treatment of all grades of inflammation affecting the mucous membrane
and connective tissue of the bronchial tubes--namely, _(a)_ to diminish
or overcome the morbid excitability of the inflamed part; _(b)_ to
relieve the vascular hyperæmia or fulness of blood in the vessels, and
thereby limit the amount of exudation or morbid secretion and
consequent dyspnoea; _(c)_ to counteract or relieve secondary
functional disturbances, such as increased heat and dryness of the
skin, diminished renal and intestinal activity, and nervous
restlessness; _(d)_ to hasten the removal of such plastic exudations as
may have caused thickening and induration of the inflamed structures or
formed layers or patches of false membrane on the bronchial surface,
and to lessen the tendency to establish a stage of purulent
degeneration or suppurative action in the inflamed part; _(e)_ to
regulate diet, drinks, exercise, and clothing in such a way as to
sustain healthy nutrition and prevent the further action of
predisposing and exciting causes.
The first three objects to be accomplished belong more particularly to
the early stage of acute and subacute attacks, but are present in some
degree throughout the whole course of the disease; while the last two
belong to the latter stages of the acute and to all stages of the
chronic grades of the inflammation. While the foregoing indications to
be fulfilled or objects to be accomplished are present in all the
various grades and stages of inflammation of the bronchi, the
particular means for accomplishing them will be modified by the age and
previous physical condition of the patient, the nature of the
predisposing and exciting causes, the extent of the disease, and the
stage of its advancement; or, in other words, the nature and extent of
the pathological changes already accomplished. For instance: the same
remedial agents that would be most efficient in relieving the morbid
excitability and the vascular fulness of the first stage of acute
inflammation in a young or middle-aged and previously healthy, vigorous
subject might be positively injurious, or even fatal, if used in the
same stage of inflammation in a subject previously anæmic and feeble or
debilitated from age or from causes capable of impairing the quality of
the blood and favoring a typhoid condition of the system. Consequently,
the practitioner who not only sees clearly the objects most desirable
to accomplish, but who most judiciously selects and adjusts the means
or agents he uses to the special conditions of each patient, will meet
with the highest degree of clinical success.
In the first stage of acute attacks involving the bronchi of both lungs
in vigorous adult persons, and especially if the inflammation extends
into the smaller tubes, causing much dyspnoea and dry râles, there is
no single remedy that will so certainly and speedily check the intense
engorgement of vessels in the bronchial membranes, and thereby gain
time for the action of other remedies, as one prompt and liberal
abstraction of blood by venesection. In cases of a little less
severity, and in children, the application of from two to twelve
leeches to the upper and anterior part of the chest, the number being
regulated by the age of the patient, will be a good substitute for the
venesection. And in case leeches are not at hand extensive dry cupping
over both the anterior and posterior parts of the chest may be applied
with much benefit. Immediately after the venesection, leeching, or
cupping, and without these in cases of only ordinary severity, the
whole chest may be enveloped in an emollient poultice or in folded
napkins wet in warm water and covered with oiled silk. At the same time
the following combination may be given internally: {179}
No. 1. Rx. Liquoris ammonii acetatis, (60.0 c.c.) fluidounce ij;
Tincturæ opii camphoratæ, (75.0 c.c.) fluidounce iiss;
Vini antimonii, (15.0 c.c.) fluidounce ss;
Tincturæ veratri viridis, (6.0 c.c.) fluidrachm iss.
M.--Sig. Give to an adult 4 cubic centimeters or 1 teaspoonful in a
tablespoonful of water every two, three, or four hours, according to
the severity of the case. The same may be given to children, the dose
being properly adjusted to the age of the child.
If the tongue be coated, the bowels inactive, and urine high-colored,
from 6 to 30 centigrams (grs. j-v) of calomel, according to the age of
the patient, may be given, and followed in four or five hours by a
saline laxative sufficient to procure two or three evacuations from the
bowels. Under the influence of these remedies the high fever and great
sense of soreness and oppression in the chest which exist in the first
stage of the more acute cases in previously healthy subjects rapidly
diminish, giving place to more moist râles, easier breathing, and some
expectoration. As soon as such amelioration of symptoms has been
obtained, the mixture containing veratrum viride should be
discontinued, and the following formula substituted in its place:
No. 2. Rx. Syrupi scillæ comp. (45.0 c.c.) fluidounce iss;
Tincturæ sanguinariæ, (15.0 c.c.) ounce ss;
Tincturæ opii camphoratæ, (60.0 c.c.) fluidounce ij.
