Volume 3 — DISEASES OF THE RESPIRATORY SYSTEM. (continued 6)

It may happen that in either a superior or inferior tracheotomy no time will be allowed for careful and slow dissection as here described. In such instances Durham advises that the surgeon grasp the trachea between the fore finger of his left hand on the left side and the thumb on the right, and make uniform, steady, deep pressure, thus firmly securing it and at the same time protecting the large vessels of the neck. The fingers thus placed are not to be moved until the trachea is reached, which is accomplished by rapid incisions confidently made. The pressure of the fingers causes the wound to gape and the trachea to advance. The latter reached, it is caught by the tenaculum and the operation completed as before described.

The operation of median tracheotomy may require a word. As has been stated, that part of the trachea covered by the isthmus of the thyroid gland is very commonly encroached upon in performing either or both superior and inferior tracheotomy, the isthmus being slightly displaced from its site. Other than this the site here mentioned would rarely be selected as the point for opening the trachea. Certain conditions, it is true, might render it necessary, but they would be rare. The danger lies in the hemorrhage which, theoretically at least, is to be expected when the isthmus of the thyroid gland is either torn or cut through; but opinions vary very greatly as regards this danger. With a thin, narrow isthmus in children I have frequently, in performing superior tracheotomy, cut my way through to a sufficient extent to clear a suitable space upon the trachea through which to introduce a tube without difficulty or danger. I should not recommend the procedure, however, were the isthmus to be seen to be, when reached, thick, wide, and exceedingly vascular, but at the same time believe that the danger even here of cutting into it is much overestimated.³ Roser's recommendation to apply a ligature to the isthmus on either side of the median line previous to its division is not generally applicable. Hueter has shown that the fibrous capsule of the thyroid gland enclosing it and its blood-vessels is firmly attached to the trachea and sides of the larynx, and that from the isthmus this fascia extends upward over the larynx (fascia laryngo-thyroidea), and thus prevents, in a measure, attempts at displacing the gland downward. Bose⁴ recommends that this fascia be divided transversely over the anterior convexity of the cricoid cartilage, when a director can be passed behind the isthmus, to lift it from the trachea and depress it far enough to expose three or four of the rings: the capsule of the gland thus remains unbroken and no hemorrhage occurs. The procedure certainly merits trial; twice it has succeeded well in my hands.

³ See Foulis, "Some Points on Tracheotomy," Glasgow Med. Journ., vol. xv. No. 2, p. 123.

⁴ Archiv für klin. Chirurgie, vol. xiv. p. 137.

Cricotomy, the division of the cricoid cartilage alone, is an operation which, as far as I am aware, is rarely ever performed. The objection urged against it, however, that in the adult the elasticity of the cricoid cartilage is so great that a wound through its ring cannot be made to gape sufficiently to allow of the introduction and retention of a canula without discomfort and danger of necrosis of the cartilage, is not borne out by experience. In children the objection cannot of course be urged.

The description of the operative steps which has been given, and which comprises the routine in an ordinary and easy cure, should not mislead. The operation is not always as simple and safe as would appear from what has been said. At times complicated and difficult, at times dangerous in practice from the delay involved, it demands in all, but especially in certain urgent cases, a trained hand and eye, sound anatomical knowledge, coolness, self-reliance and presence of mind on the part of the operator. Despite the greatest caution, and even in apparently favorable cases where time for dissection and deliberation is allowed, certain mishaps may occur which complicate the operation to a serious, dangerous, or even fatal degree. Some of these, as will be seen, are avoidable with care, but others may happen that are not only unavoidable, but totally unforeseen, and from their very suddenness all the more embarrassing.

Accidents may occur during the dissection of the soft parts overlying the larynx and trachea, and the importance of carefully determining by palpation the location of the various parts prior to making the preliminary incision, and of studiously preserving their relation and location during the dissection, cannot be overestimated. Neglect of this precaution has in more than one instance led to the air-passages being opened through the thyroid cartilage or thyro-hyoid membrane, instead of at the intended point. It should not be forgotten also that the natural laxity of the several layers of connective tissue of the neck is much increased by their division, and that the trachea, being naturally freely movable, is thus very easily displaced from its normal position during the act of dissection; especially will this happen when unskilful attempts are made to hook aside or retract the divided structures during the operation. Thus it may easily occur that the entire trachea is drawn to one side and entirely lost, or, more commonly, is turned upon its vertical axis, and finally opened at the side instead of anteriorly in the median line. It may not be opened at all, either being altogether missed by the surgeon in his dissection, which is continued past it, even down to the vertebral column, or the tracheal tube may be passed into the tissues lying in front of the trachea, under the mistaken idea that the latter has been incised. Persistence in keeping to the median line during dissection—a golden rule in the operation of tracheotomy—will render the first accident impossible; the second may be avoided by hooking up the trachea, as has been described, before incising it. If the opening into the trachea has not been made large enough to receive the tube, as often happens to the young operator, and even to the experienced when he fears to extend his incision on account of the proximity of the thyroid isthmus, no resource remains but to carefully enlarge it, pushing the thyroid isthmus or veins from before the course of the knife. If the opening be small, and be lost both to touch and sight, a second should at once be made, especially in urgent cases, and no time lost in searching for the first. This opening must be made directly in the median line, otherwise the canula will stand awry in the wound and be easily dislodged from its position in the trachea. If the first opening made is faulty in this respect, it is better to at once make a second. It may seem unnecessary to warn the surgeon against thrusting his sharp-pointed bistoury too far inward at the moment of incising the trachea; but as a matter of fact it has been driven through both anterior and posterior walls, and even through the oesophagus, until it has struck the spine. The converse, or a too superficial incision, is an accident more likely to occur, the point of the knife not being made to penetrate the mucous membrane of the trachea, which is probably swollen and thickened. No relief in such cases follows the incision, and an attempt to introduce a tracheal tube may cause it to pass between the mucous membrane and tracheal walls into the submucous tissue, thus stopping up the tube as it progresses. The disastrous result of such an accident can readily be foreseen unless the complication be quickly appreciated as to its nature, the tube withdrawn, and the incision completed. Much more frequently will a somewhat similar accident occur in the operation of tracheotomy for croup or diphtheria. The pseudo-membrane overlying the walls of the air-passage is not penetrated, but pushed before the knife, which has properly incised the walls of the tube; the introduction of the canula now crowds this membrane still farther back toward the posterior tracheal wall, and a complete tracheal stenosis is added to the pre-existing laryngeal one; sudden and urgent dyspnoea follows, and prompt relief alone wards off fatal suffocation. Fortunately, in such instances the forcible efforts at respiration and struggles of the patient are often sufficient to break through the occluding membrane and allow the respiratory current to pass. Violent cough often follows, and more or less of the membrane is forced out through the tube. Should these events not come instantly to pass, the surgeon must not wait for the efforts of the patient, he being often cyanosed and unconscious at this point, but by passing an elastic catheter down through the tracheal tube break through the occluding membrane forcibly. The occurrence of such an accident is always denoted by absence of respiration through the canula and by alarming asphyxia, and its cause needs but little reflection to be appreciated.

Much the same train of events happens if during the introduction of the canula large portions of the false membrane are completely detached and drawn down into the lower trachea by the violent inspiratory efforts of the patient, or stripped up from the mucous membrane and pushed downward into the air-tube. No time should be lost in either case in removing the tracheal tube, dilating the tracheal wound by forceps or otherwise, and in endeavoring to clear the trachea by seizing the obstructing membrane with forceps. If this be unavailing, the suction-syringe must be adapted to the mouth of the canula and the trachea cleared by aspiration. A large elastic catheter may take the place of the canula. Sands recommends in such instances as the foregoing that another opening should be freely made below the first one in the trachea, when respiration will probably be re-established. The success of this procedure of course depends upon the depth to which the false membrane has been drawn in the trachea.

Schüller regards the moment at which the trachea is opened as the most important and most dangerous of the whole operation. Certain of the accidents which may occur at this period have been detailed; others remain to be spoken of, one of which at least—viz. hemorrhage—requires special mention. Even before the tube is cut into it may cause an important question to arise for the surgeon's decision. A bleeding, often copious and persistent, which arises during the course of the operation from the accidental or unavoidable wounding of the thyroid veins, especially when they are large and numerous, the patient unruly, and perhaps with a short fat neck, and the fact that having wounded one the blood flows so over the parts as to obscure and increase the chance of wounding others, constitutes one of the commonest difficulties met with in the operation of tracheotomy. Hemorrhage arising from a wound of the thyroid isthmus is much rarer, and neither, as a rule, need be feared if due care and promptitude be exercised. But should it occur in a case in which the urgency of the dyspnoea allows of no time in which to employ the ordinary methods by ligature, torsion, pressure, or otherwise of checking it, shall the incision be made and the risk boldly incurred of blood passing to a dangerous degree into the trachea, and this in the face of the oft-repeated advice—the, in some quarters, absolutely given rule—that the trachea is never to be opened until all hemorrhage has ceased? I hold that it unquestionably should be, and that he who waits in many instances until the former moment will have to wait until his patient is dead. Durham truly says that it is useless to let the patient die from suffocation while attempting to prevent death from loss of blood; and yet this has been done.

