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Volume 1
Calculus Volume 1

SENIOR CONTRIBUTING AUTHORS

EDWIN "JED" HERMAN, UNIVERSITY OF WISCONSIN-STEVENS POINT
GILBERT STRANG, MASSACHUSETTS INSTITUTE OF TECHNOLOGY
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 Table of Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1: Functions and Graphs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.1 Review of Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.2 Basic Classes of Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
1.3 Trigonometric Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
1.4 Inverse Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
1.5 Exponential and Logarithmic Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Chapter 2: Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
2.1 A Preview of Calculus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
2.2 The Limit of a Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
2.3 The Limit Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
2.4 Continuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
2.5 The Precise Definition of a Limit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Chapter 3: Derivatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
3.1 Defining the Derivative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
3.2 The Derivative as a Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
3.3 Differentiation Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
3.4 Derivatives as Rates of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
3.5 Derivatives of Trigonometric Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
3.6 The Chain Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
3.7 Derivatives of Inverse Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
3.8 Implicit Differentiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
3.9 Derivatives of Exponential and Logarithmic Functions . . . . . . . . . . . . . . . . . . . . . 319
Chapter 4: Applications of Derivatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
4.1 Related Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
4.2 Linear Approximations and Differentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
4.3 Maxima and Minima . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
4.4 The Mean Value Theorem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
4.5 Derivatives and the Shape of a Graph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
4.6 Limits at Infinity and Asymptotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
4.7 Applied Optimization Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
4.8 L’Hôpital’s Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
4.9 Newton’s Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
4.10 Antiderivatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Chapter 5: Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
5.1 Approximating Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
5.2 The Definite Integral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
5.3 The Fundamental Theorem of Calculus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
5.4 Integration Formulas and the Net Change Theorem . . . . . . . . . . . . . . . . . . . . . . 566
5.5 Substitution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584
5.6 Integrals Involving Exponential and Logarithmic Functions . . . . . . . . . . . . . . . . . . 595
5.7 Integrals Resulting in Inverse Trigonometric Functions . . . . . . . . . . . . . . . . . . . . 608
Chapter 6: Applications of Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
6.1 Areas between Curves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624
6.2 Determining Volumes by Slicing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636
6.3 Volumes of Revolution: Cylindrical Shells . . . . . . . . . . . . . . . . . . . . . . . . . . . 656
6.4 Arc Length of a Curve and Surface Area . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
6.5 Physical Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685
6.6 Moments and Centers of Mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703
6.7 Integrals, Exponential Functions, and Logarithms . . . . . . . . . . . . . . . . . . . . . . . 721
6.8 Exponential Growth and Decay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734
6.9 Calculus of the Hyperbolic Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 745
Appendix A: Table of Integrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 763
Appendix B: Table of Derivatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
Appendix C: Review of Pre-Calculus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865
This OpenStax book is available for free at http://cnx.org/content/col11964/1.12
Preface 1

PREFACE
Welcome to Calculus Volume 1, an OpenStax resource. This textbook was written to increase student access to high-quality
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About OpenStax
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You can access this textbook for free in web view or PDF through OpenStax.org, and for a low cost in print.

About Calculus Volume 1

Calculus is designed for the typical two- or three-semester general calculus course, incorporating innovative features to
enhance student learning. The book guides students through the core concepts of calculus and helps them understand
how those concepts apply to their lives and the world around them. Due to the comprehensive nature of the material, we
are offering the book in three volumes for flexibility and efficiency. Volume 1 covers functions, limits, derivatives, and
integration.
Coverage and scope
Our Calculus Volume 1 textbook adheres to the scope and sequence of most general calculus courses nationwide. We have
worked to make calculus interesting and accessible to students while maintaining the mathematical rigor inherent in the
subject. With this objective in mind, the content of the three volumes of Calculus have been developed and arranged to
provide a logical progression from fundamental to more advanced concepts, building upon what students have already
learned and emphasizing connections between topics and between theory and applications. The goal of each section is to
enable students not just to recognize concepts, but work with them in ways that will be useful in later courses and future
careers. The organization and pedagogical features were developed and vetted with feedback from mathematics educators
dedicated to the project.
2 Preface

Volume 1
Chapter 1: Functions and Graphs
Chapter 2: Limits
Chapter 3: Derivatives
Chapter 4: Applications of Derivatives
Chapter 5: Integration
Chapter 6: Applications of Integration
Volume 2
Chapter 1: Integration
Chapter 2: Applications of Integration
Chapter 3: Techniques of Integration
Chapter 4: Introduction to Differential Equations
Chapter 5: Sequences and Series
Chapter 6: Power Series
Chapter 7: Parametric Equations and Polar Coordinates
Volume 3
Chapter 1: Parametric Equations and Polar Coordinates
Chapter 2: Vectors in Space
Chapter 3: Vector-Valued Functions
Chapter 4: Differentiation of Functions of Several Variables
Chapter 5: Multiple Integration
Chapter 6: Vector Calculus
Chapter 7: Second-Order Differential Equations
Pedagogical foundation
Throughout Calculus Volume 1 you will find examples and exercises that present classical ideas and techniques as well as
modern applications and methods. Derivations and explanations are based on years of classroom experience on the part
of long-time calculus professors, striving for a balance of clarity and rigor that has proven successful with their students.
Motivational applications cover important topics in probability, biology, ecology, business, and economics, as well as areas
of physics, chemistry, engineering, and computer science. Student Projects in each chapter give students opportunities to
explore interesting sidelights in pure and applied mathematics, from determining a safe distance between the grandstand and
the track at a Formula One racetrack, to calculating the center of mass of the Grand Canyon Skywalk or the terminal speed
of a skydiver. Chapter Opening Applications pose problems that are solved later in the chapter, using the ideas covered in
that chapter. Problems include the hydraulic force against the Hoover Dam, and the comparison of relative intensity of two
earthquakes. Definitions, Rules, and Theorems are highlighted throughout the text, including over 60 Proofs of theorems.
Assessments that reinforce key concepts
In-chapter Examples walk students through problems by posing a question, stepping out a solution, and then asking students
to practice the skill with a “Checkpoint” question. The book also includes assessments at the end of each chapter so
students can apply what they’ve learned through practice problems. Many exercises are marked with a [T] to indicate they
are suitable for solution by technology, including calculators or Computer Algebra Systems (CAS). Answers for selected
exercises are available in the Answer Key at the back of the book. The book also includes assessments at the end of each
chapter so students can apply what they’ve learned through practice problems.
Early or late transcendentals
Calculus Volume 1 is designed to accommodate both Early and Late Transcendental approaches to calculus. Exponential
and logarithmic functions are introduced informally in Chapter 1 and presented in more rigorous terms in Chapter 6.
Differentiation and integration of these functions is covered in Chapters 3–5 for instructors who want to include them with
other types of functions. These discussions, however, are in separate sections that can be skipped for instructors who prefer
to wait until the integral definitions are given before teaching the calculus derivations of exponentials and logarithms.

