Localized bullous emphysema associated with pneumonia in children

LOCALIZED BULLOUS EMPHYSEMA

ASSOCIATED WITH

PNEUMONIA IN CHILDREN B.

BENJAMIN,

M.D., A~CD A. E. IVioNTI~I~AL~ Qum3Ec

CI-IILDE, M.D.

B O U T two decades ago, a n u m b e r of r e p o r t s a p p e a r e d in the literature dealing with the frequent occurrence of so~called " a n n u l a r " shadows in r o e n t g e n o g r a m s of chests of a d u l t patients: with p u l m o n a r y tuberculosis. Up to t h a t time, these h a d usually been diagnosed as "silent" intrapulmonary cavities, but it had become obvious thas this interpretation was incorrect. As far back as 1917, Fishberg I discussed the i m p o r t a n c e of differentiating b e t w e e n tuberculous cavities within the lung p a r e n c h y m a a n d abnormal, air-filled spaces within the thorax, which he considered were localized a n d i n t e r l o b a r pneumothoraces. A f e w y e a r s later, Sampson, Heise, and B r o w n 2 p o i n t e d out t h a i ann u l a r or ringlike shadows, v a r y i n g in shape, were seen in n o r m a l or mildly infiltrated lung fields in 50' (11.8 p e r cent) of 423 consecutive cases admitted to T r u d e a n Sa~lator~um. T h e y stated t h a i these shadows did not r e p r e s e n t i n t r a p u l m o n a r y cavities, b u t were due to i n t e r l o b a r or localized p n e u m o t h o r a c e s or h y d r o p n e u m o t h o r a c e s . A m b e r s o n 3 coneluded t h a t p l e u r a l a n n u l a r shadows were realities which h a d to be differentiated f r o m i n t r a p u l m o n a r y c a v i t y shadows. S e r g e n t 4 questioned the existence and, moreover, the f r e q u e n c y of so-ca]led " s i l e n t " cavities, unless a u t o p s y p r o o f could be obtained to s u b s t a n t i a t e their presence. The t r u e n a t u r e of the a b n o r m a l i t y which p r o d u c e d these " a n n u l a r " ' shadows b e g a n to be realized a f t e r Miller 5 published his results of a s t u d y of the h u m a n pleura p u l m o n a l i s in its relation to the blebs and b u l l a e of emphysema. He, described a bleb as a " s a b p l e u r a l e m p h y s e m a , " which f o r m s as a r e s u l t of the rupt~tre of the wall of an alveolus, allowing air to escape into the a r e o l a r l a y e r of the pleura. The air t h e n t r a c k s b e n e a t h the p l e u r a in a m a n n e r similar to the f o r m a t i o n of a dissecting a n e u r y s m along the wall of an artery. I t s extension m a y be a r r e s t e d where the septa, which m a r k out a s e c o n d a r y lobule, join the p l e u r a ; or it m a y e x t e n d over a n u m b e r of s e c o n d a r y lobules. I f the alveoli are di]aied a n d a t r o p h y and rupt u r e of the a l v e o l a r walls take place, a bulla is f o r m e d which comm u n i c a t e s with a bronchiole or a l a r g e r division of the bronchial tree. The bleb which b u l g e s on the surface of the lung in life is p r a c t i c a l l y e m p t i e d of its air w h e n respiratio~L ceases, a n d at necropsy, an a r e a of loose p l e u r a w h i c h slides freely over the lung m a r k s its location. The p l e u r a over a bulla is not movable, and the u n d e r l y i n g space gives l~rom the Department I-Iospital ~, M o n t r e a l .

o f P e d i a t r i c s , M c G i l l U n i v e r s i t y , a n d t h e C h i l d r e n ' s 1VIemorial 621

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the impression of an air-filled cavity. Miller w o n d e r e d if some of the " a n n u l a r s h a d o w s ' " a n d " s m a l l p n e u m o t h o r a c e s " ' m i g h t not be blebs. E x p e r i m e n t a l l y , Laurell 6 p r o d u c e d bullous e m p h y s e m a t o u s spaees by inflating excised calves" lung's and showed histologically t h a t there was a s u r r o u n d i n g zone of ateleetatie alveoli due to pressure of the air-filled space, which was seen as. a ringlike shadow in the roentgenogram, t I a y a s h i 7 and Fiseher-Wasels s called attention to the f o r m a t i o n of e m p h y s e m a t o u s spaces, which t h e y called valve-vesicles, as. a result of sear tissue due to a small localized i n f l a m m a t o r y process, p a r t i c u l a r l y tuberculosis, in the apices of the l u n g s in adults. K j a e r g a a r d 9 described a ease of simple e m p h y s e m a t o u s valve-vesicle w i t h o u t the presence of sear tissue, with r u p t u r e of the pleura causing spont a n e o u s p n e u m o t h o r a x in an a p p a r e n t l y h e a l t h y person. Jiiderbolm 1~ n o t e d the occurrence of bullous e m p h y s e m a at the base of the left l u n g in a b o y 18 y e a r s old, who h a d pneumonia, lV[iller 1~ f o u n d a i a r g e e m p h y s e m a t o u s bulla, which h a d been m i s t a k e n for a tuberculous c a v i t y in a negro man, 66 y e a r s old. F r e e d m a n ~2 observed five p a t i e n t s whose chest r o e n t g e n o g r a m s showed evidence of bullous e m p h y s e m a . Of f o u r who came to autopsy, in one an i n c o r r e c t diagnosis, of a tuberculous c a v i t y h a d been made. F o u r were adults, and one was a male infant, 7 weeks.old, whose lung's showed some ateleetasis and emphysema w i t h bleb f o r m a t i o n in the right, a p e x ; none of t h e m were associated w i t h pneumonia. Duken, la Vollmer, 14 K l e i n s e h m i d t ] 5 and Zarfl TM used the t e r m " p n e u m a t o e e l e " " to designate l a r g e intrathoraeie air-containing spaces in children. Peiree and Dirkse ~7 h a v e also e m p l o y e d this designation more r e c e n t l y f o r localized bullous e m p h y s e m a ; and they stress the. f a c t that. most so-called " c y s t i c " lesions of the lung are not congenital but acquired. Lereboullet, Lelong, and B e r n a r d ~s r e p o r t e d the presence, in the, chest r o e n t g e n o g r a m of a 4-month-old boy, reedvering f r o m bronehopneumonia, of an i n t r a p u l m o n a r y bullous e m p h y : sematous space which r e m a i n e d u n c h a n g e d f o r two and a half m o n t h s . I t then became p r o g r e s s i v e l y smaller until a m o n t h later it was. not discernible a n y more. U n d e r the h e a d i n g " a p n t r i d p u l m o n a r y n e c r o s i s , " KesseP 9 described the finding' of definite cavities in chest roentgenog r a m s of adults at the time of p n e u m o n i e resolution, w i t h o u t the production of symptoms. These decreased in size and d i s a p p e a r e d a t the end o f a b o u t two weeks. F i v e of the p a t i e n t s who showed w h a t was i n t e r p r e t e d as cavities recovered, b u t of three who came to a u t o p s y a n d showed anatomic and histologie evidence of a p u t r i d necrosis, no roentgenograms, were available. The r o e n t g e n o g r a p h i e r e p r o d u c t i o n s fit i.n v e r y well with the appearm~ee of localized bullous emphysema.. .In the p a s t .six y e a r s we fe.e~ we h a v e observed nineteen t y p i c a l instances in which localized e m p h y s e m a t o u s air spaces have been associated w i t h p n e u m o n i a in children. In most of these there was some