In any case, then, where there is great venous congestion, marked venous bleeding, and little time, the patient being on the point of suffocation, the surgeon should carefully but boldly proceed and complete his operation in spite of the hemorrhage, opening the trachea and introducing the canula even though the entire field of his operation be obscured by blood. The tracheal opening once made under such circumstances, the patient, if the blood which enters the windpipe be not coughed up again, may be turned upon his face, so that the blood will gravitate toward the tracheal opening and the lips of the latter compressed about the rigid tube; or the blood may be aspirated from the trachea by means of the suction-syringe through an elastic catheter in the wound or the tracheotomy-tube by the operator's mouth, according to the urgency of the case. These measures answer for the slighter cases, but where the patient has suffered from urgent impending suffocation before the opening of the trachea, the entrance of the blood and its suction downward by the first inspiration may make it complete, and the danger is great. Still, the choice lies between the two evils, and the advice given above holds good. To the treatment there recommended will now have probably to be added artificial respiration and faradization. Comfort in any case may be taken in the fact that the re-establishment of respiration through the tracheotomy wound quickly relieves the pulmonary capillaries and the right heart of their distension, the venous circulation resumes its natural course, and the venous bleeding, perhaps alarmingly free, ceases almost immediately or is readily checked by pressure.

Where time is afforded and despatch in the operation is not a necessity, the trachea should not be opened until all hemorrhage has ceased. This, as a rule, is readily controlled by the usual measures, and in a large percentage of operations is not excessive. A direct fatal hemorrhage is very rare; likewise an arterial hemorrhage of any extent, especially if the possible anomalous position of certain arteries, such as the thyroidea ima, be borne in mind and care in making the incision exercised. Nothing but gross carelessness on the part of the surgeon and entire loss of presence of mind can account for the opening of the carotid or innominate arteries, as has been done. During the performance of the low operation of tracheotomy the finger of the operator must more or less frequently be pressed into the lower angle of the wound, and his anatomical sense constantly on the alert.

The entrance of air into a vein during the operation is a possible accident, especially when it is much enlarged and imbedded in dense tissue, as sometimes occurs in malignant disease of the throat or when large tumors of the parts exist. Should such an unfortunate complication occur, the proper treatment, according to Erichsen, should be compression of the wounded vein with the finger and its immediate ligation if possible; compression of the axillary and femoral arteries and a recumbent position for the patient to favor cerebral circulation; and, lastly, artificial respiration.

At the moment of opening the windpipe two conditions may suddenly supervene, both of which need, as may usually be easily done, differentiation from the asphyxia produced by the entrance of blood into the trachea. The first of these is the apnoea which not unfrequently arises in children suffering from urgent dyspnoea the moment that a free opening is made and the air-stream rushes unimpeded into the lungs. The condition lasts but a moment or two, and need excite no alarm. The second is based upon the fact that the operation itself not seldom excites an alarming asphyxia, probably by provoking laryngeal spasm. The introduction of the tube serves to promptly relieve it.

Finally, I may refer to those rare but unfortunate and unpreventable cases where the introduction of a tracheotomy-tube after a carefully conducted operation fails to give relief. Such instances are reported by several authors, and depend upon the existence of some unascertained pathological lesion, such as the presence of a stricture of the trachea below the site of the operation, compression of this tube from without or a tumor within, stricture of the primary bronchi, or some similar condition. A careful preliminary examination and study of the case will in the majority of instances do much to fix the indications for the operation and perhaps account for the surgeon's failure.

The operation itself having been practically completed with the introduction of the canula, the after-treatment of the case now becomes the important consideration. This naturally varies in accordance with the accident or disease which has rendered the opening of the trachea necessary. In the instance of a foreign body lodged in either larynx or trachea the tube may at once be removed as soon as the former is removed or expelled. Indeed, the introduction of the tube is often unnecessary, as the offending article flies out through the wound as soon as the trachea is opened. The only contraindication would be to this rule when the foreign body is of a sharp and irritating character, and has been impacted in the larynx, especially of a child, and consequent inflammation and swelling of the parts may confidently be looked for. Should the operation have been called for on account of laryngeal or tracheal obstruction due to syphilis, both constitutional and local treatment are indicated, the latter varying with the special conditions presented, and being fully described in the section of this work treating of that subject. The patient not infrequently is obliged to wear the tracheal tube permanently. In croup and diphtheria the first efforts of the surgeon after introduction of the tube should be directed toward the removal of such shreds of the membrane as present through the tube or may be reached by forceps introduced through it into the air-passage. Large quantities may thus often be gotten away, to the manifest relief of the patient. A pseudo-membrane covering the vocal cords and causing glottic stenosis has thus also more than once been removed through the wound. A feather carefully passed through the tube into the trachea, by exciting cough and through its mechanical effects, is of assistance in promoting the expulsion of membrane lodged in the trachea below the wound. The use of an elastic catheter and aspirating syringe for the same purpose is advised by Roux and Hueter. In any case, constitutional treatment as well is indicated, and other measures—viz. the inhalation of steam, direct local applications, and the like—such as may meet the views of the particular operator.

Granted that the operation has been performed to meet the indication in cases of sudden and urgent dyspnoea arising from the passage of blood into the trachea or the accumulation of serous fluids in the lower air-passages, as well as in cases of dangerous intoxication from the effects of poisonous gases and narcotics, aspiration of the trachea in the former instances, followed by artificial respiration in all, and perhaps the catheterization of the trachea in the latter, as advised by several recent writers, will tax the surgeon's energies as the primary consideration after his operation. The catheter may be first used for the purpose of aspiration in the former cases, if necessary, then for the injection of air, it here taking the place of the natural upper air-passages.

In cases of acute laryngeal oedema, certain chronic inflammatory processes, neoplasms in the larynx or trachea, and injuries or wounds of the air-passages, the proper treatment, aside from that of the necessary tracheotomy, will suggest itself on ordinary surgical principles, or is elsewhere specially treated of in this work in connection with the subjects themselves.

Aside from these special indications for after-treatment, which must be met as they arise, there are certain general rules for the management of any case after the tracheotomy-tube has once been inserted: they relate mainly to the care of the patient, the dressing of the wound, and the care of the canula.

A variable period of intense and exhausting suffering from dyspnoea having probably preceded the operation, the sooner the patient is allowed to seek refreshing sleep the better; and this may be allowed if there be no danger of hemorrhage. Nourishment of a fluid character and stimulants, if necessary, are to be allowed in quantities and at times dictated by good judgment. The patient's first attempts at swallowing must be watched and directed, as the fluids frequently pass in part for a short time into the larynx, and may appear at the tracheal wound. If the condition persist, it may be, no other apparent cause existing, because the tracheal tube is too long and presses on the posterior wall of the trachea, thus interfering with deglutition. For the first day or two at least a competent nurse must be in attendance, and the care of the tube entrusted, after explicit directions, to her. For the first twenty-four hours the secretions usually need to be constantly cleared from the mouth of the inner tube as they are coughed up by the patient, and the tube itself occasionally removed and thoroughly cleaned in carbolized water (or water to which a little borax or potash has been added) by means of a bristle brush, such as is used for cleaning pipes. As the case progresses, the secretions are not as profuse or annoying, and the patient learns to assist himself, in caring for his tube and to remove and replace the inner one. Attempts at using the voice are to be abstained from, and a slate or pencil and paper used until, if the case progress favorably, the third day, when he may be shown how to produce it by closing the outer fenestrated tube (the inner being removed) with the finger. The outer tube does not require usually to be removed, except in diphtheria, for cleansing until the third or the fourth day, prior to this it being done by means of a feather. The removal of the tube should always be done by the surgeon himself, and the occasional danger of its difficult reintroduction, caused by the swelling of the parts, not forgotten. At the same date, the wound sutures may be cut and removed. After its first removal the outer tube is taken out, cleansed, and replaced at each daily dressing, which consists in the washing of the wound with carbolized solutions, the application of adhesive strips, if necessary, across it after the sutures have been removed, and the insertion between the neck-plate or collar of the tracheotomy-tube and the skin, upon which it presses, of a layer of sheet lint covered by a little simple cerate or like dressing. The tapes attached to the canula for fastening it about the neck need changing, and care must be taken to regulate each day their degree of tension about the neck in proportion to the amount of inflammatory swelling attendant upon the wound through the soft parts overlying the trachea.

The patient, during, especially, the first few days after the opening into the trachea has been made, should be kept in a well-ventilated room with a uniform temperature. There is rarely any occasion, except in cases of croup and diphtheria, when it may be advisable, to envelop him in steam. Some surgeons place a small wad, two or three layers of gauze, wrung out frequently in hot water, over the mouth of the tube for the first day or two. A large, coarse sponge answers the same purpose; and the precaution seems to me to be a good one, preventing, as it does, air of a low temperature from entering the lungs, and rendering it moist and free from adventitious particles. The difficulty is in keeping it in place.

The question as to the final removal of the canula is a difficult one to answer here, depending as it does upon the various causes for which the operation was originally performed. In certain cases, as will be seen from what has been said, its sojourn in the trachea will only be from a few moments to a few hours; while, on the other hand, in cases, for instance, of severe syphilitic disease of the larynx, with cicatricial stenosis of its cavity, the tube, once introduced, has to be worn during the lifetime of the patient. Between these extreme limits the period varies greatly. As a general rule—perhaps from the fourth or fifth day to the end of the first week—an attempt to cause the patient to breathe through the natural passages, the outer end of the outer fenestrated tracheal tube being closed, will partially succeed. Each day will now make success greater; the voice in part returns, and a period is soon reached when the outer tube may be closed with a cork (at first during the daytime only) and respiration carried on entirely through the larynx. The speedy removal of the tube and the closure of the tracheal wound then follow as a matter of course. I have never found it necessary to employ any of the various forms of after-treatment canulas, and believe them to be unnecessary. The original tube, preferably a fenestrated one, as heretofore described, is to be worn until convalescence is established, then permanently withdrawn.

