page break

Chapter III.

Bronchitis.

If this were a systematic treatise, instead of a popular one of very small dimensions, I should speak of the various forms of laryngitis, especially of croupy laryngitis, before treating of bronchitis. But as these diseases are comparatively rare, and utterly beyond the range of domestic treatment, I shall merely mention that croup is of two kinds, the one spasmodic and comparatively harmless, the other inflammatory, attended by the production of a false membrane on the mucous membrane of the larynx, and fearfully fatal. Both are attended by a peculiar hard ringing metallic cough, which generally first comes on in the night. Not a moment should be lost in sending for medical assistance. The only thing the parents can safely do will be to administer an emetic of ipecacuanha, if that should be in the way, and to prepare the materials for a warm bath.

Bronchitis may be either acute or chronic. The acute variety may be either little more than a common cold, or a disease eminently dangerous to life, and requiring the utmost skill for its treatment.

Now, a great many people talk of having bronchitis, of suffering from bronchitis, of having just recovered from bronchitis, whose knowledge of the bronchi and of bronchitis is of the haziest description. But at a very trifling expenditure, any person may see what are the bronchi, and will be in a much better position to understand the symptoms of bronchitis. Let him purchase at the butcher's a pig's or sheep's "lights," i.e. lungs, and he will find that the windpipe, by which it is generally hungup in the shop, divides into two branches, which again divide and subdivide into innumerable ramifications: these are the bronchi or bronchial tubes. They consist of a number of incomplete rings formed of cartilage, which serve to maintain their shape; inside they are lined by a mucous membrane, continuous with the mucous membrane of the windpipe (or trachea). When this mucous membrane is inflamed the disease is called bronchitis.

It is attended in the very earliest stage by unnatural dryness of the membrane, but this very speedily gives way to over-secretion of the natural mucus of the part. This causes cough and expectoration, which is in some instances enormous. Supposing the case goes on favourably, after a time the secretion of mucus is lessened, the cough and expectoration lessen also, and ultimately cease. Now in acute cases bronchitis is attended with much fever, there is also some degree of pain on the affected side, but more of tightness and oppression upon the chest. Thus patients feel a constant disposition to sigh, but are unable to relieve themselves by doing so.

page 13

Instead of entering into an elaborate description of all the varieties of bronchitis, I shall merely state that this condition of the lung may be either acute or chronic, that it may attack one lung or both, and that it may involve only the larger divisions of the air-tubes, or extend to their minutest ramifications. Bronchitis may be caused by various things,—by cold, by the presence of tubercle in the lungs, as an accompaniment of several other diseases, such as measles, scarlatina, fever, disease of the kidneys, pneumonia, emphysema, and many others. It may also be caused by the irritation of small particles of dust, like the grinders' asthma (as it is called) of Sheffield, the potters' asthma in the Staffordshire Potteries, (both these diseases commencing with repeated attacks of bronchitis), or it may arise from unwholesome gases inhaled into the lungs. In all these instances however, the physical signs when the chest is examined are alike. We find sounds called rhonchi, indicating the presence of mucus in various states. In acute cases when the mucus is copious and fluid, we find crepitant rhonchus, in the later stages of the acute disease, and in chronic cases, we find cooing, whistling, sonorous and other rhonchi, indicating the presence of tough dryish mucus. At the same time, except in very young infants where collapse of the lung has taken place, percussion is much the same as in health. When the bronchitis is of very long standing and has given rise to other changes in the lung, the percussion sound may be altered.

Now bronchitis may be a very trifling or a very serious disease; it may require the most energetic treatment, continued day and night without intermission; or it may so little inconvenience or distress the patient as to require no treatment at all. Simple uncomplicated bronchitis, involving only one lung, ought always to be followed by perfect recovery. If a patient dies of it, he dies of the treatment, not of the disease. The tendency of bronchitis is always to recovery. What then are the reasons why death occurs in this disease?

In acute bronchitis death occurs, either because the original cause of the disease continues in action, and so one part of the lung after another is attacked, as is the case sometimes in consumption; or because both lungs are attacked, and the blood cannot be properly oxygenated, or the patient dies worn out by cough, rapid breathing and profuse discharge from the bronchial tubes. In chronic cases the patient dies from the changes produced in the lung, by repeated inflammatory attacks, and by heart disease, emphysema, and other secondary affections, the effects of which are aggravated by harassing cough, and in some cases enormous expectoration of mucus.

