AIM & OBJECIVES

1)

To highlight the efficacy of Homoeopathic Remedies in the management of

2)

chronic bronchitis.
To establish fundamental understanding, to what extent, an chronic bronchitis

3)

can be effectively managed with Homoeopathy.

To estimate the importance of individualization for each taken case.

INTRODUCTION
BRONCHITIS
There are two different types of bronchitis acute and chronic. They are both an
inflammation of the airways leading to the lungs, but have different causes and, obviously,
durations. Chronic bronchitis is a lifelong condition that results from continued exposure to
lung irritants, such as smoke. While they have similar names, acute and chronic bronchitis are
different illnesses. A person with chronic bronchitis can have flare ups of the disease and can
even get acute bronchitis. Acute bronchitis is a relatively short illness that results from an
infection.

Normal bronchi

Bronchitis

ACUTE BRONCHITIS
Acute bronchitis is usually due to an infection and generally lasts for no more than a
few weeks and will resolve either with treatment or on its own. It can be caused by the same
viruses that cause the common cold and is a common complication of the cold or flu.
Symptoms of acute bronchitis include:
1.

Dry cough

2.

Shortness of breath

3.

Chest tightness

4.

Wheezing

5.

Fatigue

CHRONIC BRONCHITIS
To be diagnosed with chronic bronchitis, a person must have a productive cough for at
least three months in two consecutive years. Chronic bronchitis is a disease that develops in
people with underlying lung disease and may come and go but is never gone completely.
Chronic bronchitis is a chronic inflammation of the airways and is most frequently caused by
smoking, but can also be a result of air pollution, exposure to chemicals or dust in the
workplace and certain rare genetic diseases. Sadly, chronic bronchitis is common.
Most common symptoms of chronic bronchitis exacerbation include:
1.

Worsening cough that produces yellow or green

2.

Mucous

3.

Shortness of breath

4.

Chest tightness or pain

5.

Increased tiredness or fatigue

6.

Swelling of legs, ankles or feet

REVIEW OF LITERATURE
EPIDEMIOLOGICAL ASPECTS OF CHRONIC BRONCHITIS

The most common chronic Lung Disease that is chronic bronchitis is a leading global
health problem causing significant worldwide disability. Approximately 20 per cent of
Adult Males have the condition yet only a minority is clinically disabled. According to
surveys females are less affected than males. Cigarette Smoking is single most important
etiological factors especially after the age of 45 years. Now a day's occupational &
Environmental exposure also plays role is causing chronic bronchitis.
Illness arising in the respiratory tract account for over 25 per cent of the cases seen
in Medical Practice in Great Britain today, upper respiratory tract infection is more
common in children and lower respiratory disease in adults. These various ailments may
arise from a primary respiratory infection or be a complication of an acute general disease
as in the acute specific areas and other infective disorders overcrowding in the badly
1

ventilated atmospheres increases the risk of infection from person to person

About 20% of adults in the United States have chronic bronchitis, which is the fourth
leading causes of death.
Most patients will relate a history of cigarette smoking for at least 20 years or so
before the onset of symptoms but not all patients with chronic bronchitis report a history
2

of cigarette smoking.

It commonly commences after the age 40 and is nearly five times more
common in men than women; many cases start after an acute respiratory infection,
especially after pneumonia or influenza but in an equal number of onset is insidious.

DEFINITION OF CHRONIC BRONCHITIS

Chronic bronchitis is presence of productive cough for at least 3 months in each
2

of 2 successive years.

The bronchi are narrowed by thickened edematous mucous membrane and

viscous, infected, mucous. As a rule of bronchioles are involved more than the larger
bronchi. Hence the term obstructive air ways disease is preferable to chronic
3

bronchitis.

The patient has a chronic cough; there is no elevation of temperature, and on

auscultation RHONCHI and RALES are heard over the chest. The disease is chronic
1

Bronchitis.

Chronic Bronchitis is characterized by production of excess

mucus

persistently

for 3 months and successively for 2 years.

Kenneth M. Moser Chronic bronchitis is a clinical syndrome chararacterized by

increased responsiveness of the trades bronchial tree to a variety of stimuli that basic
definition then is expanded to include Major Symptoms Crrariable paroxysms of dyspnea
Wheezing and cough, primary physiological abnormalities. (Airway obstruction) and
histological changes (Eosinphilic bronchitis)

A CIBA FOUNDATION GUEST SYMPOSIUM IN 1958 SUGGESTED :

Chronic Bronchitis refers to the condition of subjects with wide spread
narrowing of the bronchial airways, which changes in severity over long periods of the
time either spontaneously (or) under treatment and is not due to cardiovascular diseases.
The clinical characteristics

are

abnormal

breathlessness

which

may

paroxysmal (or) persistent, wheezing and most cases relief by bronchodilator drugs.
7

be

Kendigs Chronic Bronchitis is a disorder of the tracheo bronchial tree

characterized by reversible obstruction of airflow (but not completely so some patients)
which may improve spontaneously or may subside only after specific therapy, airway
hyper relativity defined as the inherent tendency of the trachea and bronchi to narrow in
6

response to a variety of stimuli such as allergens nonspecific irritants (or) infection.

AETIOLOGY:

Chronic bronchitis may be primary or secondary in origin. Primary cases may follow
recurrent infections especially with Pneumococci, influenza virus A. and less extent
staphylococcal and streptococcus haemolyticus in recent years more and more emphasis has
been placed on the influence of air pollution by noxious gases, dust and smoke, this explains
why it is five times more common in industrial than in non industrial cities.

It is also

more common in heavy cigarette smokers and in mouth breathers.

Secondary chronic bronchitis occurs after measles and whooping cough as a
complication of obesity, gout, chronic nephritis, with chronic nasal sinusitis and in those
lungs have been scarred by fibrosis following healed pulmonary tuberculosis,
pneumoconiosis, or sarcoidosis.

Varieties of Chronic Bronchitis:

1)

Bronchitis with winter cough attended by slight or abundant expectoration,

mucous or muco-parulent.

2)

Sometimes fibrinous, sometimes containing

streaks of blood
Dry Bronchitis [Catarhe see of Laennec] is attended by a frequent cough and
soreness of the chest, but little or no secretion.

3)

It is of a very obstinate

character and occurs mostly in elderly people of a gouty diathesis.

Purulent or foetid bronchitis Bronchiolitis [Catarrhe Suffoquont of
Laennec] is characterized by expectoration of large quantities of purulent and

offensive sputum and is associated with bronchial dilatation. [i.e. bronchititis].

4)

Bronchorrhoea. Signifies expectoration of very large amounts of sputum.

Often of a thin clear nature or else thick and ropy.

5)

Plastic bronchitis is inflammation of the bronchi, with the formation of fibroplastic caste, which are expectorated by a severe bout of coughing.

ANATOMY OF LUNG
The lungs are a pair of respiratory organs situated in the thoracic cavity. Each lung
invaginates the corresponding pleural cavity. The right and left lungs are separated by the
mediastinum.
The lungs are spongy in texture. In the young the lungs are brown or gray in colour.
Gradually they become mottled black because of the deposition of inhaled carbon
particles. The right lung weighs about 625 g. it is about 50 g heavier than the left lung.
Features to be seen on the lungs:
Each lung is conical in shape. It has (1) an apex at the upper end; (2) a base resting on
the diaphragm; (3) three borders; anterior, posterior and inferior; and (4) two surfaces; costal
and medial.

The medial surface is divided into vertebral and mediastinal parts.

Fissures and lobes of the lungs:

The right lung is divided into 3 lobes (superior, middle and inferior) by two fissures,
oblique and horizontal The left lung is divided into two lobes by the oblique fissure.
Bronchial Tree:
The trachea divides at the level of the lower border of the 4th thoracic vertebra into two
primary (principal) bronchi, one for each lung. The right principal bronchus is shorter (1
inch),wider and more in line with the trachea than the left principal bronchus. Inhaled
particles, therefore, tend to pass more frequently to the right lung, with the result that
10

infections are more common on the right side than on the left. The left principal bronchus is
longer (2 inches), narrower and more oblique than the right bronchus.
Each principal bronchus enters the lung through the hilum, and divides into secondary
(lobar) bronchi one for each lobe of the lungs (3 on the right side and 2 on the left side).
Each lobar bronchus divides into tertiary (segmental) bronchi, one for each broncho
pulmonary segment (10 on the right side and 8 on the left side). The segmental bronchi
divide repeatedly to form very small branches called terminal bronchioles. Still smaller
branches called respiratory bronchioles.
Each respiratory bronchiole aerates a small part of the lung known as a
pulmonary unit. The respiratory bronchiole ends in microscopic passages which are termed
(in the order) (i) alveolar ducts. (ii) atria, (iii) air saccules, and (iv) pulmonary alveoli.
Gaseous exchanges take place in the alveoli.
Bronchopulmonary Segments
Definition : These are well defined sectors of the lung, each one of the which is aerated
by a tertiary or segmental bronchus. Each segment is pyramidal in shape with its apex
directed towards the root of the lung.
There are 10 segments on the right side and 8 on the left.7
PHYSIOLOGICAL ASPECT OF RESPIRATORY TRACT
Inspiration and Expiration:
Respiration occurs in two stages namely, inspiration and expiration. During inspiration
air enters the lungs from atmosphere and, during expiration air leaves the lungs.

In normal

breathing, inspiration is the active process and expiration is a passive process.

External and Internal Respirations:
Exchange of respiratory gases i.e. oxygen and carbon dioxide between alveoli of lungs
and blood is called external respiration. And, the exchange of gases between blood and

11

tissues is called internal respiration.

Respiratory Tract:
Anatomical structure through which air moves in and out is the respiratory tract. It
consists of nose, pharynx, trachea, bronchi and lung tissues.

Trachea bifurcates into

two main or primary bronchi called right and left bronchi. Each primary bronchus enters
the lungs and divides into lobar or secondary bronchi. The secondary bronchi divide into
segmental or tertiary bronchi. In right lung, there are ten tertiary bronchi and, in left lung,
there are eight tertiary bronchi.
The tertiary bronchi divide several times with reduction in length and diameter into
many generations of bronchioles. When the diameter of bronchioles becomes 1 mm or less, it
is called terminal bronchiole.
Terminal bronchiole continues or divided into respiratory bronchiole, which has a
diameter of 0.5 mm.
Respiratory Unit :
Respiratory unit is the terminal portion of respiratory tract. The exchange of gases
occurs only in this part of the respiratory tract.
Structure of Respiratory Unit:
The respiratory unit starts from the respiratory bronchioles. Each respiratory bronchiole
divides into alveolar ducts. Each alveolar duct enters the enlarged structure, the alveolar
sac. The space inside the alveolar sac is called antrum. The wall of the alveolar sac contains
the alveoli. Few alveoli are present in the wall of alveolar duct also.
Respiratory Membrane:
The blood vessels in the lungs form capillary network beyond the terminal bronchiole
i.e. in the respiratory unit. The capillaries are formed by endothelial cells.

12

The alveolar membrane and the capillary membrane are together called the respiratory
membrane. The respiratory membrane separates air in the alveoli from the blood in capillary.
Respiratory membrane has a surface area of 70 sq. meters and thickness of 0.5 microns.
Non-Respiratory Functions of respiratory Tract :
1. Temperature Regulations :
During expiration, through the expired air there is evaporation of water. During the
evaporation of water some amount of heat is lost from the body.
2. Maintenance of water Balance :
During expiration, small amount of water is also lost along with the heat. Some amount
of body water is reduced by this process.
3. Regulation of Acid Base Balance :
Lungs play an important role in maintaining the acid base balance of the body by
regulating the carbon dioxide content in blood. Carbon dioxide is produced during various
metabolic reaction in the tissues of the body. When it enters the blood, carbon dioxide
combines with water to form carbonic acid. Since carbonic acid is unstable, it splits into
hydrogen and bicarbonate ions.
CO2 +H2O

H2CO3

CO2 + H2O

As carbon dioxide is volatile, it is practically blown out by ventilation. When

metabolic activities are accelerated, more amount of carbon dioxide is produced in the tissues
and the concentration of hydrogen ion is also increased leading to reduction in pH. The
increased pulmonary ventilation i.e. hyperventilation by acting through various mechanisms
like chemoreceptor

in aortic and carotid bodies and in medulla of the brain. Due to

hyperventilation, the excess of carbon dioxide is removed from the body fluids and the pH is
brought back to normal.