The tube should be removed at the earliest safe and practicable moment. Its lengthened sojourn is not devoid of danger, as will be shown; and an atrophy of the laryngeal muscles, especially the abductors of the vocal cords, may follow their prolonged disuse, or at least inactivity, thus giving rise to a narrowing of the glottic opening perhaps inconsistent with respiration.

The wound, covered by granulation-tissue if the tracheotomy-tube has been worn for any length of time, quickly closes, when the latter is removed, and needs to ensure this but a few narrow strips of adhesive plaster to be passed across it and attached to the side of the neck, to prevent the air being forced out through it during the first day or two when the patient coughs or attempts to speak.

In cases where the tube has been worn for a long period, and the edges of the opening have firmly cicatrized, their freshening by the knife or scissors is a necessary preliminary to their being brought together by means of a suture or two.

The wound in the trachea closes not by the formation of a cartilaginous, but rather of a dense connective tissue, and the cicatrix is so smooth and small as to be with difficulty discernible. The cicatrix remaining externally upon the neck need be but slight and linear, and cause no disfigurement, especially if the wound have been properly treated and watched during the healing process.

Among the complications and accidents which may occur after a tracheotomy successfully performed,⁵ none is commoner, and none, perhaps, is more to be feared, than the broncho-pneumonia which may develop at any time within the first three or four days, and especially in those cases where the operation has been rendered necessary by a diphtheritic inflammation of the throat or air-passages. Bronchitis is common when much blood has escaped into the trachea during the operation. The periodical and careful auscultation of the chest is therefore desirable, in order that the earliest physical signs of these morbid conditions may be detected.

⁵ See Parker, "On Some Complications of Tracheotomy, with Illustrative Cases," Lancet, Jan. 24, Jan. 31, and Feb. 7, 1885.

Secondary hemorrhage is rare: should it occur, the wound must be opened, enlarged if necessary, and the bleeding vessel sought for and secured. A slight hemorrhage may be checked by pressing the parts firmly about the tracheal tube and the use of styptics locally.

When the pathological condition of the parts has demanded that the canula be worn for a long time, and in cases where sufficient care has not been taken to select one suited to the age of the patient or to the particular form of operation that has been chosen, perhaps to the needs of the special case, an ulceration of the anterior or posterior wall of the trachea, the result of the pressure of the lower edge of the tube or of its upper posterior and convex side, may occur. Usually, it happens on the anterior wall, rarely on both, and the main trouble to which they give rise lies in the repeated hemorrhages that proceed from the laceration of granulation-tissue, in changing the canula, for instance, and the descent of the blood into the trachea and lungs. Cases of extensive ulceration, with erosion of the large vessels at the root of the neck, and fatal hemorrhage, have been reported. Considerable care should then be exercised in so adapting a canula to a special case that it will lie as free as possible within the lumen of the trachea. Ulceration of the tracheal walls, it is claimed, never occurs with the right-angled canula of Durham. Occasional change of form in the canula or the use of canulas with rounded extremities (perforated with numerous slits) is often advisable when the tube is worn for a length of time.

Another complication following the prolonged sojourn of a tracheal tube—rare, it is true—is the development of a mass of granulation-tissue, a veritable tumor, which may occlude the lumen of the trachea and lead to serious disturbances of respiration. The growth usually occurs about the inner edges of the tracheal wound, extending thence inward and upward or downward, as the case may be, and is most frequently met with, perhaps, after tracheotomies undertaken for diphtheria, although it may occur as a result of the ulcerations mentioned above, and develop even from the cicatrix in an old and perfectly-closed tracheotomy wound. The size of the mass, its location, and the amount and manner of its interference with the respiratory current vary much, but the condition must ever be regarded as a troublesome, even dangerous, one, and may always be suspected when attempts at the removal of the canula temporarily or permanently are followed by sudden and urgent dyspnoea.

The exuberant granulation-tissue which forms about the outer edges of even a recent tracheotomy wound, and occasionally renders the reintroduction of the tube difficult, as well as closing the wound while it is out, is a much simpler matter, and is easily remedied by cutting it away with the scissors or checking its formation by caustic applications.

A subcutaneous emphysema not infrequently occurs as the result of poor surgery and delay at the time of introducing the tube into the windpipe, or may come on later when the tube fits the tracheal wound incompletely. In either case it need excite no apprehension, and usually quickly subsides. Cervical cellulitis is a more serious matter, but is fortunately rare if unconnected with disease of the cartilages of larynx or trachea. It probably depends upon injury to the tissues and a too extensive opening up of the intermuscular strata at the time of the operation. Should the complication arise, the tendency to the burrowing of pus must be prevented by free drainage and, if necessary, incisions. The other surgical indications are to be treated on general principles.

When the incision necessary for the introduction of a tracheotomy-tube has been made through healthy tissue, necrosis of the cartilage in contact with the tube belongs to the rarest of the complications of the operation. The simple traumatic perichondritis set up by the operation shows no tendency to eventuate in death of the parts. Equally rare is cicatricial contraction of the trachea as the direct result of the operation. That it may follow the healing of the extensive defects sometimes left by the syphilitic and other processes can readily be understood; and the same defects, involving as they occasionally do the loss of large amounts of tissue and destruction of important parts, may eventuate in the formation of an aërial fistula during or after the healing process is completed. The occurrence of such a fistulous opening as the result of a simple and uncomplicated tracheotomy wound could only be regarded as the evidence of unskilful surgery and after-treatment. The various plastic operations undertaken for the repair of such defects are described in the works on general surgery, notably in the able monograph of Schüller. Dislodgment of the canula out of the trachea as the result of an insufficiently long tube, or of neglect to fasten the tapes which hold it properly about the neck, so that it slips during coughing or the movements of the patient, is an accident which may not for the moment attract the attention of an inexperienced surgeon unless laryngeal dyspnoea is urgent. The patient breathes quietly, the air passing by the sides of the tube, which apparently is correctly placed. The simple test of ascertaining whether air be passing through the canula or not, or of making a trial whether the patient breathe as well when the finger closes the opening of the outer tube, as he will do if the tube is out of the trachea, will decide the question. Should the tube have slipped, it is of course at once to be replaced.

The breaking off of a portion of the inner canula, and the terminal piece falling down the trachea—several instances of which have been reported during recent years—is more apt to happen with the right-angled canula of Durham, the inner tube of which is necessarily made up of segments held by small rivets: these become in time loosened and the piece that they held detached. The outer tube of the hard-rubber canula also has become detached from its collar and dropped into the trachea. An occasional inspection of the condition of the tube is therefore desirable.

DISEASES OF THE BRONCHI.

BRONCHITIS, ACUTE AND CHRONIC; CATARRHAL; MECHANICAL; CAPILLARY; AND PSEUDO-MEMBRANOUS.

BY N. S. DAVIS, M.D., LL.D.

DEFINITION.—Inflammation of some part or of the whole of the mucous membrane lining the bronchial tubes between the bifurcation of the trachea and the alveoli or air-cells of the lungs. The inflammation may vary in grade from simple hyperæmia, with increased irritability, to the most intense engorgement, exudation, and tumefaction of the membrane, and in activity from the most acute and rapidly-progressive to the most chronic and protracted in duration.

SYNONYMS.—By the earlier writers the disease was called Peri-pneumonia notha, Angina bronchialis, and sometimes Erysipelas pulmonis. More recently it has been called Catarrhus suffocativus, Catarrhus pituitosus, Catarrhus bronchialis, Bronchial catarrh, and Bronchitis; Fr. Bronchite; Ger. Bronchialentzundung. Adopting the simple name of bronchitis, acute and chronic, in the further consideration of the subject I shall group the cases as they occur in general practice under the heads of Catarrhal, Mechanical, Capillary, and Pseudo-membranous Bronchitis.

HISTORY.—During all the earlier periods of medical history bronchitis was generally confounded with inflammation of the membrane lining the larynx and trachea on the one side, and with pneumonia and pulmonary phthisis on the other. Among the earliest writers who gave more accurate descriptions of bronchitis as a distinct disease were Badham, J. P. Frank, and Broussais, in the latter part of the eighteenth century. Full and accurate descriptions of the disease, differentiating it from inflammation of other parts of the respiratory organs, were not given, however, until the discovery of auscultation by Laennec, and its practical application aided by percussion to the physical examination of the chest. This important addition to the previous means for studying the exact location and extent of all diseases within the chest, and the largely increased attention given about the same time to the study of morbid anatomy, soon led to as accurate an appreciation of the existence and extent of disease in any part of the organs of respiration and circulation as in any of the structures of the human body.

