- Email: [email protected]
Superficial venules in pulmonary tuberculosis
January, 1025]
ODLITERATIVE
IG5
'I'NEUMOTIIORAl(
induced and it is impossible to tell from the course of the disease where tho treatment was started or stopped. In such cases it is usually found postmortem that there is much active disease in the other lung, or that dense patches of adherent pleura are preventing the collapse of that portion of the lung where the disease is most active, or that there is a general miliary tuberculosis. In artificial pneumothorax treatment the ideal is to keep the diseased lung collapsed and at rest until the disease is completely arrested. Thus only can one hope for permanent good results in It large number of cases. If the lung is collapsed for a short time only there is danger of the symptoms returning when the lung re-expands, as shown in cases 7 and 8If the symptoms do not return and the case is converted into one of chronic fibroid disease life may be prolonged considerably and in some cases the disease may be completely arrested, but there is not the same chance of 0. lasting arrest as there is after a full time pneumothorax. Moreover, the chronic fibrotic cases are very liable to attacks of hromoptysis. At the same time great improvement may follow a collapse of lung of very short duration and the gradual obliteration of the pneumothorax cavity docs not of necessity indicate a bad prognosis, for some of these patients do extremely well. My thanks are due to Dr. Stanley Melville for the skiagrams illustrated in this paper.
SUPBUFICIAL VENULES IN PULMONARY TUBEHCULOSIS. By A.
NIVEN RODERTSON,
M.D.,
xr.n.c.r.,
D.P.H.
Medical Superintendent, Derbyshire Oounty Sanatorium; VENOUS DIAORAMS.
IN over 250 cases I made a diagram which I called a venous diagram" of each case on admission, and as a result I found that the enlarged superficial venules on the trunk are arranged as n. rule in definite areas, and according to 0. plan more or less definite, although n. certain number of tho venules appear to be scattered in a somewhat haphazard pattern. 'I'hose on tho front of the trunk can be grouped into two semi-circular arches with their apex directed upwards, one of which I have called the H sterno-coste!" or II costal arch" and the other tho ,. diaphragmatic arch." In the former the apex of the arch is formed by little venules over the sternum at the level of the second or third ribs or sometimes higher. while the limbs of the arch are formed by venules in line with these spreading out on each side; the further out the vcnules are traced the lower in position do they lie. As n. rule only one costal arch is present or sometimes unilaterally only one half of the arch or perhaps a fraction of any one part of the arch alone may be present. Sometimes, as .in the venous diagram pictured (taken from an actual case), two costal arches are present, one above the other, like a double rainbow. In the case shown the summit of the upper costal arch is at the Ie
Hju
TUBERCLE
[January, 1925
upper border of the manubrium and it spreads out on each side like n. fan to the third rib as far out as the mid-clavicular lines, while the lower arch reaches from the level of the angle of Ludovic to the fifth rib in the anterior axillary line on each side. The double costal arch is uncommon in such a complete form as in the case shown, but fractions of a double nrch arc less rare. 'I'ho diaphragmatic arch is the well-known line of venules corresponding to the line of attachment of the diaphragm. Owing to the frequency of tho phthinoid chest in pulmonary tuberculosis, associated with an acute subcostal angle, this arch oCten approaches an inverted V shape. U becomes more Gothic, whereas the costal arch is usually Norman in type. Ono patient had such a well marked diaphragmatic arch composed of innumerable fine radiating strim that I called it the " Sunrise Pattern."
20ne of 'Sterno-
~ombardi
,ost,a\ arch. Diaphragmatic arch.
Crist.a' line
FlO.
t.-Schomo or venous groups,
Posteriorly, the venules arc also arranged into two definite groups and nreas : (a) round the seventh cervical and first and second dorsal spines and (b) along tho crests of the ilium. 'l'he former group has had much attcntion paid to it, especially as a sign of pulmonary tuberculosis in children, and is called tho Zone of Lombardi. The second group I originally called tho lumbar lino (Indian Medical Record, II The Early Diagnosis of fJ.'ubcrclo "). A better name, however, would be the" criatal line." The vcnules in this line Corm 0. semi-circular arch with its apex or summit ' pointed downwards forming 0. horizontal line over the sacrum and extending up on each side ns lateral limbs along the line of the iliac crests. Sometimes only one limb is present or only 0. fraction of any part of the arch, Buuuuuriscd the venous groups nre:Antcriorly.-(l) Costal or sterno-costal arch j (2) diaphragmatic arch. Posteriorly.-(l) Zono of Lombardi; (2) cristal line. Besides theso definite groups, little venulcs may be scattered irregUlarly Over tho other anatomical areas, o.g., along the clavicles, along the spines oC tho scapula, in the suprasternal notch, in the lumber region, &c.
January, 1!J25]
SUPERFICIAL
VENULES
167
Superficial Venous Varix. Also frequently besides these little twig-like terminal venules there is enlargement of the whole length of veins, as large as the veins on the back of the hands of the elderly, forming a superficial varix . A varix may be
FlO. 2.-Photogro.ph of thoracic venous varix. Extensive fibroid pulmonary tuberculoeis, both lungs.