13

4. Defense Mechanism :
i)

Nose
The dust particles entering the nostrils are prevented from entering lungs by the

filtration action of the hairs of nasal mucus membrane. Small particles escaping the hairs are
caught by the mucus secreted by the nasal mucus membrane.
ii) Alveoli
The alveoli are lined by pulmonary alveolar macrophages. Those dust particles,
which escape the nasal hairs and nasal mucus membrane are destroyed by the phagocytic
action of the macrophages.
iii) Reflexes
The particles which escape the above protective mechanisms in nose and alveoli are
thrown out by cough reflex and sneezing reflex..
iv) Leukocytes and Macrophages
The leukocytes, particularly the neutrophiles and lymphocytes present in the alveoli of
lungs play an important role in the defense mechanism against bacteria and virus.

The

pulmonary alveolar macrophages also play an active role in the defense mechanism of lungs.
Macrophages also

play

an

active

role

in

the

defense

mechanism

of

lungs.

Macrophages engulf the dust particles and the pathogens entering the alveoli and thereby act
as scavengers in lungs.
5. Anticoagulant Function :
Lungs contain the mast cells, which secrete heparin. Heparin is an anticoagulant
and it prevents the intra-vascular clotting.
6. Activation of Angiotensin:
Endothelial cells of the pulmonary capillaries secrete the angiotensin converting
enzyme (ACE). This converts the angiotensin I into active angiotensin II.

14

7. Synthesis of Hormonal Substances:

Lung tissues

are

also

known

to

synthesize

the

hormonal

substances

prostaglandins, acetylcholine, bradykinin and serotonin. 8

PATHOGENESIS :

Chronic Bronchitis is a chronic inflammatory disorder of the airways with recurrent

exacerbations.
Chronic airway inflammation is invariably associated with injury and repair of the
bronchial epithelium, which results in structural and functional changes known as

remodeling.
Inflammation, remodeling, and altered neural control of the airways are
responsible for

both recurrent exacerbations of chronic bronchitis and more

permanent airflow obstruction.

The potential to develop excessive airway narrowing is the major functional

abnormality in Chronic Bronchitis.

Excessive airway narrowing is caused by altered smooth muscle behaviour, in close
interaction with airway wall swelling, parenchymal retractile forces, and intra luminal

secretions.
Exacerbations of Acute Bronchitis are associated with an increase in airway
inflammation and, in susceptible individuals, can be induced by respiratory infections,

allergen exposure, or exposure to occupational sensitizers.

Respiratory failure in Chronic Bronchitis is a consequence of airway closure,
ventilation/perfusion mismatch, and respiratory muscle exhaustion.
The current concept of Chronic Bronchitis pathogenesis is that a characteristic chronic

inflammatory process

involving the airway wall

causes the

development

of

airflow limitation and increased airway responsiveness, the latter of which predisposes the
airways to narrow in response to a variety of stimuli. Characteristic features of the airway
inflammation are increase number of activated eosinophils, mast cells, macrophages, and T

15

lymphocytes in the airway mucosa and lumen. These changes may be present even when
patient is asymptomatic, and their severity of the disease. In parallel with the chronic
inflammatory process, injury of the bronchial epithelium stimulates processes of repair that
result in structural and functional changes referred to as remodeling.
episodes of symptoms and reversible airflow limitation

that

The recurrent

characterize

wheezing

represent an acute inflammatory response acting upon structurally and functionally altered
airways.
Airway inflammation in bronchitis is extremely complex in origin, regulation and
outcome. The mechanisms involve a cascade of events involving many different kinds of
cells, factors, and mediators that interact to create the characteristic inflammatory and
tissue remodeling processes of bronchitis.
THE PATHOGENESIS CAN BE DISCUSSED IN 4 POINTS. :
1.
2.
3.
4.

Immunological Theory
Classical theory or Allergenic theory.
Reflex theory or Neurogenic theory.
Other theories.

IMMUNOLOGIC MECHANISMS OF AIRWAY INFLAMATION :

The immune system is separable into antibody-mediated and cell-mediated processes.
Antibody-mediated processes are characterized by production and secretion of
specific

antibodies by B lymphocytes, while cell-mediated processes depend on T

lymphocytes. T cells control B lymphocyte function and also exert pro inflammatory actions
through cytotoxic activity (by CD8+ killer T cells) and the secretion of cytokines.

In many cases, especially in children and young adults, bronchitis is associated with
atopy manifesting through immunoglobulin E (IgE) dependent mechanisms. At a
population level, the contribution of atopy to the asthma phenotype has been estimated to be
16

40 per cent in both children and adults. Nonanaphylactogenic anti- IgE monoclonal antibody
(E-25) is able to markedly attenuate the early and late airway responses, the increase in
airway hyper responsiveness, and the influx of eosinophils into the airway lumen that
inhaled allergen challenge. This anti-IgE antibody is also effective in improving wheezing
control in clinical trails. These observations provide unequivocal evidence for a pivotal role
on IgE in a proportion of Chronic Bronchitis patients.
At lease two distinct-helper (Th), cD4 lymphocyte subtypes have been
characterized on the basis of their profile of cytokind production.

Although both T

lymphocyte subtype secrete IL-3 and GM-CSF, the th1 sub type preferentially
produces IL-2, stimulating T lymphocyte

proliferation, interferon-y (IFN-y) (which

inhibits B lymphocyte activation and IgE synthesis), and tumor necrosis factor - (TNF).

The Th2 subtype, the primary subtype involved in asthma, secretes the cytokines

IL-4, IL-5, IL-9, IL-13, and IL-16, Th2 cytokines are responsible for the development of
the classic delayed-type or cell-mediated hypersensitivity reaction.
IL-4 is a cytokine central to the allergic response, promoting iso type
switching of B cells to IgE synthesis, directing T cells along the Th2 differentiation
pathway, up regulating the expression of vascular cell adhesion molecule-1 (VCAM-1),
and controlling the level of expression of IgE Fce, cytokine and chemokine receptors,
and leukocytes involved in the allergic cascade. Administration of soluble IL-4 receptor
(which binds to free IL-, preventing it from binding to cell-associated IL-4 receptors) has
shown beneficial anti-inflammatory effects both in animal models and in preliminary
human bronchitis trials. IL-13, another Th2 cytokine that has multiple effects on immune
and structural components involved in bronchitis may also prove a target for therapy.
A pivotal step in the generation of an immune response is the activating of T
lymphocytes by antigen appropriately presented to them by accessory cells, a process that
17

involves major histocompatibility complex (MHC) molecules (MHC class II molecules

on CD4

T cells and MHC class molecules on CD8 T Cells), Dendritic cells are the

primary antigen presenting cells in the airways. They originate from precursors in the
bone marrow and form an extensive network of interdigitating cells beneath the airway
epithelium.

From this location they migrate to local lymphoid collections under the

influence of granulocyte-macrophage colony-stimulating factor (GM-CSF), a cytokine

released from activated epithelial cells, fibroblasts, T cells Macrophages, and mast cells.
Following antigen uptake, this is enhanced by cell- surface IgE, dendritic cells move into
lymphocyte-enriched regions.

There, under the influence of additional cytokines, they

mature into effective antigen presenting cells. Dendritic cells can also drive the polarization
of nave T-helped cells (ThO), towards the Th2 subtype that

coordinately secretes

cytokines encoded in a cluster on chromosome 5q31-33(IL-4 gene cluster).

The presence of activated lymphocytes and eosinophils in bronchial biopsies of
atopic and non atopic patients with bronchitis suggests that a T-lymphocyteesosinophil interaction is important, a hypothesis further supported by the finding of cells
expressing IL-5 in bronchial biopsies of atopic patients with bronchitis IL-5 is an important
cytokine for eosinophil regulation its level of expression in the airway mucosa of
patients with bronchitis correlating with markers of both T lymphocyte and eosinophil
activation.

18

19

CLASSICAL THEORY
In response to an extrinsic allergen )antigen), immunoglobulin IgE (Reagin
antibody) is produced by plasma cells and lymphoid tissues.

The allergens can be

transmitted by air (pneumo allergens) or by the gut (alimentary allergens). These IgE
molecules always have the tendency to attach themselves to mast cells.

The antigen

antibody reaction which then occurs on the surface of the mast cells results in the release
of mediator substance. The release of mediators is modulated by the intra cellular levels
of cyclic adenosine 35 monophosphate (CAMP) cyclinc Guanosine- 3 5
monophosphate (CGMP) which will cause the further pathogenesis like airway
inflammation, Broncho constriction and mucus production, which will produces i) cough,
ii) breathlessness, iii) wheeze - Which are the classical symptoms of Bronchitis.
REFLEX THEORY
The automatic nervous system plays a major role. Neural broncho constrictor activity
is mediated through the cholinergic portion of the automatic nervous system. Stimulation
of the receptors in the airway epithelium called irritant receptors or superficial
receptors by the release of mediators causes reflex broncho constriction via the vagus nerve.
RESPIRATORY SYNCYTAL VIRUS (RSV)
Viral infection like bronchiolitis in early childhoodnotably during the phase of
myelination caused by lead to increased bronchial reactivity, thresholds for response to
stimulation, resulting in bronchial hyperreactivity.

20

a. Mucosal lesion
b. Exposure of nerve receptors
Viral
c. Infection
Hyper permeability of allergens

Bronchil
Hyper
Reactivity

d. Production of lgE
e. Diminution of Beta adrenergic effect

HOW ALLERGENS INITIATE (PROVOKE) BRONCHITIS

A dilemma exists about how the antigen can rapidly reach a sub mucosal mast cell
to initiate an acute reaction. It is now known that mast cells and sensory nerve endings
are also located intra mucosal in the airway lumen and not only sub mucosal as formerly
thought. Thus mast cell antigen interaction can occur initially at the mucosal surface of
the airway and the chemical products of the interaction can facilitate the penetration
of additional antigen into the more numerous sub mucosal mast cells by opening the right
junctions. Neural receptors are also activated so as to amplify the response. Thus the mast
cells which are located in respiratory tissues in both mucosal and deep peri vascular
sites, can be triggered not only by immune response and perhaps also by non immune
9

mechanisms.

PATHO PHYSIOLOGY
The combination of mucosal edema, bronchospasm and mucous plugging results
in airway obstruction and increased resistance to airflow through trachea and bronchi and
decreased ability to expel air from smaller airways which results in hyperinflation.
Because of this hyperinflation the pulmonary circulation is also affected; hyper
inflation also increases the intra plural and intra alveolar pressures. Thus the increased
intra alveolar pressure, decreased ventilation and decreased perfusion lead to variable
uneven ventilation-perfusion relationships (V-Q imbalance) within different lung units.
21

This results in hypoxemia (No Hypercapnoea initially, because of the high diffusion
capacity of the Co2 across the alveolar capillary membranes, about 20 times that of
O2) and increased work of breathing. As the obstruction becomes more severe, a point
reached at which Co2 retention occurs i.e. RESPIRATORY FAILURE. Early n the course
of bronchitiss, respiratory alkalosis may occur because of hyperventilation.