ETIOLOGY.—The causes of bronchitis, like those of all other acute diseases, may be divided into two classes—namely, predisposing and exciting. The first embraces all those influences that are capable of rendering the mucous membrane of the air-passages more susceptible to impressions, whether by direct increase of the irritability of the structure or indirectly by altering the quality of the blood and the tone of the smaller blood-vessels. The second embraces such influences only as are capable of exciting a direct increase of irritability of the lining membrane of the bronchial tubes, with congestion of blood in its capillaries. Among the most common predisposing causes may be mentioned age, sex, occupation or modes of life, and climatic influences. As a general rule, the several grades of bronchitis are more prevalent during childhood and old age than during the active period of adult life. The British Registrar-General's Report for 1868 contained 33,258 deaths attributed to bronchitis, being 1344 for every million of inhabitants. Of the whole number, 10,550 died during the first three years of life, and 18,485 over forty-five years of age, leaving only 4223 to occur between the ages of three and forty-five years. This, however, is very far from indicating correctly the relative prevalence of the disease at the different periods of life, for the reason that the disease is far more fatal both in early life and in old age than in the early and middle periods of adult life.¹ During the months of February, March, and April, 1882, in San Francisco, there were 65 deaths reported from bronchitis, of which 37 were of children under five years of age, 25 adults over forty years, and only 3 persons between five and forty years. During the same months there were reported 154 deaths from bronchitis in the city of Chicago, with about the same ratio in regard to age. In the city of Philadelphia, during the seven years from 1862 to 1869, the deaths from bronchitis at all periods of life aggregated 969, of which 495 were of children under five years of age, 14 over five and under fifteen years, and 460 of persons over fifteen years of age.² These and similar mortuary statistics have led to the very general adoption of the opinion that early childhood and old age are pre-eminently susceptible to attacks of bronchitis. Yet my own clinical observations and records relating to the time and number of acute and subacute cases of bronchitis coming under my own care lead to a very different conclusion. By reference to those records I find a larger number of cases occurring between the ages of ten and thirty years than at any other period of life. Thus, during the first six months of the present year (1882) I recorded 59 cases of primary bronchitis; that is, cases not arising secondarily as complications of other diseases. Of this number, only 5 were children under ten years of age, 38 between ten and thirty years, and 16 over forty. It is probable that similar results will be obtained by all who will take the trouble to record the whole number of cases, instead of simply the number of deaths. The statistics of mortality in relation to this disease are deceptive, not only in regard to relative susceptibility of the human system to attacks at the different periods of life, but also in regard to the ratio of mortality of the disease itself. It is generally conceded that the chief mortality from this disease occurs during infancy or early childhood and in old age, cases rarely terminating fatally in youth or the more active period of adult life. Careful examination of cases will show that this fatality at the extremes of life is owing mainly to the greater tendency of the inflammation at those periods to extend directly from the bronchioles into the lobules of the lungs, thereby complicating the bronchitis with lobular pneumonia; and in more than half the cases reported under the head of bronchitis the fatal result was caused by the pneumonia instead of the bronchitis.

¹ See Reynolds's System of Medicine, Amer. ed., vol. ii. p. 318.

² See A Practical Treatise on the Diseases of Children, by J. F. Meigs, M.D., and William Pepper, M.D., 4th ed., p. 189.

Neither recorded facts nor my own clinical observations show any decided difference in the susceptibility of the sexes to attacks of bronchial inflammation.

Those occupations which confine the parties pursuing them much indoors, and at a temperature either too warm or too cold, strongly predispose to attacks of inflammation of the membrane lining the respiratory passages. Habitual exposure to a warm, confined air invites free exhalation from both the bronchial and cutaneous surfaces, with increased susceptibility, and consequently renders the individual more susceptible to all external impressions. Habitual passive exposure indoors to a low temperature represses the exhalations and causes the retention of some of the products of tissue-change which by their presence in the blood render the individual more liable to attacks of inflammation on the supervention of any exciting cause. For the same reasons the habitual wearing of too much warm clothing on the one hand, or too little on the other, predisposes to attacks of bronchial disease. Another error of importance is the unequal adjustment of clothing to different parts of the cutaneous surface. In children especially we often see an abundance of warm clothing over the whole body, while the legs and feet and neck have but a single covering, and sometimes none. And even adult women often go out loaded with warm clothing, while their feet and ankles are protected only by thin shoes and stockings. All those occupations that surround the workmen with an atmosphere filled with irritating gases, floating particles of stone, metal, or charcoal, or with the dust from grain and many vegetable substances, increase the liability of such workmen to attacks of all grades of bronchial inflammation.

It is universally conceded that bronchitis, as well as inflammation of all other parts of the mucous membrane lining the air-passages, prevails most in such countries as are characterized by a cold, damp, and variable climate. This can be well illustrated by comparing the prevalence of this class of diseases in that belt of our own country lying north of the fortieth parallel of latitude and east of the Rocky Mountains with the prevalence of the same class in the belt south of the thirty-third parallel and bordering upon the Atlantic and Gulf of Mexico. In the former the summers are comparatively short, with brief periods of high temperature, the winters cold, and the transition seasons, spring and autumn, long and exceedingly variable, with a predominance of cold and dampness. In the latter all the conditions just mentioned are substantially reversed. Perhaps the earliest reliable statistics we have bearing upon this subject are those collected by Samuel Forrey from the several military posts occupied by the United States Army, and given in a series of articles in the American Journal of Medical Science, and subsequently in an octavo volume, on the climate of the United States and its influence over the prevalence of diseases. The valuable facts presented by Forrey were added to by Daniel Drake, and given in full in his large work on the topography and diseases of the great interior valley of this continent. From these sources we learn that the average annual number of attacks of inflammation of the mucous membrane of the respiratory passages in every 1000 soldiers at Fort Snelling, in Minnesota, latitude 44° 53' N., was 600. At Fort King, fifty miles from the Gulf of Mexico, latitude 28° 58' N., the annual number of attacks average only 101.2 in every 1000 persons. Again, at Madison Barracks, near Sackett's Harbor, New York, the average number of attacks for every 1000 persons was 637.2, while at Key West, Florida, the average number of attacks was 208.9, and at Baton Rouge, Louisiana, only 207.2. Lest it should be thought that these five posts had been selected for the purpose of showing the most extreme contrasts, it may be added that Drake, after a laborious comparison of the statistics at all the military posts in the great interior valley from Fort Snelling at the north to Fort Jessup in Louisiana, the most southern, makes the "ratio of decrease in bronchial inflammations" as we pass from the north to the south as 31.5 for each degree of latitude.³ A similar comparison of the statistics of all the posts on the Atlantic Slope from Madison Barracks to Key West gives nearly the same results. The general inference here drawn concerning the much greater prevalence of bronchitis in the colder and more variable climate of the northern belt of our country than in the southern is fully corroborated by all the facts to be gathered from observations in civil life.

³ See A Systematic Treatise on the Principal Diseases of the Interior Valley of North America, etc., etc., 2d Series, pp. 795, 796.

A study of these same military statistics, representing the mean ratio of the prevalence of diseases of the respiratory passages for a period of ten years at nearly all the posts, will justify some other inferences of interest besides the one just stated. According to this general inference or rule, which is assented to by all the authors within my reach, the three important factors in the climates most favorable for producing bronchial inflammation are cold, variableness, and dampness, the latter being emphasized by most writers as of predominating influence. Yet the tables before us show that the highest ratio of prevalence of inflammatory attacks of the mucous membrane of the respiratory passages in the northern part of the interior valley was at Fort Snelling, in the immediate vicinity of St. Paul, Minnesota, being 600 attacks for every 1000 soldiers, while the lowest ratio was at Fort Dearborn, on the site now occupied by the city of Chicago, being only 102 for every 1000 soldiers. Looking at the posts in the eastern part of the northern belt of country, Madison Barracks, at Sackett's Harbor, at the eastern end of Lake Ontario, gives a ratio of 637 attacks for every 1000 soldiers, while Fort Niagara, at the mouth of the Niagara River, near the western end of the same lake, gives a ratio of only 355. Again turning to the posts in the southern belt of country, the tables show at Fort Jessup, in the interior of Western Louisiana, a ratio of 432.8, while at Fort Jackson the ratio was only 47.5 and at Fort King 101.2. As Fort Snelling is on the high rolling prairie of the interior of Minnesota, noted for its cold and dry air, and Fort Jessup on the elevated arid plateau between the head-waters of the Sabine and the Red River, they cannot be noted for a high degree of atmospheric moisture. On the other hand, Fort Dearborn was located on the south-west shore of Lake Michigan, on the borders of a low and wet prairie with a substratum of impervious clay, giving all the conditions favorable for the prevalence of a high degree of atmospheric moisture. And Forts Jackson and King are both on low alluvial lands only fifty miles from the Gulf. Again, Fort Niagara is surrounded by all the conditions favoring a high degree of atmospheric moisture, certainly equal to those surrounding Madison Barracks in nearly the same latitude, and yet the ratio of attacks in the latter was nearly double those in the former. It is evident, therefore, that there exists some important factor in the climatic relations of the inflammatory affections of the respiratory passages besides temperature, humidity, and changeableness. A glance at the topography of the whole country will show that each of the posts giving a high ratio of attacks—namely, Madison Barracks and Forts Snelling and Jessup, to which may be added Forts Gratiot, Crawford, and Wood—are so located as to be exposed to the prevalence of unusually severe winds or atmospheric currents either from the north-east or the north-west and west, with certain relations either to high mountain-ranges or ocean-currents. For instance, from Madison Barracks the open valley of the St. Lawrence River extends in a north-easterly direction to the Atlantic Ocean, where the cold ocean-current is from the north, favoring the pressure of cold atmospheric currents directly up the valley from the north-east, reaching its termination at the eastern end of Lake Ontario with but little diminution of force. The mountains of Northern New York, Vermont, and New Hampshire seem to prevent the deflection of these currents to the south, and help to keep them directly in the line of the valley. That the high ratio of attacks of bronchial and catarrhal affections at Madison Barracks is largely due to the influences here described is corroborated by the fact that the same class of diseases are much more prevalent in the province of Quebec, through which the valley of the St. Lawrence extends, than in the province of Ontario, as shown by the Registrar-General's Report in reference to the several military posts in the Canadas. Turning to Forts Snelling and Crawford at the north and Jessup at the south, we find them so situated in relation to the great mountain-chains to the west as to be fully exposed to the cold and strong atmospheric currents that sweep over the Plains from the north-west and west with such force as to justify the popular title of blizzards. Without consuming more time in details, it may be said that the force and direction of atmospheric currents have quite as much to do with the development of inflammations of the air-passages, including all grades of bronchitis, as either temperature or humidity.