FlO. 3. -Superficial venous varix in skin of R. side of abdomen, due to previous typhoid fever.
formed between the anterior thoracic veins and the internal mammary, or between the internal mammary, the anterior thoracic veins and the veins of the upper arm. A varix may also form between the internal mammary, the upper anterior thoracic veins and the intercostals, The patterns
lGS
[January, !025
TUDERCLE
Cormcd by these vnnces vary greatly like the veins on marble• .. marbling." They are analogous to n remarkable abdominal varix which I observed in a patient who had suffered from typhoid. Possibly these thoracic varices arc sometimes due to partial obstruction of the subclavian vein by tuberculous pleuritic adhesiona dragging on this vein, in cases in which there hils been a pleurisy of the apex of the lung involving also a thickening and dragging oC Sibson's fascia.
Total Yenules -in each Anatomical Surface Area. In 250 cases I added the total venules found in each anatomical area in each case, and then adding the totals of each area for the ~50 cases together obtained the total venules in each area in the 250 patients. Tho results were :-
CriRto.l arch
L. diaphragmatio arch R. II " TJ. criB tOol line •• L. 8uInrascapular area '
1n.r,
..
H. cristal line
••
"
•• 8Upramo.mmo.ry aroa ••
H.
..
"
:~~ ven,u,les} represent diaphragmatic arch 835 vcnulos 824" ~ Zone 0 £ L ombard"1. 2!)5" 200" 228 venules} costal arches. 219"
Tho venulcs in the other areas were 0.11 much fewer (i.e., in the supraspinous, infraspinous, supra-clavicular, clavicular, axillary, interscapular urcns, &c.). They ranged from 80-20 as totals. This again showed how tho veins wero clustered into the definite groups already described and named.
Frequency of Group Venules. Pruent
(1) COBLI~1 arch Rroup
.. (~) Dinphragrnatlc lLrch group (3) Zono of Lombardi group •• (4) CrlIlLl\l arch group ..
42 ca.ses
91 "
AbRent
Totale
22-1 caaes
2CG cases
lOG
2(;0
II
123 ..
142 ..
87 ..
10 "
2€15 157
"
.. ..
In tho first sroup I only included those with a complete arch, in tho other threo I included fragmentnry groups. 'I'he importance of the cristal lino group is seen from tho fact that this group alone is more often present than absent. 'l'hia group has not been investigated previously because 1I)0st observers have overlooked it as the body requires to he stripped to n. lower level than usual for its observation. On the other hand, the previous totnla show tho.t when tho diaphragmatic arch is present the number of vcnules in it nrc more numerous per case than in any of the other groups . Pathological Cause oj Superficial VCl1ules. Hutchison and Rainy state that the veins of the thoracic wall may bo unduly conspicuous (a) when the patient's skin is unusually trnnsparent. (b) when tho patient has been undergoing considerable exertion, especill.lI,>: when tho cffort is of such 0. kind as to throw 0. strain on the respiratory system; (c) when intra-thoracic tumours impede tho return of blood to tho hcnrt : (d) when the action of tho right side of the heart is laboured; (e) when in consequence of portal obstruction or of blockage oC the inferior caval system tho blood.returning Crom the abdominal viscera or lower limbs
January, 1925]
SUPERFICIAL VENULES
lGO
is forced to find its way through collateral channels. All these factors, except the last, come into play in pulmonary tuberculosis. The skin is frequently thin and atrophic, and the thin ivory skin of children with tho disease is well recognised. Pulmonary tuberculosis causes a marked respiratory strain due to defective aeration from lung destruction. 'I'ho third factor includes as IL mediastinal tumour tuberculous enlargement of the mediastinal lymph glands." 'rhat the action of tho right heart is affected in pulmonary tubercle is probable by the frequency with which one finds neeentuntion of the second pulmonary sound due to obstruction of the lung circulation. Hutchison and Rainy state that in 0. number of instances where the right side of the heart is slightly overworked a belt of dilated capillaries appears along the line of attach~nt of the diaphragm. I havo already pointed out how frequently this belt is"found in pulmonary tuberculosis. It corresponds to my second group. Riviere states in regard to the first group that they are often most visible on tho right side and generally double, and that their course is generally inwards towards the sternum. 