Later

Metabolic acidosis may occur because of increased work of breathing, increased Oxygen
consumption and increased cardiac output. This is a problem especially I children because
of their little glycogen reserve and inadequate, pulmonary arterial pressure may increase
to match the increasing intra-alveolar pressure, possible resulting in pulmonary
hypertension and right heart strain. Again hyper-inflation is matched by increase residual
volume and decreased vital capacity.10

22

PATHAOPHYSIOLOGY OF CHRONIC BRONCHITIS

BRONCHOSPASM +

MUCOSAL ODEDEMA + MUCUS PLUGGING

AIR FLOW OBSTRUCTION
INCREASED AIRWAY
RESISTANCE HYPERINFLATION
OF LUNGS

INTRA ALVEOLAR VENTILATION

VITAL CAPACITY

PRESSURE INCREASED

PERFUSION

DECREASED
VENTILATION PERFUSION
IMBALANCE
HYPOXAMEMIA

PULMONARY
VASCULAR
CONSTRUCTION
INCREASED WORK OF
BREATHING

EARLY STAGES

LATE STAGES

NO HYPERCAPNIA

DEHYDRATION

HYPOXIC DRIVE

OBSTRUCTION

SEVERE
WASHOUT OF CO2

STARVATION

CO2 RETENTION

RESPIRATORY
ALKALOSIS

RESPIRATORY
23

ACIDEMIA
RESPIRATORY
FAILURE
Ph

24

The basic factor of Chronic Bronchitis is a reduction in diameter of airway

brought about by the following.
a) Oedema of the bronchial wall.
b) Thick tenacious secretion.
c) Hypertrophy of the bronchial muscles.
d) Contraction of the smooth muscle of bronchial tubes secondary to hereditary
in co-ordination (sycosis) or mal formations and in co-ordination both at the
same time (syco-syphilis) or allergic reaction between allergens and mast cells
resulting in increased IgE in serum (psora). In allergic cases, due to
interaction of allergen and mast cels, a substance like histamine or
prostaglandin D2 or leucotrine C, D or E, is liberated which reflex stimulates
the vaso-constrictor fibres of vagus resulting in bronchial spasm.
PATHOLOGY
Microscopic examination of bronchitis person reveal mucosal edema and
sloughing of mucosal cells, opening of the intercellular spaces with hyperplasia and
hypertrophy of bronchial and bronchiolar smooth muscle. The mucosa is often
Infiltrated with eosinophils, lymphocytes, and plasma cells; histiocytes and mast cells are
also present in smaller numbers. The opening of inter cellular spaces exposes irritant
receptors to direct stimulation by allergens and irritant. Goblet cell hyperplasia and
enlargement of submucosal glands occur in bronchitis. Mucus which is abnormally
tenacious may form casts of bronchial tree, containing debris of shed mucosal cells
(creola bodies) and other cellular elements. Within the lumen are layers of fibrin and mucus
(Churchmans spirals) and crystalline structures from break down of the large number of
eosinophils (charcot-layden crystals.)

25

CLINICAL FEATURES
Symptoms The common symptoms are a chronic cough and the expectoration
of mucoid sputum breathlessness on exertion appears. In the warmer summer months the
patient is comparatively well and may lose all symptoms, but in damp cold and foggy
weather the symptoms returns and with a fresh catarrhal infection an acute attack of
bronchitis super persistent and may last the whole year round the patient become more
and more breathless and in the presence of super added emphysema marked pulmonary
hypertension results, particularly following an acute attack of bronchitis or of bronchopneumonia right aided heart failure supervenes and is the common cause of death.
Physical signs In the eater stages these patients present a characteristic
appearance; they are often stout in build, with a florid and slightly cyanosed complexion,
they have a short thick neck with pulsating jugular veins, the breathing is short the
26

respiration is wheezy and the chest barrel shaped with emplysema. In absence of
complication there are no febrile or constitutional symptoms chronic bronchitis
patients have a subnormal temperature, physical examination of the chest shows poor
movements on both sides palpation confirms this and may reveal bronchial fremitus on
percussion the note is either normal or hyper resonant in proportion to the degree of
emphysema present. Auscultation reveals some prolongation of expiration at times the
chest may be dry but on other occasions there are sonorous and sibilant rhonchi and rales
when the smaller tubes are involved, some patients also show a considerable degree of
bronchospasm.
Diagnosis is usually not difficult the history of onset following an acute respiratory
illness or with a gradual onset and with winter exacerbations is most helpful. Except in the
course of acute attacks patients with chronic bronchitis tends to gain weight largely
because of their enforced in activity.

The x-ray appearances show exaggerated

peribronchial markings and evidence of emphysema but there are no areas of

1

consolidation.

ASSOCIATED SIGNS OF ALLERGY

The recognition of signs of upper respiratory allergy, which often coexists with
chronic bronchitis may aid in achieving better control of asthma by identifying aggravating
factors (e.g. sinusitis) or coexistent physical disability (e.g. serous otitis with conductive
deafness). Because nasal polyps occur rarely in the child with uncomplicated chronic
bronchitis their presence suggests cystic fibrosis in the young child or paranasal sinusitis
with aspirin sensitivity in the adolescent. (Allergy is an unusual cause of nasal
polyposis). Eardrums should be examined with a pneumatic otoscope for serous otitis.
The conjunctivae should be examined for edema, inflammation, and tearing. A slitlamp examination fro cataracts also is indicated in the patients who is receiving chronic
27

treatment with corticosteroids. The texture of the skin and subcutaneous tissue should be
noted, as it relates to nutrition and fluid balance, and flexor creases and other areas of
skin should be examined for active or healed atopic dermatitis.
LABORATORY INVESTIGATIONS LEUKOCYTE
WBC and RBC counts are normal in uncomplicated chronic bronchitis.
Treatment with steroid produces leukocytosis with eosinopenia and lymphopenia. (When
the case is reffered from other systems.)
EOSINOPHILS
This is an important diagnostic feature of bronchitis Sputum eosinophils
increase. Peripheral blood eosinophilia in the range of 2500 cell/ml and levels of
eosinophils and eosinophil protein in Broncho Alveolar Lavage (BAL) are increased in
Allergic chronic bronchitis patients.
SPUTUM EXAMINATION
During bronchitis

relapse,

sputum

production

is

scanty. With

recovery,

moderate amounts of clear or yellow mucoid material may be produced. With

prolonged relapse, there may be daily clearing of bronchorrheoic secretions of 100ml or
more; with recovery expectoration of kite strings or miller seed bronchial casts are seen.
Microscopic examination of sputum from patients of chronic bronchitis reveals
bronchial epithelial cells in cluster (Creola bodies), eosinophils, Charcot Leyden
crystals and Curschmanns spirals or mucinous materials of varying sizes from small
airways. These features help to distinguish chronic asthma from chronic bronchitis.
ARTERIAL BLOOD GASES
These are typically normal in patients with chronic stable bronchitis. In an acute

28

episode, hypoxia is often present.

Arterial PCO2

is typically reduced owing to

hyperventilation. With severe obstruction, PCO2 is increased

due

to

fatigue

of

respiratory muscles. PH may be lower than predicted.

IMMUNOLOGICAL STUDIES
IgE antibody : Elevation in total IgE is strongly associated with bronchitis and skin
test reactivity is associated with allergic rhinitis. Elevated IgE level (>100IU) is seen in
allergic patients but is not specific for bronchitis. Normal IgE level cannot be used to
exclude diagnosis of bronchitis.
IgG antibody : Late response show high level of IgG antibody. Levels more than
1800 mg% is considered significant. It is estimated by ELISA method.
ECG : Uncomplicated chronic bronchitis shows sinus tachycardia. In acute
exacerbation with respiratory failure ECG shows right axis deviation, P-pulmonale, RBBB
and Right ventricular strain.
PEAK FLOW
Peak expiratory flow (PEF) is the greatest flow velocity which can be
generated during a forced expiration starting with fully inflated lungs. PEF provides a
simple, quantitative, reproducible measure of airway obstruction. Peak flow meters are
cheap, lightweight and

portable. Repeated measures are usually highly reproducible

with each individual patient.

PEF measurement is an important clinical tool which can be used to :

Aid in the diagnosis of chronic bronchitis.

Assess the severity of asthma to guide immediate management decisions.

Monitor the response to treatment during an acute attack.

29

Monitor the progress and response over sequential visits.

Facilitate patient understanding by providing objective measurements. There

are several limitation PEF measurements:

The test is effort dependent. A sub maximal effort invalidated the reading.
This especially important in children.

Most children under 5 years of age cannot perform reproducible peak flow or
spirometry measurements.

The normal range for PEF determined from population studies is so wide that it limits
the usefulness of single measurements as a diagnostic tool. Some people will have
readings below the population mean when they are well and others will be above

the mean.
The usefulness of PEF readings can be improved by measuring the response to

medication and by sequential measurements at subsequent consultations.

PEF is mainly a test of large airway function and will not detect asthma in patients

with predominantly small-airway disease.

Because of the wide normal range, do not assign a target reading to a patient by
looking up a table or a graph. The preferred method is to have the patient take
regular readings during sable phase of bronchitis to establish their personal

best.

These readings can then be used in the patients chronic bronchitis Action

Plan.

This means that it may take more than one visit to construct an Action Plan

based on PEF.
Readings should always be done on the one instrument. There is considerable
variation between instruments and between brands. Readings done at home by the
patient may not, therefore, correlate well with readings taken in the doctors
office. There are liable to be differences between PEF measured on an electronic
spirometer and a peak flow meter.
The same peak flow meter should be used for all measurements on the one patient.

30

Spirometry is generally preferred for diagnostic testing.

What is normal PEF ?
Charts and monograms are available which describe normal PEF values. These
give mean PEF (+ standard deviation) for selected populations based on age, sex and
height. As there are limited published data for many ethnic populations and a wide normal
range of PEF, the mean value should be used as a guide only.
It is more important to use and individuals best PEF rather than the normal PEF
value in devising an chronic bronchitis management plan.
Daily variability =

PEF evening PEF morning x 100

(PEF evening + PEF morning)

Use of Peak Flow Meter

A peak flow meter is a device that measures how well air moves out of lungs. During
a bronchitis episode the airways of the lungs begin to narrow slowly. The peak flow meter
can be used to find out if there is narrowing in the airways hours or even days, before you
have any symptoms of bronchitis. By taking your medicine early (before symptoms) you
may be able to reverse the episode quickly and prevent it from getting worse. Peak flow
meters are used to check lung function the way that blood pressure cuffs are used to check
blood pressure. The peak flow meter can also be used to help you and your doctor.
How to use a Peak Flow Meter :
All patients of age 5 and older who have a moderate or severe chronic
bronchitis should think about using a peak flow meter. Some children as young as age 3 can
also use it. (Ask your doctor or nurse to show you how to use peak flow meter).

31

1. Place the indicator at the base of the numbered scale.

2. Stand up.
3. Take a deep breath.
4. Place the meter in your mouth and close your lips around the mouthpiece. Do
not put your tongue inside the hole.
5. Blow out as hard and as fast as you can.
6. Write down the number you get.
7. Repeat step 1 to 6 two more times.
8. Write down the highest of the three numbers achieved.

32

33

34

35

36

Characteristics

Mild

Moderate

Severe

Frequency of
exacerbations

Exacerbations of
cough and wheezing
1-2 times / week.

Exacerbation >
than 2 time/week.
Urgent care
treatment in ER or
office < 3/ year.

Virtually daily wheezing,

Exacerbations frequent
often severe. Tendency to
have sudden severe
exacerbations. Urgent
visits to ER or office >
3/year. Hospitalization > 2
years.

Frequency of
symptoms

Few clinical signs or

symptoms between
exacerbations

Cough and low

grade wheezing
often present

Continuous albert lowgrade cough and wheezing

almost always present.

Exercise
tolerance

Good exercise
tolerance but may
not tolerate vigorous
exercise (e.g.
running)

Exercise tolerance
diminished

Very poor exercise

tolerance with marked
limitation of activity.

Nocturnal
asthma

Nocturnal asthma 12 times/month.

Nocturnal asthma
2-3 times/week

Considerable almost
nightly sleep interruption.
Chest tight in early A.M.
Poor school or work
attendance.

School or work
attendance

Good school or work

attendance

School or work
attendance may be
affected

Poor School or work

attendance.

