Cancer of external parts. Inflammation (acute or chronic) of the surface of the Body, (including Abscess, Ulcers, Erysipelas, Carbuncle, Chronic Cutaneous diseases.) Hemorrhage from uncertain cause, (seat to be stated.) Purpura. Debility (including deaths from old age.) But when we consider the very large proportion of fatal cases in which a complication of diseases exists, and the importance of recording as much as possible of the causes tending to the fatal event, we are decidedly of opinion that it is impossible to obtain the whole pathological information which such registers, in so far as they are filled up by practitioners, ought to covey, without a subdivision of the column assigned for the name of disease into two compartments, the one stating the "disease causing death,” the other the "previously existing disease, if any," It is true, that different practitioners may arrange the information conveyed in those two columns differently; but as both columns will always be examined by any one wishing to obtain statistical information from them, this is of little importance. The advantages of the plan which we propose for the keeping of these registers, will be best shown by the following schedule and examples:— *The columns containing names of diseases, only to be filled up by medical practitioners, except in cases of death from notoriously epidemic diseases, such as smallpox or hooping-cough. The only other observation which occurs to us on this subject is, that the tables of mortality abstracted from the register may easily be made to exhibit the differences of health of towns and districts of the country, more satisfactorily than those published in England. The importance of the data thus afforded, is very well stated by Mr. Lister, in his first report, as follows: "I have felt that it was of great importance, not only to give an abstract for the whole kingdom of England and Wales, but to exhibit the difference that prevails in different portions of the kingdom, to compare town with country, agricultural districts with manufacturing and mining districts, the hilly with the low and level, the maritime with the inland, the eastern and northern with the western and southern parts. Nor are these diversities matters of merely curious speculation, but may be made the source of important benefits, especially to the poorer classes. It was stated in evidence before the committee on parochial registration, in 1833, by the actuary of the National Debt Office, that the extent of difference which then existed was utterly unknown; that tables for the use of the poor, in reference to sickness and mortality, and in reference to the regulation of their friendly societies, could not then be constructed for two districts differing in character, from the want of such information as an improved system would afford; and that if two societies of poor men, residing in districts of a totally different character, were, at the same time, to apply to him for tables to guide them in preserving their societies solvent, he should be under the necessity of giving the same tables to both, though knowing perfectly that the rates which were adequate in one case, were inadequate in the other.' It was also stated to the committee on laws respecting friendly societies, by another eminent actuary (Mr. Milne), that no one table or scale of contributions can, with propriety, be adopted by all friendly societies; that one composed of members living in or near a manufacturing town, required a table very different from that which would be required in places where the population is less dense, and where a considerable proportion of the members are chiefly employed in the open air; but that these are differences which he could not 'pretend to estimate for want of data.' The useful principle of comparison may, if requisite, be carried out into a more minute system of subdivision than I have, in this first instance, deemed it necessary to adopt. But there was danger lest, in attempting a more subtle discrimination, we should lose sight of broad distinctions which it was important to observe; and it was necessary to remember, that to diminish by subdivision the number of facts on which calculation could be brought to bear, was materially to diminish their value. The extent to which division should be carried, is a question not to be decided by any established rule, and which necesarily admits of much diversity of opinion; and I have endeavoured (not unaided by judgments which I respect) to pursue a middle course between the opposite extremes of subdivision and condensation, dividing the kingdom into the twenty-five portions in which are exhibited abstracts of deaths at different ages.” According to the division thus adopted by Mr. Lister, the five largest towns in England, London, Manchester, Liverpool, Leeds, and Birmingham, are separated from the adjoining districts of country, and the mortality in each exhibited separately; but all the second-rate towns in England are united with the surrounding districts of country, and constitute but a small part of the population of the districts (containing from 200,000 to above 1,000,000 inhabitants) of which the mortality is given. The deficiency of the information given by these tables, appears distinctly from attempting to compare the mortality in Edinburgh with that in any of the English towns. All the towns of which tables are given, separately from country districts, are commercial and manufacturing towns, and, therefore, not proper objects