A system of practical medicine. By American authors. Vol. 3

by Unknown

PROGNOSIS.—The circumstances, apart from treatment, which especially affect the prognosis of emphysema are the form in which the disease occurs and the ability of the patient to secure immunity from influences which may increase the malady itself or the attendant bronchitis, such as hard work, great exertion of the respiratory organs, and exposure to cold and damp.

Acute supplementary emphysema, even when it affects considerable portions of both lungs, may entirely disappear and the vesicles be restored to their integrity on the removal of the underlying cause. Thus, the vicarious dilatation of air-cells following acute bronchitis or whooping cough in children may leave no sign of its previous existence after recovery from these diseases. In general, the shorter the duration of the causal diseases, the more likely is the emphysema to disappear; for if it be maintained for a considerable time, the elasticity of the cells may be so damaged that they may never return to their natural size.

In hypertrophic lobar emphysema the prognosis in most cases is unfavorable as regards perfect recovery; while yet the disease may not materially shorten life, and with proper care may be compatible with a fair degree of comfortable existence. And, indeed, even in this form of the disease, provided it do not affect a great extent of lung and have not been of very long duration, there is in some cases ground for hope of ultimate recovery, with restoration of the air-cells to their normal condition. Modern methods of treatment have rendered the prognosis in such cases somewhat less unfavorable than it was once held to be.

TREATMENT.—The treatment of emphysema comprises several distinct objects: 1st, the arrest of the degenerative changes which may be going on in the walls of the air-vesicles, and which favor their dilatation; 2d, the restoration, as far as is possible, of the integrity of the lungs, so that they may resume their natural size; 3d, the relief of bronchitis, asthma, and dropsy, which are associated as secondary affections with the primary disease.

To meet the first of these indications, the arrest of degenerative change, iron is among medicinal agents the one most to be relied upon; for, though neither it nor any other means has power to restore loss of tissue or to reproduce integrity of structure when several alveoli are fused into one cavity by the breaking down of their partition-walls, yet by enriching the blood it may improve the nutrition of these cell-walls so that the tendency to dilatation and rupture may be checked. Iron steadily administered in small doses is the best means for effecting this end, and if the patient object to one form of the metal after using it for some time, it may be changed for another. The best preparation of the drug is probably the tincture of the chloride, and one of the best forms for administering this medicine is the mixture of acetate of iron and ammonium (Basham's mixture) introduced into the U. S. Pharmacopoeia of 1880. This is especially valuable, when any dropsical effusion exists, on account of its gentle diuretic action. In addition to iron, other agents promotive of nutrition, such as cod-liver oil and the hypophosphites, may be used with the same view. Stomachic tonics, such as the simple bitters and pepsin, may be useful by aiding digestion and nutrition; and at the same time, by preventing the formation of flatus, they may relieve the dyspnoea caused by upward pressure on the diaphragm. That real benefit may be derived from such measures is beyond doubt; and it is to be feared that some practitioners, in their conviction that no cure can be wrought in those parts of the lung which have actually undergone wasting and rupture, have to too great an extent neglected the use of means which may at least prevent the advance of similar changes in other parts, and thus tend to stay the progress of the disease.

Deep and hurried respiration will increase the air-pressure within the yielding vesicles; for this reason active exercise is objectionable, especially walking up hill, and the use of wind instruments is to be strictly prohibited. Indeed, as regards this last cause of respiratory pressure the patient's inability to practise is in general warning enough, but in the early stages of the affection a caution against it may be necessary.

The suggestion of the use of strychnia against emphysema is not founded on a correct knowledge of the mode of action of this drug; for, although it may stimulate muscular contractility, it has no influence upon the elasticity of the air-cells and no power to restore them to their natural size. Whatever benefit may result from it is due solely to its action on digestion and the improvement in nutrition to which it may thus contribute.

The second indication of treatment, the restoration of the dilated air-cells to their natural size, is possible, if at all, only at an early period of the disease or in portions of the lung which have not gone beyond a moderate degree of cell-dilatation. An enlarged space formed by the fusion of several cells cannot be lessened in size by any means, medical or mechanical, and the loss of respiratory power from the destruction of the cell-walls in which oxygenation is effected does not admit of permanent relief. Where, however, such destruction has not yet taken place and distension is not extreme, there is reason to believe that a return of the cells to their natural size may in some cases be accomplished. The inhalation of condensed air has been recommended with this view; and no doubt good may result from it, due chiefly to the retardation of the breathing and of the heart's action which it occasions, while dyspnoea is relieved by the larger supply of oxygen taken in at each inspiration. This improvement in respiration causes more complete tissue-metamorphosis, and thus aids nutrition and all the functions.

Still greater benefit is to be derived from the exhalation into rarefied air—a measure which acts upon mechanical principles, and has been found to give relief not only to the symptoms of emphysema, but to the organic disease itself; for the retention and stasis of the residual air, which is far larger in amount in emphysema than it is in health, serve at once to keep up the dilatation of the cells and to increase the dyspnoea; and therefore any means which will effect the withdrawal of this air will favor the return of the cells to their normal size, and at the same time relieve the dyspnoea. This benefit is accomplished by the method of expiration into rarefied air, which acts by suction—or pneumatic aspiration, as it may be termed—drawing out the air from the distended vesicles, and relieving them of the continual presence and pressure of this air. Better results would appear to be gotten from the conjoint use of the two methods—the inspiration of compressed air and expiration into rarefied air—than from either one alone.

By the persistent use of these means in cases which have not advanced so far as to defy all treatment not only may the symptoms of dyspnoea, cough, asthma, and impaired nutrition be improved, but the size of the chest may be diminished, as shown by measurement; and this can result only from the return of the distended air-cells, in some degree at least, to their normal capacity.