Peripheral airways of 2mm or less in diameter were observed in cases of peripheral airway lesions by means of a very thin bronchofiberscope, 1.8mm in outside diameter. On the basis of the observed and photographed endoscopic findings, an endoscopic classification of peripheral airway lesions was proposed. The endoscopic findings showed changes in the bonchial wall consisting of redness, pallor, lack of luster, edema, vascular engorgement, and uneven or elevated mucosa. In the lumen, stenosis, obstruction, ectasis, and deformation due to pressure were recognized, in addition to excessive secretion and pigmentation as morphological abnormalities or abnormal substances at bifurcations. In performing endoscopy, special efforts were made to obtain as natural a color tone of the bronchial mucosa as possible.
Ordinary endoscopic findings of the peripheral airway and specific findings from patients with peripheral airway lesions were also investigated in order to achieve further understanding of endoscopic findings in peripheral airway lesions.

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Methyl hepatine carbonate is a new primary sensitizer to examine the delayed, cell-mediated immune system. Seventy-four patients with pulmonary tuberculosis and ten healthy controls were tested for skin reactions to methyl hepatine carbonate. Methyl hepatine carbonate skin reactions of patients with pulmonary tuberculosis were investigated in relation to the types of pulmonary tuberculosis. In the healthy control group, 100% showed positive response to methyl heptine carbonate, while on the other hand, the tuberculosis group showed positive reactions in 78% to methyl heptine carbonate. There were significant differences in response to methyl heptine carbonate between the tuberculosis and healthy control groups. All of AB, C and F types according to the Gakken classification showed reductions in methyl heptine carbonate skin reactions as compared with D types. According to the NTA classification, the positive rate of methyl heptine carbonate decreased in proportion to the extent of the lesions. There was significant correlation between the extent of lesions on chest roentgenogram and the rate of negative reaction to the methyl heptine carbonate skin test.

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Concentrations of creatine kinase isoenzymes (CK-MM, CK-MB, CK-BB) in tumor tissues and in sera of patients with various lung carcinomas were determined by use of a sensitive enzyme immunoassay method. Although the CK-BB levels were increased in the tissue of small cell carcinoma of the lung, the CK-MM, CK-MB levels were not increased in the tissue of any lung carcinoma. The average tissue contents of CK-BB in small cell carcinoma (SCCL), adenocarcinoma (ADCL), squamous cell carcinoma (ECCL), other carcinoma (OTCL) of the lung, and normal lung were 2000, 95, 85, 110, 100, ng/mg, respectively. The serum CK-BB levels were enhanced in all types of lung carcinoma examined, but the serum CK-MM and CK-MB levels were not enhanced in any type of lung carcinoma. The mean values and standard deviations of serum CK-BB were 2.65±3.44ng/ml in SCCL, 1.09±0.95ng/ml in ADCL, 1.20±1.10ng/ml in ECCL, 1.04±1.60ng/ml in O TCL. The serum CK-BB concentrations of healthy adults were estimated to be 0.32±0.14 (mean±SD) ng/ml, ranging from 0.11 to 0.68ng/ml. When the values above 1.0ng/ml were tentatively considered abnormal, abnormally elevated cases were seen in 28/40 (70%) of patients with SCCL, 25/67 (37%) with ADCL, 21/51 (41%) with ECCL, 4/11 (36%) with OTCL. Since serum CK-BB concentrations in patients with lung cancer changed in parallel with the clinical course, serum CK-BB may be an useful biomarker for monitoring the clinical course of patients with lung cancer, especially in SCCL.

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Of 180 autopsies at Nagoya-shi Koseiin Geriatric Hospital during the period from January 1979 to February 1982, pneumonia was found in 102 (57%) of cases. It was the most frequent cause of death (53 cases). In order to investigate this fatal infection, a clinicopathological study of pneumonia in the elderly was conducted.
Cerebral vascular disease and heart disease were the most frequent underlying diseases. There was a positive correlation between the death rate caused by pneumonia and the extent of the pneumonic process as determined by the number of lobes involved at autopsy. Focal pneumonia was the most frequent pathological type of pneumonia, and was found in 87% of the cases. Hypostatic and aspiration pneumonia were found in some of these cases. There were only seven cases of lobar pneumonia. Cases of lobar pneumonia, aspiration pneumonia and pulmonary suppuration have a greater likelihood of the cause of death being recorded as pneumonia. According to the classification of pathologic features of the pneumonia based upon the distribution of lesions, alveolar pneumonia was found in 70% of the cases, followed by mixed interstitial-alveolar pneumonia (10%), and others (20%). Congestion and/or edema were found in 49% of the cases suggesting that these might play an important role in the pathogenesis of pneumonia.

