Chronic bronchitis, when it occurs for the first time in any given case, is probably merely an unusual prolongation of an acute attack which has been neglected, or has found the patient in a conclition of general debility ; the history is merely that cough has continued after the symptoms of febrile disturbance, pain, ice., have subsided the expectoration is more or less puru lent ; the auscultatory signs give no evidence of consolidation ; nothing is discover beyond the persistence of moist sounds. In such cases, however, careful search must be made for signs of early phthisis.
More generally there is a history of previous coughs and colds, and the present attack is either an aggravation of a constant con dition of ill-health, or has come on insidiously without acute !symptoms; there seems to be a permanent liability to chronic inflammation of the mucous membrane, and this ns sometinie,s coupled with a condition of emphysema. The patient is not feverish ; the pulse is sometimes quick and weak, and the tongue may be accidentally foul, but it is not dry, and there is no heat of skin ; the e,ondition of the bowels is important, because occa sional diarrhcea would lead to the suspicion of phthisis. If ema ciation exist, the peculiar thinness of skin, and clubbed nails of tubercle, are not found in simple bronchitis; the faoe is often dis colored, dusky, or muddy, when the &seas() is severe, becoming remarkably so when emphysema is present, and having a more distinctly blue or purple color when it is associated with disease of the heart. In severe chronic bronchitis the gait is stooping, from the shoulders being elevated, and in bed the patient cannot lie down ; orthoEceasees, is, however, commonly associated either with emphysema ot • of the heart. The bre,athing is labored, but not hurried ; the cough is generally frequent, and loose; ex pectoration usually easy, but sometimes only possible aftr a good deal of coughing ; it is muco-purulent, or almost wholly pus, in simple chronic bronchitis; it is watery, frothy, and abundantwhen the bronchial secretion is secondary on disease of the heart or kidneys.
Percussion either detects no difference between the two sides, or excessive resonance is especially observed on one. Sonorous sounds seldom exist in chronic cases, except when emphysema is present; moist sounds are heard loudest at the back of the chest, and in the most depending positions, where they are louder and coarser than elsewhere, except when the movement of the air in the small tubes and vesicles is impeded ; and then scarcely any sound is heard, or at most a few large bubbles; sometimes local absence of breathing, in consequence of one of the larger tubes being temporarily plugged up, may perplex the observer.
In chronic bronchitis, it is to be remembered that both voice and breath sounds may be locally exaggerated by the thickening, dilatation, and rigidity of the tubes, but it seldom happens .that such changes are of very unequal
extent on the opposite sides. A single dilated tube at one apex may cause some difficulty in diagnosis : but if there be dulness on both sides, it is nearly equal, and depends only on want of resiliency of the ribs ; if there be dulness on that side on which the large tube is found, its real interpretation is, that there is excessive resonance on the other, where want of breatbiag indicates emphysema ; if resonance be more marked over the dilated tube, it has none of the hardness and hollowness, or local characters of a cavity, but is diffuse, and Accompanied by elasticity and resilience. This is the only case of real difficulty in chronic bronchitis, when, by many of its concurrent symptoms, it simulates phthisis : the converse case, in which phthisis simulates chronic bronchitis, will be referred to in I 9 of this chapter. In a few words we may say, that all changes of percussion resonance, as well as most of those con nected with breath and voice-sounds, indicate something beside bronchitis; either tubercles, or emphysema, or pleuritic effusion, or inflammatory consoli dation, or even oedema; and the correct explanation of the phenomena depends on considerations belonging to each of those states, not on anything specially connected with the moist sounds themselves, which only arise from the coinci dent bronchitis.
Bronchorrhcea is probably the best name for that condition of the lungs in which the secretion from the mucous membrane is due, not to inflammation, chronic or acute, but to secondary congestion induced by disease of the heart, or more properly to edema of the lung, associated both with disease of the heart and of the kidneys. Except when partial dulness is produced by pleu ritic effusion, there is nothing in the physical signs to indicate that this is not simple bronchitis ; there is usually a difference in the expectoration, when there is no inflammatory condition of the membrane, and there is the still more important fact of disease existing in other organs. In other cases, bronchitis is engrafted upon persistent disease of the heart and kidneys, and its symptoms are greatly aggravated in consequence. Among the complica tions of this disease, changes in the condition of those organs are the most common, and ought especially to be sought for in chronic cases; after all that has been said, it 18 scarcely necessary to repeat that the existence of emphy sema and tubercular deposit are each to be inquired into : in the acute form we find bronchitis complicating pleurisy and pneumonia, or even pericarditis, and often present as a result of congestion in most disease* having a febrile character.