The apparatus best fitted to effect this double purpose is that of Waldenburg, as modified by Tobold.12 The method of using it is simple, and can readily be understood by examining the instrument. It must be said that the most valuable action of this apparatus consists in the withdrawal of the air from the cells which it effects, for this tends to produce an organic change for the better—viz. the diminution of the enlarged cells by a sort of suction; while its other action, the supply of condensed air, gives relief to symptoms mainly. In emphysema the expiratory act is relatively more impaired than the inspiratory, and the apparatus is best adapted to the relief of this greater deficiency. Henry Saltzer, formerly of Germany and now of Baltimore, has recently obtained very favorable results from its use in emphysema, not only as regards the dyspnoea and other symptoms, but also in the way of lessening the size of the chest as determined by measurements.13
12 This instrument is made by Messrs. J. Reynders & Co. of New York.
13 A reference to Saltzer's observations and measurements may be found in Weil's Handbook of Topographical Percussion, pp. 107, 108, Leipzig, 1880.
The third indication of treatment has reference to the complications of emphysema. Of these the most common, and one of the most important, is bronchitis, which is to be treated in the same way as when it occurs as an independent affection. Expectorants to promote and remove secretion and agents to allay cough are very important means, because the retention of secretion and the effort of cough to expel it cause a strain upon the air-cells, and thus increase the emphysema. The local use, by inhalation or spray, of opiates, belladonna, hyoscyamus, and other agents of this class, is often most serviceable by giving relief to the cough without disturbing digestion. As bronchitis is in many emphysematous patients a very chronic affection, and is attended with submucous thickening in the bronchial tubes and consequent diminution of their calibre, the iodide of potassium is an agent of special value for its relief. Whether the influence of this remedy is due to a sorbefacient power or to some other unexplained mode of action, there is no doubt of its great value in chronic bronchitis, so that for this complication of emphysema it claims a very high rank among medicines. The rapidity with which relief is afforded to the cough and dyspnoea of bronchitis, and to the asthmatic paroxysms attending it, by full doses of 10 or 15 grains of iodide of potassium at intervals of four hours, makes it probable that its action is partly neurotic in character. It is remarked by Austin Flint, Sr., that when the iodide has effected a marked improvement in the chronic bronchitis he has known the characteristic deformity caused by the emphysema to be notably diminished.14
14 Clinical Medicine, p. 131.
A dangerous symptom which sometimes arises in the course of the chronic bronchitis accompanying emphysema is profuse bronchial catarrh, which may destroy life by producing apnoea, the surface becoming cold and the pulse feeble and vanishing as the patient seems to be drowning in his own secretion. In this condition the writer has in several instances found prompt and unmistakable benefit from the hypodermic injection of hydrobromate of quinia, and he would strongly advise the use of this agent. The solution he has employed is of the strength of 4 grains of the salt to 20 minims, and of this 15 to 20 minims has been the dose given. Under the action of this remedy the pulmonary capillaries would appear to be so toned that further effusion is checked, and the gasping and cyanotic condition has been speedily succeeded by comfortable breathing. For the same symptom Waters advises the use of moderately large doses of turpentine (drachm doses in aromatic water every two hours) on a plan suggested by Sir D. Corrigan of Dublin.15
15 Diseases of the Chest, p. 172.
As bronchitis has so much power to produce emphysema when the conditions favorable to its occurrence exist, and to increase it when already established, everything tending to prevent it is of great importance. With this view the avoidance of cold and wet, and, when practicable, recourse to a mild climate in winter, are advisable.
The attacks of asthma to which emphysematous patients are subject are to be treated in the same way as the purely spasmodic form occurring independently of discoverable organic disease. If the difficult breathing has come on suddenly and the patient is not laboring under advanced dilatation of the heart, prompt relief may be given by a hypodermic injection of morphia; but if the heart is much dilated, this might endanger too great depression. Chloral is generally unsafe for the same reason. The bromides in full doses may be serviceable in the less severe attacks, and the tincture of lobelia in doses of 10–20 drops every fifteen minutes until slight nausea is felt is often of great benefit, as is also the smoking of stramonium-leaves.
The dropsy met with in advanced stages of emphysema may be so prominent a symptom as to require special treatment. Its cause is found in dilatation and weakness of the right chambers of the heart, which result from obstruction to the circulation through the lungs when compensative hypertrophy is no longer efficient, for then these give rise to passive congestion of the liver and kidneys and remora of the general venous system, with dropsical leakage, seen first and chiefly in the lower extremities. Treatment is therefore to be directed chiefly to increasing the tone of the heart; and for this purpose digitalis is most useful, as it is in other forms of cardiac dropsy. The chief indication of its beneficial action is seen in the better action of the kidneys consequent upon the increased impulsive force given to the heart. When acting favorably, marked relief both of the dropsy and the dyspnoea may be obtained from the use of this agent in the dose of 2 to 4 drachms of the infusion or 10 or 15 drops of the tincture every three or four hours. If the stomach should not bear the digitalis, as is sometimes the case, or if it fail to act or lose its power, the fluid extract of convallaria, recently introduced as synergistic with foxglove, may be employed as a substitute for it.