This study was made in an attempt to assemble ideas, to confirm
or refute the views of other writers and to suggest uncomplicated investigations
which are of diagnostic value in suspected cases of bronchial
carcinoma. Comparisons are made with bronchial adenoma and a group of
bronchiolar carcinomata is reviewed.
A special study was made of the effects of bronchial carcinoma
on the movements (28 cases) and contour (200 cases) of the barium -filled
oesophagus and 500 cases of bronchial carcinoma which came to operation
The main conclusions are:
(1) There is a surprisingly small proportion of females (1 :13) in
a group of bronchial carcinomata subjected to thoracotomy.
(2) Bronchial adenoma is 10-20 times less common than is often
(3) In spite of the right lung being larger than the left, an
operative series of cases of bronchial carcinoma contains more tumours
on the left than on the right side. Highest operability rates occur
in tumours of the left lower lobe and lingula.
(4) Epidermoid carcinoma accounts for two -thirds of cases which
come to operation and three- quarters of those which are resected.
(5) Very few cases of bronchial carcinoma were truly asymptomatic.
(6) Haemoptysis requires careful investigation but considerable
numbers of cases are seen in which no cause can be found. This symptom
suggests that a peripheral "coin" lesion in the lung is most likely to
(7) The presence or absence of pain bears no constant relation
to the extent of mediastinal spread from bronchial carcinoma.
(8) Finger-clubbing occurred in 20 of cases of bronchial carcinoma. Epidermoid carcinoma was 4 times as common as anaplastic tumour
in these cases and accordingly operability rates were slightly higher
in cases with clubbing than in those without it.
(9) Asymptomatic hypertrophie pulmonary osteoarthropathy was not
found in any of 100 cases of finger -clubbing due to bronchial carcinoma.
(10) Bronchoscopic biopsy provided a positive diagnosis in 57% of
cases of bronchial carcinoma and in 87% of bronchial adenomata. In
carcinoma, the highest incidence of positive findings at bronchoscopy
occurred in the right lower lobe (79%) and the lowest in the middle
(11) Lateral oesophageal shift with respiration is an easily
elicited sign of lower lobe or main bronchial stenosis.
(12) More than 1 out of every 4 cases of bronchial carcinoma referred
to a surgical clinic showed varying degrees of extrinsic pressure
on the oesophagus, most frequently seen in the P.A. and L.A.O. positions.
This is a highly reliable sign of inoperability and may be of
considerable diagnostic value when bronchoscopy is negative. In 68%
of cases showing oesophageal deformity the primary tumour was on the
right side and in the same proportion the histology of the lesion was
(13) Fifteen out of 24 bronchial carcinoma M.M.R. pick -ups were
inoperable. Only 4 were asymptomatic and 1 of these was inoperable.
(14) Common errors in x -ray interpretation are reviewed and
suggested remedies are: careful study of operative specimens, the
collection and continual review of all known radiological errors, and
the use of a series of test films to detect the "blind spots" of different
(15) Obstructive emphysema, unaccompanied by other radiological
abnormalities, is a rare sign of bronchial carcinoma and apparently
a very rare sign of early carcinoma.
(16) 11% of cases of bronchial carcinoma were of peripheral type;
76% of these were operable. Lobulation of outline, frequently visible
on plain films, was common but valueless in differential diagnosis.
(17) Cavitation in a peripheral carcinoma occurred in 6.2% of cases;
74,b of these were in the left lung and none occurred in a female. Ope-
rability rates were lower than in solid peripheral tumours. Different
mechanisms probably operate to produce cyst -like cavities in different
cases; only 3 out of 500 carcinomata showed this appearance.
(18) Unilateral engorgement of interlobular septa in a case of
bronchial carcinoma indicates inoperability.
(19) Carcinoma arose in the middle lobe in 3.8% and in the lingula
in 5% of cases; the latter were more frequently diagnosed by bronch-
oscopy than the former. Middle lobe carcinoma is less common than would
be expected from the size of the lobe itself but by no means as rare
as has been suggested by some writers. Bronchoscopy is frequently
negative in middle lobe carcinoma and evidence of oesophageal deformity
at barium swallow may suggest the correct diagnosis. No case of the
"middle lobe syndrome" was seen over the age of 35.
(20) 75% of 12 cases in which a benign lesion was misdiagnosed
as carcinoma occurred in the right upper lobe. Benign inflammatory
conditions not infrequently take several months to resolve. Full
radiological and clinical records of all cases wrongly diagnosed as
carcinoma should be kept for ready reference at any time. Knowledge
of the common sources of error should help to reduce misdiagnoses.
(21) Thin, watery sputum occurred in only 1 out of 7 cases of
bronchiolar carcinoma in which a satisfactory history was available.
This symptom may also occur in cases of metastatic disease which can
resemble bronchiolar carcinoma clinically, radiologically and even
histologically. A correct diagnosis of bronchiolar carcinoma cannot
be made from the radiological appearances when the lung lesion is
solitary; it may be possible when lung shadows are multiple and full
regard is given to the clinical picture. Bilateral disease is associated
with an extremely poor prognosis but if a lesion is unilateral, resection
may result in survival for several years.