right apex. 
4. Congestion of lungs in mitral disease. 
5. General mottling of lung due to passive congestion. 
6. Enlargement of conus arteriosus with open ductus Botalli. 
7. Congenital enlargement of the pulmonary artery. 
8. Aneurysm of the pulmonary artery. 
9. Enlargement of the pulmonary conus. 
10. Infarct of lung. 
11. Arterio-venous aneurysm of the pulmonary artery. 
12. Calcification of the trachea. 
13. Carcinoma of the trachea. 
14. Tracheo-oesophageal fistula with carcinoma of oesophagus 
15. Aspirated barium in bronchi, in bulbar palsy. 
16. Multiple bronchiectases. 
17. Multiple globular bronchiectases. 
18. Multiple bronchiectases in indurated lung. 
18a. Bronchostenosis due to tuberculous lymph nodes. 
19. Fibroma of bronchus with bronchostenosis. 
20. Early tuberculous infiltration. 
21. Early tuberculous infiltration. 
21a. Detail of fig. 21. 
22. Early tuberculous infiltration, infraclavicular. 
23. Early tuberculous infiltration, apical. 
24. Early tuberculosis with pneumonic exudate. 
24a. Detail of fig. 24. 
25. Early tuberculosis, showing tubercles. 
25a. Detail of fig. 25. 
26. Bilateral apical tuberculosis. 
27. Early tuberculosis with a variety of infiltrations. 
28. Earliest tuberculous infiltration. 
29. Tuberculous infiltrations resembling metastatic tumors. 
30. Tuberculosis showing beginning fibrosis. 
31. Absorption of early tuberculous infiltrations. 
32. Beginning fibrosis in early tuberculosis. 
33. Healing infiltrations of early tuberculosis. 
34. Fibrous network in healing tuberculosis. 
34a. Detail of fig. 31. 
35. Fibrosis ot healed early lesion in infraclavicular region. VIII 
List of Illustrations 
36. Scar of healed tuberculosis. 
37. Unique network of fibrosis in tuberculosis. 
38. Fibrosis in moderately advanced tuberculosis. 
39. Fine network of fibrosis in healed tuberculosis. 
40. Vascular network at apex with healed tuberculosis. 
41. Calcified apical tuherculosis, with recent pneumonic exudate. 
41a. Disseminated calcified deposits, with healed tuberculous broncho- 
pneumonia. 
42. Calcified apical tuberculosis. 
43. Massive lime deposits in healed tuberculosis. 
44. Normal apices, showing upper limit of lung. 
45. Retraction of apices with healed tuberculosis. 
46. Retraction and scarring of both apices. 
47. Vertical scar of old apical process. 
48. Pleural thickening with fibrosis of apex. 
49. Retraction and fibrosis of apex. 
50. Calcified tuberculosis of left apex, with recent exudative process 
in right lung. 
51. Chronic tuberculosis of right upper lobe, with broncho-pneumonia 
in lower lobe. 
52. Caseating apical tuberculosis. 
53. Acute pneumonic tuberculosis. Old apical cavity. 
54. Moderately advanced tuberculosis with partial fibrosis. 
55. Desseminated tuberculous broncho-pneumonia; infection from 
apical cavity. 
56. Tuberculous broncho-pneumonia, confluent, after hemorrhage. 
57. Fibro-caseous tuberculosis of right upper lobe ; exudative tubercu- 
losis in left lung. 
58. Bilateral tuberculosis showing fibrosis. 
59. Chronic miliary tuberculosis. 
60. Same case as fig. 59 five years later, showing fibrosis and cavita- 
tion. 
61. Chronic fibro-caseous tuberculosis with cavities. Thoracic 
deformity and cardiac displacement. 
62. Chronic fibro-caseous tuberculosis with marked diminution in 
volume of right lung. 
63. Fibro-caseous tuberculosis of right upper lobe. 
64. Chronic fibroid tuberculosis with asthma and emphysema. 
64a. Chronic fibro-caseous tuberculosis, extensive cavitation and 
pleural thickening. 
65. Disseminated fibrosis. 
66. Chronic fibroid tuberculosis, with emphysema and asthma. Calci- 
fied broncho-pneumonia. 
67. Acute general miliary tuberculosis, pulmonary form. 
68. Acute general miliary tuberculosis. List of Illustrations 
IX 
69. Miliary tuberculosis of upper lobes, secondary to old apical 
process. 
70. Miliary tuberculosis, broncho-pneumonic form. 
71. Miliary tuberculosis, confluent, with exudation. 
72. 73, 74. Series of plates in same patient showing the evolution of a 
hematogenous submiliary tuberculosis. 
75. Caseous pneumonia, with cavitation. 
76. Confluent lobular tuberculous pneumonia. Gelatinous pneu- 
monia. 
77. Acute tuberculous pneumonia with rapid, extensive caseation 
and cavitation. 
78. Disseminated lobular tuberculosis with universal softening and 
multiple small cavities. 
79. Early apical tuberculosis with small cavity. 
80. Annular type of cavity and annular pleural shadow. 
81. Apical cavities defined by artificial pneumothorax. 
82. Fibrous-walled apical cavity. 
83. Large oval cavity; pneumothorax. 
84. Complete excavation of right apex. 
85. 86. Large cavity in left upper lobe, before and after emptying its 
contents. 
88. Hilum tuberculosis on right side; left apical tuberculosis. 
89. Hilum tuberculosis with cavity. 
90. Hilum tuberculosis with cavity. 
91. Hilum tuberculosis with crescentic cavity. 
92. Hilum tuberculosis with fibrous-walled cavity. 
93. Primary tuberculosis of lower lobe in a diabetic. 
94. Solitary cavity along left border of heart. 
95. Solitary cavity without infiltration of lung. 
96. Same case as fig. 95, in lateral position, showing shift in level of 
cavity fluid. 
97. Extensive unilateral, fibro-caseous tuberculosis. 
98. Chronic fibroid tuberculosis of upper lobe with bronchiectases. 
99. Unilateral fibroid tuberculosis with pleuro-pericardial adhesions. 
100. Acute pneumonic tuberculosis, with absorption of infiltration in 
one year. 
101. Acute tuberculous pneumonia about a large apical cavity. 
102. Rapid absorption of pneumonic exudate shown in fig. 101. 
103. Acute caseous tuberculosis with cavitation. 
104. Rapid absorption and disappearance of cavities shown in fig. 103. 
105. Primary basal tuberculosis in child with tuberculous adenopathy. 
106. Primary tuberculosis in infant at hilum of lung with marked 
glandular enlargement. 
107. Calcified primary lesion at apex, in child. 
108. Multiple calcified primary lesions of tuberculosis. 
109. Fibrosis of primary lesion in child. X 
List of Illustrations 
110. Infantile phthisis; caseous pneumonia with cavitation. 
111. Caseous pneumonia in infant with multiple small cavities. 
112. Tuberculous adenopathy in infant, unilateral. 
113. Bilateral tuberculous adenopathy in infant. 
114. Tuberculous adenopathy simulating thymic enlargement. 
115. Massive enlargement of tuberculous lymph nodes, in infant; dis- 
seminated lobular tuberculosis. 
116. Tuberculosis of bronchial lymph nodes with vascular engorge- 
ment of lung. 
117. Tuberculosis of paratracheal lymph nodes. 
118. Calcification of bronchial nodes in older child. 
119. Vascular network in right upper lobe due to pressure of enlarged 
lymph nodes. 
120. Tuberculosis of middle lobe in child. 
121. Recurrent hilum tuberculosis during active and remission stage. 
122. Miliary tuberculosis in child, conglomerate type. 
123. Miliary tuberculosis. 
124. Adult form of tuberculosis in child, showing beginning fibrosis 
and cavitation. 
125. Adult form of tuberculosis in young child, showing fibro-caseous 
process with cavity. 
126. Disseminated lobular tuberculosis. 
127. Development of adult form of tuberculosis in child. See fig. 118. 
128. Evolution of adult form of tuberculosis in case shown in fig. 105. 
129. Pneumonia of right upper lobe. 
130. Pneumonic triangle in child. 
131. Partial consolidation of right upper lobe. 
132. Pneumonia of middle lobe. 
133. Pneumonia of lower lobe. 
134. Early stage of pneumonia of lower lobe. 
135. Pneumonia of left lower lobe. 
136. Partial consolidation of right lower lobe. 
137. Right upper and lower lobe pneumonia; dorsal view. 
138. Pneumonia of right upper and lower lobes; ventral view. 
139. Resolution of lower lobe pneumonia. 
140. Mottling of lung after pneumonia, resembling tuberculosis. 
141. Atypical resolution of pneumonia, resembling cavity. 
142. Residual pneumonia at the root of the right lung. 
143. 144. Two stages in the atypical resolution of pneumonia, simulat- 
ing mediastinal tumor. 
145. Residual pneumonia of lower lobe, simulating tumor of lung. 
146. Unique shadow of residual pneumonia. 
147. 148. Pleuro-pneumonia undergoing resorption. 
149. Central pneumonia, one day old. List of Illustrations 
XI 
150, 151. Confluent lobular pneumonia, with resolution. 
152. Influenzal type of confluent lobular pneumonia. 
153. Persisting broncho-pneumonia; cardiac enlargement. 
154. Abscess of lung with extensive consolidation. 
155. Acute abscess, post-tonsillectomy, with large cavity. 
156. Acute lung abscess with excavation of entire lobe. 
157. Indurative pneumonia with gangrenous bronchiectases. 
158. Abscess of the middle lobe. 
159. Abscess of upper lobe with secondary infection of lower lobe. 
160. Abscess of lung with secondary gangrenous pneumonitis. 
161. Chronic abscess cavity of upper lobe. 
162. Multiple abscess cavities with pneumonic consolidation. 
163. Multiple bronchiectatic abscesses with fibrosis of lung. 
164. Chronic upper lobe abscess with induration of lung. 
165. 166. Healing of abscess cavity of upper lobe in one month. 
167, 168. Residual infiltration after lung abscess with recrudescence 
three months later. 
169, 170. Residual infiltration after lung abscess with subsequent 
extension of process. 
171, 172. Abscess cavity in right upper lobe before and after expector- 
ation of contents. 
173, 174, 175. Different appearance of abscess cavities, depending on 
their air content and density of surrounding infiltration. 
176. Abscess of middle lobe, shown in the oblique position. 
177, 178. Abscess of left lower lobe, partly obscured by heart, shown 
in upright and lateral recumbent positions. 
179, 180. Abscess of three lobes of right lung, before and after lobec- 
tomy. 
181. Perforation of lung abscess with pyo-pneumothorax. 
182, 183. Abscess of lung obscured by pleural effusion, before and 
after removal of the latter. 
184. Chronic suppuration of the lung following aspiration of metallic 
foreign body. 
185. Chronic lung abscess simulating lung tumor. 
186. Chronic indurative pneumonia with multiple bronchiectases. 
187. Chronic non-tuberculous disease of lung; pleuro-pulmonary 
fibrosis. 
188. Organizing pneumonia, with clinical and Roentgen picture of 
lung tumor. 
189. Actinomycosis of lung and pleura. 
190. Actinomycosis of lung and pleura. 
191. Echinococcus cyst of lung. 
192. Multiple echinococcus cysts of lung. 
193(a), 193(b). Syphilis of the lung, before and after treatment. 
194, 195. Syphilitic infiltration at right base, before and after treat- 
ment. XII 
List of Illustrations 
196. Probable gumma at right apex. 
197, 198. Gumma at root of left lung; pressure on bronchus, with 
secondary suppuration. Before and after treatment. 
199. Syphilitic fibrosis of lung and pleura. 
200. A probably benign tumor of the lung. 
201. Medullary carcinoma of right upper lobe. 
202. Early carcinoma of parenchyma of lung. 
203. Carcinoma of left upper lobe; phrenic paralysis. 
204. 205. Adeno-carcinoma of right bronchus with subsequent invasion 
of both lungs. 
206. Adeno-carcinoma of right upper lobe. 
207. Adeno-carcinoma of right upper lobe with necrosis; metastases 
in left lung. 
208. Infiltrating carcinoma of lung with bronchial occlusion. 
209. Alveolar carcinoma of lung, with secondary abscess formation. 
210. Adeno-carcinoma of left lower lobe with bronchial occlusion and 
atelectasis of lung. 
211. Carcinoma of right lower lobe, chronic in course, simulating 
indurative pneumonia. 
212. Carcinoma of lung with clinical picture of lung abscess. 
213. 214. Hilum carcinoma masked by pleural effusion. 
215. Primary sarcoma of lung. 
216. Clinically benign type of lung tumor, lower lobe. 
217. Clinically benign type of lung tumor, upper lobe. 
218. Clinically benign type of tumor involving lung and pleura. 
219. Metastatic sarcoma of lung, primary in periosteum. 
220. Multiple metastases in lung, secondary to fascial sarcoma of 
thigh. 
221. Metastatic sarcoma. 
222. Metastases in lung with sarcoma of testis. 
223. Metastatic carcinoma of lung, primary in stomach. 
224. Large metastatic carcinoma of lung. 
225. Metastatic carcinoma secondary to thyroid tumor. 
226. Metastatic carcinoma secondary to tumor of prostate. 
227. Metastases secondary to carcinoma of testis; pleural effusion. 
228. Miliary carcinosis of lung, secondary to adeno-carcinoma of lung; 
rib metastasis. 
229. Metastatic hypernephroma. 
230. Miliary carcinosis of lung; perforation of cortical tumors with 
localized sero-pneumothorax. 
231. Metastatic tumors of lung, secondary to carcinoma of breast. 
232. Large metastasis in lung from carcinoma of stomach. 
233. Small pleural effusion. 
234. Moderate sized pleural effusion; apical tuberculosis. List of Illustrations 
XIII 
235. Beginning- empyema with plastic exudate on pleura. 
236. Postpneumonic empyema with thick fibrino-plastic exudate. 
237. Beginning empyema after pneumonia. 
238. Diagram of figure 237. 
239. Bilocular pleural effusion. 
240. Diagram of figure 239. 
241. Encapsulated pleural effusion in lateral part of chest. 
242. Bilocular encapsulated effusion. 
243. 244. Encapsulated pleural effusion at left base, before and after 
operation. 
245. Pleural effusion encapsulated at the base of the chest. 
246. Encapsulated apical empyema with involvement of dependent 
part of chest. 
247. Apical empyema with extension toward the base. 
248. Empyema encapsulated in upper two-thirds of the chest. 
249. Large encapsulated empyema. 
250. Upward extension of an encapsulated empyema. 
251. 252. Mesial empyema before and after operation. 
253. Encapsulated bilocular empyema. 
254. Empyema shown in figure 253, after operation, showing develop- 
ment of a mesial pyo-pneumothorax. 
255. Residual apical empyema. 
256. 257. Bilocular empyema before and after operation, showing 
residual apical empyema. 
258, 259. Infrapulmonary empyema, before and after operation. 
260, 261. Mediastinal effusion, before and after absorption. 
262. Mediastinal empyema before and after operation. 
263, 264. Pneumonia of right lower lobe, before and after develop- 
ment Qr interlobar effusion. 
265 Diagram of figure 264 showing interlobar effusion. 
266. Interlobar empyema following lobar pneumonia. 
267. Interlobar effusion on left side. 
268. Interlobar effusion associated with effusion in general pleural 
cavity. 
269. Diagram of figure 268. 
270. Effusion in upper and lower interlobar fissures following pneu- 
monia. 
271. Diagram of figure 270. 
272. Small interlobar effusion following hilum tuberculosis. 
273. Primary interlobar pleurisy, probably tuberculous. 
274. Large effusion between the right upper and lower lobes. 
275. Interlobar pleurisy. 
276. Acute pleurisy with effusion in right upper interlobar fissure. 
277. Encapsulated pyo-pneumothorax secondary to ruptured lung 
abscess. 
278. Encapsulated pyo-pneumothorax with pulmonary tuberculosis. XIV 
List of Illustrations 
279. Multilocular encapsulated pyo-pneumothorax; patient in lateral 
recumbent position showing three fluid levels. 
280. Large empyema in child showing separation of the ribs and dis- 
placement of the heart. 
281. Spontaneous pneumothorax, showing separation of the lobes of 
the right lung. 
282. Pyopneumothorax with apical adhesion of lung. 
283. Tension pneumothorax with hernia of the mediastinum. 
284. Large pneumothorax, with engorgement of the lung on opposite 
side. 
285. Complete pneumothorax, depression of diaphragm and compres- 
sion of lung. 
286. Spontaneous pneumothorax with miliary tuberculosis of the 
lungs. 
287. Artificial pneumothorax; air under tension with diaphragmatic 
and mediastinal displacement. 
288. Pneumothorax under tension, with extensive bilateral tubercu- 
losis. 
289. Pyopneumothorax. 
290. Pneumopericardium complicating pyopneumothorax. 
291. Pneumothorax encapsulated by adhesions, simulating cavities. 
292. Two stages in complete collapse of lung by artificial pneumo- 
thorax. 
293. Calcified tuberculosis of the pleura. 
294. Chronic tuberculosis of pleura, with thickening, and calcified 
tubercles. 
295. Bizarre form of calcified tuberculosis of the pleura. 
296. Miliary tubercles on the pleura in case of tuberculous meningitis. 
297. Endothelioma of pleura. 
298. Tumor of pleura, with shrinkage of chest and metastases in 
opposite lung. 
299. Massive endothelioma of the pleura, obliteration of the pleural 
cavity and pulmonary metastases. 
300. 301. Two stages of tumor of pleura, showing initial thickening 
and later massive growth and pulmonary metastases. 
302. Neoplastic thickening of apical pleura, secondary to adeno- 
carcinoma of bronchus and lung. 
303. Carcinoma of the interlobar fissure secondary to carcinoma of 
the breast. 
304. Pleural thickening following empyema. 
305. Pleural thickening following absorption of pleural exudate; 
secondary changes in thoracic viscera. 
306. Mediastinal abscess following lobar pneumonia. 
307. Chronic mediastinitis secondary to multiple bronchiestases. 
308. Chronic mediastinitis secondary to fibroid tuberculosis; oesopha- 
geal obstruction. List of Illustrations 
XV 
309. Chronic mediastinitis with diaphragmatic adhesion, secondary 
to aneurysm of aorta. 
310. Actinomycosis of superior mediastinum, secondary to actinomy- 
cosis of the neck. 
311. Small mediastinal tumor, unilateral, with recurrent paralysis. 
312. Large mediastinal tumor encasing the heart. 
313. Rapidly growing mediastinal lympho-sarcoma. 
314. Angio-sarcoma of mediastinum. 
315. Infiltrating mediastinal lympho-sarcoma associated with Hodg- 
kin’s disease. 
316. Infiltrating mediastinal tumor. 
317. Mediastinal tumor infiltrating right upper lobe. 
318. Necrotic carcinoma of posterior mediastinum, perforating 
oesophagus. 
319. Metastatic carcinoma of mediastinal lymph nodes, secondary to 
bronchial tumor; clinical picture of heart failure. 
320. Large unilateral mediastinal tumor; cardiac displacement. 
321. Large lobulated mediastinal tumor. 
322. Leukemic mediastinal tumor; pleural effusion. 
323. Mediastinal tumor with pulmonary metastases. 
324. Mediastinal sarcoma, resembling aneurysm of the aorta. 
325. Two stages in the growth of a tumor of the superior mediastinum. 
326. Mediastinal tumor in acute myeloblastic leukemia, simulating 
enlargement of the pulmonary artery. 
327. Ganglio-neuroma of superior mediastinum, demonstrated by 
artificial pneumothorax. 
328. Sarcoma of pericardium. 
329. Small substernal thyroid gland. 
330. Cervical goiter with intrathoracic extension. 
331. Intrathoracic goiter with calcification. 
332. Large substernal goiter with tracheal displacement. 
333. Adeno-carcinoma of the isthmus of the thyroid. 
334. Unilateral intrathoracic goiter; compression of trachea. 
335. Calcification of right lobe of thyroid. 
336. 337. Calcification of old colloid goiter of the isthmus; dorso- 
ventral and oblique view. 
338. Variation of the normal mediastinum in infant in deep inspira- 
tion and expiration. 
339. Enlarged thymus in infant 12 hours old. 
340. Large thymus showing typical keystone shape. 
341. Large thymus in 19 day old infant, without symptoms. 
341a. Very large thymus in infant, without symptoms. 
342. Tumor of thymus; thymoma; pleural effusion . 
343. Dermoid cyst of the mediastinum. 
344. Dermoid cyst of the mediastinum. 
345. Fusiform aneurysm of the ascending aorta. . XVI 
List of Illustrations 
346. Fusiform aneurysm with calcification of the transverse arch. 
347. Large fusiform aneurysm of the entire aortic arch, involving also 
the innominate artery; calcification and periarteritis. 
348. 349. Sacculated aneurysm of the ascending arch, showing growth 
after three years. 
350 Sacculated aneurysm of the beginning of the ascending arch. 
351. Sacculated aneurysm of the asending and transverse arch. 
352. Sacculated aneurysm of ascending and descending arch of aorta; 
tracheal displacement. 
353. Sacculated aneurysm of the ascending and descending arch. 
354. Large aneurysm of the transverse arch. 
355. Aneurysm of the transverse arch. 
356. Large aneurysm of the transverse arch. 
357. Fusiform aneurysm of the descending arch of the aorta. 
358. Perforating aneurysm of the ascending arch. 
359. Globular dilatation of the entire arch of the aorta. 
360. Oblique view of aneurysm of the aorta, show compression of the 
trachea and oesophagus. 
361. Dynamic dilatation of the aorta in case of luetic aortitis with 
aortic insufficiency. 
362. Aneurysm of the innominate artery. 
363. Acute bronchial lymph-adenitis secondary to retropharyngeal 
abscess. 
364. Hyperplasia and induration of bronchial lymph nodes. 
365. Calcification of tuberculous bronchial lymph nodes. 
366. Enlargement of right paratracheal lymph nodes in syphilis. 
367. Enlargement of bronchial nodes in a syhpilitic. 
368. Enlargement of upper mediastinal lymph nodes in acute myelo- 
blastic leukemia. 
369. Enlargement of bronchial lymph nodes in acute leukemia. 
370. Enlargement of bronchial lymph nodes and infiltration of lung 
in chronic lymphatic leukemia. 
371. Mediastinal tumor in Hodgkin’s disease. 
372. Mediastinal tumor in Hodgkin’s disease. 
373. Unusual infiltrating form of Hodgkin’s disease. 
374. Hodgkin’s disease; diffuse infiltration of both lungs. 
375. Enlargement of bronchial lymph nodes in Hodgkin’s disease; 
infiltrations in the lungs. 
376. Hodgkin’s disease; characteristic enlargement of the bronchial 
and paratracheal lymph nodes. 
377. Hodgkin’s disease; very large paratracheal nodes, diffuse infiltra- 
tion of right lower lobe. 
378. Hodgkin’s disease; characteristic enlargement of the bronchial 
and paratracheal lymph nodes. List of Illustrations 
XVIII 
380 Prominence of mesial portion of right diaphragm, due to elevation 
of the central tendon. 
381. Subphrenic abscess; dry pleurisy at right base. 
382. Subphrenic abscess on left side. 
383. Subphrenic infected hematoma. 
384. 385. Subphrenic gas-abscess secondary to duodenal perforation. 
386. Large subphrenic gas abscess. 
387. Elevation of left half of diaphragm by echinococcus cyst of the 
spleen. 
388. Eventration of the diaphragm, left side, with displacement of the 
heart. 
389. Eventration of the diaphragm, left side. 
390. Eventration of the diaphragm, right side; dilatation of the colon 
and ptosis of the liver. 
391. Hernia of the stomach through bullet wound of diaphragm. 
392. Eventration of the diaphragm distinguished from diaphragmatic 
hernia by means of pneumoperitoneum. 
393. Chronic atonic dilatation of the stomach with elevation of the 
diaphragm. 
394. Induced pneumoperitoneum showing outlines of diaphragm, liver 
and spleen. 
395. Subphrenic pneumoperitoneum following perforated gastric 
ulcer. 
396. Accidental pneumoperitoneum following artificial pneumo- 
thorax. 
397. Ptosis of the liver, with interposition of the colon between it and 
the diaphragm. 
398. Pointed diaphragmatic adhesion with chronic pulmonary tuberc- 
ulosis. 
399. Fixation and distortion of the diaphragm by adhesions follow- 
ing empyema. 
400. Fixation of the left leaf of the diaphragm by adhesions. 
401. 402. Pneumonia of the right lower lobe, followed by adhesions 
and deformity of the diaphragm. 
403. Postoperative mesial pyo-pneumothorax. 
404. Thickening of parietal and visceral pleura following empyema; 
gradual expansion of lung. 
405. Deformity following extrapleural compression of chest for 
chronic empyema; thickening of pleura. 
406. Persisting empyema sinus, with retention of pus. 
407. Chronic bilocular empyema sinus injected with bismuth. 
408. Chronic empyema sinus injected with bismuth. 
409. Thoracic deformity resulting from decortication of lung for 
chronic empyema. 
410. Extrapleural compression of residual lung abscess by means of 
injected paraffin oil. XVIII 
List of Illustrations 
411. Extrapleural compression of residual lung abscess by means rub- 
ber balloon. 
412. Maldevelopment of right first rib. 
413. Fusion of left first and second ribs. 
414. Deformity of right half of chest due to aplasia of upper ribs. 
415. Bifid sternal end of left third rib. 
416. Sarcoma of right seventh rib; dorso-ventral and oblique views to 
distinguish from pleural disease. 
417. Multiple rib sarcomata. 
418. 419. Sarcoma of right seventh rib, extensively invading soft 
tissues, before and after operation. 
420. Osteoma of sternal end of second left rib. 
421. Multiple myeloma of ribs, spine and shoulder girdle. 
422. Sarcoma of cervical spine and adjacent ribs, simulating a medi- 
astinal tumor. 
423. Pott’s abscess in lower dorsal region. 
424. Pott’s abscess almost obscured by the heart. 
425. Deformity of the chest with kyphosis. 
426. Deformity of the chest with kyphosis. 
427. Deformity of the chest with kyphoscoliosis. 
428. Carcinoma of the breast casting shadow simulating intrathoracic 
disease. 
429. Calcified cervical and supraclavicular lymph nodes overlying the 
apical lung fields. 
430. Axillary lymph podes in Hodgkin’s disease overlying the pul- 
monary field in the right axilla. SECTION I 
The Normal Lung Chapter I 
The Normal Lung 
A satisfactory description of the normal lung is very difficult owing 
to the great variation in the shape and arrangement of the pulmonary 
shadows. There is, strictly speaking, no normal lung type, because no 
two lungs are alike anatomically. This difference is reflected in their 
Roentgen appearance and it is only through a study of a large number of 
plates that the Roentgenologist learns to set the dividing line between 
the normal and the pathological lung. 
If we consider for a moment the anatomic variations of the normal 
lung, their influence on the appearance of the Roentgen plate will be 
apparent. In no two individuals are the size and the arrangement of 
the pulmonary vessels the same and therefore the shadows which they 
cast will constitute a network of various density and pattern. The 
amount of connective tissue in the lung will also modify the appearance 
of the plate. With increasing age peri-vascular and peri-bronchial 
deposits of connective tissue together with anthracosis will manifest 
themselves by an increased density of the shadows. 
Aside from inherent anatomic variations, we must keep in mind 
the numerous deviations from the healthy normal lung which arise from 
the inflammations to which we are subject, the effects of which are 
manifest on the plate. It happens therefore, that in our search for a 
normal lung plate we will in the vast majority of cases be confronted by 
the evidences of previous disease, which will commonly be found at the 
roots of the lungs and occasionally within the parenchyma. It is evident 
that the Roentgenologist in his study of the plates for signs of pulmonary 
disease must not place an undue emphasis on these changes which are 
of almost universal occurrence; he must learn that they are not associ- 
ated with clinical disease and he must be prepared to regard such lungs 
as normal, at least in the Roentgen understanding of the term. 
The character of the Roentgen plate is notably influenced by the 
technique employed in its production. When the distance of the tube 
from the patient is short, the pulmonary shadows are exaggerated in 
size and acquire a haziness which interferes with their interpretation. 
For careful work it is also necessary to make the examination in the 
upright position. Only thus it it possible to avoid engorgement of 
the pulmonary vessels and a corresponding blurring of their shadows, 
which vitiate the Roentgen examination when the patient is in the 12 
The Normal Lung 
horizontal position. If any conclusions of value are to be derived 
from a Roentgen examination of the lungs it is absolutely necessary that 
such extrinsic sources of error be avoided. For this reason, the exam- 
ination should whenever possible, be made with the patient in the 
upright position and at as great a distance from the tube as is consistent 
with a thorough exposure. 
A description of the features of the normal lung may conveniently 
be divided into two parts. The first deals with the aerated lung fields 
in which are included the parenchyma, the bronchi, the blood vessels 
and the lymphatics. The second is concerned with the lung roots. 
Normal lung of a young adult woman. Root shadows are approximately normal. 
Exposure at 5 feet, upright position. 
FIGURE 1 The Normal Lung 
13 
THE AERATED LUNG FIELDS 
The lung fields comprise a space enclosed by the bony thorax and 
the diaphragm; it is divided into two parts by the heart and the medi- 
astinum. Each of these fields is traversed by a network of shadows 
which are produced by the bronchi, blood vessels and lymphatics and 
by the small amount of connective tissue about them. They are capable 
of casting recognizable shadows by virtue of the air containing lungs 
in which they lie, which afford them the necessary contrast. (Fig. 1 
and Fig. 2.) 
Normal lung of a young adult man. 
FIGURE 2 14 
The Normal Lung 
These shadows are worthy of closer description. It will be noted 
that they spread out radially from the root of the lung to the periphery 
and that they correspond in their arrangement to the branching of the 
bronchial or the vascular tree. Because these so-called markings of the 
lungs are a composite picture in the one plane of the plate, of number- 
less structures which lie in different planes in the lung, this net work 
is not a continuous and distinct one but is fragmentary and indistinct in 
outline. Only at the roots of the lungs where the vessels and bronchi 
are larger may we speak of the shadows as corresponding to a single 
and recognizable structure. 
The anatomical basis of the lung markings has long been a cause 
of dispute. They have variously been ascribed to the bronchi, to the 
blood vessels and to both of them together. At the present time, 
opinion, based both on experimental and clinical grounds inclines to the 
belief that the lung markings owe their origin in varying degrees to 
both the blood vessels and the bronchi. At the roots, the trachea and 
large bronchi contribute perhaps to a considerable degree to the pro- 
duction of the shadows, although even here the blood vessels play the 
greater role. As one approaches the periphery, the blood-filled vessels 
have a greater and greater share in the production of the shadows until 
at the surface of the lung the fine mottling is probably exclusively due 
to the small branching vessels. The markings become progressively 
smaller as they approach the periphery so that the lung acquires a 
mottled or marbled appearance and in the average individual they are 
no longer visible in the apices and in the axillary region of the chest. In 
these locations the lung has a homogeneous gray or black appearance 
depending upon the intensity of the exposure. 
There are certain portions of the lung in which the markings are 
normally more prominent than in others; for example, in the para-verte- 
bral portion of the upper lobes there are numerous coarse strands which 
extend vertically upward from the hilum to the clavicle and at the bases 
also there are large branching shadows of the pulmonary vessels which 
extend from the roots of the lungs along the right and left borders of 
the heart to the diaphragm. The significance of the latter shadows will 
be discussed at greater length in another connection. 
THE LUNG ROOTS 
The root or hilum of the lung is represented on the plate by an 
irregular shadow situated near the mid-line along the borders of the 
heart. Within it are merged the shadows of the large pulmonary 
vessels, the bronchi, lymph nodes and the connective tissue wrhich sur- 
rounds these structures. With such heterogeneous components, it is 
obvious that the hilum shadows can have no definite or constant shape 
and that there is room for considerable variation in their Roentgen 
appearance. The Normal Lung 
15 
The interpretation of the hilum shadows has given rise to much 
confusion from a failure properly to appraise the pathological changes 
which are so frequently present at the roots of the lungs. Pathological 
studies show the almost universal occurrence either of hyperplasia and 
anthracosis of the bronchial lymph nodes and also caseation and calcifi- 
cation resulting from tuberculous involvement of these nodes. In 
addition there is often an increase in the connective tissue about them. 
The root shadows which we see in adults therefore practically never 
reflect a normal condition. Nevertheless, so common are these changes 
at the root and so rarely are they responsible for any symptoms that no 
clinical importance need be attached to them. It is particularly 
unfortunate that an enlargement of the shadows at the roots of the lungs 
has so often been made a basis for the diagnosis of pulmonary tubercu- 
losis by Roentgenologists. 
In the normal hilum the shadows are of moderate density, shade 
off almost imperceptibly into the lung tissue and the markings of the 
large vessels and bronchi are faintly indicated within it. The normal 
lymph nodes are not distinguishable as they are merged in the general 
shadow mass. Such a hilum for the reasons given above, is rarely 
encountered. In the average adult the hilum extends further into the 
lung fields, sometimes for a considerable distance. The shadows are 
denser and some of them, representing hyperplastic lymph nodes, are 
discrete and distinct in outline. Anthracotic and calcified nodes and 
those which are caseous cast very dense clearly outlined shadows. 
Irregular dense shadows, sometimes in ring form may be due to deposits 
of lime in tuberculous nodes. Although the bronchi are as a rule not 
visible, they may occasionally be seen in outline at the root of the lung 
if the tissue in this region is infiltrated. Thus they may be seen as small 
annular shadows, or in double contour, depending on the incidence of 
the Roentgen Ray. 
An increase in the size of the hilum may be apparent rather than 
real. Thus, a narrow heart or one which is median in position permits 
more of the hilum to be seen and it may therefore appear to be larger. 
In cases of emphysema or chronic bronchitis, aside from the actual 
enlargement of the lymph nodes, the roots may appear to be larger and 
denser because of the vivid contrast furnished by the over-aerated lungs. 
The individual groups of lymph nodes are only distinguishable in 
a general way. The tracheo-bronchial nodes are covered by the heart 
and are only demonstrable to a limited degree by an oblique examina- 
tion. Only the broncho-pulmonary and the bronchial nodes are visible 
where they are not obscured by the heart shadow. Occasionally the 
para-tracheal nodes especially on the right side are seen when they are 
enlarged by disease. 16 
The Normal Lung 
Although the hilum of the lung has up to recent times loomed large 
in the reports of Roentgenologists, experience has taught that inferences 
drawn from it are of little value in clinical diagnosis. In the vast 
majority of cases, particularly in adults, the changes which are dis- 
covered at the roots have no clinical significance and aside from noting 
their presence, they are best disregarded. 
AERATION OF THE LUNGS 
The aeration of the lungs is a variable element which is arbitrarily 
estimated by the photographic character of the plate. For this reason 
it is scarcely necessary to state that in determining the air content of 
the lungs one must be informed as to the intensity of the exposure. It is 
for example, hazardous to regard a lung as emphysematous because the 
plate looks abnormally black. Note must be taken of the bones and 
the soft tissues in order to determine whether the chest has been over- 
exposed. Aside from this, the apparent aeration of the lungs is affected 
by the thickness of the chest wall and also by the depth of lung tissue 
which the rays traverse. The upper and axillary portions of the lungs 
which are covered by muscle and fat will not appear as well aerated as 
the remaining portions and due note must be taken of the shadows cast 
by the pectoral muscles in men and by the breasts in women. At both 
bases, along the border of the heart, the presence of large blood vessels 
decreases the apparent aeration of the lungs. 
Particular caution must be exercised in estimating the aeration of 
the apices. Well developed supraclavicular muscles and deposits of 
fat above the clavicle added to the relatively small mass of air con- 
taining tissue at the apices will make them appear poorly aerated. The 
shadows cast by cervical ribs and fleshy neck muscles will have the 
same effect. It must also be remembered that in some cases, owing to 
the conformation of the chest it is not possible to bring the apex in close 
apposition to the plate and for this reason it will appear to be less 
aerated. On the other hand, one of the best aerated portions of the 
lung is situated just above the diaphragm in its axillary portion. There 
is here great depth of lung tissue which is not covered by excessive 
muscle or fat. It will be evident that only when these normal variations 
both in the real and the apparent aeration are kept in mind, may 
reliable conclusions be drawn from a difference in the illumination of 
any portion of the plate. 
On fluoroscopic examination of the lungs one may observe the 
influence of respiration on their air content. Very little change is noted 
on inspiration in any portion of the lungs, except in that just above the 
diaphragm. At this point the lungs have their greatest expansion and 
light up considerably. In the apices, on the contrary, there is little or The Normal Lung 
17 
no respiratory change in the aeration. Only on coughing there is noted 
a sudden distention of the apex associated with a distinct increase in 
aeration. 
In addition to the shadows which are cast by the lungs themselves, 
it must be borne in mind that there are numerous other shadows arising 
from the tissues of the chest wall and the other thoracic viscera which 
are projected over those of the lungs. With these shadows, which may 
at times cause difficulties in interpretation, the Roentgenologist must 
become familiar if he is to avoid error. It is particularly in the upper 
aperture of the chest that confusion is apt to arise because in this 
situation the aorta, the innominate vessels, the upper ribs and the 
trachea may produce a complicated shadow mass. Occasionally also, 
unique shadows, as in figure 3 are seen at the apex, whose significance 
is not clear. 
Unique falciform shadow at right apex. This shadow is found in a small 
percentage of patients and is always seen on the right side. 
It appears to have no clinical significance. 
FIGURE 3 SECTION II 
The Pulmonary Vessels and Circulation Chapter II 
The Pulmonary Vessels and Circulation 
In our discussion of the anatomical basis of the lung markings, we 
have indicated to what extent the pulmonary vessels are responsible 
for their production. Although all the component parts of the lung 
combine to produce the lung arborizations, the blood vessels undoubt- 
edly cast the major portion of the shadows. We are therefore justified, 
to some extent, in estimating the vascularity of the lungs by the intensity 
and width of its linear markings. 
Unfortunately we have no definite standard by which to judge 
deviations from the normal vascularity. There are numberless varia- 
tions in the size of the lung markings which have no relation to patho- 
logic alterations in the filling of its blood vessels. Some of these 
variations are intrinsic in the lung and are due to changes resulting from 
previous infection, whereas others depend on such extraneous factors 
as the technique of the exposure and the position of the patient. We 
must accordingly keep these sources of error in mind when we seek to 
interpret the Roentgen shadows in terms of an altered vascularity of the 
lungs. 
In the Roentgen study of the circulatory changes in the lungs, it will 
be convenient to discuss first those which affect the intra-pulmonary 
blood vessels and secondly those which involve only the conus of the 
pulmonary artery. 
PASSIVE CONGESTION 
The commonest cause of an increased vascular filling of the lung 
is the congestion of heart disease, which occurs in its most pronounced 
form in mitral lesions. In the early, compensated stage of this disease, 
no change is to be noted in the size of the vessel markings. With a 
failure of the heart muscle and dilatation of its chambers, stasis in the 
pulmonary veins ensues, which manifests itself on the Roentgen plate 
in various ways. In the first place, the large vascular trunks which issue 
from the heart and normally comprise the hilum, become enlarged and 
are seen as wide branching shadows which extend toward the periphery 
of the lung. (Fig. 4.) Two groups of vessels are especially prominent; 
one extends upward in the para-vertebral region to the apices and a 
second, larger one, traverses the lower lobes along the borders of the 
heart. A second change in the pulmonary fields results from an engorge- 
ment of the smaller vessels within the parenchyma of the lung. The 22 
The Pulmonary Vessels and Circulation 
Enlargement of the large branches of the pulmonary vessels in mitral disease 
FIGURE 4 
lungs appear poorly aerated and the dilatation of the vessels produces 
a diffuse mottling in which the normal appearance of the bifurcating 
vessels is lost. (Fig. 5.) This mottling is usually more noticeable in 
the lower lobes. In the later stages of decompensation, especially in the 
presence of some pulmonary edema, the pulmonary fields become quite 
hazy and on fluoroscopic examination the normal increase in aeration 
during deep inspiration may be entirely lacking. 
The Roentgen evidences of pulmonary congestion, as we have 
described them, are in themselves of minor importance. They arrest 
our attention however because the question will occasionally arise, 
whether, in addition to the valvular lesion, the patient also has pulmon- 
ary tuberculosis. Rales and dulness are common accompaniments of 
pulmonary congestion and infarction of the lung may be associated with The Pulmonary Vessels and Circulation 
23 
General mottling of the lungs due to the passive congestion of mitral disease 
FIGURE 5 
frequent hemoptyses and fever. The clinical picture may therefore 
closely resemble tuberculosis. It is therefore important, when we read 
the plate in cases of heart disease to recognize the changes which are 
due to vascular engorgement and not to confuse them with the infil- 
trations of tuberculosis. The similarity between congested lungs and 
tuberculosis may in some cases be so close that the distinction between 
them cannot be made with certainty. This is particularly true of mitral 24 
The Pulmonary Vessels and Circulation 
disease in which the blood vessels in the para-vertebral part of the upper 
lobes are often enlarged and nodular so that they closely resemble 
tuberculous infiltrations. 
In coming to a decision in these cases we are fortunately aided by 
the knowledge that tuberculosis of the lungs rarely complicates a 
valvular defect. The coincidence of these two diseases is so uncommon 
that in a case of chronic endocarditis the Roentgenologist will wisely 
interpret the abnormal pulmonary shadows as the result of pulmonary 
congestion, unless there are indubitable infiltrations in the periphery of 
the lung. Fortunately a mitral heart presents a characteristic configura- 
tion on the Roentgen plate which cannot easily be mistaken and its dis- 
covery will lend assurance to our interpretation of the questionable 
shadows. 
A passive congestion of extreme degree may occasionally be seen 
in the lungs in cases of pressure on the roots by mediastinal new growths. 
(Fig. 319.) 
ABNORMALITIES OF THE PULMONARY CONUS 
An abnormal prominence of the conus of the pulmonary artery is 
regularly found in cases of mitral disease and it contributes, together 
with the enlarged left auricle, to the heart silhouette which is so char- 
acteristic of this valvular lesion. It is questionable whether the artery 
is in most cases as much dilated as it is displaced upward by the dilated 
and hypertrophied right ventricle. Unlike the aorta, little or no pulsa- 
tion is visible in the artery, even when it is much enlarged. It is not 
improbable that the rough systolic murmurs which are so often heard 
in the region of the pulmonary artery in cases of advanced mitral 
disease, have their origin in this vessel, whose enlargement and conse- 
quent nearness to the chest wall will favor the transmission of adventi- 
tious sounds generated within it. 
Next to mitral lesions, the commonest cause of a dilatation of the 
pulmonary artery, is congenital heart disease. It may result from an 
anomalous development of the vessel itself or it may be associated with 
congenital defects in other portions of the heart. 
PERSISTENT DUCTUS BOTALLI is by far the most common con- 
genital lesion in which the pulmonary artery is much dilated. This 
vessel, being the recipient of blood from both the right ventricle and 
from the aorta through the ductus arteriosus may assume unusually 
large proportions and exhibits a forcible systolic pulsation of such ampli- 
tude as is rarely to be seen in any other condition. In young children 
the enlargement of the vessel is usually slight; with the passage of 
years however, it gradually becomes greater until in early adult life, The Pulmonary Vessels and Circulation 
25 
coincident with the development of the continuous, so-called “machinery 
murmur,” the characteristic prominence of the pulmonary artery will 
be evolved (Fig. 6). At this stage of the disease, there will usually be 
FIGURE 6 
Enlargement of the conus of the pulmonary artery with open Ductus Botalli. 
found on physical examination the area of para-sternal dulness on the 
left side, which Gerhardt early associated with a dilatation of this 
vessel. 
It must be borne in mind however, in interpreting an enlargement 
of the pulmonary artery that a mal-development and hypoplasia of this 
vessel may accompany the most diverse congenital malformations, aside 
from a persistent Ductus Botalli. The thin, distensible artery yields 
to the pressure of the blood within it so that it may cast an unusually 
wide shadow on the plate. For this reason, it is safe to attribute the 
enlargement of the pulmonary artery to a persistent ductus, only when 
it can be brought into harmony with the more or less characteristic 
physical signs which are found in this condition. 26 
The Pulmonary Vessels and Circulation 
The pulmonary artery may be congenitally larger from an unequal 
subdivision of the primitive conus arteriosus into a larger pulmonary 
and a smaller aortic portion. This anomaly need in no way affect the 
efficiency of the heart or the circulation and it may remain clinically 
latent. It was thus accidentally discovered in a middle aged man who 
ultimately died of suppurative pylephlebitis. In figure 7 there is to be 
Congenital enlargement of the pulmonary artery and its branches. Hypoplasia 
of aorta. The shadows at the roots of the lungs are the large branches of the 
pulmonary artery; one on the right side is seen in cross section. 
FIGURE 7 
seen an enormous enlargement of the pulmonary artery which pulsated 
forcibly. At the root of the right lung, its main branches, which were 
also congenitally larger, cast large, dense shadows which extend far 
into the pulmonary fields. The aorta is hypoplastic and its shadow 
barely extends beyond the spine. There were no murmurs, dyspnoea, 
or cyanosis. 
Syphilis must be numbered among the rarer causes of an enlarged 
pulmonary artery. An aneurysm of this vessel does not signalize its 
presence by the striking symptoms of aortic disease nor are these symp- 
toms of such a character as to cause an investigation of the pulmonary 
artery. It therefore happens that this rare affection may be discovered The Pulmonary Vessels and Circulation 
27 
on the plate incidentally during a routine examination of the heart or 
lungs. Just as to the clinician the region of the pulmonary valves is the 
area of cardiac romance, so to the Roentgenologist this portion of the 
cardiac contour is replete with surprising disclosures of which the 
clinical examination supplies no inkling. The physician who has ex- 
hausted the resources of physical examination without finding any 
definite evidence of disease of the pulmonary artery, may be pardoned 
a feeling of astonishment when the Roentgen plate reveals an enormous 
aneurysm as shown in figure 8. 
Aneurysm of the pulmonary artery. 
FIGURE 8 
Minor grades of dilatation are observed when the pulmonary- 
artery is the seat of athero-sclerosis. A similar pathological change is 
occasionally found in emphysema and some observers see a significant 
relation in certain cases between the atheroma and dilatation of the 
pulmonary artery and the accompanying dyspnoea and cyanosis. 
It remains for us to consider certain types of real andothers of 
apparent enlargement of the pulmonary artery, which have apparently 
no clinical significance. For example, in figure 9 is illustrated an 
abnormal prominence of the vessel, unassociated with any cardiac or The Pulmonary Vessels and Circulation 
FIGURE 9 
Enlargement of the pulmonary conus, 
pulmonary disease, the significance of which we are at a loss to explain. 
At times these patients exhibit an accentuation of the second pulmonic 
sound and if the heart is overacting, a pulsation may be visible in the 
second left intercostal space. Clinicians have in certain cases sought 
to explain these phenomena as a result of the retraction of the edge of 
the lung due to tuberculosis, which permits a more ready trans- 
mission of the pulmonary second sound to the chest wall. Although 
this may be the mechanism in some cases, it is not true of all and we 
must concede the existence of a dilated pulmonary artery in some of 
these patients without coincident disease of the lung. The enlarged 
pulmonary artery here represents only an interesting variant from the 
normal. 
Finally we must take note on the Roentgen plate of an enlargement 
of the pulmonary artery, commonly observed in hypoplastic and true 
drop hearts, which is however apparent rather than real. The drop 
heart represents probably an earlier type in the phylogenetic scale in The Pulmonary Vessels and Circulation 
29 
which this organ is situated centrally nearer the anterior chest wall and 
is also rotated on its vertical axis. This movement brings the pulmonary 
artery into greater prominence on the Roentgen plate without any 
actual enlargement. It is also calculated to increase the intensity of 
the second pulmonic sound. As pulmonary tuberculosis frequently 
develops in the asthenic individual with a drop heart, we have here a 
possible explanation for the accentuated basal sounds which are often 
noted in pulmonary disease. 
Occasions will arise when it will be difficult to distinguish the 
shadow of a pulmonary artery from that of a neoplasm of the lung or 
mediastinum. How closely the shadows of these two diverse conditions 
can simulate each other will be evident from a study of the mediastinal 
tumor illustrated in figure 326. It will be necessary in such a case to 
have recourse to the fluoroscopic examination in order to determine the 
presence of a pulsation and particularly to view the abnormal mass in 
the oblique position. It is characteristic of an enlarged pulmonary 
artery to become more prominent in the first oblique position, whereas 
most neoplasms in this situation will wholly or partly disappear from 
view. 
FIGURE 10 
Infarct of the left lung. 30 
The Pulmonary Vessels and Circulation 
PULMONARY INFARCT 
Infarcts of the lung cast recognizable shadows on the plate only 
when they are large. It is a common experience to find at autopsy 
numerous small infarcts of which the Roentgen examination gave us no 
evidence during life. In their typical forms they appear as large 
triangular shadows, with their bases toward the axilla, which may 
occupy a large part of a lobe. (Fig. 10.) On the other hand, the lung 
about them may be in such a state of inflammatory reaction that the 
resulting shadow may be indistinguishable from that of a pneumonic 
Arterio-venous aneurysm of the pulmonary artery following lung abscess. 
FIGURE 11 
process. It is important, however, not to regard every extensive shadow 
in the lung, occurring in cardiac disease, as of embolic origin. The 
clinician is well aware of the frequent incidence of true pneumonias, 
due to the virus of rheumatism or allied micro-organisms, during the 
course of chronic endocarditis. They are often atypical in their clinical 
course and puzzling in their physical manifestations; they may, like 
infarcts, be a terminal event in the case and unfortunately the Roentgen 
shadows will leave us in the dark as to their true nature. The Pulmonary Vessels and Circulation 
31 
In conclusion it may not be amiss to illustrate the following rare 
circulatory condition which exemplifies the versatility of the Roentgen 
examination in thoracic diagnosis. Figure 11 represents an arterio-venous 
aneurysm which was clinically symptomless, following a lung abscess. 
The circular shadow in the left lung was found at autopsy to be an 
encapsulated blood cyst which communicated on one side with the 
pulmonary artery and on the other with the pulmonary vein. The 
abscess had completely healed. SECTION III 
The Trachea and Bronchi Chapter III 
The Trachea 
In a thoroughly exposed plate, the lumen of the trachea may be 
seen as an air space against the spine which forms its background. It 
traverses the upper part of the chest, usually in the midline, although 
occasionally it deviates slightly to the right or to the left. At the level 
of the fourth dorsal vertebra it bifurcates into its two branches. Its 
calibre is generally uniform and varies in width with the size of the 
individual. There are several points at which it may be slightly nar- 
rowed notably below the cricoid cartilage and also at the bifurcation. 
The topographical relations of the trachea and bronchi in the living 
subject are graphically set forth in figure 15 in which they are outlined 
by aspirated barium. 
The wall of the trachea casts no shadow on the plate except in its 
lower portion where, on the right side, it may encroach on the pulmon- 
ary field, especially when the head is turned. The tracheal rings are 
invisible, unless, as in older subjects they are calcified. They are best 
seen in the lateral position. (Figure 12.) 
Calcified tracheal cartilages, seen in the oblique position. 
FIGURE 12 36 
The Trachea and Bronchi 
Study of the trachea by means of the Roentgen ray does not derive 
its interest from any intrinsic diseases of this structure, which are very 
uncommon. Its importance depends rather on its position in the thorax 
where it comes into relation with a number of organs, disease of which 
is often reflected in an altered configuration of the trachea. The latter, 
together with the superior mediastinum constitutes a movable and 
non-rigid structure which readily yields to any abnormal pressure 
which may be applied to it. The numerous causes for such pressure 
which may arise in the mediastinum, lungs and pleura may result in a 
displacement of the trachea or its compression or both. 
DISPLACEMENT OF THE TRACHEA 
The commonest cause of a displacement of the trachea is pulmon- 
ary tuberculosis, particularly of the upper lobes. The causes of this 
displacement are probably various. In the first place a diminution in the 
volume and respiratory movement of the affected lung, due either to 
infiltration or atelectasis may, even in early tuberculosis upset the 
balance of pressure on the two sides of the trachea; consequently the 
distention of the sound lung pushes it to the affected side. This will 
account for the slight deviation of the trachea in cases of early tubercu- 
losis, in which there is no evidence of fibrosis or traction. 
The more marked degrees of tracheal malposition are associated 
with the fibrosis of older lesions. In these cases, the trachea, being 
relatively fixed at two points, namely, at the cricoid cartilage and at the 
bifurcation, is drawn to the affected side and also takes a tortuous 
course through the upper chest. This is almost a regular appearance 
in advanced pulmonary tuberculosis. In cases of bilateral disease, it 
indicates the side of the older lesion, as the trachea is drawn over to the 
side of the original process. Here will be found the evidences of great- 
est fibrosis, thickening of the pleura and cavitation. (Fig. 397.) 
In patients with chronic tuberculosis, who have been coughing 
for years, the trachea in addition is frequently dilated, especially in 
that portion situated just below the cricoid cartilage. 
A displacement of the trachea by traction may be found in any 
disease, aside from tuberculosis, in which there is an induration and 
fibrosis of the lung. We thus encounter it in chronic pleuro-pulmonary 
disease of a non-tuberculous nature (fig. 187), in certain forms of bron- 
chial carcinoma and in the indurative form of syphilis of the lung. The 
displacement may be so extreme that the trachea is drawn completely 
over into the affected half of the thorax. This is well seen in figure 199 
which illustrates the effect of an extensive syphilitic fibrosis of the lung 
and pleura in a tabetic woman. The adhesions resulting from a chronic 
pleurisy may also cause a marked malposition of the trachea without 
any associated fibrosis of the lung. (Fig. 305.) The Trachea and Bronchi 
37 
It is worthy of mention that an extreme displacement of the trachea 
and mediastinum may be caused by stenosis of a main bronchus with 
consequent atelectasis of the lung. Here the trachea together with 
the mediastinum yields to the pressure of the opposite lung, which 
becomes overdistended. This was apparently the cause of the tracheal 
displacement shown in figure 19 in which a fibroma so completely 
occluded the left bronchus, that no evidence of entrance of air into the 
left lung was found on auscultation. After the removal of the tumor, 
the left lung promptly expanded and the trachea resumed its central 
position. 
A general displacement of the trachea and mediastinum, without 
tortuosity, is found in cases of pleural effusion. It is however, not an 
invariable finding and it depends on different factors, all of which are 
not entirely clear. The most marked displacement accompanies non- 
inflammatory effusions which completely fill one side of the chest. On 
the other hand, in cases of inflammatory exudate, whether free or 
encapsulated, a displacement of the trachea and mediastinum is fre- 
quently absent or very slight and may bear no relation to the size of 
the effusion. In some cases this may be explained by the presence of 
encapsulating bands, in others by a fixation of the mediastinum or by 
a diminution in the volume of the lung on the affected side. 
An extreme displacement, perhaps the greatest, occurs in associa- 
tion with pneumothorax with or without effusion. In these patients 
the trachea may occupy a position beyond the mid-clavicular line of 
the opposite side. This is particularly noted in cases of valve pneumo- 
thorax with a constantly increasing intra-pleural pressure. (Fig. 238.) 
Tumors of the lung and pleura which are of considerable size usually 
push the trachea to the opposite side. This is especially true of mas- 
sive new growths of the upper lobes. (Fig. 207.) With new growths 
of the pleura the pressure on the trachea is usually due, in part at least, 
to the associated pleural effusion. Yet, as is illustrated in figure 299, 
this effect may be poduced by the growth alone, without a complicating 
effusion. A contrary effect may in rare cases be exerted by tumors of 
the lung or pleura, the trachea and mediastinum being drawn over to 
the affected side. This phenomenon is seen in figure 208, a case of 
bronchial carcinoma of considerable size. The mechanism of such an 
unusual displacement is not clear. Although it may be the result of a 
scirrhous growth, it must be kept in mind that an occluding carcinoma 
in the lumen of one or more large bronchi may produce an atelectasis 
and collapse of the lung with a resulting pressure on the mediastinum 
from the distended healthy lung. 
As may be expected, a trachea which is displaced laterally, so that 
it comes to lie within the pulmonary fields, may be the cause of abnormal 
physical signs whose interpretation is fraught with difficulties. When 38 
The Trachea and Bronchi 
the displaced trachea is surrounded by infiltrated lung, as in pulmon- 
ary tuberculosis, the respiratory sounds along the border of the upper 
sternum may acquire an amphoric quality identical with that of a cavity. 
For this reason, the clinician learns to appraise the physical signs of a 
cavity in this region critically and to palpate the trachea at the root of 
the neck in order to determine whether it deviates from the mid-line. 
In cases of extensive fibrosis of the lung, as illustrated in figure 199, 
the trachea may even be situated in the infra-clavicular region, where 
physical signs indistinguishable from those of a large cavity may be 
found. 
COMPRESSION OF THE TRACHEA 
The commonest site of compression of the trachea is at the root 
of the neck because here it is confined in the narrowest portion of the 
thorax and is surrounded by unyielding bone. The compressed trachea 
is often at the same time displaced to one side or the other. Among 
frequent causes of a narrowing of the trachea are mediastinal new 
growths, especially tumors of the thyroid, benign or malignant. En- 
largement of a normally situated thyroid usually does not result in com- 
pression of the trachea; exceptions to this rule are malignant tumors 
which actually invade its lumen, or occasionally the tense cysts of a 
colloid goitre. Thus the trachea may be compressed between an en- 
larged lobe of the thyroid and a cystic isthmus. A much more common 
cause of tracheal narrowing is a substernal or intra-thoracic goitre. 
The narrowing is usually confined to a small area and may be extreme. 
Stenosis of the trachea from this cause results as readily from adenom- 
atous or colloid goitres as from truly malignant ones. 
The various mediastinal neoplasms, especially the lympho-sarcom- 
ata and lymphomata including Hodgkin’s disease are very prone to 
produce a compression and deformity of the trachea and the relation 
of these changes to the most distressing symptoms of these diseases is 
susceptible of accurate demonstration on the Roentgen plate. In young 
children tracheal compression finds its most frequent cause in the pres- 
r ire of tuberculous lymph nodes and rarely in an enlargement of the 
thymus. Especial attention should be directed to a tumefaction of the 
para-tracheal lymph nodes on the right side, which may attain a con- 
siderable size when they become tuberculous. Because of their posi- 
tion at the side of the trachea, which in infants is easily compressible, 
marked dyspnoea and stridor may result. In adults, owing to a greater 
rigidity of the trachea, tuberculous nodes are less prone to produce 
compression. 
Finally, aneurysm of the aorta, from its position in relation to the 
trachea is calculated to compress it. It is probable that few aneurysms 
attain any considerable size without diminishing the caliber of the The Trachea and Bronchi 
39 
trachea. The Roentgen plate thus discloses in most cases a distinct 
decrease in its lumen, due to direct pressure of a sacculation or it may 
be flattened between two adjacent sacculations. The narrowing of the 
trachea may however be obscured by the shadow of the overlying 
aneurysm so that it may be visible only in the oblique position. (Fig. 
360.) 
TUMORS OF THE TRACHEA 
The very rare tracheal tumors are difficult of demonstration 
because of the obscuring shadows cast by the vertebrae and aorta. In 
the oblique position however, the lumen of the trachea may be pro- 
jected into the lung fields, which will supply the contrast necessary to 
set off a soft tumor within it. Thus in figure 13 is shown a sessile 
Tumor growing from posterior wall of trachea and projecting into its lumen. 
Just below it is the bifurcation. Oblique view. 
FIGURE 13 40 
The Trachea and Bronchi 
tumor springing from its posterior wall, which was invisible on 
the antero-posterior plate. For some months this patient had dyspnoea, 
stridor and recurrent laryngeal palsy. Tracheoscopic examination 
revealed a carcinoma in the situation indicated on the plate. More 
often, the trachea is invaded by tumors originating in nearby structures 
such as the thyroid and the oesophagus. In the case of oesophageal 
tumors, abnormal shadows are usually not visible and we are led to 
suspect an involvement of the trachea by the unusual train of symp- 
FIGURE 14 
Tracheo-oesophageal fistula secondary to carcinoma of oesophagus. 
Arrow indicates site of tumor. From this point barium passed into the trachea 
outlining the right lower bronchial tree. The Trachea and Bronchi 
41 
toms which result from a tracheo-oesophageal fistula. Suspicion of 
this complication is aroused when the ingestion of food is followed by 
violent, paroxysmal coughing. If we visualize the oesophagus by the 
ingestion of barium, it is at times possible to observe the passage of the 
latter through the fistulous opening in the oesophagus into the trachea 
and finally into the bronchial tree, which may be outlined by the barium 
to its smaller branches. Thus, in figure 14, the right lower lobe bronchi 
are full of barium, radiating from the funnel-shaped stenosis of the 
oesphagus. 
The ingestion of food may also be followed by violent coughing 
whenever the pharygneal muscles are paralyzed, notably in cases of 
bulbar palsy. As in cases of tracheo-oesophageal fistula, the bronchial 
tree may be outlined by the ingested barium. There is this difference 
FIGURE 15 
Bronchi filled with aspirated barium in case of bulbar palsy. Trachea also outlined by barium. 42 
The Trachea and Bronchi 
however; the barium will also be visible in the upper trachea and 
examination of the oesphagus will fail to disclose an obstruction to the 
downward passage of the meal. Thus, in the case illustrated in figure 
15 during the fluoroscopic examination the barium passed directly into 
the larynx and then downward into the bronchi. One day later the 
patient died of respiratory failure due to bulbar palsy. Chapter IV 
The Bronchi 
Although the bronchi are not distinguishable on the Roentgen plate 
from the other structures which go to form the lung markings, we can 
nevertheless by a correlation of clinical and Roentgen data, derive con- 
siderable information regarding bronchial diseases. 
CHRONIC BRONCHITIS 
Roentgen examination of the chest is probably undertaken more 
often for the diagnosis of chronic bronchitis or its underlying causes 
than for any other disease. When we interpret the Roentgen plate 
in this disease it is important to realize that the abnormal shadows 
which may traverse the lungs are only to a minor degree the result 
of inflammatory changes in the bronchi. They are to a greater degree 
the result of associated conditions such as pulmonary emphysema 
and a general fibrotic process which may affect not only the peri- 
bronchial but also the peri-vascular and interstitial connective tissues. 
In long standing cases we therefore find the lung markings abnormally 
prominent, this being due both to an increase in the connective 
tissue of the lung and to the greater contrast furnished by the over- 
oerated lungs. The latter are usually emphysematous and are con- 
tained within a bony thorax which has acquired the well-known barrel 
shape of emphysema and chronic bronchitis. In addition, the bronchial 
nodes which are chronically inflamed, are enlarged and indurated so 
that the hilum extends into the lung fields for some distance. The low, 
flat diaphragm which scarcely moves in respiration, the median, narrow 
heart and the calcified costal cartilages complete a rather characteristic 
Roentgen picture. 
However, the value of the Roentgen examination consists less in 
the demonstration of these changes than in the discovery of abnormal 
conditions in the heart and lungs, to which the bronchial disease may 
be secondary. The thoughtful clinician is not content with a diagnosis 
of chronic bronchitis until he has excluded other more serious disease 
as a cause of it. It is frequently only a symptom of a more grave 
affection which, because of the associated emphysema may be com- 
pletely masked. It therefore frequently happens that the Roentgen 
plate brings to light an apical indurative tuberculosis, the physical 
evidences of which are obscured by the bronchitis. In fact, the so- 
called asthmatic form of tuberculosis in older individuals, may clinically 
furnish no other evidence of its existence than a chronic bronchitis and 
asthma and only the Roentgen examination may reveal the underlying 
tuberculous process. 
Similarly, a new growth of the lungs, chronic cardiac disease and 
the cardiac hypertrophy of chronic nephritis may be discovered as the 
underlying causes of a chronic bronchitis and decisive light may thus 44 
The Trachea and Bronchi 
be thrown on an otherwise obscure case. Such experiences invest the 
diagnosis of chronic bronchitis with so much uncertainty that the 
clinician hesitates to make it until he has exhausted the resources of his 
examination. 
BRONCHIECTASIS 
In the clinical differentiation of the various types of bronchial 
dilatation, it is of value to distinguish between the multiple, usually 
small dilatations which result from a gradual weakening of the bron- 
chial wall and the gangrenous bronchiectases which are such an 
assential element in the cases of acute and sub-acute pulmonary sup- 
puration and gangrene. A discussion of the latter we will reserve for 
the chapter on Abscess and Gangrene of the lung. 
Bronchiectases are usually the sequel of a pneumonic process in 
which the growth of fibrous tissue about the small bronchi results in 
their gradual dilatation, probably under the influence of a prolonged 
period of coughing. In interpreting the Roentgen plate in this disease, 
we have therefore to keep in mind the existence of two pathological 
changes, one, the pneumonic infiltration, the other, the bronchial dilata- 
tion. The Roentgen appearance in different cases may be quite dis- 
similar depending on the relative intensity of these two processes. 
Thus, multiple small bronchial dilatations lying within a consolidated 
lung will not be visible through the dense shadow of the lung about 
them. The Roentgen shadow will therefore be simply that of a pneu- 
monia. On the other hand, when for any reason the bronchiectases 
attain a larger size and become globular, they may contain so much air 
that they are visible even through the shadow of an indurated lung. 
We may roughly distinguish two forms of multiple bronchiectases 
on the Roentgen plate. In the less common type one or more lobes of 
the lung are occupied by numerous globular cavities whose walls are 
formed by the thinned out, dilated bronchioles. The cavities are often 
of considerable size, their diameter being at times as much as one inch. 
Lying next to each other and entirely replacing the lung parenchyma, 
they may convert the lung into a honey-comb or sponge-like structure. 
(Fig. 16.) Usually, this form of the disease is acquired in childhood 
subsequent to a pneumonia, which is followed by a long period of cough- 
ing during which the characteristic symptoms, consisting among others 
of profuse purulent expectoration and clubbing of the fingers, develop. 
This appears to represent a mild form of the disease, which is borne 
with very little discomfort and is consistent with robust health for many 
years. The probable reason for this becomes evident when we study 
the Roentgen plate in these cases. It will be noted that there is no 
evidence of a pneumonic process which, as we shall see, is a potent 
factor in extending and perpetuating the bronchiectatic process. It is 
probable that here the pneumonic process has completely subsided, per- The Trachea and Bronchi 
45 
FIGURE 16 
Multiple bronchiectases, showing typical spongy appearance of left lower lobe; 
also at root of right lung. 
haps years ago and that the disease is now a purely bronchial one. The 
patients therefore suffer from the mechanical effects of a bronchial 
dilatation, with a super-added bronchitis and a stasis of accumulated 
bronchial secretion. Aside from the discomfort incident to the evacua- 
tion of this secretion, they may enjoy good health for many years. The 
physical signs of this affection are rarely definite enough to warrant a 
diagnosis of bronchiectasis, which is rather made from the history, the 
symptoms and the almost constant presence of clubbed fingers. The 
cavities are too small to furnish characteristic signs, which are only 
those of a bronchitis. In some patients the bronchitis may even subside 
to such a degree that the sputum is no longer profuse; under these cir- 
cumstances, the condition may pass entirely unrecognized by the 
physician. For example, the middle aged patient, whose left lung 
presented the numerous bronchiectases seen in figure 17, had only a 
slight morning cough for many years and passed through a major 
operation under general anesthesia with no untoward results. In these 
cases the physician is entirely dependent on the Roentgen examination 
for a diagnosis. 46 
The Trachea and Bronchi 
FIGURE 17 
Multiple globular dilatations of bronchi in left lower lobe, 
In the more frequent form of bronchial dilatation, the pneumonic 
process to which it is secondary is a persistent one and leads to greater 
fibrosis which in turn tends to aggravate the bronchiectases. In general, 
the prognosis in this form of the disease must be regarded as graver 
than in the previous one as it is often later complicated by pulmonary 
suppuration and gangrene. It therefore not infrequently happens that 
a patient will pass through an acute pneumonia, which persists and 
organizes, followed by a period of subacute pneumonitis during 
which bronchiestases are formed. Following a variable interval of 
months or years, during which large amounts of purulent sputum are 
brought up, anaerobic infection of the lung may supervene, with the 
complete picture of lung abscess and gangrene. 
As a rule in this group of cases the bronchial dilatations are small 
and cylindrical in shape, as they are probably prevented from becom- 
ing larger and globular by the surrounding indurated lung. They are 
also obscured by the latter, so that on the Roentgen plate we see only a 
dense pneumonic shadow, within which occasionally the outlines of The Trachea and Bronchi 
47 
enlarged bronchioles, replete with secretions, are faintly indicated. 
Rarely, the bronchiectases, being larger and perhaps more superficially 
situated, are visible even in consolidated lungs. (Fig. 18.) In this 
FIGURE 18 
Multiple bronchiectases within a chronically indurated lung. 
patient, a child of eight years, the disease was of four years duration 
and followed pneumonia. The characteristic symptoms of bronchial 
dilatation were present and in addition, at various times, the sputum 
was fetid, an almost certain indication of an actual involvement of the 
lung in a gangrenous process. 
It will be evident that the Roentgenologist must be prepared to 
make the diagnosis of multiple bronchiestases on meagre data. Often 
he sees no evidence of them on the plate and he must infer their existence 
from the presence of a pneumonic shadow. This, however, he can only 
safely do if he has the support of the clinical history and physical find- 
ings. 48 
The Trachea and Bronchi 
The influence of disease of the pleura on the development of 
bronchiectases must also be considered. The fibrosis which may begin 
on the surface of the lung secondary to an empyema, may pene- 
trate the parenchyma and give rise to so-called pleuro-pneumonic 
bronchiestases. These cases are difficult to interpret by the Roentgen 
examination alone because the fibrosis may cause such a thickening of 
the pleura as to obscure the more deeply seated disease. In cases of 
unoperated or unrecognized empyema, a slowly progressive inflam- 
matory process may lead in a few months to the formation of bronchial 
dilatations, the striking symptoms of which may completely divert 
attention from the untreated empyema; the first sign of the latter may 
be its rupture into a bronchus and the consequent expectoration of a 
large amount of pus. Here a careful clinical history is of the greatest 
importance in order to determine the sequence of events because the 
converse possibility exists of primary bronchiestases with rupture of one 
of them into the pleural cavity resulting in an empyema. Instances of 
the latter are not uncommon and they explain certain cases of per- 
sistent empyema in which the ruptured bronchus becomes the starting 
point for the formation of a pleuro-pulmonary fistula. This sequence 
of events must especially be kept in mind in the case of children in whom 
bronchiectases following a pneumonia or the aspiration of a foreign 
body may be unrecognized until their rupture and the resultant empy- 
ema draw attention to them. 
The multiple cylindrical or globular dilatations which are a result 
of the distention of terminal bronchioles must be distinguished from a 
diffuse enlargement of the larger bronchi. The latter are usually 
present in lung abscess and gangrene and although not visible on the 
Roentgen plate, they can be seen through the bronchoscope. There are 
also rare forms of chronic indurative pneumonia in which the terminal 
bronchioles are unaffected, the dilatation involving only the larger 
tubes. However, this widening of the bronchi is only exceptionally 
visible on the plate as they are completely obscured by the pneumonic 
lung about them. 
Of the various causes of stenosis of a main bronchus, certain ones 
such as an aneurysm or an extra-bronchial tumor may readily be seen 
on the plate. The mechanical effect on the lung of such a stenosis is often 
an impairment in the aeration and a consequent atelectasis of the area 
of the lung supplied by the bronchus. This manifests itself on the plate 
as a homogeneous cloudiness of the lung which may be of any grade, 
from a slight haziness to an appearance indistinguishable from a con- 
solidation. When the stenosis is due to a tumor the shadow of the 
atelectatic lung may merge with that of the tumor so that the latter 
will appear larger than it actually is. Thus, in figure 210 the shadow 
STENOSIS OF THE BRONCHI The Trachea and Bronchi 
49 
in the left lower lobe has two components. The portion near the root 
of the lung was cast by a small adeno-carcinoma originating in a main 
bronchus, which it occluded. The greater part of the shadow was how- 
ever due to a collapse of the left lower lobe. The physical signs, con- 
sisting of dulness and absent respiratory sounds were naturally enough, 
though erroneously, attributed to a pleural effusion. 