M.--Sig. Give to an adult 4 cubic centimeters in a little additional
water every three or four hours.
If the patient suffers much from severe sore pain in the head,
aggravated by coughing, or from nervous restlessness, the addition of
bromide of potassium, 16 grams (drachm iv), to the above formula will
render it more efficient in relieving these symptoms and in promoting
rest. Under such quieting and expectorant influences, aided by a mild
laxative when needed, the cough, soreness, and oppression in the chest,
and all other active symptoms, diminish from day to day, and
convalescence ensues in from seven to nine days.
If after the first three or four days the temperature rises in the
evening and the cough becomes more troublesome, interfering with rest
during the first part of the night, followed by some sweating in the
early morning, a single dose composed of sulphate of quinia from 3 to 6
decigrams (gr. v-x), pulverized sanguinaria-root 3 centigrams (gr. ½),
and codeine 16 milligrams (gr. ¼) given between six and eight o'clock
each evening for three or four evenings, will often contribute to the
rest of the patient and hasten the establishment of convalescence.
Cases are sometimes met with, especially in patients debilitated by
previous ill-health or age, in which the fever subsides after the first
three or four days, leaving the patient with a feeling of unusual
weakness, a deep harassing cough, copious muco-purulent expectoration,
and little or no appetite. In such cases tonics and the more
stimulating class of expectorants are indicated. A mixture of equal
parts of the syrup of Prunus virginiana, syrup of senega, and
camphorated tincture of opium, given in doses of 4 cubic centimeters or
one teaspoonful every four or six hours, and 13 centigrams (gr. ij) of
quinia three times a day, will often cause a rapid improvement in all
the symptoms. In some of the cases last described there is added to the
other symptoms a troublesome nausea and disposition to vomit with the
paroxysms of coughing, in which I have found the following formula a
good substitute for the mixture containing the prunus virginiana and
senega:
No. 3. Rx. Acidi carbolici, (0.50 grams) gr. viij;
Glycerinæ, (30.0 c.c.) fluidounce j;
Tincturæ opii camphoratæ, (60.0 c.c.) fluidounce ij;
Aquæ, (60.0 c.c.) fluidounce ij.
{180} M.--Sig. Give 4 cubic centimeters (fluidrachm j) or 1 teaspoonful
before each mealtime and at bedtime, giving the quinia a little after
the meals.
If more anodyne influence is required to procure rest at night, 16
milligrams (gr. ¼) of codeine may be added to the teaspoonful of
carbolic acid mixture given at bedtime. If, as sometimes happens in
cases of acute bronchitis, both of the catarrhal and capillary
varieties, the inflammation invades some of the lobules of the lungs,
as indicated by undue rise of temperature, greater expansion of the
wings of the nose during inspiration, with short expiration, and
diminished resonance with fine crepitation over limited portions of the
chest, I have found the most certain and speedy relief to follow the
application of a blister over the seat of the pneumonia and the
internal use of the following formula:
No. 4. Rx. Ammonii chloridi, (12.00 grams) drachm iij;
Antimonii et
potassii tartratis, (0.13 grams) gr. ij;
Morphiæ sulphatis, (0.20 grams) gr. iij;
Extract, glycyrrhizæ fluidi, (30.0 c.c.) fluidounce j;
Syrupi, (90.0 c.c.) fluidounce iij.
M.--Sig. Give to adults 4 cubic centimeters (fluidrachm j) or 1
teaspoonful, mixed with a tablespoonful of water, every three or four
hours until some relief is obtained, and then at longer intervals. For
children the doses must be diminished in proportion to the diminution
of age. Quinine and laxatives may be used in these cases under the same
indications as in uncomplicated bronchitis.