Pulmonary
function

PEFR>80%
predicted

PEFR 60-80%
predicted.
Variability 2030%

PEFR<60% predicted
Variability >30%

37

DIFFRENTIAL DIAGNOSIS
This has been summarized succinctly by Chevalier Jacksons famous dictum: All
that wheezes is not asthma. The differential diagnosis of wheezing in infancy and childhood
includes a host of conditions but the following are some important causes of wheezing in
childhood.
Asthmatic Bronchitis: Spasmodic asthma is met with much more commonly in
practice. Here the children have wheezy colds three or four times each winter and when the
attacks subside, they are perfectly well until the next attack. In one group there may be some
evidence of sensitivity tendency. In the other group, infection itself is sufficient to initiate
the attacks. The prognosis is better in this group of children.
Acute Bronchiolitis: This occurs mostly in infants and the differentiation from
chronic bronchitis may be difficult especially in the early stages. The family history and the
patients past history of allergic disorders may offer a clue to the diagnoses. The most striking
feature is the lack of correlation between the clinical severity of symptoms (like dyspnoes,
indrawing of the lower chest, etc), and the paucity of clinical signs in the chest.
Tropical eosinophilia: A dry hacking cough with expiratory dyspnoea and wheezing
are typical in this condition. The evolution of the symptoms coupled with lack of family
history should suggest the diagnosis. An absolute eosinophil count of over 4,000 proves the
diagnosis. It should be remembered that there may be a rise in the eosinophil count even in
chronic bronchitis. Radiographs may show well-marked
broncho-vascular markings.
Endocardial fibroelastosis: There may be dyspnoea and a respiratory wheeze and in
severe cases cyanosis and left ventricular failure (elevated JVP, enlarged liver, etc) Murmurs
may be heard depending on the degree of valvular involvement.

38

Vascular Rings: There is often a history of repeated respiratory infection since birth,
which usually becomes worse after crying, exercise or activity, especially after feeds. Many
of these infants prefer to keep their heads instinctively extended as in this position their
respiratory difficulty is considerable lessened.
Pericardial effusion: This is characteriszed by cardiac enlargement with the apical
impulse being located with difficulty. Heart sounds are often muffled, distant and a
pericardial rub may be present along with other evidences of congestive heart failure. The
cardiac silhouette tap may help to decide not only the nature of the fluid but also to relieve
the cardiac embarrassment.
Spontaneous pneumothorax: Dyspnoea, cyanosis and pain are ushered in abruptly
with large collections of air into the pleural space, with a mediastinal shift to the healthy
side and

hyperresonant percussion note on the affected side. Diagnosis if a large

pneumathorax is not difficult but a small-sized one may pose difficulties in deagnosis.
Mediastinal Adenopathy: May produce the so called wheezing wasting syndrome
characterized by progressive cough (occasionally brassy) and the bronchitis wheeze in
children with primary tuberculoses, Para-vertebral dullness may occasionally be made out
on percussion. Skiagams reveal the enlarged nodes and a positive tuberculin
test may help in the diagnosis.
Hysterical Hyperventilation: is easily diagnosed from the rapid shallow breathing and the
absence of expiratory wheeze, Besides, the child may be able to hold his breath (which is
impossible in true asthma) and also exhibits suspicious or sighing respiration.
Harkavy Syndrome is

the

pulmonary

component

of

periarteritis

nodosa characterized by cough , dyspnoea and occasionally hemoptysis. There may be a

peripheral blood eosinophilia and X-ray of the chest may show military mottling or confluent
opacities and varying degrees of infiltration. Other evidences of periarteritis nodosa in other

39

systems may be present.

Allergic pulmonary disorders

related

to

cows

milk

hypersensitivity,

allergic alveolitis (hypersensitivity pneumonitis) and other conditions where peripheral blood
eosinophilia and pulmonary infiltrations are present may have to be entertained in the
deferential diagnosis.
Cystic fibrosis (Mucoviscidosis) May Produce respiratory symptoms as a result of
progressive

bronchiectasis. The characteristic cough which is paroxysmal may

resemble pertussis but

there

is no whoop in mucoviscidosis. Clubbing and

emphysema leading to chest deformity (barrel chest) may be present. The disease is,
however, rare in India. Differentiation is made on the basis of family history,
steatorrhoea, pancreatic enzyme deficiency and high sweat chloride content.6
COMPLICATIONS
Complications of chronic bronchitis comprise those related to the lungs and those
remote from the lungs,
Pulmonary complications include (1) pulmonary Hypertension (2) atelectasis, (3)
Pneumomediastinum and pneumothorax, (4) Emphysema and (5) Bronchiectasis.
Extrapulmonary complications include (1) vasopressin excess, (2) flaccid
paralysis of an arm or leg, (3) sudden alteration in theophylline metabolism, and (4) Right
sided heart failure Pulmonary and extrapulmonary factors may combine to cause acute
12

respiratory failure, resulting in cardiorespiratory arrest with brain damage or death.

Management
GOALS OF THERAPY

Preventing chronic and troublesome symptoms.

Maintaining nearly normal pulmonary function.

40

Maintaining recurrent normal activity level (including exercise).

Preventing recurrent exacerbation and minimizing the need for emergency

care and hospitalizarion.

No sleep disturbance.

Normal growth.

CHRONIC BRONCHITIS

Prevent attacks.

Reverse acute episodes.

Maintain normal bronchial physiodynamics.

Take care of psychological factors.

Once the diagnosis of chronic bronchitis is established, a treatment plan must then
be devised that is tailored to meet the needs of the individual patients. The management
of patients with chronic bronchitis should primarily take place in the community (9, 10).
The long term goals of chronic bronchitis therapy are to abolish symptoms, maximize
lung function, and allow patients to lead normal lives with minimal inference from their
illness. In order to achieve these objectives,

attention needs to be directed to three

fundamental areas.
a. Patient education and supervision
b. Preventative and environmental control measures and
c. Pharmacologic therapy.
In addition, immunotherapy and behavior modification may be indicated for
41

.6

selected patients with chronic bronchitis

Parent/Patient Education

Chronic bronchitis nature, aggravating factors and prognosis.

Avoidance of trigger factors.

Medications actions, administration.

Acute exacerbations recognition, treatment (written instructions), when and

where to get medical help.

Monitoring-diary card, peak flow meters.

Preventative and environmental control measures

Although pharmacological intervention to treat established chronic bronchitis is
highly effective in controlling symptoms and improving quality of life, every attention
should given to measures to prevent this chronic disease.
Chronic bronchitis exacerbations may be caused by a variety of risk factors
including allergens, pollutants, foods and drugs, Tertiary prevention aims to reduce the
exposure to these risk factors to improve the control of chronic bronchitis and reduce
medication needs.
Primary Prevention is introduced before exposure to risk factors known to be
associated with a disease. The goal is to prevent the onset of disease in susceptible (at- risk)
individuals. This is not yet possible in chronic bronchitis. Increasing evidence indicated
that allergic sensitization is the most common precursor to the development of chronic
bronchitis. Since sensitization can occur antenatally, much of the focus of primary
prevention will likely be on perinatal interventions.
Secondary

Prevention

is

employed
42

after primary sensitization to

allergen(s) has occurred, but before there is any evidence of disease. The aim is to
prevent the

establishment of chronic bronchitis disease in people who are

susceptible and who have early signs of the disease. This is currently being
investigated in bronchitis. Secondary Prevention of bronchitis is likely to focus very
specifically on the first year of two of life.
Tertiary Prevention involves avoidance of allergens and nonspecific triggers when
asthma is established. The goal is to prevent exacerbations or illness that would otherwise
occur with exposure to identified allergens or irritants. It is considered that tertiary
prevention should be introduced when the first signs of chronic bronchitis have occurred.
However, increasing evidence would suggest that the histopathology of the disease is fully
established by the time chronic bronchitis symptoms occur.

Household Precautins:
1) Clean your house regularly to avoid accumulation of dust pollens and molds
etc.
2) Do not allow your pets on the furniture and bed.
3) Keep your closets/almira clean and dry. Do not keep non-clothes items in
same closet.
4) Store all your clothes that are not often in allergen proof plastic cover.
5) Clean your carpets with vacuum cleaner regularly to minimize dust and dust
mites.
6) Discourage smoking and tobacco sniffing in AC environment.
7) Throw out newspapers, old magazines and books that clutter your house.
8) Use Scarf and mufflers while cleaning your house.
43

Out-doors Precautions:
1) Garden and exercise outdoors on damp days when the pollen levels are lowest,
Avoid strenuous outside activities on dry, high-pollen days (Usually during
spring).
2) Cut grass short and keep bushes and trees well trimmed.
3) Plant less allergenic flowers, shrubs and trees; ask your local nursery for
advice.
4) Get rid of weeds and wet leaves they are major allergy triggers.
5) Move flowering plants and other high-pollen plants away from doors and
windows.
6) Never paint where someone with severe allergies or bronchitis is nearby.
7) Use a scarf or muffler to cover your mouth and nose when you leave an indoor
environment and go into cold outside air.
School Care
A child spends about a third of his/her day at school. It therefore becomes
important to convince parents regarding the role of the teacher in school care of
bronchitis child. Participation in games, camps and other physical activities should be
strongly encouraged. Exercise should be looked upon as the only trigger of the
bronchitis child he/she should learn to conquer rather than avoid.

44

13

HOMOEOPATHIC BACKGROUND OF CHRONIC BRONCHITIS

CONCEPT OF HEALTH AND DISEASE
Hahnemann considers health as a state indicating harmonious functioning of the Life
Force leading to a peculiar sense of well-being. Paradoxically enough, we are more aware of
this sense of well-being when it is denied to us rather than when we are

actually

experiencing it. Our unawareness of the various processes that are constantly taking
place within, characterizes that sense of well-being.Thus, the concept of health, from the
descriptive standpoint, is a negative one an absence of symptoms.
Hahnemann considers disease as state indicating disharmonious functioning of the
Life Force. We become aware of this disharmony by the loss of the sense of well being
which we have learnt to accept as normal. A little later, we become aware of some of the
processes within, which are thrown out of gear. To begin with, this awareness is only vague.
As the disharmony progresses, more definite indications start appearing, first in the form of
Symptoms, then followed by signs. The former indicate abnormal subjective sensation and
complaints incapable of being verified by a physician; the latter indicate abnormal objective
data, capable of being verified by the physician. Signs and symptoms, therefore, furnish the
only external evidence of disease.
Hahnemann took firm stand that nothing can be known of disease except through
signs and symptoms and that all speculation about the nature of disease and its ultimate
causes not only proves fruitless but leads to all sorts of empirical and, at times, dangerous
treatments.
The Homoeopathic physician, therefore, considers disease as a deviation from health
which is made known to him only through signs and symptoms. It logically follows from
this that a rational system of therapeutics will have these very signs and symptom pointing
unmistakably to a curative remedial agent.

45

The

disharmonious

functioning

of the Life Force results

mostly from

unfavourable factors in the environment of person. A close study of these, is naturally,

expected of the Homoeopathic physician.
Hahnemann considers that the natural tendency of the Life Force is to assert itself
and thus restore the state of harmony. The physician is expected to promote this natural
tendency and not to impede it by therapeutic measures which, in the long run, either deplete
the Life Force or interfere with the manifestations of the disease.
This natural tendency, in some instances, is affected unfavourably by certain stigmata
which result from either hereditary factors or previous indiscretions on the part of the
patient. These stigmata lead to chronic relapsing states of ill health, generally difficult
to cure and represent to us the various defective constitutions. This particular concept was
developed by Hahnemann in The Chronic Diseases which he published after nearly forty
years of close observations of the patients he had treated according to the Law of Similars.
Hahnemann considered drugs as powerful agents capable of including a state of
disharmonious functioning of the Life Force, thus leading to the drug-induced disease which
is made known to us through signs and symptoms. He believed drug- induced diseases to be
stronger than natural disease because they could be produced at will and this led him to
advance his probable explanation of the efficacy of the Law of Similars, viz., the stronger
drug-induced similar disease annihilates the weaker natural disease. The validity of this
explanation, however, need not concern us; a phenomenon exists independently of the
validity of its explanation.
As disease signifies the presence of symptoms and health their absence
Hahnemann

conceives of Cure as the process of removal of symptoms, not their

suppression.
We thus find Hahnemann taking an extremely practical view of things and directing a

46

clinician to an exhaustive study of the manifestations of a disease with special emphasis on

the causative environmental factors. We also find Hahnemann directing him to study the
patients an individual instance of the disease, noting the characteristics that differentiate one
from the other instance of the same disease.