A valuable sign of stenosis of a bronchus may be observed on the 
fluoroscopic screen. This consists in a displacement of the mediastinum 
toward the affected side during inspiration and is caused by the expan- 
sion of the normal lung which is unopposed by that of the atelectatic 
lung. This phenomenon may be of value in the diagnosis of obstruction 
by bands in bronchial syphilis, by endobronchial growths, by bronchial 
FIGURE 18a 
Broncho-stenosis by tuberculous nodes. Atelectasis and collapse of right upper 
lobe. Partial occlusion of lower lobe bronchus with over-distension of lobe, 
displacement of mediastinum to left and depression of diaphragm. Arrow points 
to compressed, airless upper lobe. 50 
The Trachea and Bronchi 
exudates as in diphtheria or by foreign bodies which cast no shadows 
on the plate. It is not however, exclusively found in these conditions. 
In any pulmonary disease in which the alveolar area is much diminished, 
as by extensive fibrosis, a similar movement of the mediastinum may be 
seen. 
Under special conditions, when a bronchus is only partially 
obstructed, there may result an over-distention of the affected lobe 
rather than an atelectesis. Such a phenomenon is occasionally observed 
with foreign bodies which partially occlude a bronchus in such a way 
that air may more easily enter the lung than it can be expelled. The 
lung therefore becomes progressively more and more distended to such 
an extent that the mediastinum may be displaced and the diaphragm 
depressed. It is probable that edema of the mucous membrane at the 
site of the obstruction contributes to this valve-like action. In figure 18a 
are illustrated in the same case the effects of a complete obstruction of 
one bronchus and the partial obstruction of another by a mass of tubercu- 
lous nodes in the superior mediastinum. It will be noted that the right 
upper lobe is completely airless so that it has contracted to only a frac- 
tion of its normal size, its lower border being at the level of the second 
rib. On the other hand there is a partial occlusion of the right lower 
bronchus as a result of which the lower lobe has become over-distended. 
It has crowded the upper lobe to the apex of the chest, it extends far 
beyond the mid-line to the left side and the diaphragm is depressed. 
These changes were discovered in a child of three months who pre- 
sented paroxysmal attacks of dyspnoea and a more or less constant 
stridor. Tuberculin test positive. 
TUMORS OF THE BRONCHI 
The malignant tumors which take their origin in the large bronchi 
rapidly invade the adjacent lung; their diagnosis may therefore more 
logically be considered in the chapter devoted to pulmonary new 
growths. When such tumors are still confined to the bronchus, they can- 
not be diagnosed as such by a Roentgen examination. 
Benign tumors which spring from the wall of a large bronchus 
will also elude the examiner; the changes which may result from 
occlusion of the bronchus such as atelectasis of the lung or secondary 
suppuration, present nothing on the plate that is characteristic. Only 
the physical signs, such as a complete absence of breath sounds or 
symptoms suggesting the obstruction of a bronchus, may arouse a 
suspicion of the real condition. The great extent of the secondary 
changes in the lung from even a small endo-bronchial tumor are illus- 
trated in figure 19. The Trachea and Bronchi 
51 
Fibroma of left bronchus. Stenosis of bronchus with atelectasis of lung. Trachea and 
heart displaced to left. 
FIGURE 19 
This patient for a few months suffered with a dry harrassing rough and attacks of dyspnoea, 
to which was later added a profuse expectoration of purulent sputum. Physical examination 
revealed a marked decrease in expansion of the left lung, together with a complete absence 
of breath sounds on that side. There was no fluid in the left chest. The plate shows a retrac- 
tion of the left chest, displacement of the mediastinum and heart to the left by the emphysemat- 
ous, uninvolved lung and a replacement of the left lung field by a dense shadow. The signs 
all pointed to an obstruction of the left bronchus. This was corroborated by the broncho- 
scopic examination which disclosed a fibroma occluding the left main bronchus. The rapid 
improvement which followed the removal of this tumor is remarkable. Within two weeks, 
hand in hand with the expectoration of much retained mucus and pus, the left lung became 
completely aerated and the heart returned to its normal position. It is probable that in 
addition to an atelectasis, there was a pneumonic process from retained secretions, which had 
not yet developed a permanent character and was still capable of resolution. SECTION IV 
The Lungs 
Pulmonary Tuberculosis in Adults. 
Pulmonary Tuberculosis in Children. 
Pneumonia. 
Pulmonary Suppuration: Abscess and Gangrene of the 
Lung. 
Chronic Non-tuberculosis Infections: 
Indurative Pneumonia, 
Actinomycosis, 
Echinococcus Cyst, 
Syphilis. 
Tumors of the Lungs: 
Primary Tumors, 
Metastatic Tumors. Chapter V 
Pulmonary Tuberculosis in Adults 
There are few diseases whose prompt and accurate diagnosis is of 
greater moment to the patient, than pulmonary tuberculosis. It is 
therefore gratifying that in the Roentgen Ray we possess a method of 
examination which in its accuracy and timeliness is rivalled by few 
diagnostic procedures. 
It must however be remembered that like any diagnostic method 
its value will be measured by the technical skill of the physician in the 
making of plates no less than his ability to interpret them. The plate 
must be clear and its markings well defined in order that the normal 
shadows may be distinguished from the pathological. The interpretation 
of hazy or otherwise imperfect plates has as little justification as a 
physical examination of the lungs without disrobing the patient. 
Skill in interpretation presupposes not only a familiarity with 
Roentgen shadows but also a working knowledge of the clinical and 
pathological features of tuberculosis. Unless such knowledge is at the 
disposal of the examiner he will not be in a position to profit fully from 
his study of the plate nor will he be able to express in appropriate 
language, as is often possible, the clinical or pathological type of the 
disease. It is scarcely necessary to point out that only a physician is 
possessed of the knowledge which is a necessary pre-requisite of such 
an intelligent interpretation. It is an affront to the clinician to offer 
him, as is so often done, the opinion of a non-medical technician in a 
case of tuberculosis. The Roentgen diagnosis will inspire respect in the 
mind of the clinician commensurate with the medical knowledge of 
the Roentgenologist. 
There are two methods which may be employed in the Roentgen 
diagnosis of pulmonary tuberculosis, fluoroscopy and radiography. 
Although in the early days of Roentgenology these methods enlisted 
opposing adherents, it is now agreed that they are co-ordinate parts of 
a complete examination. There was a time when, for technical reasons, 
good chest plates were difficult to make, so that there may have been 
grounds for preferring the fluoroscopic screen. Individual workers by 
dint of practice became expert in the interpretation of screen findings, 
yet they became so, not from choice but from necessity because good 
chest plates were not available to them. Fluoroscopy can reveal only 
the coarser shadows associated with more advanced disease of the lung; 
it often fails to discover the finer infiltrations of incipient tuberculosis. 
METHODS OF EXAMINATION 56 
The Lungs 
The fiuoroscope nevertheless has a definite and unique function 
in the Roentgen examination. It should always precede the making of 
the plate and any data thus ascertained should be utilized to supplement 
the radiographic findings. It is of supreme value in the observation of 
moving structures such as the diaphragm and the heart and of the 
shifting fluid levels in cavities and in the pleura. It is often of greater 
value than the plate in determining the extent and localization of areas 
of pneumothorax and of effusions and it has the advantage of a view of 
the chest in any desired position of the patient. Slight differences in 
aeration are perceived more easily on the screen and this is particularly 
true of the apices, where atelectasis is so often found. 
Having conceded these advantages of the screen, it must be repeated 
that the ultimate diagnosis, especially of incipient tuberculosis, must be 
based on a well executed Roentgenographic examination. It is espec- 
ially unsafe to deny the existence of tuberculosis of the lung from nega- 
tive fluoroscopic findings. 
STEREOSCOPIC VERSUS SINGLE PLATES 
Stereoscopic examination of the chest affords us a plastic imagine 
of the lungs in which the ramifications of the pulmonary vessels are 
visible with remarkable clearness. Infiltrations whose depth and 
density can only be guessed at on the single plate are seen in their true 
relation to surrounding structures and their proximity to the anterior 
or posterior chest wall can be determined. This applies particularly to 
deposits on the pleura, the shadows of which cannot otherwise be dis- 
tinguished from pulmonary infiltrations with any degree of certainty. 
So much can fairly be said for the stereoscopic examination. There 
is, however, a tendency among Roentgenologists to exaggerate its 
importance, to consider it indispensable for the diagnosis of pulmonary 
tuberculosis and finally to regard a single plate as of minor value. Such 
a view we wish to controvert as emphatically as we can because it is 
contrary to fact. True, to those who have not mastered the art of 
making excellent single plates the striking plasticity and apparent 
detail of even a mediocre stereoscopic set, will be pleasing to the eye. 
Yet, if the truth were told, in many of these cases the Roentgenologist 
has achieved nothing more than a pleasing optical illusion. 
The test of a good Roentgen examination is the single plate. If it 
is properly made, so that its markings are sharply defined and free from 
haziness and distortion, the examiner will have no difficulty in dis- 
tinguishing the infiltrations of tuberculosis. On the other hand, if a 
proper technique is not observed, stereoscopy will avail him as little as 
the single plate. The Lungs 
57 
The earliest lesions of tuberculosis are regularly found somewhere 
in the upper lobes, usually near the apex. They are nearly always 
unilateral. On the plate they appear as distinct circumscribed shadows 
which may be solitary or as is oftener the case they occur in groups of 
smaller shadows with indistinct outlines. The individual shadows may 
be as small as millet seeds or they may be one to several centimeters in 
diameter. Usually they are roughly circular although they may exhibit 
a great variety of shapes, which are probably dependent on associated 
inflammatory changes. 
A common type of beginning tuberculosis is illustrated in figure 20 
and figures 21 and 21a. The deposits are fairly large and well outlined, 
INCIPIENT TUBERCULOSIS 
Early tuberculous process in left infraclavicular region. (Arrow.) 
FIGURE 20 58 
The Lungs 
Early tuberculous infiltration in left infraclavicular region. (Arrow.) 
FIGURE 21 
although of only moderate intensity, so that they are easily obscured by 
overlying ribs and muscles. Again in figure 22 an exceedingly faint, 
almost circular infiltration is distinctly seen as it is projected on the first The Lungs 
59 
Left apex of figure 21, natural size, showing infiltration of early 
tuberculosis in infraclavicular region. (Arrow.) 
FIGURE 21a 60 
The Lungs 
FIGURE 22 
Early tuberculous lesion below right clavicle. The Lungs 
61 
right intercostal space. In figure 23 may be seen an early involvement 
of the very summit of the right apex. 
Early tuberculosis at extreme apex of right lung, 
FIGURE 23 
The smaller infiltrations, probably composed of miliary tubercles, 
may be grouped into masses of tiny shadows of different densities, 
(figs. 24 and 25 and 24a and 25a) which lack the homogeneous appear- 62 
The Lungs 
FIGURE 24 
Early tuberculosis at right apex. Large group of tubercles surrounded by pneumonic exudate. The Lungs 
63 
FIGURE 24a 
Right apex of figure 24, natural size, showing early tuberculous 
infiltrations in infraclavicular region. 64 
The Lungs 
FIGURE 25 
Farly tuberculous process below left clavicle. A group of tubercules imbedded in pneu- 
monic exudate. The Lungs 
65 
Left apex of figure 25, showing a group of small infiltrations of 
beginning tuberculosis in the infraclavicular region, 
FIGURE 25a 
ance of the solitary deposits. Such miliary tubercles cannot of course 
be recognized as infiltrations unless they occur in groups, which is 
usually the case. In figure 26 both apices have a faintly granular 
appearance from large numbers of closely studded tubercles. 66 
The Lungs 
Bilateral apical tuberculosis, consisting of numerous tubercles. 
FIGURE 26 
Of course, these early infiltrations may also be seen in cases of 
more advanced tuberculosis when for any reason there is a renewal of 
the infection. Their great variability in size and shape is well illus- 
trated in figure 27 where they are associated with the more advanced 
lesions shortly to be described. 
In picturing to ourselves the pathological changes which are 
responsible for these diverse shadows in beginning apical disease, two 
facts must be borne in mind. First, in incipient disease, before necrosis 
of the tuberculous tissue has taken place, the infiltrations have little 
absorptive power for the Roentgen Rays. The shadows are therefore The Lungs 
67 
FIGURE 27 
Illustrates a great variety of tuberculous infiltrations. In left infraclavicular region, the 
deposits have the faint shadows of recent lesions. On right side the infiltrations are under- 
going fibrosis. 
faint and lack the intensity which, as we shall see later, is a consequence 
of caseation. Secondly, an almost invariable accompaniment of the 
tubercle is a zone of exudative inflammation in the alveoli about it. This 
accounts for the indistinct outlines of many of the earliest deposits and 
the homogeneous shadows which they may cast. These features of early 
tubercles are seen in figure 24 where there is only a very faint cloud- 
like shadow in the right infraclavicular region, in which the tubercles 
are obscured by the surrounding exudate. 68 
The Lungs 
In the further course of our study we shall see that these two 
pathological processes, caseation and pneumonia, together with the sub- 
sequently developing fibrosis, will determine to a great extent the 
Roentgen appearance of tuberculosis of the lungs in its protean mani- 
festations. 
AT HOW EARLY A STAGE CAN TUBERCULOSIS BE DIAGNOSED? 
It is apparent, from the facts thus far presented that relatively 
small deposits at an apex are susceptible of certain demonstration on 
the Roentgen plate. It is proper to inquire at this point whether the 
shadows we have described represent the actual beginnings of the 
disease or whether there has preceded a stage in which the infiltrations 
were too small to cast recognizable shadows. Although this query does 
not admit of a positive answer, experiment has thrown some light on it. 
It has been determined that an area of infiltration, situated near the 
surface of the lung must be at least 4 mm. in diameter in order to cast a 
distinctive shadow on the plate. The more deeply seated the diseased 
area, the less clearly will it be perceived. 
Obviously, a solitary miliary tubercle, assuming that it may usher 
in the disease, cannot be recognized as such on the plate; if it casts a 
shadow at all it will not be distinguishable from the shadows of bifurcat- 
ing or intersecting blood vessels which contribute to the normal mottling 
of the lung. It may be taken for granted therefore that it is possible for 
a tuberculous focus to exist, which is so small as to escape discovery by 
the Roentgen Ray. Tuberculosis of the lungs offers no exception to the 
rule that diseases are never discovered in their very incipiency by the 
clinical means at our disposal. A latent period intervenes during which 
the foci of the disease increase in size and activity until they make 
themselves clinically evident. 
It is questionable, however, whether in actual practice this circum- 
stance seriously affects the value of the Roentgen examination. In the 
first place, as we have stated, the earliest deposit of tubercles is fre- 
quently associated with a surrounding pneumonia which measurably 
increases the area of infiltration. A more practical consideration is the 
fact that during its incubation the symptoms of the disease are apt to 
pass unrecognized by the patient and for this reason, the question of 
diagnosis, whether clinical or Roentgenological, does not arise. It is 
our experience that when pulmonary tuberculosis is of sufficient extent 
to produce clinical symptoms, it is already susceptible of Roentgen 
demonstration. The Lungs 
69 
The Roentgen Ray has disclosed the interesting fact that the earliest 
evidences of the disease are less often found in what is clinically known 
as the apex of the lung than in the infraclavicular region. Further- 
more, the axillary half of the lung is more apt to be involved in the 
beginning than the mesial half. (Fig. 28.) 
THE LOCATION OF THE EARLIEST LESIONS 
Incipient tuberculosis, right infraclavicular region. This is the earliest recognizable type 
of tuberculosis. This is also the most frequent site for the beginning of the disease. 
FIGURE 28 
The bearing of these facts on the clinical diagnosis of incipient 
lesions is an important one as it throws some light on the discrepancies 
so often found between the physical and the Roentgen examination. In 
looking for rales or breathing changes the clinician customarily devotes 
most attention to the extreme apex of the lung. If perchance the 
tuberculous process is situated at the apex, he will be successful in his 
search. On the other hand, in a large percentage of early cases, the 
infiltrations occupy exclusively the infraclavicular region and abnormal 
physical signs are accordingly absent at the apex. But they are also 
frequently absent below the clavicle because the transmission of 
adventitious sounds is hindered by the pectoral muscles. It therefore 
happens that the large group of cases in which the infiltrations first 
make their appearance in the infraclavicular region are unrecognized 
by the clinician for some time. In these patients physical signs may 
come to light only later when the process has extended to the apex. In 
other words, a process which may clinically involve only the extreme 
apex and therefore seem to be incipient, is often found by the Roentgen- 
ologist to involve also the infraclavicular region and therefore to be 
moderately advanced. 
Unlike the physical examination, the Roentgen plate enjoys a dis- 
tinct advantage in the diagnosis of infraclavicular lesions. In this 
region, far removed from the complicated shadows at the root of the 70 
The Lungs 
lung, the pulmonary fields have an almost homogeneous texture, as 
the arborizations of the small vessels are almost invisible. Infiltrations 
in the lung can therefore easily be recognized as they stand out against 
the background of aerated lung. This is not true to the same degree 
of shadows in the mesial half of the lungs. The presence near the pul- 
monary hilum of the larger blood vessels and of masses of lymphoid 
tissue which may be enlarged by disease, may render a distinction be- 
tween the normal markings and pathologic deposits difficult. For this 
reason, the Roentgenologist will have to exercise caution in the inter- 
pretation of the nodular shadows which he will frequently see in the 
mesial half of the lungs. If there is no evidence of tuberculosis at the 
sites of selection which we have indicated, he will wisely err on the 
side of caution and regard the questionable shadows as due to dis- 
tended blood vessels and lymphatics. Although a rule of this sort may 
be considered arbitrary, it is sanctioned by experience which teaches 
that isolated tuberculosis of the mesial part of the lung is uncommon, 
whereas involvement in other locations is the rule. 
In very rare cases the first evidence of tuberculosis may be found in 
the lower part of the upper lobe or even in the lower lobe. We shall 
see in a subsequent discussion that this unusual site of the disease is 
not uncommon in infants and in children. In adults, it is undoubtedly 
among the rarities and clinical investigation of such cases will often 
bring to light some underlying local or systematic condition which has 
favored the unusual location of the tuberculous process. 
IS THE ROENTGEN APPEARANCE OF TUBERCULOSIS TYPICAL 
OF THIS DISEASE? 
The Roentgenologist is often asked whether the abnormal shadows 
which we have described are characteristic of tuberculosis and whether, 
based on them alone, we are warranted in diagnosing this disease. May 
not such shadows be cast by pathological processes other than tubercu- 
losis? 
Strictly speaking, a single shadow or a group of shadows has no 
intrinsic tuberculous character. Any inflammatory deposit or even a 
neoplasm, may cast shadows which occasionally similate those of 
tuberculosis. In exercising his judgment therefore, the Roentgenologist 
must take into account such facts in the clinical history of the case and 
in the pathology of lung diseases which will help him to exclude causes 
for the abnormal shadows other than tuberculosis. We may accept it 
as a cardinal rule however, that infiltrations in the apical and infra- 
clavicular regions are tuberculous, especially if they are small, nodular, 
and occur in groups. The exceptions to this rule are few and, in practice, 
unimportant. For example, occasionally a resolving pneumonia of an 
upper lobe may leave a residuum of infiltration at the apex which, in The Lungs 
71 
the size and arrangement of its shadows may resemble an early 
tuberculous process. The clinical symptoms may or may not be of help 
in distinguishing between the two conditions. Obviously, the ultimate 
decision may have to wait on a subsequent examination after complete 
resolution, which will involve a delay of several weeks, at the most. 
Again, an early metastatic new-growth, especially when it is soli- 
tary, may closely resemble an incipient tuberculosis or a tuberculous 
infiltration may simulate a new growth. (Fig. 29.) Error can usually 
Circular infiltrations of tuberculosis resembling metastatic tumors. 
FIGURE 29 
be avoided by the clinical examination which will discover a primary 
growth and also by a later increase in the size and number of the 
metastases. In these cases the Roentgen examination should be 
repeated after a suitable interval in order to determine a significant 
change in the shadows. It is scarcely necessary to point out that in 
doubtful cases the Roentgenologist should no more be denied the 
opportunity to check up his findings, than the clinician. 72 
The Lungs 
ASSOCIATED CHANGES IN THE CHEST IN INCIPIENT 
TUBERCULOSIS 
A complete Roentgen examination in cases of suspected tubercu- 
losis should always include a preliminary fluoroscopy. Although the 
screen findings in incipient cases are rarely decisive by themselves, they 
may be suggestive and in the case of doubtful plates, they may be cor- 
roborative. 
In the first place, fluoroscopy is better adapted for the determina- 
tion of a slight deficiency in the aeration of an apex which is a com- 
mon accompaniment of early lesions. In the interpretation of such a 
deficiency, the various causes for it must be kept in mind. The air con- 
tent of an apex may be diminished and the apex may therefore, appear 
less illuminated because of actual infiltration which reduces the amount 
of aerated lung. In cases of this type the apex remains darker even 
after deep breathing and after coughing. Such a persistent atelectasis 
is therefore strongly suggestive of actual disease of an apex, a pre- 
sumption which will often be corroborated by a positive plate finding. 
It should however be remembered that the same phenomenon may be 
observed in the case of healed lesions at an apex with thickening of the 
pleura or with fibrosis and retraction. As such healed lesions are very 
common in otherwise healthy individuals, the value of a unilateral 
diminution in areation is very much restricted. An atelectasis may 
moreover have other causes than actual infiltration. A small deposit 
at an apex, by reflex inhibition may restrict the movement of the upper 
chest and therefore interfere with its ventilation. In these cases, the 
lung can be caused to clear up by deep breathing or coughing. 
A slight diminution in the aeration of an apex can only be gauged 
by a comparison with the other side. In case both sides appear darker 
than the normal, there is no longer a standard for comparison and any 
judgment as to aeration should be made with caution. There are 
numerous causes, aside from tuberculosis, which may obscure the apices. 
Some of these have no relation to their air content, such as fat deposits 
in the supra-clavicular region or excessive muscular development and 
an unusual conformation of the bony thorax. Cervical ribs, calcifica- 
tion of costal cartilages or over-lapping of the sternal ends of the 
clavicle and the ribs may entirely obscure the apices. Again, some 
individuals habitually under-aerate their apices; this occurs especially 
in mouth breathers in whom the so-called collapse atelectasis is found 
at both apices. It will be seen that the fluoroscopic finding of a dimin- 
ished aeration, either on one or both sides, has a limited value; 
ultimately, the Roentgen diagnosis of tuberculosis must be based on a 
positive plate finding. The Lungs 
73 
A corroborative sign of apical tuberculosis is immobility of the 
diaphragm on the affected side. This occurs in a large percentage of 
early cases and in conjunction with a cloudy apex, creates a strong 
presumption of recent disease. The reason for this immobility is not 
quite clear. It is evidently not a paresis of the diaphragm because the 
latter is not found in the expiratory position as in cases of acute pleurisy 
or pneumonia. The diaphragm appears rather to be in a condition of 
tonic contraction; it is normal or low in position and the immobility may 
perhaps be best explained as a reflex rigidity similar to that of the 
intercostal and pectoral muscles in the vicinity of the apical process. 
A number of other abnormalities are to be noted in the chest of 
cases of early tuberculosis which have no direct bearing on the apical 
disease itself. It is not uncommon to find evidences at the extreme 
apices of a previous lesion which has resulted in retraction and 
scarring and it is important in interpreting the plate, not to assign an 
undue importance to these changes. 
The same observation may be made in regard to the enlarged lymph 
nodes at the roots of the lungs. A more detailed discussion of these 
will be reserved for a later chapter. It will suffice, for the moment, to 
point out that enlarged, calcareous and caseous regional nodes are an 
almost regular accompaniment of pulmonary tuberculosis. Their size 
however bears no significant relation to the extent or nature of the in- 
filtrations in the lungs. Tuberculous bronchial lymph nodes are so 
commonly present in otherwise healthy individuals that their discovery 
by the Roentgen examination has no clinical significance and they 
should therefore bear no weight in our estimate of the case. 
THE PROCESS OF HEALING IN INCIPIENT TUBERCULOSIS 
Tuberculosis of the lungs has an inherent tendency to become 
quiescent and ultimately to heal. It is natural therefore to inquire into 
the changes, if any, which take place in the Roentgen shadows of this 
disease when the process has become arrested and is going on to cure. 
If we observe a group of infiltrations which are undergoing involu- 
tion, the first change noted will be a disappearance of the inflammatory 
zone about them, which has given the shadow its ill-defined outline. 
The shadows therefore acquire a sharper, more definite contour. Fre- 
quently also, they become denser owing to partial caseation of the 
tubercles. An illustration of these changes is seen in figure 30. There 
may further be a progressive decrease in the size of the shadows which 
ultimately are barely visible. (Fig. 31.) It must be borne in mind that 74 
The Lungs 
FIGURE 30 
Healing of tuberculosis. On left side, below the clavicle is seen an area of fibrosis which 
has completely replaced the tuberculous infiltrations. On the right side, the individual tubercles 
can still be made out. They are however acquiring the sharpness of outline preceding fibrosis. 
this transformation is very gradual, requiring usually years before it 
is completed, during which period the alteration in the shadows is im- 
perceptible. It is probable moreover, that only the smallest incipient 
lesions are capable of complete disappearance; more extensive infiltra- 
tions practically always leave in their wake distinct evidence of their 
previous existence, which is due to the introduction of two new elements 
in the healing process, namely, fibrosis and calcification. The Lungs 
75 
FIGURE 31 
Healing tuberculosis. Absorption of early infiltrations without fibrosis. The shadows at 
right apex are exceedingly faint and small. 
The development of fibrous tissue offers us the clearest evidence 
of healing of the disease. We may find it as a fine or coarse network 
which is woven into the infiltrated area or after the absorption of the 
latter, it may entirely replace the tuberculous tissue. We may graphic- 
ally trace the transition from infiltrations to pure fibrosis by observing 
a series of plates of different individuals in which all the phases of this 
process are represented. Figures 27, 32 and 33 portray the earliest 76 
The Lungs 
FIGURE 32 
Mealing of early tuberculous infiiltration in left upper lobe. The shadows are more sharply 
defined and elongated, indicating begnning fibrosis. The Lungs 
77 
Healing tuberculosis at right apex. Shadows are sharply defined and dense. 
FIGURE 33 
stages of fibrosis. The infiltrations lose their distinctness and merge 
into one another; they are elongated and assume the radial disposition 
of the lung markings, from which however, they can be readily dis- 
tinguished. A later stage of the same process is seen in figure 30 where 
the individual infiltrations below the left clavicle are no longer visible 
because they lie in a coarse network of fibrosis which is strictly local- 78 
The Lungs 
FIGURE 34 
Fibrous network of healed tuberculosis in left infra clavicular region. See figure 34a. 
ized to a small area. A similar process is beginning to take place on 
the right side. The complete metamorphosis of the lesion, consisting 
of its entire replacement by fibrous tissue is well shown in figures 34, 
34a, 35 and figure 36. In the last, only a sigle linear strand of scar The Lungs 
79 
FIGURE 34a 
Left apical region of fig. 34, natural size, showing development of 
fibrosis in a small tuberculous infiltration. (Arrow) 80 
The Lungs 
FIGURE 35 
line fibrosis of healed tuberculosis in right infraclavieular region. The Lungs 
81 
FIGURE 36 
Fibrous strand of healed tuberculosis in left upper lobe. (Arrow.) 82 
The Lungs 
tissue extends across the upper left chest from the root to the axilla. At 
times a complicated mosaic may be produced from the interlacing of 
great numbers of connective tissue strands. (Fig. 37.) 
FIGURE 37 
Fibrous tissue at left apex producing a unique network of shadows. 
In figure 38 we may observe the healing of a more extensive apical 
process by a coarse fibrosis. The arrangement of the fibrous strands 
usually conforms in direction to that of the lung markings. In the 
extreme apex the network is disposed vertically whereas in the lower 
part of the upper lobe it is oblique or horizontal. The Lungs 
83 
FIGURE 38 
Fibrosis of healed tuberculosis at right apex. 
The fibrous strands of healing incipient deposits as they have been 
thus far illustrated, are coarse and arrange themselves in a well defined 
network, usually limited to a small area in an upper lobe. There is 
another form of fibrosis in which the lung is over-laid by a fine veil- 
like network whose strands are so tenuous as to be almost invisible. This 
may be seen in the lower part of the right upper lobe in figure 39 where 
the increased density of this part of the lung becomes obvious only by 
comparison with the opposite, normal lung. It is probable that a net- 
work of this type is due both to a fine fibrosis and to a condensation of 
the lung brought about by obliteration of a number of air vesicles. 84 
The Lungs 
FIGURE 39 
Fibrous network in lower part of right upper Thickening of interlobar fissure. 
A very unusual manifestation of the healing process is illustrated 
in figure 40. At the left apex there is a fine network whose vascular 
nature is so apparent that it requires little effort to believe that the 
tuberculous process has resulted in an obstruction to the small pul- 
monary veins or lymphatics whose distention is responsible for the 
unique Roentgen picture. Here we are leaving the realm of fact for that 
of conjecture yet we cannot without comment pass by so striking an 
appearance, even though we can only surmise its meaning. The Lungs 
85 
FIGURE 40 
Vascular network at apex probably secondary to healed tuberculosis. 
Of course the fibrosing deposits of early tuberculosis may be 
associated in the same case with other infiltrations in various stages of 
regression or advance. Thus in figure 41 we may observe in the one 
plate not only the process of healing characterized by sharply circum- 
scribed shadows of calcified tubercles and fibrosis but also an irruption 
of recent miliary and sub-miliary tubercles. 
Besides fibrosis, calcification of the infiltrations affords us the clear- 
est evidence of cure of the disease. Usually deposition of lime is but 
an incident in the course of a tuberculous process which is progress- 
ing elsewhere in the lung. (Figure 41.) Less often a tuberculous 86 
The Lungs 
Coincidence of calcified tuberculosis in left lung with recent pneumonic tuberculosis at 
right apex. 
FIGURE 41 The Lungs 
87 
infiltration undergoes calcification in its entirety. The Roentgen 
shadows are then unmistakable in their denseness and irregularity. 
(Fig. 41a and Fig. 42.) Bizarre shadows as in figure 43, due to massive 
lime deposits are very uncommon. 
FIGURE 41a 
Healed tuberculous bronch-pneumonia, showing disseminated calcified infiltrations. 
Scar at right apex. 88 
The Lungs 
Calcified apical tuberculosis. 
FIGURE 42 The Lungs 
89 
FIGURE 43 
Calcified tuberculosis. 
We must finally discuss certain shadows which are often found 
at the extreme apices of both healthy and clinically tuberculous individ- 
uals, which have the greatest significance for the diagnosis of healed 
apical lesions. The healing of an apical tuberculosis is often followed 
by a decrease in the volume of the apex, due either to atelectasis or to 
fibrosis of the lung and pleura or to both. In the average individual, on a 
properly exposed plate, aerated lung may be seen as high as the lower 
border of the second rib posteriorly. (Fig. 44.) With a diminution in the 
volume of the apex from any cause, the upper limit of the lung is found 
at a variable distance below its usual situation and the soft tissues at the 
root of the neck and the subclavian vessels descend and cast a shadow 90 
The Lungs 
Appearance of normal apices, showing the upper limit of aerated lung. 
Dorso-ventral view. 
FIGURE 44 
which traverses the apex parallel to, and just below, the second rib. 
(Fig. 45.) Such a retraction of the apex is of significance only when 
FIGURE 45 
Retraction of apices with healed tuberculosis. Fibrous strands dipping down from apical 
pleura into lung, on right side. The Lungs 
91 
it is unilateral. When it is found on both sides, its value for diagnosis 
is limited by its frequent occurrence in individuals who under-ventilate 
their lungs, either from habit or as a result of nasal obstruction. 
A retraction of the apex is often associated with strands of con- 
nective tissue which extend downward from its surface into the par- 
enchyma. (Fig. 45.) In figures 46 and 47 are illustrated other forms 
FIGURE 46 
Retraction and scarring of both apices 
FIGURE 47 
Chronic apical tuberculosis. Vertical scar at right apex. 92 
The Lungs 
of apical fibrosis. Another cause of apical induration is a thickening of 
the pleura, which gives rise to dense homogeneous shadows which 
obscure the apices. Thus in figure 48 the entire left apex is clouded 
FIGURE 48 
Fibrosing process in left upper lobe with thickening of apical pleura and irregular re- 
traction of the apex. 
by a thick pleura whose lower margin presents a unique crenated 
border. Here the apical disease is combined with a fibrosing process 
below the clavicle. In figure 49 there is a marked induration of the 
extreme right apex. The Lungs 
93 
FIGURE 49 
Fibrosis and retraction of the right apex by old tuberculosis. 
The frequent finding of retracted and scarred apices without 
evidence of tuberculosis elsewhere in the lungs lends some support to 
the belief that in some of these cases the infection is derived from 
the cervical lymphatics and runs its course primarily in the apical 
pleura rather than in the lung. We may thus explain the entire 
absence of symptoms of antecedent pulmonary disease in many of these 
cases. 
We may profitably dwell for a moment on the clinical significance 
of retracted or scarred apices especially in respect to the diagnosis of 
active lesions. These apical changes are so often found in healthy in- 
dividuals that no clinical significance attaches to them. However, in a 
number of patients whose apices show the marks of past tuberculous 
infection, rales are occasionally heard and it becomes a matter of 
importance to determine whether these rales indicate an active process 
or not. 
Of course, in resolving this question, the clinician is governed not 
alone by the physical signs but also by the clinical signs of activity. 
The significance of apical rales taken by themselves may easily be 
exaggerated. We have thus found in many cases, in which rales were 
heard at the apices, nothing more than the retraction and induration of 
an old tuberculous process and it is fair to assume that these rales were 
not any evidence of activity but were a result of atelectasis or of inflam- 
matory processes other than tuberculosis. We have, on the other hand, 
found that whenever rales at the apices are due to an active, recent 
tuberculosis, the infiltrations which we have described as characteristic 
of early tuberculosis are present in the apices of the lungs. 94 
The Lungs 
THE EVOLUTION OF THE TUBERCULOUS PROCESS FROM 
ITS INCIPIENCY 
The diagnosis of diseases in terms of pathologic changes in particu- 
lar organs is the goal toward which the true clinician bends his efforts. 
Each advance in the art of diagnosis is accomplished by a widening of 
our knowledge either of the abnormalities of function or of the structure 
of diseased tissues. To this rule the Roentgen Ray is no exception and 
it has measurably enriched our knowledge of the gross changes that 
occur in the lung when it is infected by the tubercle bacillus. 
It is not unnatural for the Roentgenologist who is confronted with 
the great diversity of shadows seen on the plate in cases of pulmonary 
tuberculosis, to seek a correlation between them and the morbid changes 
in the lungs with whose pathology he is already familiar. He will not 
be content with the mere knowledge that the lungs of a patient he has 
examined contain infiltrations; he will endeavor to ascertain more pre- 
cisely the nature of these infiltrations and to bring their multiform 
shadows into relation with definite pathologic processes. 
When we pass from a consideration of incipient tuberculosis to 
the manifold forms of the disease which result from its gradual or 
rapid extension, we become aware of an alteration in the appearance 
of the shadows which is dependent on a change in the inflammatory 
reaction in the lungs. These reactions, comprising three distinct patho- 
logic types, namely, the proliferative, the exudative and the fibrous, are 
registered on the plate in a manner which is more or less distinctive. 
The proliferative form of tuberculosis we have already encountered 
in our discussion of incipient disease. Its prototype is the tubercle, 
whether miliary or conglomerate and it manifests itself on the plate 
as a small, faint, nodular shadow of varying size, which is often sur- 
rounded by a pneumonic zone. 
The exudative form is represented by the acute inflammatory reac- 
tion of a specific nature which is commonly associated with a rapid 
dissemination of the disease. Its shadows are dense and homogeneous, 
often involving large areas of the lung. In distribution it may be 
lobular or lobar, or coalescence of smaller infiltrations may result in 
a pseudo-lobar infiltration. It probably accompanies to a slight degree 
most cases of the proliferative type but it may exist alone as an exudate 
in the air vessicles with no evidence of tubercle formation. Although 
in occasional cases it is susceptible of resorption, it is usually the pre- 
cursor of caseation and cavity formation and is ominous in its import. 
We shall note its presence wherever there is a widespread dissemina- 
tion of the tubercle bacillus or its products, either through the circula- 
tion or by way of the bronchial tree. The Lungs 
95 
The third type of tuberculous tissue is the fibrous, which repre- 
sents its indurative or healing form. Evidence of it as fine, interweaving, 
linear shadows may be met with in even early lesions. It is to be seen 
to some extent in the plates of all but the most acute forms of tubercu- 
losis, such as the miliary and acute tuberculous pneumonia. In the more 
chronic cases, fibrous tissue will be associated with evidence of destruc- 
tion of the lung parenchyma such as caseation and cavity formation. It 
then appears usually as dense bands of scar tissue or as coarse strands, 
the results of whose contraction will be noted in a retraction of the lung, 
displacement of the thoracic viscera and deformity of the bony thorax. 
Two important secondary changes in tuberculous infiltrations re- 
main to be described, namely, caseation and calcification. The former 
especially exerts a marked influence on the types of shadows which are 
produced; it manifests itself by an increase in their density and in the 
case of the proliferative lesions, by an added definiteness of outline. 
The dense, homogeneous shadows of lobar and confluent lobular pneu- 
monia are partly at least, the result of caseation. Calcification of 
tuberculous infiltrations is always an indication of chronicity and may 
be looked upon as the best evidence of healing or of a tendency to it. 
The shadows are circumscribed, very dense and irregular. Lime 
deposits may present the only vestige on the plate of a previous tubercu- 
lous process; more often, however, they are found in conjunction with 
evidences of more recent disease and we will occasionally encounter 
foci of calcification within an area of pneumonic tuberculosis. 
MODERATELY ADVANCED TUBERCULOSIS 
We are now prepared for a consideration of moderately advanced 
tuberculosis as it is revealed to us on the Roentgen plate. It will be 
found in practice that few patients come under observation during the 
early stage of the disease which we have already described. It is 
probable that in a great many, this period of minimal infiltration is 
unassociated with any distinctive symptoms or physical signs and that 
it goes on unnoticed to quiescence and cure. That this is so and that 
the particular manifestation of the infection which brings the patient 
to the physician’s attention is often not the first invasion of the disease 
is attested by the frequent discovery, side by side with a recent infiltra- 
tion, of a healed lesion elsewhere in the lungs. Thus in figure 50, the 
area of pneumonic tuberculosis in the right upper lobe was directly 
responsible for the patient’s symptoms and physical signs, yet in the 
opposite apex and infraclavicular region there are unmistakable signs 
of a calcified tuberculous infiltration which was in process of cure, and 
which had never given rise to any symptoms. 96 
The Lungs 
Exudative tuberculosis of right lung with evidences of old, calcified lesions in both upper lobes. 
FIGURE 50 
It therefore happens that in many patients who for the first time 
present symptoms and signs of tuberculosis, we already find so con- 
siderable an area of infiltration in an upper lobe, that, from the Roent- 
gen viewpoint at least, it is no longer permissible to regard them as 
incipient cases. The shadows which characterize this stage of the 
disease are in general similar to those of the earliest process, except 
that they are of greater extent and are apt to be denser and more irregu- 
lar owing to beginning fibrosis or caseation. Figures 51, 52, 53 and 54 
illustrate only a few of the many forms which these moderately ad- 
vanced cases may assume. The Lungs 
97 
FIGURE 51 
Pneumonic type of tuberculosis, with signs of moderate fibrosis in upper lobe. Heart and 
mediastinum drawn to right. Adhesion of mesial part of right diaphragm. 98 
The Lungs 
FIGURE 52 
Apical tuberculosis; disease is moderately advanced, showing denser shadows of caseation. The Lungs 
99 
FIGURE 53 
Acute pneumonic type of tuberculosis; old cavity at left apex. 100 
The Lungs 
Moderately advanced tuberculosis. 
FIGURE 54 The Lungs 
101 
It is of interest to inquire into the manner in which these moder- 
ately advanced infiltrations arise in the lung. It is unlikely that they 
are evolved by a gradual extension of the small deposits of incipient 
tuberculosis because the latter exhibit a marked constancy in size when 
observed over extended periods and do not appear to increase in size 
by peripheral growth. It is more probable that from the beginning the 
disease is of greater extent, a small initial focus being rapidly con- 
verted into a large one by an irruption of tubercle bacilli into the bron- 
chial tree or into the circulation. We are confirmed in this conjecture 
by the appearance of the Roentgen shadows, which often indicate the 
operation of a more acute exudative process. 
THE ROENTGEN FINDINGS OF ADVANCED TUBERCULOSIS 
The transition from tuberculosis of moderate extent to the more 
advanced forms in which larger areas of the lungs are brought under 
the influence of the disease, brings us face to face with an embarrassing 
wealth of material which taxes the power of description. We will find 
it both necessary and advantageous to depart from the traditional 
classification of Albrecht and Turban because they cannot be made to 
harmonize with the Roentgen findings and also because the latter will 
speak to us in a manner which is more picturesque and instructive. 
As we have already pointed out, the spread of tuberculosis in the 
lungs is accomplished only to a limited degree by a gradual extension 
peripherally. The major strides of the disease are usually made in a 
more rapid fashion and their effects may truly be described as 
catastrophic; a patient who today harbors only a small focus in an apex, 
may on the next day be seized in the throes of a fatal infection. The 
means by which this is brought about are the following: (1) hem- 
orrhage, by means of which previously uninvolved areas of the lung 
become inundated with blood, containing tubercle bacilli; (2) a similar 
dissemination of tuberculous pus through the bronchi; (3) metastatic 
invasion by way of the pulmonary blood vessels and lymphatics. 
The inflammatory reaction which results from the deposit by these 
means of large numbers of tubercle bacilli or their toxic products in 
previously healthy lung tissue, is usually an acute one and is mani- 
fested as an acute tuberculous pneumonia, which may be lobular or 
lobar in distribution. We are dealing here no longer with a pathologic 
process whose normal tendency, as in the apex, is toward fibrosis but on 
the contrary with one which is prone to undergo caseation and softening 
and to form cavities. 
When we therefore analyze the Roentgen shadows in cases of 
advanced tuberculosis, there will always be noted at one or both apices 
evidence of the original process from which the more recent acute 102 
The Lungs 
infiltrations have been derived. The former is often in a condition of 
partial fibrosis and frequently discloses a smaller or larger cavity sur- 
rounded by infiltrations. The shadows of more recent involvement of 
the lung will then be found in more remote regions in the upper or in 
the lower lobes, either on one side or on both. 
A simple illustration of the evolution of advanced tuberculosis may 
be seen in figure 55. In the right upper lobe, there is a cavity which 
has probably existed for some time. We see also in the left upper lobe, 
FIGURE 55 
Advanced tuberculosis. Disseminated tuberculous broncho-pneumonia secondary to cavity 
in right upper lobe. The Lungs 
103 
undoubtedly due to a more recent involvement, a disseminated lobular 
pneumonia, the shadows of which are indistinct in outline and show 
evidence of fibrosis. Again in figure 56 we may observe the pernicious 
effect of pulmonary hemorrhage. This patient, a young woman, was 
for some time affected with an apparently benign apical process of small 
extent. Shortly before she came under observation, she had a large 
hemoptysis which was followed by a long period of acute illness. We 
Acute tuberculous broncho-pneumonia with confluence of the infiltrations at right base. 
Secondary to hemorrhage from an incipient lesion at apex. 
FIGURE 56 104 
The Lungs 
see graphically on the plate the disseminated broncho-pneumonia in the 
upper lobe and the dense shadow of a confluent pneumonic process, 
which is probably undergoing caseation, at the base. At a stroke, 
through a complication of a minor tuberculous process, this patient 
became acutely ill and emerged from her malady a hopeless invalid. 
The acuteness of the infection is in a measure reflected in the type 
of infiltration on the plate. The shadows are dense and flocculent, hazy 
in outline and irregular in shape and within some of them we can 
already see small circular defects, due to beginning softening and cavity 
formation. These small cavities are commonly not visible in the lower 
lobes, as they are obscured by the dense overlying infiltration; yet under 
favorable conditions when there is a preponderance of softening, they 
may come to light in great numbers and they will then impart a moth- 
eaten appearance to the lung. (Fig. 78.) The larger cavities which 
are associated with fibro-caseous tuberculosis result from the breaking 
down of extensive areas of pneumonia and they may excavate a whole 
lobe or an entire lung. (Fig. 64a.) 
The extent of the pneumonic reaction which immediately follows 
a hemorrhage or the diffusion of purulent secretions from the bronchi, 
does not always afford a just estimate of the permanent damage to the 
lung. After a short interval there will often be noted a decrease in 
the size and density of the infiltrations which must be attributed to a 
resorption of a part of the exudate. In fact there are occasional cases, 
to which we shall refer later, in which the exudate is of such a char- 
acter, that caseation does not set in but complete resorption occurs. 
In this form of pneumonia, which is often associated with the overflow 
of the contents of an apical cavity, very few tubercle bacilli may be 
found and the pathologic process may be regarded as a reaction to the 
toxic products of the tubercle bacillus rather than to the micro-organ- 
ism itself. 
The Roentgen plate depicts not only the acute process which is 
running its course at that particular time but registers also the effects 
of previous similar invasions of the disease. Tuberculous lobular, or 
broncho-pneumonia does not invariably go on to softening. The disease 
may become quiescent or caseation may progress slowly hand in 
hand with fibrosis so that the clinical picture of fibro-caseous phthisis is 
evolved. Meanwhile another accession of pneumonia may extend the 
process elsewhere in the lungs. We may observe this progression in 
figure 57. The right upper lobe presents the typical picture of a chronic 
fibro-caseous tuberculosis with a large cavity at the apex. We can 
dimly see the horizontal strands of fibrous tissue; the marked reduction 
of this lobe to at least one-half its former size is apparent. We perceive 
here the evidence of an old pneumonic process in which the elements 
of healing and destruction are contending with each other. At the The Lungs 
105 
Disseminated lobular (broncho-) pneumonia, secondary to chronic fibro-caseous process in 
right upper lobe. Note shrinkage of right upper lobe as a result of fibrosis. 
FIGURE 57 
same time, in contra-distinction to this, there is revealed in the left lung 
a more recent, extensive lobular pneumonia, which no doubt owes its 
origin to the older process on the right side. 
A study of these advanced forms of the disease which we have 
illustrated cannot fail to impress the observer with the menace of an 
unhealed apical lesion and the unfortunate consequences to the patient 
which result from its activity. It would, however, present our subject 
in an altogether too gloomy light, were the results of a rapid extension 106 
The Lungs 
of the morbid process conceived as leading invariably to a hopeless 
issue. There is ample proof that in many cases the reaction in the lungs 
following a dissemination of the disease, may be a relatively mild one 
in which proliferative processes may dominate the exudative and 
necrotic. We are dealing here with the delicate balance between the 
virulence of the tubercle bacillus on the one hand and the local tissue 
resistance on the other, in regard to which we can only speculate. The 
fact remains, however, that in numerous cases of even widespread 
disease, the plates show considerable evidence of absorption of the 
FIGURE 58 
Bilateral upper lobe tuberculosis showing marked tendency to fibrosis. The Lungs 
107 
broncho-pneumonic areas and of different grades of fibrosis. Figure 
58 illustrates a common Roentgen type in which both upper lobes and 
at times the lower lobes, show marked signs of fibrosis, in spite of the 
presence of an extensive broncho-pneumonic tuberculosis. Such patients 
may remain in good health under favorable conditions for many years, 
with all the clinical signs of a complete arrest of activity. We may 
therefore in some cases speak of a true chronic lobular or broncho- 
pneumonia in which the interplay of the conservative and destructive 
influences in the lung is so evenly adjusted that the progress of the 
disease is almost imperceptible. An instructive instance may here be 
cited. 
FIGURE 59 
Chronic miliary tuberculosis in a diabetic, of at least five years duration. See fig. 60. 108 
The Lungs 
A middle aged diabetic woman had suffered for several years with fibrinous bronchitis 
which was apparently the only manifestation of her pulmonary disease. The Roentgen exam- 
ination, figure 59, showed an extensive tuberculous process, sub-miliary in type, which in- 
volved both lungs from apex to base. The infiltrations were fairly distinct and closely studded 
and an immediate impression of a rapidly fatal tuberculosis was created; yet, six years later 
this patient was still alive and in satisfactory health. As a more recent plate illustrates, (fig. 
60), the areas of lobular or broncho-pneumonia had to a great extent been absorbed or replaced 
by fibrous tissue and at the same time a slow disintegration had occurred at the apices where 
two cavities were formed. Yet this destructive process progressed so insidiously that at no 
time has she been acutely ill or had other than minor pulmonary symptoms. 
FIGURE 60 
Same case as fig. 59 six years later, showing disseminated fibrosis and formation 
of apical cavities. The Lungs 
109 
FIBRO-CASEOUS AND FIBROID TUBERCULOSIS 
The ultimate outcome of advanced tuberculosis, as far as the 
integrity of the lungs is concerned, is determined by the constant activ- 
ity of two opposed processes, namely, caseation and fibrosis. This con- 
flict is often protracted over many years, during which the opportunity is 
given us to observe on the Roentgen plate a series of variegated pic- 
tures. At one end of the scale we observe the predominantly caseous 
form of the disease, at the other, the purely fibroid type and between 
them all gradations of each. In figure 61 is illustrated a typical example 
of a fibro-caseous process. The disease involves the entire left lung 
FIGURE 61 
Chronic fibro-caseous tuberculosis with cavities. Contraction of left chest and 
displacement of heart and mediastinum to left. no 
The Lungs 
in a massive consolidation in which there are distinct signs of multiple 
cavitation. The fibrosis is manifested in the usual way by shrinking of 
the chest and displacement of the heart and mediastinum to the left. 
As is usual in these cases, there is also an involvement, though slight, 
of the other lung. In figure 62 we may observe a greater degree of 
fibrosis associated with caseation. The remarkable diminution in the 
size of the right lung at once arrests attention; it is roughly one-half 
the volume of the left. The trachea and mediastinum are drawn over 
to the right side by adhesions which have also involved the phrenic 
nerve. The paralysis of the latter is responsible for the abnormally 
high diaphragm which further reduces the volume of the chest. Again 
in figure 64a fibrosis has extensively involved the right lung and has 
induced a marked derangement of all the thoracic viscera. In this case, 
however, caseation and softening have kept pace with the fibrosis, with 
the result that almost the entire right lung is excavated by irregular, 
trabeculated cavities. 
FIGURE 62 
Chronic fibro-caseous tuberculosis. Note decrease in volume of right chest and 
displacement of heart and mediastinum. Right diaphragm in paralytic position. The Lungs 
111 
Of course, fibro-caseous tuberculosis may involve only a restricted 
area of the lung, such as an upper lobe and it may thus persist for years, 
presenting the common clinical picture of chronic bronchitis with 
seasonal exacerbations. Often these patients acquire a secondary 
emphysema, the physical signs of which may completely mask the 
underlying tuberculosis and we are then apt to find such a Roentgen 
picture as figure 63. Here belongs the so-called asthmatic form of 
FIGURE 63 
Dense fibro-caseous tuberculosis of right upper lobe with cavity. Recent tuberculosis 
in right lower and left upper lobes. 112 
The Lungs 
tuberculosis in which, especially in older individuals, an indurative 
process at the apices, which is often latent, is probably the cause of both 
bronchitis and asthma. (Fig. 64.) 
Chronic fibro-caseous tuberculosis at the apex is also responsible 
for the numerous cases of a solitary cavity in this situation which is 
surrounded by a dense fibrous capsule. 
FIGURE 64 
Chronic fibroid tuberculosis of both upper lobes. 
Although pure or nearly pure fibrosis occurs in localized areas in 
the various forms of tuberculosis we have described, a disseminated 
pure fibrosis is one of the rare manifestations of the disease. It is true 
that an extensive fibrosis may develop in the process of healing of a 
tuberculous broncho-pneumonia, yet it is nearly always combined with The Lungs 
113 
Chronic fibro-caseous tuberculosis with extensive excavation of right lung. Recent process 
in left lung, thickening of pieura, displacement of mediastinum and thoracic asymmetry. 
FIGURE 64 a 114 
The Lungs 
the evidences of a more acute process. Therefore, when we speak of 
fibroid tuberculosis, we do so to indicate a preponderating tendency to 
the formation of fibrous tissue and in this sense, figure 65 may well 
illustrate this tendency. The entire lungs are here interwoven with a 
network of more or less linear shadows through which may be dimly 
discerned the nodular infiltrations of a less chronic process. It will be 
noted that in this case there is also a large irregular cavity, which 
Disseminated pure fibrosis. Large eavity in left apex, 
FIGURE 65 
occupies the entire left apex and is probably responsible for a constant 
re-infection of the lung. In figure 66 a wide-spread coarse fibrosis is 
associated with other evidences of a chronic lesion, consisting of calcifi- 
cation of multiple broncho-pneumonic areas. 
Finally, we come to the rare cases of pure disseminated fibrosis of 
the lung, the diagnosis of which must always remain uncertain. The 
fine, universal fibrosis of this disease is indistinguishable on the plate The Lungs 
115 
Fibroid tuberculosis in a patient with emphysema and asthma. The punctate shadows 
represent the very rare calcified tuberculous broncho-pneumonia. 
FIGURE 66 
from that which results from the inhalation of particles of mineral 
matter in some occupational diseases. In both cases the lung is the 
seat of a chronic, more or less benign inflammatory process. The normal 
mottling of the lung is replaced by a fine or coarse network which 
differs from the normal lung in its greater definition, the irregularity 
and density of its shadows and the presence at an apex of a primitive 
lesion. The relation of anthracosis to tuberculosis is still unsettled and 
in the absence of clinical data in a case, the Roentgen plate will provide 
no reliable points of distinction between these two conditions. 116 
The Lungs 
THE ACUTE FORMS OF PULMONARY TUBERCULOSIS 
The almost universal tendency of tuberculosis in adults, at least 
in its early stages, to undergo fibrosis determines from the beginning, 
its chronic character. Only in its later development, owing to what 
may be regarded as fortuitous circumstances, does the process at times 
take on a sudden activity which will convert an indolent infection into 
an active one. 
Tuberculosis may however, assume an acute course from the very 
beginning which may be marked by an excessive toxemia out of all pro- 
portion to the extent of the changes in the lungs. As a rule, the infec- 
tion in these cases is blood- or lymph-borne, the tubercle bacilli being 
deposited in the lungs in large numbers from a focus either in the lung 
or in a remote part of the body. 
Acute tuberculosis occurs in two forms, each of which has a distinct 
pathology and Roentgen appearance. The first we speak of as miliary 
tuberculosis, which in the one case is a general infection which attacks 
every organ of the body and in ..the other is confined to the lung. The 
pathological process in this group of cases is a proliferative one. The 
second form comprises the various tuberculous pneumonias, in which 
the pathological process is essentially an exudative one. 
(1) ACUTE GENERAL MILIARY TUBERCULOSIS 
There are few diseases of the lungs in which the Roentgen exam- 
ination exhibits such accuracy and such superiority over other methods 
of diagnosis as in acute general miliary tuberculosis. At a time when 
the signs of localization in the lungs have not yet developed and when 
the disease manifests itself only as a violent intoxication, the plate 
already reveals an unmistakable and pathognomonic picture. Scat- 
tered throughout the lungs from apex to base, filling every lobule, there 
are myriads of closely studded infiltrations, pin-head in size. (Fig. 67.) 
In general the infiltrations appear to be more numerous and somewhat 
larger in the upper than in the lower lobes. The shadows which we 
see on the plate are not those of individual tubercles but arise from the 
coalescence of numbers of overlying tubercles. They may be so closely 
set as to impart a general haziness to the lung fields (Fig. 68), in which 
individual infiltrations are barely distinguishable. During the course 
of the disease the shadows increase only little in size; owing to its short 
duration, caseation has no time to develop and the shadows retain their 
faintness and lack of definition to the end. The Lungs 
117 
FIGURE 67 
Miliary tuberculosis of lungs associatied with acute general miliary tuberculosis. 118 
The Lungs 
FIGURE 68 
Acute miliary tuberculosis. The tubercles are so numerous and closely studded that a 
general haziness is imparted to the pulmonary fields. 
It is characteristic of this disease that, unlike other forms of acute 
tuberculosis, there is no evidence either in the apices or elsewhere in 
the lungs, of a previous tuberculous infection. In other words, the 
tubercle bacillus, transported to the lung by way of the circulation from 
some focus such as caseous lymph nodes, finds virgin soil for its further 
development; the disease is therefore not modified or restrained by 
previous infection. 
The clinical advantage of such an accurate diagnostic method is 
obvious. The physician is now and then confronted by a symptom com- 
plex of high fever, sweats and marked toxemia, the cause of which The Lungs 
119 
may for a long time not be apparent. His diagnostic skill is tested to 
the utmost and the resources of the laboratory may be exhausted in 
vain to differentiate between such possible causes of the clinical picture 
as malaria, a general bacterial infection, latent Hodgkin’s disease and 
general miliary tuberculosis. It is possible at once from the typical 
Roentgen appearance to establish the diagnosis of miliary tuberculosis 
or by a negative finding to exclude it and thus to narrow the problem. 
(2) MILIARY TUBERCULOSIS OF THE LUNGS 
In contra-distinction to the disease which we have just discussed 
we have to consider a miliary infiltration of the lung in which the 
infection is a purely pulmonary one. Unlike the other, it is not neces- 
sarily fatal. Although it is commonly marked in its beginning by the 
symptoms of a severe infection, it may after weeks or months become 
quiescent and undergo the secondary changes which are found in sub- 
acute and chronic tuberculosis. At this point it may be well to clarify 
our minds in regard to the usage and meaning of the term “miliary” 
tuberculosis in order that our Roentgen interpretations may, as far as 
is possible, conform to a pathological entity. Strictly speaking, a 
miliary tubercle is an agglomeration of epitheloid cells, which is just 
visible to the naked eye and has a definite microscopic picture. A 
group of several such tubercles adjacent to each other and coalescent 
is also often described as a single tubercle. In cases of longer duration, 
there is often an associated exudative process in the alveoli immediately 
about them. The symptoms of miliary tuberculosis are due to a wide- 
spread dissemination of these units of the disease throughout the lung 
and the resulting absorption of toxins from them. They may arise in 
various ways. Probably the most common mechanism is the rupture 
or growth into a pulmonary vessel or lymphatic of a caseous focus, by 
which means numbers of tubercle bacilli are deposited in the alveolar 
walls. The resulting tubercles are not intra-bronchial or alveolar, they 
are rather interstitial. On the other hand, conceivably, miliary tubercu- 
losis may have a bronchial origin, due to the transport of tuberculous 
secretions along the bronchial tree. In the exact interpretation of our 
plates we are therefore confronted with the necessity of distinguishing 
between so-called miliary broncho-pneumonia and hematogenous or 
lymphogenous miliary tuberculosis. We may well question the wisdom 
of drawing our distinctions too fine and of presuming to read too much 
into our plates. A miliary tubercle or a group of them will cast the 
same shadow on the plate, no matter what its anatomic situation. For 
this reason we shall err less in our interpretations if we are guided by 
the clinical course of the case and by the physical signs. We shall thus 
expect to find more physical signs of bronchitis in the bronchial form 
of the disease, whereas the situation of the tubercles in the hematogen- 
ous variety will explain the frequent absence of physical signs, even 
when the disease is extensive. 120 
The Lungs 
In figure 69 we see a partial involvement of the lung in a miliary 
tuberculosis, which is apparently secondary to an older lesion at the 
right apex. The denser shadows surrounding several small cavities in 
FIGURE 69 
Miliary tuberculosis of left upper lobe secondary to an old tuberculosis at right apex. The Lungs 
121 
the right upper lobe are in marked contrast to the numberless miliary 
infiltrations in the rest of the lungs, which represent a recent acute 
miliary tuberculosis. 
A more universal process is illustrated in figures 70 and 71. A 
significant feature may be observed in many of the tubercles. They are 
larger and denser, indicating a greater age than is possible in an acute 
general miliary tuberculosis and in places there are signs of an inflam- 
FIGURE 70 
Miliary tuberculosis of the broncho-pneumonic or lobular type. Note older lesions at 
apices with small cavity behind left clavicle. 122 
The Lungs 
FIGURE 71 
Miliary tuberculosis of broncho-pneumonic type. The individual shadows are larger owing 
to exudation about the tubercles. At left base the infiltrations are confluent. 
matory reaction in the alveoli about them; they may perhaps be better 
described as submiliary in size. The great similarity exhibited by these 
two Roentgen plates might lead us to anticipate a correspondence in 
their clinical pictures. Lest we indulge in such an inference, be it set 
down that these patients presented the greatest clinical diversity. In 
the one, figure 71, death ensued in a short time from an overwhelming The Lungs 
123 
toxemia. In the other, figure 70, the patient recovered at least for the 
time being. He was up and about, and only mildly ill at the time of 
the examination. Nor in respect to the character of the physical signs 
does the Roentgen plate offer any basis for judgment. It is remarkable 
that such extensive infiltrations may be productive of few or no physical 
signs. The vicarious emphysema of the adjacent uninvolved lung may 
effectually mask all dulness and may even give rise to a tympanitic note. 
Rales are often absent during the stage of tubercle formation and may 
only appear with the development of an exudative inflammation about 
them. 
FIGURE 72 
Beginning of an acute tuberculosis which completely involved the lungs in three weeks. 
Process began in right upper lobe where a moderate number of submiliary infiltrations 
are seen. See figure 73. 124 
The Lungs 
The opportunity is rarely afforded to observe on the Roentgen 
plate, the very beginning of such acute disseminated processes because 
at their onset there may be no localizing signs or symptoms in the lungs 
to direct our attention to them. For this reason, the following case, 
illustrating graphically the gradual evolution of an undoubtedly 
hematogenous tuberculosis is of absorbing interest. 
The onset of the illness in this boy of 14 years who was previously in good health, had 
all the signs of an acute infection, including very high fever and prostration. There were 
neither cough, dyspnoea nor other symptoms to indicate a disease of the lungs. During the 
FIGURE 73 
Same case as figure 72 one week later, showing increasing number of infiltrations. 
See figure 74. The Lungs 
125 
period of observation which extended over six weeks, there were remittent fever and progres- 
sive anemia; no physical signs except latterly a few small, scattered rales. The plates taken at 
weekly intervals, a few of which we reproduce, clearly portray the life story of a submiliary 
tuberculosis. 
It will be noted that in figure 72, the first plate made at the onset of 
the infection, only a few small shadows are visible in the right infra- 
clavicular region. In the next plate, figure 73, more and more infiltra- 
tions make their appearance, becoming also more distinct, until finally 
in figure 74 we have the complete picture of a disseminated tuberculosis. 
At this point the temperature subsided and at least temporarily the 
disease became quiescent. 
FIGURE 74 
Same case as figure 73 one week later, showing lungs closely studded with innumerable 
submiliary tubercles. 126 
The Lungs 
While the Roentgen examination can thus play an important role 
in the clarification of the pulmonary features of acute tuberculous 
infection, it is worth bearing in mind that it may be equally valuable in 
a negative sense. There are rare cases of generalized glandular 
tuberculosis in which, associated with an enlargement of single lymph 
nodes or groups of them, a high temperature and other symptoms of 
toxemia may continue for long periods. In these cases there is always 
present the disquieting thought that there may be a concomitant 
miliary tuberculosis of the lungs. It is apparent that the assurance that 
the lungs are uninvolved, which only the Roentgen plate can give, will 
encourage the physician in a more favorable prognosis. 
(3) ACUTE PNEUMONIC TUBERCULOSIS 
We have already referred to the various lobular and pseudo-lobar 
exudations which are secondary to existing tuberculous lesions. In 
most cases, these pneumonias are incidents in the course of a more or 
less chronic process in the upper lobes and their connection with the 
more primitive infection is usually obvious both to the clinician and to 
the Roentgenologist. 
Of a different nature, at least clinically, are those cases of tubercu- 
losis which, beginning acutely, in previously healthy individuals, run 
their course as a pneumonia which is often rapidly fatal. Although it 
is true that frequently a history of previous pulmonary disease may be 
obtained, the evidence of which is unmistakable on the plate, this is 
often so remote that it will not appear to have any relation to the 
patient’s immediate illness. 
As is well known, tuberculous pneumonia during its early stage 
may closely simulate a lobar pneumonia and only the persistence of 
the symptoms and signs for weeks or even months or the discovery of 
tubercle bacilli in the sputum will supply a clue to the correct diagnosis. 
Neither may the Roentgen examination disclose anything distinctive 
unless there is a rapid softening of the caseous exudate with cavitation. 
Even then, a cavity may be completely obscured by the overlying con- 
solidation. The Roentgen appearance of a tuberculous lobar pneumonia 
of the right upper lobe is illustrated in figure 75, in which cavity forma- 
tion is already indicated. The history was of three weeks’ duration, 
with symptoms indistinguishable from those of lobar pneumonia. Of 
significance latterly was the expectoration of the green viscid sputum, 
often regarded as characteristic of gelatinous pneumonia. 
The acute tuberculous pneumonias are more often lobular in type 
consisting of irregular, widely disseminated areas of exudation, whose The Lungs 
127 
FIGURE 75 
Caseous pneumonia showing an irregular area of softening at right apex 
coalescence frequently results in a pseudo-lobar appearance. (Fig. 76.) 
Physical signs, especially moist and metallic rales are found in great 
profusion with early signs of cavitation. In respect to the latter the 
physical examiner enjoys an advantage over the Roentgenologist, on 
whose plates the cavities may long remain unseen, hidden within the 
dense shadow of the pneumonic exudate. When they become visible, 
they are usually irregular, appear punched out of the infiltration and 
grow rapidly in size. 128 
The Lungs 
FIGURE 76 
Confluent lobular tuberculous pneumonia. Clinical picture of gelatinous pneumonia. 
The clinical course of tuberculous pneumonias is usually progres- 
sively downward and is characterized by a rapid destruction of the lung 
parenchyma. We may thus observe on the plate the ravages of the 
disease, unstayed by any effort at fibrosis. Whole lobes may be excavat- 
ed en masse leaving only a shell of tissue about the cavities, figure 77, The Lungs 
129 
FIGURE 77 
Acute tuberculous pneumonia with rapid and extensive excavation of left upper lobe. 
Shows trabeculation. 130 
The Lungs 
or again the lung may be so riddled with smaller cavities that it appears 
moth-eaten. (Fig. 78.) 
There are however other cases which begin equally acutely, yet, 
after months of illness the infection takes a subacute course until finally 
the clinical picture of chronic pulmonary tuberculosis is evolved. The 
Roentgen shadows are here also extensive and there may be considerable 
softening, yet there soon appear signs of fibrosis which is more or less 
effectual in checking the spread of the disease. 
FIGURE 78 
Disseminated lobular tuberculosis with small areas of softening, producing 
honey-comb appearance. The Lungs 
131 
Although tuberculous pneumonia, as a rule is ultimately, if not 
immediately fatal, its clinical course offers many surprises to the physi- 
cian. At times the course of the infection is stayed and extensive 
consolidations resorb almost as rapidly as they arose, before the onset 
of caseation. (Fig. 100.) More remarkably, in cases in which caseation 
has begun, in which both on the plate and to the ear, signs of extensive 
cavitation are evident, the disease may come to a halt and the patient 
who has wavered at the brink of death, rapidly and completely recovers, 
while subsequent plates show the disappearance of both infiltrations 
and cavities. (Figs. 103 and 104.) 
TUBERCULOUS CAVITIES 
The important role which cavities play in the progress of the 
tuberculous infection, warrants a more minute description of their 
Roentgen features. There is perhaps no phase of this disease upon 
which the Roentgen examination has shed more light. It has been of 
special value in the diagnosis of the smaller cavities, the occurrence of 
which in even early tuberculosis has been shown to be much more fre- 
quent than was supposed. It has taught that the classical amphoric 
signs of cavities are distinctive only of the larger ones, whereas the great 
majority, which are small, do not betray their presence by abnormal 
physical signs. 
The favorite site for the development of cavities, namely, the apices 
and upper lobes, facilitates their recognition on the plate because they 
are here superficially situated. It is important to realize that cavities 
in this region may be found at a relatively early stage of the disease 
and that the clinical classification of a case as incipient may have to be 
revised and the prognosis correspondingly changed after the discovery 
of a cavity by the Roentgen Ray. 
Thus in figure 79, although as far as the extent of the process in the 
upper lobe is concerned, this case may be regarded as incipient, there 
is already a very small cavity at the left apex whose influence on the 
future course of the infection must be reckoned with. 
The appearance of tuberculous cavities depends both on their age 
and on the nature of the pathologic tissue in which they are formed. 
In general we may recognize three forms, with minor modifications 
which are due to the transition of one form into another. 
The first and perhaps most common type is the annular cavity, 
which is found especially in early tuberculosis and represents probably 
an early stage in its evolution. It appears to result from a slow breaking 
down of the more chronic proliferative type of infiltration, in which 
caseation is not extensive and is gradual in its development. It there- 132 
The Lungs 
FIGURE 79 
Cavity in left upper lobe, showing fluid level, in the course of tuberculous process 
of small extent. 
fore lies in lung which is not densely infiltrated and may often only be 
recognized by a thin line of demarcation from the surrounding lung. 
(Fig. 80.) The cavity in the left apex in figure 60 was thus slowly 
formed during the course of a chronic submiliary tuberculosis which 
was under observation for a number of years and in which the destruc- 
tion of the lung parenchyma was a very slow one. 
It is probable that in some cases at least, these annular shadows 
represent a zone of demarcation about an infiltration which will eventu- 
ally result in a cavity. Only thus can we explain the occasional absence 
of air within them and the persistence of lung markings which traverse 
them. 
These cavities are practically always situated near, but not in, the 
apex of the lung. Their favorite site is in the infraclavicular region 
near the axilla. In fact it may be stated as a general rule that cavities The Lungs 
133 
FIGURE 80 
Annular type of cavity at left apex. At right apex, annular pleural shadow 
of moderate size usually do not occupy the extreme apex. The smallest 
annular cavities may be only a fraction of an inch in diameter; the 
largest may attain a size of two to three inches. They usually occur 
singly. This form of cavity is commonly not discovered by the physical 
examination for reasons which are obvious on the plate. As it is not 
surrounded by consolidated lung and, as in many cases, it does not 
communicate with a bronchus, the characteristic physical signs of a 
cavity are either not produced in it or are not transmitted to the surface 
of the chest. 
The second type of cavity lies in densely infiltrated lung, in which 
it probably arises from a rapid breaking down of caseous tissue. It 
has a punched-out appearance, is air-containing and often shows a 134 
The Lungs 
fluid level. (Figs. 55 and 103.) It is surrounded by a dense well defined 
wall which is composed both of fibrous tissue and the'adjacent con- 
solidated lung. The demarcation of these cavities is rendered more 
striking by the introduction of a small amount of air into the pleural 
cavity. (Fig. 81.) 
Two cavities in right upper lobe whose walls are accentuated by pneumothorax. 
FIGURE 81 The Lungs 
135 
Like the cavities of the first variety these are also most frequently 
seen in the upper lobes but they may be found in any situation where 
there is a rapid softening of the lung. Their shape will be determined 
by the character of their walls, which in turn will depend on the degree 
to which a fibrous capsule is formed about them. Thus the rapid 
necrosis which occurs in acute caseous pneumonia may give rise to an 
irregular excavation (fig. 77), with no evidence of a limiting mem- 
brane. On the other hand, when time is afforded for the formation of 
a capsule they are usually circular in outline. 
