Severe Irreversible Airways Obstruction without Emphysema.

A combination of clinical, radiological, and physiological changes commonly called 'emphy-sema' is so often confirmed at necropsy that it is interesting to find that some patients whose condition seemed to be clinically indistinguishable from emphysema during life did not in fact have it. In a large series of patients who were intensively studied during life in a clinic for 'emphysematous' patients, 22 died between December 1958 and Feb-ruary 1960. A careful necropsy study was made in all, and three showed little or no evidence of emphysema. This paper is concerned only with those three patients, who are reviewed to see if emphysema could have been excluded during life. METHODS PHYSIOLOGICAL The ventilatory capacity of the lungs was determined in patient 1 and partly in patient 2 by measuring the volume of air expired in 15 or 20 seconds during maximum voluntary effort. In patient 3 and partly in patient 2 the forced expiratory volume and maximum expira-tory flow rate were measured using a kymograph and special spirometer (Bernstein, D'Silva, and Mendel, 1952). The average of three readings was taken. The arterial blood C02 content and 02 saturation were determined using the manometric Van Slyke method (Van Slyke and Neill, 1924). The pH was measured at room temperature on a Cambridge pH meter, using the Stadie electrode system, after standardization to pH 4 and 7 buffers. The observed pH was corrected to 38°C. by using Rosenthal's factor (1948). Arterial C02 tension was calculated from the total C02 content of the plasma and the pH using the Henderson-Hassel-bach equation. The fractional uptake of CO by the lungs was measured according to the method of MacNamara, Prime, and Sinclair (1959). PATHOLOGICAL Lung slices were prepared, usually from the left lung, and the middle slice was lightly impregnated with barium sulphate and examined by the dissecting microscope (Heard, 1958; 1960). The percentage of a slice that was emphysematous was estimated as described previ-RADIOLOGICAL A series of postero-anterior and lateral chest radiographs of each patient taken over a period of several years was examined without a knowledge of the clinical and pathological findings. The radiological criteria for diagnosing em-physema have been described (Laws and Heard, 1962). The most important were a reduction in the number and calibre of the peripheral pulmonary arteries, often with an increased transradiancy of the background due to a local destruction of the vascular bed. THE THREE PATIENTS PATIENT 1 This …