'I'hey owe their presence to pressure on the right and left superior intercostal vein or on the vena az}'gos major, and are thus evidence of enlargement of the tracheobronchial or bifurcation glands in the mediastinum. The vena azygos major receives blood from all the intercostal spaces save the upper. two or three on the left side which are drained by the left superior intercostal. The enlarged radicles, therefore, represent a collateral circulation and not engorged vcnules, since in Riviere's experience the flow is inwards towards the sternum and internal mammary veins. With his observations I am in entire agreement. Fishberg recorded that 8 per cent. of children out of tuberculous households had enlarged thoracic veins. He divided these children into threo croups: Amongst those with active tuberculosis he found 37 per cent. who showed this sign; 25 per cent. of those with latent tuberculosis showed it, while only 1 per cent. of the healthy showed it. Riviere also regards those of the third group, spinal telangiectases, which he found mainly round the seventh cervical, and first and second dorsal spines, but often as low as the third to fifth dorsal spine, as due to the samo cause. These also represent lL collateral circulation. He found that in 24 children from tuberculous households spinal venules were present in 41'7 per cent., while in 22 children from healthy households they were present in only 23 per cent. He found them twice as often in children with manifest signs of tubercle as in children with healthy chests. He wisely, however, does not over-rate their diagnostic value as they arc present in his opinion in 40 per cent. of healthy young persons. Acting on the principle that the majority of these venules were due to the calargement of mediastinal glands pressing on the vena azygos major, and as this vein as well as the vena azygos minor commences in the small lumbar veins, I was led to examine the point whether the commencements or these veins in the lumbar region was dilated by backward pressure. 'l'hus I came to discover the vennles along the crests of the ilium. 'I'he small venules, however, that I found along the crests and over the sacrum nil run downwards over the crests and are therefore also a collateral circulation. This collateral circulation opens into the gluteal sciatic and
170
[January, 1925
TUDERCLE
sacral veins and ultimately therefore into the common iliac veins and inferior vena cava. Thoracic disease, therefore, produces the opposite of abdominal disease. Pressure in the thorax obstructs the azygos veins (part of the superior vena. caval system) and collateral communication is made by the lumbar venules with the inferior vena caval system. In abdominal pressure (tumour pressing on inferior vena cava,' cirrhosis, &c.) the inferior vena caval system is obstructed and collateral parietal circulation is made with the superior vena caval system. A few dilated venules found in the lumbar areas sometimes above the ilium are probably dilated terminals of the azygos veins. The second or diaphragmatic group are also collateral in origin since they all converge downwards opposite to the intercostal flow of blood. In thoracic disease the production of all four venous groups as collateral circulations is mainly due, therefore, to the obstruction of the azygos part of the superior vena. caval system.
Clinical Value of Dilated Venules. Under this heading I investigated the relationship of the venules: (1) As to age of the patient; (2) as to duration of the disease : (3) as to anatomical extent of disease (Turban stages) ; (4) as to pulmonary fibrosis; (5) as to amount of cough; (6) as to locality of disea.se; (7) as to whether they were trophic or reflex in character (in relation to Head's areas). (1) Age of the Patient.-(a} Age period 10 to 20 years of age . There were 30 cases at this age and the total number of venules was IDO or 633 per cent. (b) Age period 20 to 30 years. In this group there were 76 cases and the total number of venules was 770 or 1,013 per cent. (c) Age period 30 to 40 years; 80 cases. Total venules 1,296 or 1,620 per cent. (d) Age period 40 to 50 years; 46 cases. Total venules 825 or 1,793 per cent. (e) Age period 50 to GO years; 12 cases. Total venules 109 or 908 per cent. Age, therefore, apparently increases the number of venules up to 50 years of age when there is a. decline. Probably above this age they become fewer owing to atrophy. The age periods which have the highest percentage of venules correspond to the period of middle age phthisis of Brownlee which is a, more chronic type and therefore associated with more prolonged illnesa causing cough, fibrosis and other factors which produce a strain on the circulation and also, as will be shown later, cause in this way a greater number of enlarged venules. (2) Duration of the Disease.-As age apparently influences the number of venules, the cases had to be divided into the above age periods to get correct results. (a) Age period 10 to 20 years. Duration of iUneu 6 1 "., 18 2 S
"
"
"
"
4
months. year. months, years.
"
"
19 uses. 6 2 " " 1 case. 1 1 "
"
Average number of venules 6 8 It " "I t 8 II
"tt
"
"
" " ",t
23 8 12
January, 1925]
SUPERFICIAL
171
VENULES
(b) Age period 20 to 30 years. Duration of illness 6 months. .. .. 1 year. .. 18 months. .. 2 years. " "
tt
S! cases. 19" ..
3
' 7 6 6
4
8
n
.. ....
..
Average number of venulcs 9 13 7 " 9 10 It
.
11
(C) Age period 30 to 4(5 years. Durs.tion of illness 6 months. .. .. 1 year. .. .. 18 months. It .. 2 years. tt
"
u
(d)
13 8 10
:>
8,.
4
86 cases.
7
u
.. It
•• tt
Average number of venules 17 .. .. tI 15
... .. ." .
... ...
8 20
12 8
Age period 40 to 50 years. Duration of illness 6 months. .. .. 1 year. 18 months. 2 years. If 3.. It 4..
..
..
21 cases. 11 4 .. 3 2 .. 5
Average number of vcnules 16 ,. u .. !:2.t
. .
.
"
If
,.
..
