Chronic Bronchitis And Bronchial Asthma
( Originally Published 1912 )
The Microbe's "Apologia pro vita mea"
"Blindly we seem to labor,
"Patient unceasing toilers
IN this chapter I propose to discuss the origin and treatment of that form of chronic bronchitis, often connected with asthma, that so cripples and shortens the lives of elderly people. The disease called pure spasmodic asthma, which may begin without bronchitis, belongs almost entirely to earlier years and does not come within the scope of this article, though the vaccine treatment that I am going to describe will often cure it. Especially in large towns with impure smoky atmosphere this disease among the elderly gives us a large part of our work, and often much worry and disappointment; but that is of little consequence compared with the wretched health and the premature deaths that it causes among our patients, and among the working classes the shortening of the working years that it entails is a matter of serious moment both to the individual and to the nation.
The original causes are not always the same. It may begin by frequent attacks of simple head catarrh, which gradually extend to the bronchial mucous membrane; it may begin with influenza; it may arise from a slight attack of pneumonia or of broncho-pneumonia, which are often unrecognized and untreated ; or it may becaused by continued inhalation of irritant gases or particles that belong to their trade. Among men and women who have to live and work in such unhealthy surroundings we have to fight this disease chiefly in its own lair—change of air and work are rarely possible—and this is a fight which needs all the weapons that modern science can give us, all our patience and all our skill ; but when one weighs up the results it is a fight worth the fighting.
Whatever the original cause of the condition may be, we find that sooner or later, in almost every case, we have a microbic infection to deal with. It is very rarely that one finds the sputum sterile. The microbes that we find are chiefly and I am trying to give them in the order of their frequency—the Micrococcus catarrhalis, pneumococcus, one or other variety of staphylococcus, and streptococcus. The Friedlander and proteus are more rarely found, but in my experience are very important. When one has attacked these poisonous microbes with autogenous vaccines, and has watched and weighed the results, one must, I think, arrive at the conclusion that they are the chief factors that maintain and perpetuate the disease. I am by no means claiming that we always get good effects from this treatment, but the number of cases that are either cured or much relieved by this method are so far in excess of the failures that I must come to this conclusion. In fact, I have almost come to the further conclusion that failure is the result of some error either in the selection of the microbes or in the technique of the preparations. The numberless cases that have been cured by vaccine during the last few years should encourage us to further scientific investigation, and the failures should only serve to reveal our defects.
There is one point that I must emphasize, in this place—that is, the importance of a good, careful bacteriologist. The preparation of these vaccines, if done in a careless, unintelligent way, will only lead to failure and disappointment; and, what is perhaps worse, will cast a stigma on us and on that subject of our pride, medical science.
I am not speaking like this without good reason, for even in large, well-known bacterial laboratories I have known very poor work done. I am inclined to think that private workers, and preferably medical men, will oftentimes make better vaccines than institutions where individual watching and direction is very difficult. As an example, we who have had any considerable experience of these methods must have come across cases which have been cured by one man's vaccine where another man's has totally failed. It is perhaps hardly necessary to say that all vaccines for this disease should be autogenous; and yet I have known stock vaccines sent out and recommended as equally good. We may say that this is a case of pneumococcus poisoning or of streptococcus, but we are still in the dark as to how many strains or varieties there may be of the same named microbe. In a few cases of acute pneumonia, where there has been no time to make an autogenous vaccine, I have known a stock vaccine do wonders, but they are quite the exception; in such cases a shot in the dark is justifiable.
Hitherto I have been looking at this disease from the point of view only of the invader, and I have been considering only the destruction of the enemy by our artillery. The wise physician will soon see that this is only part of the problem. The patient who has unluckily got the disease is really the man who has to do the fighting; we can help him much by attacking the enemy from without, but we must also teach him and help him to put his natural defences in order. Strictly speaking, we must look on these poisonous bacteria as foreigners, but as a matter of fact they are almost always with us. Very rarely does a microscopical examination of the mucus of the nose or mouth fail to show the presence of one or other of them, even in health. Our natural powers of resistance, our internal secretions, and our phagocytes, are generally able to deal with them effectually and to ward off their importunities; but it is when these powers fail or are caught nap-ping, when the bacteria multiply by millions and there is nothing to destroy them, when they pass out of their place and invade the internal organs, that disease is established. The prevention of this failure of resisting power must be our first aim.