This leads us on to the concept of

Individualization.
A Short Summary of the Homoeopathic System of Medicine
Life : The Vital force of Life-principle endows the body with sensations functions
and power of self-preservation (within certain limits.)
Disease: It is nothing more than alterations in the state of health of the
individual which express themselves by perceptible symptoms Diseases

are

not

mere

mechanical or chemical alterations of the material substance of the body and not
dependent on the existence of a material morbific substances but that they are primarily
qualitative derangements of the vital part of the organism. For treatment point of view the
totality of perceptible symptoms constitute the disease.
Cure: It is only possible by a change to the healthy condition of the state of health of
the diseased individual.
Medicine: Could never cure disease if they did not possess the power of altering
mans state of health which depends on sensation and functions; their curative power must be
owing solely to this power they posses of altering state of health.
Health: A state of case and comfort of the lying body depending on sensation and
functions.
HAHNEMANNS CONCEPT OF CHRONIC DISEASES
Hahnemann sought an explanation for the frequent relapses e observed in certain
patients with chronic complaints whom he treated according to his new system. He
observed them in greater detail and classified them in three broad groups with definite

47

attributes and predispositions. He observed a close association between these groups and the
diseases of Itch, Syphilis and Gonorrhoea which were rampant in those times. This
association led him to postulate a causal relationship between these three groups and the
three diseases. He studied the drugs in Homoeopathic material medica in greater detail and
classified them into the three groups. Then, on the basis of the Law of Similars, he directed
the physician to ensure that the selected remedy belonged to the similar group. By that time
he had experimented with a number of new drugs that have the capacity to affect profoundly
the human economy. These he classified in the light of this division and based his
therapeutic recommendations accordingly. All these observations were published in The
Chronic Diseases.
The controversy raged round the postulated casual relationship. This relationship
was seized on by Hahnemann as an explanation of his Theory and developed further.
It is quite possible to accept the classification made by Hahnemann on the basis of the
distinctive attributes of the three great types which are seen in patients with chronic diseases
and in the drugs that comprise Homoeopathic material medica while rejecting his
explanation as scientifically unwarranted. Subsequent clinical experience of

all

careful

Homoeopathic prescribes upholds the utility of this division.

We, therefore, accept the basic correctness of the Theory, although we reject the
casual relationship with the diseases of Itch, Syphilis and Gonorrhoea which Hahnemann
considered as established. 14
CLASSIFICATION OF DISEASES
By the time Hahnemann found that the clinical classification of diseases is the
classification most relevant for his purpose his attention was drawn to the differential points
in the clinical picture of the acute and chronic types of disease. The complete clinical picture
of any diseases comprises its onset, duration and termination.

48

Acute Disease : Certain types of diseases started with a sudden and definite onset, a
more or less fixed course of duration and ended in death or recovery (with or without
treatment).
Chronic Disease : There was a second type whose onset was insidious, course
indefinite with progressive changes in the structure and functions of the organism until at
last the organism is destroyed.
A. Patients with no history of Venereal Infection: These patients generally gave a
history of some manifestations on the skin characterized by intense itching, which
manifestations were suppressed by some local treatments and the general ill-health
dated from that period.

These suppressions, according to him, produced the Miasm of

Psora that affected the Vital Force adversely and led to distinctive features and
predispositions to diseases in patients thus afflicted. These patients he called Psoric
patients and the Homoeopathic remedies useful for this state as Anti Psoric remedies.
B. Patients who gave a previous history of Venereal Infection with i) Syphilis ii)
Gonorrhoea
The general ill-health started after the local manifestations were suppressed by local
measures. These suppressions, according to him, produced the Miasms of Syphilis and
Sycosis respectively. These affected the Vital Force adversely and led to distinctive features
and predisposition to diseases in patients thus afflicted.

These

patients

he

called

Syphilitic and Sycotic patients and the Homoeopathic remedies useful for these states as
Anti-Syphilitic and Anti-Sycotic remedies.
We have indicated in the Chart the broad distinguishing features and
predispositions to diseases of these three Miams.
Hahnemann

postulated

that

as

result

of these

previous

unfortunate

experiences, the Vital Force was impeded and the natural processes of recovery and cure

49

were interfered with Clinical observations soon convince him that these patients would never
be cured unless some deep-acting remedy was administered to them on the basis of the Law
of Similars. The tendency of the disease in these patients was to progress relentlessly.

detailed clinical study of these patients enables him to describe in great detail the
characteristic symptoms of these groups and also to indicate their disease potentials.
This information is of inestimable value to a Homoeopathic physician. Hahnemann,
in his later years, experimented with many inert substances and found that the process of
Potentization enabled him to reveal the great powers in these remedies which, by and large,
he found extremely useful in relieving the miseries of these chronic patients. Accordingly,
he evolved a similar grouping of the remedies a defect in the constitution which
interfered with the processes of recovery and cure. Naturally, the remedies were termed
Anti- miasmatic.
COMBINATION OF MIASMS:
According to Hahnemann, Psoric Miasm represents the oldest defect which has
thoroughly permeated mankind so that hardly anyone could be said to be born free of its
pernicious influence.

As already indicated it leads to functional disorders only. Any

structural change occurs only when the other Miasms supervene on the Psoric base.
Whenever such combinations occur, the propensity to the development of disease is
enhanced considerably. The manifestations of a disease, however,, are generally limited to
one Miasm at a time, usually the Psoric. After the Psoric manifestations are treated
with the appropriate anti-Psoric remedies, the dormant Syphilitic or Sycotic Miasms,
as the case may be manifests itself and calls for appropriate changes in the prescription.
Some of the most complicated diseases, difficult to cure, represent the combination of
all the three Miasms, e.g. Cancer, Psoriasis, etc.

Some of the common disorders which

result from a combination of these Miasms have been indicated in the chart. But more

50

important is to learn to identify the various symptom groups with the different Miasms and
to determine the dominant Miasm at a particular time in the course of treatment.
THERAPEUTIC IMPLICATIONS
The three Miasms represent three broad constitutional types which indicate different
susceptibilities to the development of illness.In other words, when we consider Miasms, we
consider them on the same plane as Diathesis. A detailed study in the three planes
emotional, intellectual and physical enables us to identify the dominant Miasm responsible
for illness and to prescribe accordingly. The chronic case with mixed-up symptomatology
can be tackled only when analyzed from the standpoint.
Homoeopathy offers a life of service to humanity and it is only method of healing,
that surely sets the sick man on the permanent road to recovery. Thats why it is called as
holistic approach. Dr. Hahnemann, the founder of this system of medicine has elaborated
on this, these in his Organon of Medicine.
Homoeopathy considers the man as a whole and not just his individual parts. There is
some energy which controls the body and mind and named as vital force without which the
whole body or cell becomes inanimate and is dead. Only with the help of vital energy,
physical action and of the exercise of mental powers and the ability to take hold on the
spiritual forces are possible. The development of this vital energy in one differs from that in
another and thus no two individuals are alike.
Any disturbance of this vital energy results in a disfigured or disturbed
development

of the whole human economy and makes itself known only by the

manifestation of disease in the sensation and functions of those parts of the organism
exposed to the senses of the observer and physician that is by morbid symptoms. These
signs and symptoms which are outwardly reflected picture of the internal essence of
the disease form of totality. Susceptibility also plays a role in disease. It varies in degree

51

indifferent patients and at different times in the same patient. Homoeopathic

application of a remedy meets the susceptibility and fill the vaccum that is present in the sick
individual. It also satisfies the natural susceptibility and establishes immunity. 15
If the patient is in unendurable stage of the disease, a remedy selected on the basis of
the law of similars has a palliating effect. The physician who will follow this law with the
use f single remedy in potentised form will give quicker relief and more sustained relief than
all the massive doses of narcotics and sedatives under ordinary medicine .
Regarding Chronic bronchitis every physicians have given their own ideas.
According

to

Dr. Vishapala 17

Bronchial asthma is nothing but a chocking

syndrome.
Man unable to meet the demands of wife and life Retreatsand Proclaims
his inability to cope By a choke. When a man is not able to meet the demands of his situation
emotional or physical, he chokes. This is termed bronchial asthma, the hypersensitivity of
the bronchioles to stimuli, leading to narrowing of the airways through contraction, spasm or
plugging of the bronchioles. It denotes man refusal to accept and deal with his situation and
environment whether it is dust, smoke, pollen, foods like chana, wheat, chocolate or
allergens like animal fur or even emotional factors like a scolding or rejection. All the
treatment therefore should be directed at unplugging or release. This is best done by the
holistic Homoeopathic approach of getting the patient to accept his situation and
environment.
Emotion may modify the immunological or allergic mechanism responsible for some
cases of asthma. A number of studies have suggested a relationship between asthma and a
cyclothymiacs or hysterical personality. The personality of the typical asthmatic is
hypersensitive and obsessive with strong depended traits. The psychodynamic process in
asthma is the unconscious fear of loss of the mother or mother figure. Sexual temptations,

52

competitive feelings, narcissistic desires and hostile impulses may precede asthmatic
attacks. The dependency observed in asthmatics may be secondary to the disease process.
The asthmatic attack itself could give rise to an acute need to cling to a mother figure and
may therefore tend to reinforced the helpless dependency seen in these patients.
Asthma said Bonnier, Is a functional bulbar disequilibrium principally of the
mortor apparatus with the latter unusually, sensitive to respiration. It is an irritation of
the pulmonary branch of the pneumo gastric nerve, the irrigation being accompanied by a
pause in the respiration. Inspiration and expiration become a voluntary cerebral act. In order
that the bulbar disturbance may exist, there must be a centripetal path of irritation leading to
a bulbar crossroad and a centrifugal path for the irritating to again reach the respiratory field.
We need 2 causes to produce an attack and irritation, transmitted over a centrifugal path and
a special predisposition in the so called asthmatic subjects. One of these two causes alone
does not suffer to bring an attack.
Bronchial asthma17 commonly affects children and the danger is that parents, in
trying to protect the child in dealing with their own anxieties may :
1. Impair the mature personality development of the child baryta, calcarea.
2. Give over attention which can restrict or retard their natural freedom- staphysagria.
3. Convey to them their own worst fears and accede to their every requiest. This may teach
the child to use breathlessness for his own gain Ignatia Moschus.
4. Parents can transfer their own frustrations on the child.
Dr.

S.K. Dubey

has

described

Bronchial

asthma as

nosological

manifestations of chronic miasmatic state and he classified the causes under three main
headings. They are :-

53

1. Fundamental causes :
a)

Sycosis

b)

Sycosyphilis

c)

Psora

d)

Mix miasmatic state

2) Exciting Causes :
a)

Various antigens

b)

Environmental factors- eg. Mill workers.

c)

Occupational factors Wool workers

d)

Physical exercise.

e)

Emotional stress.

3) Maintaining Causes :
a)

Living in damp grounds.

b)

Persistent exposure to allergens.

c)

Persistent mental worries and anxieties.

d)

Not antidoted (1) Vaccination / inoculation (2) Suppression of measles (3)

Whooping cough
Miasmatic Aspects :
Chronic Bronchitis is a chronic disease (Q.Q.) and multi miasmatic disorder of the
respiratory tract. The expressions differs in psoric sycotic, tubercular and syphilitic
constitution.
Dr. Hahnemann called the manifestations of chronic disease condition as miasms.
According to the common definition, miasm is an invisible polluting substance or
malarial poisons which once gains entrance into the system of a living human being and over
powers the vital dynamics, pollutes the person as a whole in such a way that it leaves

54

behind a permanent stigma or dyscrasia which is not completely eradicated with the
help of suitable miasmatic treatment, will persist throughout the life of the patient
and may be transmitted to generations after generations. 20 This he has mentioned in the
aphorism 80 and 81 in sixth edition of
Organon of Medicine
After 12 years of practical experience, Dr. Hahnmenann found that many times even
the best indicated remedy did not cure permanently as expected and the cases came back
again and again and thus he arrived at the conclusion of miasmatic states. He propounded
that true natural chronic diseases are those which owe their origin to a chronic parasitic
miasm. Germs (or chronic micro-organisms, as we could call them now-a-days) and this
fifty years before Koch and Pasteur discovered micro- organisms, as the cause of illness. He
called them chronic because they constantly extend their tentacles and not withstanding the
most carefully regulated mental and bodily habits, diet or a robust constitution, they never
cease to torment their victim with constantly remained suffering to the end of life.
In repeated relapsing cases, Dr. Hahnemann could find out history of
suppression of skin eruptions in childhood.