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Preface 3

Comprehensive art program

Our art program is designed to enhance students’ understanding of concepts through clear and effective illustrations,
diagrams, and photographs.

Additional resources
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4 Preface

About the authors

Senior contributing authors
Gilbert Strang, Massachusetts Institute of Technology
Dr. Strang received his PhD from UCLA in 1959 and has been teaching mathematics at MIT ever since. His Calculus online
textbook is one of eleven that he has published and is the basis from which our final product has been derived and updated
for today’s student. Strang is a decorated mathematician and past Rhodes Scholar at Oxford University.
Edwin “Jed” Herman, University of Wisconsin-Stevens Point
Dr. Herman earned a BS in Mathematics from Harvey Mudd College in 1985, an MA in Mathematics from UCLA in
1987, and a PhD in Mathematics from the University of Oregon in 1997. He is currently a Professor at the University of
Wisconsin-Stevens Point. He has more than 20 years of experience teaching college mathematics, is a student research
mentor, is experienced in course development/design, and is also an avid board game designer and player.
Contributing authors
Catherine Abbott, Keuka College
Nicoleta Virginia Bila, Fayetteville State University
Sheri J. Boyd, Rollins College
Joyati Debnath, Winona State University
Valeree Falduto, Palm Beach State College
Joseph Lakey, New Mexico State University
Julie Levandosky, Framingham State University
David McCune, William Jewell College
Michelle Merriweather, Bronxville High School
Kirsten R. Messer, Colorado State University - Pueblo
Alfred K. Mulzet, Florida State College at Jacksonville
William Radulovich (retired), Florida State College at Jacksonville
Erica M. Rutter, Arizona State University
David Smith, University of the Virgin Islands
Elaine A. Terry, Saint Joseph’s University
David Torain, Hampton University
Reviewers
Marwan A. Abu-Sawwa, Florida State College at Jacksonville
Kenneth J. Bernard, Virginia State University
John Beyers, University of Maryland
Charles Buehrle, Franklin & Marshall College
Matthew Cathey, Wofford College
Michael Cohen, Hofstra University
William DeSalazar, Broward County School System
Murray Eisenberg, University of Massachusetts Amherst
Kristyanna Erickson, Cecil College
Tiernan Fogarty, Oregon Institute of Technology
David French, Tidewater Community College
Marilyn Gloyer, Virginia Commonwealth University
Shawna Haider, Salt Lake Community College
Lance Hemlow, Raritan Valley Community College
Jerry Jared, The Blue Ridge School
Peter Jipsen, Chapman University
David Johnson, Lehigh University
M.R. Khadivi, Jackson State University
Robert J. Krueger, Concordia University
Tor A. Kwembe, Jackson State University
Jean-Marie Magnier, Springfield Technical Community College
Cheryl Chute Miller, SUNY Potsdam
Bagisa Mukherjee, Penn State University, Worthington Scranton Campus
Kasso Okoudjou, University of Maryland College Park
Peter Olszewski, Penn State Erie, The Behrend College
Steven Purtee, Valencia College
Alice Ramos, Bethel College

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Preface 5

Doug Shaw, University of Northern Iowa

Hussain Elalaoui-Talibi, Tuskegee University
Jeffrey Taub, Maine Maritime Academy
William Thistleton, SUNY Polytechnic Institute
A. David Trubatch, Montclair State University
Carmen Wright, Jackson State University
Zhenbu Zhang, Jackson State University
 Preface

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Chapter 1 | Functions and Graphs 7

1 | FUNCTIONS AND
GRAPHS

Figure 1.1 A portion of the San Andreas Fault in California. Major faults like this are the sites of most of the strongest
earthquakes ever recorded. (credit: modification of work by Robb Hannawacker, NPS)

Chapter Outline
1.1 Review of Functions
1.2 Basic Classes of Functions
1.3 Trigonometric Functions
1.4 Inverse Functions
1.5 Exponential and Logarithmic Functions

Introduction
In the past few years, major earthquakes have occurred in several countries around the world. In January 2010, an
earthquake of magnitude 7.3 hit Haiti. A magnitude 9 earthquake shook northeastern Japan in March 2011. In April 2014,
an 8.2-magnitude earthquake struck off the coast of northern Chile. What do these numbers mean? In particular, how
does a magnitude 9 earthquake compare with an earthquake of magnitude 8.2? Or 7.3? Later in this chapter, we show
how logarithmic functions are used to compare the relative intensity of two earthquakes based on the magnitude of each
earthquake (see Example 1.39).
Calculus is the mathematics that describes changes in functions. In this chapter, we review all the functions necessary
to study calculus. We define polynomial, rational, trigonometric, exponential, and logarithmic functions. We review how
to evaluate these functions, and we show the properties of their graphs. We provide examples of equations with terms
involving these functions and illustrate the algebraic techniques necessary to solve them. In short, this chapter provides the
foundation for the material to come. It is essential to be familiar and comfortable with these ideas before proceeding to the
formal introduction of calculus in the next chapter.
Other documents randomly have
different content
fore finger of the operator is placed in the lower angle of the wound
to securely protect the large blood-vessels here located, and the
incision made through some three tracheal rings from below upward.

