Intralobar Pulmonary Sequestration

Intralobar

Pulmonary GLADYS

Sequestration

BOYD,

M.D.,

Toronto,

Pulmonary

displacement

frequently

described

adequate

report

D#{252}sseldorf

of

such

thesis, by

Rektorzek2

son4

(1908)

are

quoted

were

all

autopsy

was

no

case.

death

and

It

autopsy

diagnosis, up

record

of

to

of

described.

of

sequestration rather

likely

intralobar and

They

were

to

(Cole6).

all

of

seen

at

the

resected

lung a

was

something

of

but having himself as

read Pryce’s9 a diagnostician.

being

problem.

The

surgeon,

paper Some

the of

been

this

made

applied The

by

to these purpose

published noses

Haight1’

cases, can

be with

cluded

in to

mention done.

and

Sick

the

We

be

to

It

time

of

Dr.

F.

R.

despite the

the

same

should

be

made

would

not

subscribe

‘From the Hospital for Sick the University of Toronto.

of

anomaly at

fact

that

embryonic three to

Children,

cases a theory Toronto, 162

in

the

its

accident which

as

distinguish paper were surgeon had Pryce’#{176} had paid to the of two cases has

to

clinical those

the

been list

of

clinical

diag-

course

make

seen have

since

1948.

not

been

observers

now

consider

produced

earlier.

all the

1948. late,

pneumonectomies

attributing and

in

arrived

add

hospital most

in

was

able to in this

to

all

were

conference

whereby

and

made

the cases

and

sequestration

suggestions

recent

by examination aberrant artery

The the mass. appeared mention

in 1948. cases is

seen

an

further

Wilkinson,

intralobar

been

in

operation

pathological

night before, was the cases reported

the

has

agenesis

paper due

of

easy.

usually

Hospital,

a

some

after

published

six

others of an

at

term

make

Awareness

pulmonary

this

The

is

has

Children’s and the finding

Pryce’s paper the following

perhaps

diagnosis

Cases

1941.

cases since reporting

made.

preoperative

them

in

in

6,000 there

a severely

reported

paper

seen prior to this time, but diagnosed in retrospect. however, noted the systemic artery when he removed reported the condition earlier but little attention first paper until the second one was published. Brief was

over

be

hand

Kergin7

In

discussed

In

one.

then

the

Simp-

25 years,

may

his

McCotter

finding

it

have

one.

age. past

other

remain

diagnosed in part clinically preoperatively of the specimen after excision and by when the portion of lung was removed. The first of these cases diagnosed at The

the

Since

Bruzzoni8

the

albeit

sequestration

1951

cases

on

later by

pathological

young,

in classical

and

of

in

a rare

the

Tissler

reviewed

years

been

earliest

Earlier

(1884) cases

two

appear

disease

November

five

Humphrey3

The

to

Muller.’

Children

has

surgery.

attributed

These Sick

artery

chest by

under

for

therefore

and

cases

quoted

children

Extralobar

Forty-two

are

would a killing

one.

generally and

anomalous

much

is

McCotter.5

Hospital

an

of

but (1861),

in

the

not

crippling

years,

a case

by

cases at

with

advent

unpublished

descriptions

post-mortems

the

F.C.C.P.

Canada

associated since

*

kinds

Pediatric

InBrief were

and Department

degrees of

Vol.

INTRALOBAR

XXIV

of cystic Kirkland’s’2

lung

to amputated estimate of

cases alluded to in young children. Inculpated. combed was

when

such

geon was

noted removed.

their

of

little

an

itself

in

been

or

involved associated shift

the

confined

to

embryo.

If

cases

and were be

honeyfound. expected

found.

The

to Rosenthal.’3

these

lung

cases

lung

He

must

and

be

considered

have

states

states

bud,

may

bud

sur-

the lung preclude

that

then

occurred

the

accident

and at the latter of sequestration teratological explanation of these with the growth of ducts and

normally continue faulty growth may

changes.

This

cystic

disease

of

They were could be

would

was

of the

Bruwer’4

agenesis, The only other was interference

Probably The three

to the child when found. This does not

the

in

as

case

severing

aorta.

to Strukow’5 states such

those one

the

14 mm

results lung. there

such

according

the

arteries. is right.

