The remote complications of broncho-pneumonia do not come within the scope of this article, nor does any reference to its pathology. It may, however, be mentioned that the association of several micro-organisms that occur in this disease show the importance of avoiding all depressing measures, and of raising the tissue resistance, in dealing with broncho-pneumonia.

ABSTRACTS.

THE PATHOGENESIS OF BRONCHIECTASIS. BY D. BARTY KING, M.D., Journal of Pathology and Bacteriology, July, 1904.

In this paper the author gives his views as to the influence of pleural adhesion in the production of bronchiectasis. As a preliminary, it is stated that a delicate balance exists between the many portions of the intra-thoracic respiratory organs the bronchi, lung tissue, and pleuræ. Any lesion of any one of these, it is presumed, will upset this balance. The lung tissue is the weakest of all, and the most liable to give way under continued extra pressure. But the bronchi may also yield and dilate. To explain this latter occurrence, the writer believes that "there must be either an extra continued pressure on the walls of the weakened tubes, a great diminution of the surrounding lung resistance, or a combination of these two in a variable degree."

Primary morbid conditions in the bronchial and pulmonary arteries and lymphatics are at once put out of court, having no bearing on the process of bronchial dilatation. Increased or diminished inspiration are the morbid changes occurring in the inspiratory mechanism next discussed. As, however, increased inspiration is due to acute changes-bronchitis, bronchiolitis, and broncho-pneumonia, and therefore temporary changes--can have merely a subsidiary importance. Adhesion of the pleura pleura of a fairly normal lung may lung may produce continuous spiratory effort. If a simple chronic pleuritis occurs, and presuming there be continued cough with closed glottis," increased air pressure in the tubes and alveoli results, competent to cause bronchiolectasis of the one and emphysema of the other. But emphysema is very rarely associated with pleural adhesions, though it is a very common

in

66

associate of chronic bronchitis." Therefore, bronchiolectasis is a more important and more common terminal affection. There is increased inspiration; the alveoli contain more air than normal, hence the effect of the expiratory effort on the bronchial tubes is lessened by the support given to them by the over-filled alveoli around." The writer then concludes that the morbid effects of pathological pressure must be greater in the bronchioles and alveoli. But, seeing that the bronchi are diseased, and the lung tissue healthy, "or almost so, the factor which apparently plays an important part as to whether emphysema or bronchiolectasis is to be the result is adherency of the pleura." The author doubts if it be possible to get bronchiolectasis "apart from some degree of adherency of the pleura.'

In

Decreased inspiratory effort is associated with chronic alveolar disease, such as fibrosis, tubercular or other. the cases which are general and accompanied by pleural adhesion, inspiration being diminished, there is increased expiratory effort." One would expect that the results of this would be a uniform dilatation of all the tubes, especially those of the larger size." The writer then remarks that the alveoli are but barely liable to dilatation owing to surrounding fibrosis. But "the adherency of the pleura to the chest wall, and also the adherency of the lobes to one another, play their part during forced expiration with closed glottis in preventing excessive alveolar dilatation. Hence, by these factors, associated with closed glottis during increased expiratory effort, the diaphragm being fixed and the abdominal muscles brought into play, the tendency is all towards the extra-air pressure being exerted on the larger tubes." In this manner he accounts for general bronchiectasis, and emphasises the important rôle of the adherent pleura as a factor in its production. In answer to the possible question of why we do not get bronchiectasis with every case of chronic pulmonary tuberculosis, where pleural adhesion is so common, it is laid down by Dr. Barty King that in most cases of pulmonary tuberculosis, pleural adhesion supervenes late, and he expresses his opinion "that those cases of chronic pulmonary

tuberculosis in which we have associated early pleural adherency, however slight, are prone to develop bronchiectasis under certain conditions."

66

Referring to lesions of the bronchi alone, the writer states that the sequence of events is bronchitis, peri-bronchitis, possibly chronic interstitial changes, then cough, with increased air pressure and emphysema. Here there is no associated pleural adherency." In some few cases the bronchioles may dilate, and there is then slight pleural adherency.

Changes in the pleura alone are next discussed, and it is stated that bronchiectasis, saccular in character, may follow upon pleurisy with effusion. In these cases the lung is generally very much fibrosed. The writer states his inability to determine the part played by the pleural adhesion in such cases. The author remarked that the root glands of the lung were enlarged in his cases of bronchiectasis, and he concludes that there is some connection between the two conditions, and suggests that the course of events is bronchitis, absorption by the glands from the bronchi, enlargement of the glands, stagnation in the lymph channels, vicarious action of the sub-pleural lymphatics, and stagnation in these latter, leading to chronic pleuritis, and then to adhesion, and, as a remote result, the bronchi may dilate.

In speaking of pulmonary fibrosis, the writer does not subscribe to the view expressed by Corrigan and others that this may arise from pleuritis, and subsequently by contraction dilate the bronchi. He believes such fibrosis to be independent of the pleural lesion, and therefore not the cause of bronchiectasis. He admits that, given dilatation of the tubes, pulmonary fibrosis may tend to increase it.

The author's conclusions are, therefore :-(1) Pleural adherency, however slight, occurring either locally or generally, is a factor of marked importance in the initial production of bronchiectasis, chiefly through the support which it thus gives to the lung tissue during continuous expiratory effort with closed glottis, especially when associated with diminished inspiratory effort.

(2) Pleural adherency alone, especially when the pleura is thickened, leads to a greater diffusion of the air pressure away from the terminal parts of the respiratory tracts, and so tends to a greater degree of dilatation of the larger tubes. "In some cases, where the bronchiectasis is of the saccular variety, with associated cylindrical dilatation higher up the same tube, there was marked adherency, with marked thickening of the pleura; and in other cases, with purely saccular dilatations, the pleura was only slightly adherent or non-adherent."

DOUGLAS STANLEY, M.D.

PERFORATION OF THE STOMACH BY ULCER. BY F. AND G. GROSS.

AN interesting and most exhaustive paper has been running through the Revue de Chirurgie, from February to August, on this subject by the above authors, containing not only a review of the subject up to date, but practically summarising the published writings and statistics thereof. The preamble, so to speak, lies in two cases which came under their care. The first was a woman of twenty-nine, with three weeks' history of pain after food, with vomiting; no hæmatemesis; then a sudden attack of intense pain in abdomen in morning; better towards evening, but vomiting; constipation. She had a good night, but general condition worse next day. The third day she walked to hospital, over three miles, where she was found to be in the following condition-Slightly anxious expression of face; pulse, 80; temperature not raised; respirations short and thoracic in type; abdomen somewhat distended, and rather rigid; epigastric region more distended than other parts; tympanitis all over abdomen; liver dulness decreased; some prehepatic tympanitis; no dulness in flanks perceptible. A diagnosis was made. of either appendicitis or intestinal obstruction. Next day, the patient being worse, a laparotomy was performed in median line below umbilicus. Gas escaped when peritoneum was incised; a greenish flaky lymph covered the coils of