Overwork, intemperance, improper feeding, exposure to damp and chill, all tend to lower the vitality and to expose us to attack. These we must fight as best we can and as circumstances allow. The enemy is always round the corner waiting for his chance. It is to our frontiers that. we must always be looking.
Our most vulnerable points are probably the nose and mouth. The nose in health should act as a dust and germ filter so effectually that no live germ should gain entrance into our system, but the mucous membrane of the nose, especially in impure atmospheres, often becomes irritated and thickened, and proper nose-breathing becomes a difficult thing; then mouth-breathing becomes more or less a habit. This, though a natural passage for air, is not an effective filter. One sees how very liable children with adenoids are to bronchitis and bronchial asthma. The nose, then, is the first point to attend to. The physicians and surgeons who have devoted themselves to this branch of work can often give us great help, by restoring a proper nasal passage and by attention to the tonsils. There is often a congested, tender spot in one or both nostrils, which seems to act as a centre from which proceed the nerve storms that cause spasmodic asthma. Here, also, hay fever seems to originate. This spot needs great care in treatment, and harm can easily be done; but some of our chief specialists, by their skill, produce in these cases something like a miraculous revolution. Our largest frontier, of course, is the skin, and this many working folk habitually neglect. Their work often causes sweating, and the skin that sweats needs careful washing and protection. They often wear clothes that do not absorb the moisture, and so, when work ceases, their skin is in contact with a damp, chilly material. Much may be done by bathing and after-rubbing with a rough towel to keep the circulation of the skin in a healthy resisting state. Bronchial folk, as a rule, cannot stand a cold bath, and a hot bath often relaxes the pores and leaves them liable to chill. The best plan is to thoroughly wash and soap in hot water and then, standing up with the feet still in the hot water, to have two or three good sponges down with cold, beginning at the head. This produces a good reaction of the circulation and is a pleasant stimulant. The clothing should be not too light, nor so heavy as to produce perspiration when not at work. Light woollen materials are, I think, the best, but some of the modern cellular makes of cotton seem to answer well.
It is clear, then, that anyone with a tendency to bronchial catarrh or asthma needs to lead a most careful and watchful life; he is incessantly almost open to attack from hostile germs, and every chill weakens his defences. We, on our part, can do much to help these cases by looking to the heart and blood vessels, the digestion and the kidneys. Many of these patients, especially in middle life, have overstrained, dilated hearts, and often some degree of arterio-sclerosis, and there may be early kidney trouble. The action of the liver often is sluggish, and the organ may be. congested; this, of course, causes indigestion and the flatulence which bothers many of them so much. Careful attention to all these points will help much towards cure, especially in conjunction with the vaccine treatment. To gain real success the old therapeutics and the new must go hand in hand.
There is a distinctly gouty form of chronic bronchitis which often alternates with true gout and eczema. This, in the first instance, will only yield to appropriate gouty treatment—alkalies, sulphur, etc.; but even this form becomes bacterial in the end, and the sputum should always be examined. Most of the remedies (and they are almost innumerable) that we have used empirically in the past have acted chiefly as bactericides--for example, the tars, turpentine, terebene, the balsams, the benzoates; the great favorite, iodide of potassium, acts probably in this way, directly by its iodine and indirectly by stimulating the output of thyroid secretion. Chloride of ammonium, again, probably acts in the same way. Antimony, which in the acute early stages of bronchitis was our forefathers' sheet-anchor, and which has fallen out of use far too much, is probably a bactericide (vide its action on trypanosomes). While carrying out the vaccine treatment, even if there be no cardiac complication, the patient will need helping in every possible way. Arsenic and iron are often very useful. The judicious use of internal secretion preparations will often help wonderfully. In cases with high tension and threatening arterio-sclerosis, thyroid will often bring about a better state of general health and help to reduce abnormal deposits of fat about the heart. In others suprarenal extract will do good, especially if arterial tension be low; in others one of the poly-glandular preparations will raise the general tone and resisting power.