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degree of pleurisy, which was often quite localized in the region containing tile bullous emphysema. T w o of the children h a d empyema, a n d two others developed p n e u m o t h o r a x , resulting f r o m r u p t u r e of the p l e u r a over the bullous e m p h y s e m a t o u s space. The t y p i c a l a p p e a r a n c e of localized bullous e m p h y s e m a m the roentg e n o g r a m consists of a thin, r a t h e r s h a r p l y defined, smooth shadow, ahnost like a white pencil line, s u r r o u n d i n g an air-filled space of decreased density in which lung m a r k i n g s are diminished or absent, By m e a n s of stereoscopic, lateral, and oblique r o e n t g e n o g r a m s , one can d e m o n s t r a t e t h a t the e m p h y s e m a t o u s spaces in the lung are spheroid, ovoid, or loeulated. Occasionally t h e y contain a small a m o u n t of fluid and show a s t r a i g h t line fluid level in the u p r i g h t position, as occurred in Cases 4, 11, 13, 16 and 17. They do n o t persist b u t v a r y in size f r o m t i m e to time until t h e y disappear. The shortest period over which one was visible was seven days, and the longest, in a case now being followed in which the shadow has persisted, for 10 months. He is entirely well clinically (Case 15). I t has not been possible to follow one o t h e r p a t i e n t , but in the r e m a i n i n g seventeen, r o e n t g e n o g r a m s t a k e n at intervals show eventual complete clearing.

Fig.

I,

Fig.

Fig. 1.--Case 1, Aug. 31, 1932. There is a rounded area a thin dense m a r g i n in the right lower lung. This does there is very little infiltration in the surrounding lung. l~ig. 2.--Case 1, Aug. 31, 1932. Direct lateral view diminished density is spherical and situated posteriorly in

2.

of di}ninished density with not cbntain a n y fluid, and showing t h a t the area of the right lower lobe.

CASE. R~O.lgTS CASE I . - - M . G., male, 2 years old~ was iirst seen Aug. 15, 1932. There was a his~ to]'y of cough for a b o u t six weeks, more m a r k e d f o r the first two weeks, when it was accompanied b y fever. H e h a d lost his a p p e t i t e and h a d become weak. He was a poorly nourished, pale, and irritable boy. Physical examination showed pneumonia at the base of the r i g h t l u n g ; the pneumonia soo~ disappeared, and the boy was dis~ charged well Sept. 9,' 1932~ a f t e r be had been afebrile f o r three weeks, t i e remained well until Oct. 15, 1932, w h e n he developed pertussis, t i e recovered a f t e r t h e usual

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course b u t was readmitted Oct. 22, 1934, a f t e r he h a d been coughing and h a d had fever f o r f o u r days. There were signs of p n e u m o n i a involving the left lower lobe. The t e m p e r a t u r e dropped to n o r m a l b y crisis on Oct. 28, 1934, and he was well when last seen Nov. 16, 1934.

Fig. 3. Fig. 4. Fig. 3.--Case 1, Aug. 31, 1932. Right anterior oblique view, again demonstrating the t r a n s p a r e n t area and also the small associated pleural exudate. Fig. 4.--Case 1, Oct. 27, 1932. There has been some increase in size of the area of diminished density, although the child remained symptom-free. Note the absence of a fluid level and the complete clearing of the adjacent lung.

Fig.

5.--Case

1, Nov. 16, 1934. Follow-up roentgenogram, changes at the base of the right lung.

showing no residual

Roentgenolo,giv Ex~minat~o~.--On Aug. 15, 1932, there was consolidation involving the lower p o r t i o n of the r i g h t lung. Ten days later most of this had cleared, b u t there w a s a r o u n d e d area of diminished density 3.2 cm. in diameter, situated in the lower p o r t i o n of the right lung, reaching almost as f a r down as the dome of the d i a p h r a g m . The m a r g i n s of this area were clear-cut and thin. On Aug. 31, 1932, posteroanterlor, r i g h t and left oblique, and direct l a t e r a l films showed the area of diminished density to be the same in size as it was six days before and definitely proved t h a t it was spherical. I t was situated superficially in the posterior p o r t i o n of

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the lower lobe. There was also a small pleural exudate which reached a maximum w i d t h o f 4 ram. (Figs. 1, 2, and 3). By Oct. 27, 1932, t h e area h a d become larger and h a d a diameter of n e a r l y 4 cm. I t s m a r g i n s were even t h i n n e r t h a n before, and all t h e surrounding infiltration h a d disappeared ( F i g . 4). A t no t i m e did i t contain any fluid. On May 5, 1933, no abnormality could be found. On Oct. 28, 1934, there was consolidation involving t h e ]eft lower lobe. There was no evidence of a n area of diminished density in the r i g h t lung. This p n e u m o n i a h a d practically cleared b y Nov. ]6, 1934 (Fig. 5). CASE 2.--1%. tI., male, 7 years old, was a d m i t t e d J a n . 6, 1934. H e had been in the A l e x a n d r a H o s p i t a l since Nov. ]3, 1933, where he h a d pneumonia at the right base a n d developed fluid in t h e r i g h t side of the chest. On Dec. 10, 1933, 250 c.c. o f serous fluid were aspirated, and on Dee. 18, 1933, 8 e.e. of similar fluid were removed. :No organisms were found in smears or culture. On J a n . 5, 1934, thoracentesis yielded no fluid. There were diminished movement, diminished b r e a t h sounds, and increased vocal resonance over t h e lower half o~ the r i g h t side o f the chest. On J a n . 10, 1934, bronchoscopie examination showed some edema of t h e bronchus to the r i g h t lower lobe at its opening, b u t this h a d lessened b y J a n . 17, 1934. Smears o f a bronchoseopically aspirated specimen showed a few gram-positive cocci r e s e m b l i n g pneumoeoec% b u t no acid-fast organisms. A guinea pig inoculated with pleural fluid showed no tuberculosis. Stomach washings revealed no tubercle bacilli. The boy h a d slight f e v e r during the first week a f t e r admission, t h e highest recorded b e i n g 101 ~ F . H e was discharged a f t e r an u n e v e n t f u l recovery on A p r i l 30, 1934. M a n t o u x test (1:1,000) was positive.

Fig. 6. Fig. 7. Fig. 6.--Case 2, Jan. 6, 1934. There is a moderately large pleural exudate on the right side. An area of diminished density is visible in the right lower lung, close to the cardiac border. Fig. 7.--Case 2, "Jan. 6, 1934. Direet lateral view, showing the t r a n s p a r e n t area to be spherieal and situated posteriorly in the right lower lobe. It is emDty.

l~owtge~o,log~c Exa~inatio~.--On Jan. 6, 1934, t h e r e was right-sided pleural exudate reaching a w i d t h of 3 cm. in the lower lateral p o r t i o n of t h e chest. There was also infiltration in t h e lower portion of ~he r i g h t lung. I n t h e lower lobe adj a c e n t to the pleura there was an area of diminished d e n s i t y with a diameter of 2.8 cm. This Was visualized n o t only in the ordinary posteroanterior film, b u t also in t h e r i g h t a n d l e f t oblique and direct lateral films. This area did not contain any fluid (FigsJ~6 and 7). On J a n . 10, 1934, films a f t e r bronehoscopy and liplodol in-

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stillation showed the chest t o be essentially t,he: ~a~e, except that the area of diminished density was considerably ~maller .and.~hat .none of the lip[odol had~p~sed into it. On Jan. 17, 1934, it ~as very~.poorly: de.mareated, and by Jan. 26, .1fi34, it had disappeare.d. The pleurisy g~adually re_solved~ a n d it-had entirely disappeared b y March 3, 1934. The area of~ diminished density did :not reappear, and re~examination of the chest on April 7, 1937,~ showed i t to be-essentially normal. A small .calcified area in the right axilla was present w h o a he was first examined, and this probably accounted for the positive Mantoux test. CASE 3.--1VL S., femalej 10 years old, was first seen in the Outpatient Department July 26, 3937. She was a well-develolJed, slightly undernourished pale girl with a temperature of 101.8 ~ F. There were no at)normal physical s in the chest. Mantoux test (1:1,000) was positive. ~ o history of contact with tuberculosis could be established.