17
13 11 18
It is obvious that the number of cases is often too small for one to be able to found any theories on the resulting data. For this reason I omit the age periods 10 to 20 and 50 to GO years during which the total cases.were so few. Also in the other age periods the cases are few where the disease had lasted for a considerable time. The general result is, however, that between the ages 20 to 30 the maximum number of venules occurs after one year's illness, and so also in the cases of patients between 40 and 50. In , the age period 30 to 40 the maximum is after six months and two years' illness. It is also shown that the greatest number of venules go:s along with the middle age type of phthisis associated with a more chrome and prolonged period of ill health. The obstruction of the venous ~ircula. tion in these cases is due sometimes, perhaps, to dust, &c., enlargmg the mediastinal glands and obstructing the vena azygos major. and also to industrial conditions causing at these periods a greater strain on the arteries, capillaries and veins. (3) Anatomical Extent of Disease.-The cases were classified by Turban stages. 124 cases Turban I. 56.. .. II. 79.. It III.
Average number of venules per ease, 12 .. .. .. It 13 .... 13
As the observations were all made on sanatorium cases the number of first stage cases was greatest, but the number of venules appeared to be independent of the extent of the disease. The number of venules is therefore of no value as a guide to prognosis. (4) Extent oj .Ltt1tg Fibrosis.-The number of cases with very marked chronic ~br?sis was 34. '!'heir average number of venules was 15 per case. 'When this IS compared With the average number in 200 cases of all types -ll-it shows that fibrosis is a factor in the production of these venules. Probably the cause is fibrosis round the hilus obstructing the azy&:{os veins as well as general fibrosis throughout the lungs generally, obstructing the .pulmonary circulation and the venous system. (5) Amount of COltgh.-Cough was divided into four degrees of severity.
172
[January, 1925
TUllERCLE Cough Cough Cough Cough
a.bscn~
+ ++ +++
55 ceses, 60" 62 It 67 It
Average ago 26. t' " 83. " I t · 84. " " 8G.
Average number of venules 7 II to ,,13 " " It 16 " " tI 18
These figures show that the amount of cough has an effect on tho venous circulation and on the number of venules, although tho fact that the age of those without cough is younger must be taken into account. It shows that the strain on the venous system is greater in the middle ·ago group. (Q) Locality oj Disease.-An attempt was made to find out whether there WIlS any connection between tho side of the disease and the sido on which the venules were greater in number. This was studied in 120 cases. Bilateral disease.-(a) Equal in extent on the two sides, 30 cases ; venules equal in number on the two sides in only 14 of these; (b) disease more extensive on the right side, 31 cases. In. only 11 were the venules greater in number on the right side; (0) disease more extensive on tho left side, 10 cases. In 7 the venules were also greater in number on tho left side. Unilateral disease.-(a) Right-sided disease, 32 cases. In only 11 cases were tho venules greater in number on the right side; (b) left-sided disease, 8 cases. In G cases the venules were more in number on the left side. There was thus no connection between side of disease and side of body on which the venules were greater in number. An inspection of tho venules therefore is no ready-to-hand means of deciding the location of tho disease. This was as expected, since the effect of unilateral disease is n strain on tho whole general venous circulation. (7) Trophic Al'eas.-No connection was found between the position or tho enlarged veins and the site of the disease. The venules are therefore not locally reflex in origin or trophic in nature affecting the skin over tho area affectod by tubercle. Permanency or Otherwise of the Vellulcs. In 50 COBes tho number of distended venules was examined after var~' iog periods during treatment. It was found that in 20 cases the venules had increased in number, in 10 the number was less, and in G cases tho number remained the same. 'I'his perhaps indicates tho relative inadequacy or tho various commonly used expectorant mixtures in relieving tho strain or cough in pulmonary tuborculosis.
Number oj Venules in Normal Persons (Staff). This was found to bo nn average of four. Thero is thus a distinct. excess or thoracic vcnules in persons with pulmonary tuberculosis. Theso venules may therefore be accepted as a. sign associated with this disease and should always be looked {or during inspection of the putient's ches~: 'I'his ngroes with the observations of Riviere and Fishberg. CONCLUSlO~S.
Tho number of distended venules in tho trunk depends on :(1) Ago: an increase with advancing years till tho atrophy of old age (2) Duratlon of disease: increase with duration of the disease. .
January, 1925]
SUPEnFICIAL
173
VENULES
(3) Cough: increases with the amount of cough. (4) Fibrosis: increases according to its extent. (5) Anatomical extent of disease : independent of it; no use in prognosis. VJt:-l0t18 DJAGnUfS FROM Two ACTUAL CASES.
(TAKEN FnO~f MY SERIES OF
250
OUES.)
r FIG. 4.-Showing also venous varix.
, FIG. 5.- Bhowlng doublo sterno-costal arch.
(0) Locality of disease in the lung: independent of it; not 0. means of Jocalising the disease at first sight. (7) Not reflex or trophic in cause, as is, for example, local muscls change. (8) Definitely associated with pulmonary tuberculosis, and in the main duo to obstruction of the vena azygos veins by enlarged mediastinal ~lands and hilus fibrosis (especially in children) although also due to general lung fibrosis and strain on pulmonary and general venous circulation.