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A 70 year-old male was referred to our hospital with a complaint of edematous rash on his face and anterior upper chest. Desite steroid ointment therapy, the rash deteriorated and spread over both knees and elbows. The patient also complained of proximal limb weakness and muscular pain. Muscle biopsy showed perivascular infiltration with round cells. Diagnosis of dermatomyositis was made and tests for malignancy was carried out. Chest X-ray showed a nodular shadow in the left lower lobe. The result of cytological examination of sputum was class IV and small cell carcinoma was suspected. Left lower lobectomy and mediastinal nodal dissection were performed. The lung tumor was diagnosed as small cell carcinoma, intermediate type and hilar nodal involvement was found.
The itching disappeared the day after surgery and the rash subsided gradually. Elevated levels of serum LDH, CPK, myoglobin and urinary β-microglobulin became normal 2 weeks after operation. In spite of postoperative chemotherapy with vincristine and endoxan, the patient had episodes of abdominal pain three months after operation. Computed tomography of the abdomen showed findings suggesting the possibility of metastasis of lung cancer to the right adrenal gland, the left renal hilum and para-aortic lymph nodes. Although chemotherapy was repeated, the tumor metastasized to the left abdominal skin. The patient's condition deteriorated and died of acute pneumonia without recurrence of dermatomyositis 8 months after left lower lobectomy.

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Diffuse panbronchiolitis (DPB) is a new clinical entity, characterized by a chronic inflammation localized mainly in the respiratory bronchioles, developping severe respiratory failure in the end stage. In this study, 109 cases of DPB, including 31 autopsied cases in our hospital were investigated in terms of the clinical course and prognosis.
Results obtained were as follows:
1) The mean survival time after the initiation of dyspnea was 7.7 years, and that from the beginning of productive cough was 21.1 years.
2) There was no significant difference in the mean survival time from the initiation of dyspnea between male and female patients.
The mean survival time of the group of the patients in which productive cough developed under the age of 40 was significantly longer than that of the other group in which it developed over 40 years old (p<0.05). Furthermore, the mean survival time of the group of the patients in which dyspnea developed under the age of 40 was also significantly longer than that of the other group in which it developed over the age of 40 (p<0.05).
4) Chronic sinusitis was observed in 87% of all cases of DPB. The initiation of dyspnea or productive cough in the group without sinusitis was later than that in the group with it. However, there was no significant difference between the two groups in terms of the duration from the beginning of dyspnea up to Pseudomonas aeruginosa infection.
5) The mean survival time of the 35 dead patients after Pseudomonas infection was 35.5 months, and that from the beginning of respiratory failure (Pao₂<60 torr) was 27.9 months.
These results indicate that almost all the patients with DPB develop Pseudomonas infection and fall into respiratory failure after a long clinical course, and that the prognosis of the disease is generally poor. The clinical course of DPB resembles that of cystic fibrosis (C. F.) from some points of view, but DPB is quite different from C. F. because of the older age of onset, the lack of both the disturbance of exocrine system of pancreas and electrolytic abnormality in sweat.

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To identify the causal organisms of pulmonary infection and colonized flora in the lower respiratory tract of lung cancer patients, a bacteriological study of the material obtained by transtracheal aspiration (TTA) was carried out.
The causal organisms in pulmonary infection of lung cancer were obtained in all cases of obstructive pneumonia and 7 of 13 cases with opportunistic pulmonary infection by TTA. Gram-negative bacteria, especially H. influenzae and P. aeruginosa, were found frequently. K. pneumoniae which was naturally thought to be an important organism in pulmonary infection of lung cancer patients was not isolated significantly in any cases.
In 50% of lung cancer patients without any symptoms of pulmonary infection organisms were obtained by TTA. The rate of positive culture in cases with hilar type lung cancer exceeded that of peripheral type cases. The incidence of cases, in which degree of bacteria growth ≥ (+) isolated by TTA, was 41.4% in hilar type cases. H. influenzae and P. aeruginosa were isolated frequently, and agreed with the main causal organisms in pulmonary infection of lung cancer described above. On the other hand, the incidence in peripheral type cases was 9.5% and only Viridans strep., which was thought to be a normal bacterial flora of the upper respiratory tract, was isolated.
In conclusion, it was considered that TTA is a useful method to detect colonized flora and causal organisms in the lower respiratory tract for the prevention and treatment of pulmonary infection in lung cancer.

