to it, and that we should endeavour by a continued exposure to a bracing degree of cold, with the other means already mentioned, perseveringly to conquer inch by inch the ground that has been lost until the habit of fatdigestion has been perfectly established and health restored. Med. Times and Gazette, June 13 and 20, 1868, pp. 633, 658.

31. SOME POINTS IN THE PATHOLOGY AND TREATMENT OF ACUTE CAPILLARY BRONCHITIS.

By Dr. J. K. SPENDER, Bath.

Acute capillary bronchitis has had several synonymes. It is the peripneumonia notha of the older authors: the acute suffocative catarrh of Laennec; the asthenic bronchitis of Dr. Copland. The nomenclature which I use now is that adopted by the most recent writers; it seems to convey accurately what is meant, to wit, an inflammation of the terminal bronchial tubes-tubes nearest to the air-cells in size and function-followed by an exudation which more or less obstructs them.

I have been surprised by the comparatively little prominence given to this appalling disorder in the best professional text-books. Either it is scarcely noticed at all, or it is discussed as a variety of common acute bronchitis. The disease is certainly not very common, but it is by no means rare; and I now venture to plead the substantive entity of acute capillary bronchitis, and its claims to a distinct nosological position. Dr. Addison employed the term "capillary bronchitis" to signify the irritative action set up in the lung by tubercle; but it is obviously unwise to apply the same term to two diseases so etiologically different.

An adult person suffering from general capillary bronchitis of the acutest kind presents very well-marked symptoms; and, as might be expected, those that are most urgent belong to the respiratory system. (a) He breathes with extreme quickness; the pulse and breath ratio deviates from the norm sometimes so much as to be 2 to 1; ratios of 24 to 1, and 3 to 1, belong to the ordinary characteristics of the disease. (b) He coughs very often, and expectorates a light foamy sputum. (c) His skin has a dusky-purple tint, the intensity of which is commensurate with the blood-stasis in the lungs.

(a) Concerning the first of these symptoms-the rapidity of the respiratory act is governed by the law so clearly laid down by Dr. Hyde Salter, that the urgency of dyspnoea is in direct proportion to the soundness of the lungsubstance, free access of air being cut off to the functioning portion of the lung by obstruction of the air passages. And this formula applies with precision to the case of acute capillary bronchitis; for, according to the conditions of the problem, the physiological area of the lung is everywhere free and capable of fulfilling its duty. The dyspnoea is severe enough even in partial capillary bronchitis; but when the disease is more or less universal, we have every condition present for producing a difficulty of the most extreme degree.

(b) Concerning the second point specified-the frothy sputa with which the finer air-tubes are choked; I remark, firstly, that this exudation does not afford so complete an obstacle to the inspiratory and expiratory currents of air as spasm of the air-tubes. Narrowing of these tubes by spasm makes the breath-currents narrow, and therefore slow. The muscular element is prolonged to the terminal bronchia; but notwithstanding this, the respiratory movements go on at a tremendous pace, and produce the well-known auscultatory phenomenon of coarse bubbling crepitation-like "squeezing a sponge half saturated with water." Next. I have to indicate the probable double origin of the sputum. It is, of course, partly a true exudation from an inflamed surface, and in the ultimate stage it contains pus-cells. But there is a transudation of serum into the bronchial tubes, arising, as Dr. G. Johnson has sagaciously pointed out, from engorgement of the bronchial veins; this engorgement being a sign and a consequence of a blockade in the pulmonary

circulation. And there must be a very great disturbance of the pulmonary circulation when there is such terrible apnoea. If the pulmonary œdema, which so often occurs in the course of uræmia, is a true dropsy of the connective tissue of the lung-of the inter-tubular structure, in fact-then the transudation of serum from congestion of the bronchial veins is an intratubular dropsy, a dropsy of the true "parenchymatous" sort; and often not less fatal.