Mostly, however, in acute bronchitis, people die of the treatment, as Molière says, they die "of two physicians and an apothecary." Chronic bronchitis, though not rapidly, is surely fatal—unless cured. The person of fifty who has his or her attack of "winter cough and spitting," as soon as the cold weather sets in, will die of it in the course of a very few years, unless he or she obtain a speedy relief. It is quite a mistake to allow these attacks to wear themselves out, or to consider them as so much a matter of course that they need no treatment.

The treatment of acute bronchitis will differ very considerably in the infant and in the adult, or those beyond the age of infancy.

page 14

Bronchitis in the infant is generally called, even by medical men (of the old school), pneumonia. The fact is that in infants pneumonia is almost unknown. Some of the most scientific practitioners, and those who have had the greatest experience, have hardly ever seen a case of the disease. Speaking generally all those cases called "inflammations of the lung," in infants are cases of bronchitis.

Now these cases are exceedingly frequent, and their treatment is very much misunderstood. It is a very common practice to treat infants who are labouring under acute bronchitis, with lowering remedies, such as leeching, tartarized antimony, ipecacuanha, and even mercury in the shape of calomel, or grey powder. This is done because there is often—nay generally, high fever, indicated by rapid pulse, intensely hot skin, thirst, dry tongue, restlessness, &c. And yet if the lowering plan of treatment is adopted, it is almost sure to prove fatal. Ask any mother who has had a large family, and has lost several children, and she will be almost sure to tell you that some one or more of them "went off with the inflammation on the chest." It would be impossible to make intelligible to a non-professional reader, the condition of the lung described by the word "atalektasis," but it must suffice to say that as a consequence of infantile bronchitis the lung has a tendency to collapse, and resume the condition it had previous to birth.

The treatment of bronchitis must be directed to the prevention of this state, or to its removal when present. Hence from the very beginning a sustaining and stimulating plan must be adopted :—no antimony,—no ipecacuanha,—no leeches. Quinine, or the inspissated solution of bark or cinchonine, together with chloric ether, and accompanied by beef tea, and if need be, by wine or even brandy and water will prove almost universally successful. Under this kind of treatment I have never lost a case of bronchitis in an infant under two years of age, unless the child has been first seen by me when actually dying. I was called in to a child a few months ago for instance, who was already blue in the face and extremities, and although I have had several such cases recover, I do not consider them fair tests of the treatment.

Where both lungs are affected, it is absolutely necessary to give wine or brandy and water freely, or the infant will certainly sink. It may surprise many to hear of giving brandy and water to babes of only a few months old; but the experience of scores of cases has shown me, that it is not only harmless, but is essential to recovery. When this plan of treatment was first suggested to me, some six or seven years ago, I was as much astonished at it as any one could be. It seemed so contrary to all the traditions of medicine to give stimulants in any inflammatory disease with rapid pulse, and hot skin. At first I watched the cases most anxiously, seeing them every three or four hours, fearful lest any mishap might occur from the treatment. But I soon found that no fear need be entertained on that score. The good effect of the stimulants and tonics is almost invariable, the difficulty lies in getting parents to give them regularly, and to persevere long enough. I might quote a large number of cases, but one or two must suffice.

1st.—A child five weeks old; bronchitis in both lungs; loud mucous rales heard both in front and behind;—ordered half a teaspoonful of sherry every two hours, and a mixture with quinine, chloric ether, page 15 and compound tincture of cardamons; as often. The chest to be well fomented and kept poulticed. This was on the 18th September, 1861. The child rapidly improved, continuing the same treatment. On the 20th, the report is "much better," sucks well; the upper lobes of the lungs nearly free from mucus; the lower part of both filled with crepitation—continue treatment.

On the 23rd, the child had its last bottle of medicine, being then only a little feeble and having a slight cough. Thus, in five days, a case of bronchitis affecting both lungs was cured.

2nd.—A child four months old; had been ill several days from bronchitis; had been under the treatment of the assistant of another practitioner, who had mistaken the case altogether, and treated it as a slight febrile attack. When I arrived the skin was hot, pulse rapid, lips livid, countenance dusky, and the breathing extremely feeble and shallow, with all the auscultatory signs of double bronchitis : ordered a teaspoonful of wine every half-hour, and the quinine mixture every hour. Beef tea ad libitum.

