Emphysema

Used in a general way, emphysema is a term which implies the presence

of air in the interstitial tissue, but when applied to the lungs

there are two applications of the term, having widely different

significations, viz: Interlobular or interstitial emphysema and

vesicular emphysema.

=Interlobular Emphysema.=—This is caused by rupture of air vesicles,

deep in the lung structure, the air escaping into the interlobular

connective tissue. It is not a very serious condition, rarely produces

symptoms and affords no physical signs. It usually results from violent

acts of coughing in which the expiratory strain is very great, as in

whooping cough and in bronchial asthma; also, from wounds of the lung.

The air bubbles escape into the interlobular septa and are sometimes

seen like little rows of beads outlining the lobules. The pleura

may become detached and larger vesicles may form. In rare cases the

rupture may take place at the root of the lung and the air passes

along the trachea into the subcutaneous tissue of the neck and chest

wall, which gives rise to a very peculiar and distinctive crepitation

upon palpation. Rarely there is rupture of the superficial vesicles,

producing pneumothorax.

=Vesicular Emphysema.=—Dilatation of the infundibular passages and

alveoli or an increase in their size either symmetrical, involving both

lungs, or localized. Vesicular emphysema is divided into compensatory,

hypertrophic and atrophic forms.

=Compensatory.=—This occurs when a region of the lung has been disabled

from any cause and does not expand fully during inspiration; the

healthy portion of the lung must then distend and do vicarious work

or the chest wall will sink in to occupy the space. This happens with

portions of healthy lungs in the neighborhood of tubercular areas and

cicatrices, areas of collapsed lung or parts prevented from expansion

by pleuritic adhesions (in this case the compensatory emphysema

is chiefly at the anterior margins of the lungs). As a rule this

distention is physiologic and beneficial, the alveolar walls being

simply stretched. Later they may atrophy, the air cells becoming fused.

=Hypertrophic Emphysema.=—This is enlargement of the lung, due to

dilatation of the air vesicles and atrophy of the walls.

=Osteopathic Etiology= and =Pathology=.—An important predisposing cause

of emphysema is often found to be due to derangements of the tissues,

usually vertebræ and ribs, which affect the innervation to the lung

tissues. Such lesions are found in the vagi and spinal dorsal nerves.

The atlas may be involved, but it is generally the ribs and dorsal

vertebræ. Distinction should be made between cause and effect in the

skeletal changes. No doubt in many instances a vicious circle is thus

established. Congenital weakness of the lung tissues, probably due to

non-development of the elastic tissue, is a predisposing factor. This

disease has a markedly hereditary character and frequently starts

early in life. The heightened pressure within the air cells upon an

already weakened lung tissue produces emphysema. Hence, the obstinate

cough of chronic bronchitis and expiratory straining of asthma are

sometimes the immediate cause. In all attacks of severe coughing or

straining efforts, the glottis is closed and the air is forced into the

upper part of the lungs, forcibly expanding them, and here is where

emphysema is found to be most advanced. This disease is also found

in players of wind instruments, in glass blowers and in those whose

occupation necessitates heavy lifting or straining.

=Pathologically=, the thorax is barrel-shaped. The lungs are enlarged

and do not collapse when the thorax is opened, as they have lost their

elasticity. The organs are pale, soft and downy to the feeling and

pit on pressure. Enlarged air vesicles may readily be seen beneath

the pleura. Microscopically, there are seen atrophy of the vesicular

walls and a diminished amount of elastic tissue. There is more or less

obliteration of the capillaries, and the epithelium of the air cells

undergoes a fatty change. There is usually chronic inflammation of the

bronchial tubes, which may be roughened and thickened. The diaphragm

is lowered and the subjacent viscera are displaced. The most important

morbid changes are found in the heart, the right chamber being dilated

and hypertrophied. This is caused by the increased tension in the

pulmonary artery, which is enlarged and the seat of atheromatous

degeneration. In long standing cases the hypertrophy is general.

Changes in the liver, kidneys and other viscera are those associated

with prolonged venous engorgement.

