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·CHEST EXAMINATION ·THE RADIOLOGY OF BOND AND JOINTI JALALSFOLD ND TRI Intolapal Door LA LIGyty of in 209 LAH AKOINT ADYANA IN PRATORY TURUL CULOS ( URL ANG JEAD TRCT NL RUNT BV MRCPF in. Tak TURD CU OCH AND CHOT DALAM POR NUESO DOI ERWIN MD MDLY N mod DELATA OR INANCY AND CHILDHOOD DOILERID VOLDOV MR.F.RCP Thom for De Chiko chlorem to Outpat, IS H Sor Bakan Cuptor Ludoc PA fine 1431 Surend KAINT ADVANCO IN JUROMY th HAROLD PDKARDI, Cor HO TRCS TH PACTA O INDUTTUAL MID CIN DZT TA LLOYD DAVIEK, MD HRC i Duran MOJAMS IN UNICAL MEDICIN Anh Tehote XMOND DART. DEN HRC DT 2 J&A CHURCHNL LL

·CHEST EXAMINATION
THE CORRELATION OF PHYSICAL AND
X RAY FINDINGS IN DISEASES OF THE
LUNG
By
RICHARD RTRAIL
MAMD (Abend ), FRCP (lood)
d Dirar l'Ente Whage de
Col Port to the Ind (hox Hap is!
(d1 for
W th Freno d by
SIR WALTER L LANGDON BROWN
MAND FRCP DE LLD
Profone M UNTERT Candy
The him
LONDON
] & A CHURCHILL LTD
4 GLOUCLSTER PLACL W

·To
M1 DT
AND
DRT
Ev Edit an
Second Edit on
Th d Edit on
1943
1945
1948
Trybunden
banne
Wohnort
NOW NUS DX 400 UN
TOLD ML001

·arous FORETYORD WHILE rull a medical student Iſ It strongly that the next Benrnt on would ondemn the practi Sherding care of proved pulmonar, tuberculowo in our patient'partments There they Mould n rom among the other patients ougbog them ultimat ly to be rowurded by a bottl of od Deol and some Itact But did ha the pportonlty of arning our pby kcal gra from these unf rtunito To-day I can affirme from my Thence a clamort is that the rehat part of the candidates quipment ther ecogn tion and mt prettion of phincal sigram the bunga T sobie xtent thu ray the degree hon früber los con nto departmenn where gudents do not freely ent but it ll moet the tiden t short routther Lam nation by flying th ny flowing tubstitut confirmation f ordinary clmnat methode Th t acheti homener re not entirely free from blame parthulath the matter of multiplying Labels fo the arxun sounds he d through the stethoscope the degree of muray thereby pledu Largely Hlusury and merely onfusca th tudent Ine of the many merits of Wong Commandet Tral book that h i llow the tradition f my own chen D Gerona Dhamuel Want hy is ng a few t ma powble and relat 2 ach th to pathologrual significa Thin plan k haradt rain of the whole work anatoom phi ko Ingy pathology imptomus phayu al gran X ray forumga ar loreli orrelated cabing the todet r practition to build T ment l concept of cultly what o happening trade the heat my will be interested to 1 am bmw greatly modern X ray technique has wont pretation in Bled banda E Ji be surpreedi tond what h Ipful Jeductions from phs folng proxiples they tab tually ngwe And Jl. U be releed tu tuned for step of the host principios im I ed all cable them meet upmion # thout mposing burdenone deta is on th mmon trm 1 xhe I know how aluablontribution thn hand malet the undertanding of P bleno hk the freshno il proxchu ll be puteat toll VY LANGDON BROWN YO ] t Au

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·PREFACE TO THE THIRD EDITION This Thind Edition has gain been slightly courged Reference has been med to recent work on the broncho-pulmonary wegments of the lung chapter hom been added on millary thadoning and the lat chapter of the second edtion has been replaced by short description of lung tumoun To llustrat there additions atralizures and been Included and tor som of th x ays he e produced I wish to express my gr teful thank D p't K Hey and to Dr Fandtt, who has don such excellent work on radiological ndence in homut imore #h RR TRAIL nys ha 3 tral 88 PRIFACE TO THE FIRST EDITION This book # founded on court of lectures which has been the writ good f rtunk tgl to tudent and post graduate They ow the present form m great part t attempts made t araner the diffeult es I those students who honed an im rest pproach to esam natum f the ctiar funded on bono ledge of opled anat my physiology and pathology without whih to naturally uncles to attempt a reasonable i terpretation nd correlations of phy Ical and X ray Crelatlo not modificult to acquire as many student xem t fear Much comfinion has arden of Late) an because of the bgamis mod by best phy klan speculats on the one hand and hext dlology yechalat on the other More recently honor there has been a todetty to combine these branches in the hot phral lan cu radi loglet r the chest physician who like to ind hie om This is 11 t the good of tho modem tudent tendat bring a hack to fundamentala We for it rctralngły wyt go beyond th oblective reading of film W an ninett phy ke tigra with defolte bnormalities of Yri ·0 appear to be PREFACE obadow and combine both with the changes in normal anatomy and physiology an ably expressed nowadays by the speclalved lung pathologist who lo le must remember hout the first of hoot of that type of leamed physiclan who laid his firm foundatio for practice n his carlier post mortem çoom retearrhes when I raja did not exist The first Section of the book lo ther fore devoted to reminder on those wallent point of normalaratomy and physiology hich explain the abnormalities of the commoner chest dents of general practice Ilhe other polnts of equal importance they are repeated by reference to oth s sections In the second Section on Applied Patholog mereld rtho main gross and microkoplcal changes Induced by these di este and in noting the physical signs and the alterations from the normal postero-anterior film that ac omping them in the lr various lages an attempt la nude to cors Late all three sp* cts Art in amunt of detail d description u necesary but thl la contmed is nuch as powlble to fundamentals even if by this statert nt v begging th question There has been of Late yeans much discussion on the reading of abnormal films and of necesit to much od ildwal antation In reports that an attempt has been made in son e qunen to contine thm to objecti ording 4s already indiated th ter fe is that can go furhr that we should attempt t arrive at Hteria for interpretatlon Bing it ulk of the phy i lan the pathologut nd the radiolgut a combined whole shall lagre that change of microscopical detall cannot be expect to reflect thensel s in stethoscopic Igms and on the ual pont ro-anterlo film e know that al bulc on the lung urf fcks no more than about one-yurt r fan inch In ito longest dlanet T New other it is felt that a honro 1 dge of parhagenau a fundamental for the stud nt who ould orrelate hbo physical and Yray find ng e en f these are demontrable only | Thứ 7 C vh n comparately grow areas of lung are 1 oled can find a know that in phthis stethoscoplc sigro lat but rexson why th ya c lat and so why we hould look for ther and important physkal g7 such as lack of so ment and note ill preced these stethoscopic signs and a wam w of the presence of a peedfic pathological change It may be moved that the prime correlation bere detailed re bullt on poder reasoning even if the be jutifiable critichem It will be admitted that they that ·PREFACE L an 8 wme Inrentals that may combine the all too-H 11 defned mpartment f the pathokunt the radlobogbt and the phyet ut Ir a mett workabl planation mold be betts than no ban t 11 Section III sums up the phy Indngs in the ducok diskused n Section 1 od gi akhemc f nt pretation fatethoscopo fundings that may at was f dugnosis thout Y ny fodbg It nipt is mal t d al with li normal and abnormal tetha PK is but only wth wh ad cntitout sounds : in be telated #th underlying pathogenes 10 n taken fr granted that th tudent has listened to large number of normal heru anda ufficient numbe abnormalst undentand their plu und rty ng the int rpretation of breath rounds and ce lounda 9 the din rete between the prolongad p ratio of emphyter nd the high ptch fant loudt the a that omhotos bronchial N breth ne wed on OVCT k nereiseth to be It ll be seen that all these sel trono de Int corrected They are nonete th parts of an nteresung ing en puiza! Trom the plane personal lives on the individual piec the me but they re the result the nt oneous attempt nal of raub plece by using pult t Itrit hape to that fits more con lv wth to 1 Ilow h nen problem ni mg pathogens ontinu minut wh 1 in het the appeti fo till furthe problemi The ult mat im of this handbook o to bring added help to the tundent malergo dut ord pool-graduat in the sament of the ingaw hanging p thote this indersidwl patient only by to dong * r moned boat that wider problem Ind wual te tment huh mit be the bject and balmas the 1 true crd f the happy pły rezan Al thanh re duket sh Logdon Brown frho kod пипt g Torrnord HL JA Kennedy f read ng proof and preparing the nda od to Mr of Alemn ] A Churchill of Fb valuabl bell thered of d ffu Its * Ith paper al pront t t tanc RR TRAIL ·CONTENTS MAT SECTION I APPLIED ANATOMY CHALTER THE BRONCHIAL TREE 11 THE ALVEOLI THEIR STRUCTURE AND FUNC TIUN IN THE PLEURA AND THE DAPIIRAGM IV LUNG AND MEDIATINAL MOVEMENT IN HEALTH AND DISEASE THE NORMAL CHIST FILM 10 24 29 36 VI 48 50 SECTION II PHYSICAL EXAMINATION PHYSICAL EXAMINATION-INSPECTIIN PALPATION AND PERCUSION O Clubbing of Fingen (6) Inspection of the Chest 1 ITATION (c) The Sterno-marold Sign (6) Lung movement PERCUSSION (0) General (6) Dlaphragmatic Movement ASCULTATION (1) Crepitations (2) Sibill and Rhonchi Rala 30 32 VI 52 53 34 36 $8 59 Vull 62 62 IX SECTION MI THE ABNORMAL FILM SOME GENERAL POINTS AND THE VISUAL OBJFC TIVE DESCRIPTION or THE ABNORMAL JLAS The Visuai Dekription CHE INTERPRETATION OF ADRONAI SHADOWS STREAMINEN AND ADENCE OF NORMAL MARKINGI Homogeneous Shadow Non-homogeneous Shadons 64 66 68 ·CONTENTS NE 69 69 GLUTE Y ROUND SHADOW ( R ng Shadows round Area f Compan d Translucency (b) Ring Shadom round Arew of Compan Density XI MSK DORS to 71 76 SECTION IV APPLIED PATHOLOGY 88 88 89 91 XIU 95 100 102 110 XTV XV BRUNCHM AND EM HYSEX Aut Bronchitus Chron Borxhitla Emphywema BONCHTECTAHI Bronchiolectal THỊ PNEUMONLAU Bronchopneumon ATELECT Upper lobe At lectarls Rght M ddl Lobe At lectosha Low r Lobe At lectus LUNG ASS Tunt cu ONS UP TO F RLY ADOLESCENCE Tuberculorus Infancy und Childhood T berculosi Lat ih kdhood upt Early Adolescenie ADO TKCENT ND ADULT Tun CULOS Acuto Exudatt Phthiol f Adolckence and Ad It LE PURT Pneumothora 115 118 119 123 130 XVI XVII 135 135 137 142 XVIII 152 XIX 153 159 XX Tuvouro MD UNNUNA DLUNG Carcinoma 161 168 INDEY 171 ·CONTENTS 1 PARL ] SECTION I APPLIED ANATOMY CHATTER THL BRONCHIAL TREE 11 THE ALVEOLI THEIN STRUCTURE ANI) FUNC TION IN THE PLIURA AND THE DIAPHRAGM IV LUNG AND MEDLASTIN I MOVEMENT IN HEALTH AND DISEASE THE NORAL CHIST FILA 16 24 36 VI SECTION II PHYSICAL EXAMINATION PHYSICAL LAHINATION-INSPECTION PALPATION AND PENCUSSION Clubbing of Finger 48 48 50 50 52 PALPATICN The St M mastold Sign Lung movenient PERCUSION ( ) General (b) Di phragmatic Movement AuxcULTATION (1) Crepitations (2) S bili and Rhonch YIT 52 53 54 56 58 59 (3) Ralen VIT 62 62 IX SECTION III THE ABNORMAL FILM SOME GENERAL POINT AND THC VUAL, Onjec HIVE DESCRIPTION OF THE ADNORHAL FILM The V sual Description THE INTERPRETATION OF ANONKAI SHADOWS, STREALINESS AND ARSINCE OF NOWAL MARINGA Homogeneous Shadows Non-homogeneous Shadows 64 66 68 ·CHEST EXAMINATION SECTION I APPLIED ANATOMY CHAPTER 1 THE BRONCHLAL TREE t Tire trache lies behind the great rewels embedded in the clastic reolar imue which sheather all the structura lying to the med last num It dyklos t about the level of the fifth done! crtebra nt it to main branches the right and left bronchi To this potne it can be seen on the normal postero-mterior fibor of the chest as clear area, bearing lightly t the Hght of the mld line of the thorax The potit of dirblon is important in all cood toru which cause displacement of the medwstar to that it ller not far below the thurd dortal ertebra opposite which the weakest part of the medittram On this point the bed tham wigs laterally as on a hitiye Any pull on the himg structures connected with one main bronchus leily transmit ted along the lower part of th tracbet g to the al pont W shall sec later that the truhen responds more than myrthe mediantbalstructure to lmg changes, and that therefore If food vidence of ti dosturbance w reason backward to find the cause in Rxch lung hanger fortunately its Mocent quickly reflected on the ut moment d muscle so that we hav an oily demonstrable in of its de Fra i The Westhoe dl the placement The maternical relatom of the į the er betere broers to the StarDomestond Sera muc! explam the reaction (me i The the lower babe broncho Fug ) On the mterior sorface of The best apper be brooch the tracheales band of the alled the whole of the The left or lobe bronchon the pretrache I facta connected be podem low with the Latke areolar thraxe of The most of the pect 7 I pretrachew from the medlastinum, odabor with the The sterom

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·THE BRONCHIAL TREE 3 ca of rubateral thyrold and in denone of one bobe of the gland which pubes the tracho out of io centnl poulthon. Along with other mediastinal structures the trachem a dupliced to the common abnormality of dorul scollons which is all conter to the right. Th is really et non of the thoracic age pushing the rgbt lower half Erwards and outmode and paling the left bone ball inmana and beckwards 8 viewed unterhorly When we look t the patient from th fro ti ko ho right Lower Hibs forced apart to produce bulgog whil the left lower balf appean t be fallen m xactly the pport to found on booktag at the back the Hight low bon flatter and th left lower mooo more prominent tho the pormal In the ride th rolam of the chest crvrty as whole u not reduced The effect of the Fra 2 Normal postero-Ondor thon totalon on the badow of the bart and of the main rewel will be documed in the chapters on th med låtbumi health and discurt and on the normal portero-anterlo filo ·2 THE BRONCHIAL TREE deep lascia of the neck The latter fascia which meets from both sides in the middle Line divide us it goes backward to close the sterdo-matold muscle ud i thus in close contact with it tendinoa part which bus its origin at the anterior ruperior border of the manabrum itern! Wo ke therefore how it to that tracheal displacement is reflected to an increased tension of the stemno. mutold muscle in the tendidow part on the same olde os that to which the medtattnum is palled or puhed by traction on one sklo or presure from the other As we proceed with our studies we uhall find that a pull on the trachea b'effected by all procesos which interfere with the clutc truo of the lung Thla elutk tlaue la continuou throughout tho broochial tree ind carried from ith smallat dleblon to the elytic Around of the ur cells indeed with the finat ultimate arterioles It form the actual alveolar wall All branches of the bronchial tree are also intimately surrowded by • brding of connective tinue which acts as a supporting truc turo like scaffolding It lo resilient md moves in response to Dorements of the bronchi u they alter in length and dancter by Ispiration and expiration but it is not an integral part of the bronchu like the elastic clave and so lo pathologlal changes havo not the sainho opportunity to reflect themselves on the med latinum Its changes appear to act only secondartly lo comumoonest patho loglal change is in the deposition of fibroblasts which produce peribronchial fibroche Increase tn depth of tlove lenda only to ultimate thrinlage md log of resilience what seems to happen is thut the fibrosis obliterates bobalan it ww meant to support and wa ruch a drog on others in its neighbourhood that it destroy their chatic tuuc efter datending them Direct and indirect destruction of elastic true occun quito carly in adult pulmonary tuberculoob Material from diseased Lobula enten and then blocks the supplying terminal broocitolo As alr cannot dow reach th alrcoli empty one collepee, and full ones organize and both love their cloudty Th trachea is thus pulled to the discused side and we ford a sharp immer border to the itornomastoid moclo on the same shade The effect of the medlastthal hinge on tracheal dbplacement for well abown In deze confoed to the upper lobes It pot munal to find that the part above the thind dorul vertebro to dngged into a definite bow by localled Infraclaykular tubercu lott In the mme way a kórk to this region be seen in several ·THE BRONCHIAL TRXE the upper lobe is supplied by two brmctes convex Olanda that come well down towards the left aandac border supplying the then triergular part of the lobe that lies in front of the lower lobe I my of these normal markbongo ve altered to detribution or have disappeared we che conclad which part of the bronchial tree how been Interfered with by diseme and so get a very belpful and to diagnosis Thu on the film of right lower lobe preumonk we wo no shadow of the blood supply to the decured lok llow the workings of the rest of the blood supply to the lung wo 17 ne an Fm. shell find them quite ponnal to the dribution (wt Fig 4) feb deseme ba nghi pleural effusion * can find the shadons of congested blood vowels in the comprened lung, Internal to the shadow cast by the fulle There is no obliteration of blood supply (sce Phg 5) On the kilom o plewal effusxn corp lasting loner lobe prent monlaw shall mist out the shadow of the fuld tom do the periphery internal t it n se no mariloga blood opply u the dreamed lobe The rest of the blood super to normal in dhtnbutrom (sce FE) 1 are darling with Co of collpre of the debt met lobe shall not (wo effects on the shantom of the blood supply not there no markings in the area of collapse which a more olem opaque md appeare't be contido nith tbe heart hachon Second in the lower babe ba ollapsed od shred the more I ·4 THE BRONCHIAL TRER It is interesting to note that the effect of Kollosh on mbico to no longer seen when pulmonary tuberculoob supervene Compensatory emphysema seems to undo It British and Continental writen give differing description of the bronchial divblom The latter describe the branchings monopodlal coming off what they coulder to be the primary broncto in the continuous item from the bifurcation to the base of the hung Butbh wolters bare used the nomenclature of Emirt who do cribed tho bronching u dichotomon This is not exactly the beauc consecutive divisions often follow on ach other too clovely to demonstrate debotomy and the indivkdul division differ to much in diameter that three or more may seem to arbre at one point. We cannot follow these division on the chest film, but wo an sec the main divisions of the racular supply and there arc so stmilar and so closely approalmated to the matn bronchial division that they form a practical gulde to them. They can be unced on a good portero-interior film throughout three-quarters of the lung fields from their origina in the bllar region. There : oro polot of difference that is important when reading aboommal filmas blood vessel continue below tho sbadow of the diaphragma brondblal shadows do not unless they are cnlarged by discuro The diagram of the blood rupply abow the branches of the pulmonary arteries as they appear on good postero-mt ortor film The right pulmonary artery make a Tobaped obudow at the hilum It give off three broncha to the upper lobe, ono to the middle lobe, od three to the lower lobe The lat artery gira m elbow shaped ubadow at the left hilum, about helfen inch higher than the Hght one on : 15 X 2 trsch film It Fra 1 The Blood Bupply The glver firo banches to the uppet portmor broad of the opt opper and four to the lower bbw bood party at the bibod apply to the bottle of the left opper lobo It will be noted that much of the left lower lobe of supply b hidden by the beart shadow and that the lower Lobe bobo en born in dotted .. part ·THE BRONCHIAL TREE 7 off-shoots become uch conditions - tuberculords abucer of lung od collapse may be in an area d limited by the ar apply from ODC particular broochus This area le conse-abaped the per of the che term Tro Cortel The Chaplicated by colup od brochucents les bud lobe come lying the entranco f the broncho This aplain why diocese of my one ach area which liet laterally in th' lmg will trumgula lom of translu exy on the postero-unterkor film ID 932 Krame ind Glaw of America introduced th broncho-pulmonary. Kegment They defined It - tbe va of parenchyma mupled by a constantly placed broddbus rb c opens off large lobar broochun and eally found by broncoscopy This was the bretoning of prope locallation of long does. It led to a nonexclatus of lung diublon based on the position of the broncho-pulposury kgroot uitbtn each lobe o found by the study of films and bronchogram in rlow pooldos ·THE BRONCHIAL TRER 6 has nailed In filled by the upper and mld lobes whkh enlarge by einphysem so that their blood supply k splayed out a spelet in normal distribution see Fig (7) Fra 8 From 7 Fig * show the effects of collapse of the right upper lobe. There is no sign of the blood supply to the collapsed are that to the middle and lower lobes is spread laterally as agalmi the Darma! distribution Now and sgala we come acron rublects in whom the sotmsal dirison of the bronchs has gone wrong Developmenic heas comed At one point of hfurcation and instead of a branch we have an alr containing space blown out by air from the bronchu and kegut open by rurrounding lung structura It may be mall or large mod is Imed by the normal clement of the broschus it be known *1 congenital crit of the bronchia It can be found in forms which maintain their connection with the original branches, but many are chored of from the fint or later in life Some coctatn * vrou sterile fluid but most are empty The wall and the but well enough defined in the bigger ones may give demonstrable pretture on surrounding stnictura When tbe connection with the original bronchus x maintained through a nalrular like flop these cats may have clinical significance but the word form hand no effect on the subject On the filen these appear as thugle or multiple circlas sometima superimposed on each other like betapa of thin curtain ring We theed not know all the details of the forer bronchill out divisions but we must know the principal branches onad thelr matn ·THE BRONCHIAL TREE 9 respiratory infection the former ares will be infected where the patient w lying on his back and the latter where he to lyng oo hk sklo Further we shall be added to treatment as we know the cxxct location of the abucou we know bon to position the patient fr portural drainage where to fiert the bronchoscope for bronchoscoplc drainage or where t opcrate for rurglaal drainage Similrly we have learnt that bronchiectul is not recently a Lobar disease We now know that the lbgular wegment only of the left upper lobe sa frequently in olved that the upper ecpment of a lower lobe may be entirely clear lthough its posterior segments are gronly dressed and that only segmentul divblone of the main bobar parenchyma may be inrol od The bs of material importance t the patient and to the thoracic surgeon who can now adapt his technique to deal with dbene of las extent than one lobe There are four broochl of purtkular interest to the student all are in the right lung, three conpected with the main upper lobe bronchin and one with the malo lower bobo broncha The right upper lobe гер terul bronchis has three main dirabota the apical the allery and the pectral The epal branch po upuards outwardo dallille bachn ros Itapplies that part of the uppe tone of the fung wbkh - weak in supporting structure and so common alt for emptyma and Ir the first ros tobar collapose from bronchial blocleg Fra 11 Broncedat luonner! containmg celle soon fa}} n when to when reeton branches they me not lopt fully supplied referred to not by Taskul 1 which b thel Apel AA te be otro lateraldotlen od pectorid principal method f maintaining breacht AVL tror machte C, their position They may fet Cordonci Dordre bored Horse Luther De La Hretched and become mpay Dekle be MB, power bu rematou by their lack of upport , pour lami i walk doweb) and when they nopture by wch tretching may care a ring the iceral pkura to product pontaktors preumothon The type of pneumothorax nknown U AL ·8 THE BRONCHIAL TREE AL The actual shape and site of the major segments differ but the pattern of each bu fodividul characten to that och lobe an be divided foto recogolable urta There are ptc of thicre in the Hght lung und eight in the left lung The lingular section of the left upper lobo u comparable with the right middle lobe other changes in the pattern of the left lung are due to a combination of two segment in the upper and two in the lower lobe Abrormal shadows seen on films which approximate to these known arts and bear almibar relations to the bony thout can therefore beklentified os dieno conditions in definite segments It L almy necessary however to supplement this opinion with bronchoscopy One of tho LA great advantage of this method of locallation that i regmenttalabadow NOT focused attendan on its supplying bronchu To MO shadow may be due to collapse on consolidation the bronchus will almost certainly be found to be abnormal elther blocked or broochie tree, Nonna che me Fro. 10 The antector for to the contricted and what is of brow to the ingrepat Dord ich then rnaterial importance to the A, plal AD, antalor bado patient, the cause may be some utero-lau ALI Anthor mache! thing remomblo AP peo-poererar, C, Cardos; The benefit to the diagnos Lateral modello MB, de benci PB, postenor belo PL, posturor ticlan are very marked Thus through the work of Blatr we know that tho lalora of pocomonla reldom stick to regmetal boundaries they elther allect an area lems than that of whole segment or they overflow into adjoining segment to that a truly segmental abadow bogatrat the dlagnosis ot umple pneuponla It also against the diagnosis of phthbb cicopt in its bronchłal form but truly segmental shadono occur tn childbood tuberculosis where branchus is considered by enlarged gland We now realize that lang abscow is frequently found jo the upTCT posterior part of the low lobe and the anterior portion of the We so why this can octur from gravity In uppet ACECCO AL M "pper lobe ·Carles Darwo 9 THX BRONCHIAL TREE resprutory Infection the former area will be mfected where the partient te lying on her back and the latt r where be bo lolog om bude further we shall be added in treatment #melbow the exact location of the abaco loop bow to position the patlent for postural drainage where to meet the bronchoscope for bronchosophe drainage or where to operate for purgkaal dramague Similarly we have learnt that bronchlectats i sot necesarly * tobar dibene We now know that the lingular segment only of the left upper lobe is frequently in lved that the upper segment ofalow rlobe may be more clear although its posterior segment are growly diseased and that only segmental dibione of the main kaber parenchyma may be irrol ed Pihl of matertal importance t the patient and to the thorsk surgeon who co now adapt bbs techniqoc to deal with doeme of ler extent than one lobe There are four bronxhi of pertkular interest to the student all are in the right tung three conrected with the main upper lobe bronchum done with the natn horren hobe bronchus The right upper lobe or art nalbroncho has three mam dbrincond the apical the villary and the pectoral The apkcal branch gove puando outwards and write bookmards It supplies that part of the uppe tone of the lang n bab tu al in emporting tructure and wa combin te for emphysema and Ir the AB FB first igra of lobar collpes from bronchul blochage Tro. 1 Braxto od ratahang in Lecaral contamng celbroon fall in when on thom mladon broche they are bat kopt futh supplied by roxual what is the wal AR umur berk Aly oteto-lendi wh acaben and rectoral principal method of maintaining brancher A to bille , ther They may get on mailbe MB, stretched and become emphy M power towc Hematou be the of sport the poorten beter per sport, and when they rupture by senh treaching may conre Keral ploun to produce. spon mou meumothorar This type of pareumothorax to ironn MO referred to mu rue trom me the ·10 THP BRONCHIAL TREE rimple origin to detinguish it from pneumothorax of tuberculos F. 12 8ople pontaneous parumothors, with emphytotoo bun. on the opper border of the collapod lupy The apical branch is not often affected by pneumonia but to especially important in that it gi a off donul branch supplytog a sector of the parenchyma commonly affected in adult tuberculosbe When this occur we see in the supraclavicular area of the hong fiald small rounded deposit more or lo defined in outlino wod dense in the centre Reference will be made later to the difficultla tn Int rpretation af shadows In thla urca In the meantime it is nufficient to Ay that it b fairly mfe rule not to rext evidence of plal tuberculous unlew one can sec quit definite areas of low of trumlucoxy or leat ftv rounded dots lying under internal or extemal to the abadow of the interior and of the fint db bove the collar bone The adllary branch come off th main trunk close to the pectoral brmch towards the centre of the upper med pone of the Hght long field and I directed outwards to apply the outer area of the lobe below the claricular tone ·THE BRONCHIAL TREE 11 To 11. Apec tuberculote lett tung When the branch is invohed in much doe pneumonia we be therefore on the film triangular rea of low it trarskuenca which has its past the entrance of the branch, and la base along the walle Lthe the apical branch igna of a dorul broncu Important In duit tuberculos Later in the rectxon on pplied pathology wholl dhcm the differential dlagnons of the film sadom of parul parumronla moling the willity bronchu and i wdult pulmonary tuberculoals the out bone of the pht uppe Lobe The rectoral branch bends a Itthe outward tarvd then como furand in HMK roul fahlon tbe a thing the compem trg branch of the pulmonary n ny sometimes shon up protninetilly mon compt ty twrmal bilms if it pectorul e half casty will the wire half beng Uncat pe ( med try the neillatinal shadon wbudo ottet mctor of thu bronchu km lidi poconla there Irlangu la kum of tramlorem rather the rotor binago of the allan vetor the time be hase I past the media thal oc If the lung ·12 THE BRONCHIALTREX shadow and the apex towards the contre of the upper med zone of the lung In some cases the shadow I fint noted when the Fro. 15 Porucos o the allery breach of the opet upper babe broochen of the trlangle is rounded off thl mayadro conubderable difficulty in dlagroska u against turnour or cyut Serial films wally clinch tho dlagroala by the comparatirely rapid changes that occur in the partial preumonla u the desse resolus The principal branch to remember from the Hght lower lobe bronchia the posterior horizontal (doral or first dorul brunch). It doar cu tly what lo namo describes Il comes off the main stem of the louver lobe bronchu posteriorly practically opposite the origin of the middle babe broachus and therefore near the centre of the hilar hadomy or the film It goed almost hontzontally back If therefoi It Involved in dixwse the abnormal shadow 4 clove to the hilur This is why woulted central poeumonia commoner in children than in adults appears to be part of the medllatinut: As It books backwards over the орех of the loner lobe the branch is a common sit for blockage to long segment as often insolved in adult pbtbals Septic material bobily caught in it to gi & the foundation for an baie walk the

·THE BRONCHIAL TREE
ccompanyin !rophattar round 10 blood supply are equally cally
occluded by phagocytos containlog tubercl bacilu
Fre 16.
Pof te pecond hand and upper lobe bom.com
19 ocelulon becominon cause of charact Hatle film of adult
tuberculosh When a tuberca louna has formed in the uren, lowo
trapection of the postero-Interior film will often maalalbe
running down in and outwards from the
bulves and forma ng the outer bondary of
trangular loss of translacemicy The ligule of
the loner habe has shrunk downmard md
tnwand on to the main intobber framt
There is collate of the spes of the long lobe
From the foregoi goutline It will be seen that
broocho-pulmonary womenu mpiled by daylor
low of the bronct that go hawards are star
of election 1 mult tubete! e munt Low
perekulty the dorul branches of the plaal
Olkry and pretoral dh bloot of the eplatterlal
Tis 17 bronchus ad the posterior bortzontal brandt
of the right lower lobe bronchus

·THE BRONCHIAL TREE
14
They are similarly the cartiest sites for evidence of blochege of
lymphatics In docue of dust inhalation ruch as siliccais The
Pro 11 Porson try tuberculose The collapoing pool raht loma
lobe toepasbeped shadow is third menpice
broncho-pulmonary a car supplied by these branches are like all
axch area conical in shape but on the postero-w lerlor film are
photographed along a line drawn through ther
norto at point at the entry of the bronchiole
It follow therefore that disease in them
throw a rounded or oral shadow becauc
the bronchus and abo theref te the segment
of lung It supplier lle antcro-poeterborly in
the chest An ant ro-posterior film (I c one
With the patient back to the screen) All
show how the disewed area goes
backwards
The shadow to much bigger
It is important to note that the right middle
lobe bronchus comes off the Hght matn bron
Fra 18 Comoroon sites chus at an angle of almost 90 degrees and that
tuberculo
perdonary its brancher go out almost horlzontally towards
posti, upphed by the periphy of the lung This makes the
bronchi
sector of parenchyma supplied by its bron
chlolas appear as small triangles with their apfcet innarch and thetr
b

·15
THE BRONCHIAL TREE
boscos outnards when they are affect d by die nie It abo makos
then other man at m difficult to dren and any of blockage
Ano's focu nkh lower lobe.
hall fou n this the explanaren Fr the comparatie
frequeixy [ umple trora
n this lobe
Idlecases which in orher
Lobat of the lungo
no exhauer worry to the physklan
W ta already noted that all branches of the bronchi carry
throughout the lung lautk te comentou th that of the triche
By that the these they re able to return the nortul prosieben
of restart they hey been kngated and passed up the act of mapas
arton
too that by wh distribution the both the u
anchored in the hilizm, so that the long bale y llmg, the more
Itn pulled ourn roc return to this polne fenchorario
Sumu barly all branches carry ite tracheal structure of ar lage
and make and have found then sheaths of connecti
myporting them but moring Ith thoro m no ration These
sheaths carry the blood cb from the beachbl artery and are
lovely related the wompany recirculation from the pulmonary
Artery Through them run.bo the lymph channch The sand
oot strand which support the long parenchy
ekker the correct (sex in more detail when d ling thibe
structure nd functke of the aheal

·CHAPTER II THE ALVEOLI THELR STRUCTURE AND FUNCTIONS WHOI tho bronchl continue to divide they retain the component artilage muscle and elastic fibros pito the foul subdivisions called the terminal bronchbolo There is much anya ment among research worken on the details of what exactly happens thereafter und wo reach the air cell or al coll but what matters to the student that while all the bronchial elements remain up to the termntral bronchiole, tho llige disappean after this sub dirison bet stroog muscle od elastic fibres condnue Into the final cyllndrical channel the bronchiolus raptratorius This bronchiola with its commumicating wr-cells form that matute section of lung alled the actius The Adnu The acinus lo so important in the under standing of many diseases of the chest and is the base of erplanation of so many phyt ical and Y may finding that we must par como particular attention to los detaller construction and its relation both anatom- Ical and physiological Its bancha af air cells or alreoli con tain the residual or of the long that b air that remains ofte maximales plratory effort has been made to expel bat 2 Tonton of munche bru. is alled supplemental alr 3 Tennotion the.de words the residual or can be mpelled Abrn A Terminal brooctele only by collapse of the celle it to ta B. Broncolorin contact rith cublaal epithellam, which has replaced the cohimpar cilbred epithelium of the bronchl, and through it is brought into close contact with the fipat apilaries of the blood pupply for gaseous Interchange Roidal att bo s to ospheric prepure being the The 3s that Fic 21 'Ibo Accu 1 Tamunaton o arti In other C. The then.

