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Bronchoscopic diagnosis of carcinoma of the lung
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or other of these being the first complaint in 35 out of 39 eases. Laryngeal palsy usually means a fairly extensive growth, and is of no serious value to diagnosis. Pain is usually the second symptom complained of, occurring as a rule about two months after the onset of cough or dyspnoea. Physical signs vary considerably according to whetlmr there is any obstruction of the lumen of the bronchus by tile growth, and whether this is partial or complete. Pleurisy with effusion is as a rule a late manifestation. This was present in I6 o1:.4o cases when first exanfined, in nine as a clear effusion, in six haemorrhagie, and in one purulent. Complete obstruction of tile lumen of tim bronchus results in collapse of the lung beyond, with flattening of the chest, diminished movement, impaired resonance, and diminished breath sounds. Partial obstruction leads to the development of bronchiectasis in the lung peripheral to the growth, with clubbcd fingcrs, foul sputum, and tim physical signs of bronchial dilatation. Only four cascs showcd venous obstruction from pressure on vcins--not nearly so frequently as in mcdiastinal t u m o u r s - three oesophageal obstruction, and one ttle physical signs of solid tumour in the chest, only one case showing no abnormal physical signs. P R I M A R Y C A R C I N O M A O1: T i l l ' : I . u N G R A I ) I O I . O G I C A I A A ' C O N S I D E I { E I ) . By G. B. BusH. Bristol Med. Chlrurg. Journ., 1936, Lm. I31. When the disease is confined to thc lung, and the growth is in the endobronehial stage with a small tumour and incomplete obstruction, there may be no X-ray findings. Delayed or incomplete deflation in the affected lobe or Iobule may, however, be seen if films are taken on inspiration anti expiration, anti lipiodol injection may show a filling defect, particularly in scrim fihns. Later, with occlusion of a bronclms, an opacity in the area supplicd by the bronchus, gcncrally a lobe, will be scen on the film. Tim interlobar fissures are altered in position, as will usually be seen on antero-posterlor or lateral films. I'urther, if the stenosis is in a bronchus of the first degree, the mediastinum and trachea are displaced to the side of the lesion, tim displacement being increascd on inspiration. Where there is no bronchial stcnosis, the growth may crode througta the bronchial wall and infiltrate the .lung. "l'he X-ray findings here are of the nodular type ofstmdow in the lung field, most commonly in tim hilar zone, the lesion producing no physical signs, although the symptoms may be suggestive. A third type of ease is that in which infection supervcnes distal to tim bronchial
ER(~ LI"
October
i937
obstruction with bronchiectasis, necrosis, abscess~ formation, and possibly gangrenc. The X-ray will lmre show clearer areas with fluid levels within tim tumour shadow. Other pathological changes that may occur in ttm tmnour are thoge of mucokl degeneration, which rnay be detected and demonstrated radioscoplcally. Secondary changes occurring outside the hmg will contraindicate any radical removal of the growth by lobectomy. These changes include (x) infection of the lymph glands at the root of the hmg ; (2) compression or infiltration of the phrenic nerve, producing paralysis of one half of the d i a p h r a g m ; (3) involvement of the vagus, or secondary deposits in the abdomen, producing gastro-intestinal symptoms. The chest should ahvays be screened as a routine in abdominal cases; (4) pleural involvement with effusion; (5) a very snmll primary growth in a bronchus may rapidly invade a blood-vessel, producing one or more secondary nodules in the lung. IH~,ONCHOSCOPIC I)IAGNOSIS OF C A I t . C I N O M : \ O F Till'; L U N G . By G. SCARFI,. Bristol Mcd. Chlrurg. Journ., x936 , 9L m .
137.