Large cysts hypoplasia

acquired

disturbance were

of

inflammatory to

an

amputation

and

lung. alveolar

mediastinum

cause

from

according MUller’6

whole

factor

may

the

postnatal

applicable

the

teratogenic

artery

4 mm.

163

this minority group. causing bronchiectasis

with

lack of vessels

separated

which year.

of

in

the

case the anomalous

at the 4 mm. stage of only a portion of lungs would be that alveoli seventh

belong infection

with

sequestrations, the

to

involvement

anomalous

between

appear ordinary

no

each No

become

as

or

SEQUESTRATION

lung buds caused by aberrant 5 per cent due to this etiology

changes tissue

general

having

that

would No

The areas

There

PULMONARY

explanation

to

grow up to the due to prenatal

be would

developing

after

appear birth

more and

not

lung. Etiology

The

production

supply of

is now

of

a primitive

lung

Cockayn&7 theory was

in 1917. supported

of the lung They believed

as

The

age

of

extent of conception correct,

bud

only be

most

by

an

of

writers

embryo

at

anomalous

which

lung

to be

with This

amputation

involvement

of the lung. later other

whole

Rusby and disruption. congenital

was

amputation

pointed

out

by

not acceptable now. from the stomach.

occurs

of one

arterial

the

thing in 1941. The of such distortions

and others are anlage developed

early separation results of the pneumonectomy

a portion of Is due to still associated with

by

the same explanation

the

a systemic

produced

vessel.

by Eppinger1#{176} to an accessory

damage. Thus of the etiology

to extensive

involves sequestration likely to

portion

by

Berry18 demonstrated by Pryce#{176}’#{176} Earlier

advanced them due

the

the

a dislocated

considered

determines

the

in agenesis, or cases alluded lung.

Later

if our to be

disruption

Sellors2#{176} consider extralobar The latter is therefore more anomalies.

Pathology Essentially

these

with

alveolar

times may

supplies be large

The

mass

The

contigious

displaced

hypoplasia.

may

An

part blebs

of or

be

within

lung

masses

may

are

aberrant

the adjacent small, giving a be

lobe involved

of

characterized artery

enters

normally the lung lung in

by

or the

polycystic

this

mass

developed a honeycomb completely infection

disease

lung.

and

separate and

some-

The cysts appearance.

show

from bronchi-

it.

164

BOYD

GLADYS

ectasis. are This

Normal usually was

bronchi

pulmonary

tension

dependent on in our cases. Fatty

sepsis of

one

ruled

it

They

changes

were

due

vessels

entered

degree suggest

the

than

associated this series cysts

Clagett

et

mass,

vessel. commonly out

5 per

seen.

from

and

tubercle

lung

marked

one

case

they

were

their

results

bacilli

but

no

wise

in

but the

associated

large child’s

cause,

that

the

infection

in

no

of

said

reported. were

relate

four

another

is the

(1950)

been masses

to vessel,

case,

in

as

of

similar

decided

our

appeared

had

was

attempted aberrant

Bruwer’4

tuberculosis The sequestrated

case

In

occurs

cysts.

them

vary

is strange if sepsis seen in bwnchiectasis.

tuberculosis of

considers

the

breakdown. area

however

not

writers from

and

due

The

1953

is common. to increased

were In

These

similar It

that cent

sequestration had tuberculosis.

containing

fat

a

They

supply

bronchi

Bruwer

pneumonia.

tissue

but

The

Endarteritis might be

supply.

often al.22

the

mass.

patient.

blood

endogenous

pointed

more

of

lipoid

analyzed to

blod

are

increased

lung with no anomalous changes are not more Kirklin12

age

to the

out.

not

the

by

to

the pouches. changes

systemic

some

reported

changes

the

and

magnitude

the

the

enter

only by blind by Betts.2’ Such

from

changes

sufficient to

sometimes

represented pointed out

Aug.,

cases

Two formed

resembling

cases in by large

tuberculous

cavities. One

case

in

tissue.