·TIE ALI ROLI STRUCTURE AVD PL YCTIOYS 17 This matomy of toptred al and therefore the same a that continually prostog on the outakde of the thoracl cage In other words, Its one oftet to the attempt of outuld alr to push to the borry thorax The nunc ultimate ffect would be got by my other occupying material of the alreoli 9 pneumonic exudate long the preure to the ume Thn we shall see to an important pobot In the diferentlal dlagnosh of chat dibex The macho fibra continue along the bronchiolo respiratorius od At Readily stronger imill we reach the last page that can be wid i be lumin where ne mint not they for wh by becoming clecolar only botond i longitudinal and circular eplanes many fundamenub of normal physiologzallog motement und of the changer løtlused by dbeste procena By the act of Inspiration there to a lengthening of the muscle fibres throughout the whole bronchul tree as far as the xonus thus thereu tretchmg and opening of Excelentettuning huren The muscle to mooth musc! and so maintains movements along the bronchil even when the long to treat thus keep my oth fout of al to th al coll with m actlon Imilar to that of the bagpipe Dertruction of mol in the bronctilalm 11 the efore of serious COTAL Cortice to the actnl their residual alr is dot malntained and they are apt to collapse Muuel span in sa h dikeases asthurna hay ako retion offect the teady opum induced by the locate een dorthglang rest accentuated by the mos metus of operation, and is communicated to the rcular fibres which lount I le chion over the entranx to the acim The patient ha there ro Inwentng dutrese in bis ufficulty in ma nurning suffie kant rekhul Ir Such in de tion to his ready establnhed emphysema plus the tren y most often noted in the boru bual whme of the chiruni broncholic The point will be betrumentood When we consider the effects of cohjesma Elastic bruke continues Il the way to the col fmihing roumd cach x If it were net hag round temo ball tnt nous from the muin ronchill diskon in the med latinum hxcts may be comblertd as it point finchorage Inhape on natant LTE in my direction throughout the funt held by the ar in the al coll What thb como t b that the now ai cach 1 colunt il small dostenible black which hay trophysiologlul effects In It keep up teraton on the Latic to wo that the pull on the anchongi konstant and therefore the long to inay atempting to retrat tonarts tbe h hom t I ·18 THE ALVEOLI STRUCTURE AND FUNCTIONS wall Second it has a marted effect on the itrength of the outmod pul of the presure to the plearl cavity which is below that of tho troosphere and I therefore alled the sub-utmospheric or negedre fatrapleural proure The malateruence of raldual air at detonito 41 level is thus necenity for proper por sloboglal working of the lug both at rext and during the act of inspiration If It to cut off by blockage of to supplying chanel or destroyed by the breaking dow of its drcolar confirming wolle wo aball find definite change in tho pouldan of the lunag and the med Lettum A few samples will h Ip la to understand the ultrate effects of certats diverse pro Fm. 22 Ali Atr promoting on the best comes by noting the phylological effect of thell" pathological changes on lang A2. Abr la treola AL Lp #omata clarity broochu. C Interpol per (c) Destruction of chotic terme along the bronchial will occurs in bronchlectual and tuberculosis As some of the tension is the removed from the palat of anchorage of the clustic Harue at the main bronchial dirblon in the mediasdom the lung medial to such a break to comtinaity tends to contruct towards the hillon (b) Destruction of musclo in the bronchla) wall is seen in tuber culori and broochiectuh ur is not maintained in those lobulos dependent for rupply on the affected bruch because the bagpłpc uction of the smooth mucle has been last md the and resilt b the ane w in (a). () Cutting off roadual air which Inaintain the stretch on the clatíc rurround of the alveoli bappers if anything blocta the supplying lumen pu blood or e forelgn body That happen to azalt phthals Tuberculous material from dressed alrcoll enteri and later bloco the bronchłole supplying them Empty or calls then collapse those that still contain material organize and 11] lose their outward pall on the mediatinum The ucini ure bound together into lobula by connective thatoo tepta Thla comective than which runs throughout the lungs a abeath accompanying the bronchial distribution acts the bapporting Tracture It bloda bundles of wr-cells together lato Lobulas ind ucta o barrier which triest confonc dbesc to ·THE ALVEOLI STRUCTURE AND PUNCTIONS 19 these mall secton of luog substance The function It can performs because it is rich in blood supply able to mul edly to raponse to Irritation thua ghing inflammation is the coldce of rabstance Continued inflammation however bring pouch Increnc in celb which are later permeated by Dew capulita from the rollen blood reseb The repult to the formation of fibroblastic cells which oblitetue the per capillario to that Dature inttempt at ropar of the damage leads to thiendial fibrosis Such repair thue 1 fraught with demper to the broochi and the parenchyma What w formerly rellent supporting structure be now i fbrotd and restrictog bood which impedo the normal cIpanskom md elongation of the bronchi with trapiration It ako Interfere with the blood supph of the branchial artery which runs through it Further by lo abrolage it pull on the suttomding lobula through the supporthg wepte with which it b cor Dected In lu drzced stoga ucho are seen in bronchiectwo the traction can actually obliterat aheall by crushing them This combloed action of coortriction of the bronchi mod destruct loo, and connequent collen of nearby bobukes to well dem. onstrated in the film of carly bronchiectab Wem ke that the bronchi of the Inner bundle of the right Lower Lobe art crowd ed together just out asde the lower third of the Hght candlac border The outline are congested and the Larged so that they are mach more prominent than normal d Taal. Eesty breacheco Crondonga know there has been broocantoroptv wght dettraction of the lobaks in thei lonxdhate berghbourhood becane find the talon of lung markings in th out tone of the long where competisatory emphaana has mal d ·20 THE ALI EOLI STRUCTURE AND FUNCTIONS Later we shall lam that increase to commective tlaue round the bronchits one cause of the Increase in the normal struation on the film, and that it gives chancterfatic dry crepitation when we laten by stethoscope The Supporting Structure of the Lobulo The connecting septa round lobula can be so datended that it breaks down in the dweud of emphysema This can be recognized on the film # a low of normal marking to this point wo shall return more fully Later in our studies on applied pathology It can also be broken do vn by septic material lo iu blood venelas when this la carried to them a emboll from an infected focus in thu my many small scattered abecenser can ppear throughout the connective tissue over Large area of the long in the daeace of pyamla Lymphatic Supply Lyrophatto are in abundant supply in the connective thorne round the lobales Ther presence explains the fint steps in the pathogerels of certam lung dbenes The whole system in the lung is divided into two sets a superficial and a deep which communkato with each other in the pleure and at the hilum The superficial set lle In the pleun which we shall comelder Liter The decp met runs with erery subdivision of the bronchl the pulmonary artery and the pobomary reina endø It follows that ibe connectire toue between the lobules hus metceedingly sch lymplute nupply This connatre tbve upply is final), ked with lyo po spaces that bathe Indi kual acini and of the fact nc must make cipecial note wit ba by tho route that tubercle bucllll finally enter the long parenchyma in adult phthbls The bachill crculate and multiply in the lymph spaces from which they penetrate the wall of the alr-celli All lympbold toue in the body is meant to be a protecting facto both at the point of any disease process where It acts as an abworbent gent and also in It canal stem whereby actul body Imitants and thelr products may be arried to the glade In other word the glands are the drains the lymph channcha ur We see these lyroph channels act a 1 comeyor oystem in ylicob they transport dust-containing cells from the alveoll to the lymph spaces round the acinl from there to the the gutteri ·THE ALVEOLI STRUCTURE AND FUNCTIONS 21 All lug coomealre the lymphatio and thence by pert-racular and pertbronchial chamel to the lymph gland's Lymphold thosue carros out the same function in childhood tubercukoek drainby the primary focus to the gloods in the hilam But ta ndalt tuberculosis of the proliferative type w see that it be the lymph spaces y con the alreoll that start the first reaction towards the production of the echar laslon not only d the lymph pace fal to perform thel proper function in this case but they actually break down to become culture ground for tho in ding bacili lymphold timco Increases with age It to the breedhong ground fr that whepread form of tubercl known a senlle phthis But it KITA to do Its utmost to revert Ita protective power Tho pathent i no Littl upret constitutionally that he may be a dangeroth but aspected carrier of the discute ad u often treated for what he appean to be a chronic bronchitka The Blood Supply The al coll reery rich in blood supply the final capillaries of the pulmonary ant y benog wo numerous at be component of their wil while their connecting and blooding spta or more the Then an almost equally abundant supply nutrithe tweelin derted from the bronchul artery The dbtnbution of these arterias explaire many points of difficulty m chet decres and belpatos to und ratand many of the marlings on ruumal and abnormal klagram The function of th pulmonary artery box oxygenation of the blood It originate from the right tricke ind under the rch of the sorta di kley Int It Hight and left branches At the biluun the Hight brandalas in front of the right be bronchor the left brandt ut bo the left main bronchus It follon there fure that the malo pulmonary artery and branchey enter in In the long cach arterir llons the bronch hng behind and lightly lateral to them in all their sub-dn bakom They are the pode ** noted n the last hater to the brombul doutbution. murt remember hones that while close to the h hon the art n and the bronhus are practicall the site are the urtet Text In she et Ext a compared with the bronkhor and to At many more hranches within the same dotac thbbwhy when look ting at an abnormal blm cant lhethe the radialloro of translucens, we in Areal blord neb or bronchi Atrean ·22 TPE ALVROLI STRUCTURE AND FUNCTIONS Within a distance of an inch towards the middle of the lung field bronchus might be seen a continuou parallel Lines with no bruches while in urtery will not to appear By the time the pulmonary artertal rub-divblon has rached in actous It has only about one fifth of the diameter of the nupplying bronchiole to the Ureolus We mut remember however the the arteriet aanbe materially changed in size by rurou dbenos The in congortive fallure they may be considerably swollen they then give increded soft marking generalized throoghout the hing fields and leaning towards the peripheries of the filmo The opposite effect can be noted in conditions assoclated with extreme mamia where ther thin flaced tubes are indistinguisbable from the normal striatloos of connective throse Th changu nill of course be scconpepled by relative changes in the shape od obce of the curdlac shadow and be apparent in both lung fields The function of the bronchial artery to bring Decemary nutrition to the framework of the long That for the night long coma uually from the thoracic sorta but occasionally from the first or third intercostal artery the left supply how mually two origins from the thoracko sorta. It ta important to remember the difference of ongth of the pulmonary and bronchial supplier the Litter - direct from the main arterial perkel let the higher pressure so a wound or other came of a break in its wall can prove much more japidly fatal than tho involvement of materiale from the pulmonary artery As soon u the bronchial arterdes enter the long they enter the connective tue Layer round the bronchi two or three subdivisions accompanying ach broochtal branching The bow by any condition increwing blood supply has the powlbilder of marked effect on the bronchial walls why such conditions of long+tanding inflammaton : chronic bronchitts and bronchiectos con ne the havoc of fibrosis round the bronchi affected in the dbcoe Here we have the exploration for the film of chronk bronchitis The nomal supply from the bronchialartery a very rich When this sopply bewolken by chronic inflammation, and brings the consequent deposition of fibroblasts we get the elderice on the film in the appearance of parallel lino in the affected are outlolog We can the larger broochi in the lower DODA of the long fickle find the name effect in other parts of the lung In other daca in the upper tones In chronic pulmonary tuberculos ·THE ALVEOLI STRUCTURE AND FUNCTIONS 23 Soch rich blood supply is the reason *by quite severe hemor phage can occur by eren trall abrasion of the brandulal mall by Irritant material inspired Into the reallast divisalons of the bronchi trecj and why the breaking down of the bronchial mall in bronchitec tush can prodoc the biggest or I harportbager to lung disease ·CHAPTER IL THE PLEURA AND THE DIAPHRAGM They do The pleura is in two layers connecting at the hiluma Tho Got or visceral layer is closely applied to the long It reflects at tho hilum to form the second or parietal layer which lines the Inno carface of the structures Internal to the thoracic cags, and the dupbrugm Tho parfetal layer is sensitive Pain and severo shock can occur when u needle is pushed through it in the Induction of artificial pneumothorax, and tho pull of adhesions on Its Inflamed rurface may well be the reason for the acute stabbing pabo with ach respiration In lobar pneumonla The two layen bave between them a potential space not adhere In health but more cually on each other by vince of a thin lining of scrous fluid in which the viceral layer aan olide on the parletal In the space there is a preure which is negative In that it is below that of the atmosphere a needle inserted in this spaco and connected with a water manometer shows that the pressure varies on an averago between — 10 cm of water premature with inspiration and — 5 cm with explratlon It th refore exerts 1 contant outward pull on the clastic tbsue of the lung, adding to that of the ruldual air in the alycoll esch inspiration adds to the pull thus lengthening and opening up the bronchl to receio tbe inhaled air It follow that any pathological alteration of tho negativo intrapleural premuro has a marked effect on the elastic tissue of the lung If it bo reduced to the level of etidospheric posure by al in paeumothorax or fuld in pleural effission the long minat tend to recede to the anchorage of its elastic tone at the bilum retracting to olzo len than that of completo expiration The stretch on the elastic Hlove of the long is now maintained only by th rabdual alreolar dr Rabatng of the pressure boo that of the atmosphere mod therefore above that of randulal will bring presoro collapse of the alveoll and consequent still further retrac Hon of the lumg for now the pull of the al coll on the bronchli clutc tlwue la belng lemned As we shall see later when dhe coulng the medlastinum there are the ruling factor in the di placement of mediastinal structures to pleurtry with effusion ·TIIB PLEURA AYD THE DIAPHRAGJI 23 In going round the long a described she beni pleura dhe between the lobes lloing the under surface of the one abone od the upper garface of that belon It One och lining, may spear on a normal portero-terior Elen of the chest It is the lesser wure betreen the upper and middle boabey of the night long, and It shows a a thin barlik ke running out alizout lotionally from the bikim in the third o fourth nib-interpce Sometimes It cau a double line as the X raye bare cut across it tangentball Ito position is exally recognized when it be forced spart by Plustel or ius rida lymphutke supple a Infined or thickened n anh dhemen * poseumonia lang abscen and tuberculosta Na Ex seen on the postero-Merfor Nm its location and direction hould be noted carefully this mas gran dication of doctose process that can be clarified only by further film exemination yg Lasersi film This it is displaced opnares and towards the infazla xule tutte in collapse of the right upper lobe Other pasuroy do not allow on the normal portero anterior film and it taky tal lateral or fondorse films to show their im komment its pabalogical onditions Some todenu fond dtxculty in the Interpretation of bnormal Flow because they rget that the interlola fissur the bulic them are bare the pomu of Return of the pleura which ma completely ring any loke mat melomaly comer by the rectal Lay the lewering trungular edge Lnonns the ligula The shadow cast by normal ling being but the uperingard shadows of a none arutus Irom front To back on the port romteriorblm It follow that drranty of hadow in der loped kobar pneumonia arhes by depth of tissue and not by interesis of doethe walch » equal to the bund and the longues of the ffected babe cutut mapect dhe shkost of right apper Laber meumonia to be a desire in ju bonet limit us on it upper besatse be bobe him out comedetabh * it pon dan paras * recogalie mikille babe parution because It has a dere handlow in the right med tunc warb kans adiri n rate the base o that though its lon an ve the right duphragm 11 ·THE PLEURA AND THE DIAPHRAGV at the upper This explains too why colluplng bobes cat characteristik thadons why the lever Interlobar farure throna a henry dernity upwards and outwards as the Hingule receda on to It In right upper lobe collapse Utewik we realize that ben a Hght lower lobe collupees the ligula has already shrink dowwerde a long way before we Ree on the film the upper limit of tbe lobe defined by a linc running down Harde and outwards towards the Conto-phrenic angle from a polot of the right auricle on the right alde of the cardiac ahadow (co Fg 86) P4 25 Prewoon' or be right modelle The position of these fissures in bobc, mod of the kant lower lobe. the lateral film is decurred in Chapter V With such changes in shape of lobes we shall leam to correlato changes in the normal strlations that appear on the film by shadow of vascular supply and supporting structure Then we ho carente noted that in Highe upper lobe collapse we can no longer see the three normal branchings of the pulmonary artery which supply it, while in the rest of the lung field we shall find spread out much more horizontally than normal the blood vects of the middle od lower lobes which have been blown out by complementary emphytetoa to occupy the spaco vacated by the shrunk upper lobe In the empbyrematous aree re shall at the same time find mach Increased translucepcy against the normal because the aupporting structure of the realcles is considerably stretched We therefore make our diamond by noting two opporlte process lacreated dersity and increascal tremelucancys on whh loos of blood supply the other with spread of blood supply and of supporting atrxture In other words where we suspect a change in one type of long strlation we must look for a corresponding change in the other and If we fall to fund one in the presence of another on a posters mterfor film we must make other investigations such the tilting of Lateral films or the injection of liptódol Thus in complete collapec f the left lower lobe te may see on the portero anterior film only the gross emphysema of the upper lobe filling the ·THE PLEURA AYD THE DIAPHRAGA 27 bemi thorus we may not be reebog the collapsed lobe because it is completely hidden by the cardiac shadow ile taken to the postero-Interior and later position before and fter the injection ofl plodol will ald in the diagnols The Diaphragm The diaphragm to the most troportant muscle in respirethon and therefore next to the beart the most important muscl fo the mantauance of life It consist of thin, mor ble partition lying between the thoru od the abdominal contents It is convex upwards for Hght half being oughtly higher than ts left and takty . position ſwot below the nipple at torpirat ret There to central tendinou very trong portion and three fleshy portions which me from the bath sternum ord the spin and art therefore named coutal t mal od rert bral of these we must Doto especially th contal; Its orlytra are from the tromer surface of the lower itx corbal artilages on cach ald When th duph rigm is deprewed they may be keen on a postero-enterfor film in thel dbphragmatic Insertion a depressions between convexither the f moing miles of ad such plcture while commoner in cophycema does not nece arily como ny docese procen They or sometimes wrongly interpreted as erlence of boulon of old pleurity fthere I really adhesion of the dbphng there will bo no clear outline but mergting of hung shadon, Into the decper demily the muscle These pormal alternloos in the dome may ako be coolued ttb ibe ery common finding of tent lil shadow that it on the dlaphragm about Ius middl thd This is the end reruh of plural reaction to the main focure The central tendinous portion may appear hump on the middle of the dipinto it is without loucal onlficance but may require Fra X. To corta Imestigation almost the comparati ly rare Vad be pleural growth that can desclop at this point Leptiring By the contraction of lu fleshy portions through the action of the phrenic an the diaphragm becomes les como ad no Increan the Ttkal duameter of the tborn In Inspiration In ordinary brenhing this range of mosenknt bout three-quarten ·26 THR PLEURA AND THE DIAPHRAGJI This explains too why collapaing lobet cant chancterliche thadons why the lever Interlobur fissure throws a hatty denety upwards and outward at the fingula tecedor on to it in Hgbt upper lobe collapse Likewise pre realize that when a night lorer lobe collapse the lingula has already thrink downward long may before we see on the film the upper limit of the lobe defined by a line running down wards and outwards towards the costo phrenic angle from u potat at the uppe edge of the night aurich on the right side of the cardiac ebadow (Lee Fig") Po 25. Pour of the night ankletle The position of these fourche lobe od other lett lorer lobe. the Lateral film to dhewed to Chapter V With such changes in shape of lobes we shall leam to correlate changes in the normal struations that appear on the film by shadon of vascular rupply and supporting atracture Thus we hnie already Doted that in right upper lobe collapse we cam no longer see the three normal branchings of the pulmonary artery which supply # while in the rest of the hmg field we shall find spread out much more borizontally tham normal the blood vessels of the middle me lower lobes' mhich have been blown out by courplementary Emphysema to occupy the space vacated by the shrink upper lobe In this emphysematous area we shall at the same time &nd much lbcrtued translucency as against the normal because the supporting structure of the voiclab coralderably stretched We therefore make our dlagrionta by noting two oppoolte proceset letrated denalty and increased troslucony one with low of blood supply the other with spread of blood oupply and of supporting structure In other words where we suspect a change in one cope of her stration ne miat look for a corresponding change in the other and if we fail to find otse In the presence of another ons, posters anterior film we must make other Inregigations such as the taking of Lateral filma or the injection of lipadol Thus in complete collapte of the left loret lobe xe may vet on the postero-osterior film only the grou antime of the upper lobe fillong the ·It b con a 27 TIIE PLEURI AND THE DIAPHRAG11 bemi-thorax; we may not be seeing the collapsed lobe because it to complet ly bucken by the cardbc shadow film alen in the porteromterkt ood Lateral positions before and after the injection of liptocol - Ill ald in the diagnol The Diaphragor The daphragm to the most important muscle in respiration and therefore next to the heart the most important muscle for the maintenance of life It conukels of thin morable partition hy mg between the thoru od the belommal content qards its nght half betong lightly higher than lis left and taking pooltlon Just below the nipple at respiratory rest There ba central, tendinou ery strong portion and threr lahy portions which come from the inibe the temum, ard the spine md are therefore mamed costal ternal md vertebral Of there we must not copecially the costal its origira re from the inner urfaces of the lon r abx costal cart lages on xh ed When the diapb- Tagmal depread they may be seen on a postero-ant sor film in their daphragmatk inacrtione' depremtons between comvelties thus forming cerkes of were ad ruch picture while commoner in cmphyserra does not nec urlly coruote my docx procem They are sometimes wrongly, nt rpreted a cidence of dbalone or fold pluray. If there is really adhesion of the diphragm there will be no clear outline bat merging of lune shadom foto the decper density of the muscle Tbene normal lterations in the dooxe may abo be confused with the ery common fuding of a tent lik shadow that it on the dlaphragm about its mildle third Thbo b the end rooh of a pleural rextion in the main forure The moral tendinous portion may appear as hump on the middle of the dlaphing to witboat maal bgafficace but may require Pro * The peal Im estoperion gabut the comparati ch nare pleural growth that can det lop at the port deponga By the contraction of u fleshy porucne through the action of the phrenic Dert the dlaphragm becomes les convek and to Increases the ential dumeter the thoru in inspiration m ordtrary breathing the range of monement bout three-quarten Dorto the ·28 THE PLEURA AND THE DIAPHRAGM of an inch and in every examination of the chest It should be looked for by peicimulon of the lung bases posteriorly and in the udlo uince deep inspiration should move the dlaphrago down wards by at lent a finger 1 breadth u zbown by the higher pitch of descending ar-containtog lung It follo y that interference with the phrenic perve it to point throughout its couro over the cupola and past the hillum to the insertion of it fibra will cause ilme of the diaphngm Evidence of this la common powdays in the filma of patients in whom the nerre has been crushed or erubed aatraatment forpulmonary tuberculosbe Such filtru deroonstrate that the diaphragm mores downwards In Inspiration exerta dbalnet pull on the apes of the lung, for when it is immobilized on rpial tuberculows Leston uhrink od gets the rest It requlre to ald healing Adbolon between 16 pleura lining and the visceral pleura of the lobes to contact with It will for tho dlaphragm while eropbyucuma wih deprea and flatten It Contraction of the hing by low or clasticity will cause it to be eg in collapse of the right middle lobe Tho recognition of roch changes in ito poaldian and more ment by physical and film onmination can therefore be of very dutfact help in the dlagdosis of underlying lung dlcare It ·CHAPTER IV LUNG AND MEDLASTINAL MOVEMENT IN HEALTH AND DISEASE The medwstbrum na spuce running mtero-post story to the mal loc of the thorax between the sternum and the spine It shows on the portero anterior film as the shadow of parts of o contents so that we can hennfy the rx.be to point just above Ius bifurcation the outline of the ardhac hudow the morte Dotch, and the structures that mak up ach hitum Awhe already noted all these melletinal tructares re embedded treolat taste which coren and btnes them together but yet a clate in composition, so that it comes with ou le and diant le of the heart and the great blood ewek Where already pored too that it > cosmected by the lay r of pretracheal fascia with the investing facua of the structures in the neck and that thereby its displacement to one other ud of its central position is relected to an tetraed teibion of the tendinous portion of the st momentos muscle on the same roke Again aw that the seedlastinum hu awal point on which hinge wed that the trache san mos Laterally both ebon and below the hunger for example that can be definitely Inked by diseme locallied in the parerxchryma below ibre collar bone The heart a duplaced much low reud hy A mub bener tructure thes its greatest neight in the lower medt mion so that it be moved laterally only by done condon the lower half of the thora or throughout axe whole and of the thonu Thus the pa beat as seldom brormal m portion in tuberculosis of one upper lobe but it can be mond quite markedly t the oppoute alde in the presence at pleural effusion and to the me ade in post-preumonk fibross this being decae which commonly affectibe whole of one lung field An mportant point to not that the heart wing rond los long uk makch more readily than twill more laterally The explans the romake outline i prevents in th normalabnormality of'kolloss which b# it uwi concat ty to the left In lymg into tabs hollow the heart owing on its long ex night border 20 ·LUNG AND MEDIASTINAL ASOF EVENT recoding and its left border coming forward to betoging the pulmonary coon on the left side Into undue prominence and Flo, 77 Plutad sobomba with corrachy to the right uncovering the right hilar region On the postero-roterfor filo there is therefore a filling in of the normal trlangle of tremalucente that has its aper between the sortic potch and ibe normal prome nence of the conut giving an outlino that olmulates that of mistral stenorth on the left side while the shadows of the right Whum and of the branches of the pulmonary estety to the right lower bobo stand out prominently' soch abnormalities might be read evidence of dbene If we did not note the accompanying widenta of the nght lower Hib-Interspucos and the composting fall of the left lower rib-interspacos We can see too why it to by the tendency to swing on lu long and that the position of the heart *t replatory raat may mblead us in auch adbene a collapse of the Hght lower lobe As It shrinks from ruch a cause x broochiul arcinoma the lobe goes downwards Inwarda od bach words and Sauses the heart to swing on ito lang axis so that the right loner с ·31 LUNG AND DIEDLASTINAL BIOI EVENT border recedes towards the spine the left lon et border comes formand Lat r the whole beirt pocs backwards If we have to rely on physical signs for our diagnose * xhall often find more help ton and the opinion that the mediastinum is affected by nottig the tense right stemo-matold then by concluding anything from the position of the apex beat If* can watch the patient on the Kreen homesct we shall see the heart more laterally md bodily to the right in its lower half with cach treptration and come back to its former position with expiration this la becawe the matn plural premure becomes more negatie at each trupiration and drag the whole medlastinum tomards the periphery A little Later we shall see why the beart goes backwards in collapse of the right or left lower lobe Experience show that mobility of medwstinal atructures arles conabilerably in different individuals The promure in the pleural arity in two subjects may be the same Judged by the ume m.mometer in conditions as nearly equal >> we can mak them yet the amount of deplacement from normal a dacne of comingly equal extent may be entirely different In one small pneumothor an great bulging of the ant rar med bantinum in mother it will hardly more this area This means that the meduttrum & never fue id innurlable ont tym cannot by working backwards & an infallible estimat of the amount f Img dhene borg bling it on the amount of medwatinal shift and all we can uy to that some damage has taken place On the other hand must reallre that dincm of the med lastinum can bere definit stiffening effect thkloning of the med wat time pleun can combat pertpheral changes of prenure Thus we may get much more fallmg m of Hbe and rating of the dlaphragm than w would expect from the amount of damage esdent in the parenchyma The mediatinton mort im ) be entkaged one entity not a womething m two babes one for ach bemi-thora It hono central lok tructure both maintaining and being maintined by one more thoracic preure If there fall of premure on one Ahde of the thoru there o an immedute De on the other Fibrosis on the right implica cumphryarth on the left Now w can understand why the best post backwards in right lower lobe collopee The pronunc in the right boner medwothum lencsed It como per up normal reslatorce to the pressure in the left bon medasthumth the retult that the left lower utomati ·32 LUNG AND MEDIASTINAL MOVEMENT in three way D lobe more across the front of the beat and pushes it backward. We are now in a position to sum up our coolerations of pplied Anatomy to discuss the action of the various hng and intra pletoral forca on the mediatinum in health and see box they state ach other and on this control eluth structure in diese In the accompanying dlagrim, D represents the mediatinum A prezenta utmospheric pretture which acts (1) As proming in on the chest wall (1) As 1, the pressure of residual alr In the alveoli we have seen that this is maintained by the bagpipe action of the mooth price of the broochi Az ects in acry direction throughout the fung fielde prossing painst the pert A2B phery the diaphragm and the Fra 21 The force to mediatorum We besc ft on the medicum demonatrate its force aga tout the Ai Air Pro use an chox mediatinum in collapse of the A2 Air on throun. Hght lower lobe It ako presse A3. Air pored into brooch on surrounding alrcoll so if it be Lout in any area the surrounding C. In plan prore. D Medicom alrcoll immediately dotend, giving localized emphysemana (3) As A, the alr entering by the main bronchu represents th elastic istue of the long, which runs with av Ty bronchial divokon from the hllum to th dreoli The more picco of chotic stretched the more It tria to contract to its As himg clastic Hade is on constant stretch by the action of the rolul ur in the arcoll (12) It s always attempt to pull th long inwards to its anchorage at th hilum, where it is contmoon with the elastic there of the tracbea Therefore in proportion with the datruction of the Latic tbwaeth lung wil always contract townd the hilum C represent the sub-ataxopheric negatiic prendre the plean arity This acrta steady outward pull on the lung, and to increased with each implration Aguln we must remind oneha that all these force are acting to exactly the opposite direction against the mediathum on the B. Elor to fixed point ·opposite side ten LUNG AND JIEDIASTINAL VOVEMENT Ay on the right poshing to the left Az on the left is pushing to the right Thus the central balanced posttion of the mediantinal structures Let us now consider cumples of discute conditions affecting each of these fxton and see how they reut on the mediatimum Ab coracant factor m all ordboary conditions of life in health and obene A may lter by much conditions de ( ) blockage of the bronchuss through arcinoma or septic careated met mal (2) destruction of the acull as in tuberculow of adult og pe There H therefore los otroxual air A balor reatmce offered to it to the hom thorax tends to shrink and the ribs tend to fall There is les restance to the dlaphragm so it will risc higher t rest and with complet expi atkin There ! los rabtance to neighbouring lveoli and so they show emphy There la rentance to the medlemum vo the forer on the opposito end * u prish the malurtinum to the diseaed de Hnally there has low pull on the clothc totue anchored to the trachea through the mam bronchus and no the long will retract t the hilum and this means that Cho now anh lan opposed mnd drugs the whole long outwarde W uw n extremod cxample of the action to the detailed discium bonos f what happens In collapse of the nght kommer lobe We noted that the former balf of the mountinum ratudmg the lowe half of the heart, wings out to the nght with eact Topmotion, and come back to mort entral position with each expiration We can represent the ti a imple luxe dr mong (sce hg 28) remembering that I procent cing cqually in the r vere direction n the oppout hemi-thony A w destroyed B therefo thotnie towards D C now mopposed puilla B and D outwards The meduntmun therefo dnils to the side of the utekettub, tbe umount depending on how moach of Ag be destroyed We see now why to that we get por the Hemomistond Ige with low freindul a It to not due directly to the collapsed Unse but to suh lmg tbc remains affected and dragged over bod ly by the mtra-pleura] prostre its dry to communicated to the trachea. If we tare followed these arguments w cm me why much dbcwrs u met nal tuberculouso broochiectata mot dupla the mediasztorum to the side of the losion ·34 LUNG AND MEDIA STIMAL VOVEMENT Isterno- We have here too an explanation of cavity formation There is marked localized loss of elastic tior by organlation and collapse of lobules and therefore love of the presure of their residul air Immedlately surrounding lobulos art mopposed in their own Inherent premuro and blow out to become cmphysematous and to their weakened wall are dragged In crery direction towards the periphery both by those cxtemal to them mod by the Intra pleura) propure Apart altogether from my extension of the actual duene process there to physical force behind the production of increasing carltation It is poaible to follow now why dicses which replace reskiol ur by material which keeps the alreolar wall distended caloc mo duplacement of the medlastinum umle they overfill the resicles and o pull the mediatinum a little towards them Pneumonia fills the alreoli with exodate they cannot move but they keq the clatic Hosue of the lung on stretch a full inspiration does. Therefore uncomplicated lobar pneunonla does not gi matold ugn nor does an uncompliated abacem of lung which u we shall ducas later is merely , filling of lobules by Inspired Kepti material Tuberculosis on the other band will do wo It destroy th alcooli Collapse of the long does it taka andy ruldul ur We he e therefore here very dutinct ald towards diff rential diagnols Let us now consider dneve conditions affecting the sub atmospheric Degative intra pleural pressure If we ha e a cum of adhel e pleurisy C dlappeen A now attempts to fill the spaco rated by C and drags B and therefore D with it get positive ternomastoid sign on th same side o the dease If fuld or alr ent n the plural spac to remov the negatic pressure and bring it to zero A, donc maintay stretch on B the long retract to th hitum and do not mored outwards by Inesplntion But the force in the opposite pleurla ity is com pondingly greater and so we have i drag to the opposite kde on which the stemomatold sign will be positive In other rels it does not require actual push from the right to a right-uded pleural effilon, to produce mediastinal displacement to the lift If the intra-pleurl presure the above tmospheric by In crening alr or huid it will be greater than Az The lungs now puhal bn by presure collapse The outward pull of A, ks lost to Biblch retracta dll more towards D Thus fuld to the right pleural cavity pushes on the mediatimum ad t the same time ас ·LUNG AYD NEDLASTINAL VOI EVENT 35 th pull from th lit du till more strengthened nd we baro DOW very mahed left t momatold tenslon Much will depend non the condition of B If there is much 6bror's of ling opposing th Latity of Bth lung will not retract to th mediat num D but only mo e towards D if it poohed on bodily Thua a poeumothon wh h compliata established pulmonary tuberculosis con gl e muh more doplacement f tho med stor on than Imple non tuberculou pneumothorax which doe to ruptur of bulla The luong without dbene collipsei qut readily If i llom the explanatio flung and mediastinal movement we shall be in a better posloon to understand th phyiial and X ny bgn of tbove commone chest desses whose pathological hoger are consld red i Section !

