CHRONIC INTERSTITIAL PNEUMONIA. 205 



but little, expectorating small quantities of catarrhal sputa. This will 

 be followed by a violent paroxysm of coughing, in which, in course of 

 a short time, the patient will eject enormous quantities of putrid secre- 

 tion. When the fit is over, another long period of exemption begins, 

 the spit-cup remaining empty for six or eight hours, or receiving but a 

 few expectorations of mucus, when another attack will soon fill it to 

 overflowing. The walls of bronchiectatic cavities seem to be tolerably 

 insensible, and the irritation of the putrefying secretion does not appear 

 to give rise to cough. It is only when the sac is completely full, and 

 when its contents reach the neighboring bronchi, which still retain 

 their normal sensitiveness, that the cough begins. We may, therefore, 

 assert that violent coughing-fits, which recur at long intervals, and 

 during which large quantities of putrid sputa are expelled, are pathog- 

 nomonic of the existence of a bronchiectatic cavity. 



In addition to the symptoms hitherto described, there is usually 

 well-marked cyanosis, and, at a later period, dropsy. In bronchiectasis 

 of long standing, I have hardly ever failed to find the clubbed enlarge- 

 ment of the terminal phalanges such as usually forms in cases of per- 

 sistent cyanosis. These signs of venous engorgement are not, however, 

 directly dependent upon bronchiectasis, being due rather to the con- 

 comitant induration of the lungs (see above), and hence they are absent 

 in the very rare instances in which bronchiectasis is not accompanied 

 by extensive induration. 



Physical examination always affords very characteristic results 

 when the bronchial sacculation lies close beneath the thoracic wall. 

 When the pulmonary substance about the cavity is consolidated and 

 contracted, the thorax is also depressed at the point corresponding, 

 the percussion sound is exceedingly dull, and the sensation of resist- 

 ance consiuerably increased. Upon auscultation, if the patient have 

 not coughed for some time, we hear either an enfeebled respiratory 

 murmur or else indistinct moist rales. Upon compelling him to cough, 

 BO as to provoke copious expectoration, the enfeebled respiration is 

 often replaced by loud bronchial or even cavernous breathing. On 

 the other hand, there are some cases in which physical examination 

 furnishes no aid to diagnosis, because the cavity is situated more 

 toward the centre of the lung, and is surrounded by normal paren- 

 chyma. In spite, however, of the absence of physical signs of a cavity, 

 we may diagnose its existence with positive certainty when a patient, 

 without suffering any precursory dyspnoea, expectorates half a pint or 

 more of purulent secretion in the course of a few minutes. Such enor- 

 mous quantities of matter could only come from a large cavity, as its 

 presence in the bronchi would render respiration extremely difficult, if 

 not impossible. 



