Lynne Reid

Reduction in Bronchial Subdivision in Bronchiectasis

Bronchiectasis, as the derivation of the word implies, is the name given to any condition in which there is dilatation of one or more bronchi. Since it is clear that increase in the diameter of a bronchus may result from a variety of conditions, among them infections and massive collapse, the term describes an anatomical abnormality rather than a single disease. A wide range exists both in the form and degree of the dilatation and in its distribution among the bronchi. As the reason for the diversity is not clearly understood, it is not possible at present to make a satisfactory classification of the miscellaneous conditions which are all grouped together as bronchiectasis. In this, as in any other disease, accurate study of the pathological anatomy is an essential step in its elucidation. But, although the abnormal morphology of the dilated bronchi is the outstanding feature, it has been imperfectly described. During the examination of the large number of bronchograms and specimens seen in the routine work of a chest unit, it was noticed that the number of subdivisions of the bronchi between the hilum and the periphery of the lung differed from case to case, and was frequently much smaller than in the normal lung. It was decided to investigate this apparent reduction, and, in the event of its being demonstrated, to determine the fate of the missing subdivisions. This paper is a report on the findings.

Development of the Intrasegmental Bronchial Tree: the Pattern of Branching and Development of Cartilage at Various Stages of Intra-uterine Life

The purpose of this study is to establish the progress of branching of the intrasegmental part of the bronchial tree at different phases of intrauterine life and the relation to it of the development of bronchial cartilage. The importance of the topography of the pulmonary segments to both the surgeon and the clinician has led in recent years to the study of the growth of the segmental structures (Boyden, 1955), and, in order to establish that post-natally new branches of the bronchial tree appear, the most peripheral parts of the respiratory system have previously also been studied (e.g., Willson, 1928). But there is little published work describing the development of the region in between, i.e., the intrasegmental bronchi and bronchioli.

The secondary lobule in the adult human lung, with special reference to its appearance in bronchograms.

Anatomical descriptions of the peripheral part of the lung are varied and inconsistent. They are difficult to relate to bronchographic and radiographic appearances (Twining and Kerley, 1951 Fischer, 1953) or to morbid anatomy. The units in which the periphery has been described may broadly be grouped into two types. The smaller units, measured in millimetres, include those described as the acinus and the primary lobule, and the larger, measured in centimetres, has usually been known as the secondary lobule. To date, attempts to define the secondary lobule have been especially unsatisfactory and, although this paper is concerned primarily with this unit, some preliminary consideration must be given to the smaller units of which it is composed. This smaller unit is concerned with respiratory tissue lying beyond the bronchial tree (Fig. 1), i.e., the alveolar region of the lung.

Cyanosis with hepatic cirrhosis: A case with pulmonary arteriovenous shunting

A case is reported of cirrhosis of the liver associated with cyanosis and finger clubbing in a man of 31 years. The chest radiograph showed diffuse nodular shadows in both lower zones. Pulmonary function tests gave an arterial oxygen saturation of 91% at rest, falling to 68% on exercise; the single breath diffusing capacity for carbon monoxide was reduced to 55% of the predicted value and there was an estimated right-to-left shunt of 23%. Post-mortem injection of the lungs with Micropaque-gelatin suspension showed numerous pleural spider naevi, denser over the lower lobes, arteriovenous communications in the infrahilar regions, including leashes of dilated vessels in pleural adhesions on the diaphragm and diffuse arterial vasodilatation in the lungs; although the injection mass could be traced into the pulmonary veins in only a few regions of the lung, the dilated arterioles and spiders were possible additional channels through which blood might be shunted from the alveolar surfaces. The very low arterial oxygen saturation on exercise was probably caused by a shunt greater than the 23% estimated at rest, but the low diffusing capacity may have been partly responsible. The cause of the low diffusing capacity remains uncertain.