In the evening the child was somewhat better. The next day there was great improvement. The child was lively and had sucked a little. To continue the wine every hour.

The next day was summoned in great haste, it being stated that the child was dying. Found the statement correct, all the family in the room, the child almost comatose, lips, hands, &c. blue, and in a very much worse state than at first. Found that the parents had neglected giving the wine and medicine, thinking the child did not want it as it was so much better. Determined to save the child if possible, I immediately administered a teaspoonful of strong brandy and water (half and half), and stopped with the child, giving it the brandy and water myself every twenty minutes, for two or three hours. By this time the child was better, the pulse had rallied, and the skin was not so blue. Told the parents to give the brandy and water, every twenty minutes, till I came again. This was done, and in a few days the child was quite well. This case attracted a good deal of attention in the neighbourhood in which it occurred, and was an unmistakeable proof of the value of stimulants in bronchitis. After the first few hours of the second attack, of course the brandy was not given quite so often, and quinine was given as well; but at first so extreme was the collapse, I relied exclusively on the brandy.

3rd.—A child a year and a half old; double bronchitis; dusky lips; pulse about 130; cough severe. The usual treatment ordered. Next day better, but not so much better as I should have wished; had had a quarter of a grain of quinine for a dose every two hours; doubled the dose of quinine. The next day there was a very marked improvement, which continued uninterruptedly. Discharged quite well on the 11th day from being first seen.

It is useless to multiply cases, as they are all so similar and so uniform in the result, that it would only weary the reader. In those cases where only one lung is affected, the recovery is more rapid. For example, I was yesterday called to a child about ten months old, suffering from bronchitis of the left lung; there was crepitation over the whole of the lung behind, at the flank and in front. Ordered the usual treat- page 16 ment. To-day he is no longer feverish, the cough and breathing are much better, he can take the breast pretty well, and there is crepitation only at the lower part of the lung behind, and in a few scattered spots besides; in other parts the breathing is clear. This child took the mixture every hour.

In older children it is not necessary to be so prompt in the use of stimuli; generally the quinine or cinchonine mixture will suffice, and occasionally an emetic of ipecacuanha, may be useful to clear away phlegm, but it should never be given in repeated doses. The ipecacuanha wine, which is so much given to children, kills hundreds.

Adults require a somewhat different treatment. If the disease is uncomplicated, and the result of cold, a few leeches, say half-a-dozen, applied to the affected side, will if the patient be tolerably strong, give very marked relief to the tightness and difficulty of breathing of the earliest stage. This must be followed by assiduous fomentations or linseed poultices, when the bleeding has ceased. Internally in robust persons, seen early, small doses, say the J of a grain of tartar emetic given every three hours, for about twenty-four hours, will relieve cough and promote expectoration. It is not necessary to continue the tartar emetic long. Afterwards, for a day or two, small doses of ipecacuanha may be given. If the lungs do not show signs of speedy recovery, a blister should then be applied, and a vegetable bitter, as gentian or cascarilla combined with nitric acid, and a little paregoric given. During the whole course of the disease, beef tea, arrowroot, and milk, may be freely administered, and if the rest is disturbed by the cough, a dose of Dover's powder at bed-time is very useful. In the latter stages of the complaint, bottled stout, bitter ale, or wine, aid recovery. Throughout the room should be kept cool but not cold, and thoroughly well ventilated. Much relief may be afforded in the early stages by inhaling the steam of warm water, which may be medicated if thought fit. Treated thus, few cases will become chronic.

Chronic bronchitis is a difficult disease to cure, especially when it has existed for a long time, or occurred repeatedly. If the patient can remove to a warmer climate, or possesses all the means and appliances of wealth, he has of course a much better chance than the man who has to work for his daily bread, and must live near his work. The first thing to be done, if the patient cannot have change of air, is to make the air he does breathe as pure as possible. Above all the bed room should be well ventilated. The fire-place should always be open, and the door or the window open too. Now the English have such a firmly fixed idea that fresh air gives them colds, and that it is better and more wholesome to breathe a foul hot air than a pure cold one, that this first step is often attended with considerable difficulty. It has cost me more speeches than any other point of treatment.