Cartilage

similar The

changes pleura

resected The

specimen. abnormal

but

may

this

arise

more

showed bone

in some Is always

elastic

most

artery origin

0.5 and

Intralobar

of

discovered This may

The

clinical

occurring

or

may

history birth.

lung. are is It

no

sputum.

in of

from

uniform. usually

Offensive may occur. obtained

odour

Some

on

physical

the

to

abdominal

Its

diagnosed

serious

to

the

the

aorta,

leash

of

vessels

systemic These are

clinically

case

was until

nature thicker

if

found later in

when infection

causative

Subsequently bouts of fever.

surface

a large

diameter. its walls.

develop spread of usual

farily

shaggy

reported

Symptoms

readily

The lacking.

a

cartilaginous Pryce

circulation.

and

is not

of the mass develops. There are recurrent

Severe hemoptysis Several findings

be

other.

form

lesser

surveys. Symptoms hematogenous

adjacent in children

from

infection is noted. little

the

may

in mind. The fact that no such lesions may be quiescent

by x-ray result from

disease in bronchiectasis

the

Findings

sequestration borne that

comes It

and

one

becomes

to 0.7 cm. the nature

vessels Clinical

possibility is would suggest

in

frequently

intercostals.

plaques

present

patients, and

the

than

calcareous

was

of his thickened

artery from

or be a single large is indicated by its and

series

without

infection or from

infections

cough and

may only

occurs. severe

be

reported

becomes

deterioration is worse. There

breath

or

sputum are

a

producing

general Cough

examination

such

at autopsy life, unless

so

as when

in health is usually

is infrequent. significant.

No

Vol.

INTRALOBAR

XXIV

clubbing the This

has

been

seen

size of the mass fixity is commonly

greater

and

PULMONARY

more

in and

our

cases.

apparent noted at

permanent

The

mediastinal

pulmonary operation. The

than

in

165

SEQUESTRATION

ordinary

shift

collapse, physical

compared

is slight signs are

to if any. usually

bronchiectasis.

Radiology The is

x-ray

often

film

of

usually

demonstrates

the

considerable

visualized

in

true

density, it or

in

at

nature

of

times

nearby

the

case.

homogenous.

portions

of

the

The

mass

Cystic lung.

The

itself

areas

are

mediastinum

is mid-line. The

bronchogram

Occasionally, complete is

usually it

bronchial

important.

mass

may

and

leaving that

for

tree,

Careful

assumption

shows

enter

a mass a short

diseased attention

behind

or to

is all

The

only infected

effective

therapy

normally

(male)

this

detail

lipiodol

penetrates.

demonstration

extraneous will

portions

and

is surgical

developed

to

prevent of

lung

of the

removal with

a

mass, of

the

false

plus

a

1: A.P.

Prognosis removal

lung.

The

of

results

the

abnormal

lung

are

unusually

good.

Reports

ae. 7, 1930. Child was In addition to the hilar mass in the right lower

FIGURE

no The

excised.

Case Case 1: A.B. tinal tuberculosis. large homogenous

which

otherwise,

bronchiectastic

disease

Treatment any

into distance.

of Chest

admitted at age six because lymph nodes, the radiogram chest. The tuberculin test

showing

cystic

areas.

of

mediasshowed was positive.

a

166 There were

was

GLADYS was made

done

a large to obtain

October

with great intercostal in

1932

after

difficulty from artery entered

Specimen: cavity

tuberculous a good

the

There

were

apex

of this

ulcer bronchogram

in

preliminary

the that

the of

tough

specimen.

right this

and

pleural The

posterior

1953

main bronchus. Five attempts area without success. Lobectomy

phrenicotomy.

diaphragm mass.

many

Aug.,

BOYD

the

The

mass

adjacent

adhesions. portion

was

separated

pulmonary

There of

lobe.

was the

a large specimen

An

cystic showed

practically no normal lung tissue. The great bulk of the lobe was filled by a large irregular cavity traversed by numerous partitions. The largest cavity measured 6 x 2 cms. There were many smaller ones. The cavities contained small amounts of pus. Microscopically the whole lung presented a similar picture. There were a few alveoli lined by cuboidal epithelium. There was little or no elastic tissue, Cilia were rare. The degree of destruction was out of all proportion to the fibrosis seen. Case

an acute and had

2: R.A. (male) ae. 5. Child had not been well for six months when he had attack of bronchitis. Since that time he coughed a great deal, tired easily, bouts of high fever. His tuberculin test was positive as was also his sputum.