of comparison with Edinburgh. The English towns which resemble Edinburgh most, in the condition and occupations of their inhabitants, are Bath, Oxford, Cambridge, and some of the Cathedral towns; but we have no record of the mortality of any of these, disjoined from large districts of surrounding country. In Scotland there are only seventeen towns, of which the population exceeds 10,000; and in order to have a fair exposition of the effects of town life, and of the mode of life in different towns, as compared with country districts, it would be of great importance that the mortality in all these should be stated separately from any country districts. If these observations on the best plan for keeping public registers of deaths shall be approved by the Royal College, we would suggest that they should be made known, along with the earnest recommendation of the general principle of the measure by the Royal College, in whatever quarters may be thought advisable, in the view of aiding the object of obtaining a Registration Act for Scotland. W. P. ALISON, Convener of Committee. ART. III.—CASE OF SUBACUTE BRONCHITIS, WITH PLASTIC TUBULAR SECRETION. BY W. F. RANKING, M. D. CANT.,' Physician to the Suffolk General Hospital. Bury St. Edmunds, August 12, 1841. I was summoned on the morning of the 2d of June last to meet Mr. Robinson, of Mildenhall, in consultation upon the following case:— The patient, a gentleman, ætat. 20 years, of a nervo-sanguineous temperament, was seized on awaking by a paroxysm of coughing, accompanied by expectoration of sputa, tinged with blood. He had suffered three separate attacks, previous to the present one, of what was considered to be pure hæmoptysis, and dreaded accordingly as the forerunner of phthisis. He appears to have been for some time subjected to dyspnea and palpitation upon exertion; and catarrhal attacks, to use his own expression, always "settled upon the lungs." The first seizure of his present ailment occurred in January last, a second Occurred in February, and a third in April, all of which yielded to topical bleeding and digitalis. The present attack came on rather unexpectedly; our patient having been noticed the day before to be in excellent health. The expectoration consisted of masses, which, upon casual observation, appeared to be mucus, tinged with blood, and was expelled by an effort more resembling "hawking" than cough. Upon more minute inspection, these sputa were seen to consist of a whitish membrane, distinctly tubular, and accurately moulded to the form of the bronchial tubes, even to their most minute ramifications. The consistence of these varied; in some portions the membrane was tough and opaque; in others thin, and raised into minute pouches by bubbles of air. The blood was small in quantity, and could be easily removed from these tubes by agitation in water. There was little disturbance in the system beyond that produced by mental agitation; the appearance of the blood having given rise to the greatest anxiety both to the patient and his friends. The pulse was 80, and soft; the skin cool, and tongue natural; and there was little or no pain in the chest. I made a very careful stethoscopic examination relative to the existence of the tubercular deposit, but could not discover any grounds of apprehension. The chest was of an unusually round figure, and gave a clear 1 London Medical Gazette, August, 1841, p. 832. sound on percussion throughout. The respiratory murmur was of an intensity almost puerile, and audible every where, with the exception of the neighbourhood of the larger tubes, where it was marked by a sibilous râle. There was considerable præcordial dulness, and extensive but not forcible impulse. There was less difference than natural in the "timbre" of the first and second sounds. "The diagnosis I formed from these was, subacute inflammation of the bronchial mucous membrane, with plastic secretion; many tubes obstructed partially by membranous deposit; and a dilated heart of less than average power." Under the impression that digitalis, which had been prescribed on former occasions, was not suitable to the state of the heart, I gave him internally the acetate of lead-a remedy which has been found so useful in bronchitis, by Henderson, guarded in the usual manner by acetic acid draughts: aperient medicine had been exhibited before my visit. Externally to the chest I applied the unguent. acet. potass. tart. The acetate of lead was suspended after forty-eight hours, and eight-grain doses of alum were substituted. Under this treatment considerable amendment was perceptible on the third day, and by the end of the third week every unpleasant symptom had vanished. The patient now remains in average health, and improves daily under a more generous diet than he had been allowed by his former medical attendant, and the daily use of tepid salt-water sponging, followed by friction with horse-hair gloves. Upon every tendency to catarrh, he applies the linimentum terebinthine to the chest. The secretion of a membranous substance by the pulmonary mucous membrane is familiar to every one, as it occurs in croup; in fatal cases of which disease the bronchial tubes are often found to be filled with the same plastic material as is furnished by the lining membrane of the trachea. But the production of membranous secretion in the lungs of the adult, and unconnected with tracheal disease, must be considered as a rare event. We have, however, several instances on record, by Barthollini, Ruysch, Tulpius, and