In the severe attacks of capillary bronchitis in young children many
writers recommend emetics, and subsequently nauseating doses of
antimony or ipecacuanha. But I have not seen sufficient benefit result
from emetic doses of these agents to compensate for the early
prostration, and sometimes continued gastric irritability, which they
induce. I prefer the proper application of leeches at the very
beginning, followed by emollient applications to the chest, and the
same remedies internally as already mentioned, aided, perhaps, by an
earlier use of quinine and digitalis if the cardiac action becomes weak
and frequent. In all this class of cases, however, much caution should
be exercised in regard to the use of opiates, either alone or in
combination with other remedial agents, lest their narcotizing
influence should diminish the force and frequency of the respiratory
movements too much, and encourage the accumulation of the inflammatory
products in the smaller bronchi to such a degree as to produce apnoea
or death by the exclusion of air from the alveoli or air-cells of the
lungs. And yet just enough of these quieting agents to diminish
excitability and allay excessive restlessness is as desirable in
children as in adults.
In the plastic or pseudo-membranous form of bronchitis it is an object
of much importance, in the first stage, to limit the amount of plastic
exudation, and later to hasten the loosening and disintegration or
discharge of such layers of false membrane as may have formed on the
bronchial mucous surface. For these purposes alterative doses of
calomel may be given alternately with the doses of the formula
containing the liquor ammonii acetatis already given (see Formula No.
1) during the first twenty-four hours, and subsequently pretty full
doses of the iodides of sodium or potassium or of the bicarbonates. In
acute cases in children, when the symptoms indicate that the false
membrane is loosening and the dyspnoea is great, an emetic that will
induce prompt and free vomiting may hasten its expulsion and afford
much relief.
In the cases which have been described as rheumatic bronchitis of the
more acute or active grade I have seen the most prompt and satisfactory
degree of relief follow the administration of the following combination
of remedies in the early stage: {181}
No. 5. Rx. Sodii salicylatis, (25.00 grams) drachm vj;
Glycerinæ, (15.00 c.c.) fluidrachm iv;
Vini colchici radicis, (25.00 c.c.) fluidrachm vj;
Syrupi scillæ compositi, (45.00 c.c.) fluidounce iss;
Tincturæ opii camphoratæ, (60.00 c.c.) fluidounce ij.
M.--Sig. Give 4 cubic centimeters (fluidrachm j) every three or four
hours in a little additional water.
In several cases in which this grade of inflammation was located
chiefly in the smaller bronchi, causing very distressing and persistent
dyspnoea, I have found an equal mixture of the wine of colchicum-root
and the acetated tincture of opium, given in doses of 25 to 30 minims
every three hours at first, to afford more relief than any other
remedies I could use; and after some degree of relief had been
obtained, by lengthening the interval between the doses to four or six
hours and continuing it a few days, all the symptoms were removed. When
the disease occurs in old persons, accompanied by severe paroxysms of
coughing and only a scanty and very viscid mucous expectoration, much
benefit may sometimes be derived from the use of the carbonated
alkalies, such as the carbonate of ammonium or bicarbonate of sodium,
dissolved in an equal mixture of the fluid extract of the Phytolacca
decandra, liquor ammonii acetatis, and camphorated tincture of opium,
in such proportions that the patient will get 3 decigrams (gr. v) of
carbonate of ammonium in each dose of the mixture.
It is proper to remark that there are many mild attacks of bronchitis,
caused by exposure to sudden and severe meteorological changes, which
if seen during the first twenty-four hours can be speedily arrested by
a hot or stimulating foot-bath and a full dose of the compound powder
of opium and ipecacuanha (Dover's powder), taken in the evening, and
followed the next morning by a saline laxative and two or three
moderate doses of quinine during the day. Similar results can also be
obtained in some cases by the use of any agents that will allay
irritability and at the same time produce a free or copious elimination
from the skin and kidneys. An efficient diaphoretic dose of
pilocarpine, or a full warm bath, followed by two or three moderate
doses of quinine, will succeed well if employed in the initial stage of
the disease. Unfortunately, but few cases come under the care of the
physician until after this stage is past.