Right pneumonectomy was supposedly done in 1940 but upper and middle lobes were found undisturbed at a subsequent At operation dense adhesions bound the lung to the chest It was necessary to remove a portion of the latter to free also many adhesions between the mediastinum and the edge of these was a fair sized blood vessel which came through the aorta.

eight

years later his operation. wall and diaphragm. the lung. There were of the lung. In one the diaphragm from

Specimen: The surface was ragged. There was a cavity 6 x 5 cm. in the portion. The medial portion of this extended toward the mediastinal border sort of bay 3 cm. long filled with yellow caseous material. No dilated bronchi found. There was a large thrombosed vascular channel 6 mm. in diameter

FIGURE

2: A.P.

and

lateral

bronchogram.

lower in a were filled

Vo..

with

INTRALOBAR

XXIV

thrombus.

fibers

There

a large

fibrosed

SEQUESTRATION vessel

on

the

base.

167 There

were

elastic

in its wall.

Case 3: N.G. pneumonia. She complained

she had showing without

was

PULMONARY

of

frequent the left success.

(female) was well weight

bouts lower

ae. 4. 1939. This child was after this until a few months

loss,

lassitude,

and

later

of fever. The x-ray mass, Many attempts

film

in hospital in infancy with before admission, when she

anorexia

presented were made

and

cough.

Subsequently

is typical of the to fill this with

disease lipiodol

Left lower lobectomy was done in 1948. The lobe appeared grossly diseased. There was no air containing lung except at the upper part. The remainder of the lobe was firm on palpation. There were many adhesions in mediastinal and diaphragmatic areas. There was a large leash of vessels coming from the aorta four inches below the arch to the postero lateral aspect of the lobe about one and one half inches from the diaphragmatic surface. Three of these were as large as the radial artery.

FIGURE

3: Specimen Large artery

of sequestrated entering the

mass. Note emphysematous mass. Cut sections of mass.

blebs.

168

GLADYS

BOYD

Aug.,

1953

Specimen: The lobe was or normal size. A consolidating process involved the whole of the postero-lateral portion. There were fibrous adhesions. The remainder of the lung was deep bluish color while the affected part was pale greyish yellow. Four large arteries entered the posterior aspect of lobe 2 cm. from the diaphragmatic surface, These arose directly from the aorta and broke into ramifications through the parenchyma (See celloidin injected lung picture). Water forced through with considerable pressure entered the pulmonary artery. The vessels appeared to be large bronchial arteries with a large anastomosis with the pulmonary arteries, The posterior basic and the middle half of the adjacent middle basic appeared to be the only parts involved, The posterior basic division was. constricted about 2 cm. from the hilum. From this point on the bronchial divisions appeared as greatly dilated cystic spaces and fibrous tissue. They were between 1 and 1.5 cm. in diameter. Yellow granules were imbedded in both the spaces and the fibrous tissue. They were filled with pus, Microscopically all the bronchi and bronchioles were dilated cystic spaces filled with pus. Most were lined with columnar epithelium but some small spaces showed cuboidal epithelium. The cysts were separated by oedematous fibrous tissue with extensive lymphocytic infiltration, and great vascularity. There were some phago-

Sequestration

of the

Lung

S. 372./52.

-Api cal

Medial basal

bro

broncKu

nchtia

artery.

Anterior Cysts

bronch.u ..

-

-

iuirtLofl. r I

‘ ‘c rtery.

“I

FIGURE

4: Artist’s

drawing

of lung

showing

systemic

vessel

and

blind

bronchus.

Vol.