As might be inferred from what has already been said in relation to the influence of climatic conditions, season of the year is also found to exert a marked influence over the prevalence of bronchial affections. Those parts of the year characterized by a low temperature, high winds, and frequent thermometric changes are accompanied by the highest ratio of prevalence of inflammations of the respiratory passages. Thus, the statistics compiled from the records of all the military posts by Drake show an average ratio for the four quarters of the calendar year of 119.8 for the first quarter, 72.7 for the second, 48.7 for the third, and 99.6 for the fourth.⁴ This corresponds closely with the results of clinical records kept under my own observation through a series of years.

⁴ See Drake on the Principal Diseases of the Interior Valley of North America, p. 792.

That tubercular deposits in the lungs, cancerous growths, emphysema, and previous attacks of bronchitis, all strongly predispose the patient to further attacks of the last-named disease, is proved by universal clinical experience.

EXCITING CAUSES.—Exposure to sudden and extreme changes in atmospheric temperature from warm to cold is almost universally regarded as the chief exciting cause of inflammation of the bronchial as of all other parts of the mucous membrane of the air-passages. More accurate and detailed observations, however, show that such changes of temperature are seldom productive of diseases of this class unless accompanied by coincident high winds and humidity. My own studies concerning the relations between special meteorological conditions and the prevalence of particular diseases have led me to the following conclusions in regard to bronchitis and inflammation of the mucous membrane of the air-passages generally:

First. Many sporadic cases are caused, at any and all seasons of the year, by exposure of limited portions of the cutaneous surface to cool or cold currents of air while the rest of the body is well protected. Females going out with thin shoes and stockings or sitting before open windows with low-necked dresses, and children out on cold days with naked legs from short trousers and defective stockings, afford many and familiar examples of bronchitis from this cause.

Second. The sudden transition from a protracted period of intense dry cold to a higher temperature with increased atmospheric humidity. Almost every winter season, in the northern belt of the United States, east of the Rocky Mountains, is characterized by several periods of steady dry, cold air, varying from one to three weeks in duration, during which the mercury in the thermometer often descends more than 20° C. (8–10° F.) below zero, and which generally ends in a sudden change in the direction of the winds and a marked elevation of temperature, constituting what is popularly called a thaw. Such changes are very uniformly accompanied by a general prevalence of catarrhal affections of the air-passages, including many cases of bronchitis. This class of cases occur principally in the months of December, January, and February.

Third. The occurrence of those cold north-east winds that during the latter part of autumn and early part of spring so often sweep over the whole extent of our Atlantic coast and press up the valley of the St. Lawrence to the great interior lakes, and the still more severe currents that come during the same seasons from the north-west and west, over all the wide plains that intervene between the great mountain-chains to the west and the upper lakes and Mississippi River to the east, are also accompanied by a high ratio of prevalence of bronchial affections, as has been already shown from the records of the several military posts. Most of these severe storms of wind are accompanied by either snow or rain and a marked increase of ozone or active oxidizers. In some of the severe snowstorms from the north-east, occurring in the latter part of February and in March, I have found an unusual amount of free ammonia. Whether either the ozone or the ammonia has had anything to do with the production of the bronchitis cannot be determined until the observations and records now being made under the auspices of the American Medical Association have been continued for a few years, by which adequate data will be furnished for reliable deduction.

Besides ordinary meteorological conditions, bronchitis may be produced by inhaling irritating substances, such as steam, irritating gases, steel-dust, or minute particles of other metals or stone in workshops, and the dust encountered in handling grain, etc. The disease has often occurred in epidemic form without the presence of an obvious exciting cause. It also frequently occurs in connection with certain general fevers, more particularly with typhoid, measles, influenza, and pertussis. It also sometimes, though more rarely, accompanies rheumatism, constitutional syphilis, and erysipelas. The presence of tuberculous and cancerous deposits in the lungs almost always provokes more or less bronchial inflammation during some part of their progress.

Acute Bronchitis.

SYMPTOMATOLOGY.—The most common form of acute bronchitis, by many writers styled catarrhal bronchitis, acute bronchial catarrh, etc., presents considerable variety of symptoms, according to the extent of the membrane involved and the intensity of the inflammatory process. As a general rule, the disease commences with slight chilliness or unusual sensitiveness to slight changes of temperature, accompanied by a sense of soreness and oppression behind the sternum and sometimes across the whole chest, with a frequent and rather dry, harsh cough. In many cases there is during the first day or two coincident congestion of the membrane lining the nostrils, fauces, and larynx, causing sneezing, with some feeling of soreness in the throat and hoarseness, also a heavy dull pain in the head, much increased by coughing. By the second day a moderate general fever has supervened, characterized by dryness and moderate heat of the skin, flushed face, slight increased frequency and fulness of the pulse, more sense of oppression and soreness in the chest, with a continuance of harsh, dry cough, which often causes soreness in the epigastrium, radiating laterally in the direction of the attachments of the diaphragm to the inner surface of the ribs. On the second or third day the inflamed membrane begins to be less dry and the paroxysms of coughing bring up a scanty expectoration of a tenacious, somewhat frothy mucus, which gradually increases until about the fourth or fifth day, when it becomes more opaque, sometimes yellowish, and much more easily expectorated. At the same time that the expectoration changes to a more opaque condition, the general febrile symptoms begin gradually to abate, and the cough is accompanied by less sore pain both in the chest and head.

In the milder class of cases, the decline in all the general symptoms is so rapid that by the seventh or ninth day, convalescence is established. But in the more severe cases the more important symptoms may continue through two weeks, and convalescence not be complete until the end of the third week. And in some of the cases the inflammation does not disappear on the subsidence of the febrile symptoms, but degenerates into a chronic form, causing a continuance of cough, with some muco-purulent expectoration and slight soreness in the chest, through an indefinite period of time. The disease is most likely to take this course when it occurs in young persons having a scrofulous diathesis, or in connection with eruptive fevers or pertussis, or in the aged afflicted with rheumatism.

During the active stage of ordinary cases of bronchitis the urinary secretion is diminished in quantity, redder than natural, and deficient in chloride of sodium, and the bowels are inactive. But after the crisis of the disease is passed, as indicated by the character of the expectoration, the renal and intestinal discharges soon return to their normal condition.

The results of auscultation and percussion in ordinary bronchitis, limited to the membrane lining the larger bronchial tubes, are mostly negative. In some instances during the first or dry stage, the respiratory or vesicular murmur may be slightly harsher or more dry than natural, and after the exudation or secretion of mucus, as indicated by expectoration, there may be some coarse, moist râles, which are removed temporarily by coughing, but return again in a little time. These râles are heard much more in cases occurring either in infancy or in old age than in youth or the middle period of adult life. Percussion elicits only the natural degree of resonance throughout the whole course of the disease, except in those rare cases in which complete occlusion of the bronchial tube has taken place, causing exclusion of air from certain lobules of the lungs, and consequently a shade of dulness on percussion over such lobules.

Mechanical Bronchitis.

By mechanical bronchitis is meant those cases in which the inflammation is caused by the direct action of mechanically irritating substances floating in the inspired air, as fine particles of steel and other metals, particles of stone, charcoal, and various vegetable powders and fungi. Such substances, when inhaled, are liable to impinge on the surface of the bronchial membrane and produce direct irritation and inflammation, both acute and chronic.

Cases originating from this class of causes differ from ordinary acute bronchitis chiefly in the mode of beginning and in the greater tendency to continue in the chronic form. Instead of slight rigors, coryza, and early development of moderate general fever, the patient generally complains first, and for several days, of a sense of tickling or fulness in the air-tubes, with occasional paroxysms of violent coughing and little expectoration. Sometimes particles of the foreign substance that is producing the inflammation may be seen mixed with the mucus or matter expectorated. In many of these cases there is much soreness in the chest and considerable dyspnoea, especially during the night, followed by severe coughing in the morning, and a more free discharge of mucus occasionally containing little streaks of blood, but which is never intimately intermixed with the sputa as in pneumonia. If the patient, by change of occupation or otherwise, ceases to be exposed to the further action of the exciting cause, the symptoms soon begin to abate, and a complete recovery may take place in from two to four weeks. If exposure to the further action of the exciting cause is not avoided, the disease will necessarily assume a chronic form, and in many cases produce such changes as to materially shorten the life of the patient.

Capillary Bronchitis.

By this term is meant inflammation in the smaller bronchial tubes, but not necessarily involving the true bronchioles as they terminate in the air-cells. It may arise from all the causes that are capable of exciting inflammation in the larger and medium-sized tubes. It may occur at any period of life, but is most frequent in infancy and early childhood, and next in persons past the middle period of life.

The chief differences in the clinical history of this and ordinary catarrhal bronchitis arise from the greater obstruction to the ingress and egress of air through the inflamed tubes. The same degree of tumefaction of the membrane that occasions but little obstruction in the larger tubes is capable of completely obstructing many of the smaller ones, and thereby causing much dyspnoea and sense of oppression, with frequency of respiration, accompanied at first by an abundance of dry râles in all parts of the chest, followed later by the complete intermixture of dry sounds and moist submucous râles, the latter caused by more or less exudation or secretion of mucus from the inflamed mucous membrane. The addition of the tenacious mucous exudation to the previous tumefaction of the membrane, often so far obstructs the ingress of air to the air-cells of the lungs that the respirations become short, very frequent and noisy, with blueness of the lips, coldness of the extremities, drowsiness, and soon death from suffocation. This result, however, is seldom met with except in quite young children and in persons enfeebled by age or by previous disease.