·CHAPTER V out THE NORMAL CHEST FILM A Pull understanding of what comtitutes i normal film of the chest bo necealty for the student who bopes to interpret the abruormal The following description relates only to the points on postero-interior and lateral film which concern the average practuing phyiclan. It does not go into all the finer detall which concerns the speciellast chest phyichan the cardiologist or th pure radiologist, which detall the stodent may ford to pechalized text boola It tha to set forth only those polots which the pbyalclan can correlate with his physical alga od thelr canoat pathology so that he can go beyond the noxerely objectivo reading of abnormal lang abandows Some praltmimary observations on prime principles must be wet Thus we have already noted that a film is merely a composte photograph of uperimposed abudows of varlowa structure through which the rin pan With shadows of disewe at any onc depth we shall therefore see the shadows of normal structures in front ! of or behind then An early adult tuberculow focuu to com pletely bomogeneous to tomograph cumination and much more defined on an antero-posterior than on a postero-anterior film. On this Lat film It muy yppen to be strated because being posterior lakon it Lubown with much normal lung fa front of it, md such normal lung will now throw ito strations in greater compantive relief gainst the background of the dieze toca In tho ume way we shall sec vurying obedom of bronchopulmonary segment in the lung fields If It be supplied by Laterally directed bronchiole this cone of time will postero-unterlor film o trlangle with ita apes at the point of entry of the bronchlolo If it be supplied by a bronchiole that goes domully it will ppear circular or oval or photographed along line between lo per and the centre of Ito circular base A good film is the result of good posluioning proper exponere # fodgod by muscular development of the rubject and good processing Although the result is by no means a sturtoscope picture there u no doubt in the mind of the writer that viewing auch a film but at close quarter and then at a donance of Hono appear on the ·THE NORMAL POSTERO ANTERIOR FILM s feet will tell the obecniet touch of the compoltlon of bmormal shadone if not of thelr depth in the log fello Of Late years medial literature has abond much leuk anlation k the objecthzod interpretative reading of chest dbrose because certain criteria of a good postero-mtento film have been more or less generally accepted There are that it may show the boxer fare of the night long to the third o fourth lotertpace that it should show the wuperlor rena ar with dens ty lightly low thm that of the hart, and that t mat show the bodom i of the branches of the pulmonary urteria radulog from the hul through out some three-quarten of the lumg fields It must be bome in mind that the hila shad are themselves predominantly xular As the pulmonary Herkes and cene the main part of the rather indefost semi-circular opacity on chade of the carduoc Ahadow It follom that the opaciry will boc incremcd by all conditions duracteraed by bypertamla Seeing the left one be already denset by the promuence of the conus to the normal abnormality of scollons such a condition - bronchopneumonia in kolloxic subfect will produce ery heavy left bllar detalty both durtne the acute tee of the decat ord for long after inal recovery The Normal Postero-enterior Flm Th first lemon the student muut leam to read cv ry film pormal and abnormal on definit pre-trtonged plan if this bo not done consistently to the exqert oben er pray fund bwg has been urrated by some striking area of demnity or contrast or by one Interestig detall in on area of the long fickla od that bo hos mined on aboortoality fleuet extent or contrast that la nevertheless of the first mportance in dlagpont For example • fillog in of one costo-pbredlc ngle is dependent fr the inter pretation of its real ignificance on the presence o abrence of We bay already noted how * gnrt mistake may be made in the futerpretation of th film fuglarpl scollowed to do not conect the narations in the heart outline mod the right hilar shadows with the changes in size of the lower rb mtr pace A simple plane w to ed nery postero-mterior film woder the following reven beadng The thoracic cage The trachea; hape od poulton long focus ·The heart size shape and poaltion The dlaphragm pooltion and contour The upper mones of the lung fields The middle zona The lower 2010 comparing the right with the left in each care The Thoracic cage 1 The fint thing the student of chat films should leam bo to recognize the shadows of the bony thorax and those of mascle fucla and skin that can appear on a normal film The ribs aro seen more clearly or low larly than normal to certain pleunal and lung Alexa Tuberculous pleural effusion duploca the long shadowy inwards through the even tight long of translucency cast by the full in the periphery the Hba abort more clearly than nonu! Th y are still more prominent in the film of pneumothorax in empyera and pneumonia they are le prominent owing to the demac shadows thrown by those dood The anterior ends of the Nba often continue into the shadow of caklication of cartilage which is more dense and low evan, ko Pia 2 Ton of toner andere and reconchillo ·TITE THORACIC CAGE 19 Froo On the hat mencker-dadleped frut me. On the hot be und pocket on td wood nbu nben ommon that com mulut the shadow cast by pulmonary dsede especially tuberculosbe Uowlly the ondition to seen n more than one mb Ithough its mo at in the first db Een tben it b Imost Imaya bileceral and to a fairly of old to remembe that hing lalons renarch milar 1 position md characterista on both klas of th hest Funion ad Wuruation the anterlo ad or Speculture may be neonary t doimmut between the hadom nd those of underlying long diwezte TH COTOMODct all these mal abnormal ties forlon of the anterioad the first ad ond ribs Port of it rection and overlapf nbshadow Latin considerable dfficulty The o apecully on at the space where the rlo Tubo below of the Like fobe terroinntold tuba musck and folin and fecual los complicat for ay be locken D + an ·THE NORMAL CHEST FILAI the picture Fig 32 illustrata bon these abadors Dry be recognized That cost by the sterno-mutold musck may need 5 7 F32Dre to wow normal shadow at the per bich many culty meme ne 1 - Stomato 14 min. 2- Corn bbade of bird nok 3 - Shado don to the med letom 4 - Tre Pro of tabel 3-Tip of Anx nb. 6 - Calafation of in contul artibu 7 - Am o decay da to superimportion of the abedoni o tome Crong and mother Natt to the apmon bown on the commode cond bm I Comuto dricka careful crutiny a it lles in the area trvolved in tuberculosbe anging in and around the posterior aplal branch of the upper lobe broncho Bad pooltiontog causes the shadons of the scapulæ to obscure the outer part of the lung fields but these should be rognized u readily o the rounded budom due to the breasts in the lonet pona tn femala The shedo e of the pectoral muscles and thehr blood supply muy give qulte pronounced stilations and boos of tramolocency in the Infraclavicular od mld pong of the king field opeclally, on the Hight side bat generally in this come the lower edge of the pectorali con be seen u a sbarp line running downwards und Inyrds The Trachca Th tracher should be seen a band in front f the votebra Ughtly laclined to th right and with no clearly defined walk. It may be a litt! to one side In Hoollook and to generally seen far as it blfuration at the level of the fifth dorul crtebre.