XXIV

INTRALOBAR

PULMONARY

SEQUESTRATION

169

cytes containing fatty material. The blood vessels were large and thick walled and had organized well developed elastic tissue. There was little elastic tissue in the walls of the bronchi. The remainder of the specimen showed the usual type of bronchiectasis and did not communicate with this portion. Case 4: A.S. (female) ae. 13, 1940. This child had acrodynia at three years of age with cough ever since. Olle year ago she had pneumonia, since then cough has been much worse and of late has been accompanied by hemoptysis. Physical signs were all in the left chest. In this same area, there was a rounded mass behind the heart. It was impossible to fill this area with lipiodol but above it, the bronchogram showed definite bronchiectasis. Left lower lobectomy was done supposedly but later x-ray films showed the bronchiectasis still present and only the rounded shadow removed. At 18 this diseased area was removed at hospital for adults. Death followed two days later. The first operation showed dense pleural adhesions. There was much haemorrhage from a vessel of fair size in the vicinity of the pulmonary ligament. Its origin was not determined. The lung was removed by excising proximally to a noose. The specimen consisted of an irregular portion of lung. There were no normal landmarks. The pleural surface was shaggy and haemorrhagic. Palpation showed Irregular consolidated areas. The cut surface showed large vessels and bronchi. The intervening lung tissue was fibrotic and consolidated. The bronchi as shown in the bronchogram were not found. Sections showed general bronchial dilatation. The bronchi were lined with stratified columnar epithelium and were greatly thickened. The thickening was for the most part due to increased lymphoid tissue and infiltration with chronic inflammatory cells, The muscle coats were gone. There were a few islands of cartilage. There were also spicula of bone in one fibrotic area. Many alveoli were hypoplastic and lined with cuboidal epithelium.

Case 5: J.L. (female) ae. 9’/2 yrs., 1949, This child has never been really well, but worse since pneumonia at two years. She has had persistent cough without much sputum since. During this period she had five bouts of fever, 103 to 105 degrees F., and pneumonia again nine months ago. There has been general deterioration in health since that time. Operation: The whole left pleural cavity was obliterated by adhesions. These were more marked along the main fissure between the upper and lower lobe. On palpation, the lower lobe was firm and rubbery, with slight crepitations. At the base of the lung, on the lateral portion, there was a large artery coming from below the diaphragm but it was impossible to determine its origin. The specimen showed an enlarged and firm lower lobe and lingula. The aberrant artery entered 3 cm. from the posterior tip. The cut surface showed numerous cavities filled with pus. Microscopically all the bronchi and bronchlolae were dilated and their walls infiltrated with inflammatory cells. The muscle tissue, glands, and elastic tissue were replaced by fibrous tissue. The abnormal vessel was a systemic artery. Case 6: B.N. (male) ae. 6, 1952, Child was well until five years of age he had pneumonia, following which his general health deteriorated. He had many bouts of fever. Cough developed, without sputum and became progressively worse. Both his radiograph and bronchogram showed the changes characteristic of cystic fibrosis. Lobectomy was done in 1952. At operation many cysts were seen over the left lower lobe. There was a large artery in the pulmonary ligament running from the aorta below the diaphragm. Pathology: The left lower lobe measured 14-9 x 3 cm, The dorsal segment was the only portion that inflated well. The large cysts over the base could not be filled by inflation. On the cut surface the dorsal segment appeared normal. The

170

GLADYS

posterior containing cysts.

basic segment clear fluid There

was

BOYD

Aug.,

was composed of many multiloculated, but no air. There was no communication

some

alveolar

tissue

between

them.

The

thin wall between anterior

1953

cysts these

and

middle

segments were compressed to about 1.5 cm. in thickness. The dorsal bronchus was normal. The middle and anterior bronchi were displaced superiorly and fanned out over the cystic regions. The bronchus to the posterior basal segment was defective, being represented only by a few short bronchioles descending just under the pleura on the mediastinal surface. The pulmonary artery measured 0.3 cm. in diameter while the aberrant vessel was 0.7 cm. across. It entered the lung at its posterior surface about 1 cm. above the Inferior border at the end of the pulmonary ligament. It penetrated the lung about 0.8 cm. and broke into four branches which arborized into all of the cystic portion (see drawing). At the bifurcation, there was a small linear area, yellow and slightly thickened. Two of the branches accompanied a bronchus that did not communicate with the exterior. The vessels were large for only 2 cm. before they arborized. The isolated bronchus was probably a sequestrated posterior basal bronchus. It was about 0.4 cm. wide. It branched into bronchioles when the artery divided. Some of the branches entered into small centrally placed cysts by small atria but never connected with any normal airway. Microscopic examination showed the walls of the cysts to be composed of columnar ciliated epithelium lying on a smooth muscle wall. In places there was continuity between the cysts and normal alveoli and ducts. The wall of the blind bronchus was composed of ciliated columnar epithelium, smooth muscle, cartilage, collagen, glands, vessels and nerves. The intervening parenchyma appeared normal. The walls of the main bronchi were heavily infiltrated with chronic inflammatory cells. The cyst walls showed little inflammation. The walls of the aberrant artery were composed of alternating layers of elastic tissue and smooth muscle fibre. There were approximately 14 wide elastic lamina as well as numerous finer elastic fibres. SUMMARY 1)

and

Six further cases of a congenital clinical interest are described. 2) The anomaly consists of a portion

cavity

with

hypoplastic

honeycombed a systemic intralobar 3)

