very far advanced, or the skin peculiarly irritable. The inhalation of tar vapour, creasote vapour, iodine, or chlorine, most unquestionably reduces the irritability of the mucuous membrane, and the quantity of secretion; the results of M. Cottereau, with chlorine inhalations, are peculiarly important, and show that singular advantage may be obtained through them, even where the general symptoms closely simulate those of phthisis.*

The choice of expectorant medicines will vary with the condition of the discharge from the tubes. If there be little expectoration, and excited circulation, and a tendency to congestion of the parenchyma, tartar emetic in small doses, ipecacuanha, or colchicum, are the best agents, combined variously with hydrocyanic acid, lobelia inflata, belladonna, stramonium, hyoscyamus, &c. If there be but little vascular excitement, squill, senega, ammoniacum, with opium, are preferable combinations. Balsam copaiba and the compound tincture of benzoin may be joined to the above agents, the former especially seems to exercise some specific effect on the mucous membrane. Medicinal naphtha may be used to control (which it certainly does) superabundant discharge.

The jellies made from Iceland and Carrageen moss both sooth the cough and afford nourishment. If emaciation occur, cod-liver oil should decidedly be employed;-many of the good effects of the oil, as observed in phthisis, are yet more readily produced in chronic bronchitis. Bark and the mineral acids are useful in controlling debility, and improving the appetite.

The diet should be nutritious and non-stimulant. Where circumstances permit, change of climate should be tried,-the selection of a spot mainly turning on the dry or moist character of the bronchitis. The dry form is benefited by the climates of Torquay, Penzance, Ventnor, Pau, Pisa, Rome, and Madeira; the moist by those of Hastings, Clifton, Nice, Genoa, Naples, Cadiz, and Egypt.

During the paroxysm of bronchorrhoea the hot bath, sinapisms to the extremities, emetics, full doses of lobelia inflata, and, if there be failure of vital power, sesquicarbonate of ammonia, are the chief remedies.

In the treatment of an acute attack, supervening on the chronic disease in a person of advanced years, the caution already given as to blood-letting in simple acute asphyxiating bronchitis, seems to me of yet greater importance. Here it is

Louis, Op. cit. p. 620.

not the inflammation that kills; it is the vast accumulation of muco-purulent secretion supplied by a congested surface,secretion which prevents oxygenation of the blood, and which the strength of the patient fails to throw off-that really kills: the brain and tissues become poisoned, too, with venous blood. Sesquicarbonate of ammonia is, in such cases, required almost from the first: it is best given in combination with squill and nitric ether. If any sinking tendency appear, chloric ether acts as a more powerful stimulus in these cases than any medicine I am acquainted with.

It is commonly held that the fatal result is immediately brought about by pneumonia: a notion derived sometimes from the occurrence of dulness under percussion at one or both bases, --sometimes from post-mortem examination,—sometimes from both sources. I have already pointed out the source of fallacy in the percussion-dulness referred to; and I have great doubts of certain consolidations found after death (peri-pneumonia notha in more senses than one) being truly pneumonic. It has not occurred to me to meet with such consolidation, except where there was co-existent heart-disease, and more especially of the mitral orifice,-consolidation hence obviously mechanically, and not actively, congestive.

In a practical work, it is unnecessary to consider all the varieties of bronchitis; but a certain number of them possess characters so peculiar, that special reference to them seems unavoidable. These are plastic and mechanical bronchitis, hay asthma, influenza, and syphilitic bronchitis.

PLASTIC BRONCHITIS.

Plastic bronchitis, an affection of great rarity, is anatomically characterized by the formation of solid or tubular concretions of exudation-matter of low type* within the bronchial tubes, reaching, more or less extensively, from their finest to their largest divisions. The disease has little tendency to spread upwards: the trachea remains unaffected; the voice, though sometimes becoming slightly husky, habitually retains its natural quality and strength. On the other hand, plastic inflammation extends downwards from the larynx to the bronchi in a small proportion of cases of croup,-but with these cases we have

* I have found them to contain exudation-cells; some nucleated, the majority not so. In the main, the substance is fibrillar or amorphous.

nothing to do here. Clinically the disease is distinguished by its chronicity, and frequent acute recrudescences, and its comparatively slight influence on the general health. The physical signs are also peculiar: disappearance of all respiratory murmurs in given spots of the lung from time to time, marks complete obstruction of the communicating bronchus, and dulness, as complete as in pneumonic consolidation, probably from collapse of the lung-substance, may occur co-extensively with the deficiency of respiration.* Local pneumonia, attended with pain, true crepitant rhonchus, and blowing respiration, also occasionally occurs in these cases,-generally speaking, running its course uninfluenced, at least perceptibly, by ordinary treatment. Where a very large tube chances to be blocked up, asphyxia may be temporarily threatened; † and oppression of breathing, disproportionate to the apparent amount of disease, is always a prominent symptom.

The expectoration of the casts is generally preceded by some hours' dyspnoea and hacking dry cough; and during the periods of acute attack, I have found the pulse-respiration ratio vary from 2.2:1 to 3.5:1. During these attacks, casts of notable size are brought up generally from three to six or seven times a week,-but small fragments are much more frequently expectorated. Unless the sputa be closely examined under water, particles of concretion escape notice amid the viscid mucus with which they are generally associated.