It may happen that in either a superior or inferior tracheotomy no

time will be allowed for careful and slow dissection as here
described. In such instances Durham advises that the surgeon grasp
the trachea between the fore finger of his left hand on the left side
and the thumb on the right, and make uniform, steady, deep
pressure, thus firmly securing it and at the same time protecting the
large vessels of the neck. The fingers thus placed are not to be
moved until the trachea is reached, which is accomplished by rapid
incisions confidently made. The pressure of the fingers causes the
wound to gape and the trachea to advance. The latter reached, it is
caught by the tenaculum and the operation completed as before
described.

The operation of median tracheotomy may require a word. As has

been stated, that part of the trachea covered by the isthmus of the
thyroid gland is very commonly encroached upon in performing
either or both superior and inferior tracheotomy, the isthmus being
slightly displaced from its site. Other than this the site here
mentioned would rarely be selected as the point for opening the
trachea. Certain conditions, it is true, might render it necessary, but
they would be rare. The danger lies in the hemorrhage which,
theoretically at least, is to be expected when the isthmus of the
thyroid gland is either torn or cut through; but opinions vary very
greatly as regards this danger. With a thin, narrow isthmus in
children I have frequently, in performing superior tracheotomy, cut
my way through to a sufficient extent to clear a suitable space upon
the trachea through which to introduce a tube without difficulty or
danger. I should not recommend the procedure, however, were the
isthmus to be seen to be, when reached, thick, wide, and
exceedingly vascular, but at the same time believe that the danger
even here of cutting into it is much overestimated.3 Roser's
recommendation to apply a ligature to the isthmus on either side of
the median line previous to its division is not generally applicable.
Hueter has shown that the fibrous capsule of the thyroid gland
enclosing it and its blood-vessels is firmly attached to the trachea
and sides of the larynx, and that from the isthmus this fascia
extends upward over the larynx (fascia laryngo-thyroidea), and thus
prevents, in a measure, attempts at displacing the gland downward.
Bose4 recommends that this fascia be divided transversely over the
anterior convexity of the cricoid cartilage, when a director can be
passed behind the isthmus, to lift it from the trachea and depress it
far enough to expose three or four of the rings: the capsule of the
gland thus remains unbroken and no hemorrhage occurs. The
procedure certainly merits trial; twice it has succeeded well in my
hands.
3 See Foulis, "Some Points on Tracheotomy," Glasgow Med. Journ., vol. xv. No. 2, p.
123.

4 Archiv für klin. Chirurgie, vol. xiv. p. 137.

Cricotomy, the division of the cricoid cartilage alone, is an operation

which, as far as I am aware, is rarely ever performed. The objection
urged against it, however, that in the adult the elasticity of the
cricoid cartilage is so great that a wound through its ring cannot be
made to gape sufficiently to allow of the introduction and retention
of a canula without discomfort and danger of necrosis of the
cartilage, is not borne out by experience. In children the objection
cannot of course be urged.

The description of the operative steps which has been given, and
which comprises the routine in an ordinary and easy cure, should
not mislead. The operation is not always as simple and safe as
would appear from what has been said. At times complicated and
difficult, at times dangerous in practice from the delay involved, it
demands in all, but especially in certain urgent cases, a trained hand
and eye, sound anatomical knowledge, coolness, self-reliance and
presence of mind on the part of the operator. Despite the greatest
caution, and even in apparently favorable cases where time for
dissection and deliberation is allowed, certain mishaps may occur
which complicate the operation to a serious, dangerous, or even
fatal degree. Some of these, as will be seen, are avoidable with care,
but others may happen that are not only unavoidable, but totally
unforeseen, and from their very suddenness all the more
embarrassing.

Accidents may occur during the dissection of the soft parts overlying
the larynx and trachea, and the importance of carefully determining
by palpation the location of the various parts prior to making the
preliminary incision, and of studiously preserving their relation and
location during the dissection, cannot be overestimated. Neglect of
this precaution has in more than one instance led to the air-
passages being opened through the thyroid cartilage or thyro-hyoid
membrane, instead of at the intended point. It should not be
forgotten also that the natural laxity of the several layers of
connective tissue of the neck is much increased by their division,
and that the trachea, being naturally freely movable, is thus very
easily displaced from its normal position during the act of dissection;
especially will this happen when unskilful attempts are made to hook
aside or retract the divided structures during the operation. Thus it
may easily occur that the entire trachea is drawn to one side and
entirely lost, or, more commonly, is turned upon its vertical axis, and
finally opened at the side instead of anteriorly in the median line. It
may not be opened at all, either being altogether missed by the
surgeon in his dissection, which is continued past it, even down to
the vertebral column, or the tracheal tube may be passed into the
tissues lying in front of the trachea, under the mistaken idea that the
latter has been incised. Persistence in keeping to the median line
during dissection—a golden rule in the operation of tracheotomy—
will render the first accident impossible; the second may be avoided
by hooking up the trachea, as has been described, before incising it.
If the opening into the trachea has not been made large enough to
receive the tube, as often happens to the young operator, and even
to the experienced when he fears to extend his incision on account
of the proximity of the thyroid isthmus, no resource remains but to
carefully enlarge it, pushing the thyroid isthmus or veins from before
the course of the knife. If the opening be small, and be lost both to
touch and sight, a second should at once be made, especially in
urgent cases, and no time lost in searching for the first. This opening
must be made directly in the median line, otherwise the canula will
stand awry in the wound and be easily dislodged from its position in
the trachea. If the first opening made is faulty in this respect, it is
better to at once make a second. It may seem unnecessary to warn
the surgeon against thrusting his sharp-pointed bistoury too far
inward at the moment of incising the trachea; but as a matter of fact
it has been driven through both anterior and posterior walls, and
even through the oesophagus, until it has struck the spine. The
converse, or a too superficial incision, is an accident more likely to
occur, the point of the knife not being made to penetrate the
mucous membrane of the trachea, which is probably swollen and
thickened. No relief in such cases follows the incision, and an
attempt to introduce a tracheal tube may cause it to pass between
the mucous membrane and tracheal walls into the submucous
tissue, thus stopping up the tube as it progresses. The disastrous
result of such an accident can readily be foreseen unless the
complication be quickly appreciated as to its nature, the tube
withdrawn, and the incision completed. Much more frequently will a
somewhat similar accident occur in the operation of tracheotomy for
croup or diphtheria. The pseudo-membrane overlying the walls of
the air-passage is not penetrated, but pushed before the knife,
which has properly incised the walls of the tube; the introduction of
the canula now crowds this membrane still farther back toward the
posterior tracheal wall, and a complete tracheal stenosis is added to
the pre-existing laryngeal one; sudden and urgent dyspnoea follows,
and prompt relief alone wards off fatal suffocation. Fortunately, in
such instances the forcible efforts at respiration and struggles of the
patient are often sufficient to break through the occluding
membrane and allow the respiratory current to pass. Violent cough
often follows, and more or less of the membrane is forced out
through the tube. Should these events not come instantly to pass,
the surgeon must not wait for the efforts of the patient, he being
often cyanosed and unconscious at this point, but by passing an
elastic catheter down through the tracheal tube break through the
occluding membrane forcibly. The occurrence of such an accident is
always denoted by absence of respiration through the canula and by
alarming asphyxia, and its cause needs but little reflection to be
appreciated.

