BRONCHIECTASIS.
Definition.—A. more or less uniform dilatation of the bronchial tubes, of one or both lungs, which may be localized or extend to the finer ramifications.
Varieties. — The dilatation may be cylindrical, involving the medium-sized tubes and, less frequently, the smaller bronchi and bronchioles, or saccular, the caliber of limited portions of the bronchi being enlarged, and forming bag-like cavities of various dimensions. "Bron chiolectasis" is a term proposed by Kan thack for those cases in which only the bronchioles are involved.
Symptoms. — In practically all the cases of bronchiectasis there is a his tory of prolonged bronchitis, of pleu risy, catarrhal pneumonia, broncho pneumonia, or some other acute pulmo nary disorder. A few follow the inhala tion of some foreign body of sufficient size to occlude a bronchus. When bron ehiectasis follows bronchitis, the symp toms of this disease assume a modified character: the cough becomes more severe and paroxysmal and the amount of expectorated material is greatly in creased. This copious expectoration— which may reach over a pint a day —especially occurs early in the morn ing or after a sudden change of post ure, even when the patient is in bed. At first giving off a sour odor, it gradu ally becomes foetid, and this foetor be comes so marked that the atmosphere around the patient is almost unbearable. In cases of long duration the expectora tion is brownish and, when examined microscopically, is found to contain Charcot-Leyden crystals and masses or bundles of fatty-acid crystals. Various kinds of bacteria, leptothrices, etc., are also found, some of which are of external origin. The tubercle bacillus is seldom detected unless the patient be concomi tantly suffering from tuberculosis of the lungs.
The temperature, which during the presence of bronchitis alone may have been normal or slightly above the normal level, now shows a tendency to rise near evening. The curve is irregular and may reach 105°. When the disease fol lows pulmonary disorders, attended with pyrexia, this is increased with the ac cession of fcetor. As a result of septic absorption, manifestations simulating those of hectic, as observed in consump tion, usually occur, and the patient may succumb. Pulmonary gangrene is not an infrequent complication and promptly leads to a fatal ending in the vast ma jority of cases. Intense pain in the head in these cases indicates involvement of the meninges, while the cerebral press ure induced may give rise to hemiplegia, athetoid movements, and finally stupor. This complication occurs in about one half of the cases.
In children the disease is frequently the result of whooping-cough or of bron chopneumonia, the mechanical origin of the dilatation of the bronchi being mainly due to repeated and forcible coughing, the weakened resistance of the bronchi through inflammatory softening causing them to yield to the undue air pressure. This is especially the case
when inflammatory disorders involving the bronchi have repeatedly occurred in the patient. Cases of broncho-pneu monia or chronic bronchitis in which recurrences have repeatedly shown them selves are therefore the most prone to bronchiectasis.
When the cylindrical dilatation is not great, the physical signs do not differ markedly from those observed in the causative disorder. But a comparative point of value is that furnished by ex amination during a fit of coughing, when marked gurgling may usually be noticed, which gurgling varies according to the amount of accumulated secretion. Dur ing normal and even deep respiration increased roughness as compared to the ordinary signs of the primary disorder may be present; but the information thus obtained is not sufficiently dis tinctive to warrant for this symptom more than a confirmatory position among the signs present. Loud gurgling dur ing coughing and fcetor of the sputum are conjointly, however, strong evidences that bronchiectasis is present.
When distinct saccular bronchiectasis is present, the characteristic signs of pul monary cavities are pre-eminent, but most marked in the majority of cases at the base instead of the apex of the lung involved. Cavernous and amphoric signs are usually marked. The disease being unilateral in a larger proportion of the cases, confusion with tuberculosis is pos sible when the left side is involved, and when the bronchial dilatation is not con fined to the base.
In many eases in which the diagnosis is doubtful, or the auscultatory signs do not give reliable results and fail to lo calize with precision the bronchieetasic cavities, the Roentgen rays will reveal them on the fluorescent screen. A radiographic examination will, in most instances of multiple cavities, reveal the presence of all. Radioscopy, however, is not an absolutely infallible means of diagnosis. Tuffier (Bull. at Mem. de la, Soc. de Chin, Mar. 6, 1900).
When bronchiectasis is due to the presence of a foreign body, it is caused by the violent cough induced, which gives rise to undue pressure within the tubes. The excessive coughing may also cause free portions of the lung to be come dilated. The same condition may be brought about by stricture or com pression occurring in the course of mor bid processes which mechanically inter fere with the free passage of air through the tubes. It may, in this manner, com plicate phthisis and aneurism.
Diagnosis.—The conditions for which bronchiectasis is apt to be taken are pul monary tuberculosis and circumscribed empyema.