When we come to the practical use of vaccines, we have first to find out what the sputum contains—for there will rarely be only one enemy—and then to decide on a single or multiple vaccine. I think we must give the pneumococcus the place of honor. He is as common as any, and perhaps the most easily cured. It is very surprising how many cases of chronic bronchitis, with or without asthma, have pneumococci, even when there is no history of any attack that one can suspect of being true pneumonia. One must, I think, come to the conclusion that many attacks of acute bronchitis are pneumococcic in origin, even when there have been no signs of lung consolidation or of rusty sputum. In the British Medical Journal of June 14, 1913, Dr. Pirie, in an article that is very instructive both to the physician and to the bacteriologist, gives the following statistics :
Bacteriology of Sixteen Cases of Chronic Bronchitis without Asthma.
Pneumococci 12 cases
In sixteen cases of chronic bronchial asthma he found:
Pneumococci 16 cases
The almost universal absence or non-discovery of the influenza bacillus, even with a clear history of a recent attack, is remarkable. The selection will, to a certain extent, depend on the predominance of one or other bacillus in the culture, and, generally speaking, a multiple vaccine, with the possible exception of the pneumococcus, is more likely to be effectual than a single one. The following is the experience of my son, Dr. Arthur Scott, of Bournemouth, who has for the last three years made most of my vaccines :
" Much disappointment and doubt as to the value of vaccines in chronic chest complaints is, I believe, prevalent among the medical profession. Yet I think that those medical men who have given them, in chronic cases, frequent and prolonged trial be-come more and more convinced of their general value; I say general value, for one meets with many failures in cases which one thinks would promise well. Granted a definite curative value in vaccines, it becomes difficult to explain their complete failure in certain cases. Making an attempt to group these causes of failure, there is in the first place the unknown condition in some patients that negatives immunity; for example, from an attack of measles one person becomes immune for life, another may get it again in a few months. It seems that there is a failure on the part of some patients to retain their antibodies in the system.
" In a second group, and it is a large one, the vaccine is at fault. In nearly all bronchial cases there is a mixed infection, and the difficulty in choosing from which bacteria to make the vaccine arises. Make a separate vaccine of all the likely bacteria present and mix them together is the apparent solution of the problem, but this entails making subcultures into several generations, and vaccines from subcultures have very little power of conferring immunity. Probably the most efficient way is to make a solution from the primary culture, then estimate the relative proportions of the varieties of bacteria to each other, by naked-eye examination of the cultures (this is rather guess-work), or where possible by examining a prepared slide of the solution. The predominating variety is then not subcultured, but the varieties occurring in smaller numbers are subcultured and added to the original solution in proportion to the dose required for ad-ministration. This method is necessarily faulty, but not more so than the use of impure subcultures of all the varieties. Subcultures can only be obtained pure after several generations have been made.
" Often the method of sterilization of the vaccine destroys its value; for example, a pneumococcal vaccine begins to lose its virtue when heated to 55 ° C., whereas a staphylococcal vaccine may not be killed at 6o° C. This explanation shows that it is not necessarily the principle of vaccination that is the cause of failure, but often the so far insuperable difficulties of the bacteriologist. It is possible that in the future the X rays may help to solve some of these difficulties.
" In a third group error in administration is the cause of failure. The size of the doses and the intervals between them can only be determined by the patient's symptoms. The opsonic index will not help, as in bronchial cases it is a question of local or tissue immunity rather than of general immunity. Of more importance than all is the duration of the treatment. Most patients are not kept under treatment nearly long enough. It is to be remembered that the bacteria present are probably leading a saprophytic as well as a parasitic existence. This I personally believe to be always the case in chronic bronchitis. Thus the organisms present are living not only on the bronchial epithelium, but also on the bronchial secretions; these are, in the first place, set up by repeated bacterial attacks on the epithelial cells, which are then kept actively secreting by the irritation of the toxins, a vicious circle being thus formed. Hence, if both general and local immunity are obtained, it will not follow that the symptoms of bronchitis will at once disappear ; for the saprophytic existence of the bacteria is not only active, but is waiting for lowering of immunity to attack again. For these reasons I think that vaccine treatment of chronic chest catarrhs, etc., should be continued for very much longer periods of time than is now usually done, so as to allow the bronchial epithelium to regain a normal, healthy condition. I believe that in old-standing cases of bronchial asthma treatment of less than two years' duration is of little use. The vaccines will not need to be given very frequently after the first six months; once a fortnight, or once in three weeks, is generally sufficient."