TREATMENT OF CHRONIC BRONCHITIS.--Most of the cases of chronic
bronchitis are treated satisfactorily by a more moderate use of the
same remedial agents that have been recommended in the acute and
subacute grades of the disease, aided by a judicious regulation of
diet, dress, and exercise. In the great majority of cases of the
ordinary chronic catarrhal variety of bronchitis the formula already
given, numbered 4, or the one numbered 2, if given to adults in doses
of 4 cubic centimeters (fluidrachm j) before each meal and at bedtime,
mixed with a tablespoonful of water, will afford the necessary relief
without confining the patient to the house. If the bowels become
constipated while using either of these prescriptions, the evil may be
obviated by taking one of the following pills every evening:
No. 6. Rx. Extract. hyoscyami, (2.00 grams) gr. xxx;
Ferri sulphatis, (2.00 grams) gr. xxx;
Pulveris aloës, (2.00 grams) gr. xxx;
Pilulæ hydrargyri, (2.00 grams) gr. xxx.
M. et ft. pil. No. XXX. If one pill taken every evening does not prove
sufficient to prompt one natural intestinal evacuation each morning,
another can be taken after breakfast. The patient should adhere to a
plain, nutritious, and easily digestible diet, avoiding the use of all
varieties of alcoholic drinks, wear good warm underclothes of flannel
all the time, and take moderate daily outdoor exercise so long as the
strength will permit.
{182} In addition to the several remedies that have been mentioned as
applicable to the treatment of the different varieties of acute and
subacute bronchitis, there are many others that have been found more or
less beneficial in the treatment of chronic cases. Among the more
important of these are the iodide of potassium and sodium, the
grindelia robusta, eucalyptus globulus, oenothera biennis, cimicifuga
racemosa, asclepias tuberosa, balsams copaiba and tolu, gum benzoin,
turpentine, cod-liver oil, and the hypophosphites of sodium, calcium,
and iron; and a still larger number that have been used for inhalation.
As a general rule, when the cough is harsh and the expectoration
scanty, with the predominance of dry râles, such remedies as the
muriate and iodide of ammonium and the iodides of potassium and sodium,
given in conjunction with small doses of antimony and some mild
anodyne, will produce the best effects. On the other hand, if the
expectoration is abundant and of a muco-purulent character, the
balsamic and terebinthinate remedies, given in connection with such
tonics as the lacto-phosphate of calcium, phosphate of iron, sulphate
of quinia and strychnia with codia, hyoscyamia, or lupulin, at night to
procure rest, will afford the greatest relief. In some of these cases I
have obtained very good effects from a combination of two parts of the
syrup of iodide of calcium with one of the fluid extract of hops, given
in doses of 4 cubic centimeters (fluidrachm j) each morning, noon,
tea-time, and bedtime.
When chronic bronchitis is complicated with pharyngitis and
laryngo-tracheitis, much palliative influence may be obtained by
judiciously-directed inhalations, either in the form of vapor or
atomization. But when the disease is limited to the bronchi alone,
inhalations have much less influence over its progress or in relieving
the more distressing symptoms. And unless the nature of the material
used is judiciously selected with reference to the particular stage and
grade of the disease, the inhalations will be more likely to do harm
than good. There are two conditions of the bronchi met with in
different cases of chronic bronchial inflammation to which local
applications can be made in the form of vapor with much benefit. The
first is indicated by an abundant purulent or muco-purulent
expectoration, sometimes fetid and at other times not. For such the
full deep inhalation of aqueous vapor impregnated with some antiseptic
and anodyne will be of great service. One of the best combinations that
can be used for this purpose is that of carbolic acid with camphorated
tincture of opium in the proportion of 2 grams of the former (gr. xxx)
to 90 cubic centimeters (fluidounce iij) of the latter; 4 cubic
centimeters (fluidrachm j) of this mixture may be put into 250 cubic
centimeters (fluidounce viij) of hot water in an inhaling-bottle and
the vapor inhaled freely, five minutes at a time, two or three times
each day.