It is this form of cavity whose progressive invasion of the adjacent 
diseased lung is responsible for the cases of extensive excavation of a 
lobe or a whole lung, which illustrate most exquisitely the destructive 
tendencies of this disease. Under favorable conditions it is here pos- 
sible to make out trabeculations in the walls of the cavities. (Fig. 77.) 
At times they are multilocular and they may assume bizarre shapes. 
(Fig. 90.) 
The third type or fibrous-walled cavity represents the terminal stage 
of either type described, in which conservative influences limit its exten- 
sion and attempt to encapsulate it. The indurative tendency of apical 
disease here manifests itself in its most pronounced form and as a result 
we commonly find cavities of moderate size at an apex surrounded by a 
zone of connective tissue of varying depth and density. (Figs. 63 and 
82.) They are frequently adherent to the chest wall by a much thick- 
Fibrous-walled chronic cavity at right apex. 
FIGURE 82 136 
The Lungs 
ened pleura, which often interposes an insurmountable obstacle to their 
collapse by artificial pneumothorax. (Fig. 83.) The great density of 
their capsule is well illustrated in figure 84. Clinically, these cases are 
FIGURE 83 
Large oval cavity in right upper lobe, adherent to chest wall; pneumothorax. 
often characterized by remarkable chronicity. They are cons'stent 
with fair health and when, as is often the case, the cavities are com- 
pletely lined by smooth connective tissue, the expectoration may be 
negligible and may contain no tubercle bacilli. The Lungs 
137 
FIGURE 81 
Complete excavation of right apex; smaller cavity below. 
Although in the upper lobes the Roentgen Ray enjoys distinct 
advantages over the clinical examination in the diagnosis of cavities, 
this condition is often reversed in the lower lobes. In the latter location, 
their greater distance from the surface of the chest and the interposi- 
tion of infiltrated lung will obscure any but very large cavities. It 
therefore often happens that the multiple small cavities which so fre- 
quently result from the rapid breaking down of a caseous lobular 
pneumonia are not seen on the plate. In other cases, numerous 
small circular defects, no larger than a pea may appear throughout the 
consolidated area, due to multiple areas of softening. Under special 
circumstances, when such an excavation occurs in patients who survive 138 
The Lungs 
this disease for a time, the surrounding infiltration may be absorbed, 
leaving behind innumerable thin-walled cavities. Thus in figure 78 we 
have all the evidences of a wide-spread tuberculosis in which necrosis 
and absorption of the exudate have been so universal and active that the 
infiltration has almost everywhere given place to cavity formation. 
FIGURE 85 
Tuberculous cavity in left upper lobe, full of fluid, simulating a 
consolidation of the lung. See figure 86. 
It is noticeable that the contents of tuberculous cavities are not as 
often represented on the plate by a fluid level as is the case in lung 
abscess. In the annular type of cavity, a fluid level is rarely seen. It is 
more common in the punched-out air-containing variety. Even in the 
very large vomicae which excavate a whole apex it is surprising how The Lungs 
139 
rarely a fluid level is seen on the plate. Under these circumstances we 
must assume a very complete drainage which prevents the accumulation 
of secretion. We may occasionally observe the opposite condition in 
which the cavity, owing to deficient drainage becomes full of 
fluid, to the exclusion of its air content. A fluid level will then not be 
seen and the interpretation of the unbroken shadow may encounter 
insuperable difficulties. The following case illustrates the problem in 
diagnosis which may be presented under these unusual circumstances: 
A middle aged man who for many years had a mild cough without acute illness, began 
gradually to lose weight and to have a slight daily fever. He presented a cachetic appear- 
ance which aroused a strong suspicion of cancer. This seemed to be corroborated by the 
physical signs in the left upper lobe, which were those of a massive consolidation. The plate, 
(fig. 85), made at this time revealed a dense homogeneous shadow in the left upper lobe, 
which plausibly enough was regarded as a carcinoma. During the next few weeks however, 
the expectoration became more profuse, the temperature subsided and with the evacuation of 
its contents, the physical signs of a large cavity made their appearance. A second plate now 
showed a large cavity, at the bottom of which there remained a small amount of fluid. (Fig. 
86.) 
A word may be said in regard to the interpretation of certain 
shadows in the lungs, which by a fortuitous arrangement, may simulate 
cavities. It is not uncommon, especially at the roots of the lungs, for 
the shadows of blood vessels and indurated lymph nodes to be so dis- 
posed as to resemble a cavity wall. It need only be stated that tubercu- 
lous cavities at the hilum of the lung are very rare and that a careful 
scrutiny of these shadows will disclose their true nature. A confusion 
between the cross section of a bronchus and a cavity is possible only to 
the inexperienced. Of greater importance than these sources of error, 
are the annular shadows of pleural adhesions which may be circular in 
outline and may closely simulate a cavity. (Fig. 80.) The distinction 
cannot always be made and resort to stereoscopic examination may be 
necessary in order to determine their true nature. 
UNUSUAL TYPES OF TUBERCULOSIS 
Most cases of pulmonary tuberculosis as they are revealed to us on 
the plate, conform to a few recurring types which we have thus far 
illustrated. With these the Roentgenologist soon becomes familiar and 
he learns to recognize them at a glance. We shall now consider some 
atypical forms of tuberculosis whose shadows differ in their location 
and appearance from the usual and in which, for this reason, the diag- 
nosis cannot so readily be made. The Roentgen examination in these 
cases is of especial importance because the location of the disease or 
the nature of the pathological changes themselves may be such as to 
enhance the difficulties of the physical examination. 140 
The Lungs 
FIGURE 86 
Same case as figure 85 showing partial emptying of cavity and 
horizontal level of residual fluid. The Lungs 
141 
HILUM TUBERCULOSIS 
By hilum tuberculosis we understand a form of the disease in which 
the infiltrations are situated at the root of the lung from which they 
extend outward into the parenchyma for a variable distance, usually 
however, not to the periphery. It represents therefore a centrally situ- 
Hilum tuberculosis on right side and left upper lobe process. 
FIGURE 88 
ated process, the physical signs of which are often obscured by the 
overlying healthy lung. It should be noted that the term hilum is 
used in a topographical sense and conveys no suggestion as to the 
pathological process which is present. 142 
The Lungs 
It is scarcely necessary to point out that such a localization of the 
disease is very unusual, so much so, that in adults we have encountered 
scarcely a dozen cases. What their pathogenesis may be, why the 
tubercle bacilli are not, as is the rule, deposited in the apical region, we 
do not know. We may assume as the most likely cause a direct involve- 
ment of the pulmonary tissue about tuberculous bronchial lymph nodes. 
The resulting inflammation may be in the nature of an exudative 
reaction which is susceptible of resorption, a form of hilum tuberculosis 
which is more apt to occur in children; or the infiltration may be of 
the proliferative type and may go on to caseation and cavity formation. 
FIGURE 89 
Hilum tuberculosis with cavity showing fluid level. The Lungs 
143 
The infiltration more often involves the root of the upper lobe on 
either side and is seen in characteristic form in figure 88 at the hilum 
of the right lung. It may be associated as in this case with an apical 
tuberculosis, a combination which removes all doubt as to the true 
nature of the condition. 
The breaking down of the infiltration at the hilum may result, as 
elsewhere, in the formation of cavities which consequently will have 
an unusual location. Thus in figure 89 a small cavity partly full of 
Hilum tuberculosis on right side with unique clover-leaf cavity. 
FIGURE 90 144 
The Lungs 
fluid occupies the summit of the infiltration. In this case, the course of 
the disease was very rapid, dating back only two and one-half months, 
during which time the patient was acutely ill and had frequent hemop- 
tyses. 
Left hilum tuberculosis with unique crescentic cavity. 
FIGURE 91 
Figures 90 and 91, illustrate bizarre forms of cavities situated 
within the hilum infiltration. In figure 92 the infiltration has been 
almost completely excavated by a cavity. The Lungs 
145 
FIGURE 92 
Fibrous-walled cavity. Hilum tuberculosis. 
Cases of hilum tuberculosis are remarkable for the paucity of 
physical signs which may be associated with even an extensive process. 
The deep situation of the disease and the interposition of healthy lung 
between it and the chest wall are unfavorable for the propagation of 
rales or the demonstration of dulness. It will be seen therefore that 
for the disclosure of this unusual type of tuberculosis, the Roentgen 
examination is indispensable. Yet it must also be evident that in many 
cases the tuberculous nature of a root infiltration will not be susceptible 
of proof by the Roentgen examination alone. In view of the rarity of 
hilum tuberculosis, other diseases which may involve the roots of the 
lungs, such as abscess, tumor, or even lung syphilis, must take prece- 
dence in the diagnosis. Occasionally the presence of typical tuberculous 146 
The Lungs 
infiltrations elsewhere in the lungs or a tuberculous cavity will afford 
confirmation of its tuberculous nature; otherwise the diagnosis must 
finally rest on a firm basis of clinical symptoms and signs. We would 
especially emphasize the desirability of imposing a greater restriction 
on the use of the term “Hilum Tuberculosis” than has been customary 
in the past. It has too frequently been applied to the chronic changes, 
whether tuberculous or indurative, in the bronchial lymph nodes and 
to an increase in the connective tissue about them, which are almost 
regularly found in adults. The interpretation of these root shadows as a 
true hilum tuberculosis has been responsible for the promiscuous 
diagnosis of tuberculous disease in healthy individuals and lies at the 
bottom of much of the distrust with which the clinician in the past has 
viewed the Roentgen findings. 
ISOLATED LOWER LOBE TUBERCULOSIS 
Although infiltration of a lower lobe is a frequent happening in 
advanced tuberculosis where it is commonly secondary to an apical 
process, a primary involvement of the lower lobes belongs to the 
rarities. For this reason the Roentgenologist will wisely hesitate to 
predicate the tuberculous nature of an isolated lower lobe process, unless 
supported by a positive sputum finding. 
The character of the infiltration differs little, if at all, from that of 
non-tuberculous diseases, such as chronic pneumonias or bronchiectases; 
consequently it is necessary to scrutinize carefully the apices for 
evidences of tuberculosis, into relation with which the basilar process 
can be brought. In basal tuberculosis, cavities are usually not visible 
on the plate, even in the more acute caseous forms of the disease. In 
deciding whether an isolated basal process is tuberculous, it is import- 
ant to seek in the clinical history of the case those associated diseases 
which are known to predispose to a basal process. The most important 
of these is probably diabetes mellitus which, in the few cases observed 
by us was its most common precursor. 
In figure 93 is illustrated a tuberculous process in a young diabetic 
which involves the summit and base of the left lower lobe, the inter- 
vening tissue being unaffected. The patient’s sugar tolerance was very 
slight; the tuberculous process exhibited physical signs of great activity, 
all of which were over the left lobe posteriorly. 
Other causes which may determine a basal tuberculosis such as 
kypho-scoliosis and deformities of the chest following trauma, will 
usually be evident on the plate. The Lungs 
147 
FIGURE 93 
Tuberculosis of left lower lobe in a diabetic. 
SOLITARY CAVITIES WITHOUT INFILTRATION 
The cavities which are found in the upper lobes of cases of chronic 
pulmonary tuberculosis are practically always surrounded by infiltrated 
lung. The discovery of a cavity which lies in apparently healthy lung 
is calculated therefore to arrest attention and it will be proper to in- 
quire into the clinical history for corroborative evidence of tuberculosis, 
before such a rare manifestation of the disease is presumed to exist. 
Yet rare as they are, such cases undoubtedly occur and one must 
assume that the infiltration which had previously been present was 
completely absorbed, only the cavity remaining. 148 
The Lungs 
Thus in figure 94 may be seen the outlines of a cavity situated to 
the left of, and behind the heart, which contains a small amount of 
fluid. Similarly in figure 95 a circular cavity occupies the lower portion 
FIGURE 94 
Annular cavity near left border of heart lying in normal lung. Patient later 
developed extensive tuberculosis. 
of the left upper lobe. Here the walls of the cavity are not completely 
developed and it required an examination in the tilted position shown The Lungs 
149 
FIGURE 95 
Cavity with incomplete wall in left upper lobe. Lung about cavity is not 
infiltrated. See figure 96. 
in figure 96 to convince us of the presence of a true cavity with a shift- 
ing fluid level. In each of these cases, the presence of tubercle bacilli 
in the sputum and the subsequent development of an extensive tubercu- 
lous process, left no doubt of the true nature of the disease. 
The diagnostic difficulties which face the clinician in these cases 
are inherent in the nature of the pathological process. The character- 
istic physical signs of cavities of moderate size are to a great extent 
dependent on the transmission of sounds generated in them through the 
medium of consolidated lung tissue. Where there is little or no infiltra- 
tion of the lung about the cavity, physical signs of the latter may be 
absent. In neither of the cases above illustrated were there any signs 
in the chest to suggest the presence of cavities; in fact in one of them, 
figure 94, there were no abnormal physical signs of any kind. 150 
The Lungs 
Same case as figure 95, showing shift of fluid level in cavity. 
FIGURE 96 
It is of interest to note that the cavities in these cases are not 
located in the usual situation in the apex or infraclavicular region but 
rather in the lower part of the upper lobe. Apical cavities are usually 
an accompaniment of an indurative process with fibrosis, a type of 
reaction which is characteristic of tuberculosis at the apices. This 
tendency diminishes as we recede from the apex and one is tempted to 
believe that the absence of infiltration and fibrosis about the cavities 
we are considering may be due to the fact that they resulted from a 
softening of an acute pneumonic tuberculosis. The Lungs 
151 
UNILATERAL ADVANCED TUBERCULOSIS 
It is a rule to which there are few exceptions, that advanced 
tuberculosis is bilateral. Even in cases with a moderate involvement, 
both apices will commonly be found affected although usually to an 
unequal extent. It is therefore of interest to consider briefly a group 
Extensive unilateral tuberculosis of many years’ duration. 
FIGURE 97 
of cases in which for a long period the tuberculous process although 
extensive, confines itself to one lung. The clinical history is commonly 
that of a chronic pulmonary inflammation with profuse expectora- 152 
The Lungs 
tion in which tubercle bacilli may be found only with difficulty, 
together with the preservation of a fair degree of health. In these 
cases one may find a dense shadow which obscures one lung almost 
completely, the opposite lung remaining uninvolved. Often the 
thoracic deformity and the displacement of the heart and mediastinum 
indicate a chronic fibrosing form of the disease which affects also the 
pleura. In other cases again the infiltration may be in the nature of 
a pneumonic consolidation of a considerable portion of a lung in which 
there is a minimum of fibrosis. (Fig. 97.) 
Finally there is a small group of cases in which the induration of 
the lung and pleura terminates in the formation of tuberculous bron- 
chiectases which may affect one lung exclusively. The bronchial 
dilatations may involve an upper lobe as in figure 98 or as in figure 
99 predominantly the lower lobe. In each of these cases there is seen 
a striking thoracic deformity and a displacement of the heart and 
mediastinum. The case illustrated in figure 99 was of many years’ 
standing; toward its end, the patient who had considerable dyspnoea, 
presented evidence of cardiac weakness. The bronchiectases, which 
affected mainly the lower lobe were complicated by a chronic pleurisy 
with pleuro-pericardial adhesions. The heart is drawn to the left and 
its outline is obscured by pleural thickening. On fluoroscopic examina- 
tion, in deep inspiration, a forcible systolic impulse was visible in the 
diaphragmatic region. This was evidently due to an adherent peri- 
cardium; clinically there was a corresponding Broadbent sign. 
This group of cases has an additional interest because of the diffi- 
culty which is often experienced in distinguishing them from chronic 
non-tuberculous disease of the lung. These patients not infrequently 
remain in good health for a long period during which tubercle bacilli 
are not found in the sputum after repeated examination. For this 
reason they are apt to be regarded as tuberculous or nontuberculous 
by the examiner according to his personal bias until either the discovery 
of tubercle bacilli or some complication of the disease clears up the 
diagnosis. 
THE PERMANENCE OF THE ROENTGEN SHADOWS IN 
TUBERCULOSIS 
The fact that so many cases of tuberculosis, especially those in the 
incipient stage, become clinically cured, naturally suggests a query as to 
what becomes of the shadows seen on the plate. With the subsidence 
of the inflammatory process, are all the infiltrations absorbed and does 
the lung resume its normal appearance? An answer to this question 
must take into account both the extent of the disease and the nature of The Lungs 
153 
FIGURE 98 
Chronic fibroid tuberculosis of right upper lobe with multiple bronchiectatic cavities. 
Displacement of mediastinum. 154 
The Lungs 
Chronic unilateral fibroid tuberculosis with multiple cavities. Deformity of 
chest and pleuro-pericardial adhesions. 
FIGURE 99 
the pathological process in the individual case. There is no doubt that 
a few small infiltrations at an apex may entirely disappear so that sub- 
sequent Roentgen examination will show no trace of them. This, how- 
ever, usually requires considerable time, perhaps months or years, dur- 
ing which the shadows persist with remarkably little change in their 
size. As a rule, in the ordinary process of healing with the develop- 
ment of fibrosis, definite evidences of the previous disease remain on the 
plate. To these we have already referred in a previous section. The Lungs 
155 
When tuberculosis has passed beyond the incipient stage, espec- 
ially when caseation has already supervened, we may look upon the 
Roentgen shadows as more or less permanent. The disease may become 
arrested and the symptoms subside; yet, aside from the changes due to 
fibrosis and calcification, the shadows will persist. 
Nevertheless there are notable exceptions to this rule, cases in 
which most extensive infiltrations are susceptible of complete resorption 
with a restitution of the integrity of the lung. That we may under- 
stand such an unusual occurrence, it is necessary to call to mind the 
nature of the inflammatory reaction which underlies an acute tubercu- 
lous process. It will be recalled that its characteristic product is a sero- 
cellular exudate in the alveoli, which occurs either alone as an extensive 
pneumonia or as a zone of exudation about a group of tubercles. Now, 
it is a matter of common observation that pneumonic exudates do not 
necessarily go on to caseation but that after a variable period they may 
undergo partial or complete absorption, depending on the virulence 
of the toxin. We may instance in this connection certain cases of 
tuberculosis which are perhaps more common than is suspected, which 
begin as a pneumonic process at the apex of the lung. Judging from the 
plate and from the extent of the physical signs one is led to conclude 
that the patient has an advanced tuberculosis. Yet after a lapse of 
several months the exudate may entirely resorb, leaving behind only a 
few fibrosing tubercles. We may thus observe in figure 100 the com- 
plete disappearance within six months of a pneumonic tuberculosis of 
the right upper lobe which began with high fever, cough and hemop- 
tysis. 
FIGURE 100 
Tuberculous pneumonia of right upper lobe, showing its complete resorption 
with cure, one year later. 156 
The Lungs 
The tuberculous pneumonias which complicate the more advanced 
forms of tuberculosis supply us with the most striking examples of 
evanescent Roentgen shadows. These pneumonias are frequently the 
result of the overflow from an apical cavity, whose toxic secretions may 
involve a whole lobe in an exudative process. We may illustrate this 
occurrence by the following case: 
FIGURE 101 
Acute tuberculous pneumonia about a chronic apical cavity. See figure 102. 
A young woman who had had occasional cough and hemoptyses for some time, became 
acutely ill. For two weeks she had all the signs of an acute respiratory infection. The 
temperature was continuously high and she brought up quantities of muco-purulent expectora- 
tion mixed with bright blood. Physical examination revealed marked dulness over the right 
upper lobe with amphoric breathing and a few rales. At the height of the disease the plate, 
figure 101, revealed a dense pneumonic shadow involving the lower half of the right upper 
lobe which partly concealed a large cavity. 
After two weeks the fever subsided gradually and with it all her symptoms. At this time 
the pneumonic shadow had entirely disappeared, bringing to light a large fibrous-walled 
cavity. (Figure 102.) The Lungs 
157 
Same case as figure 101 three weeks later, showing complete absorption of 
pneumonia. Shows fibrous-walled cavity and displacement of mediastinum. 
FIGURE 102 
In cases of this type the question may properly be raised whether 
such a pneumonic process is a specific tuberculous one or whether, in 
view of its rapid disappearance, it may not be an ordinary lobar pneu- 
monia. Of course in the individual case, this question cannot be 
positively answered as ordinary pneumonias may occur in tuberculous 
patients. Nevertheless, clinical experience emphasizes the wisdom of 
regarding them as tuberculous, especially when, as in this case, there 
is such an obvious cause for their production, as a chronic cavity. In 
the case which we have cited, we must assume that the virulence of the 
organisms or their toxins, which were generated in the old apical 
cavity, were so attenuated that the reaction to which they gave rise was 
an exudative one, in the nature of a gelatinous pneumonia, which did 
not go on to necrosis. 158 
The Lungs 
A like phenomenon may be observed in an interesting group of 
cases which occur especially in children in whom such an acute reaction 
develops about tuberculous bronchial lymph nodes. These children 
may suffer with recurring attacks of acute respiratory disease at inter- 
vals of several months. During the attacks, pneumonic shadows are 
seen extending from the root of the lung oftenest on the right side. 
After several weeks these shadows, which must represent acute 
exudative reactions, entirely disappear. (Fig. 121.) It is not improb- 
able in view of these observations that many of the acute febrile attacks 
which mark the course of chronic tuberculosis are due to outbreaks of 
acute tuberculous broncho-pneumonia, which may later disappear. 
As Fraenkel has shown, the toxic products of the tubercle bacillus are 
capable of producing such reactions in the lungs, which may resorb 
without going on to caseation. 
A consideration of these cases will make the examiner hesitate to 
render a prognosis and cause him to reflect with bewilderment on the 
vagaries of this remarkable disease. An early lesion whose insignificant 
Acute caseous tuberculosis of both lungs with rapid breaking down and 
cavity formation. See figure 104. 
FIGURE 103 The Lungs 
159 
size betrays him in an unguarded moment into a sanguine prognosis may 
go on uninterruptedly to a fatal ending, whereas a caseous pneumonia, 
so extensive as to discourage the confirmed optimist, may terminate 
most happily for the patient. Not only infiltrations but actual cavities, 
hollowed out of caseating lung may disappear in an unbelievably short 
time. Instance the following case whose outcome borders on the 
miraculous. 
A woman of 38 years, suddenly overwhelmed by an acute tuberculous infection, presented 
the picture of extreme toxemia, high remittent fever and cough. During two weeks she lay 
at the point of death, which was momentarily expected, with exhausting sweats, rapid shal- 
low breathing, extreme cyanosis and constant expectoration of purulent sputum, containing 
tubercle bacilli. Physical examination, borne out by the Roentgen plate, revealed extensive 
consolidation and rapid breaking down of the lungs, in which several large cavities had 
already formed. Rash indeed would have been any but a fatal prognosis. Yet, after three 
weeks, the temperature subsided and with a rapid improvement in well being the pulmon- 
ary infiltrations retrogressed and continued to almost complete resorption. (Figs. 103 and 104.) 
Same case as figure 103 three weeks later. Absorption of most of the exudate in the lungs 
and disappearance of cavities. Subsequently, infiltration absorbed entirely and patient 
completely well. 
FIGURE 104 160 
The Lungs 
THE ROENTGEN EXAMINATION IN CASES OF 
HEMOPTYSIS 
The occurrence of hemoptysis justly creates a strong presumption 
of pulmonary tuberculosis in an individual so affected, unless there is 
some other obvious cause to explain it. This presumption is amply 
justified by clinical experience, with which the Roentgen findings are in 
complete accord. The Roentgen examination, by bringing to light foci 
of tuberculous disease in these cases has emphasized the frequent 
association of hemoptysis not only with advanced tuberculosis but also 
with incipient cases in which the infiltrations are too small to be recog- 
nized clinically. 
We wish in this place to devote especial attention to the occasional 
cases of hemoptysis occurring in individuals who are otherwise well 
and in whom neither the physical examination nor the Roentgen plate 
bring to light any evidence of pulmonary tuberculosis. Such cases are 
very trying both to the patient and to the physician because, in spite of 
negative findings the disquieting suspicion remains that the patient 
harbors a small, undiscovered tuberculous focus. 
The question arises under these circumstances whether we are 
justified in assuming that the hemoptysis is not tuberculous in origin. 
This query, which is so often propounded, merits a definite answer and 
if the Roentgenologist has confidence in his work, he will not hestitate 
to give it. It has been our experience that when a hemoptysis is due 
to tuberculosis of the lung, infiltrations can invariably be demonstrated 
on the Roentgen plate. Conversely, if such infiltrations cannot be found 
the hemoptysis has some other cause than pulmonary tuberculosis and 
it becomes imperative for the clinician to investigate the respiratory 
tract for other evidence of disease. 
In our experience with these patients we have encountered a not 
inconsiderable number in which the spitting of blood was due to lesions 
in the respiratory tract other than tuberculosis. We may mention 
among others the cases of bronchial varix and congestion of the bron- 
chial mucosa from ill understood causes. There are also cases of 
familial hemoptysis and others which show a purpuric tendency in 
which blood is expectorated without any pulmonary disease. Chronic 
cardiac disease, new growths, pulmonary syphilis and the various 
chronic non-tuberculous infections of the lung may be cited as causes of 
hemoptysis which the Roentgen Ray may be instrumental in disclosing. 
Finally, vascular sclerosis affecting the bronchial arteries, which may 
be associated with arterial hypertension, is also an occasional cause of 
severe hemoptysis. In this condition the Roentgen plate may reveal a 
hypertrophy of the left ventricle and thus throw indirect light on the 
cause of the hemoptysis. The Lungs 
161 
Although vicarious menstruation is not as commonly invoked as a 
cause of hemoptysis as formerly and should not seriously be con- 
sidered until the resources of physical examination have been exhausted, 
we have nevertheless encountered a few cases in which during the 
premenstrual period or during menstruation, hemoptysis, which could 
not be explained in any other way, has frequently recurred. 
We have finally to consider the possible relationship between 
hemoptysis and tuberculosis of the bronchial lymph nodes. In the 
absence of any tuberculous infiltration in the lung the question arises 
whether the enlarged lymph nodes which are so frequently found at 
their roots, may by themselves be the cause of the spitting of blood. 
Bronchoscopic examination in these cases has at times revealed a con- 
gestion of the bronchial mucosa from which the bleeding occurred and 
to which, it is conceivable, the enlarged lymph nodes may have con- 
tributed. Yet when it is remembered that disease of the bronchial 
lymph nodes is very common, whereas hemoptysis in this type of case 
is extremely rare, it is not probable that there is a causal relationship 
between them. 
Hemoptysis is a symptom of the greatest gravity and its importance 
always warrants a most painstaking examination of the lungs. Particu- 
larly in cases in which its cause is obscure does it demand most critical 
consideration and it is no exaggeration to say that here the Roentgen 
examination, especially in its negative aspects, is of transcendent value. 
THE BEARING OF THE ROENTGEN FINDINGS ON THE QUESTION 
OF ACTIVITY 
What information does the Roentgen plate afford us in regard to 
the activity of a tuberculous process? This query is constantly pro- 
pounded by the clinician in the natural desire to enlighten himself as 
to the prognosis and treatment of his case. In resolving this question 
we can do no better than to consider for a moment what constitutes 
activity. Clinical activity is the result of certain changes in the tubercu- 
lous focus, by virtue of which a general bodily reaction is produced. It 
is important to realize that these changes are biochemical, not histologi- 
cal and that they cannot be inferred from the microscopic or macroscopic 
appearance of the lung. Thus, a tuberculous individual may at one 
time exhibit all the clinical signs of activity and a short time thereafter 
be free from them. Yet, as far as the eye or the microscope can deter- 
mine the pathological process in his lungs may remain unaltered. 
It is not to be expected therefore that the Roentgen plate, which is 
but a rough imagine of the actual deposits in the lungs, will be more 
informative than the microscope. In fact, there is no character of the 
Roentgen shadows of pulmonary tuberculosis from which either activ- 162 
The Lungs 
ity or quiescence of the lesions may be deduced. This statement finds 
its confirmation in the daily experience of the Roentgenologist both in 
incipient and advanced cases. A shadow which is discovered during 
the incipient stage of tuberculosis may and often does remain unchanged 
in appearance long after the signs and symptoms of activity have sub- 
sided. Even in the acute disseminated forms of the disease in which 
the appearance of the shadows leaves no doubt of the virulence of the 
infection, the Roentgen plate furnishes us no basis for assuming that the 
disease is an active one. It is true that such shadows bear witness to the 
acuteness of the process, which must therefore at some time have been 
active; yet this activity need not exist at the moment. 
The same observations will apply to the healing and quiescence of 
tuberculous infiltrations. The presence of strands of fibrous tissue in 
the infiltrations will merely indicate that there is a tendency to healing, 
not that healing has actually been accomplished. The greater the 
amount of fibrosis, shrinking of the chest and displacement of the 
thoracic organs, the greater is the probability that the disease is no 
longer active. But it must be remembered that even a fibrosing process 
may be associated with activity and inferences as to actual quiescence 
must be made reservedly. In our analysis of the Roentgen plate we 
may appraise the contending forces which on the one hand make for 
activity and on the other hand strive for the arrest of the disease and 
though we may note a preponderance of one or the other, we cannot 
express our conclusions in terms of activity. 
It would therefore mark an advance in the interpretation of plates 
if such terms as “active” and “quiescent” and similar adjectives, as 
descriptive of infiltrations, were discarded. As shadows, they have no 
character of activity or quiescence. It would be more in conformity 
with our knowledge to describe them in general terms, as, for example, 
“of recent” or “remote origin” or even as “acute” or “chronic.” If a 
more exact pathological interpretation is desirable, such terms as 
caseous, exudative or fibroid may properly be applied to them. 
THE BEARING OF THE ROENTGEN FINDINGS ON THE 
PATHOLOGY OF TUBERCULOSIS 
We have sought, in the foregoing pages, so to interpret the Roent- 
gen shadows of pulmonary tuberculosis, as to bring them into harmony, 
as far as this is possible, with recognized pathological types. In essay- 
ing such a correlation, we must however remember that the morbid 
changes in the lungs are so complicated that the conglomerate of 
shadows which we see on the plate can only roughly outline the under- 
lying disease. The conservative Roentgenologist, bearing in mind the 
inherent limitations of his art will therefore refrain from reading too 
much into his plates and he will be content to make such general state- The Lungs 
163 
ments in regard to the infiltrations as we have indicated. The more 
exact determination of the pathological or clinical type of the disease 
and especially the question of its activity, he will wisely leave to the 
clinician. 
There are however, other aspects of this disease concerning which 
the thoughtful examiner is tempted to speculate. As the tuberculous 
infection in its manifold forms is revealed to him certain problems in 
regard to its pathogenesis, especially its original site in the lung and 
its mode of progression, will arouse his interest. We have in the Roent- 
gen plate, a means of inquiry into these questions, which in some respects 
exceeds in value the autopsy itself. In no other way have we the oppor- 
tunity, usually denied to the pathologist to observe the very beginnings 
of this disease and by successive examinations to study its gradual or 
rapid propagation throughout the lungs. 
THE SITE OF THE INCIPIENT LESION 
It is the common belief, amply supported by evidence from various 
sources that pulmonary tuberculosis in adults is a metastatic infection 
from a previously existing focus, which is usually located in the bron- 
chial lymph nodes. For reasons not well understood the apical or sub- 
apical regions are especially predisposed to the disease, so that the 
tubercle bacilli are there deposited. The earliest lesion is therefore 
situated at a remote distance from the lymph nodes at the root of the 
lung whence the infection originated. This theory of the mechanism of 
pulmonary infection receives a striking confirmation from the Roentgen 
examination. On the plate the infiltrations of incipient tuberculosis are 
almost invariably located in the upper lobes near their periphery. The 
deposits are small and circumscribed and, what is of particlar interest, 
that portion of the lung which lies between the diseased area and the 
hilum is uninvolved. 
Opposed to this theory, a number of Roentgenologists have 
advanced a contrary one namely, that tuberculosis begins at the root of 
the lung whence it extends to the periphery. This theory of a primary 
hilum tuberculosis with a secondary pulmonary involvement early 
enlisted many adherents, who based it almost entirely on a reading of 
the plates, with little pathological or clinical support. 
These opposing views have more than a theoretic interest. They 
are founded on fundamentally different interpretations of the Roentgen 
plates, both of which obviously cannot be correct. Such being the case, 
it is necessary to clear up the points at issue before the Roentgen inter- 
pretation of tuberculosis can achieve a firm and rational basis. We 
therefore propose to discuss them at greater length. 164 
The Lungs 
We shall first consider the evidence which has been adduced to 
support the theory of a central origin of the tuberculous process. The 
fact that this is contrary to accepted pathological doctrine is an added 
reason for examining this evidence critically. 
In the early era of Roentgenology when it was realized that 
pathological deposits in the lungs could be recognized on the plate, 
enthusiastic observers, who for the first time saw the massive hilum 
shadows, promptly regarded them as evidence of tuberculosis. The 
fact that these shadows were occasionally associated with clinical signs 
of respiratory disease and the absence of infiltrations in the periphery 
of the lung, naturally strengthened this belief. 
Having assumed that tuberculosis begins at the root of the lung, 
it was next necessary to explain the method whereby the outlying 
portions of the lungs are involved. This was conceived as an extension 
of the infection outward from the root, along the peribronchial 
lymphatics to the surface of the lung. The complete theory therefore 
involves two distinct suppositions. (1) A hilum tuberculosis, as the 
origin of the disease, and (2) its peribronchial centrifugal extension. 
It will be our task now to test the truth of the Roentgenological basis 
for these assumptions. 
THE ROENTGEN EVIDENCE OF A PRIMARY HILUM 
TUBERCULOSIS 
When we inquire into the evidence on which Roentgenologists have 
based their belief in a hilum tuberculosis, it will be found that this is of 
the slenderest and is founded on a misinterpretation of the root shadows. 
These shadows are cast by different structures, such as blood vessels, 
bronchi and lymph nodes, all of which are anatomically distinct from 
the lung parenchyma. An increase in the size of these structures from 
disease brings about a widening of the hilum shadows, which may 
extend for some distance into the pulmonary fields, without the lungs 
themselves being involved in the disease. In fact, there is every reason to 
believe, that in adults, an enlargement of the roots may be traced to the 
almost universal disease of the bronchial lymph nodes. Strictly speak- 
ing, there is no such thing as a normal hilum. Practically all individuals 
bear the marks of numerous respiratory infections, whether tuberclous 
or otherwise, which are visible in the bronchial lymph nodes. These 
exhibit, in varying degrees such diverse pathological changes as hyper- 
plasia, anthracosis, calcification and caseation which are revealed on 
the plates as widened and irregular root shadows. 
The advocates of the theory of primary hilum tuberculosis attach 
great importance to these shadows and in cases of suspected tubercu- 
losis regard them as confirmatory of the diagnosis. And yet, every- 
day experience is strongly opposed to such a view. Enlarged and The Lungs 
165 
diseased bronchial nodes are almost universal, whereas clinical symp- 
toms resulting from them are relatively rare. Especially in respect to 
tuberculosis of these nodes, must we realize that although they are 
infected, the pathological process is usually in a state of quiescence 
and that symptoms arising from their activity are of rare occurrence. 
When such symptoms occur in patients who exhibit enlarged root 
shadows, it will be nearer the truth to explain them as the result of 
chronic bronchitis and emphysema or the various respiratory infections 
which are secondary to accessory sinus disease. To regard these 
shadows as evidence of an involvement of the lung root in a tuberculous 
infiltration is fatal to a rational interpretation of the plates; a large 
percentage of mankind would then be pronounced clinically tubercu- 
lous and the Roentgen diagnosis would be reduced to absurditiy. 
THE ROENTGEN EVIDENCE OF PERIBRONCHIAL 
TUBERCULOSIS 
The Roentgen evidence in suppot of a peribronchial tuberculosis 
is derived from the coarse radiating strands which traverse the chest 
from the root to the periphery, whose irregular and at times nodular 
outlines seem to suggest a tuberculous infiltration about the bronchi. 
This assumption has made such an appeal to Roentgenologists, that 
peri-bronchial tuberculosis has for a long time had a pominent place 
in the diagnosis of this disease. And yet, it is undoubtedly founded on 
an error in interpretation which arises mainly from a misconception of 
the anatomical basis of these radiating shadows. There are ample 
grounds for believing that these shadows, even when they are much 
enlarged, have no connection with the bronchi at all, but represent a 
dilatation of the blood vessels and lymphatics of the lung and that there- 
fore they cannot be regarded as evidence of a peribronchial or other 
form of tuberculosis. The reasons for this belief are the following: 
(a) The pulmonary markings, which are predominantly the 
shadows of blood vessels, may become broader and irregular under 
various circumstances, when there can be no question of tuberculosis. 
Plates of healthy individuals, made in the prone position, especially 
when the tube is very close to the patient, exhibit coarse radiating 
shadows which are identical with those of so-called peribronchial 
tuberculosis. Aside from these external agencies, any obstruction to the 
return flow of blood from the lungs, will effect a widening of the lung 
arborizations and lead to a similar Roentgen appearance. The most 
striking example of this will be found in cases of advanced mitral 
disease, in which the pulmonary fields are traversed by irregular linear 
shadows of distended vessels which issue from a much enlarged hilum. 
(Figs. 4 and 5.) Were these shadows consistently interpreted in 
accordance with the peribronchial conception of tuberculosis, a large 166 
The Lungs 
majority of cardiac patients, would have to be considered tuberculous. 
This we know to be contrary to medical experience which teaches only 
the exceptional association of tuberculosis and heart disease. 
(b) A similar mechanism will explain the exaggerated markings 
so often seen in adults with enlarged anthracotic or tuberculous bron- 
chial nodes. Pressure of these nodes on the afferent vessels at the root of 
the lung and consequent engorgement of the pulmonary blood vessels 
and lmphatics offers a more rational explanation of these shadows, than 
does a peribronchial tuberculosis. Failure so to interpret them has in 
the past brought chaos to the Roentgen diagnosis of tuberculosis. 
Untold numbers of patients, with no more serious ailment than a chronic 
bronchitis or a quiescent glandular tuberculosis have been pronounced 
tuberculous because in the reading of their plates the exaggerated 
shadows of a normal component of the lung have been mistaken for 
disease. 
(c) A more convincing proof of the vascular basis of these strands 
may be found in the plates of children. As is well known, tuberculosis 
in children is usually confined to the bronchial lymph nodes and in only 
a small proportion does it involve the parenchyma of the lung. Clinic- 
ally, the most prominent symptoms of this adenopathy are due to pres- 
sure of these nodes at the roots and we may expect to find on the plate 
evidence of this pressure in an increased vascularity of the lungs. This, 
in fact, is the case. It is almost the rule, in cases of well marked 
glandular tuberculosis in children, to see coarse, nodular strands which 
extend outward into the lung from the roots, being most prominent in 
the paravertebral and infraclavicular regions. (Fig. 116.) From the 
frequency of their occurrence and the known variety of pulmonary 
involvement in childen, we are forced to conclude that these shadows 
are not cast by tuberculous infiltrations but are rather blood vessels and 
lymphatics which are distended because of an interference with the 
return flow of blood and lymph from the lungs. 
ROENTGEN EVIDENCE OF THE PERIPHERAL ORIGIN OF 
TUBERCULOSIS 
The positive evidence in favor of a peripheral origin of tuberculosis 
has been set forth at length in the section devoted to incipient tubercu- 
losis. We have there fully illustrated the characteristics of the early 
infiltrations, which do not show in their distribution, any relation to the 
course of the bronchi nor any connection with the hilum of the lung. 
In fact, in truly incipient cases, that portion of the lung situated between 
the infiltrations at the periphery and the hilum, is absolutely devoid 
of abnormal shadows, a condition which is in complete harmony with 
the theory of pulmonary infection here set forth. The Lungs 
167 
We have dealt with this subject at some length because it is of 
crucial importance in the rational interpretation of the Roentgen plate. 
Beginners especially are too prone to attach significance to every 
shadow on the plate even though it be normal and to seek an explana- 
tion for it in terms of disease. We believe that only by restricting the 
Roentgen evidences of tuberculosis to definite pulmonary infiltrations, 
will the diagnosis achieve the decisive character to which it may justly 
aspire. We are further convinced that, far from circumscribing the 
scope of the Roentgen examination, such a restriction will extend it and 
enhance its value and wdll bring it into harmony with the coordinate 
branches of clinical medicine and pathology. 
THE ROENTGEN EXAMINATION AND THE PHYSICAL SIGNS 
When we compare the extent of the tuberculous process as seen on 
the plate with the physical signs, especially in respect to dulness, a 
marked discrepancy will frequently be noted. One will be amazed to 
see extensive shadows, involving a large part of the lungs in certain 
cases in which little or no dulness can be elicited. This is especially 
true of the lower lobes where emphysematous lung, overlying an area 
of consolidation, may mask the dulness. We must constantly bear in 
mind that the phenomena of percussion are purely acoustic and have 
no necessary correspondence with those of the Roentgen Ray, which are 
purely optical. The attempt to correlate them is therefore often 
attended with discordant results. 
To an even lesser degree is there a correspondence between the 
appearance of the Roentgen shadow and the presence or absence of 
rales. An extensive consolidation due to pneumonic tuberculosis may 
in the one case be accompanied by an abundance of rales, whereas in 
another case with an identical Roentgen picture, rales may be absent. 
It is however in the interpretation of incipient tuberculosis that an 
accordance between the plate and the physical signs, especially in 
respect to apical rales, is most eagerly sought. Are these rales neces- 
sarily an evidence of pulmonary tuberculosis? Do the Roentgen findings 
support such an assumption? We are confronted here by a problem of 
great moment in the solution of which the Roentgen examination is 
bound to play a prominent role. 
Apical rales are justly invested in the mind of the physician with 
an ominous significance and experience proves a large percentage of 
them to be of tuberculous origin. With this the Roentgen examination is 
in entire accord. Nevertheless we encounter from time to time patients 
in whom despite the presence of more or less constant rales at an apex, 
the Roentgen plate shows no corresponding infiltrations. Shall these 
patients none the less be considered tuberculous? In a matter of such 
practical importance dogmatism is unbecoming both in the clinician and 168 
The Lungs 
the Roentgenologist. Neither can the apical rales be lightly dismissed 
by the one nor the evidence of the ngative plate be disregarded by the 
other. In a doubtful case it will therefore be wise to keep the patient 
under observation. We wish however to emphasize that there are 
undoubtedy cases with apical rales which are not tuberculous and in 
which the negative Roentgen finding will encourage the physician to 
take a less serious view of the case. 
What the pathological process may be which gives rise to these 
rales, it is difficult to say. Other respiratory infections besides tubercu- 
losis can certainly induce an apical catarrh. The influence of apical 
atelectasis in the production of rales must also be kept in mind. Finally 
the scars of healed tuberculous lesions, with a retraction of the apices 
are a prolific source of apical rales which may persist for a considerable 
time after the cure of the disease. Although ultimately the decision as 
to whether an actual tuberculosis exists must depend on the clinical 
symptoms such as the temperature, pulse rate and sputum, it has been 
our practice to regard these cases, in which the Roentgen plate is per- 
sistently negative, as non-tuberculous. The wisdom of this attitude has 
almost invariably been confirmed by their subsequent course. These 
patients practically always recover promptly or some other cause for 
their respiratory symptoms is found. 
THE RELATIVE VALUE OF THE ROENTGEN AND PHYSICAL 
EXAMINATION 
It is to be deplored that even at the present time there is much 
difference of opinion as to the relative value of the physical and the 
Roentgen examination in the diagnosis of tuberculosis. It is often asked 
whether the Roentgen Ray represents an advance over the older clinical 
methods of percussion and auscultation. Is it possible by means of the 
Roentgen plate to discover infiltrations of incipient tuberculosis at a time 
when physical signs of the disease are not yet present? 
The clinician who, as a rule, is unskilled in the use of the Roentgen 
Ray has been reluctant to concede its value for a number of reasons. In 
the first place he was possessed of an unwarranted fear that the Roent- 
gen examination would overshadow or even supplant the clinical exam- 
ination. Secondly, the shortcomings of the Roentgenologist himself, on 
whom the clinician has had to depend for the reading of the plates, have 
engendered a distrust for the Roentgen findings. The Roentgenologist has 
too often based his diagnosis on technically imperfect plates and he 
has consequently fallen into error. Ignorance of the anatomical basis 
of the normal lung shadows also led him to advance erroneous theories 
of the origin and mode of spread of the disease in the lungs which have 
completely vitiated his interpretations. These interpretations are more- 
over clothed in a picturesque phraseology which is both inaccurate and The Lungs 
169 
confusing to the clinician. Finally there has been so little unanimity 
among Roentgenologists in the interpretation of the plates that the 
clinician has not been encouraged to depend on them. 
The clinician however bases his preference for the physical exam- 
ination on more positive grounds than the foregoing. Stated in its 
most uncompromising form, the belief of many specialists in physical 
diagnosis is that incipient tuberculosis cannot be determined by the 
Roentgen Ray or at least that it is sooner discovered by auscultation and 
percussion. We have here a simple issue of fact which is worthy of 
most careful consideration. 
In the first place, it is proper to inquire whether the physical signs 
of incipient tuberculosis are of such a definite character that physicians 
as a rule find themselves in agreement in its diagnosis. Now as a matter 
of fact this is far from the case. Assuming that a patient has such 
equivocal signs at an apex as diminished or granular breathing and 
slight dulness, different examiners will not put the same interpretation 
on these changes. The conservative physician will demand more positive 
evidence upon which to diagnose tuberculosis and will hold his opinion 
in abeyance pending the result of sputum examinations and other 
clinical tests. There is however a school of clinicians among whom are 
numbered many specialists in this disease, who unhesitatingly base a 
diagnosis of tuberculosis on slight abnormalities in breathing associated 
with more or less constant apical rales. 
To those who hold the physical examination in such high regard, 
the Roentgen plate with its frequent negative finding, will of course, 
be disappointing. The clinical extremist, confident of his skill and 
fortified by his personal bias will at once conclude that the Roentgen 
plate is of little value. Yet we venture the opinion that the importance 
of slight breathing changes and apical rales has been altogether 
exaggerated and that in many cases such changes have been due to 
catarrhal processes other than tuberculosis. It would make an instruc- 
tive commentary on the physical examination were it possible to 
estimate the number of patients who in the past have mistakenly been 
pronounced tuberculous because of slight apical changes. It is not the 
least of the achievements of the Roentgen Ray that in these doubtful 
cases the negative Roentgen finding may afford the conservative exam- 
iner the assurance that his patient is not tuberculous. 
It is our belief, which daily experience is strengthening, that in the 
vast majority of cases of so-called incipient tuberculosis, definite infiltra- 
tions can be demonstrated by a well executed Roentgen examination. 
The converse of this is equally true, namely that a negative Roentgen 
plate effectually excludes tuberculosis. We wish to emphasize, how- 
ever, that by infiltrations are meant the definite shadows which we 170 
The Lungs 
have described as characteristic of tuberculosis, not the so-called peri- 
bronchial infiltrations and root shadows, which are so often, to the 
detriment of the patient, regarded as tuberculous. 
We are moreover firmly convinced, that the Roentgen examination, 
when properly performed, is the most certain method for the early 
diagnosis of pulmonary tuberculosis and that by means of it the disease 
can usually be discovered previous to the development of physical signs. 
Increasing experience is strengthening the impression that in many 
cases in which distinct physical signs are present, the tuberculous 
process has already passed beyond the incipient stage, as is shown by 
the extent of the shadows on the plate. We have had occasion to point 
out in our discussion of beginning tuberculosis how frequently the 
deposits are situated in the infraclavicular region. Here the Roentgen 
plate enjoys a pronounced advantage over the physical examination 
because the signs are hard to elicit. When rales are finally heard it is 
often found that the process has already extended beyond the incipient 
stage. 
The superiority of the Roentgen Ray in the detection of the advanced 
lesions of tuberculosis is contested by scarcely any one today. It is an 
almost invariable experience that the plate discloses a much larger 
area of infiltration than the physical examination leads us to expect. 
This is increasingly true the further we recede from the apices and 
approach the bases where the infiltrations may be deeply seated. An 
extensive tuberculous broncho-pneumonia in a lower lobe may thus be 
entirely overlooked because of a surrounding compensatory emphysema 
which will mask both dulness and breathing changes. The physical 
examination here relies mainly on rales, which may be inconstant and 
which are, roughly, an evidence of activity. The Roentgen Ray on the 
other hand, unearths infiltrations, which are an expression of the total 
tuberculous process, active and inactive. 
Particularly in chronic and quiescent cases, the extensive shadows 
to be seen on the plate may be out of all proportion to the meager 
physical signs. The diversity of pathological changes such as calcifica- 
tion, caseous broncho-pneumonia, miliary infiltrations, extensive fibrosis 
with cavitation and displacement of the thoracic viscera, are faithfully 
mirrored forth on the plate where they supply a wealth of information 
which the physical examination can never hope to rival. 
It should not be presumed, from this catalog of the merits of the 
Roentgen examination that it is all-sufficient for purposes of diagnosis 
and that therefore the physical examination can be dispensed with. A 
Roentgen plate cannot take the place of a careful clinical examinaion; 
to attempt this would be to pervert its function. Nothing can replace 
the periodic percussion and auscultation of the chest for evidence of The Lungs 
171 
activity or quiescence of the lesion or of its extension. The Roentgen 
examination must be utilized by the clinician as an adjunct to his other 
methods in order to achieve their greatest usefulness. When it is so 
used, it is safe to say that few clinicians at the present day will be con- 
tent to forego the great help which the Roentgen Ray can afford them. Chapter VI 
Pulmonary Tuberculosis in Children 
The tuberculous infection manifests itself so differently in infants 
and children from adults that it is desirable to treat its Roentgen 
diagnosis in a special chapter. 
In recent years our knowledge of tuberculosis of the lungs in 
children has been extended in various directions. This we owe to the 
pathological studies of Albrecht and Ghon, to the extensive application 
of the various immunity reactions to the living child especially the 
von Pirquet test and finally to the correlation of clinical, laboratory and 
autopsy findings which led to the illuminating conception of the disease 
advanced by Hamburger. Further, the obscure and difficult problems 
involved in the origin and mode of dissemination of tuberculosis in the 
lungs have engaged the experimental pathologists, notably Bacmeister, 
the results of whose experiments have helped to explain the mechanism 
of human infection. 
Until recently, the clinical diagnosis of tuberculosis in children had 
not kept abreast of the brilliant strides of pathology and immunology. 
Its progress was stayed by the difficulty of accurately determining the 
site, extent and type of tuberculous lesions which were present in the 
individual case, a difficulty which is far greater in infants and children 
than it is in adults. It is a peculiarity of tuberculosis in children that in 
its most common forms it occasions but few physical signs and these are 
difficult to elicit. It is essentially a disease of symptoms in the inter- 
pretation of which the physical examination too often fails. 
Happily, the Roentgen-Ray has brought to the diagnosis a method 
of great exactitude, whose application is not subject to the limitations 
of the older methods. It penetrates the remotest recesses of the chest 
and regardless of the absence of physical signs, reveals in the one case 
the very beginnings of the disease and in the other its most advanced 
forms. 
It will be desirable to rehearse briefly the pathology of tuberculosis 
particularly as it refers to the child, in order that we may interpret 
intelligently the data furnished by the Roentgen examination. 
Perhaps the most useful conception in relation to this subject we 
owe to Hamburger. He has pointed out the marked similarity in the 
sequence of their manifestations, between tuberculosis and syphilis. 
Just as in syphilis, there is a primary, secondary and tertiary stage, each 
characterized by distinct kinds of inflammatory reaction, so in tubercu- 
losis we have a chronic infection, beginning nearly always in childhood The Lungs 
173 
which, in its evolution in the body assumes various forms. Here also 
we can recognize a primary stage or initial infection which is shortly 
succeeded by a secondary stage, to be followed after a longer interval 
by a tertiary tuberculosis. Just as the tertiary form of syphilis or gumma 
does not occur at the time of the initial lesion, so with rare exceptions the 
tertiary or adult form of tuberculosis does not occur in childhood, the 
period of initial infection. 
Let us now observe the sequence of events which follow the 
entrance of the tubercle bacillus into the body. Be this by way of the 
bronchial tubes by inhalation or through the blood or lymphatics from a 
focus elsewhere in the body, the primary lesion of the disease is prac- 
tically always an agglomeration of tubercles within the lung paren- 
chyma, which varies in size roughly from that of a pea to a cherry. 
Most often it is found in the anterior part of the upper lobe just beneath 
the pleura and it is often accompanied by changes in the latter. 
So ubiquitous is this disease, that up to the age of puberty, over 
90% of city dwelling children have passed through such a period of 
pulmonary infection. Since a majority of the children recover from 
this primitive infection, the initial lesion being of small size, it is fair to 
assume that the number of invading organisms is small or their virulence 
attenuated. In cases of presumably massive infection, especially when 
this occurs in infants, the disease may be a very virulent one and result 
in early death. The initial focus may then be of great extent and 
present the clinical picture of infantile phthisis. 
The second period of the disease follows closely on the primary 
infection. During it there is a tuberculous enlargement of the regional 
bronchial lymph nodes which remains after the pulmonary focus has 
completely healed. Disease of these nodes, situated at the roots of the 
lungs with the manifold symptoms and signs resulting from their 
tumefaction, furnishes the dominant features of the tuberculous infec- 
tion in childhood. 
Of greater importance however than merely local changes in the 
chest are the subtle reactions of the tissues to the tubercle bacillus which 
result on the one hand in a condition of allergy, as evidenced by the 
response to tuberculin injections and on the other hand in a partial 
immunity to further infection. The significance of the latter must be 
appreciated for a proper understanding of the evolution of tuberculosis 
in children. The existence of the initial lesion, with the continued ab- 
sorption from it of small amounts of tubercle toxin, apparently so affects 
the reactivity of the lungs that their response to subsequent infection 
by the tubercle bacillus is notably modified. In the first place the child 
is shielded from massive infection and dissemination of the disease by 
the resistance it has acquired; secondly, the type of reaction in the 
lungs to later infection is changed from the acute, exudative and 174 
The Lungs 
caseous, to the more chronic, indurative form. This indurative form of 
tuberculosis, which we may speak of as its tertiary stage, is practically 
confined to adult life or later childhood. It is usually apical in situa- 
tion, has a great tendency to fibrosis and is regarded as the unique 
reaction of a lung, which has become habituated to the tuberculous 
virus by previous and long standing infection. It always presupposes a 
primary focus in the lung which has usually existed from early child- 
hood. 
We may then summarize the events which follow the entrance of 
the tubercle bacillus into the child’s lungs as follows. If the attack is a 
massive or virulent one, the child is overcome by an acute, caseous and 
often rapidly fatal disease. If the invasion is mild, there results a 
primary lesion of small extent, situated anywhere in the lung, which 
usually goes on to cure by fibrosis or calcification. Coincidently there is 
a tuberculous adenopathy which may remain latent or may manifest 
itself clinically some time after the primary focus has healed. Finally, 
toward puberty, or more commonly in early adult life, there may be a 
tertiary infection of the lung from the mobilization of tubercle bacilli 
in the bronchial nodes or by massive infection from without. This 
tertiary form of the disease which is found nearly always in the upper 
lobes, because of the altered reactivity of the lung, is a chronic indura- 
tive one and is characteristic of the disease in adults; its further course 
has already been discussed in the chapter on adult tuberculosis. 
We shall now proceed to the interpretation of the Roentgen find- 
ings and we shall attempt to apply to them, as far as we may, the fore- 
going considerations. 
With respect to the classification of the various stages of the 
disease, we will find that the division into the conventional first, second 
and third stages is inapplicable to children, because the infection does 
not progress, as it does in adults, from the apex to the base. We shall 
therefore depart from it entirely and, unhampered by the uncertainties 
of physical signs, base our description of the different forms of the 
disease on the appearance and distribution of the infiltrations as seen 
on the plates. The various types of tuberculosis in infants and children 
will then be found to conform to the following grouping: 
I. Primary Tuberculosis: 
(a) Focal primary lesion. 
(b) Caseous pneumonia; infantile phthisis. 
II. Tuberculosis of the Intrathoracic lymph nodes. 
III. Hilum Tuberculosis. 
IV. Recurrent Hilum pneumonia. 
V. Miliary Tuberculosis. 
VI. Apical Tuberculosis and other adult forms. The Lungs 
175 
PRIMARY TUBERCULOSIS 
(a) FOCAL PRIMARY LESION. The initial lesion of tuberculosis 
practically always passes unnoticed. Its small size renders it recogni- 
tion by physical examination impossible and its symptoms are probably 
mistaken for those of the numerous respiratory or other infections which 
are so prevalent in the early years of life. The Roentgenologist rarely 
has the opportunity to observe these cases in their acute stage, especially 
as they usually go on to rapid healing. Only in rare cases will he be 
fortunate to discover them while they are still active. He will then find 
on the plate a pneumonic infiltration of moderate extent in any one of 
the lobes. Thus in figure 105 an early tuberculous process, pneumonic in 
Primary tuberculosis in right lower lobe in 11 year old child. Enlargement 
of bronchial and paratracheal nodes. 
FIGURE 105 
type, is seen in the right lower lobe, in a girl eleven years of age. She 
had no previous pulmonary disease and her infection could be traced to 
a tuberculous mother who had died recently. It was sudden in onset 
and virulent, causing high remittent fever and cough. A bronchial 176 
The Lungs 
adenopathy, unusually marked for a child of this age was present and 
confirmed the probability of recent infection. After two months of 
acute illness, the symptoms subsided and the child was apparently well. 
The plate then showed a resorption of the initial focus, only a thick- 
ening of the interlobar fissure remaining. There was, however, a 
notable increase in the size of the bronchial lymph nodes. Again, in 
figure 106, the initial lesion occupies the region of the right hilum 
FIGURE 106 
Primary tuberculosis in infant. The process consists of an infiltration at the root 
of the right lung. Bronchial nodes are much enlarged. 
where it is in close proximity to large masses of tuberculous nodes. In 
this case, the extreme youth of the child, who was only a few months 
old, renders it probable that the pulmonary infiltration represented a 
primary rather than a secondary invasion of the lung. 
More often, the Roentgenologist will find only the healed remains 
of the primitive infiltration, incidentally to the examination of the 
lungs for other forms of disease. While it is true in the larger number 
of cases that the primary lesion, having undergone fibrosis or other The Lungs 
177 
form of healing, is no longer visible on the plate because of its small 
size, there are nevertheless numerous instances in which small discrete 
shadows are found on the plate, which can be nothing but the scars of 
past infection. As in figure 107, we then see small shadows, oftenest in 
FIGURE 107 
Calcified primary lesion in right upper lobe. - Calcification of bronchial nodes. 
the upper lobes whose density and sharp outline indicate that they are 
the fibrous or calcified remnants of a primary tuberculous focus. In 
figure 108 the deposits are multiple and are found in both upper and 178 
The Lungs 
FIGURE 108 
Multiple healed lesions of primary tubers ulosis in left lung. 
lower lobes. In figure 109 is illustrated a different type of healed 
lesion consisting of a strand of fibrous tissue in the left upper lobe. 
These healed lesions, whose pathogenesis presents so many points of 
interest, have no clinical importance. They are the cause of no symp- 
toms on the part of the child, whose complaints can more often be 
referred to the enlarged, tuberculous lymph nodes whose shadows are a 
prominent feature of the Roentgen plates. The Lungs 
179 
FIGURE 109 
Fibrosis of primary lesion in left upper lobe. Tuberculous bronchial nodes, 
The pleura over the site of the initial lesion is often involved in the 
inflammatory process. The changes are so slight however that except 
in the region of the interlobar fissure, they escape detection. In this 
region, a thickening of the pleura is demonstrable as a sharp linear 
shadow which traverses the chest from mid-line to axilla at the level 
of the fourth rib anteriorly. Routine study of the plates of children 
will reveal this shadow in a considerable number and it may be 
regarded in most cases as evidence of previous tuberculous infection in 
its vicinity. | , 180 
The Lungs 
(b) CASEOUS PNEUMONIA. INFANTILE PHTHISIS. Before 
pathologic studies revealed the frequency of pulmonary infection begin- 
ning in the early months of life and increasing year by year, tuberculosis 
in infancy was regarded as almost invariably fatal. We now know that 
even in infancy a tuberculous lesion can and frequently does completely 
heal. It remains true however, that the susceptibility to massive infec- 
tion is very great in infancy and it may terminate in a most extensive 
caseous consolidation and necrosis of the lung, to which the term 
“infantile phthisis’’ is applied. Whether these extensive infiltrations 
are the result of the primary infection or whether they are secondary 
is not deducible from the Roentgen plate. They are insome case at 
least due to the rupture of a caseous lymph node into a bronchus with 
consequent bronchgenous dissemination of the disease. The type of 
infiltration seen in these cases is shown in figure 110 in which there is a 
caseous pneumonia of the right upper lobe with cavity formation. As 
is often the case with these advanced forms of infantile tuberculosis, 
other organs besides the lungs were affected. On the plate there may 
thus be seen a tuberculous abscess about the lower dorsal spine, which 
FIGURE 110 
Infantile phthisis. Caseous pneumonia of right upper lobe with cavitation. 
Tuberculous abscess about lower dorsal spine, (arrow.) The Lungs 
181 
casts a pyriform shadow in the mid-line just above the diaphragm. The 
virulence of the infection in these cases is evidenced by the acute pneu- 
monic type of reaction in the lung which rapidly terminates in cavity 
formation. (Fig. 111.) 
FIGURE 111 
Caseous pneumonia with multiple small cavities in an infant. 
Disease of the intrathoracic lymph nodes is by far the most com- 
mon clinical manifestation of tuberculosis in children. Investigation 
has conclusively shown that involvement of these nodes is invariably a 
sequel of the primary lesion in the lung. Be the latter healed or in a 
condition of caseation and softening, certain groups of nodes will be 
found enlarged and caseous or calcareous, their situation conforming to 
the law of regional node involvement. Owing to the greater frequency 
of primary disease in the right upper lobe we will often find the greatest 
degree of enlargement in the upper and lower tracheo-bronchial chain 
on the right side and also in the upper broncho-pulmonary nodes. The 
communication by means of lymphatics across the median line however 
accounts for the frequent glandular enlargement on both sides, even in 
cases of unilateral pulmonary disease. 
It is a noteworthy fact that the glandular enlargement, especially 
in infants, is often out of all proportion to the size of the pulmonary 
lesion; a small caseous focus in the lung, draining through the pulmonary 
TUBERCULOSIS OF THE INTRATHORACIC LYMPH NODES 182 
The Lungs 
or pleural lymphatics may thus be the cause of a most extensive cheesy 
tuberculosis of the nodes at the hilum, which in size greatly over-shadow 
the pulmonary lesion. This may be attributed to the wide lymphatics of 
infants which facilitate free drainage. 
When we consider the clinical aspects of tuberculosis of the lymph 
nodes, we are impressed by the meagerness of the physical signs which 
they produce. It is essentially a disease of symptoms rather than of 
physical signs. The questionable value of the latter may be gauged by 
the number of alleged signs which various observers have described as 
characteristic, such as bronchial breathing over the manubrium (Heub- 
ner) , Petrushky’s spinalgesia, dilatation of the thoracic veins, Koranyi’s 
dulness below the fifth dorcal vertebra and finally D’Espine’s sign. 
Some of these are present in individual cases and they are independent 
probably on a considerable enlargement of certain groups of nodes 
which are favorably situated for the production of the particular physi- 
cal sign in question. Greater reliance is placed by the clinician on 
symptoms due to pressure on the bronchi, such as cough, dyspnoea and 
occasionally, a more or less characteristic stridor. 
FIGURE 112 
Tuberculous adenopathy in infant, unilateral. Enlargement of upper and 
lower broncho-pulmonary nodes on right side. The Lungs 
183 
On the other hand, when we study the Roentgen plate for evidences 
of glandular tuberculosis, the great advance in diagnosis afforded by 
this method of examination is at once apparent. The diseased lymph 
nodes in all their variety of size, shape and situation are projected on 
the plate in dense shadow masses which extend beyond the mediastinum 
into the pulmonary fields. 
We shall first discuss the tuberculous adenopathy of infants in 
whom it assumes a unique form. In them, the enlargement of the lymph 
nodes is relatively much greater than in older children, so much so, that 
the glandular mass may have the dimensions of a neoplasm. The first 
nodes which bear the brunt of the infection are the broncho-pulmonary 
groups, which lie within the lung fields close to the border of the heart 
and also the upper tracheo-bronchial group. The lower tracheo- 
bronchial or so-called bifurcation nodes are centrally situated and, 
being obscured by the heart, are not visible. Inability to see these 
nodes on the plate does not however limit the value of the Roentgen 
examination because their involvement is always associated with a 
tumefaction of the lower or upper broncho-pulmonary groups. 
We may now illustrate the various Roentgen types which result 
from disease of different groups of nodes. In figure 112 we see an 
enlargement of the upper right group of nodes which have produced 
Tuberculous adenopathy in infant, bilateral. 
FIGURE 113 184 
The Lungs 
a one-sided widening of the mediastinum. It will be noted that the 
border of the shadow mass is convex and smooth and that the shadow 
is of uniform density. Usually, as in figure 113 the nodes on both sides 
are enlarged, the result being a marked, though irregular widening of 
the mediastinum. We may explain the homogeneity of the shadows by 
the pathological change in the nodes, which are often in a condition of 
complete caseation and are matted together into a solid mass. A rather 
common Roentgen picture of glandular disease in infants is shown in 
figure 114 where there is an almost uniform widening of the medi- 
FIGURE 114 
Tuberculous adenopathy in young child, simulating thymic enlargement. 
astinum whose borders are sharply defined. The association of stridor 
and dyspnoea with such a shadow has frequently led to a diagnosis of 
enlarged thymus, which the autopsy almost invariably fails to confirm. 
Tuberculosis of the paratracheal group of nodes, which attain 
their greatest size on the right side, has a special interest for us in view 
of its symptomatology. Attention has been called to a remarkable 
dyspnoea and stridor in infants which may be caused by the pressure 
of this chain of nodes on the lower trachea, when they become enlarged. 
On the plate they cast a dense elliptical shadow which extends from The Lungs 
185 
the sterno-clavicular articulation to the eparterial bronchus. (Fig. 128.) 
They are as a rule associated with an enlargement of other bronchial 
lymph nodes and when they occur at the early age of two or six months 
usually have a bad prognosis. 
Although the primary lesion in the lung which is responsible for 
the glandular swelling is occasionally to be seen on the plate, as a rule 
it is too small to be recognized. In fact, it is often with the greatest diffi- 
culty that it is found at autopsy after careful dissection of the lung. The 
relation which the massive consolidations and the miliary and con- 
glomerate infiltrations that are occasionally seen on the plates of in- 
fants, bear to the tuberculous nodes, cannot always be defined from the 
Roentgen plate alone. While it is true that the pulmonary process may 
here be the primary one, it may on the contrary be a secondary infection 
due to the transport of bacilli through the circulation. For example, 
in figure 115 the enormous bilateral enlargement of the lymph nodes 
undoubtedly antedated the extensive lobular tuberculosis which was 
presumably metastatic in origin. Furthermore, some of the cases of 
Massive enlargement of the bronchial nodes in an infant. Disseminated 
lobular tuberculosis. 
FIGURE 115 186 
The Lungs 
infantile phthisis, with caseous pneumonia and cavitation are without 
doubt caused by the rupture of a cheesy lymph node into bronchus. In 
these cases the mechanism of the pulmonary affection can only be sur- 
mised but not proven from the Roentgen plate. 
The extreme glandular enlargement in infants which we have 
described is justly invested with an ominous import, as the disease is 
commonly fatal. Yet there are striking exceptions which make it 
unwise to utter a hopeless prognosis. Within a few months or a year 
there may be an almost complete recession of the greatly enlarged 
nodes. In some degree this decrease in size is only apparent because 
with the rapid growth of the chest and of the thoracic viscera during the 
first year of life the lymph nodes become relatively smaller and lose in 
prominence. 
There can be no doubt as to the tuberculous nature of this extreme 
glandular enlargement in infants. Other diseases in which similar 
shadows are found, such as mediastinal tumors, Hodgkin’s disease and 
leukemia are of rare occurrence in infants. Furthermore the uniform 
presence of a positive tuberculin reaction, whose value in infants is 
decisive, testifies to their tuberculous basis. 
The diagnosis of tuberculosis of the lymph nodes in older children 
raises a problem which has for a long time vexed both clinician and 
Roentgenologist. A decade ago, the Roentgenologist, carried away by 
enthusiasm for a new art, ascribed to the shadows of enlarged lymph 
nodes at the roots of the lungs an importance which sober afterthought 
has not justified. Since we have learned from extensive pathological 
studies and correlated tuberculin tests that tuberculization of over 90% 
of urban children has occurred by the time puberty is reached, it need 
occasion no surprise that the Roentgen plate almost invariably reveals 
shadows at the root of the lungs, which are presumably due to glandular 
tuberculosis. We must however discriminate between tuberculous 
infection, whose existence under the circumstances may be taken for 
granted and clinical disease, which will depend on the activity of the 
process in the lymph nodes. In regard to its activity, the Roentgen plate 
affords us no information. 
In view of these facts the scope of the Roentgen Ray in the clinical 
diagnosis of tuberculous bronchial lymph nodes is much circumscribed. 
When the Roentgenologist affirms that these nodes are diseased his stae- 
ment is of little value to the physician, because in most cases tuberculous 
glandular disease may be presumed to exist. The physician is more 
interested to know whether there is any causative relation between the 
enlarged nodes and the patient’s symptoms. This can only be deter- 
mined by the clinical and not by the Roentgen examination. This un- 
fortunately is not always an easy matter. There are numerous The Lungs 
187 
respiratory infections of non-tuberculous origin to which children are 
subject, which may give rise to cough, fever and swelling of the bron- 
chial nodes. Before these symptoms can be attributed to tuberculosis it 
is necessary therefore to exclude such other causes as adenoids and para- 
nasal infections and it may require a long period of observation before 
a decision is arrived at. It must moreover be remembered that it is not 
easy to distinguish on the plate between the moderate tumefaction of 
hyperplastic lymph nodes and the enlargement of tuberculous nodes, 
especially if caseation and calcification have not taken place. 
FIGURE 116 
Tuberculosis of bronchial lymph nodes. Note shadows of engorged vessels in upper lobes, 
often misinterpreted as “peribronchial” tuberculosis. 188 
The Lungs 
Tuberculous nodes in older children rarely attain the dimensions 
of those we have described in infants. With rare exceptions, (fig. 128), 
there is only a moderate increase in the extent and density of the root 
shadows which is due almost entirely to a swelling of the broncho- 
pulmonary nodes. As a rule the enlargement is greater on one side than 
on the other and usually the dense well outlined shadows resulting from 
caseation are visible. (Figs. 116 and 117.) The irregular and at times 
FIGURE 117 
Tuberculous enlargement of right paratracheal nodes. 
bizarre shadows of calcified nodes are seen only in older children and 
are practically never found in infants. (Fig. 118.) 
It is worth while to emphasize once more the precautions which 
must be observed in the interpretation of certain pulmonary shadows in 
cases of bronchial node disease. When these nodes are so situated as 
to press on the effluent pulmonary vessels and lymphatics, the latter 
become over-distended with blood and lymph. The influence of this 
vascular congestion on the pulmonary markings is similar to that The Lungs 
189 
Calcification of left broncho-pulmonary nodes in an older child. Healed 
primary lesion at right base. See figure 127. 
FIGURE 118 
observed in cases of chronic valvular disease. The markings become 
broader and form a coarse network corresponding to the ramifications 
of the blood vessels and lymphatics, which is most prominent in the 
upper lobes. (Figs. 116 and 119.) 
These shadows are often erroneously interpreted as a tuberculosis 
of the lungs spreading outward from the diseased lymph nodes, an 
interpretation which is calculated to exaggerate the seriousness of an 
otherwise mild infection. It also does violence to our conception of the 190 
The Lungs 
FIGURE 119 
Vascular network in right upper lobe produced by pressure of lymph 
nodes at root of lung. 
pathology of tuberculosis in children which, as we know, does not invade 
the lung in this manner but practically always remains confined to 
the lymph nodes. These shadows in themselves are not an evidence of 
pulmonary disease but are only a secondary result of the enlarged 
nodes and they have no significance. 