Much the same train of events happens if during the introduction of

the canula large portions of the false membrane are completely
detached and drawn down into the lower trachea by the violent
inspiratory efforts of the patient, or stripped up from the mucous
membrane and pushed downward into the air-tube. No time should
be lost in either case in removing the tracheal tube, dilating the
tracheal wound by forceps or otherwise, and in endeavoring to clear
the trachea by seizing the obstructing membrane with forceps. If this
be unavailing, the suction-syringe must be adapted to the mouth of
the canula and the trachea cleared by aspiration. A large elastic
catheter may take the place of the canula. Sands recommends in
such instances as the foregoing that another opening should be
freely made below the first one in the trachea, when respiration will
probably be re-established. The success of this procedure of course
depends upon the depth to which the false membrane has been
drawn in the trachea.

Schüller regards the moment at which the trachea is opened as the

most important and most dangerous of the whole operation. Certain
of the accidents which may occur at this period have been detailed;
others remain to be spoken of, one of which at least—viz.
hemorrhage—requires special mention. Even before the tube is cut
into it may cause an important question to arise for the surgeon's
decision. A bleeding, often copious and persistent, which arises
during the course of the operation from the accidental or
unavoidable wounding of the thyroid veins, especially when they are
large and numerous, the patient unruly, and perhaps with a short fat
neck, and the fact that having wounded one the blood flows so over
the parts as to obscure and increase the chance of wounding others,
constitutes one of the commonest difficulties met with in the
operation of tracheotomy. Hemorrhage arising from a wound of the
thyroid isthmus is much rarer, and neither, as a rule, need be feared
if due care and promptitude be exercised. But should it occur in a
case in which the urgency of the dyspnoea allows of no time in
which to employ the ordinary methods by ligature, torsion, pressure,
or otherwise of checking it, shall the incision be made and the risk
boldly incurred of blood passing to a dangerous degree into the
trachea, and this in the face of the oft-repeated advice—the, in some
quarters, absolutely given rule—that the trachea is never to be
opened until all hemorrhage has ceased? I hold that it
unquestionably should be, and that he who waits in many instances
until the former moment will have to wait until his patient is dead.
Durham truly says that it is useless to let the patient die from
suffocation while attempting to prevent death from loss of blood;
and yet this has been done.

In any case, then, where there is great venous congestion, marked

venous bleeding, and little time, the patient being on the point of
suffocation, the surgeon should carefully but boldly proceed and
complete his operation in spite of the hemorrhage, opening the
trachea and introducing the canula even though the entire field of
his operation be obscured by blood. The tracheal opening once
made under such circumstances, the patient, if the blood which
enters the windpipe be not coughed up again, may be turned upon
his face, so that the blood will gravitate toward the tracheal opening
and the lips of the latter compressed about the rigid tube; or the
blood may be aspirated from the trachea by means of the suction-
syringe through an elastic catheter in the wound or the tracheotomy-
tube by the operator's mouth, according to the urgency of the case.
These measures answer for the slighter cases, but where the patient
has suffered from urgent impending suffocation before the opening
of the trachea, the entrance of the blood and its suction downward
by the first inspiration may make it complete, and the danger is
great. Still, the choice lies between the two evils, and the advice
given above holds good. To the treatment there recommended will
now have probably to be added artificial respiration and faradization.
Comfort in any case may be taken in the fact that the re-
establishment of respiration through the tracheotomy wound quickly
relieves the pulmonary capillaries and the right heart of their
distension, the venous circulation resumes its natural course, and
the venous bleeding, perhaps alarmingly free, ceases almost
immediately or is readily checked by pressure.

Where time is afforded and despatch in the operation is not a

necessity, the trachea should not be opened until all hemorrhage has
ceased. This, as a rule, is readily controlled by the usual measures,
and in a large percentage of operations is not excessive. A direct
fatal hemorrhage is very rare; likewise an arterial hemorrhage of any
extent, especially if the possible anomalous position of certain
arteries, such as the thyroidea ima, be borne in mind and care in
making the incision exercised. Nothing but gross carelessness on the
part of the surgeon and entire loss of presence of mind can account
for the opening of the carotid or innominate arteries, as has been
done. During the performance of the low operation of tracheotomy
the finger of the operator must more or less frequently be pressed
into the lower angle of the wound, and his anatomical sense
constantly on the alert.