RoenCgenalogiv Examination.--On July 28, 1937~ the right root shadow was em larged and contained calcification, and there was infiltration at the r i g h t base. Opposite the fifth rib anteriorly there was a circular area of diminished density about 2 ern. in diameter wi~h comparatively thin, discrete margins. This did not contain any fluid. By Sept. 36, 1937, the a r e a o~ diminished density had completely disappeaxed~ and almost all the infiltration in the right lower lung had e]eared. There was still calcification ia and some enlargement of the right root shadow. On 1Y[ay 26, 1938~ there was no evidence of recurrence of the area of diminished density. CASE 4.--S. N., female, 9 years old, was admitted Nov. 23, 1937. She had become acutely ill five days previously with high fever and delirium followed b y cough: the next day and pain in the left side of the chest twenty-four hours before admission. She ,did not appear very ill, was fairly well developed~ but somewhat undel/hourished and pale. Examination showed dullness ~n the left lower posterior part of the chest. She ran a remittent fever up to 102.4 ~ F. for eight days after which the temperature remained normal. On Dec. 9, 1937, she was discharged.

Ro.entgenolog~c 2~.~aminati.on.--On Nov. 23, 1937, there was pneumonia in the left lower lobe. By ~7ov. 30, 1937~ the pneumonia had resolved considerably~ but there was an oval area of decreased (lensity in the lower portion of the ]eft lung, opposite the fifth interspace anteriorly. This had a diameter of 2.4 em. and contained a small quantity of fluid. I t was still visible the next day, when oblique films showed it to be situated posteriorly in the lower lobe. There was a small overlying pleurisy. On Dee. 8, 1937, it was still very faintly visible but quite indistinct, and most of the infiltration in the lower portion of the left lung had disappeared. On Aug. 5, 1938, the chest was entirely clear. CaSE 5.--M. ~.~ male, 2 years and 11 months old~ was admitted ~[arch 15~ 1933. ~ever and cough had been present for five days. He was very ill, delirious, and had marked dyspnea with expiratory grunting and movement of the alae nasi. The nutrition was good. There were signs of consolidation in the left upper l o b e . The fever subsided by lysis, the temperature reaching normal March 28, 1933. A slight cough persisted for another two weeks~ but he w a s otherwise welt and continued so throughout the remainder of his stay in the hospital, which lasted until May 22, 1933.

Rae~tgenologic 2~xa~n~natio~.--On March 16, 1933, there was an area o f consolidation in the left lung extending from near the apex downward almost as far as the base. This cleared slowly so that considerable increased density still remained fifteen days later. On April 6, 1933, there was a suggestion of a rounded area of diminished density with a ,diameter of about 2 cm. in the left lung, opposite the secopd rib anteriorly. A small pleural exudate was present on the left side. The infiltration i a the lung gradually diminished in extent, but the area o~ diminished density re-

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mained, undergoing some slight fluctuation in size. By J}fly. 3, 1933 , it was considerably more apparent, having a diameter of 3 era. with t h i n and discrete margins. I t did not contain any fluid. Tile final examination on Sept. 1, 1933~ showed complete disappearance of the area of dlminishad density and clearing of the lung. CASE 6 . - - J . J., male, 19 months old, was admitted Jan. 9~ 1934. t i e had been coughing for five days, and fever, dyspnea, and expiratory grunting had been present for three days. He was a well-developed, well-nourished boy who did not appear very ill. There were dullness9 diminished breath sounds, and moist r~les over the right lower postel'ior part of the chest. His temperature became no~mal b y Jan. 21, 1934, but a f t e r two days, it rose again because of bilateral o t i t i s media. He was discharged well on ~'eb. 19, 1934. ~oe~tgenolagic l~xaminatio~.--On Jan. 1O, 1934, there was consolidation involving the lower h a l f of the right lung. Ten days later this had resolved slightly. There appeared to be a tiny ~ ' h o l e " surrounded by increased density in the right lung, situated opposite the seventh rib posteriol~ly. This - t r a n s p a r e n t zone gradually increased in size, and by l%b. 1, 1934, the appearance suggeste,d t h a t two small ~ ' h o l e s " were present. These were again shown on Feb. 8, 1934, situated opposite the third and fourth interspaces anteriorly. The larger had a diameter of 1.7 cm. and was surrounded by a thin, discrete margin. The smMler was just below and had a diameter of 0.9 cm. Laterally there was a small pleural exudate. By April 30, 1934, the ' ~ h o l e s " had completely disappeared, and the chest was no longer abnormal excepting for a very tiny residual pleurisy. CAS~ 7.--C. G., female, 10 months o~ age, was ~dmitted Sept. 1~, 1937. There was a history of pneumonia at six months of age, which cleared uneventfully. She had been coughing and had had fever for three days. Examination showed pneumonia at the right base. The temperature dropped gradually, reaching normal Sept. 19, 1937. She was discharged well Oct. 12, 1937, but was readmltted Nov. 21, 1937, with a third attack of pneumonia involvilig the ]eft lower lobe. The fever subsided by crisis three days after admission, and she made the usual uneventful recovery. While in the hospital for gonoeoccM vaginitls, she developed pneumoni~ for the fourth time March 7, 1938. I t was on the right side. The temperature gradually subsided over a period of five days, and she made a good recovery~ Roe~tgeuolo,giv Exa~,inat~an,.--On Sept. 15, 1937~ there was consolidation in the lower portion of the right lung. A t that time the left base was quite clear. On Nov. 22, 1937, there was a pneumonia at the left base, and a circular area of diminished density, 8 ram. in diameter, was visible just lateral to the apex of the heart. By Nov. 30, 1937, the pneumonia of the left lower lobe ha~d cleared, and the area of diminished density had d~sappeared. On ~ a r . 7, 1938, consolidation was demonstrated at the r i g h t base, t h e ]eft base being clear. CASE 8.--J. G., female, 21~ years old, was admitted Oct. 26, 1934. She h a d been coughing and had had fever for five d a y s . She Was a we]l-deveIoped, well-n0tirished child, quite ill, with flushed eheeks~ harsh edugh/ and expiratory grunting. T h e r e were dullness, bronchial breathing, and moist r~les over the l e f t u p p e r lobe: The fever gradually subsided, and the temperature Was normal b y Oct: 30, 1934: S h e ]eft the hospital well Nov. 27, 1 9 3 4 . She was readmltted on J u n e 12, .1935, with pneumonia of the r i g h t u p p e r and lower lobes , which' resolved uneventfully, and she went home well J u n e 29, 1935. l~oentgenologic Examination.--Examination Oct. 27, 1934, revealed a n extensive left-sided pneumonia, extending from the apex almost to the base. By Nov. 9, 1934, this had undergone a good deal of clearing, but opposite the lower border of the third rib anteriorly on the left side, there was an area of diminished density measuring 1.3