·THE HEART 8 of the squat ZONES 10 The Heart Ad understanding of the smal card Lax outline is a necessity tnc tt alteration companies md can and in the diagnost of discares which are primartly pulmonary n origti The fol con ing description does not gne FPERT ZONE deta be required for th tudi of primary carduc dbesse MDOLES The ardiac online abono ZONE an opaque pear-shaped shador Txe tramme duameter bo of po LOWER pathological significance unler the beart be of the longitudmal type. It cannot belp where it is transverse type In this Latter ca the outline of the left lower bord to usually Indefinit * the beart is pushed Fro J. Pwants to be Deted radost upwards by the diphragm To the postero-decor Alm of the chant tudent bould learn to recognize that the hadon of such heart lessen steadily from t mid point outwards and not that under its indem te míerior border hecm ull see the density of the dia phragm all the yo the car drophrem angle H will then hry no fear of confusing it with the characterist shadow of low er lobe collope (compare Fig 16 wyd 87) Here there nll be denne lose of translucency filmg the cardiophrenic angle the opacity b equal to thet of the mid-point of the carduc shadow Fro. 44 Crocs bronceador with which the continuous by en boroberto iu oater border is sharply de Lolded morte, plines of the be fimed od Bochnoy of the depling The duphragm does not show defimto lipea outline below it, while the costo-phreni mele is abnormally fee from trutions because it is filled by the empruematous uppe lobe ·42 THE NORMAL CHEST FILAI Thb boold Two memurements are taken in memot of the size of the longitudinal heart - (1) The transverse diameter of the heart that is the distance between two parallel perpendiculars drawn downward from the outermost parts of its shadow (2) The Internal duameter of the chost that to the distance between the outermost point of the thorax ilong and drawn hortzontally just over the Hght dlaphragm For normality (1) should be just under half () Let w now follow the cardiac outline starting at the right upper border and working downwards and following the same order on the left sido The Night upper border is defined by the superior vena cavalos This is ruperimposed on the shadow of the accending morta It has a light low of translucency similar to that of the inferior vena cava that b it be elightly low dense than the main cardic muaclo shadow Below it we find the T shaped shadow of the Hght branch of the pulmonary artery (3) entering into the indistinct semi-circle of the hulum Next coma the border of the Hight aurice (4) Icading to the cardio-phrenic angle be cally recognized but not clear-ct with pronounsed cake In 16 Inner engle we can wally see the downward and outward rweep of the Interior vena an(s) At the upper left border wo find the world knuckle (C), and bolow it the elbow shadow of the left pulmonary artery () then the conos () and finally the outer border of the left ventrick (9) leading to the cardio-phrenlc angle In the angle we may at light down rard and outward loss of translucency comparable to that of the Inferior vena ar this be the pleuro-pericardi! pad of fat In Ito widat part the normal longitudinal bean bs roughly con third of its width to the right and two-thirds to the left of the mid line of the spine This is why the blood supply to the right lower lobe u so much more evident than that to the left lower bobe and why this normal difference is to exaggerated in the nortal abnormality of the bul scolloals vlth its conre ity to the right. The absol tely nomal film has a falrly clear trlang! of trat locency with lo apex Inwards above the coms area which be filled in by a Ilne gi ing apparent continulty between th pulmonary artery and th uppe outer edge of the left veneriche when the com caringforvards in scoliosis Thbh tbc ·THE HEART 43 f mall ut OTKC on eithe bs Normal glande do not appear on film indeed ly the trachea bronchul group and th broocho-pulmonary group glende are uncovered by normal med Laxnal cont nts It l unwire dlagnose alarped glanda onlen they reundo btedly prominent They can be demonstrated only f they placed and the means that they show iganet lung time which they com that they mint ppear on the post ro-antenor film sound th hilum o junt cod r the right upper lobe bronchus between the sortke koucle and the uppe borde of the left entricle The Diaphngo The dlaphragm appen a two clear cut dome-shaped shadow Ide of th cardu shadow acting oth low r limits to th boal tramalucency f the long-fielda The right which shes to the Lxth mterspace Title higher than the left wally to be extent of one Int mece Th blood vowel hadows may be seen to co tinue below it, but nethe in health o durere unless they are injected wth liplodol do see the broochi in the portion Th are two common findings that munt not be read - ovidence of abnormality of Imlal import The first so-called tenting of the diaphragm A small to angle of short besc iting on the diaphngru, rathe bongated pez u Pla 35. Shop Koen towards the innend of the mid potnt brooch den tot of one or other half of the muscl of the drepturum oblandede coco Hight pleural reaction in the mam fame pregle common finding with broocho-pneu monu even when by the history this condition has been of to low-greed that the not upeet th patient afi ently + muk hum week odnice It repairs fo long time a permanently It mut not be read - an dhalon w evdence of long dicke unless defint pulmonary focua baxon when t buy bed contraction of the fibres f the pbrent nery hurch has been mvolved dwebe proces in some part of it course ver th cupola and post the bitum Such parking is nex then t the posltón of th man foued its commodest aur is pral fibroals usually tuberculow to ongla This is and u t ·44 THE NORMAL CHEST FILA The second is a filling in of the costo-phrenic angle on one or other side by an opaque Thadow This is gain a common quence of previous pneumonla or broncho-pneumotla the aubte a the vkcenl layer of the pleun has orgunbred It is not evidence of present lung disease and of no dgnificance unless a long forces la reen with it, in which case It's wually evidence of a secondary pleural reaction to u tuberculou deposit Tho Zones of the Lung Flelds The zona of the lung fields are defined in accordance with the dlagram in Figure 33 The upper dones are the areas lytng between the upper aplica and a line drawn borizontally across the anterior lower code of the second ribs The middle pones lle between the line and one drawn similarly icrow the anterior lower ends of the fourth rhy The lower zona lic between this second horizontal line and the lung beses Theso conca are used to designate the position of any abnottoality Fra 1. Truye lobe ·ZONES OF THE LUNG FIELDS 7 + noted on the film Exch Font should be compared carefully with dos fellow on the Apostte uke before any condillon noted by Jodpod a definite departure from the normal It has already been noted that datant processes are never cantly repeated to oppoolte sonce and that of the emple precaution ha sot employed It bo pomible for the common condition of ald&cation of the fint costal cartilage to be boterpreted a . tuberculona forte Normal lugs upper a dark caith many lipcar murklip chroughout them tuc to the shadow of the malo pulmonary arterul bruncha od to reporting structure of the parencbymua W have seen that the bar the lot of the leper fure can appear in the third or fourth b intenta no other part of the pleon or Ita fissures should appear in a brolutely normal film although it # not tool to fad an my por lobe in the night upper conc Hero fine lae dinida che righer cupola by rumong downwards und inwards to tho upper part of the cardmc border it wlucha point there may appear a well marked but small oral gacity which is the wrygon yeln Food bach the visceral plura ha dipped during development The lobo has a light loss of trans locency on contains leu renkdwal aur than the outer part of the LPner I the Weba already noted that the radiation due to the pulmonary arterial supply go outwarch from each batur which w strelf dwe In most part of its coofused shadow to the main arteries and the pulmonary retos Along their course and also lessening stendur towards the periphery me muy cer Rand opaque shadow of blood remek canight ad-on by the rays they go back marca In the urey while we do not het normal broncht which to Laterally we can see the sound ll-defmed circles with clear retro slucher the shadows cut by backnard going bronchola (see Ft 35) They may be of faratze near the hulum and bould not be read a curtos or mistaken for primary fucs of childhood robercle which are opaque frregular od bard looking and wyalty mell out tomards the periphery At the danger of repetition to must be remed that arutom la the normal merlatopa ure Doch almace of abnormality - the shadow of the drame proces which causes that If we see in the outer part of the right bowet done the shadow of plemel effioboo we mat book carefully at the strations in the Dudad dext parts of the bone I the long has no deue to it * cupect to see hearter Artations chined by hypertthu from tho wutres ·46 THE MORMAL CHEST FILA prenure collapse of the parenchyma if we can see no pot marking re know we are dealing with a pleural effusion wbich ba secondary to a consolidation of the lower lobe The Latenl Film OGo០០០០០០០$ Annougopal Fo. 37 The Left lateral film. Fia 371. The pytt battro Sol A Lateral film may be taken to give additional information in the localization of lung disease For ample It will throne shadov that appear to be hilar into Itu true position in the apex of the low rl be in the che of abscem formation in that broncho-pulmonary segment hich is supplied by the posterior borizontal branch of the right lower lobe bronchus Lateral 6lms may be taken of th Hght and left hung ficklas must be realized that the hado vt or the opposite od although out of focu lways contribute to the picture in th accompam ing diagrammatic representation of the left lateral film there.com be scen between thyert bal column and the tem m The daphngm Th portertor recess of the costo-phrenic angle The cardiac abadow rating on the anterior surface of the duphragm and continuous in ito upper limit with the arch of the sorta Th pooltion of the main intertobar figure is hown as a line (4) rmning from a point below and post for to the aper downnarda od forwards to a point near the junctl n of the mbille und anterior thirds of the diaphragm The lower lobe therefore occuphas the area below this lin ·THE LATERAL FILII On the diagram of the right hat nal film the poetion of the great resure bs shown the Ibne marked (5) while in addtion ith kerset fosure la stonn ás (6), running between the hilum and the posterior border of the termum It may appear on the Lateral, o It doce on the past ro-ent no film n the absolutely normal subtect ·SECTION JI CHAPTER VI PHYSICAL EXAMINATION INSPECTION PALPATION AND PERCUSSION PHYSICAL examination of the chest han suffered cerere attela in tho past few years The la duc mainly to the realization among tuberculosis workers that phthbals can exist for months and eten joan without produclag symptoms and that to its earlier stages it may give no abnormal findings to the most expert comune whil showing definite abnormal shadow on the film The Introdaction of man rodbography was urged for the remote it antival has accentrated the criticam Nevertheless physica oamination like bacteriological etamkuthan most recen for ultimate dlagnosis The X ray ly not the whole patient to the hands of an expert it can give detail of diagnosis with uncanny socuracy but without serial examinations it can reldont give the answer on activity or retrogression of the dense proces The chnical condition as a wbole purt of which an be cumuoated only by expert physical xamination can alone lead tho phynkcon to an opinion on the present pathogenesis on which ho mot bare det Immed Lato treatment Nor mut we confine phyical examination to any one of the purts Eya fint, hands next and can list U a good It is the wilter caperience that many students concer irate too much on the stethoscope and that the stateorent that th re are no physical slgne tacans wually that the complaer Bus found nothtog abnormal to auscultation It will be mumed that the student la familur web aI the Dual methods only uch Decemary aids and such points as the writer has found of h lp to port-graduate will be detailed () Clubbing of the fingen frospection of the term bud phalanges would be mad in all patients suspected of chest dimeco scute or chronic Clubbing the phalangeal forn of hyper trophic pulponary osteo-urthropathy which caused by ebe forming of a thin subpe fostal layer of bone and thkhening of gulde 4 ·PALPATION 19 cance This con corseth tot oser tt. It is found in chronic heart affections and chrono dice bat la mort corumonly wroclated wth long direits Toxins and chronic congeation are uid to have como thing to do with t but its real cause the wolnown. We do not kompor why to the termal phelingo it thom puch marked thich ebong of the soft toe n some cases which he no parent d Berence in the king pathology against the colleagues with no lmper changes Its abuence then of no dlugosc ignif to particolar type when present can be so chancerit decua to be du poem betu.com septle and abrold between s lung aberu and pulmonary tuberculosis Ttve tw mattyper show hnt stage in common wa filling in of the connectly tave at the root of the nat! so that there a no gap between the hon fold and the proximal end of the nail nich appear on the verage normal finger addition, tbb een the lightly named and panking up the im fold, I always cytota med glistening, tf by ontmul polishing While the mical change later m appearance phthuso then in the caut septic conditions where x in Int Hobar empyerta complicating persons it can yppear within a few days of the otrset it can be very belpful as a funt of the poolble preartce of ymptomien phthione In the further hangi buoclated oth proliferante tubercle of adult trpe the ball become humped bon ed doruly mooth and rather pearly-pink, while the palmas murfar of the phalana become more and mo pendulous md baggy thun tren a chw like appearance and may eren look topening the dorul paloar alteration not offset by any marked change in the Lateral de son The entirely unlike the effect of Kapthe dock athet kuto or chrool o la long abacan od bronchito's where the alter thon lo generalized over the phalou Thb alteration in all dimensions from and dramatic in effect often bulging sharply at the point ith the proztrol pbaboy to wand out our It on come on w naprdly In kuat repues to be noted in growth almost from day to day it and appear a nopidly 1 efter efficient merglal drage of interobar empre Motorally this form an lowly replace the more wual tuberculous ype m long andmg fitold the were broochlolectats i not trae wrance broochiectas a communion and pected complication The patient to bb cwe is mufering more from the The hunger is + btott stump ·50 PHYSICAL EXAMINATION consequence of his dicate than from present suvity and bronchitha or bronchiectasis is all too easily given u e label to one who ka chronic source of tuberculoi Infection to all his contacto In this connection we may note that cmphysema to given a one of the awe of clubbing of the fingers From our comideration of pathology we shall see that emphyreoma to almost alnas secondary cord Hon. Ia primary caused the reason for the finger changes in tho vat majority of caves (b) Inspection of the chest as a whole should be made before any palpation methods are employed Much confusion an real In all examinations up to film Inspection If the presence of the normal abnormality of scollosh is not recognized from the beginning A general Inspection of the chest back and front should warn the examiner of the true condklon, and Leep him from making some diagnosis of pathological Import it all prepare I m abo for those changes from the absolute portual which he will not on the radiograph, in the shape and poolbon or the heart, and Ir the prominence of hilar and large pulmonary Verrel shadow Mart a PALPATION (c) Tho Sterno-mastoid Sign Several methods of dlagnosing mediatinal shift by mouth the doplacement of the trachea have been described these rely on deep palpation in the monasternal fara a procedere to which most patients object very Itrongly A much easier and more reliabl method is that to which reference is made several dres in the course of these studia It consists in gentle palpation scrow the tendinous origin of th sterbo-must ld muscles it the uppe anterior surfac of the manubrium W bave seen in various chest conditions bow the apos beat is dot darly co relable « guld to mediatinal duplacement bow the heart iwings on its long axis much more readily than it doo boddly to one or other side 20d how for this reason while it responds to inspiratory movement u shown in Kreening of CACT of atelectuals It does bot give at positions of rest the ume amount of fixed change to act o a guld to the examlaer Thus it por backwardha (from left lower lobe emphysema) in Hght lower lobe collapse and lo per beat to palpation or stethoscope marghe Do aid to the actual dagnouds while the stema-mitold her will be strongly poslulye on th right alde ·PALPITION 51 The main nalue of the sign 1 reen man of unilatenal disease t be only to be expected that bilateral disse Ill gi bilateral Fra H Post Wat orgadod up change of bailar type The onset of disewe In the left alde followlog mestabibbed dbacare in the right, will toovitably do the rulue of the in previoral proment to the right corpo metod. In caute conditions Buch as complicated poeum.oou, broncho poeumonla and liabi, in cystic disease of the bronchi and the epituberculosis of childhood it to negative Wo bero descued the rezon for the These diend do not destroy berti terve and have no effect on the normal pound woully exerted by rakul ur n the ahcoll I chronic condition with low of alertic there telectual and lat with Gbros topoul- Hre in tuberculosis and bronchiectas Fo ita ducovery the patlent sho l be placed in good ligbt, tanding Tuting Jong relued pooltion with th beul contral to the thorn Gentle palpation with the todas finger icrow the muscle tadonu q t ufficient the sharper edge of th efected tendon which a paint ts mofte rounder neighbour ·52 PHYSICAL EXAMINATION will rett pressure to easily felt With very little practice the observer will see the sign before he applies palpation (b) Lung Movement Many student attempt to wc lung movement by placing the palous of the funds over the mammury reglans with the begin pointing upwards and outward towards the outer sub-chorlab roglod By to doing they cannot hope to find anything beyond the anterior forward movement of the thorar which minimal a against the downward excusion of the lungo in remporme to dlaphngmatic contraction and the lateral movement in response to the increased sub-atmospheric premure of the Intra pleural spaces The assement of downward movement by percuslar will be dbucured below for proper assessment of Lateral morennent by palpation the palms and closely approximated fingers should be placed gently bart firmly in contact with the ultime with a wide un angle w ponible between the foreningen and thuniby The whole hands are then moved in wards still in close contact with the chest walls until the thumb-tips meet in the mid line of the stemnun The patient to then asked to tako in a long, slow breuth, filling hlu chest without heaving up hla shoulden Lack of mone ment on one vide us against the other is Immediately evident it will not more the palma and fingen outwards and the thumb oo which there act as a lorer will move but little from the mid point augalast la fellow If the method is properly employed cupla don should bring the thumb-tipa together again at the mid-potor of the itemam The method is much more eaty of application poster sly Where bilateral emphysema le present the thumbs move from the mid (the hardly at all while the whole hands more upwarto rather than outwards with deep Inspiration PERCUSSION () General. The note in the lungo la Individual and compare tlye ono old with the other The normal for any patient should be cleaned on the finding at the left apa to gentle pertumbo with the understanding that whilo sound enter into shCADES the feeling of resttanco trammitted to the pledoxeter finger by the underlying throue is of equal importance Heavy producer much poble but Iltle to add to the knowledge of the ·53 PERCUSSIOY caminer Grades of departure from the normal can be described a trompairment, dwiness up to dead doliness tympany and marked tympany A Doll on the left pex equal to that of the right must lead to u smpicion of left apkcal aboormality Its pictorial reprehentation by one line belmas un to compar it with mot marked abnormalitian Thus two lines will represent the wal dullness of tuberculuha and bronchiectas's three the underlying raabtance of premoola and fuid, kod four the toncleraxes and maried resatarce of Dwukre atelectuals and nety growth Tympaay be found in the bigher pitch and kewened resetoxce of the bacal corphysema af stironic broertuts and courted towary in the lows of lung is replaced by air to preumothorus (6) Diaphragmatic Movement. Percussoon to be complet abould bclud crammation of the clungo of bote at the lung bases wth inspiration and expiration by the mems daphragmati excursion can be used A Bormal duphragm bould mov down arda at least one finge breadth n the alla and one od a half breuiths in the mid Ime of each twlf posteriorl with deep Leaming of extent of axh moremat wil dicat adhesion up to complet fixture of the dupbragm Examples of the wefulness of pertumn in dugonis ro - The dulbes of upper lobe plahok na predformntly post erior ne bo Doted cor ral de bon tuberculoss in ufulto be Wer theref rt a demon has to be made or physical sigra berneem opper lobe pneumonia phthaa and collips from mtra bronchual obatraction this findmg a help coetng the collapecell savo sta duuna tauly mterro und mot marked bount ono funger breadıb below the home third of the colla bone at which pott n the entrance of the eparterul bronchas (1/4 collapsing right for r babe will show dead dulles in the Inner laalf of the right boner sone posteriori ofiset by gyorpany from emphysema of the uppe lobe in the Octo pb en dygte As against the box cr lobe prepona sbox delines anterioris and posteriorly eqwl at any one fez 1 from the alla to the media atinum while the dullness of pleural fusion Il be wollary and ther of Collapsmg right milile lobe anteno and mixt marked it below the nippk Insp ration postersor decake ut ne ·CHAPTER VI AUSCULTATION No student can hope to be able to distinguish the varico abnormal rounds that can be found by auscultation unlea beba Accustomed himself to the many vartatlans of the normal they present thenseel a to hta bradividual retse of hearing and tone. He should avail himself of every pouble opportunity to crophe healthy lustg in the fat the thin and the muscular withg one uniform rule u hos beste lineag always lbtening in the upper all or to the inner side of the lower inner border of the Kapala, whlle the rubject taka long quict breatha through the mouth He will soon find the following three characterbatio of the normal (1) The sound us a gentle ruste o lf made by an infinite number of indivkual sounds that ran together an occantonal one of these beingolghtly louder than its neighbours (2) Inspiration is lightly longer than expiration Inspiration fada Into explration with no mterval If now he will listen by placing hu stethoscope o or the trachas ho mil find four distinct chango (1) There is a distinct gap between the end of Inspiration ood the beginning of explradon 13) inspiration and exploatlon are of cqual length 3) There to an entirely new quality the rounds They ut pitched higher than normal u if the normal sounds of a large area were concentrated at one point or the patient were blowtime gently through a tube (4) The sounds are louder the first and second are present in crery 13 pe of breath sound that talled bronchial breathing the third and fourth vary considerably in different desso conditions all of which are described u gluing bronchial breathing Naturally every techer demonstrates his own aculty of beurt und set of tone Tho wilt r has used the f l loving rough rok of thumnb Ore scattered area of fibrosis and ate lectus suce sont H ·AUSCULTATION 55 Pitch + rean of found in chronic pulmonary tuberculosis and bronchlectuals and o ralperringhe una al compressed hong (wobortime ubo * pleural effioxa) we get the attacks described without the loudren That bb O rannall area, ts over the power of occasion of branschen filled nith new growth a foreign material and pret • Loger area of corollarioa, a to bobar prxcumonk » hunc comparat) ly Pitch ++ bouten + O e a city connecting with patenat bronchus we have Pitch ttt loudnes + + Here the plan o puch hupher that the Ibtener has the Kenan that has patient a mon bloning over the end of e tube not through it What nou floms to built on the writer tbute that chart diseasca produce Interference rich normal breach out by glykeng en mount which can be reduced to a ony for baule iper and that what denone the Indivxual deze proces producing there In the prostorn of onset and interaity during toprat.com That theid is built on a conscious effort o rtmenty ñ obeert to rretat intents a study of these sound with the corresponding uldmate dugoon It follow that its definition and conecquent statemenu w zmeny appear to beg the question, wwd to other to be cogmaats They are sot meant to be wo they re stated as the write han employed them w hbo procter and has ateroprol to teach then to modenta Every mucent abo kd scquue the table of lacering Intently to the whole phase of imparation while the potent tako long quhet breath through the mouth, so that potter BRONCT WUROCROSS Nam of posible salohanc txibo at mterfere With the first breath he PUCHTB COHOTOn now doald try to the OR MI hum Tutto length of upiration How to drdtop It comconly with traddly ent three porte 1 mhxh me that der the brohul broodin partaceo maroc phases The wetter behera the student will be able to place boormal sound in accordance wth their aut dieses THEO UNA tha und parenchy ·56 AUSCULTATION those affect the bronchial and/or the parenchymatou structura We hear the sounds known #olbili in both bronchiti od pal monary tuberculoals but where in the former we hear them mainly in the first or bronchial phase in the latter they are mably on the list or parenchyroatowa stage Thus the sot actual sound.com be of very differing import to the examine and the patient. ** see why it is so evry for a case of acthe tuberculob to be inter preted 2 merely broschitis There appears to be consalderable confiplom in the mind of many student because they have no clar undentanding of the true meaning of the many described abnormal pounds heard inter fering with inopinatlon They are so rubdivided in the usual teaching that they lead to confulon What is read be one phirst can as the only true sign of wrly tuberculos may be read by ubother us ovldence of a late stage of the dbcute For all practical purposes the writer believes that added sounds can be reduced to three main types each with the particular significance of fos underlying cause They are (9) Crepltations fino and courte (u) sibili and rhonchl (coarser sibill) (1) Rilles fine medium and coatie (consolating or metalike> I Crepitations If the name crepitation be confined to a round which has dry quality to the car Wo an correlate it with fibrosis il Increased deposition of connective tlove which we shall not Ocaun in various disease considered under the section of applied pathology The breath rounds are now to changed that thet individual components appear to be a series of dry crackla coarrer these muodi become the lo veoma to be their trumbet They will bodicate to us permanent structural chmge which is not removed by cough a restricting matertal wblh lhes round the bron hi and attempt to interfero with their natural expansion and elongation in response to the act of inspiration In the pleunl carity fibrouls the result of adhesion bet een ploural surface A Wnh act of cough in poval thod be crepitations therefore at two . With honoun points in our cumimation (1) First thoy an oppar by the act of coughing They are Th --- 1 AX 3 + B Fra +0. We o ·57 t common state of compact 3 Metre temie CREPITATIONS then forme approximating to the sound produced by rubbing the hair abon the art W are hearing the daturbaxc of inter pleural adhesioru which cough producet Thecy r tanding to pulmonary tuberculants and lead us to conclude that there b irritation of the pleura rom a wderhy ung lung lesken lose to the surfac Naturally once the layer are firmly pprox imated and no longer at the bread and butter organiong fibrin they wil disappear The findmg can be of significmce in prognoals and in treatment conudering the warisability of incumg ribicul pneumothorax, (1) The comparath corner crepitations are peridro.chul Abroek of heard throughout mspiration and do not disappes after cough They are beard in all chronic dacases from churon bronzate to pulmonar tuberculosis sertlerc of chronic Hyperemia and the consequent deposition of fibroblou m the If we lasten arefully may be able to food by their coarsetett mot particular phase the part of lung structure on which the man brunt of the dosease is faliis Thuot of they are most to Cienended foron trasept in the art or bronchul phase B. Smetode pembawachows talling off in the second and third phone webhow are listening bbrots round the larger bronchi in olyme wurrounding bobules and that the patient has the may open to enlargement of these broechu up to enabisbed bronchiectuu (H 4 ) The bs what persemua hon occur in cma of contmung upper sma mſection whxh Cate cuentant arritation of besar broocht In the middle of bronchial parenchymatows phase they md cat that combination of broschiaand lung fibrous that accun to lung becau af a chronic character The diecas begram the hing Ho Dow Infecting the branch that suppl the deemed area of hung true and are bearing the resultant hb os In the to parenchimaton phase they are most intense mtbe presence of does that begin the parenchym Soch fibromass getieral in fung were meamonu has healed by qui rather than resolution In the mo localized area of chronic wult penthesis it shows the i lectors that has occurred in th kobal onstituents of the affected parts Fibrows in the three proses wat u of the danger of de koping creation m each of them i precede the gre of cmitation 41 ·58 AUSCULTATION and remains when they appear As already stated the creptation are ladicative of a change that will not recede, that may be pated by emphysema later but may abo lead to much more workom damage if the prime como cantona If we read into then the lemons they try to con cy they will add w In prognoub o well in dlagnoul thus thelr continuance in the mid-phone after the apparent complete chciation of a lung abecers want u that our patient is not yet clinſally well that I bo-alle recurrence of his abeceu may follow and that what is really threatening sa consequent bronchlectuals by Involvement of the bronchus SOUHOU مقهعهلر 2 Sibili and Rhonch! There are best interpreted as indicating moliture aberucting the pauge of air through bronchi omall and large While pery Little motature in the smaller bronchi 10 produce sibili allemaller amounts to VYYY bronchl under contraction will gtve the A Are round wwwVYYYYB The quality of the sound P. 42 does not differ by the origin of the A Bronchi obstructing materiál In other worth, B Pulmonary tuberculo wo can bear olbili that are due to utrip ping of the clllated epithellum In scute bronchitis and Duithar are due to material catering bronchl from breakdog down pares chyme in phthab Agato we hear them in acuto uthma, bronse even tho natural mobture normally removed by the action of the clla cannot be dealt with the last drcular muscular fibras art contracting wo severely in th terrainal bronchioles It therefore we apply our achety of dividing impération find three parts we can correlate abili and sbonchi with their patho logical ane In the first phase they will be brunchtal In origin they indicate bronchitu od bronchiectesh In the second phase they will be bronchlal-parenchymatowe We are lbstening to diseases which affect both bronchi and longe broncho-pneumonia that # retolaing and long shares dbcbarglog In the fint they will be over a comiderable area of the lung in the second, they will be loalted In the third phase they will be parenchymaton la coriglen material is entering terminal bronchi from th lung wually from tuberculous depoulos that are creating .8 Now the Mbili od ·S RALES mo 59 rhonchi begth tonards the end of the second phase and become and more intense to the end of Inspiration 3. Rales According to the thesis we aer Llon ing the student should ainsider thut rila mean that there is definite int Irement of the kung parenchyma which a breaking down und docharging int bronchus They indicat greater amount of occlusion of the lument of the bronchous than is present with abili ad Hronchi If they re especially course and consonating and metalls in charact r they should be cada caldence of caritation By their position m intration cm get a definite and to the underlying pathogenesis Thus it they are most marked in the first bronchial stage we can Orrelate them with bronchial condition, and cooclude they are extensions fa doseme that has first produced a bronchul and later a parenchyinatous pathological change Thut te why hea them in alus bronctixectab winch has invaded the bobukes through the penetrated bronchu) fondamnation Rentals and Turnen They berald the formation of A tung unity connected with the A culation As the parenchymatora Tro. 43. destruction contrakt they get more A Lang beceu. A Bronch.ch and more consonating and metallo in character Their finding to then dug north of bronchiectatic lung arvitation In the writer experiene coarse conscrutig metallk Ales . more comtant finding than whakapering pector boquy in all types of citation They can help towards dugnows when the cantys comparatively full of du integrating material and pectombo quy and loud bronchial breathing may be abecent toe riles ar beard in the brooctul-parenchymistons middl phase of Irapiration in congestic failur They lodicat inability of the patient to mor bobula RES they are the first signs of that water logging which increases it ad lyin 2 the chronic bronchuti of gra prognoss Resol mg bronchopneumopu gives them in the phone bo medłum intemity thm come through to the ar almost a A. Pinunoon. ind wulsmall bubbles raing n number > Droocb poc moon a B ith lung ar montur un B Tro. 44 ·AUSCULTATION and force to mid Inspiration and then falling off again toward the and of inaplnation We are hearing dechargthg bobulos porto their liquefying pneumonlc erudate into the bronchloles They are atill more Insbtent and coarser in the dlacharyting lung abeces although they are confoed to one area as an those heard in the disseminated discue of broncho-porunanu They become more and more cottonating md metallic abere bronchial blockage has led to breaking down of the long cobounct In a cae now going on to chronio abaces We hear now each the same sounds we heard In bronchlectuals There we berd them begin and bave their greatest intensity in the fint or bronchial phase and they were heard over a fairly large area of the lung Now we hear them to a localized area and most intense in the mid phase of Inspiration The same pathological procom is at work to both conditions In bronchiectasis the disease progrewed from the bronchus into th parenchyma in lung abscow it progrewed from the parenchyma to the bronchus Chronic lung abecem bo only localired form of bronchiectasta In both cues as the desease progress the riles get more and more metallic in type telling that communication between cavitation in the lung and an enlarged brochur is now ostablished In the lat, parenchymatous phase Walic nila find them in pulmonary tuberculosis With an advancing lalon they lowly replace the ubill and thandel of lewer obetruction while like them they are due to material ent ring the terminal bronchioles they breaking down of the parenchymou As the condition goes on to establisted cavitation the rola get more and more metallic reaching their crescendo of sound at the cry end of the inspiration The scheme of Interpretation of added sowods b wummed Flg 39 which the writer has found useful in teachlog on borpital coes for practal demoratration Two cumple will illustrate diagnools from physical alorie (1) Chronic fibrocreous tuberculo's wit arization of the Hght long upper half Clubbing of tuberculow type present in most case right sterdo-matold is strongly positive movement over the whole of the right side dullness in the upper HO Fa 45 taberculous citation are now due to actual up be Tbc There marked Lut of

·61
RALES
half especially posteriorly ad tympany from emphysema One
the lower half
Careful listening to the whol inspiration till present crepila
tions throughout orery phase becoming more and more coane
in the turd phase there are from fibrown At the end of impina
tion there will be cuare metallte råka from the contedon
Both
crepitatlons and rilas ill remain and may be no more intent
efte cough
With the et of oughing showen of fine crepitations
Indiate plural thi kening
(2) Acute bobar pneuponla right low r lobe before remolution
There is no clubbing of th fingers There is no terro-mrtold
Ion
There is marked lack of mo maent over the night id
und dalbneu both anteriorly and postenorly
er its box half
There are no added sounds to breathing b bronchul all over
the affected lobe

·SECTION UI CHAPTER VI SOME GENERAL POINTS AND THE VISUAL, OBJECTIVE DESCRIPTION OF THE ABNORMAL FILM مايا In the section we shall gather together such changes from the normal as we shall see in the films of diseases discund in detul to the section on applied pathology It is possible to group the under their main characteristia For example most dea of tho lungo bave in common in Inflammatory exudate filling lobales u rerult of irritation of thelr alveolar wall the common procom has a common homogeneous X ray hadow It is donger than that of thickened plastic pleurlay burt far les derate than that of ateter It therefore followi that the shadows seen in these three separate conditions are all objectively described a homogeneous although they may by the experienced eve be correlated with thele lodi idial underlying pathology specially if they are staded In conjunction with the clinial details These should alwayo accompany the request for a report on the film of a parlent who were not been clinically examined by the reader In other words a film report abould be in two part the fint a voual obfeathe description of what is actually seen the second an opinion on the It goes without saying that anyone attempting to go opinion on an abnormal film must have an extensive knowledge of the normal and of all normal abnormalities been made several times to difficulties that an ertze by the reading of a pathological come into the normal eboormalities of motor, or imple calcification of the cootal cartilages Even the Best experienced observer does not despite the wstance of a good example of the normal ce Reference by THE VISUAL DESCRIPTION Somo general rules for guidance may be set down (1) Read every film, according to 1 fwed routine such other gtven to the chapter on the normal film ·SONE GENERAL POINTS 63 a their (2) In reporting n the trachea, h art and draphragm not any change in ulce shape od porttio (3) In th fung zones look firet fo th el marking and the laner fwure of the right lung, noting any increme decreate or change in portion enchu bunching o opLying of ocular shadow (4) Describe aboormal shadom kccording their basic type remembering that in front of them behind them there may be shundone of nomal struktura They may be considered und fire bonic types streikines homogeneous abadow Don-bamo gencou badom nog shadows and miliary badow Streadores do the same pplied t crevo in the normal hung marking Homogeneou shadows are those which do not alte CTC throughout thel atent Ithough they may Ite to density they do not d so ruddenly mod interruptedly Non-bomogeneous hadow are those that alte ruddenly m denalty ut one more points throughout th I extent Rimg shadows ba les circumambing Ilmito hn thel centra they may ta hordozencouro Don-homogeneous shadows of translucency Similarly thel Ilmating boundarle may conubt of ono ther f these typo fabandom These hadows will be described in more detail in the bext chapter (5) Gire the nze and shape of todividual shadone they may be nog luple Large o wall well ill-defined dufume along the formal marking confluent r patchy round malo triangular The term mottling often wed in descriptions of shadows It convey th Ide folituro fopaque and non-opaque rem In this recom It cm ply to much bacon occur in the fire of um.complicated broocbo-poetepona Itu however aften med to describe a mixture of bowogeous and non-homogeneou creus ruchure found to the film of pulmonary tuberculosis and como Interpretations confone it to the memlog It be theref ro not a good word to use beog to the literature ball descrtpthre und half interpretat and with no accepted definition moder etthet heading ITXOTE 0 ur m ·SECTION LII CHAPTER YILI SOME GENERAL POINTS, AND THE VISUAL, OBJECTIVE DESCRIPTION OF THE ABNORMAL FILM In this section we shall gather together such changes from the normal u we shall see In the films of discoe dicuped bi detall In the section on applied pathology It is posible to group thom under the main characteristics For chample roost doucea of the lungs have in common an Inflammatory exudate fillong bobades u rerult of Irritation of their alreolar walls the common proces has a common bomogenicow X пу thudow It k democr than that of thickened plastic pleurboy but far less derive than that of ate koc It therefore follows that the abadows seen in these three separate conditions are all objectively described as homogeneoh although they may by the xperienced eye be correlated wood thelr individual underlytog pathology especially if they are studerd In conjunction with the clinial detail There abouk zhuinys accompany the request for report on the film of a patient #bo bos not been clintally examined by the reader la ochier word ? film report should be in two parts the first everal obferte description of wat is actually seen, the second en opinion on the It goes without mying that anyone attempting to opinion on an abnormal film must have an extensive knowledge of the normal and of all portal abnormalitia been made several time to difficulties that an arde by the readers of a pathologłcal came into the norteal abnormalities of scollant, o simple alcification of the costal cartilages expertexced observer does not despbe it instance of a pood example of the normal caure Reference bo Ech the most THE VISUAL DESCRIPTION Some general rula for guldance may be set doen (1) Read every film, according to a fared routine suck on that glven to the chapte on the normal film 47 ·SOVE GENERAL POLYTS 63 0 may be in their : Dort 0 (1) hn reporting on the trachea heart and daphngo potany change in uze uhape and posttion (5) In the lung dona look fint cel marking md the lemer Gart of the right lung noting any increwe decrem change in position coch a bunching or playing of scular shadows (4) Describe abnormal hadom scording to their best typo remembering that in front of them o behind them there hudont of normal structura They may be considered under Hve buic typo freaknes homogeneous shadow non-bomo geneous abedom ring shadows and millary hadom Streakbrew u the negde pplied t locus in the normal long marking Homogeneous shadow are thore which do not Ite creme throughout thelt atent although they may alte to density they do nord co ruddenly and brtaruptedly Non-bomogeneous shadom are those that alter suddenly in demity tone more points throughout thel extent. Pung shadows ha les circumcnbing limita the contra they may ha c bomogeneous o non bomogeneous sudom w of translucency Stmllarly thelr lim ting boundaries by combt of one other of these typer fabudom There abadons will be described in more detail in the Dext chapter (5) Give the lze od sbapo ffodivkaal shadow they may bo ing! multiplo Large or small well Ildefmed diffime along the ima f pormal markings conftuent r patchy round onal trangula The term bottling ta often used to description of shadows It conveya th bdea of a mlature of opeque od non-opaque re In thta ke It can apply to much shadow as occur in th' film of uncomplicated broocbo-portocool. It is howrover often wed to describe mlature of bomogeneous and doo-homogeneou irem ruch wire found in the film of pulmonary tuberculosis and como interpretatione confine it to tha meuntog It k therefore not pood word to me a bemg to the literature balf descriptive and Balf nt pretthy od with no accepted definition unde etther beading O ·1 CHAPTER LX THE INTERPRETATION OF ABNORMAL SHADOWS. STREAKINESS HOMOC ENEOUS AND NON- HOMOGENEOUS SHADOWS BEPORE giving an opinlon on the diagnosis of a patient under review the examiner should now Inspect the film more clovely at about 1 foot from the viewing box and then go back slowly to a distance of some 5 or 6 feet The writer realiza that this will not make the film stereoscopic what it will do ba to male lodna dual more opaque areas within a shadow that looks more or lom bomogeneola on closo Inspecdon stand out against any back ground cothmon to them Unfortunately the point cannot lime demonstrated by prints but only by the study of floa on vle wtrong bora There will always be the difficult case where shadomy art to confused or ill-defined that thelr undedying pathology cannot be dlagroved There is no such thing as the typical him for every duce there are always Individual differences Furthermore, we all undertand that X ny examinati nb at best only an Accessory to general and specialized phyalcal and laboratory Investigatkan Coralderation of the general condition, the temperature the blood-count cellular content of clusion and the result of bronchoscopy and blopsy may have to come into the rummation of the interpretation together with serial hlm examination, before we know In any one hypothethal case whether we are looking at: lobar atalectass which is baically post pneumonic post operatie or due to carcinom of the broncha There are, however from the crperience of varlou dbene conditiom a reviewed todet applied pathology certato guldance to be had If we look now more closely into the main types of shadow defined in the basis chapter it in understood of course that while there are read Individually thelr accompany long shadom and the esidence of Interference or non-Interference with other tructuro of the thors are read with them for Interpretation Thw the shadows of pneumonia and of telectuals of the Hght upper boabe ere 4 ·STREAKINESS 65 both bomogeneous in tipe but we ha keen that there & Do change in the blood supply f the middle and lower loben in pneumonle, where in leczak there to splaying fther blood tupply love they have become mphysematou Streakiness and Absence of Normal Markings Decrease and increase of normal lng marking art cqually Important Decrease by found in pnevmotho ax cyathe dibezle of the bronchi ad emphrete in pneumothorax the low of markings pean outside the love of the collapsed limg, while thu boflect bo Increased markinga mahin It w th cotxe dere forme faint markmg of normallung in front of or bebind the cat may occafonally be seen but wally there a Ircunscribed To of the translucency of peimothorax Often there are with larger sno definit increted markmg outulde the cat due to presure collapse of mirrounding bobules nd the crowding togeth of their normal nut ral connecttre tube and blood supply With emphysema there is decrease o small or large sem of the lungs mg o Increued translucency of the affected part Where coralderable portion is affected smth grou bowl empbyxoa chronx bronchitw or mtbe osto-phrenic wigle compagnera f the upper lobe der lower lobe telectats saty the faint markings of the supporting "tructure of Druck-dbtended Lobulas can be seen Such film diagnos's of emphysemna may be of great Import to the patient As lready stated ft is not octompanied by apparent X ny cruset ordinary fit eumtration It may call fo ipecial camratha by uprodal injection or bronchon Increased streakinu. I found in hyperemla He bull kee how hyperemia bs the fast ind atlon of acute bronchith and the constant accompaniment if not the bas cause of chronk bronchi th Who vern too that look for hyperchouc Marthings in a lung und r collapse from pleurisy wth ffuton und how mot atspect courollation of th lung if ket thero The distinctive feat net of all shados condoting fibrous that they stand out n lncreasing relief f we bwery th film we go backwards to corpo 5 feet from It This characteristic they shart With those student hare named noor bomogeneou In chronic bronchitis they are almost invariably along dehave likes or bad.com tog that there to locrease in perib vachulconective and caused oggtr do pot ·66 INTERPRETATION OF ABNORMAL SHADOS by the hyperæmla of Ita vesela With hibrosis we muy KC COTTO borative evidence of the true pathology in disturbance of the normal pooltion of other recognizable structures eg change b the poulthon or density or both in the lesser fraure store of the diaphragm and pertup displacement of the heart and med letom In such ducase * bronchlectals Again He see streakinan perluapo dlosociated from the usual normal marking in carchom, pecially in the nodular medial and barel types We find it almo with or without discrete nodula in the reticulations of olla when we are viewing the congested and thichened lymphatas Dociated with the disease u a hox al Homogeneow Shadons Thae shadom when in the lung result f on endaten ond de-verallon in the pleural avity they are due to exudates and occasionally to tranuudates On the whole it can be taken x a ufc rule that homogeneoa thadows Indicat acute lımg doen They are found in preumon, broncho-pneumonia and in the scute progremire parts of tuber culon lalons Their varution in derulty can gi their underlying pathology Homogeneous low of translucency of lever density & founu the X ray evidence of bflaminator) rouction in the alveoli This & duc to irritation of the walls of the cells by the organisme which later penetrate the walls and fill the cell with caudat Such cyurlate throm a denser but still hooo &mcod shadow It follows that und r this type of shadow falls that called by the name of pr umoniti This term by Justifiablo If it ba merely dacriptive and not meant to be specific and interpretatire it be not a pathological entlty It to the shadow corumon to every procewlmltative to lung parenchyma belog the codema or catarrhal crudate seen in paeumonia, broncho-pneumonia lung der bronchiectabs and tuberculosis Ito presence means that cox speaffic dueno lo t work, & it may be the shadow of ſheetting typo rich u wo ec in tropical cosloopbilla In every case in requlre serial films and we may require lateral ord i mograph camination and even llplodol injection of bronchoscopy to reveal the wderlying cause In acomplicated pneumonks and broncho poscumonia e Re * bomogeneous shadow involve the broncho-pulmonary art of # mala bronchus or one or more of it brincto In phone ·HOMOGENEOUS SNADOPS se it in the toxalted rots of dorel bronchioles ja both *0 cao lolle its progrew from the canaritual to the specific besner Sundow so that we are not able of the Alma to monet the a sachang edges of the dece proxen Sim Lurly we may pote the fert box of transluency in tekactax which can witha absorption of oxygen and trace t to the host #bich is det et hoc actual mulon of the prescynu by carcinoma mim Thus Lost od dewest cage boa most entenc fometimo From the begang at the site of bronchial blochaze On the plean we recognute tbc first geswerallyed for lower of ceny that come with plastu pleurny to often the back proximad to tuberculous lung losion to an opuleriythie lung aboxa. The same fare one of translucerey a land in the studow of the Opalescent Husion of tuberaben ungio cremalon dernity with the organization of fibrta zhroughout it and a copied on the visceral layer of the pleura ngainet the lung which under promoure collappar lese mesoon becoins kaculated land begin to oryanboe to the pleural cavity r becorrer par t gen mart and more opaque mal n reached the opuits of preronic catat by the hung Wetu then the demnity of the shadow of empremtua All hotroproton hudom share one partxular charwtent whether they be due to lung or pleural pathokney they do notats by their und mity when bred at a datara The chudom of pneumcak ortal no preumonia bronxho preumonks and long Wacra, ere homagicons in this seru The wall of a proliferattu tuberculos on It) ball ke s peter homogenen Wth two examples we hall be able to ilustrate the por more fully to bronchopremont n millor she progress of the dirt bez whickom first evident near the upper tualue of the right aurkcabar or left ventricul bord n of the heart, going then outwa kod dowowards along the lines of the man blood supply lower lothes in the developed toxin * recognize akong turne Phoes, homogeneoux ornguhr like areas of equal tour of trum hacency ner guit secrete but never gulte condhent because between them reiren of faxcr hotrvog cena lot of tra baciency The firm shadow s dve pre monk Andar the maand to the pon-spectfic traumatory catarrhal gaudat Natter dan bos y por or sharpnes by distant is wainst war viewing that hate not urzmited tre koking at the end the long, Lobster There a no collapse of lung celle here corroborati eride In the abrence of medittaus whilft W