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In this study, we examined the types of cells observed among alveolar inflammatory cells in PIE syndrome, obtained from bronchoalveolar lavage (BAL) and investigated which cells might attract eosinophils to the lung in PIE syndrome. Our working hypothesis was that if certain cells attract eosinophils to the lung these cells may increase in number in the lung. Furthermore, we examined the changes in the alveolar cell proportions during steroid therapy after abnormal shadows disappeared.
Bronchoalveolar lavage (BAL) cell characteristics were investigated in 12 cases with PIE syndrome (7 cases of PIE syndrome both before and during steroid therapy) as compared to 12 normal controls. Eight cases were prolonged type, 3 cases were asthmatic type and one case was simple type according to Crofton's classification.
The results were as follows.
The following characteristic findings for BAL cells were seen in patients with PIE syndrome:
1) Marked increases of total BAL cell numbers and eosinophil counts.
2) The eosinophil proportion was usually much higher in BAL than in peripheral blood.
3) Lymphocyte counts were elevated.
4) Basophils were found in the BAL fluid of 6 patients and basophil counts were elevated.
Characteristic findings on BAL cells in patients with PIE syndrome during steroid therapy were:
1) Normalization of total BAL cell numbers and eosinophil counts.
2) Lymphocyte counts remained elevated.
The above results suggest that not only eosinophils but also lymphocytes, and in some cases basophils, play a role in the profile of PIE syndrome. Furthermore, there may be a possibility that lymphocytes or basophils (mast cells) attract eosinophils into the lung in PIE syndrome.

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Bronchial provocation test using mite extract as antigen was carried out in 13 asthmatic patients who were RAST-positive and/or skin-test-positive to mites.
FEV_1.0, antibodies (Ab), complement, chemical mediators, cortisol, blood cells and blood sedimentation rate were examined before and after inhalation. Results were as follows.
1) Twelve cases showed immediate response (IR) and 7 out of the 12 cases showed late asthmatic response (LAR). There was one case that showed no asthmatic response. There was no case that showed isolated LAR.
2) All six cases having high IgG1 Ab to mite (OD>0.10) showed LAR. Six cases with low IgG1 Ab (OD<0.10) did not show LAR. Only one case having with low IgG1 Ab showed LAR.
3) There was significant difference of IgG1 Ab levels between LAR-positive and negative groups (P<0.05) whereas there was no significant differences of IgE Ab and IgG4 Ab levels between the two groups.
4) There was significant difference in the immune complex level between the two groups (Clq-solid phase immunoassay, P<0.05 and monoclonal rheumatoid solid phase immunoassay, P<0.02).
5) Decrease of eosinophilic cells was observed in 6 of examined 7 cases after IR.
6) IgE level, serum Ab, complement, immune complex, chemical mediators including histamine, leucotriene C₄ and neutrophil chemotactic activity, cortisol, blood cell counts except eosinophil and blood sedimentation rate did not have a consistent relation to the changes of FEV_1.0 after inhalation.

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A morphological study of the bronchus-associated lymphoid tissue (BALT) of normal rats, rabbits and cattle was performed with light and electron microscopy. Remarkable morphologic similarities of the BALT in these animals were recognized. The BALT was fundamentally divisible into 4 different areas: (1) the lymphoepithelium, (2) the subepithelial zone of lymphoid mass, (3) the central area of lymphoid mass, and (4) the peripheral zone of lymphoid mass.
Inhaled dust and alveolar macrophages containing phagocitized materials of various forms and sizes were occasionally observed between the epithelial cells and in the crypt of the lymphoepithelium. Lymphocytes are occasionally found migrating between not only epithelial cells of the lymphoepithelium but also endothelial cells of the high endothelial venules and the lymphatic vessels in the BALT.
Lymphocytes in the BALT come into contact with alveolar macrophages containing phagocitized antigen as a first line of defense and thus may be expected to play an important role in the immunologic defense mechanisms of the respiratory tract.

