VoL. 120, No.

E D I T 0 R I A L
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BRONCHITIS, EMPHYSEMA, AND AIR

C HRONIC obstructive lung disease is a Determination of the causes of chronic

not entirely felicitous term which has bronchitis and emphysema other than
evolved to include chronic bronchitis, em- smoking has been hampered in adults by
physema, bronchiectasis, asthma, or some the prevalence and overwhelming signifi-
combination of these. The term covers cance of smoking. British workers24 have
clinical and morphologic features of all of therefore investigated children who are
them. Asthma and bronchiectasis are the under the usual age when smoking begins,
most clearly defined of the group and usu- and have uncovered startling results.
ally afford no great problem in diagnosis Chronic bronchitis develops in children,
and classification. The other two, chronic produces changes in pulmonary function
bronchitis and emphysema, pose many tests, and is related not only to the ambient
problems. atmosphere but also to the social milieu at
These two diseases frequently coexist, home.3 As expected, chronic bronchitis oc-
and the contribution of each in a given pa- curs more frequently in children who live in
tient is difficult to assess. Emphysema is the polluted atmosphere of a city rather
determined on the basis of its gross and than in a relatively less irritating rural at-
microscopic changes, which correlate only mosphere, but, more surprisingly, the dis-
fairly well with symptoms, while the defini- ease occurs much more frequently in chil-
tion of chronic bronchitis has been based dren of semiskilled or unskilled laborers
entirely on its clinical manifestations. Re- than among the children of managerial or
cently, some attempts have been made to professional groups, whatever the surround-
assign histologic criteria to chronic bron- ing atmosphere.4 In general, the significance
chitis, but the lack of clean-cut end points of childhood disease in the background of
makes tissue interpretation variable. Fur- adult disease has been underestimated. The
then difficulty is encountered in epidemio- changes of chronic bronchitis, once estab-
logic investigations because of varying lished, are inexorably progressive and this
practices ofreporting deaths. The incidence has led one author to paraphrase Words-
of chronic bronchitis in Great Britain is worth: the bronchitic child is father of the
much greater than in the United States, bronchitic man.
for example, and in the latter any combi- Thus far, only one specific cause for
nation of bronchitis and cardiovascular dis- emphysema has been uncovered. Con-
ease is reported as heart disease. Bronchitis genital deficiency of alpha,-antitrypsin
is reported as a cause of death much more leads to early and severe emphysema in at
frequently in Great Britain. The same type least 50 pen cent of individuals in those
of patient is seen in emphysema clinics families which have been studied. The part
in the United States as is seen in chronic
bronchitis clinics in Great Britain. 3 HOLLAND, \V. W., HALIL, T., BENNETT, A. E., and ELLIOTT,

A. Factors influencing onset of chronic respiratory disease. Brit.

M. 7., 1969, 2, 205-208.
1 THUELBECK, W. M., HENDERSON, J. A., FRASER, R. G., and COLLEY, J. R. T., and REID, D. D. Urban and social origins
BATES, D. V. chronic obstructive lung disease. Medicine, 1970, of childhood bronchitis in England and Wales. Brit. M. 7.,
./9, 81-145. 1970, 2, 213-217.
2 REID, D. D. Beginnings of bronchitis. Proc. Roy. Soc. Med., ERIKSSON, S. Pulmonary emphysema and alphat-antitrypsin
1969, 62, 311-316. deficiency. 1cta med. scandinav., 1964, 175, 197-205.

923
 924 Editorial APRIL, 1974

played by lesser degrees of deficiency is less naphy may show nothing. Bronchography
clear. The pant played by smoking is vastly may disclose rironchial pitting or ob-
greater. struction in bronchial branches. The pitting
The roentgen diagnosis of both chronic probably a manifestation of the same
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is
bronchitis and emphysema has always pne- feature as is measured by the Reid index in
sented a problem. In emphysema, where the histologic diagnosis.
there are clear-cut pathologic changes, The incidence of chronic bronchitis and
these may be masked on mimicked by the emphysema, together on singly, is rising,
technique of the examination and by the and rising rapidly in urban centers. Thus
patients body type and breathing capabili- the advantages of city life are being
ties. It appears that pulmonary oveninfla- purchased at an ever ascending price. Ac-
tion is an unreliable sign. A more reliable tive mixing of the atmosphere has been
sign is alteration in the smaller pulmonary demonstrated,9 and this ensures that air
vessels,6 admittedly a more subjective contamination is eventually a world-wide
matter. Tomography has been used to problem. The death rate for all respiratory
great advantage to display the pulmonary diseases is second only to that for candio-
vessels and has led to reliable correlation vascular disease, and this, too, has been
with subsequent pathologic findings. Dr. rising.
Robert G. Fraser7 discusses the more subtle The implications of these factors for the
application of vasculanity to the diagnosis future are clear,
and we can look to the
of emphysema in this issue of the Journal brewers yeast Saccharomyces carisbergensis
in his Caldwell Lecture-an exhaustive for a lesson. The planet earth has been
treatment of the place of radiology in the likened to a space ship with a finite proven-
evaluation of bronchitis and emphysema. den, and in particular, a finite atmosphere.
Also in this issue, Dr. Isitman and his co- With increasing pollution and mixing of
workers8 describe the use of a new carrier this precious commodity, it eventually be-
for radioactive isotopes which may be de- comes lethal. We are then in the position of
posited on alveolar walls and which will the yeast organisms. As they metabolize
permit another avenue of approach to both the malt, producing alcohol and carbon
anatomy and physiology. dioxide, they are creating their own doom.
In chronic bronchitis the situation is Although the carbon dioxide bubbles off,
even more clouded. Plain film roentgenog- they live only until the increasing amount
of alcohol reaches a level sufficient to kill
651MoN, G., PRIDE, N. B., JONES, L., and RAIMONDI, A. C.
them. We must live in the atmosphere we
Relation between abnormalities in chest radiograph and changes
in pulmonary function in chronic bronchitis and emphysema. are polluting. The increasing incidence of
Thorax, 1973, 28, 15-23.
bronchitis and emphysema indicates our
FRASER, R. G. Radiologist and obstructive airway disease:
Caldwell Lecture, 1973. AM. J. ROENTGENOL., RAD. THERAPY & danger.
NUCLEAR MED., 1974, 120, 737-775.
E. FREDERICK LANG, M.D.
ISITMAN, A. T., MANOLI, R., SCHMIDT, G. H., and HOLMES,
R. A. Assessment of alveolar deposition and pulmonary clearance
of radiopharmaceuticals after nebulization. AM. J. ROENTGENOL., NEWELL, R. E. Global circulation of atmospheric pollutants.
RAD. THERAPY & NUCLEAR MED., 1974, /20, 776-781. Sc. ,lm., 1971, 22, 32-42.