From my own experience I would further say that in these long-standing cases it is good policy to have a fresh bacterial examination made every six months or so, and if the bacterial conditions have altered, to have a fresh vaccine made. One of the most successful cases I have ever seen is an old lady, now seventy-nine years of age, who lived out of England for many years in the hope of getting rid of persistent bronchial asthma. She finally came to Bournemouth to end her days as a hopeless case. She has been under treatment now for four years, having a vaccine, which is changed from time to time, every fortnight. Under this she has regained a very fair degree of health, and the bronchial asthma is almost cured. Age is no bar to this treatment. Quite old people of seventy-five to eighty-five do very well and get no alarming symptoms. Children also of two or three years old respond equally well. The most disappointing cases, perhaps, are in over-worked, anxious, neurotic, middle-aged folk. Con-firmed emphysema has, by some, been thought to be unsuitable for vaccines, but that is not at all my experience. On the contrary, I have seen bad cases of emphysema very much improved, and surely it is only what one would expect; if catarrh, cough, and expectoration are lessened or cured, the lung substance has again a chance to recover its elasticity. As I have said before, pneumococcic cases often respond quickly and well. Catarrhalis cases vary, but are generally rather obstinate, and it is not always easy to find the suitable dose to begin with. Too big a dose will sometimes increase dyspnoea. Staphylococcus cases are generally in con-junction with pneumococci or more often with catarrhalis, and a double vaccine often answers well. Streptococci cases will often need a long course, but do very well in the end. There are two other microbes which are more rarely found—genus tetra-genus and proteus. These make excellent vaccines, and the addition of one or other of them will often cause a pneumo or strepto vaccine to succeed perfectly, when before there was failure. In plastic bronchitis the proteus may be found buried in the casts only, and not in the general mass. This microbe will not seldom be found with pneumococci. It is well to begin with a small dose, ten or fifteen millions, and to watch for symptoms of irritation such as increased cough or dyspnoea; a rise of temperature is very rare, and if it occur should cause no alarm. The smaller doses should be given every four or five days. When one has found the dose that does good, it is better, I think, to stick to it, and to give it every ten days or so till one has got the symptoms well under control, and then to carry it on at intervals of every two or three weeks for a year or more.
Many physicians in our large manufacturing towns, where there is always a more or less contaminated, irritating atmosphere, have had poor results with this treatment, and have consequently abandoned it. This is not very surprising, but I have found the cases of failure do very well if the treatment is carried out in a pure air. The constant irritation of the inhaled air or, it may be, continual reinfection, is enough to turn the balance against the vaccine. This is a case in point : A man of sixty-five was living in Manchester. He came to Bournemouth four years ago in very bad plight —chronic bronchitis, asthma, dilated heart, emphysema, and high blood-pressure. He was unable to lie down and got but little sleep. The vaccine treatment had been forbidden in Manchester, by one of its chief physicians, because he had such marked emphysema and high blood-pressure; the logical process involved in this opinion remains a mystery. He wisely consented to a trial. The sputum contained pneumococcus and catarrhalis. In three weeks he was much better and was able to lie down at night, and what this means none but the sufferers know. In two months he was able to go back to Manchester. Living in such a climate, he has of his own accord had a fresh vaccine made each year, and has a dose about once a month or rather oftener in winter. He has been all this time practically well. He has a little phlegm and is rather short of breath, but is able to enjoy his life quietly.
