Chronic Catarrhal Bronchitis.
Synonyms:—Chronic bronchitis; chronic bronchial catarrh; winter cough.
Definition:—Chronic bronchitis is a chronic catarrhal inflammation of the mucous and submucous tissues of the bronchial tubes, differing from the acute form in its slow development, characterized by a persistent cough, which is subject to remissions and exacerbations and by ultimate structural change in occasional cases.
Etiology:—Primarily, the disease follows an acute attack of bronchitis, or it is the result of persistent or long continued exposure to unfavorable climatic conditions such as cold, damp weather and sudden atmospheric changes, or to continued working for a long period in a dust-ladened atmosphere. Bronchitis in its chronic form is usually secondary to chronic constitutional disorders such as lithaemia, gout, rheumatism, syphilis or tuberculosis, or to chronic alcoholism. The form known as hypostatic bronchitis is a not uncommon complication of chronic interstitial nephritis, or of chronic valvular disease of the heart.
The primary form of the disease may occur at any time during early adult age, but the secondary form is much more common above middle life and during old age, it having persisted often for many years.
Symptomatology:—Persistent, intractable cough, varying greatly in different cases, is the commonest evidence of this disease. Usually there is no fever. Where the temperature runs persistently above normal, there are usually co-existing conditions upon which this is dependent. With the cough there is persistent bronchial secretion, which may be mucoid in character, mucopurulent or in extreme cases purulent and fetid. Where the expectoration is free the cough occurs in paroxysms, but is not accompanied with any great discomfort. Where the expectoration is scanty the cough is more violent, there is a sense of soreness and constriction under the sternum, and tbe muscles of the upper abdominal walls become sore and lame from the violence of the cough.
The cough varies greatly with the season. In a large number of the cases it disappears entirely during the hot period of middle and late summer, while in the early fall and spring and during the winter months if there is much exposure the cough becomes exceedingly violent, and often incapacitates the patient for labor.
Each individual is apt to have a characteristic form of the cough which, in successive years, is alike. Thus if there is a dry, hoarse, ringing, metallic cough in one winter it is apt to assume the same form in the following winters. This fact is true also of the character of the expectoration.
The pulse is not influenced early in the disease unless there is a slight fever which may be present only in the night. The respiration is usually normal, except in aged patients.
When the cough is persistently dry or when but little expectoration is present with tenacious sputum difficult of expulsion, the condition is known as dry bronchial catarrh. When the cough exists with persistent asthmatic breathing, it is designated as asthmatic bronchitis. When the expectoration is profuse, and as it occasionally is, exceedingly offensive, the condition is designated as fetid bronchitis, although this condition may be one of bronchiectasis or it may be due to abscess or gangrene of the lungs, depending upon other chronic organic disease. In rare cases bronchitis exists in patients where those conditions are present which result in rheumatism or gout. There has been much written concerning uric acid in great excess as a cause of bronchitis, asthma and catarrh. The etiological influence of this substance is not positively determined. When thought to depend upon these causes, it has been designated as rheumatic bronchitis.
There is a form of bronchitis in which the secretion is persistently abundant, usually not thick and tenacious, but watery and more like serum, of which it is largely constituted. From one to two quarts of this serum may be expectorated in twenty-four hours. This is designated as bronchorrhoea.
Diagnosis:—A difficulty in the diagnosis of chronic bronchitis is in determining whether or not it is the result of other chronic disease which may be overlooked in the treatment. The possibility of pulmonary tuberculosis must first be excluded. The kidneys must be carefully examined to determine that parenchymatous or interstitial nephritis are not present. Valvular heart disease must be excluded as well as all constitutional diatheses. It is also important to determine that the cough is not the result of reflex irritation, from the coexistence of chronic disease in the gastro-intestinal canal or in some remote organ. Uterine disease is not an uncommon cause of reflex cough.
Treatment:—But little benefit will result from treatment if the condition is secondary to other disease, which does not receive successful treatment as the primary cause. In uncomplicated cases the disorder is amenable to treatment and should be studied with special reference to the specific indication for direct medication. If there are evidences of chronic congestion of the mucous or submucous tissues belladonna is a favorite remedy of the author's. It is especially useful where soreness with slight chilliness are present. If the cough is very dry, the dosage should be very small and frequently repeated; the physiological action of the remedy should not be observed in dilatation of the pupil nor in the drying up of secretion. If the secretions are excessive and expectoration is very free, the agent should be given in larger doses for a short time to obtain its apparent physiological influence.
With this remedy bryonia acts in perfect harmony. It operates on the changes which have resulted or are taking place from the chronic inflammatory processes. It should be given, if the cough is very dry, especially if it be persistently short, sharp and hacking in character—not paroxysmal; also if with persistent soreness in the chest, there are short, quick, sharp, cutting pains, with a nocturnal rise of temperature. The author has combined these two remedies with the happiest results in many cases.
In cases of comparatively short duration the application of persistent heat to the chest is of much service. This may be best applied upon retiring at night and retained for two or three hours, when in an extremely chronic case it is sometimes beneficial to occasionally apply sharp external derivation, the use of the thapsia plaster is very serviceable. The eclectic "fathers" used the compound tar plaster. This is now considered unnecessarily severe as is also the cantharides blister. Good results are now obtained from the use of turpentine or other penetrating oils or from our compound stillingia liniment. Ordinary cough medicines are of little avail in this disease. The persistent use of the ammonium chlorid in small doses is of service where the cough is very dry. Where the expectoration is excessive or profuse turpentine is an important remedy. In the asthmatic form of the disease grindelia robusta with yerba santa may be given. Their use should be persisted in.
Verbascum thapsus will be found of much service also in this form. In winter cough which is persistently hoarse in character or which is deep, resonant, metallic or barking, without secretion, lippia mexicana has cured many cases for the writer without other medicine. It has proved almost specific. It may be given in from ten to twenty minim doses in syrup of tolu or wild cherry. Small doses of lobelia may be given in those cases where there is a constant sense of constriction with but little secretion, or where the respiration is at all asthmatic in character. If spasmodic asthma occurs as a complication this remedy may be given in a single large full dose, of perhaps half a dram, to relieve the paroxysm. If the mucous membranes are dark red or purplish in character and show relaxation and atonicity capsicum may be added to the combination or it may be given alone, or with remedies indicated for other conditions, when these symptoms are present with the other conditions. When the expectoration is fetid in character echinacea or the calcium sulphid should be given with perhaps minute doses of turpentine or the oil of eucalyptus and these volatile antiseptics should be also administered by inhalation. Creosote will also ameliorate this condition, and should be administered in a proper menstruum. Other remedies which will be found of service are thuja, drosera, sticta, piscidia and grindelia robusta.
In the treatment of chronic bronchitis constitutional conditions must have direct and positive attention, and organic disease must be persistently treated. The nervous system must have attention. Nerve tonics, alteratives and general restoratives are usually indicated during the course of the disease. The stomach and digestive apparatus must not be overlooked, for while the appetite is usually good, digestion and appropriation are often faulty, and consequently the general nutrition of the system is imperfect.
The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.