(c) The dusky hue of the skin is sometimes loosely called cyanotic. I submit, however, that the term "cyanosis" ought to be restricted to regurgitation of imperfectly aerated blood from heart-distress, and not to mere stasis caused by difficulty in the lung. Not quite two years ago, I had under my care a case of typical cyanosis in the person of an otherwise healthy young woman, the daughter of a farmer near Bristol. The whole stress of the matter seemed to arise from a slight narrowing of the pulmonary artery (without lesion of its valves), which a dilated and weakened right heart had not power to overcome. The entire face looked as if smeared with black currant juice of the deepest dye, the lips being fearfully crimson. The dyspnoea was most intense. Now this was a true cyanosis; and the absence of any irretrievable cardiac malformation was proved by the perfect success of a ferruginous treatment, which imparted tone to the right heart, and restored the natural tint to the complexion in a few months. Compare this with the mere dull purple colour developed by capillary bronchitis and other analogous affections of the lungs, and the difference is sufficiently conspicuous to be diagnostic.

The compound condition known as "collapse" is very marked in acute capillary bronchitis. The skin is cold and sweating; the bowels are confined; the urine is turbid and very scanty. The likeness of this condition to what happens in cholera, and during a paroxysm of asthma, is evident enough.

A few words on diagnosis. It might be summarily asked-Is there any disease which can be possibly confounded with acute capillary bronchitis? Listen to this short story. One day last winter, there was brought to me at the Eastern Dispensary, Bath, a young girl who was wheezing, panting, and purple. Before asking the mother (who accompanied her) a single question, I said to myself-Is this child suffering from capillary bronchitis, acute tubercle, or mitral regurgitation of heart with secondary lung-disease? I ordered her home, and examined her in bed the same evening. A glance at the thermometer decided the matter; the temperature was above 103 deg., and the child was dead within three days. But I was almost amazed at the similitude of many of her objective signs to those of capillary bronchitis; the main point of unlikeness being the very scanty sputa (mixed with a little blood), and the decided heat of skin. And the history of the case was very distinct in its indications of tuberculosis.

A person who has suffered severely from capillary bronchitis is often long in recovering the usual bright florid hue of skin. You may see him all the next summer carrying about a sure legend of the peril he has undergone; he looks metallic and dull, and is chary of any swift exertion. He has been smartly hit in a vital point, and he dreads what the next winter may bring forth. Influenza is perhaps one of the most serious epidemic maladies which he has to fear. There is usually some emaciation. Capillary bronchitis in children is always a most dangerous disease.

Treatment. We start from the postulate, that capillary bronchitis is often amenable to skilful and decisive treatment, if it be begun early enough. The pathological picture which has been drawn is rather dark, but by no means discouraging. Certain land marks stand boldly out, which we may follow without hesitation.

On Sunday morning, April 14, 1867, I was asked to see a labouring man, a patient of the Eastern Dispensary, Bath, who was in the collapsed stage of this disease. Every feature was well marked, and he seemed in great danger. My internal remedies were-a table-spoonful of brandy every two hours; five grains of sesquicarbonate of ammonia every two hours, alternately

with the brandy; and a small quantity of fresh cold milk whenever it could be taken. My external remedies were—a warm atmosphere rendered moist by steam; and a hot linseed meal poultice over the whole of the back of the chest. In the evening he was better; the skin was warm, the dyspnoea less urgent, and the urine was less scanty. The same means were continued with the same success. He improved day by day; he gradually took strong broths and less and less alcohol, and within a week was rapidly convalescent. In some excellent clinical remarks on capillary bronchitis written some years ago by my friend Dr. Hyde Salter, he objected to using alcohol in this disease, on the ground of its giving the lung more eliminatory work to do dur ing an emergency when physiologically it ought to be kept quiet. My apology on the other side must rest on the facts so clearly substantiated by Drs. Anstie and Inman, that (a) alcohol affords a positive dynamic support to the nervous system; and (b) it is a temporary food which sustains vital function until more complete compounds can be appropriated. And all à priori objections vanish before the favourable test furnished by actual experience.

Concerning sesquicarbonate of ammonia, I am amused by the divergent opinions which prevail among my medical friends about this drug. I know two physicians, one of whom literally prescribes it for almost everything; and the other as unqualifiedly declares that he has no faith in it for any curative purpose whatever. Adopting a kind of middle view, I incline to the doctrine that this salt is a valuable therapeutic auxiliary to other measures when we have to contend with certain forms of bronchial distress. I am sure of its capability to do good service in the proper asthenic bronchitis of old people. I claim for it no higher virtue, because I know our proneness to call any drug a specific which we know particularly well how to work with.