It

is probably

due

artery, history,

diagnosis

diagnosis 5)

and

anomaly

of displaced dilated

of

both

lung

bronchi

teratological

tissue

which

in the

give

the

or cystic appearance. This displaced lung is the vascular supply usually from the aorta. It has come sequestration since Pryce’s paper was published.

aberrant 4) The its

alveoli

lung

Three

the

process

than are

agenesis amputated.

the

amputation

in the findings,

are

easy, is

to

occurring physical

of

a primordial

discussed.

The

clinical

bud

changes

by

which

importance

its

recipient of to be called

lung

4 to 14 mm. embryo. and radiographic

chest

lung

of

its

an

make correct

indicated. cases and

are

mentioned

the

question

when

earlier

In

which

raised more

If such massive

the

whole

lung

a result

could

portions

of

was not

the

involved ensue

in rather

bronchial

tree

RESUMEN 1)

Se

describen

seis

casos

inter#{233}s tanto clinico como 2) La anomalla consiste

mas

de

una

teratologico. en una porciOn

anomalia de

congenita tejido

pulmonar

pulmonar desplazada

de

Vol.

XXIV

en

la

INTRALOBAR cavidad

dieron

al

tenla mado

tor#{225}cica con pulmOn

3)

facil

su Se

panal

debe

se discuten.

Este

generalmente que se publicO

a la

amputaciOn

La

171

y bronquios

o cistica.

de

arteria aberrante ocurriendo los hallazgos flsicos y los

diagnOstico, se

5)

se

por una historia,

SEQUESTRATION

hipoplasicos

de

vascular emergiendo intralobar desde

Probablemente

nOstlco

alveolos

apariencia

un sistema secuestraciOn

pulmOn 4) La

PULMONARY

en camblos

importancia

dllatados

pulmOn

que

displ#{226}stlco

de la aorta. el trabajo

Se de

ha llaPryce.

llema

primitiva

del

una

el embrion de radlogr#{225}ficos clinica

de

su

4 a 14 mm. que hacen

correcto

dIag-

indlca.

mencionan

tido por el ocurrir mas

tres

proceso que la

voluminaosas

del

casos

en

y suscitaron agenesia

arbol

los

que

el cuando

bronquial

todo

problema mas

son

el pulmOn

estaba

de si tal tempranamente

comprome-

resultado porciones

podrian mas

amputadas.

RESUME 1)

L’auteur

2)

un int#{233}r#{234}t clinique L’anomalie consiste

tent la

cavite

donne anormal

thoracique au

ment de intralobaire” tif

d#{233}critsix

cas

d’anomalie

congenitale

et teratologique. en une portion

de

avec

un aspect kystique syst#{232}me vasculaire

l’aorte.

est la

pass#{233}dans publication

ou de

a

que tionne

L’auteur et

des

discute alterations

l’histolre radiologiques

l’importance

clinique

5) L’auteur rapporte trois int#{233}ress#{233}e par ce processus. ne pourrait pas #{234}treplutOt plus

importantes

du

de

l’arbe

en “rayon suppl#{233}ance,

qui

d’un

en

diagnostic

cas dans Ii pose la en cause bronchique

les

qui

dilat#{233}es, qui

de miel.” provenant

d’un de

pr#{233}sen-

d#{233}plac#{233} dans

bronches

de l’appeler de Pryce.

la separation chez l’ambryon

malade,

poumon,

pulmonaire et

les habitudes de l’article

3) L’anomalie est due probablement par une art#{232}re aberrante, survenant 4)

tissu

alv#{233}oles hypoplastiques

poumon re#{231}oit un Ii depuis

du

Ce

poumon generale-

“sequestration bourgeon primi4 a 14 mm.

#{233}l#{233}ments de l’examen

facilitent

le diagnostic,

physiet

men-

correct.

lesquels la totalit#{233} du poumon #{233}tait question de savoir si un tel r#{233}sultat que l’agenesle lorsque des portions sont

amputees.