When plates are interpreted with due regard to such sources of 
error, the clinician is apt to be disappointed at the limited positive value 
of the plate in the diagnosis of glandular tuberculosis. He will soon 
find that there is no correspondence between the size of the lymph 
nodes and the severity of the clinical symptoms. Nevertheless, the 
value of the Roentgen examination in these cases is surpassing, although 
in a negative sense. In cases of suspected tuberculosis in a child it is of 
paramount importance to determine whether there is actual pulmonary 
disease or whether the infection is confined to the bronchial nodes. In- 
filtration of the lung itself adds immeasurably to the gravity of the case, The Lungs 
191 
whereas glandular tuberculosis is a relatively benign affection which in 
a majority of the cases becomes quiescent. It is because the diagnosis 
of pulmonary lesions in children, especially the relatively frequent 
infiltrations at the roots, is so uncertain by the ordinary methods of 
physical examination, that it becomes important whenever possible to 
exclude them by other means. For this reason the Roentgen plate has a 
major function in establishing an accurate diagnosis and therefore in 
providing a firm basis for prognosis. 
HILUM TUBERCULOSIS 
Tuberculosis of the hilum of the lung is a more common form of 
the disease in children than in adults. Aside from the interest which 
its usual situation arouses, it commands our attention because we owe 
FIGURE 120 
Hilum tuberculosis involving the middle lobe. 192 
The Lungs 
our knowledge of it as a clinical entity mainly to the Roentgen ray, by 
means of which alone, it is usually discovered. As its name implies, 
the tuberculous process originates at the root of the lung, from which 
it may extend outward a variable distance. 
Two types of hilum tuberculosis must be distinguished inasmuch 
as they differ in their pathology and prognosis. The first occurs com- 
monly in infants below one year of age and consists in a cheesy tubercu- 
losis of the root tissues of the lung. It is essentially a caseous primary 
lesion which is rapidly progressive and has a bad prognosis. (Fig. 106.) 
Aside from the clinical symptoms which will serve to distinguish these 
cases from non-tuberculous pneumonia, the Roentgen examination re- 
veals a difference in the configuration of their respective shadows. 
The pneumonic triangle usually has its base at the periphery, whereas 
in tuberculosis it is at the root. 
A second variety of hilum tuberculosis occurs in later childhood, 
being most common at the age of six. It is clinically a milder infection 
than the infantile form and appears to have a relatively good prognosis. 
In its spread from the root of the lung, it may involve the upper, middle 
or lower lobes or the contiguous portions of all of them. Figure 120 
illustrates in characteristic form a hilum tuberculosis invading the 
middle lobe, which was of some months’ duration and presented the 
clinical picture of a subacute tuberculous pneumonia. 
RECURRENT HILUM PNEUMONIA 
There remains to be described a very interesting variety of hilum 
tuberculosis which is characterized by the recurrence of symptoms of 
pulmonary infection at intervals of weeks or months, during which 
there are cough, fever and at times a few physical signs, which are com- 
monly audible anteriorly. During these attacks there will be seen on the 
Roentgen plate a triangular shadow whose base is at the root and is 
sharply outlined below by the interlobar fissure. After a lapse of sev- 
eral weeks the symptoms will subside and the Roentgen examination 
will show a complete disappearance of the shadow although a thicken- 
ing of the fissure may remain. Such a cycle of events may occur every 
few months. In the case illustrated in figure 121 we were able to observe 
the appearance and resolution of the pneumonia on three occasions with- 
in a few months, associated each time with cough and fever and slight 
dulness, with a few rales over the right upper lobe. There can be little 
doubt that these recurrent infiltrations are tuberculous in origin. That 
they are not due to the ordinary pneumonic bacteria is probable from 
the mildness of the symptoms, which do not even cause the patients to 
take to bed. On the other hand the evanescent character of the exudate, 
which may disappear in a week, makes it necessary to assume that the 
inflammatory reaction is an exudative one which is susceptible of rapid The Lungs 
193 
FIGURE 121 
Recurrent hilum tuberculosis involving right upper lobe. Plate (a) represents the active 
stage of the disease. Plate (b) taken during interval, shows complete absorption of in- 
filtration. 
absorption without undergoing caseation. If we may speculate as to 
their nature we may conceive these hilum pneumonias as mild reacions 
in the vicinity of tuberculous lymph nodes which are similar to the 
exudative processes that are often found about recent lesions in the 
lungs of adults. 
The difficulties in the physical diagnosis of hilum tuberculosis are 
in striking contrast to the ease of its demonstration by the Roentgen 
Ray. The infiltration is so deeply seated at the root of the lung that 
few if any physical signs are transmitted to the ear and the belief of 
the clinician is severely tested when, in a case with no physical signs, he 
is informed that an extensive infiltration nevertheless exists. In respect 
to the symptoms, these are often mild and differ little, if at all, from 
those which result from tuberculous lymph nodes. It is evident that in 
the diagnosis of hilum tuberculosis and especially in its differentiation 
from uncomplicated tuberculosis of the bronchial nodes, we are almost 
entirely dependent on the Roentgen examination. 
BASAL TUBERCULOSIS 
Tuberculosis of the lower lobes, without coincident involve- 
ment of the apices is a more frequent happening in children than 
in adults. Not only the primary lesion but also later infection of 
the lung may have such a localization. Some of these basal infiltra- 
tions may be explained as an extension of the inflammatory process 
from tuberculosis of the hilum into the lower lobes. In other cases 
undoubtedly the lobe becomes involved independently. The Roentgen 194 
The Lungs 
appearance in these cases is that of a consolidation of the lower 
lobe which presents no point of distinction from ordinary pneu- 
monia. For this reason its tuberculous character cannot be determined 
at once. Here the evidence derived from the clinical symptoms and 
signs outweighs the Roentgen findings and we are usually compelled to 
observe the further course of the disease, especially in respect to the 
persistence or disappearance of the infiltration, before any conclusions 
as to its nature may be drawn. 
Miliary tuberculosis of the lungs occurs more frequently in children 
than in adults and in most cases it is but a part of a general miliary 
tuberculosis. It is thus often found in association with tuberculous 
meningitis. (Fig. 122.) In general, the Roentgen appearance of 
MILIARY TUBERCULOSIS 
FIGURE 122 
Miliary tuberculosis; conglomerate type. The Lungs 
195 
tuberculosis in children is identical with that in adults. There is prac- 
tically never evidence of an older lesion in the lungs, in spite of the fact 
that at autopsy small primary lesions are usually present. 
In one respect the shadows of miliary tuberculosis in children may 
differ from those in the adult. In some cases, the tubercles are grouped 
into small masses surrounded by a zone of exudation so that conglom- 
erate tubercles are formed. This is illustrated in figure 122, the plate 
of an infant who succumbed to the infection. At autopsy, the tubercles 
were not of the miliary type, but were larger and easily visible and 
agglomerated into masses by exudation about them. The softening of 
a subpleural tubercle may lead to a perforation of the lung and 
spontaneous pneumothorax. (Fig. 286.) The purely pulmonary form 
of miliary tuberculosis is very uncommon; as it is usually secondary to 
an older focus in the lung, it is more apt to develop in later childhood. 
Miliary tuberculosis 
FIGURE 123 196 
The Lungs 
The infiltrations are less regular in distribution and there may be some 
evidence of caseation or fibrosis. (Fig. 123.) These cases often date 
their first symptoms from such diseases as measles or whooping cough 
which, as is well known, predispose to a dissemination of the tuberculous 
infection. In this child, who was nine years of age, the pulmonary 
symptoms followed an attack of measles. In spite of the extensive 
involvement of the lungs the temperature range was not high and the 
only physical signs were slight dullness over the right upper lobe with 
a few subcrepitant rales. 
ADULT FORMS OF TUBERCULOSIS IN CHILDREN 
The types of tuberculosis which we have thus far described com- 
prise its commoner forms, which are met with during infancy and 
childhood. As we approach puberty we encounter occasionally 
Adult form of tuberculosis in child. Disseminated lobular infiltrations with beginning 
fibrosis in apices with cavity formation. 
FIGURE 124 The Lungs 
197 
examples of the disease in which are seen evidences of greater chronicity 
and a tendency to induration which we have found so characteristic of 
adult or tertiary tuberculosis. For reasons which are still but imper- 
fectly understood the apical regions are especially susceptible to 
tertiary tuberculosis and we there find evidence of its earliest develop- 
ment. (Fig. 124.) The subsequent course of apical tuberculosis in the 
child is similar to that in adults and for this reason an extended descrip- 
tion of it is omitted. The antagon stic influences of caseation and 
fibrosis may here also result in the multiform pictures of fibro-caseous 
tuberculosis with cavitation, (fig. 125), and lobular or broncho-pneu- 
FIGURE 125 
Adult type of tuberculosis in a young child. Fibro-caseous tuberculosis with 
cavitation in upper lobe. 
monia. (Figs. 126 and 124.) We must, however, regard these adult 
types of the infection as very exceptional and when they occur in early 
childhood, as analagous to the precocious tertiary manifestations of 
syphilis. We may appropriately conclude our subject by a recital of 198 
The Lungs 
FIGURE 126 
Disseminated tuberculous lobular pneumonia. Adult type. 
two cases, which illustrate the evolution of the tuberculous infection in 
children as it was observed over a period of years. The first child came 
under observation at the age of six, when she presented the usual symp- 
toms of tuberculosis of the bronchial lymph nodes. The plate, (fig. 
118), showed in both lower lobes the cacified remains of small initial 
lesions which had apparently run a symptomless course. There was in 
addition a marked enlargement of the bronchial nodes in which lime 
deposits were already visible. After a lapse of six years, during which 
she was in good health, she was reinfected. She became acutely ill and 
presented the signs of an apical process. On the plate, (fig. 127), we The Lungs 
199 
Evolution of tuberculosis in adolescent child, showing development of an apical cavity. 
Previous plate, (fig. 118), made 6 years before shows only tuberculous adenopathy. 
FIGURE 127 
see a typical adult form of tuberculosis, consisting of nodular infiltra- 
tions in the right apex surrounding a circular cavity. 
The second case illustrates in an even more complete manner the 
cycle of changes which ran their course in three years. We have 
already alluded to the symptoms which ushered in the disease in this 
child of eleven years as a primary lesion of the right lower lobe. (Fig. 
105.) After the subsidence of the acute symptoms of the onset of the 
infection, this child remained apparently in good health for three years. 200 
The Lungs 
although her lungs bore the fruits of the disease in a marked adeno- 
pathy. Finally at the age of fourteen she once more presented herself 
with the signs of an apical infection. We now find on the plate the 
typical nodular infiltrations of adult tuberculosis at both apices, includ- 
ing a cavity at the left apex. (Fig. 128.) 
Evolution of tuberculosis in a child. Previous plate, (fig. 105), showed initial 
lesion and glandular enlargement. In this plate, 3 years later, upper lobe 
infiltration with cavity has developed together with marked increase in size 
of nodes. Arrow points to large paratracheal nodes. 
FIGURE 128 Chapter VII 
Pneumonia 
LOBAR PNEUMONIA. The Roentgen shadow of a lobar pneu- 
monia owes its more or less characteristic appearance both to the nature 
of the pulmonary exudate and to its lobar distribution. To the former 
we can ascribe the homogeneity of the shadow which results from a 
consolidation of the lung; the latter accounts for its configuration which 
is determined by the shape of the individual lobe or lobes which are 
affected by the disease. 
We must however not expect to find an exact correspondence in 
shape between the pneumonic shadow and the lobe of the lung, because 
a number of factors come into play which may considerably modify 
the former. In the first place, a lobe may be only partially consolidated 
so that its Roentgen shadow will not be coextensive with nor have the 
exact shape of the lobe. This is particularly true of upper lobe pneu- 
monias in children in whom the apices are often not involved. Of 
greater importance in modifying the pneumonic shadow is the position 
of the diseased lobe relative to the adjacent uninvolved ones. Owing 
to the oblique plane of the main interlobar fissure, the lobes overlap 
FIGURE 129 
Pneumonia of right upper lobe 202 
The Lungs 
each other at certain levels. Wherever this overlapping occurs, the 
shadow cast by a consolidation of an individual lobe is attenuated and 
its contour altered by the superjacent air-containing lung. It will also 
be apparent that the height of the target of the tube with respect to the 
consolidated area and the position of the patient, whether this be dorso- 
ventral or the reverse, will exert a marked influence on the size and 
appearance of the pneumonic shadow. 
UPPER LOBE PNEUMONIA. A consolidation of the right upper 
lobe usually casts a well defined Roentgen shadow in which the lower 
limit of the lobe is clearly outlined. (Fig. 129.) This is not the case on 
the left side because here the interlobar fissure is oblique so that the 
lower border of the pneumonic shadow becomes somewhat hazy. It 
will be noted that in many upper lobe pneumonias the apex remains 
uninvolved to the end of the disease. This is particularly the case in 
infants and young children in whom the consolidation may not be truly 
FIGURE 130 
Pneumonic triangular infiltration in right upper lobe in a young child. The Lungs 
203 
lobar but rather has a triangular shape with its base to the axilla. (Fig. 
130.) Later in the progress of the disease the triangle may encroach 
on the apical region without however completely filling it. (Fig. 131.) 
FIGURE 131 
Partial consolidation of right upper lobe. Ventro-dorsal view. 
An isolated pneumonia of the middle lobe is extremely rare. Its 
shadow, in the dorso-ventral direction, which is best adapted to bring 
it out, is characteristic. (Figs. 158 and 132.) It is not imabobable 
that it occurs more often in association with disease of the lower lobe 
in which case it merges with the shadow of the lower lobe pneumonia 
and is correspondingly modified. 204 
The Lungs 
FIGURE 132 
Pneumonia of the middle lobe. 
LOWER LOBE PNEUMONIA. The most varied shadows are 
found with pneumonia of the lower lobes, depending on the extent of 
the consolidation, the stage of the disease and on the technique of the 
exposure. Thus in figure 133 is seen a typical sharply outlined con- 
solidation of the right lower lobe, the tube being focussed relatively The Lungs 
205 
FIGURE 133 
Right lower lobe pneumonia; high focus of tube. 206 
The Lungs 
high near the level of the interlobar fissure posteriorly. On the other 
hand, in figure 134, the tube is in a lower position so that the margin 
of the pneumonic shadow is projected upward and attenuated by the 
FIGURE 134 
Lower lobe pneumonia at an early stage of disease. The shadow is extensive 
and its upper portion is indistinct due to the low focus of tube. Interlobar 
fissure outlined. 
interposed, aerated upper lobe. When the tube is focussed on the 
cervical region the shadow may be projected so far downward that 
it may be entirely obscured by the diaphragm in expiration or it may 
appear as only a narrow band above the latter and parallel with it. In 
the ventro-dorsal position, owing to the closer proximity of the lower 
lobe to the plate, the pneumonic shadow is of greater extent. With a 
low tube target the shadow may be projected almost to the apex as 
though there were a consolidation of the entire lung. Under these cir- 
cumstances, however, the upper border of the shadow lacks the sharp 
definition which is obtained with a higher position of the tube. (Fig. 
135.) i M'3 The Lungs 
207 
FIGURE 135 
Pneumonia of Left lower lobe. Owing to the low tube position, the pneumonic 
shadow is projected to the level of the second rfb anteriorly. 
In numerous instances the shadow of a lower lobe pneumonia does 
not present a completely lobar form. The lung may be only partially 
consolidated as in figure 136, in which the periphery is uninvolved. 
Occasionally a triangular shadow similar to that in the upper lobes 
may be found in the axillary portion of the chest just above the dia- 
phragm. 208 
The Lungs 
FIGURE 136 
Right lower lobe pneumonia with partial consolidation. 
Multiple lobe involvement, either simultaneous or in succession is 
often seen. Thus in figures 137 and 138 there is a consolidation of 
both the upper and lower lobes on the right side, whose shadows can 
easily be distinguished. 
The shadow of a lobar pneumonia is usually homogeneous. In its 
earliest stages it is of moderate density so that the lung structure may 
be distinctly seen through it. (Fig. 134.) As the disease progresses 
toward gray hepatization, the shadow increases in density. With rare 
exceptions it is not as dense as the liver, whose dome can always be dis- 
tinguished from the consolidated lung; the ribs are also visible through 
it. Shadows in the upper lobe are of greater intensity than those in the 
Tower lobes. The Lungs 
209 
FIGURE 137 
Right upper and lower lobe pneumonia. Yentro-dorsal view. 210 
The Lungs 
FIGURE 138 
Pneumonia of right upper and lower lobes. Middle lobe not involved. The Lungs 
211 
The resolution of a lobar pneumonia, which can be observed by 
successive Roentgen examinations, presents numerous points of interest. 
As a rule, the absorption of the exudate begins at the periphery of the 
lung and progresses toward the root (Fig. 189) ; it may, however, begin 
FIGURE 139 
Resolution of lower lobe pneumonia. 
in any portion of the diseased lung. Thus in figure 148 there is an 
atypical absorption of the exudate, which began at the base and gradu- 
ally extended upward. Complete resolution may require several weeks 
and distinct shadows are almost invariably found on the plate long 
after all physical signs of the disease have disappeared. In fact it is 
not uncommon for the affected lung to retain a mottled appearance due 
to deficient aeration for a considerable period after a pneumonia. Such 212 
The Lungs 
a mottling, unless the examiner is informed of the existence of a recent 
pneumonia, may give rise to errors in interpretation. Thus in figure 
140 the left upper lobe exhibits a fine granulation which is not unlike 
FIGURE 140 
Mottling of left upper lobe after pneumonia, closely resembling a miliary 
tuberculosis. 
that of a miliary tuberculosis. It persisted for a few weeks after a 
lobar pneumonia and finally disappeared entirely. 
At times the progress of resolution is very irregular; it may be 
much more rapid in some portions of the lungs than in others, so that a 
small area may have entirely cleared up while the surrounding lung is 
still consolidated. There may thus be formed circular defects or pseudo- 
cavities which it is important not to confuse with abscess cavities. (Fig. 
141.) In general, the shadows disappear most rapidly from the The Lungs 
213 
Atypical resolution of a lobar pneumonia. The light area within the con- 
solidated lung simulates an abscess cavity. 
FIGURE 141 
periphery of the lung; as the hilum is approached resolution is retarded 
and there will occasionally be noted a persistence of the shadows at the 
root for a number of weeks. (Fig. 142.) If the patient is observed for 
the first time at this stage of the disease, the Roentgen picture may be 214 
The Lungs 
Residual pneumonia at the root of the right lung 
FIGURE 142 The Lungs 
215 
very confusing. For example, in figure 143, there is a homogeneous, 
sharply outlined shadow extending outward from the root of the right 
lung, which by itself might pass for a mediastinal tumor. Resolution of 
FIGURE 143 
Slow resolution of a pneumonia with a persistence of the infiltration in the 
mesial portion. Note unusual sharp delimitation of pneumonic from normal 
lung. See figure 144. 
the pneumonia was arrested at this stage for over a week, when it was 
rapidly resumed. A second plate, made two weeks later showed a 
small, residual hilum pneumonia. (Fig. 144.) During resolution circu- 216 
The Lungs 
FIGURE 144 
Same case as figure 143 two weeks later, showing further resolution. Small 
residual infiltration at right hilum. 
lar islets of infiltration may be left within the lung, which may so closely 
resemble new growths that only their subsequent disappearance will 
clear up their true nature. The semi-circular consolidation seen at the 
right border of the heart in figure 145 persisted for weeks after a pneu- The Lungs 
217 
FIGURE 145 
Residual pneumonic area along right border of heart suggesting a tumor. 
The shadow disappeared one week later. 
monia and was the occasion for the liveliest speculation until it finally 
disappeared. Occasionally bizarre shadows of resolving pneumonia 
may be observed as in figure 146. 
Associated with pneumonia of the lower lobes, there is commonly 
an immobility and elevation of the diaphragm on the affected side 
which is presumably dependent on a dry pleurisy. This immobility is 
present not only during the active stage of the disease but may persist 
for some weeks after complete resolution. We may thus be enabled 
from the Roentgen plate alone to infer the previous existence of a pneu- 
monia in cases which have undergone complete resolution, or in which 
a few shadows of doubtful significance are seen at the base. The 218 
The Lungs 
FIGURE 146 
Unique shadow of residual pneumonia along left border of the heart. 
pleural complications of pneumonia, especially empyema, will receive 
detailed consideration in a separate chapter. Reference may here be 
made to those cases of pneumonia in which the pleura is covered by 
such a thick exudate that the physical signs of an elfusion are similated. 
On the plate also the differentiation may be difficult or impossible. The 
shadow of a pleuro-pneumonia is as dense as that of an effusion and for 
this reason the diaphragm may be invisible through it. In the case 
illustrated in figure 147 the massive shadow in the right chest was pre- 
sumed to be due to fluid, a presumption which received much support 
from the physical examination. Yet, repeated aspiration was fruitless The Lungs 
219 
FIGURE 147 
Pleuro-pneumonia. The dense shadow was due to a very thick pleural exudate. 
Repeated aspiration was negative. See figure 148. 220 
The Lungs 
and the subsequent resorption of the exudate, beginning at its most 
dependent point, figure 148, clearly proved that the shadow was not due 
to fluid in the pleural cavity. 
FIGURE 148 
Pleuro-pneumonia showing unusual resolution beginning at the base and extend- 
ing upward. Same case as figure 147, two weeks later. 
THE RELATION OF THE ROENTGEN TO THE PHYSICAL 
DIAGNOSIS OF PNEUMONIA 
In the case of adults, the opportunity is rarely given to examine 
with the Roentgen Ray the earliest stages of lobar pneumonia. For this 
reason the relation of the development of definite consolidations to the 
physical signs is a matter difficult of determination. It seems to be true, 
however, that lobar shadows on the plate are at least contemporary 
with the physical signs of pneumonia and it is likely that in many cases, 
the former precede the latter. The discovery of a lobar pneumonia on 
the screen or plate one or more days before the appearance of physical 
signs, has given a renewed interest to the conception of pneumonia as The Lungs 
221 
originally a central process which only later reaches the surface of the 
lung, a conception which in recent times has fallen somewhat into dis- 
favor among clinicians. For we occasionally see cases of pneumonia, 
showing extensive shadows on the plate, located at the root of the lung, 
which are difficult to explain otherwise than as deeply seated or central 
pneumonias. Thus, in figure 149 the right hilum pneumonia, which at 
FIGURE 149 
Hilum or central pneumonia, probably one day old. Process later extended 
to periphery. 
the time of the examination was perhaps one day old, produced neg- 
ligible physical signs. Only after its gradual extension to the surface 
and with an involvement of the peripheral portion of the right lower 
lobe did outspoken signs of consolidation appear. 
In infants it is well known that Roentgen shadows frequently pre- 
cede the physical signs of pneumonia. The localization of the pneu- 
mococcic infection in the lung may remain clinically latent and may not 
be discovered by physical examination for days after a shadow can be 
distinctly seen on the fluoroscopic screen. In older children especially, 222 
The Lungs 
this fact has an important practical bearing. For example, one of the 
difficult problems which is not infrequently encountered both by physi- 
cians and surgeons, is the differentiation in children between lower lobe 
pneumonias on the one hand and intra-abdominal conditions, such as 
peritonitis, especially of the pneumococcus type and appendicitis, on 
the other. The well known tendency of the pleuritic pain of a lower 
lobe pneumonia to be referred to the abdomen and to produce the reflex 
signs commonly associated with peritoneal irritation, may make it im- 
possible clinically to distinguish between the two. This is the more true 
because the uncertainty arises usually during the earlier stages of pneu- 
monia when physical signs may be entirely absent. In these cases the 
Roentgen examination is of incalculable service, as the discovery on the 
screen or the plate of a pneumonic consolidation may spare the child 
an unnecessary laporatomy. On the other hand, a negative Roentgen 
finding will confirm the diagnosis of intra-abdominal disease and lead 
to a timely operation. The Roentgen examination is peculiarly reliable 
in these cases because, in the earliest stages of lobar pneumonia en- 
countered clinically, even before physical signs are present, well marked 
shadows are already to be seen. 
FIGURE 150 
Confluent lobular pneumonia, probably due to aspiration. Duration two months. 
See figure 151. The Lungs 
223 
BRONCHO-PNEUMONIA AND LOBULAR PNEUMONIA 
The shadows of a broncho-pneumonia are often not demonstrable 
by a Roentgen examination. Unless the areas of pneumonia are large 
or confluent, they will cast only indefinite shadows, which it is difficult 
to distinguish from the normal lung markings. This is particularly true 
in children. The common location of broncho-pneumonia at the bases 
of the lungs, adds to the difficulties in diagnosis, because most of the 
lesions are apt to be deeply situated and therefore will be obscured by 
adjacent areas of normal or emphysematous lung. It is a common ex- 
perience therefore, for the clinician to obtain physical signs of a 
bronchiolitis and lobular pneumonia when the Roentgen examination is 
entirely negative. 
In cases of conffuent lobular or broncho-pneumonia on the other 
hand, the shadows may be very dense and extensive, involving com- 
monly the basal portions of the lungs. In figure 150 is seen such an 
extensive broncho-pneumonia of both lower lobes which followed pro- 
longed submersion in water. The clinical course was prolonged for 
over two months and during it there was much cough and dyspnoea. 
The gradual resolution of the process is indicated in a subsequent plate. 
(Fig. 151.) 
FIGURE 151 
Same case as figure 150 showing slow resolution. 224 
The Lungs 
In so-called ether or postoperative pneumonias similar shadows, 
though of less intensity, are frequently found in one of the lower lobes. 
The introduction into the community during the past few years, 
of epidemic influenza with its accompanying pneumonia has necessi- 
tated a change in our ideas with regard to the Roentgen diagnosis of 
lobular and broncho-pneumonia. The pneumonias which complicate 
influenza are characterized by an exudate which has great absorptive 
powers for the Roentgen ray so that shadows of great density are pro- 
duced. Further, the diversity of the pathological processes, comprising 
Confluent lobular pneumonia of right upper and lower lobes in epidemic 
influenza. Appearance indistinguishable from tuberculosis. 
FIGURE 152 The Lungs 
225 
hemorrhagic, exudative and purulent elements, scattered indiscrimin- 
ately throughout the lungs, has been responsible for a multitude of 
Roentgen types which were previously not encountered. Lobular areas 
may coalesce to form pseudo-lobar consolidations which cannot be dis- 
tinguished from true lobar pneumonias. This process frequently affects 
more than one lobe as in figure 152 and there is also a common involve- 
ment of the upper lobes. In some forms of the disease, the individual 
infiltrations remain small and discrete and their general appearance 
and frequent occurrence in the upper lobe creates the greatest difficulty 
in distinguishing between influenza pneumonia and tuberculosis. 
The presence of hemoptysis may add to this difficulty so that dur- 
ing epidemics the decision between tuberculosis and influenza has 
Persisting universal broncho-pneumonia. Cardiac enlargement. 
FIGURE 153 226 
The Lungs 
to be left open pending further Roentgen examinations. In the case 
illustrated in figure 152 both the clinical picture and the Roentgen plate 
were compatible with a tuberculous process in both upper lobes. Yet, 
the occurrence of the illness during an influenza epidemic made it 
advisable to await the outcome, before definitely affirming its tubercu- 
lous nature. The wisdom of this course was confirmed by the favor- 
able termination of the disease within a few days when a second Roent- 
gen examination showed a complete disappearance of the pneumonic 
shadows. 
Although the rapid disappearance of the shadows of influenza 
pneumonia may thus be regarded as a proof of their non-tuberculous 
character, we must bear in mind that in occasional cases, there is an 
imperfect resorption of the exudate together with intersitial fibrous 
changes, which may make for a persistence of the Roentgen shadows 
for a shorter or longer time. Thus in figure 153 there is an almost uni- 
versal lobular pneumonia which was still present four weeks after the 
subsidence of the fever. The patient suffered from marked dyspnoea 
which could readily be explained by the extent of the pulmonary involve- 
ment and perhaps also because of obliterating bronchiolitis. The 
constant, extreme dyspnoea lasting for weeks, had apparently effected 
a weakening and dilatation of the right heart. 
One of the surprising disclosures of the Roentgen examination is 
the frequency with which unsuspected broncho-pneumonia at the bases 
is found in patients who are clinically regarded merely as cases of acute 
or chronic bronchitis. These pneumonias are commonly so mild and 
their physical signs are so completely obscured by those of bronchitis 
and emphysema, that they are overlooked and the symptoms are there- 
fore regarded as an exacerbation of an existing bronchitis. The 
shadows of the pneumonia, usually in one of the lower lobes is of 
course readily perceived on the plate. Frequently the persistence of 
these pneumonic infiltrations is responsible for a chronic cough with 
expectoration which, in the absence of physical signs, is apt to put the 
patient under suspicion of tuberculosis; the Roentgenologist will here 
frequently have the grateful task of dispelling the fear of tuberculosis 
and of giving the proper direction to the treatment. Chapter VIII 
Pulmonary Suppuration—Abscess and 
Gangrene of the Lung 
Suppurative lung disease includes a number of affections of diverse 
etiology whose common basis is an inflammatory process which leads to 
necrosis of the lung parenchyma. Clinically we further differentiate 
them into cases of simple abscess and of gangrene of the lung. The 
latter are dependent on invasion of the lung by the micro-organisms of 
putrefaction which impart to the sputum its fetid odor, on which the 
diagnosis of gangrene is essentially based. Here also, as in the diagnosis 
of tuberculosis, it is necessary to be informed in regard to the pathology 
and clinical aspects of the disease, if the Roentgen shadows are to be 
intelligently interpreted. There will be frequent occasions when the 
plate will exhibit shadows which are not characteristic of lung abscess 
and the distinction between it and other disease will not be obvious. 
The Roentgenologist will then have to draw on his knowledge of the 
pathology of the disease and of the clinical symptoms in the particular 
case in order to eke out the diagnosis. 
For practical purposes we may classify cases of lung suppuration 
roughly into two groups, the larger one of which includes the abscesses 
which develop acutely and are characterized by an early onset of 
gangrene and the formation of one or more necrotic cavities. There is 
reason to believe that the cause of the suppurative process in these 
patients is the aspiration of septic material from the mouth, especially 
during anesthesia or other unconscious states, with the growth in the 
bronchi and lungs of anaerobic bacteria. 
In contrast to this group stands a second in which the disease is 
slower in its development, whose pathogenesis is probably quite differ- 
ent. The most prominent members of this group are the cases of 
pneumonia which have become chronic and have later, as an incident 
to fibrosis and bronchial dilatations, developed a secondary gangrene 
and abscess of the lung. 
It will contribute to a clearer understanding of the manifold causes 
of lung abscess and its probable mechanism if we indicate, by a tabula- 
tion of the first 100 cases which we observed, the various causative 
factors which preceded their onset. 228 
The Lungs 
Aspiration Abscess— 
Post Operative: 
Tonsillectomy 21 
Other operations 6 
Following Unconscious States: 
Submersion 2 
Morphine 1 
Alcoholic 1 
Foreign Body 2 
Acute Pneumonic Gangrene 16 
Non-Aspiration Abscess— 
Chronic Pneumonic 21 
So-called Grippe 21 
Empyemic 1 
Miscellaneous— 
Embolic (Suppurative Thrombo-phlebitis) 1 
Tuberculous 2 
Secondary to Carcinoma of Lung 1 
Secondary to Carcinoma of Esophagus 1 
Actinomycotic 1 
Diabetic 1 
Syphilitic 1 
As will be seen in the development of our theme, this division into 
aspiration and noil-aspiration abscesses, in which the majority are com- 
prised, not only bears on their causation and mechanism but is also re- 
flected in the pathology of the disease, its mode of progression in the 
lung and therefore also in its Roentgen appearance. 
PATHOLOGY 
Let us rehearse briefly the probable sequence of events which 
terminate in an acute lung abscess. If we conceive this as due to the 
aspiration of infectious material, which, in our experience is most often 
derived from diseased tonsils, during operation, we may picture to our- 
selves the lodgment of this material in one of the smaller bronchi. At 
the point of its arrest there develops an acute inflammation of the 
bronchial wall and a pneumonia of the adjacent lung. Of great 
significance for the further course of the disease is the presence in the 
aspirated material of putrefactive bacteria, which exert their destruc- 
tive influence on the wall of the bronchus, which they weaken and dilate 
and finally destroy. The termination of this process, which is com- 
monly a rapid one, is marked by the formation of a smaller or larger 
cavity, whose walls are formed by the consolidated and necrotic tissue The Lungs 
229 
in which it has been excavated. This consolidation, consisting of a 
pneumonic infiltration may involve a small portion of a lobe or a whole 
lung. The further course of such an abscess may result either in com- 
plete resolution or in early death or finally in a subacute and chronic 
stage. 
It is important to remember, and this has a bearing on the Roentgen 
interpretation, that the pneumonic process which is invariably associated 
with a lung abscess, exercises a determining influence on the further 
course of the case. This pneumonic process, under the stimulus of the 
gangrenous focus in its centre, may acquire a persistent, chronic char- 
acter which leads to induration and occasionally, in long standing cases, 
becomes fibrotic. Conditions are therefore favorable for the secondary 
formation of multiple, cylindrical dilatations of the bronchi which may 
be infected by anaerobic organisms and may in turn be converted into 
necrotic cavities. We therefore usually find in these cases one large 
cavity which is the original one and numerous smaller gangrenous 
bronchiectases. 
In the non-aspiration cases, the course of the disease is frequently 
more chronic from its inception. Primarily the process is not sub- 
purative or gangrenous. There is an insidious development of a sub- 
acute or chronic pneumonitis with fibrosis, which, as in the other forms 
of the disease, is responsible for multiple bronchial dilatations. The 
disease may be arrested at this stage for a variable period of time, for 
months or years, during which evidence of suppuration or gangrene of 
the lung may be absent. It is only with the advent of putrefactive 
bacteria, under conditions which we cannot explain that the disease 
assumes a really suppurative and destructive form; it then becomes 
clinically indistinguishable from cases of aspiration abscess. 
It will be evident from this short description of the pathology of 
lung suppuration, that putrefactive bacteria play a dominating role in 
the evolution of the disease. In fact, the essential element in acute 
or aspiration abscess is putrefaction, which is rarely or never absent. 
We may therefore properly speak of it as an acute gangrenous pneu- 
monitis, which in our experience has a definite incubation period and a 
unique pathology. The external evidence of the gangrene, consisting 
in a fetid odor to the breath and sputum, appears regularly on the 12th 
to the 14th day from the time of aspiration, be this postoperative or 
from some other cause. 
ROENTGEN DIAGNOSIS 
Let us now inquire in what manner a lung abscess reveals itself on 
the Roentgen plate. Its earliest stage can best be observed in the case 
of acute or aspiration abscess, as the chronic types do not come under 
early observation. If patients are examined even a few weeks after 230 
The Lungs 
the onset, there will usually be found a cavity of varying size, 
surrounded by an area of pneumonia. There is no constant relation 
between the size of the cavity and that of the surrounding pneumonia. 
Frequently they seem to stand in inverse relation to each other. Thus 
the cavity in figure 154 which is of moderate size, is surrounded by a 
FIGURE 154 
Abscess cavity surrounded by an extensive area of consolidation. Duration eleven weeks. 
consolidation of the entire left lower lobe. In this case the disease was 
of eleven weeks’ duration. The excavation of the lung may reach great 
proportions very early in the disease. The abscess cavity in figure 155 
which is half full of fluid must have resulted from a rapid breaking 
down of the lung, as it had already attained this size three weeks after The Lungs 
231 
Lung abscess three weeks after tonsilectomy. 
FIGURE 155 
tonsillectomy. Again in figure 156, six weeks after the onset, we have a 
complete destruction of the right upper lobe which is converted into a 
cavity half full of fetid secretion. It is likely that these large cavities 
are formed by the rapid necrosis of an extensive pneumonic area which 
must have preceded them. 
The typical finding therefore in the early stages of acute abscess 
and gangrene of the lung, in those cases which are not progressing to 
cure, is a large cavity usually partly filled with fluid, surrounded by 
more or less pneumonia. These patients are usually acutely ill, have 
high fever and expectorate large quantities of characteristically foul 
sputum and they not uncommonly succumb at this time from a putrid 
intoxication. 
When we turn now to the chronic postpneumonic type of abscess, 
we are struck by the preponderance of pneumonic infiltration and by the 
minor role which the necrotic process may play. For a long time the 
plate may disclose no evidence of suppuration or cavity formation, but 
only a pneumonic infiltration at the base. In fact, during this insidious 232 
The Lungs 
FIGURE 156 
Excavation of the entire right upper lobe by an acute abscess in six weeks. 
development of a chronic pneumonia, it is only potentially a case of lung 
suppuration; the conditions which will favor a secondary anaerobic 
infection are in process of creation. It is even probable that the indur- 
ated lung offers a greater resistance to necrosis than an acutely 
inflamed one, so that the cavities which are formed are small and slow 
in their evolution. The small irregular gangrenous bronchiectases are 
frequently entirely obscured by the surrounding lung. For this reason, 
the clinician will often detect the signs of suppuration before typical 
evidence of it is found on the plate. 
The development of fibrosis in the pneumonic lung may be traced 
by successive Roentgen examinations until dense irregular shadows, 
such as are seen in figure 157, are found. We have in this case a lung 
gangrene which terminated a persistent pneumonia of eight months’ 
duration. Although no cavities were visible on the plate, the profuse 
purulent and fetid expectoration left no doubt of their presence and this 
was confirmed by the necropsy findings. The Lungs 
233 
FIGURE 157 
Indurative pneumonia with secondary gangrenous bronchiectases. Eight months’ 
duration. 
While the suppuration of chronic pneumonias involves most often 
the lower lobes, this situation of the process has numerous exceptions. 
The upper lobes may be the seat of the disease and in rare cases, there 
may even be an isolated involvement of the middle lobe. Because of 
its great rarity we illustrate such a case in which the Roentgen plate 
shows the characteristic appearance of a middle lobe pneumonia. 
(Fig. 158.) In this patient the disease, of insidious onset, progressed 
gradually to the complete picture of lung suppuration. Aspiration 
near the right border of the sternum in the 4th interspace revealed a 
collection of pus in this region which at operation was found to be a 
subpleural abscess cavity of the middle lobe. Here again the outlines 
of the cavity were obscured by the shadow of the infiltrated lung. 234 
The Lungs 
FIGURE 158 
Indurative pneumonia of middle lobe with abscess. 
THE FURTHER COURSE OF ASPIRATION ABSCESS 
Acute lung abscess may result fatally within a short time during 
the stage of extensive necrosis and cavitation. When, on the other hand, 
the patients survive for months or years, as they frequently do, 
the inflammatory process undergoes an evolution which is reflected in 
a constantly changing clinical picture. In the portrayal of these 
changes the Roentgen examination can render us invaluable service. 
It faithfully depicts the extension or recession of the diseased area, it 
notes the existence and growth of cavities in situations inaccessible to 
physical examination and provides the only certain information as to 
the cure of the patient. Finally, by an accurate localization of the 
disease, it guides the surgeon in the precise application of his operative 
procedures. 
We will attempt to reconstruct in a fragmentary way the life 
history of pulmonary abscess by the study of a number of plates which 
illustrate its various phases. The great role which the abscess cavities The Lungs 
235 
and their highly infectious secretions play in the aggravation of the 
disease is constantly brought to our attention. The overflow of this 
secretion is an ever-present menace to adjacent or distant portions of 
the lung which are thus involved in the suppurative process. Figure 159 
FIGURE 159 
Abscess of left upper lobe with secondary infection and abscess formation 
of the lower lobe. 
illustrates this clearly. The patient acquired an abscess of his left 
upper lobe following an operation. The contents of this abscess, whose 
fluid level is seen at the 2nd rib anteriorly, have infected the left lower 
lobe which is consolidated. A second cavity at the left base resulting 
from the necrosis of the pneumonic lung has already formed. Again 
in figure 160 we see a large cavity in an upper lobe which was presum- 
ably due to the aspiration of gastric contents incident to a spasmodic 
stricture of the oesophagus. For months this woman presented the 
symptoms of lung suppuration without, however, being acutely ill or 236 
The Lungs 
FIGURE 160 
Abscess of left upper lobe. Secondary gangrenous pneumonia of lower lobe. 
suffering from the effects of toxic absorption. There came a day 
however, when the purulent contents of the cavity infected the rest of 
the left lung. She became acutely ill, with signs of consolidation of 
her left lower lobe and died in a few days with the symptoms of putrid 
intoxication. 
The clinical course of the disease is thus frequently punctuated by 
attacks of broncho-pneumonia which may undergo resolution or become 
necrotic; the exacerbation of cough, fever and expectoration may often 
be explained by such an extension of the process which is reflected on 
the plate by an increase in the size of the pneumonic area. 
When acute abscesses progress to the subacute stage, it is usual 
for the infiltration to undergo considerable resorption so that the 
original cavity is surrounded by a relatively small area of pneumonia. The Lungs 
237 
In fact, as seen in figure 161, the infiltration may entirely disappear and 
leave a walled-off cavity within the lung. It is probable that such a 
condition, unless the cavity itself becomes obliterated, is only temporary; 
the basis for infection of the lung still exists in the secretions of the 
cavity, whose pernicious effects sooner or later manifest themselves. 
FIGURE 161 
Chronic abscess cavity with well-marked capsule. 
With increasing chronicity of the abscess, the fibrotic tendency of 
the infiltration becomes marked and secondary bronciectases are 
formed. In the older cases therefore, multiple smaller cavities are 
usually found in addition to one large one. The lung abscess seen in 
figure 162 followed tonsillectomy and was of eight months’ duration. 
The pneumonic area is well defined and encloses the original large cav- 
ity and two smaller secondary cavities above it. 238 
The Lungs 
FIGURE 162 
Multiple abscess cavities in right upper lobe, eight months after tonsillectomy, 
The extreme coarse fibrosis which is so characteristic of the fibroid 
form of tuberculosis, is rarely seen in chronic lung abscess. For this 
reason, marked deformity of the chest and displacement of the medi- 
astinum are not often encountered. When this is the case, as sometimes 
happens, the distinction between suppuration and tuberculosis is diffi- 
cult and final dependence must be placed on the clinical features. In 
figure 163 there is an extensive unilateral fibroid disease of the lung 
with multiple small cavities in the upper lobe. It will be noted that 
the right chest is smaller in volume than the left, the ribs are drawn 
together and the mediastinum is displaced to the right side. There is a 
noticeable absence of any disease in the left lung. The presumption of 
a long duration of the disease in this case is confirmed by the clinical 
history which informs us that the patient contracted her illness seven 
years before. During the interval she constantly expectorated purulent 
sputum which was occasionally fetid, in varying amounts up to ten 
ounces daily. We have here a form of chronic pulmonary suppuration 
which, because of its benign course, frequent hemoptysis and clubbed The Lungs 
239 
Chronic indurative pneumonia and fibrosis, with multiple bronchiectatic 
abscesses. Seven years’ duration. 
FIGURE 163 
fingers is often treated as a tuberculous affection. When we weigh the 
conflicting evidence in a case of this sort, the absence of tubercle bacilli 
must not be permitted to bear too heavily in the scales; the possibility 
of secondary suppuration and gangrene engrafted on a tuberculous 
process has to be borne in mind. 
While the distinction between tuberculosis and suppuration may 
therefore not at once be apparent from the plate, there are other cases, 
and these constitute the majority, in which the Roentgen features render 
tuberculosis improbable. For example, a young man for four years had 
occasional fever, spat up large quantities of purulent sputum, and spent 
several years in tuberculosis sanatoria. The unusual shadow in his 
right upper lobe, so unlike tuberculosis, (fig. 164,) immediately cast 
doubt on the diagnosis. At operation, a large abscess cavity, sur- 
rounded by dense connective tissue, was found. 240 
The Lungs 
FIGURE 164 
Chronic abscess of right upper lobe. At operation a large abscess cavity was 
found within the indurated area represented by the shadow. 
The Roentgen study of acute abscess and gangrene may furnish 
us objective evidence of the progress of the disease to a complete cure. 
It must be clear from the nature of the inflammatory process that this 
can most readily take place in the early period of the disease before 
fixed tissue changes have occurred in the lung. We find in fact, that a 
spontaneous cure results in approximately one-third of the cases of 
acute abscess and gangrene, practically always within three months of 
their onset. The Roentgen evidence of such a cure will consist in a 
complete disappearance of the cavity and its surrounding infiltration. 
To illustrate, the abscess in the right upper lobe (fig. 165) was of 
about two weeks’ duration and was acquired presumably by aspiration 
during alcoholic coma. Within one month, cough and expectoration 
THE HEALING OF ABSCESSES The Lungs 
241 
ceased and the patient was completely restored to health. The only 
vestige of the abscess which was then to be found on the plate was a 
few coarse strands of scar tissue at its previous site. (Fig. 166.) 
FIGURE 165 
FIGURE 166 
Abscess cavity in right upper lobe (arrow), 
two weeks’ duration. 
Same case one month later. Abscess healed, 
leaving only a few strands of fibrous tissue. 
(Arrow.) 
Even considerably larger cavities may disappear in the course of 
a few weeks. Thus, no remains of the large cavity seen in figure 155 
could be found on the plate taken three weeks later. This capacity for 
healing defects so promptly and completely is characteristic of the 
lung and it depends on its unique spongy structure. Acute abscesses 
do not heal slowly by granulation as is the rule elsewhere in the body. 
They are on the contrary, quickly obliterated by the expansion of the 
surrounding lung when the exudate which fills the alveoli is absorbed 
and they are once more distended with air. This occurs as soon as the 
gangrenous wall of the cavity, which has maintained the surrounding 
lung in a state of consolidation, is sloughed out and expectorated. In 
the chronic abscess cavities on the other hand, where a rigid fibrous 
wall has been formed, such a rapid healing of the cavity is precluded; 
in fact these cavities, with rare exceptions, cannot heal spontaneously. 
When the progress of a lung abscess is thus observed on the Roent- 
gen plate, we are forced to the conclusion that little or no dependence 
can be placed on the disappearance of the symptoms or the physical 
signs, as a proof of the patient’s cure. It is not uncommon, a few weeks 
or months after the onset of the disease, for the patient to experience a 
great improvement; the cough, expectoration and fever may entirely 242 
The Lungs 
disappear and both patient and physician congratulate themselves on 
the happy issue of a dreadful malady. Nevertheless, when we make a 
careful Roentgen examination there will be found in a numbe of these 
cases, an apparently insignificant residue of infiltration in the lung. If, 
as may happen, this focus of disease contains the germs of anaerobic 
infection, the latter may lie dormant for some time until they later 
become the starting point for a renewed infection of the lung. 
The observer who is disposed to disregard such residual foci will 
profit by an experience such as the following: 
A young woman acquired a postoperative abscess of her right lower lobe. After two 
months of the usual symptoms she improved to such a degree that she was unwilling to submit 
to further treatment and left the hospital. There were no abnormal physical signs in the chest 
and the bronchoscopic examination revealed only a slight dilatation of the right lower 
bronchus, from which issued a minimal amount of secretion. On discharge from the hos- 
pital her plate showed a small pneumonic area in the middle of the right lower lobe. (Fig. 
167.) Witness the unfortunate outcome of this case. Three months later the patient appeared 
with a recurrence, in an aggravated form, of all her earlier symptoms, including large pul- 
monary hemorrhages and high fever. The plate then made, (fig. 168.) showed an extensive 
infiltration in the upper part of the right lower lobe, at the summit of which a small cavity 
is to be seen. 
FIGURE 167 
FIGURE 168 
Residual infiltration in right lower lobe 
(arrow.) Two months after a postoperative 
abscess of lung. Clinical cure. 
Same case three months later with a recru- 
descence of symptoms and an extensive sup- 
purative process in right lower lobe. 
The significance of even vague shadows on the plate of patients 
who are known to have had a lung abscess and in whom symptoms 
which may be attributed to a simple bronchitis persist, cannot be over- 
estimated. These shadows acquire an unwonted importance when we 
view them in retrospect and realize with what ominous possibilities The Lungs 
243 
they were freighted. In figure 169, only on close examination can we 
discern in the right upper lobe a small annular area of infiltration and 
a few coarse shadows near the root of the right lung. The patient 
traced his illness back seven months when he contracted influenza and 
pneumonia. This was followed by a persistence of the fever and 
FIGURE 169 
Residual infiltration after postinfluenzal abscess of seven months duration, (arrow.) 
See figure 170. 
expectoration which gradually became purulent and fetid. These 
symptoms continued until the time of the examination. His only signs 
consisted of dullness and diminished breathing in the right infra- 
spinous region. The clinician, were he ignorant of the previous history 
of the patient might be pardoned for doubting the adequacy of these 
few Roentgen shadows to explain a persisting suppuration. Yet the 
sequel proved this to be so. A plate, (fig. 170,) made eight months 
later, revealed a fluid-containing cavity, which developed at the site of 
the previous infiltration. A residual necrotic focus, for a long time 
lying dormant and causing only a bronchitis, had reinfected the lung 
about it and brought in its train the outspoken symptoms of lung sup- 
puration. 244 
The Lungs 
FIGURE 170 
Same patient as in Figure 169 eight months later. Extension of infiltration 
with abscess formation. 
Such illustrative cases could be multiplied to emphasize the need 
of conservatism in pronouncing a gangrenous lung abscess cured when 
it has lasted more than a few months. As we have seen, relief from 
symptoms cannot be accepted as an index of cure and equally little 
weight should be attached to an absence of physical signs. No one who 
has had any experience with these cases can fail to be impressed with the 
meagreness of the physical signs in many cases of suppurative lung 
disease. Even large areas of infiltration may produce only slight dul- 
ness and diminished breathing. The smaller residual foci, especially 
those at the roots of the lungs, which play so important a role in the 
exacerbation of the process, are nearly always latent and only the Roent- 
gen examination brings them to light. 
ABSCESS CAVITIES 
Abscess cavities, because they are the most striking manifestation 
of lung suppuration, may properly lay claim to a more detailed con- 
sideration. Although cavities are invariably to be found in the lungs at 
autopsy or operation, in only a small percentage of the cases can their 
presence be determined by the physical examination. This percentage The Lungs 
245 
is notably increased when we resort to the Roentgen-Ray, yet even with 
this aid they entirely elude us in at least one-half of the cases. Thus in 
one hundred cases of lung suppuration in which this feature was investi- 
gated, there were indubitable physical signs of a cavity in only twelve, 
where excavation of the lung was demonstrated on the plate in fifty. 
Various reasons may be assigned for this circumstance. Cavities 
which are full of secretion, especially when they are small, may be 
entirely obscured by the infiltrated lung about them. If they are later 
emptied by expectoration, they may come to light as circular defects 
within the consolidated area. Thus, the lung abscess in the right upper 
lobe in figure 171 revealed on the plate only a dense pneumonic con- 
solidation. Yet, two days later, after an unusually profuse expectora- 
tion, the outlines of several small cavities appeared. (Fig. 172.) In 
Lung abscess, right upper lobe. Cavities not 
seen. 
FIGURE 171 
After profuse expectoration, several small 
cavities are visible. 
FIGURE 172 
truth, the Roentgen shadows, in whose lineaments we attempt to trace 
the pathology of this disease, represent but an imperfect image or sil- 
houette of the affected lung. The limitations of the examination 
cannot be better exemplified than by the following series of three plates 
of a patient taken at short intervals. Figure 173 portrays the area of 
suppuration on admission to the hospital. No cavity was visible. When 
again examined, a few weeks later, a large cavity was noted on the 
plate. (Fig. 174.) But it would be a mistaken view to regard this as 246 
The Lungs 
Pneumonic consolidation at root of lung. 
No abscess cavity seen. 
FIGURE 173 
FIGURE 174 
Same case as figure 173. a few weeks later. 
A large cavity now visible. 
See figure 175. 
FIGURE 175 
Same case as figure 174 after partial resection of lung. Shows a number of 
cavities previously hidden by consolidated lung. The Lungs 
247 
the extent of the necrotic process. A short time after, the patient was 
operated on and a considerable portion of the diseased upper lobe was 
resected. There were then visible five cavities of different sizes which 
had been entirely obscured by the overlying lung. (Fig. 175.) Finally, 
when at autopsy it was possible to examine the lung in detail, it was 
found to be full of innumerable small and large necrotic abscess cavities. 
At times the Roentgenologist must vary his procedure in order to 
detect cavities which are located in unusual situations. In figure 176 
is illustrated an irregular cavity which lies within a diseased middle 
lobe. It was necessary to resort to the oblique position in order to dis- 
close this cavity, as it was completely obscured by the heart in the dorso- 
ventral position. The same difficulty was encountered to a lesser degree 
FIGURE 176 
Consolidation of middle lobe, with irregular abscess cavity, twenty-two months 
after tonsillectomy. Cavity only seen by oblique examination as it was situated 
behind the heart. 248 
The Lungs 
in anothe erase of lower lobe abscess on the left side. (Fig. 177.) Here 
again, the cavity was partly hidden by the left ventricle in such a way 
that the fluid level was incomplete and doubt arose as to the nature of 
the shadow. The patient was re-examined in the recumbent position, 
lying on his right side. By this manoeuvre the fluid level was shifted 
clear of the heart shadow and all doubt as to the existence of a cavity 
was removed. (Fig. 178.) 
FIGURE 177 
FIGURE 178 
Abscess of left lower lobe, partly obscured 
by the left ventricle. 
Same case as figure 177, in lateral recum- 
bent position showing change in level of 
fluid in cavity. 
The Roentgen demonstration of larger cavities seems often to be 
facilitated by an increased density of the lung about them. This 
phenomenon has been observed in cases associated with pneumothorax. 
A cavity which may not have been previously visible may be clearly 
outlined within the compressed lung after the entrance of air into the 
pleural cavity and in doubtful cases this procedure may be resorted to 
for purposes of diagnosis. 
In general, abscess cavities are circular and smooth in outline; 
occasionally, and this is true of the smaller ones, they may be oval or 
irregular. They are rarely surrounded by a recognizable capsule but 
appear rather as defects within the pneumonic infiltration which sur- 
rounds them. Cavities which have attained a moderate size practically 
always communicate with a bronchus; the free access of air causes their 
fluid contents to assume a horizontal level which is surmounted by a 
hemi-spherical air space. Such a fluid collection, which can be caused 
to shift its level by a change of position, is so characteristic that it The Lungs 
249 
constitutes positive evidence of a cavity, even when, as frequently hap- 
pens, the wells of the latter are indistinct or invisible. Cavities vary in 
size from some which are barely distinguishable to others which occupy 
a whole lobe. The larger cavities are found with much greater fre- 
quency in the acute aspiration abscesses than in the chronic pneumonic 
forms. This finding is in harmony with the greater role which the 
gangrenous process plays in the former. The rapidity with which 
abscess cavities may form is astounding. In virulent cases we have 
observed on the plate the necrosis and complete excavation of a lower 
lobe within forty-eight hours and have verified this by autopsy. 
LOCATION OF THE ABSCESS 
Suppurative disease may affect any lobe of the lung and in the 
longer standing cases a multiple lobe involvement is frequent. If we 
analyze a sufficiently large number of cases in respect to the localiza- 
tion of the disease, a distinct difference will be found to exist between 
the acute aspiration or post-operative abscess and the chronic pneu- 
monic type. In the former there is a predilection for the upper lobes, 
which are involved twice as frequently as are the lower lobes. In only 
two instances have we encountered isolated middle lobe suppuration, 
one of which, figure 176, followed tonsillectomy, the other developing 
insidiously after a pneumonia. The diagnosis of these cases of middle 
lobe disease presents unusual difficulties to the physical examiner 
because of the central location of the morbid process, whose physical 
signs are notoriously meagre. 
Abscess involving contiguous portions of 
right upper, middle and lower lobes. Cavity 
with fluid level. 
FIGURE 179 
Same case as Figure 179 after removal of 
entire right lung. 
FIGURE 180 250 
The Lungs 
The exact localization of the abscess, which we owe in such full 
measure to the Roentgen examination has a practical bearing which 
transcends its value as a mere method of diagnosis. To the surgeon 
who contemplates the drainage of a cavity or the incision of a lobe, the 
situation of the abscess will determine his method of approach and for 
this purpose an accurate localization is essential. Even with the Roent- 
gen examination this is not always possible. Especially on the right 
side, the overlapping of the three lobes in the middle third of the chest 
will render it difficult to assign an infiltration in this region to any one 
lobe or to the adjacent portions of all three lobes. Here stereoscopic 
examination may be of service. In figure 179, for example, it is impos- 
sible to deduce from the plate alone, whether the abscess is situated in 
one or more lobes; at operation a considerable portion of all three lobes 
was found to be diseased. In these cases, dependence must be placed on 
the location of the physical signs to distinguish between an affection 
of the lower part of the upper lobe and the upper part of the lower 
lobe, the shadows of which will be super-imposed on the plate. 
COMPLICATIONS OF LUNG ABSCESS 
During the clinical course of a lung abscess the patient is con- 
stantly threatened with serious complications. As some of these involve 
the lungs and pleura, they may well engage our attention. Perhaps 
the commonest complication of lung abscess is a pleural effusion, which 
may be due to the rupture of a cortical abscess into the pleural cavity. 
If, as is usually the case, there is a communication with a bronchus, a 
pyo-pneumothorax results with all its attendant symptoms. The com- 
plete picture of the abscess with the associated effusion may then be 
visible on the plate and the entire sequence of events may be reconstruct- 
ed from it. As an example we may instance the following: 
A middle-aged man contracted pneumonia which in five weeks assumed the typical char- 
acter of lung abscess. Increasing dyspnoea and fever brought him to the hospital where the 
Roentgen examination revealed a pneumonic consolidation in the mesial portion of the 
right upper lobe and a collection of fluid and air at the right base. (Fig. 181.) Above the 
latter the lung was partly attached to the chest wall by adhesions. 
The slow approach of an abscess toward the pleural surface of the 
lung may permit the formation of adhesions beween the parietal and 
visceral surfaces of the pleura before it perforates. When this finally 
occurs, the pyo-pneumothorax which develops may be entirely encapsu- 
lated and a unique Roentgen picture such as figure 277 may be the 
result. Here again, following an acute influenzal lung abscess with 
gangrene, perforation occurred on the posterior aspect of the lung. The 
adhesions about the pleural effusion, which are well shown on the plate, 
were found at operation to be firm and effectually walled the effusion 
off from the general pleural cavity. The Lungs 
251 
FIGURE 181 
Abscess in mesial part of right upper lobe with small cavity. Perforation of 
abscess with pyo-pneumothorax. Falciform shadow due to adherent lung. 
A characteristic symptom which may arise when there is a free 
communication between the pleural cavity and a bronchus, consists in a 
paroxysm of coughling and the expectoration of a large amount of 
purulent sputum when the patient changes his position. If the open- 
ing of the pleuro-pulmonary fistula is situated above the level of the 
fluid, the latter will flow upward and be discharged through the fistula 
when the patient assumes the recumbent position. It may thus be pos- 
sible to localize accurately the fistula by noting on the fluoroscopic 
screen at what position of the fluid level the patient begins to cough and 
to expectorate pus. 
It is not necessary for an abscess actually to perforate the lung, in 
order to stimulate the pleura to inflammatory reaction. A nonpurulent 
effusion may thus result from a subpleural abscess and with an 
increasing intensity of the reaction we may observe the gradual 
change in the character of the fluid from a serous to a frankly purulent 
one. The problems which present themselves to the clinician in these 252 
The Lungs 
cases are complex and their solution is often facilitated by the Roentgen 
examination. This is especially true of some cases of chronic suppura- 
tion of the lung which have lasted for years and in which the symptoms 
of pulmonary disease may to a great extent have subsided. At any time, 
however, the process may be aroused to activity and if by chance the 
pleura is then infected from a cortical abscess, the resulting pleurisy 
may so dominate the clinical picture that it may on a cursory view 
appear to be the primary condition. When the chest of such a patient 
is aspirated it may happen that at one level clear fluid is obtained from 
the pleura and at a higher one, pure pus from an abscess cavity. The 
clinician is here under the necessity of distinguishing between an abscess 
with a secondary serous effusion in the pleural cavity and a bilocular 
empyema, which contains purulent fluid at one level and serous fluid at 
another. The Roentgen plate may supply the solution, as it did in the 
following case: 
Lung abscess of four years’ duration with secondary pleural effusion which 
obscures the abscess. Purulent fluid obtained from middle of chest and clear 
fluid at base. See figure 183. 
FIGURE 182 The Lungs 
253 
The patient, a young man, had contacted a lung abscess four years previously, possibly 
from the aspiration of a foreign body. Following its insidious onset his disease become 
almost quiescent until the recent development of a pleural effusion. Figure 182 shows the 
Roentgen appearance of his chest at the first examination. When his left chest was aspirated 
at the base, clear, polynuclear fluid was withdrawn, whereas insertion of the needle higher 
up in his axilla, brought forth pure pus. The latter issued from a walled-off abscess cavity 
which had been entirely obscured by the pleural effusion. After the removal of the latter, 
a plate made in the lateral recumbent position clearlv revealed this cavity and its purulent 
contents. (Fig. 183.1 
FIGURE 183 
Same case as figure 182 after removal of pleural effusion. Shows a large 
abscess cavity with purulent contents. Shifting fluid level in lateral recum- 
bent position. 
We must especially keep in mind the possibility of latent suppura- 
tion of the lung in the case of children who, with no adequate antecedent 
disease, develop encapsulated effusions. As the basis of the suppura- 
tion there may exist a foreign body which has been aspirated into a 
bronchus, of which everyone, including the patient, may be ignorant. 
The cough, lasting for many months may be attributed to a bronchitis 254 
The Lungs 
until the rupture of a bronchiectatic abscess and the resulting empyema 
lead to a closer scrutiny of the case and the discovery of the underly- 
ing infection of the lung. (Fig. 184.) 
Chronic suppuration of lung in a child following aspiration of foreign body. 
First sign of acute disease resulted from perforation of a cortical abscess with 
empyema. Arrow points to piece of metal in bronchus. 
FIGURE 184 
Although the pleural complications of lung abscess are usually of 
serious import and often add to the difficulties of operation, there are 
cases in which they appear to exert a favorable influence on the out- 
come. Thus in acute abscesses, especially those following influenza the 
early rupture of a cortical focus with the resulting empyema, has often 
led to prompt drainage of the suppurating lung and a rapid cure of the 
patient. 
Only casual reference is necessary to embolic abscesses of the lung 
which are secondary to septic thrombosis of the systemic veins. The 
small abscesses, which are usually multiple and produce a furunculosis 
of the lung play but a minor part in the clinical picture. On the Roent- 
gen plate they cast smaller or larger irregular circular shadows which 
are indistinguishable from a lobular pneumonia. The Lungs 
255 
Although in the vast majority of cases of lung abscess, especially 
of the acute variety, suppuration is associated with gangrene, there are 
occasional cases, usually following lobar pneumonia, in which resolu- 
tion is complicated by simple suppuration without gangrene. The pul- 
monary cavity, which is easily seen on the plate, does not communicate 
with a bronchus and the disease may run its course to complete healing 
without the expectoration of pus. 
We have attempted to show in our discussion of lung suppuration, 
that the Roentgen examination is qualified to supply the clinician with 
valuable information in regard to the diagnosis and prognosis of this 
disease and also at times to point the way to intelligent treatment. One 
of the Roentgen features of lung suppuration, the abscess cavity, is 
sufficiently typical to warrant an immediate diagnosis; on the other 
hand, we must be prepared, in the numerous instances in which it is 
absent, to make the diagnosis without it and to interpret correctly the 
FIGURE 185 
Chronic postpneumonic lung abscess. Shadow has circular shape and definition 
of a lung tumor. 256 
The Lungs 
less characteristic infiltrations which are nevertheless an essential 
element in the disease. It will be necessary at times to distinguish these 
from tuberculosis, new-growths (fig. 185) and even encapsulated 
effusions, which is not always an easy matter. As an isolated method of 
examination there are definite limits to the application of the Roentgen 
ray in cases of lung abscess; regard for these limitations will impel the 
examiner constantly to turn to the patient himself for confirmation of 
his interpretations. The Roentgenologist left to his own resources may 
therefore frequently be at a loss, unless he summons to his aid such 
significant facts of the clinical history as a previous operation or a pneu- 
monia. It must also be evident that the expectoration of fetid sputum 
and the finding in it of elastic fibres and clubbing of the fingers will 
exert a determining influence on the interpretation of questionable 
shadows. As in other thoracic diseases, the Roentgen examination has 
its greatest usefulness in the diagnosis of lung suppuration when its 
findings are made a co-ordinate part of the whole clinical picture and 
are brought into harmony with it. Chapter IX 
Non-Tuberculous Chronic Infections 
of the Lungs 
Aside from tuberculosis, which accounts for the vast majority of 
cases of chronic lung infection there is a not inconsiderable number of 
cases in which other agencies than the tubercle bacilli are responsible 
for chronic pulmonary disease. Among these we find the ordinary 
pathogenic bacteria of acute pneumonia which under favorable con- 
ditions may incite a more persistent inflammatory process and such 
rarer causes as the virus of syphilis and the various mycotic organisms. 
Of these cases, chronic indurative pneumonia constitutes the great 
majority, whereas the other forms of pulmonary disease are excep- 
tional. 
CHRONIC INDURATIVE PNEUMONIA 
Clinically the chronic pneumonias constitute an ill-defined group of 
cases of widely varying symptomatology. Their insidious development 
and their frequent similarity to pulmonary tuberculosis often lead to 
their confusion with this disease, while in other cases the presence of 
particular symptoms, such as frequently recurring hemorrhages, may 
arouse a strong suspicion of new-growth. This variable clinical picture 
is dependent on the peculiar pathology of the disease as it passes from 
the stage of persisting pneumonia through different degrees of organiza- 
tion and induration to fibrosis. In the course of this organization, 
secondary changes such as bronchial dilatation and abscess formation 
are not uncommonly produced, which impress their characteristic symp- 
toms on the clinical picture. 
The commonest form of indurative pneumonia is found in older 
individuals and frequently follows an acute basal pneumonia. Of 
greatest interest are the cases of the “grippe” type in which the symp- 
toms and signs of pulmonary inflammation are so slight that they are 
not recognized. Frequently only the persistence of cough and expectora- 
tion and the almost invariable spitting of blood with slight temperature 
indicate the existence of pulmonary disease which, often as not, is 
looked upon as pulmonary tuberculosis. 
The Roentgen picture in these patients commonly reveals a shadow 
at the base of the lungs, which in the one case may have the density of 
a consolidation, whereas in the other it has the faintness of a resolving 
process. The basal situation of the process at once serves to distinguish 
these cases from tuberculosis. 258 
The Lungs 
Marked structural changes in the lung may be induced in the sub- 
acute stage of indurative pneumonia, which are reflected in striking 
Roentgen shadows. Thus, the massive consolidation seen in figure 133 
was found at operation, when the lobe was excised, to be due to a sub- 
acute organizing pneumonia, with beginning bronchial dilatation and 
purulent bronchitis. The illness of the patient dated from a pneumonia 
contracted seven months before and at the time of operation the disease 
acquired an acute character. 
As the subacute stage of the disease is passed and with an increas- 
ing tendency to fibrosis, we may at times observe on the Roentgen plate 
an increasing density and coarseness of the shadows. At this point the 
final direction which the pathological process will take is determined 
by a number of secondary factors. In certain cases there develops a 
general bronchial dilatation to which, especially in older individuals, 
there is super-added an anaerobic infection. The wall of a bronchus 
becomes gangrenous and the complete clinical picture of suppuration 
of the lung is evolved. Thus in figure 157 are seen the coarse shadows 
of an organizing pneumonia of eight months’ duration which terminated 
in gangrene of the lung. Although abscess cavities originating in 
the dilated bronchi are invariably found in the excised lungs, they are 
rarely visible on the plates as they are imbedded in and obscured by the 
indurated lung. 
In the absence of anaerobic infection the disease is apt to remain 
a mild one and to continue for years with few or no serious symptoms. 
These are the cases which we have already described in the chapter on 
bronchial diseases, as multiple bronchiectases, which are characterized 
by a profuse expectoration and the almost universal presence of clubbed 
fingers. The disease here most often involves the lower lobes. 
Of greater interest, because of the diagnostic problem presented, 
are the occasional cases of chronic pneumonia with bronchiectatic forma- 
tion which involve also the upper lobes. The history of these cases ex- 
tnds usually ovr so long a period that the symptoms attending their onset 
have passed from the memory of the patients, who only know that they 
have been coughing for years. In many instances the disease has been 
regarded as tuberculous and the patients have been inmates of tubecu- 
losis sanatoria. For this belief there is often much justification, as the 
physical signs, the profuse expectoration and the occasional hemoptyses 
would lend credence to such a view. The constant absence of tubercle 
bacilli and the remarkably good general health of these patients sooner 
or later shakes the confidence of the physician in the diagnosis of 
tuberculosis, which the Roentgen examination makes even more doubt- 
ful. The plate in these patients commonly shows unilateral fibrosis of The Lungs 
259 
the lungs in which numerous thin-walled cavities may be seen. (Fig. 
186.) There is also usually a retraction of the chest wall and a dis- 
placement of the thoracic viscera toward the diseased side. 
Chronic indurative pneumonia with multiple bronchial dilatations. Displacement of heart 
and mediastinum. 
FIGURE 136 
In distinguishing these cases from tuberculosis, the absolute limita- 
tion of the process to one lung is of the greatest importance. While 
fibroid tuberculosis may be restricted to one lung, usually, if the case 
is of some duration, the Roentgen examination will disclose some degree 
of infiltration of the opposite lung. 
From a practical therapeutic point of view much interest attaches 
to chronic disease of the lung incident to the obstruction of a bronchus 
by a foreign body. The partial or complete occlusion of a bronchus, 260 
The Lungs 
whether by an external tumor or aneurysm or by an intrabronchial 
growth or foreign body, may result in a stasis of bronchial secretion 
with subsequent infection which, if unrelieved, may terminate in sub- 
acute or chronic indurative pneumonia. Provided the obstruction is re- 
moved in time, as in the case illustrated in figure 19, permanent damage 
to the lung may be obviated. In case of continuing occlusion however, 
the damage to the lung will be permanent, leading to greater and 
greater fibrosis. In chronic pulmonary disease in children one must 
especially have in mind the possibility of the aspiration of a foreign 
body into a bronchus. This may happen without the child being aware 
of it and it becomes the starting point for a long train of symptoms 
characterized by fever, cough, profuse expectoration and ultimately 
clubbing of the fingers. The Roentgen examination usually shows 
extensive pulmonary shadows, pneumonic in type and at times the 
shadow of the foreign body. (Fig. 184.) In this patient who, probably 
four years before, aspirated a portion of a tin whistle, serious attention 
was only drawn to the pulmonary condition by the sudden perforation 
of a cortical bronchiectatic abscess with empyema. Unfortunately, 
after such a long duration, removal of the foreign body and drainage 
of the pleural cavity had little or no influence on the chronic lung 
disease. 
In the types of induration which we have thus far considered, the 
lung is solely involved, to the exclusion of any disease of the pleura. 
There is, however, a group of cases in which the fibrosis may be 
described as pleuro-pneumonic in that, either primarily or secondarily, 
the pleura shares in the fibrotic process. In the complete clinical 
picture of pleuro-pulmonary fibrosis, it may be a matter of some 
difficulty to determine the priority of the process in the lung or in 
the pleura. There are undoubtedly some cases in which the inflam- 
matory process is initially a pleuro-pneumonia in which the fibrosis 
progresses simultaneously in the lung and pleura. In these cases, with 
or without pulmonary symptoms, there is a progressive shrinkage of 
the chest with a marked thoracic deformity and cardiac displacement 
and an obliteration of the pleural cavity. 