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·CHAPTER X ROUND SHADOWS "pper tud uppe out portions of th margins of RING chudow may circumstibe tens of companti denalty or comparati e translucerky The ring frmation may be at homogenicom or non homogeneous type whethe tu thin or heavy in outline (Ring Shadow round Arcus of Comparativo Trant lucency The thinnest of all bomogeneous boundara s t und for employcematom bolhe o here it comes only of the vible Hrands of stretched supportmg troue round m area to which Do connective tenue streken is keen ther because normal throuxe o tretched or broken beyond recognitio because the throue babeent by congealtal abnormality We le auch are particularly ton rds th upper l be and along the Infer and lower ut n the lower lobes which are art ruturally weak in connecti W recognise there bullz sometida in the lung fu child who has had we ere whooping cough oft n to the chron] bronchitke towards the base and occnlonally in th ongenital and so-called mental empbyxema funknown recogntable Mgin. There bulle don t look to anywbe different from Hogadow Kimetimes seen to know moses of pulmonary tuber culoria the watt ha watched many of them code and go in that type of me whu h seems t ba o more than rotary pleur! ronction to the und Flying doseoke Some dbuppear altogeiber * quickly as they appeared but many lea in th I low ragged fibrotke looking shadow which now produco in predloumly Hient tre tbove dded sounds which we umociated with pleuni thickening burit f fine cropitations with the act of coupotring They would there te ppear to be the localaed emphysematou bocalized premnothonca ore wall loskog 1 more reb? but all bomogeneow outline rounded nthe than anal hen to congenital coc disease of th bronchi There may be Ingle o multipl separate o apparently type of 1000 bulle the lung ·68 INTERPRETATION OF ABNORMAL SHADOITS which show that these materials are replactng the reldolar and not altering the normal premre which residual als melotabo. Again in the film of adult prolifendre phthil we bog at come stages of the disease when exacerbations are taking place, tho powibility of three homogeneous shadows Fint there ba genenlized fine love of translucency forming a background to el other shadow this is the platic pleurtay, of slow Imaton od odhesion of the overlying layers of the pleura Second Text kcattered areas on the edges of the matn shadow they bune demity slightly greater than the fint, and equal to that of libre catarrhal orudate of broncho-pneumonia Next we see the deket homogencow shadow of tuberculous crudate In lobakes where the tuberclo bacilli bave Invaded bunches of acini to prodoce true tuberculow exudate None of these alter materially on distant vlering while all three Incline to merge when we book 1 closely The distant view will however throw into wrong relief any non-bomogeneow shadom also prevent Non-homogeneous Shadow There are shadows which alter materially in their density within their extent on viewing at ordinary distances and still more so when viewed at a greater dbtance geneous shadom which mean acute hing disease we can take # cafe rule that they mean chronic disease-bronchiectasta od pulmonary tuberculosis being the commonet In other words, we om correlate them with fibrous and organlzation, and with the type of telectasis which results from these two procce. They are denset more clear cut and harder looking and woully very irregular in outline They may on close lospection appear to be confluent with the ret of the abnormal shadow of which they are part but on distant viewing they stand out sharpaty This is because they are surrounded by Lobular complementary emphrema the continual accompaniment of steleltasis in all Its forma We have already noted that there can be no collapse in elther small or large area of th lung, witbout corresponding crophyrena The traralucency of these cmphysematow bbockey act us a foll It offset the o golzed wau It' bs' therefore possible an interpretative report of tuberculowa Infiltration, fibrosis and pleural thickening As against homo U writ ·ROUND SHADOS more common in the lung abacen which w not enxuating freely because th broschuss connected with the block d 71 () Round Shadom of Ares of Comparative Density An abnormal shadow may be rounded re of Lont of trans. lucency of comparati denis ty The Aumann'. focer lk fimg bount nmd I those parti colar megments supplied by dral branh of the branch It is homogeneous rathe fluffs ni dges but on distet ming stanch out as a whole against its mmunal ng taux verial 0 F 46 Ano focuongbt upper libe film it may main unchanged to borde bl d When It breaks down toccasionally dor nsho exceedingly bear ent mully to t has set blanco round shadon be ming dragged ut n!! into the Chaptrad bloud sel markings of the mfamed bonchi borg whkh the ontents I the nun niccted pa enchyma a ttempting A dating i mot atusto n qull to train to the plands t ·70 ROUND SHADOIS uperimposed (see Fig. 9) They may have walle any bag in thicknad but seklom of more breadth than a 1/16-inch on usby 12 Inch film They may contain Muld level If connected with their originating bronchus they can share in bronchlalaffection up to the seat of bronchiectas and can sometimes be recognized in a collapsed lobe Ordinarily borrever in their incompleted itate they have two definite charactertata in addition to thore stated which can ald us to give an interpretative reading Art they have no associated evklerxce of fibromid round them xood they have no soclated medlestinal shift The outline of lung absce which is ukscharging gl as the next more evident homogeneous ring shadow enclosing an area of comparat e translucency The boundary is now round I to i-touch In depth It woully his a generaltad hary loss of trarolocency external to it and over lo enclosed lung love the betng duc to thickened pleura and on Its outer edge to catarttual crudate to those alveoll which he e been inltated but not actually invold In the dbene process The actual boundary is made of pneumoon exudate and to does not alter materially in whole or in part with dbtent vie Ing a against clover Inspection It has no surrounding fibroas It is therefore in cvery way a single entity in the back field o al rather than rounded It homogeneous character tendo to remain up to it change to the secondary stage of bronchiectab, Its inner pneunion constituent appearing to be frozen to the cven while it outer lining aboy increasing and decreasing dan sitles with advancing Invalon of lo sepsis in the urrounding hing Moreover it still remains an endly and not just part of a generallzed invol ement of the particula lobe or of the long bele to which it to situated at nearly always the case with the tuber culous ca ity Apart from the acut cxa allon of an Aman focus tuberculous cavity b reklom without definite surrounding fibrout The average tuberculous syltz an be bulized from what hoo been already described (see Fig 103) Iturround in both baternal and xtemal borden is irregular and uneren ſt met to Ito outer zone with evidence of fibros organized and collapsed lobules that are fused together and opaque form lo wall which stands out in boll relief to disant Ylewing It is seldom the only evidence of disease in the long It may contal a fluid I el which showssa homogeneous shadow with a straight horizontal upper border but a flux land mach Thb fibrous much ·ROUND SHADONIS formation It has much more paque e mi ih postmonle caudat due to atarrhal anuleten wir wing fudes Into normal nuk shaken trom cixation hy not kca inst the brorxhix aluno hili hahd I from the center of the han sx I Huth 73 Tai Illed Alm nay hulllll le & pin la d k acting fro. 45. Lun Aber there be tage be! drappearance of Il borimal shadon ng when the catarrhal baru runt rent has disapprt d and the Central hensy honderhede sopac os teus beren rop loc bor home of translucetuy whl h Income graduall denke i the contra a I ly detsed ning shadow The ring to be homopericom it kcast by alveol which are all filled with poretomank exudate The do niel dlagncent of bronk Excru and tubercubu a luation discussed later brdatkd fun to not a fordmg ahhough potmary are tot than Kamary cuts The shadow of the inde i hul primary cynt ry dcrise clear in putitre ind ant bomogeneous ·T2 ROUND SHADOIS will therefore be the assoclated fibroah in and around its supph thg bronchus The Agmann focus is therefore nerer uke the gat in congenital cytic disease hich is affected by mute broncblike the cyat does not stmd out so clearly against its hackground and the Infection subsides it all return to the characteristic thin outlic vith no resulting fibrosit round It There is a type of nolula garcinomp w ich sons in a small bronchus and invol o tle parenchyma through the lion ht/ mall to produce a single rounded shado It can resemble an Almann 1 1 bove er F 0.47 Nodular Cardoor focus so closely that It may lxe imposil to dlagane Il with the fullest radiological examination Only krtal fl is may contually give the true dignos a happened I in case illustrated Valy uch a thadon is basal and though it k mainly homogent cow I much mo e dems than the Ammann focus and has definite itreaks connecting It inner bord with the hilum An acute lemg abecos, often o al rather than rounded ho not the clar outl ne of the Aammans focus and does not stand out galnat it background on distant viening Seen fut after its ·ROUND SHADOIS 775 The hydatki will be found to collapse with lung tioru while the other retain thetr previot relatl poetion to th mediastinum od the bony tbores A large altfied tuberculous focia unlikely to cause d fficulty calctbed hilar glands will be evklent Sertal film will differentlate against an Ambon focis o lung abecea During the period when we ctpect changes in the headly outlined abscam modth the las cut Assen focw which began by coding out against fto background on ditmt bewing th bydatid will cut the ume derse bomogeneou and rounded shadow The Am characteristic of remaining static in stce and density for coneiderbl period will d m dlagoons of orultipl hydatki gathat the shadowi of metastati growth of these are confmed t the night lower lobe They increur density with a c d ffer in hoe and grow steadily Unully they u large numben which s dlagnostic feature The milury appearanc they can prod when they soddenly appear in both lungs to considered n the next chapter The conduction of tuberculosu id diabetes cang! round thedoni Two point d In dlagnosis they stand ut well op ditant lewing arost surrounding mphysema od they aro confined to the upper and mxd cona many ·74 ROUND SHADOIYS right Jung and In lo lower lobe It can vary coralderably in Ho Naturally if hydatid cyst is suspected precipitin coorplemou foration. Casoni and blood testi must be done the majorlty a coa will gl e a poulti e Cooni and in costaphila Multiple secondary hydatido occur wwlly in the right come lobe and a they are common results of rupture of a mh-pbreak abecen the li er must be examined and special attention paid to the shadow of the right duphragm tha shadow will often be robed or dome-thaped or indefinite in outline As agalmat the singl hydatid we may ha c to consider the more true benign-sbondroma and the occalonal neyn-fibroma and dermold which appear to be in lung touc The I became af Fio. 49 Dermollo Lung threr may be founded clearly defined den and homogeneous. While the chondroma goes on to lard entral area whkh are very d nae by oxification of th cartilage remnant from which it der loped as against th peripheral derelty of the hydatid It Day be necessary for differental dlgnoab to induce pricamothorar ·ROUND SHADOWS 75 The hydated will be found to collapse 1 ith lung tue while the other retain the previous relath positront the meditimum und the bony thorur A large alified tuberculos focia a unlik ly to cause d fficulty a calibed bilar glands will be endent Serlal film will differentiat against an Anmann focus or lung abecer During the period when we expect changes in the hanty outlined abeceu and in the leer cut Ammann focus which began by standmg out at lu background on distant rewing the hy dath will cut the same dense homogeneous and rounded strador This same characteristic of remaining tatit in ite and density for acorderable perlord will win dapnon of multip! hydatubo gabrut the shadows of metatatie gron tha f thes onformed t the right lower lobe They nerede nderst) with gta da state and gron steadily Usually they are m large numbers which diagnostic featur The mulury appearance they can produ when they suddenly appear m both lumas Orard ed in the net Chapter The conjuction of t berculosis and d abeta cang many und shalom Two potnos ad dlagroom then tand out w fi ditant lewing against surrounding emphysema and then forned to the upper and mid tonet ·CHAPTER XI MILIARY SHADOWS Fany did Numerous or uncountable areas of loss of tramalucmcy cm appear in certain or in all songs of the lang fields Interpretation of the under lying care depends to a very great extent on the quality of the film especially on los penetration The ts and resca why there lo still such rarlance on the diagnosis of retkulathon, which may be read us present in a soft film end bo entirely absent on hard film Any film of condition to Deceoorly like the film of a normal ling a photograph of ruperimposed otructura 10 that wo may be quite unable to differentiate muliert wbudows unlew we know the patient a part blatory and la particular bu occupational history Indeed without rerlal exambaton me mary cven then fail to make a utifactory differential dlagnosis es between miliary tuberculosis ullcorit od alderola With the authon, however we may find it possible to give u redoned option fac take the tollowing five criteria fn conjunction the predomost distribution the site and shape of individual shadow the deadly of there abadows their type of background and the clarity with which they stand out against that background Only some of the more cool condition will be considered Such conditions us buginosis derobe and asbestos are too specialized to warrant disculan bert Acuto Millary Tuberculosis The acute form of millary tuberculosis gira a standard post which other conditions may be considered Both log field ut corered in every pone from apex to base with dots which vary to size and shape because they we photographs in different places of the catandal sextion to maicroscopic deposite of tubercke They are crpally at mort three milmetra in their largest este lodht dwal shadom har Ught loss of translucency but are often CTO rded togeth r dut no long marltogs are ybible with the result that thelr background appeans a dirty off white discoboara

·MILIARI SI DOms
threeThis background da Lens Icklily on
the hodh bual deponit coalescem worne
al-defused modge ith supx rimpared in
UE
filonnh
pea mer
n. 50. deote Ustry tarberculos
Chronic Millary Tuberculosis
The chronic mi
Its caly tages may d ſeat lo ential
duymosh as sgainst th cut mon mgle film wammation abono
Itu soal pe incideix of ad lexox and Jy wult find th
btency of the chesse must be taken mto consideration Of
plents who murri some shox Ppa ent larmc of the
bastons others show graduallenanong m the number of deposits
those remaining being Katt red in all contes but tenemgt abon
preference fr the upper ord med Bones
They re demise md
sharp in outline u ially the background is mor
transluc nt
tham porrl but there may be focreased struikt of fibronk
round both bilir regions and over the upper pices
In several

·78 VILIARY SHADOIVS na there is marked enlargement of hilar glands woolly more evident on one side This stage of the disease u better described a calcified millary tuberculosis T 51 Hased muligy tuburtulon Bronchiolius This condition is a blackage of the fine bronchioles on a result of their Inflammation It can occur in children with mealos or at any ge u compllation of influenza or of poboning by irritant geen auch u phosgene and chlorine When the blockage, bo complete there be a resulting collepee of bunches of ur cels whose they supply If the air cells re-expand a consequence of the clearing of the brondblas so ultimate damage to the parereby me will rauſt It may be that in some che in children the recovery be more apparent than complete od that tbh produces a clindri cal enlargement of bronchi' which to later interpreted as cooperata] to origth Whete moules is the prime cause the majority of ca bow i marked coincident onlargement of hilar sond branchtal مهاg ·JULIARY SHADOWS The predominant distribution of th shad no i la tho kamer nes talling off datinctly int the mid ard upper rones eren In atrcme cares There is a Im barn to the film f cut mliary 79 27755 7 Fr. 52 Broadu.tr to the pract tuberculona m the low of translux ency and Indefint outline of Indirktaal shadow but careful inspection hon that they tend to be larger and to coalese because banches of alveol ar Emolied The oc luded bronchrol can bully be ditt rubedas cry here but defint dot m the centre of the bench By film alone the condition may be mpou ble dll rentiate from the results F inhalation of paraffin particles from loop continued neal med cation for th inding in caso rech survivors who hn mbuled oll All three conditon rally clar up OTCT short r longer periods This is not the case with Broncholitas obliterans where w ko permanent condition Onsequent on th Inhalation of iritant illummution has proceeded t fibrush within the bronchiola which do not cover Blat injuries during the war produced fahip

·ALLIARY SILADOIS
in cuctly Imllar picture Bronxhlolcatask is a cry common
and roult I lie distribution i Imilar to that al cady described,
21477 26
Fia 53
Sur patient u Fry $2 mother
but todi kwa ludo y art much more clear cut bil permanent
organlation of th tu gives a more opzque shadow to watch
we can final no ce tral Jot
Broncho-pneumonia
Broncho-oncordonla Li unlikely to cate difficulty owty to be
predilection for the lover zones
to its todency to follow the

·NILIR SHADOWS
81
Ine of tb brunchi and to its comparatively mold changes on
merlal filme between the hilum and the periphery
Fra 54
Bill lower lobe brooche poem ook
Lato
L
Sicools
Medial Iterature has contained many decual
reticulation which is stated t be the first Hage of
exporure to udallumonot follica ant in
tarting the lympbatta which re therefore
mpat it The result be blockage of
ood the appean furt t the blfurathon
The film now whom fine fibroshe
t

·22
VILIARI SHADOWS
dots of silica accumulated at the bifurcattom
Experts uy that it
Is the composite photograph of these dot talent in superimposed
planes of the lung which can grie on a soft film that first abnorma
lity kono yn urticulation
1
Pro. 55
Robeulapon ad art coderemeh
bere PT
When definit milary hados ppear donse and mell defined
nodules are seen standing out clearls against a background of

·NITIARI SHADOWS
empbgema Such
tage w noculomally reached qut mphly
so that there may be trenx d fficulty in differential diagnos:
vatnet one stage of hronic or of a alcified mlury tuberculoola.
Tta. 4. The model apa
both minor
Serul foll tben
th answer because th nodula will
calarge mpidly to Ive much beyond that of tuberculos deposits
md will coalic It irregular demostas Rood that w loper
buch fibrous and marked emphyseme ind Indlodoal noduleo may
be no longe recognabl

·MILIARY SHADOS opper lobes In the wul courte of the dease datribution of nodula ka good guide to dlagnosis They fint ppear in the periplety of the As they gradually increase in number they appear more and more towards the upper nedlastinum in the posterior wurface of the upper lobes and in the posterior spices of the lower lobas As se have already noted they har predllection for the ume dostal branches of the bronchia the deposits of phtfubiecte Anthncosts Anthracokin or coal miner black long ba condition closely Ned to silicon la indeed It may be extremely difficult to different lute between them By long xposure to small amoub of olika Flo 57 Anthracods, moty to In the coal dust the blockage we have noted in silicogls take place at the blfurcation of the mallr bronchiola Beyond the potent carbon acumulata unul It fills and later distends the surrounding ar cell When present this localized distorsion which can be

·ASILIARI SHADOWS
15
op to come the millimetres in dlanet gl a characteristk film
Dersity of Individual shadows varies coneid rably some nearest
the film appear quit hard Apical and basal emphysema i uld
to be a charact Matbc finding
F:
01 Antonces with typical
Mitral Stenork
The opearance of m lary abadon n mitral tonoun u of Tre
Ignificar o they re xdence of a falling heart Iod ndual
hadone te munded and bomogeneou the loss of translucency
Clare tropection of th film will box tbot they learen u adily in
every direction from the h lum to the periphery because they are
the Bhadow f blood wek cmend on
Th hlar shadom are
confoed udm Ven and ontat in acasonal drive shadow
thrown by the principal blood peb
The muld lon ftrary
hacercy in the antiam gradually merge mto generalized
Lighter loss of translucent due to heart failure
Ik wbich rt
Glicos the al coll

·86 MILLARI SHADOS The condition may cause difficulty u against one stage of a millary tuberculomis or occasionally of in early preumocopianto 1000 5649 21 Fra 59 Actronend mith wool with modery bedwing but the dense hilar shadow and the gradation in size of Individual badom which are less clear-cut In outline because of their dark background will generally help in differentul dlagnosh Malignant Metastases Blood borrie metastaa of millary form from a primary growth outside the lung are arely seen The individual thadons are usually ill-defined blotcha of irregular Sze and density Onco Jonally they can resemble miliary tuberclo o tbe nodala stage of protupocontais but they are usually more ragged In outline tend to increase more rpklly in size and to concentrate from sure who is a oke ok qilus zr compriser Their sudden appearance od their failure to stand out on datant Hewing became they have no background of emphyma, II abo eld in differential diagnose While the form is practically unknown a result of primary lang malignancy growth may remain insuspected in one of the ·XILIARY SBADOTS 87 Luger bronchi unul It has reached the thoracic duct through the glanda od Blooded all the pulmonan lymphatron with malignant cells The long then pean to be covered from spext base by a lovely noven for hair net This du to thickened lymphatka bere they crop or ppear Dext the film end-on W can kee tiny rodila If a large meditaal gland to reen this will h lp m dugolia The condition is known as tymphangiels srcinomatos ·SECTION Iy APPLIED PATHOLOGY CHAPTER XII BRONCHITIS AND EMPHYSEMA Acute Bronchitis IN bronchith both acute and chronic there are two changer from the normal of which ve must take particular pote There ere increased blood supply and more or lee destrxtion of the toner constituents of the bronchial trall The increaed blood nupply contribute to our film findings We bare motrd scanal ume that the branches of the bronchll tree are closely assoclated with those of the blood vessels and thut the latter show on 1 normal film in bronchitis these markings become more evident, being due et post to the congested blood reach and later to Increased connective thuc round the bronchi a result of thb hypercmis In scute bronchitis congestion auen swelling of the mucom! boat wille all th cout become infiltrated with large number of polymorpha As a result the duted epithelium peel off and mored with degenerated and broken-up polymorphe maker stringy exudate on the mucosa to form the muco-pua which the patient expectorates Thla naturally torxda to obstruct the bronchlal lumm and u aur attempts to pun it giro is the stethoscopic wounds of rbonchl and abile in the larger and smaller branchen There lourds may be heard throughout for spiration but If we llsten critically we find 1- th y are most inaistent in the first third of the breath sound and thereafter tall off to А wards its end -WYVYB This position i implrathon ts un laport fra 60. ent diagnostic fature a ganat pulmonary R Pantry tabs tuberculosis There is no fundamental difference in the quality of the olbili and stancıl heard in both conditions but the sound denoting actre tuberculosk do not ppear multbo third stage of inspiration HOCH wm A contin about ·89 ut As the CHRONIC BRONCHITIS and get more and more marked until it and the condition be very mute and to produces a her y much ciudatlon this may be seen on the film in larger bronchi - bow of tralucency raming between thm ill-defined parallel The low of trwalocency I due to the crudat on th DUKON and in the lumen of the bronchi It » cien md bomo geneous in type The lines are the congested reneb of the bronchial blood supply which lle to the connective the round the walls They are seen ruming downwards and wandet kanda both boomen in the lowe * bronchitw la mainly = bual dheuse W cm til they are bronchial shadons hall remember from our appired anatomy that a parrot the blood coch they keep the same width for some datan and within that datance hue no branches Ibwlh they r not * 11- defired except near the hilum md they d not continue below the dlaphragm a racular shadows do even with long continued Intation that he producing th complication of fibross patient reconen from mp? xute bronchita thene shadows dbppear and the film turns to normal There has been no perma Dent danneget the bronchi the hyperemle of the brom hul blood supply hawe Dot Lied long enough to bring the fixed bangran fond in chronic bronchitie From their origin it follows that congenital cysts of the bronchi can share in the infamatory tudation of aut bronchutis Sometimes were d tm increme oth h Lr shadow Thos I due to hyperæmi me hall remember that the h lar shadow pe in the main due to blood reneb This increase dmappean bb as the patient reco en If he has the common type of Koloss Ith con erity to the right this textion bully appen moro Intense and sendent for a longer tina then n the absolutely mal subject in the left bilar region Chronic Bronchitb The ondition > especially rocuted with any prime Increased blood supply to th lung this one is to commonly clated with chronic 1 hr dbext of the heart The con lingual congestion has two fact on the bronchus ( ) It contributes to the consid rabl hypertrophy of the mucous membrane The gindok I epithell mbi destroyed and replaced by cubical epitbellum so that there a much low peerd sputum than in the acut tim but on the othe hand to the proces the LDC of ·90 BRONCHITIS AND EMPHYSENA cilia which thouldıwerp out the dehru jothe lumen, have been lost to that there is much more obetruction by material which be dow mainly pus from degenerated polymorpho We see therefore why it is that the abnormal sounds of rhonchi are much corner than those we heard to xcute bronchhi but also why we get from les viscid sputum lex lon of translucency within the lines of more Inflamed bronchial walls (b) It air small mound celb to invade all the broochial costs from the miLOR outirarda There cell becomc Infiltrated by apllria and the consequent deposition of fibroblasts with endarterltba of the caplllarles leads to trycrening fibromle Tbc main brimt falls on the connective touc coat because of the lang continued hyperzemla of los blood supply On the film we can recognize It In demite white streats along the lines of the affected bronchi continuing more clarly mod much further outwards from the hillum than any normal atriations We may sce connected with rascular merking or with the cop porting atructure of the lung They are particularly evident long the inner bronchll bundles of the lower loban on boch ada only the fact that the heart shadow coren len of the right tower wone makes them more apparent in this area salost the left lowe zone If we stand some distance from th film wc am nec these itreaks give much more evident ouimos to the affected bronchi Abron gives 13 A new stethoscopic sign beyond the shoudal of bronchial obstruction We hear dry crepitations throughout iepiration which remain after cough These obaw w that fibrotic material round the branchus resistingitt attempt to elongate and What open up by the ct of inspiration ww previously only supporting more round expanding and contracting with A. Gecond trota. the norral mo cent of the bronchl, R. Lutod perbunchal material is statk and not moniker mucho by cough it is a stady finding in all chronic inflammatory decorar of the chest In la tum it produto emphyaena which Tye eball deca a Uttle later A still further effect is born on the fum ( f the xranced come) ln an alteration of the normulcardia outlige due to rouluing hyper temion An arly sign of this complication to be un CHIPTUTO IN in 61 1 now As the coratrictug band fibrod ·ZIPE Y SENA 91 breakyutee of the sortie michka ilmlar to that found on the trteriom berods of druncing years Later comes unfolding of the porta, where the increase of the truck le contmoed downwarde and lowdee. bead of loan of truslarency bhab poow the balcon o the como Salt Luter coma Lestening of the departy which becomo mon ad Doto Anectic in id movements froro sdrun cing emporion Experience abows this warranty grave prings Wiate that we try aborthy st protuding repertor mau rad the outward displacement of stre right wirkula border that horld congesthefallut Emphum The surte emphytenu oplied to whar o crentually duten dom of the alreoli 'Mary types are dexcribed in medical literatare Far practical porposes in the sound ist und altimate effecte he 12 Begrenti collocar of the right last late a broadhe paran Toe het oe besede ·92 BRONCHITIS AND EXPRISEMA on lung structures and through this on the patient two type many be distinguished temporary and urophic Temporary emphysema account with temporary collapse to other words the daterelor of the erophyrematom ulreolar will is complementary and for a comuderable time there is apparently u fudged by after result fo evidence of darpage by the stretching of the walls and of the later lobular COTIDEHye tortibkb retum to normal Such a condition is found with truporary bloclage of the bronchi mall or large W shall rec ft can occur In localized form in the ephemeral collapse that often compliant broncho-pneumonla (rce Fig. 62) and in the lobar collipse by toreign body in a main bronchu - In the condition of so-called post-operative preumonia The atrophic fom to asociated with destruction of alreol brcakmg down of their walls irreparable stretching up to tearing of their eatic there and distriegration of the binding upta which knit them into lobules and linkos them for support with the peribronchial connecore true It resulo from two prtone facton fint a weakening of the wall that occun to all chronk unentcs such as bronchitis bronchlected and tuberculoobs and second a dutension from continued cough that destroy alreoler clasticity by the constant stretch of forced impinion and expira. tion There is an Internediate form that occur in generalized tbrowh, which produce u generalized but light complementary detailoo of lobules from shrio kage of thelr supporting connectly throc. We sbull note Later how the occur in preinmonla which heab slowly and badly by repalr instead of resolution koown * port pneumonic fibross the condition commonly affect th bole of one lung Th contracting perlbrotschlal toue drug on th cepta of the bbules bringing, generalized stretching of the elite thege of individual lveoli but It can also become so muxta thickened that it crushes and datron the alveoll in loh neighbour hood In other words we hare both complementary and trophic types All forms of emphysemna occur most chally where the opporting tasue is normaally weakest The la xby the tung bans so cally blow oot in chronic bronchit's why tb loats anterior edge of the Hght long 10 readily dktende when the middle lobe rollpy It to the top to fill in the space szcated by the receding! be too why yrith the collapse of om forter lobe th other one o ·EMPHYSEMA 933 th lung, readily bulyas xron the interlo mediatinum to m attempt to take 16 place The Luck of rupport to the case why we occoronally Kee localized emphyeme over the prices of the long that may rupture without below cause of stran od prosent with simpl pontaneous pneumothora through kakage of ur it the plunl cavity (ree Pg 12) It is the ume natural walne that will cause the outer and uppe picat uffer first in blockago of the upper lobe bronchus their lob la collapuc cry, csily and to love their rakul att Thu tb sometimes pom ble to see slight low of truslocexy feven, homogenoom type ntbe octer infr-clavicular region quit early in coe of carcinoma f the upper lobe brooche Whave already learnt how closti theue allons pas on u It responds to muscular stretchtong throughout th bronchial tree, and how it forally confines th extent of such ciparalon by to network t rmination round thiveoli N the action take place when empbyxeta w prevent Affected parts have but theft power fmo ement they are constantly at f 11 dutenakon They can be moved only boduly being dragged by other unaffected lung structures Hexce the heaving nom Latril movenient of the luog bores in chroot bronchite and the perma Dent hyper resonance from constant expansion, whu h bwa tympany definitely beyond that of freed trapiration to normal thombe Prolonged esp rat y ffrt be to be expected from tho miferer nature tempting to frco ar ut of the blown-out Tekla co why exptration now equal to length to o longe tban foupiration Blood rensels in the al coll and to the upporting comective true of Lobulos are drawn out into thin wisy structures and some Te occluded togethe with two rorult Fint there Ichou circle th repta camot Il e without blood supply and po break roll furtbe recond th narrowed wel in th alreoler lla reght the pulmonary circulation and to reflect on the nght he it and open the way to Il the stages up to congoth fallure Close terpection of the filon hom corresponding change to th pal mooury art Has which are rollen od indent mich furth from the hilum than in the normal film The rezon b Dot Fart veel Such drgmg ut and occasional obliteration of th cepilloles in the 1 Col walk oxeos that less blood be open to the realmal at there is cooklerablo lowoning out ·94 BRONCHITIS AND BAPHISEMA of goooun interchange les chance for the liberation of carbon donde ad Its replacement with Stypen. At the ume time there le movement of the alveoli they cannot get the steady renewal of residual a This is the explanation or the cymouth of the chronic bronchitic and abo of the Increming condut to the brorxhlal usthmatie He has the added difficulty of the muscular contraction that brings clorure of the terminal love to the acto.com We ar the rezon In dl cuming the muscle fibre structure of the bronchial tree it ends in circular fahion round the last recogniz able lomen at the entrance to the acinu (see Fig 11) The alterations on the X ray film of ad adypored near DO cally realised The nb inter-spaces are dared The voickat are fewer and larger than normal so there is an increase of tran fucency by decrease of strations due to their walls monary vesel markings are more in evidence At there baka Yen CMD return the heart smaller The dlaphragm flattened u the blown-out vesicle prea against It We an see the ardio phrenic angles opened out and to percumalon we find moch decreue in the muscle movement downwards with Inspiration The continual fattening elowly bring paresh of the muscle with coniequent basal stats of the accumulated debris Thc pul ·CHAPTER XII BRONCHIECTASIS BRONCHIECTAM meirs a widening of the bronchual tube This may occur over leogth f the bronchus in the form called cylondral or be localized in the fan called uccula It may be congenital on the KTO that it is complication of PTIOT developmental abnormality of the bronxhe but a wally recognized being frankly an acqu ed cond trom For its production both obstruction of the lurpen and mfcction of the weeker.ed walls uro Decorary Because of the liability t debrit xccumulat by in Ity and stars in the dependent parts f the hoge fond that Dort s re banal but It may appea in any part f the pa cutchyma a tho renult of blockage its upplyong brondul lumen wbere kmall brannbogs are thus Inyol od w broocho lectual We shall see that this cont mual accompaniment of Hic grome fm i volvong tb maup branches of the lower lobo W now recognize that broochiectas - not of necrmity a kobar dacac. Certam segonents are known to be particularly affected There are the bawal segroenta fthe bow lobe th left more than the right the lingula f the left uppe lobe alone or with lower lobe baul quents and the right middl lobe If othe Inglese re discwed th y as almost thranably the od reults of prerioa Infections W would theref re ruspert that bronch ec talo.confined to the superto segment of th left lower lobe had resulted from lung abecess n that Kyment It i llom that prope treatment w l depend on proper dlagnione which means film mogato f the whol bronchial plodol bo tbere re fplected on day ande beervation to the the operat can ensure hilling of every broocto-pulononary wymient The pathogensen's b mort wil understood it be en baged a further des loprocent of chron bronchitr which has become centre At akenmg th Hall by ito hronk ty it bar destroyed II the omponents of the Il from the cpithehura to the muscle and at fibres and has finally penetrated the cartilage to Infect the surrounding pa cixhrona mont three

