Emphysema

Emphysema (Gr. ἐμφυσᾶν to inflate) is a word vaguely meaning the abnormal presence of air in certain parts of the body. At the present day, however, there are two conditions to which it refers, “pulmonary emphysema” (and the word pulmonary is often omitted) and “surgical emphysema.” Of pulmonary emphysema there are two forms, true vesicular and interstitial (or interlobular). Vesicular emphysema signifies that there is an enlargement of air-vesicles, resulting either from their excessive distension, from destruction of the septa, or from both causes combined (see Respiratory System). In interstitial emphysema the air is infiltrated into the connective tissue beneath the pleura and between the pulmonary air-cells.

The former variety is by far the more common, and appears to be capable of being produced by various causes, the chief of which are the following:—

1. Where a portion of the lung has become wasted, or its vesicular structure permanently obliterated by disease, without corresponding falling in of the chest wall, the neighbouring air-vesicles or some of them undergo dilatation to fill the vacuum (vicarious emphysema).

2. In some cases of bronchitis, where numbers of the smaller bronchial tubes become obstructed, the air in the pulmonary vesicles remains imprisoned, the force of expiration being insufficient to expel it; while, on the other hand, the stronger force of inspiration being adequate to overcome the resistance, the air-cells tend to become more and more distended, and permanent alterations in their structure, including emphysema, are the result (inspiratory theory).

3. Emphysema also arises from exertion involving violent expiratory efforts, during which the glottis is constricted, as in paroxysms of coughing, in straining, and in lifting heavy weights (expiratory theory). Whooping-cough is well known as the exciting cause of emphysema in many persons.

4. Another view, known as the nutritive theory, maintains that emphysema depends essentially on a primary nutritive change in the walls of the air-vesicles. Thus these are impaired in their resisting power, and are far more likely to become distended by any force acting on them from within.

5. Again in certain cases the cartilages of the chest become hypertrophied and rigid, thus causing a primary chronic enlargement, and the lungs become emphysematous in order to fill up the increased space (Freund’s theory).

In whatever manner produced, this disease gives rise to important morbid changes in the affected portions of the lungs, especially the loss of the natural elasticity of the air-cells, and likewise the destruction of many of the pulmonary capillary blood-vessels, and the diminution of aerating surface for the blood. As a consequence an increased strain is thrown on the right ventricle with a consequent dilatation leading on to heart failure and all its attendant troubles. The chief symptom in this complaint is shortness of breath, more or less constant but greatly aggravated by exertion, and by attacks of bronchitis, to which persons suffering from emphysema appear to be specially liable. The respiration is of similar character to that already described in the case of asthma. In severe forms of the disease the patient comes to acquire a peculiar puffy or bloated appearance, and the configuration of the chest is altered, assuming the character known as the barrel-shaped or emphysematous chest.

The main element in the treatment of emphysema consists in attention to the general condition of the health, and in the avoidance of all causes likely to aggravate the disease or induce its complications. Compressed air baths and expiration into rarefied air may be useful. During attacks of urgent dyspnoea and lividity, with engorgement of veins, the patient should be repeatedly bled until relief is obtained. Interstitial emphysema arising from the rupture of air-cells in the immediate neighbourhood of the pleura may occur as a complication of the vesicular form, or separately as the result of some sudden expulsive effort, such as a fit of coughing, or, as has frequently happened, in parturition. Gangrene or post-mortem decomposition may lead to the presence of air in the interstitial tissue of the lung. Occasionally the air infiltrates the cellular tissue of the posterior mediastinum, and thence comes to distend the integument of the whole surface of the body (surgical emphysema). Surgical emphysema signifies the effusion of air into the general connective tissues of the body. The commonest causes are a wound of some air-passage, or a penetrating wound of the chest wall without injury to the lung. It may, however, occur in any situation of the body and in many other ways. Its severity varies from very slight cases where only a little crepitation may be felt under the skin, to extreme cases where the whole body is blown up and death is imminent from impeded respiration and failure of the action of the heart. In the milder cases no treatment is necessary as the air gradually becomes absorbed, but in the more severe cases incisions must be made in the swollen cellular tissues to allow the air to escape.