ODLITERATIVE
IG5
'I'NEUMOTIIORAl(
induced and it is impossible to tell from the course of the disease where tho treatment was started or stopped. In such cases it is usually found postmortem that there is much active disease in the other lung, or that dense patches of adherent pleura are preventing the collapse of that portion of the lung where the disease is most active, or that there is a general miliary tuberculosis. In artificial pneumothorax treatment the ideal is to keep the diseased lung collapsed and at rest until the disease is completely arrested. Thus only can one hope for permanent good results in It large number of cases. If the lung is collapsed for a short time only there is danger of the symptoms returning when the lung re-expands, as shown in cases 7 and 8If the symptoms do not return and the case is converted into one of chronic fibroid disease life may be prolonged considerably and in some cases the disease may be completely arrested, but there is not the same chance of 0. lasting arrest as there is after a full time pneumothorax. Moreover, the chronic fibrotic cases are very liable to attacks of hromoptysis. At the same time great improvement may follow a collapse of lung of very short duration and the gradual obliteration of the pneumothorax cavity docs not of necessity indicate a bad prognosis, for some of these patients do extremely well. My thanks are due to Dr. Stanley Melville for the skiagrams illustrated in this paper.
SUPBUFICIAL VENULES IN PULMONARY TUBEHCULOSIS. By A.
NIVEN RODERTSON,
M.D.,
xr.n.c.r.,
D.P.H.
Medical Superintendent, Derbyshire Oounty Sanatorium; VENOUS DIAORAMS.
IN over 250 cases I made a diagram which I called a venous diagram" of each case on admission, and as a result I found that the enlarged superficial venules on the trunk are arranged as n. rule in definite areas, and according to 0. plan more or less definite, although n. certain number of tho venules appear to be scattered in a somewhat haphazard pattern. 'I'hose on tho front of the trunk can be grouped into two semi-circular arches with their apex directed upwards, one of which I have called the H sterno-coste!" or II costal arch" and the other tho ,. diaphragmatic arch." In the former the apex of the arch is formed by little venules over the sternum at the level of the second or third ribs or sometimes higher. while the limbs of the arch are formed by venules in line with these spreading out on each side; the further out the vcnules are traced the lower in position do they lie. As n. rule only one costal arch is present or sometimes unilaterally only one half of the arch or perhaps a fraction of any one part of the arch alone may be present. Sometimes, as .in the venous diagram pictured (taken from an actual case), two costal arches are present, one above the other, like a double rainbow. In the case shown the summit of the upper costal arch is at the Ie
Hju
TUBERCLE
[January, 1925
upper border of the manubrium and it spreads out on each side like n. fan to the third rib as far out as the mid-clavicular lines, while the lower arch reaches from the level of the angle of Ludovic to the fifth rib in the anterior axillary line on each side. The double costal arch is uncommon in such a complete form as in the case shown, but fractions of a double nrch arc less rare. 'I'ho diaphragmatic arch is the well-known line of venules corresponding to the line of attachment of the diaphragm. Owing to the frequency of tho phthinoid chest in pulmonary tuberculosis, associated with an acute subcostal angle, this arch oCten approaches an inverted V shape. U becomes more Gothic, whereas the costal arch is usually Norman in type. Ono patient had such a well marked diaphragmatic arch composed of innumerable fine radiating strim that I called it the " Sunrise Pattern."
20ne of 'Sterno-
~ombardi
,ost,a\ arch. Diaphragmatic arch.
Crist.a' line
FlO.
t.-Schomo or venous groups,
Posteriorly, the venules arc also arranged into two definite groups and nreas : (a) round the seventh cervical and first and second dorsal spines and (b) along tho crests of the ilium. 'l'he former group has had much attcntion paid to it, especially as a sign of pulmonary tuberculosis in children, and is called tho Zone of Lombardi. The second group I originally called tho lumbar lino (Indian Medical Record, II The Early Diagnosis of fJ.'ubcrclo "). A better name, however, would be the" criatal line." The vcnules in this line Corm 0. semi-circular arch with its apex or summit ' pointed downwards forming 0. horizontal line over the sacrum and extending up on each side ns lateral limbs along the line of the iliac crests. Sometimes only one limb is present or only 0. fraction of any part of the arch, Buuuuuriscd the venous groups nre:Antcriorly.-(l) Costal or sterno-costal arch j (2) diaphragmatic arch. Posteriorly.-(l) Zono of Lombardi; (2) cristal line. Besides theso definite groups, little venulcs may be scattered irregUlarly Over tho other anatomical areas, o.g., along the clavicles, along the spines oC tho scapula, in the suprasternal notch, in the lumber region, &c.
January, 1!J25]
SUPERFICIAL
VENULES
167
Superficial Venous Varix. Also frequently besides these little twig-like terminal venules there is enlargement of the whole length of veins, as large as the veins on the back of the hands of the elderly, forming a superficial varix . A varix may be
FlO. 2.-Photogro.ph of thoracic venous varix. Extensive fibroid pulmonary tuberculoeis, both lungs.
