Resperatens dry, sometimes painful and constrained; it preserves this character during the course of the disease. There is no expectoration; the respiration is quickened, becomes panting, as in pneumonia, and soon assumes the jerking character of groaning and expiratory respiration. in a bud The countenance remains pale and motionless; the features are often deformed by the contraction of the respiratory muscles of the face and by the agitation of the nostrils, phenomena which are in relation mbles. with the frequency of the respiration. With respect to the decubitus, Rés of Phen it is nearly useless to mention it, since the children are not at liberty to select it, and remain, imprisoned in their swaddling clothes, in the mourn position in which they are placed. At the commencement there may be remarked a weakness of the respiratory sound in the affected side, increasing with the effusion which invades the lateral, superior, and anterior parts. Bronchial respiration is then observed; it is not constant, and seems to disappear to return at intervals. The conditions favourable to the production of this sound have not, however, changed. This momentary disappearance is explained by the inequality of the respiration of children, or is, in consequence of an obstacle offered to the passage of air by the mucosities, accumulated in the bronchi. Thus, in pleurisy, when the forces which concur touch. inspiration are too feeble, respiration takes place without an abnormal bruit. The same takes place when the mucosities obliterate the principal bronchus of a hepatized lung, or one compressed by an effusion. This portion does not receive the air, and cannot therefore give rise to bronchial respiration. To this quality of respiration, bronchophony and ægophony must y necessarily be referred, which it is scarcely possible to distinguish amongst children at the breast. In the cases of pleurisy with bronchial tentous respiration, the echo of the cry replaces these phenomena; it extends itself to the infra-spinous fosse, and to the summit of the crest of the lesions scapula. It is intermittent like bronchial respiration, and ceases as soon as the effusion has become too considerable. When the pleurisy has arrived at this stage, the absence of respiration in the affected side is complete; the bronchial respiration, and the bronchophony, which were previously verified, are no longer heard, and the dulness is complete. The succession of these phenomena should then be sufficient to indicate in a positive manner the presence of a considerable quantity of liquid in the pleura. Percussion is a means of exploration without value in the diagnosis at the commencement of diseases of the chest in children at the breast, and consequently of little service at the period of the invasion of pleurisy. The reason of this is entirely physiological; we have previously pointed it out, in remarking that the resonance of the chest of children at this age is so obscure as not to allow the appreciation of a slight modification of its natural state. When the pleurisy fusis well developed and the quantity of fluid considerable, then on percussion we obtain a dulness which limits the height of the liquid contained in the pleura. In some cases this dulness extends to the Baltus entire side of the chest; it then coincides with the complete absence of respiration. The inspection of the chest does not furnish any important information unha at the commencement of the pleurisy and even in those cases of pleurisy which rapidly accomplish their stages. But such is not the case when kicome the disease is sufficiently prolonged to allow the formation of a considerable effusion. Then the diseased side dilates; it may acquire as Cendedmuch as 39 inch more in circumference than the other side; the ribs are straightened and the intercostal spaces are scarcely to be perceived. The sternum and the vertebral column undergo a similar change. Palpation of the thorax suffices, in some cases, to reveal the existence of the pleurisy accompanied by a considerable quantity of effusion. The hand does not appreciate any vibration in the walls of the affected side at the time of the respiration or of the cries. This symptom, pointed out by MM. Taupin, Baron, Rilliet and Barthez, and which M. Trousseau and myself have had opportunities of verifying, appears to me of great value. Its importance is so much the greater as in pneumonia precisely a contrary phenomena is observed. Thus in pneumonia the vibration of the thoracic walls is considerably augmented. Here we possess, then, a valuable differential sign which must be especially attended to, and which absolutely separates acute pleurisy followed by effusion, and inflammation of the pulmonary parenchyma from each other. Primary pleurisy of children at the breast is observed, like the pleurisy of children of more advanced years, in the acute and in the chronic or latent state. In the acute form, the invasion is signalized by the cough without it being possible to verify the pain of the side, by any remarkable acceleration of the respiration and by a moderate fever. The child appears oppressed; it sucks less willingly; its temper is sad; its respiration feeble, accompanied by bronchial respiration without râles; percussion gives no results. When the disease is well established, these symptoms persist and become aggravated; the child becomes thin, loses all appetite, and sometimes has diarrhoea; the fever becomes remittant with nocturnal exacerbations; the respiration is more and more embarrassed and becomes panting or expiratory. The cough remains the same. Auscultation reveals the presence of bronchial souffle, and afterwards the complete absence of respiration. Percussion affords a dull sound throughout the whole of the affected side. Palpation does not discover any vibration in the thoracic parietes. Book VI, Chap. III.] ON PLEURISY. 337 In the chronic or latent form, the febrile reaction is less, there is scarcely any cough, and the external signs of difficult respiration are slightly marked. Auscultation discovers feeble respiration, the bronchial souffle, and lastly, total absence of respiration. The dulness is complete, the vibration of the thoracic walls is destroyed. Chronie At this period acute and chronic pleurisy cannot be distinguished from each other. The symptoms, determined by the presence of a considerable effusion into the cavity of the pleura, are the same, always excepting the intensity of some symptoms, which is always greater in the clasp primary acute pleurisy. The dyspnoea is considerable, and asphyxia soon comes on to put an end to the existence of the child. The primary, acute, or chronic pleurisy of children at the breast, is always a very serious disease, which rarely terminates by resolution, Federabl and which often causes death. The two children, of whom we have & Asphyr. spoken, died without it being possible to arrest the fatal progress of we may udlev it.. indlevith assure ourselves on reference to the works of MM. Baron, Barrier, Life & Rilliet and Barthez. DIAGNOSIS. Amongst the diseases of infancy, which may possibly be confounded with pleurisy, one alone deserves