1) Lipiodol injections were used to visualize pulmonary changes in 3 tuberculosis patients with dense shadows obscuring lung details on standard x-rays. 2) In Case 1, lipiodol revealed dilated bronchi, bronchioles and cavities in the upper lower lobe, indicating incomplete compression during prior thoracoplasty. 3) In Case 2, a cavity in the lower lobe and bronchiectasis in the upper lobe were found, suggesting the need for further operation. 4) Case 3 showed a cavity in the compressed lung that precluded further operation due to active disease in the other lung.

1. THE CANADIAN MEDICAL ASSOCIATION JOURNAL
X-RAY DEMONSTRATION OF PULMONARY CIIANGES IN
TUBERCULOSIS BY LIPIODOL INJECTION
EDWARD ARCHIBALD
Surgeon-in-Chief, Royal Victoria Hospital, Montreal
THE Frenieh, who have always been to the fore
in the field of pharmaceutical products,
have recently given us a most valuable sub-
stance, lipiodol, the chief use of which hitherto
has been to render visible in the x-ray plate the
interior of body cavities, in a way quite im-
possible to obtain with the ordinary opaque sub-
stances previously employed. Its value lies in
the fact of its being entirely non-irritating. Dr.
Ballon, in an article appearing in this issue,
reviews the literature of the subject. The object
of the present communication is merely to refer
to the use of lipiodol in demonstrating cavities
and bronehiectasis in tubereulous lungs. The his-
tories of three patients will be given, all of
whom had undergone, from two to three years
previously, the operation of total posterior thora-
coplasty. After improvement lasting a variable
period the symptoms of cough and increased
sputum reappeared. In such cases the effect
of extensive rib removal, with reforniationi of
new bone, irregular ouitline, ancd with also
a considerable thickening of the pleura such as
usually occurs, is to obscure the x-ray plate with
such a dense and uniform shadow that the detail
of lung structure cannot be made out either in
the ordinary plate or in the Buckey dia-
phragm plate. Neither can we get help from the
ordinary methods of physical examination. The
compressed lung and the general thickniess of
the tissue prevent any precise interpretation of
whatever sounds nmay be heard. 1Uiider these
cireumstances any method which can reveal the
actual condition present must be of considerable
value, either for casting a prognosis or forl plan-
ning the lines of treatmenit. Difficulties of this
sort confronted one particularly in the threce
eases mentioned, and it may be said that the in-
jection of lipiodol, performed very skilfully
by Dr. Ballon, at my request, afforded us infor-
mation that was both new and necessary.
Without further preamble I shall now relate
the essential facts of the case records.
Case 1.-Aiss K. W. Age thirty-five. This
patient was refeired to miie for thoracoplasty by
Dr. Woods Price, of Saranac Lake, N.Y.. Her
illness began in June, 1920, with a pleurisy on
the right side. By November cough and expec-
toration had appeared, and in February, 1921,
upon the occasion of a bout of fever, the diag-
nosis was made and she was sent to Saranac.
She did fairly well for about a year, but in
February, 1922, a change for the worse occurred.
From that time until October 5th, the date of
h.er admission to the Royal Victoria Hospital,
except for a short period of improvement dur-
ing May and July, she suffered more or less
continuously from niight sweats, with occasional
chills, fever from 1000 to 1030, and a pulse of
100 and over. Sputum increased to four boxes
in twenty-four hours, and cough was very fre-
quent and troublesome. She was steadily going
down hill. X-ray examination showed a dense
uniform shadow over the whole right side in
which no detail could be made out. The left
lung was sound, save for slight and old trouble
at the apex. Extrapleural thoracoplasty was
done in two stages, on October 11th and Octo-
ber 31st, reiimoving portions of' the tenth to first
ribs inclusive, thirty-five iniches of rib in all.
She made a splendid recovery and was dis-
charged on November 21-st. Cough was almost
abolished, sputumi was not over half an ounce,
she felt very well, had a good appetite, her
toxvemic cyanosis had given place to a good red
colour of the imiucous memibranes; she had gainied
weight and was enthusiastic about the change in
her condition.
This marked improvement continued for over
two years, although the amounit of sputum grad-
ually increased to between one and two ounces.
In the third year, however, she began to lose
slightly. Some cough returned, sputum in-
creased somewhat, and she began to have a little
fever at times. From about February, 1925.
to the end of the surnmer, it was clear that she
1000