The entrance of air into a vein during the operation is a possible

accident, especially when it is much enlarged and imbedded in dense
tissue, as sometimes occurs in malignant disease of the throat or
when large tumors of the parts exist. Should such an unfortunate
complication occur, the proper treatment, according to Erichsen,
should be compression of the wounded vein with the finger and its
immediate ligation if possible; compression of the axillary and
femoral arteries and a recumbent position for the patient to favor
cerebral circulation; and, lastly, artificial respiration.

At the moment of opening the windpipe two conditions may

suddenly supervene, both of which need, as may usually be easily
done, differentiation from the asphyxia produced by the entrance of
blood into the trachea. The first of these is the apnoea which not
unfrequently arises in children suffering from urgent dyspnoea the
moment that a free opening is made and the air-stream rushes
unimpeded into the lungs. The condition lasts but a moment or two,
and need excite no alarm. The second is based upon the fact that
the operation itself not seldom excites an alarming asphyxia,
probably by provoking laryngeal spasm. The introduction of the tube
serves to promptly relieve it.

Finally, I may refer to those rare but unfortunate and unpreventable

cases where the introduction of a tracheotomy-tube after a carefully
conducted operation fails to give relief. Such instances are reported
by several authors, and depend upon the existence of some
unascertained pathological lesion, such as the presence of a stricture
of the trachea below the site of the operation, compression of this
tube from without or a tumor within, stricture of the primary
bronchi, or some similar condition. A careful preliminary examination
and study of the case will in the majority of instances do much to fix
the indications for the operation and perhaps account for the
surgeon's failure.

The operation itself having been practically completed with the

introduction of the canula, the after-treatment of the case now
becomes the important consideration. This naturally varies in
accordance with the accident or disease which has rendered the
opening of the trachea necessary. In the instance of a foreign body
lodged in either larynx or trachea the tube may at once be removed
as soon as the former is removed or expelled. Indeed, the
introduction of the tube is often unnecessary, as the offending article
flies out through the wound as soon as the trachea is opened. The
only contraindication would be to this rule when the foreign body is
of a sharp and irritating character, and has been impacted in the
larynx, especially of a child, and consequent inflammation and
swelling of the parts may confidently be looked for. Should the
operation have been called for on account of laryngeal or tracheal
obstruction due to syphilis, both constitutional and local treatment
are indicated, the latter varying with the special conditions
presented, and being fully described in the section of this work
treating of that subject. The patient not infrequently is obliged to
wear the tracheal tube permanently. In croup and diphtheria the first
efforts of the surgeon after introduction of the tube should be
directed toward the removal of such shreds of the membrane as
present through the tube or may be reached by forceps introduced
through it into the air-passage. Large quantities may thus often be
gotten away, to the manifest relief of the patient. A pseudo-
membrane covering the vocal cords and causing glottic stenosis has
thus also more than once been removed through the wound. A
feather carefully passed through the tube into the trachea, by
exciting cough and through its mechanical effects, is of assistance in
promoting the expulsion of membrane lodged in the trachea below
the wound. The use of an elastic catheter and aspirating syringe for
the same purpose is advised by Roux and Hueter. In any case,
constitutional treatment as well is indicated, and other measures—
viz. the inhalation of steam, direct local applications, and the like—
such as may meet the views of the particular operator.

Granted that the operation has been performed to meet the

indication in cases of sudden and urgent dyspnoea arising from the
passage of blood into the trachea or the accumulation of serous
fluids in the lower air-passages, as well as in cases of dangerous
intoxication from the effects of poisonous gases and narcotics,
aspiration of the trachea in the former instances, followed by
artificial respiration in all, and perhaps the catheterization of the
trachea in the latter, as advised by several recent writers, will tax the
surgeon's energies as the primary consideration after his operation.
The catheter may be first used for the purpose of aspiration in the
former cases, if necessary, then for the injection of air, it here taking
the place of the natural upper air-passages.

In cases of acute laryngeal oedema, certain chronic inflammatory

processes, neoplasms in the larynx or trachea, and injuries or
wounds of the air-passages, the proper treatment, aside from that of
the necessary tracheotomy, will suggest itself on ordinary surgical
principles, or is elsewhere specially treated of in this work in
connection with the subjects themselves.

Aside from these special indications for after-treatment, which must

be met as they arise, there are certain general rules for the
management of any case after the tracheotomy-tube has once been
inserted: they relate mainly to the care of the patient, the dressing
of the wound, and the care of the canula.

A variable period of intense and exhausting suffering from dyspnoea

having probably preceded the operation, the sooner the patient is
allowed to seek refreshing sleep the better; and this may be allowed
if there be no danger of hemorrhage. Nourishment of a fluid
character and stimulants, if necessary, are to be allowed in
quantities and at times dictated by good judgment. The patient's
first attempts at swallowing must be watched and directed, as the
fluids frequently pass in part for a short time into the larynx, and
may appear at the tracheal wound. If the condition persist, it may
be, no other apparent cause existing, because the tracheal tube is
too long and presses on the posterior wall of the trachea, thus
interfering with deglutition. For the first day or two at least a
competent nurse must be in attendance, and the care of the tube
entrusted, after explicit directions, to her. For the first twenty-four
hours the secretions usually need to be constantly cleared from the
mouth of the inner tube as they are coughed up by the patient, and
the tube itself occasionally removed and thoroughly cleaned in
carbolized water (or water to which a little borax or potash has been
added) by means of a bristle brush, such as is used for cleaning
pipes. As the case progresses, the secretions are not as profuse or
annoying, and the patient learns to assist himself, in caring for his
tube and to remove and replace the inner one. Attempts at using the
voice are to be abstained from, and a slate or pencil and paper used
until, if the case progress favorably, the third day, when he may be
shown how to produce it by closing the outer fenestrated tube (the
inner being removed) with the finger. The outer tube does not
require usually to be removed, except in diphtheria, for cleansing
until the third or the fourth day, prior to this it being done by means
of a feather. The removal of the tube should always be done by the
surgeon himself, and the occasional danger of its difficult
reintroduction, caused by the swelling of the parts, not forgotten. At
the same date, the wound sutures may be cut and removed. After
its first removal the outer tube is taken out, cleansed, and replaced
at each daily dressing, which consists in the washing of the wound
with carbolized solutions, the application of adhesive strips, if
necessary, across it after the sutures have been removed, and the
insertion between the neck-plate or collar of the tracheotomy-tube
and the skin, upon which it presses, of a layer of sheet lint covered
by a little simple cerate or like dressing. The tapes attached to the
canula for fastening it about the neck need changing, and care must
be taken to regulate each day their degree of tension about the neck
in proportion to the amount of inflammatory swelling attendant upon
the wound through the soft parts overlying the trachea.