·98
BRONCHIECT 4SIS
upper sint Intection
This is a
cry common finding often
accompanying an acute antrum trouble Fypert opinion on the
upper ginust including ray should of cours' be obtained
but the following points may ald in comparing the chest film
F a65
Tbongtu ardoo-perrun yliopper boa olection
The film due to upper sinulth wally shows much more homo
genelty in 10 boul shadow
We do not get the same eklence of
hbrotu unless the condition la of ery long ganding with com
tinued reinfection of the bronchi when of course the patient a
developing resultant bronchkectab Furththe film shows a
confused shadow of the inner third of the diaph om merging into
that to the cardio-phrenic angle w do not see the loner bronchi
arving Inwards
We ro looking at hyperzemla of sense con
Anuing below ti daphragm
If we look at the film ol bronchiectasis at some Jbtance from the
viewing bor we shall see that the striations pound out clearly *
—

·BRONCHECTASIS 99 ALL A B becon well-defined parallel lies tere and there interrupted where the cartilage to dyppearing Around them me se small opeque and hard looking hodom which are due to the colloped and organized lobules w 11 defined because they are offset by other more them wblh luve complementary emphysema That to the disexx by tending by bronchlolectab The next stage to perf ration of the bronchial wall and copre quent extenwon of the repuls into recognrable areas of parenchyma les occurmet k heraklerl by the I thoscope finding of Files which mean that parenxhynutou mat rulhent Hng the bronct Obten critically shall hund they in the mildle third of the traspiration that the brogue blal parenchymator phase They rte in Intensity to it from ht the fint phase and then tall of in the third They re due to alr ent mmg bronchioles I'which catarral rudat bescharge FX 4. ng frien lobolan that has been filled with A Long 8. Brooctureth lunt that first to fummatory fluid which is the rwcation firritation fth walls In othe do they are the rla of locallan lung abscesa W can recognize this exudate on the film It htbe ordema of many radiologlal report and bo lw y homogeneous m to whadow ha ing a light loss of translucency comparable with that thrown the Inf TKY In the partxolar patoxe It # Kto on the utreders of a more opaque and I hem re homo So whiclox cant by lobales that ba pored the stage of inflammatory ewalilon and are now filled with reptic materia) W Inow it commotes ad ancing bronchlettual ooly becatre nc real with It the haraxt ratke fudores of fibrosa and organlatkom Jetaled abm It arrean thach x Hation of th Abrze Liter pet dere becoming true wha! mulat and Later rull 11 the nomboring cowo change of collapse and forests Whath non b cavity to the bronchar connecting with u ty in the long kptic bronch! re continuar u th puc pareix lame To 11 Intent and purposesha In auctal ras What me shall fund later k the end owlt f hron lung bem where the k log hos miested the bruschuss upplymg the drexed bronchoprolimunan segment ind that the adhe talen on datinct metall Orimatme quity There sotme in present thmophout two-thirds ܗܘ ܢܗ ITT WY البلد ·100 BRONCHIECTASIS of the Inspiration over a considerable area of the lung Geld Liplodol introduced at this stage will demonstrate every step of the destructive proces here we aball see only cylindrica F1 67 Liplodel in bowl bruncilet enlargement there accultiom at still another point nothing resembling a bronchus but only a large Irregular opaque area with cotton wool edges which merge with the fiset loss of travahrctixy that indicata catarrhin irritated lobulos Medlamtinal shift will be more vident still to both film od phy sical finding The fingen will show grow clubbing of the drumstick reptic type Dullnes will be much more marked and the foul sputum will contain tho elstic fibras of the destroyed parent chyma. Bronchiolectads We have notad how bronchlertal multiplia Itself in the entrar form of bronchlolectasis by the involvement of bronchioles. Sacha condition is almost always a secondary on the lumen ho been blocked and then lofected by septic material in the babuler ·BRONCHIECTASIS 101 le rappler a proces which copies the pathogenesis of adolt taber culo w shall me in the next chapter that its common Cun primary broncho-pneumop la which has not been abl to get rid of id cudate It is always a fully localbed condition and this belp us to differblare it picture that has lement not dballlr to those of broocho-posconxok tuberculosis where the proceso much more nderpread into the mid tones The condition is not the same pathologically or radiologially bronchiolitts condition which is disctuned in the chapter on Milury Shadom ·CHAPTER XIY THE PNEUMONIAS way. COCCIA The patbogeness of pneumonla end broncho-pneumoabe are fundamentally the ume corobting in the intentitial reaction to the infecting organism In both dieses the organ lams penetrate the wall of the bronchus to los turrounding connective tave and by lo lymphatla are carried to the walls of the alreoli which they fint irritate, and later penetrate In this the pneumo cocci of pneumonia and the streptococct of broncho-poeumonia differ from the bacilll of Influctua and Friedlanderbucl}ll which We have noted are carried direct to the lobules by th 1 apply Ing terminal bronchiolas The connective twue puta up a poor reslatance to the preuno- In the great majority of me th organbom seems to penetrate the wall of a math bronchu ruch as that to the right lower lobe cloro to Its origin It finde no protectivo barrier against it invasion of the parenchyma and therefore rapidly tnvolves th whole lobe On the other hand the connective time puts up an intense rektance shown in marked Infilaromatory reaction to the streptococcu to that it confines the disease to patches of Lobula We an see why loba pneumonia is a dbcne which spreads from the hilum fn radial fashion los progress is rapid the landing army 15 too strong and onceps aside any light oppoultion it may meet It is posible bowever now and again to se an example where pneumonk erudate is already der hoped near the hilum before the fint evidence f inflammatory reaction K evident in lobulas nearer the periphery The manner of onset crplains to w abo the manner of clearance by ither roolution or repair which must be galo radial from the hilum to the peripbery The bronchl ha ea chance to recon from any slight reaction in their commective there before they are called on to deal with the parenchymal erudate which will flood them in due course to produce the typical precononic spartum This manner of clearance of th diseme be an important one in differential dlagpost by film cxumbatlon It is the opposlt of chi Whood to that seen in the po-alled "epłtuberculose ·103 THE PIEUVONLAS truet nad ang Serial fils will help us to decide which w are d aling with The picture of poeumonia len napadly afte the cra bat cpituberculosks will tak many wels n months to resoh mnd wll lea on the film mlarged and crenated hilar glands and perhaps to Il marhed Ghon fact at the ait of the onginal Infection thank the perphen of the flect d part Let us try to t llom the pathogeness f der loping poumons nn more et il 27 * ke It on the film It there is any reation n the onnect the penetrtion of the bronchial * !! by the preunwa M sregel triation along the lines of bronhul branxhing due to congestion by polymorphs in the pertbronchiul pen neula and nt lobula onnectic touri There may be endent the outcome of the flected late while 1 Inne regia a homogeneous bou of tramlik my Thos hamkowa f the ume type 2 forol in the teneron of sepaus from brons un to parerah ma bronxhrectos On the out odge ne see the ume hinne low of translu ency duet the non-specific int tron of al clar * !! Nrer th hlum have the dense hadow of true pneumon udate onesting of polymorphe same lange mononucle n and lymphoxyten, n ont Ining ning quantity of fibri dependent on the tinue rexton The Hobukes so affected fill quickly and dutcom! and thn tret hmg at the r Lastket sue h lps them ont ut lat rm that the cut the udat mt the hronxhoko It ha fundamental t the understanding the pln uologne ! eflects the ray hlm and the ph Ical lgm, to realize that when pemand is the mpikat d the udat rplaces the reanual The same phy bologle I strom * that of roboal r remains on the bath tour of the branch alreol re filed Il pact and the Lastk rtw th of the Talk then n tret hint x It would be in f Ilumpiration There is no hlox hage of t rminal brona hlukes, nd theret re no ollape of katrules and no resultant hift of the medusturum to the kit of the dreare The me thing roles to ut omplx ted bror ha proumonu and womplic ted lung aire so that they are tot ll unlk in pathogenese physiologie I flects and phynte 1 o to hurth hrun hectars and stolt phthek to those Littr are prolf rain diseases The I rantzatkan and Pape flatuks and her from the beginning *** bied had They will therelore **e the mouldestinum to Inft mrd the part of serum onnect t Tho ·10+ THE PNEUMONIAS tho lang they affect to that we shall find the heart and the trachea displaced toward them Onco fully developed pneumonia outlines tho lobe anatomically and the dense homogeneous shadow of its crudate remains until the crtats Thas being to the shape and dealty in any one lobe mut ring with the shape and alter with the depth of there in the normal lobe a we my in our reminder on applied anatomy The night middle lobe must be defined and denso just below the line of the lower mure and became more translucent towards the lower zone and unlen the lower lobe by also invol od wo mot 100 a clear area between the lower limits of love of translucency and the diaphragm because the area is occupled by the lower lobe (uee Fig 25 ) In the same way the shadow of lower lobe pneumonia, den ett in thn lower zone over the diaphragm must lossen steadily upwards towards the mld zonac It is sometimes confused with that of tuberculow pleural effusion The physiologłcal effects to be expected in these condition should add is cffualon pihen the mediatinum to the opposite side where we shall find a poultiro sterbo-mastold sign if we look critically at the shadow of tuber culow pleural efimon Herball see that is peripheral density to for les than that of pneumonia and that w can owlly see the best through it (see Figs and 1 6) lo low of translucency lucremes Iteadily towards the middle of the ling field giving an impression of a band running from the axllla downwards and Insand to the diaphragm The effusion is compressing the lung and we are looking at the area to compressed when we see this hand of greater denalty The la quite unlike the preumonic denpity which is equal at any one level throughout its extent along a honrontal li drawn between the periphery and the medlastinum flere the denuity must lezen a It goes upwards as the lobe thins out to los Ungula in other words there is less and low depth of parenchyma to be filled by the pneumcic erudate Moreover we shall rezember the further and to differendal dlagporba An un complianted pleunl effulon will not blot out the vegel nurtingo in the underlying Immg but exaggerate the there is hyperæmla but pneumonia blou out all normalstrite and le usually so derse in its shadows that we annot rake out the outline of the tbs The picture of fuld compliating loner lobe pneumonia con not be readily voulard for it combines both pictures Tom and ·THE PNEUVONIAS 105 the periphery we shall see the lighter lors of translucency of the flold and through it we can generally see thobe quite clearly dans far as the outer edg of the describedor at by the poeumonia No ling markings will appear in either sbadon Nom the medbe #lam will be to the opposftr ke xhema moral loog the primary pewootila Tomtencomplicated Before the full developed there wano temo-matord am not the muscle on the opposite oldes under distmet teraton From what he learnt so far it Collome that the light and temporary shift ufficient to be noted by film exmiration to Kome cma of pneumonia is due elther to overdbtalom the lobuki by the exudate or t mphoma) blochat of theu bronchiola Close inspettlon of the picture should I us which * are lemng for the Hect of the former will be traction on the Dredhatten without en done of ollapse the latter will present accompanying endence of what has taken place for examplif thb has occurred as omplication of right upper lobe meumot Wo hall see a ditut lomac edge of the detuty to a sharp line This is proof that the itgule of the labe bas shnok upande to the Ibne of the keer wure nhi h becomes convru upwords and to higher than it thon hal We Areat we om see about the third or fourth lat mpact on the normal hilo Furthermore the tits.complicated preconnu showed normal blood rensei markings in the mall and lower lobes but now there are play d out in order to Fataly the emphysematar med and low r babes To physical iga prctomonla ghia us dulled due to exudat A the lobular Latk ebpur on full stretch and maintains the inspiratory position of the bronchial walla base no Moscount of the affected part There 11 tberefore be bance of truc breath mxonda but brunchial breatbing » Ill occur # the str mit mmg the mas bobar bronchu at its orientar la conducted through the comoldarlon which ts n sounding board The method of learance of the mounonia and the rapidity of the poeto ka fortunate Pal for the patient Considering all the poslalike i complication may well man i that sa fer cases (reaking fibrocht the peribronchial and pest culr tu o ecently recovered from the nitial reaction to the trading organam hae oor to deal with Immpho tes and platna la There agata produse trations on the filos md they can return a comorable time They should not prognombor by reading them werdence, Kt kad to it ·10% THE PNEUMONIAS Fro. 61. fibrosis umlau e find they ure accompanied by the characteristic crepitations of this condition But they can produce fibrook 3 We thall duris in more detail later Tho firmow cruxdate in the lobules is coughed up or abworbed after being liquefied by a proteolytic ferment supplied by its accom panying polymorphs It because of the liquefaction that no hear the so-alled redua crepitations of pneuronu Lasten to them critically we shall find that they are really stickr bounds at the ry end of inspiration and are rales ratha thier crepitations We are hearing alr entering the al coll through the crodate which is noi dhcharging 1 to tenninal bronchioles RULES It may be that poo supply of polymorphs in the crudate the halc cause in those case that go on to hbrosb capillardes ha e B time to enter it before it la liquefied In any cac we do know that fibroblasto replace Powerporis the fiban passing through the alreolar B Broncho-pneumon. walls and from lobule to lobule causing organization of the c. udate that remains and consequent shrinkage collapse Although others around these lobules are bound to show some complementary emphysenu there will be shift of the medustinum to the affected de normal unaffected twue is being dragged o er by the Inter plcural PrxUTC Chronic Int notitial preumonla a itu called is therefore exaggerated repair those It bually found in one lung and we can see how It differ from the fibrooks of chirunko bronchitu due to bilateral long-standing hyperxmla beatse this Latte ha pen bronchial sue increase not an 1 ter lobular one If it 16 very severe ft can crush the supplying bronchi la und gleiche scattered areas of lobular collapse what is not an umuual funding. It follows that the tray of chronic Intendtlal pneumonia will tbow the ribs on the ffected side cloor together than normal and that the diaphragm will be higher than normal while the heart and medussti um will hay dufted toward th fibrosed long Throughout the discared lung Ill be trands of fibrosis which bare no detribution corresponding nith that of the normal blood supply These ill be more prominent n distant jening and will be seen to ba csattered among them xed los lhe shados which are cut by organized bunches of ah 1 Auculation will gi * widespread repitations het rach thelr Lowest point tox ich the cd of inspiration they are parenchymatous In origin ·TUE PNEUMONIAS 107 The condition is quite unlike the result of the pevanonls of the new bom benne here at lector preceding entity the lobulet de er opered at 11 which neceunly a d fferent condition from acquired collepee It is abo quit unlik so-called post-operats neumonia shich is not pneumonia, but * purely brunchul duce Avoin thxh sticky erodat from the wall bloch the lumeni sith the une dramatic effect seen with an Inhaled foreign body Redwal ruannot be repened the prenchym collipact and there ke no obetacle to the action of the Intra pleural prewore of a lobe that perforre mot hirmk to its main bronchus at the h fun Screening the patent or thong two filmas one on complete op ratboo and the other on omplet expiration will stron what neve happens in ordinary pneimo cox cal pneumonia wmg of th collapued lobe the heart and ปม mum ach mpiration to the aftected the There will be some corn with wh piration but anit diaplacerat med wastinum wbtuh will be when by the poolt termo-manstol samt even be mpoemble dmonert by the position of the apar beat If the glutinous mat rullnet cked out by postural drainage or broncine Opk suktion the comequines can be ery serwis Organizaron can lead to cry ruage of bronxchreceas the eme end mut so often reen the pneumonia of the nen bom To this last and it on the name ongenital bromheetons may be applied with us at lectus present from birth there is often maldes lopment 1 bronxhi to that you are frequently found and those the super moned infeccon tutta mo ump of spil mar rul to add to the man hiectack cul truult From what has been und I the pathogenes of poumon, the probiury of localled for can be ally on med da el conte may along the main from his befre ptering the wall of our brunch Tha ompuran 1 ominum in the pocumopla of chillhood hxbo rod in forma the sotalked hilar moutonla bn hing the postettu torloont! branch of the right her babe bronchus Innot LMOTTUTIN to adult that only the precimal ur the avilan rawh of the Highest per lite bronx hu has her afieuled o that On the film thar trunguh bebost of the purch ob wy referred to in the westion mappio satom (ut ha 14 and s) The der kant of the dwar lost the mom hatur permonla il prezte muth nih town the point at which the Thir ons Re ·103 THE PNEUMONIAS bacilli penetrated the bronchil wall so that all the segment of lung cupplied by that bronchus is involved The shadow cut by these loaltzed preumonlas b never really like that of tuberculosis with which it la Doually considered to differential diagnosis Both may ghrettangular low of time lucency in the outer udllary region of the right upper bbe the pacurponlc one betog duo to trvolvement of tho udlart brach of tho main bronchus while the tuberculow apo I due to a tuber culous deposit in the peripbery of the outer base of the upper lobe that is commonly just above the peripheral end of tho leser fuerunt Both cause thickening of the fmure Both a show aboommal filme for a long time after onset beawe localized pocu monla tends to heal by repalr rather than by Trolution If however we look critically at serial films me aball fod that the tuberculous shadow almy hu its main continuing deralty against the periphery o it boerentially • parenchymatou decide the bronchi are involved only wecondarily at all stages This not so FE, 69 Recorate Perdid porcomonde Hytte apper babe ·TJIE PNEUMONIAS 109 ntranc with the localized preymob healing by repute the manos depsity to now at the apex of the trlangle that a round the supplying bronchts at la Secondary Invat meni of bronchitin tubercle but the ite of the deposit; there the bronchi dilte steadily until, in most can defmite caritation is sem Another shadow that may take considerable tlore to clear after pneumonia la chut of the exudate on the pleun spectally the toturtobar pleun has been affected In all cars there is a true 2963 Fra o folo corto-phalencon prenoon. pretinonl molition in the sceral layer and the cand whalom to the inflamed pumetal lyer me vement by Impiration therefore so thar rabbing pum Laudation utally lead to mpta absorption but k Խ. breeds buted how absorption may take longe me in the auto-phrenic ample and in the 1 i Hoher fourt so that filling of the conto-phone molen toime of the dlpture that pe pamant but of no clnkal larport in the + ·110 THE PNEUMONIAS ume way the lesser fisur may be thickened for a comiderable perlod after a partial pneumonia - Fra 71 Lateral ken of sold in mare producing ting. Broncho-pneumonia Broncho-pneumonia us already hated may be considered a consisting of localized patches of pneumonia confined by the strong resistance of the peribronchial connecti e true which Ilmits tho ducase to bunches of lobules It is commonly bilateral from its onset, but It may be completely un lateral, o develop on one side later than the other It is usually in the lower lobes but is not uncommon in the nghe middle lobe Its progrens can be followed on the post so anterior film, nhich demonstrates shadon that begin near the card lac bord r and increase in size and in spread along the bronchildetribution to that they go downnards and outra ds In lower lobe involucrent and almost horizontally outtvards in middl lobe direxe Th In olsed areas show th uume homogeneous buses of translucenicy w Tree In pneumonia only nou then Fx 72. Bracker Ponde are in the greate densities trlangular in shart ·BROICHO PNEUMONIA particularly in the middle lobe x the latauks are pltured along tbe sld of their cone shaped bronchopulmonary segments The FIG TS. "Contact and the boner lobente 34 tko 1122 Lotrule in 1 ed her pour nl exudat are no tirely disk rete because they be rural them those storn mg the fint lovlamsaxtory non-gectha catarrhal udate Ther ino heft of the mediatinum. The picture as therefore in two cha *terbitkulu that of broncho-cumont phthkos hrely the deale b fibro-creo and il hann le uut area of actuar collap® among others with omplement emphysema ipite of the fact that both condi surroundior arckematou hadra Thla Il bac qut excent kol the tists at Kook entank tronx when the chaton of streptococal bom ho preu man will be no more Klint but theme of tuber loxun brorxho meumonu will become much mor kar! Se and there 11 In he KTY Ilyme en they fre some duplemento the modustunum wth phthirsk w it thors st น to Yra 11 le to pb ik Irum natiom The ph a tool ng n be explund by the pathogenan and hell fod paths tea of knx on lobuks nikit demi Ith pneumonk mulat nd imuned ut | the docachfll des koprila hall get go of the exudat ent mos the tal hronahk lo The kiben hem niet kening hos t 1 the xri putu ·112 THF PNEUMONIAS of coune completely silent there are parts which have escape altogether and other where only inflammatory exudate oraples lobolan still maintaining some arxay If we lista carefully sc hoar rather bubbly rtles in the mid third of bmpirat.co because this credato da dtachanging into tetrul bronchioles (see Fig 68) This to a distinctiv stethoscoplc finding throughout the clinical tllets the only difference belng that the rila get more marked og the pneumonic exudare Ilqueria The dubineer will osturally be much less than that of pneumonia o the lorolvement is patchy but there will be district Lack or borenent laterally in cases where the lower loba are deel By rexon ot the mach moro Interne connectire tbove reaction many cases proceed to mall area of aclectuala The lacrcmed trave naturally gathers round the termthal branch lolos of the affected lobulos The interferes with the natural morenent of the bronchioles in respome to respiratory action; that their Moscle Gore action to inhibited Their entic tuae reaction which is dependent on the stretching of the alreoli to raklumlar by already faiterfered with, atner thoalveoll are trued at full export alon by the audato in them When the deae tria to resolve there brorschlokas are therefore aught at a distinct deadrantzgt. They have no time to recover from this in tel Lillation of their surrounding connective thoue before they are flooded by lympho qytes and plasma cell from the crudate now trying to escape from the alveoli u resolution sets to We have now Intation of the toner mall of the bronchioles added to their coupective than Irritation on their outer wall They are therefore all too cually blocked to that alreoll that have mmaged to empty go on to collape while there will containtog exudate go on to pantation We can voc therefore the inherent danger of too arly bovetoient, perhaps advised by the belief that modern methods of treatment by redactng temperature ba e brought resolution If thu is dangeroua tn Lobar pneumont It A moch mom dogteroon In broncho-pocymonis If 'the broncbbolet do not copty their walls weaken and the way is open to bronch bokep cod biet to bronchiectab We This is especully posible fr right mikille hobe deemme have already noted that la msin bronchus goes out almost borttontally from the right main brunchts It is therefore difficul to drain If it goes on to blocklace in its terminal bronchloka te have a slowly changing picture and recomperyong changes the ·BRONCUO PNEUVONIA 113 physkaal in The areas that on preslows dbtant vening merged with the currounding catarrhul inflammatory endote Dom Kund out with the Larty of broschopneumnon c phtheb with which we may confuse them because the companying ahlft of the Tdntum shall not hones or that they are confoed to Latenl dens tla i onc area of the loner mld zone - igalot the wickpread dktnburn of t berculous broncho-pneumonla ood that they ha much more contrated peribronchbal fbrols Alat ral film hul show on bow much mort the letter hmure shares in this fibrosks than t dort in phthash and of course, che general cond trom mdth lower and lemonging temperature will be f rther d Both ond tror will I counce glve u tho crepitations of fibronn but they ll be much more localized and definitely course and more insotent in a mplic ted streptococcal broncho-poumonla Many cases rectn to go on to impl fibromb ner mld zone indeed the fortunat patxat may escape turther clinical upret but many go on to lowly In reaming broochila lecture and t citablished and pronun bronchlectands Thw us common end result long aft wards on superimpoord infections F. 74 Fibroen balora neta mulle kobe broadto prestare ·114 THB PNEUMONIAS The patient may for a long time be unaware of bat has happened Mas radiography has sho in that many apparently complich T 75 Lordbook of rape patient F. 74 are presence cf bronchrecovered cases of middle lobe broncho pneumonw has been left with much tib oss The X rays sho n In Fly 14 and 75 are an cxample The fint demonstrates a low of transluc pxy in the right lower mid zone The patient had alguns of bbrosis in th's The lordotc picture shows hon the middle Icbe bas shume ery considerably Liplodol Later pro od the ettanta An mportant point to remember ts that e ery case of bronchopneumonia crua marked Increase in Hola abadon because of the interse hyperremla of its reglatance the hilus glanda iho swell with adema This hilar i creme take a long time t clear up ud thus bespecially noted ith the wil type of souliol which bring the left hilum into prominente There be the power gra, dugnouis of localized glandular disease but the swelling to acki m of the entent of Hooghtne doce and the swing of the P I Ebatein feve and the blood count will be further aldt in doubtful caci The enlargement remains bog after the patient le linically well bility of ·CHAPTER XV ATELICTASIS In dealing with thik coodrtion wh ali may be detmed. collapse parenchyma through low f residual als shall confone ou dicunlon i the acquired f m duet obstruction of the lumen neopplying bronchopulmonary area Thh may occur by bome thing froide tbe bronchus roch s gronth o tnhaled foreign body blood muci o granulation thosue or by something pressing on the wall of the bronchim rxh a manlarged gland or tumo tormation As we uw in our studies of applied matomy and in the dancription of post broncho-pneumonic Kekectacles in the right Idhulle bbc the ate of the affected cone depende nth otre of the benchial honen Thume wahall find to be true to the secon dary roots of blockinge of th termal respirator bronchrole in ad lt phthab where gran lation there enten it from the primary ucina depoult It main bronchus 4 octhuded, tn post grerative pneumonla then the whole lohe collapot unco tho rodule to every trhal aleolus is aboor bed In ruch condition oxygen to first aboorted by the capillaries in the alreoler walle and get on the film fine lors of tram lowoncy. W cannot see tha taling place in the small telectatic W of bronchietako complicated broncho-meumonia but can follow it quite olly where a whole lobe bubutting donn, and we shall in fond tht light bomogeneoushadow beg nning in the lent supported areas of parenchyma Thass in the uppet dobe it wil occu first in the outer apex od in the loner lobe along the anterio bal margin: we un the reason to decinsing tractunl upport under our oaklerations of pled anatomy theke iton are dependent alonoot complet ly for thelr normal potrin on the od he but like wyport from thei Kaffolling onnecth thwoe Later the nitrogen k trorbed and the shadow while till brimogeneou become Jheluit by more dette up to the time when och density cores the whold the allected habe it may be pretekle to choot cars that are due to cardhoma of the branchen to differentiat on the film the box opacity of له لحالهام ·114 THE PYEUNION 4S The patient may for a long time be aware of what has happened. Mən radiography has shown that many apparently completeh Fa 75 Lordock hom of more petsont oF 74 area recovered ca of middl lobe hioncho-pneumonia have been left with mich fibroal The X rays aho n in Figo 74 od 15 are un e ample Th fint d monstrates a los of translucen) In the Hght lost mld 2011 The patient had sigro of fibroad in this The lordotic picture shone bor the middle kobe bathrink Yety considerably Liplodo] later prored the prenetice f bronchit ectual An important point to r m mber is that e ery cate of bronto pneumonia causes marked increase in hile shadon because of the mteke byperama of lo resletance the Wlar glunda abeo twell ith demua This hilar Increase take long time to ckar up and this to carecally noted with the cul typ of xohosts which brings the left hilum Into prominence There is the pool bility of gra e dlagrost of locali ed glandular darose bust the velling wekdom of the extent of Hodgkins deste and the swing of the Pel Ebatein fee and the blood oint, - Ill be further ads in doubtful care The enlargement remains late after the patient is clinically well ·CHAPTER XY ATELICTASIS T In daling with this condidon wh h may be defined collapse of parenchyma through loss of residual shall confine our dbcuelon to the required fro dos to obetruction of th tumen supplying a broncho-pulmonary are. Thib tony actu by come tbing treldo the bronctus Buch * * growth o tnhaled foreign body blood mocno granulation time by something prenog on the wall of the bronchus ruchu an nlarged gland or tumou formation As we a* In our studies of applied anatomy and a th description of post-broocho poromonte selection to the right middle lobe th tre of the affected conse depends on the tre of the bronchial laren The ume e shall find to be trao in the won dary multe or blockage of the termoal respiratory bronchrole n mful phthala where granulation time moters it from the primary acima depoult If a matn broochun tocchided in post operativc-poeamonla, then the whol lobe collapres loco the ralduai utt crcry terminal alveohn aborbed In much condition oxygen to fint absorbed by the capillarken on the alcolar wall and we get on the film a forme hoe of trans locancy H camot see the taking place n the wall atolectate area of bronchiectabs or complicated broncho-pneupona, but of low it quit sily where a whole lobe o zhutting down and we shall always find this light bomogeneoun shadow beginbag in thc lent supported area of parenchyma Thu in the upper lobe it will occur first the outer spet ind in the lower lobe mong the wt nor bal margin w the respon In doctomtng structunl mupport unde our consideration of applied matomy these are ar dependent almost complet ly fo their normal potom on the randual a wyd hay but little support from thel kaif bag of connecttre the Later the rutrogen brorbed od the hudom while all bomogeneous become defnit by more denne Upt the thone when auch density cor n tbe bole fthe flected Lobe it to be poruble in those car that are due to artidoma of the brunchro to dfferentiat on the film the beat opacity of ·16 116 ATELECTASIS the actual growth near the hilum, next to it the slightly lem opusty of those areas already completely collepeed and towards the peri pbery the finer loss of transluceny of early colline We hne here characteristic hitewash brush filma It looks of the bruah bad been applied heavily over the point of entry of the brow chus and then a it was swept outwards towards the periphery had been preved with continuing less force The apex of the broncho-pulmonan area ! demet It bose let dense Later as the lobo become imaller by shrinkage and 6 followed up by los proylma! babe which develops port ponu its complementary emphysema the Interlobur fosure ses and the demalty becomes throughout equal to that of the carattre growth, which Indeed in most cases hus by this dmc extended by io cell, Fo. 7 Cartnoms left upper lobe or its mocidow exudate into branches, compered with tuberculow pommonka ofight upper lobo. considerable portion of the surrounding parenchyma In many there appean by now the further complication of absces bringtog a more or lem central area of translucency From the beginning there will be lack of movement and dullness will deepen with increaslog Involvement of the growth. The med lastinum will drift to the mme olde We sball find the evid ence of shrinkage in alteration of the normal lesser fosure or the appearance of the greater favore on the postero-unterfor film and in the change in blood supply striations in those parts of the lung that are blown out by complementary emphysemua Lateral filons and of particular substance as we have already noted in all conditions effecting change in size and shape of lobes It follower that the dulness of collapse must be companied by the tyopany of omplirsema This to why broncho-preumonia ood its complkation of terminal bronchiolé blockage deres glc over all dulloes and why with the dead dalhiers of the collywed right upper lobe we find marked tympany to the compensatory distorsion of the middle od lower lobes 1 ·ATELECTASIS 117 Bronchial breathing may be rery marked fat short of the actual growth at the one of the effected broschus Auded monds Somide the collapsed lobe do not present manable in the To 77 Cartoon net spes labe upper lobes inters there a dammtorg back of secretion and the compbeation of abucen nepertm poved Once the tendon of growth begin to prow on the brookhus to a lower lobe oro geta bernd this second bronchas very high pitched mural abbihan from posite the obstruction, in to production of a mother montal whistle It opetrece la of grne import The most constantly of colla in !! to form to the Hero told sign which to any positiit on the affected the b the difficulties of differential damous it brouch pote relable fooding them any other ringle old even tractadtng competion of cort kete temptation and complete poration W burro already noted twow the trucher reacts to change to normal long elatiety the shrinkage of the affected part berting the remanlar portaal te open to both fortened pal? on the page thate bd bocrated path from the other While the truchal reaction ! fibre on ·118 ATELECTASIS constant the position of the heart is variable for a we uw iba greatest weight is in the lower mediastinum, and it will react only to lower pone disease or complete unilateral disease Even thon it is unwillmg to respond to anything mhr in force it will swmg on lo long axis and can be pahed backward by the crophy xoma of the opposite alde before it has mored bodily and laterally to the affetted side While it most certainly always be located by palpation and by stethoscope the poultion of the apex beat in collapse may be a misleading sign Em to screen examination the heart may show no definite shift with Inspiration If the dead area is above the origin of the worta These tests we shall set applied in more detail in considering atelectuals of Indhidal babes Upper Lobe Atelectuais The commonat caure la carcinoma of the bronchos It k bere we see best demonstrated the whitewah brush effect on the film although the rery first evidence of interference with reaktual air may appear in a fue lor of tramluency in the outer Infra clavicular region. Quite early we can see the accepory ako to shift of the trachea and the med Latinum to the affected alde od in the upward shrinkage of the Interlobar figure on to which the thin trangular lingula retreat steadily The Interlobar framure become more and more evident because the rays are posting through more and more timue It has added to it all the thone of the retracting lingule of the babe These findings are always more ally ecognized on the right against the left side as the shadow of the upper right cardiac border is made in great part the morable ruperior vena car, wually lo x ll confined than other medlartial structures by the autounding arrolar bone The heart does not mo o much in the lower two-thirds of lo citent and so th re may be no appreciable change in the poulton of the apex beat to palpation or sukultation cien with colorable shrinkage of the upper lobe It is quite porible that in jo carly to the film con sedemble that of a der loping pneumococcal preumonla although tempera turo symptoms and the examination of serial fibu ibould help w to avoid mwinterpretation, and we know that an incomplicated pneumonia does not produce med lastral shift ald us because we shall see the retraction of the lobe on to the inner end of the lesser mure In a manner nes r displayed och deteloped peudonta Further we aball found that while pewmonla da A lirral Ebro will ·1TELECTASIS 119 duines both Hy and posteriorly that of collapec in als r interlo ad belo the nnd f the coll bone t tha dt of rgm of th bronchus Th dut renc int f¢ullnes fdlitinct belp of the dugnola 6 gamat upper lobe pneumont phthas h re the dullnow 1. pottero u tubercl madult f mis port to do we oncluded to trach parenchyma cupplied by d really melmed bruncha of the bonchial tree Again tuberculous parenchymatous dome In its patbogenal hot bronhlal dosense and the greatest dealty In its pictu h noted below th moldle third of the collar bone and not f the entranc fth wann brunch the t Right Middlo l.obe Atelectus's no ed when dealing th right middl Lobo bronchopneumonia that the danger of inefficient bronchial blockage are corakderabl ming to th angle tryb h the main loba bronchus FTOL 70 Colpad ne podobe troon broodbo pro copies of the night befuratke Post peoklepu by xd putum ery common and occn n many come with pertup Ilttle uuedat hat grave afte effects It can code on quit ·120 ATELECTASIS suddenly or very slowly In the latter case the pain has a derec teristic position along · bond belon the right nipple coming to ware of interalty up to a pitch of severe discomfort The postero-anterior film gira 1 shadow outlining the lobe, harlent along the line of the larver fissure and lessening to an tren of trawhucency above the dlaphragm in splte of the fact that Fra 79 Calcun ditt mobilabbe, by ook intorbroechlel powth the muscle rises towards its pooltion of expiration about the cmphyseme of the lower lobe The Gatepl film b caracteristic od unlike that of any other disease It is almost alm of the whitewoh brosh type denke at the entrance of the bronchos and funding towards la base The upper side of the trangle saloog line beginning at the Junction of the middle and low r thirds of the medlestinura and go tog bortocalally outwards to the posterfor spect of the stemom The froer side of the trlangle goes down. wards and outwards to a point bear the middle of the diaphragm The cure demonstrated to Fig 79 was one of collapec doc to

