What we have observed on bleeding, may suffice to determine the cases in which its employment is necessary.

Emetics, moderately administered, are here of most decided service. Some give them when the obstruction to the bronchi appears to les be considerable, with the intention of producing efforts susceptible of communicating to the thorax violent movements of ampliation, which facilitate respiration and the expulsion of mucosities from the bronchi; others, to modify the energy of the circulation, and to arrest the congestion of the pulmonary parenchyma. The former employ ipecacuanha, the debilitating influence of which is very decided; the latter, on the contrary, extol, as in the adult, the use of tartar emetic, a sedative to which they attach the greatest value. syrup of ipecacuanha should be given in the dose of 3j, or the ipecacuanha in powder, in the dose, and in the manner previously indicated; sometimes the tartar emetic is given in a draught in the dose of three fourths of a grain to the iss of the vehicle, and 3 iiss of the syrup of poppies, a teaspoonful every quarter of an hour until vomiting is produced; on the second or third vomiting, its use should be suspended, and the remainder of the draught put aside.

The

This therapeutic method is most advantageously made use of. It seldom fails to produce at least a momentary amelioration. It often arrests the progress of the disease, and the thoracic symptoms disappear under its influence.

From the

We give the preference to the ipecacuanha in powder. The tartar emetic is sometimes followed by serious inconveniences. first dose it determines a considerable prostration, a rapid emaciation, a remarkable alteration in the physiognomy, with sinking of the eyes, and its administration cannot be prudently continued. To seek to obtain the tolerance of the medicine would be dangerous; it would be to run the risk of serious consequences which could not be easily removed. If the tolerance of tartar emetic is a usual phenomena in children of advanced age, it is very rare in children at the breast.

This treatment may be combined with bleeding, at least such is the opinion of M. Valleix. This author thus expresses himself: "There is, I believe, too much apprehension on the employment of this means in infants; with respect to the emeto-cathartic effect, it acts nearly as in the adult, that is to say, tolerance is soon established. It appears to me then, that the treatment should be based upon the employment of bleeding and of tartar emetic."

We may also give, in addition, oxysulphuret of antimony, one and a half grain to two grains, or the white oxide of antimony, in doses of three grains; but these means have never appeared to me very efficacious.

At this second stage of pneumonia, blisters are evidently less useful

te

than in the first stage. Their employment, however, should not be rejected. We may reasonably believe that the revulsive action, brought about in the dermis, is of such a nature as would impede ster the series of transformations which follow the congestion of the pulmonary lobules. A sufficiently large blister should be prescribed, alect and applied in front, in such a manner as slightly to cover the two sides of the thorax.

This means is not at all dangerous.

This means is not at all dangerous. It does not produce in the young child, as in the adult, vesical tenesmus and the retention of urine. It is only at a more advanced age that we have the opportunity of observing these symptoms in connection with the bladder.

There are certain cases of pneumonia in which the reaction is very feeble, or nearly entirely wanting. It is thus, perhaps, advantageous to prescribe some aromatic infusions, such as the infusion of sage, melissa, &c., or even quinine in a small dose. This slightly exciting plan of treatment, of which we speak à priori, is often successfully employed in adults placed in similar circumstances. It may be useful in a prostrate and enfeebled child, which only requires a little strength and a degree of vitality necessary for the reabsorption of the products accumulated in the pulmonary parenchyma.

Amongst the complications of pneumonia there are few which should seriously occupy our attention. Thus, the slight pleurisy which accompanies this disease disappears under the influence of the treatment of the principal disease. The tubercular productions of the lung and of the bronchial glands, even when they are well developed, can offer no obstacle to the employment of the means of which we have spoken. There is scarcely any disease but entero-colitis which can modify the treatment of pneumonia; we may again state that the presence of this disease is only a contra-indication of tartar emetic, the employment of which may increase the irritation of the digestive canal. The other therapeutical agents may be indifferently employed, without fear of observing the aggravation of the intestinal disease.

APHORISMS.

168. Primary pneumonia which is also called pneumonia d'emblée, is rare in children at the breast.

169. Pneumonia usually follows simple bronchitis, or bronchitis complicating fevers, or acute febrile diseases.

170. Primary pneumonia is usually lobar.

171. Consecutive pneumonia is always lobular.

172. Lobular pneumonia is sometimes discrete, sometimes confluent. 173. The pneumonia of children at the breast is almost always double, and usually attacks both lungs.

174. Lobar or lobular pneumonia is observed under two anatomical

forms slightly differing as to structure, these are intra vesicular and extra vesicular pneumonia.

175. Intra vesicular pneumonia, usually primary, leads to congestion and thickening of the walls of the cells of the lung, with the formation of an internal plastic deposit which constitutes the character of red and grey hepatization.

176. Extra vesicular pneumonia, always consecutive, only produces congestion and thickening of the walls of the pulmonary vesicles without fibrinous plastic secretion in the interior of these vesicles.

177. Chronic pneumonia, more common in the infant at the breast than in the adult, is always lobar.

178. Pneumonia often engenders the formation of fibro-plastic miliary granulations in the interior of the cells of the lung, in lymphatic and scrofulous children, or in the issue of parents tainted with scrofula.