FlO. 3. -Superficial venous varix in skin of R. side of abdomen, due to previous typhoid fever.
formed between the anterior thoracic veins and the internal mammary, or between the internal mammary, the anterior thoracic veins and the veins of the upper arm. A varix may also form between the internal mammary, the upper anterior thoracic veins and the intercostals, The patterns
lGS
[January, !025
TUDERCLE
Cormcd by these vnnces vary greatly like the veins on marble• .. marbling." They are analogous to n remarkable abdominal varix which I observed in a patient who had suffered from typhoid. Possibly these thoracic varices arc sometimes due to partial obstruction of the subclavian vein by tuberculous pleuritic adhesiona dragging on this vein, in cases in which there hils been a pleurisy of the apex of the lung involving also a thickening and dragging oC Sibson's fascia.
Total Yenules -in each Anatomical Surface Area. In 250 cases I added the total venules found in each anatomical area in each case, and then adding the totals of each area for the ~50 cases together obtained the total venules in each area in the 250 patients. Tho results were :-
CriRto.l arch
L. diaphragmatio arch R. II " TJ. criB tOol line •• L. 8uInrascapular area '
1n.r,
..
H. cristal line
••
"
•• 8Upramo.mmo.ry aroa ••
H.
..
"
:~~ ven,u,les} represent diaphragmatic arch 835 vcnulos 824" ~ Zone 0 £ L ombard"1. 2!)5" 200" 228 venules} costal arches. 219"
Tho venulcs in the other areas were 0.11 much fewer (i.e., in the supraspinous, infraspinous, supra-clavicular, clavicular, axillary, interscapular urcns, &c.). They ranged from 80-20 as totals. This again showed how tho veins wero clustered into the definite groups already described and named.
Frequency of Group Venules. Pruent
(1) COBLI~1 arch Rroup
.. (~) Dinphragrnatlc lLrch group (3) Zono of Lombardi group •• (4) CrlIlLl\l arch group ..
42 ca.ses
91 "
AbRent
Totale
22-1 caaes
2CG cases
lOG
2(;0
II
123 ..
142 ..
87 ..
10 "
2€15 157
"
.. ..
In tho first sroup I only included those with a complete arch, in tho other threo I included fragmentnry groups. 'I'he importance of the cristal lino group is seen from tho fact that this group alone is more often present than absent. 'l'hia group has not been investigated previously because 1I)0st observers have overlooked it as the body requires to he stripped to n. lower level than usual for its observation. On the other hand, the previous totnla show tho.t when tho diaphragmatic arch is present the number of vcnules in it nrc more numerous per case than in any of the other groups . Pathological Cause oj Superficial VCl1ules. Hutchison and Rainy state that the veins of the thoracic wall may bo unduly conspicuous (a) when the patient's skin is unusually trnnsparent. (b) when tho patient has been undergoing considerable exertion, especill.lI,>: when tho cffort is of such 0. kind as to throw 0. strain on the respiratory system; (c) when intra-thoracic tumours impede tho return of blood to tho hcnrt : (d) when the action of tho right side of the heart is laboured; (e) when in consequence of portal obstruction or of blockage oC the inferior caval system tho blood.returning Crom the abdominal viscera or lower limbs
January, 1925]
SUPERFICIAL VENULES
lGO
is forced to find its way through collateral channels. All these factors, except the last, come into play in pulmonary tuberculosis. The skin is frequently thin and atrophic, and the thin ivory skin of children with tho disease is well recognised. Pulmonary tuberculosis causes a marked respiratory strain due to defective aeration from lung destruction. 'I'ho third factor includes as IL mediastinal tumour tuberculous enlargement of the mediastinal lymph glands." 'rhat the action of tho right heart is affected in pulmonary tubercle is probable by the frequency with which one finds neeentuntion of the second pulmonary sound due to obstruction of the lung circulation. Hutchison and Rainy state that in 0. number of instances where the right side of the heart is slightly overworked a belt of dilated capillaries appears along the line of attach~nt of the diaphragm. I havo already pointed out how frequently this belt is"found in pulmonary tuberculosis. It corresponds to my second group. Riviere states in regard to the first group that they are often most visible on tho right side and generally double, and that their course is generally inwards towards the sternum. 