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PHILOSOPHY: MAGNIFICENT REALM OF FREEDOM
ROENTGENOGRAM OF THE MONTH Diagnosis: Anaerobic Pneumonia (C. Welchii and Anaerobic Streptococci) Figure 1 shows a diffuse infiltrate in the left lung. Areas of lucency within the infiltrate represent either uninvolved lung or breakdown of lung tissue. Figure 2 shows multiple small radiolucencies surrounded by pulmonary opacity consistent with many small areas of lung destruction. Some radiologists might consider the appearance a honeycomb pattern which would indicate that the process is primarily interstitial. There are over 40 causes of honeycomb lung. Most are unlikely in this case, but interstitial fibrosis, giant cell pneumonia and tuberculous bronchopneumonia must be considered. Dilated bronchi can also cause this pattern. On the day after the second roentgenogram, three separate sputum cultures showed a heavy growth of C. welchii, anaerobic streptococci and coliform bacilli. The patient was given anti-gas gangrene serum and penicillin to which the anaerobes were sensitive. He improved clinically, but the chest film remained unchanged. A pneumonectomy was performed one month later. Histology showed destruction of the normal alveolar pattern by poorly defined confluent areas of consolidation which were composed of relatively mature granulation tissue and a cellular infiltrate of mononuclears, lymphocytes and syncytial giant cells. This was surrounded by interstitial fibrosis. The bronchi showed some dilatation and foci of epithelial hyperplasia. No vascular thrombosis or caseation was seen. The findings were consistent with an unresolved bronchopneumonia. The bronchiectasis and hyperplastic epithelium with giant cells suggest an antecedent giant cell pneu-
201 monia, commonly seen with measles in Nigeria. The radiographic appearance was probably due to the focal areas of destruction although dilated bronchi and interstitial fibrosis may have contributed to the honeycomb appearance. Anaerobic organisms, considered to b^ secondary invaders here, may be normal inhabitants of the intestine. They are not infrequently found in pneumonia and lung abscesses. 18 Infarcted pulmonary tissue or, as it is sometimes called, pulmonary gangrene,4 is not required to support their growth. C. welchii is an aero-tolerant anaerobe, ie, it can continue to grow with an 0 2 tension of 10-30 mm Hg, and growth is not restricted until the 0 2 tension reaches 70-80 mm Hg. 5 (In contrast, C. tetani requires 0 2 tension of less than 2 mm Hg for growth.) Utilization of tissue oxygen by aerobes in a mixed infection may also lower oxygen tension so that aero-tolerant anaerobes can also grow. ACKNOWLEDGMENT: We are grateful to Dr. C. Sinnette, who cared for this patient, for allowing us to publish this report. REFERENCES
1
S W E E T I N G , J., AND ROSENBERG, L.: Primary clostridial pneumonia, Ann. Int. Med., 51:805, 1959. 2 G L A S E R , L . F . , G L Y N N , R . , AND H A N A N , E . B . : Gas bacillus gangrene of lung, JAMA, 118:827, 1941. 3 O ' D O N N E L L , A . E . : Primary clostridial pneumonia—report of a case, Lancet, 2 : 3 8 7 , 1 9 5 2 . ' 4 D A N N E R , P . K . , M C F A R L A N D , D . R . , AND F E L S O N , B . :
5
Mas-
sive pulmonary gangrene, Amer. J. Roentgen., 103:548, 1968. W I L L I S , A . T . : Anaerobic Bacteriology in Clinical Medicine, (2nd Ed.) Butterworths, London, 1964, p. 164.
Reprint requests: Dr. Bohrer, Department of Radiology, University of Ibadan, Ibadan, Nigeria.