I would beg special attention to the absolute mortality of the smallest quantity of opium, and to the still more destructive effects of worphia.

If a patient be teased by residual catarrhal sputa, a short mercurial course will clear it away; and after that (or even at the same time) an iron tonic will help to restore the general health.

Great care must be taken at all seasons of the year that the skin is properly protected.

To recapitulate: I would specify the following points as deserving notice in the clinical history and management of acute capillary bronchitis :1. The extraordinary pulse and breath-ratio, and the intense dyspnoea. 2. The pathological origin and character of the sputum.

3. The quasi-cyanosis of the skin, together with the so-called "collapse." 4. The occasional indistinctness of the diagnosis from acute tubercle. 5. The necessity of a supporting and alcoholic treatment.-Brit. Medical Journal, Sept. 19, 1868, p. 304.

32.-CASE OF PLASTIC BRONCHITIS, WITH

THERITIC EXUDATION.

By Dr. DOUGLAS, one of the Vice-Presidents of the Edinburgh Medico-Chirurgical Society. [The patient, whose case forms the subject of the following article, was a letter-carrier, aged 31, a spare delicate-looking man. He complained of acute pain in the left mammary region, catching his breath, and aggravated by the least motion. Yet, with all this, the most careful examination failed to detect any physical sign of pulmonary disease.]

On the following day, his distress was in no degree abated. Pain was intense; he was flushed, with suffused eyes. Pulse 104. Tongue coated; bowels torpid; breathing little distressed. He had slept none, and had perspired profusely. On examination of the chest, the left dorsum was found dull on percussion, with tubular breathing and other signs of consolidated lung; but neither crepitation nor pulmonary rattle existed.

[The administration of half-grain doses of tartar emetic was not productive of relief. On the fifth day, dull percussion, with tubular breathing existed, and there was a gray pellicle in the throat and mouth.]

The antimony was replaced by solution of nitre, and he had a drachm of chlorine-water every three hours. Speedy abatement of his distress followed, though the pulse increased in frequency to 120. Pain with breathing ceased, the gray pellicle commenced to separate from the throat and mouth, and was not reproduced; at the same time, a rare subcrepitating rattle was developed in the contiguous confines of the left subclavian, mammary, and axillary regions.

On the eighth day of his attack, he presented a marked improvement in appearance; the respirations had fallen to 27: pulse to 112. Perspiration, which had been considerable, nearly ceased. Progressive separation of the pellicular exudation was going on; and, for the first time, le expectorated, with no great difficulty, dense globular masses of a pearly-like mucus which sank in water. These dense masses attracted my attention by their curious lobulated configuration, and the lobules or nodules on the surface unfolded themselves when the mass was shaken in water, and appeared to consist of rolled-up casts of the bronchial tubes. Examined with the microscope, the casts presented the cells and fibrous structure of epithelial mucus and plastic lymph. The subcrepitating mucous sounds already mentioned could now be traced extensively in the left dorsum.

From this date improvement was but little interrupted, though it was slow. On the eleventh day the pulse was 72; and the pellicular exudation had disappeared from the throat, leaving the subjacent mucous membrane of an intense red colour. Dull percussion persisted in both dorsal regions, with the sounds of respiration masked; and in the right there existed the sound of friction. He was unable to be out of bed till the 12th of October (the thirtieth day of his illness), and as late as the 21st of October he was liable to acute pleuritic attacks, with catching pain and febrile heat of the skin. To the end of October augmented thrill of the voice and soft submucous rattle existed over the upper parts of both lungs, while in both lower dorsal regions there was dulness of percussion, faintness of the respiratory murmur, and diminished thrill of voice.

He resumed his official duty on the 13th of December, and he has not had occasion for medical aid since that date. I examined his chest a few days ago, and found the sounds of percussion and respiration in the normal condition. His general health is good, and he is an active and efficient officer. He complained, however, that the state of his throat interfered with his comfort in speaking and singing; but this has ceased since the removal of the uvula, which was excessively relaxed and tumid.

Plastic or pseudo-membranous bronchitis occurs as an acute and idiopathic disease in only a small proportion of cases. I have not met with it except in the case I have described. It is more usually observed as a chronic and remitting or recurrent malady, and often complicating other and organic lesions.