The second condition alluded to is characterized by a persistent,
harsh, irritating cough, with little or no expectoration, indicating a
sensitive and congested condition of the mucous membrane with
diminished secretion. Such cases may generally be much relieved by
adding to the antiseptic and anodyne mixture just given some one of the
oleo-resin or balsamic preparations, of which perhaps none are more
efficient than that which is known in the shops as oil of Scotch pine.
Four cubic centimeters (fluidrachm j) of this may be added directly to
the quantity of the other ingredients already given, and then used in
the same manner. The combination thus used appears to allay the morbid
sensitiveness and speedily establishes a better secretory action.
There is another important class of cases met with most frequently in
persons of both sexes between twelve and twenty years of age. They
present a narrow, imperfectly-developed chest, with so sensitive a
condition of the bronchial membrane that every trifling exposure to
cold and damp air renews the vascular hyperæmia and cough, until both
become permanent and the morbid process extends into the connective
tissue of the pulmonary lobules, {183} establishing what some call
interstitial pneumonia and others fibroid phthisis. In the earlier
stage of all this class of cases the systematic daily practice of full,
deep inhalations of pure atmospheric air, coupled with a judicious
exercise of the muscles of the chest and arms, will do more to remove
all symptoms of bronchial disease and preserve the general health of
the patient than all the medicines that have been hitherto devised.
There is much evidence in favor of using compressed air for inhalation
in these and some other cases of bronchial inflammation. The late F. H.
Davis of this city, who during his brief professional career gave much
attention to the treatment of diseases of the respiratory organs, and
had good opportunities for clinical observation, says, when speaking of
the same class of young subjects, that "the inhalation of compressed
air for from five to ten minutes once or twice a day produced marked
and rapid improvement in all the cases. The size of the chest on full
inspiration was increased from one-half inch to one inch in the first
month, and a habit of fuller, deeper breathing and a more erect
carriage was established."[8] But he adds, with proper emphasis, that
the inhalations to be permanently curative must be continued faithfully
for many months, and be accompanied by a judicious regulation of all
the habits of life.
[Footnote 8: See paper read before the Chicago Society of Physicians
and Surgeons, April, 1877, on "The Respiration of Compressed and
Rarefied Air in Pulmonary Diseases."]
Every physician of much practical experience knows, however, that, in
defiance of all the remedies and methods of treatment hitherto devised,
there are many cases of chronic bronchial inflammation which will
continue, and be aggravated at every returning cold season of the year,
so long as the patient lives in a climate characterized by a
predominance of cold and damp air with frequent and extreme
thermometric changes. And yet a large proportion of these, by changing
their residence to a mild and comparatively dry climate, either greatly
improve or entirely recover. Consequently, in all the more severe and
persistent cases such a change is of paramount importance, and should
be made whenever the pecuniary circumstances of the patient will
permit. Probably the best districts in our own country to which the
class of patients under consideration can resort are the southern half
of California, the more moderately elevated places in New Mexico and
the western part of Texas, Mobile in Alabama, Aiken in South Carolina,
and most of the interior parts of Georgia and Florida. My own
observations lead me to the conclusion that the unfortunate invalid,
suffering from any grade of chronic bronchial inflammation, can find in
some of the regions named all the relief that could be gained in the
most celebrated health-resorts on the other side of the Atlantic. But
adherence to strictly temperate and judicious habits of life, with
regular daily outdoor exercise, is essential to the welfare of the
invalid in whatever climate he may choose to reside.
In the foregoing pages I have said nothing concerning the management of
those cases of asthma, emphysema, interstitial pneumonia, etc. which
often occur either as complications during the progress of bronchial
inflammations or as sequelæ, simply because they will all be fully
considered in the articles embracing those topics in other parts of
this work.
{184}
BRONCHIAL ASTHMA.
BY W. H. GEDDINGS, M.D.
SYNONYMS.--Asthma convulsivum (Willis); Spasmus bronchialis (Romberg);
Asthma nervosum; Krampf der bronchien.
DEFINITION.--A violent form of paroxysmal dyspnoea, not dependent upon
structural lesion; characterized by wheezing respiration, with great
prolongation of the expiration, and by the absence of all symptoms of
the disease during the intervals between the attacks.