Multiple Segmental Resection in the Treatment of Bronchiectasis

DISEASES

of the CHEST

XIII

VOLUME

NOVEMBER-DECEMBER,

Multiple

Segmental

Resection of

RICHARD REEVE

in

specialists most

especially

30

since and

is only that

In

only

1.8

his

years

the

fatal

years. and

indefinite

disease. of

caring

changes

ectasis

during

of

would

more that the

have past

to

who taken few

1947,

by

the

the

and

place

in

have

an the

drugs

In-

has

excisional

therapy. to form

with

suffer

longer

the

an An

has provided Furthermore,

faced

been

for

condition.

chronic

is

live

years

had on

succumbed

therefore,

patients

their

for

otherwise

was who,

went

antibiotic

need

found

death

bronchiectasis them

In

the

age

physicians,

assumption treatment.

reconverted

specialist,

of

change

have

to

many with

most

the

the

of symptoms

et a12 further

to

of this surgical

and

untreated having

beyond

diagnosis

patient

much

Putney

much

from

that

* om the Department of Surgery, New England Deaconess Hospital, the 13th Annual Meeting, American tic City, New Jersey, June 6, 1947. Copyright,

development

and

who

now

live

Bradshaw,

the

very

decreased

chest

for

disease. The

that

Bradshaw,

the

a surprise

assumed

than are

The

as

chemotherapy

patients

exacerbations

cases.

is a disease Many reports,

of bronchiectasis the average patients

not

duration

came

the fallacy perfection

of

do

fatal

without

rather

and

after

the

recognized

the

introduction creased

the

cases

downs,” of

to

King,7

childhood

This

time

appreciation impetus

and

bronchiectasis by surgery.

the seriousness shown that on

expectancy in

they

“ups

Many

life

13.5

although

Perry

early

that

Treatment

Massachusetts

recognize that best treated

Is

emphasized They have

symptoms of

now of

the

6

H. OVERHOLT, M.D., F.C.C.P.,5 H. BETTS, M.D., F.C.C.P.5 and FRANCIS M. WOODS, M.D.

cases

those

Clerf,2 have by excision.

in

NUMBER

Bronchiectasis

Boston, Chest which

1947

surgery

acute of

a

with of

the

problem the

bronchi-

outstanding.

There

Tufts College Medical School, and the Boston, Massachusetts. Presented at College of Chest Physicians, Atlan-

American

College

of

Chest

Physicians.

583 One

OPAW-7NF

-TBX9

584

OVERHOLT,

is

little

resemblance

of

pulmonary

crude

between

tissue

lobectomy

as by

AND

BETTS

the

carried

the

WOODS

precise out

dissection

today

tourniquet

and

method

two-stage Postoperative

operation

stead one

of being expected

common a few days

sequelae are rarely to a week of rather

and

critical

illness.

for ment

further of this

answer the

which

been

superceded no

of

however, by

to

a lobar disease. the frequency lobe that

is involved frequently

disease

pulmonary bronchiectasis,6 was

an

was

found

the

in the

when

and Deterling4 may involve method for

sizable

lobe.

our own it was found involved.

be

involvement

are

Roentgenography

appreciation all

of

bronchopulmonary

the

of

a lung.

The

(100 Such

with

previously that in In

the

its

application

disease. is not

have segment the

called of

necessarily

attention the left

to upper

They also pointed out lower lobe is free of Blades,1

and

Clagett

that bronchiectasis a clamp and suture magnitude than

reported only 15 per

experience cent of the

majority

cases

In

over)

figures,

well-localized

in

unilateral

of

or

of

approximately

the

a

with cases disease

30

per

cent

of

accurate

bilateral.

and localization. taken

or

cent.

involved.

multi-segmental. was

treatwhich developed

cases

bronchiectasis

bronchiectasis. segment

segments

lobe to

factors prospects

resection

of

limited

and Belsey3 the lingular

In

be

1 per cases

been from

that

Segmental

of

as

have also emphasized the fact only segments and have described removing portions of lung of less

entire

pulmonary roentgenograms

low

suffering

cases of superior

basal

the

for lobe

groups

as has

however,

Churchill with which

are

benign,

the

a technique

uncomplicated

patients

Formerly prostration are

mortality pulmonary

treatment

known,

of in-

dissecting the hilum of the lobe, now has proved to be highly successful. to a 3 or 4 per cent mortality have of

to

past.

periods empyema

in the surgical and developments

that

a mortality

surgical

large

is well

others

or

years

is short,

What What

acceptable

excision,-a

mainly

since

and It

by

apply

an

excision

presented.

essential

used in practice, reduction

mortality

course

refinement experiences

be

was in

dissection technique in almost universal First reports of a

disease

will it

units

with

and

result

simplest

postoperative

Recent

questions

beginning would

the

these

improvement disease?

these

In

the

few

encountered. profound

very uncomfortable. gratifying changes?