The complete recovery made by this patient entitles the case to our attention; but additional and great practical interest attaches to the case, considering the pneumonic character of its early stage, and the "quasi" diphtheritic state of the throat which it subsequently presented.

In the remarks I offer I shall not attempt anything like a full analysis of the case; it will be better to note shortly some of the particulars which gave it peculiarity. In commenting upon a solitary case, there is no call to discuss the history or pathology of muco-plastic exudations; and, indeed, in following the history of a case to a termination so favourable, the diagnosis and therapeutics of the disease more naturally present themselves for our consideration.

It is to be noted, that I visited the patient on the first day he was confined to the house, and, though he had shivered on the second day previously, he had performed his duty as a letter-carrier on the preceding day. It will be observed, that on my first visit my attention was fixed upon his intense suffering in the left breast (impeding movement) and upon the general fever. It seemed more than probable that this was not the suffering of a mere pleurodynia, and I was the more readily led to infer that acute pneumonia was

being developed, having repeatedly met with cases of pneumonia especially involving the upper lobes of the lungs, in which distressing pleurodynia existed. I hesitated, however, in this opinion, considering not only the absence of physical signs-no exaggerated respiration, crepitation, nor any pulmonary rattle-but also considering the general state of the patient, with a look of depression so marked, and the severity of his local pain. The treatment was accordingly in some measure expectant and soothing. But on the following day the signs of consolidation in the lung of the suffering side confirmed me in the opinion and led to a more active contra-stimulant treat

ment.

It must be noted, however, that the consolidation arose not in the situation I anticipated, but low down in the part usually so affected in cases of pneumonia, and that it was followed almost immediately by a similar consolidation of the opposite lung. Viewing the facts of the case retrospectively, I believe that the seat and occurrence of these consolidations were determined by a broncho-pneumonia originating in communicating ramifications of the tubes, as well as independently in the cells or parenchyma of disconnected lobes of the lungs. From the hurry of respiration (42) which now occurred, it is reasonable to suppose that both lungs were involved to an extent greater than was indicated by the external physical signs. I was now shaken in the opinion that the case was one of pneumonia; and as he had taken large and repeated doses of tartar emetic with absolute tolerance, I examined his throat lest there might be any sign of local irritation from the antimony, and, to my great surprise, I found it in the state described in the narrative I have read. In these circumstances, it was a sufficiently natural inference that the case had acquired, if it had not possessed from the outset, a diphtheritic constitution, and that the pulmonary lesion participated in this. This view, however, could not be maintained, on satisfactory grounds, though the patient's general condition in a measure suggested it, and the further changes in the pulmonic symptoms appear to justify the view that the case was one of bronchitis with muco-plastic membranous exudation, the parenchyma of the lungs and the pleura being involved in the inflammatory state.

It was not until the eighth day of his illness that the peculiar expectoration set in, and on the preceding day we observe that the pellicular exudation began to separate from the throat, concurrently with submucous sounds in the chest indicative of a change in the character of the exudation there. The concurrence of these changes and the abatement of the general symptoms is evidence of the close relation of the affection of the lungs and that of the throat; but to prove or explain their mutual relations it is not needful to suppose the existence of a diphtheritic constitution. On any theory of the case, it is remarkable that the larynx and trachea should have escaped the local disease; but I shall not detain you by speculative explanations of these points.

I have not met with any other case in which the expectoration presented the peculiar dense masses which, by shaking in water, were shown to contain so fragile muco-plastic casts of bronchial tubes, larger than the smallest subdivisions. The only description of a similar expectoration I have seen is by Dr. Hyde Salter, in a case communicated by him to the Pathological Society of London, in May, 1860. Dr. Salter's case was chronic, and the bronchitis appeared to be limited in extent. I incline to think, however, that such a state of expectoration is the result of recent and more or less acute action. In many of the cases described by authors, blood was observed mingled with the expectoration. The absence of all appearance of blood in the case of my patient is not by any means singular, though tinting of the expectoration might as a rale be anticipated, especially in cases so acute. In the present case, the distinctive peculiarities of the expectoration were the delay in its appearance, and its general as well as its minute physical characters.

I have previously said that the condition of the patient suggested that his illness was diphtheritic, though I could not maintain that opinion on grounds satisfactory to my own mind, and I am now less than ever inclined to take that view of the case.