The patient, during, especially, the first few days after the opening
into the trachea has been made, should be kept in a well-ventilated
room with a uniform temperature. There is rarely any occasion,
except in cases of croup and diphtheria, when it may be advisable,
to envelop him in steam. Some surgeons place a small wad, two or
three layers of gauze, wrung out frequently in hot water, over the
mouth of the tube for the first day or two. A large, coarse sponge
answers the same purpose; and the precaution seems to me to be a
good one, preventing, as it does, air of a low temperature from
entering the lungs, and rendering it moist and free from adventitious
particles. The difficulty is in keeping it in place.

The question as to the final removal of the canula is a difficult one to

answer here, depending as it does upon the various causes for
which the operation was originally performed. In certain cases, as
will be seen from what has been said, its sojourn in the trachea will
only be from a few moments to a few hours; while, on the other
hand, in cases, for instance, of severe syphilitic disease of the
larynx, with cicatricial stenosis of its cavity, the tube, once
introduced, has to be worn during the lifetime of the patient.
Between these extreme limits the period varies greatly. As a general
rule—perhaps from the fourth or fifth day to the end of the first
week—an attempt to cause the patient to breathe through the
natural passages, the outer end of the outer fenestrated tracheal
tube being closed, will partially succeed. Each day will now make
success greater; the voice in part returns, and a period is soon
reached when the outer tube may be closed with a cork (at first
during the daytime only) and respiration carried on entirely through
the larynx. The speedy removal of the tube and the closure of the
tracheal wound then follow as a matter of course. I have never
found it necessary to employ any of the various forms of after-
treatment canulas, and believe them to be unnecessary. The original
tube, preferably a fenestrated one, as heretofore described, is to be
worn until convalescence is established, then permanently
withdrawn.

The tube should be removed at the earliest safe and practicable

moment. Its lengthened sojourn is not devoid of danger, as will be
shown; and an atrophy of the laryngeal muscles, especially the
abductors of the vocal cords, may follow their prolonged disuse, or
at least inactivity, thus giving rise to a narrowing of the glottic
opening perhaps inconsistent with respiration.

The wound, covered by granulation-tissue if the tracheotomy-tube

has been worn for any length of time, quickly closes, when the latter
is removed, and needs to ensure this but a few narrow strips of
adhesive plaster to be passed across it and attached to the side of
the neck, to prevent the air being forced out through it during the
first day or two when the patient coughs or attempts to speak.

In cases where the tube has been worn for a long period, and the
edges of the opening have firmly cicatrized, their freshening by the
knife or scissors is a necessary preliminary to their being brought
together by means of a suture or two.

The wound in the trachea closes not by the formation of a

cartilaginous, but rather of a dense connective tissue, and the
cicatrix is so smooth and small as to be with difficulty discernible.
The cicatrix remaining externally upon the neck need be but slight
and linear, and cause no disfigurement, especially if the wound have
been properly treated and watched during the healing process.

Among the complications and accidents which may occur after a

tracheotomy successfully performed,5 none is commoner, and none,
perhaps, is more to be feared, than the broncho-pneumonia which
may develop at any time within the first three or four days, and
especially in those cases where the operation has been rendered
necessary by a diphtheritic inflammation of the throat or air-
passages. Bronchitis is common when much blood has escaped into
the trachea during the operation. The periodical and careful
auscultation of the chest is therefore desirable, in order that the
earliest physical signs of these morbid conditions may be detected.
5 See Parker, "On Some Complications of Tracheotomy, with Illustrative Cases,"
Lancet, Jan. 24, Jan. 31, and Feb. 7, 1885.

Secondary hemorrhage is rare: should it occur, the wound must be

opened, enlarged if necessary, and the bleeding vessel sought for
and secured. A slight hemorrhage may be checked by pressing the
parts firmly about the tracheal tube and the use of styptics locally.

When the pathological condition of the parts has demanded that the
canula be worn for a long time, and in cases where sufficient care
has not been taken to select one suited to the age of the patient or
to the particular form of operation that has been chosen, perhaps to
the needs of the special case, an ulceration of the anterior or
posterior wall of the trachea, the result of the pressure of the lower
edge of the tube or of its upper posterior and convex side, may
occur. Usually, it happens on the anterior wall, rarely on both, and
the main trouble to which they give rise lies in the repeated
hemorrhages that proceed from the laceration of granulation-tissue,
in changing the canula, for instance, and the descent of the blood
into the trachea and lungs. Cases of extensive ulceration, with
erosion of the large vessels at the root of the neck, and fatal
hemorrhage, have been reported. Considerable care should then be
exercised in so adapting a canula to a special case that it will lie as
free as possible within the lumen of the trachea. Ulceration of the
tracheal walls, it is claimed, never occurs with the right-angled
canula of Durham. Occasional change of form in the canula or the
use of canulas with rounded extremities (perforated with numerous
slits) is often advisable when the tube is worn for a length of time.

Another complication following the prolonged sojourn of a tracheal

tube—rare, it is true—is the development of a mass of granulation-
tissue, a veritable tumor, which may occlude the lumen of the
trachea and lead to serious disturbances of respiration. The growth
usually occurs about the inner edges of the tracheal wound,
extending thence inward and upward or downward, as the case may
be, and is most frequently met with, perhaps, after tracheotomies
undertaken for diphtheria, although it may occur as a result of the
ulcerations mentioned above, and develop even from the cicatrix in
an old and perfectly-closed tracheotomy wound. The size of the
mass, its location, and the amount and manner of its interference
with the respiratory current vary much, but the condition must ever
be regarded as a troublesome, even dangerous, one, and may
always be suspected when attempts at the removal of the canula
temporarily or permanently are followed by sudden and urgent
dyspnoea.