In others, there was a history of either

suppression of primary chance or condylomatous growths in some parts of life. He thus

prescribed medicines for those patients covering the dyscrasis or states resulting from such
suppression and the patients were cured. 22
Thus he came to the conclusion that the so called nosological chronic diseases were
nothing but the secondary manifestations of these suppressed states psora, syphilis and
sycosis resulting from psoric, syphilitic and sycotic miasm respectively.23
In The Chronic diseases, of Hahnemann, he described that asthma is one of the
most important manifestations of psora. For a long time that Homoeopaths have applied the
word psora without knowing what it really meant.

55

The term psora leads us to the

phenomenon of periodicity morbid phenomena appearing not only every month, or every
season, but also every year, every five years etc. This periodicity may extend upto the
successive generations.24 According to Muzumdar the psoric phase can be identified through.
1. Emotional factors; any physical attributors as a result of emotional states like anger,
rage, hate, anxiety, love etc., are seen in hypersensitive patients. Nostalgic
memories of yester years especially of unpleasant occurrences can throw a sensitive
system into a spasm. Obsessional, under confidence sensitive dependent traits
may also precipitate Bronchial asthma and the patient undergoes stress. Few
rubrics from Kent such as Anger (2) , Anguish (3), Anxiety (4), Fright (49), Fear (42),
Discontentment (36), Forsaken (49), Grief (50), mortification (68) may have to be
considered as causative factors of Bronchial asthma. Under chapter respiration two
rubrics Asthmatic and difficult are given (764, 765). Some sub rubrics like:
Emotions after, excitement, Hysterical, Mental exertion, Vexation from music, are
also useful in practice.
2. Allergic traits: The man is becoming extremely

hypersensitive

to

environmental

stimuli and allergens like pollens, protein food, shelled fish, milk

and

milk

products, eggs, pesticides, chemicals used for spraying, synthetic clothing,

perfumes, Aromas and odours etc. play an important role in this. It is often associated
with family or personal history of allergy, like urticaria eczema, rhinitis etc. Factors
such as cold air, fog, cigarette smoke or Industrial

gases

may

irritate

and

aggravate asthma in patients with hypersensitive bronchi. Kent on pages 764

under Respiration gives sub rubrics like: change of weather, autumn, cold from
taking, cold air, damp air, water, dust, from inhaling hay asthma, rose, cold from
wet weather and winter. Since allergy is a generalized state of health, chapter on
generalities and rubric Food may be consulted.
varieties see Phataks repertory too.
56

For some of the Indian food

3. Suppressed skin disorders/discharges; an infantile eczema, Atopic dermatitis in

infants and children when suppressed by topical application trand imards and more
dangerous disorder like asthma appear in later life. Even an infantile diarrhea
when suppressed by strong binding drugs, seems to produce Asthma in later life.
Kents Repertorium

general,

Kunzli

in

chapter Respiration Pg. 651 gives

some important sub rubrics; suppressed skin, eruption after suppressed, Rash
suppression of acute.Alternating with eruption, suppressed measles etc.,19
4. Heredity : Persons belonging to strong Psoric or tubercular trait are more prone to
develop Bronchial asthma. The onset will be with running of nose, Rhinitis, sneezing
and wheezing. The discharges will be thin, watery and acrid and the coughs will be
dry, teasing, spasmodic, annoying and bronchial with scanty and tasteless
expectoration19. Mostly the carbonitrogenoid constitution of grauvogl, where there
is excess of carbon and nitrogencomes under this. In psoric cases, Eosinophil count
will be higher.25
If the environment continues to be adverse, the over sensitive and alert
responsive system gets disoriented and tends to loose all controls which results into
appropriate but inefficient aberrant immune response. So there will be slowing down of
activity proversses, faculties and RES functions due to increased activity of the
parasympathetic nerves. The system goes into a state of exhaustion and the psoric patient
slips into sycosis. The defective RES functions produce erratic wandering and spasmodic
reaction causing cramps, colics and spasm. This also reduces the resistance to germs
and viruses. The patient in sycotic phase will have sycotic personality sluggishness,
slowness, indolent response and erratic behaviour41. At the mental level, the expression of
anxiety fear complex is enhanced due to dullness imperceptions and thinking. It causes
aberration and causes delusions, hallucinations and illusions. The constitution is
predominantly hydrogenoid.

Here the aggravations are due to moisture and increased

57

humidity in atmosphere and feels better during dry seasons. Secondly

super

imposed

infections are common and this will throw the system into spasm and reactive secretions.
These secretions cause rattling in the chest with humid and productive cough. Sometimes
there may be a history of genitourinary infections and a family history of asthma.24
In Kent, the available rubrics are sadness (76), indifference (54), indolence (55), and
fear (47) and these come hand in hand for their use as ailments from. The sycotic
expressions of Bronchial asthma are running nose, rhinitis, sneezing, with cough cold.
This quickly moves down the chest causing congestions bronchitis pneumonitis
and wheezing will start slowly.26 But according to Dr. S.K.Dubey after taking cold, there
want be coughly and sneezing but patient will suffer from breathing difficulty directly. The
patient will get aggravated by humidity, sultry hot weather, working in water or getting wet
in the rains etc. according to Phyllis spiget, there will be cough with little expectoration
which is usually of clear mucus, occasionally ropy and may also be a cotton nature. A great
deal of coughing is required to raise it.19
There is early morning aggravation which is better by expectoration. Here

the

eosinophil count will be realized but less than psoric. If this slow indolent system continues
to live under adverse conditions for a prolonged period, the system makes a last ditch effort
to return to normally. Suddenly an increased activity is seen at all leads that is at intellect,
emotional and physical. This beings on debility in course of time which takes the individual
down hill to an irreversible state and finally to death. The patient might have the history of
recurrent upper respiratory tract infection with glandular swellings. There will be heightened
sensitivity which is easily triggered by emotional factors. This tubercular constitution is very
sharp, intelligent and creative but physically very weak and debilitated. This fails to
translate creative ideas and that goes into spasms. Most of the time, frustrations
produce spasms. These patients have no energy to take full breath and besies cold air

58

aggravates them, particularly when the body is exposed to chill. There is generalized
oppression around the chest causing laboured inspiration and great tiredness in the morning.
As days advances, they become better or as the sun ascends their strength reviews a little but
as it descends they seem to loose the warmth again. Since the tubercular miasm is the
combination of posra and symphilis both the phases will be present in the single patient but
only one miasm will be dominant at a time.
The nasal discharge soon becomes thick, purulent and sometimes bloody and it has
an odour of old cheese or sulphate of hydrogen which is constantly dropping down the
throat. There will be constant desire to hawk or clear the throat of an viscid scanty mucus.
Cough will be deep and prolonged and more in the morning and when patient first lies down
in evenings and on exposure to cold air.

The expectoration becomes purulent or

mucopurulent and in advanced cases, greenish yellow often offensive

and

usually

sweetish/salty to taste. Sometimes it smells musty or offensive.25

When there is continuous difficulty in breathing over a long period, the
processes becomes more and more irreversible. The elasticity of the alveolar tissue is lost
and become fully permeable to air causing intercellular gap to be filled in this reduces the
exchange of oxygen and carbon dioxide and we call this as emphysema.
Similarly dilation of medium sized bronchi can take place with the destruction of
bronchial elasticity and the muscular element. Infection is the usual cause of this condition.
If this emphysematous lung continues to function under stress then the right heart
enlargement followed by hypertrophy may take place. 41Finally failure may result. This is
an acute cor-pulmonale. The chronic cor-pulmonale is produced because of chronic
obstructive pulmonary emphysema or chronic asthmatic bronchitis which later can lead to
pulmonary fibrosis.46 Even when asthma is complicated with status asthmatics, it comes
under syphilitic phase. There may be a family history of syphilis with symptoms of latent

59

syphilis and developed sycosis in the patient without any apparent cause. Family history of
syphilis may or may not be present. Here the patient will be suffering from a fatal cold and
cough but on the contrary, there will be a decided hope of surviving the attack, without any
anxiety. Cough will be one or two distinct barks like a dog. It becomes more during
winter and summer seasons, midnight and while sweating. The patient desires open air
even in damp weather.19
Dr. Dhiraj Nanda has stated that the paroxysmal asthmatic attacks are indication of
psoric miasm but when asthma is persistent or perennial, the miasmatic condition is not
purely psoric When patient complains constant suffering by catarrhal conditions are checked
the dominant miasm is sycosis. Early onset of asthma and family history of alcoholism(for
alcoholic parents)go in favour of syphilis.
Evolutionary disease response is necessary a multi miasmatic one; but in its
expression at any single point of time, it is generally uni-miasmatic in the sense that one of
miasms steals the show combined miasmatic diseases expression presents a variegated
appearance on account of the permutations and combinations of qualitative and quantitative
expressions that characterize each phase. Thee

phases

in

their

precise

sequential

relationship require to be appreciated in the full Anamnesis of the case; their characteristic
concomitant expressions are essential for establishing the similar remedy at a particular
moment of time. We rarely find one remedy running through all these phases.
1. Psora Sycosis
2. Sycosis Syphilis
3. Psora Syphilis (pseudo-psora/tubercle discussed earlier)

4. Combined maisms (all 4)

Are the different types. These combinations can interpreted readily in terms of

60

nosological diagnosis and pathology.11 Some of the most complicated diseases are difficult to
cure, represent the combination of all 3 miasms. In order to avoid the confusion one should
clear to identify various symptom groups with the different miasms and to determine the
dominant miasm at a particular time in a course of treatment. 10 If the upper most miasm is
removed, the next prominent miasm must be carried out by taking the totality of the
symptoms present, until the patient is freed from the inheritance of generations.27
MANAGEMENT OF CHRONIC BRONCHITIS :
This can be discussed under two headings general and specific / Homoeopathic
management.
General Management:
Avoidances - Dietary allergens, exposure to house dust and other dusts, exposure to
sudden temperature changes, getting wet in rains, exposure to smoke from kitchen, factories,
industries or traffic vehicles, cigarette smoking, sleeping in a recently white washed or
painted rooms, using strong smelling perfumes, soaps, and oils, keeping pets in the house,
eating preserved and tinned foods and milk in case of lactose intolerance.
Diet : It plays an important role. Diet should be light and small in bulk,. A heavy
meal should not be taken at night. Simple vegetable diet without extreme taste should be
taken. Take only freshly prepared warm foods. Diet should contain fresh leafy vegetables
and seasonal fruits. Bananas and strawberries should be avoided as they release histamine
in the body. Dietary precautions to be taken with different Homoeopathic medicines are:
fatty diets. Avoid frozen rood rich and fatty diets when puls is given. Honey in Nat carb
patients melons vith Zingiber onions with Lyco and Thuja Eggs in Colchincum and Ferrum
patients Tea with Silicea. GreenVegetables with Nat sulph. Bread with Bry and puls. Beans
and peas with Bry and Lyco. Fish in plumbum patients.
Bowels : should not be constipated and abnormal bowel habits should be practiced.

61

Exercise : Abdominal breathing exercise, expansion of lower chest exercise (where

the patient should try to expand the lower chest during inspiration by allowing upper chest
and shoulders to be releasaed) and candle flame exercise (where the distance between the
flame and mouth should be 15-20 cms and with expiration, the patient has no extinguish the
flame) can be advised.Suitable yogasana like shavashana, pranayama, stimitasana etc. for 510 minutes daily.
Emotional Cause : Emotional upsets, a hearty laughter etc. which may provoke an
attack should be avoided.

Individual psychotherapy, group therapy, hypnosis and

behaviour modification techniques can also help to prevent the attacks.

Specific Management Chronic Bronchitis is a chronic miasmatic disorder of the
lungs but flares up, with acute exacerbations from time to time. Treatment therefore be
directed towards these acute attacks followed by constitutional anti miasmatic intercurrent
remedies to induce greater resistance to various vectors acute attacks, we may have to
consider the exciting cause, position of the patient during an attack decubitus
characteristic modalities,

most

important is

time

and

factor and concomitants.