In cases which do not thus tend to an early fatal result from the direct obstruction of the bronchi the respirations continue frequent, in young children sometimes reaching 50 or 60 respirations per minute, with much dyspnoea and restlessness; the pulse is quick, but not in proportion to the respirations; the expression of countenance is anxious and often slightly bloated, with a leaden hue of the prolabia; the wings of the nose expand and the chest heaves with each inspiration, giving a great variety of dry, whistling sounds generally throughout the whole chest, which after the first two or three days become mixed with sharply-defined submucous râles, and in the later stages give place to the latter entirely. The cough is frequent and inefficient, on account of the difficulty of getting sufficient air to make it satisfactory. The temperature varies from 38° to 39.5° C. (101–103° F.), seldom rising above the latter figure unless complicated with lobular pneumonia. The urine is generally scanty and deficient in the chlorine salts, and the bowels are inactive. The labored efforts of breathing in many cases make the upper and anterior part of the chest appear more prominent than natural, and even more resonant on percussion on account of temporary emphysema from over-distension of the air-cells in those parts, while in some parts of the lower and posterior portions there is less expansion and less resonance than natural from the occlusion of some of the bronchi and the partial obstruction of others leading to those parts of the lungs.

Between the third and fifth days usually the mucous exudation, which up to that time had been scanty and tenacious, becomes more abundant and more opaque, and in two or three days more assumes a distinct muco-purulent character and is much more easily expectorated. As that which comes from the smaller bronchial tubes is less mixed with air, and consequently less frothy than that which comes from the larger tubes, the two qualities of matter may often be recognized in the same mouthful of sputa; and if the whole be placed in water, that from the smaller tubes will drop lower in the water, or sink to the bottom if detached from the other, which floats freely upon the surface.

In acute cases, at the same time that the expectoration becomes more opaque and more easily dislodged by coughing, all the more important symptoms begin slightly to improve, and by the end of the second week convalescence is fairly established. Many cases, however, are less acute, slower in progress, and do not reach convalescence in less than two or four weeks; and many of this class manifest a strong tendency to continue indefinitely in a chronic form, more especially in persons past the middle period of life. In some of the cases that do not continue in a chronic form, the bronchial membrane is left in a condition of such susceptibility that the attack is renewed on the slightest exposure to the exciting causes.

Rheumatic Bronchitis.

Although many systematic writers on practical medicine make no mention of this form of bronchitis except as a complication of general rheumatic fever, yet cases both of acute and chronic inflammation of the bronchi, of unmistakable rheumatic character, have so often come under my observation that I am constrained to recognize it as a distinct form of disease. In regard to the relative frequency of the occurrence of this class of cases, I find in a brief report concerning 965 cases of chronic pulmonary disease, read in the medical section of the American Medical Association by F. H. Davis in 1877,⁵ the following classification of the cases:

Chronic catarrhal bronchitis 403

Chronic rheumatic bronchitis 283

Chronic bronchitis accompanied by gastric derangement and spasmodic dyspnoea 119

Chronic bronchitis, modified by syphilitic disease 37

Hereditary pulmonary tuberculosis 56

Inflammatory pulmonary phthisis 67

Total 965

It will be seen that, of the 842 cases of chronic bronchitis included in the table, the writer classes 283, or a trifle more than 33 per cent., as of rheumatic character. That the relative proportion of acute cases of a distinct rheumatic character is less than those of a chronic grade I have no doubt, and yet their number is not so small as to be insignificant or unworthy of careful attention.

⁵ See Transactions of American Medical Association, vol. xxviii. p. 269, 1877.

They differ in clinical history from ordinary acute bronchitis chiefly in the following particulars: Etiologically, a large proportion of them occur in persons of a rheumatic diathesis, either hereditary or acquired, and at those seasons of the year characterized by a predominance of cold and damp air with frequent changes of temperature.

Symptomatically, they are characterized from the beginning by more continuous dull pain in the chest, often extending to the attachments of the diaphragm, the shoulders, and the dorsal portion of the spine; by more persistent dry, harsh cough, often exhibiting a marked spasmodic character and accompanied by a great aggravation of the pains in different parts of the chest. When the smaller bronchi are involved the stage of dry râles is much more protracted, the dyspnoea and suffocative paroxysms of coughing more uniformly aggravated at night; and when mucous exudation does take place it remains scanty and viscid, rarely presenting a distinct muco-purulent character unless the case is protracted into a chronic form, and sometimes not then. During the active stage the urine is less in quantity and more decidedly acid in reaction than natural, and the bowels generally costive.

When not interfered with by appropriate treatment, these cases run a much more protracted course, and more frequently degenerate into a chronic form, than those of an ordinary catarrhal character. When they are thus allowed to run a protracted course or to continue in a chronic form, they manifest another tendency of great importance—namely, to have the inflammation extend by continuity from the fibrous and muscular structures of the small bronchi into the connective tissue of the pulmonary lobules, inducing sclerosis of the latter tissue and consequent compression or obliteration of the alveoli or air-cells, and permanent contraction of the chest. Much and careful clinical observation has satisfied me that many of the cases now classed by writers as fibrous and inflammatory phthisis began as simple acute or subacute rheumatic bronchitis, which, being renewed at every return of the cold, damp, and changeable part of the year, not only ultimately caused permanent thickening of the bronchial structures, but gradually invaded portions of the connective tissue of the lungs, and induced similar pathological changes in it, constituting the sclerosis just mentioned.

Pseudo-membranous Bronchitis.

This affection has been described by different writers under the additional names of plastic, croupous or croupal, and diphtheritic bronchitis. The extension of the inflammation and membranous exudation to the bronchial tubes in cases of diphtheria and pseudo-membranous tracheitis and laryngitis or croup, is of frequent occurrence. But as a distinct disease limited to the bronchial membrane it is of comparatively rare occurrence.

In 1854, T. B. Peacock noticed in the Transactions of the London Pathological Society 34 cases collected from European sources; Biermer in 1867 increased the number to 58; Kretschy in 1874 added 10, and Chevstok 4 more cases—making in all 72 cases in Europe. In 1879, W. C. Glasgow of St. Louis read to the medical section of the American Medical Association an interesting report on the subject of plastic bronchitis, in which he notices 23 cases which had occurred in this country, accounts of which were obtained from an extensive correspondence with leading physicians in all parts of the United States, as well as from reference to our periodical medical literature.⁶ These statistics are certainly sufficient to justify the statement that the disease is of rare occurrence both in this country and in Europe.

⁶ See Transactions of the American Medical Association, vol. xxx. p. 177, 1879.

The statistics thus far collected show a much greater prevalence of the disease in males than in females, and that the larger number of cases occur between the ages of fifteen and fifty years, although one case is reported by T. G. Simons of Charleston, S. C., as quoted by Glasgow, at four years of age, and Goumoens one at seventy-two. In a large proportion of the cases reported the disease existed in a chronic form. When acute, and affecting a large portion of the bronchial membrane, it is liable to lead to an early fatal termination from obstruction to the ingress of air to the air-cells of the lungs. But in many cases the disease has extended to only a limited number of the bronchi, and recovery has generally taken place in from two to three weeks.

The symptoms differ from those of ordinary bronchitis in only two important particulars—namely, the more violent and suffocative character of the cough, and the actual appearance of shreds, patches, or casts of pseudo-membrane in the matters raised and ejected by coughing. The latter is the only reliable diagnostic symptom by which it can be certainly differentiated from all other forms of bronchial inflammation. When the membranous exudation is discharged in shreds or small pieces, it may readily escape the attention of the physician, and even considerable casts when expectorated are in some cases so surrounded with mucus and collapsed into a slightly yellowish mass in the central part of the mouthful expectorated, that they might be regarded as only a more muco-purulent part of the mucous secretion. If the whole is thrown into water, however, and agitated a little, the membranous patches and casts will be quickly unfolded in such a manner as to be easily recognized. It is distinguished from mucus by placing it in a solution of acetic acid, which causes it to swell, while mucus contracts in a similar solution. It has the appearance of having been formed in concentric layers, and is sometimes cast-off so complete as to present a continuous representation of one or both primary and several of the secondary bronchial tubes. Under the microscope it has the same fibrillated appearance as other pseudo-membranous formations.

Chronic Bronchitis.

Cases of acute and subacute bronchitis belonging to either of the five varieties just described may be protracted until they assume a chronic form, and other cases of each variety are met with which have been chronic from the beginning. This form of the disease is met with in aged persons more frequently than at an earlier period of life. In children it sometimes follows as a sequel of measles and whooping cough, and in adults is often associated with tuberculosis, emphysema, and cardiac diseases.

ETIOLOGY.—Chronic bronchitis is capable of originating from any and all the causes that have been enumerated as capable of producing the more acute forms of the disease, and consequently prevails most under the same conditions of topography, climate, and social relations.

SYMPTOMATOLOGY.—The symptoms of ordinary chronic catarrhal bronchitis differ from those accompanying the acute form of the disease, chiefly in the absence of general fever and the existence of much less pain or feeling of soreness and oppression in the chest. The patient generally complains of a rather harsh, full cough, usually more severe on first retiring to bed at night and on rising in the morning, but occurring at intervals through the day, and accompanied by a mucous or muco-purulent expectoration varying much in its amount and tenacity. In the great majority of cases occurring in young persons and in the first part of adult life, the expectoration is simply a whitish or slightly opaque mucus, more or less frothy from the intermixture of minute bubbles of air, and easily dislodged, especially in the mornings. In old persons and in cases which have continued a long time, the expectoration often becomes more copious and more decidedly purulent, with slight feverishness at night and some loss of flesh.