179. The development of lobular pneumonia is favoured by the crowding of children in the wards of a hospital.

180. Ordinary and frequent cough, accompanied by fever and anhelation, should make us fearful of an invasion of a pneumonia. 181. Expiratory, groaning, and jerking respiration is a certain sign of the existence of a confluent lobar or lobular pneumonia.

182.. Panting respiration, accompanied by a continual movement of the nostrils, is a sign of pneumonia.

183. Dulness of the chest is generally but slightly defined in the pneumonia of children at the breast.

184. When dulness of the chest exists in a young child with a very bad cold, pneumonia should be feared.

185. Dulness confined to one side of the chest, in a young child, rather indicates pleurisy than pneumonia.

186. The subcrepitant râle which accompanies the cough, the fever and anhelation, confirm the diagnosis of confluent lobular pneumonia. 187. Bronchial respiration, which is rare in children at the breast, always belongs to lobar pneumonia, and sometimes to confluent lobular pneumonia.

188. Bronchophony, that is to say, the resounding of the cry, indicates that the pneumonia has arrived at its last stage.

189. The exaggerated vibration of the thoracic walls at the time of the cries indicates pneumonia, whilst their absence, on the contrary, points out the existence of pleurisy with considerable effusion.

190. The acute or moderate fever, at first continued, presents numerous exacerbations in the course of the pneumonia.

191. Primary pneumonia, or d'emblée, is less severe than consecutive pneumonia.

192. Pneumonia consecutive to simple pulmonary catarrh is often cured.

193. Pneumonia consecutive to measles, scarlet fever, smallpox, is a very serious disease.

194. The pneumonia of children at the breast is especially a serious disease, in consequence of the complications which precede or follow its development.

195. The pneumonia of children at the breast has a great tendency to pass into the chronic state.

196. The pneumonia which is consecutive to the development of fibro-plastic miliary granulations, or to tubercular granulations, is usually fatal.

197. Expiratory, groaning, and jerking respiration, accompanied by movements of the nostrils, announces that the life of the child is in great danger.

198. The swelling and oedema of the hands or of the feet which comes on in the course of pneumonia indicates an approaching death. (Trousseau.)

199. The return of the secretion of tears, which had been suspended in the attack of pneumonia, is a good augury for its favourable termination. (Trousseau.)

200. One or two leeches at short intervals, several blisters in front of the chest, and doses of ipecacuanha, are sufficient for the treatment of simple acute pneumonia.

CHAPTER III.

ON PLEURISY.

Intelligimus profecto passionem pleuriticam difficulter pueros incurrere.

COELIUS AURELIANUS.

Pleurisy has long been considered as a very rare disease amongst children. This opinion, first mooted in the writings of Coelius Aurelianus, of Aretæus, Triller, and Morgagni, was adopted by pathologists and transmitted to modern authors. It was, however, modified by some physicians, who, passing from doubt to absolute denial, looked upon the development of pleurisy amongst children as impossible.

Then appeared works of Billard, Constant, Barrier, Rilliet and Barthez, and of C. Baron, in which pleurisy is accorded the position which it ought to occupy in the outlines of pathology. Hundreds of facts demonstrate its existence in the most incontestable manner. According to these authors, the diseases of the pleura are more uncommon in the first years of life than in the rest of childhood, and they are more frequently observed as secondary affections than as primary diseases.

Pleurisy is met with amongst infants and children at the breast. W It presents itself under two forms, which it is necessary to distinguish. In the first, which is the rarer form, inflammation of the entire pleura is the only and real cause of the disease, and constitutes primary

Эришиг pleurisy. In the second, on the contrary, the pleurisy is nothing lubolone

more than a secondary symptom, and usually is not severe; the lesions of the pleura are very slight, and follow, without being of much importance, a disease previously established. This form is much more

the Wikile common than the preceding; we will term it secondary pleurisy. Pleura.

This last variety is observed in children attacked with acute pneumonia, in the tubercular, and in most of those subjects who die 4 of entero-colitis or of cerebral affections, when the engorgement of the lung has had the time to produce its effects before death. In these cases the pleura encloses a small quantity, perhaps a teaspoonful, of a limpid or yellowish serum, sometimes opaque, but without albuminous every shreds. The pleura is a little reddened, without capillary injection, and covered on some parts of its visceral surface by a plastic exudation which is delicate and transparent, and rarely sufficiently thick to be out de: completely opaque. This exudation is usually hardly appreciable; it is more especially observed at the situation of the angles formed by the fissures of the lung; here it is rather thick, of a greyish white colour, and often serves as the means of the agglutination of the two lobes.

We have often had the opportunity of establishing these lesions of the pleura with slight variations in extent, but without any other [4. anatomical character. In sixty-eight post mortem examinations we have met with them twenty-three times.

These lesions were only recognized on the dead body. During life they ad had been masked by the severity of the other symptoms.

They are evidently closely connected with pleurisy, but, as may St be observed, they are very different from those which are seen in primary inflammation of the pleura. They ought, then, to be considered in a special manner, and cannot be isolated from the diseases which they complicate.

In this point of view pleurisy is rather frequent amongst children t at the breast; but it does not constitute a disease, the invasion, progress, and development of which it is necessary to describe separately. Like all secondary diseases, it only deserves a simple mention. C This bariety, quite