Chronic Bronchitis.

Definition.—An inflammation of the mucous membrane of the trachea and bronchi, that has existed beyond the period of acute inflammation, and has lost the acute symptoms of sthenia. It may be primary, following the acute or secondary.

Etiology.—Chronic inflammation is of frequent occurrence, and may result from many causes. A badly treated acute bronchitis or one where the patient stops treatment before a thorough cure is effected, often results in the chronic form. Neglect is a very common cause; the acute symptoms giving way, the patient, in his hurry to be about, pays but little heed to his cough, and before he realizes it, it has become firmly established. Sometimes it comes on very slowly; the patient coughs in the winter and spring whenever exposed to cold, but with the arrival of pleasant weather the cough disappears, to return more severely with the first attack of cold weather; by the following spring the chronicity is so well established that fair, pleasant weather, while mitigating the paroxysms, does not entirely relieve the sufferer, and the disease is well established.

Again, a pneumonia may set up a subacute bronchitis, which persists after the primary lesion has subsided.

Organic heart disease, especially of the right heart, is sometimes responsible for this condition, as may be chronic Bright's disease. Rheumatism, syphilis, tuberculosis, and chronic alcoholism may also be important factors in giving rise to the disease.

Old people are very prone to this affection, especially if they are sufferers from any organic disease and are not carefully sheltered in inclement weather. Children are not often troubled, unless it follows whooping-cough or measles.

Pathology.—The mucous membrane presents very different conditions. In some, the epithelial layer will have disappeared over a large surface, the mucous membrane becoming quite thin, or there may be thickening of the mucous membrane, with infiltration; in others, there is more or less ulceration. Again, there will be atrophy of the mucous follicles, dry bronchitis; in others, hypertrophy, with increased secretion—bronchorrhea.

The mucous membrane presents a livid violet color, in the place of the light red of the acute form. Where the disease is of long standing, with severe paroxysmal coughing, there is dilatation of the tubes, bronchiectasis. The changes in other organs are not so constant, being secondary and the result of complications.

Symptoms.—In chronic bronchitis we have to consider both local and constitutional symptoms. Of the local, the cough, the expectoration, and the respiration are the most prominent. Cough is the most troublesome and characteristic feature, being persistent and annoying, usually of a deep bronchial character, or short and hacking; again, asthmatic, with difficulty in breathing, causing exhaustion. It may be dry and ringing in character where but little mucus is secreted, or moist and loose where the secretion is profuse.

There is generally but little pain, although, when the paroxysms are difficult and long continued, there is soreness in the substernal region. The expectoration varies greatly in regard to quantity, appearance, and consistency, depending upon the type of the disease, of which there are three forms: (a) Dry catarrh, the catarrhe sec of Laennec; (b) Bronchorrhea serosa; (c) Putrid bronchitis.

Dry Catarrh.—This form is characterized by severe and prolonged paroxysms of coughing, but attended by little or no expectoration; the expectoration, when present, is tough and viscid and removed with difficulty. After the paroxysms, the respiration is hurried and asthmatic, the face being flushed and the patient quite exhausted. This form is usually found in elderly people. There is often emphysema, and not infrequently heart disease is associated with this type.

Bronchorrhea.—In this form, the secretion is profuse and expectoration abundant and easily expelled; each paroxysm of coughing is attended with a free expectoration of a watery character, mucopurulent, or fetid and of a greenish color. Where the mucus is purulent and offensive, it may be the beginning of dilatation of the tubes and fetid bronchitis. From two to four pints may be expectorated in twenty-four hours. After a night's rest the paroxysms of coughing are prolonged and severe, in order to remove the accumulation of the night.

Putrid Bronchitis.—In this form the expectorated material is abundant and fetid, the odor being characteristic of the decomposition of animal matter. This may be associated with tuberculosis of the lung, empyema with lung perforation, dilatation of the tubes, abscess or gangrene of the lung, although the odor may be present independent of these. "The expectoration is usually copious, and, upon standing, separates into three layers, of which the uppermost is composed of frothy mucus, the intermediate of a serous liquid, and the lowest of a thick sediment which presents a granular appearance, and is made up chiefly of small yellow masses, the so-called Dittrich's plugs. These plugs are characteristic of fetid bronchitis, and are the causes of the fetor. On microscopic examination, the Dittrich's plugs are seen to be composed of micro-organisms, chief among which is the Leptothrix pulmonalis; they may also contain pus corpuscles, fat granules, and crystals of margarin. (Anders.)