In all the cases except those last mentioned the general health of the patient is but little impaired, the appetite and secretions usually remaining nearly natural. Those who pursue indoor occupations or are sedentary in their habits will be prone to constipation and imperfect digestion—more, however, from the circumstances just mentioned than from the effects of the bronchial disease. All cases of chronic bronchitis are subject to temporary aggravation by exposure to a cold and damp atmosphere, whether indoors or out, and are also very susceptible to increase from the inhalation of air containing dust or floating particles of solid matter or of irritating gases.

Cases of ordinary chronic bronchitis rarely prove fatal without the intercurrence of some other disease, and yet there is no natural limit to their duration. In many cases the symptoms almost disappear during the warm months of summer, but return with the first period of cold and wet weather of autumn. Such patients usually find permanent relief by changing their residence to a mild and dry climate.

The symptoms of the rheumatic grade of chronic bronchitis differ from those just described mostly in the more severe paroxysmal character of the cough, with either no expectoration or only a scanty quantity of a glairy, tenacious mucus; in the more soreness or dull pain in the intercostal muscles and attachments of the diaphragm; and in the more marked influence of sudden and severe meteorological changes. Perhaps the most marked and distressing cases of this variety of bronchitis are those we occasionally meet with in old persons whose joints, especially those of the extremities, have long been stiffened and sometimes enlarged from chronic rheumatism, and who are harassed and worn from a harsh, suffocative cough, the worst paroxysms of which are almost always during the latter part of the night and the early morning, accompanied by the expectoration of considerable quantities of a thick, viscid, and very tenacious mucus, which is dislodged with so much difficulty that in the midst of the more violent paroxysms of coughing the action of the stomach is reversed and its contents ejected by vomiting. This is very liable to happen just after breakfast, and to occasion the loss of the morning meal. The condition of these patients is very generally ameliorated during the warm months of summer, but on the whole they emaciate and grow more helpless from year to year, until they die either from exhaustion or the supervention of pulmonary sclerosis (fibroid phthisis), endocarditis, or chronic diarrhoea. There is one grade of rheumatic irritation which is liable to attack the fibrous texture of the smaller bronchi and to give rise to a very persistent form of asthma, which increases with every returning cold season of the year; but as asthma in all of its forms is treated in other parts of this work, I only allude to it in this connection.

PATHOLOGY AND MORBID ANATOMY OF BRONCHITIS.—The special pathology of inflammation involving the mucous membrane and other structures of the bronchi does not differ from that of similar grades of inflammation in any other structures of the body. It consists essentially of an increase or disturbance of those properties of living organized matter which regulate the molecular movements constituting nutrition, disintegration, secretion, and cell-evolution to such a degree as to cause accumulation of blood in the capillaries, followed by exudation and increased cell-proliferation, which may organize into plastic material or pseudo-membrane or degenerate into pus, according to the coincident circumstances and condition of the patient.

Consequently, the anatomical changes resulting from acute catarrhal bronchitis are, in the early stage, more or less intense congestion of blood in the vessels, causing redness and tumefaction of the membrane, soon followed by an increased flow of mucus, with increase or proliferation of mucous corpuscles and epithelium-cells, while leucocytes or white corpuscles are seen permeating the capillary walls and penetrating the submucous tissue or mingling with the increased epithelium upon the surface. These several inflammatory products are seen adhering to the surface of the inflamed membrane and in the smaller tubes, often so filling their calibre as to greatly interfere with the ingress and egress of air through them, and of course adding to the dyspnoea that characterizes the capillary form of bronchitis. During the latter stage of the disease pus-corpuscles are seen freely intermingled with the mucus, and, owing to the exfoliation of much of the epithelium, the surface of the mucous membrane often appears irregular, abraded, or ulcerated.

When the inflammation has been protracted into a chronic form, the vessels appear less congested, but the cell-proliferations continue both in the mucous and submucous structures, causing thickening and increased density, with a still more purulent quality of secretion. The bronchial glands are also sometimes found enlarged, and either softened, colored with pigment, or, more rarely, calcified.

In addition to the foregoing changes, in many cases of the capillary form of bronchitis some lobules of the lungs are found collapsed from the complete occlusion of the bronchi leading to them by the accumulation of tenacious mucus with other inflammatory products. And in the same cases the air-cells in other parts of the lungs, more frequently the upper and anterior parts, are enlarged from over-distension, constituting a degree of emphysema.

In very chronic cases, especially of the rheumatic variety, considerable hypertrophy of the connective tissue of the bronchi has been found, and in other cases atrophy of the same tissue, the latter generally accompanied by more or less dilatation of the tubes.

In pseudo-membranous or croupous bronchitis the bronchial tubes are found lined, and in some cases filled, with a plastic exudate. Usually, only a limited number of the bronchi are affected. The tube-casts that may be expelled are generally in the form of balls, which may be unrolled, and which will then be found to be fragments or complete cylindrical casts of the tubes. They are, when expelled, usually yellowish and often sanious. When washed they are white. There are frequently points of enlargement along the casts which are caused either by the presence of air-bubbles within them, or by a more rapid exudation from that point on the bronchus. The largest casts are usually solid and laminated in structure; the smaller ones more frequently are hollow, containing a greater or less number of air-bubbles; the smallest consist of a single solid thread. Under the microscope the casts seem to be composed of a structureless or fibrinous substance holding numerous mucus and pus-cells, more or less numerous globules of fat, and occasional epithelial cells; seldom red blood-corpuscles, although these may be numerous on the surface. The casts are usually moderately compact, firm, and elastic. Toward the end of the disease, however, they may be less firm. In some cases toward the close of life epithelial cells are abundant in them, but in other cases on post-mortem examination the epithelial lining of the bronchi is found nearly or quite entire. The mucous membrane may be much reddened, or, on the other hand paler than normal. The submucous tissues are also sometimes involved in the swelling, and occasionally infiltrated with serum.⁷

⁷ For a representation of one of the most complete specimens of pseudo-membranous casts from the bronchi the reader is referred to the paper of Glasgow in the Transactions of the American Medical Association, already referred to.

DIAGNOSIS.—The principal diseases from which acute inflammation of any part of the bronchial mucous membrane needs to be differentiated are pneumonia, pleurisy, laryngitis, tracheitis, and asthma, while it is still more important to keep a clear line of diagnosis between the chronic grades of bronchial inflammation and the earlier stages of pulmonary phthisis and of emphysema. From nearly all the diseases named it is separated by negative evidence or the absence of symptoms and physical signs characteristic of those affections. It neither presents the rusty expectoration or high temperature or fine crepitant râle of pneumonia, nor the acute pains or short stifled cough or friction-sounds of pleurisy in the early stage, and still less is there in the middle and later stages any of the dulness on percussion that characterizes the corresponding stages of the other two diseases. In true asthma the active symptoms are distinctly paroxysmal, without fever or increase of temperature, and the respiration during the paroxysms is slow, with marked prolongation of the expiratory act; while in bronchitis, both catarrhal and capillary, the symptoms are continuous, the temperature increased, and the respirations more frequent than natural. All grades of bronchitis are easily distinguished from laryngitis and tracheitis by auscultation, which enables us to trace all the morbid sounds to the chest in the former, and to the front part of the neck in the two latter.

The great advantage of recognizing pulmonary tuberculosis and other forms of phthisis in the early stage of the disease makes the diagnosis between it and chronic bronchitis a matter of primary importance. This can be readily done by all practitioners who have acquired a reasonable degree of skill in the practice of auscultation and percussion. In all forms and stages of pulmonary phthisis, whether from primary tubercular deposits, pneumonic exudation followed by caseous degeneration, or from interstitial fibroid sclerosis, there is increased vocal fremitus and diminished resonance on percussion; neither of which is present in any grade of uncomplicated bronchitis. It is true that in the advanced stage of some very severe cases of capillary bronchitis there occurs sufficient pulmonary oedema to increase the vocal fremitus and diminish the resonance over some parts of the chest; but the accompanying symptoms and immediately preceding history of such cases are sufficient to separate them from any stage of phthisis. The same remark is applicable to those rare cases in which an attack of pseudo-membranous bronchitis results in the complete occlusion of one or more of the bronchi and the permanent collapse of the pulmonary lobules to which the occluded tubes lead. If in addition to the plain difference in the physical signs already mentioned we remember that in all the forms of phthisis there is progressive loss of flesh, some increase of temperature and acceleration of pulse, with a contraction of the upper and anterior part of the chest, while none of these changes result from bronchitis alone, there should be no difficulty in keeping the line of diagnosis clear between these two diseases. And yet there is probably no more frequent or important error committed in diagnosis than that of mistaking the early stage of pulmonary phthisis for bronchitis. This may arise in part from the fact that bronchitis often supervenes and continues coincidently with phthisis. But the practitioner should remember that whenever there is increased vocal fremitus and diminished resonance in any given case there is some altered condition of the lung-structure, and consequently some form of disease besides bronchitis, however plain the ordinary symptoms of the latter may be at the same time.

From pulmonary emphysema, chronic bronchitis is distinguished chiefly by the abnormally-increased resonance on percussion in the former, especially over the upper and anterior parts of the chest, and the peculiar depression of the spaces above the clavicles and between the ribs at the beginning of the inspiratory act, and their return to over-fulness near its close; while none of these changes accompany any grade of simple bronchial inflammation.