On the Roentgen plate these changes are strikingly in evidence. As 
seen in figure 187, the pleura is greatly thickened so that the details of 
the underlying lung are obscured and the heart and mediastinum show 
an extreme displacement. In the physical examination of these patients 
the clinician is placed at a great disadvantage. The thickened pleura 
usually does not permit the transmission of breath sounds; the dis- 
placement of the trachea to the side of the sternum, by the production 
of pseudoamphoric breathing, simulating a cavity, leads to a diagnosis 
of pulmonary tuberculosis. The Lungs 
261 
FIGURE 187 
Chronic non-tuberculous disease of lung and pleura. Pleuro-pulmonary fibrosis. Deform 
ity of chest and displacement of heart and mediastinum. 
The cases of pleuro-pulmonary fibrosis which begin in the pleura 
are probably the sequel of untreated empyemata. Often they have 
been incompletely evacuated, leaving behind a residuum of inflammatory 
material which progresses to organization. In some cases the pleural 
exudate perforates the lung which it infects and involves in the inflam- 
matory process; in other cases, fibrosis invades the lung along the inter- 
lobular septa. In either case the clinical and Roentgen picture of pleuro- 
pneumonic induration which we have described, ultimately develops. 
The many-sided clinical picture which chronic indurative pneu- 
monia may exhibit is nowhere better illustrated than in the cases which 
simulate a new growth of the lungs. Beginning insiduously as a pneu- 
monia, the pulmonary infiltrations may progress to carnification in six 
or eight months. In addition to the usual symptoms of the infection, a 
persistent, almost daily hemoptysis and thoracic pain may be present. 
Such a train of symptoms, especially if there is some loss of weight, 
cannot fail to arouse the suspicion of a new growth of the lung. The 
Roentgen examination in some of these cases may even add to the diffi- 262 
The Lungs 
culties in diagnosis as the type of shadow found may easily be confused 
with that of a tumor. The area of induration in the lung may be sharply 
circumscribed and have the density and contour of a malignant growth. 
Thus in figure 188 is seen a dense, tumor-like shadow which was found 
Organizing pneumonia. Both clinical and Roentgen picture that of a tumor 
of the lung. 
FIGURE 188 
six months after a lobar pneumonia and which was presumed to be due 
to a neoplasm. At operation, however, a carnified lung was found. If 
these patients are observed for a short period and repeated Roentgen 
examinations are made, it will be discovered that the size of the infiltra- 
tion is subject to an alternate rapid increase and decrease in size which 
is not consistent with a tumor growth. The Lungs 
263 
It will be evident that in the diagnosis of a disease which has so 
protean a clinical picture and Roentgen appearance as chronic indura- 
tive pneumonia, a knowledge of the chronology of the symptoms and 
their sequence is of the greatest moment to the examiner. The definite 
history of a pneumonia or of antecedent pleural disease or of the 
aspiration of a foreign body may point clearly to the true nature of the 
disease. 
In the interpretation of the extensive unilateral infiltrations and 
bronchiectases the clinical examination is of major importance. The 
discovery of clubbed fingers within a few months after the onset of the 
disease is of the greatest significance, as they develop very rapidly in 
non-tuberculous infections, whereas it requires years for them to make 
their appearance in cases of tuberculosis. Finally, in occasional cases 
of this type also a positive Wasserman test or the discovery of actinomy- 
cosis in the sputum will place an entirely nover interpretation on the 
Roentgen shadows. Chapter X 
Actinomycosis of the Lungs 
Actinomycosis is one of the rarer causes of chronic non-tuberculous 
disease of the lung. The nature of the inflammatory process, in which 
suppuration and induration of the lung are combined with bronchial 
dilatation and abscess formation makes for a Roentgen shadow of great 
density and usually of considerable extent in the involved lung. In 
interpreting these shadows we must keep in mind the tendency for 
actinomycosis rapidly to invade the pleura which becomes thickened 
and also to infiltrate and finally to perforate the chest wall. The dense 
shadows which we see when the disease is fully developed are therefore 
as much due to inflammatory thickening of the chest wall and pleura 
as to the pulmonary infiltration itself. Thus the dense shadow in the 
left upper lobe region in figure 189 was found in a patient who for some 
months had the symptoms of suppurative lung disease. Gradually a 
prominence of the left upper chest began to form until, at the time of 
the examination, there was a red fluctuating mass over the left upper 
FIGURE 189 
Actinomycosis of lung, pleura and chest wall. The Lungs 
265 
chest. This was incised, disclosing an induration of the chest wall com- 
municating by tortuous sinuses with the pleural cavity, where consid- 
erable pus containing the ray fungus was found. The lung beneath was 
so indurated that after the evacuation of the pus, the Roentgen shadow 
was of the same density as before. A similar case is illustrated in 
figure 190. 
FIGURE 190 
Actinomycosis of lung and pleura 
It will be seen that the Roentgen picture by itself presents little 
that is characteristic. The shadows are those of an indurative pleuro- 
pneumonia, such as may be found in other forms of lung suppuration. 
If, however, with such a shadow, there is associated a prominence and 
infiltration of the chest wall, the Roentgenologist may with some assur- 
ance infer that it is due to actinomycotic infection of the lung. Chapter XI 
Echinococcus Cyst of the Lung 
It is the frequent experience of the Roentgenologist that diseases of 
the chest which are most difficult of diagnosis by the conventional 
methods are often most easily discovered by the Roentgen Ray. No- 
where is this more strikingly illustrated than in the case of echinococcus 
cysts of the lungs. Situated deeply in the parenchyma of the lung and 
having no communication with the bronchial tubes, they often remain 
clinically latent during the period of their greatest growth. It there- 
fore happens that echinococcus cysts are accidentally discovered when 
their existence is least expected and the clinician is amazed that such 
large masses in the lung are consistent with a total absence of physical 
signs. 
The two cases of echinococcus cyst of the lung which we herewith 
illustrate exemplify these features of the disease. The first, (fig. 191) 
FIGURE 191 
Solitary echinococcus cyst of the lung. The Lungs 
267 
is a solitary cyst of large size in the right lung of a man of 55 years. His 
symptom was precordial and right thoracic pain which naturally directed 
attention to the heart and coronary arteries. There were no abnormal 
physical signs. 
The second case, (fig. 192), shows multiple cysts of different sizes. 
Here also the patient, a young man who had spent some years in the 
Orient, had no physical signs of thoracic disease and the cysts were 
symptomatically latent. They were discovered incidentally to a gastro- 
intestinal Roentgen examination. 
FIGURE 192 
Multiple echinocoecus cysts. One cyst partly seen above the left diaphragm. 
The Roentgen appearance of echinococcus cysts is so typical as to 
offer no difficulty in diagnosis. They are uniformly circular or slightly 
elliptical. The shadow is homogeneous, of considerable density and 
is sharply defined from the surrounding lung. No other type of pul- 
monary shadow excepting that of metastatic tumors, even remotely 
resembles it. However, pulmonary tumors which have attained the 
size of a cyst are rarely so uniformly circular nor so dense; moreover, 
the primary tumor will usually have made itself manifest in some other 
part of the body. Chapter XII 
Syphilis of the Lungs 
The history of pulmonary syphilis as a clinical entity from the time 
of Pancritius, who popularized it, to the present day, illustrates the 
vagaries into which medical diagnosis may be led when it is subject to 
the enthusiasm or bias of the observer. In the pre-Wasserman era, the 
occasional discovery of a case of luetic disease of the lung only too often 
led to its promiscuous and unwarranted diagnosis. More recently the 
introduction of the Wasserman test and the recognition of the wide 
diffusion of syphilis have again given impetus to the diagnosis of pul- 
monary syphilis. Periodically such cases are reported for no other 
reason than the occurrence of physical signs of pulmonary disease in a 
syphilitic patient. 
Yet it is common knowledge that syphilitic lesions are rarely found 
in the lungs at autopsy and therefore the clinical diagnosis of lung 
syphilis, even in the luetic patient, is always precarious. 
These considerations apply with equal force to the Roentgen 
diagnosis of this disease. In view of the wide dissemination of tubercu- 
losis it will not be an uncommon happening to find infiltrations in the 
lungs of patients who present clinical signs of lues or who exhibit only 
a positive Wasserman reaction. Nevertheless in spite of the overwhelm- 
ing preponderance of tuberculosis as a cause of such infiltrations, these 
cases are periodically reported as examples of pulmonary syphilis. 
This practice is to be deprecated. A positive serum reaction should not 
of itself create a presumption in favor of syphilitic disease of the lung. 
On the contrary, if the Roentgen shadows have the features which we 
have learned to associate with tuberculous deposits, it is wiser, in view 
of the much greater frequency of the latter, to regard them as tubercu- 
lous. A suspicion of syphilis may be aroused by an atypical arrange- 
ment of the shadows or by some unusual circumstance of the case and 
the Roentgen and other data should then be so correlated as to be 
mutually confirmatory, if possible. In any case the diagnosis should 
be advanced with caution. It will gain probability in so far as Mher 
diseases can be excluded and it will attain certainty only by the chera- 
puetic test, that is, by the disappearance of the infiltrations under 
antispecific treatment. 
From the Roentgen standpoint, because of the few cases which are 
encountered, no systematic description of the different forms of pul- 
monary syphilis can be attempted. We can however try to interpret 
the plates in terms of the various pathological processes which are 
known to occur in syphilitic disease of the lung. They are as follows: The Lungs 
269 
(1) Gummata, (2) Intersitial pneumonitis, resulting in fibrosis, 
which probably arises from the peribronchial and perivascular con- 
nective tissue, (3) Diffuse, lobular syphilomatous infiltrations. 
Having imposed on ourselves the limitations in diagnosis above 
indicated, a few cases of lung syphilis will here be recorded. Four of 
them responded to the therapeutic test and may therefore, be consid- 
ered as proven. The other cases for various reasons to be indicated, 
could not be so tested and the diagnosis must therefore, remain in 
doubt. The clinical history however, taken with the Roentgen findings 
and the exclusion of other causes for the pulmonary changes, render 
the diagnosis at least probable. 
Case 1. A middle aged man with symptoms of gastric ulcer had 
for some months been coughing and occasionally spitting blood. The 
Wasserman reaction was positive. Physical signs of dulness with some 
moist rales were made out at the right base posteriorly. The Roentgen 
examination made at this time showed the infiltration at the root seen 
in figure 193 (a). The day after this examination the patient brought up 
Syphilitic infiltration at root of right lung. Clinical picture of lung suppur- 
ation. See figure 193. 
FIGURE 193(a) 270 
The Lungs 
fetid sputum in large amounts with some blood. The temperature 
ranged from 101° to 103°. An intensive course of antisyphilitic treat- 
ment was instituted with prompt relief of the symptoms. In three weeks 
the infiltration had entirely disappeared. (Fig. 193b.) Here we evi- 
FIGURE 193(h) 
Same case as figure 193(a). Disappearance of shadow at right root after anti- 
syphlitic treatment. 
dently had to deal with a syphilitic process, perhaps a gumma, which 
broke down and clinically presented the features of lung suppuration 
and gangrene. 
Case 2. A woman, 63 years of age, for four months had a pain- 
less swelling of the sternal end of the left clavicle. The Wasserman 
reaction was strongly positive. Although she had no cough and was 
apparently in good health, the discovery of a few sibilant rales at the 
right base led to the Roentgen examination. This revealed the infiltra- 
tion in the right lower lobe shown in figure 194. After a course of anti- The Lungs 
271 
Pneumonic infiltration of right lower lobe in syphilitic patient. Process was 
latent. See figure 195. 
FIGURE 194 
syphilitic treatment, both the swelling of the clavicle and the infiltration 
in the lung disappeared. (Fig. 195.) Here we have illustrated a differ- 
ent type of syphilitic infiltration which manifested itself as a benign 
pneumonic process giving rise to no symptoms. The absence of fever or 
other symptoms of an acute inflammatory affection of the lungs and the 
prompt cure under treatment justify the diagnosis of lung syphilis. 272 
The Lungs 
FIGURE 195 
Same case as figure 194. Disappearance of infiltration after anti-syphlitic 
treatment. The Lungs 
273 
Case 3. This patient, a very anemic woman showed evidence of a 
severe degenerative kidney disease with marked albuminuria, associated 
with oedema of the lower extremities. In addition she had persistent 
oedema of the right arm. The Wasserman reaction was strongly posi- 
tive. Roentgen examination of the chest revealed a circular shadow 
at the right apex, the periphery of which showed evidence of fibrosis. 
(Fig. 196.) Pulmonary physical signs were absent. The similarity of 
this shadow to that of a new-growth prompted a re-examination of the 
patient at intervals of some months. There was no increase in the size 
of the shadow. Owing to the renal condition, thorough antispecific 
treatment could not be instituted. 
1IGURE 196 
Probable gumma at right apex. 
In this case it is presumed that the syphilitic lesion was a gumma of 
the upper lobe probably on or near the pleura which, by pressure on 
tie subclavian vein accentuated an existing tendency to oedema. In 
spite of the positive Wasserman reaction, however, the diagnosis of 
syphilis was only ventured after other more common conditions, espec- 
ially a neoplasm, were excluded as improbable. 274 
The Lungs 
Case 4. The following case, in its variegated features, illustrates 
the complexity of the clinical picture to which luetic lung disease may 
give rise. A woman of 38 years, who probably acquired syphilis from 
her husband a few years previously had moderate cough with muco- 
purulent expectoration for a few weeks. She then became acutely ill 
with high fever and copious expectoration. For a month before she 
entered the hospital she was thus very ill with daily fever, occasional 
chills, was much prostrated and became extremely emaciated. The 
examination of the lungs brought to light an unusual combination of 
physical signs. The left chest was immobile. The percussion note 
above was a dull tympany, whereas at the base there was flatness. The 
respiratory murmur was almost absent over the upper lobe; at the base 
the breathing was amphoric and accompanied by numerous musical 
rales, some of which were tinkling. Sputum was brought up in large 
amounts and was purulent, most of the pus cells being degenerated. 
There was evidently a consolidation of the lower lobe with an abscess 
cavity and atelectasis of the upper lobe. 
The Roentgen plate, figure 197, shows a marked displacement of 
the trachea to the left. The absence of any retraction of the left chest 
indicates that tins displacement is dim to pulmonarv atelectasis rather 
than to fibrosis, as the sequel showed. The entire left lung is consoli- 
FIGURE 197 
Syphilis of lung. At arrow is probably indicated a gumma of lung com- 
pressing left bronchus. (X) Symptoms of suppurative pneumonitis. Atelec- 
tasis of left upper lobe. See figure 198. The Lungs 
275 
dated. At the origin of the left main bronchus there is an oval denser 
shadow of about the size of an olive. The patient was given vigorous 
antisyphilic treatment to which she responded immediately. The fever 
subsided, the expectoration progressively diminished and within a few 
weeks all signs of consolidation and cavity disappeared. The condition 
of the lung four weeks after treatment was begun is shown in figure 
198 where only a small residual infiltration, with a diaphragmatic 
adhesion is seen. 
Same case as figure 197 after antisyphilitie treatment. Gumma has absorbed; 
residual infiltration at left base which subsequently disappeared. 
FIGURE 198 
It is not easy to interpret in pathological terms the nature of the 
inflammatory process in this case. We may venture to assume from the 
history, that there was a subacute, diffuse syphilitic process, perhaps 276 
The Lungs 
associated with gummata, which became necrotic. The entire absence 
of disease of the right lung is worthy of notice. 
Case 5. Perhaps the most common form of pulmonary syphilis 
encountered, if it may at all be characterized as common, is the so-called 
syphilitic fibrosis. Pathologically this consists of broad connective 
tissue bands which extend radially outward to the periphery, often 
involving the pleura. In the development of this fibrosis there may 
result large or small bronchiectatic cavities and stenosis of the bronchi. 
Such a type is illustrated in figure 199. The patient was a young woman 
FIGURE 199 
Syphilitic fibrosis of right lung and pleura. Heart and trachea drawn over to 
right side. Edge of trachea and bronchus indicated by arrows. 
who had outspoken symptoms of tabes dorsalis. She had no pulmonary 
symptoms and was unaware that she had any disease of the lung. There 
was a marked asymmetry of the chest. The whole right chest was dull 
to percussion, and, except in the upper lobe, the breathing was dimin- 
ished. In the latter region there was tracheal (pseudoamphoric) 
breathing. The plate shows a marked retraction of the entire right 
chest. The heart and mediastinum are drawn over to the right. The 
extreme displacement of the trachea to the right apparently accounted 
for the amphoric breathing in the right upper lobe. There was in this 
case evidently a marked pleuro-pulmonary fibrosis. The absence of 
any pulmonary symptoms and tubercle bacilli in the sputum and the The Lungs 
277 
strongly positive Wasserman reaction warrant a tentative diagnosis of 
syphilis. Of course, in this type of case, disappearance of the infiltra- 
tion under antispecific treatment is not to be expected. 
These cases of syphilitic interstitial pneumonia, in spite of their 
great extent are remarkable for their benign character. One is struck 
by the almost entire absence of cough and expectoration, in which 
respect they are in marked contrast to fibroid tuberculosis, which they 
otherwise resemble. In their differentiation from tuberculosis and from 
other chronic non-tuberculous infections of the lungs, the positive Was- 
serman reaction is of transcendent value. 
The cases of pulmonary syphilis which we have here presented 
illustrate the futility of any attempt to formulate, from the Roentgen 
standpoint, rigid criteria for diagnosis. Reflecting a varied pathology, 
the Roentgen plate exhibits a great diversity in the type of its shadows, 
none of which can be regarded as pathognomonic of this disease. 
Clinically also there is little in the character of the symptoms to 
guide one to a correct diagnosis. In the presence of subacute or chronic 
inflammatory disease of the lungs, the clinician is bound to give prece- 
dence to other more common diseases, such as tuberculosis. Only the 
continued absence of tubercle bacilli, or some unusual feature of the 
case should direct serious attention to the possibility of syphilis. When 
this possibility is entertained however, great help may be derived from 
the Roentgen plate. In some cases at least, the appearance of the 
shadows will at once serve to exclude tuberculosis and the problem of 
diagnosis becomes narrowed to include suppurative lung disease, the 
various mycotic infectious and occasionally new-growths. It is at this 
stage of the problem that the Wasserman reaction may play a decisive 
role. 
In conclusion, reference should be made to effusions in the pleura 
and other evidences of mediastinal pressure which may result from 
large gummatous masses at the root of the lung. In such cases the 
marked dyspnoea and the hemorrhagic character of the pleural effusion 
will naturally suggest a diagnosis of mediastinal neoplasm until the 
rapid disappearance of all the symptoms following antiluetic treat- 
ment. Chapter XIII 
Tumors of the Lungs 
The tumors which arise in the thoracic cavity may be divided with 
respect to their most frequent origin into mediastinal and true pul- 
monary or pleural growths. Although anatomically these varieties are 
easily separable, it is not always possible to make the distinction between 
them from their clinical or even their Roentgen aspects. This is because 
pulmonary tumors usually spring from the root of the lung and there- 
fore in the early stages of their growth appear to extend outward from 
the mediastinum very much as mediastinal tumors do. On the other 
hand the latter, in their further development often invade the lung and 
may produce both symptoms and Roentgen shadows similar to primary 
pulmonary neoplasms. Consequently, just as in other intra-thoracic 
diseases, the Roentgen diagnosis of tumors will fare best when it is 
firmly based on the clinical data. The age of the patient, the symptoms 
which marked the onset of the disease and the character of the second- 
ary growths elsewhere in the body, will often furnish significant data 
which will throw light on the nature and anatomical situation of the 
primary tumor within the chest. 
Pulmonary tumors may be conveniently classified for our purpose 
into primary and metastatic, because their Roentgen appearance serves 
to distinguish them from each other. 
PRIMARY LUNG TUMORS 
BENIGN TUMORS. As may be expected from their great rarity, 
benign tumors are not often encountered. From the Roentgen stand- 
point the essential characteristic of a benign tumor will be its failure to 
increase in size during a sufficient period of observation. Once a shadow 
suggestive of a neoplasm is discovered on the plate, we are bound to 
subject it to this test before the diagnosis of benign tumor may be ser- 
iously entertained. Even then, it will not be possible to exclude definitely 
inflammatory processes as a cause of the questionable shadow. A 
tentative diagnosis of non-malignant tumor of the lung was ventured in 
this spirit in the case illustrated in figure 200 after other possibilities 
were excluded. The Lungs 
279 
A probably benign tumor of the lung. 
FIGURE 200 
The patient, a woman of twenty, suffered from an intractable form of asthma for one 
year. This was preceded by no circumstance which would suggest an inflammatory disease 
of the lung as its cause nor was evidence of sensitization to foreign protein obtained. Neither 
laboratory nor bronchoscopic examination threw any light on the origin of the condition. 
Although the Roentgen examination was frequently repeated during a period of eight months 
before she died, the circumscribed shadow illustrated above maintained its size and shape 
unaltered. 
MALIGNANT TUMORS. Carcinoma. By far the largest number 
of primary lung tumors belong to the carcinomata. Their Roentgen 
appearance to a certain extent reflects the different pathological varie- 
ties of tumors and for this reason, with certain reservations, we may 
infer from the plate the particular type with which we have to deal. 
We can thus roughly recognize two forms, one beginning at the root of 
the lung and progressively involving more and more of its parenchyma 280 
The Lungs 
and a second which has a lobar distribution. The former is the adeno- 
carcinoma which originates as an endobronchial tumor in one of the 
primary bronchi and spreads by extension through the wall of the 
bronchus to the adjacent lung. It is probable that dissemination along 
the peribronchial lymphatics also accounts for a considerable growth 
of the tumor. Lobar carcinoma on the other hand arises extrabronchi- 
ally probably from alveolar epithelium anywhere in the lung; it is a 
tumor of flat cells which are often of indeterminate type. 
LOBAR CARCINOMA 
This term is applied in a descriptive sense to large tumors which 
involve a whole lobe in a dense neoplastic consolidation. Like most 
other primary cancers of the lung which we have observed, this tumor 
affects most frequently the upper lobes. Its origin outside the bronchial 
tree and the absence for a long time of any symptoms due to bronchial 
irritation explains its clinical latency. One is struck by the great size 
which these tumors have already attained when they begin to produce 
symptoms. On the plate the shadowr of the tumor is often sharply 
FIGURE 201 
Medullary carcinoma of right upper lobe. Central Necrosis. The Lungs 
281 
limited to one lobe, beyond whose confines it does not extend. Thus in 
figure 201 the tumor occupies the entire right upper lobe and is arrested 
sharply at the interlobar fissure. This was apparently a rapidly grow- 
ing tumor, having a duration of only six months; during this time the 
major symptom was increasing dyspnoea, with only little cough. At 
operation, a necrotic medullary carcinoma was found. Because of 
their latency, it is only by a fortunate chance that such tumors are dis- 
covered early in their growth before they have involved an entire lobe. 
As will be seen in figure 202 such an early lobar carcinoma develops 
within the parenchyma of the lung, having no connection with the root 
and probably increases in size concentrically, unlike an adeno-carcinoma 
beginning in a bronchus. 
FIGURE 202 
Early stage of carcinoma beginning in the parenchyma of the lung. 282 
The Lungs 
The shadow of a lobar carcinoma in the left upper lobe will differ 
in shape from that in the right owing to the oblique direction of the 
inter-lobar fissure. Thus in figure 203 the lower border of the tumor 
has a curved contour which faithfully follows the line of the fissure. It 
will be observed that in carcinoma of the upper lobe, the extreme apex 
of the lung is frequently not invaded by the tumor. 
FIGURE 203 
Carcinoma of left upper lobe, lobar type. Phrenic paralysis. Lower border 
of tumor follows the line of the interlobar fissure. 
BRONCHIAL CARCINOMA 
The relative frequency of bronchial and lobar carcinoma is some- 
what in dispute. This may partly be explained by the difficulty of 
formulating reliable statistics from a relatively small number of cases. 
From the Roentgen standpoint this difficulty is in part due to the various 
appearances of the tumors at different stages of their growth. Thus, a 
bronchial carcinoma arising from the root of the lung, may by a gradual The Lungs 
283 
extension invade a whole lobe so that it will be indistinguishable from a 
true lobar neoplasm. Of the cases which we have observed, the bron- 
chial, infiltrating tumor was the commoner type. 
Although the bronchogenous tumors because of their situation 
produce symptoms much earlier than the lobar variety, nevertheless 
until they have extended through the bronchial wall into the lung, 
they cannot be directly demonstrated on the Roentgen plate. Their 
existence may occasionally be inferred from the fluoroscopic changes 
which result from stenosis of a main bronchus. Otherwise we are de- 
pendent almost entirely on the bronchoscopic examination for the diag- 
nosis of these early cases. 
Sooner or later these tumors grow through the wall of the bronchus 
and infiltrate the lung in the region of the hilum. The shadow of such 
a “hilum carcinoma” as it is called, cannot be distinguished in the be- 
ginning from the usual hilum shadows. For this reason, the Roentgen 
shadows in these early cases must be interpreted in the light of the 
symptoms from which they may acquire an unwonted significance. The 
following is a case in point: 
FIGURE 204 
Hilum ( Carcinoma. Adeno-carcinoma of right main bronchus beginning to in- 
filtrate the lung. See figure 20;'). 284 
The Lungs 
A man, 65 years of age, otherwise well, began to have a constant unproductive cough, with 
paroxysms of dyspnoea. He occasionally raised some blood-tinged sputum. Because ol his 
age and the dyspnoea a Roentgen examination was made, and the small, sharply defined tri- 
angular shadow seen in figure 204 was found at the root of the right lung. The unusual shape 
of this shadow, together with the symptoms warranted a strong suspicion of new-growth. This 
was verified by the excision of a small piece of the tumor through the bronchoscope. The 
subsequent rapid increase of this shadow and its unusual bilateral extension as an infiltrat 
ing adeno-carcinoma of the lung are indicated in the plate (fig. 205) made four months 
later. 
FIGURE 205 
Bilateral adeno-carcinoma of the lung. Same case as figure 204 after an inter- 
val of four months. 
The importance of re-examining patients with suspected new- 
growth for evidence of extension into the lung requires no further 
emphasis than is afforded by this case. 
The larger bronchial carcinomata, when they involve the whole or 
a greater part of a lobe, resemble somewhat the true lobar type. (Fig. 
206.) They usually lack, however, the sharp outlines of the latter, 
their shadows are less dense and homogeneous and they exhibit an 
infiltrating border. These features of bronchial carcinomata are The Lungs 
285 
FIGURE 206 
Adeno-carcinoma of right upper lobe. 
brought out in the extensive upper lobe tumor shown in figure 207. In 
the smaller tumors the infiltrating margin is usually very evident and 
serves to distinguish them from mediastinal tumors, which in other 
respects they closely resemble. (Fig. 205.) 286 
The Lungs 
FIGURE 207 
Adeno-carcinoma of right upper lobe, showing areas of softening. Metastases 
in left lung. 
Bronchial carcinoma may occur in a very unusual form as a diffuse 
bronchial or peribronchial growth in which a whole lung may be infil- 
trated by radiating nodular strands extending from the root to the 
periphery. The Roentgen picture is similar to that of chronic pneu- 
monitis and if the clinical picture, as may happen, is that of inflamma- 
tory disease of the lung, the possibility of new growth may not occur to 
the examiner. The problem presented by this type of case may be 
realized by the following history: The Lungs 
287 
Carcinoma of lung resembling chronic inflammatory disease. Heart and medi 
astinum displaced to side of tumor. 
FIGURE 208 
A man of 47 years had cough and purulent expectoration for three years. There was 
occasional hemoptysis. For four months, in addition, he was very weak and had pain in 
the back and slight dyspnoea. He was much emaciated. Over most of the left chest there 
was dulness with distant bronchial breathing, excepting at the base where the respiratory 
murmur was diminished. This was later found to be due to a small hemorrhagic pleural 
effusion. Bronchoscopic examination disclosed a squamous-cell carcinoma which nearly 
filled the left main bronchus. The plate, (fig. 208,) sets forth this unusual type of tumor in 
which the cancerous deposits appear to follow the course of the bronchi to the periphery 
of the lung. The similarity to a chronic inflammatory process is maintained even to a dis- 
placement of the trachea and heart toward the diseased side. 288 
The Lungs 
SECONDARY CHANGES ASSOCIATED WITH NEW- 
GROWTHS OF THE LUNGS 
When interpreting the shadows in the lungs which are presumed 
to be due to a tumor, we are often aided by pathological changes else- 
where in the chest. Thus, occasionally, either in the same or the 
opposite lung, small circular shadows of metastases may be seen which 
place the nature of the main shadow mass beyond doubt. However, 
the metastases occur only in the later stages of the disease, at a time 
when the characteristics of the primary tumor are fully developed. 
(Fig. 207.) 
A careful inspection of the ribs and bony thorax in general, should 
never be neglected. The discovery of a pathological fracture or the 
typical cancerous erosion of a rib may shed a decisive light on an other- 
wise doubtful infiltration in the lung. (Fig. 228.) 
FIGURE 209 
Alveolar carcinoma of left upper lobe, of two years’ duration. Necrosis of the 
tumor resulted in formation of a large cavity with clinical picture of lung 
abscess. Recurrent laryngeal paralysis. The Lungs 
289 
Large tumors of the lung are frequently necrotic and at autopsy or 
operation irregular cavities are found in them. On the Roentgen plate 
the cavities are rarely seen as they are obscured by the dense tumor 
about them. Thus, in the case illustrated in figure 201 although there 
was no sign of a cavity on the plate, at operation there was found an 
irregular excavation of the tumor, the size of a lemon. It is particularly 
the massive lobar tumors which are apt to undergo extensive necrosis. 
The greater part of the growth may thus slough out leaving only a rim 
of tumor tissue at its periphery. The resulting cavity may then be con- 
verted into an abscess by secondary infection. Neither clinically nor 
with the Roentgen plate is it then eas yto distinguish between a new- 
growth and a lung abscess especially as these cases are apt to be chronic 
in their course. The large cavity seen in figure 209 was due to the 
necrosis of an alveolar carcinoma of the left upper lobe. Clinically, the 
duration, which was over two years and the expectoration of foul 
sputum in large amounts rendered the presence of an abscess of the 
lung likely. However, one significant symptom, a recurrent laryngeal 
paralysis, which at autopsy was shown to be due to invasion of the 
nerve by tumor growth, lent greater probability to the diagnosis of 
tumor. 
The shadow which we see on the plate in a case of carcinoma of the 
lung, does not always correspond in its extent to the size of the tumor. 
At times a considerable portion of the shadow is the result of secondary 
changes in the lung from occlusion of the bronchi. In this manner even 
small bronchial tumors may, by obstructing the lumen, lead to inflam- 
mation and suppuration of the affected lung. These secondary processes 
may completely mask the underlying tumor. The Roentgen examina- 
tion will then reveal an infiltration of the lung, whose great extent gives 
an entirely erroneous idea of the size of the tumor. Often only the 
bronchoscopic examination will discover the small endobronchial 
growth which is at the bottom of the trouble. It will be clear that the 
complicated clinical and Roentgen picture will require the most care- 
ful judgment in its interpretation and that even with our best efforts 
we will at times fall into error. 
Stenosis of a bronchus by a tumor will, in the absence of secondary 
infection, result in a simple atelectasis of the affected lobe. The physi- 
cal signs over the airless lung will be added to those of the tumor itself 
and they will therefore create an impression of more extensive disease 
than actually exists. On the Roentgen plate also, the shadow of the 
atelectatic lung will merge with that of the tumor and an incorrect 
idea of the size of the latter will be given. Thus in figure 210 the 
shadow which obscures the entire left base was due mainly to an air- 
less lower lobe, whose bronchus was occluded by a small tumor at the 
root of the lung. 290 
The Lungs 
FIGURE 210 
Small adeno-carcinonia of left lower lobe. Most of the shadow is due to 
atelectasis of the lung resulting from stenosis of bronchus. 
In their influence on the position of the heart and mediastinum 
pulmonary new-growths observe no invariable rule. The massive lobar 
tumors are more apt to displace these structures than are the infiltrating 
growths. Upper lobe carcinomata usually displace the trachea to the 
opposite side, whereas the heart, unless the tumor is in apposition to its 
borders, may retain its normal position. (Fig. 201.) When the heart is 
not displaced by a massive tumor, investigation may show that this is 
due to an atelectasis of the affected lobe caused by an occluding tumor 
in the main bronchus. Evidently this mechanism explains the failure 
of the heart to be displaced to the right in figure 210. In exceptional 
cases the heart is drawn over toward the side of the tumor. This was 
observed in the case of diffuse bronchial carcinoma already described 
(fig. 208) and it is not improbable that here also a decrease in the 
volume of the affected lung consequent on a closure of the main 
bronchus, was responsible for the displacement. The Lungs 
291 
ROENTGEN-CLINICAL CORRELATIONS 
During the early growth of lung tumors, especially of those at the 
hilum, the physical signs which later result from their extension to the 
surface are absent and the clinician has reason to be grateful for the 
help which the Roentgen examination affords him. In the case of the 
larger tumors, it is unfortunate that their symptoms and signs are 
not unlike those which characterize other, less serious pulmonary 
affections. In their clinical aspects they are frequently lacking in 
those features whose presence alone make the diagnosis more 
than a shrewd guess. It is noteworthy that pulmonary cancers are 
rarely associated with the cachexia of tumors found elsewhere in the 
body. It is not unusual therefore to observe patients who appear to be 
in excellent physical condition, yet in whom an enormous carcinoma of 
the lung is found. We have especially in mind an infiltrating form of 
carcinoma of a lower lobe which for a year or more may pursue a 
relatively benign course during which no suspicion of new-growth will 
be aroused. The clinical picture and physical signs in these patients 
are those of a sub-acute or chronic pneumonia at the base. As the onset 
of the disease is a so-called “cold,” its insidious progression finds a 
ready explanation in the diagnosis of a persistent pneumonia. 
FIGURE 211 
Carcinoma of right lower lobe, with chronic course, simulating indurative 
pneumonia. 292 
The Lungs 
The patient whose plate is reproduced in figure 211, for one and one-halfi years had 
cough with blood-streaked sputum and signs of a basal infiltration. At one time, frequent 
fevers, sweats and a leukocytosis led to a futile operation for emyema. Only the develop- 
ment of a rib metastasis toward the end of his illness threw light on the true nature of the 
malady. From the Roentgen plate alone the differentiation from a pneumonic process could 
not be made. 
In other cases, after a period of months during which the clinical 
picture of indurative pneumonia may be presented, the tumor may 
break down and, becoming secondarily infected, induce all the symptoms 
and signs of a lung abscess. This sequence of events marked the course 
of the case illustrated in figure 212. There is here seen an infiltration 
Carcinoma of right lower lobe. Slow breaking down of tumor with cavity 
formation. Clinical picture of lung abscess. 
FIGURE 212 
in the right lower lobe which is readily mistaken for a pneumonic 
process within which a cavity with a fluid level is seen. After a dura- 
tion of six months frequent hemorrhages and expectoration of necrotic 
tissue prompted a bronchoscopic examination which revealed an adeno- 
carcinoma of the right lower bronchus. 
Such cases demonstrate the importance of keeping new-growths in 
mind as a possible cause of pulmonary symptoms which are first 
complained of at the cancer age. The Lungs 
293 
The development of a pleural effusion secondary to a tumor of the 
lung introduces a number of new factors into the diagnostic problem 
which are of interest to both the clinician and Roentgenologist. It is 
usually a late phenomenon of the disease when the outspoken symptoms 
of the tumor have already manifested themselves. It may however 
arise during the early growth of the tumor and can then be explained 
as either due to an early involvement of the pleura or to the pressure of 
cancerous lymph nodes at the root of the lung. Such a pleural effusion, 
developing in an individual who previously has had few symptoms 
pointing to disease of the lung, may be the dominant feature in the 
clinical picture and may divert attention from the under-lying tumor. 
In the same way, on the Roentgen plate, the shadow of the fluid 
in the chest will obscure all evidence of disease of the lung. The 
significance of these “masking effusions,” as they are called is well 
known clinically and their malignant origin is often at once evident 
from the red blood and tumor cells which they contain. After the 
pleural effusion has been evacuated it may be possible to see the tumor 
itself. The value of this procedure is emphasized by the following 
case: 
Pleural effusion masking an underlying carcinoma of lung. See figure 214. 
FIGURE 213 294 
The Lungs 
A middle-aged man complained of cough, expectoration and occassional dyspnoea for 
several months. The symptoms seemed to find a partial explanation in a fairly large pleural 
effusion in the right chest. (Fig. 213.) However, the occurrence of small hemoptyses aroused 
a suspicion of underlying lung disease, which was confirmed by a second Roentgen examina- 
tion after most of the fluid was removed from the chest. The plate then showed a hilum 
carcinoma which had been effectually concealed by the pleural transudate, a small residue 
of which remained in the chest. (Fig. 214.) 
FIGURE 214 
Same patient as in figure 213 immediately after removal of pleural effusion. Shows 
hilum carcinoma. Small residual effusion at base and elevation of diaphragm, (arrow.) 
Of the rarer pleural complications of lung tumors should be men- 
tioned the empyemata which result from the rupture of bronchiectatic 
abscesses following stenosis of a bronchus by a new-growth. In these 
cases the Roentgen plate has only a limited value; the complicated 
picture in which the shadows of pleural effusion, inflammatory infiltra- 
tion and tumor are commingled defy interpretation. 
In recent years the bronchoscope, a new and valuable method has 
been enlisted in the diagnosis of pulmonary tumors. In the early diag- 
nosis of bronchial carcinoma which, fortunately for the successful 
use of this instrument, commonly begins in the mucosa of a large The Lungs 
295 
bronchus, the bronchoscope takes precedence over other methods of 
examination, in respect to both the accuracy and the timeliness of its 
findings. In the case of lobar carcinomata which presumably originate 
in the parenchyma of the lung, it is of less value, as the growth itself is 
not visible in the bronchial walls, except in the rare instances in which 
the latter are perforated by the extrabronchial tumor. Even in these 
cases, bronchoscopy often furnishes confirmatory evidence in the dis- 
covery of a narrowing, displacement or tortuosity of the bronchial canal 
which is caused by the pressure of the tumor mass. It is thus frequently 
possible by a correlation of the bronchoscopic and Roentgenologic find- 
ings to infer the pathologic type of tumo present and to bring it into har- 
mony with the features of the clinical history. It will be found that the 
tumors which cast large massive shadows involving a whole lobe do not 
invade the bronchial tubes, although they may compress them. In these 
patients there is a long latent period during which there are few or no 
symptoms of bronchial irritation. On the other hand in those cases, 
whose Roentgen shadows correspond to the primary bronchial form of 
new growth, the bronchoscope almost invariably reveals an intra- 
bronchial carcinoma. In these patients, cough, dyspnoea and hemop- 
tysis are apt to be early and prominent symptoms of the disease. 
SARCOMA OF THE LUNG 
By far the larger number of primary tumors of the lung belong to 
the carcinomata. Sarcoma is so uncommon that only some unusual 
feature of the case warrants its diagnosis. It is not unlikely that some 
of the cases of primary sarcoma which have been reported were in 
reality tumors which originated in the mediastinum and secondarily 
invaded the lung. The earlier incidence of sarcomata, the majority of 
which are found before the age of forty, may have some value in dis- 
tinguishing them from epithelial tumors. 
As far as we may draw any conclusions from the observation of a 
few cases, the Roentgen shadow of primary sarcoma is an extensive, 
dense, homogeneous one which has already reached an enormous size 
when the patient comes to the physician. This form of neoplasm is 
illustrated in figure 215. The entire left lower chest was occupied by a 
solid tumor which, on aspiration with a trocar was found to be a spindle- 
cell sarcoma. These tumors are extra-bronchial and they are there- 
fore not apt to occasion much cough. The symptomatology of this case 
offered a striking contrast to that of a carcinoma of similar size, as it 
was marked by an absence of severe cough and dyspnoea and by the 
presence of high fever, sweats and rapid emaciation, which are uncom- 
mon even in advanced carcinoma. Both cases of primary sarcoma 296 
The Lungs 
FIGURE 215 
Primary sarcoma of left lower lobe. 
which we have observed occupied the lower lobes, a situation which is 
unusual in the cases of lobar carcinoma which we have nearly always 
found in the upper lobes. 
In conclusion reference may be made to occasional cases in which 
the Roentgen plate shows a massive tumor of the lung whose size is out 
of all proportion to the mildness of the clinical symptoms. The absence 
of dyspnoea and cough and the continued good health of the patients 
for months or even years are so little consistent with malignancy that 
we are forced to regard them as relatively benign tumors, at least in 
the clinical sense. Two striking instances of this type of neoplasm are 
illustrated in figures 216 and 217. These patients remained in The Lungs 
297 
FIGURE 216 
Clinically benign type of lung tumor. Only symptom is slight dypnoea and dysphagia. 298 
The Lungs 
FIGURE 217 
Clinically benign type of lung tumor. Practically no symptoms. 
good health for many months with only minor thoracic symptoms, yet 
the physical signs, the history and the evidence of the exploring needle 
left do doubt of the existence of a solid tumor of the lung and in one of 
them, (fig. 218) perhaps also of the pleura. The pathology of these 
tumors remains unknown and we can only suggest that they are fibro- 
sarcomata or endotheliomata or similar tumors of slight malignancy. The Lungs 
299 
FIGURE 218 
Clinically benign type of tumor of lung, probably involving pleura. Patient 
in good health for over one year. 
DIFFERENTIAL DIAGNOSIS. From a study of the plates which 
have been presented to illustrate the Roentgen appearance of tumors of 
the lung, it will at once be evident that in certain cases a diagnosis can 
not be arrived at from these plates without reference to the clinical 
history. In some instances the shadows are little different from those 
occurring in such other pulmonary diseases as lung abscess, pneumonia 
and occasionally caseous tuberculosis of a lobe of the lung. We believe 
it wiser to recognize this fact and frankly to appeal to the history and 
physical signs for confirmation than to advance specious points of 
differentiation which are at best uncertain. A decade ago, the diagnosis 
of tumor of the lung was regarded as a brilliant accomplishment and a 
clinical tour de force; to-day it may truthfully be said that by a proper 
combination of clinical and Roentgen evidence, few pulmonary neo- 
plasms need escape discovery. Chapter XIV 
Metastatic Tumors of the Lungs 
Primary tumors in various organs so frequently occasion metastases 
in the lungs, that the Roentgen examination of the latter is endowed 
with an unusual importance. The clinician is thereby enabled, not only 
to discover metastases which elude his physical examination but he is 
also afforded decisive, though indirect evidence as to the nature of 
disease elsewhere in the body. This is fortunately facilitated by the 
distinctive character of the shadows which permits of their easy and 
early recognition. 
In respect to their pathology, we have to do practically with three 
kinds of metastatic tumors namely, carcinoma, sarcoma and hyper- 
nephroma, differences in whose size, number and distribution in the 
lungs lead to a great diversity of Roentgen appearances. With rare 
exceptions, the metastases are multiple. The obvious reason for this is 
that secondary tumors are usually symptomless during their early 
growth and they are therefore not discovered until they have developed 
in great numbers. 
The earliest metastases appear as small, faint, circular shadows 
which are clearly outlined in the lung. They are first seen in the lower 
lobes where they are apt to attain their greatest size. As they increase 
in size they usually retain their circular shape, although occasionally, 
especially in the case of carcinomata and hypernephromata, they may 
become oval or irregular in outline. Sarcomata on the other hand, even 
when they occupy a whole lobe, usually remain smooth and circular. 
As a rule it is not possible to make a pathological distinction be- 
tween the various forms of secondary tumors. In general it may be 
stated that the very large tumors with sharply circular outlines are 
sarcomatous. The carcinomata are of slower growth and for this 
reason the patients succumb to the disease before the secondary tumors 
have attained a large size. 
SARCOMA. Metastatic sarcoma of the lung is in a large propor- 
tion of the cases secondary to tumors of the bones. In one form the 
tumors are few in number and they increase in size with astounding 
rapidity. This feature is brought out in figure 219 in which the greater 
part of the left upper and lower lobes was already involved four weeks 
after amputation of a leg for periosteal sarcoma. The Lungs 
301 
FIGURE 219 
Large metastases in left upper and lower lobes and at root of right lung. Pri- 
mary tumor periosteal sarcoma. 
In other cases the individual neoplasms are smaller and more 
numerous. The tumors shown in figure 220 were discovered six months 
after amputation of a lower extremity for a fascial sarcoma. While 
this type of tumor usually presents no difficulty in diagnosis, it is not 
always easy to distinguish an extensive metastatic involvement of the 302 
The Lungs 
FIGURE 220 
Multiple small metastases, secondary to fascial sarcoma of thigh. The Lungs 
303 
Metastic sarcoma. Primary tumor in femur 
FIGURE 221 
lung from certain forms of pulmonary tuberculosis. Thus in figure 221 
the individual metastases are so small and numerous as to resemble a 
confluent, lobular tuberculosis. We are aided in the distinction by an 
absence of disease at the apices and by finding somewhere in the lower 
lobes typical circular metastatic tumors. 
An unusual form of metastatic sarcoma, secondary to a tumor of 
the testis is shown in figure 222. 304 
The Lungs 
FIGURE 222 
Metastases secondary to sarcoma of testis. Note irregular shape and lobu- 
lation of tumors. 
CARCINOMA. We are here confronted with a greater diversity 
of shadows which depends on the numerous sources of the primary 
growth. The most common Roentgen type is illustrated in figure 223 
in which the tumors were secondary to a primary neoplasm in the 
gastro-intestinal tract. The Lungs 
305 
FIGURE 223 
Metastatic carcinoma secondary to carcinoma of the stomach. The Lungs 
306 
It is characteristic that the tumors increase in size and number from 
the apex to the base, although exceptions are found, as in the occasional 
case of large metastases in the apex. (Fig. 224.) 
FIGURE 224 
Metastatic Carcinoma. 
More irregular tumors, both as to shape and distribution, may 
occur secondary to thyroid and prostatic new-growths. Thus in figures 
225 and 226 the neoplasms are marked by an irregularity in shape and 
also in density not often found in the other forms. The Lungs 
307 
FIGURE 225 
Metastatic carcinoma. Primary in thyroid. Note shadow of thyroid gland at 
root of neck. 308 
The Lungs 
FIGURE 226 
Metatatic carcinoma secondary to tumor of prostate. 
Secondary carcinoma of the lung from primary testicular tumors 
appears to be exceptional in its development and resembles in all 
respects the larger sarcomatous metastases. In figure 227 is pictured 
a large tumor of the right lung which was discovered two months after 
the removal of a carcinomatous testis. The effusion in the left pleural 
cavity speaks for an involvement of that side also. It is remarkable that 
with such an extensive growth, the patient was ambulant and had but 
minor symptoms consisting of cough with occasional hemoptysis for a 
period of four weeks. 309 
The Lungs 
FIGURE 227 
Large metastasis involving right lower lobe secondary to carcinoma of the 
testis. Left pleural effusion. 
A rare variety of metastatic carcinoma known variously as miliary 
carcinosis or carcinomatous lymphangitis of the lung is worthy of men- 
tion, both because of its unique pathology and its remarkable Roentgen 
shadows. The lungs are studded with innumerable miliary and sub- 
miliary nodules which apparently are disseminated by way of the 
lymphatics both within the lung and on the surface of the pleura. On 
cursory inspection the plate closely resembles a miliary or submiliary 
tuberculosis, yet on a more careful examination, especially in the less 
densely infiltrated portions of the lungs, the shadows are seen to have 
a smoothness of contour and a circular shape not found in tuberculous 
lesions. 
In the literature miliary carcinosis of the lungs has commonly been 
associated with primary tumors in the gastro-intestinal tract. We have 
found them also secondary to carcinoma of the breast and of the lungs 
and pleura and they have been remarkable for the long latent period 
which has intervened between the onset of the primary tumor and the 
development of the metastases. In figure 228 is illustrated a well 310 
The Lungs 
FIGURE 228 
Miliary carcinosis of left lung. Primary adeno-carcinoma at root of right lung, 
Arrow indicates metastatic growth and erosion of rib. 
developed example of this disease which was secondary to an adeno- 
carcinoma of a bronchus. In our experience these cases have usually 
been regarded clinically as tuberculous, an error to which the Roentgen 
plate if casually studied, may contribute. However, the absence of 
fever, the disproportion between the extent of the lung involvement and 
the mildness of the symptoms and finally, evidence of metastases else- 
where should remove all doubt as to the nature of the disease. 
HYPERNEPHROMATA, as a rule, bear resemblance to the car- 
cinomatous tumors. They occur either as numerous small growths or as 
larger ones in lesser numbers which occasionally exhibit an infiltrating 
border. The metastatic tumors in figure 229 were found in a patient 
two months after the removal of a hypernephroma. The Lungs 
311 
FIGURE 229 
Metastatic Hypernephroma. 
The complications of metastatic growths which may be observed on 
the plate are few. Pleural effusions are associated usually with the 
larger tumors. A cortical neoplasm may rupture into the pleural cavity 
and produce either a free or encapsulated sero-pneumothorax. (Fig. 
230.) 312 
The Lungs 
FIGURE 230 
Miliary metastases in left lung secondary to carcinoma of bronchus. Perfor- 
ation of cortical tumors with localized sero-pneumothorax. Note two fluid 
levels in right chest. 
ROENTGEN-CLINICAL CORRELATIONS 
It may not be amiss to dwell on the practical importance of the 
Roentgen examination of the chest for evidence of secondary new- 
growths. To the surgeon, who is debating the excision of a primary 
tumor or the amputation of a limb, it is a question of superlative im- 
portance whether there is a secondary involvement of the lungs. It is 
evident that if metastases have already developed, he may desist from 
operation altogether; in the case of a tumor of an extremity, a cure 
being precluded, he may be content to excise the new-growth rather 
than to subject the patient to a fruitless amputation. It has been our 
experience on more than one occasion to find metastases in the lungs 
shortly after operative removal of the primary tumor; these metastases 
were undoubtedly present previous to operation and their discovery The Lungs 
313 
would certainly have influenced the surgeon against a radical inter- 
ference. The tendency of bone sarcomata and hypernephromata to 
metastasize very early in the lungs should make a pre-operative Roent- 
gen examination of the lungs a routine procedure. 
Metastatic tumors in their early growth are absolutely latent both 
as to symptoms and physical signs and extensive metastases in the 
lungs are consistent with apparently robust health and good color. 
Even when they have attained large proportions they may produce 
neither subjective symptoms nor dulness nor altered breathing. For 
example, the large tumor in the right lower lobe in figure 227 was un- 
recognized clinically, because it was centrally situated and was covered 
by normal lung. 
FIGURE 231 
Metastatic tumors secondary to carcinoma of breast. Destruction of 5th dorsal 
vertebra by secondary tumor. 314 
The Lungs 
While the positive Roentgen finding of metastases has thus great 
clinical value, it is unfortunate that a negative plate does not absolutely 
exclude them. Thus, the extensive infiltration of the lung in figure 221 
was discovered shortly after amputation of the thigh for sarcoma, 
although the lungs immediately before operation showed no abnormal- 
ity. It is probable that at the time of the first Roentgen examination the 
tumors were in process of growth and were still too small to be demon- 
strated. The possibility exists, of course, that the malignant cells were 
mobilized by the manipulation during operation. It is particularly in 
cases of carcinoma of the breast that it is difficult to exclude metastatic 
growths. The cancer cells may apparently lie dormant in the bronchial 
nodes for some time and months or years may elapse before metastases 
are found on the plate. The extensive involvement of the lung in figure 
231 was thus found over a year after removal of the breast. 
Equally with the surgeon, the internist has much to gain from the 
Roentgen examination in cases of suspected metastases. In patients 
with obscure disease elsewhere in the body, the lungs offer a fertile and 
accessible field for investigation in which at times the most surprising 
disclosures come to light. Of such diseases we may instance severe 
FIGURE 232 
Large metastasis from carcinoma of stomach. The Lungs 
315 
anemia for which no cause is found, but in which the suspicion ever 
arises that an undiscovered neoplasm, perhaps in the stomach, is at the 
bottom of the trouble. A latent carcinoma of the gastro-intestinal tract 
may thus incite a profound anemia which will challenge the acumen of 
the examiner until its cause is betrayed by the discovery of a lung 
metastasis. The large metastasis of the left upper lobe in figure 232 
was thus found in the course of a systematic examination of the viscera 
for evidence of a new growth in a patient who for several months 
presented a progressive anemia of the aplastic type. The discovery of a 
metastasis directed attention at once to the stomach, where a carcinoma, 
which had produced no direct symptoms, was found. There come to 
mind also cases in which the only sign of pulmonary disease consists of 
repeated hemoptyses which are apt to be attributed to tuberculosis of 
the lungs. In the case illustrated in figure 229 it was only the discovery 
of pulmonary metastases which prompted an investigation of the urin- 
ary tract, where a large hypernephroma was found. It is particularly 
in the cases of miliary carcinoma of the lung that this confusion with 
pulmonary tuberculosis is apt to occur. On more than one occasion 
we have found, in patients whose only symptom was hemoptysis, a uni- 
versal involvement of the lung in a miliary cancer. Because of an 
almost entire absence of physical signs these were regarded as cases 
of incipient pulmonary tuberculosis. (Fig. 230.) SECTION V 
The Pleura 
Dry Pleurisy 
Pleural Effusions 
Pneumothorax 
Tuberculosis of the Pleura 
Tumors of the Pleura 
Chronic Pleurisy Chapter XV 
The Pleura 
There are few intrathoracic diseases, in which the Roentgen exam- 
ination is attended with more interesting and instructive disclosures, 
than in those which involve the pleural membranes. The great extent 
of the pleura and its proximity to important organs both in the chest 
and abdomen make it a frequent site of pathologic processes of the 
most varied sort, to the diagnosis of which the Roentgen Ray is pecul- 
iarly adapted. Owing to the intricate topography of the pleural mem- 
branes, however, the Roentgen interpretation encounters more than the 
usual difficulties, especially in respect to pleural effusions. Whether 
the latter are situated on the anterior or posterior aspect of the chest or 
buried within the depths of a fissure or confined in the mediastinal 
recess, they lose their topographical features when they are projected 
on the plate and become merely flat shadows. Our interpretations then 
have imposed upon them the task of reconstructing from simple shadow 
masses, the spatial relations of effusions which are frequently complicat- 
ed. In spite of these inherent difficulties, the Roentgen diagnosis of 
pleural diseases has achieved a remarkable exactitude which has reliev- 
ed the physical examination of much of its uncertainty. No longer need 
indecision attend the distinction between such clinically similar condi- 
tions as a small pleural effusion or congested bases nor need one for 
days remain in doubt regarding the development of empyema following 
a pneumonia, before definite physical signs indicate its presence. These 
and numerous other questions which are constantly arising during the 
clinical course of a case are now quickly and decisively resolved by the 
Roentgen examination. 
DRY PLEURISY 
The Roentgen diagnosis of dry pleurisy is apt to be as disappoint- 
ing as the search for pleuritic rales. The cause of the thoracic pain 
so often complained of in rheumatism or latent tuberculosis is only 
rarely evident on the plate, as a thin fibrinous deposit on the pleura is 
completely permeable to the Roentgen Ray. Only in situations where 
the pleura is reflected into a fissure will such an exudate be visible. It 
most often takes the form of a sharp linear shadow at the site of the 
right upper fissure which extends transversely across the chest. (Fig. 
235). This shadow may also be found in cases of chronic pulmonary 
disease and therefore it only has a significance in the diagnosis of acute 
pleurisy if the symptoms indicate that the process is a recent one. 
Larger fibrinous masses, with corresponding Roentgen shadows, appear 320 
The Pleura 
to result from pyogenic infections and are more apt to be seen in the 
fibrino-plastic pleurisies secondary to lung suppuration or subphrenic 
abscess. The character of these shadows is shown in figure 381. 
Acute inflammation of the pleura is usually accompanied by an 
inhibition of the movement of the diaphragm. In patients who have 
pleuritic pain the discovery of an elevated, immobile diaphragm on the 
affected side, even in the absence of shadows of a pleural exudate, will 
be strongly suggestive of a pleurisy. This phenomenon is most marked 
on the left side where the diaphragm, unsupported by the liver, readily 
yields to the upward pressure of the intestines. 
PLEURAL EFFUSIONS 
Fluid may accumulate freely in the pleural cavity or it may be 
localized by adhesions or confined in one of the many pleural recesses. 
We shall first discuss free effusions as they are the more usual form. 
FREE EFFUSIONS 
The Roentgen features of pleural effusions are determined first 
by the great absorptive power of fluid for the Roentgen Ray, which 
causes it to cast a dense homogeneous shadow completely obscur- 
ing the lung beneath it and secondly, by the elasticity of the lung 
which is responsible for the unique configuration of the shadow. 
We may best observe these features in nan-purulent effusions such 
as the hydrothorax of cardiac disease. The increase in the size of 
the effusion is here often so slow that the various stages of its accumula- 
tion may be minutely studied. The first evidence of fluid will always be 
found at the base, in the costo-phrenic sinus, which becomes obscured 
by a dense shadow. The upper border of this shadow is concave. 
(Fig. 233.) As the effusion increases, the shadow extends progres- 
sively upward, being considerably higher in the axilla and sloping 
obliquely down toward the diaphragm. (Fig. 234.) The upper border 
of the shadow is sharply defined from the lung as long as the effusion 
is still small. However, as it enlarges, owing to a compression of the 
lung, the latter becomes less aerated and the distinction between fluid 
and lung is less clear. In some cases, especially with purulent 
effusions, fibrinous deposits on the surface of the lung will have the 
same effect. For these reasons, a pleural effusion may actually not be 
as large as its shadow would lead one to believe because the compressed 
lung contributes materially to the extent of the shadow. A pleural 
effusion is usually, though not always, to be distinguished from a con- 
solidation of the lung, by the greater density of its shadow which The Pleura 
321 
FIGURE 233 
Small effusion at right base with oblique level. 322 
The Pleura 
FIGURE 234 
Moderate sized pleural effusion. Tuberculous infiltration, left infraclavicular region. 
approximates that of the liver below it. Its shadow is therefore con- 
tinuous with that of the liver whose upper border it early obscures so 
that the diaphragm is not visible. 
The Roentgen plate has amply confirmed the deductions of Gar- 
land in regard to the configuration of the area of dulness in pleural 
effusions. The upper surface of fluid owes its shape to a combination of 
antagonistic forces, namely, the weight of the fluid and the elastic 
tension of the lung. The former causes the effusion to gravitate to the 
base of the chest; the latter, as the lung is separated from the chest 
wall, exerts a pull on the surface of the fluid, which is greatest near 
the lower axilla, drawing the fluid upward. The effusion therefore 
rises obliquely from the mid-line, reaching its highest point in the axilla, 
thence descending toward the spine, once more obliquely. This so- 
called “S” curve will, in different individuals, vary in height and The Pleura 
323 
obliquity depending on the elasticity of the lungs. Thus, in young per- 
sons, the elasticity of whose lungs is unimpaired, the margin of the 
shadow takes a more perpendicular course, reaching a higher point in 
the axilla. 
The movement of free fluid in the chest may be demonstrated both 
on the plate and on the fluoroscopic screen. When the patient is 
recumbent the fluid flows upward to the apex so that the pulmonary 
field is entirely obscured and the level of the fluid disappears. On the 
screen, the movement of the fluid level may be seen as the patient’s chest 
is tilted to the side. Unless there is air in the pleural cavity, this shift 
in the fluid level is a slow, almost imperceptible one. It is best seen 
with effusions of moderate size. When the chest is almost full of fluid, 
or in the presence of adhesions on the pleura, it may be absent. 
PURULENT EFFUSIONS. The Roentgen features which we have 
thus far considered apply particularly to nonpurulent effusions. In 
empyemata, on the other hand, the early inflammatory exudate may 
not be fluid and for this reason the Roentgen appearance, at least in 
the beginning, will differ from that which we have found in transu- 
Beginning empyema with plastic exudate over right lung. Note retraction of 
lung from chest wall with narrow shadow of exudate. Right lung hazy and 
interlobar fissure outlined hy pleural thickening. 
FIGURE 235 324 
The Pleura 
dates. As is well known, in the early stage of an empyema, the pleura 
may be covered by a shaggy fibrino-purulent exudate of some thick- 
ness, within whose interstices a small amount of fluid may be enclosed. 
Such a layer of fibrinous exudate completely encasing the lung may 
be recognized on the plate by a distinctive shadow, which is visible in 
the axilla as a narrow band extending from apex to the base. This 
shadow is due to a slight retraction of the lung, between whose surface 
and the chest wall the exudate is interposed. The peculiar shape and 
situation of this shadow is due to the incidence of the ray as it tangent- 
ially traverses the edge of the lung and the exudate. The influence of 
the exudate on the surface of the lung will be seen as a general decrease 
in the illumination of the pulmonary field. The following illustrations 
depict the Roentgen features of these early empyemata. In figure 
235 is seen a beginning empyema in a child recovering from pneumonia. 
It will be noted in the first place that the entire right lung is poorly 
aerated. The lung is also retracted from the chest wall, from which it 
is separated by a narrow shadow of uniform width, due to a non-fluid 
Beginning empyema after pneumonia of right lower lobe. Uery thick fibrino- 
plastic exudate over lung. 
FIGURE 236 The Pleura 
325 
pleural exudate. The width of this shadow varies in different cases, 
depending on the thickness of the inflammatory deposit. Thus in figure 
236 the axillary shadow is of considerable width. 
This shadow of a fibrino-purulent exudate on the pleura is of the 
greatest value in the early diagnosis of empyema complicating pneu- 
monia, as it precedes definite physical signs of an effusion and it is 
found before pus can be obtained in any quantity by the explor- 
ing needle. Thus in figure 237 and 238, although the pneumonic 
process in the right lower lobe is still at its height the evidence of a 
beginning pleurisy is unmistakable. A narrow axillary shadow ex- 
tends from the apex to the base and it can even be recognized on the 
surface of the consolidated lower lobe. 
The early fibrinous deposit on the pleura is followed usually in a 
few days by a true fluid exudate which gravitates to the base of the 
chest. When the pleural effusion is secondary to pneumonia of the 
Pneumonia ot right lower lobe with beginning empyema. Lung separated 
from ehest wall by fibrino-purulent exudate. See figure 238. 
FIGURE 237 326 
The Pleura 
FIGURE 238 
Diagrammatic representation of figure 237. 
a Fibrino-purulent pleural exudate. 
b Pneumonia of right lower lobe. 
lower lobe the shadow of the former is accordingly superposed on that 
of the latter. It is, however, so much denser than the pneumonic 
shadow that the demarcation between the lung above and the liver 
below is lost. The consequent disappearance of the curve of the dia- 
phragm may therefore be looked upon as the characteristic sign of a 
purulent effusion, complicating lower lobe pneumonias. Thus in figure 
236, the upper half of the chest exhibits a fibrinous nonfluid exudate, 
whereas at the base there is a composite shadow of pneumonia and 
fluid. 
ENCAPSULATED EFFUSIONS 
Although free pleural effusions offer few difficulties in diagnosis 
which cannot be overcome by the experienced examiner, this is not true 
of the encapsulated variety. The physical examiner is at a great disad- 
vantage when he seeks to determine the size, shape and location of the 
almost endless variety of atypical effusions which may form within the 
pleural cavity. The Roentgen Ray on the other hand labors under no The Pleura 
327 
such disadvantage. The limits of the effusions are unerringly defined 
and collections of fluid deep within the chest are pictured with the 
same precision as those more superficially situated. 
Pleural effusions are more often encapsulated than is commonly 
believed. It is not unusual for even very large effusions to be walled off 
by adhesions and although the latter are not discoverable by physical 
examination, they are usually evident on the Roentgen plate. There 
are two major influences which determine encapsulation of a pleural 
effusion, first, the character of the exudate and secondly the extent of 
the respiratory movement of the chest wall. Undeniably, infection 
plays a predominant role in determining the sacculation of an effusion. 
Evidently this is because the plastic exudate of an inflammatory process 
tends to agglutinate opposing pleural surfaces and thus to wall off the 
effusion. For this reason, empyemata are frequently encapsulated 
whereas the transudates of cardiac or renal disease or of neoplasms 
are rarely so. In our discussion of encapsulated effusions, we are 
therefore concerned mainly with those of inflammatory origin, be they 
acute, purulent and pyogenic or chronic, non-purulent and tuberculous. 
The second factor involved in encapsulation is of lesser importance 
and determines the situation of the limiting adhesions. The mobility 
of the chest during respiration is not everywhere of equal extent. It is 
greatest in the axillary and basal regions, whereas it is much restricted 
at the apex and toward the mediastinum. In the latter situations, the 
movement of the pleural membranes is accordingly less active and 
adhesions can more readily form. We therefore find encapsulated 
empyemata oftenest in the axillary half of the chest and rarely, at least 
primarily, in its mesial portion. Finally, the reflex rigidity of the chest 
wall which results from an inflammation of the pleura will also con- 
tribute to a limitation of the respiratory movement and will thus facili- 
tate the formation of adhesions. 
The Roentgen shadows of encapsulated effusions exhibit the great- 
est variety in respect to their size, shape and situation, this being depend- 
ent mainly on the location of the limiting adhesions. For our purposes we 
may most conveniently divide them as follows: 
A. SUPERFICIAL EFFUSIONS 
These are effusions encapsulated in the general pleural cavity 
or “parietal encapsulated effusions.” 
B. CONCEALED EFFUSIONS 
I. Effusions encapsulated between the lung and the dia- 
phagm. “Diaphragmatic or Infra-pulmonary effusions.” 
II. Effusions encapsulated between the lung and the medi- 
astinum. “Mediastinal Effusions.” 
III. Interlobar Effusions. 328 
The Pleura 
This classification, which emphasizes only the topographic features 
of these effusions is of practical importance, because it lays the basis 
for an exact localization of the fluid to the end that exploratory aspira- 
tion and subsequent operation may be performed with the greatest pre- 
cision. This, after all, is the main purpose of the Roentgen examination. 
(A) SUPERFICIAL OR PARIETAL ENCAPSULATED EFFU- 
SIONS. These represent the commonest variety of sacculated effusions. 
They are usually secondary to pneumonia or cortical abscesses of the 
lungs; in rare instances they are metastatic infections from foci else- 
where in the body. As a result of the fibrinous adhesions which wall off 
the fluid at one or more points, the lung cannot retract from the chest 
wall and consequently its elastic tension is not exerted on the effusion in 
the usual manner. We will accordingly note in most cases an absence of 
the oblique upper surface of the fluid, which is so characteristic of free 
effusions. One of the simplest forms of encapsulation is illustrated in 
figures 239 and 240. In this case an adhesion in the region of the 
interlobar fissure has divided the pleural cavity into an upper and a 
lower half, in each of which the usual intrapleural forces have come 
FIGURE 239 
Pleural effusion divided into two sacculations by adhesions at the interlobar 
fissure. See figure 240. The Pleura 
329 
FIGURE 240 
Diagram of Figure 239 showing outlines of two separate effusions 
into play, in such a way as to reproduce in miniature two “S” curves. 
Evidently the upper and lower lobes have separately retracted and 
drawn the fluid upward with them. 
The fluid may occupy any part of the general pleural cavity and 
we may accordingly recognize an axillary, a basal, an apical and a 
mesial form of encapsulated effusion. 
(1) AXILLARY EFFUSIONS. The most frequent site for the 
encapsulation of pus is in the axillary portion of the chest, the adhesions 
being situated either in the anterior or posterior axillary region, or both. 
The character of the Roentgen shadows in these cases is illustrated in 
figure 241, where the empyema occupies the lateral half of the chest 330 
The Pleura 
FIGURE 241 
Effusion encapsulated in lateral half of chest. 
from apex to base. The adhesions do not always limit the empyema 
strictly to the axillary region. It may encroach on the apex or on the 
base and thus produce a greater variety of shadows. In figure 242, for 
example, the axillary effusion is large and also invades the apex of the 
chest. As is so often the case with purulent pleurisies, this one consisted 
of two sacculations which were completely separated from each other 
and required two operations for its evacuation. 
The clinical features of axillary empyemas may profitably detain 
us for a moment because of the light which may be thrown on them by 
the Roentgen examination. The physical signs are often puzzling 
especially in respect to percussion dulness. The extreme dulness of 
free effusions is often lacking, owing to the fixation of the lung along 
the edge of the empyema. It is especially noteworthy that in the 
presence of an axillary effusion which extends to the posterior aspect 
of the lung, a loud tympanitic note may be heard anteriorly. The 
diagnosis may be further confused by the occurrence of numerous rales 
along the borders of the effusion. The Pleura 
331 
FIGURE 242 
Bilocular encapsulated empyema. 
It is, however, particularly in respect of exact localization and 
exploratory aspiration that a consideration of these unusual signs is 
important. In aspirating a free elfusion, the operator is accustomed 
to insert the needle in the scapular line at the base of the chest, where 
fluid is usually obtained without difficulty. In axillary effusions, on the 
other hand, aspiration at this point is often unsuccessful because the 
fluid is more laterally situated. Dulness, if present at this site may be 
due to thickened pleura at the margin of the empyema or to compressed 
lung, rather than to the effusion itself. Therefore whenever there is 
reason to suspect an encapsulation of the empyema, it is wise to aspffiate 
either in the anterior or posterior axillary line. With a single puncture 
the needle may be pointed in any direction and usually the pus will be 
discovered. Needless to say, when aspiration is performed on the left 
side in the anterior axillary line, one must inform oneself by a previous 
Roentgen examination of the exact position of the heart, lest it be in- 
jured. 332 
The Pleura 
(2) BASAL EFFUSIONS. An empyema at the base of the chest 
is not uncommonly found by the surgeon to be encapsulated, although 
this may not have been suspected from the physical examination. Sim- 
ilarly the Roentgen plate may fail to reveal the presence of adhesions. 
Thus in figure 243 although a free effusion was closely simulated, a 
Encapsulated empyema at left base. See figure 244. 
FIGURE 243 
subsequent plate, made after operative removal of the pus, revealed 
the fixation of the lung to the chest wall along the margin of the empy- 
ema. (Fig. 244.) The physical signs in these cases are apt to be 
ambiguous and may, when taken by themselves, make it difficult to 
decide between an empyema or a persistent pneumonia with a thickened 
pleura. The dulness may not be marked, the upper level of the effusion 
may be horizontal as with a pneumonia and rales may be heard along 
its borders. The Pleura 
333. 
FIGURE 214 
Encapsulated empyema at left base after operation, showing adhesion of lung 
above empyema. See figure 243. 
In other cases, and these are the majority, encapsulation of the' 
empyema may at once be inferred from the Roentgen plate. A char- 
acteristic example is seen in figure 245 in which the effusion followed 
the rupture of a lung abscess. 
(3) APICAL EFFUSIONS. Empyemas are less often confined to 
the upper portion of the chest than to the base. An apical effusion is 
not necessarily a complication of upper lobe disease as it may also fol- 
low an inflammatory process in the apex of the lower lobe. Such an 
origin for the empyema is sometimes indicated by its clinical course and 
the operative findings, although all the physical signs may have been 
found over the upper lobe. 
The Roentgen and physical diagnosis of an apical empyema in its 
early stage may be equally difficult. This is especially true of children 
in whom the signs of fluid and consolidation are so apt to be alike. For 
this reason apical empyemas may be overlooked for some time until the 
clinical symptoms render the true condition unmistakable. The Roent- 334 
The Pleura 
FIGURE 245 
Basal encapsulated empyema 
gen shadow may also leave us in doubt, as the appearance of an effusion 
which is co-extensive with the upper lobe, may be identical with that of 
a pneumonia. However, sooner or later, a characteristic change occurs 
in the Roentgen shadow which indicates its true nature. The limited 
space in the apical region is capable of containing only a small amount 
of fluid. As the effusion increases it soon extends beyond its limiting 
adhesions and involves the dependent portion of the chest. 
The first evidence of an extension of the apical empyema may be 
a fibrino-plastic exudate on the neighboring pleura, whose significance 
as a sign of early empyema we have already discussed. (Fig. 246.) 