Connection to the there are some important rubrics from Kent and Boenninghuasens
repertory, Emotional Anger (2), Anguish, (3) Anxiety, (4) Freight (49), Jealousy (60),
Fear (40), Discontentment (36) Forsaken (49), Grief (50), Intellectual frustration (36),
Mortification etc., similarly rubrics like Respiration asthmatic (763-765), Respiration
Difficult (760-772) Respiration impeded (773), Respiration (774), Respiration wheezing
(776), Respiration Asthmatic (B.690-691), obstructed (B.696), oppressed (B 693), Ratting
(B.694), Impeded by (B.695), Tight (Wheezing) (B.694) etc.27

As we know Chronic bronchitis is a multi miasmatic disorder, that means it can

present I various types of miasmatic expressions which is discussed earlier. The cases of

62

asthma can be cured if we succeed in removing the miasmatic underlying condition.

Homoeopathy is the only system of medicine that possesses curative means of
removing the miasms for this, the case must be studied in its evolution from conception
onwards Evolution phases susceptibility Miasms and chronology makes the whole.
Only then during the course of treatment. Herings law can be demonstrated that is cure
takes place form within outwards from above downwards and from more important organs to
less important organs and a complete cure can be achieved. 19 Thus asthma teaches one to
think patient instead of Disease.

It is does not yield permanently to anything but the

similimum. 17 J.H. Allen says that By the study of organon of medicine and the chronic
Disease, are can get the knowledge about existing, active chronic miasms. By the study of
each chronic miasms psora syphilis and sycosis, in all their stages and in all their
bleedings, one can learn the symptoms of the miasms which will help in selection of suitable
remedy. In selecting the remedy, we should arrange the symptoms according to their
value, giving preference to those last appearing for they are the symptoms of active miasm
and classifying the remainder as belonging to the latent grouping. Our

Homoeopathic

treatment must be according to the three main principles of (1) Similarity (2)
Minimum dose and (3) Application of only one medicine at a time. If we make a mixture
of two or three medicines or if we prescribe either at a time or in alteration or if we use
medicines of too low potency, our prescription will be far from Homoeopathy and it
brings about no permanent cure; even if it relieves some of the symptoms of the patient., It
leads to Homoeopathic Suppression.28
Homoeopathy teaches to look at each patient as a unique individual, hence the
constitutional approach. If we are to cure Chronic Bronchitis cases, to the point of being
convinced that their treatment will have to be over a long period of tie, long enough to
successfully cure, together with the bronchitis condition the most chronic constitutional

63

remedy that forms and gives shape, mentally and physically, to this whole being without
which he will never be cured of his chronic bronchitis or even will be able to enjoy complete
health. The most proper time to institute this constitutional remedy will be the apparently
healthy intervals between the attacks, when the patient usually feels even to report to the
Doctor because of his feeling better. How long that period of time will be, it is hard to pre
determine, but it will surely be in direct proportion to the patients co-operation. It is observed
that chronic bronchitis cases showed marked improvement in the frequency, intensity and
duration of subsequent attacks after Homoeopathic treatment29.
According to Dr. Fortier, the therapeutic plan of asthma includes
1.

Nosodes and Constitutional remedies.

2.

Functional and drainage remedies (acute remedies)

Nosodes and constitutional remedies a described above, depends upon underlying

miasm. The commonly used Nosodes remedies are Psorinum, Thuja, Medorhinum,
Syphilinum, tuberculinum, bovinum, Bacillinum, and aviare, Constitutional remedies should
be based on the totality of psychological and physical characteristics.
Fucntional and frainage remedies are nothing but the acute remedies which acts
especially on the asthmatic fits because they have precise symptoms of asthmatic fits. He
has classified a small group of remedies which proved to be effective into two groups.
1. Asthma when oppression predominates over the cattarhal element (pure asthma)

Ethyl Sulphur diet, lobelia inflate, Bryonia, Drosera, Cactus grandiflorus,

sambucus nigra, passiflora, valeriana, cup-mt, cup-aretic, Hydro cyanic acid, Mg

phos, Spongia, Moschus and Napthalin.
2. Asthma with predominant catarrhal element Ant.tart, Ant.ars, Ipecaca, Puls,
Senega, Squilla, Kali carb, Kali Bick, Kali Iod, Kali Nitro, Kali ars, Kali Chlor,
Chromico Kali Syulphusicum, Hep Sulph, coccus, C.grindelia, Ars.Iod, Blata Or,
Eriodictyon.30
64

Dr. K.P.Muzumdar has discussed the various types of miasmatic expressions with Ant
miasmatic remedies. Psoric personality reacts to any stimuli very fast but it also returns to
normally quickly.

Most of the time, patients come with upper respiratory symptoms but

they may not necessarily end in asthmatic dysphonea. When

the

attack

of

upper

respiratory infection quickly descends in the chest causing dyspnoea then one must thin of
Ars. Alb,Cup ars, Aralia R. Lobalia Infla, Kali carb, Brom. Carbo Veg.
In sycotic personality, the upper respiratory infection quickly moves down the
bronchi causing increased secretions difficulty of breathing and wheezing.

Here the

remedies are Antim tart, Ant ars, Nat sulph, Ipecac, Med. Thuj, Senega,Stann met, Kali bich.
In tubercular personality, there is an increased response to stimuli which is more than
the psoric personality and the remedies corresponding to this are Phos, Kali carb, Iod, Samb,
Branium, hepar sulph.
In syphilitic personality, the signs and symptoms reach the irreversible stage very
soon

and

the

patient

progresses

towards

death

through

cardio

pulmonary

complications. Remedies like Merc. Hep sulph, Arg nit, Aur met, Senega, Stann met, etc. are
indicated and act more or less as palliatives. These reduces the sufferings but can hardly
cure the condition. Almost all these remedies are polychrest remedies and aprt from this
there are some rare drugs which are not thoroughly proved like Histamine Hydro
chloride, Berryllium metal, Naphthaline and Eucalyptus globules.
According to Dr. S.K.Dubey, the medicinal treatment includes (a) Palliative during
acute attack, modality and concomitant should be considered. The remedies are Aconmite,
Ant ars, Blata O, Pothos, Adrenaline, Asidosperms, Yerba santa, Zingeber, Ambra
grasia, Mephitits,

Ferr-phos, Digitalis, K. Chlor. (b) Curative Constitutional anti

miasmatic treatment and change in the plan of treatments as per as necessary eg. Anti sycotic
followed by anti syphilitic or antisyphilitic followed by anti sycotic or anti psoric medicines

65

should be practiced.
If the patients come after much drugging of Homoeopathic or Allopathic
medicines, that should be antidoted first and then the constitutional antimiasmatic medicine
should be prescribed.19
The recent study is that the patients can be de-sensitized to the known allergens,
using Homoeopathic doses of the allergens like house dust mite, grass pollens, animal
danders, moyulds and so on. Homoeopathic preparations can be made of any allergens and
acute reactions to their administration have never been recorded and it has a dramatic effect
on its own.17
Course and Prognosis:
Chronic Bronchitis itself doesnt cause death unless it is complicated with
emphysema or cor-pulmonale. Homeopathically, the prognosis is very good, if treated in
early age. It is a slowly progressing disease condition unless treated with constitutional
anti-miasmatic medicines. After Homoeopathic treatment, it was found that, in children
100% cure, in young adult groups 80% and I advanced cases it acts as a good palliation.31
MIASMATIC BACKGROUND OF CHRONIC BRONCHITIS
MIASM : Literally means Any noxious emanation or effluvia or polluting
factor32
Definition : Miasma are supposed to be dynamic disease producing powers which
pollutes the human organism and become the producer of every possible disease
condition.33

Miasmatically Chronic Bronchitis can be classified into the following types along
with its detailed characteristics:
A. PSORIC Chronic Bronchitis
66

1. Psoric personality with ready swing and functional disturbances.

2. Active skin complaints or history of skin complaints.
3. Often one finds in the history that there has been suppression of skin eruptions and
onset of Chronic Bronchitis can be traced to a period after that suppression.
4. Purely psychogenic Chronic Bronchitis is represented in the predominantly hysterical
group of remedies in Homoeopathic material medica.
5. Sudden appearance and disappearance of spasm with minimal secretory phase.
6. As there are less secretions, the expectoration is scanty, mucoid and tasteless.
7. Sudden breath holding spasms.
8. Re-establishing skin symptoms and Chronic Bronchitis is better.
9. Chronic Bronchitis better by treatment of skin complaints.
10. Emotional and psychological conditions acts as triggering factors.
11. Irritable, anxious and excitable.
12. Alteration of skin complaints with episodes of Chronic Bronchitis.
13. Chronic Bronchitis episodes is eruptive diseases.
B. SYCOTIC CHRONIC BRONCHITIS
1. Sycotic personality.
2. In the past history, there will be a history of suppression of discharges from mucus
membranes, the suppression of sweat and other discharges should be considered as a
point favouring towards this miasm.
3. Bronchial cough, marked secretions, scanty, difficult expectoration. Dry racking
cough following Coryza and sneezing.
4. Expectoration is thick, greenish, yellow.
5. As a rule cannot breathe through nose.
6. Characteristic sycotic inflammatory discharges. Stuffed up feeling.
7. Chronic Bronchitis aggravated by damp, rainy season and getting wet in rain.
8. Very sensitive to barometric changes, can foretell a change, it appears days before.
9. Amelioration in dry weather.
10. Amelioration by re-establishment of discharge.
11. Concomitant musculo-skeletal manifestations such as pain, arthritis, myalias etc.
12. Tropical eosinophilia.
13. Mentally sluggish.
14. Slowness, poverty of ideas.
C. TUBERCULAR CHRONIC BRONCHITIS
History of viral infection and of upper respiratory infections leading to Chronic
Bronchitis.
1. Attacks are erratic and the severity may increase or decrease rapidly.
2. Tubercular base and expression may be present.
3. Cough with excessive expectoration. Cough is deep and prolonged, giving us the
67

lower chest tones.

4. Expectoration is purulent, mucopurulent or even bloody, often offensive and usually
sweetish to taste or salty.
5. Aggravation by viral or bacterial infections.
6. Aggravation by cold air, exposure to cold.
7. Aggravation at night.
8. Amelioration as day advances (under sun).
9. They need abundance of fresh air.
10. Chest narrow, weak persons easily exhausted. The curves and the lines of the chest
are imperfect.
11. Easy suppuration, tendency to superadded infection and fever.
12. Enlarged lymph glands.
13. Tendency to fibrotic changes complicating the respiratory function.
14. Anxiety with imaginations. Building castles in the air, always hopeful for a cure.
Never skeptical of results. Least over exertion exhausts beyond which is natural.
Born tired always tired.
D. SYPHILITIC CHRONIC BRONCHITIS
1. Cough like the bark of a dog.
2. Whatever be the cause, provocating factors etc; when irreversible changes occur in
lung parenchyma the miasma predominating is syphilis.
3. Emphysema ultimately leading to cor pulmonale.
Allergic Chronic Bronchitis is manifestation of Psora. Paroxysmal Chronic
Bronchitis attacks are indication of psoric miasm. But when Chronic Bronchitis is persistent
or perennial, the miasmatic condition is not (purely) psoric. When the patient complaints
constant sufferings by catarrhal condition and Chronic Bronchitis attacks occur whenever
these catarrhal conditions are checked, the dominant miasm is sycosis. Early onset of
Chronic Bronchitis and a family history of alcoholism (or alcoholic parents)34.
Symptomatic diagnosis of the probable miasmatic state
i)

Typical midnight aggravation is suggestive of syphilitic or syco-syphilitic

ii)
iii)
iv)

miasmatic state.
Early morning aggravation is suggestive of sycosis.
Evening aggravation is suggestive of psora.
First dyspnoea, then cough followed by expectoration is suggestive of sycosis. v)

68

v)
vi)

First cough, then dyspnoea followed by expectoration is suggestive of psora.

Dyspnoea and cough at the same time is suggestive of sycopsora.
Sneezing, coryza and cough lasting for 1-2 days followed by dysnoea is

vii)

suggestive of allergic origin (psora).