The exuberant granulation-tissue which forms about the outer edges

of even a recent tracheotomy wound, and occasionally renders the
reintroduction of the tube difficult, as well as closing the wound
while it is out, is a much simpler matter, and is easily remedied by
cutting it away with the scissors or checking its formation by caustic
applications.

A subcutaneous emphysema not infrequently occurs as the result of

poor surgery and delay at the time of introducing the tube into the
windpipe, or may come on later when the tube fits the tracheal
wound incompletely. In either case it need excite no apprehension,
and usually quickly subsides. Cervical cellulitis is a more serious
matter, but is fortunately rare if unconnected with disease of the
cartilages of larynx or trachea. It probably depends upon injury to
the tissues and a too extensive opening up of the intermuscular
strata at the time of the operation. Should the complication arise,
the tendency to the burrowing of pus must be prevented by free
drainage and, if necessary, incisions. The other surgical indications
are to be treated on general principles.

When the incision necessary for the introduction of a tracheotomy-

tube has been made through healthy tissue, necrosis of the cartilage
in contact with the tube belongs to the rarest of the complications of
the operation. The simple traumatic perichondritis set up by the
operation shows no tendency to eventuate in death of the parts.
Equally rare is cicatricial contraction of the trachea as the direct
result of the operation. That it may follow the healing of the
extensive defects sometimes left by the syphilitic and other
processes can readily be understood; and the same defects,
involving as they occasionally do the loss of large amounts of tissue
and destruction of important parts, may eventuate in the formation
of an aërial fistula during or after the healing process is completed.
The occurrence of such a fistulous opening as the result of a simple
and uncomplicated tracheotomy wound could only be regarded as
the evidence of unskilful surgery and after-treatment. The various
plastic operations undertaken for the repair of such defects are
described in the works on general surgery, notably in the able
monograph of Schüller. Dislodgment of the canula out of the trachea
as the result of an insufficiently long tube, or of neglect to fasten the
tapes which hold it properly about the neck, so that it slips during
coughing or the movements of the patient, is an accident which may
not for the moment attract the attention of an inexperienced
surgeon unless laryngeal dyspnoea is urgent. The patient breathes
quietly, the air passing by the sides of the tube, which apparently is
correctly placed. The simple test of ascertaining whether air be
passing through the canula or not, or of making a trial whether the
patient breathe as well when the finger closes the opening of the
outer tube, as he will do if the tube is out of the trachea, will decide
the question. Should the tube have slipped, it is of course at once to
be replaced.

The breaking off of a portion of the inner canula, and the terminal
piece falling down the trachea—several instances of which have
been reported during recent years—is more apt to happen with the
right-angled canula of Durham, the inner tube of which is necessarily
made up of segments held by small rivets: these become in time
loosened and the piece that they held detached. The outer tube of
the hard-rubber canula also has become detached from its collar and
dropped into the trachea. An occasional inspection of the condition
of the tube is therefore desirable.
 DISEASES OF THE BRONCHI.
BRONCHITIS, ACUTE AND CHRONIC; CATARRHAL; MECHANICAL;
CAPILLARY; AND PSEUDO-MEMBRANOUS.

BY N. S. DAVIS, M.D., LL.D.

DEFINITION.—Inflammation of some part or of the whole of the

mucous membrane lining the bronchial tubes between the
bifurcation of the trachea and the alveoli or air-cells of the lungs.
The inflammation may vary in grade from simple hyperæmia, with
increased irritability, to the most intense engorgement, exudation,
and tumefaction of the membrane, and in activity from the most
acute and rapidly-progressive to the most chronic and protracted in
duration.

SYNONYMS.—By the earlier writers the disease was called Peri-

pneumonia notha, Angina bronchialis, and sometimes Erysipelas
pulmonis. More recently it has been called Catarrhus suffocativus,
Catarrhus pituitosus, Catarrhus bronchialis, Bronchial catarrh, and
Bronchitis; Fr. Bronchite; Ger. Bronchialentzundung. Adopting the
simple name of bronchitis, acute and chronic, in the further
consideration of the subject I shall group the cases as they occur in
general practice under the heads of Catarrhal, Mechanical, Capillary,
and Pseudo-membranous Bronchitis.

HISTORY.—During all the earlier periods of medical history bronchitis

was generally confounded with inflammation of the membrane lining
the larynx and trachea on the one side, and with pneumonia and
pulmonary phthisis on the other. Among the earliest writers who
gave more accurate descriptions of bronchitis as a distinct disease
were Badham, J. P. Frank, and Broussais, in the latter part of the
eighteenth century. Full and accurate descriptions of the disease,
differentiating it from inflammation of other parts of the respiratory
organs, were not given, however, until the discovery of auscultation
by Laennec, and its practical application aided by percussion to the
physical examination of the chest. This important addition to the
previous means for studying the exact location and extent of all
diseases within the chest, and the largely increased attention given
about the same time to the study of morbid anatomy, soon led to as
accurate an appreciation of the existence and extent of disease in
any part of the organs of respiration and circulation as in any of the
structures of the human body.