·ATELECTASIS
121
ben'ga tumour of the middle babe bronchus
terrored through a bronchoscope
the growth w
Lo non MW F 79
The lateral film of collapsed middle bobe can convac d faulty tn
Bhagrion's u amat effulon n the lette fare
The upper

·122 ATELECTASIS border of th fluid b seklom straight as in collares It b ichied to buige up ards in con er fashion and een if it is com ox do a wards because the fluid is no r en nated ie do not get et hence of emphysema In other perts of the lung Phulal algne should abo help The fluid will be encisted denuo and restricted in area before it cawan dit of the mediatinum to arda It and it will not give us the marked tympany of compk mentary emphyaema which is bound to accompany collapse Tho aning of the heart to the affected ide by Inspiration for more marked in middle lobe than that found in upper lobe collupe The two characterials to physical eumation are the poolt iteroo-mastold sign and dullness hichi anterior in the lower mld Th emphvematous lower hohe gives definlt pontedor tympany donc Fr 62 Fhuld met mierlober Avon The only other condition giving wh marked a terfor Julder help ftuld in th muln Intert bar forsure but its filios antero-posterior lordotic and Lteral are entirely diffrent the first showing about ·ATELECTASIS 123 of tromlucenic Hitog bo c the diaphragm lil that I pleuruy condaryt rubphrenic abuces, the lordotk tent Il shadow with lobe of the diaphragma and the lat nal devalt, beta con the cardiac shadow and the diaphragm As already noted many cases of post bronctro-pneumonk collapse of the middle Lobe company recognued t the time of the clinical When as there h much less upset in pubo and tetyperatus than occur in the berge case of loner lobe post-pneumonic collaper Only comiderably later aftr what then appears to ha e been a rather protracted comalescence doo the patient complain f dragging pana; full investigation including Liplodol mection, commonly shows comsad nable d Latation of the bronch Bronchi octas ba by no mea nire sometimes by super Impored infection but often only by the comthouing effects of the collapse which has Pady led to hacen formation by the damming Do dyonc. back of the exudat This type of care often presents one of the most difficult probbeme differental dlugnande beense the abacen moet alm ) produces tbe compliantion of a frank pleuray with the danger of consequent crop ma We are now presented with a condition wblh ball too emily read a pleural effaxon Fortunately th traccal dwplacement in response to t lectau is als murled than the premure of the ſubd n the rds th motold ugn remains poitty on the ight The writer bat Ken keveral case where this as the mala Indication to the truc dug maak It b of ourse taken for granted that all othe linalarda including reedling Il be employed for every ultimat dugnante wondd to do more terpo Lower Lobe Atelectas The commonxit type mult from preumonia broncho metodo post operative peumonia nd new gronth of th broochu Of these tbe mat odden in onset od th pott maste In realt b the post-operative du har bready noted to the formation of a glatinou udet on the wall of the ale rotat The pocuronic in bronho-premunt vou M 1 ·122 ATELECTASIS border of the fluld I seldom atraight as in collapec It Is Inclmed to bulge upwards n conser fashion and e en if it is convex down wards because the Auld I now encytted we do not get evidence of emphysema in other parts of the lung Phnial sigra should also help The Auld will be encuted dense and nutricted to sea before it cawa drift of the mediatinum tor arde it and it will not give us the marked tympany of complementary emphysema which is bound to accompany collapse The swing of the heart to the affected sld by Inpiration by more nurked in middl lobe than that found in upper lobe collapse The two charactertatio to physlal examination are the poolthe sterno-mastold sign and dullneo which Is anterior in the lower ruld The emphrematous lower lobe gi a definlte posterior tympany rone Fie 2 Fold bn kt nterthur Sort The only other condition gli ing such marked anterfor dullness 4 fuld in th main Interlobal fissure but it film anteroportortor Lordotic and Lt sal are enttrely different the first showing a loss ·ATELECTASIS 123 The twing the bosken structural support, nell necewardly we los residual air for absorption The blood meb of th partially collapeed lobe me crowded towards the mediatorom whico u displaced to the side of the lelon With the the most mured change in plokcal sigos is the thars tension of the steno-mator o th uume that It is affected by uncomplicated pneumonia At the kime te note that the d lines which had been learng both coterorty and posteriorly to Dow again marked posterlo ly this ba beause the lungshiinla downwards and backwards a nell w trwards The last two moments tend to make the heart wtory on lo arsti in night lower lobe collapse the Night Low border receder and th left loner border coma forn ardı end to the right. The apex br t may therefore be but littl dbturbed from the normal, and not a reliabl ald to the dlagnosh of the heart on topination to the affected olde will be quit erldent to keen extration In the second rage the shadow is mxch more denec bot border focs dowards and outward towards the told.poft of the daphirgm on the affected uld So denke the shadow that It appears t be conttouoou with and equal to the heavi at deoaity of the heart badow tonards its mild point. There be therefore total oblite tlon of the ardlophrenke mgle It follows that the shadow ought not to be confused with that of squat beart fr ao f left Lower lobe collapse True the diaphragm hlpher than normal In both conditions duet bbar shrinkage in collape and to la behing pooked up by bdombral fat in the case of Fo 5 Lona be the qort beart but the shadow wonent lect, for IL fyddaat. Loreover there are further film and phyical funding whah art Copeluda Collapse is w noted must bring empbyeetna in the cae It to th' costo-phrenk angle, beron boven of normal love marketing on the Alm wbile in the uppe mofd toog we find the wel-markings played out much more ndaly them in the normal. There will there to be marked upany in the aul, off-setting the bitewing dulles in the hower inber third postertorty and shall hear the blowing breuh round troo the broncho ore ito point fantry near the can rec marked ad ·are usuully slower in development and therefore approelmate to the ato ter shrinkage seen in bronchial carcinoma. The character the shadow of the preceding pneumonia has been described and the changes to bronchopneumonly which goas on to lobolar and Lobar collapse have been detalled in poeumonia there has bually been considerable progress towards recovery with clearance of the homogeneous dealty from the costs in temperature before the complication occurs Wheo collapse reu lo by blockage of the matn broschus by a plug or sputumn the film goes through a series of alteration similar to thote seen in both post-operatiic parumonla od brunchul carti noma that a density begins again at the bllum It is essential to remember that the same picture can result from absces and from tuberculoob at the apex of the lobe (*e* Fig 17) Radlogaphy co fall altogether to gire the true cadour of what to seet It may be c been powible to follow the developlog collapse from a rounded opacity close to the bllom but usual one scan only partial collapre in the fint X ray the spex of the lung being already hidden in the bilar shadow Fall clinical and bacteriologlal investigation and verlal Y rays must be conakdered in every case Three stage of lower lobe collpre may be detailed cart har and complete collapse All three have the bomogeneous type shadow that to it may alter in denalty but not in mootbncas throughout its extent, no part of it but only the wboke standart out on distant viewing the concurrent einphrema is outside the boundary of the effected lobe All three stages bare the same upper point to their low of translucenicy Thibe like upper Umit of the ventricular or auricular shadow on the ardiac border left md right shed cae are almilar in this epleal bilar limit to the triangular shape The fint itage sbom a los of translocency dimtalahing from the polat dominerande and outwards to the perſpbery the upper border being made by the interlobur favore be realized from tbe anatomy of the lobe that stolet, og L this means that los epi bu already tondergone I considerablo fall through whrinkart of the triangular lingula, and that we would orpect's the lingula betong of at the Fia. H Low bobo

·ATELECTASIS
The third tage shown on the film
om dera
res hearte
than that of the carduc bord rather bl a
Loremg ton balloon
with it neck ttached t thì
upper
cardiac borde On the
right side la ter alge HRU
Is COMMUTTET WIth the right
cardus border on the post mo
ansetto him while on th left
tri thin it
much ca in particula that th
complementar emph sema may
be the only indre tion abno
mality Br this tage thet a
emphytu on the opport *
ll on the affected w and
chos lus on Important bean gn
Fo. A. Lour kabe helt
plrysical finding We ha
& TIL
learnt to that th medi
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·126
ATELECTASIS
clghth or ninth dorul vertebra because the collapsed lunga
ucting as a sounding board
Pro 86 Riktlemet lobe call to mond war.
Frain Brum beat

·ATELECTASIS 129 0 this wil mio the tendency to bg It has brought the rub koopberk presure rearer to almospberte bo e it. The made tenka dll remains the poll on the truches by the un! kopeed parenchymna be still present If theref re we find patt who lidul all over th love half of bh chat both front and back and in the arilh, on the left side ind till bw a teme loft t mo matod be cumot bere complicated pneumonia because pocamonla does not mo the mediatinum equally he annet bare left bewer lobe pneumno la with pleural effuilo bcate thos would give a right stemo-matold ogn od so h mint ha colped Left lower babe with plearl effokon.

·128 ATELECTASIS Hght and lett oldos Ar ono alde of the thorax shrinky, therefore the mediatinum dHfts a whole In collapse of the right lower lobe with drift of the mediatinum to the right there is alto drift to the right of the left lower lobe which by emphyvema attempts to fill the zated space This It does by occupying the lower anterior medlastinum ad In doing so It Dorcast perforce overlap the mteror surfac of the heart pushing it bach wards We have therefore seen tivo rexons hy the heart swings and goa backwards rather than more to the skde of the atelectuals during conditions of respiratory rest Herein ile the reason by we get with complete collapse anterior dullness in the affected cardio-phrenic mgle we are percusing the heart prezed back to be continuous in note with the moch shrok lower lobe AB over the remainder of the lung and particularly in the lower udllary bone we shall find marked tympany If bowever eve screen the patient or take two pictures onca complete implntion and the second on complete xpirationc shall see the effect of the strengthened Intra-p) unl pull on the affected alde for the heart coma well over with each Inspiration This finding combined with a tende stemno-mastold muscle will ald om in diagnosis but we shall find the latter the better help if the patient hus the complication of Auld in the pleural cavity for wth modo per Fra 90 Letra bbe collepes wicht do ·ATZLECTASIS 129 the will undo the tendency t ming It has brought the subatmospheric premure nearer to almospheric rabose it Dorsche tension still remains the pull on the tracker by the uncol Lapued parenchyma is still present If the e re ne fund e patient who i doll all over the lon er half of his chat both front and back and in the xilla on the left sid and still is a terme left at ro mastond he cannot have uncomplicated poseumnonia because paremment does not moore the mediatimum qually he cannot batre left borer lobe pneumonit with pleural effusion beau thos would gtv z right iterno-nastold igns and to be moat ha ollapsed i fton lobe with pleural chaston 2 ·132 LUNG ABSCESS for the name rezonu it to Dot of equal dersity in for founded are of low of tralucency on the film It t karlat in io centre hore are the lobulas nearest the bronchial branch along which came the uplrated material Outulde these are the lobules which brie been irritated in their alveolar walla so that they contain catarrhal Inflammatory exudate giving the fme lot of translucency of cedera The bomogeneity of shadow dizgnostic X ray feature and nc shell see it remains until cavity formation occur in thote case that go on to blockage of the bronchu We see therefore that It is of the Ardo comhtaky u the abadow of lobar pneumonla and of the Individual shadow of broacho-pn umonla all three having In common material which ta filling lobules and replacing their readonl ar Putting the in another form, the preylous lobar abadow of pacumonla le now in a more or let dicular localized wa the shadow of broncho-pneumonia are row canfluent in a larger single area Sometimes abscess involves I considerable area showing po special dever central region but only a widespread area of bornogedoow lon of translucerny There is no particular defini Hon noch o appear in lobar pneumonia, making out a defolto lung segment 7 te FIG. 92 Long shot ·LUNG ABSCESS plewaal rub 133 Out At first the tre muat be silent part from its complicating It will couro no shift of the mediastinum material bes the eme physiological ffect on lobular Lotk thue the residual alr tt replaces Thero Il be no termo-mastoid sign not will it be found in the bal following stage of the abucess which enacita oluntarily This stage is often referred to a 1 cavitation because the picture on the film ta mbread there be po real dif rence except in extent ben een the second tage and the second oracun ttg stage of broncho-pneumonic imglo bobular affection. Neturally the bobulos Dearest tho dnaming broschus enacuate fint so they make central trmo lucenscy within * circular bomogenscow abadow med up of those babalas sull andrained Thi mmg shadon ha no components of organization or collapae It does not alter within tself or tand out jumst any furrounding emphysema with distant viewing e tuberculotos cavity wall does (xco Fig :) Stethoscopic fmdinge bear this beur just the same ilón ve heard in broncho pneumonia La the mid-phase of inspiration indicating lung materul entering the bronchos bat naturally they re hcrened in number and coane neu na bloger circumscribed area is affected It is necesary to repeat again cven If It appean redundant that the wual lung abaceu la not city > many students seem to visualize the proces It is merely to Il mtents and purposes • very localized przewrnonia filling lobulas with crudat poeu monla does and differing only by the method whereby it was caused in these lobuki It distends them a pneumonic erudate did and does not destroy thel batic tree unless t cannot get ogt hrto the bronchar Most patients erecut the material lum tantly at tage when it contains no Latke fibre Moreo er this method of curre never has with t any hubbing of the finger the septic material has not been dammed back should bowerer the Ciecuating material block tb bronchita towa) dosen to serious consequences from amitation to bronchi cctab The fint hint om aften be gut by the film exemton the euudat now fuld and thin by the proteolytik etyme of in polymorpha to dammed back and Lere! Within the disened area, confined by the arcula rod hape of outlying bobules which are Hll Giled with Large motor clean plagocytes and polymorphis Should this not be errated by drutage by COOrTuah argical methods then repal and not resolution will take plac in these surrounding lobules They annot fmd en OT ·134 LUNG ABSCESS The septic ait for their material content and slowly fibroblats will enter tiem organization and collapve will follow drog on the broncha be the inevitable rault and bronchiectatic avitation by adrinatog septs from lobules to bronchu by the final picture material now destroys the parenchyma, and the foolsputum contains clatic fibra There will be an immediate reaction in the media stinum To all intents and purposes we have one single artty of bronchlectaba There we uw how sepas lo the brotschw extended through all the couts of the bronchial wall until it reached the parenchyma and produced avity in the lung connected with a haccular cavitation of the bronchos This I just the mere proces leading to the same end result The diremo con now extend like any Individual cavity in primary bronchlectab The physical signu are now tbove of organization fibrob and atelectatic collapse By dastruction of clantic there we have duft of the mediatinum with a posldre stemo-mutold finding to the stethoscope we have the crepitations of fibrob mnd the coane metallic rila of bronchial dilatation od Its connection with long the are heard throoghout the first and mld phuo of boxpiration That are exactly the same added soundow we found In adrenatog bronchlectus Clabbing of the fingers of the septic type comes on npidly with the blockage of the bronchu If evacuation bv efficient drabuge Is carried out the clubbing dkappen qulte coon; if It does not do 10 then the observer should be doubtful if the lung condition really cared Many cases are shown byt mography to bogobong steadily if slowly forward to the stage of bronchlectabs to spite of apparent cure by operation This why there are so many kocalled recurrencos of lung abecome they art pot recurrence but continuance of the came foitial uncured lesion. We are now dealing with secondary bronchiectwb not a long abscom ·CHAPTER YUDI TUBERCULOSIS UP TO EARLY ADOLESCENCE t WRATETE be lo out of entry to the body by nhalati o aperto the tubercle bacillus can almayı reach the hings When It comes in connect with my mucou torfuce its ingested by phonest carried by it through the mocown membrue to enter the lymph peces and thence is conveyed to the lymphati node or hoe draining the particulares Ito peat rage on the farbET the resou blood and so the night hans reached od, throgh the pulmonary croulation the lung true Should it be held up mn i small capillary the phagocyte ple ce the wall to enter the surrounding lymphold turve and the fm focus of dhane I other word whatever be the manifestation of the dete the lungs from childbood to old age tuberculosia a patmuty kymphatt desene Ita forma depend on the reaction of lymphold thorno It Iways ttempo to dram along the lymph channel which we uw in our coralderation of applied watomy are part of the protectiv um together with th lymph space and the globe It succeed to most comes in th infection of childhood type but Ita cry credence of quired inomuntry into efforts to conforth Infection t Localted areas can be the wodatng of the infected robject ouge advoka ince the lymphold terenca o hedged about become the breeding ground fo. bacim and to itself breaks dow It worthy of not that in Crawing you bring much Increase in lympboiled there throughout the lung thu ti doublem in great part in osplanation of the widespread ringo frenule phthin which yet maintain ruch Tabstance a tolmulat only hronx bronchita Althoogh there are no sharp les f demarcation dinding the dece Into form f different ago It convenient to deathe te farther development and the heading of Infecy and Darly Childhood Childhood t Eurly Adolescence und Early Adolescence pd Adult lif they show falrly deformed typom of response of the now nfected orgroom to f cth tection Tuberculodi in lofancy and Early Childhood The forms of the dbreme shown in thh age group to millary the 13 ·CHAPTER XY ADOLESCENT AND ADULT TUBERCULOSIS EHTUDENCULOUS lesions are found up to about the fifterett year of life although most of them occur before the age of twelve Th reafter we come to the manifestadons of tuberculosos tom commonly met with In general practice Fundamentally they are the ume as those of earlier age in their interplay of infection and Immunity that be they se probably due in the most part to reinfections oreanakening of previous primary Infection It is higłuy posible ho ever that many of them are continuing primary Infections in Individuals who have not been infected before the ge of wolescence Some patients show cudetton with no foregoing or with destroyed foregoing Immunity others show levered Immunity and thus varying amounty of consequent fibrxu Some th refore show the spread of the blood-borne type of milian tuberculosis some show this frm combined with fibrosla in the individual scattered lastory of chronic millary tuberculosis hile others show break lato e bronchus and giro broncho pneumonlc or pneumonic types Most however thow the dische commenche a far u we know by the diagnosti through Y ray films in those special broncho-pulmonary segments of dorul branches of bronchi which we studied under applied anatomy and ww Involved in the commoner alto for fomation of lung abucets Conuld rable fibrosla the ul response to that fibro-coroou dbewe and a tendency to consequent avity formation is the fording in the majority of patients We do pot know if ruch wul adult manifestations are really a secondary or tertiary of the dlewe because we hare no mane X ray obervations under the age of seventeen or elghteen Similarly we do not know what really happens to . primary infection to Adolescence or adult life Recent experience oggests that . yolog wult bo i negat e to tuberculin and gets tint contact with an open cac of tuberculos shows film findings cactly lik There bu those which can accompany m rythema nodorm Large confused hilar shadow often with cattered fodhcrete pal These latter may be area of lymphorgith and 1 - monary thedom 11 ·ADOLESCENT AND ADULT TUBERCULOSIS 143 consequent collapse f bunches fulreoli Som are complicated by pleurs effusion It is not uncommon to recover tubercle bacil from the stomach wing Th X ray ruch a bowo to thg 95 Fro. 9 TO X-oy poch huch can cont pony ery podo un I wally read - Sarcoidosba of lung Th wat ho fllowed pomeroch cover by serial film. through stag f flecting abadon ha De both plat d fumt nfraclavicular deport with poniti • sputum within Ighteen mo the Ith appearanc oythema nodorum In the favol emunt of Inoacho-pulmotary cyment the track gan through the lyophatt system there u so chong 1 the fondamental patbogenest the dresse Ou tudo on th butonlaal relations f the al coll crounded us that th y connect ith the lymphatila through lymph space wh ch unround th bbulas it into the spaces that the phazoezt conta ning the tabacle bacill now enter after being caught in the lymphatics Koompany th donul bronchiola and th to eaction to aantal erudat in th al coll from indtatto fth tr valbo This a non-specific inflammatory oedema th de reaction which cuw in pituberculosis ·146 ADOLESCRNT AND ADULT TUBERCULOSIS os not uncommon to fund the fint recognizable foct of adult tubercle o rounded arts of bomogeneou loo of boslucency In the met or outer thirds of the Hight Infra-claricular reglan They are round because we have noted before the code of infected parenchymal photographed through its long as they may be in fmall and multiple arex up to about Inch in pro who first noted but are mually slmglo nd about three times the size They are the lown - Aamann, foc They are then faltty well defined, and entirely homogencous The apparent strations on them are really the normal marlongs of lung the lying anterior to them on the portero-enteror film a can be shown by taking either an Aditro posterior filin which pretou them nearer to the surface and therefore to the film or by doing a tomograph (net Flg 46) There is one reaction to the focus that l quite commoa h the upper lobe especially the right and often called crroncotaly tuberculous pneumopla We fir that la spltuberculorile there is a powibility that lymphatdos round. bronchus can be so mwollen by reaction that they acclude the lumen rod produce a localized area of collapse to complication, Acomparable reaction can take place in ropotse to in scute Axmann a focus Swelling in the lymph-spaces together with much catarrhal crudate in Irritated alveoll round then congdrea bary shadow part of which is due to actual lobular collapse The Interlobur fisure drawn up and the medlasthum well dwplaced to the affected olde. The lymphatic inflammation de qulakly pused to the Interlobur fourt which la almaya haviest la lo shadow lot below the lesion Thb the condition that was compared for differential dlagposts with upper lobe telectal (ece Fig 76) Rost and serial film will often show the true state of afin Jwt - the catarttual roution often doppar round foci in othet parts of the parenchyma now both the catarsh and the lymph ungttts can be seen on serial filme to retrogrou to Dore nd more tranalucency while in the rounded area of the calmative depoult we not infrequently see a repldly forming arity with a Rold level The condition has been therefore but a man fanation of the severity of the attack The temperature and constitutional dutu bence may emulate pneumonia at oiset but the dullness of the upper habe is more posterior than interlo and we shall find ugrs of medlestinal displacement which we have seen co octor only in complic utions of pneumococcal pneumonia Later the film con similite ·ADOLESCENT AND ADULT TUBERCULOSIS 147 uoco formation in a lobe collapsed by bronchial ardiooms but a the artthon develops in the tuberculown care te imt of the babe clars above the lodet fort where the remotostou telectual the rustounding dersity remains By thus tunt sputum elandations will generally clinch the lagooses The large rounded form of the Armand's focuon we have seen by no means a necesity Indtydul Kind may be seen on the film mothy individual dot like focl congregated together and givining omklence of inflammatory exudate We hay already noted that auch slogle or multiple foci co be cocealed by on Hipping boory wbudoms Where there be any doubt the rib Interaction but be stolted very closely od at utero posterior new aken AB thb me ta that there to lom kut Invasion or that we are looking * lutet stage when the sudate how pooc it does not mem that these men will not go on to the same after effects Seruit fibro show they en proceed to another folower met altboogh they oo the whole more foclined to your organization and fibrosia without much dog on the bronctum If however they cacate cod affect by extero on other action their immediat neletubourhood they are no d fferent in their film fuding from chave Asmarin foci which appear to break up into tbetr coord Proverite parti pod produce picturt of wall triangular with that merg toto the shadow of the inflamed lymphana round congested bronchi tracking towards the hillum The dwewe following for Comurtant pathogenas ft 4 attempting to drain by the lyophetla to the billar glad This type of Indrekhul on deposit u comenon in the airpra dovlanlar per and was that the portarlor hoe brood of ther upper lobe bronchet has beco wiected (sce Hg 1) Exper her with me radlography shows that to lor commonet site of dwuction was formerly believed and many chart that show with Anm.com foct below the collar bone hayt orldence of previous true wplal deporte Indeed the so common that it appean probable det intra-clavrcular tubercle by a second o perhaps secondary stack in previous and oraupected more peripheral derse namet que bealed Whether och try wlal tubercle on ootport of the primary focus of bildhood that rruang dormant until adoles Emne * may by the modern ponibilita of serial tum erantna lou kon be able to state It can be atremely difficult to decide whether auch der te present in the popn-cliculas pet o nam ·148 ADOLESCENT AND ADULT TUBERCULOSIS shadow the abadow of the iterno-matold pleural tenting and pleural stile can all give confusing ahadom The mteropoulelor Flow is often of great help in the final opinion If we dont looked at the cut rurface of the post mortem specimen wo obould see a collection of tiny nodules of collapsed and organized acini exch round a central more or less occluded, bronchbole. We might abo recognize many white stranda due to fibroaba of the perbronchial and perivoxular connective than the latter der roving tho blood ventel and helping to contribute to the endarter liis oblitering which to a consimt feature of the dicato The hilar glands are hardly If at all affected the fibrosb has allowed but few bacilli to reach them It is little wonder that tuberculosis as without symptoms or grous physical ilgry opecially to stethoscope for Iconaldenblo Hme after loatabllhment In Kult form It doar prodace lack of movement however and very soon afterwarde destruction of elastic touo begins by organization and the results of bronchial blockage The storno-mostold regn reflects dng on the medias tham, but only careful stethoscopic Ibtening will demonstrate the first round of the materiel evacuating from the lobula into their upplytog bronchiola We shall then hear orldence of the broochiole content in fine albill at the very end of Iospinulon Incealog tn Intensity to reach a crescendo at the very end. Remembering our stethoscope findings in bronchita wro recognize a distiloctire and dlagnante de ference in the position to Inopinton of Vyrir this round which is exactly the ume in 16 quality to the car In both demo In wwwVB bronchith we haard it at the beginning of Inpiration, lessening with th increasing 1. Pulmonary tubercabado depth of breathing and connoting obstructive material conabuing of breaking down elemnants of the wall what we hear lo phthik te maleta? crxuating into the terminal distal ends of the bronchiola from ther connecting lobula With these abili or coarser rhonchl we wall woon hear the dry crepitations of fibrosis also mort marked at the ad of in- B spiration and not dippearing with cough; these are the ulgts of the pert A Wed concreto pred bronchial fibrosis In other worda B Dbrois long DURCH A FIC 94. A Broocytt GOTS قهقهلي + ·ADOLESCENT AND ADULT TUBERCULOSIS 149 مطر المیرا wt hero stethoscoptc adence of infiltration and fibrosa Thickening f the pleon Oerlying the bronchopulmonary wegoert Lollowı very soon Its sethoscopic sign and bra burst of fine dry teplotions with the et of cough which diturbo the fore adhesions of organizing cudate between the Huoeral and purletal uren The progres of a focus that keeps its rounded form for votre time bom by Krul films that It may although rarely wenn to dtuppear alto fether It may put u already noted int mall individual lesions or go on to a drawn out mom of fibroticatranda and organised areas Sorocttone there will be mold cavitation with Occonally afturd level ut fint Y ry ecogs bition. laully bowote the cavity bs dux to show weakening of the walls which are drgand pertherally in rugged fahlon by organ bation here and collapse there so that the film Fra 100 Cmtadion whom a area that has lost in great part tu rounded formation and la merging into the shadow obrtad ·150 ADOLESCENT AND ADULT TUBERCULOSIS of the larger broncht now outlined by surrounding thickening.com Dective thru a they track downwand od inwards to tbc bilen Crital impection of the film of an established cate with activity gives us a lemoo in living pathology If we look at it closely we see It has a background of lino generalized lod of tramlucency this to thickened plastic pleurisy At the edges of the latlon we bec eren of ulightly greater low of translucency they are due to the catarrhal exudate in irritated lobulas in the process of Invalon 1. the area of advancing infiltration merging Into the herler shadow of lobules now containing tubercle bacilli that have penetrated their walla and are producing creation Mort cett trally we see still denser Individual lalons clear cut standing out on distant viewing like the thickened bronchial wall because they havo round them lobula distended by complementary, mphysema. These denser areas of collapsed and organized lobula are fused and would in clumps round the dilated and destroyed bronchlal wall to form the heavy but broken up outline of cavity La dhtinctive and dlagnostic unlike any other in cheat ducte Thero la poæible confusion with the cavity of truc lung abec but, as we have already seen the cavity surround in the came looks The picture arty pro Pia 101 Sto F 102. AP In bon