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era. in width by 0.5 em. in height. There was also a small pleurai exudate in the lateral portion of the left side of the chest opposite the remaining consolidation. One week later there had been additional clearing of the pneumonia~ and the area of diminished density was not definitely visible. On Dec. 10~ 1934, the pneumonia had almost completely resolved, and there was no area of diminished density, l~oentgenograms in June, 1935, showed a right-sided pneumonia which migrated from the upper t~ the lower portion of the chest a~d cleared in the course of sixteen days. The left lung remained normal in appearance throughout this illness. CAsE 9.--G. A., ma]e~ 19 months old, was admitted Sept. 17, 1935. There had been cougl b fever, and g r u n t i n g respirations for five days. ~Ie was a large, well-nourished, pale child with some dyspnea. On admission there were no definite signs of consolidation in the chest. Ite was given a transfusion of 200 c.e. of blood Sept. 22, 1935. His temperature dropped to normal abruptly Sept. 26, 1935, and he was sent home well Oct. 4~ ]935. l~oentgeno~oyio Examinatio~.--On Sept. 18, 1935~ there was pneumonia involving the upper po{tlon of the left lung. This spread so that, b y Sept. 26, 1935~ it involved nearly all the l e f t lung, particularly its lower part. By Oct. 3, ]935, most of the pneumonia had resolved, but there was a rounded area of diminished density in the left lung opposite the t h i r d interspace anteriorly. This area had a diameter of approximately 1.2 cm., and its margins were thin, rounded, and discrete. Contact with the p a t i e n t was lost, so t h a t no further examinations were possible. C]SE ]0.--C. L., female, 11 months old, was admitted April 21, 1938. She had had an i n t e r m i t t e n t cough since her discharge from the hospital in ~qovember, 1937, when she suffered from an acute upper respiratory t r a c t infection. Four days prior to the second admission~ she developed a marke.d cough and refused some of her feedings; two days later, she began to have a high fever and became listless. She was fairly well developed, undernourished, and pale. The eardrums were reddened, and there was a purulent discharge from the right ear. The temperature ran an irregular febrile course due to complicating bilateral otitis media and mastoiditis. Bilateral mastoideetomy was performed ~ a y 27~ 1938. She was discharged cured July 4, 1938. t~oen,tgenoloy{o Ex~miuatio~.--On Nov. 3, 1937, there was nothing definitely abnormal except some increase of linear markings to the r i g h t base. On April 22, 1938, there was consolidation involving the right upper lobe. By l~ay 2, 1938, the upper medial portion of the right upper lobe was clearing, b u t considerable consolidation still remained. Four days later there was still consolidation in the upper lobe, and~ in addition %0 t h i s , there was a circular area of diminished ,density with a diameter of 0.8 era., situated opposite the first interspace and second rib anteriorly on the right side. On !Vfay 9, 1938, the consolidation had increased, but the area of diminished density was still visible in the same region. On 1V[ay 13, 1938, the diminished density h a d disappeared and i t did not reappear. The consolidation resolved gradually so t h a t b y J u n e 6, 1938, most of i t h a d cleared. A t i n y pleural exudate appeared in the right upper chest a f t e r the disappearance of the area of diminished density, but this never became at all large. CAS~ 11.--1~. B , female, 2 years old, was admitted April 16, 1938. She had entered t h e hospital three times previously, in November, 1936, 1Viareh, 1937, and J a n u ary, 1938~ with pneumonia which r a n a n uneventful course each time. She had had fever, cough, and occasional vomiting for three days and dyspnea, anorexia, and restlessness for 2 days. A mucopurulent discharge from the left ear was first noticed five days before admission. She was well developed and well nourished, acutely ill, very dyspneic, with rapid grunting respirations. She had an irregular fever up to

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101.6 ~ F. until May 22, ]938, with the exception of a period of ten days between April 20 a~d 30, 1938, when it remained normal. Postural drMnage twice daily for one hour from May 24 to May 28, ]938, yielded no sputum whatsoever. She was discharged well on July 8, 1938. Ro entge~oto~giv F~Xa~n.in.~ion.--On Nov. 3, 1936, bilateral bronchopneumonia was demonstrated. I n March, 1937, there was pneumonia on the left side, and in J a n u a r y , 1938, pneumonia at the right base. On April 19, 1938, infiltration was present at both bases. :By April 27, it had partially cleared. On May 4 there was a large area of consolidation in the left lung opposite the second, third, fourth, and fifth interspaces anteriorly. By May 13 consolidation involved nearly all the left lung, although its lower lateral portion was relatively clear. An area of diminished density was seen May 20, 1938, in the upper portion of the left lung, a~d a fluid level was visible within this area. The following day posteroanterior and right and left oblique films, as well as a film made with the patient lying on her r i g h t side, confirmed the presence of this area of diminished density and showed it to have a diameter of about 3 era. I t was more than half full of fluid and was surrounded by infiltration in the adjacent lung. On May 25, 1938, it was smaller and contained consi.derably less fluid, and the infiltration surrounding it was resolving. There was stilt an area of diminished density on May 31, ]938, and it was very faintly visible on June 10. I t had disappeared by June 18~ and by June 28, 1938, most of the infiltration had cleared. There was no evidence of recurrence. CASE 12.--1~. L., male, 8 months old, was admitted April 26, 1934. He h a d been well until five weeks previously when he began to cough; the coughing was followed occasionally by yellowish sputum. There had been fever for nine days and dyspnea, expiratory grunting, and anorexia for four days before admission. He was well developed, somewhat undernourished, slightly eyanosed, and b r e a t h i n g rapidly. There were slight dullness, diminished breath sounds, and moist rs over the right base posteriorly. He developed bilateral otitis media and chicken pox. On May 23, 1934, he showed signs of pneumonia involving the right upper lobe, and the temperature rose to 104 ~ 1~. This persisted until May 30, with a few temperature rises to 102.9 ~ F. a f t e r that. Postural drainage daily for three weeks yielded no sputum, and it was discontinued June 16. He was sent home in good condition June 29, 1934, although there was still some discharge from both ears. lloentgenologio Examination.--On April 27, 1934, there was a rather extensive consolidation involving most of the right lung except its upper portion. By ~Vfay 11 a large portion of it h a d disappeared. On May 25 there was dense consolidation in the right upper lobe, as well as some infiltration in the lower me,diM portion of the right lung. On J u n e 5, 1934, a large area of diminished density, 2 cm. in width and 3 cm. in height, had appeared i n the right upper lobe, opposite the first and second interspaees anteriorly. This was surrounded by infiltration. By J u n e 11 it had almost disappeared, but infiltration still remained, particularly in the l u n g above it. On June 20 there was still residual infiltration in the right upper lung but no definite urea of diminished density. Re-examination on Jan. 5, 1939, revealed no abnormality of either lung. CASE 13.--P. D., male, 2 years old, was admitted May 17, ]938. He had been coughing for ten days with fever up to 105 ~ F. for eight d~ys and had some epigastrie pain. He was fairly well developed and nourished, acutely ill, with flushed face, dyspnea, a~d hacking cough. The breath sounds were impaired over the left upper lobe. B y May 20, there was acute r i g h t purulent otitis media, necessitating myringotomy. On May 22, he was given a blood transfusion_ of 200 c.c. The temperature, which was high with slight remissions, dropped to normM abruptly on May 28. I t rose slightly on two occasions during the following week, and there

630

TttE JOURNAL OF PEDIATRICS

was intermittent fever up to ]02.4 ~ F. during the next week. Thereafter the temperature remained normal. On June 7, ]938, there was a slight cough but no sputum. On June 21 the chest had partially cleared, and the b o y w a s discharged, feeling )vell.