REFERENCES 1 Muller, M.: “Handbuch der speciellen pathologiche Anatomie und Histologie,” (Henke u Lubarach), 3:577, 1928. 2 Rektorzik: “Ueber acces. Lungenlappen. Zeitschrlft der Gesellsch. der Aerzte in Wein,” Jahrg. 1861 S.4 quoted by R. Vogel in Virch. Arch., 155:246, 1899. 3 Humphrey, L.: Jour. Anat. and Phys., 19:345, 1884. 4 Simpson, G. C. E.: “A Case of Accessory Lobe of the Right Lung,” Jour. Anat. and Phys,, 42:221, 1908. 5 McCotter, R. E.: “On the Occurrence of Pulmonary Arteries Arising from the Thoracic Aorta,” Anat. Record, 4:291, 1910. 6 Cole, F. W., Alley, F. H. and Jones, R. S.: “Aberrant Systemic Arteries to the Lower Lung,” Surg., Gynec. and Obst., 93:589, 1951. 7 Kergin, F. G.: “Congenital Cystic Disease of the Lung Associated with Anomalous Arteries,” J. Thoracic Surg., 23:55, 1952. 8 Bruzzone, P. L.: “Anomalies of the Pulmonary Vessels; A Case of Intralobar Sequestrum of Lower Left Lobe Due to Accessory Pulmonary Artery,” Minerva Med., Tor., 42:921, 1951. 9 Pryce, D. M., Sellors, T. W. and Blair, L. G.: “Intralobar Sequestration of Lung Associated with an Abnormal Pulmonary Artery,” Brit. J. Surg., 35:18, 1947-48. 10 Pryce, D. M.: “Lower Accessory Pulmonary Artery with Intralobar Sequestration,” J. Path. and Bact., 58:451, 1946.

172

GLADYS

BOYD

Aug.,

1953

11 Haight, C., Discussion: “Method of Treatment of Large Air Cysts (Baloon Cysts) by Endocutaneous Flap” by A. L. Brown and W. Brock, J. Thoracic Surg., 11: 617, 1942. 12 Kirklin, B. R.: “Congenital Cysts of Lung from Roentgenologic Viewpoint,” Am. J. Roentgenol., 36:19, 1936. 13 Rosenthal, S. R.: “Isolated Giant Growth of Branch of Pulmonary Artery Associated with Congenital Bronchiectasis; Report of Case,” Arch. Path., 12:387, 1931.

14 Bruwer, Associated 15 Strukov,

A., Clagett, T. and McDonald, J.: “Anomalous Arteries to the Lung with Congenital Pulmonary Anomaly,” J. Thoracic Surg., 19:951, -950. A. I.: “Die Grundsatze der Lungenhistostruktur,” Ztschr. /. Anat. U. Entwcklngsgesch., 98:348, 1932. 16 Miller, J. A.: “Pathogenesis of Bronchiectasis,” J. Thoracic Surg., 3:246, 1934. 17 Cockayne, E. A. and Gladstone, R. J.: “A Case of Accessory Lungs Associated with Hernia Through a Congenital Defect of the Diaphragm,” J. Anat., 52:64, 1917.

18 Berry,

19 Eppinger,

F. B.:

H.:

“Pneumonectomy,” “Krankheiten

der

Ann. Surg., 114:32, Lungen, Ergebnisse

1941.

der

Ailgemeinen

Aorta,”

J.

Patho-

logie und Pathologischen Anatomie des Menschen und der Tiere,” 8 (pt. 267, 1902. 20 Rushby, N. L. and Sellors, T. H.: “Congenital Deficiency of the Pericardium Associated with a Bronchogenic Cyst,” Brit. J. Surg., 32:357, 1944-43. 21 Batts,

M.

Jr.:

8:565, 1938-39. 22 Clagett, 0. T.

“A

and

Pulmonary

Artery

McDonald,

Associated with Large Clinic, 20:1, 1945.

Aberrant

Arising

.1. R.:

from

“Bronchiectasis

Pulmonary

the

Artery,”

and

Proc.

Lipoid Staff

Thoracic

Surg.,

Pneumonitis Meet.,

I):

Mayo