Physical Signs.—The physical signs depend upon the type, but are so characteristic that, taken with the symptoms above described, a diagnosis is readily made. Thus, in the dry form, auscultation reveals a dry, whistling, or sibilant rhonchus, and, upon percussion, a resonance is elicited showing that the lungs are not involved. Where the secretion is profuse, the mucous rhonchus is heard, and if the smaller tubes are involved, a slight crepitant sound may be heard. Where there is great relaxation of the mucous membrane, with the secretion increased, a flapping or gurgling sound is heard.

General Symptoms.—These depend upon several conditions. If there is no serious complication, the general health may be but little affected and the patient may follow his vocation with but little interruption. There is usually more or less emaciation, but aside from this, and a hurried respiration after exertion, he complains but little.

Where there is organic complications, the symptoms peculiar to the affected organ are generally so prominent that our attention is at once directed to it. Thus cardiac trouble would be known by the sense of weight and oppression in the region of the heart, the dyspnea being a marked symptom. The pain of rheumatism and gout are characteristic, while Bright's disease has a train of symptoms that are not misleading.

Where the lungs become involved, especially if the disease is of years' standing, the patient rapidly loses flesh and strength, is compelled to take to his bed, hectic fever and night-sweats follow, and the patient's condition resembles that of phthisis.

Diagnosis.—The diagnosis is usually made with but little difficulty, the only disease with which it might be confused being phthisis, and if we bear in mind that in phthisis there is fever and loss of flesh and great prostration, while in bronchitis the health is comparatively good, we can distinguish the two without much difficulty. In phthisis we get localized dullness, usually in the apex, while in bronchitis there is resonance on percussion. The history will also throw much light on the case, although the physical signs are the ones upon which most dependence is to be placed.

Prognosis.—The prognosis will depend upon the length of time the patient has been affected, his previous history, and the complications existing. Bronchitis being so many times secondary to diseases that of themselves are serious, our prognosis must be guarded.

Treatment.—One who can profit by our advice we would send to Southern California or Florida for the winter months, for nothing can take the place of change of climate,—a warm, even temperature, where the patient can remain out of doors the most of his time, being especially desirable. Unfortunately the greater number of our patrons can not bear the expense, and we have to do the best we can at home. Except in inclement weather, our patient must have plenty of outdoor air; but when the weather is wet and disagreeable, we must insist on his keeping indoors.

His sleeping apartment should be large and well ventilated. In the morning the patient is to flush the neck and chest with cold water, to be followed by thorough rubbing with a dry, coarse towel, till the skin has a healthy glow and all moisture disappears.

All nauseating remedies should be avoided, as we do not wish to disturb the stomach; for in order to make a good blood—an important factor in the treatment—we must have good digestion. We must also see that the excretory organs are in good condition.

The general treatment would look to a correction, where possible, of the primary lesions. The diet should be nourishing and easily digested, while pastries and rich desserts should be avoided. The bitter tonics and restoratives may be called for; yet, unless each remedy is given for a direct purpose, our patient will fare better without them. The cough is the most distressing feature, and one that calls loudly for relief. This will yield more satisfactorily to direct medication than by giving the usual expectorant compounds.

Drosera.—Where the cough is dry and hoarse, add from fifteen to thirty drops of drosera to half a glass of water. A teaspoonful every one or two hours will give good results.

Sanguinaria.—Where there is laryngeal irritation, a tickling in the throat, and a persistent cough, sanguinaria must not be overlooked, as it is one of our best agents for this condition.

Sticta Pulmonaria.—Where the cough is hard and dry, sticta alone, or in combination with bryonia, will be the remedy.

Ammonium Carbonate.—Where the mucous membrane is relaxed and the secretion profuse, from three to six grains of the carbonate of ammonium will give good results; syrup of tulu and simple syrup may be the vehicle for its administration.

Calcium Sulphide will be the remedy in fetid bronchitis. Where the cough is irritable and persistent, preventing sleep, an opiate may be necessary. In such cases,

Inhalations will be of much benefit, where there is but little secretion, there being dryness of the mucous membrane. If the larynx be involved, it will be doubly indicated. Steam inhalations, in which eucalyptus, lobelia, and hops are used, will prove very helpful.

Stillingia liniment in drop doses on sugar is a good remedy for a night cough. Esculus glabra is an excellent remedy where there are asthmatic symptoms.

A persistent hacking cough will frequently yield to the following cough mixture when all others fail:

Counter Irritation.—The older practitioners obtained splendid results from the old compound tar plaster, though few patients today would suffer the use of it. In the place of this, we may use a thapsia plaster.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.