RoenttTenoloyiv Exa~i~t~at~on.--On admission there was consolidation ii~ the left upper lung, extending downwar,d as far as the third rib anteriorly. Four days later this consolidation had spread so t h a t it also involved the lower portion of the left side of s chest. On June 3, 1938 , posteroanterior, oblique, and direct lateral upright films, as well as a posteroanterior film with the patient lying on his right side, revealed the consolidation to be entirely in the upper lobe of the left lung, the lower lobe being clear. A cluster of four areas of diminished density was-demonstrated in the upper portion of the left upper lobe. None of these extended downwar.d beyond the second rib anteriorly/. They contained a moderate amount of fluid. They were still: present June 7, ]938, but not so apparent. Three days later, an area of diminished density, somewhat irregular in shape and containing a small amount of fluid, was Visible opposite the first rib and first inter'space anteriorly. Consolidation remained surrounding this area, but the lower portion of the chest had almost cleared. On June ]6, ]938, there was still a trace of this transparent area in the upper portion o f the ]ef~t lung. By July 4, 1938, there was a small amount of residual infiltration at the left apex, but no ,diminished density was visible. CASE ] 4 . - - R . B., male, 5 years old, was admitted June 6, 1938. He developed measles April 26, 1938 , and was allowed up nine days later. Cough, sore throat, headache, general malaise, sneezing, and a chill appeared oi1 that day, and he continued to b e i l l thereafter and consequently was sent to the Alexandra Hospital May ]6, ]938. The temperature on admission there was 105 ~ F.; the pulse rate, 140 per minute; and the respiratory rate, 30 per minute. He looked quite ill. His throat was slightly reddened, and the right base of the chest presented dullness, f a i n t breath sounds, and moist rhles. Ten cubic centimeters of clear straw~eolored fluid were aspirated from this region; from the fluid were isolated pneumococci which did not belong to Types I-VIII. The b o y ' s general condition improved and the fever gradually subsided, but the signs at the right base persisted. On May 31 the temperature rose to ]01.6 p 1~. and remained above normal with daily remissions for five ~]ays. The respiratory rate was 30. On June 6 aspiration yielded no fluid. I-Ie was then transferred to the Children's Memorial IIospitah l i e was pale and thin, weighing 39 pounds, b~t not acutely ill. There was a loose cough. The chest signs at the right base remained as previously noted, and on June ~4 thoracentesls was again performed, but no fluid was obtained. He improved a f t e r that and was discharged July 29, 1938.

I~ovntge~,ologiv J~xc~minc~tio~.--On June 7, 1938, posteroanterior and oblique films demonstrated a moderately large pleural exudate on the right side, situated mainly in the posteroinferior portion of the right pleura] cavity. There was also some infiltration in the lower portio~ of the right lower lobe. On June 13, 1938, there wes very little change. On June ]8 a rounded area of diminished density was visible in the right side of the chest, just lateral to the right root shadow. This was 1.5 cm. in ws and 2 cm. in height. I t contained little, i f any, fluid. Oblique examination showed it to be situated well posteriorly in the chest. Ten days later it had c]isappeared, and the increased density ]n the lower portion Of the right side of the chest had cleared considerably. On J u l y 8, ]938, there was still a t i n y residual pleural exudate on the right side, but no area of diminished density was visible. CASE ] 5 . - - N , R., malei 7 years old, was admitted May 10, ]938. He had typhoid fever and developed pneumonia during convalescence toward the end of July, ]938. He made an uneventful recovery.

BE;I~JA~IIN AND CHILD]E:

LOCALIZED BULLOUS E~[PIIYSE~IA

63]

l~oentgenologic Exa,mination.--On May 11, 1938, there was some slight general increase of linear markings throughout -both lungs. Ou J u l y 26, 1938, a large fanshaped area of infiltration was visible extending outward and upward from the region of the right root shadow. Opposite the second interspace and third rib auteriorly on the right side there was an area of diminished density, 2.5 cm. in diameter. This had a rather smooth, discrete margin and did not contain any fluid. The interlobar fissure between the right upper and middle lobes was superimposed on it. By Aug. 24, 1938, practically all the infiltration had disappeared, but %here was a very thinwalled area o f dhnlnished density lateral to the root shadow with a ,diameter of 3.2 cm. I t was again quite empty. This area was again demonstrated on Sept. 19, ]938, and at %he last examination, on May 8, 1939. CASE ] 6 . - - E . A., male~ 13 years old, was admitted Feb. 29~ 1936. I{e had been ill with fever, headache, chills, and pain in the back for four days. He was a welldeveloped, well-nourished boy, quite toxic, with Hushed cheeks. There was evidence of consols in the right side of the chest and a friction rub at the right base. He developed signs of fluid, and on Feb. 2~, 1936, right thorace~tesis yielded 75 e.c. of sanguinopurulent fluid from which a culture of Staphylo,oocc~s pyege~es was grown. On Feb. 27, 1936, 400 e.c. were aspirated from the right hemithorax. Closed drainage was instituted Feb. 28, 1936, and thoraeotomy with insertion of a drainage tube was performed March 5, ]936. The tube was removed April 4, 1936, and the boy was discharged well April 23~ 1936. Roe~tge~oIoyic Exa~uknc~t~on.--On Feb. 21, 1936, there was infiltration as the right base as well as a moderate-sized urea of pleurisy. There was also a rounded area of decreased density, 3 era. in diameter~ situated well posteriorly in the right lower lobe, opposite the ninth posterior rib and ninth posterior interspace. This contained a very small amount of fluid and was demonstrated in posteroanterior, direct lateral, and in right and left oblique films. I t was also shown iu a posteroanterior film taken with the patient lying on his left side. Three days later, a large amount of fluid had formed in the right pleural cavity, but the area of diminished density could still be faintly seen. Pleural fluid was aspirated but re-formed rapidly, and drainage was instituted. The urea of diminished density was seen in subsequent examinations through the fluid, and it remained empty. I~ was displaced medially when tiu~d accumulated in the pleural cavity. By March 9, ~[936, it had attained a diameter of 3.5 cm. and was quite rounded with a thin, discrete margin. I t was still presen~ March 20, but very much smaller and empty; by April 9 it had disappeared. On May 26, ]936, the lung was well re-expanded. There was no sign of any recurrence of the urea of diminished density in subsequent examinations of the chest. CASE ~7.--~. V,., female, 8 years old, was admitted]Dec. 7~ 1937. She had become acutely ill two. weeks ~.orevions]y with fever, cough, and some vomiting, and pneumonia was ,diagnosed. A f t e r a week the fever subsided but rose again a~d was accompanied . b y . p ~ i n ' i n the chest, a~d there was malaise ~hree days before admission. She was a thin, pale girl with marked dyspnea and appeared very toxic. There were signs of a large amount of fluid in the right hemithorax. Between Dee. 17, 1937, and' J / n . 3, 1938, 1400 5.c. o f fluid were removed from the. right p]eural cavity. Culture yielded Type V I I I pneumococci. On Jan. 4, 1938, closed drainage with two rubber tubes was established, and this proved adequate. On Feb. 16, 1938, the temperature, which had been more or less above normal since admission, rose t o 102 ~ F. and ran along up to 105 ~ F. until l~eb. 24, 1938. This was due to pneumonia of the l e f t lower lobe which r e s o l v e d satisfactorily. ICier course Was rather stormy during January and Felhruary, and she became quite emaciated bu~ began %0 stiow de'finite improvement about the middle of March.- There was no discharge from the=wound a f t e r April 15, 1938.

