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 Cluster the series of transformations which follow the congestion of the pulmonary lobules. A sufficiently large blister should be prescribed, te alects 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 en 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 discase 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. CELIUS 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.-norms It presents itself under two forms, which it is necessary to distinguish. In the first, which is the rarer form, inflammation of the entire pleural is the only and real cause of the disease, and constitutes primary pleurisy. In the second, on the contrary, the pleurisy is nothing more than a secondary symptom, and usually is not severe; the lesions tubolone of the pleura are very slight, and follow, without being of much the hel importance, a disease previously established. This form is much more common than the preceding; we will term it secondary pleurisy. This last variety is observed in children attacked with acute pneumonia, in the tubercular, and in most of those subjects who die 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, re. 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 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 tel had been masked by the severity of the other symptoms. They are evidently closely connected with pleurisy, but, as may be observed, they are very different from those which are seen in primary inflammation of the pleura. They ought, then, to be con- Onesidered 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 th 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. This bariety quite scare It has never yet entered one's mind to describe the cedema which It is Primary pleurisy, from its analogy with that of the adult, deserves to be more attentively considered. It is very seldom met with amongst children, and this more decidedly the case in proportion as the period of birth is approached. This fact justifies the observation of ancient writers: Intelligimus profecto passionem pleuriticam difficulter pueros incurrere. MM. Rilliet and Barthez have only met with it three times in Par children from one to three years old. M. Barrier has never met with Зачи it at this age. I have collected two examples of it in the practice of M. Trousseau; one of the two children was eighteen and the other sixteen months old. This variety of pleurisy presents anatomical characters precisely resembling those of the adult; it is useless to recapitulate them. In the two patients to whom we have just alluded, the lung was compressed against the vertebral column and carnified. The effusion which filled the cavity of the pleura was composed of purulent serum, containing purulent and albuminous flakes. Same as visceral and parietal pleura was reddened, intensely injected, and covered in its whole extent by a greyish false membrane, thick, very in adherent, and roughened on the surface, which remained free. The [West observes that "some writers on diseases of children, indeed, have left pleurisy altogether unnoticed, on account of its supposed extreme rarity in early life; but this opinion is certainly erroneous so far as regards that secondary pleurisy which comes on in the course of pnenmonia, and which is almost if not quite as frequent in childhood as in adult age. Acute idiopathic pleurisy, unconnected with pneumonia, or in which the inflammation of the lung bears but a very small proportion to that of the pleura, and is certainly an uncommon affection during the first years of childhood, and as a cause of death its rarity is extreme." In the fifth report of the Registrar General it appears that of seventy-five fatal cases of pleurisy that ocurred in London in 1841, only three or four per cent, took place in children under five years old. West has only on four occasions had the opportunity of observing acute idiopathic pleurisy run a fatal course in children under five years of age; after five years of age, however, the frequency of pleurisy manifestly increases, and during the latter years of childhood it is little, if at all, less frequent than in the adult.-Op. Cit., p. 211.-P.H.B.] SYMPTOMS. Primary pleurisy only occupies one side of the chest; it is announced in the young child by a considerable depression of strength, want of appetite, slight cough, and fever. Then the pain of the side comes on (C. Baron), very difficult to appreciate, the seat of which can be discovered by the cries which the child utters when the painful spot is percussed. The cough gradually becomes more frequent, it is small, |