Portraits of our lungs

Manoel de Abreu’s invention opened the door to early detection of TB

Men in line for the test

Images from the book O mestre das sombras – um raio X histórico de Manoel de AbreuMen in line for the testImages from the book O mestre das sombras – um raio X histórico de Manoel de Abreu

In 1922, Manoel Dias de Abreu returned from a seven-year stint as a physician in Paris to find Rio de Janeiro under attack by a dramatic epidemic of tuberculosis (TB). What he saw reinforced his belief that mass screening was the only way to control TB. The sick were arriving at hospitals in critical condition, at a point when treatment and isolation were useless in staving off imminent death. There was little Abreu could do right then, but he went back to developing a broad-use, low-cost technique for the early diagnosis of TB, an endeavor he had begun in France. In 1936 at Rio’s former Alemão Hospital, where Abreu was head of the radiology department, he employed a device of his own creation and finally obtained the first clear images that allowed him to see signs of TB not yet detected by other diagnostic techniques.

The first chest photofluorography, 1936

Images from the book O mestre das sombras – um raio X histórico de Manoel de AbreuThe first chest photofluorography, 1936Images from the book O mestre das sombras – um raio X histórico de Manoel de Abreu

Engineers from Casa Lohner, a subsidiary of Siemens in Rio de Janeiro, built the first devices, based on the doctor’s drawings—even though they did not think the invention was going to work. Conjoining the technologies of radiology and photography, his machine emitted an X-ray beam, which was radiated onto a screen, turning it fluorescent; visible to the naked eye, the resulting image was captured by a camera. “The image was recorded on 35mm film, which was much cheaper than the 30×40-cm film then popular in alternative processes, like radiography,” said journalist and historian Oldair de Oliveira in the book O mestre das sombras – Um raio X histórico de Manoel de Abreu (Master of shadows: a historical X-ray of Manoel de Abreu), published in 2012 by the São Paulo Society of Radiology. “Although the film was smaller in size, the image was fully effective for the purpose of diagnosis, with the simple aid of an X-ray viewer or magnifying glass.”

In 1939, the physicians in attendance at Brazil’s First National Conference on Tuberculosis voted unanimously to give the new method the official name “abreugraphy” in honor of its inventor, who had originally dubbed the technique “roentgenography.” More commonly known in English as chest photofluorography or mass miniature radiography, the method enabled the early diagnosis and treatment of people who had TB but were presenting no symptoms and could pass the illness on to others. This helped to contain the spread of the disease, which was effectively brought under control starting in the 1950s through the use of antibiotics. Brazilians over the age of 40 might still find an old chest photofluorograph of theirs lying forgotten in some drawer or among their parents’ personal documents, because for many decades the exam was mandatory for any child enrolling in school or anyone starting a new job.

Poster from one of the TB campaigns

Images from the book O mestre das sombras – um raio X histórico de Manoel de AbreuPoster from one of the TB campaignsImages from the book O mestre das sombras – um raio X histórico de Manoel de Abreu

Born in São Paulo in 1891, Abreu lived in Lisbon and Paris after graduating from the Rio de Janeiro School of Medicine. At New Mercy Hospital in Paris, he developed original techniques for taking photographs of surgical samples and, using recently discovered X-rays, identified a case of TB that had been missed during examinations by his superior, who was a much more experienced doctor. At another hospital, Abreu studied the radiology of the lungs in greater depth and devised a method for measuring different lung densities, called “densimetry”; it was also there that he first thought about photographing the fluorescent screen of the X-ray machine as a low-cost diagnostic technique. “Unfortunately, technical obstacles kept him from developing his chest photofluorographic method in 1919,” observes Rubens Bedrikow, professor at the School of Medical Sciences of the Santa Casa of São Paulo, in an article published in the Jornal de Radiologia (Journal of radiology). After building a safe machine, Abreu worked for the intensive application of the new method in the fight against TB. According to Bedrikow, the first apparatus, set up at a clinic in Rio, was used to examine 758 people in the first two weeks alone and detected pulmonary lesions in 44 of them.

Because the technique is simple and inexpensive and also makes it possible to identify signs of cancer and heart disease, it spread quickly and was adopted by public health agencies in Brazil and abroad. After its intensive use came under attack, limits were put on application of the method; in the late 1970s, it was dropped as a compulsory test for school enrollment and employment purposes. Abreu was the recipient of many tributes and was nominated for a Nobel three times; he also published poetry books, some illustrated by Brazilian artist Di Cavalcanti and others by the lung specialist himself. Ironically, he died of lung cancer in 1962. He was an inveterate smoker.