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T H E J O U R N A L OF PEJ)~ATYCICS

Eoentgenotoyiv ]~xazr~ina.tion.--On a d m i s s i o n t h e r e w a s a l a r g e collection os fluid in t h e r i g h t pleura1 cavity. T h i s was drained, b u t t h e r i g h t l u n g did n o t e x p a n d s a t i s f a c t o r i l y . On J a n . 10, 1938, t h e r e w a s no flui~d in t h e r i g h t p l e u r a l cavity, b u t a n a r e a of d i m i n i s h e d d e n s i t y was p r e s e n t in t h e p a r t i a l l y collapsed r i g h t lung, opposite t h e second i n t e r s p a c e anteriorly, close to t h e v e r t e b r a l column. T h i s p e r s i s t e d a n d soon became larger. I t w a s s h o w n i n several e x a m i n a t i o n s , a n d by J a n . 25, 1938, it c o n t a i n e d a s m a l l a m o u n t of fluid. I t t h e n h a d a d i a m e t e r of 3.5 cm., a n d t h e r e was also a smaller c e n t r a l a r e a os d i m i n i s h e d d e n s i t y a b o u t 1 cm. in d i a m e t e r , s u p e r i m p o s e d on t h e l a r g e r area. I n t h e n e x t six d a y s t h e y i n c r e a s e d in size a n d t h e n a l m o s t d i s a p p e a r e d , only to r e a p p e a r on Feb. 17, ]938. A t t h i s date, t h e y were e m p t y a n d h a d t h i n discrete m a r g i n s . T h e l a s t t i m e t h e r e w a s a n y t r a c e of these a r e a s of d i m i n i s h e d d e n s i t y w a s M a r c h ]8, ]938. E x a m i n a tions since t h e n h a v e s h o w n no recurrence. CASE ] 8 . - - T . L., female, 1 y e a r old, was first e x a m i n e d Dec. ]5, 1932. She h a d been p e r f e c t l y h e a l t h y up to t h e age of 9 m o n t h s , w h e n she weighed 27 p o u n d s . She ~hen b e c a m e ill, a n d a p h y s i c i a n who a t t e n d e d h e r f o r t e n d a y s d i a g n o s e d t h e c o n d i t i o n as p n e u m o n i a . She h ~ d some c o u g h a n d " n o i s y b r e a t h i n g " f r o m t i m e to t i m e a n d h a d lost weight. D u r i n g t h e p r e c e d i n g tw~ weeks t h e r e h a d been m o r e m a r k e d d y s p n e a a n d n i g h t sweats. She w a s a well-developed, poorly n o u r i s h e d (weight, 15 p o u n d s a n d 14 oz.), pale girl w i t h m o d e r a t e d y s p n e a a n d s l i g h t eyanosis.

Fig. 8.

Fig. 9.

Fig. 8 . - - C a s e 18, Dec. 15, 1932. There is a l a r g e right-sided p n e u m o t h o r a x . The a r e a of diminished density is scarcely visible in t h e illustration, a l t h o u g h it w a s s h o w n plainly in the original r o e n t g e n o g r a m . Fig. 9 . - - C a s e 18, Dee. 29, 1932. The positive p r e s s u r e in the right pleural c a v i t y h a s been relieved by the insertion of a needle, a n d t h e r i g h t lung is not as completely collapsed as formerly. The a r e a of diminished d e n s i t y is now distinctly visible in the central portion of the chest. The b r e a t h s o u n d s were d i m i n i s h e d on t h e r i g h t side, a ~ d the h e a r t w a s displaced to t h e left. B y Dec. 28, 1932, t h e d y s p n e a a n d cyanosis were m o r e m a r k e d . D u r i n g a n a t t e m p t e d m a n o m e t r i c r e a d i n g f r o m t h e r i g h t side o f the chest, t h e fluid i n t h e m a n o m e t e r w a s forced out i n a j e t 3 f e e t high. A b o u t 200 e.e. of air w a s withd r a w n b y syringe. She w a s t e m p o r a r i l y s o m e w h a t relieved b y allowing t h e air to escape i n t e r m i t t e n t l y u n d e r w a t e r t h r o u g h a cla~nped tube. A s she w a s g e t t i n g worse, a t h o r a c o t o m y w a s done J a n . 5, 1933, b u t t h e l u n g was n o t as well exposed as w a s p l a n n e d , o w i n g t o t h e c h i l d ' s poor condition. 2~ r u p t u r e d ballooned a r e a was f o u n d ; a n d a n a t t e m p t w a s m a d e to close t h e o p e n i n g in t h e p l e u r a b y a p u r s e - s t r i n g sutm'e, b u t air e m e r g e d t h r o u g h t h e needle holes. The t e m p e r a t u r e

BENJAMIN AND CHILD]~:

LOCALIZED BULLOUS EMPHYSEMA

633

ranged up to 103 ~ F. until Jan. 8, 1933, but subsequently it remained normM. She was definitely improving by Jan. 14, 1933, and on Jan. 31, she was discharged in good condition. She continued well until she was readmitted July 5, 1933, with bronchopneumonia. She had a remittent fever up to 105 ~ F. for telx days a~d made a good recovery.

Roentgenolog~a Exam~nc~tior Dec. 15, 1932, the heart and trachea were displaced to the left. There was an extremely large right-sided pneumothorax associated with marked collapse and compression of the righ~ lung. I~1 the central portion of the chest, an oval area of diminished density was visible with its longest diameter lying obliquely and measuring 4 cm. (Fig. 8). This was persistently present in many examinations (Fig. 9). A film made shortly after thorucotomy showed the area of ,diminished density a little smaller than before, but still present. By Jan. 25, 1933, there was evidence of some re-expansion of the right lung and considerably less cardiac displacement, but the area of diminished density was still visible. On May 5, 1933, the right lung had completely re-expanded and there was no longer any area of diminished density in the right side of the chest (Fig. 10). A rather large pneumonic area was shown on the left side on July 6, 1933, but no

Fig. 10.--Case 18, May 5. 1933. The Pneumothorax has disappeared, and there is no longer any demonstrable abnormality of the right lung. abnormality could be seen in the right lung. On Aug. 16, 1933~ the left side of the chest had almost cleared. At no time did any fluid develop in the right pleurM cavity despite the large pneumothorax, except for a very small amount following thoraeotomy. CASE 19.--E. L., male, 2 months old, was admitted June 8, 1936. He had failed to gain weight since birth, and diarrhea had been present for three days prior to admission. He was very poorly nourished (6 pounds, 13 ounces). There were no other physical findings. On proper feedings he gained weight for a few weeks, then begun to cough, and on July 16, 1936, rapidly became dyspneic, dehydrated, and cyanosed. There were a few moist rs in the right side of the chest. The following morning there were dullness and diminished b r e a t h sounds over the left upper lobe, and fine moist rs were scattered throughout the chest. Tim temperature was normal except for three occasions, when i t rose to between 100 ~ and 101 ~ F., and just before death on July 17, 1936, it reached 101.6 ~ F. Necropsy reveMed chronic bilateral interstitial and lipoid pneumonia, interstitial emphysema of the ]eft lung with ~ntrapleural bullae, rupture of an intrapleural bullu with massive ate]ectasis of the left lung, mild colitis:, and mild periportal hepatitis.