Morgagni, under the names of bronchial polypus and bronchial worms. Hippocrates,' also, probably witnessed something of the kind in the case of Phericides, whom he describes as spitting up "axaax," "white milky substances." Dr. Bergen, of Frankfort on the Maine, has left us a description of an epidemic catarrh, accompanied by the expectoration of membranous tubes, which occurred in 1759. "Hanc tristem experientiam in propriâ filiâ feci, in quâ hoc singulare simul se obtulit phænomenon, quod ante mortem, tussi et screatu rejecerit tubulum membranaceum. Hunc tubulum judico esse portionem membranæ tubulosæ per ramos bronchiorum, durante morbo, generatæ." Another case is related by Dr. Warren, who is generally thought to be the first person who has given an accurate description of the disease. It will be seen, however, that he did not entertain any more concise ideas concerning it than Berger, who preceded him by many years. The case is as follows: A girl, æt. eight years, of strumous habits, was suddenly seized with dyspnoea and cough, which yielded to medical treatment. At the end of six weeks she had a second attack, accompanied by night sweats; the symptoms ceased upon the expectoration of what Dr. Warren calls "a large polypous concretion." The girl suffered several relapses, but was at length freed from them entirely by the formation of an abscess, connected with caries of the os calcis. Baillie had never met with a case of what he calls "bronchial polypus,” but had seen preparations of it. 1 De Morbis Popular, lib. vii. ss. xli. 2 Med. Trans. vol. i. art. 16. Cheyne describes two forms of "bronchial polypus;" one of which is evidently nothing more than the fibrinous portion of blood effused into the bronchial tubes. The instance given by Laennec, as occurring in the progress of a case of phthisis, was of the same nature. Dr. Casper' has published the case of a girl, æt. twelve years, also of strumous constitution, who, in the course of inflammatory catarrh, coughed up "a whitish yellow poly pous body, of a tenacious character, and corresponding to the bronchial ramifications." A case will be found in the Med. Repository, vol. xviii, by Mr. Iliff, and also in a memoir read before the Royal Academy of Medicine, on obliteration of the bronchial tubes, by M. Reynaud. The last case I shall mention, is one published by Dr. Starr, of Daventry, under the denomination of "chronic croup," and which exactly resembles the case of my patient. A girl, ætat. 22 years, complained of pain in the chest, with a sense of general oppression. Membranous tubes accurately moulded to the bronchial tubes, and, as in my case, tinged with blood, were expectorated. The blood was doubtless effused from small vessels, ruptured in the exertion necessary to dislodge the tenacious sputa. Authors are far from agreeing as to the precise pathological condition of the bronchial mucous membrane which gives rise to the plastic secretion. There are two principal and opposite opinions; one, which attributes the production of membrane, instead of the ordinary more fluid secretions of inflamed mucous tissue, to the existence of a high degree of irritation; another, which ascribes the phenomenon to an excess of the albuminous constituent of the blood. The generality of writers are in favour of the first opinion; the latter is embraced, among others, by Copland.3 The question is discussed at some length by Andral, by whom it is decided that a high degree of irritation is not sufficient per se to cause the secretion of plastic membrane; but that there must be, in addition, some special conditions of innervation or sanguification. It appears to me that neither of these opinions is the correct one, and that the true explanation is still to be sought for. If the more frequent formation of plastic membrane in children than in adults be due to the existence of a larger quantity of albumen in the blood of the former, then ought we to see such productions the common consequence, in them, of inflammations of the mucous tissues. Such, however, is not the fact. One half, at the least, of the diseases of infancy and childhood, consist of irritations, of greater or less intensity, of the pulmonary and gastro-intestinal mucous membranes. Yet in cases only of croup and diphtherite do we see the production of plastic membranes-cases which, numerically considered, are rare. The same objections hold good against the opinion which refers this peculiar secretion to the intensity of the vascular excitement. If the degree of irritation were the true cause of such secretion, we ought to see it more frequently among the numerous cases of bronchitis and gastro-enteritis which present themselves to our notice. In our patient, as well as in that of Dr. Starr, every symptom opposed the idea of high vascular excitement; yet was the formation of the membrane of the most perfect kind. It is, however, in this as well as in many other points connected with our difficult science, far more easy to find objections to any particular opinion, than to frame a better; nor in the present instance do I pretend to do so. The treatment pursued, was directed by the two following indications:1st, To allay the existing irritation; 2d, To prevent its recurrence. The first end was accomplished by counter-irritation, and the internal use of the acetate of lead and alum, the sedative and astringent properties of which 1 Wochenschrift für die Gesammte Heilkunde. 2 Medical Gazette, Feb. 7, 1840. 3 Vide art. Croup, Copland's Dictionary. |