Again, the downward spread of the effusion may be more gradual; the 
pleuritic shadow slowly extends downward to involve more and more 
of the chest. The Roentgen picture may exhibit great variety, yet it The Pleura 
335 
FIGURE 246 
Encapsulated apical empyema, with fibrino-plastic exudate below, indicating 
beginning involvement of general pleural cavity. 336 
The Pleura 
is scarcely possible to mistake the shadows for those of a consolidation. 
(Fig. 247.) When such an empyema occupies nearly the entire chest, 
FIGURE 247 
Apical empyema, showing extension downward toward base. 
so that only the costo-phrenic sinus remains free, the difficulty of dis- 
tinguishing it from a large free effusion by physical examination is 
almost insuperable. (Figs. 248 and 249.) The Pleura 
337 
Empyema encapsulated in upper two-thirds of chest. Beginning involvement 
of right base. 
FIGURE 248 
FIGURE 249 
Encapsulated empyema involving the entire chest with the exception only of 
the extreme base. 338 
The Pleura 
Less commonly we have a sequence of events which is the opposite 
of that just described, namely, the upward extension to the apex of an 
encapsulated empyema which began lower down in the chest. Unless 
the patient has been observed from the beginning and the situation of 
the physical signs noted, the Roentgen shadows can easily be confused 
with those of a primary apical empyema. This is illustrated in the 
following case: 
In a young child, one week after the onset of its illness, both physical and Roentgen 
examination showed an encapsulated effusion, limited to the lower axillary region of the right 
chest, extending somewhat posteriorly. During the next two weeks the effusion rose to the 
apex, the Roentgen plate (fig. 250) then showing the apical empyema, and also a downward 
prolongation of the shadow which represents the original axillary effusion. At operation, 
there was found a bilocular empema, one sacculation of which occupied the axillary portion 
of the chest and the other, the posterior aspect of the lower lobe. Its cau:e was a ruptured 
cortical abscess. 
FIGURE 250 
Encapsulated empyema. In this case, the extension was from below upward, 
as observed clinically. The Pleura 
339 
The effusion need not surround the lung on all sides but may be 
situated on its anterior or posterior aspect. The physical examination 
is better adapted to determine this point than the Roentgen plate. In 
the case just described all the physical signs of effusion were found 
posteriorly and, as is so often the case, the percussion note anteriorly 
over the compressed upper lobe was tympanitic. 
(4) MESIAL EFFUSIONS. That portion of the general pleural 
cavity which borders on the heart is the least common site for encap- 
sulated effusions. Owing to the limited respiratory movement of this 
part of the chest adhesions often wall it off from the lateral half of the 
pleural cavity so that it is shielded from infection. 
These effusions possess a special interest for the surgeon because 
they are the occasional cause of puzzling complications after empyema 
operations. Owing to their unusual situation and the altered physical 
conditions in the chest consequent on the postoperative pneumothorax, 
they are only with difficulty found by physical examination. We there- 
fore owe their timely discovery to the Roentgen Ray. 
Mesial empyema. Shadow in region of pulmonary artery was a residual col- 
lection of pus which remained after operation. Note drainage tube in oper- 
ative pneumothorax. See figure 252. 
FIGURE 251 340 
The Pleura 
The problems in diagnosis and treatment involved in these cases 
are set forth in the following clinical history of a unique case of mesial 
empyema: 
A chilfl two and one-half years old had cough and fever for thirteen days with signs of 
a large left-sided empyema. A thoracotomy was performed and a large amount of pus, con- 
taining staphylocuccus aureus was evacuated. Although drainage appeared to be free, high 
temperature continued for four weeks. At length, during a search for a hidden undrained 
collection of pus, there was found an area of dulness along the left border of the heart, 
extending from the 2nd to the 4th ribs. This area of dulness corresponded exactly to the 
semi-circular shadow which is seen at the left border of the heart in figure 251. An inter- 
costal incision was made at this point and two ounces of pus removed. In the subsequent 
plate, (fig. 252,) made after operation, this shadow had disappeared. The child promptly 
recovered. 
FIGURE 252 
Same case as figure 251 after drainage of mesial empyema. 
A mesial empyema, as in this case, may be a residual one and may 
have existed from the beginning of the illness. On the other hand there 
are cases in which it is a later development resulting secondarily from 
an empyema in the lateral half of the chest. We have observed this 
complication several times after the evacuation of pus from the outer 
part of the chest and it may be presumed that during the operation the The Pleura 
341 
severance of mesial adhesions permitted the infection to gain access to 
the hitherto uninvolved mesial part of the pleural cavity. This is illus- 
trated in the following case : 
The patient, whose plate is reproduced in figure 253 was operated on and a collection of 
pus, walled off in the lateral half of the chest, was removed. A few days later he had a chill 
with high fever. As there appeared to be no retention of pus in the original empyema cavity, 
a secondary collection was sought elsewhere. On examining the chest there was found an 
area of dulness along the right border of the sternum in a situation not previously involved. 
The Roentgen plate proved this to be a collection of fluid surmounted by air in the mesial 
part of the chest. (Fig. 254.) As is seen, the original empyema had been effectually evacu- 
ated leaving a large area of pneumothorax bounded by the adherent lung. There can be no 
doubt that the surgeon while probing with his finger the limits of the original empyema, 
broke through the adhesions, thus permitting both infecion and air to gain access to the 
mesial part of the chest. 
FIGURE 253 
Encapsulated, bilocular empyema. See figure 254. 342 
The Pleura 
Encapsulated effusion shown in figure 253 after operation. Removal of pus 
has left a pneumothorax limited mesially by adherent lung. Secondary pyo- 
pneumothorax along right border of heart. Arrow points to adherent lung. 
FIGURE 254 The Pleura 
343 
(5) MULTILOCULAR EFFUSIONS. The adhesions which cause 
effusions to be encapsulated are also effective, in most cases, in confin- 
ing them to a limited area of the pleural cavity. For this reason, they 
may also be described as “localized.” Such a localized effusion usually 
consists of a single collection of fluid which can readily be drained 
through an opening. 
Encapsulated empyemata however, need not be localized. They 
may occupy a large part of the pleural cavity and may then consist of 
two or more adjacent sacculations which may or may not communicate 
with each other. Naturally, the physical signs produced by such 
sacculations lying next to each other, may be identical with those of a 
large free effusion. For similar reasons the Roentgen plate will fail to 
make this distinction. Usually the multilocular character of the 
effusion is only suspected when a drainage operation is not successful 
in relieving the symptoms. Under these circumstances, a residual col- 
lection of pus may later be found near the apex, which is shut off by 
Residual empyema at apex after evacuation of basal effusion. Note small air 
bubble at summit of effusion. 
FIGURE 255 344 
The Pleura 
adhesions from the empyema at a lower level which is being drained. 
For the early discovery of these residual effusions, the Roentgen plate 
is almost indispensable because their physical diagnosis is made excep- 
tionally difficult by the previous operation. The ease of the Roentgen 
diagnosis on the contrary is illustrated in figure 255. There is clearly 
shown a residual emypema at the right apex, which remained after 
the evacuation of what appeared to be a large free effusion. It gave 
rise to urgent symptoms after operation, until it was discovered and 
drained through a separate opening in the chest. 
Certain clinical aspects of multilocular effusions may profitably 
detain us for a moment because of the light which may be thrown on 
them when they are correlated with the Roentgen findings. The fluid 
in the various sacculations may be of different characters so that 
aspiration of the chest may at one point bring forth pus, whereas at 
another the effusion may be slightly turbid or even serous. Such an unus- 
ual circumstance is apt to occur when a lung abscess is near the surface 
or actually perforates it. There usually results an encapsulated empy- 
FIGURE 256 
Bilocular pleural effusion. The two effusions are adjacent to each other so 
that they appear to form one large effusion. See figure 257. The Pleura 
345 
ema, localized to the site of the perforation. If the infection spreads 
beyond the adhesions the neighboring pleura is stimulated to progressive 
reaction. In the beginning this is fibrino-plastic, it then passes rapidly 
through the various stages of an inflammatory effusion, from an aseptic 
serous polynuclear one to a true empyema. When under these circum- 
stances the chest is aspirated over the secondary nonpurulent effusion 
the original empyema will escape detection until a persistence of the 
symptoms leads to a search for it. We may illustrate the interesting 
clinical problem here presented by the following case: 
A young woman, some weeks before her present illness, was affected with a succession 
of furuncles. For one week she had high fever and pain in the right chest. The physical 
signs were those of a large pleural effusion nearly filling the right chest. The high fever and 
the blood examination indicated that this was a purulent effusion. However, the fluid aspir- 
ated from the base of the chest was clear and sterile. It was significant that it showed a 
differential count of 90% polynuclear cells. Such an aseptic polynuclear pleurisy is due to 
one of two causes, either a cortical lung abscess or a near-by encapsulated empyema. There 
being no evidence of a lung abscess, search was made for a localized collection of pus in the 
pleura. After repeated aspiration, thick, white pus, containing staphylococcus alhus was found 
in the supraspinous region. Judging from the nature of the infecting organism, we had here 
evidently an encapsulated empyema at the apex, which was either metastatic or secondary to 
a furunculosis of the lung, with an aseptic pleurisy of the dependent part of the pleura. At 
this stage of the disease, owing to a confluence of the shadows of the separate effusions, the 
Roentgen appearance was that of one large effusion. (Fig. 256.) A few days later the aseptic 
lower effusion became purulent and a low thoracotomy was performed. After a temporary 
improvement, and although drainage appeared to be free, the patient once more became 
acutely ill. It was at once suspected that an apical encapsulated empyema had not been 
drained by the Operation and this suspicion was strikingly confirmed by the Roentgen exam- 
ination. The plate, (fig. 257) showed that the lower empyema had been emptied. The apical 
collection, whose outlines had previously been obscured, could now be made out and it was 
seen that the drainage tube was arrested at its lower limits by the encapsulating adhesions. 
After a secondary operation this residual collection was evacuated and the patient recovered. 
(B) CONCEALED EFFUSIONS. The effusions which we have 
thus far considered are aptly described as “parietal” in that they are in 
contact with the chest wall. Although their physical diagnosis is at 
times difficult, yet because of their superficial situation an approximate 
diagnosis and localization is usually within the powers of the clinician. 
This is not the case with so-called “concealed” effusions. They do not 
come in contact with the chest wall. Here the collection of fluid is 
buried within one of the recesses of the pleura or it is enclosed between 
the lung and the adjacent organs. Its physical signs are either absent 
or so modified by interposed lung that a certain diagnosis is rarely pos- 
sible. According to their location, we may recognize the following 
forms of concealed effusions: 
(1) Infrapulmonary, 
(2) Mediastinal, 
(3) Interlobar. 346 
The Pleura 
Same patient as figure 256 after drainage of lower collection of fluid. There 
remains a well encapsulated apical empyema just beyond the tip of the drainage 
tube. 
FIGURE 257 
(1) INFRAPULMONARY or diaphragmatic effusions are formed 
between the lower surface of the lung and the diaphragm. The fluid 
is retained in this position by adhesion of the edge of the lung to the 
chest wall or to the diaphragm. It is obvious that the physical signs 
of such a fluid accumulation will be difficult to interpret. It will espec- 
ially be necessary to distinguish it from suppurative disease of the liver 
or the subphrenic space. In figure 258 is shown such a diaphragmatic 
empyema in a man, whose chief symptoms were cough, remittent fever 
and copious expectoration lasting some months. At the right base 
there was an area of dulness extending from the angle of the scapula to 
the base, where it was flat. The upper line of dulness was convex. 
Breath sounds were diminished above and absent at the base. At 
operation there was found a large collection of pus, which rested on the The Pleura 
347 
FIGURE 258 
Diaphragmatic or infrapulmonary empyema. See figure 259. 
right diaphragm and was enclosed above and at the sides by adherent 
lung. The relation of the empyema cavity to the surrounding struc- 
tures may be seen in the post-operative plate. (Fig. 259.) 
(2) MEDIASTINAL EFFUSIONS. A collection of fluid between 
the mediastinum and the lung is undoubtedly the rarest of all effusions. 
Its development presupposes a fixation of the anterior or posterior 
margin of the lung, by which the fluid is retained in the mediastinal 
recess and is prevented from communicating with the general pleural 
cavity. An effusion in this situation lies in contact with the heart and is 
entirely enclosed by the overlying lung. For this reason physical signs 
are not well marked and even when present they are scarcely of a char- 
acter to suggest a deep seated effusion. We therefore owe the clinical 348 
The Pleura 
Diaphragmatic empyema shown in figure 258, after operation, showing lower 
margin of lung adherent. 
FIGURE 259 
diagnosis of this interesting condition almost entirely to the Roentgen 
Ray. We may illustrate the Roentgen appearance of mediastinal 
effusions by the following two cases which also bring out their medical 
and surgical features. 
A woman, twenty-four years of age, bad a moderately advanced pulmonary tuberculosis. 
She was acutely ill for four weeks with fever, dry cougli and pain in the left chest. On 
admission to the hospital she had signs o0 a small effusion at the left base, which proved to 
be clear fluid, containing 95% lymphocytes. A week later there was noted an area of slight 
dulness along the left border of the sternum at the second and third interspaces. There were 
no breathing changes. The heart was slightly displaced to the right. The Roentgen plate, 
(fig. 260)was most unusual. In addition to a bilateral upper lobe tuberculosis and an effusion 
at the left base, there was a dense shadow along the left border of the heart and continuous 
with the latter. This was presumably due to a mediastinal effusion. The subsequent course 
confirmed this presumption. After two weeks, all the symptoms subsided and a second plate, 
(fig. 261,) showed that both the basal and mediastinal effusion has been absorbed. The only 
evidence which remained of the previous pleurisy was a pieuro-pericardial adhesion at the 
base which had probably been effectual in walling off the mediastinal effusion. In this case 
there is every reason to believe that the effusion was of tuberculous origin and it is not 
improbable that it was secondary to a tuberclous process on the mediastinal aspect of the 
lung. The Pleura 
349 
FIGURE 260 
Mediastinal effusion with effusion at left base. Upper lobe tuberculosis. 
See figure 261. 350 
The Pleura 
Absorption of mediastinal effusion shown in figure 260. Adhesion of left 
diaphragm to pericardium. 
FIGURE 261 The Pleura 
351 
The surgical aspect of mediastinal effusions is brought out in the 
following case whose complicated clinical features found a counterpart 
in a most unusual Roentgen picture: 
The patient was three months old. For fourteen days previous to admission the child 
had pneumonia. On admission the temperature was high and remittent and on the left side 
there were signs of a large pleural effusion which, there was reason to believe, was unencapsu- 
lated. At operation a considerable amount of thick pus was evacuated through the usual 
posterior incision. In spite of apparently free drainage, the temperature continued and the 
child became increasingly septic. A physical examination at this time disclosed a slight 
widening of the area of cardiac dulness in its left upper portion, which was presumed to be 
due to a pericardial effusion. The Roentgen plate, (fig. 262,) taken at this time showed a 
large cardiac shadow, whose shape seemed to confirm the clinical diagnosis of pericarditis. 
An operation for the drainage of the pericardial sac was thereupon undertaken. After resect- 
ing the left fifth costal cartilage, the anterior margin of the left lung was found to be adher- 
ent to the pericardum. The latter was incised but no pus or fluid was found within the 
pericardial cavity When, however, the lung was stripped away from the heart there were 
found, situated between the mediastinal surface of the lung and the heart, six ounces of pus, 
which had cast the unusual shadow simulating a pericardial effusion. The disappearance of 
this shadow, after evacuation of the pus is shown in a subsequent plate, (fig. 262). The 
proximity of these effusions to the heart may make them appear to be a part of it and the 
distinction between them and a pericardial effusion or a cardiac lesion may be impossible. 
FIGURE 262 
Mediastinal empyema, before and after operation. Shadow closely resembles that of 
perieardial effusion. 
(3) INTERLOBAR EFFUSIONS. Of all effusions in the chest, 
excepting only the mediastinal form, the interlobar varieties offer the 
greatest difficulty in diagnosis and localization. Situated as they are, 
within the pulmonary fissures and completely enveloped by the lungs, 
physical signs are either entirely absent or they are so modified by 
interposed lung tissue, that their diagnosis is at best very uncertain. 352 
The Pleura 
The lack of physical signs may also be attributed to the usually small 
size of these effusions, which is determined by the narrow confines of 
the fissure. 
It is not improbable that many interlobar effusions are clinically 
unrecognized. This is especially true of the nonpurulent variety which 
is often latent and finally becomes absorbed. Even interlobar empy- 
emata frequently pass through a period of latency until rupture into 
the general pleural cavity or into a bronchus draws attention to the 
pleural cavity. 
Interlobar effusions are as rare as they are difficult to diagnose by 
the usual clinical means. There is little justification for regarding an 
effusion as interlobar, as is so often done, because the physical signs 
are atypical and are situated in the region of one of the fissures. It 
will be found in most cases of this sort that the effusion is in reality 
encapsulated in the axillary region rather than interlobar. 
FIGURE 263 
Pneumonia of right lower lobe before development of interlobar effusion. 
See figure 264. The Pleura 
353 
The clinical recognition of interlobar effusions we owe almost 
entirely to the Roentgen examination, which reveals accurately their 
situation within a fissure. An interlobar collection of fluid will lie in 
the plane of the fissure and will cast a more or less characteristic 
shadow, depending on its size and situation. It is therefore necessary 
to bear in mind the topographical relations of the interlobar fissures. 
The essential points to keep in mind are the following: The upper 
interlobar fissure, present only on the right side, extends transversely 
across the chest from the axilla to the sternal end of the fourth rib. Its 
plane is practically horizontal. The lower fissure begins at the sternal 
end of the sixth rib, curves upward to the axilla and then ascends 
sharply upward on the posterior aspect of the lung to the level of the 
second or third dorsal vertebra. 
Interlobar effusions occur most commonly on the right side because 
of the presence these of the upper interlobar fissure which is their 
most frequent situation. Only occasionally is fluid found between the 
upper or middle and lower lobes. 
We may clinically recognize three types of interlobar effusions 
as follows: (1) Metapneumonic; (2) Tuberculous; (3) Idiopathic. 
FIGURE 264 
Interlobar effusion developing during course of pneumonia shown in figure 263. 354 
The Pleura 
(1) METAPNEUMONIC INTERLOBAR PLEURISY: The 
effusions in the interlobar fissures which occur during the course of a 
pneumonia, may be either of a serous or purulent character. The former 
are usually overlooked as they promptly resorb without giving rise to 
any symptoms. Purulent interlobar effusions complicating pneumonias 
may occur either alone or in association with an empyema of the general 
pleural cavity. They cast a characteristic shadow in the region of the 
fissure which is easy to distinguish from the surrounding pneumonic 
infiltration. (Figs. 263, 264 and 265.) When such a shadow appears 
on the Roentgen plate during the course of a pneumonia we need seek 
no further for the cause of a continuation or a recrudescence of the fever 
and other symptoms. The following case illustrates the value of the 
Roentgen examination under these circumstances: 
Diagram of interlobar effusion complicating lobar pneumonia shown in figure 264. 
(a) interlobar effusion; (b) pneumonia. 
FIGURE 265 The Pleura 
355 
A child, one year old, coninued to have high fever two weeks after the onset of a pneu- 
monia. The physical examination showed only the signs of a resolving pneumonia of the left 
lower lobe, which did not seem to be an adequate cause for tlie high temperature. The 
Roentgen plate, (fig. 266,) however, showed a significant shadow in the region of the right 
upper fissure, pathognomonic of a pleural exudate. Death ensued in a few days from 
toxemia. At autopsy a small amount of pus was found between the right upper and middle 
lobes in the position indicated on the Roentgen plate. 
Early interlobar empyema on right side; resolving pneumonia at left base. 
FIGURE 266 
In figure 267 a similar effusion is shown on the left side, which is 
very unusual. The lower position of the shadow is here due to the 
lower situation of the fissure on the left side. Naturally, where so little 
fluid is present, only a fortunate chance will enable the operator to dis- 
cover it with the exploring needle, owing to the narrow limits of the 
fissure. It is very probable that interlobar empyemata, as they increase 
in size, soon extend beyond it and involve the pleural cavity in a general 
empyema. It is obvious that the underlying interlobar pleurisy will 
then be completely obscured by the larger effusion so that it will only 
be discovered by operation. Of course, at this stage of the disease, it 356 
The Pleura 
FIGURE 267 
Very rare interlobar effusion on left side. The shadow has a lower position 
than a right sided effusion, corresponding to the lower position of the fissure. 
will not be possible to determine whether the interlobar and general 
empyema developed simultaneously, as may happen, or in succession. 
We may illustrate this interesting combination by the following case: 
A child of sixteen months contracted measles about one month before admission to the 
hospital. During the previous two weeks she had cough and slight temperature. When first 
observed the child was very dyspnoeic. Examination showed flatness in the right chest from 
the spine of the scapula not quite to the base in the axillary half of the chest. Operation in 
the eighth space, posterior axillary line, brought to light an encapsulated effusion containing 
twelve ounces of pus. In addition, on separating the upper and middle lobes, a small amount 
of pus was found in the fissure. The condition is graphically portrayed on the plate, (figs. 
268 and 269,) which was made shortly before the operation. The irregular shadow in the 
apical and lower axillary regions corresponds to the encapsulated effusion The small inter- 
lobar empyema is distinctly shown as a lenticular shadow extending transversely across the 
middle of the chest. The Pleura 
357 
FIGURE 268 
Interlobar empyema associated with encapsulated empyema at apex and fluid 
at base. See figure 269. 
FIGURE 269 
Diagram of figure 268. 
(a) Encapsulated empyema at apex. 
(b) Interlobar empyema. 
(c) Effusion at base. 358 
The Pleura 
A more complicated picture is presented in figures 270 and 
271 in which, following pneumonia, an empyema developed not only 
in the upper fissure but also in the lower one, together with a beginning 
empyema of the general pleural cavity. One may well marvel at the 
clearness with which all the details of this complicated empyema are 
exposed to our view and speculate on the futility of the physical exam- 
ination to unravel its intricacies. 
Effusion in upper and lower interlobar fissures following pneumonia. 
See figure 271. 
FIGURE 270 
(2) TUBERCULOUS INTERLOBAR PLEURISY. Eusions of tuber- 
culous origin may develop within an interlobar fissure, as well as in the 
general pleural cavity. They appear to be more common in children 
and occur with the greatest rarity in adults. This circumstance is pos- 
sibly related to the frequent occurrence in children of tuberculous The Pleura 
359 
FIGURE 271 
Diagram of figure 270. 
(a) Resolving pneumonia. 
(b) Small effusion between upper and middle lobes. 
(c) Effusion between middle and lower lobes. 
(d) Small effusion in general pleural cavity. 360 
The Pleura 
infiltrations in the right upper lobe, near the fissure. An interlobar 
effusion may thus occasionally complicate a hilum tuberculosis in 
young children (fig. 272) and for some years after its resorption the 
pleural reflection at the fissure may show a marked thickening. 
FIGURE 272 
Residual hilum infiltration with a small interlobar effusion. 
Naturally, a small interlobar exudate in a tuberculous suspect is 
easily overlooked and it may not be until the general pleural cavity is 
involved, that attention is drawn to it. The long period during which 
such a pleurisy may remain latent, is well brought out in the following 
case: 
A child of eight and one-half years, for three months had headache, fever, weakness and 
cough. Six weeks before examination she developed pain in the right side with an increase 
of the cough. The child was pale, undernourished and was apparently toxaemic. There 
were signs of fluid in the lower third of the right chest. Blood count, 16000 leucocytes; 63% 
polynuclears. Only a small amount of lymphocytic fluid could be aspirated. On the plate, 
(fig. 273) may be seen an interlobar effusion which appears to communicate with a small 
exudate in the general pleural cavity. The clinical facts all point to the tuberculous nature of 
the pleurisy. It is very probable that the onset of the pleural symptoms was coincident with 
an extension of the inflammatory process to the general pleural cavity. The Pleura 
361 
FIGURE 273 
Interlobar effusion, probably tuberculous. Small effusion in general pleural 
cavity communicating with interlobar effusion. 
In the following case also, the tuberculous nature of the effusion, 
which was very unusual in situation, cannot be open to doubt: 
The child of twenty-one months had pneumonia four months before. Since that time 
cough was persistent with slight rises of temperature, usually in the evening. Latterly, a 
number of tuberculous nodes appeared in the neck. The patient appeared only slightly ill. 
The physical signs were puzzling and pointed to a pleural effusion in an unusual situation. 
Posteriorly, there was dulness from the apex to the angle of the scapula; below this and 
extending to the axilla, the note was tympanitic. Anteriorly also there was a tympanitic note. 
The breath sounds behind were bronchial in the upper chest and broncho-vesicular below. 
The Pirquet test was strongly positive. A needle was inserted posteriorly below the angle of 
the scapula, but no fluid was obtained. A deep puncture in the axilla however, brought out 
a considerable amount of gelatinous fluid, which contained no bacteria The physical exam- 
ination suggested a deep seated effusion covered by compressed lung, giving rise to a tympanitic 
note. The Roentgen plate, (fig. 274,) shows a well encapsulated collection of fluid which is 
limited below and laterally by the lower fissure. The plate may be regarded as fairly typical 
of a large effusion between the upper and lower lobes. 362 
The Pleura 
FIGURE 274 
Large effusion between the upper and lower lobes. Probably tuberculous. 
(3) IDIOPATHIC INTERLOBAR PLEURISY. Occasionally an inter- 
lobar effusion is found unassociated with existing or previous pulmonary 
disease. The etiology of these cases is obscure and they may perhaps 
be regarded as primary interlobar effusions, due to the virus of rheuma- 
tism or other infectious agents which are responsible for pleurisies 
occurring in the more usual situations. In some cases they are entirely 
latent clinically; others run their course as acute respiratory infections 
which, because of an absence of physical signs, are mistakenly regard- 
ed as deep-seated pneumonias. 
For example, following a mild respiratory infection a patient 
developed symptoms of exopthalmic goitre. On the Roentgen plate of 
the chest made to determine the size of the heart, an unsuspected 
effusion was found in the right upper fissure. (Fig. 275.) The patient 
had no pulmonary symptoms and in two weeks the abnormal shadow 
had disappeared. A more acute form of this disease is illustrated by 
the following case: The Pleura 
363 
FIGURE 275 
Interlobar effusion. 
A child of three years had cough, dyspnoea and high fever for ten days. ’ y cal exam- 
ination of the lungs was entirely negative. Yet on the plate, (fig. 276,) there was a fairly 
large collection of fluid between the upper and middle lobes. After a few days the tempera- 
ture came to normal, the child rapidly improved and the shadow disappeared. We were here 
evidently dealing with an interlobar pleurisy, whose acute inflammatory character was further 
attested by the high leucocyte count, which was 22000, polynuclears 80%. At no time were 
dulness or rales to be heard over the affected area of the chest. This fact and the peripheral 
position of the shadow will serve to exclude central pneumonia as a cause of the condition. 
ENCAPSULATED EFFUSIONS WITH PNEUMOTHORAX. The 
presence of air in addition to fluid within a pleural sacculation adds 
measurably to the difficulties of the physical examiner. Whereas the 
larger collections of air and fluid in the chest betray their presence by 
such characteristic signs as tympany and succussion, the smaller 
amounts of air, which are usually found with sacculated effusions, are 
easily overlooked. Moreover, an area of pneumothorax situated above 364 
The Pleura 
FIGURE 276 
Acute pleurisy with effusion in right upper interlobar fissure 
a small effusion will render accurate localization of the latter difficult, 
by masking its dulness. While the physical examiner thus finds his 
difficulties multiplied, the presence of air in the chest is a fortunate cir- 
cumstance for the Roentgenologist and it is to him that we owe 
our intimate knowledge of his condition. Whenever air and fluid 
coexist in the chest, the latter acquires a horizontal level, the shadow 
of which is one of the most distinctive features of the Roentgen plate. 
We commonly associate the condition of pyopneumothorax with 
pulmonary tuberculosis, yet it is surprising to note the frequency with 
which encapsulated collections of air and pus are encountered with 
pyogenic disease of the pleura. Aside from tuberculosis, perhaps 
their commonest cause is the extension of a lung abscess to the pleural 
surface or its actual perforation. This perforation in the majority of 
cases is for some time preceded by a fibrinoplastic pleurisy so that the 
subsequently developing empyema is encapsulated. It communication 
with a bronchus permits the free access of air to the effusion. This 
complication of a lung abscess or a bronchiectatic cavity may develop 
during the early acute stage of the disease or it may be a late and 
terminal event. In figure 277 is shown a localized pyopneumothorax The Pleura 
365 
FIGURE 277 
Encapsulated pyopneumothorax secondary to ruptured lung abscess. The fluid 
has a horizontal level and is walled off by dense pleural adhesions, (arrow). 
which occurred during the course of a gangrenous abscess of the lung, 
eighteen days after the onset of a pneumonia. The encapsulation of 
the fluid below is clearly shown. Above and laterally pleural adhesions 
wall it off from the general pleural cavity. At operation, a small per- 
foration was found on the posterior surface of the lung. 
The frequent pleural adhesions which complicate pulmonary 
tuberculosis will occasionally confine to a limited region of the chest 
the effusions which follow a spontaneous pneumothorax. Usually the 
fluid is walled off in the axillary part of the chest. At times it may 
have an unusual situation, as in figure 278 where it is supported in the 
middle of the chest by the adherent lower lobe. Among the rarer 
causes for an encapsulated seropneumothorax is the perforation of a 
tumor nodule in the lung. The small collection of air and fluid in the 
right upper lobe in figure 230 was found in a case of miliary carcinosis 
of the lung. 
In contradistinction to the cases we have thus far discussed, in 
which the air is derived from the lung through a perforation, we must 
consider those in which the air is introduced from without, either dur- 366 
The Pleura 
Encapsulated pyopneumothorax; pulmonary tuberculosis. Note collapsed upper 
lobe containing cavity. The fluid occupies the middle third of the chest and 
shows a horizontal surface due to the air above it. 
FIGURE 278 
ing operation or exploratory aspiration of the chest. By this means the 
shadows of sacculated effusions, which might otherwise be difficult of 
interpretation acquire a distinctive appearance. Thus, the mesial 
empyema in figure 254 followed the evacuation of the axillary 
effusion shown in figure 253. The communication of this effusion with 
the outer wound was responsible for its horizontal upper level which 
removed all doubt as to the nature of the shadow. It is not unusual for 
a small amount of air to be drawn into the chest during exploratory 
aspiration. This is more apt to occur in encapsulated effusions because 
the lung, being bound down by adhesions is prevented from expanding 
after the removal of the fluid. The appearance of such a partial pneu- 
mothorax surmounting a fluid level after aspiration of the chest is there- 
fore at times an evidence of sacculation of the fluid. 
The phenomenon of fluid levels in the pleura is of the greatest value 
in the diagnosis of multilocular effusions. When a number of saccula- 
tions lie adjacent to each other the dulness of the individual saccula- The Pleura 
367 
tions becomes merged in such a way that a large single effusion is 
simulated. If in such a case the chest is aspirated the operator will not 
be able to evacuate the effusion by a single puncture. It will be neces- 
sary to insert the needle separately into each sacculation. When a Roent- 
gen examination is made after such multiple punctures, the separate 
loculi may be found partly filled with fluid and air, so that their size 
and situation can be defined. The following case is an instructive 
example: 
Following pneumonia the patient, a young woman, presented the physical and Roentgen 
signs of a large effusion in the left chest. The chest was aspirated at three points posteriorly 
and each time from 50 to 100 cc. of clear fluid were removed. A plate made the next day, 
after air had apparently entered the plural cavity, showd three fluid levels of various lengths, 
situated one above the other. The vertical dimensions of the saceulations could be accurately 
determined from the Roentgen plate made in the lateral recumbent position, consequent on 
the shifting of the fluid. (Fig. 279.) The sequel of this case is of some interest. The fluid, 
presumably as a result of frequent aspirations became infected with anaerobic organisms. 
The physical signs then became those of a large unencapsulated pyopneumothorax. Evidently 
under the influence of the putrid infection, the adhesions were dissolved and the various 
saceulations coalesced into one large effusion, as is shown in figure 289. 
FIGURE 279 
Encapsulated pyopneumothorax. Patient in lateral recumbent position showing 
three fluid levels. See figure 289. 368 
The Pleura 
SECONDARY CHANGES IN THE CHEST ASSOCIATED WITH 
PLEURAL DISEASE 
Some of the classical physical signs which result from disease of 
the pleura are due to mechanical effects on the various intrathoracic 
structures. The position of the heart and mediastinum, the volume of 
the chest and the movement of the diaphragm are all under the scrutiny 
of the Roentgen Ray, which is eminently fitted to register these secondary 
changes and to supplement by an accurate objective method the find- 
ings of the physical examination. Roentgen studies are in the main in 
agreement with commonly accepted ideas in regard to the effect of 
effusions on adjacent organs. Pleural effusions of moderate or large 
size frequently cause a displacement of the heart to the opposite side. 
This is especially true of noninflammatory effusions, such as the transu- 
dates of cardiac or renal disease. It is equally true of the rapidly 
forming large empyemata in young children, in whom the heart may 
suffer an extreme displacement. (Fig. 280.) 
Large empyema in child. Note separation of ribs and displacement of heart 
and trachea to right. (arrow.) 
FIGURE 280 The Pleura 
369 
It is however, surprising to note the frequency with which the heart 
is not at all affected in its position by the presence of fluid in the pleural 
cavity. Even a very large collection of fluid may cause no malposition 
of the heart. If we inquire more closely into this phenomenon, it will 
be found that cardiac displacement depends not only on the size of 
the effusion but also on the nature of the pathological process which 
causes it. Thus with empyema, especially in adults, even if it be large, 
the heart is frequently found in its normal position. Evidently other 
causes than the pressure of the fluid on the heart must be operative. In 
the first place, with inflammatory exudates the mediastinum may be 
fixed by adhesions so that it and the heart are not easily displaced. 
Secondly, lessened respiratory movement of the lung and consequent 
atelectasis, due to the inflammatory process, will tend to displace the 
heart to the same side and thus counteract the direct pressure effect 
of the effusion. These opposing forces may be so well balanced that in 
a large percentage of empyemata in adults, the heart appears to main- 
tain its normal position. The paradoxical phenomenon of a displace- 
ment of the heart to the pleuritic side may occasionally be seen, even 
with an effusion of fair size. Here again we must assume a reflex im- 
mobility of the lung with atelectasis, whose effects are sufficient to 
overcome the pressure of the fluid and the elastic pull of the opposite 
lung. A similar phenomenon may at times be seen in pleurisies without 
effusion or in the early stages of empyema, before effusion has occurred. 
The reflex immobility of the chest and the decrease in the volume of the 
lung may cause a noticeable displacement of the heart toward the 
affected side. 
When we observe on the Roentgen plate these unusual displace- 
ments of the heart, which are so much at variance with traditional 
teachings, we are impressed with the minor role played in their causa- 
tion by the effusion itself. One is inclined rather to seek an explana- 
tion for them in variations of the elastic tension of the lungs and of the 
intrathoracic pressure. 
The influence of encapsulated effusions on the position of the 
heart presents some points of interest. Whether the heart is displaced 
or not seems to depend entirely on the position of the encapsulated fluid 
with respect to the heart borders. When sacculated effusions are situ- 
ated in the lateral portion of the chest or at the apex, the heart main- 
tains its usual position. If, however, the fluid is in the mesial portion 
of the chest and is applied to the cardiac surface so that it can exert 
direct pressure on it, the heart will be displaced. Thus the large axil- 
’ary effusion in figure 253 had no influence on the position of the heart, 
whereas the small effusion seen in figure 243 which was close to the 
the apex of the heart caused a distinct dislocation of the latter. After 370 
The Pleura 
the evacuation of the fluid the heart resumed its normal position. (Fig. 
244.) In a similar way the mediastinal effusion in figure 260 by virtue 
of its position close to the heart, caused its displacement. 
Changes in the conformation of the thorax secondary to effusions 
can be estimated with great accuracy on the Roentgen plate. In har- 
mony with clinical experience we find in rapidly forming effusions, 
especially in young children, a separation of the ribs with a widening 
of the intercostal spaces and an increase in the volume of the affected 
side. (Fig. 279.) However, the Roentgen findings reveal in many cases 
a surprising divergence from the accepted clinical view in respect to 
these thoracic changes. A separation of the ribs is frequently absent in 
large purulent effusions and in emypemata of moderate size it is prac- 
tically never found. On the contrary, in a considerable percentage of 
cases, the ribs are actually drawn closer together so that the affected 
half of the chest is smaller than the healthy side. Nor need we look 
upon such a retraction of the chest, as is frequently done, as evidence 
of an encapsulation of the empyema. Although it is true that retrac- 
tion of the chest wall is often associated with encapsulated effusions, 
it is also found with free effusions of a purulent character. It may be 
regarded as a result of the reflex rigidity of the intercostal muscles, 
similar in its mechanism to the abdominal rigidity of peritonitis. Chapter XVI 
Pneumothorax 
The presence of air in the pleural cavity even in small quantities 
may readily be detected by Roentgen examination. Depending on the 
amount of air and the presence or absence of pleural adhesions, the 
lung recedes from the chest wall for a variable distance; between the 
margin of the retracted lung and the chest wall there is a homogeneous 
air space, situated usually in the apical and axillary regions, which on 
the Roentgen plate is characterized by an absence of the pulmonary 
markings. (Fig. 281.) 
The great variety in the size and shape of pneumothoraces is deter- 
mined by two factors, namely, pleural adhesions and the condition of 
the lung. When there are no adhesions and the lung is normal, the 
Spontaneous pneumothorax. Right lung concentrically retracted, showing separ- 
ation of upper and lower lobes at arrow. 
FIGURE 281 372 
The Pleura 
latter is contracted concentrically as the amount of air increases, so that 
finally it forms a small dense globular mass at the root of the lung. 
(Fig. 292.) Rarely the air gains access to the mediastinal portion of 
the chest, (fig. 282) and at times it may insinuate itself within the 
interlobar fissures so that the individual lobes become visible. (Figs. 
281 and 292.) 
FIGURE 282 
Pyopneumothorax; lung adherent in midclavicular line; air has gained access 
to mediastinal pleura. 
The compressed lung becomes progressively more dense until it 
finally has the opacity of a consolidation. Such a complete collapse 
however, is not the rule, as either infiltration of the lung or firm pleural 
adhesions will retain it in contact with the chest wall at one or more 
points. The commonest situation for these adhesions is at the apex, 
which is evidently due to the frequency of apical fibroid changes result- 
ing from chronic tuberculosis. For this reason, the lower part of the 
lung is often found compressed, whereas the upper lobe remains adher- 
ent. In some cases the adhesions are extensive (fig. 283) ; in others The Pleura 
373 
FIGURE 283 
Pneumothorax. Upper lobe firmly adherent. Hernia of mediastinum to left 
side due to extreme pressure of pneumothorax. Heart displaced to left. 
(figs. 284, 285 and 286) they may be localized to a small area. Less 
commonly the apical region may be quite free and the lung may be 
adherent at its middle (fig. 287) or even at the base. 374 
The Pleura 
Almost complete pneumothorax, right side. Lung adherent in infraclavicular 
region. Compensatory engorgement of left lung. 
FIGURE 284 The Pleura 
375 
FIGURE 285 
Complete pneumothorax, showing compression of lung. Diaphragm depressed 
and ribs separated. Lung adherent at apex. 376 
The Pleura 
FIGURE 286 
Spontaneous pneumothorax with miliary tuberculosis of lungs. Apical adhesion. The Pleura 
377 
FIGURE 287 
Artificial pneumothorax. Lung completely collapsed except at middle where a 
few adhesions are seen. Heart displaced to right. Note engorgement of right 
lung. Depression of diaphragm. 
Displacement of the heart is a more regular phenomenon with 
pneumothorax than with pleural effusions. The loss of tension of the 
collapsed lung upsets the balance between the two halves of the chest 
so that the heart is drawn away from the affected side. This is true 
even though the intrapleuial tension be negative. Whenever the pres- 
sure increases until it becomes positive, as in cases of tension pneu- 
mothorax, the displacement of the mediastinum may be extreme. In 
fact, under these conditions, there may result a hernia of the medias- 
tinum to the normal side. (Fig. 283.) It is in these cases that the 
intercostal spaces are much widened by the increased volume of the 
thorax and the diaphragm is depressed. (Figs. 287 and 288.) There 378 
The Pleura 
FIGURE 288 
Extensive bilateral tuberculosis with spontaneous pneumothorax under tension. 
Separation of ribs and marked depression of diaphragm. The Pleura 
379 
may also be observed on the fluoroscopic screen an inspiratory displace- 
ment of the mediastinum to the side of the pneumothorax and a para- 
doxical upward excursion of the diaphragm. 
A pneumothorax produces profound changes both in the lung on 
the affected side and in the opposite one. The compressed lung acquires 
a denser shadow which one must not confuse with the infiltrations of 
disease. Small lesions in the collapsed lung may thus readily be 
obscured. Occasionally collapse of the lung operates to some advantage 
in diagnosis. Thus, in a tuberculous or suppurating lung, a cavity fre- 
quently becomes more distinct when the pulmonary tissue about it is 
slightly compressed by the pneumothorax. (Fig. 81.) Marked changes 
may also be observed in the unaffected lung. When there is an exten- 
sive pneumothorax, this lung must perform the function of both and 
accordingly it is over-supplied with blood. This results in a marked 
accentuation of the vascular markings, (fig. 287) which must not be 
confused with disease of the lung. 
FIGURE 289 
Later stage of ease shown in figure 279. Pyopneumothorax. 380 
The Pleura 
A number of interesting complications are occasionally associated 
with pneumothorax which are visible on the Roentgen plate. The most 
common of these is a pleural effusion, whose characteristic horizontal 
level is an unmistakable sign of air in the pleural cavity. (Fig. 289.) 
Usually the fluid is unencapsulated, as in tuberculous cases; yet there 
are numerous instances, especially in cases of suppurative lung disease 
in which the fluid is walled off by adhesions so that one (fig. 277) or 
more collections of fluid and air are found. When much fluid with air 
is present in the pleural cavity, it may depress the diaphragm so that it 
presents a downward convexity. Under these circumstances there may 
be visible on the fluoroscopic screen a paradoxical upward movement 
of the fluid level during inspiration. Another frequent complication 
which occurs especially after induced pneumothorax, is subcutaneous 
emphysema, in which the air may be seen to infiltrate the tissues for a 
Pyopneumothorax complicated by pneumopericardium. Arrows indicate peri- 
cardial membrane raised from the heart hv air in pericardium. Patient in 
lateral recumbent position. Air and fluid in left chest, below. 
FIGURE 290 The Pleura 
381 
considerable distance. A very rare complication of pneumothorax is 
a perforation of the pericardium as a result of which the unique picture 
of pneumopericardium is produced. (Fig. 290.) 
Roentgen studies have done much to extend our knowledge of 
pneumothorax. It is no exaggeration to state that before the intro- 
duction of the Roentgen Ray the majority of cases, especially of partial 
pneumothorax, were unrecognized. It has been shown that little de- 
pendence can be placed on the classical syndrome of sudden pain, 
collapse and cyanosis, as these symptoms are absent in many cases. 
Physical signs also, except in the presence of much air, are very am- 
biguous. For the diagnosis of the small pneumothoraces, which are so 
frequent in pulmonary tuberculosis and the local pyopneumothoraces 
of lung abscess, dependence must be placed entirely on the Roentgen 
Ray as physical examination rarely discovers them. 
FIGURE 291 
Irregular pneumothorax, due to pleural adhesions, following pneumonia, resem- 
bling cavities in lung. Complete restoration to normal in a few weeks. 382 
The Pleura 
The distinction between a localized pneumothorax and a large 
pulmonary cavity which is often uncertain clinically, presents little 
difficulty to the Roentgenologist. Cavities which could be thus con- 
fused are usually the large tuberculous excavations in an upper lobe. 
In these cases, although very little pulmonary tissue may remain about 
the cavity and although the latter may superficially resemble a pneu- 
mothorax, the thickened wall of the cavity can practically always be 
seen. Irregular encapsulated pneumothoraces however, as in figure 
291, present much difficulty in diagnosis unless the clinical history is 
available. 
ARTIFICIAL PNEUMOTHORAX 
Since the introduction of the operation for artificial pneumothorax, 
the Roentgen examination of the chest has acquired a practical im- 
portance as an adjunct to therapy. Although an artificial pneumothorax 
may be induced and maintained without the control of the Roentgen 
Ray, it is so performed at the cost of scientific exactitude and also at 
some risk. In the first place, the preliminary examination is of the 
greatest value in determining the extent of the disease, whether both 
lungs are involved and which side is the more advanced. It will there- 
fore determine the side on which the pneumothorax should be induced. 
In the second place, the examination may locate adhesions or thick- 
ening of the pleura and may thus guide the operator in choosing the 
site of puncture. Further, after the gas had been introduced the Roent- 
gen examination is almost indispensable to ascertain with any degree 
of exactness when the lung is completely collapsed. Only by means of 
it will the operator become aware of firm, inseparable adhesions which 
will discourage any attempts further to compress the lung. The Roent- 
gen examination will also control the time of the re-injection of the gas 
and finally it will very early disclose the development of an effusion 
which may make it inadvisable to attempt a further injection. 
In many cases these purposes are better served by the fluoroscopic 
than by the plate examination. On the fluoroscopic screen one obtains 
a better impression of the firmness of adhesions and the likelihood of 
severing them. Frequently a single dorso-ventral plate gives an entirely 
erroneous impression of the amount of air introduced and the degree of 
the collapse of the lung. Thus it is not an uncommon experience to find 
on the plate evidence of only a small pneumothorax in the axilla. The 
fluoroscopic examination in such cases may show a considerable amount 
of air in the posterior portion of the chest, whose presence is obscured 
on the plate by the overlying lung. 
Only a Aw illustrations of the Roentgen appearance of artificial 
pneumothorax in its various phases need be presented, as they differ 
little if at all, from spontaneous pneumothorax. In figure 292 are seen The Pleura 
383 
FIGURE 292 
Two stages in artificial pneumothorax, with complete collapse of lung. Note separation of 
lobes and later depression of diaphragm and cardiac displacement with increasing pressure. 
two stages in the progress of a therapeutic pneumothorax terminating 
in a complete collapse of the lung. In figure 287 the gas is under such 
great tension that the mediastinum and heart are displaced for a con- 
siderable distance into the opposite chest. Occasionally the Roentgen 
plate discloses the reason for the failure of the injected gas to effect 
a collapse of the lung. Thus in figure 397 because of a low insertion 
of the needle, which penetrated the diaphragm, considerable gas was 
injected into the peritoneal cavity, where it is visible. In other cases, 
an extensive subcutaneous emphysema offers a ready explanation for an 
unsuccessful injection. Chapter XVII 
Tuberculosis of the Pleura 
As is well known, inflammation of the pleura is a frequent mani- 
festation of the tuberculous infection. The commonest form of pleural 
disease is associated with a tuberculous involvement of the lung and 
consists of a fibrino-plastic exudate which later organizes and gives rise 
to the pleuro-phrenic adhesions which are such a familiar feature of the 
Roentgen plate in these cases. A thickening of the pleura in other situa- 
tions than at the base is not readily demonstrable on the Roentgen 
plate unless it is considerable, as the rays traverse it readily. At the 
interlobar fissure however, on the right side, which is a favorite site 
of pleural thickening, the pleura at the anterior edge of the upper and 
middle lobes becomes visible as a sharp linear shadow which traverses 
the chest from hilum to axilla. It will be found on routine examination 
of the lungs of adults that from five to ten percent of all individuals 
show this shadow more or less distinctly. In all probability it is 
dependent on a previous tuberculous infection in this portion of the 
lung or conceivably it may stand in relation to the neighboring tubercu- 
lous lymph nodes at the hilum. 
The extreme thickening of the pleura associated with chronic 
fibro-caseous tuberculosis is of course very common and it contributes 
considerably to the density of the shadows found in advanced cases of 
this disease. 
Next in frequency to pleural adhesions and thickenings are serous 
effusions. Although clinically the tuberculous origin of pleural effusions 
is taken for granted in a large percentage of the cases, it is only occa- 
sionally, as in figure 260 that it is possible to demonstrate a coincident 
lesion in the lung. As a rule, the effusions do not differ in appearance 
from other forms of pleurisy, be the exudate serous or purulent. 
Among the rarer forms of pleural tuberculosis are localized 
deposits which, like the lesions in the lungs, may undergo caseation and 
calcification. The Roentgen shadows are characterized by great density 
and owing to their proximity to the surface of the chest, by a sharpness 
of definition not seen in more deeply seated processes. These features 
of pleural tuberculosis are brought out in the calcified deposits in the 
right lower chest shown in figure 293. In figure 294 the pleura is 
studded with numerous large tubercles which are associated with a 
general thickening of the pleura and a retraction of the chest wall. The Pleura 
385 
Calcified tuberculosis of the pleura. Calcified bronchial lymph nodes. 
FIGURE 293 386 
The Pleura 
Chronic tuberculosis of pleura with much thickening and calcified tubercles. 
FIGURE 294 The Pleura 
387 
Bizarre forms of pleural tuberculosis with calcification as in figure 295 
suggest the “Perlsucht” of cattle and the likelihood of a bovine infec- 
tion. 
FIGURE 295 
Bizarre form of calcified tuberculosis at left base. Chronic tuberculosis at left apex. 388 
The Pleura 
Finally, miliary tubercles in rare cases become visible on the pleura 
during the course of an acute miliary tuberculosis. Such a group of 
tubercles is seen at the extreme left base in figure 296. They were dis- 
covered in a patient with tuberculous meningitis in whom, shortly before 
death, showers of fine rales were heard at the base of the left lung. It 
will be noted that the lungs themselves show no evidence of miliary 
tuberculosis. 
FIGURE 296 
Milary tubercules on the pleura at left base in a case of tuberculous meningitis, (arrow.) Chapter XVIII 
Tumors of the Pleura 
The diagnosis of tumors of the pleura presents a problem of some 
difficulty, in the solution of which the Roentgenologist is apt to be at 
sea unless he has the support of clinical and pathological data. Even 
these aids may fail him because pleural tumors exhibit a varied symp- 
tomatology in which the pathognomonic signs of tumors found else- 
where in the body may be lacking. Thus, their remarkably long dura- 
tion, extending at times over years and their clinically benign behavior, 
are at variance with their truly malignant character. 
Endothelioma of left pleura. 
FIGURE 297 390 
The Pleura 
In the clinical course of a pleural tumor three phases of its growth 
may at times be recognized. The first phase, that of initial pleural in- 
volvement is often latent. In other cases it is associated with consid- 
erable pain and for this reason it is often mistaken for simple pleurisy. 
The growth of the tumor soon effects a restriction of the respiratory 
movement and there is a rapid decrease in the volume of the affected 
side of the chest. On the Roentgen plate the neoplastic thickening of 
the pleura results in a dense, more or less homogeneous shadow which 
occupies the axillary zone of the chest. (Figs. 297 and 298.) In this 
respect they differ noticeably from primary lung tumors which originate 
commonly at the hilum and in which the peripheral part of the chest is 
only later involved. Clinically also the absence of cough and other pul- 
monary symptoms for a long time distinguishes pleural tumors from 
those developing in the lung. 
FIGURE 298 
Tumor of left pleura with shrinkage of chest. Small metastases in right lung. The Pleura 
391 
The growth of the tumor may early cause an agglutination of the 
opposing pleural surfaces so that the pleural cavity is obliterated. It 
is probable, however, that before this occurs, there is in most cases a 
pleural effusion. It is in this second phase of the disease that patients 
are most often observed clinically. The rapid recurrence of the fluid 
after evacuation, without fever or pulmonary symptoms, soon leads to a 
suspicion of its neoplastic origin. In these cases the Roentgen examina- 
tion will do no more than reveal the pleural effusion, regarding whose 
nature it will give us no information, unless by chance metastases are 
visible in the opposite lung. The clinician here depends mostly on the 
microscopic examination of the pleural fluid for evidence of tumor cells. 
In the third or final stage, which often succeeds that of effusion, 
the pleural cavity is obliterated by the growth which may be of great 
thickness, encasing the lung in a neoplastic shell and often invading it. 
Such a tumor may measurably increase the size of the lung on the 
affected side so that the heart and mediastinum suffer an extreme 
displacement to the opposite side. The sequence of events which 
we have described, lasting one and one-half years, beginning with 
FIGURE 299 
Large endothelioma of right pleura. Heart and mediastinum displaced to left. 
Small metastases at left base. Shadow in right chest is caused by a solid tumor 
of pleura of great thickness. 392 
The Pleura 
pleural pain and passing successively through stages of effusion and 
consolidation, were present in a case illustrated in figure 299. This 
represents the final phase of the disease in which the right pleura was 
completely filled with neoplasm and metastatic growths were present 
in the left lung. In spite of such extensive disease in the chest and 
metastases in the subcutaneous tissues of the flank, the patient exper- 
ienced only slight dyspnoea and very little nutritional disturbance. 
The following case is an instructive example of the many-sided 
clinical picture presented by some pleural tumors in their evolution 
from initial involvement to their termination: 
The patient when first observed three years ago showed the symptoms and signs of a 
pleural effusion on the right side. Aside from the insidious onset and rather severe pain, 
there was nothing to indicate the neoplastic origin of this effusion However, the finding 
of tumor cells in the aspirated fluid rendered the diagnosis certain. When the patient was 
discharged the Roentgen plate, (fig. 300,) showed an irregular and extensive thickening of 
the pleura. The effusion ceased and for three years the patient remained in tolerable health, 
having no complaint except a slight though constant pain in the right chest. There was, how- 
FIGURE 300 
Tumor of pleura, early stage, characterized by pleural thickening. See figure 301. The Pleura 
393 
ever, a gradual, progressive shrinkage of the right chest. At her last examination, three 
years after the onset, the Roentgen plate, (fig. 301,) showed a marked induration of the 
right pleura, invasion and collapse of the right lung and a miliary involvement of the left 
lung. Yet clinically, so benign was this neoplasm, that in spite of this extensive process, the 
patient had no cough, only slight dyspnoea and was able to walk about. 
FIGURE 301 
Same case as figure 300 three years later. Right chest shrunken by dense 
pleural growth. Miliary metastases in left lung. Ascites. 
One is constantly struck by the marked contrast existing between 
the inordinate size of pleural tumors, especially the endotheliomata and 
the few symptoms which they occasion. Massive shadows which 
obscure nearly an entire lung field will be found in patients who, aside 
from slight dyspnoea, have no symptoms pointing to a serious disease. 
The clinical picture and the Roentgen shadows may show so little change 
over a period of months that the clinician may be pardoned for doubting 
the neoplastic nature of the disease. Yet the resistance of the tumor 
to the exploring needle or the decisive evidence of metastases in the 
cervical lymph nodes or elsewhere, usually confirms the diagnosis. 
Secondary involvement of the pleura occurs frequently with 
primary tumors of the lungs when the latter reach the surface. On the 
Roentgen plate this extension rarely manifests itself by any change 
which would lead to its recognition. Occasionally, as in figure 302, the 
growth on the pleura may exceed in size the primary tumor in the lung 394 
The Pleura 
Tumor of pleura secondary to adeno-carcinoma of bronchus and lung. 
FIGURE 302 
from which it originated. In this case a small bronchial carcinoma was 
found in the mesial portion of the right upper lobe; the shadow on the 
plate, as autopsy proved, was due almost entirely to a very thick neo- 
plastic pleura. 
In conclusion, reference may be made to an interesting form of 
new-growth which is probably due to a subpleural lymphatic dissem- 
ination of tumor cells from the bronchial lymph nodes. When, as may 
happen, the region of the interlobar fissure is the site of the disease, 
the pleura is thickened in this situation so that it casts a linear shadow 
which outlines the fissure. In this so-called “fissural carcinoma” the 
shadow appears to extend outward from the root of the lung where it 
is widest, in contradistinction to the thickening of inflammatory disease 
in which it is widest peripherally. We have found this shadow of great- 
est significance in cases of carcinoma of the breast as it indicates prob- 
ably metastatic disease of the bronchial nodes with retrograde involve- 
ment of the pleural lymphatics. (Fig. 303.) The Pleura 
395 
FIGURE 303 
Carcinoma of pleura visible along right interlobar fissure. Secondary to carci- 
noma of breast. Right breast removed. Chapter XIX 
Chronic Pleurisy 
Chronic disease of the pleura may be an isolated affection or it may 
be part of a pleuro-pulmonary inflammation. The latter has already 
been considered in the section devoted to nontuberculous disease of the 
lung. The effects of a chronic pleurisy may be noted on the Roentgen 
plate not only by the abnormal shadows cast by the thickened pleura 
but also by the secondary changes which operate on the other thoracic 
viscera. 
In the first place the commonest result of a chronic pleurisy is the 
production of localized adhesions, whose visibility will depend on their 
location. Thus, diaphragmatic adhesions are most easily visible and 
Unique pleural thickening following empyema. 
FIGURE 304 The Pleura 
397 
they are rarely absent in the chronic pleurisy of pulmonary tuberculosis. 
Pleuro-pericardial adhesions may cause small pointed projections on 
the cardiac surface which are best seen in deep inspiration. A common 
form of chronic pleurisy is often seen in the region of the right upper 
interlobar fissure. It is usually a manifestation of some inflammatory 
process in the underlying lung, which is most often a healed tubercu- 
losis, although it may be a sequel of acute diseases. The chronic 
pleurisies at the apices of the lungs which result in their retraction 
have already been described in the section on tuberculosis. 
A slight uniform thickening of the pleura is readily missed on the 
Roentgen plate as it opposes no obstacle to the passage of the Ray. The 
FIGURE 305 
Chronic pleural thickening following absorption of pleural effusion. Note 
shrinkage of chest, displacement of heart and pleural adhesion at arrow'. 398 
The Pleura 
fluoroscopic screen is better adapted to distinguish the slight difference 
in illumination between the two sides which such a pleural thickening 
will produce. 
The most striking and bizarre forms of chronic pleurisy are a 
sequel of effusions in the pleural cavity. Especially after empyemata 
which have not yielded promptly to treatment, the whole parietal 
pleura may show an extreme induration. In other cases, a localized 
well demarcated area at the site of a persistent sinus, will show this 
change. (Fig. 304.) There is in these cases usually a marked second- 
ary effect on the thorax, whose volume is much diminished with a conse- 
quent displacement of the heart and mediastinum. Similar changes 
may be found in cases of nonpurulent effusion, especially if they have 
been of long standing and have absorbed spontaneously. Thus in 
figure 305 the entire left chest is obscured and its volume is much dimin- 
ished. A dense pleural adhesion extends from the apex down to the 
pericardium which probably represents the mesial boundary of an 
encapsulated effusion which had been absorbed long ago. SECTION VI 
The Mediastinum 
Mediastinitis 
Tumors of the Mediastinum 
The Thyroid 
The Thymus 
Mediastinal Cysts 
Aneurysm of the Aorta Chapter XX 
The Mediastinum 
The mediastinum occupies a position in relation to the two halves 
of the chest which is analagous in some respects to that of the 
diaphragm in relation to the thoracic and abdominal viscera. Under 
conditions of normal intrathoracic pressure the mediastinum maintains 
regularly a central position. It is however, sensitive to any change of 
pressure on either side of it. The slightest upset in the balance of ten- 
sions exerted on it is at once registered by its displacement to the one 
or the other side. We have therefore in the position of the mediastinum, 
a delicate index of changes both in the lungs and in the pleura which 
the Roentgenologist is constantly on the watch to detect. This is best 
determined by the position of the trachea, which is readily seen on the 
Roentgen plate in the very middle of the upper mediastinum. 
We have already, in our discussion of various pulmonary and 
pleural diseases, pointed out the mediastinal changes which are inci- 
dental to them. It remains for us to consider some of the diseases which 
originate within the mediastinum and which may affect its Roentgen 
shadows. 
ACUTE MEDIASTINITIS 
Acute inflammations of the mediastinum are usually so deeply 
seated that symptoms arising from them do not become apparent for 
some time. The medistinum also is usually involved secondarily to 
organs in its vicinity, the symptoms of which commonly over-shadow 
the mediastinal inflammation. For this reason, it is not improbable that 
acute mediastinitis is often over-looked. On the Roentgen plate a 
diffuse cellulitis of the mediastinum will produce a general widening of 
its shadow which may be of help in the diagnosis, although by itself 
it is not characteristic. 
In the recognition of mediastinal abscess the Roentgen plate may 
be of the greatest service because the physical signs are very difficult to 
interpret. We illustrate in figure 306 an example of this condition 
which occurred during convalescence from a lobar pneumonia. The 
physical signs were situated on the posterior aspect of the chest and 
were those of a pleural effusion encapsulated between the right lower 
lobe and the spine. At operation a large quantity of pus was found in 
the posterior mediastinum, the pleural cavity being uninvolved. The 402 
The Mediastinum 
similarity of the Rentgen picture to an effusion in the mediastinal 
pleura is so close, that the distinction between these two conditions can 
scarcely be made. 
FIGURE 306 
Mediastinal abscess on right side, following lobar pneumonia. 
CHRONIC MEDIASTINITIS 
Chronic inflammatory changes in the mediastinum, whose com- 
monest cause is pulmonary and glandular tuberculosis, occasionally 
make themselves manifest on the Roentgen plate. Oftenest they are 
evidenced by irregularities of the cardiac contour which result from 
adhesions between the pericardium and the mediastinal surface of 
the pleura. In other cases there is an actual induration of the medi- 
astinal tissues with a consequent widening of its shadow. This is 
usually associated with fibrotic processes in the upper lobe. Thus 
in figure 307 the upper medistinum is both widened and distorted by a 
chronic inflammatory process secondary to multiple bronchiestases at 
the root of the right lung. The Mediastinum 
403 
Widening of superior mediastinum as a result of chronic mediastinitis, secondary 
to multiple bronchiectasis. Note multiple cavities at root of right lung. 
FIGURE 307 
In most cases these changes in the mediastinum are of no clinical 
importance and give rise to no symptoms. Occasionally however, the 
presence of mediastinal bands is responsible for disturbances in swal- 
lowing which are of sufficient severity to arouse the suspicion of organic 
obstruction. This is most apt to occur in cases of chronic pulmonary 
tuberculosis. These bands are rarely directly visible on the plate and 
their presence has to be inferred from the disturbed function of the 
oesophagus. We may thus see on the screen a momentary retardation 
of the ingested barium in the upper part of the oesophagus, or even a 
slight deviation in its course. In other cases the signs of fibrosis are so 
apparent in the mediastinum and the adjacent pleura and lung as to 
leave no doubt as to the nature of the obstruction. (Fig. 308.) 
Syphilis probably ranks next in frequency to tuberculosis as a cause 
of chronic mediastinal disease. Unfortunately, gummatous or indurative 
changes are not readily seen on the plate and their presence must 404 
The Mediastinum 
FIGURE 308 
Fibroid tuberculosis of left upper lobe, involving the mediastinum. Oesophageal 
obstruction at (x). 
be inferred from such suggestive symptoms of mediastinal obstruction, 
as vascular engorgement of the face, a paradoxical pulse or a pleural 
effusion. A striking Roentgen picture is produced when the syphilitic 
process causes adhesions to form between the mediastinum and the 
diaphragm. The central tendon of the latter is then drawn obliquely 
along the heart border, obliterating the cardio-hepatic angle. This 
unique appearance is illustrated in figure 309 in which the mediastinitis 
is associated with a sacculated aneurysm of the aorta. 
Actinomycosis is one of the rarer causes of mediastinal disease. In 
most cases it is probably a descending infection from the neck. The 
Roentgen shadow may be similar to that of a mediastinal tumor. In the 
case illustrated in figure 310 there were multiple sinuses in the neck 
from which typical actinomyces granules were obtained. The Mediastinum 
405 
Aneuyrsm of aorta. Mediastinitis. Adhesion of diaphragmatic and mediastinal 
pleura on right side. 
FIGURE 309 The Mediastinum 
406 
Actinomycosis of superior mediastinum. Infection extended downward from 
the neck. 
FIGURE 310 Chapter XXI 
Tumors of the Mediastinum 
Mediastinal tumors are more often seen by the Roentgenologist 
than are tumors of the lung because they give rise to serious symptoms 
at an earlier period in their growth. For the same reason they are diag- 
nosed earlier than are pulmonary neoplasms. The dyspnoea which is 
such an early and characteristic symptom of tumor of the mediastinum 
is apt to bring the patient quickly to his physician; on the other hand 
the cough and expectoration which mark the onset of a tumor of the 
lungs are such common symptoms of less serious respiratory diseases, 
that the patient is prone to disregard them for a considerable time. 
From the Roentgen standpoint, mediastinal tumors are best classi- 
fied as to their location. We can distinguish in the first place those 
which involve the superior mediastinum from others which develop in 
its lower portion or finally from those which completely fill it from apex 
to base. Their frequent location in the upper mediastinum can be 
accounted for by the presence in this region of the bronchial lymph 
nodes, from which a large number arise and also by the presence there 
of the thyroid the thymus and epithelial inclusions which may be the 
occasional sources of mediastinal tumors. 
The shadows cast by mediastinal tumors are homogeneous and 
dense. They stand out sharply against the surrounding lung and only 
rarely show evidence of infiltration of the latter, although this is often 
seen at autopsy. They are nearly always bilateral, especially when 
they are well grown and this in most cases will serve to distinguish 
them from primary tumors of the lung. The growth on the two sides 
is however unequal in extent. Fluoroscopic examination in the oblique 
positions may be of considerable help in determining whether the 
growth originates in the lung or the mediastinum. 
The notable result of the growth of a mediastinal tumor is an in- 
crease in the width of the median shadow which projects for a variable 
distance into the lung. This shadow may exhibit the greatest diversity 
both in size and shape, depending on the situation and the mode of 
growth of the tumor. Thus, the outlines of the mass may be smooth 
and lobulated or irregular and infiltrating, or even rectilinear. Its 
greatest length may be vertical or again it may extend transversely 
across the chest. In the latter case it may be difficult to distinguish it 
from a hilum carcinoma. 408 
The Mediastinum 
The smaller tumors, which barely project from the root of the 
lung, as is to be expected, will present little that is characteristic upon 
which to base a diagnosis of such a serious disease. It will thus not be 
easy to differentiate the moderate increase in size and density of the 
root shadows from that due to indurated lymph nodes. The diagnosis 
will here be suggested by such unusual symptoms as deep thoracic pain 
or a recurrent laryngeal paralysis which are more readily explained by 
the assumption of a tumor than otherwise. Thus, in figure 311 the small 
lobulated tumor at the left root produced only a paralysis of the left 
vocal cord and considerable pain, without other symptoms or physical 
signs. 
FIGURE 311 
Beginning mediastinal tumor easting lobulated shadow at left root. Symptoms 
were precordial pain and paralysis of left vocal cord. 
The larger mediastinal sarcomata produce such characteristic 
Roentgen appearances as to leave no doubt of the diagnosis. We may 
illustrate them, in their great variety, by the following cases. In figure 
312 is shown a large bilateral tumor which involves the greater part of 
the mediastinum, the heart being encased in it. This was apparently 
a slowly growing tumor; it is remarkable that such an enormous mass 
occasioned few symptoms and caused no embarrassment of the heart’s The Mediastinum 
409 
FIGURE 312 
Large mediastinal tumor encasing the heart. 
action. In contrast to this, a rapidly growing tumor, although much 
smaller in size, may produce extreme dyspnoea and cyanosis by 
compression of the trachea and bronchi. The mediastinal sarcoma 
shown in figure 313 had existed for only four weeks yet the patient was 
at the point of death from asphyxia. The semi-circular shadow at the 
right of the heart represents probably a rapidly growing portion of the 
tumor. The patient presented all the clinical signs of a compression of 
the vena cava. 410 
The Mediastinum 
FIGURE 313 
Mediastinal tumor. Rapidly growing lympho-sareoma. (arrow.) 
The lobulated border of mediastinal tumors is their most constant 
Roentgen feature. This is clearly indicated in figure 314, a case of 
angio-sarcoma which produced such a degree of dyspnoea that a 
thoracic decompression was required. The exaggerated mottling of 
the pulmonary fields which was due to venous engorgement, is a strik- 
ing evidence of the pressure of this tumor on the roots of the lungs. 
Lobulation is also manifest in the tumors shown in figures 320 and 325. 
All of these were lympho-sarcomata. The Mediastinum 
411 
FIGURE 314 
Mediastinal tumor. Angio-sarcoma. 
In the rare, infiltrating new-growths the smooth lobulated contour 
is at times lost. Their outlines may be indistinct and they may shade 
off into the surrounding lung. Thus in figure 315 the infiltrating mass, 
which at autopsy proved to be a lympho-sarcoma, extends transversely 
across the chest, very much like a carcinoma. Again, in figure 316, the 
ray-like projections from the tumor may be regarded as an infiltration 
of the pulmonary tissues. In figure 317 the mediastinal growth ex- 
tensively invades the right upper lobe. 412 
The Mediastinum 
Mediastinal tumor. Lympho-sarcoma. Associated with cervical and axillary 
Hodgkin’s disease. 
FIGURE 315 The Mediastinum 
413 
FIGURE 316 
Mediastinal tumor. Infiltrating type. 414 
The Mediastinum 
Mediastinal tumor invading right upper lobe 
FIGURE 317 
The distinction between carcinoma and sarcoma of the mediastinum 
cannot be made from the Roentgen examination. Carcinoma is un- 
doubtedly rare and for this reason only some unusual circumstance 
would make the diagnosis a safe one. Aside from metastatic carcinoma 
of the bronchial lymph nodes, which rarely is responsible for the clinical 
picture of mediastinal tumor, we have observed only two cases of 
carcinoma of the mediastinum. They were both unilateral tumors and 
exhibited the invasive tendencies of cancer by a perforation of the 
oesophagus. The unusual character of the cases may be illustrated by 
the following history: 
A man of sixty years, for some months had the symptoms of a new-growth at the cardia. 
He had great difficulty in swallowing and was much emaciated. One day before his death 
he vomited a large amount of necrotic material. At autopsy there was found, in the posterior 
mediastinum, immedediately behind the heart, an encapsulated, broken down tumor about 
four inches in diameter, which had ulcerated into the lower end of the oesophagus and in 
this manner discharged its contents. Miscroscopic examination proved this tumor to be an 
epithelial new growth, which developed probably from fetal rests. 
The plate, (fig. 318,) shows the outline of this tumor, which is almost obscured by the 
heart shadow, projecting slightly beyond its right border. The main mass of the tumor 
however, lay behind the heart and for this reason the interpretation of the shadow was uncer- 
tain. The Mediastinum 
415 
FIGURE 318 
Tumor of posterior mediastinum. Necrotic carcinoma which perforated the 
lower oesophagus. Tutnor partly concealed by the right side of heart, (arrow.) 
Secondary mediastinal tumors are more often due to carcinoma 
than to sarcoma. Ordinarily the new-growths, consisting of cancerous 
lymph nodes, remain small and do not attain the size of a tumor mass. 
On the other hand, in occasional cases these nodes may become so large 
that they completely overshadow a primary neoplasm of the lung from 
which they originated and whose existence is unsuspected. The medi- 
astinal shadow seen in figure 319 presented the typical appearance of 
a primary mediastinal tumor, which caused marked dyspnoea from 
pressure on the trachea and bronchi. The bronchoscopic examination 
was in harmony with this supposition as it revealed a narrowing of 
the trachea at the bifurcation, by an extrabronchial mass. At autopsy, 
the tracheo-bronchial nodes were enormously enlarged and cancerous; 
the primary tumor however, was very small and was of the rare infiltrat- 
ing type of carcinoma of the wall of the bronchus which did not invade 
the lung. The Roentgen shadows were entirely due to the metastatic 
cancer of the bronchial nodes. The significance of the initial symp- 416 
The Mediastinum 
Metastatic carcinoma of mediastinal and bronchial lymph nodes. Primary tumor 
in bronchus was latent. Clinical picture of heart failure. Note vascular en- 
gorgement of lungs. Effusion at right base. 