The heart is no longer dilated and his blood-pressure has come down to the normal without any medicinal help. During these four years he has had no medicines for his bronchial trouble. I believe this to be a typical case, and if physicians working in our manufacturing towns would try this treatment, and have it carried out in a pure air, their results, in my opinion, would be as good. A pure air is of more importance than a warm air.
The following case, which I have watched for ten years, is very instructive : A lady, seventy-eight years of age, had had bronchial asthma for many years, resulting in much emphysema; when she came under my care the bronchitis and asthma were so severe and so incessant that she had not been able to lie down for seven years—in fact, she had no bed in her room. The feet and legs were oede-, matous, and her life was a misery. I found her sputum contained catarrhalis and Friedlander. Under a vaccine she slowly began to improve. The vaccine was changed from time to time, and in two years she was almost without cough and quite with-out asthma. The heart and arteries were much affected by the years of strain; the heart was dilated, blood-pressure was often very high, and there was still at times a tendency to oedema of the feet and legs, and shortness of breath on exertion. She suffered much from vertigo and tinnitus. Under hip-prates and strophanthus the conditions gradually improved, but she had two very severe attacks of nose-bleeding. About four years after the treatment began her blood-pressure was generally normal, and she lost her vertigo, but her heart was still feeble. She went on in much the same condition till the summer of 1915, when she got a very bad attack of laryngitis, with some bronchitis but no asthma. She, rather to my surprise, pulled' through this ordeal, but her heart was very weak and dilated. In spite of her former high blood-pressure, I gave her suprarenal extract, a 5-grain tablet of the fresh gland three times a day. This acted wonderfully as a circulation tonic, and has never raised the pressure above 140 mm. She does not know what she %is taking, but both she and her maid have come to the conclusion, after two or three trials, that she is never well without them, and she has taken three tablets a day almost without intermission for eighteen months. I look on this case as a triumph for modern therapeutics.
It is hardly necessary for me to say that all vaccine treatment should be carried through with strict antiseptic precautions. I find that washing the syringe and needle inside and out with a weak lysol solution is a quick and safe plan; the patient's skin should be cleaned with the same solution or with iodine. If lysol is left in the syringe, more pain is caused than is necessary; so I wash it out, be-fore drawing in the vaccine, with boiled water. The collection of sputum should be done in the morning, if possible, before food is taken, and the mouth should be washed out previously with hot water, not with any antiseptic wash. The sputum should be expectorated straight into a wide-mouthed bottle with glass stopper that has been sterilized by boiling the previous night, and should be sent with little delay to the examiner.
In many of these cases one will find high tension and early symptoms of arterio-sclerosis ; this has been thought by some to contraindicate vaccine, but my experience has, with these cases, been very favorable. The high tension, etc., has been to a large extent brought about by the continual strain of coughing and dyspncea and by broken rest, and the relief of these will alone lower tension. It is very common for old people who have had a chronic cough to die of a sudden unexplainable pneumonia, without any chill or exposure to infection ; these cases are all latent pneumococcic affections. For some reason the resisting power has given way, and the invasion has taken place. Such cases could probably be easily prevented by the occasional use of pneumococcus vaccines, for the microbe could have been detected in the sputum of the chronic state.
Further, arterio-sclerosis is thought by many to be caused in some cases by auto-intoxication from the abnormal bacteria of the digestive tract; is it not reasonable to think that it may be caused also by auto-intoxication from the abnormal bacteria of the respiratory tract? Whatever the cause may be, you will generally have the satisfaction of seeing the high tension satisfactorily subside, with all its accompanying symptoms, and this will take place without using any depressor remedies.
With such a varied pathological cause for the group of morbid symptoms that we call bronchial asthma, is it reasonable to expect that any medicinal course of treatment, either by the stomach or by inhalation, can ever effect a radical cure, or have any but a passing action? A symptom here and there can be relieved and the patient made more comfortable (vide the endless list of patent and proprietary cures that are no cures). As scientific men we should go, if possible, to the roots of the disease, and the modern science of bacteriology is helping us to do this most effectually. We have much to learn, and something to unlearn, but patience and honest work will produce undreamt-of results. Finally, I look on this treatment as a true and logical extension of my dream—organic or endogenous therapeutics.