attention: this is pneumonia. In children at the breast, pneumonia always follows bronchial catarrh ; it is characterized by the presence of mucous and subcrepitant râles in both sides of the chest; by bronchial respiration, bronchophony, and a considerable vibration of the thoracic parietes at the time of the cries. Pleurisy, on the contrary, is not accompanied by any râle; the respiration is feeble on one side only; here the souffle is first heard, to which succeeds total absence of respiration, complete dulness, and the absence of all vibration at the time of the cries. Nothing more is required to distinguish clearly these two diseases from each other. We shall pass over in silence that which relates to the diagnosis between pleurisy and pericarditis, hydrothorax, and some other diseases which are so rarely observed in children at the breast. CAUSES. The causes of pleurisy are much the same as those of pneumonia. This disease is indifferently observed in boys and girls; it is more frequent in winter than in summer; it is developed in preference amongst weak and delicate children, which are imperfectly nourished, placed in the hospital in a state of prolonged dorsal decubitus, and in an atmosphere vitiated by the accumulation of patients. Primary pleurisy is exceedingly rare at the period of existence comprised Y between the moment of birth and the end of the second year; secondary pleurisy is then very frequently met with. It is observed at the same time as bronchitis, which terminates most of the diseases of the young child, and especially as a complication of acute or of tubercular pneumonia. TREATMENT. What we have to say on the treatment of pleurisy of children at the breast only really applies to cases of primary pleurisy, as we have purposely, on account of their slight importance, put aside cases of secondary pleurisy. It is scarcely possible, at so tender an age, unless there is considerable febrile reaction, to have recourse to the employment of the abstraction of blood. If a case does occur, great precautions must be used, and only one or two leeches should be applied Juscully at a time on the diseased side, the physician being at liberty to repeat 2 Jurches them if necessary. Diuretics are not very convenient remedies to administer to a young child; still, in place of the nitrate of potash usually employed, the tincture of squills, or of digitalis, may be made use of. If the urinary diacrisis is not brought on, these medicines have at least the advantage of lessening the force of the circulation, and of calming the febrile reaction. These medicines may be given in a draught. Purgatives, the employment of which is adopted by Bandelocque, are cited by M. Baron as likely to produce very advantageous results. Manna should be given dissolved in milk, tartar emetic in solution in the dose of one sixteenth of a grain. These are the mildest purgatives, and those most easy of administration. Cutaneous revulsives have been made use of by a great number of physicians who have given themselves much credit for having employed them. As these practical results especially relate to the pleurisy of the second stage of childhood, we cannot draw decided conclusions as to the efficacy of blisters in the treatment of the pleurisy of children in the cradle. Nevertheless, if we are to judge by analogy, which is, in fact, the only guide of experiments in therapeutics, we must look upon vesication as a very useful resource to bring about the cure of the disease we are now considering. It is nearly useless to add that the employment of these different means should be seconded by the observations of rules of the strictest hygiene. The child should be placed in a mild atmosphere, equally sheltered from sudden chills and from too high a temperature. It should be restricted to a rigorous milk diet, and the nurse should often hold it in her arms and walk about with it in the room, without bringing it to the out-door air. These conditions should necessarily vary according to the strength of the patients; there are some which require to be well fed, and this also may be necessary in chronic pleurisy; others should be carried about out of doors in the sun, in kill feir order to counteract the cachexia which affects them. If the progress of the disease has not been impeded, and "if the quantity of the effusion is such as to threaten existence, and if the patient is deprived of every other method of safety" (Trousseau), the operation for empyema must be had recourse to. It has been performed several times with success, by Heyfelder, in children from six to eight years old. It has been also practised by other physicians and by M. Trousseau, uffuu who read, at the Academy of Medicine, a very interesting paper, in which the utility of this operation is shown in the most strikingl manner. It has not been yet performed in children at the breast, * but I do not consider, the indication being urgent, that the age should h be considered as a contra-indication to its employment. [Dr. Archambault (Archiv. Gén. de Med.; Juillet, 1853) relates some instructive cases of paracentesis thoracis in children, which occurred in the practice of M. Trousseau, at the Hopital des Enfants Malades. Case 1. Excessive pleuritic effusion, dating from eight days; operation; cure. The patient, a little boy aged four years, had been ill eight days. The illness began with dry cough, oppressed breathing, and slight fever, but without any shivering or pain in the side. When admitted (January 6th, 1852), the breathing was laborious, and seventy in the minute; the pulse one hundred and twenty, and small; the left side of the chest prominent, not taking any part in the respiration, Case 47 and everywhere dull on percussion, and without respiratory sounds, except imme- ple diately underneath the clavicle. The spleen was pushed considerably below the level of the false ribs, and the heart very much to the right of its proper position. The right side of the chest was healthy. The day following, the respiration being more laborious, the surface dusky and cool, and asphyxia imminent, paracentesis thoracis was performed, under the sanction of MM. Trousseau, Blache, and Guersant, when a pint and half of yellowish transparent fluid was evacuated. Immediately afterwards, the respiration becomes less frequent, the sound on percussion clear, the respiratory murmur audible, and the heart returned to its proper place. On the 9th, the effusion returned to some extent, and a diuretic mixture with digitalis was ordered. On the day following there was vomiting and much depression, but the dulness diminished. From the 12th to the 30th the patient progressed favourably, until the lung had recovered its healthy action, and all pleural rubbing had disappeared. Convalescence was retarded by a severe attack of measles, but in the end the child got perfectly well. Case 2. Excessive sero-purulent effusion; operation; death. The patient was a little boy aged two years, whose previous history was not ascertainable. When admitted into the hospital he was in a state of imminent asphyxia; the face pale, *Annales de la Chirurgie Française. Paris, 1844; t. xii, p. 223. |