634

TI-IE J O U R N A L OF PEDIATRICS

Roentgenologiv Examination.--On J u l y 17, 1936, t h e h e a r t a n d m e d i a s t i n u m were displaced to t h e right. T h e r e was a l a r g e l e f t - s i d e d p n e u m o t h o r a x w i t h a b o u t 85 per cent collapse of the ]eft lung. -The r i g h t l u n g p r e s e n t e d conss h a z y increased density. T h e only p~rtions which were relatively clear were the extreme a p e x a n d its lower l a t e r a l portion. No definite a r e a s o f d i m i n i s h e d d e n s i t y were d e m o n s t r a t e d in either lung. CASE 2 0 . - - C . D., male, 6 m o n t h s old~ w a s a d m i t t e d Sept. 15, 1934. H e was a f u l l - t e r m infant~ w e i g h i n g 7 p o u n d s a n d 8 ounces at birth. T h e r e h a d b e e n a p u r u lent d i s c h a r g e f r o m t h e r i g h t e a r for six weeks. H e h a d b e g u n to r u n f e v e r A u g . 28, 1934. D i a r r h e a c o m m e n c e d five d a y s l a t e r a n d congh t h e n e x t day. The b r e a t h s o u n d s over t h e l e f t side of t h e chest were diminished. On Oct. 29, 1934, d i s t a n t b r o n c h i a l b r e a t h i n g a n d m o i s t rales were h e a r d over t h e ]eft h e m i t h o r a x . The i n f a n t died Nov. 5, 1934. N e c r o p s y showed a congenital cyst of t h e u p p e r lobe o f t h e l e f t lung, p r o b a b l y b r o n c h i a l in origin, chronic peribronehitis of t h e left l u n g , a n d mild a c u t e p e r i b r o n c h i t i s of t h e r i g h t lung.

Fig( Ii.

Fig. 12.

Fig. l l . - - C a s e 20, Sept. 4, 1934. A l a r g e a r e a of increased density is p r e s e n t in the upper portion of the left lung. There is d i s p l a c e m e n t of the h e a r t a n d t r a c h e a to t h e right. Fig. 1 2 . - - C a s e 20. Oct. 24, 1934. A n a r e a of diminished density occupies a l m o s t all the left side of the chest. A u t o p s y revealed a congenital cyst of the left upper lobe.

Roentge~otegi~ Exa,~dnc~ti.o,k--On Sept. 4, 1934, t h e r e w a s a l a r g e axea of increased d e n s i t y in t h e u p p e r p o r t i o n of t h e lef% lung. The h e a r t a n d t r a c h e a were s l i g h t l y displaced to t h e r i g h t ( F i g . :H). N i n e ,days l a t e r v e r y little c h a n g e h a d occurred. O n Sept. ]7, 1934, a n area o f d i m i n i s h e d d e n s i t y w i t h a d i a m e t e r of 1.5 era. h a d a p p e a r e d ~h t h e l e f t u p p e r lung. T h i s w a s s u r r o u n d e d b~/ increased d e n s i t y w h i c h also e x t e n d e d d o w n w a r d a n d obscured t h e l e f t bor,der of t h e h e a r t . The a r e a of d i m i n i s h e d d e n s i t y persisted, g r a d u a l l y i n c r e a s e d in size, a n d r e m a i n e d empty. B y Oct. 24~ :[934, it occupied n e a r l y all t h e l e f t side of t h e chest. A t t h i s t i m e t h e r e was p r a c t i c a l l y no cardiac d i s p l a c e m e n t ( F i g . 12). CASE 2 1 . - - T . W., male, Chinese, 2 m o n t h s o~d, w a s a d m i t t e d on Sept. 4~ 1934. t i e h a d b e e n c o u g h i n g , r e f u s i n g f e e d i n g s , losing w e i g h t , a n d v o m i t i n g occasionally f o r t h r e e weeks. I-Iis condition was poor~ a n d he w a s v e r y e m a c i a t e d a n d w e i g h e d 6 pounds. Ihe h ~ d a f r e q u e n t h a r s h cough. T h e r e s p i r a t i o n s were 40 p e r m i n u t e . T h e r e were l a g g i i a g of t h e r i g h t side o f t h e chest, dullness a n d i m p a i r e d b r e a t h s o u n d s over ~t h e r i g h t u p p e r p a r t a n t e r i o r l y a n d posteriorly, a n d coarse a n d sibilan~ r~les were hear~d at t h e r i g h t base i0osteriorly a n d in t h e a x i l l a . A s o f t ~ systolic

BENJAMIN

A N D CI-IILDE-:

LOCALIZED B U L L O U S t , ~ M P H Y S E M A

635

apical-murinur of the heart was present. On Sept. 6, 1934, he became cyanotic while taking his feeding and died soon after. A large tuberculous cavity, measuring 4 cm. in diameter, occupying the posterior two-thirds Of the upper lobe of the right ]ung, was found at autopsy. It contained air and pus and was connected with a small bronchus. Smears from the wall showed tubercle bacilli. There were bilateral ~cubercul0us bronehopneumonia, miliary tuberculosis, tuberculous pericarditis, pleural adhesions in the right pleural cavity, and a small left pleural effusion. ~oe~tgenoZog~e Examinatio~u--On Sept. 5, 1934, there was a cavity in the upper portion of the right side of the chest, measuring 4.5 era. in height, 3 era. in width, and 4.5 cm. anteropos'terior]y. This eontaine.d considerable fluid and was surrounded by dense lung tissue. It:did not have a thin, fine margin. There was also depression of the great fissure on-the right side: The trachea was very fractionally displaced to the ]eft, but there was-no cardiac displacement. There was mottling throughou~ the remainder of the lungs (Figs. 13 and 14).

l~ig. 13.

Fig.

14.

l~ig.> 13.--Case 21, Sept. 5, 1934. There is a very large cavity of the right lung, and this contains considerable fluid. There is also mottling throughout the remainder of the right lufig and the left lung. I~ig. 14,--Case 21, Sept. 5, 1934. Lateral view showing anteroposterior extent of the cavity and the depression of the great fissure of the right side. Autopsy showed a very large tuberculous cavity in the upper lobe of the right lung.

Cases I to 15 i n c l u s i v e r e p r e s e n t t y p i c a l u n c o m p l i c a t e d i n s t a n c e s of localized bullous e m p h y s e m a associated with p n e u m o n i a . I n general, these c h i l d r e n d i d n o t c o u g h a n y m o r e n o r w e r e t h e y s i e k e r t h a n the o r d i n a r y r u n of c h i l d r e n w i t h p n e u m o n i a : Cases 16 a n d 17 show the c o n d i t i o n c o m p l i c a t e d b y e m p y e m a . . I n : C a s e s 18 a n d 19 p n e u m o t h o r a x d e v e l o p e d as a r e s u l t of r u p t u r e of t h e p l e u r a o v e r t h e b u l l o u s e m p h y s e m a t o u s spaces. T h e ages of t h e c h i l d r e n r a n g e d f r o m :3 m o n t h s to 13 y e a r s . T h e r e were t e n boys a n d n i n e girls. None of t h e c h i l d r e n showed a n y clubb i n g of t h e fingers, a n d n 0 n e h a d a n y f o u l s p u t u m . U s u a l l y t h e r e w e r e no s i g n s or s y m p t o m s a s c r i b a b l e to the b u l l o u s e m p h y s e m a , a n d the

636

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t e m p e r a t u r e , pulse, respiration, and leucocyte count remained normal, unless some complication was present. The condition was recognized from the appearance of the roentgenogram. Case 20 is included to show a congenital air cyst of the h n g , p r o v e d at necropsy, in contrast to bullous emphysema; a a d Case 21, to illustrate a p r o v e d tuberculous cavity in the lung. DIFFERENTIAL