1947

comparatively

a

the prolonged fistulae and

bronchial

Now not

and

and

the of

Gone is the hospitalization.

and, surprisingly, responsible for

Nov-Dec.,

Localization

bronchography The value in various

necessity

for segments

are

the

of fluoroscopy projections complete is of

basis is

and well

a study known.

bronchographic more

recent

of An study

development.

Volume

MULTIPLE

XIII

For

the

bronchiectasis

cannot of

be

all

segmental

segments a preferable material be

will under

may

the

oblique

the

bronchi A number

for and

not plan

is

and

be

filled

mapped

out

projections

each

chosen lungs

and prevents of acceptable

lobe

lung to do

is homologous

pattern left

their differ

not of

the

result

posterior) The

two

to

opaque

as

frequently

of

same

taken.

The

if

medium some

their systems

position

the

the

segments

of

of thereby than definition,

BI?oNci.o’

any to lobal

lower

discuss area. more

newer more With

detailed

N

Jackson segments

lobe.

We

right of the

the

lobes upper

systems

10. Post

8. Ant.

study

of

and

nomen-

EN

CLATU

E

1 2,.

‘ior

pup. Inf.

Basal----

-

Med

3.

}

Lin u1a

r0t.B

Basal---.

a

appraisal

SEGMENTB OPdI

Anterior

Basal 7

the

accurately anatomithe availability of

4. Lateroi 9. Lot.

the

(antero-medlal).

2.

Medial--

in on

(apico-

-ApkalPost.

3.

have

and left left upper

changes

lower of

lobe

these

PULMaN’ g y -

and

segments

the of

The

Other

upper

of two

in

images. of nomenclature

within

lobe.

left

both

separates

have been devised. bronchopulmonary

middle

right in

of

position

to

the

bronchi roentgenograms

oblique of

segments ten basic their

The time

(Figure 1). lingular segment

ability of less

JAc,oN

condition

the

nomenclature greatly. The

advantage

method

treatment

the

injecting

certainty.

the

a combining

and main

clature is the cal divisions precise

the

segments

from

of

of

sufficient

overlapping arid workable

according use

not

with at

are

the bronchopulmonary Huber5 have named

of

plan

knowledge

fill adequately by such a method. We believe is to do the actual injection of the contrast fluoroscopic control in order that the segments

visualized

lungs

Simply

patient

585

intelligent

accurate

bronchi. the

RESECTION

an

without

positioning

can

patient,

outlined

the

and

SEGMENTAL

-Post

+ 5.

9. Basal

10.

kiIBc*sal-E.AnterIor Med. 7 B . Superior.-) Superior’ 6. FIGURE 1: Diagram of the 18 bronchopulmonary segments and their names suggested by Jackson and Huber. This nomenclature is based upon the position of the segment within each lobe. On the left side there are eight instead of ten segments. The left apical and posterior segments have a common trunk. Likewise the anterior and medial basal segments are best considered as one surgical unit because of a common origin of their segmental bronchi.

OVERHOLT,

586 of disease for

processes

some

time

quently

has that

situated

(superior (anterior appreciates areas.

with

the

from

the

a

lower

WOODS

It has

been

Nov-Dec.,

generally

abscesses,

upper

patient

patient

is

of the anterior in

the

naso-pharynx into

for

posterior

lobes,

frequently the

left

part

supine

1947

appreciated

instance, of

are

the

position,

is directly bronchus

decubitus

fre-

lower

lobe

shows often

by a are

than

the

of

superior

dependent. of the upper

position.

segments

areas involved

more

the

other

dependent likewise

Most

in

lower lobe segmental

lateral or

these

Bronchiectasis ments.

the

AND

segment) or in the anterior portion of the upper lobe segment). The explanation for this is obvious when one the anatomy of the segmental bronchi supplying these When

way

resulted.

pulmonary

in

divisional bronchus same is true of the

its

BETTS

the

The lobe

Thus

material

lung

will

find

gravity.

predilection

for

the

basal

the

right.6

I IGHT

certain

segments Quite

segof

the

commonly

LEFT

A.