FIGURE 319 
toms in this case, which were obstinate cough and hemoptysis was only 
realized when the primary bronchial origin of the tumor was deter- 
mined at autopsy. 
A study of the plates in cases of mediastinal tumor often throws 
light on the origin of the distressing symptoms which are occasioned 
by the pressure of the growth on neighboring structures. Owing to 
their frequent occurrence in the upper, narrow portion of the chest they 
are prone to compress and displace the trachea, bronchi and oesophagus, 
the symptoms of which are the immediate occasion of the patient’s 
visit to the physician. On the plate, the narrowing and displacement 
of the trachea are readily seen. A similar involvement of a main 
bronchus is to be inferred from an atelectasis of a lobe and from the 
other fluoroscopic evidences of broncho-stenosis which have already The Mediastinum 
417 
been described. The position of the heart is not ordinarily influenced 
by a mediastinal growth because the latter is usually bilateral and 
because the bulk of the tumor is commonly situated in the upper 
mediastinum away from the heart. Here it may depress the arch of the 
aorta or displace it laterally. Only when the growth is disproportion- 
ately large on one side or when there is an associated pleural effusion, 
may the heart suffer a notable displacement. (Figs. 320 and 321.) 
FIGURE 320 
Mediastinal tumor with lobulated border. Heart displaced. Pleural effusion. 418 
The Mediastinum 
Mediastinal tumor. Heart displaced to the right 
FIGURE 321 
COMPLICATIONS 
One of the most frequent results of a mediastinal tumor is a pleural 
effusion, which is usually unilateral. It is found in the terminal stage 
in most cases and is then probably due to venous compression. Thus, 
in figure 322 the massive lymphomata at the root of the lung were re- 
sponsible for the effusion which half filled the right chest. In other 
cases, the effusion may be a relatively early symptom of the disease and 
it may be interpreted as an extension of the growth to the pleural mem- 
brane which is actually invaded by the tumor. The sequence of the 
symptoms indicating pleural involvement may be significant, especially 
the onset of pleural pain, which is unusual with mediastinal growths. 
For example, a woman of nineteen years, complained for three months of dyspnoea, 
cough and edema of the legs. Latterly she suffered in addition from severe pains in her left 
chest. On physical examination her chest was prominent and contained a large quantity of 
bloody fluid which entirely obscured the underlying tumor. After removal of the latter a 
large lobulated mass was seen extending from the left mediastinum, which displaced the 
heart to the right. (Fig. 320.) The pleural fluid contained large numbers of tumor cells 
which presumably were derived from the pleura. The Mediastinum 
419 
FIGURE 322 
Mediastinal tumor. Chronic leukemia. Pleural effusion 
In rare cases, very large effusions may be the result of pressure on 
the root of the lungs, by tumors which are either obscured by the 
effusions, or which are so small that they are completely hidden by the 
heart. One is here reminded of the metastatic carcinomata in the 
bronchial lymph nodes following cancer of the breast. The character- 
istic feature of these cases is a persistent dyspnoea with an effusion 
which rapidly re-accumulates after its evacuation. The Roentgen 
examination in these cases does not clear up the diagnosis and depend- 
ence must be placed on examination of the pleural fluid for evidence of 
blood or tumor cells. 
Aside from their direct involvement by extension of the tumor into 
them, the lungs may show true metastases which are similar in appear- 
ance to those following new growths elsewhere in the body. (Fig. 323.) 
The Roentgen plate may also show abnormal shadows due to metastases 
in other thoracic structures such as the thyroid. 420 
The Mediastinum 
FIGURE 323 
Mediastinal tumor with metastases in the lungs. 
The occasional compression of the phrenic nerve by mediastinal 
tumors is reflected on the fluoroscopic screen by a high paralytic dia- 
phragm on one side. This must not be confused with the high diaphragm 
occasionally seen with chronic mediastinitis, which may complicate 
both mediastinal tumors and aneurysms. (Fig. 309.) 
DIFFERENTIAL DIAGNOSIS 
The shadows cast by mediastinal tumors are so characteristic that 
the necessity of distinguishing them from other intrathoracic diseases 
rarely arises. They are more often confused with aneurysms of the 
aorta than with any other condition. (Fig. 324.) The resemblance is 
at times so close that only the growth of the tumor as determined by a 
subsequent Roentgen examination will clear up the diagnosis. (Fig. 325.) 
A mediastinal tumor may be so situated as to simulate an enlarge- 
ment of some portion of the heart. It may thus resemble an enlargement 
of the right auricle, as in figure 318. In figure 326 the small mediastinal The Mediastinum 
421 
Mediastinal sarcoma resembling aneurysm of the aorta. 
FIGURE 324 
Mediastinal lympho-sarcoma showing growth of tumor after four months. 
FIGURE 325 422 
The Mediastinum 
FIGURE 326 
Mediastinal tumor. Acute myeloblastic leukemia. Simulates enlargement of 
pulmonary artery. 
tumor has the position and shape of a dilated pulmonary artery. In 
this case, no confusion in diagnosis arose, because there was an absence 
of pulsation, whereas an enlarged pulmonary artery practically always 
exhibits a marked pulsation. 
The introduction of gas into the pleural cavity may be of decided 
service in distinguishing mediastinal growths from other diseases, 
especially encapsulated effusions, which may at times cast the dense 
circumscribed shadow of a tumor. For example, the shadow in the 
right upper chest in figure 327 had all the characteristics of a localized 
effusion. After the introduction of air into the chest and the collapse of 
the lung, it was at once apparent that a solid tumor was present. This 
was found at operation to be a ganglio-neuroma. The Mediastinum 
423 
FIGURE 327 
Mediastinal tumor. Ganglio-neuroma. Artificial pneumothorax with collapse of 
lung served to distinguish this tumor from an encapsulated effusion. 
ROENTGEN-CLINICAL CORRELATIONS 
The more general use of the Roentgen Ray will lead, it is hoped, to 
an earlier diagnosis of obscure intrathoracic diseases such as tumors 
of the lungs and mediastinum. This is desirable, among other reasons, 
because the symptoms which usher in a mediastinal tumor may be so 
little characteristic that they are often mistaken for those of pulmonary 
tuberculosis or even of trivial affections such as bronchitis. Physical 
signs are rarely present at this early stage of the disease and it is not 
until major and urgent symptoms make their appearance that the 
seriousness of the situation is appreciated. Although it is too much to 
hope that all patients who present such minor symptoms can be radio- 
graphed, there are certain symptoms the presence of which should 
make a Roentgen examination imperative. The significance of laryngeal 
paralysis, for example, as an evidence of new growth of the mediastinum 
cannot be overestimated. This symptom should always lead to a search 
for some mass in the superior mediastinum, which is often rewarded by 
the discovery of a tumor or an aneurysm. See figure 311. 424 
The Mediastinum 
A rapidly developing and persistent oedema of one arm will in the 
same way suggest the likelihood of a mass in the upper mediastinum 
which is causing pressure on the subclavian vein with thrombosis. In 
such cases the plate will often repay the examiner for his efforts. Thus, 
the mediastinal shadow in figure 342 was found at autopsy to be due to 
a tumor of the thymus. The pressure of this tumor on the left sub- 
clavian vein caused oedema of the arm, which was almost the first 
symptom of the tumor growth. 
In addition to these more obvious signs which point to mechanical 
pressure, it is well to bear in mind that mediastinal tumors, especially 
while they are yet small and undiscovered, may produce symptoms 
which are easily confused with those arising in neighboring organs. 
Symptom complexes due to intrathoracic pressure may thus arise which 
will bear a striking resemblance to various forms of heart disease. An 
initial symptom of mediastinal tumor may be a deep seated pain in the 
chest which may be so like that of angina pectoris as to justify the diag- 
nosis of coronary disease. This error was made in a patient whose only 
symptom for some time was the typical precordial pain of angina 
pectoris; the subsequent development of a recurrent paralysis led to 
the Roentgen examination which revealed a small tumor at the root of 
the left lung. (Fig. 311.) There was neither cough nor dyspnoea. 
In another form of tumor, whose growth is manifested especially 
by a stenosis of the trachea or bronchi the clinical picture of decompen- 
sated heart disease may be simulated to the smallest detail. The 
dyspnoea, cyanosis, tachycardia, pleural effusion and even a cardiac 
murmur would seem to leave no room for doubt as to the cardiac origin 
of the symptoms. It will be noted however that neither the evacuation 
of the pleural effusion nor the administration of digitalis brings relief 
to the patient and the marked engorgement of the veins of the face 
and neck will suggest a mediastinal obstruction. In the case illustrated 
in figure 319 in which these symptoms were present, the discovery of the 
upper mediastinal tumor which compressed both main bronchi supplied 
an adequate cause for them outside of the heart. The Roentgen appear- 
ance of the heart, which was little enlarged, was not such as would be 
expected in a decompensated valvular lesion capable of producing 
such alarming symptoms. The tumor was found at autopsy to be a 
mediastinal carcinoma secondary to a bronchial neoplasm. 
TUMORS OF THE PERICARDIUM 
New growths of the pericardium are of extremely rare occurrence 
and the difficulty in their diagnosis is proportionate to their rarity. It 
is desirable therefore whenever the opportunity presents itself to make 
known the findings in cases in which the diagnosis is proven. The large 
shadow in figure 328 which is co-extensive with that of the heart was The Mediastinum 
425 
FIGURE 328 
Sarcoma of pericardium 
found at autopsy to be due to a spindle-cell sarcoma which formed a 
layer, in places one inch thick, about the heart, completely obliterating 
the pericardial cavity. In places the tumor invaded the heart muscle. 
During life the symptoms were those of a pericardial effusion which 
produced considerable cardiac embarrassment. Aspiration of the peri- 
cardium revealed a small amount of bloody fluid in which some 
atypical cells, suggesting tumor cells, were found. The Roentgen plate 
by itself would not warrant the diagnosis of such a rare condition; the 
heart silhouette is that found in cases of an asymmetrical distension 
of the pericardium with fluid. Chapter XXII 
The Thyroid Gland 
In the diagnosis of disease of the normally situated thyroid gland 
the Roentgen Ray occupies a position of minor importance. A cervical 
enlargement of the gland can more easily be determined by palpation 
and the exact pathological change in it can readily be ascertained. The 
normal thyroid is usually not visible on the plate because its shadow, 
which is of only slight density is obscured by the spine and the muscles 
of the neck. Slight degrees of hyperplasia of the gland are however 
so common, especially in women, that it is not unusual to see ill-defined 
shadows of the thyroid at the root of the neck which extend a short dis- 
tance beyond the margin of the sterno-mastoid muscles into the apical 
pulmonary fields. A similar shadow is often seen in cases of exoph- 
thalmic goiter. 
FIGURE 329 
Small substernal goiter on right side. Cervical thyroid of normal size. The Mediastinum 
427 
When the shadow of a cervical thyroid is at all dense the patho- 
logical change has usually gone beyond simple hyperplasia; in such 
cases colloid or cystic goiters will be found, often associated with a 
visible compression of the trachea. (Fig. 330.) 
The Roentgen examination plays a greater role in the diagnosis of 
substernal or intrathoracic enlargements of the thyroid. By means 
of it a downward extension of thyroid tumors may be visualized and 
their relation to adjacent structures defined. Goitres are in only rare 
instances entirely intrathoracic. Nearly always the intrathoracic 
portion is a downward prolongation of a cervical goiter which extends 
in some cases only as far as the clavicle or the manubrium and in others 
further invades the chest down to the heart. Roentgen study of cases 
of colloid and cystic goiters has shown that such a downward exten- 
sion of a cervical struma occurs in a large percentage and that little 
dependence can be placed on the physical signs to determine its down- 
ward growth. 
The intrathoracic portion of an enlarged thyroid is rarely sym- 
metrical ; usually one side is larger than the other, this being more often 
the right side. The thyroid shadow is a uniformly dense one and it is 
Cervical goitre extending a short distance into chest. 
FIGURE 330 428 
The Mediastinum 
continuous with that of the aorta which it often overlies. Its borders 
are smooth, convex and sharply defined. 
The Roentgen features of intrathoracic thyroids are brought out in 
the following cases. In figure 329 the unilateral thyroid tumor is 
entirely substernal, the cervical portion of the gland being normal in 
size. This goitre is of a type not uncommonly seen; in spite of its small 
size and the absence of physical signs it may be the cause of pronounced 
pressure symptoms. More often the growth is bilateral and it extends 
a greater distance into the chest. In figure 330 the cervical colloid goiter 
just dips into the upper aperture of the chest; in figures 331 and 
332 the downward growth is considerable. 
FIGURE 331 
Symmetrical enlargement of an intrathoracic goiter. Calcification in right lobe 
of goiter. Trachea displaced to left. The Mediastinum 
429 
FIGURE 332 
Substernal thyroid. Displacement of the trachea to left side. 
As a rule the pathological type of the goiter cannot be inferred 
from the appearance of the Roentgen shadows. It is probable however, 
that the denser shadows are associated with the presence of much colloid 
whereas the fainter ones represent adenomatous changes. 
There is no essential difference between the shadow of a benign 
and a malignant tumor of the thyroid. The latter shows no infiltrating 
border and it remains well circumscribed throughout its course. It 
therefore happens that when carcinoma developes in a previously exist- 
ing goiter, aside from an increase in its size, there may be nothing to 
indicate that the pathological process has changed. For example, the 
globular tumor situated behind the sternum in figure 333 was found 
at operation to be a carcinoma of the isthmus. This tumor had existed, 
according to the patient, for fifteen years with only minor symptoms. 
The Roentgen shadow afforded no basis for a diagnosis of malignancy 
and it differed in no wise from a cystic enlargement of the gland! Only 
the sudden onset of severe dyspnoea aroused a suspicion of cancer. In 
this connection it is to be borne in mind that benign growths of the 
thyroid may also take on a rapid growth with urgent dyspnoea. Here 
again the Roentgen ray is likely to fail us in the distinction between a 
benign and a malignant struma. 430 
The Mediastinum 
FIGURE 333 
Adenocarcinoma of the isthmus, developing in a goiter of 15 years’ standing. 
In order to determine the malignancy of a goiter on the Rentgen 
plate we must therefore look elsewhere than in the thyroid shadow 
itself. The presence of metastases in the lungs may be the first sign 
of a cancerous degeneration of the goiter. For example, in figure 225 
the purely cervical goiter, whose shadow on the plate appeared innocent 
enough, gave rise to numerous metastases in the lungs. 
Bearing in mind the frequency with which cancers of the thyroid 
metastasize in the bones, the Roentgenologist will not fail to make a 
close inspection of the bones of the thorax in order to discover second- 
ary tumors in the spine or in the ribs which may have resulted in 
pathological fractures. In fact, pain in the bones of the thorax or else- 
where in the body may be the first clinical evidence of malignant disease 
of the thyroid and it is a peculiarity of neoplasms of this gland that the 
primary tumor may be very small and yet give rise to large secondary 
tumors. The Mediastinum 
431 
When we investigate on the plate the relation of the enlarged 
thyroid to the other structures in the upper part of the chest, we find 
graphically portrayed the reason for its most striking symptom namely, 
dyspnoea. With the larger tumors the trachea suffers varying degrees 
of compression and, depending on the conformation of the growth, the 
trachea is displaced either to the right or to the left. (Figs. 332 and 
334.) Even with minor grades of thyroid enlargement, whether this be 
FIGURE 334 
Unilateral intrathoracic goiter of rapid growth. Marked displacement and 
compression of trachea indicated hy arrow. 
in the neck or within the thorax, the trachea rarely escapes some degree 
of constriction. So true is this that whenever on the Roentgen plate the 
course of the trachea is altered or its caliber narrowed, a thyroid en- 
largement may be suspected, even though no definite shadow of the 
gland can be seen. The only other common cause of such a change 
in the trachea is a chronic tuberculous process in the lungs, which is of 
course, easily recognized. 432 
The Mediastinum 
The greatest compression occurs at the superior aperture of the 
thorax, that is, at its narrowest point; here the trachea may have its 
calibre reduced to that of a lead pencil. Yet, smaller growths, if they 
are favorably placed may exert an even greater degree of pressure 
than the larger ones. Thus the tumor of the isthmus in figure 333 is 
relatively small in size, yet it is so situated that the trachea, as it 
traverses the upper chest, is thrust from its normal course and com- 
pressed between it and the arch of the aorta. 
Other pressure effects, such as a downward displacement of the 
aortic arch, can occasionally be seen on the plate. Noncancerous 
goitres rarely come into relation with the oesophagus and are therefore 
not prone to cause dysphagia. Carcinomata on the other hand may 
invade it and thus interfere with deglutition. When the thyroid tumor 
is large, the cause of the symptoms is at once obvious. Occasionally 
the new growth is so small and its Roentgen shadow so vague that 
visualization of the oesophagus with barium may be necessary in order 
to establish the site of the constriction and its relation to the thyroid. 
The cardio-vascular symptoms associated with goitres are of more 
than ordinary interest. Aside from the more obvious circulatory dis- 
turbances, such as cyanosis and engorgement of the superficial veins of 
the neck and chest which result directly from the pressure of the large 
FIGURE 335 
Lime deposits in right lobe of thyroid. The Mediastinum 
433 
thyroid, our interest is arrested by an obscure group of cases in which 
a marked derangement of cardiac function seems to stand in some rela- 
tion to a substernal thyroid. In general, these patients present the 
picture of myocardial disease, the striking clinical manifestation of 
which consists in a fibrillation of the auricle. The heart often shows an 
enormous enlargement for which no adequate cause can be found in 
the previous history nor in the present status of the patient. If we 
examine the superior mediastinum in these cases a substernal thyroid 
will not infrequently be found. The shadow of the latter will oftenest 
be seen on the right side beneath the inner extremity of the clavicle; 
owing to its small size and the faintness of the shadow, it is better seen 
on the screen than on the plate. This shadow must of course, not be 
confused with the innominate vessels which are occasionally prominent 
in this situation. Whether we are warranted in assuming a relation 
between the cardiac disease and the enlarged substernal thyroid may 
well be open to doubt. None the less the clinician cannot fail to take 
a lively interest in the discovery of pathological changes in the thyroid 
in cases of circulatory disease whose causation is obscure and he will 
seek to ascertain by appropriate tests of thyroid function what relation, 
if any, exists between the heart condition and the thyroid enlargement. 
Calcification of an old colloid goiter of the isthmus. (See figure 337.) 
FIGURE 336 434 
The Medialtinu.,1 
In addition to an enlargement of the thyroid, the Roentgen plate 
at times reveals more minute changes in it. Of these the most striking 
is a calcification of the gland which may be seen in one of the lobes, as 
in figure 335, or in an enlarged isthmus. (Figs. 336 and 337.) In the 
Oblique view of figure 336, showing calcification of the thyroid isthmus. 
FIGURE 337 
latter case the unique arrangement of the lime deposits is best brought 
out in the oblique position. These concretions are usually seen in long 
standing goitres, with colloid degeneration. (Fig. 331.) Chapter XXIII 
The Thymus 
At birth, the thymus is relatively large and occupies an appreciable 
space in the superior mediastinum. It is however so situated between 
the sternum in front and the spine behind that its Roentgen shadow is 
obscured by these bones. Laterally its borders do not extend beyond 
the vena cava and aorta which normally limit the mediastinal shadow. 
Below it merges with the heart and the aorta from which it is not dis- 
tinguishable. 
An enlargement of the thymus will make itself manifest on the 
plate by a widening of the superior mediastinum and also by a change 
in its contour. As this condition has a clinical importance especially in 
infants and young children, it is necessary to familiarize ourselves with 
the appearance of the mediastinum in them in order that we may recog- 
nize deviations from the normal. If, with this object in view, we exam- 
ine the chests of presumably normal infants a surprising variability in 
the width of the mediastinum will be found. In some cases, it is so 
narrow as to lie entirely behind the shadow of the sternum whereas in 
others it may extend laterally to the parasternal line. This variability 
in the width of the mediastinum is little, if at all, dependent on the size 
of the thymus. It is rather due to a change in the volume of the vascular 
structures contained within the mediastinum, brought about by extran- 
eous causes such as the posture and respiration of the child, whereby 
the large vessels, especially the vena cava, are more or less distended 
with blood. Thus, when the child assumes the prone position in which 
the exposure is usually made, these vessels, relieved of the weight of 
the heart, become shorter and broader and their shadow is correspond- 
ingly altered. An even greater influence on the mediastinal shadow is 
exerted by the respiratory movements. During deep inspiration the 
vena cava, which marks the limits of the mediastinum on the right side, 
is emptied of its blood so that its shadow approaches the mid-line. The 
mediastinum is therefore narrowed. During expiration or when the 
breath is held, as it frequently is when the child cries, the vena cava is 
distended with blood and the mediastinal shadow is widened. So 
marked may this change be that two plates made in different phases of 
respiration may be so unlike that they will scarcely be recognized as 
belonging to the same child. (Fig. 338.) 
Of equal importance in estimating the width of the mediastinum 
is the position of the patient with respect to the tube. The latter must 
be centered exactly over the mid-line of the chest. The slightest rota- 436 
The Mediastinum 
FIGURE 338 
Appearance of the mediastinum in deep in- 
spiration. Note low position of diaphragm. 
Shows widening of mediastinum in same iu- 
fant during expiration. Note high position 
of diaphragm. 
tion of the chest will also entirely vitiate the examination as it will cause 
a broadening of the mediastinal shadow and project it outward into one 
or the other pulmonary field. 
It must be evident from the preceding observations that the 
mediastinal shadow in children is not a fixed, unalterable one. 
Its interpretation is fraught with difficulties and a widening can 
only be regarded as evidence of disease, when the above men- 
tioned sources of error are eliminated. There is no doubt that 
many so-called cases of thymic enlargement have been reported in the 
literature, in which the diagnosis is open to serious doubt because of 
failure to observe these necessary precautions in the Roentgen inter- 
pretation of the normal mediastinum. 
The Roentgen examination for an enlarged thymus is usually 
undertaken in infants to explain the stridor and dyspnoea which char- 
acterize attacks of thymic asthma. In newborn infants particularly, 
such attacks will at once arouse a presumption of enlargement of the 
thymus, which may find confirmation on the Roentgen plate. The 
shadow of an enlarged thymus is in some respects characteristic. It 
has the shape of a keystone, with its broad base at the root of the neck, 
its sides converging slightly as it extends down over the aorta to the 
heart. Thus in figure 339 is illustrated an enlarged, rather broad 
thymus in an infant twelve hours after birth, which gave rise to fatal 
suffocative attacks. The Mediastinum 
437 
Enlarged thymus in infant 12 hours old. 
FIGURE 339 
These characteristics are more clearly brought out in figure 340 
in which the thymus has the dimensions of a large tumor. In this case 
also, there were outspoken symptoms of tracheal compression, consist- 
ing of cough, crowing respiration and paroxysms of dyspnoea. 
Although in the vast majority of cases the normally persisting 
thymus in infants cannot be seen on the plate we occasionally encounter 
a large thymic shadow unassociated with any symptoms to suggest 
disease of this organ. For example, in an infant nineteen days old 
who suffered a birth fracture of the humerus, a large thymic shadow was 
accidentally found. (Fig. 341.) The infant was re-examined a number 
of times during a period of several months, yet no respiratory or other 
symptoms developed and the thymic shadow remained unchanged. The 438 
The Mediastinum 
FIGURE 310 
Large thymus showing typical keystone shape. The Mediastinum 
439 
Large thymus in a 19 day old infant. Accidentally discovered, no symptoms 
FIGURE 341 
absolute clinical latency which may characterize even a very large 
thymus, is illustrated in figure 341a. In this very young infant there 
were no symptoms which even remotely suggested the presence of such 
a large mass in the mediastinum. 
Because of the undoubted rarity of thymic enlargement it is proper 
to interpret critically any shadows in the superior mediastinum of 
children and to assure one’s self that they are not cast by diseased struc- 
tures other than the thymus. In the case of very young infants the thymic 
origin of these shadows may be assumed with some assurance not only 
because of their typical shape but also because of the absence at this 
age, of other pathological conditions which could give rise to the clinical 
symptoms. 
In children who are more than a few months old however, the inter- 
pretation of abnormal masses in the superior mediastinum is rendered 
less certain because of the increasing frequency of disease of the lymph 440 
The Mediastinum 
FIGURE 341a 
Very large thymus in young infant, without symptoms. 
nodes which is a more common cause of stridor than enlargement of the 
thymus. In practice, tuberculosis of the tracheal and bronchial nodes is 
found so much oftener than is thymic enlargement that the former will 
have to be excluded before an assumption of thymic disease can safely 
be made. Tuberculous lymph nodes also produce a wide mediastinal 
shadow. In most cases this differs in several respects from that of a 
thymus. The shadow is commonly denser, its borders are convex and 
owing to the usual involvement of the lower group of nodes, it is widest 
near the root of the lungs, and narrowest above. (Figs. 112 and 114.) 
Only in case of enlargement of the paratracheal lymph nodes can there 
be any confusion with the thymic shadow. These nodes are situated 
in the superior mediastinum along the lower part of the trachea, in the 
same situation as the upper pole of the thymus. (Fig. 105.) There is 
added difficulty in the diagnosis because tuberculosis shows a pre- 
dilection for these nodes in early infancy and a stridor due to their pres- 
sure on the trachea may also be present. The shadow of the para- 
tracheal nodes is however usually unilateral, being especially marked The Mediastinum 
44 L 
on the right side and frequently its sharp delimitation below and toward 
the trachea will serve to distinguish it from the thymus. In doubtful 
cases, recourse must be had to careful tuberculin tests, which at this 
early age have considerable value. 
In older children, the Roentgen examination may be of considerable 
importance to the surgeon in the determination of a persistent thymus 
in cases of so-called status thymo-lymphaticus. There is no doubt that 
the pre-operative examination of the chest would thus prevent at least 
some of the sudden and unaccountable deaths in individuals of this 
bodily habitus. Unfortunately, in most cases of this type, a thymus is 
either not found by the Roentgen examination or the degree of enlarge- 
ment is so slight as not to be demonstrable. Equally disappointing is 
the Roentgen examination for a large thymus in cases of exophthalmic 
goitre. Although certain investigators have affirmed the frequent 
enlargement of the thymus in this disease, we have rarely encountered 
it on the Roentgen plate. 
Tumors of the thymus, so called thymomata, may cast a dense 
shadow in the superior mediastinum which does not differ from other 
mediastinal new-growths. We illustrate herewith an example of this 
very rare condition, (fig. 342) with the following clinical history: 
FIGURE 342 
Tumor of the thymus. Pleural effusion, right base. 41-2 
The Mediastinum 
The patient was a boy, sixteen years of age. He became suddenly ill with dyspnoea and 
oedema of the left arm. The rapid growth of the tumor caused extreme engorgement of the 
head, neck and chest. Multiple, subcutaneous tumors rapidly developed. Death from suffo- 
cation occurred within two months. At autopsy a large tumor mass was found in the 
superior mediastinum extending from the root of the neck down over the aorta and per- 
cardium. Pathologically, this tumor was a thymoma. 
DERMOID CYST OF THE MEDIASTINUM 
If we may judge from the small number of cases reported, dermoid 
cyst is probably the rarest disease of the mediastinum. As is the case 
with other growths situated deeply in the chest, a dermoid cyst may 
produce no abnormal physical signs, even when it has grown to a large 
size, as it may be completely covered by lung tissue. The slowness of 
its growth also permits the lungs and bronchi to adapt themselves to 
even a large cyst so that few or no symptoms result. It is only when 
trauma or infection initiate a sudden growth of the cyst that symptoms 
arise, the most characteristic of which result from its rupture into a 
bronchus with the expectoration of its sebaceous or hairy contents. 
FIGURE 343 
Dermoid cyst of mediastinum. Heart displaced to right. Dorsal view. The Mediastinum 
443 
The definite Roentgen appearance of a dermoid cyst is in marked 
contrast to the vagueness of the clinical symptoms. As is illustrated in 
figure 343 the shadow extends outward from the mediastinum and has 
a hemispherical shape. Its contour is smooth and well defined. Owing 
to the nature of the contents of the cyst, the shadow is very dense. 
This patient was a young woman whose only symptom for a few years was occasional 
cough with mucoid expectoration. Otherwise she was in good health. Latterly she felt a 
slight oppression in her chest and there was some increase in the intensity of her cough. 
The physical examination revealed only a slight increase upward of the area of cardiac 
dulness. At operation a dermoid cyst the size of a grape fruit was found. Springing from 
the root of the left lung and growing outward, it occupied the depths of the interlobar fissure 
and was completely covered by the lung anteriorly. The heart was displaced to the right side. 
Mediastinal cyst on the right side, extending beyond the mid-line at arrow 
FIGURE 344 
In figure 344 we have a very large mediastinal cyst in a child, which 
only recently showed signs of rapid growth. In this case the cyst, 
whose main mass is situated on the right side, also extends beyond 444 
The Mediastinum 
the mid-line so that it is visible beyond the transverse aorta on the left 
side. 
Although, as may be seen, a dermoid cyst casts a definite and in 
some respects a typical shadow, there are other diseases which are 
more often responsible for shadows of this kind. We must keep in mind 
certain massive pulmonary tumors and also encapsulated pleural 
effusions which occasionally produce a similar shadow. (Fig. 274.) In 
view of the extreme rarity of dermoid cysts it is therefore wise to have 
the support of fairly conclusive clinical evidence before the diagnosis 
is made from the Roentgen examination. Two points of distinction are 
of especial importance: (1) dermoid cysts are always found in the 
anterior portion of the chest, and (2) they are encountered most often 
in early life, especially at puberty when they are prone to take on a 
rapid growth. Chapter XXIV 
Aneurysm of the Aorta 
The symptoms and Roentgen shadows of aneurysm are so similar 
to those of tumors of the lungs and mediastinum that their differentiation 
from the latter is an ever recurring problem in diagnosis. For this 
reason aneurysms may profitably be considered in a treatise on the 
respiratory organs, even though the aorta is anatomically not a part of 
them. 
It is conservatively estimated that fifty per cent of aortic aneurysms 
are clinically latent or devoid of characteristic physical signs. Physical 
examination encounters insuperable obstacles in this disease, especially 
when the aneurysm has not extended to the chest wall; moreover, 
aneurysms of the descending aorta are so inaccessible to the examiner 
that they may escape discovery even when they are of large size. 
Fusiform aneurysm of ascending aorta. 
FIGURE 345 416 
The Mediastinum 
In the majority of cases, the Roentgen appearance of an aneurysm 
is so typical as to be immediately recognized. Its shadow is superim- 
posed on that of the aorta whose contour it modifies in a number of 
ways, depending on the size, shape and location of the sacculations or 
dilatations with which it is affected. 
In general we may distinguish two types of aneurysms, the fusiform 
and the sacculated. These types may exist alone or they may be associ- 
ated in the same case, as when a sacculation forms in a fusiform 
aneurysm. The simplest form of aneurysm consists in a fusiform en- 
largement of a localized portion of the aorta. When this occurs in the 
ascending arch it is apt to produce few or no objective signs and it 
attracts attention to itself only because of associated changes in the 
aortic valves or the coronary arteries. (Fig. 345.) This early stage 
of the disease is however so commonly latent that when they come 
under observation, fusiform aneurysms have usually attacked the whole 
aortic arch. There is then presented the picture of a diffuse dilatation 
of the entire vessel as in figure 346. It will be noted in this ca&e that 
Fusiform aneurysm with calcification in the transverse arch. 
FIGURE 346 The Mediastinum 
447 
the contour of the widened aorta is maintained and that the shadow is 
of great intensity. This is due both to a thickening of the vessel wall 
and to deposits of lime which are seen in its periphery. 
Fusiform aneurysms rarely reach the great size of the sacculated 
variety, yet figure 347 illustrates the enormous dimensions they may 
attain. Here also we observe in the wall of the vessel concentric lime 
deposits and also the slight irregularity of its surface which we may 
attribute to periarteritis. These aneurysms bear intrinsic evidence of 
their age and the density of the shadows which they cast testifies to 
the rigidity of their walls. 
FIGURE 347 
Large fusiform aneurysm with concentric lime deposits. Aneurysm of innomi 
nate artery. Periarteritis. 
When aneurysms have grown to a considerable size they rarely 
preserve the uniform contour noted in the cases so far described. They 
tend, in some portion of the aorta to increase in size disproportionately 
to +he others so that localized prominences or sacculations are produced. 
The resulting shadow masses may assume a great variety of shapes. The Mediastinum 
448 
Because of a predilection of the syphilitic process for the root of 
the aorta and also because this part of the vessel receives the first im- 
pact of the blood, the sacculations are usually most prominent in the 
ascending arch. As they grow ,they extend upward, outward and fre- 
quently forward so that they encroach on the right lung. 
A simple form of sacculation of the ascending arch is illustrated 
in figure 348, in which apparently the rest of the aorta has remained 
free of dilatation. The mass of the aneurysm in this case grew back- 
ward and laterally so that it did not come into contact with the thoracic 
wall. For this reason it produced no physical signs. As is so often 
the case with aneurysms it manifested itself by symptoms referable to 
other organs within the chest, in this case, the lungs. Repeated small 
hemoptyses which aroused a suspicion of tuberculosis led to the Roent- 
gen examination and the unexpected finding of the aneurysm. The slow 
growth of this aneurysm, unassociated with any further symptoms is 
brought out in figure 349 which represents the condition three years 
later. 
FIGURE 348 
Sacculated aneurysm of ascending arch. Only symptom, recurring hemoptysis. 
See figure 349. The Mediastinum 
449 
Same as figure 348, three years later, showing slow growth of aneurysm. 
FIGURE 349 450 
The Mediastinum 
Usually aneurysms of the first part of the aorta grow upward; they 
may however in exceptional cases extend downward and over-hang 
the right auricle. (Fig. 350.) In this case the proximity of the aneurysm 
to the aortic valves and their involvement in the syphilitic process re- 
sulted in a valvular insufficiency. 
FIGURE 350 
Sacculated aneurysm of ascending arch, extending down over right auricle. 
Aortic insufficiency. 
Sacculations of the aorta are more often multiple than single. 
Thus in figure 351 there are dilatations both of the ascending and 
transverse arch. In this case also the greater size of the aneurysm of 
the ascending arch speaks for the earlier involvement of this portion of 
the vessel. The great diversity in the size, shape and situation of the 
sacculations is brought out in figures 352, 353 and 354. The Mediastinum 
451 
FIGURE 351 
Sacculated aneurysm of the ascending and transverse arch of the aorta. Physical 
signs of mediastinal tumor. 452 
The Mediastinum 
FIGURE 352 
Sacculated aneurysm of ascending and descending arch of aorta. 1 racliea dis- 
placed to right. The Mediastinum 
453 
FIGURE 353 
Sacculated bilocular aneurysm of ascending and descending arch. 454 
The Mediastinum 
Sacculated aneurysm with depression of transverse arch of aorta. 
FIGURE 354 The Mediastinum 
455 
Aneurysm of transverse arch 
FIGURE 355 
Solitary aneurysms of the transverse arch (fig. 355) are less com- 
mon than those thus far described; they may attain an enormous size. 
(Fig. 356.) Aneurysms of the descending aorta are perhaps the most 
difficult of diagnosis by the ordinary clinical means. They are inac- 
cessible to examination and for this reason, they may remain latent 
even though of considerable size. In figure 357 is illustrated a large 
fusiform aneurysm of the descending aorta which gave no direct symp- 
toms or physical signs. The dense shadow, extending to the left of the 
heart, showed a marked systolic pulsation; viewed in the oblique posi- 
tion, its continuity with the descending aorta was demonstrated. An 
aneurysm of this type may be the cause of symptoms which are mis- 
takenly referred to the oesophagus or stomach and it is therefore apt to 
be discovered by the gastro-enterologist, as was the case with this 
patient who complained of vague gastric symptoms. 456 
The Mediastinum 
FIGURE 356 
Sacculated aneurysm of transverse arch. The Mediastinum 
457 
FIGURE 357 
Fusiform aneurysm of descending aorta. Clinically latent. 
Aneurysms of the lower part of the thoracic aorta present extreme 
difficulty in diagnosis. They may be completely obscured by the heart 
and require a fluoroscopic examination for their certain recognition. 
They are best seen in the oblique positions. 
In addition to intrinsic changes in the wall of the aneurysm such 
as peri-arteritis and calcification, the Roentgen plate occasionally dis- 
closes a weakening of the arterial wall at one point which may be sug- 
gestive of an impending perforation. Such a perforating aneurysm is 
shown in figure 358. The small semicircular prominence, superim- 
posed on the body of the aneurysm, indicated, by the thinness of its 
wall and its excessive pulsation, the imminence of rupture at this point. 458 
The Mediastinum 
FIGURE 358 
Fusiform dilatation of aorta. Secondary dilatation of ascending arch. 
PRESSURE EFFECTS OF ANEURYSMS 
Aside from the actual demonstration of the aneurysm, the Roent- 
gen examination supplies instructive facts in regard to its pressure 
effects on the other thoracic organs. For this purpose, fluoroscopic 
examination is of especial value, as it enables us to observe the rela- 
tions of the aneurysm when viewed from various directions. The 
origin of many of the symptoms which arise in the trachea, bronchi 
and oesophagus thus become manifest to us and occasionally we 
may observe an encroachment on, or even a perforation of the bony 
thorax. 
Perhaps the most frequent pressure of effect of aneurysms espec- 
ially when they are sacculated, is exerted on the trachea, which may 
suffer an extreme constriction. The trachea may be flattened ventro- The Mediastinum 
459 
dorsally against the spine; usually however, it is compressed laterally 
between adjacent sacculations. Its uneven lumen may then be seen 
as a light area traversing the dense shadow of the aneurysm. The de- 
tails of malposition and distortion of the trachea may at times be best 
seen in the oblique positions. Thus, in figure 359 the large globular 
aneurysm had effected a marked narrowing and displacement of the 
trachea whose lumen is almost completely obliterated. 
Uniform dilatation of entire aortic arch. 
FIGURE 359 
Pressure on one of the larger bronchi, which is a frequent result 
of aneurysm is not directly visible but may often be inferred from a 
diminished air content of the affected portion of the lung. If the aera- 
tion of a sufficiently large portion of the lung is affected, a broncho- 
stenotic phenomenon may be visible on the screen; during inspiration 
there occurs a displacement of the mediastinum toward the affected 
side. Gross pulmonary changes, resulting from a long-standing narrow- 
ing of a bronchus, such as bronchiectasis and abscess of the lung which, 
because of their similarity to tuberculosis have become known clinically 
as aneurysmal phthisis are, of course, readily discernible on the plate. 460 
The Mediastinum 
Compression of the oesophagus occurs less often than that of the 
trachea; it may however be marked and be the first symptom to draw 
attention to the aneurysm. The patient whose aneurysm is illustrated 
in figure 360 complained mainly of dysphagia, which caused him much 
distress. The degree of narrowing may be judged from the thin column 
of barium in the oesophagus; the tortuous course of the latter over the 
surface of the aneurysm is also evident. 
FIGURE 360 
Oblique view of aneurysm of transverse arch of aorta showing constriction of 
trachea. Marked tortuosity of oesophagus indicated by ingested barium at arrows. 
DIFFERENTIAL DIAGNOSIS 
Although most aneurysms may be recognized as such immediately 
by means of a Roentgen examination, occasionally the shadows are so 
similar to those of new growths of the mediastinum, that all our re- 
sources, both clinical and Roentgenological are taxed to make the 
distinction. Of course, in doubtful cases the value of a Wasserman 
reaction cannot be over-estimated and a positive test should outweigh 
the Roentgen findings even when the latter are suggestive of a new- 
growth. Of the greatest service in such doubtful cases is the thorough 
fluoroscopic examination of the patient, in every possible position. This The Mediastinum 
461 
procedure will usually determine the relation of the shadow to the 
aorta. The great similarity which some mediastinal tumors may bear 
to aneurysms will be evident by a study of the new growths illustrated 
in figures 324 and 325. 
The following points of distinction between aneurysms and new 
growths may be pointed out: 
1. The outline of an aneurysm is smooth and curved, whereas 
tumors are frequently lobulated and their borders may be irregular. 
The latter may also invade the lung so that their outlines become indis- 
tinct. 
2. The shadow of a tumor can frequently be distinguished from 
that of the aorta which it overlies, as it is usually of lesser density. It 
may even displace the arch of the aorta downward by pressure on it. 
3. Examination of the patient in the oblique position may show 
that a questionable shadow is not a part of the aorta. For this purpose, 
fluoroscopy in the second oblique position is of special value, as it 
visualizes the aorta throughout a great part of its course. In this posi- 
tion only, can the smaller aneurysms which occasionally form in the 
concavity of the aortic arch, be brought to light. 
4. Evidence of aortic valvular insufficiency with dilatation of the 
left ventricle will favor aneurysm. 
In spite of these points of distinction, there are occasional cases of 
tumor of the mediastinum which cast shadows that are absolutely like 
those of undoubted cases of aneurysm. In these patients, the physical 
signs, unfortunately, are of little help as they are apt to be identical in 
both conditions and we are forced to observe the further progress of the 
case before we may reach a decision. Aneurysms are of slow growth, 
whereas tumors increase in size more rapidly; a second Roentgen exam- 
ation after a short interval may therefore settle the question. The 
discovery of a pleural effusion during the progress of the case or the 
sudden swelling of an arm due to thrombosis of the subclavian vessels 
will incline the examiner to a diagnosis of new growth because of the 
tendency of tumors to produce vascular compression with subsequent 
thrombosis. Aneurysms, on the other hand, even when they are very 
large, are rarely responsible for these symptoms. 
PULSATION OF ANEURYSMS 
It is customary, in making a differential diagnosis between 
aneurysm and tumor, to emphasize the importance of a pulsation of the 
shadow, as an evidence of the former. It is true that a systolic pulsa- 
tion may be regarded as a valuable corroborative sign of aneurysm. 
But it is not present in every case or even in a large percentage of the 462 
The Mediastinum 
cases and for this reason it is not a dependable sign. Even very large 
aneurysms may not show the faintest evidence of pulsation. The causes 
for this may be various. In the first place, the wall of the aneurysm is 
often thickened by disease and by the deposit of a lamellated clot, 
whose rigidity interferes with the transmission of pulsations. Further, 
in sacculated aneurysms, the communication with the main channel of 
the aorta may be a small one and the impulse of the stream of blood 
may not be strongly felt in the aneurysm. In the fusiform variety, for 
a contrary reason, the pulsation is usually well marked. 
In nearly all cases however, the pulsation, if it is at all visible, is 
of no greater amplitude than in the normal aorta. The pulsation seems 
to be greater on the screen because of the larger size and density of the 
aneurysmal shadow, which make it more obvious. The reasons for this 
absence of marked pulsation are readily understandable. As will be 
pointed out, in most cases of aneurysm there is no enlargement of the 
heart and therefore during systole, the aneurysm is not distended with 
a greater amount of blood than is the normal aorta. It is only when 
vascular disease affects the root of the aorta and implicates its valves, 
that the resulting aortic insufficiency with its increased stroke volume 
produces a wide expansile pulsation of the vessel. Under these circum- 
Syphilitic aortitis with diffuse dynamic dilatation of aorta. Aortic insufficiency 
and congenital syphilis. 
FIGURE 361 The Mediastinum 
463 
stances, the aorta may exhibit a marked pulsation without being much 
dilated. This is strikingly illustrated in figure 361. The enlarged shadow 
of the aorta is entirely the result of a dynamic dilatation produced by 
the vigorous contraction of the hypertrophied and dilated left ventricle. 
At autopsy there was found congenital syphilis of the ascending arch of 
the aorta with an aortic insufficiency. The aorta itself was not dilated. 
Finally it must be borne in mind that tumors of the med'astinum 
occasionally pulsate. This may be due to a vascularity of the tumor 
itself; more often it is a transmitted pulsation from the aorta. Although 
such a transmitted pulsation has not the expansile character of an 
aneurysm, the determination of this point on the fluoroscopic screen 
is not always an easy matter. 
THE HEART WITH AORTIC ANEURYSMS 
Aneurysm of the aorta by itself has no influence on the size of the 
heart. When the latter is found to be enlarged, this must be attributed 
to other associated conditions rather than to the aneurysm. The com- 
monest of these is aortic insufficiency due to an involvement of the 
valves in the syphilitic process or chronic nephritis with arterial 
hypertension. Occasionally a large aneurysm of the ascending aorta 
will displace the heart to the left by downward pressure; this must of 
course not be confused with a cardiac dilatation. 
Despite these facts in regard to the size of the heart which we have 
verified by numerous orthodiagraphic measurements, there is a more 
or less prevalent belief that aneurysms cause an enlargement of the 
heart. This belief, to which the Roentgen examination has in a measure 
contributed, is due to the failure to distinguish between a true aneurysm 
of the aorta and the very common atherosclerotic dilatation of this 
vessel. In the latter condition, in which there is often an arterial hyper- 
tension the heart is frequently hypertrophied and dilated and the 
elongated transverse arch of the aorta extends prominently into the left 
pulmonary field. Only those lacking experience will interpret such an 
enlargement of the aorta as an aneurysm. It is an almost universal 
phenomenon of senescence whose familiar features receive no more 
than casual notice from the experienced clinician or Roentgenologist. 
The distinction between the atheromatous and the aneurysmal aorta 
on the Roentgen plate is as definite as that between the corresponding 
degenerative and luetic changes in the vessel wall; with the former, 
the heart is often hypertrophied and dilated, with the latter, it is rarely 
so. 464 
The Mediastinum 
ANEURYSM OF THE INNOMINATE ARTERY 
Aneurysms of the innominate artery are usually associated with a 
similar disease of the aorta. When they are sufficiently large they cast 
a shadow which begins at the summit of the aortic arch and extends to 
the sternal end of the clavicle. Such an aneurysm is illustrated in figure 
347, in which the dilatation of the innominate is an extension of a gen- 
eral aortic dilatation. In figure 362 the aneurysm appears to be a sac- 
culated one. 
FIGURE 362 
Aneurysm of innominate artery, 
Rarely, the innominate artery is involved alone and it may then 
appear as a semicircular shadow situated below the inner end of the 
clavicle, just above the aorta. This shadow bears a close similarity to 
that of a unilateral substernal thyroid, (see figure 329,) from which it 
can be distinguished on the screen by its pulsation and its failure to 
move during the act of swallowing. The Mediastinum 
465 
In patients with atheroma of the aorta, it is not unusual to feel 
pulsating vessels in the suprasternal notch or behind the insertion of 
the sterno-mastoid muscle. The Roentgen plate in these cases shows 
usually that the aorta is elongated so that its large branches become 
more accessible to palpation at the root of the neck. The latter are also 
atheromatous and cast a wider shadow than is normal in the superior 
mediastinum. They can, however, readily be distinguished from true 
aneurysms of the innominate artery. SECTION VII 
The Intrathoracic Lymph Nodes 
Infectious Adenopathies 
Non-Infectious Adenopathies 
Glandular Tumors 
Lymphomata 
Hodgkin’s Disease Chapter XXV 
The Intrathoracic Lymph Nodes 
INFECTIOUS ADENOPATHIES 
The bronchial lymph nodes, by which we mean in general the 
lymphatic tissue into which the pleural, pulmonary and bronchial 
lymphatics drain, bear the brunt of numerous and various injuries dur- 
ing the life of the individual. It is not surprising in view of the common 
and repeated respiratory infections, that the lymph nodes are almost 
universally enlarged and diseased. However common this bronchial 
adenitis is, in adults at least it maintains a subordinate place in the 
clinical picture and rarely by itself is responsible for any recognizable 
symptoms. 
We may dismiss acute bronchial adenitis with a few vords. The 
bronchial nodes are undoubtedly enlarged as a consequence of acute 
infections of the bronchi and lungs. In pneumonia for example, the 
hilum shadows are noticeably increased in size and a similar hyper- 
plasia is commonly seen during or after measles and whooping cough. 
The glandular enlargement, however, is usually moderate and it has 
no clinical significance. In infants and young children we may, on the 
other hand, observe a tendency to a more vigorous reaction of the 
lymphatic apparatus which is similar in its intensity to that seen in 
infantile glandular tuberculosis. The nodes may attain enormous pro- 
portions, so that they resemble a tumor mass; yet with the subsidence 
of the infection, they return to their usual size with astonishing rapid- 
ity. For example, in figure 363 is illustrated an acute adenitis of the 
upper and lower groups of bronchial nodes which developed during 
the course of an unrecognized retropharyngeal abscess in a young 
child. A week later, after the evacuation of the abscess, the lymph 
nodes had practically disappeared. 
Of greater importance are the adenopathies which result from the 
various chronic respiratory infections. Rarely in adults do we see a 
plate without some evidence of glandular disease at the roots of the 
lungs. It may be stated without exaggeration, that in the anatomic 
sense, a perfectly normal lung root does not exist, because practically 
no individual can escape the glandular irritation due to dust inhalation 
and the various bacterial infections including, above all, tuberculosis. 470 
The Intrathoracic Lymph Nodes 
Acute bronchial lymph-adenitis secondary to retropharyngeal abscess. Note 
shadow of lower group of nodes behind the heart. Nodes disappeared in a 
few weeks. 
FIGURE 363 
There is perhaps no subject which has given rise to more confusion 
in the interpretation of chest plates than chronic disease of the bronchial 
lymph nodes. This is mainly owing to the failure of Roentgenologists 
to distinguish between infection and clinical disease. The dense, irregu- 
lar shadows which are commonly seen at the roots of adult lungs are 
undeniably due to an enlargement of the lymph nodes; but it is another 
matter, in a case of thoracic disease, to regard them as related to the 
disease. In fact, in adults at least, it is questionable whether such en- 
larged lymph nodes, which are usually indurated and anthrocotic, con- 
tribute anything to the clinical picture. The cough and expectoration 
which may be present in these cases, are more logically referable to 
an underlying bronchitis, which causes both the symptoms and the 
glandular enlargement. We may often find these symptoms together 
with glandular swelling as a result of chronic accessory sinus disease. 
(Fig. 364.) The Intrathoracic Lymph Nodes 
471 
FIGURE 364 
Hyperplasia and induration of bronchial nodes secondary to chronic nasal sinusitis. 
These considerations have a most important bearing on our inter- 
pretation of the shadows of tuberculous bronchial lymph nodes. The 
changes in these nodes by which we recognize them as tuberculous are 
essentially caseation and calcification, which cause the shadows to 
become very dense and irregular. (Figue 365.) These changes may 
be noted in the broncho-pulmonary and tracheo-bronchial nodes and in 
adults very rarely in the paratracheal nodes. The glandular enlarge- 
ment is always moderate and never attains the dimensions of the 
tuberculous adenopathy in children. We must now ask ourselves what 
significance from a clinical standpoint is to be attached to the discovery 
on a Roentgen plate of a number of enlarged tuberculous nodes at the 
roots of the lungs. The clinician has repeatedly presented to him the 
problem of a patient who has a slight daily rise of temperature, with 
or without cough and in whom the Roentgen plate reveals only the 
shadows of presumably tuberculous bronchial nodes. The question 472 
The Intrathoracic Lymph Nodes 
Calcification of tuberculous bronchial lymph nodes at right root. 
FIGURE 365 
arises whether such nodes are a sufficiently common cause of pulmonary 
or other symptoms that their presence in an individual case will warrant 
us in assuming that they are the cause of those symptoms. Decidedly 
not. Glandular tuberculosis is almost universal in adults, yet it is prac- 
tically always a quiescent infection which gives rise to none of the 
clinical symptoms of tuberculosis. If, in a given case, no infiltrations 
are seen in the lungs, the examiner will wisely diregard the enlarged 
lymph nodes and will look elsewhere than in the chest for the cause of 
the fever. The Roentgen examination in this type of case will there- The Intrathoracic Lymph Nodes 
473 
fore be of value in a negative sense, in that it will serve to exclude 
tuberculous disease of the lungs and direct attention to other foci such 
as the teeth or the tonsils or the accessory sinuses. 
In regard to syphilis of the intrathoracic lymph nodes little that 
is definite can be said. Whether the Roentgen shadows of enlarged 
nodes should in a particular case be regarded as syphilitic will depend 
less on the appearance of the shadows themselves than on the evidences 
of syphilis elsewhere in the body which will lend plausibility to the 
diagnosis. In the two cases herewith illustrated the shadows have the 
faint homogeneous appearance which we found in the various lympho- 
mata. (Figs. 366 and 367.) 
FIGURE 366 
Enlargement of right paratracheal lymph node in syphilis. The Intrathoracic Lymph Nodes 
474 
FIGURE 367 
Enlarged bronchial lymph nodes in a syphilitic, 
NON-INFECTIOUS ADENOPATHIES 
GLANDULAR TLTMORS. The primary tumors of the intrathor- 
acic nodes belong mostly to the group of lympho-sarcomata. In 
our discussion of mediastinal tumors we have already illustrated 
the Roentgen features of these cases. The disease may be ex- 
clusively limited to the intrathoracic nodes or the latter may be only 
a local manifestation of a general lympho-sarcomatosis. In either case, 
the lymphatic enlargement may be extreme and have the dimensions 
and produce the pressure effects of a tumor. There are cases of general 
lympho-sarcomatosis on the other hand, in which the bronchial nodes 
play a subordinate role; they show a moderate enlargement and cast 
the homogeneous, well defined shadow so characteristic of new-growths, The Intrathoracic Lymph Nodes 
475 
yet they never attain the size of tumors and produce no symptoms. It is 
none the less important to recognize the significance of these smaller 
shadows as the evistence of intrathoracic disease has to be reckoned 
with in the treatment of these cases. 
Tumors of the bronchial nodes which are secondary to primary 
growths in the lungs are of little clinical importance. They are usually 
not very large and they are entirely over-shadowed on the Roentgen 
plate by the primary tumor. There are, however, occasional exceptions 
to this rule. A small primary carcinoma of a bronchus may itself be of 
slow growth. Its metastases in the adjacent nodes may, on the contrary, 
grow so rapidly that they quickly form a large mediastinal tumor, which 
may be responsible for most of the clinical symptoms. (Fig. 319.) 
Metastatic involvement of the bronchial nodes is a not uncommon 
sequel of carcinoma of the breast. This is accounted for by the direct 
communication between the subpectoral and intrathoracic lymphatics. 
In spite of the frequency of this complication, the Roentgen plate does 
not often throw light upon it. Cancer cells transplanted to these nodes 
are usually of such slow growth that a significant enlargement of them 
is not often seen; for this reason a negative Roentgen plate is no assur- 
ance that the lymph nodes are not involved. Only when, as we have 
observed in an isolated case, an enlargement occurs in an unusual situa- 
tion, as in a paratracheal node, may we attach any significance to it. 
Often as not, the first indication of an intrathoracic complication will 
be a pleural effusion which may occur months or years later, or as we 
have seen, it may take the form of a wide spread pleuro-pulmonary 
carcinosis. 
LYMPHOMATA. In the various blood diseases the intrathoracic 
lymph nodes are frequently involved together with the glandular appar- 
atus elsewhere in the body. The enlargement of the bronchial nodes 
may take one or two forms. It may be extreme, the individual nodes 
growing to an enormous size so that on the Roentgen plate they produce 
the appearance of a true mediastinal tumor. Thus in figure 322 the 
lymphoma assumes the form of a smooth, dense tumor mass, whose 
pressure has resulted in a pleural effusion. In figure 326 the broncho- 
pulmonary nodes on the left side are especially enlarged; they occupy 
the position of the pulmonary artery, with which they could readily 
be confused. In both of these cases, the clinical picture was that of a 
chronic lymphatic leukemia. In acute leukemias, a similar though more 
rapid enlargement of the bronchial nodes may occur. Thus in a case 
of acute myeloblastic leukemia, the nodes completely filled the superior 
mediastinum and also encroached on an upper lobe producing marked 
respiratory embarrassment. (Fig. 368.) 476 
The Intrathoracic Lymph Nodes 
FIGURE 368 
Enlargement of upper mediastinal lymph nodes in acute myeloblastic leukemia. 
These however, are exceptional cases; in most cases of leukemia 
the bronchial adenopathy remains within moderate limits. The root 
shadows are somewhat enlarged and present the faint, homogeneous, 
well outlined appearance which is so typical of lymphomata in general, 
especially Hodgkin’s disease. (Fig. 369.) In many instances the en- 
largement is so slight that one cannot readily distinguish it from the 
hyperplastic anthracotic nodes which are such a regular feature of the 
Roentgen plate in adults. Leukemic infiltrations in the lungs are rarely 
found. When present, they closely resemble areas of lobular pneu- 
monia, whose confluence may produce an appearance of consolidation 
of the lung. (Fig. 370.) The Intrathoracic Lymph Nodes 
477 
FIGURE 369 
Enlargement of bronchial lymph nodes in acute leukemia. 
In conclusion, it may be worth while to consider in general the 
clinical application of the Roentgen examination of the thoracic lymph 
nodes. The clinician is repeatedly brought face to face with cases 
whose essential feature is an enlargement of one or more groups of 
superficial lymph nodes. In many instances, the character of the blood 
changes or other associated abnormalities at once affords the key to 
the nature of the glandular enlargement. There are, however, other 
cases in which such aids in diagnosis are wanting. The examiner will 
then have to be guided by the physical characteristics of the enlarged 
lymph nodes themselves. Unfortunately these are not always deter- 
minant. It is not easy at times to distinguish between the glandular 
enlargement of Hodgkin’s disease, lympho-sarcoma or benign lympho- 
mata and that due to chronic infections such as tuberculosis and syphilis. 478 
The Intrathoracic Lymph Nodes 
FIGURE 370 
Chronic lymphatic leukemia. Enlargement of bronchial nodes and leukemic infiltration 
of left lower lobe. 
In this dilemma the Roentgen examination of the chest may occa- 
sionally shed decisive light on the true condition. The Roentgen appear- 
ance of intrathoracic Hodgkin’s disease is often typical. In other cases, 
the discovery of a large mediastinal mass will speak for the sarcomatous 
nature of the superficial lymphomata. And finally, a tuberculous lesion 
in the lungs, especially if it is recent, may incline one, though not 
necessarily so, to suspect that the lymph nodes felt on the surface of 
the body are tuberculous. Chapter XXVI 
Hodgkin’s Disease 
Although the symptoms and mechanical effects of intrathoracic 
Hodgkin’s disease are essentially those of true mediastinal tumors, it 
may nevertheless claim special consideration from the Roentgen stand- 
point. The Roentgen manifestations of this disease are manifold and 
they present some unique features which are of value in distinguishing 
it from malignant tumors and other diseases within the chest. 
Of course, Roentgen examination of the chest is rarely necessary in 
order to establish the diagnosis of Hodgkin’s disease, because external 
lymphomata are usually present. Yet it cannot be a matter of indiffer- 
ence in the individual case whether the intrathoracic lymph nodes are 
also involved or the lung is actually invaded by the disease. From the 
point of view of treatment also, it is evident that therapeutic measures 
applied exclusively to the external glandular enlargement can secure 
no permanent results, if the disease has invaded the chest. 
The bronchial nodes are a frequent site for the development of this 
disease. In nearly all cases in which the glandular enlargement in the 
neck or axilla was well developed, we have found on the plate definite 
changes either at the roots of the lungs or in the lungs themselves. More 
than this, in those uncommon forms of the disease in which only the 
internal organs are affected, we have almost invariably found patho- 
logical changes in the thoracic viscera, from which at times the nature 
of the process in the abdomen might be inferred. 
The value of the examination of the chest therefore requires no 
further comment. One other consideration is worthy of note. Only 
the Roentgen examination is capable of disclosing the pathological 
changes which are so frequently present in the chest in cases of Hodg- 
kin’s disease. The physical signs are rarely decisive even when large 
tumor masses are present and the clinician is usually dependent on 
the symptoms which are often absent and on the signs of pressure on 
the bronchi or vessels for evidences of the disease. 
The abnormal shadows found on the plates in cases of Hodgkin’s 
disease permit of a classification into four groups, the features of which 
may be found singly in the individual case or as is more common, they 
may be combined. 
(1) Among the rarer Roentgen types are those that resemble true 
mediastinal tumors, especially the lympho-sarcomata. The plate reveals 
a dense central shadow, the outlines of which may be irregular and lobu- 480 
The Intrathoracic Lymph Nodes 
lated and in which all evidences of individual lymph nodes are obliter- 
ated. (Figs. 371 and 372.) The patients suffer the symptoms of intra- 
thoracic pressure which are associated with tumors and the plate offers 
no point of distinction from them. This form of the disease may be com- 
bined with the other types. 
Hodgkin’s disease. Mediastinal tumor type. 
FIGURE 371 The Intrathoracic Lymph Nodes 
481 
Mediastinal tumor. Hodgkin’s disease. 
FIGURE 372 482 
The Intrathoracic Lymph Nodes 
(2) The central lymphomatous mass may extend outward into 
the lung and infiltrate it extensively. The contour of the growth loses 
its sharp definition, penetrating into the lung parenchyma and shading 
off into it imperceptibly. (Fig. 373.) In this infiltrative form, the 
FIGURE 373 
Hodgkin’s disease. Unusual infiltrating form. 
tumor masses may be continuous with the central lymphoma or there 
may be in addition isolated deposits scattered throughout the lung, the 
outlines of which are also indistinct. (Fig. 374.) More rarely the in- 
filtration may be a diffuse one and involve a whole lobe in an irregular 
consolidation, somewhat like a pneumonia. (Fig. 377.) The Intrathoracic Lymph Nodes 
483 
FIGURE 374 
Hodgkin’s disease. Diffuse infiltration of both lungs. 
As in the previous form the shadows here have the denseness of a 
true neoplasm and it may perhaps be inferred that we are dealing with 
longer standing cases in which there has been a formation of consider- 
able connective tissue. This also is one of the less common forms of the 
disease in which there is little that is typical to lead the Roentgenologist 
to a correct diagnosis. 
(3) Among the more characteristic features of the disease we must 
regard the circumscribed isolated deposits of granulomatous tissue 
which may be found anywhere in the lung. They occur as smaller or 
larger irregularly circular shadows of very slight density, so slight in 
fact that the lung markings are distinctly visible through them. In some 
respects these shadows resemble those of the metastases of malignant 
growths; they differ from them however, in that they lack the per- 
fectly circular outline of cancers and are often grouped in lobulated 
masses. 484 
The Intrathoracic Lymph Nodes 
In figure 375 these isolated deposits are situated mostly near the 
roots of the lungs; yet others are found near the periphery and they 
may even occur near the apex. Here, if viewed alone and without 
reference to other evidences of the disease, they may readily be con- 
fused with the early infiltrations of pulmonary tuberculosis. (Fig. 376.) 
FIGURE 375 
Hodgkin’s disease. Enlargement of bronchial nodes. Isolated deposits in 
lungs. Involvement of substernal thyroid. The Intrathoracic Lymph Nodes 
485 
FIGURE 376 
Hodgkin’s disease. Characteristic involvement of bronchial and paratracheal 
nodes. Isolated deposits in both lungs. 
This form of Hodgkin’s disease does not appear to occur by itself but 
is associated with its other forms. The isolated position of the deposits 
in the lung would indicate, in accordance with the accepted view of 
the pathology of the disease, their autochthonous development from the 
foci of lymnhoid tissue which are found throughout the lungs. 486 
The Intrathoracic Lymph Nodes 
Hodgkin’s disease. Very large paratracheal nodes. Lymphomata at left root. 
Diffuse infiltration of right lower lohe. 
FIGURE 377 The Intrathoracic Lymph Nodes 
487 
(4) The common and typical change in the chest in Hodgkin’s 
disease consists in a tumefaction of the intrathoracic lymph nodes, 
which is analogous to that found in the neck or in the axilla. In a large 
percentage of cases in which the disease is well developed there will be 
found at the roots of the lungs the shadows cast by these lymph nodes 
which in some respects are characteristic. They are well defined, faint 
in intensity and homogeneous. There is usually no difficulty in dis- 
tinguishing them from the lymph nodes of tuberculosis or anthracosis, 
as the latter produce the well known dense irregular shadows which 
are so commonly found at the hilum of the lungs. The outline of the 
individual nodes is often maintained, a circumstance which accounts 
for the large, lobulated masses such as are seen in figures 375 and 378. 
Of especial interest in this type of Hodgkin’s disease, is the remark- 
able predilection shown for the enlargement, at times enormous, of a 
group of lymph nodes which is rarely affected in other diseases. In 
over fifty per cent, of the cases which have come under our observation, 
there has been a marked increase in the size of the paratracheal group 
FIGURE 378 
Hodgkin’s disease. Characteristic enlargement of bronchial and paratracheal nodes. 488 
The Intrathoracic Lymph Nodes 
of nodes, either alone or associated with involvement of other intra- 
thoracic lymphoid tissue. The great size which these may attain is 
illustrated in figures 376, 377 and 378. They cast a shadow on the 
plate which is situated to the right of the trachea, extending from its 
bifurcation up to the sterno-clavicular articulation. Their deep situa- 
tion makes them inaccessible to the examiner and they produce no 
superficial physical signs. The frequency with which this paratracheal 
adenopathy is found in Hodgkin’s disease makes the association more 
than a coincidence and for this reason we regard it of major importance 
in diagnosis. It occurs with the greatest rarity in mediastinal and pul- 
monary new-growths and then the enlargement is usually very slight. 
We have found a marked enlargement of these nodes occasionally in 
other diseases which affect the intrathoracic lymphoid tissue such as 
lympho-sarcoma and lymphatic leukemia and also the glandular 
tuberculosis of infants and young children. In fact, tuberculosis of the 
bronchial lymph nodes in children may present a Roentgen appearance 
which is identical with that of Hodgkin’s disease. 
The adenopathy of Hodgkin’s disease can readly be distinguished 
from that of tuberculosis in adults. When tuberculous lymph nodes 
have attained the size of those in Hodgkin’s disease, they invariably 
show evidences of caseation or calcification and they are so matted 
together that the outlines of individual nodes is obliterated. For this 
reason, large lobulated shadows at the roots of the lungs, which are 
faint and homogeneous, will raise a strong presumption of Hodgkin’s 
disease. 
Although it will appear from the foregoing that Hodgkin’s disease 
exhibits itself in protean forms, some of them are distinctive and may 
be utilized for diagnosis when the rest of the clinical picture is incom- 
plete or atypical. There come to mind the cases of abdominal Hodg- 
kin’s disease in which the clinical picture may be confused by the high 
remittent fever; or again the so-called splenomegalic form in which 
the external glandular enlargement may be insignificant. In these cases 
especially, the Roentgen examination may bring to light a large medi- 
astinal mass the existence of which was unsuspected. This is well 
illustrated in figure 378. This patient presented the clinical appear- 
ance of a severe secondary anemia and complained chiefly of dragging 
pain in the left side due to the weight of an enormous spleen which 
extended down to the pelvis. The only palpable glandular enlarge- 
ment was to be found in the left supraclavicular fossa where one small 
hard lymph node could be felt. Yet the plate shows that the disease 
had already extensively involved the intrathoracic nodes, notably the 
right paratracheal group. The iNTRATHORACIC L4MPH NODES 
489 
The clinical distinction between glandular tuberculosis and Hodg- 
kin’s disease may at times be so difficult that only a microscopic exam- 
ination of the diseased nodes will clear up the case. Here also the 
Roentgen examination may play a role of decisive importance in reveal- 
ing suggestive, if not characteristic, changes within the chest. 
In interpreting the shadows seen on the plates of patients whose 
external nodes show the pathological changes typical of Hodgkin’s 
disease, it must not be forgotten that occasionally the disease within 
the chest may be of an entirely different nature. Glandular tubercu- 
losis has at at times been found in close association with Hodgkin’s 
disease, involving either the same or different groups of nodes. 
Of the unusual combinations we may instance a terminal miliary 
tuberculosis of the lungs the shadows of which were later seen in the 
case illustrated in figure 378 and a mediastinal lymphosarcoma (fig. 
315) in a patient whose external lymphomata were of the Hodgkin’s 
type. SECTION'VIII 
1 he Diaphragm Chapter XXVII 
The Diaphragm 
Our interest in the diaphragm from the Roentgen standpoint, arises 
less from disease of this muscle itself than from its unique position. 
Interposed between the thoracic and abdominal viscera, it may reflect, 
by an alteration in its position and contour, abnormal conditions both in 
the chest and in the abdomen. It therefore becomes a matter of im- 
portance in cases of visceral disease to scrutinize the diaphragm in 
respect to its position, shape and movement. 
Under normal conditions the diaphragm exhibits a great diversity 
in shape and position and in the range of its movement. These varia- 
tions seem to be most influenced by the shape of the chest. In long- 
chested individuals, whether they are so congenitally or as a result of 
emphysema, the diaphragm is low and its contour flattened so that the 
costo-phrenic sinus is shallow. This condition is characteristic of the 
asthenic type, in whom the low flat diaphragm is associated with vis- 
ceroptosis and an elongated centrally placed heart. On the other hand, 
in individuals of stocky build, the diaphragmatic vault is higher and 
the costo-phrenic sinus is deep. This is also true of stout persons in 
whom the exce ssive abdominal fat mechanically displaces the dia- 
phragm upward. Statements concerning the height of the diaphragm 
have therefore only a limited value and inferences from it should be 
drawn guardedly. The right leaf of the diaphragm is usually slightly 
higher than the left; it should however be borne in mind, that gaseous 
distention of the stomach and colon which may arise from physiological 
causes, will result in an elevation of the left leaf of the diaphragm so 
that it may on occasion be as high as or higher than the right. 
Having determined the position of the diaphragm the examiner is 
next concerned with its movement in respiration. This is most satis- 
factorily observed on the fluoroscopic screen. Normally the excursion 
of the diaphragm varies considerably with the individual type of breath- 
ing, depending on whether this is chiefly costal or abdominal. In long 
chested persons, in whom the arch of the diaphragm is low and flat- 
tened, the respiratory movement may be minimal and consist only in a 
slight depression of its central tendinous portion, whereas the peripheral 
portion of the muscle remains almost immobile. In the short and deep- 
chested individuals the excursions are ample and with deep inspiration 
there is a widening and areation of the depths of the costo-phrenic 
sinus. Aside from these general characteristics of its respiratory move- 494 
The Diaphragm 
ment, considerable variation in the action of the diaphragm will be en- 
countered which appears to be peculiar to the individual. Some patients 
find it impossible to contract the diaphragm voluntarily during the 
course of the examination and its motility cannot be studied until their 
attention is diverted from it. For this reason, an immobility of the 
diaphragm must not be assumed off hand and repeated effort must be 
made to instruct the patient in the proper manner of breathing. Jerky, 
irregular movements of the diaphragm are often caused by nervousness 
on the part of the patient. 
The contour of the diaphragm is smooth and uniformly convex. 
During deep inspiration however, it is not uncommon for its mesial half 
to be separated from its lateral portion by a slight sulcus. This phenom- 
enon is seen nearly always on the right side. In certain cases in deep 
inspiration this portion of the diaphragm is so elevated as to produce a 
localized projection upward into the chest which is apt to be confused 
with the prominence caused by a liver abscess or tumor. (Fig. 380.) 
FIGURE 380 
Prominence of mesial portion of the right diaphragm due to elevation of the 
central tendon in deep inspiration. The Diaphragm 
495 
It is important to recognize the cause of this abnormality in the shape 
of the diaphragm because it is not due to organic disease nor is it even 
caused by adhesions. It is in all probability produced by an upward 
suction of the central tendinous portion of the diaphragm, through the 
inspiratory traction of the lung. It disappears entirely during expira- 
tion and has no clinical significance. The sulcus between the tendinous 
and muscular parts of the diaphragm is graphically brought to view in 
cases of pneumoperitoneum, in which the presence of air between the 
diaphragm and the liver permits a more comprehensive view of the 
former. (Fig. 396.) 