'I'hey owe their presence to pressure on the right and left superior intercostal vein or on the vena az}'gos major, and are thus evidence of enlargement of the tracheobronchial or bifurcation glands in the mediastinum. The vena azygos major receives blood from all the intercostal spaces save the upper. two or three on the left side which are drained by the left superior intercostal. The enlarged radicles, therefore, represent a collateral circulation and not engorged vcnules, since in Riviere's experience the flow is inwards towards the sternum and internal mammary veins. With his observations I am in entire agreement. Fishberg recorded that 8 per cent. of children out of tuberculous households had enlarged thoracic veins. He divided these children into threo croups: Amongst those with active tuberculosis he found 37 per cent. who showed this sign; 25 per cent. of those with latent tuberculosis showed it, while only 1 per cent. of the healthy showed it. Riviere also regards those of the third group, spinal telangiectases, which he found mainly round the seventh cervical, and first and second dorsal spines, but often as low as the third to fifth dorsal spine, as due to the samo cause. These also represent lL collateral circulation. He found that in 24 children from tuberculous households spinal venules were present in 41'7 per cent., while in 22 children from healthy households they were present in only 23 per cent. He found them twice as often in children with manifest signs of tubercle as in children with healthy chests. He wisely, however, does not over-rate their diagnostic value as they arc present in his opinion in 40 per cent. of healthy young persons. Acting on the principle that the majority of these venules were due to the calargement of mediastinal glands pressing on the vena azygos major, and as this vein as well as the vena azygos minor commences in the small lumbar veins, I was led to examine the point whether the commencements or these veins in the lumbar region was dilated by backward pressure. 'l'hus I came to discover the vennles along the crests of the ilium. 'I'he small venules, however, that I found along the crests and over the sacrum nil run downwards over the crests and are therefore also a collateral circulation. This collateral circulation opens into the gluteal sciatic and
170
[January, 1925
TUDERCLE
sacral veins and ultimately therefore into the common iliac veins and inferior vena cava. Thoracic disease, therefore, produces the opposite of abdominal disease. Pressure in the thorax obstructs the azygos veins (part of the superior vena. caval system) and collateral communication is made by the lumbar venules with the inferior vena caval system. In abdominal pressure (tumour pressing on inferior vena cava,' cirrhosis, &c.) the inferior vena caval system is obstructed and collateral parietal circulation is made with the superior vena caval system. A few dilated venules found in the lumbar areas sometimes above the ilium are probably dilated terminals of the azygos veins. The second or diaphragmatic group are also collateral in origin since they all converge downwards opposite to the intercostal flow of blood. In thoracic disease the production of all four venous groups as collateral circulations is mainly due, therefore, to the obstruction of the azygos part of the superior vena. caval system.
Clinical Value of Dilated Venules. Under this heading I investigated the relationship of the venules: (1) As to age of the patient; (2) as to duration of the disease : (3) as to anatomical extent of disease (Turban stages) ; (4) as to pulmonary fibrosis; (5) as to amount of cough; (6) as to locality of disea.se; (7) as to whether they were trophic or reflex in character (in relation to Head's areas). (1) Age of the Patient.-(a} Age period 10 to 20 years of age . There were 30 cases at this age and the total number of venules was IDO or 633 per cent. (b) Age period 20 to 30 years. In this group there were 76 cases and the total number of venules was 770 or 1,013 per cent. (c) Age period 30 to 40 years; 80 cases. Total venules 1,296 or 1,620 per cent. (d) Age period 40 to 50 years; 46 cases. Total venules 825 or 1,793 per cent. (e) Age period 50 to GO years; 12 cases. Total venules 109 or 908 per cent. Age, therefore, apparently increases the number of venules up to 50 years of age when there is a. decline. Probably above this age they become fewer owing to atrophy. The age periods which have the highest percentage of venules correspond to the period of middle age phthisis of Brownlee which is a, more chronic type and therefore associated with more prolonged illnesa causing cough, fibrosis and other factors which produce a strain on the circulation and also, as will be shown later, cause in this way a greater number of enlarged venules. (2) Duration of the Disease.-As age apparently influences the number of venules, the cases had to be divided into the above age periods to get correct results. (a) Age period 10 to 20 years. Duration of iUneu 6 1 "., 18 2 S
"
"
"
"
4
months. year. months, years.
"
"
19 uses. 6 2 " " 1 case. 1 1 "
"
Average number of venules 6 8 It " "I t 8 II
"tt
"
"
" " ",t
23 8 12
January, 1925]
SUPERFICIAL
171
VENULES
(b) Age period 20 to 30 years. Duration of illness 6 months. .. .. 1 year. .. 18 months. .. 2 years. " "
tt
S! cases. 19" ..
3
' 7 6 6
4
8
n
.. ....
..
Average number of venulcs 9 13 7 " 9 10 It
.
11
(C) Age period 30 to 4(5 years. Durs.tion of illness 6 months. .. .. 1 year. .. .. 18 months. It .. 2 years. tt
"
u
(d)
13 8 10
:>
8,.
4
86 cases.
7
u
.. It
•• tt
Average number of venules 17 .. .. tI 15
... .. ." .
... ...
8 20
12 8
Age period 40 to 50 years. Duration of illness 6 months. .. .. 1 year. 18 months. 2 years. If 3.. It 4..
..
..
21 cases. 11 4 .. 3 2 .. 5
Average number of vcnules 16 ,. u .. !:2.t
. .
.
"
If
,.
..