B.

SEGMENTS

FREQUENTLY N VOLVE D

C.

AFTER

CONTRACTION

FIGURE 2: Diagrams of the lateral surface of the lungs with surface area of the segments outlined. The stippled areas of Diagrams “A” and “B” indicate those segments most frequently involved in bilateral bronchiectasis. Diagrams “C” and “D” show relative areas after the diseased segments have contracted and the healthy segments have enlarged. If the disease originated during the developmental period, the enlargement of the healthy segments is accomplished by true growth or hypertrophy. If the volume change comes later in life, the uninvolved segments enlarge by simple over-expansion (emphysema).

xm

Volume

MULTIPLE

the lingular by itself but left

lower

lobe.

generally and the of the ciated

portion usually

lung with,

instance,

the or one

perior

the that

lobe

right is, (Figure

side the 2).

occasionally of

the

sees lower

lobe is affected, occasionally with the basal segment of the

homologous

basal Only

segment rarely

areas of are

are

the lower lobe other portions

limited

following

the most

changes except whefi infectious processes.

bronchiectasis

lobe

587

RESECTION

seat of bronchiectatic as sequelae of, preceding

division

same

of the left upper In conjunction

On

involved, middle

SEGMENTAL

a lung

to

assoFor the

abscess

in

suthe

location.

The than others

knowledge

that

bronchiectasis

lobar, In Its distribution in the pulmonary

POST

is

stimulated segment as

usually

segmental,

our interest a possible unit

rather and that of excision.

of

LOB CTOMY

5

SEG.

1(3t2)

POST

SEG.

REC.

7 SEG.

(4.3)

-;

r

9

1

#{149}

i-I

, -..

:

‘,-

#{149} I’

FIGURE 3: Diagrams of the lateral surface of the lungs with the segmental surface areas outlined. Diagrams “A” and “B” show small remaining areas if lobes are used as the units of excision in bilateral bronchiectasis. See Figure 2 for illustration of the most common distribution of bilateral disease. Diagrams “C” and “D” show relative areas conserved by using the segment as the unit of excision in bilateral disease.

OVERHOLT,

588 Much

credit

to Clagett for their segmental eradicate If this

should

go

to

Churchill

and Deterling4 contributions

in

for the

resection. all goal

BETTS

One

of

AND

WOODS

and

Belsey,3

their concept development

the

goals

the disease without is to be approached in

in

Nov-Dec.,

to

of of

the the

excisional

sacrificing bronchiectasis,

any

1947

Blades,’

and

problem technique

and of

therapy normal segments

is

to

tissue. rather

A.

PRE-OP.

PATH. EMPHYSEMA

LESS EMPHYSEMA $P4

2

SEG’S.

.

3 SEG’S.

FIGURE 4: Diagrams of the lateral surface of the left lung illustrating the advantage of employing the segment rather than the lobe In bronchiectasls in adults. Diagram “A” shows the relative size of the segments in a case of bronch.tectasls of the lingular and basal segments. The three remaining healthy segments have hypertrophied because the patient developed bronchiectasis early in childhood. As the disease contracted the involved segments, the upper segments of each lobe grew to form abnormally large segments. If surgical treatment Is carried out after puberty, any further expansion will take place by a process of simple over-stretching. Diagram “B” shows the over-expansion of the remaining two segments if the entire lower lobe Is removed together with the lingula. The resulting emphysema may be pathological. Diagram “C” shows the lateral surface of the left lung after segmental resection for basal and lingular bronchiectasls. The previously hypertrophled superior segment of the lower lobe has been preserved. Its presence greatly lessens the need of the remaining two segments of the upper lobe of undergoing over-expansion.