ETIOLOGY.—The causes of bronchitis, like those of all other acute

diseases, may be divided into two classes—namely, predisposing and
exciting. The first embraces all those influences that are capable of
rendering the mucous membrane of the air-passages more
susceptible to impressions, whether by direct increase of the
irritability of the structure or indirectly by altering the quality of the
blood and the tone of the smaller blood-vessels. The second
embraces such influences only as are capable of exciting a direct
increase of irritability of the lining membrane of the bronchial tubes,
with congestion of blood in its capillaries. Among the most common
predisposing causes may be mentioned age, sex, occupation or
modes of life, and climatic influences. As a general rule, the several
grades of bronchitis are more prevalent during childhood and old
age than during the active period of adult life. The British Registrar-
General's Report for 1868 contained 33,258 deaths attributed to
bronchitis, being 1344 for every million of inhabitants. Of the whole
number, 10,550 died during the first three years of life, and 18,485
over forty-five years of age, leaving only 4223 to occur between the
ages of three and forty-five years. This, however, is very far from
indicating correctly the relative prevalence of the disease at the
different periods of life, for the reason that the disease is far more
fatal both in early life and in old age than in the early and middle
periods of adult life.1 During the months of February, March, and
April, 1882, in San Francisco, there were 65 deaths reported from
bronchitis, of which 37 were of children under five years of age, 25
adults over forty years, and only 3 persons between five and forty
years. During the same months there were reported 154 deaths
from bronchitis in the city of Chicago, with about the same ratio in
regard to age. In the city of Philadelphia, during the seven years
from 1862 to 1869, the deaths from bronchitis at all periods of life
aggregated 969, of which 495 were of children under five years of
age, 14 over five and under fifteen years, and 460 of persons over
fifteen years of age.2 These and similar mortuary statistics have led
to the very general adoption of the opinion that early childhood and
old age are pre-eminently susceptible to attacks of bronchitis. Yet
my own clinical observations and records relating to the time and
number of acute and subacute cases of bronchitis coming under my
own care lead to a very different conclusion. By reference to those
records I find a larger number of cases occurring between the ages
of ten and thirty years than at any other period of life. Thus, during
the first six months of the present year (1882) I recorded 59 cases
of primary bronchitis; that is, cases not arising secondarily as
complications of other diseases. Of this number, only 5 were children
under ten years of age, 38 between ten and thirty years, and 16
over forty. It is probable that similar results will be obtained by all
who will take the trouble to record the whole number of cases,
instead of simply the number of deaths. The statistics of mortality in
relation to this disease are deceptive, not only in regard to relative
susceptibility of the human system to attacks at the different periods
of life, but also in regard to the ratio of mortality of the disease
itself. It is generally conceded that the chief mortality from this
disease occurs during infancy or early childhood and in old age,
cases rarely terminating fatally in youth or the more active period of
adult life. Careful examination of cases will show that this fatality at
the extremes of life is owing mainly to the greater tendency of the
inflammation at those periods to extend directly from the
bronchioles into the lobules of the lungs, thereby complicating the
bronchitis with lobular pneumonia; and in more than half the cases
reported under the head of bronchitis the fatal result was caused by
the pneumonia instead of the bronchitis.
1 See Reynolds's System of Medicine, Amer. ed., vol. ii. p. 318.

2 See A Practical Treatise on the Diseases of Children, by J. F. Meigs, M.D., and

William Pepper, M.D., 4th ed., p. 189.

Neither recorded facts nor my own clinical observations show any

decided difference in the susceptibility of the sexes to attacks of
bronchial inflammation.

Those occupations which confine the parties pursuing them much

indoors, and at a temperature either too warm or too cold, strongly
predispose to attacks of inflammation of the membrane lining the
respiratory passages. Habitual exposure to a warm, confined air
invites free exhalation from both the bronchial and cutaneous
surfaces, with increased susceptibility, and consequently renders the
individual more susceptible to all external impressions. Habitual
passive exposure indoors to a low temperature represses the
exhalations and causes the retention of some of the products of
tissue-change which by their presence in the blood render the
individual more liable to attacks of inflammation on the supervention
of any exciting cause. For the same reasons the habitual wearing of
too much warm clothing on the one hand, or too little on the other,
predisposes to attacks of bronchial disease. Another error of
importance is the unequal adjustment of clothing to different parts
of the cutaneous surface. In children especially we often see an
abundance of warm clothing over the whole body, while the legs and
feet and neck have but a single covering, and sometimes none. And
even adult women often go out loaded with warm clothing, while
their feet and ankles are protected only by thin shoes and stockings.
All those occupations that surround the workmen with an
atmosphere filled with irritating gases, floating particles of stone,
metal, or charcoal, or with the dust from grain and many vegetable
substances, increase the liability of such workmen to attacks of all
grades of bronchial inflammation.

It is universally conceded that bronchitis, as well as inflammation of

all other parts of the mucous membrane lining the air-passages,
prevails most in such countries as are characterized by a cold, damp,
and variable climate. This can be well illustrated by comparing the
prevalence of this class of diseases in that belt of our own country
lying north of the fortieth parallel of latitude and east of the Rocky
Mountains with the prevalence of the same class in the belt south of
the thirty-third parallel and bordering upon the Atlantic and Gulf of
Mexico. In the former the summers are comparatively short, with
brief periods of high temperature, the winters cold, and the
transition seasons, spring and autumn, long and exceedingly
variable, with a predominance of cold and dampness. In the latter all
the conditions just mentioned are substantially reversed. Perhaps the
earliest reliable statistics we have bearing upon this subject are
those collected by Samuel Forrey from the several military posts
occupied by the United States Army, and given in a series of articles
in the American Journal of Medical Science, and subsequently in an
octavo volume, on the climate of the United States and its influence
over the prevalence of diseases. The valuable facts presented by
Forrey were added to by Daniel Drake, and given in full in his large
work on the topography and diseases of the great interior valley of
this continent. From these sources we learn that the average annual
number of attacks of inflammation of the mucous membrane of the
respiratory passages in every 1000 soldiers at Fort Snelling, in
Minnesota, latitude 44° 53' N., was 600. At Fort King, fifty miles from
the Gulf of Mexico, latitude 28° 58' N., the annual number of attacks
average only 101.2 in every 1000 persons. Again, at Madison
Barracks, near Sackett's Harbor, New York, the average number of
attacks for every 1000 persons was 637.2, while at Key West,
Florida, the average number of attacks was 208.9, and at Baton
Rouge, Louisiana, only 207.2. Lest it should be thought that these
five posts had been selected for the purpose of showing the most