Streaks of blood, either on the external surface of the casts, or, more rarely, on their internal surface, (if they be tubular) are not uncommonly seen; and spitting of florid blood in streaks, or even in drops, mixed with mucus, for a short while after their expectoration, occasionally occurs. This is especially the case at the height of the acute attack. As this wears off, the concretions and the expectoration become bloodless. Cases have been observed, however, in which copious hæmoptysis had occurred for some time previous to the expectoration of solid casts of the tubes. The nature of these cases, however, requires further investigation. It appears very improbable that they belong to the same class as true plastic bronchitis; the concretions are very probably simple fibrinous coagula from hæmoptoic

*E. g. Case of Jane Moss, U. C. H., vol. i. p. 187 (1846,) and vol. iii. p. 83 (1848.) Expectoration of casts of the tubes commenced, in this case, in the spring of 1843, and, with occasional intermission, has continued to the present time (Autumn of 1850.)

† U. C. Museum, No. 2124.

blood, itself the result of tuberculous disease. In no case of the kind that I have read the record of, was the absence of tuberculous disease proved; and, on the other hand, the occurrence of moulded coagula in tuberculous hæmoptysis, though, for obvious reasons, rare, is sometimes (I have seen it myself) positively observed.

During the period of acute seizures the treatment is to be conducted on the same principles as if the secretion-products were of the ordinary kind. 1 have not seen any benefit derived from mercurial action on the system. The young practitioner must not confound the local dulness under percussion, which may come on in a few hours in these cases, and depends on obstruction of tubes, with true pneumonic loss of resonance. The weak or suppressed respiration of the former condition, the tubular blowing of the latter, will distinguish the cases.

Few affections of the lungs are more difficult to cure permanently than this. Theory leads to the use of iodine by inhalation and otherwise, and suggests a prolonged trial of alkalies, as diminishing the tendency to hyperinosis. I have perseveringly employed these remedies without any permanent effect on the disease. It disappears for a time, to return again without obvious There is obviously a diathesis to be contended with.

cause.

MECHANICAL BRONCHITIS.

Under this head fall those well-marked varieties of bronchitis induced by the inhalation of irritating particles of various kinds. The knife-grinders' rot is primarily mere bronchitis produced by the entry into the tubes of metallic particles and gritty dust from the grinding-stones; miners (whether coal or other,) not, as was once erroneously supposed, from the inhalation of coal-dust, but really from that of the soot of the oil-lamps used in working, where the safety-lamp is not employed, are subject to a similar disease; so, too, are quarry-men, cotton-batters, &c. In all these cases the disease (grinders' rot, black phthisis, stone-phthisis, cotton-phthisis, &c.,) is essentially bronchitis at the outset, which becomes chronic, is followed by dilatation of the tubes, and, eventually, inflammatory destruction and excavation of the lung-substance itself. But there is no connexion between this destruction and the presence of tubercle,—which, if it exist, is purely accidental.

The physical signs are those of bronchitis, dilated bronchi,

occasionally of emphysema, of consolidation, and, finally, of excavation. The general symptoms are not proportional in severity to the local disease; whence a distinction between these affections and phthisis. The knowledge of the cause also aids in the diagnosis.

Cure is impossible, unless the patient change his occupation. Various mechanical contrivances have been invented for the prevention of these diseases, especially among knife-grinders. Abraham's magnetic mouthpiece attracts metallic particles, but has no effect on the stone-grit. Dr. C. Holland's revolving fan, acting by a strong current upon the spot where the metallic dust and stone-grit are formed, seems to be more successful.

HAY ASTHMA.

A singular variety of bronchitis, which has been supposed to follow the inhalation of the aroma of the sweet-smelling spring grass (anthoxanthum odoratum,) is known under this name. The entire naso-pulmonary mucous tract is implicated, however; sneezing, irritation in the nostrils, and flux (common coryza, in short,) soreness and prickling sensations in the throat, dyspnoea, post-sternal oppression and rawness, cough, and, towards the close of a seizure, thin mucous and watery expectoration, are the symptoms of the affection.

The complaint occurs only at the periods of hay-making, or when the odour of grass is powerful; and is of exceedingly rare occurrence. The susceptibility to these emanations, indeed, constitutes a very remarkable example of unalterable idiosyncracy. Persons who have once suffered, invariably have a return of the disease, if exposed even in a slight degree to the specific cause.

The only effectual way of preventing an attack is by removing at the season to the sea-side,-by getting out of the reach of grass and hay. It is affirmed that a course of sulphate of iron and quinine (Gordon,) and the use of the shower-bath, removed the disease in two persons who had been its annual victims for fifteen or twenty years. During the seizure, the æthereal tincture of lobelia inflata is a valuable remedy; there seems, in truth, to be some spasmodic element in the disease. Dr. Elliotson believes he has observed benefit felt from breathing an atmosphere with chlorine diffused through it,-saucers of

* Gordon, Medical Gazette, vol. iv.