Volume

XIII

than more, a

lobes the

become conservation

necessity

in

disease of

SEGMENTAL

MULTIPLE

excisional units of all healthy

treating

(Figures

the

the

many

3 and

patient

4).

following

middle lobe, incapacitating

and as

seems

penicillin postoperative Penicillin

little

creases

the

amount

both

of the disease

Furtherbecomes

extensive

bilateral insufficiency

lower

lobes,

left upper itself.

the

may

be

right just

as

Preparation

doubt

pre-operatively course. Its aerosol and/or

cases. tissue

pulmonary

of

lingula original

Pre-operative There

with

marked

removal

the the

for most pulmonary

patients

The

589

RESECTION

but

that

the

use

of

the

antibiotic

has contributed to a safer, smoother use after operation is likewise important. penicillin intramuscularly effectively de-

of

expectoration

and

liquefies

the

material,

thus permitting easier and more effective expectoration. These procedures, together with postural drainage, allow the patient to go through operation with a decreased hazard of postoperative .

atelectasis

or

pneumonitis

from

dissemination

of

the

bronchial

secretions. Position The

contralateral

been

spill-over

recognized

upon

in

in been three

as

the

the

side

and

face,

body,

the

thus

without

has

the

been

is

tinum,

very of

not

there

than

flow

toward

resection

appears

the

to

be

in

is placed

positioning

the

of

lying

on

weight less

of tendency

has

remainder

the

of

patient’s that

of

occurs

the

side heart

to

position, cases,

bronchiectasis

bronchial to withstand the

the

mouth

face-down in tuberculous cases

volume appear

when by

patient

contamination

large position

has

is operated

surgery for the past the pelvis, shoulders,

position. This for resection

for

encumbered

the

by

lower

contralateral

the side originally

than

risk

operation

patient

operative

intrathoracic suspended

kept

beneficial

the

this new

to

to in

better

secretion. an as

the

and

open good

medias-

mediastinal

shift

respiration.

We

also

tracheal the

active

believe intubation

use

and reflex to

be

the frequently in the prone

and

with

can

tendency

pneumothorax lung

of

types patient

secretions

patient developed

because Patients

all the

during

when

obviate This

causing

with the although

To

position.

head

secretions

hazard

position.

for With

Operation

of

a distinct

face-down employed years.6

During

of a general

lessens is not

the

use

under

of

cocaine

anesthetic,

postoperative completely

immediately

cooperate.

that

anesthesia

topical

anesthesia,

promotes

pulmonary Inhibited

afterwards

procaine

for

a smoother

during the

complications. operation

patient

with

endo-

rather

than

convalescence The cough and becomes

is conscious

enough

590

OVERHOLT,

BET S

Technique Each

bronchopulmonary

blood through

supply, the

channels to in

along

After

been

the

ligated

and

to

separate

section

the

stands

out

the

only separated divided

We

prefer are

do

made

little to

been

the

step

intersegmental

last

The for

a

avoided

found

to the

in

not

after

care

similar

to that

toward

the

following

pulmonary

left

both

the

maintenance

remaining are

of

in

are

tive

pressure

are

usually

there

is

become

the of

4 to

lobectomy. airway

is necessary of leakage

of

Oxygen

is not

a rule

72

lung

the tube to remain air from the pulmonary ordinarily

two

required

Either

attempt is as it has

unwise.

Suturing its

volume.

one

anteriorly-and moderate

after that

In

if there surface.

postoperatively,

the

nega-

drainage

operation

the

expanded. longer

of catheters

with The

is

is directed

intrapleural

water.

hours

resection

re-expansion

and of

evidence the

pad the

on

impossible

Attention

drainage

8 centimeters

and

is

reduces

and

posteriorly

roentgenographic obliterated for

a free

to

may

plane.

segmental

of

48

seg-

Care

under-water

withdrawn

to

the

cottonoid clamps It

but

following

As

to

segment

a moist use of

and

a routine

chest-one to

until

remaining

tissue

patient

tissue.

connected

needs

This may afterward. difficult

line

intersegmental

Postoperative The

After divided,

that

occasionally

unnecessary

remaining

com-

is done

been

pleura. lobe or

hazardous.

the

is

forefinger. have

after The

by then

lobe

together

the

Before

will then be excised. No of the remaining segment

only

normal

the

and

pleural of

dis-

inflated

plane

of

visceral of the

considered

precisely

be

The

is

have

blunt

demarcation

segment

it

surface

or too much tissue suture over the edges

traumatizes

as

used seg-

segment

are of

thumb the

as

segments.

splitting

usually stops few moments. and

clamps

line

is the splitting

the

a

Is possible

gentle

normal

segments

dissection actual

this

to

segments

the to

1947

arterial

It

by

separation.

this

but

is the

the

actual

vein

holding sharp the

vein

The

by

and

separated.

tissue place

from

mainly

by before

to

normal

the

-Dec.,

penetrate The venous

segments.

possible

facilitates

bronchus,

and artery segments.

ligation technique, the bronchopulmonary

and

the

and

structure

bubble slightly, has been applied

own

the

pressure.

artery,

to

its

of

then

diseased

and

define

ments

is

started,

clearly

accurately

too

it

dissection

be be

to

bronchus,

is

bronchus,

lung

artery, divided,

avascular,

blunt

the

surface

intrabronchial

paratively by

the

the

separation

raising

has

principles of individual and pneumonectomy,

Nov.