Next, all things that have tended to produce or keep up the attacks of bronchitis should be avoided, such as going suddenly from a very hot room, into draughts, or into the cold air, wet feet or garments, or getting drunk (a very common cause of chronic bronchitis). Flannel should be worn next the skin, and the flannel as well as the skin regularly and frequently cleansed. Cold water to the chest is an excellent thing, when followed by a brisk rub with a rough towel. It is a pity the working classes, generally, neglect the use of cold water so much.

page 17

The food should be simple and easily digestible, and the bowels kept in good order.

For medicine, a whole host of remedies have been recommended and tried, expectorants without end. It would be useless to give a list of all the drugs that have been administered. The principles of treatment are to allay cough which is often most harassing; to help the removal of the mucus which clogs up the air passages, and by local and general measures to give tone to, and restore to a healthy state the diseased mucous membrane. As, however, the patient when he applies for relief is often, indeed generally, suffering from some complication, such as emphysema, dilated bronchial tubesor heart disease: it is often beyond our power to do more than palliate, perfect restoration to health being impossible.

For allaying the cough, frictions with stimulating liniments such as the Croton oil liniment, the tartar emetic ointment, or the compound camphor liniment, will be found extremely useful. They really tend to cure the disease by their derivative action. In severe cases blisters are required, and will frequently do much good. Internally, morphia, opium, or prussic acid, ease the cough best.

As expectorants a number of drugs have been used. I don't believe much in any of them : they are all very uncertain in their operation. The best I have found to be ammoniacum, tolu and styrax, and in very old cases, attended by a very copious expectoration, balsam of copaiba. Squills is much used, and is a very popular remedy. I never saw it do the slightest good, or indeed produce any effect whatever. Ammoniacum is certainly useful. Camphor also seems to do good; but is more especially beneficial when the bronchitis is complicated with asthma, when it may advantageously be combined with stramonium. In these cases iodide of potassium is often of great use. Wheezy old patients find a mixture with camphor, compound spirits of sulphuric ether and laudanum, or paregoric, very useful.

But, I think, more good is to be done by attention to the general health, counter irritation by blisters or liniments to the chest, and tonics combined with carbonate of ammonia, than by special remedies. These latter are no doubt useful; but they should not be used too long to the injury of the appetite and digestion. Inhalations of creasote, or of iodine, in the steam of hot water, I have found very serviceable in old standing cases.

It must not be forgotten that when there is a great secretion of mucus, there must be and will be cough, and it would be dangerous to attempt to stop it. It is when a cough is harassing and continues either after the mucus has been expectorated, or comes on without any spitting at all, that it may be checked by anodynes or sedatives. I have not space to describe the many varieties and complications of bronchitis, such as gouty and rheumatic bronchitis, bronchitis in Bright's disease of the kidneys, plastic bronchitis, a curious and rare disease in which the patient brings up casts of the bronchial tubes, hay asthma, the various forms of mechanical bronchitis and many others.

A few lines must be devoted to epidemic bronchitis or influenza. This is, in its onset, in no way to be distinguished from an ordinary page 18 cold or attack of bronchitis, except by its severity and the extreme debility which accompanies it It is chiefly fatal to elderly people, and to those whose constitutions have been injured by previous disease. It requires, generally, from the very first, a tonic and sustaining treatment. If this is properly carried out it will rarely prove fatal except to the extremely debilitated.

Hooping cough is a disease too well known, and with symptoms too marked to require description. It commences with the symptoms of a common catarrh, but these in all but the mildest cases are in a week or two lost in the severe paroxysmal cough which gives its name to the disease. I looping cough is undoubtedly a disease or the nervous system, and is epidemic. It may be very slight, or it may be so severe as to cause death.

A vast number of remedies have been proposed for it, but it is pretty well established that no known method of cure exists. The disease will run its course, and the only thing to be done is to palliate the symptoms. Emetics of antimony or ipecacuanha are frequently of service; frictions to the chest by the compound camphor or other stimulating liniments and sedatives, such as belladonna, conium, opium, or hydrocyanic acid. The latter is particularly useful. At the same time the general health must be attended to, and the bowels kept regular. If possible the patient should have a total change of air. This often acts like magic in the cure of this most obstinate complaint. There is a specific given away at a confectioner's in St Paul's Churchyard, which has obtained great notoriety in London, as a cure. I have seen a single dose cure the complaint, and I have also seen it given without the slightest effect It is quite tasteless, and produces an emetic effect. Nitric acid in very large doses has been vaunted as a specific, I have given it without benefit, and I think the enormous doses recommended must be dangerous, especially to the teeth.