DIAGNOSIS

The characteristic picture is present when the surrounding lung field is c o m p a r a t i v e l y clear; b u t when t h e r e is infiltration a r o u n d the emp h y s e m a t o u s space, the decreased density is less m a r k e d and the contour is not as sharply defined, m a k i n g it v e r y difficult, or sometimes impossible, to rule out lung abscess. However, a more typical appearance results as the lung clears, and this is coincidental with clinical i m p r o v e m e n t and absence of p u r u l e n t sputum. It. may take a week or so to differentiate definitely between bu]lous emphysema and lung abscess, especially when fever and leucoeytosis persist, because of some infection such as otitis media, etc. I t is neither advisable, nor necessary in the m a j o r i t y of such children who are recovering f r o m recent pneumonia to inject lipiodol or p e r f o r m diagnostic p n e u m o t h o r a x . These emphysematous spaces can readily be shown to be actually within the, lung, and there is no evidence of a n y p u l m o n a r y collapse such as would be present with a localized p n e u m o t h o r a x . In true congenital air cyst, the wall is usually thicker and not so smooth, and one would not expect such complete rapid resolution. Occasionally, i t m a y be advisable to exclude diaphragmatic hernia by examination of the gastrointestinal t r a c t with barium. DISCUSSION

F r o m a clinical point of view one need h a r d l y maintain a distinction between emphysematous bullae and blebs ; in fact, the terms have often been interchanged. The distended air space m a y actually consist of more t h a n one bulla with r u p t u r e d or u n r u p t u r e d septa between them. I t would seem appropriate to group bul]ae and blebs together and r e f e r to them as localized bullous emphysema. It is unwise to use the term " c y s t " or " c y s t i c " in r e f e r r i n g to this condition, as this leads to confusion with true congenital p u l m o n a r y air cyst. The more frequent roentgenologie examinations of the chests of children with pneumonia which have been made in recent years, as well as the improved technique, p r o b a b l y account for the comparatively common finding of this condition. I t is interesting and possibly significant to note that no such instance has been found in a large n u m b e r of children with p r i m a r y p u l m o n a r y tuberculosis nor in m a n y with more advanced p u l m o n a r y tuberculous lesions who have been examined roentgenologically r e p e a t e d l y during the same n u m b e r of years.

B E N J A I ~ I l g AND C t t l L D E :

LOCALIZED BULLO,US, EMP H Y S EMA

637

Only two of the children in our series had positive tuberculin tests. Both of them were obviously suffering from pneumonia which resolved in the usual manner and showed no evidence of pulmonary tuberculosis. All of the children had negative Wassermann tests. Nothing to suggest localized bullous emphysema has been encountered in roentgenograms of the chests of healthy children. The most likely pitfall in the interpretation of the roentgenographie picture in bullous emphysema is to mistake it for lung abscess. Indeed, some. cases so diagnosed which have not exhibited the usual clinical features and which terminated ill what has been considered a "spontaneous cure,"" have doubtless represented instances of this condition. I t would also seem t hat many instances of so-called congenital solitary lung air cyst have been cases, of localized bullous emphysema. Thus, the report of Crosswell and King 2~ of an infant who had a balloonlike inflated space in the left lung which disappeared following injection of lipiodol and repeated aspirations of air, resembles one of our cases (Case 18) in many respects. Schenek 21 has included in his collection of 160 cases, of congenital cystic disease Of the lungs some which may well be localized bullous emphysema. Whereas this condition is fairly commonly associated with pneumonia in children, true congenital lung cyst is comparatively a very rare finding. Lederer 22 found none in 5,000 consecutive autopsies. At the Children's Memorial Hospital in Montreal, one (Case 20) has been observed in 903 autopsies in the last 9 years. We feel that the roentgenographie appearance which has been ascribed to so-called " a p u t r i d pulmonary necrosis" of the lung may really be that of localized bullous emphysema. The most probable explanation of the fomnation of localized bullous emphysema associated with pneumonia would seem to be plugging of a bronchiole with mucus or cxudate, producing an obstruction of ballvalve type. Air enters the surrounding lobule more readily than it can emerge from it. This. results in its dilatation, and kinking of the bronchiole may help to accentuate the obstruction. Rupture of the alveolar walls may occur, forming a large air pocket. Air may track subpleurally or intrapleurally, forming a voluminous balloonlike emphysematous space. If the pressure rises sufficiently the pleura may rupture, giving rise to pneumothorax, as occurred in Cases 18 and 19. Under these conditions even alarming symptoms of increasing intrathoracic tension, such as cough, dyspnea, and eyanosis may develop, as in Case 18, necessitating aspiration of air or surgical intervention. Ordinarily, however, localized bullous emphysema requires no treatment. One can only conjecture as to what happens when such emphysema disappears. Rupture into a contiguous lobule may occur, so th at t h e air escapes through a communicating patent bronchiole; or the ball-valve obstruction may be removed suddenly; or it may

638

'I~]-I]~ JOUIgNAL OF P ~ I A T t ~ I C S

.become gradually less and less. In the former instances the emphysematous space disappears abruptly; while in the latter, which is probably what usually takes place, it tends, to slowly reduce in size and eventually disappear. SUMMARY

Attention has been drawn to the condition of localized bullous emphysema associated with pneumonia, which has been practically overlooked, even in the more recently published pediatric textbooks. This is certainly common enough to w ar r ant a complete description" in' all volumes dealing with the diagnosis of diseases of the lung in infants and children. The term " c y s t " or " c y s t i c " should not be applied to this era> dition. In contrast, true congemtal pulmonary air cyst is encountered very rarely. It should be e~mphasized that all our cases ha.ve.b:e.en a.ssoeiated withpneumon~a and. frequently with some degree of pleu?~isy, often quite localized, in t h e a f f e c t e d ' r e g i o n . There may be an accompanying empyema or, i f rupture .of.the pleura occurs, pneumothora.x. We have not encountered it in children with puhnonary tuberculosis without pneumonia ; nor have we observed any such instance in roentgenograms, of normal children "s -chests. The characteristic roentgenotogic appearance of localized bullous emphysema consists of one o r more abnormal areas, of diminished density, surrounded by thin,-dense, smooth margins. These.are spheroid or ovoid in shape, and sometimes. ]oculated. They are easily' seen when the surrounding lung is comparatively clear; on t h e other hand, they may be merely suspected at first When infiltration is present in the contiguous lung, but t h e y become more :definite as this ct.ears in subsequent examinations. Their*location" is uSuMly subp]eural or intra.pleural. They may contain some fluid, but as a. :rule-only a small amount. The size, varies from very small, w h e ~ : t h e y may be hardly distinguishable, to volmninous bM10onlike spaces,. Which may occupy a large portion of one :lung~ Yar_iations. in: size occur from time to time until th ey .eve-ntualIy disappear. Usually this. takes place in a few weeks, but occasionally some months may elapse before the chest returns, to normal. This condition is not accompanied by any abnormal signs or symptomss unless enoi'mousinflation 'results:'or the ptem?a ruptures .with the formation of pneumothorax,.giving' ~is6 to evidence of in'creased intrathorn:tic pressure. The differential diagnosis between bullous emphysema and lung abscess, localized pneumothoI~ax, Congenital pulmonary air cyst, and diaphragmatic hernia is not difficult, if the course, of the case can be followed for' a Short time. No tr eatmen t is necessary unless complicating conditions ensue.

BEI~IJA~s

AND CtIILD]~:

L OCALIZE;D BULLO US, 15MPHu

639

I~EFF.~R~NGES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

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