Dyspnoea associated with sweating which ameliorates but avoids open air

viii)

suggests psora.
Sweating aggravates and desires cold both externally and internally suggest

ix)
x)
xi)

syphilis.
Aggravation in damp, rainy weather suggests sycosis.
Amelioration by moving slowly is suggestive of sycosis.
Amelioration by yellowish or greenish-yellow expectoration is suggestive of

xii)
xiii)
xiv)

sycosis.
Profuse, frothy expectoration which may or may not ameliorates suggests psora.
Dysponea ameliorates lying on back suggests psora.
Dyspnoea ameliorates lying on chest or abdomen suggests sycosis.35

Hahnemanns Therapy of Chronic Diseases and Allergy

Hahnemanns ideas regarding the theory and nature of chronic diseases are further
corroborated by the modern investigation in the field of Allergy.
1. An organism once inoculated, remains, forever, in a state of hypersensitivity and
responds with varying symptoms of a local and general nature to renewed contact
with even minute doses not only of the original but also of a similar or related
antigen e.g. a typhoid fever serum agglutinates also paratyphoid bacilli; an
infection with measles predisposes to tuberculosis; sensitization by Kochs bacillus
increases the susceptibility to streptococcal and staphylococcal infections.
2. The pathogenic (anaphylactic) type of responds may be likened to what
happens when the sensitized organism responds with symptoms of illness to a
renewed contact with the exogenous pathogenetic factory.
3. The immunity type of response may be considered as analogous to the effect of the
isopathic or homoeopathic remedy which is supposed to rise the body resistance to
infections by vital stimulations.
In the light of these facts Hahnemanns contention appears quite logical and
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understandable that in the train of one original infection a never-ending stream of al sorts and
kids of aliments ensues, particularly so when factors of mixed infections and the effects of
drugs and suppression add their complications to the picture.
All extra human factors, drugs, improper foods, bacteria; physical forces alike, being
potential disease producers are also capable of creating what Homoeopathy calls the
miasmatic state namely, a continued steady progression, under various guises, of the
original pathology or a weakened resistance to the original or a similar infecting agent.
There must also be a cause within us, to stop our counteraction against the outside
force-process thereby allowing for what we may term the first or primary illness or infection,
which prepares the ground for others to follow.
Our mental personality (consisting of the thoughts and feelings) sets up an inner state
which is similar to the potential effect of the outer energy; since the inner and outer resemble
each other. We no longer may oppose the outer. The barriers are down for an extension of
the extra-human process into our interior. The bacterial invasion is secondary to the
miasmatic disposition derived from the mental and emotional configuration or from the
chronic hypersensitivity resulting from earlier sensitization.
In the case of what we may call secondary acute exacerbation of the chronic
miasmatic illness the internal hypersensitivity is the pertinent factor; only a constitutional
treatment can be of real help. The term Miasm can be taken from a wider view point, in
the sense of a sum total of all the factors (exogenous and endogenous, psychological,
biological and chemico-physical etc) in the production of diseased conditions, of which the
living micro-organism factor can, of course, never be excluded incase of many acute or
chronic diseases.
In the long run Hahnemanns miasmatic conception turn out to be that of infection as
it is understood in orthodox medicine From this point of view his psora theory, forms in

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point of fact, not only a completion of the law of similars, but also an improvement and a
perfection of the homoeopathic science of healing in general, and indeed the coping stone in
Hahnemanns structure of healing art.15

71

STATE K.G.K HOMOEOPATHIC MEDICAL COLLEGE &

HOSPITAL MORADABAD
OPD CASE SHEET
CASE NO-

Name of Physician- Dr.Yashveer Singh

REG NO-

9439

Intern In charge - Vandana Rani

PATIENT NAME-

Mrs. Neelam

AGE/SEX-

44yr/ F

OCCUPATION-

Housewife

RELIGION-

Hindu

MARRITAL STATUS- Married

ADDRESS-

Hanuman Nagar, Moradabad

DIAGNOSIS-

Bronchitis
CLINICAL HISTORY

CHIEF COMPLAINTSDry Cough with no expetoration since 8 months.

Ematiation

Pain in left sided chest with tightness.

Eating well

Dyspnoea on exertion .

Weakness

HISTORY OF PRESENT ILLNESSHard in taking breath during walking since 8 month

All complaints agg- from motion, music, dampness, early morning, and after sleep.
Amelioration- in open air, patient feel better in his lawn
PAST ILLNESSHas been suffered pulmonary pneumonia before 1 yr before
PERSONAL HISTORYTall, light complexion , narrow chest, emaciated, physically weak.
Food habit- desire for milk.
Addiction-none.
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Extra marriatal relation- none

Habit - none

FAMILY HISTORYFATHER- tubercular - died

MOTHER-died due to asthma
BROTHER- 2 (NAD)
SISTER- 1 (NAD)
H/H- urticaria alive
SOCIAL STATUS- middle class
DIETETIC HABITS- good
PHYSICAL EXAMINATION

GENERAL EXAMINATIONAPPEARANCE- tall,emaciated with sunken face

BUILD - NAD

NUTRITIONAL STATE-

good

HYDRATION- NAD

ANAEMIA-

mild

OBVIOUS FOCAL SEPSIS- NAD

PULSE-

74/min

TEETH / GUMS-carries

BLOOD PRESSURE-

100/70mmHg

TONSILS-enlarged

RESP RATE-

impaired

TEMPERATURE-

EAR- offensive yellow discharge

fever at evening

SKIN-eczematous with acne

LOCAL EXAMINATION
ON AUSCULTATION, wheezing is heard and prolonged expiration
ON INSPECTION ,mild anaaemia is seen

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SYSTEMIC EXAMINATION RESPIRATORY SYSTEM-impaired

LFT-sign of bronchitis
C V S- NAD
C N S- NAD
GENERAL SYMPTOMS

PHYSICAL GENERAL
APPETITE-

increased

DES/ AVERSION- NAD

THIRST-

thirstless

SLEEP-

sleepiness in day

DREAM-

NAD

HOT/ COLD- chilly

STOOL-

sudden loose motion

URINE-

increase

GYNAE & OBS HISTORYMENSES-menopause before 1 yr

OBS HISTORY- 2 children and pregnancy history was normal
MENTAL GENERAL
WILL-LOVE- love every friend & family member
HATE- NAD
FEAR- of animals-dog
ANGER-easily anger
TEMPER- irritable nervous
UNDERSTANDINGINTELACT

THOUGHT-

NAD

ILLUSION-

NAD

HALLUCINATION-at night
74

DELUSIONS-

NAD

MEMORY-

weak
INVESTIGATION

ROUTINE INVESTIGATIONBlood examinatin-

Hb%- 9.2 gm
TLC-9720/cc
DLCESR-16ml/hr

SPECIAL INVESTIGATIONSputum examination- positive

X-ray chest-PA View- show evidence of bronchitis
ANALYSIS & GRADING OF SYMPTOMS
1. FIRST GRADE SYMPTOMS much precautious
hard dry hawking cough < after sleep
fear of dog
physical weak ness
early morning diarrhoea
2. SECOND GRADE SYMPTOMS enlarge tonsil
eczematous skin
EVALUATION OF SYMPTOMS &RUBRIC FORMATION
MENTAL much precautious
irritable & freatful
depress & melancholic, insomnia
75

 fear of animals esp dog

GENERAL ematiation rapid and pronounced
loosing flesh while eating well
sudden early morning diarrhoea
PERTICULAR enlarged tonsil
headache < by eye strain, study, mental exertation
meningitis
CONSULTATION OF REPORTORYOn the basis of grading of symptom whole case is repertorised & consult Borick & Kent materia
medica, selected medicine is as follows

FINAL PRESCRIPTIONRx
Tuberculinum 200 1 dose
S.L. 30/ 4 pills TDS
PROGRESS REPORT
DATE

PROGRESS

5-07-14

TREATMENT PROGNO

MANAGEMENT

Tub 1M/ 3dose Good

steam inhalation

S.L. 30/TDS
frequancy of cough

S.L.30/ TDS

Betternothing especial only

is less without tightness

nutritious diet

in chest
12-07-14

improved

SL30/ TDS

76

V. good

CASE NUMBER 2
Name : Raj Kumar

Physicians Name: Dr.Yashveer Singh

Age : 45 /M/Hindu

Intern In charge:Vandana Rani

Date : 25/06/2014
Reg No. : 8131

Diagnosis : Chronic Bronchitis

Occupation : Medical Representative in Cipla

Marital Status : Married

Address : Majhola,Moradabad
CHIEF COMPLAINT

Dyspnoea during damp weather since 3 year.

Pain in left side of chest.

Cough since 3 year

HISTORY OF PRESENT COMPLAINT

Cough since 3 year

Cough with thick ropy greenish expectoration

Patient must hold the chest when coughing

Rattling in chest at 4& 5 a.m.

Pain in lower lobe of left lung

Dyspnoea during damp weather.

SMOKING SINCE 20 YR
FAMILY HISTORY

Father : tuberculosis died

Social Status : Middle Class

Mother : Alive, joint pain

Wife:hypertensive

77

MENTAL GENERAL
likes to speak
Concentration : ability to manipulation
Sad, gloomy, irritable
Responsible in doing work

UNDERSTANDING / INTELLECT
Thought : inability to think
Memory : very good

PHYSICAL GENERAL
Constitution : Lean and thin and weak
Appetite: Diminished
Thirst : low
Desire : Cold drink
Aversion : Milk
Relation to weather : Hot patient
ANALYSIS OF CASE
Mental General :

Music makes him sad

Sad, gloomy, irritable

Dislike to speak

Cocentration : ability to manipulate

78

Physical General
Constitution : Lean thin and weak
Side : left lobe of left lung
Sleep : sleepiness in morning
Dream : anxious

Particular symptoms
Side left lung
Time : Morning 4 & 5 a.m.
Extension : to the to umblicus
Location : : left lobe

Evaluation / Gradation of symptoms

a) Mental General :

Music makes him sad Ist grade

Memory Good - 2nd grade

Dream Anxious 2nd grade

b) Physical General

Aggravation Damp weather 1st grade

Desire Cold drink 2nd grade

Thirst low 1st grade

Sleepiness in mornimg 2nd grade

c) Particular Symptoms

Pain Lower lobe of left lung Ist grade

79

Cough- 2nd grade

Dyspnoea- 2nd grade

Rubrics

Music makes him sad

Concentration difficult

Memory Good

Dream- Anxious

Aggravation cold in general

Thirstless at night

Desire Cold Drink

< Dyspnoea 4 & 5 a.m.

< Damp weather

Reportorial Analysis
Nat-sul 24/9
Lyco-

21/8

Phos- 19/8
Nat-m- 17/9
Merc-s- 17/8
Arsenic - 16/7
Nat-sul covers maximum number of rubrics i.e. is why Nat-sul is prescribed.
PrescriptionNat-sul 200 1 dose stat
S.L. 30 2 pills TDS.n

80

81

PROGRESS REPORT
Date
04.07.14

Progress
Sleep is

Treatment

Management
Avoid cold atm

Prognosis
wait and

better

S.L. 30 2 pills TDS.

& dust &

watch

Improving

Repeat

cessae smoking
14.07.14

Good

Signature of Physician

82

SYNOPSIS OF CASES
Case 1
Date

Progress

Treatment

5-07-14

Management

Prognosis

Tuberculinum 200 1 Avoid dust

wait

dose

Steam inhalation

watch

SL30 tds

Balanced

and

roughage diet
12-07-14

Frequency of cough SL30 tds

is

less

--do--

Good

--do--

better

without

tightness
20-07-14

improved

SL30 tds

Case 2

Date
14-07-14
21-07-14

Progress

Improving

Treatment
Nat-sul 200 1 dose

Management
Prognosis
Avoid cold atm wait
and

Placebo-30*BD 7 days
Placebo 30

& dust

83

watch
Good

and

BIBLIOGRAPHY
Boerickes Materia Medica & Repertory
Harrisons Practice of Medicine
Davidsons Practice of Medicine
Clarkes Materia Medica
Kents Repertory
Robinsons Pathology
Text Book of Pathology
Text Book of Materia Medica by Dr. S.K. Dubey.
Tortora Anatomy & Physiology text book
Allens Key Notes

Kents Lectures

Genus of homoeopathy by Stuart close

Internate site of central council for research in homoeopathy (CCRH)

84