PHILOSOPHY: MAGNIFICENT REALM OF FREEDOM Reason can be circumscribed but not defined. In its infinite scope it lets us find the way on which we come to ourselves and to the destiny in which, and which, we are. May we dare to discuss what seems impossible to discuss even though all depends on it? This is exactly what philosophy has always done. It was thus that the most profound links between men were established, that the source within us was illuminated, the foundation that upholds us, the root cause of what exists bv our means. It is bv such thinking that reason takes effect—that in the medium of intellectual determinations, the only ones in which we can think meaningfully, we perceive the realm that is hidden from the intellect and has been the fount of
CHEST, VOL. 57, NO. 2, FEBRUARY 1970
everything good and true and great that men have achieved. The new—and age-old—thinking transcends the finite thought that cleaves the objects. As speculative thought, it goes beyond the intellect to the source of thinking itself. Such speculative thought has a powerful effect on thinker, and on the listening rethinker. In concepts and in conceptual movements, in images and metaphores, and in the strength of symbols, it has created a language over the centuries. It has many meanings, as if it were done in a room full of mirrors. Jaspers, K.: The Future of Mankind (Translated from German by Ashton, E.B.) Universitv of Chicago Press, Chicago, 1961
201 monia, commonly seen with measles in Nigeria. The radiographic appearance was probably due to the focal areas of destruction although dilated bronchi and interstitial fibrosis may have contributed to the honeycomb appearance. Anaerobic organisms, considered to b^ secondary invaders here, may be normal inhabitants of the intestine. They are not infrequently found in pneumonia and lung abscesses. 18 Infarcted pulmonary tissue or, as it is sometimes called, pulmonary gangrene,4 is not required to support their growth. C. welchii is an aero-tolerant anaerobe, ie, it can continue to grow with an 0 2 tension of 10-30 mm Hg, and growth is not restricted until the 0 2 tension reaches 70-80 mm Hg. 5 (In contrast, C. tetani requires 0 2 tension of less than 2 mm Hg for growth.) Utilization of tissue oxygen by aerobes in a mixed infection may also lower oxygen tension so that aero-tolerant anaerobes can also grow. ACKNOWLEDGMENT: We are grateful to Dr. C. Sinnette, who cared for this patient, for allowing us to publish this report. REFERENCES
1
S W E E T I N G , J., AND ROSENBERG, L.: Primary clostridial pneumonia, Ann. Int. Med., 51:805, 1959. 2 G L A S E R , L . F . , G L Y N N , R . , AND H A N A N , E . B . : Gas bacillus gangrene of lung, JAMA, 118:827, 1941. 3 O ' D O N N E L L , A . E . : Primary clostridial pneumonia—report of a case, Lancet, 2 : 3 8 7 , 1 9 5 2 . ' 4 D A N N E R , P . K . , M C F A R L A N D , D . R . , AND F E L S O N , B . :
5
Mas-
sive pulmonary gangrene, Amer. J. Roentgen., 103:548, 1968. W I L L I S , A . T . : Anaerobic Bacteriology in Clinical Medicine, (2nd Ed.) Butterworths, London, 1964, p. 164.
Reprint requests: Dr. Bohrer, Department of Radiology, University of Ibadan, Ibadan, Nigeria.
PHILOSOPHY: MAGNIFICENT REALM OF FREEDOM Reason can be circumscribed but not defined. In its infinite scope it lets us find the way on which we come to ourselves and to the destiny in which, and which, we are. May we dare to discuss what seems impossible to discuss even though all depends on it? This is exactly what philosophy has always done. It was thus that the most profound links between men were established, that the source within us was illuminated, the foundation that upholds us, the root cause of what exists bv our means. It is bv such thinking that reason takes effect—that in the medium of intellectual determinations, the only ones in which we can think meaningfully, we perceive the realm that is hidden from the intellect and has been the fount of
CHEST, VOL. 57, NO. 2, FEBRUARY 1970
everything good and true and great that men have achieved. The new—and age-old—thinking transcends the finite thought that cleaves the objects. As speculative thought, it goes beyond the intellect to the source of thinking itself. Such speculative thought has a powerful effect on thinker, and on the listening rethinker. In concepts and in conceptual movements, in images and metaphores, and in the strength of symbols, it has created a language over the centuries. It has many meanings, as if it were done in a room full of mirrors. Jaspers, K.: The Future of Mankind (Translated from German by Ashton, E.B.) Universitv of Chicago Press, Chicago, 1961