164. The sibilant and snoring râle which accompanies the cough of infants is unattended with danger.

165. The mucous râle of young children is not usually of much importance.

166. The subcrepitant râle of children and infants at the breast always indicates a very serious state of health.

167. The mucous and subcrepitant râles are, in young children, the best indication for the employment of emetics.

CHAPTER II.

ON THE PNEUMONIA OF INFANTS AND CHILDREN AT THE

BREAST.

The term pneumonia is applied to inflammation of the pulmonary parenchyma.

This disease is greatly modified by age. It presents different characters in the child, the adult, and the aged. The pneumonia of new-born children itself differs from that which appears in the midst of childhood.

If we compare the morbid phenomena which children at the breast, attacked with pneumonia, offer, with those which older children placed in the same position present, it will be observed to appear with similitudes separated by important differences. The anatomical characters are nearly similar in both cases, but with respect to the symptoms, the dissimilarity will be found most complete. Now it is really the symptomatic manifestation of diseases that it concerns us most to recognize, for it is that which gives them their special aspect, and is the guide to the physician in his practice.

Up to the present time little has been done to clear up the study of the pneumonia of children at the breast; and if we except the works of Billard, MM. Valleix* and Trousseau, a complete description of this disease will not be found in other treatises of pathology devoted to childhood.

DIVISION OF THE SUBJECT.

Pneumonia is a very common disease in the first period of existence. It presents itself under a great number of forms, which it is important to recognize, and of which we shall treat in succession. In the most simple form, the disease is observed in an acute state, and runs through its stages like most purely inflammatory diseases. In other cases, on the contrary, it lasts a longer time and passes on to the chronic state.

*Clinique des maladies des enfants nouveau-nés. Paris, 1838; pp. 40 et seq.

It sometimes commences primarily, independently of any other disease, te on which is very rare at this age, and constitutes what is called primary pneumonia-it is pure pneumonia. It appears much more commonly in the course of some other disease amongst children, either as a general complication or as a consequence of bronchitis or of pulmonary tubercles. This constitutes secondary or consecutive pneumonia. In this category gr are included false pneumonia, catarrhal pneumonia, or broncho-pneumonia. Those cases which are more directly allied to the presence of fibro-plastic or tubercular granulations, should be described under the name of tubercular and granular pneumonia. The pneumonia of children at the breast may also be divided according to the innumerable variety of its anatomical forms, as some authors- MM. Barthez, Legendre, and Bailly, for instance-have done in their researches on the pneumonia of childhood. But this method of proceeding has the great inconvenience of subdividing a subject ad infinitum, which, on the contrary, requires to be simplified. Consequently, we shall pass over the anatomical division of the second portion of our table, and reserve it until we consider the pathological lesions of pneumonia.

It will suffice to observe, in this place, that primary pneumonia, very rare in young children, presents itself under the lobar form; that consecutive pneumonia always assumes the lobular form, which may be divided into discrete lobular pneumonia and confluent lobular pneumonia.

CAUSES.

The causes of the pneumonia of young children are predisposing and exciting. It is very difficult to determine their degree of influence. Too many circumstances concur at once to the same end, for one to discover the value of each in particular. Conjectures justified by observation and by reasoning are all that can be established, but these in no way rest upon a vigorous appreciation. The observations are, then, vague, and but slightly interesting.

Pneumonia in children of a tender age is so much the more frequent u the younger the child. It is very common in infants. The greater number of the children who die at the Enfants Trouvés, says M. Valleix, present hepatization of the lungs. This is not the case with those who are older. At the Necker Hospital, for example, out ofür one hundred and one deaths in the year 1842, twenty-eight only were the result of pneumonia.

This disease is as frequent among boys as among girls. It appears much more often in winter than in summer. Most of our cases have been collected during the months when the temperature is low and the atmosphere damp.

Pneumonia sometimes comes on in the midst of the rudest health,

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writing

it appears in a primary manner, this is pure inflammatory pneumonia, which assumes the lobar form; much more commonly it appears in the course of some acute or chronic diseases, which do not prevent its development. It is, then, lobular, discrete, or confluent; and it is described under the name of consecutive pneumonia.

Who is not aware of the relations of measles, eruptive fevers, with the disease we are now considering? In this case the pneumonia 5 cubitus is consecutive. Who has not met with pneumonia as a complication of entero-colitis, thrush, hooping cough, croup, sclerema, convulsions, &c.? Who has not observed it come on amongst children just brought to a hospital, under the influence of dorsal decubitus, or of the improper hygiene to which these creatures are submitted? I shall cite, on this head, the case of a little girl, eight months old, very lively, plump, and in good health, who, having the thigh fractured and confined in an apparatus, was brought to the hospital, and placed on a mattress, from which she did not move. She began to cough; pulmonary congestion was discovered; and, on the fourteenth day, she died from a double confluent lobular pneumonia.

Lastly, if we add to the influences we have just enumerated, those which result from tubercular disease, we shall see that this element very much multiplies the chances of the development of pneumonia. In fact, tubercle acts, on the one hand, as a foreign body, that is to say, as a local irritant; on the other, in virtue of the diathesis to which it owes its appearance.

LESIONS AND MORBID PRODUCTIONS.

The alterations determined by the pneumonia of infants and of children at the breast, present remarkable characters, which are also observed in the pneumonia of childhood. The inflammation does not A occupy the mass of the pulmonary parenchyma; it is first developed here and there in the lobules which constitute it.