Resection

venous return. Bronchus into the substance of the

return

ments.

Segmental

segment

and hilum

apply the lobectomy

this

of

WOODS

AND

tubes provided

pleural

space

some

instances

is still It

has it

evidence is felt

that

xm

Volume

in the

absence

ing

that

that

it

to

MULTIPLE

of definite

takes

place

and

quently.

more raise

Any

course

is

and

rapid

evidence

largely

prompt,

complete

the

retained

on

or

urged fre-

atelectasis

aspiration uneventful

An

in

are

is changed

calls

or the more postoperative

maintenance

pulmonary

breath-

advantageous

position

secretions

the

deeper

is

Patients

their

tracheo-bronchial bronchoscopy.

dependent

use,

re-expansion. and

of

its

atmosp#{241}ere

voluntarily,

for prompt transnasal positive removal by

for

a normal

591

RESECTION

indication in

encourages

cough

SEGMENTAL

of

a free

airway

expansion. Results

The

technique

segments is

of

limited

two

to

or

the

patients

ferable

as

resection

various

with or

has

and

in

one

or

and

involvement,

conservation

of

all

report,

was

bilateral

healthy

segments

segments,

of

were

employed

may

pulmonary

For

the

be

pre-

still tissue

so only

disease.

lobectomy

all

however,

whom

more

resection

multi-segmental

to

applied

This

bronchiectasis segmental

unhlobar

been

conditions.

a lobe

beginning

with with

for

lobes,

In

patient

segmental

lobes

patients

more

removed. in

of all

is

not

as

imperative. In have

our series of been treated

patients by one

as we believe at multilobar disease, that

have Figure

We

had

segments

the

found

it

of

lower

the

as a single unit. but in bronchiectasis are commonly require their

all

the

the

cases

the most improved have The

as

yet

preponderance

the

various

the

left

to remove left and

in

of

4 on

individual four right

1 and

basal

the

basal basal

right)

segments, segments

the

second

healthy

the

number

of

or

excised,

is

pa-

two factors. First, requiring bilateral more

may

disease but

it

these from

three

to

bilateral

Second,

other

2 in

6 months with

Some of symptoms

resections

the

is due processes

3 to

included.

of

and

the

and

lesions

warranted

side

removed. all

removed Figures

side first. minimal

remove

the basal group will usually bilateral case the individual

patients

been

segments

to

therefore In one

of operations have bilateral

contralateral

involved that the

not

is possible all three

Twelve have

of 53 cases Inasmuch

is primarily indicated confined to the 39 patients

practical

(3 on

a period

stages. had

lobes

number patients

Often

between

of

more

between

and the of these

operations.

location

usually

segment was were preserved.

discrepancy

tients many

procedure has been

a total resections.

resection.

involved and group removal.

posterior basal basal segments The

It

with bronchiectasis, more segmental

the report

multilobar

5 shows

have

yet

present this

or

for our

elapse

have

not

completeness practice

to

do

patients are so greatly the #{224}ontralateral side

operation. of

the

basal

segments

of

the

592

OVERHOLT,

left

lower

due

to

group,

to

when

the

our

the

sides.

thus

and

As

weight

practice

mentioned figures

patients they

disease

are

treated

of most functioning

in

by

There

was

elsewhere.

one The

fatal death

the

left

is side the

bilateral

operations

than

trilobar

as

lobe

multilobar between

uncompleted

bilateral

better

bi or

is practically pulmonary

on

1947

cases

group.

had

strikingly

upper our

distributed

the

this

have

left in

operating

equally

before,

the

frequent

generally

about

Nov.-Dec.,

WOODS

of

most

of is

AND

segments

being

lesion

the

Fourteen a group

lingular

combinatiOn

and

first two

lobe this

BETTS

the

resection.

good as parenchyma

case

in

was

not

The

before has

the

39.

with

to

As

bilateral

pulmonary

reserve

operation as no been sacrificed.