PROGNOSIS.—In the ordinary form of acute and chronic bronchitis there is very little tendency to terminate fatally except when it attacks infants or persons infirm from age. And even when it occurs at these extremes of life the fatal terminations are usually caused by the supervention of lobular pneumonia as a complication, and not from the bronchial inflammation alone. Severe cases of capillary bronchitis are more dangerous, and in young children and aged or debilitated persons often prove fatal before the end of the first week of their progress by the direct obstruction to the entrance of air into the air-cells of the lungs. The pseudo-membranous or plastic bronchitis is still more dangerous. It has been estimated that one out of every five dies. But the statistics concerning the number and character of cases are not sufficient to furnish a reliable deduction of the ratio of mortality.

The duration of acute attacks of bronchitis of all varieties from which recovery takes place is from one to three weeks. Uncomplicated cases of chronic bronchitis seldom prove fatal, neither is there any self-limit to their duration. Many cases undergo marked improvement during the warm months of summer, but suffer a renewal of all the more severe symptoms on the return of the cold and wet weather of autumn. In other cases the symptoms continue nearly the same through all the seasons of the year and until an advanced period of life.

TREATMENT.—There are certain leading objects to be accomplished in the treatment of all grades of inflammation affecting the mucous membrane and connective tissue of the bronchial tubes—namely, (a) to diminish or overcome the morbid excitability of the inflamed part; (b) to relieve the vascular hyperæmia or fulness of blood in the vessels, and thereby limit the amount of exudation or morbid secretion and consequent dyspnoea; (c) to counteract or relieve secondary functional disturbances, such as increased heat and dryness of the skin, diminished renal and intestinal activity, and nervous restlessness; (d) to hasten the removal of such plastic exudations as may have caused thickening and induration of the inflamed structures or formed layers or patches of false membrane on the bronchial surface, and to lessen the tendency to establish a stage of purulent degeneration or suppurative action in the inflamed part; (e) to regulate diet, drinks, exercise, and clothing in such a way as to sustain healthy nutrition and prevent the further action of predisposing and exciting causes.

The first three objects to be accomplished belong more particularly to the early stage of acute and subacute attacks, but are present in some degree throughout the whole course of the disease; while the last two belong to the latter stages of the acute and to all stages of the chronic grades of the inflammation. While the foregoing indications to be fulfilled or objects to be accomplished are present in all the various grades and stages of inflammation of the bronchi, the particular means for accomplishing them will be modified by the age and previous physical condition of the patient, the nature of the predisposing and exciting causes, the extent of the disease, and the stage of its advancement; or, in other words, the nature and extent of the pathological changes already accomplished. For instance: the same remedial agents that would be most efficient in relieving the morbid excitability and the vascular fulness of the first stage of acute inflammation in a young or middle-aged and previously healthy, vigorous subject might be positively injurious, or even fatal, if used in the same stage of inflammation in a subject previously anæmic and feeble or debilitated from age or from causes capable of impairing the quality of the blood and favoring a typhoid condition of the system. Consequently, the practitioner who not only sees clearly the objects most desirable to accomplish, but who most judiciously selects and adjusts the means or agents he uses to the special conditions of each patient, will meet with the highest degree of clinical success.

In the first stage of acute attacks involving the bronchi of both lungs in vigorous adult persons, and especially if the inflammation extends into the smaller tubes, causing much dyspnoea and dry râles, there is no single remedy that will so certainly and speedily check the intense engorgement of vessels in the bronchial membranes, and thereby gain time for the action of other remedies, as one prompt and liberal abstraction of blood by venesection. In cases of a little less severity, and in children, the application of from two to twelve leeches to the upper and anterior part of the chest, the number being regulated by the age of the patient, will be a good substitute for the venesection. And in case leeches are not at hand extensive dry cupping over both the anterior and posterior parts of the chest may be applied with much benefit. Immediately after the venesection, leeching, or cupping, and without these in cases of only ordinary severity, the whole chest may be enveloped in an emollient poultice or in folded napkins wet in warm water and covered with oiled silk. At the same time the following combination may be given internally:

No. 1. Rx. Liquoris ammonii acetatis, (60.0 c.c.) fluidounce ij;

Tincturæ opii camphoratæ, (75.0 c.c.) fluidounce iiss;

Vini antimonii, (15.0 c.c.) fluidounce ss;

Tincturæ veratri viridis, (6.0 c.c.) fluidrachm iss.

M.—Sig. Give to an adult 4 cubic centimeters or 1 teaspoonful in a tablespoonful of water every two, three, or four hours, according to the severity of the case. The same may be given to children, the dose being properly adjusted to the age of the child.

If the tongue be coated, the bowels inactive, and urine high-colored, from 6 to 30 centigrams (grs. j–v) of calomel, according to the age of the patient, may be given, and followed in four or five hours by a saline laxative sufficient to procure two or three evacuations from the bowels. Under the influence of these remedies the high fever and great sense of soreness and oppression in the chest which exist in the first stage of the more acute cases in previously healthy subjects rapidly diminish, giving place to more moist râles, easier breathing, and some expectoration. As soon as such amelioration of symptoms has been obtained, the mixture containing veratrum viride should be discontinued, and the following formula substituted in its place:

No. 2. Rx. Syrupi scillæ comp. (45.0 c.c.) fluidounce iss;

Tincturæ sanguinariæ, (15.0 c.c.) ounce ss;

Tincturæ opii camphoratæ, (60.0 c.c.) fluidounce ij.

M.—Sig. Give to an adult 4 cubic centimeters in a little additional water every three or four hours.

If the patient suffers much from severe sore pain in the head, aggravated by coughing, or from nervous restlessness, the addition of bromide of potassium, 16 grams (drachm iv), to the above formula will render it more efficient in relieving these symptoms and in promoting rest. Under such quieting and expectorant influences, aided by a mild laxative when needed, the cough, soreness, and oppression in the chest, and all other active symptoms, diminish from day to day, and convalescence ensues in from seven to nine days.

If after the first three or four days the temperature rises in the evening and the cough becomes more troublesome, interfering with rest during the first part of the night, followed by some sweating in the early morning, a single dose composed of sulphate of quinia from 3 to 6 decigrams (gr. v–x), pulverized sanguinaria-root 3 centigrams (gr. ½), and codeine 16 milligrams (gr. ¼) given between six and eight o'clock each evening for three or four evenings, will often contribute to the rest of the patient and hasten the establishment of convalescence.

Cases are sometimes met with, especially in patients debilitated by previous ill-health or age, in which the fever subsides after the first three or four days, leaving the patient with a feeling of unusual weakness, a deep harassing cough, copious muco-purulent expectoration, and little or no appetite. In such cases tonics and the more stimulating class of expectorants are indicated. A mixture of equal parts of the syrup of Prunus virginiana, syrup of senega, and camphorated tincture of opium, given in doses of 4 cubic centimeters or one teaspoonful every four or six hours, and 13 centigrams (gr. ij) of quinia three times a day, will often cause a rapid improvement in all the symptoms. In some of the cases last described there is added to the other symptoms a troublesome nausea and disposition to vomit with the paroxysms of coughing, in which I have found the following formula a good substitute for the mixture containing the prunus virginiana and senega:

No. 3. Rx. Acidi carbolici, (0.50 grams) gr. viij;

Glycerinæ, (30.0 c.c.) fluidounce j;

Tincturæ opii camphoratæ, (60.0 c.c.) fluidounce ij;

Aquæ, (60.0 c.c.) fluidounce ij.

M.—Sig. Give 4 cubic centimeters (fluidrachm j) or 1 teaspoonful before each mealtime and at bedtime, giving the quinia a little after the meals.

If more anodyne influence is required to procure rest at night, 16 milligrams (gr. ¼) of codeine may be added to the teaspoonful of carbolic acid mixture given at bedtime. If, as sometimes happens in cases of acute bronchitis, both of the catarrhal and capillary varieties, the inflammation invades some of the lobules of the lungs, as indicated by undue rise of temperature, greater expansion of the wings of the nose during inspiration, with short expiration, and diminished resonance with fine crepitation over limited portions of the chest, I have found the most certain and speedy relief to follow the application of a blister over the seat of the pneumonia and the internal use of the following formula:

No. 4. Rx. Ammonii chloridi, (12.00 grams) drachm iij;

Antimonii et potassii tartratis, (0.13 grams) gr. ij;

Morphiæ sulphatis, (0.20 grams) gr. iij;

Extract, glycyrrhizæ fluidi, (30.0 c.c.) fluidounce j;

Syrupi, (90.0 c.c.) fluidounce iij.

M.—Sig. Give to adults 4 cubic centimeters (fluidrachm j) or 1 teaspoonful, mixed with a tablespoonful of water, every three or four hours until some relief is obtained, and then at longer intervals. For children the doses must be diminished in proportion to the diminution of age. Quinine and laxatives may be used in these cases under the same indications as in uncomplicated bronchitis.

In the severe attacks of capillary bronchitis in young children many writers recommend emetics, and subsequently nauseating doses of antimony or ipecacuanha. But I have not seen sufficient benefit result from emetic doses of these agents to compensate for the early prostration, and sometimes continued gastric irritability, which they induce. I prefer the proper application of leeches at the very beginning, followed by emollient applications to the chest, and the same remedies internally as already mentioned, aided, perhaps, by an earlier use of quinine and digitalis if the cardiac action becomes weak and frequent. In all this class of cases, however, much caution should be exercised in regard to the use of opiates, either alone or in combination with other remedial agents, lest their narcotizing influence should diminish the force and frequency of the respiratory movements too much, and encourage the accumulation of the inflammatory products in the smaller bronchi to such a degree as to produce apnoea or death by the exclusion of air from the alveoli or air-cells of the lungs. And yet just enough of these quieting agents to diminish excitability and allay excessive restlessness is as desirable in children as in adults.