Thus, lobular congestion and inflammation of the lobule are, in the young child, the starting point of nearly all the cases of pneumonia. At first, only a small number of lobules, distant from each other, are affected. This is what is observed in discrete lobular pneumonia. At a more advanced stage of the disease, the number of diseased lobules is more considerable, they coalesce into numerous groups. It is evident that the disease is generalized. I designate this anatomical form under the title of confluent lobular pneumonia. Lastly, in a small number of cases, lobar pneumonia is met with, as in the adult. We must always take care not to mistake, as M. Valleix has done, and describe as lobar, cases of very confluent lobular pneumonia, in which, with a little attention, the eye recognizes, fused and reunited, the elements of lobular pneumonia in the different stages of the disease.

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Book VI, Chap. II.] Discrete lobular pneumonia. Partial lobular pneumonia is almost always simultaneously met with on both sides of the chest, since, out of the number of fifty-five cases of pneumonia which I have observed at the Necker Hospital, forty-six were double. The disease always predominates on the right side. It always attacks the inferior lobes, and extends upwards to the base of the middle and superior lobes, an observation which is opposed to the facts observed by M. Valleix. It is also more marked towards the posterior border and the external surface of the lung; the summit is pale, bloodless, affected with Sewel intervesicular emphysema, rarely with vesicular emphysema.

On opening the chest, the lungs slightly collapse. They are heavier

H

than in the natural state, and offer little crepitation. Their surface Conditi preserves, at the situation of the diseased parts, a granite red tint, which results from the union of a considerable number of reddish spots of different gradations of colour. Each spot represents a lobule, the degree of the congestion of which is different, and corresponds with a more or less considerable partial induration of the pulmonary tissue. The induration is the better characterized in proportion as the spot is deeper in colour. When the surface of the lung is examined by the touch, and these deep nodosities discovered, it might be imagined that tubercular granulations are met with. On the posterior border of the organ, near the apex, a series of transverse and parallel depressions, produced by the pressure of the ribs on a portion of uninflamed pulmonary tissue, are also rather frequently observed. There is no reason for believing, as Broussais would wish, that this deformation is peculiar to pneumonia.

The interior of a lung attacked with discrete lobular pneumonia, presents, under a magnifying glass, a rose coloured surface, sprinkled by a greater or less number of red spots scattered here and there. These spots are of different gradations of colour, and correspond to engorged lobules, which present the following characters: they form a slight projection; their dimension is indeterminate; their aspect smooth or granulated, as in ordinary hepatization, and their density rather great; they no longer crepitate; they are infiltrated by a reddish sanies; they are impermeable to the air, and sink in water, for they possess a greater specific gravity than that of this liquid. If the impermeability is constant during life, it is always in consequence of the imperfect action of the inspiratory muscles; on the dead body, on the contrary, insufflation causes the air to penetrate into all the obstructed cells, revives the rosy colour, and, in part, restores the suppleness of the organ, which floats on water, and becomes crepitant again, as in the natural state.

These facts have been disputed by MM. Legendre, Bailly and Barthez, who have very often practised with variable success, the

nsufficer of bugs amacked with liñaler pacumonia, and who in Consettance won't separate peumonia inse we afections-one in which the ling samt de mfatei mi wizi wad crestitute true pneumonia, and the der i via the lng can be easily insulated, forming sakini quantocom de sagie fra anite and the foetal congum minn of M. Lepadre: the hecker ongestion and bronchoFRAMEDEL ON The entry, if M. Barther. These authors, assuming fe the penegal lass of a mostingical vision the result of pulmonary insufficum, late das fund dasives necessitated to place between frimers mi qurumun var retiree new princnary diseases, which must be descriei study; exity in the same way as other JŪTSKINS WILL insumate a special pietre poremecia between pneumam mi porizer. Amempts of this kind have always failed, and such I think should be as the result with regard to the attempt vixà I m uw combating

In fact is impossitie a irn any precise division on the fact if the mafion de ma-instation of langs attacked with lobular crestin mi with pure arte forme; for in the child as in the sölt in lèdir portman is in kar poeumonia, in the first as in the seemi ani trd degree, at the stage of grey hepatization the insufficiom of the lung is the possible, air may be sent quite to the panenky vesicies, and Lew the parenchyma to foat on water.

I have many times repented the experiment, and I have nearly awars seeded in insuffating beratized lings. In the first stage the parenchyma simply congested blackish, Evil, engorged, became supple, crepitant, and of a fine scarlet red ecioar.

In the second stage, in the stage of red hepatization, the reddish eviver and the crepitation reappeared, the tissue dated, but it remained ima, and to the eye retained the other characteristics of hepatization. If a section beneath the pleurs is observed during the insufflation, the air is seen to arrive in each vesicle, and to form so many small wiinish, transparent spots, and then it appears manifest that the insured cells are less large by half than the healthy cells; this is a proof of the thickening of their walls by the inflammation.

In the insulation which is practised on a lung in the third degree of pneumonia, the result is the same, but it is not always obtained. I have only been successful three times. The lung preserves its density; it becomes distended, and crepitates afresh, but very feebly; it Boats; the distended vesicles are also observed of less size than the

resicies of healthy parts. The small number of vessels which give a rosy tint to grey hepatiration, become of a fine red again; but the grey purulent tint of hepatization remains.

In certain cases of pneumonia with very compact hepatization, the consequence of very adherent fibrinous exudation into the pulmonary