Page:The American Cyclopædia (1879) Volume VI.djvu/595

 EMPHYSEMA 587 va I r distending the cellular tissue under the ikin, the air may penetrate between the mus- es, along mucous canals, vessels, and nerves, > the inmost recesses of the organism. The eatment consists in letting out the confined air by minute punctures with a lancet, and pre- venting its reaccumulation by proper bandages, and in cases of extreme oppression by paracen- tesis or incision of the thoracic walls ; the cure may be hastened by antiphlogistic measures, and by stimulating applications and frictions. In Europe it is not uncommon for persons de- sirous of securing immunity from military ser- vice, and for purposes of mendicancy and decep- tion, to inflate with air various parts of the surface of the body, pretending that their con- dition is the result of chronic or congenital diseases ; the treatment in these cases consists in scarifications, bandages, and tonic frictions. Spontaneous emphysema may occur after ex- posure to great cold, in certain cases of inter- nal poisoning and of poisonous bites, after co- pious bleedings and various severe accidents, and in debilitated conditions accompanied by gangrene. The treatment for this is the same as for the preceding variety. Pulmonary em- physema may be either vesicular or interlob- ular. In the first the vesicles are enlarged, ruptured, and united, and the lung, when the chest is opened, may be so distended, more especially the upper lobes, as to protrude from its cavity ; when only one side is affected it presses upon and displaces the heart and the other lung ; such diseased portions are strongly crepitant, part with their contained air with difficulty, and float very lightly on water. In interlobular emphysema the distended vesicles assume an irregular form, sometimes of consid- erable size, and are situated just under the pleura ; and the emphysematous swelling may be made by pressure to move under the serous covering as far as the next lobular division of the organ. Sometimes the enlarged vesicles are not in the subserous tissue, but in the tissue separating the lobules, between which they may descend to a considerable depth. These varieties are usually combined, their symptoms re the same, and the latter is generally con- dered the consequence of the former, the dis- ntion and rupture of the vesicles proceeding a greater extent. Laennec and Piorry main- ined that pulmonary catarrh was one of the principal causes of the dilatation of the vesicles, which, unable to free themselves from the vis- cid mucus without great effort, of necessity became enlarged. Louis seems to consider that some power of active dilatation is brought into play. Admitting the connection between em- physema and obstructed bronchi, with the first named authors, there is no necessity for making the former a direct consequence of the latter ; measured by a pressure gauge, the forced expi- ratory act has been found one third more pow- erful than the act of forced inspiration ; as Dr. "W. T. Gairdner has well observed (in his work on bronchitis), whenever viscid obstructions are to be removed from the air passages, the air is gradually expelled from the affected part of the lung by expiration, and they become col- lapsed in proportion to the obstruction. Em- physema is the direct opposite of bronchial col- lapse, and its indirect consequence; because, whenever a part of the lung is obstructed or collapsed from bronchitis or any other cause, the air during inspiration must rush with great- er force and volume into the portions still freely open. Bronchitic accumulation and collapse are most common at the posterior and lower part of the lungs, and emphysema on the free anterior borders; the emphysematous portions are easily inflated from the bronchi, while the collapsed parts are not. Emphysema is, there- fore, essentially a mechanical lesion from disten- tion of the air cells, in proportion to which the flow of blood through the ultimate capillaries of the lungs is arrested, causing absorption of their walls, and tension and obliteration of their vessels. In the case of Mr. E. A. Groux, with congenital fissure of the sternum, in the course of prolonged forced expiration, the chest and abdomen became smaller, the veins at the root of the neck swollen, the upper intercostal spaces convex, and the fissure assumed its great- est width ; and above the pulsatile cardiac tu- mor was a protruding mass which percussion showed to be the anterior portion of the upper lobe of the right lung. This can throw little light on the ordinary causes of emphysema, though the cells are doubtless dilated, because the protrusion is evidently due not so much to the obstructed passage of air or blood as to active muscular effort, and to the raising of the whole .thoracic contents by the diaphragm and abdominal muscles in a cavity whose bony wall is deficient in front, where of course the free portion of the lung would protrude. Emphy- sema has been traced to compression of the bronchi by tumors; to the great respiratory efforts required in playing on certain wind in- struments, showing the connection between this disease and forced expiration, and as partly exemplified in the above case of Mr. Groux; the disposition to this disease has also been considered hereditary, and doubtless many cases of so-called hereditary phthisic or asthma are due to the vesicular dilatation consequent on spasmodic bronchial contractions. It is found in both sexes, at all ages, and in all con- stitutions ; once developed, it remains during life, sometimes stationary, but generally in- creasing, with irregular intervals of ease ; the dyspnoea is sometimes such that the patient is obliged to sit up in order to breathe; slight causes, as a catarrh, exposure to irritating gas- es or dust, or vivid emotions, are sufficient to bring on an attack. Examination of the chest will show an enlargement of the affected side at the upper region of the ribs and intercostal spaces. On percussion the chest is very sono- rous, and the respiratory sounds feeble, with rales sonorous, dry, or humid, according to the accompanying catarrhal condition, and the