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A 66 year-old male who formerly had tuberculosis which had left severe pleural adhesion in his right chest and compensatory emphysema in the left, developed spontaneous pneumothorax in his left chest and fell into CO₂ narcosis. Air leakage did not cease even after two weeks of continuous suction with a chest tube. Surgical closure of the air leakage seemed impossible due to the minimal respiratory reserve. For fear of deterioration of pulmonary pathology due to the positive pressure of mechanical pulmonary ventilation, a veno-venous extracorporeal lung assist, ECLA, with a Kolobow membrane lung was performed to supplement gas exchange and allow the lungs to rested for natural healing. The patient could speak freely and take food by mouth during ECLA. The air leakage halted within 2 days of ECLA.
Respiratory care with ECLA without endotracheal intubation and mechanical pulmonary ventilation is more acceptable for a conscious patient than the conventional ventilator therapy and may become a new means of respiratory care in the future.

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A 74 year-old female case of Cheyne-Stokes respiration (CSR) was reported. While she was admitted for hypertension, aortic regurgitation, and heart failure, cyclic oscillatory ventilation with hyperpnea and apnea was pointed out. Neurologic examination revealed that the patient had mild arteriosclerotic Parkinsonism. Because CSR continued after improvement of heart failure, further studies were carried out. She had the following conditions; (1) prolongation of circulation time, (2) increased CO₂ sensitivity, (3) decrease of hypoxic sensitivity, (4) tendency for CSR to disappear during REM sleep stage, (5) decrease of apnea after acetazolamide administration, (6) reappearance of CSR by hypoxic load after improvement of CSR, (7) ineffectiveness of naloxone for hypoxia-induced CSR.
Since CSR during admission did not disappear by 100% O₂ inhalation, it seemed likely that the instability of CO₂control system with the prolonged circulation time caused CSR. Furthermore abnormal inhibiting cortical influencing the hypocapnia-induced apnea might be a factor predisposing to CSR.

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We examined the biochemical composition of the accumulated intra-cystic material obtained from a patient with bronchogenic cyst. Supernatants of this material contained large amounts of protein and lipid. Phospholipid and cholesterol were major lipid components and constituted 36% and 37% of total lipid, respectively. In addition, lecithin was the primary phospholipid and comprised 40% of total phospholipid. In contrast to serum, free cholesterol was predominant and comprised 58% of total cholesterol in the supernatants tested. These data were similar to those in the pulmonary washings from patients with pulmonary alveolar proteinosis, as reported previously. However, supernatants of intra-cystic material showed the same pattern of protein electrophoresis as serum. Moreover, these supernatants had higher concentrations of CEA, LDH, and ferritin compared with serum. The origin and characteristics of intracystic material are discussed.

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A 51 year-old woman began to feel dull back pain, general malaise and low grade fever since February 1985. The patient was admitted to our hospital in May. Liver dysfunction, an infiltrative lung shadow of the left upper lobe, and pleuropericardial effusion improved by anti-tuberculous therapy which was started in October, but low grade fever and elevation of ESR and CRP continued and in December almost no pulse could be detected in the left arm. A diagnosis of aortic arch syndrome was made by angiography in January 1986. Following administration of prednisolone, the symptoms and abnormal laboratory data were normalized and tuberculin skin test became positive. An etiological relationship between aortic arch syndrome and tuberculosis was discussed. Immunodeficiency due to the former may have been related to the atypical clinical manifestations of tuberculosis in our case which resembled the so-called cryptic type of miliary tuberculosis.

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A 71 year-old female developed wheezing and hemosputum. Bronchoscopy revealed elevated multiple whitish nodules in the submucosa of the trachea and left main stem bronchus. A 50 year-old male complained of hoarseness and productive cough. His lesion was confirmed by tomogram. Biopsy sections of both cases showed areas of osseous tissues in the submucosa. Specific treatment of this disease was unknown. A relationship between this disease and primary tracheobronchial amyloidosis has been proposed by Sakula, who suggested that this disease was an end stage of primary lung amyloidosis.

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