=Symptoms.=—The onset of the disease is usually gradual. The first

symptom to be noticed is the shortness of breath. In rare cases it

may exhibit a more acute development, as after whooping cough, and

then the first symptom will be dyspnea. In some cases this persists

all the time, while in moderate emphysema the dyspnea is noticed

only on slight exertion, such as going up-stairs, running or walking

rapidly. The lungs are always filled with air which is charged with

carbon dioxid and does not change, as the patient is constantly making

ineffectual efforts to draw in air. The inspiration is shortened and

the expiration is greatly prolonged and is often harsh and wheezy. The

pulse-rate is accelerated; the temperature is usually normal. Cyanosis

is a characteristic symptom in well established cases and is of an

extreme grade not seen in any other affection. Bronchitis is frequently

found in combination, especially in winter. In this case there will be

the symptoms of the associated bronchitis, cough, expectoration and

sometimes oppression. As the patient advances in age and there are

successive attacks of bronchitis, the condition gets worse. In advanced

cases, the result of cardiac failures, there may be venous engorgement,

dropsy and effusions into the serous sacs.

=Physical Signs.=—=Inspection.=—There is a marked change in the shape

of the thorax. The chest is rounded with increased circumference,

giving the characteristic barrel-shaped chest. The sternum bulges,

as do also the costal cartilages. The intercostal spaces are wide,

especially in the hypochondriac region, and narrow above. The clavicles

and muscles of the neck stand out with great prominence and the neck

itself seems to be shortened on account of the elevation of the

thorax and sternum. The curve of the spine is increased and there is

a winged condition of the scapulæ. These changes give the patient a

stooping posture. The chest does not expand, but is raised up by the

scaleni and sternocleidomastoid muscles which stand out prominently

and are hypertrophied. The heart’s apex beat is invisible and there is

usually marked epigastric pulsation. On =palpation=, vocal fremitus

is found diminished, but not absent; the apex beat is rarely felt.

There is distinct shock over the ensiform cartilage. This is due to

the displacement of the heart and engorgement of the right ventricle.

There is marked pulsation in the epigastrium. On =percussion= there

is sometimes increased resonance, almost amounting to tympany. The

upper level of hepatic dullness is depressed. The heart dullness may

be obliterated and the upper limit of splenic dullness may also be

lowered. The =percussion= note is greatly extended. =Auscultation=

reveals that the inspiration is short and feeble while there is

prolonged expiration, the normal ratio being reversed. In associated

bronchitis rales are frequently heard.

=Diagnosis.=—Unless complicated the diagnosis is generally easily

made. The enlargement of the thorax, with dyspnea and hyperresonance

and a prolonged expiration will differentiate emphysema from =chronic

bronchitis=. =Pneumothorax= is of sudden development while emphysema is

of slow development. Pneumothorax is usually unilateral, and it gives a

tympanitic percussion note. In auscultation there is amphoric breathing

and metallic tinkling and absence of any vesicular murmur.

=Prognosis.=—The disease is rarely fatal, although death may result

from heart failure, dropsy or pneumonia. Thorough and persistent

treatment will generally relieve the primary condition. The disease, as

a rule, runs a long course but does not necessarily shorten life.

=Atrophic emphysema= is a senile change.

=Treatment.=—In cases of recent occurrence one may be able to build

up the altered lung tissue by treatment of the innervation to the

lung structure, viz.: the vasomotor nerves from the second to the

seventh dorsal, the vagi, and the cervical and dorsal sympathetics.

When a number of air vesicles have been converted into one sac, it is

impossible to restore the altered lung structure and a treatment to

relieve the symptoms and to prevent the further progress of the disease

is indicated. In all cases treatment should be applied to correct any

vertebræ or ribs of the upper dorsal region that may be displaced, and

to raise and spread the ribs so that the lung structure may be better

nourished and strengthened and that the aeration of the blood will

be more perfect. Treatment of the vagi nerves is important, as their

physiological action on the lungs is to increase their movement.

The general health of the patient is an important consideration

and everything should be done to promote as healthy a condition as

possible. The digestion should be carefully looked after and everything

done to restore a normal state of the blood. A change of climate may

prove beneficial.

Strengthening the cardiac action will be of service in relieving any

dropsical tendency that might occur on account of obstruction to the

pulmonary circulation. If bronchitis or asthma occurs, their respective

treatments are indicated. A general treatment of the splanchnic and

lung vascular areas should be given to prevent any disturbance in the

circulation which might cause congestion of the liver, congestion of

the hemorrhoidal veins, or catarrh of the stomach and bowels.

“Free evacuation of the bowels and measures to relieve any flatulent

distention are very needful in cases of emphysema to take off from the

diaphragm any pressure from below, and to allow it to descend as freely

as possible. With this view also the food should be concentrated,

nourishing, and not bulky.”[95]

It is a good plan to instruct the nurse or attendant to aid inspiration

by raising the arms strongly above the head during inspiration and to

compress the chest during expiration so as to coincide with natural

breathing, which will render the aeration of the blood greater and

increase the elasticity of the vesicles.