Observations on the Anatomy of the Intrasegmental Bronchial Tree

Millers (1947) detailed description of the pulmonary lobule remains a classic, and the work of Nelson (1932, 1934), Foster-Carter (1942), and Brock (1946) on the larger bronchi and their distribution has firmly established the bronchopulmonary segment as a concept which forms a basis for localization of lung disease. But the bronchial tree between the segmental bronchi and the respiratory bronchioles has received less attention than its due. No clear description of its arrangement has been made. An investigation, begun with the intention of studying the morbid anatomy of bronchiectasis, soon revealed the urgent need for further examination of this neglected region of the bronchial tree, because it is here that the dilatation of bronchiectasis occurs. The investigations described below were therefore carried out, and an attempt will be made in this paper to describe the intrasegmental bronchial tree and, on this basis, to give a method of localizing disease processes in this zone.

The connective tissue septa in the foetal human lung.

The adult human lung shows considerable variation in the arrangement and density of connective tissue septa (Reid, 1959). As various authors have considered that in the foetal lung the septa are better developed and more easily seen than in the adult (Sappey, 1874-85; Willson, 1928; Loosli and Potter, 1951), an examination of the foetal lung was undertaken to discover whether its septal pattern is the same as the adult, or whether the adult arrangement is the result of post-natal modification. Because of its smallness, the whole of the foetal lung can conveniently be examined, giving an idea of the total distribution of septa, which is described in this paper.

BRONCHIAL ATRESIA OF THE LEFT UPPER LOBE.

Mass miniature radiography has brought to light a number of unexpected, symptomless abnormalities of the lung, and one of these is bronchial atresia. It is a rare cause of a localized area of emphysema that is characterized by the presence of normally branching bronchi in the emphysematous area, but these bronchi arise from a sac which is blind on its proximal side. Three examples of this disorder have recently been described by Simon and Reid (1963), who could find only one earlier case, that of Belsey (1958), but the possibility that the condition may be more common will be discussed. Two additional cases are presented here ; the first, because it was possible to make detailed studies of the lung function and vascular arrangement in the anomaly; the second, because for the first time a presumptive diagnosis was made from the radiographic appearances.

Collapse of the lung associated with primary tuberculosis: a review of 51 cases.

In 1950, a review of 39 cases of collapse of the lung associated with primary pulmonary tuberculosis was published (Macpherson and Lutwyche, 1950). The present work is based on a further study of these patients, with the addition of 12 others. These 51 patients showed radiological evidence of segmental or lobar lesions suggesting a reduction in lung volume, and they were all selected from the 1,323 patients attending the Brompton Hospital contact clinics between 1932 and 1957 who had positive tuberculin tests. Those with pulmonary shadows without reduction in lung volume had been excluded. In 40, hilar glands were visible, indicating that tuberculous infection had taken place recently; in 11, glandular enlargement was not evident though the parenchymatous lesions still remained. In all the original 39 patients the pulmonary lesions had occurred during the early stage of a primary tuberculous infection and were usually associated with demonstrable hilar gland enlargement. Our additional ones include some in whom the acute stage had passed at the time the patient was first seen, and the pulmonary lesions had been present for several months. The original 39 have now been followed up for a further 10 years. Two patients could not be traced, in some it has been necessary to rely on postal inquiries, while the remainder have been followed up over a period from 1934 to the present time. The majority have been seen at regular intervals, varying from one and a half to 26 years, and 10 patients have attended over a period of 20 years, the average follow-up period being 12 years. Pathological interpretations have not been attempted from radiological or clinical observations, but pathological evidence is available from seven patients in whom the affected part of the lung was removed. The present work is not primarily a statistical study, since one is already in progress at the Brompton Hospital as part of a full review of all the children attending the hospitals childrens contact clinics between 1932 and 1953. The particular concern of this report is to follow the clinical course which our patlents have taken, so that some guide can be given in making a prognosis, and to consider how the findings should influence our treatment of these patients in the early stage of the disease.

Selection of Tissue for Microscopic Study from Lungs Injected with Radio-opaque Material

Choosing a suitable part of the lung by dissection distorts and often spoils the tissue for detailed histological study, especially when the peripheral part of the lung is concerned. These difficulties may be overcome by injecting the bronchial tree with radio-opaque material and choosing suitable areas from the abnormalities seen in a radiograph of the specimen. The parallax method is well suited for the localization of the appropriate bronchus in the depth of the lung, and its inclusion in a conveniently sized block without preliminary dissection. Trueta, Barclay, Daniel, Franklin, and Prichard (1947) give a critical survey of various injection solutions and techniques.