Bronclmscopy in cases of neoplasm will show an abnormal fixation of the affected arca of the lung. There is also usually some secondary infection.present, wlfich may cause reddening of the mucosa. Tiffs fixation, when associated with occlusion, partial or complete, of tim bronchus, will leave little doubt as to tim diagnosis fi'om benign new growth and chronic inflammatory conditions, but a portion of the growth should always be taken for confirmation. Treatment by bronchoscopic means is limited to treatment by radium, encouraging results having been reported by the implantation of a tubc containing radon. C A R C I N O M A 0I" T H E B R O N C I I U S ; T H I " PATIIOI,OGICAL A S P E C T . IIt 9 A. L. T,XVLOR. Bristol Med. Chirurg. Jnurn., 1936 , I.m. 139. During tile past eight years, 32 cases of bronchial carcinoma have come to autopsy in the Bristol General Hospital ; and these reln-esent 2" 3 per cent of all the autopsies, and I3-6 of all tim deaths from malignant disease. In over 9 ~ per cent of cases lung carcinoma is of lfilar origin, beginning in the nmcosa of one of the larger bronchi ; this was tile case in all but one in this series. In 16 of tile 3~ cases tim growth extended widely into the mediastlnum, infiltrating the roots of tile great vessels and even
T U B
or other of these being the first complaint in 35 out of 39 eases. Laryngeal palsy usually means a fairly extensive growth, and is of no serious value to diagnosis. Pain is usually the second symptom complained of, occurring as a rule about two months after the onset of cough or dyspnoea. Physical signs vary considerably according to whetlmr there is any obstruction of the lumen of the bronchus by tile growth, and whether this is partial or complete. Pleurisy with effusion is as a rule a late manifestation. This was present in I6 o1:.4o cases when first exanfined, in nine as a clear effusion, in six haemorrhagie, and in one purulent. Complete obstruction of tile lumen of tim bronchus results in collapse of the lung beyond, with flattening of the chest, diminished movement, impaired resonance, and diminished breath sounds. Partial obstruction leads to the development of bronchiectasis in the lung peripheral to the growth, with clubbcd fingcrs, foul sputum, and tim physical signs of bronchial dilatation. Only four cascs showcd venous obstruction from pressure on vcins--not nearly so frequently as in mcdiastinal t u m o u r s - three oesophageal obstruction, and one ttle physical signs of solid tumour in the chest, only one case showing no abnormal physical signs. P R I M A R Y C A R C I N O M A O1: T i l l ' : I . u N G R A I ) I O I . O G I C A I A A ' C O N S I D E I { E I ) . By G. B. BusH. Bristol Med. Chlrurg. Journ., 1936, Lm. I31. When the disease is confined to thc lung, and the growth is in the endobronehial stage with a small tumour and incomplete obstruction, there may be no X-ray findings. Delayed or incomplete deflation in the affected lobe or Iobule may, however, be seen if films are taken on inspiration anti expiration, anti lipiodol injection may show a filling defect, particularly in scrim fihns. Later, with occlusion of a bronclms, an opacity in the area supplicd by the bronchus, gcncrally a lobe, will be scen on the film. Tim interlobar fissures are altered in position, as will usually be seen on antero-posterlor or lateral films. I'urther, if the stenosis is in a bronchus of the first degree, the mediastinum and trachea are displaced to the side of the lesion, tim displacement being increascd on inspiration. Where there is no bronchial stcnosis, the growth may crode througta the bronchial wall and infiltrate the .lung. "l'he X-ray findings here are of the nodular type ofstmdow in the lung field, most commonly in tim hilar zone, the lesion producing no physical signs, although the symptoms may be suggestive. A third type of ease is that in which infection supervcnes distal to tim bronchial
ER(~ LI"
October
i937
obstruction with bronchiectasis, necrosis, abscess~ formation, and possibly gangrenc. The X-ray will lmre show clearer areas with fluid levels within tim tumour shadow. Other pathological changes that may occur in ttm tmnour are thoge of mucokl degeneration, which rnay be detected and demonstrated radioscoplcally. Secondary changes occurring outside the hmg will contraindicate any radical removal of the growth by lobectomy. These changes include (x) infection of the lymph glands at the root of the hmg ; (2) compression or infiltration of the phrenic nerve, producing paralysis of one half of the d i a p h r a g m ; (3) involvement of the vagus, or secondary deposits in the abdomen, producing gastro-intestinal symptoms. The chest should ahvays be screened as a routine in abdominal cases; (4) pleural involvement with effusion; (5) a very snmll primary growth in a bronchus may rapidly invade a blood-vessel, producing one or more secondary nodules in the lung. IH~,ONCHOSCOPIC I)IAGNOSIS OF C A I t . C I N O M : \ O F Till'; L U N G . By G. SCARFI,. Bristol Mcd. Chlrurg. Journ., x936 , 9L m .
137.
Bronclmscopy in cases of neoplasm will show an abnormal fixation of the affected arca of the lung. There is also usually some secondary infection.present, wlfich may cause reddening of the mucosa. Tiffs fixation, when associated with occlusion, partial or complete, of tim bronchus, will leave little doubt as to tim diagnosis fi'om benign new growth and chronic inflammatory conditions, but a portion of the growth should always be taken for confirmation. Treatment by bronchoscopic means is limited to treatment by radium, encouraging results having been reported by the implantation of a tubc containing radon. C A R C I N O M A 0I" T H E B R O N C I I U S ; T H I " PATIIOI,OGICAL A S P E C T . IIt 9 A. L. T,XVLOR. Bristol Med. Chirurg. Jnurn., 1936 , I.m. 139. During tile past eight years, 32 cases of bronchial carcinoma have come to autopsy in the Bristol General Hospital ; and these reln-esent 2" 3 per cent of all the autopsies, and I3-6 of all tim deaths from malignant disease. In over 9 ~ per cent of cases lung carcinoma is of lfilar origin, beginning in the nmcosa of one of the larger bronchi ; this was tile case in all but one in this series. In 16 of tile 3~ cases tim growth extended widely into the mediastlnum, infiltrating the roots of tile great vessels and even