17
13 11 18
It is obvious that the number of cases is often too small for one to be able to found any theories on the resulting data. For this reason I omit the age periods 10 to 20 and 50 to GO years during which the total cases.were so few. Also in the other age periods the cases are few where the disease had lasted for a considerable time. The general result is, however, that between the ages 20 to 30 the maximum number of venules occurs after one year's illness, and so also in the cases of patients between 40 and 50. In , the age period 30 to 40 the maximum is after six months and two years' illness. It is also shown that the greatest number of venules go:s along with the middle age type of phthisis associated with a more chrome and prolonged period of ill health. The obstruction of the venous ~ircula. tion in these cases is due sometimes, perhaps, to dust, &c., enlargmg the mediastinal glands and obstructing the vena azygos major. and also to industrial conditions causing at these periods a greater strain on the arteries, capillaries and veins. (3) Anatomical Extent of Disease.-The cases were classified by Turban stages. 124 cases Turban I. 56.. .. II. 79.. It III.
Average number of venules per ease, 12 .. .. .. It 13 .... 13
As the observations were all made on sanatorium cases the number of first stage cases was greatest, but the number of venules appeared to be independent of the extent of the disease. The number of venules is therefore of no value as a guide to prognosis. (4) Extent oj .Ltt1tg Fibrosis.-The number of cases with very marked chronic ~br?sis was 34. '!'heir average number of venules was 15 per case. 'When this IS compared With the average number in 200 cases of all types -ll-it shows that fibrosis is a factor in the production of these venules. Probably the cause is fibrosis round the hilus obstructing the azy&:{os veins as well as general fibrosis throughout the lungs generally, obstructing the .pulmonary circulation and the venous system. (5) Amount of COltgh.-Cough was divided into four degrees of severity.
172
[January, 1925
TUllERCLE Cough Cough Cough Cough
a.bscn~
+ ++ +++
55 ceses, 60" 62 It 67 It
Average ago 26. t' " 83. " I t · 84. " " 8G.
Average number of venules 7 II to ,,13 " " It 16 " " tI 18
These figures show that the amount of cough has an effect on tho venous circulation and on the number of venules, although tho fact that the age of those without cough is younger must be taken into account. It shows that the strain on the venous system is greater in the middle ·ago group. (Q) Locality oj Disease.-An attempt was made to find out whether there WIlS any connection between tho side of the disease and the sido on which the venules were greater in number. This was studied in 120 cases. Bilateral disease.-(a) Equal in extent on the two sides, 30 cases ; venules equal in number on the two sides in only 14 of these; (b) disease more extensive on the right side, 31 cases. In. only 11 were the venules greater in number on the right side; (0) disease more extensive on tho left side, 10 cases. In 7 the venules were also greater in number on tho left side. Unilateral disease.-(a) Right-sided disease, 32 cases. In only 11 cases were tho venules greater in number on the right side; (b) left-sided disease, 8 cases. In G cases the venules were more in number on the left side. There was thus no connection between side of disease and side of body on which the venules were greater in number. An inspection of tho venules therefore is no ready-to-hand means of deciding the location of tho disease. This was as expected, since the effect of unilateral disease is n strain on tho whole general venous circulation. (7) Trophic Al'eas.-No connection was found between the position or tho enlarged veins and the site of the disease. The venules are therefore not locally reflex in origin or trophic in nature affecting the skin over tho area affectod by tubercle. Permanency or Otherwise of the Vellulcs. In 50 COBes tho number of distended venules was examined after var~' iog periods during treatment. It was found that in 20 cases the venules had increased in number, in 10 the number was less, and in G cases tho number remained the same. 'I'his perhaps indicates tho relative inadequacy or tho various commonly used expectorant mixtures in relieving tho strain or cough in pulmonary tuborculosis.
Number oj Venules in Normal Persons (Staff). This was found to bo nn average of four. Thero is thus a distinct. excess or thoracic vcnules in persons with pulmonary tuberculosis. Theso venules may therefore be accepted as a. sign associated with this disease and should always be looked {or during inspection of the putient's ches~: 'I'his ngroes with the observations of Riviere and Fishberg. CONCLUSlO~S.
Tho number of distended venules in tho trunk depends on :(1) Ago: an increase with advancing years till tho atrophy of old age (2) Duratlon of disease: increase with duration of the disease. .
January, 1925]
SUPEnFICIAL
173
VENULES
(3) Cough: increases with the amount of cough. (4) Fibrosis: increases according to its extent. (5) Anatomical extent of disease : independent of it; no use in prognosis. VJt:-l0t18 DJAGnUfS FROM Two ACTUAL CASES.
(TAKEN FnO~f MY SERIES OF
250
OUES.)
r FIG. 4.-Showing also venous varix.
, FIG. 5.- Bhowlng doublo sterno-costal arch.
(0) Locality of disease in the lung: independent of it; not 0. means of Jocalising the disease at first sight. (7) Not reflex or trophic in cause, as is, for example, local muscls change. (8) Definitely associated with pulmonary tuberculosis, and in the main duo to obstruction of the vena azygos veins by enlarged mediastinal ~lands and hilus fibrosis (especially in children) although also due to general lung fibrosis and strain on pulmonary and general venous circulation.