This

related

completed.

patients

one

has

the

type

normal-

been

reported

of

resection

performed. Morbidity ened on occasional

and the

also to a desire longer than the lieve result

the

hospitalization

average persistent

by air

to keep patients

increased

is so

much

for 4 to leak

segmental

these patients under following a routine

morbidity superior.

the

cases

7 days. This is due from the pulmonary

is When

not

is lengthpart surface

to

observation lobectomy.

significant

the

RESECTED

in

a little We be-

when

morbidity

has

an and

the

been

final

reduced

SEGMENTS FOR

BRONCHIECTASIS

53#{176}R-39

BILATERAL

PT.

14

COMPLETE

12

INCOMPLETE FIGURE 5: Diagram illustrating for bronchiectasis. There were Upon these patients 53 operations

the

various

39 patIents, have been

segments

26 of whom completed.

that

had

have

been

bilateral

removed disease.

Volume

to

XIII

MULTIPLE

that

of

simple

extended

to

SEGMENTAL

lobectomy,

include

the

then patient

593

RESECTION

segmental with

resection

unilobar

should

be

disease.

SUMMARY Bronchiectasis process.

Is usually

Surgical

segments ments now

without advances

and

make

such All

excised.

In two

least

are

26

operations resection

multilobar ary tissue

involvement is essential.

39

a lobar all

normal pulmonary localization, and patients,

with

or

disease

the

involved

tissue. surgical

Refinetherapy

on

especially

death, and

are In

which

14.

applicable

to

conservation

re-

a segment,

bronchiectasis

completed

where

one

a lobe

bilateral

been is

with

segments,

cases

have

Segmental

than

remove

attainable.

at

had

rather

ideally,

sacrificing any in diagnosis,

operations There

bilateral

should,

a goal

Fifty-three ported.

a segmental

therapy

of

all

patients

with

normal

pulmon-

morboso

segmen-

RESUMEN Por

lo general

tario

la

m#{225}sbien

extirpe

todos

bronquiectasia

que los

es

lobular.

Lo

segmentos

un

Ideal

proceso

es

invadidos,

que

sin

la

pulmonar normal. Los refinamientos y adelantos la localizaciOn y la terapia qulr#{252}rgica permiten alcanzar este Se informa murjO.

En

o un

lObulo

teral,

en

La

objeto. sobre

todos y un

14 de los

con

resecciOn afecciOn

todo

el tejido

53 operaciones

ellos

se

Hay se han

segmentaria multilobular, pulmonar

por 26

lo

en ahora

casos

uno

con

de los

dos

cuales

segmentos,

bronquiectasla

operaciones es

tejido

el diagnostico, que se pueda

menos

completado

es aplicable en los que

quir#{252}rgica ninglln

39 enfermos,

extirparon

segmento. cuales

en

terapia

sacri.ficar

especialmente esencial

bilabilaterales.

que

a enfermos se conserve

normal. REFERENCES

1 Blades,

Brian:

“Conservation 118:353-365, 1943.

of

Lung

Ann. Surg., 2 Bradshaw, of Patients

Howard H., Putney, Floyd J., with Untreated Bronchiectasis,”

3 Churchill,

E.

4 5 6 7

D.,

and

Belsey,

Ronald:

Tissue and

by Clerf,

“Segmental

J.A.M.A.,

Partial

Lobectomy,”

Louis

H.: “The Fate 116:2561, 1941.

Pneumonectomy

in

Bronchiectasis. The Lingula Segment of the Left Upper Lobe,” Ann. Surg., 109:481-499, 1939. Clagett, 0. T., and Deterling, R. A. Jr.: “A Technique for Segmental Pulmonary Resection with Particular Reference to Lingulectomy,” J. Thor. Surg., 15:227-237, 1946. Jackson, C. L., and Huber, J. F.: “Correlated Appiled Anatomy of the Bronchial Tree and Lungs with a System of Nomenclature,” D s. of Chest, 9:1, 1943. Overholt, Richard H., and Langer, Lazaro: “A New Technique for Pulmonary Segmental Resection,” Surg., Gynec., Obstet., 84:257-268, 1947. Perry, Kenneth M. A., and King, Donald S.: “Bronchiectasis,” Amerlclpl Rev. Tuberculosis, 41:531, 1940.