Extensive Destruction of Lungs

Abstract

The case described below represents so extreme a degree of destruction of pulmonary tissue as to be of special interest. Case History.—D. H., male, aged 41 years, consulted the author in February, 1939, complaining of cough, dyspnea, and asthmatic wheezing of eight years' duration which had become progressively worse for the past three years, with marked exacerbations and partial remissions. The cough had been productive of greenish-yellow sputum which, at times, had had a fetid taste and odor. Recently the sputum had been white. Since the summer of 1938, wheezing and dyspnea had been constant. The patient had lost 27 pounds since the onset of the illness. He had worked at various forms of labor—farm hand, general laborer, and house painter—until 1931. The past history elicited the story that he had coughed since childhood, that he had had “stomach ulcers” in 1929, and gonorrhea, complicated by stricture, in 1932. The family history was irrelevant. Physical examination was negative except for chest findings. The patient was under-nourished and breathed with obvious effort, the chest wall moving only slightly. There was hypertrophy of the accessory muscles of respiration. The chest was barrel-shaped. There was tympany over both sides with distant (almost absent) breath sounds over the entire right chest except along the base anteriorly, where distant sounds and expiratory rhonchi were heard. On the left, breath sounds were almost absent at the apex, gradually increasing in intensity to the region of the eighth rib posteriorly and the third rib anteriorly. There were scattered sibilant râles below the third rib anteriorly. These findings were practically identical with those of Richard Nauen, M.D., of the New York State Hospital for Incipient Tuberculosis, who had examined the patient in October, 1938. Roentgenograms showed complete absence of lung markings in the upper half of the right lung and upper third of the left lung, with herniation of the mediastinum to the left. There had been no noticeable change since the previous roentgenograms made four months before. Repeated examinations of sputum were negative for tubercle bacilli. The Wassermann test and other routine laboratory studies were negative. A diagnosis of chronic bronchitis, asthma, and pulmonary emphysema with giant bullæ had previously been made by Dr. Nauen. Further observation threw no additional light on the subject. The examining roentgenologist, H. L. Sampson, considered that the process should be termed congenital cystic lung involvement. In an attempt to determine any allergic factor which might be contributing to the patient's discomfort, he was studied at another institution by Dr. Harold Medivetsky. Death occurred in July, 1939, but autopsy was so long delayed as to render bacteriologic study inconclusive, except to indicate the likelihood that death was due to Type XVI pneumococcus pneumonia.