·ADOLESCENT AND ADULT TUBERCULOSIS
151
Jl the affected babolat had been addenly frozen in gw to farm
a contornoux band with no areas of intervening lobular taphysema
and therefore not alterlog utentially in their detal on detent
atont close viewing We uw also that a further ad important
potot lo Rida differential o nol b that the dronic tubercalows
carlty beklom the only evidence of phthis. It le mouch more
oftonba lobe throughout which can be sen kauttered area of
filtruhom with fibrosis
Fra 101. Tuberculous and
The advent of the cavliegl olls MD ad entitious louonds
The
presence of aborsice of limpering pectorloges a not a reliable
donostic fording th more the co tenus of the anty at the timo
of listening the less the pectorloquy A much more constant
bomba the presence of coure metallicrfla
They are t quality exactly there we
beard in bronchiectab mod in lung absce
14, 104 Varble
but they are now heard beginning in the
second half of nation and become
more me more befatent *hfi the depth or Breaning wortil they
reach a cesteak at the cry and

·152 ADOLESCENT AND ADULT TUBERCULOSIS We must remind ourselves that considerable portions of tung true ere tarolred before added sounds we beurd It is a fairly pfo rule to conclude that algas heard above the clavidle mean the upper third of the lung in torolved and slgos below the clavicle Dean at least half of the long 4 involved An example of the influence of other factors In thely production that where large geal tubercle ts present wo a consider the extent three timer that indicated by our stethoscope findings Acuto Brudadre Phthisis of Adolescence and Adult Life This type of pulmonary tuberculosis fortunately nowaday rre for this country is acquired Imbrunity to widespread do however occasionally see Its a steadily advancing de unrestrated by any fibrooks Inflatmatory czudate in the lobular tonpidly replaced by curcating material which on evacuation fill the bronchi whole area breaking down to be coughed up md to lave in the lung fields ragged rancie which are therefore cavities of entirely different mode of formation from those we have already considered AJ DO banla is placed in the way of lymphatic dratrigo tubercle bacilli food the billar glands and they In turn go on to rapid creation The film therefore show many area of tradalecency among wldapread homogeneou deratia The tribalucencia are the cavite often of no clear definition but occasionally looking like ticket punchbola where there has been a adden cruciation through bronchlolo of rapidly created tuberculos material round it Bursches of betvily infiltrated lobules then make up what is only on apparently confining wall Hilar bedom i beary indistinct and confused made up of the creating glands, surrounded by much selling to lymphatia and mich increased hypermota. Movement of the chest I poor there gederalted loa of poto with no offsetting reo of emphy.coe. The predominant part of the dected some of tho lunge billent, roskalar bo replaced by codation and creation but not und gato me heer court Honchl aanged by the bronchlel obxtruction There are spec lally noted being enggerated od toolstent even after coorbi fn Weird areas going on to Cavity formation by rapid eractuation Patening to tuberculos bronchitis 'which b really a flooding of the bronchi by the encating created tuberculos depoola ·CHAPTER XIX PLEURIST T purulent n vrh lf Trou ure three main formue of pleurley fibrinoun *To-fibrtoon, of pleurisy with effolos und ege. There ha no hard ad fat delimication beta en we forma, seeing that there we stor slight Bold p creat that first while the second and third rally nonly in the amour of po be their cellular content All three forms om he case by the poeumococcus the treptococan of the tubercle bacillus Dry pleurbey may be primary to the plewe by the present Life of the battles of Koch It : lonere almost at topdury to pulmonary tuberculosis If It be tuberculona It wa mctally formd in the parietal layer in nluch cac nhat has beppened in that badll from previous frmk effunlod bu penc trated this layer to its Iptimal coat Dry pleure bbc found with pneumonia and broncho parummond and their suppurat re complication or may be duphangmatic to ite when secondary to obdorofal discue which cominonly sub-pbrenic educe fto effect on the membranes depends on to cellular ortent the bilgher tho polymorpha percentage-count the laws being tho apred of ulitmate and permanent contingut Thla w bry Lobar peremonia, while producting a beary todete on the veceral brver ret lata Hide ultimato damage in the vast majority of Chow to greytab-yellow thick deponit erou should It under Wote organitration will be removed eventually by the protected Tattoo of its preponderant pofymorph content On the other lead tuberculosis produces no sodato bich contare a baigta pentru conope of filet galt polymorpha and wo ty much more lable to proceed to permanent adhesion between Loyens f the pleasures over parts of the long rected by phthale We can follow these effects of dry pleurtsy na tbe blom \Y het much more detaily from rcent poemonic than from a Tot acondary tuberculor pleurby, but the preumonle ome Collowed to the file will alaost um dlappear while the tabertahan ona lerra behted hartsen of fine bomogeneous to ·154 PLEURISY type to act as a background to those lung shadows of Infiftration and hibrosis which are the underlying care of it appearance There are two exceptions to thú rule the fort being derson arated in so-called tending of the diaphragm We w already that localized lung affection of pneumonia type are slow of d'or appearance and incline to hosling by repair rather than by resolution as against their more generalized forme The same cflect ba sen in Interlobar pleural Infectiona We hare notcd carlfer that very often a localized tent shaped shadon is seen on « Glm about the mid point of the dlaphragm on one side more often the right than the left Fa 105. Fulbrigo conto para os har for the crumb rubengalow We noted the second hen dkeutsing the daphnom I combats in that tellung In of the extreme cottophrenic engle by : shado, which has so clinical sgnificance unless it be accompanied by a limg forts Without cthlexe of such a focus it should ne er be read a tubercubus la origin It almost always due only to o preriow known or unrecognized pleoral reaction of preumonk or broncho-paumont origin ·PLEURISY 155 KOTOT The most painful type of dry pleurneys the pennonic The program of the mergeroondary pleurisy watera Sh case is frota beetal to purletal layer cech belog in olred font by inflamm batory reactlon and then by the specific reaction of the penetr too of the contre organismo, in the une way aw sw to progression of my tong dincm lavolving the threell from cxtarsta! to pecific csodation. The premnococcus fint irritate and then bovendor the visceral pleura w it reaches the periphery of the lung it weldon dous more than milanoc the parietal Lay Elena kretches and makes the layer spersent Dragging by whaloo between the moving raceral and the staic parsetar Layer than product great pela W lung abscene parn is not frequent and with plat pleurty of tuberculos origin th patient complains more on thematic ache then mute decomfort wake wa pneumonia he be widespread reaction to the parietal layer in which coe he has almost atras sbout to develop frank offuxkon As already noted scro-fibrtnowa iwloon did not from dry pluray only by virtue of the fact that flukt b in urmount withx ent for płynal of bal demonstration The cause most cho perta in genenl practice tuberculosis the lung Its to thos Late type that shall confine ur detailed deernption t frank pleurity The fuld containa much fibrin a bigh prreratug of protein and o preponderance of lymphocyta gainst polymorphis when compared with th high polymorph content of the parumoco ! and the rarer treptococal forlore It is usually lear and tin m opulencence due to appended five particles of fibrin Ally Ken In fuld examined to sta through athoricoscope and quickly iting the typical clot in amples itheam to wool and Laboratory It is not cloudy like the parumonk caudat tu polymorpha tending t form pro 1 the fibrnoun come to los the dogerous liability t the formation of thick covering on the Tbietal and pattetal Larent when the faidas left to organuen the pleural city Tubercle hacilli reklom eppes butxean and may tall to appea tn culture if the camp i enemined unde fou days from the otact of the luston inton has not y t followed merita thon and consequent milammatory ruckathon I allure to realite and act on the almpte fact of puchopenies may ha quesses for the parkent by ineffectent treatment founded or fait examination Knucnte- ·156 PLEURISY in one laboratory examination report which has been made too soon and without clinical notes to the pathologist Fra 106. Tuberculos Plund Etusion. The out To physical cumination there will be dullness beginning in the lower auilla and extending upwards with the incretore in efiston While there will be silence in the area displacing the hmg there will naturally be increased breath sounds over that pert of the lung on the limits of the fluid which are by It pressed imwards and op wards the collapsed lumg acts as a sounding-board standing port is however the displacement of the med lostinum to the opposite side demonstrated in a positive sterno-matold on thuat side and wally pupported by evident displacement of the apex beat to palpation and buscultation We may remind ourselves how the long reacts to the presence of flod in the pleural cavity When the negatire Intra-pleural pressure is brought nearer to that of the atmosphere there will be less out and pul on the underlying Img Its elticity will come loto play therefore and draw it in mard to the anchorage full olantic time at the hilum From the first the reduction of the pleural presure on the affected side will make that on the oppoulte ilde greater in comparison and the mediatinumn will be first ·PLEURISY 157 But an of all drawn to this opporto ildo With more fuld th prestur to the pleural arlty will be greater than that of the atmosphere, od to begta to bear in on the parenchymate that greates then the prerurt of the residual air in the lobules Ko that there doct not peed to be say actual posh from the afected ude in order to give a poulthy sternomold on the other After thila potnt the reaction of the long and the mediatinum depend on whether they are healthy o already diseased A lung with preceding fibrosis will naturally rebt collapse and will move bodily against the medustinum, while a fixed mediatorum one that has been affected by previous pleurley last duplicement. What the mean that we must consider all theto eparato factory and not conclud that the amount of med latinal Laplacement la In anything like eact ratło to the amount of fluido the actual chunge la provare a th Into pleural pace While it otot be stressed that so pleural flutton bas been fully Jovestigated unlem oploratory puncture for real and Laboratory diagnose and blood film comtration, bare been arned out it n bove the len true that tuberculos exudate has characteristic film finding Unfortunately tho conot bo demonstrated by the print of the blm o it can by looking at the film itsell on th therint box In lo carly day. It has a specific fine koos of translucency through which the mos com be seen almost o clearly as they would bo with the presence of a pneumothora Twards the mid tone from abore downwards there to compartire density conce bowh running from the alla to the dlophragm, but this he not to the uncocoplicated che clea hing line of demaration It mad by the combined hedow of load od lung, the former lying to some depth Laterally both in front ad beblod the latter If there la to under Lyting hong dheexc we ought to be able to se cuperation of the notro reoel marking to Fre 107 Tuberapkan the frozet Ko of the function, on ing to the hypeterpla fn the hong contracted tomards the hun If there marling cannot be seen * Met anpect consolidation from frcumple pneumonia ·1 PLEURISY The pictures therefore bot Uke that of uncomplicated Lobar preusmonla of the lower lobe with its dezrity at the base decreslog from the diaphragm upwards towards the lingua and cquel at any are lered between the uilla and the med Last nur In pleurity there is increasing Loss of trucalucency from the all Inward to the function of fuld udlung Moreover it will be differentiated abo by the por- Fr. 104. Pomer babe, ition of the heart and the medi with fuld Note bancair acting in uno opad testium for we say in our study poreningen best deal of the preumonion that they do medint dow to complicada mo not cause deplacement If Auld has been present for some time before the film has been taken the condi e density may have asumed a sharp outline This is because orgmization of the fibrinom exudate on the kceral pleura has already taken place and the patient is thereby in danger of Incomplete re-expansion of the lung, cren with immediate and complete withdrawal of fuld Should the effusion be of sull longer standby, organization of the fibrio foccule gires a dense white shadow occupying the area between the alla and the now sharply defined border of the long fed and compressed The shadow o not now anyte different from that of the emprem although the later in lo kute stage will be dhe placement to the opposite side The Il be a definito uld I Vinul dlagoons but it must all for the accesory sick of blood and exploratort puncture cammination The al counc in groetal practice ones as the pocomococcus for the taberrylou empyema bs a rarity, and seldom met with except : complication of : previou clear ofalou especially if ruch foston has occurred · hydro-poeumothorur jot described The avenge case of such Idiopathic pleurday kany completely with no rematning evidence to pleura or lung, If we see on the film some filling of the costo-phrenic angle and ought to no lung focth to collent m e postero-enterior Him we take latenl od londotte bilms and even tomographs if we wth to ·г becken they PLEURIS: 199 be a certain a b hammnly possible of our final opinion Often the amall tuberculous deposit is in the periphery in the upper Auld tonic, or in the supra-cluykular apez from in ol ement of ibe posterior apkcal bronchus Interlobar effutons sport from that in the lever figure on tbe right side we weklom eklent or demonstrated to their true xtent the portero-enterior film A Lateral whows them I arty forcing part the Interlobar septum and usually bow shaped are prealing on the parenchyma of both lobes (sce ng Fuld in the main puro mg on the postero-untenor film thadow very like that of tru duphragmatc Buxon empy ma secondary to abdominal dhecase g mub-phreni abs.com Both att over the duphragm and re nelmed to follow it outlic The physical agra however will belp us t difit rentiate because while the latter gres ud linowe both ant Horly and post nyly the dulloem due to interlobe effusion copecully marked, m front A bordotic plature Ws we too ir the true sterlobor effusion rha through the middle of the lang field lik drand-out tent otting on the diaphragm The boal dry dlaphragmatic pleurtay ahon no rderet füm cuamtration to Account for the acut should upper art pain that accomples It Pneumothorax From what has been ard of the effects f pleural effusion on kong clothetty and mediatinal shift w an awalte the changes in poeumochons without furthe detailing them The flect on the film findings of the underlying lung is the same and the dungnosis Det rest on the It ratlons noted both thin and thout the hung held As against pleural firkon * non ha complet hance faberlore between the nb Interam outside the line of the retracted lung no ftram lucer and no lung mithings recaldent (see He to the imple or non-tuberculous one tremely rart fo flushed to mprar in the pleural spac and it may be popsible to be on the core of the collapsed ting emphysematon bullae one of which has bunt : produce the porumothora In the core hete pneumother omplicates an already demonstrahle mitrahte lung tuberculosis fuild aceeding common r ·162 TUMOURS OF MEDIASTINUB AND LONG The commonest abnormality of modlattal glands is of coure due to tuberculoals and is dealt with in the chapter on Childhood Tuberculosbe Lyopbadanan Hadgle : Dimuste This condition conually appeart fint on the postero-writertor film se moderately rzed shadow in the upper mediastinum It slightly more derse than the shadow of the wiperlor veni ara which it gesenlly covers The is because it is almost alwayı first erldent Fra 101. Lopbedom In the right para-xcbel glands een If It has been bilateral from the beginning la otter border to clear-cut but ln silu of balgan gurut the more continuou streep of the rounded or oral

·TUJIOURS OF VEDIASTIYUN AVD LUYG
163
otthor of other abnormal shadows the smo position lt lonet
hotder and the great abnormal Idth of the mediatinum lie
A
Fro. 110 Lamphaderos Obituaries of are a Fu 25.
above the uppe zortu ahadow Lehel him how lon Increme
n 12 stou the mediatinum thus displacme the trachea and
th cooptager and mo the nech Sub spread may obe ure the
in hetont fothe group of glands lthough obry 19 Out
he dentified on hard postero-ancho
at topostotoo loral
le spread includes the pulmonary tracheobronchul md
h tar groepe the picture k one of overlapping, lh
bong im Irak finit upper cardiac border
prelimonun inn IKT na to preading from the on
londer along the lines of the bronchi mdetuit notules or mi
homogenou. Irtopular shaped patches with the density !
portonda and we postips edged th a xs of ground flow
optantco became they rechals collopu tudi gahrol
may now it

·16+ TUMOURS OF MEDJASTINUM AND LUNG At thu stage he may need every xcesory ald including irradlation to which it responde len to distinguish this disexe from lympho RICOM Fto. 111 Lymphou room Lyopbo-parrow This the next commonest abnormality or glandular rigin it is generally bilateral from its onset In curly stages its density u comparable to that of lymphadenoma but it is generally more rounded in it right border Jt grows more rapidly to produce marked broadening of the superior medlastinum and may no obsaare the worth shadow that it cannot be diagnosed against worth ancurgım Dagold The oral homogeneo dermold of pericardia] laner ride and give i by the a erine "See Flp 49) num on its {

·TUDIOURS OP VEDIASTINUAL AND LUNG
165
On the postero-ant rio film lt h mully attuated lower than the level
of the north ih We may requr an anlicial pneumothorax
to be artan of its connection with the meduttum
When d mord arter from embryonic renants of th thy man
Hur blique lew* Il bom It bring in the anterio ripertor medla
itinum It does not desplac the trachen r the orophagus We
hay already wted that film erumination lone - Il not dlagnose
+
FS 112 Detoda
that rm from Lange entral neurofibroma from the
enige
huu u
the we are
Only
T) tarth do d hord
internat imm the parent ma

·166
TUVOURS OF MEDIASTINDI AND LUNA
Neuro-fibrass
This the commonet benign chat tumour erics from in
intercostal nerve It li wually dikorered by chance during more
radiography or screening It low of translu excy 11 comparable
Toow
1
113
Neurobrom.
in homogeneity and dealty with lymphadenoma but it be moc
rounded in its outer edge Antero posterior postcro anterior
lateral and oblique filme x il demonstrate it as lytog in the posterior
superior mediatinum tter Buchy film of the spine may show
It connection with th
It ta poft in structure and lor in
growth and Herefore shapes itself paint the resistance of rur
rounding Arctura hente its swell, ckrat and rounded outer
edge on the postero-enterior film It does not displxt the trachea
Tyt

·TUJOURS OF MEDIASTINUAL AND LUNG 167
the crophagus
Occadonally it developer in a central lung
position when # noted bo pneumothorax may be namry
for diferent el diagnosis agaimt dermoid and hydould gst
ta, 114
Nincobro, na
sobsternal Tyrond
A sabut mal chyrold at a triangular homogeneous shadow
in the upper interior medusstrom with the banke the thing!
1 the thorack outlet and the apex po ting cortimanuk It may
be more pronounced on one fde or be completely to one of
the mine but woully depresses the main is and pushes the
to the left so that the wonic knob I prominent Teng
often It proses backward on the trachea. Screening will show
then when the patient swallon
orta

·- 169 TUBIOURS OF VEDIASTINUM AND LUNG CARCINOMA Lobar Caraborg Other parenchynutous growth have been consered by the chapter on Round Shadow Pehmmary aroma of the lungs rare but primary carcinoma is common ft wually begtis In a large bronchu and therefore producer bobar collipte fint by increasing obstruction and later by actual alveolar involrement in the manner described in the chapter on atelectuale There we noted lo tendency to com a shadow which is dentest at the hilun Hand films may show this dessity to be pude of tiro shadow very derse on of mlarged glass within another al ghtly low dense of collapsed lung Loss of lung volume os shown by the full-og-in of the Hb-spaces outside the abiected area and by the dift of the mediastinum and ther heart to the une vide We aw why the doft by more marked Inwer lobe than in upper lobe atelectual; not only in there more kou of volume but the heart w much more readily displaced from omal in its lower and heavier half The awing from the need poshtlon of drift still further to the affected elde on trepinnon and the return on otpiration to cally seen on the Kreen aro much more marked wth lower lobe and compl te lung collapse thom with upper lobo collapec Pulmonary fibrobo pleural' blitera thon do not prodi We have already seen how c further eld in the dlagrosb of collape xgainat fibrosi If we note the position of the crophages and the tractica Nerve nolement is quite common in upper lobe arcinoma the re urrent laryngeal on the left side and the phrenic nerve on the right side un very colly become embedded and compressil Extension In mours of enlarged glands in the upper medlatinum of a right uppe lube carcinoma can therefore produce an increasing rlue of the right d aphragm until complete palk of the nerve bring romplete Hnmobility of the duphragm in the pooltion or complete explration equivalent to that kept with exchidon of the The conjunction of a rived duphragm and an atekertatło right oppe tobe u degradatic of rigtit upper lobe canctooma Screen The movement of the ng will give us still forthet ald dhphragm b paradoxical The abnormal motament occun abo In lo lobe carcinoma It cannot be reen on the right while since the shadow of the fanscle la merged with the lier Shador this swing can get nerve

·TUMOURS OR MEDIASTINUJI AND LUVG
169
but if the patient is ghen a Sledlitz ponde it possible to demon
urutett on the left side anles ther a large pleurl Atrium
When collapse of the lower lobe by caru noma hun rexheu nhat
He described as the third complet stage may requir lipdukas
Infection for diagnosks against torele body of bronchaccuatu
collepte in both them conditima art Imom crtain to find
Home liplombol in the collapsed lote
Arefectus fthe whol lunga when the growth
main bronch
W and homogenous tons of transluch all
of one side with a derrsity aging trun that pleural Himmun
to that of the premu
The fillon me ponti do to am
the true dengtos
The ribaraces a Il be tallen n on the vide
of the shadow The med Lastmom and hit * l br d nt the
Hide and mingeill furtha
er with at naps at in
The
monophanges will lean o et and the trade u Il top
a 35
Cathor at (Duduft
mot
The alue of physkal cumination the ditentually
noobs of coflupec nuh omplicate flommom has hay moned

·170 TUNOURS OFWEDI ISTINUN AYD LUNG The appearance and differentlal dlagnosis of the type of nodular carchrom which throne e single rounded sbalon has been dis custed lu tho chapter on Rounded Shadows Three other main forms of nodular arcoma reun to be mentioned med lastinal medial and basal The med batinal or hilar form originates neur the bifurcation of the trachea Instead of blocking the lumen it croda the wall and a it Involves the glands and all the med Latina) Hlaues produces a shadow which is large rounded homogeneous and extremely dente Ita edge may be well-defined or ragged If it is ragged it can caually be seen to send out irregular fibrotic like threads of differing atze and shape into uurrounding lung troue The medial form is due to carcinoma of a man bronchu close to its origin The shadon looks as if it were part of the main u shadow rating like a bump on the entricular border Th outline may be slurp or quite Irregula The shadow changes very Ittle to verlal uminations a era period of time The basal form gl as an ill-defined lung shadow attached t the hilum by many irregular utreaks It ta urually of varying dersities it has within it area of obetruction of bronchlola Very often It proceeds to the soal picture of lower lobe complete collapec ·INDEX Emby 3 1 Yol Abecen, Acte Alreol Gbon's face) Glader 3 Heart, pontua, a labor call yo Au for Uom A selectate, lower lake lownlobe w komponotusom, Hydu cym Ha Lo honek, Arrows ul. g. Xth m. y Mom Lymplu carta, 14 Lymphatarply Сурапоч Met Bretterhery broexhital broncholiek, Ihrerbitr, x Metr 1 Milk More 1 rouchohtly, to * Non homogeneosu Orsophagus, deplex anen oh Prodowe Monik inute Japo therby Pretord (the borim. Tand, mu no Trole Cakfutte le Can Crather $ 7 Chuyo Correct Charak uyler 44 Cropulos x Dr, pre #n Tom ons, 4, 44 ebens Cup

·Pronary artery
Trcben, duplement of
Tuberculos, rudern,
peal 47
dibood 15
Ranboh cooples 17
About
Fcolors,
LOL, 56
Silico,
Stou tafection
Startotold go optyka cona
thens
carad
Subtotaal thyrold, 67
Dry scute
maluery doen
Most blot
Tuberculoos potwo, 146
X-raha dona, 6
Zondking Achik 44

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