2. ARCHIBALD: X-RAY AND LIPIODOL IN PULMONARY LESIONS
was very gradually losing. Late in August, she
was readmitted to the Royal Victoria Hospital
for further examination. A lipiodol injection
was carried out by Dr. Ballon, and the findings
are seen in the accompanying photographs
(Figs. 1 and 2, Case 1). The picture in our
interpretation shows (best seen in the lateral
view) a conglomeration of dilated bronchi, bron-
chioles, and probably a number of small cavities
In the antero-posterior view these are aggre-
gated so as to form, in the main, one dense,
somewhat linear, shadow, with trailing out-run-
ners of dilated bronchi. The region affected
would appear to be chiefly the upper part of
the lower lobe, and somewhat close to the hilus.
At the original operation the lower lobe was
miuch less compressed than the upper, and the
question arises how much of the present condi-
tion is due to a gradual new in-vasion of the
insufficiently compressed lower lobe, or how much
to the gradual extension of disease originally
present there. The point is of importance as
indicating, perhaps, the necessity of greater
efforts to secure a thorough and complete col-
lapse of the lower lobe. This practically would
strengthen the argument for a routine prelimin-
ary phrenieotomy, and for shortening the inter-
val as far as possible between the two stages.
Case 2.-Miss Ml. D. Age thirty-nine. Re-
ferred by Dr. Malcolm Lent, of Saranae Lake,
N.Y., in November, 1922. This patient's ill-
ness began in November, 1919, but it was not
until August, 1921, that the disease was recog-
nized, and she was sent to Saranac, where Dr.
Lent found extensive involvement of the left
lung, while the right lung was clear. Through
FIG. 3.-Case II.--Lateral view.
FIG. 1. Case I. Lateral view.
FIG. 4.-Case II. Antero-Posterior view.
1001
5.
FIG. 2.-Case L-Antero-Posterior view.

3. THE CANADIAN MEDICAL ASSOCIATION JOURNAL
the year 1922 she gained steadily. The picture
was complicated by both laryngeal and colonic
tuberculosis, quite definitely diagnosed, but she
overcame these. On admission, November 9,
1922, to the Royal Victoria Hospital, she was
found to have an extensive involvement chiefly
of the upper lobe of the left lung, with a cavity
about the size of a small hen's egg in the apex;
there was also some consolidation in the lower
lobe. Otherwise she was in good condition.
Thoracoplasty was done on November 14th and
November 25th. She made a good recovery and
was discharged December 23rd. From that time
to the present she has renmained geinerally very
well, and was on unlimited exercise, but soimle
small amount of cough and sputum, though
without bacilli, persisted. She returned ini
September, 1925, for investigation. A lipiodol
injection, as shown in the acconipanying photo-
graphs, demonstrates the continued presence, or
more probably the later development, of a fairly
large cavity situated in the upper part of the
lower lobe, and also of some slight bronchiec-
tasis in the upper lobe adjacent to the hilus.
It is considered that further operation for the
compression of this cavity can reasonably be
undertaken, in view of her excellent general
condition.
Case 3.-Mrs. G. D. Age twenty-niine. Re-
ferred by Dr. Roddick Byers. This patient was
admitted June 9, 1923. Her illness had lasted
two years. Her right lung was extensively in-
volved, chiefly in the upper and middle lobes.
Sanatorium treatment had failed to stop) the
gradual spread of the disease through the right
lung. The left lung was fairly good. Thoraco-
plasty was done on June 14th and June 29th,
1923. She was much improved for about six
months but after January, 1925, as the result of
giving up treatinient and taking many liberties,
the disease in her good lung took on activity.
She was readmitted in September, 1925, and was
found to be in the full flush of active tubercu-
losis. A lipiodol injection showed a cavity in
the compressed lung, in the upper lobe. If it
were not for progressive disease in the good
lung it would be possible to consider a further
operation for the collapse of this cavity.
.c.
........X
FIG'j Cac III Aiit,io-Posterior view
Comment. This is, one may believe only a
beginning. The deionstration of residual
lesions after thoracoplasty, the localization of
which is miade accurately by stereoscopic and
lateral plates, is hardly possible by any other
method. It allows one to determine whether
further operation is justifiable or not. If a fur-
ther operation is attempted (and of this we have
as yet very little experiencee) the method will
allow of some reasonable control of the results
obtained. In addition it ought to be possible,
in cases that come up for an opinion as to the
advisability of thoracoplasty, when the ordinary
x-ray pictures give us no detailed iniformationi
about the condition of the lung, owing to dense
shadows, to demionstrate with lipiodol the pre-
sence, or absencee of cavitation and bronchiectasis.
One looks forward also to its use in differen-
tiating between localized pneumothorax and in-
trapulmuonary cavity, a distinction which is fre-
quently difficult to make. The problem of
annular shadows iay, in some measure, be
resolved by this method. These are a few of the
possibilities; others will doubtless appear with
increasing experience.
1002