ELEVATION OF THE DIAPHRAGM 
The commonest causes of an abnormally high diaphragm are to be 
found in the abdominal cavity and they usually result in its elevation 
on both sides. These causes in brief, are gaseous or fluid distention of 
the abdominal cavity, intra-abdominal neoplasms and a coincident 
enlargement of the liver and spleen. Frequently an enlargement of the 
liver which affects both its right and left lobes will cause an upward 
displacement equally of both halves of the diaphragm. 
We are however more especially concerned with a unilateral eleva- 
tion of the diaphragm; a consideration of its causes presents for dis- 
cussion a large number of pathological conditions in both the thoracic 
and abdominal cavities, on which the position and shape of the dia- 
phragm may throw much light. 
(1) Pleurisy without effusion commonly causes an upward dis- 
placement of the diaphragm. The elevation is usually of moderate 
degree and in most cases it is the only Roentgen evidence of the disease. 
Its cause is probably a reflex inhibition of the muscle due to the neigh- 
boring inflammatory process and it is therefore also present in lobar 
pneumonia and other acute inflammatory diseases of the lung which 
involve the pleura. In effect, the diaphragm does not contract in 
respiration and remains in the expiratory position. The immobility 
and elevation of the diaphragm are evidenced not alone throughout 
the acute stage of the disease but may persist for weeks thereafter. 
The presence of a small amount of fluid during the course of an 
acute pleurisy, in no way alters the high position of the diaphragm. It 
is only when a larger amount of fluid has collected, that its weight will 
depress the diaphragm. 
(2) SUBPHRENIC ABSCESS—is responsible for some of the 
most extreme upward displacements of the diaphragm. The presence 
on the right side of those organs which are most often responsible for 
suppuration in the subphrenic space namely, the appendix, pylorus, 
duodenum and liver, accounts for the great frequency of the disease on 
that side. It is evident that the degree of upward displacement of the 496 
The Diaphragm 
diaphragm will depend on the amount of fluid in the subphrenic space 
and also on the position of this fluid with respect to the diaphragm. 
Thus, a collection of pus on the posterior aspect of the liver, or a peri- 
nephritic abscess which has just extended to the subphrenic space, may 
in no wise influence the position of the diaphragm. For this reason, 
in a suspected case, a normally placed diaphragm should not be per- 
mitted to impugn the physical evidences of a subphrenic abscess. 
Aside from these exceptional circumstances, it is probable that in most 
cases, sooner or later the accumulation of pus will thrust the diaphragm 
upward to a noticeable degree. If this displacement is marked and if 
the causative factors warrant it, a Roentgen diagnosis of subphrenic 
abscess may be made with some assurance. Thus, the high diaphragm 
in figure 381 was the result of a collection of pus which followed an 
infected retrocolic appendix. When the upward displacement of the 
diaphragm is extreme the right lower lobe may suffer considerable 
compression. Under these circumstances the clinician may have some 
difficulty in defining the upper limit of liver dulness. On the Roentgen 
plate, however, the compressed lung may easily be distinguished from 
the elevated diaphragm. 
FIGURE 381 
Subphrenic abscess. Diaphragm elevated and immobile. Fibrinous exudate on 
pleura at right base. The Diaphragm 
497 
An inflammatory process below the diaphragm has the same effect 
on its mobility as one above it. The diaphragm is therefore fixed in 
respiration. It will be recalled that a pleurisy also brings about a slight 
elevation and immobility of the diaphragm. This fact has to be borne 
in mind because at least one-third of the cases of subphrenic abscess 
are complicated by either a dry pleurisy (fig. 381), or a pleurisy with 
effusion. It will therefore not always be an easy matter to decide 
whether the diaphragmatic elevation, especially when it is only slight, 
is due to a subphrenic abscess or to a pleural effusion or whether both 
these conditions, as frequently happens, coexist in the same case. It 
will be clear that in the diagnosis of subphrenic abscess, the observer 
can adhere to no arbitrary rule. An elevation of the diaphragm will be 
significant in proportion to its height; if the elevation is slight, its im- 
portance will lie in forcussing the attention on the subprenic space so 
that by repeated observation, both clinical and Roentgenological, an 
FIGURE 382 
Subphrenic abscess, left side. Stomach obscured by the fluid under left leaf 
of diaphragm. Pleural effusion on right side. 498 
The Diaphragm 
increase in the size of the abscess may be noted. Only in the extreme 
grades may the diagnosis be ventured with certainty from the Roentgen 
examination alone. 
The shadow of a subphrenic abscess on the right side is super- 
imposed on that of the liver from which it is indistinguishable. The 
diagnosis is therefore an inference drawn from an upward extension of 
the liver shadow. On the left side however, a collection of fluid in the 
sub-phrenic space may be directly visible owing to the presence in this 
situation of gas containing viscera which favor its visibility. The 
shadow of the fluid will then be seen in the region of the fundus of the 
stomach, which it may actually depress. An elevation of the diaphragm 
may therefore be entirely absent. This is graphically illustrated in 
figure 382. The left subphrenic abscess is indicated by the dense 
crescentic shadow which occupies the space normally filled by the 
gastric air bubble. It will be noted that the diaphragm is normal in 
position. At operation a collection of pus was found posteriorly, in the 
subphrenic space; its origin was an abscess of the spleen. 
Attention has been drawn by observers to the occurrence of sub- 
phrenic effusions which undergo resolution without suppuration. The 
absorption of such effusions will no doubt explain the occasional reces- 
Subphrenic infected hematoma following cholecystectomy. 
FIGURE 383 The Diaphragm 
499 
sion of the diaphragm in cases in which subphrenic infection has been 
suspected. It is also worth while to call attention to the occasional 
rapid development of large non-purulent collections of fluid in the 
subphrenic space after operations on the liver and gall bladder. In 
these cases post-operative hemorrhage may occasion an enormous sub- 
phrenic hematoma, which, as in the case illustrated in figure 383. may 
extend up to the second rb. The rapid development of dulness on the 
right side of the chest and diminished breathing, with little or no 
temperature may easily lead to confusion with intrathoracic disease, an 
error which the Roentgen examination will at once set right. The 
hematoma may undergo prompt absorption with a return of the dia- 
phragm to its normal position. 
It is proper to add that an upward progression of the diaphragm 
under observation does not necessarily signify an exudate beneath it; 
a similar phenomenon may be observed in the rapid growth of a liver 
abscess and, like a subphrenic abscess, it may be associated with a 
pleural effusion. 
Subphrenic gas abscess secondary to perforation of duodenum. Early stage 
showing only a small amount of gas. Pleurisy at right base. See figure 385. 
FIGURE 384 500 
The Diaphragm 
(3) SUBPHRENIC GAS ABSCESS. The difficulties in the diag- 
nosis of ordinary subphrenic abscess no longer exist when in addition 
to pus, gas obtains access to the subphrenic space. The presence of the 
latter causes the fluid, which is otherwise indistinguishable from the 
liver shadow, to assume a horizontal level, above which the bubble of 
gas is sharply outlined by the curve of the diaphragm. In order to 
demonstrate this fluid level, the examination must of course be made 
in the upright position. The gradual increase in the effusion can be 
gauged by an extension of the fluid level and also by the amount of gas. 
Thus in figure 384 a small collection of gas was found beneath the 
diaphragm a few days after an operation on the common bile duct, dur- 
ing which the duodenum was perforated. A few days later the gas and 
fluid had increased so that they extended entirely across the subphrenic 
space on the right side. (Fig. 385.) In the case illustrated in figure 
386 the gas became evident only when the abscess had reached a great 
size and had extended up to the level of the second rib. 
FIGURE 385 
Subphrenic gas abscess, showing increase in size of exudate. Plate made two 
days after figure 3B4. Dorsal view. The Diaphragm 
501 
FIGURE 386 
Large subphrenic abscess, with gas. 
The discovery of gas in these cases has considerable practical im- 
portance, as it usually, if not always indicates a perforation of the 
stomach or intestine, which may require more radical treatment than 
simple evacuation of the abscess. 
The term “subphrenic pyopneumothorax” which is occasionally 
applied to this condition reflects the uncertainty which may attend its 
physical diagnosis. When large amounts of gas are present in the 
abscess, the physical signs are very similar to those which result from 
an accumulation of air and fluid in the chest and it is apparent, from 
the definite nature of the Roentgen findings, that these are calculated 
at once to localize the disease in the abdomen rather than in the chest. 
(4) An elevation of the diaphragm may be caused by new-growths, 
gummata and abscesses of the liver. Although occasionally only a seg- 
ment of the diaphragm may be elevated, in the majority of cases the 
dome of the diaphragm is uniformly raised on one side and its con- 
tour is not significantly altered. The observer must again be cautioned 
to disregard the prominence of the mesial half of the right diaphragm, 
consisting of its central tendinous part, which may become separated 502 
The Diaphragm 
from the liver as a boss-like protuberance, as it has no pathological 
significance. Only on the left side has such a deformity of the dia- 
phragm any significance and here it may be due to localized disease of 
the liver or spleen. Thus in figure 387 the prominence of the mesial 
half of the left diaphragm was caused by a large echinococcus cyst of 
the spleen. On fluoroscopic examination this was seen to involve only 
its anterior half, the posterior portion remaining at the normal level. 
At operation no abnormality was found in the liver to account for the 
prominence of the right diaphragm. 
FIGURE 387 
Elevation of the left diaphragm by an echinococcus cyst of the spleen. 
(5) EVENTRATION OF THE DIAPHRAGM. It may truthfully 
be stated that this rare and interesting disease was practically unknown 
and its clinical diagnosis was almost impossible before the era of Roent- 
gen examination. It is more correctly termed diaphragmatic atrophy 
as this is the essential lesion and the eventration is but its result. Its 
etiology is shrouded in obscurity. Variously ascribed to a congenital 
atrophy or dystrophy of the diaphragm or to a neuro-muscular degen- 
eration following a phrenic neuritis or polio-myelitis, in any case the 
muscle fibres undergo a degeneration which may terminate in a fatty or The Diaphragm 
503 
fibrous replacement. Tone and power of contraction are lost and the 
diaphragm, yielding to the pressure of the stomach and intestines, is 
displaced progressively upward into the thorax together with the 
abdominal viscera. 
Closer study of this condition is warranted in spite of its rarity 
because the symptoms which it may produce are usually confused with 
those of other, more common diseases. For example, one group of 
symptoms which result probably from a sudden upward pressure on the 
already displaced diaphragm, consists in periodic attacks of dyspnoea 
and sharp pain in the left side of the chest. When such patients 
are examined, the tympanitic note over the chest due to stomach and 
gut, together with the marked cardiac displacement may readily betray 
the examiner into an erroneous diagnosis of spontaneous pneumothorax. 
The correct diagnosis is made at a glance by the plate or fluoroscopic 
screen. (Figs. 388 and 389.) The diaphragm is here seen as a sharp 
linear band high in the chest, which may extend as far as the second 
rib, bounding the distended stomach and intestinal coils beneath it. 
Invariably the heart is pushed completely to the right side. 
FIGURE 388 
Eventration of the diaphragm, left side. Dextro-cardia. 504 
The Diaphragm 
FIGURE 389 
Eventration of the diaphragm showing distended stomach and colon. Heart 
completely displaced into the right chest. 
It need hardly be pointed out, that in the diagnostic aspiration of 
the chest in these cases, in which pleurisy or pneumothorax may be 
suspected, there is a very real danger of perforating the distended 
stomach or intestines. 
Again, the patient may present symptoms due to intestinal obstruc- 
tion as a result of atony and dilatation of the loops of intestine in the 
eventration. Thus, the eventration on the right side shown in figure 
390 was associated with an enormous dilatation of the colon, which was 
responsible for most of the symptoms. Its distended coils are seen just 
below the diaphragm. At operation the diaphragm was found intact 
but atrophied. In right sided eventration the liver is displaced down- 
ward and its place is occupied by coils of intestine. The protean sym- 
tomatology of this interesting disease is illustrated by those cases in 
which the extreme displacement of the heart gives rise to cardio-vascu- The Diaphragm 
505 
FIGURE 390 
Eventration of diaphragm, right side. Diaphragm at level of second rib. 
Dilatation of colon. Ptosis of liver. 
lar symptoms. In no other disease is the heart so completely thrust into 
the right chest and this condition is not uncommonly mistaken for con- 
genital dextro-cardia. So true is this that a diagnosis of dextro-cardia 
can never be regarded as firmly established until an eventration of the 
diaphragm has been excluded by Roentgen examination. 
On fluoroscopic examination the convex linear shadow of the dia- 
phragm shows no active respiratory movement. In certain instances 
a paradoxical movement upward during inspiration may be observed; 
this may be conceived as a passive displacement due to the contrac- 
tion of the normal half of the diaphragm which forces the intestines 
upward. The distinction between eventration and diaphragmatic 
hernia is usually not possible by means of the Roentgen Ray. Occa- 
sionally a study of the intestinal contents of the hernia after the ingestion 
of bismuth may throw some light on this condition, especially in recent 506 
The Diaphragm 
FIGURE 391 
Hernia of the stomach through a small bullet wound of the diaphragm. 
Stomach filled with barium. 
cases of hernia following trauma such as are due to bullet wounds. 
(Fig. 391.) In the more extensive cases and especially in the rare 
instances of congenital hernia, the Roentgen appearance of the two con- 
ditions may be identical. This is unfortunate as the differentiation of 
these two disorders has a therapeutic importance. Diaphragmatic 
hernia may in certain cases be relieved by operation whereas we have 
no such remedy for the relief of an atrophic diaphragm. It is possible 
that the injection of gas into the peritoneal cavity may become a use- 
ful method in the differentiation of eventration from diaphragmatic 
hernia. In a recent case which we studied, after the production of a 
pneumoperitoneum, the fundus of the stomach was caused to fall away 
from the atrophic diaphragm above it, proving conclusively that the 
diaphragm was intact and that the condition was an eventration. (Fig. 
392.) The Diaphragm 
507 
FIGURE 392 
Eventration of the diaphragm, distinguished from diaphragmatic hernia by 
means of pneumoperitoneum. The diaphragm, indicated by arrow is seen to 
be intact and is separated from the stomach and colon below it by the air 
in the peritoneum. 
A sharp distinction must be drawn between the extreme upward 
displacement of the diaphragm which is so characteristic of eventration, 
and the moderate elevation which is not uncommonly associated with 
a chronic dilatation of the fundus of the stomach. The gastro-enterolo- 
gist is apt to encounter these patients in his practice and the discovery 
in them of a high diapragm due to a gaseous distention of the stomach 
occasionally supplies a clue to the origin of their symptoms. The dia- 
phragm is here not atrophic and it functions normally in respiration. 
(Fig. 393.) 
(6) PHRENIC PARALYSIS. A lesion of the phrenic nerve re- 
sults in an immobility of the affected side of the diaphragm which 
assumes the expiratory position. Aside from such causes as true 
neuritis and polio-myelitis, the Roentgen examination discloses other 
agencies for this condition as tumors of the lungs and mediastinum and 
the chronic mediastinitis of tuberculosis. In figure 62 the high, par- 508 
The Diaphragm 
FIGURE 393 
Chronic, atonic dilatation of stomach with elevation of the diaphragm. 
alytic diaphragm is probably due to pressure on the phrenic nerve by 
the mediastinal adhesions of tuberculosis. There is further evidence 
of a chronic mediastinitis in the marked displacement of the trachea, 
heart and aorta toward the right. 
DEPRESSION OF THE DIAPHRAGM 
An abnormally low position of the diaphragm is much less com- 
mon than its elevation and it results always from intrathoracic causes. 
The elastic pull of the lungs constantly exerts its force in opposition to 
any causes within the abdomen which would tend to displace the dia- 
phragm downward. It is therefore only when this force is compromised 
that the diaphragm may suffer a marked depression. This condition 
is found in its extreme form in cases of pneumothorax, especially when 
the air within the pleural cavity is under great tension. The diaphragm 
may then be flattened or it may even take an oblique course downward The Diaphragm 
509 
from its fixed point near the spine to the chest wall. (Fig. 288.) When 
the pneumothorax is associated with fluid in the pleural cavity, the 
weight of the fluid may even cause the diapraghm to become convex 
downward; this can be observed only on the left side where the dia- 
phragm is outlined against the air in the stomach. 
PNEUMOPERITONEUM 
When gas gains access to the peritoneal cavity, even in very 
small quantities, one of its notable effects is to cause a separation 
of the liver from the diaphragm. This interposition of gas between 
the diaphragm and the upper surface of the liver is such a character- 
istic feature of the Roentgen plate that it may be regarded as 
positive evidence of free air or other gas in the peritoneal cavity. 
When larger amounts of gas are present the spleen and other organs 
may be separated from the abdominal wall and they may be visible in 
their entirety. (Fig. 394.) We are here, however, only concerned with 
right-sided pneumoperitoneum, whose recognition may throw light on 
certain thoracic or intraabdominal diseases. Thus, in a patient who 
Induced pneumoperitoneum showing outline of diaphragm above and liver and 
spleen below. 
FIGURE 394 510 
The Diaphragm 
presented definite symptoms of gastric ulcer, following a violent 
paroxysm of pain and other symptoms which suggested the likelihood 
of a perforation, the Roentgen examination revealed the pneumo- 
peritoneum seen in figure 395. In conformity with this finding a large 
FIGURE 395 
Pneumoperitoneum, right side, secondary to perforated gastric ulcer. 
perforation in a gastric ulcer was found. The Roentgen examination is 
particularly adapted to the demonstration of peritoneal gas in cases of 
slow perforation of an ulcer in which the symptoms are less fulminating 
and in which it is therefore possible without danger to the patient, to 
perform the examination in the upright position. 
Gas introduced into the abdominal cavity from without either for 
diagnostic purposes or accidentally will produce an identical appear- 
ance. In figure 396 the subphrenic collection of gas followed an un- 
successful attempt at artificial pneumothorax. The needle was in- 
serted too low and, penetrating the costophrenic sinus, entered the 
subphrenic space into which the gas was mistakenly injected. The Diaphragm 
511 
FIGURE 396 
Pneumoperitoneum. Diaphragm separated from liver by air introduced during 
performance of artificial pneumothorax. 
Pneumoperitoneum must not be confounded with the condition 
of hepatoptosis in which a similar though not identical phenomenon 
may at times be observed. The ptosis and forward rotation of the liver 
may permit the transverse colon to become interposed between it and 
the diaphragm. The Roentgen plate will then show a collection of gas 
between the diaphragm and the liver; in this case however, the gas is 
enclosed within the intestinal walls, wtiose haustrations are distinctly 
visible. (Fig. 397.) In the recumbent position the liver resumes its usual 
position. 512 
The Diaphragm 
FIGURE 397 
Ptosis of the liver. Transverse eolon, showing haustrations, interposed between 
it and the diaphragm. 
Among the rarer causes of a depression of the diaphragm we may 
mention stenosis of the larynx and a unilateral bronchostenosis. The 
diaphragm is depressed only when the obstruction is of moderate grade, 
especially when the exit of air from the lungs is most interfered with, 
so that the latter are over-distended. On the other hand with a high 
degree of stenosis of the larynx or the complete closure of a main 
bronchus, the lung becomes airless and the diaphragm is elevated. This 
phenomenon is of value in the diagnosis of tumors or non-opaque 
foreign bodies in a bronchus. The Diaphragm 
513 
Perhaps the most common abnormality exhibited by the diaphragm 
is the pleuro-phrenic adhesions which result from inflammation of the 
pleura. They are most often the sequel of pulmonary tuberculosis and 
are found in association both with recent and acute disease of the lungs 
and with the older and healed lesions. The effects of adhesions are 
evidenced either by a change in the contour of the diaphragm or a 
restriction of its movement or in both of these respects. Thus, the 
smallest adhesions may not be visible as such but may cause only a 
slight lagging of the diaphragm on deep inspiration. Especial attention 
must be focussed on the mesial portion of the diaphragm as the lagging 
is often confined to this region, whereas the lateral two-thirds move 
freely. 
DIAPHRAGMATIC ADHESIONS 
I ointed diaphragmatic adhesion. Chronic pulmonary tuberculosis. 
FIGURE 398 514 
The Diaphragm 
A common site for the diaphragmatic adhesions of healed 
tuberculosis is in the costophrenic sinus which may be obliterated. 
Nothing is more common than the faint shadow which obscures the 
contour of the diaphragm as it dips down in the lower axilla. On 
fluoroscopic examination this region fails to become aerated as it 
normally should in deep inspiration. In other cases the diaphragm may 
be raised up in a tent-like prominence. (Fig. 398.) A series of 
adhesions may give the diaphragm a serrated contour. (Fig. 31.) 
Finally, its outline may be hazy consequent on a total obliteration of 
the pleural complementary space. This is especially marked in the 
cases of fibroid tuberculosis with excessive thickening of the pleura, in 
which the diaphragm may be entirely obscured by pleural adhesions 
and thickening. (Fig. 64a.) 
FIGURE 399 
Distortion ami fixation of diaphragm in chronic empyema. The Diaphragm 
515 
Aside from pulmonary tuberculosis, other thoracic diseases may 
bring about striking deformities of the diaphragm. The pleural thick- 
ening which is such a common sequel of empyemata often exerts its 
maximum effects on the axillary portion of the diaphragm, which it 
fixes in an elevated position in this region. The diaphragm may there- 
fore rise obliquely from the spine toward the axilla and thus endow the 
lower chest with an unusual conformation. (Fig. 399.) In other cases 
as a result of this fixation of the diaphragm, it no longer glides over the 
liver during respiration but it is on the contrary drawn taut in a straight 
line, which may closely resemble a fluid level. (Fig. 400.) On the 
other hand, the central tendinous part of the diaphragm may in cases 
of mediastinal disease, bear the brunt of the adhesive process. Thus 
the chronic mediastinitis associated with aneurysms and mediastinal 
FIGURE 400 
Fixation of the left leaf of the diaphragm in its peripheral part with loss of 
its normal convexity. 516 
The Diaphragm 
tumors may, through the resulting adhesions, exert an upward traction 
on this portion of the diaphragm which acquires the unusual conforma- 
tion illustrated in figure 309. 
Diaphragmatic adhesions are occasionally responsible for puzzling 
Roentgen pictures which may be difficult to interpret unless the previous 
history is available. For example, a middle aged man who had recently 
been operated on for a gastric ulcer, which was possibly malignant, 
continued to suffer upper abdominal pain and became emaciated. Dur- 
ing the gastro-intestinal Roentgen examination a prominence of the 
mesial half of the right diaphragm was noted. (Fig. 401.) Naturally, 
suspicion of a metastatic tumor of the upper surface of the liver arose. 
The patient had been in the hospital two years before with a right lower 
lobe pneumonia which persisted for some months, the Roentgen plate 
FIGURE 401 
Elevation and prominence of mesial part of right diaphragm. Secondary to 
pneumonia three years before. See figure 402. The Diaphragm 
517 
of which was fortunately available. At that time already (fig. 402) 
the diaphragm was elevated and partially adherent and the extreme 
condition found on the subsequent examination was thus foreshadowed. 
Same ease as figure 401 showing pneumonia of the right lower lobe two years 
before, with beginning elevation of the diaphragm by adhesions. 
FIGURE 402 
ABNORMALITIES OF DIAPHRAGMATIC MOVEMENT 
We have already mentioned the inhibition of the diaphragm, 
usually unilateral, which is a manifestation of an inflammatory process 
in its vicinity. In its relation to the diagnosis of pulmonary tuberculosis, 
rigidity of the diaphragm has also been considered. In this connec- 
tion it may be added that in the more chronic forms of the disease and 
especially in arrested and cured cases, the function of the diaphragm, 
provided there are no adhesions, does not appear to be impaired. 
Various abnormalities in the respiratory movement of the dia- 
phragm are occasionally to be seen on the fluoroscopic screen. In cases 
of pneumothorax and seropneumothorax a paradoxical movement 
may be visible. This may also be seen at the very beginning of inspira- 
tion, when there are extensive pleuro-phrenic adhesions. Adhesions 518 
The Diaphragm 
between the pericardium and the diaphragmatic pleura may exert a 
systolic pull on the diaphragm which becomes most evident on deep 
breathing. When this condition is complicated by an obliteration of 
the pericardial cavity, this phenomenon may express itself clinically as 
a Broadbent sign. (See figure 99.) 
In bulbar palsy the diaphragm may be immobile on both sides and 
assume a high paralytic position. A unilateral paralysis of the phrenic 
nerve results in a high immobile diaphragm on the affected side which 
is best brought out in the recumbent position. Owing to the continu- 
ance of costal breathing the diaphragm may be displaced further up- 
ward during inspiration. 
An increase in the movement of the diaphragm is less often 
observed than its inhibition. In some cases of emphysema in which the 
inspiratory movement is restricted by the rigidity of the chest wall, 
there may be compensatory over-action of the diaphragm whose con- 
tour becomes flattened to a degree never seen in other conditions. Fin- 
ally it should be noted that a marked overaction of one half of the dia- 
phragm is at once suggestive of disease on the opposite side, particu- 
larly obstruction within a bronchus. SECTION IX 
Surgical Diseases of the Chest Chapter XXVIII 
Surgical Diseases of the Chest 
Roentgenology of the chest has nowhere received a more practical 
or valuable application than in the study of surgical diseases of the lungs 
and pleura. It has become indispensable not only for the diagnosis and 
localization of intrathoracic diseases but also for the accurate oversight 
of their postoperative course and the numerous complications which 
are apt to beset a patient whose chest has been opened. 
We will first discuss some of the surgical aspects of empyema which 
is by far the commonest thoracic disease that is surgically treated. We 
have in a previous chapter considered certain unusual features of 
empyema in the diagnosis of which, previous to operation, the Roentgen 
examination plays an outstanding part. After thoracotomy however, 
the labors of the Roentgenologist are by no means ended; residual col- 
lections of pus, which are at times situated in remote recesses of the 
chest, often wait upon the Roentgen plate for their accurate and timely 
localization. Thus it is of special help in the early recognition of resi- 
dual apical empyemata, (figs. 255 and 257) which otherwise are apt 
to remain undiscovered until they are spontaneously emptied through 
a bronchus. A second thoracotomy is usually required for their evacua- 
tion as it is not practicable to drain them through a low thoracotomy 
along a tortuous sinus. 
The mesial empyemata which occasionally develop after operation 
are of great interest from a surgical standpoint. In our experience 
they follow effusions which were originally encapsulated in the lateral 
half of the chest, its mesial portion being protected by adhesions. The 
secondary empyema is the result of a separation of these adhesions and 
an infection of the mesial part of the pleural cavity during or after 
operation. As the fluid is here walled off by adherent lung it may exert 
pressure on the mediastinum and occasion some dyspnoea. 
The mesial empyema shown in figure 254 was clearly a consequence 
of infection during operation; the larger collection of pus and air in 
figure 403 was formed some time after operation and gave rise to con- 
siderable respiratory difficulty. In each case prompt recovery followed 
localization of the pus by the Roentgen Ray and its evacuation through 
an intercostal incision made close to the sternum. The ease of the 
Roentgen demonstration of these mesial empyemata stands in marked 522 
Surgical Diseases of tfie Chest 
FIGURE 403 
Postoperative empyema with air, in mesial half of chest. Original empyema 
completely drained. 
contrast to the difficulty of their recognition clinically. The altered 
physical conditions which exist in the chest after it has been opened 
and especially the presence of air in the pleural cavity, enormously 
enhance the difficulties of the clinical examination. Moreover, ex- 
ploratory aspiration near the border of the sternum, without the help 
furnished by the Roentgen plate, is not to be lightly undertaken, where- 
as under its guidance the procedure is absolutely safe. 
In cases of empyema, after all the pus has been drained from the 
pleural cavity there remains an infected pneumothorax of variable 
size, depending on the degree of pulmonary collapse. The obliteration 
of this pneumothorax depends ultimately on the ability of the collapsed 
lung to expand and to fill up the dead space. A persistence of the 
purulent discharge sooner or later prompts an investigation of the 
mobility of the lung and of the size, shape and situation of the pneumo- 
thorax or sinus. Surgical Diseases of the Chest 
523 
The Roentgen findings associated with a persistent empyema sinus 
are usually as easy to interpret as they are instructive. In the simpler 
cases there is found an area of pneumothorax of variable extent in the 
axillary region, which is mesially limited by the partly expanded lung. 
The lung itself may be well aerated and free of adhesions (fig. 404) or 
FIGURE 404 
Healing empyema, left side. Lung almost expanded leaving a narrow zone of 
pneumothorax. Thickening of parietal pleura and also visceral pleura out- 
lining margin of lung. 
it may be thickened and covered by a dense exudate which binds it 
firmly to the chest wall. There is usually also a homogeneous shadow in 
the lateral portion of the chest which is due to a thickening of the 
parietal pleura. (Fig. 405.) Depending on the efficiency of the drain- 
age more or less fluid which exhibits a horizontal level, will be found in 
the chest. A characteristic picture of persisting empyema at this stage 
is seen in figure 406. 524 
Surgical Diseases of the Chest 
FIGURE 405 
Extrapleural compression of chest for chronic empyema. Extensive rib re- 
sections. Note dense shadow of collapsed lung along heart border and large 
pneumothorax. (x) indicates characteristic shadow of thick parietal pleura. Surgical Diseases of the Chest 
525 
FIGURE 406 
Persisting empyema sinus. Thickening of parietal pleura. Retention of pus in 
lateral half of chest. 526 
Surgical Diseases of the Chest 
In the more complicated cases the pneumothorax is irregular and 
may consist of a tortuous channel containing one or more pockets of 
infection. The unaided plate is of little avail to unravel the intricacies 
of these sinuses unless it is supplemented by an injection of the fistulous 
tract with some opaque substance, such as bismuth. The resulting pic- 
tures are very instructive as they portray with the minutest detail the 
configuration of the pneumothorax. (Figs. 407 and 408.) 
FIGURE 407 
Chronic bilocular empyema sinus outlined by injected bismuth, 
A most important factor concerned in a persistence of the pneumo- 
thorax is the rigidity of the collapsed lung. This will determine to a 
great extent, the operative procedure which may later be undertaken 
to bring about a cure. The Roentgen plate often indicates by the 
density of its shadow, whether the lung is free or is bound down by a 
thickened visceral pleura or fixed by adhesions to the chest wall. Thus 
in figure 406 the retracted lung is well aerated and presumably not Surgical Diseases of the Chest 
527 
FIGURE 408 
Chronic empyema sinus. Cavity in pleura filled with injected bismuth. 
Diaphragm drawn upward by adhesions. 
firmly bound by adhesions; as the fluid was absorbed, it rapidly expand- 
ed and obliterated the pneumothorax. In figure 404 the mobile lung 
has nearly unfolded itself so that only a narrow zone of pneumothorax 
remains between it and the thickened parietal pleura. 
The firmness of the adhesions which bind the lung can be more 
directly ascertained by fluoroscopic examination during deep inspira- 
tion or forced expiration. The ability of the lung to expand may thus 
be determined; if it is absolutely fixed it is unlikely that the minor 
palliative operations will suffice for a cure and major procedures may 
have to be resorted to. In these cases there is usually found an extreme 528 
Surgical Diseases of the Chest 
collapse of the lung which may be compressed against the spine and 
covered by a much thickened pleura. Commonly there is also seen a 
thickened parietal pleura, (fig. 405,) which, being essentially a pyo- 
genic membrane, is the origin of the purulent discharge and contributes 
much to a persistence of the disease. The shadow of the parietal pleura 
offers some difficulty in interpretation. It is not evenly diffused over 
the chest as might be expected but is most intense in the axillary region 
and it is sharply delimited from the pneumothorax mesial to it. The 
width of this shadow is not an exact measure of the pleural thickening 
as its peculiar appearance is merely an optical phenomenon produced 
by the curvature of the chest wall. 
In the various surgical procedures which are undertaken to remedy 
the conditions we have just described, the value of the constant over- 
sight afforded by the Roentgen Ray cannot be overestimated. It will 
suffice to illustrate the end results of some of these operations, such as 
decortication of the lung, (fig. 409,) and the newer thoracopiastic 
operation of Sauerbruch, (fig. 405,) in order to indicate the wide field 
of usefulness of the Roentgen examination. 
FIGURE 409 
Thoracic deformity resulting from decortication of the lung for chronic empyema. 
Extensive rib resections. Surgical Diseases of the Chest 
529 
Although diseases of the lung are much less amenable to surgical 
treatment than are pleural diseases, the field of pulmonary surgery is 
being rapidly extended. Pulmonary suppuration, new growths and 
tuberculosis, to mention the more common ones, are the diseases which, 
with increasing frequency, are referred to the surgeon. Here also, as 
in the case of pleural effusions, the Roentgen examination is indis- 
pensable, both for diagnosis and in the course of treatment. 
Especially in respect to lung abscess is there need for accurate 
localization of the diseased area of the lung. Whether the intention 
of the surgeon is merely to drain an abscess cavity or to extirpate a 
whole lobe, it is necessary to know which lobe or lobes are involved in 
order that the incision be well placed. In most cases this is readily 
determined on the Roentgen plate, especially if the shadow of the 
diseased area occupies the apex or base of the lung. When however, 
the infiltration occupies the middle third of the lung, it may be impos- 
sible to decide whether the process involves one lobe or the adjacent 
portions of three lobes. The reason for this is the overlapping of the 
three lobes in the middle third of the pulmonary field which causes 
their shadows to be superimposed. The dufficulty is especially great in 
the case of the middle lobe. When it is involved alone its appear- 
ance is characteristic, (fig. 158,) but when the adjacent portions of the 
other lobes are consolidated, its outline can no longer be distinguished. 
(Fig. 179.) In these cases, dependence must be placed on the physical 
signs, whose situation on the anterior or posterior aspect of the chest 
will be of great help in interpreting the Roentgen shadows. For the 
localization of cavities, especially to determine their depth in the lung, 
nothing is more useful than the fluoroscopic examination. A cavity 
nearer the anterior chest wall will appear smaller but more sharply out- 
lined when the rays traverse the chest in the dorso-ventral direction 
and vice versa. 
Another common query addressed to the Roentgenologist before 
operation has to do with the presence or absence of pleural adhesions, 
which will affect the operative technique. Adhesions are frequently 
present, especially when the abscess is near the surface of the lung and 
has caused an inflammation of the pleura. They may be inferred from 
an increased density of the shadows and also from a retraction of the 
ribs. The introduction of a small amount of air into the pleural cavity 
with a partial collapse of the lung may be of service to visualize these 
adhesions and gauge their firmness. It is not possible to more than 
touch on the numerous occasions when the Roentgen Ray is invoked 
after lobectomy for lung abscess. During this eventful period when 
such serious complications as mediastinal flutter, tension pneumothorax 
and putrid empyema momentarily threaten the life of the patient, we 
have in the fluoroscopic screen and the plate a rapid and certain method Surgical Diseases of the Chest 
530 
for their recognition. Finally, the Roentgen Ray cannot be dispensed 
with when we wish to judge the efficacy of the various methods em- 
ployed for the extrapleural compression of the lung for suppurative or 
tuberculous disease. (Figs. 410 and 411.) 
FIGURE 410 
Extrapleural compression of residual lung abscess after partial lobectomy. The 
shadow in upper axillary region represents paraffin oil injected extrapleurally. Surgical Diseases of the Chest 
531 
Same ease as figure 410. Extrapleural compression of lung by inflated rubber bag. 
FIGURE 411 SECTION X 
Diseases and Abnormalities of the Chest Wall Chapter XXIX 
Diseases and Abnormalities of the Chest Wall 
The soft tissues and the bones of the thorax occupy a prominent 
place on the Roentgen plate where they contribute notably to the 
shadows which traverse the chest. Under the influence of intrathoracic 
disease the chest wall is often secondarily affected leading to various de- 
formities of its bony parts to which we have already alluded. 
Study of the thoracic wall has however an interest for the Roent- 
genologist which transcends any possible bearing on disease of the intra- 
thoracic organs. We must bear in mind that when the ribs, spine or the 
soft tissues of the chest are the seat of disease the abnormal shadows 
which they cast will be projected on those of the heart, lungs and pleura. 
Usually no confusion will arise as the shadows will bear intrinsic 
evidence of their origin. On the other hand, their connection with the 
thoracic wall will not always be obvious at a glance so that the exam- 
Maldevelopment of right first rib, which articulates with the second rib. 
FIGURE 412 536 
Diseases and Abnormalities of the Chest Wall 
iner will at times be at a loss to decide whether they are due to abnormal 
shadows within or without the chest. Whenever atypical shadows are 
encountered, it is advisable therefore to inspect or palpate the chest 
wall in order to discover a tumefaction of the soft parts or of the bones 
and in doubtful cases to resort to stereoscopic and fluoroscopic exam- 
ination in various positions. 
Of the abnormal shadows which arise from the thoracic wall, the 
most striking and numerous are seen in the bony thorax, especially the 
ribs. A considerable number of diseases and congenital abnormalities 
may affect the ribs, especially in the upper aperture of the chest. 
The most common of these are the various forms of cervical ribs; 
in most cases they are symptomless and are found incidentally to exam- 
ination of the lung. There are, besides true cervical ribs, numerous 
abnormalities of the upper aperture of the chest consisting of mal- 
development of the first rib, (fig. 412.) partial or complete fusion of 
the first and second ribs, (fig. 413,) or an aplasia of the upper chest 
Fusion of left first and second ribs. Pulmonary tuberculosis. 
FIGURE 413 Diseases and Abnormalities of the Chest Wall 
537 
with a resulting deformity and asymmetry. (Fig. 414.). Although 
these bony changes are at once apparent on the Roentgen plate and 
although their influence on the pulmonary physical signs may be not 
inconsiderable, they are not always obvious to the physical examiner. 
It is therefore not uncommon for patients with atypical upper ribs to 
be suspected of tuberculosis because of the apical dulness which they 
may produce. It is easily seen how the percussion note will be altered 
at the right apex in figure 413 by the fused first two ribs, which almost 
Aplasia ol the third and fourth ribs on the right side with depression of that 
portion of the chest. 
FIGURE 414 
obscure it. Minor changes, such as bifid sternal ends of the ribs, (fig. 
415,) are occasionally seen and have mainly an interest for the anatom- 
ist. At times they produce a local prominence which is mistaken for a 
bony tumor. 
Tumors of the ribs possess a great interest for the Roentgenolo- 
gist because the shadows which they cast may overlie the pulmonary 
fields. On cursory examination, these shadows may closely resemble 
those of pulmonary or pleural diseases and one is readily betrayed into 
a wrong diagnosis. This is particularly true of the primary sarcomata 
of the ribs, in which their bony substance is destroyed and replaced by 538 
Diseases and Abnormalities of the Chest Wall 
FIGURE 415 
Bifid sternal end of the left third rib. 
FIGURE 416 
Oblique and Dorso-ventral view of sarcoma of seventh right rib. Shadow in latter position 
suggests pleural disease. Diseases and Abnormalities of the Chest Wall 
539 
a soft tumor mass. Their shadows are of moderate density and are well 
circumscribed. Usually, the healthy portion of the rib will be seen to 
terminate in this shadow and no evidence of it will be seen within the 
tumor mass. The similarity of such rib sarcomata to a localized pleural 
effusion is shown in figure 416. Although the dorso-ventral examina- 
tion may leave us in doubt as to the nature of this shadow, any uncer- 
tainty is resolved by an oblique examination in which its origin from the 
rib is disclosed. This form of bone sarcoma is often multiple and such 
circumscribed shadows may then be seen in more than one rib. Thus 
in figure 417 tumors are seen in the right apex and at the left base 
FIGURE 417 
Multiple rib sarcomata. Shadows at right apex and left base. 
arising from the ribs in these situations. In this case a bony reticulum 
is visible throughout the tumor. 
In another form of rib sarcoma, the tumor may be of the infiltra- 
tive type and may spread far beyond the limits of the rib. The abnormal 
shadow may then be extensive and its bony origin may easily be 
overlooked. Thus, in figure 418, there is a shadow in the right lower 
lobe region which by itself is not distinguishable from one arising in 
the lung or pleura. It appears to have no anatomical relation to a rib, 
yet a close inspection of the .seventh rib shows an area of bone absorp- 
tion strongly suggestive of a new-growth. At operation, a large sar- 540 
Diseases and Abnormalities of the Chest Wall 
FIGURE 418 
Sarcoma of the seventh rib on right side extensively invading the soft tissues of the 
chest. Shadow resembles a pneumonic consolidation. Note rarefaction of 
seventh rib. Dorsal view. See figure 419. 
coma, arising from this rib and infiltrating the soft tissues of the chest 
wall was found and excised. The pleural cavity was not invaded. The 
appearance of the chest after excision of the ribs and tumor, is seen in 
figure 419 in which the abnormal shadow is no longer present. In this 
case the diagnosis received no aid from the physical examination as 
the tumor was barely palpable. It gave rise however, to a severe inter- 
costal neuritis. Diseases and Abnormalities of the Chest Wall 
541 
Same case as figure 418 after excision of tumor, showing that the shadow was 
extrapulmonary. Ventral view. 
FIGURE 419 
True bony tumors of the ribs may cast very dense bizarre shadows 
over the pulmonary fields, as in figure 420, which illustrates a large 
osteoma. 
Among the rarer diseases which affect the ribs, may be mentioned 
multiple myeloma. The pathological process results in multiple areas 
of rarefaction and absorption of the bony structure, so that the ribs 
have a moth-eaten appearance. The bones of the shoulder girdle may 542 
Diseases and Abnormalities of the Chest Wall 
FIGURE 420 
Osteoma of sternal end of second left rib. 
also be affected and may appear cystic. (Fig. 421.) The Roent- 
genologist is often the first to recognize these cases because of the 
frequent pathological fractures of the ribs and spine which usually 
prompt an examination of the chest. 
Next to the ribs, disease of the vertebrae as a source of abnormal 
thoracic shadows will engage the attention of the Roentgenologist. 
Sarcomata arising from the spine may form large tumor masses whose 
shadows lead to confusion in diagnosis, especially if a swelling is not 
externally visible. The difficulties of diagnosis are strikingly shown in Diseases and Abnormalities of the Chest Wall 
543 
FIGURE 421 
Multiple myeloma. Rarefaction of ribs, spine and bones of shoulder girdle. 
the case illustrated in figure 422. The large left apical shadow was 
assumed to be due to a pulmonary or mediastinal tumor which it closely 
resembles, until severe pains in the neck led to a Roentgen examination 
of the cervical spine. Erosion of several vertebrae and the later develop- 
ment of a pathological rib fracture pointed to the probable bony origin 
of the tumors. At autopsy multiple sarcomata of the ribs and spine 
were found. The shadow was cast by a large tumor of the cervical 
spine and contiguous rib arches which, extrapleurally, projected into 
the thoracic cavity. 544 
Diseases and Abnormalities of the Chest Wall 
FIGURE 422 
Large sarcoma of cervical spine and adjacent ribs, resembling a mediastinal tumor. Diseases and Abnormalities of the Chest Wall 
545 
Tuberculous abscesses of the vertebrae are at times responsible for 
an unusual Roentgen picture. They are oftenest seen in the lower 
thoracic or in the abdominal cavities and produce a fusiform or globular 
shadow situated about the spine. As a rule they are partly obscured 
by the heart and cannot be seen in their entirety. In figure 423 the 
FIGURE 423 
Large Pott’s abscess in lower dorsal region extending into right lung field. 
On left side, outline of abscess seen within heart shadow. 
large abscess extends mainly to the right of the spine and its left border 
is only dimly seen through the heart shadow. In figure 424 the main 
mass of the abscess is situated behind the heart and only a small seg- 
ment of its periphery is seen in the right cardio-hepatic angle . In figure 
110 the abscess is symmetrically disposed about the spine. The inter- 
pretation of these shadows of Pott’s abscess can at times be made with 546 
Diseases and Abnormalities of the Chest Wall 
Tuberculous abscess of spine almost obscured by the heart. Limits of abscess 
indicated bv arrows. 
FIGURE 424 
some confidence from their situation and appearance, especially if the 
denser shadows of caseous or calcareous material can be recognized 
within them; as a rule however, the diagnosis will gain its greatest 
assurance from an examination of the spine and the discovery of 
tuberculous disease of the vertebrae. 
The thoracic deformity resulting from kyphosis is often reflected 
in a distorted Roentgen picture. The ribs are closer together than 
normally, obliterating much of the pulmonary fields, so that the recogni- 
tion of abnormal shadows in the lung becomes impossible. The chest 
is shortened and the diaphragm is relatively so high that the heart is 
to a great extent obscured by it and very little is seen above the dia- 
phragm except the aortic arch. (Figs. 425 and 426.) Diseases and Abnormalities of the Chest Wall 
547 
FIGURE 425 
Kyphosis. 548 
Diseases and Abnormalities of the Chest Wall 
FIGURE 426 
Thoracic deformity residting from kyphosis. Heart is barely visible. DISEASES AND ABNORMALITIES OF THE CHEST WALL 
549 
The deformity of kyphoscoliosis on the other hand leads to an 
asymmetry of the chest, the one pulmonary field being almost obscured 
by the spine and over-lapping ribs. It is worthy of note that even with 
extreme kyphoscoliosis, the heart frequently maintains its normal posi- 
tion. (Fig. 427.) 
The soft tissues of the thoracic wall are a much less frequent 
cause of abnormal shadows than are the bones. In fact it is uncommon 
for an inflammatory process such as a cellulitis or even a tumor of the 
soft tissues to cast any shadow on the plate at all. Only occasionally 
FIGURE 427 
Thoracic deformity with kyphoscoliosis. Note nearly normal position of heart. 
will a tumor of the breast, as in figure 428, produce an abnormal 
shadow; its appearance in this case was undoubtedly favored by an 
absence of fat about it, due to the extreme emaciation of the patient. 550 
Diseases and Abnormalities of the Chest Wall 
FIGURE 428 
Shadow over the middle of the right lung produced by a carcinoma of the breast 
A very confusing Roentgen picture may result from a peripleuritis, 
such as is occasionally secondary to a chronic osteomyelitis of a rib. 
The slight induration of the subpleural tissues will produce a faint 
homogeneous shadow which it is almost impossible to distinguish from 
a pleural thickening. 
As other occasional causes of abnormal Roentgen shadows, may be 
mentioned tuberculous cervical lymph nodes. When they are projected 
over the apical region, they may be confused with pulmonary tubercu- 
lous deposits; error can usually be avoided by noting the presence of 
similar shadows beyond the pulmonary fields. (Fig. 429.) Enlarged Diseases and Abnormalities of the Chest Wall 
551 
FIGURE 429 
Tuberculous cervical and supraclavicular lymph nodes overlying the lung fields. 552 
Diseases and Abnormalities of the Chest Wall 
axillary nodes, even when not calcareous or caseous, as in Hodgkin’s 
disease, may encroach on the lungs at the apex of the axilla and give 
rise to confusion. (Fig. 430.) Finally, it must be borne in mind that 
the nipples at times will appear on the plate as small circular shadows, 
which are very similar to metastatic new growths. Their invariable 
presence on both sides will preclude any chance for error in their inter- 
pretation. 
Axillary lymph nodes in Hodgkin's disease, overlying the pulmonary field in 
right axilla. (Arrow.) 
FIGURE 430 Index 
A 
Page 
Abscess of lung, acute 234 
aspiration, ..: 229 
bronchiectatic, 253 
cavities in, 244 
chronic, 237 
diff. from resolving pneumonia, 213 
diff. from tuberculosis, 239 
diff. from tumors of lung, 256 
embolic, 254 
etiology, of, 228 
fibrosis in, 238 
foreign body, 254 
gangrene in, 243 
pathology of, 229 
perforation of, 251 
physical signs of, 243 
pleural changes in, 250, 252, 365 
pleuro-pulmonary fistula in, 251 
postpneumonic . 229 
residual, 242 
situation of, 233, 249 
in tumors of lung, 292 
Abscess, Pott’s 545 
Abscess, subphrenic 496. 493 
Absorption of tuberculous infiltration, 152,155 
Actinomycosis, of lung, .. 264 
of mediastinum, 434 
Activity of tuberculosis, 161 
Acute tuberculosis, 146 
Adenitis, of intrathoracic lymph nodes, .. 467 
see Lymph nodes. 
Adherent pericardium, 543 
Adhesions, diaphragmatic, 513 544 
pleural, 396 
Aneurysm, of aorta, 445 
aortic insufficiency in, 450 
.broncho-stenosis in, 459 
of ascending arch, 443 
of descending arch, 457 
calcification of, 45-7 
diff. from atherosclerosis, 465 
diff. from mediastinal tumor, 460 
fluoroscopy in, 4gQ 
fusiform, 
heart size in, 4g3 
hemoptysis in, 443 
latency of 
Page 
oesophageal compression by, 460 
perforating, 451 
periarteritis in, 457 
pulmonary infection with, 459 
pulsation of, 461 
sacculated, 447 
tracheal compression by, 458 
of transverse arch, 455 
Aneurysm, arterio-venous, of pulmonary 
artery, 31 
Aneurysm of innominate artery, 464 
cliff- from substernal goitre, 464 
Aneurysm of pulmonary artery, 27 
Angio-sarcoma, of mediastinum, 410 
Annular pleural shadows, 139 
Anthracosis and tuberculosis, 115 
Anthracotic lymph nodes, 470 
Aorta, atherosclerosis of, 465 
dialatation of, 463 
displacement of, 432 
Apical empyema, 343 
Apical rales, in tuberculosis, 93 
Apices, retracted, 89 
Arterio-venous aneurysm, of pulmonary 
artery, . 31 
Artificial pneumothorax, 382 
Aspiration abscess, 229 
Aspiration pneumonia, 223 
Atelectasis, apical, in tuberculosis, 72 
with bronhostenosis, 48, 49 
with tumors, 48, 289 
Atherosclerosis, of aorta, 465 
B 
Basal tuberculosis, 146 
in children, 194 
Benign tumors, 278 
Bronchi, 43 
adeno-carcinoma of, 50, 282 
barium in, 41 
fibroma of, 51 
foreign bodies in, 50 
tumors of, 50 
Bronchial diltation, 48 
in indurative pneumonia, 258 
Bronchiectasis, 44 
cylindrical, 46 
diff. from tuberculosis, 258 554 
Index 
Page 
gangrenous, .... 46 
globular, 44 
mediastinitis with, 402 
pleuro-pneumonic, 43 
postpneumonic, 43 
tuberculous, 152 
upper lobe, 258 
Bronchiectatic abscess, 253 
Bronchitis, 43 
Broncho-pneumonia, 223 
influenzal, 224 
tuberculous, 103 
Bronchoscopy, in lung tumors, 294 
Broncho-stenosis, 48 
with aneurysm, 459 
with foreign bodies, 50 
with lung tumors, 48, 289 
partial, 50 
C 
Calcification, in aneurysms, 457 
of pleura, 387 
of thyroid, 434 
in tuberculosis, 115 
Carcinoma, bronchial, 50, 282 
cavitation in, 292, 289 
fissural, 394 
hilum, 283 
lobar, 280 
of lymph nodes, 414, 475 
mammary, 549 
mediastinal, 414 
metastatic, 288, 304 
miliary, 309 
pleural, 394 
Caseous pneumonia, 126 
Cavities, abscess, 244 
diff. from pleural shadows, 139 
diff. from pneumothorax, 328 
healing of, 159, 240 
in lung tumors, 289, 292 
solitary, in tuberculosis, 147 
tuberculous, 131 
Central pneumonia, 221 
Cervical ribs, 536 
Colloid goiter, 429 
Congestion, of lungs, 22 
with mediastinal tumors, 410 
in mitral disease, 23 
Costo-phrenic sinus, obliterated, in 
pleurisy, 397 
D 
Page 
Dermoid cyst, of mediastinum, 442 
Diabetes, tuberculosis in, 146 
Diaphragm, 493 
adhesions of, 513 
in chronic pleurisy, 515 
in empyema, 515 
in tuberculosis, 514 
abnormal contraction of, 517 
in adherent pericardium, 518 
in bronchostenosis, 513 
in bulbar palsy, 518 
in pneumonia, 217 
in pneumothorax, 517 
in tuberculosis, 73 
central tendon of, 445 
contour of, 494, 514, 515 
depression of, 508 
in partial broncho-stenosis, 512 
in pneumothorax, 377, 508 
elevation of, 495 
with chronic dilatation of 
stomach, 507 
by echinococcus cyst, 502 
by enlarged liver, 495 
in eventration, 502 
in hernia of the diaphragm, .... 506 
in liver abscess, 499 
with mediastinitis, 404 
with pleurisy, 495 
with pneumoperitoneum, 509 
with subphrenic abscess, 496 
with subphrenic gas abscess, .... 500 
with tumors of liver, 501 
fixation of, 497 
with subphrenic abscess, 497 
with tuberculosis, 73 
paralysis of, 420, 507 
in poliomyelitis, 507 
with eventration, 502, 507 
in tuberculosis, 110, 507 
Displacement of heart, 270 
with lung tumors, 270 
with mediastinal tumors, 417 
with pleural effusions, 369 
Ductus Botalli, persistent 25 
E 
Echinococcus cyst, of lung, 266 
of spleen, 502 
Emphysema, of lungs, 43 
partial, with broncho-stenosis, 50 
subcutaneous, 380 Index 
555 
Page 
Embolic abscess of lung, 254 
Empyema, apical, 333 
axillary, 329 
basal, 332 
displacement of heart with, 369 
early diagnosis of, 323 
infrapulmonary, 346 
interlobar, 352 
mediastinal, 351 
mesial, 339 
multilocular, 343 
residual, 343, 521 
retraction of ribs, with, 370 
sacculated, 326 
secondary to lung abscess, 250 
sinus, 526 
Encapsulated effusions, 326 
with pneumothorax, ., 363 
Endothelioma of pleura, 393 
Eventration of diaphragm, 502 
diff. from diaphragamatic hernia, ... 506 
displacement of heart with, 505 
paradoxical movement of diaphragm 
with, 505 
pneumoperitoneum in, 506 
Exophthalmic goiter, 426 
thymic enlargement in, 441 
Exudative tuberculosis, 155, 159 
F 
Fibrinous pleurisy, 319 
in empyema, 323 
in subphrenic abscess, 497 
Fibro-caseous tuberculosis, 109 
Fibroid tuberculosis, 109 
Fibrosis, in early tuberculosis, 75 
in indurative pneumonia, 261 
in lung abscess, 238 
Fibro-sarcoma, of lung, 298 
Fissural carcinoma, 394 
Fluroscopy, in aneurysm, 460 
in early tuberculosis, 56 
in pneumothorax, 382 
Foreign bodies, causing lung abscess, .... 254 
in bronchi, 41, 50 
G 
Ganglio-neuroma, of mediastinum, 422 
Gangrene of lung, 227 
Gangrenous bronchiectasis, 46 
Gastric ulcer, perforating, pneumoperi- 
toneum in, 510 
Goiter, colloid, 429 
Page 
cardiac symptoms with, 433 
exophthalmic, ...... 426 
intrathoracic, 427 
malignant, 430 
Gumma of lung, 1.... 273 
H 
Healing of tuberculosis, 73, 158 
Heart, size, in aneurysm, 463 
displacement, with eventration, 505 
with kyphoscoliosis, 549 
with pleurisy, 369 
with pneumothorax, 377 
with tumors of the lung, 290 
with tumors of the mediastinum, 417 
Hemoptysis, with negative Roentgen 
examination, 160 
influence on spread of tuberculosis,.. 103 
Hepatoptosis, diaphragm in, 511 
Hernia of diaphragm, 506 
diff. from eventration, 505 
Hernia of mediastinum, with pneumo- 
thorax, 377 
Hilum of lung, 14 
Hilum, carcinoma, 283 
lymph nodes, 467 
tuberculosis, 141, 164, 192 
tuberulosis, recurrent, 193 
Hydrothorax, 320 
Hypernephroma, metastatic, of lung, .... 300 
Hyperplasia, of bronchial lymph nodes,. . 470 
of thyroid, 426 
Hodgkins disease, 479 
abdominal, 488 
associated with lymphosarcoma, 489 
associated with tuberculosis, 489 
diff. from tuberculosis, 488 
glandular enlargement in, 479 
mediastinal tumor in. 480 
paratracheal nodes in, 487 
pulmonary infiltration in, 482 
I 
Incipient tuberculosis, 57 
Indurative pneumonia, 257 
bronchial lilatation in, 258 
diff. from tuberulosis, 259 
diff. from tumors, 262, 286 
pleuro-pulmonary fibrosis, 260 
secondary to bronchostenosis, 260 
upper lobe involvement in, 258 
Infantile phthisis, 180 
Infants, pneumonia in, 221 556 
Index 
Page 
Infarct, of lung, 30 
Influenza pneumonia, 224 
diff. from tuberculosis, 225 
Innominate artery, aneurysm of, 461 
Interlobar effusions, 352 
Interlobar fissure, 179 
in carcinoma of pleura, 394 
in pleurisy, 397 
in tuberculosis, 384 
Intrathoracic goiter, 427 
Intrathoracic lymph nodes, 467 
see Lymph nodes. 
K 
Kyphoscoliosis, position of heart with, . . 546 
L 
Laryngeal paralysis, with tumors of lung, 289 
with mediastinal tumors, 408 
Leukemia, enlarged nodes in, 475 
infiltration of lung in, 475 
Liver abscess, elevation of diaphragm in, 499 
Liver, ptosis of, 511 
Lobar carcinoma, 280 
Lobar pneumonia, 201 
Lobectomy, in lung abscess, . 529 
Localization of lung abscess, 529 
Lungs, abscess of, 227 
actinomycosis of, 264 
carcinoma of, 279 
congestion of, 22, 410 
echinococcus cyst of, 266 
gangrene of, 243 
Hodgkin’s disease of, 482 
induration of, 257 
leukemia of, 475 
normal, 11 
non-tubereulous infections of, 257 
sarcoma of, 295 
suppuration of, 227 
syphilis of, 268 
tuberculosis of, in adults, 57 
in children, 172 
tumors of, primary, 278 
metastatic, 300 
Lung, aeration, 16 
fields, 13 
markings, 14 
roots, 14 
Lymph nodes, axillary, 552 
cervical, calcification of, 550 
intrathoracic, 467 
Page 
adenitis, acute, 469 
adenitis, chronic, 470 
anthracosis of, 470 
carcinoma of, 475 
Hodgkin’s disease of, 479 
leukemia of, 475 
lymphomata, . 475 
lymphosarcoma of, 474 
paratracheal, 184, 487 
syphilis of, 473 
tuberculosis of, 471 
tumors of, 474 
Lymphatic leukemia, 475 
enlarged nodes in, 475 
infiltration of lungs in, ...: 476 
mediastinal tumor in, 419 
Lymphatics of lung, 188 
Lymphomata, ...... 475 
Lymphosarcoma, with Hodgkin’s disease, 489 
mediastinal, 409, 474 
M 
Malignant tumors of lungs, 279 
Mammary carcinoma, 549 
metastases with 314, 394 
Masking effusions, with lung tumors, .... 293 
Mediastinal abscess, 401 
effusions, 347 
Mediastinal tumors, 407 
angio-sarcoma, 410 
carcinoma, 414 
complications of, 418 
diff. diagnosis, 420 
diff. from cardiac disease, 424 
early diagnosis of, 408 
engorgement of lung in, '. . 410 
ganglio-neuroma, 422 
infiltrating tumors, 411 
leukemic, 419 
lympho-sarcoma, 409 
phrenic paralysis with, 420 
pleural effusion with, 413 
position of heart with, 417 
precordial pain with, 403 
pulmonary metastases with, 419 
recurrent paralysis with. : 408 
Roentgen-clinical correlations, 423 
symptoms, of, 407 
tracheal compression with, 416 
thymoma, 424 
value of pneumothorax in diagnosis 
of, 422 Index 
557 
Page 
Mediastinitis, acute, 401 
chronic, 402 
in aneurysm, 404 
in bronchiectasis, 402 
in syphilis, 404 
in tuberculosis, 403 
mediastinal obstruction with, ... 401 
position of diaphragm with, .... 404 
Mediastinum, 401 
actinomycosis of, 404 
dermoid cyst of, 442 
displacement of, with pneumothorax, 377 
in tuberculosis, 110, 152 
with tumors, 417 
hernia of, 377 
Mesial effusions, 339 
Metastatic tumors of lungs, 300 
carcinoma, , 288, 304 
hypernephroma, „ 300 
miliary carcinosis, 309 
secondary to pleural tumors, 392 
secondary to thyroid tumors, 430 
Multiple myeloma, 541 
Myeloid leukemia, 475 
N 
Non-tuherculous chronic lung infections, 257 
see Indurative pneumonia, 
O 
Oesophageal obstruction, in aneurysm, . . 460 
in goiter, 432 
in mediastinitis, 403 
Osteoma of rib, 541 
P 
Patent Ductus Arteriosus, 25 
Pathology of tuberculosis, 162 
Pathogenesis of tuberculosis, 163 
Paradoxical movement of diaphragm, 379, 505 
Paratracheal lymph nodes, in Hodgkin’s 
disease, 487 
in tuberculosis, 184 
Perforating aneurysm, 451 
Perforating gastric ulcer, pneumoperi- 
toneum wi th, 510 
Periarteritis, with aneurysm, 457 
“Peribronchial" tuberculosis, 165 
Pericardial sarcoma, 425 
Peripleuritis, 550 
Phrenic paralysis, 507 
with chronic mediastinitis, 507 
with eventration of diaphragm, 507 
Page 
in poliomyelitis, 507 
with tumors, 507 
Phthisis, infantile, 180 
Pleura, calcification of, in tuberculosis,... 387 
carcinoma of, 394 
endothelioma of, 393 
metastases in, 392 
miliary tuberculosis of, 388 
thickening of, 394, 397, 398, 523, 528 
tuberculosis of, 384 
tumors of, 389 
Pleurisy, chronic, 396 
with effusion, 320 
fibrinous, 319 
tuberculous, 384 
Pleural effusions, 320 
with abscess of lung, 365 
apical, 333 
axillary, 329 
physical signs in, 330 
exploratory aspiration in, 331 
basal, 332 
concealed, 345 
displacement of heart with, 369 
fibrino-purulent, 323 
infrapulmonary, 346 
interlobar, 352 
masking, with tumors of lung, 293 
mediastinal, 347 
mesial, 339 
with metastatic tumors, 310, 418 
multilocular, 343 
with pneumothorax, 363, 380 
purulent, 323 
residual, 343, 521 
secondary changes with, 368 
separation of ribs with, 370 
with primary tumors, 293 
Pleuro-pulmonary fistula, in lung abscess, 251 
Pleuro-pneumonic fibrosis, 260 
Pneumonia, 201 
aspiration, 223 
atypical resolution of. 212 
broncho-pneumonia, 223 
central, 224 
diaphragm in, 217 
diff. from intra-abdominal conditions, 222 
fluoroscopy in, 221 
gangrenous, 231 
indurative, 257 
in infants, 221 
influenzal, 224 
lobar, 201 Index 
558 
Page 
lobular, 223 
lower lobe, 202 
middle lobe, 203 
multiple lobe 208 
pleuro-pneumonia, 218 
post-operative, 224 
resolution in, 211 
unresolved, 226 
upper lobe, 202 
Pneumopericardium, 381 
Pneumoperitoneum, 509 
see Subphrenic pneumoperitoneum 
Pneumothorax, 371 
adhesions with, 372 
artificial, 382 
compression of lung with, 379 
in diagnosis of tumors of lung, 422 
depression of diaphragm with, .. 377, 508 
diff. from cavities, 382 
displacement of heart with, 377 
displacement of mediastinum with, .. 377 
diaphragmatic movement with, 379 
fluoroscopy in, 382 
localized, 381 
pleural effusion with, 380 
pneumopericardium with, 381 
separation of ribs with, 377 
subcutaneous emphysema with, 380 
Pott’s abscess, 545 
Pulmonary abscess, 227 
see Abscess of lung 
Pulmonary artery, 24 
aneurysm of, 27 
arterio-venous aneurysm of, 31 
dilatation of, 28 
in open ductus arteriosus, 25 
Pulmonary congestion, 22 
in mitral disease, 22 
with mediastinal tumors, 410 
Pulmonary infarct, 30 
Pulmonary tuberculosis, 55 
see Tuberculosis of lungs 
Pyopneumothorax, 380 
R 
Recurrent hilum tuberculosis, 193 
Recurrent paralysis, with mediastinal 
tumors, 408 
with tumors of lung, 289 
Residual abscess, 242 
Residual pneumonia, diff. from apical 
tuberculosis, 70, 212 
diff. from tumor of lung, 215 
Page 
Resolution, of pneumonia, 211 
of tuberculosis, 152, 155 
Retraction of apices, in tuberculosis, .... 89 
Ribs, cervical, 536 
maldevelopment of, 537 
myeloma of, 541 
osteoma of, 541 
retraction of, 110, 370 
separation of, 370, 377 
tumors of, 539 
Roentgen examination, fluoroscopic, .... 56 
methods of, 55 
stereoscopic, 56 
Roentgen vs. physical examination, in 
tuberculosis, 167, 168 
S 
Sacculated effusions, 327 
Sarcoma of lung, metastatic, 300 
primary, 295 
Sarcoma of pericardium, 425 
Sarcoma of ribs, 540 
diff. from pleural effusions, 539 
Sarcoma of vertebrae, 542 
Splenic cyst, elevation of diaphragm with, 502 
Stereoscopy, in tuberculosis, 56 
Subphrenic abscess, 496 
on left side, 498 
Subphrenic gas abscess, 497 
Subphrenic hematoma, 409 
Subphrenic pneumoperitoneum, 509 
accidental, 510 
induced, 510 
with perforated gastric ulcer, 510 
Substernal thyroid, 427 
see Thyroid 
Suppuration of lung, 227 
see Abscess of lung 
Surgical diseases of chest, 521 
abscess of lung, 529 
extrapleural compression of lung, 528, 530 
lobectomy, 529 
localization of abscess cavity, 529 
mesial empyema, 521 
persisting empyema sinus, 526 
injected with barium, 526 
with pneumothorax, 522 
residual empyema, 521 
rigidity of collapsed lung, 526 
thickened parietal pleura, 528 
thickened visceral pleura, 523 
Syphilis of aorta 463 Index 
559 
Page 
Syphilis of lung, 268 
diagnostic criteria, 268 
fibrosis in, 276 
gummata in, 273, 274 
pathology of, 269 
pleural changes in, 276 
suppuration in, 269 
Syphilis of lymph nodes, 473 
Syphilis of mediastinum, 277, 404 
T 
Thorax, deformity of, in tuberculosis, ... 110 
in kyphoscoliosis, 546 
after thoracoplasty, 528 
Thymus, 435 
enlargement of, in exophthalmic 
goiter, 441 
diff. from tuberculous lymph nodes, 440 
nodes, 440 
in infants, 435 
with stridor, 437 
without symptoms, 439 
normal, 435 
Roentgen technique, 435 
tumors of, 442 
Thyroid, calcification of, 433 
cervical, 426 
colloid, 429 
hyperplasia of, 426 
malignant tumors of, 430 
invasion of oesophagus by, 432 
metastases with, 430 
substernal, 427 
auricular fibrillation in, 433 
cardio-vascular symptoms with, .. 432 
compression of trachea with, .... 431 
diff. from innominate aneurysm, 464 
displacement of trachea with, ... 431 
displacement of aorta with, 432 
unilateral enlargement, 428 
Trachea, calcification of, 36 
compression of, by aneurysm, ... 38, 458 
by goiters, 38, 431 
by enlarged lymph nodes, 38 
by tumors, 38, 416 
displacement of, by aneurysms, 459 
with bronchostenosis, 37 
with indurative pneumonia, .... 36 
with pleural effusions, 37 
with pneumothorax, 37 377 
physical signs with, 38 
Page 
in syphilis, 36 
in tuberculosis, 110 
with tumors, 36, 416 
tumors of, 39 
Tracheo-oesophageal fistula, 40 
Tuberculosis of lungs, adult, 56 
acute forms of, 116 
acute general miliary tuberculosis, .. 116 
acute pneumonic tuberculosis, 126 
activity of, 161 
advanced tuberculosis, 101 
hemorrhage as cause of, 103 
pathology of, 104 
annular pleural shadows in, 139 
apical rales in, 93 
atelectasis in, 72 
associated changes in, 72 
broncho-pneumonia, after hemor- 
rhage, 101, 103 
calcification in, ? 85, 115 
cavities in, 131 
in acute pneumonic tuberculosis, 128 
annular, 131 
basal, 137 
fibroid, 135 
punched out, 133 
situation of, 131 
solitary, 117 
diaphragmatic movement in, 73 
in diabetes, 146 
diff. from chronic non-tuberculous 
infections, 152, 259 
exudative, 155, 159 
absorption of, 152 
healing of, 73, 153 
hemoptysis in, 160, 101 
hilum tuberculosis, 141, 164 
incipient, 57 
calcification in, 85 
fibrosis in, 75 
healing of, 73 
simulating residual pneumonia, 
.... 70, 212 
simulating tumors, 71 
site of early lesion, 69 
lower lobe, 146 
methods of examination, 55 
miliary, 119 
moderately advanced, 95 
pathology of, 162 
pathogenesis of, 163 
“peribronchial” tuberculosis, 165 
pleural thickening with, 92 560 
Index 
Page 
retracted apices with, 89 
Roentgen examination and prognosis, 161 
Roentgen examination vs. physical 
signs, 167, 168 
stereoscopy in, 56 
thoracic deformity in, 110 
Tuberculosis of lungs, in children, 172 
adult form, 196 
basal, 194 
calcifiation of, 177 
fibrosis of, 179 
healing of, 177 
hilum tuberculosis, 192 
infantile phthisis, 180 
miliary, 194 
miliary conglomerate, 196 
pathology of, 172 
pleural changes in, 179 
primary lesion in, 175 
recurrent hilum pneumonia, 193 
tuberculous bronchopneumonia 197 
Tuberculosis of lymph nodes, 
intrathoracic, .... 181, 471 
dilated lymphatics with, 188 
in infants, 183 
paratracheal nodes in, 184 
diff. from Hodgkin’s disease, .... 488 
diff. from enlarged thymus, 440 
in older children, 186 
calcification in, 188 
value of Roentgen examination 
in, 187 
Tuberculosis, mediastinitis with, ........ 403 
Tuberculosis of pleura, 381 
adhesions with, 397 
calcification with, 384 
effusions, 384, 322 
interlobar, 361 
mediastinal, 348 
miliary tuberculosis of pleura, 388 
Tuberculosis of vertebrae, 545 
Tumors of lung, primary, 278 
atelectasis with, 289 
benign, 278 
bronchial, 282 
bronchoscopy in, 294 
bronchostenosis with, 289 
Page 
carcinoma, 279 
differential diagnosis, 299 
diff. from abscess of lung, 256 
diff. from indurative pneumonia, .... 262 
fibro-sarcoma, 298 
heart, position of with, 290 
hilum carcinoma, 283 
lohar carcinoma, 280 
masking effusions with, 293 
metastases w ith, 288 
necrosis of, 289 
pleural effusion with, 293 
Roentgen-clinical correlations, 291 
sarcoma, 295 
secondary infection of, 292 
Tumors of lung, metastatic, 300 
carcinoma, 304 
diff. from tuberculosis, 303 
hypernephroma, 300 
miliary carcinosis, 309 
secondary to mammary carcinoma, ... 314 
pleural effusion with, 310 
Roentgen-clinical correlations, 312 
sarcoma, 300 
Tumors of mediastinum, 407 
see Mediastinal tumors. 
Tumors of pericardium, 425 
Tumors of pleura, 389 
chronicity of, 389 
clinical course, 390 
fissural carcinoma, 394 
metastases in, 393 
secondary to lung tumors, 394 
secondary to breast tumors, 394 
Tumors of ribs,, 539 
Tumors of thymus, thymoma,, 442 
Tumors of thyroid, 430 
Tumors of vertebrae, 542 
U 
Unresolved pneumonia, 226 
V 
Vertebrae, sarcoma of, 542 
tuberculosis of, 54d