the pulse small and excessively frequent, the respiration sixty-eight in the minute. The left side of the chest was dilated, dull on percussion, and devoid of any kind of respiratory sound or vibration, The heart beat on the right side of the sternum. The left lung exhibited signs of great congestion.

Paracentesis thoracis was performed on June 4th, 1852, at eleven a.m., and thirteen ounces of sero-purulent liquid evacuated. Ten minutes afterwards the symptoms were ameliorated in a marked manner, particularly the restlessness and anxiety. A loud râle became audible through the left side. Still the respiration continued at fifty and fifty-four, and the pulsation at one hundred and thirty-two in the minute.

Between the 5th and 8th the improvement continued, the respiration falling to forty-four, and the pulsation to one hundred and twenty in the minute.

On the 10th a relapse occurred, the effusion became reproduced, and death took place on the 13th.

After death, nine ounces of sero-purulent flaky fluid were found in the left pleura, which pleura was everywhere covered with a thick, flocculent, false membrane. The two inferior thirds of the corresponding lung were carnified and compressed against the vertebral column, the upper third and the other lung were congested and hepatized in several patches.

A third case is mentioned, of a child aged twelve years, who had laboured under hydrothorax for fifteen days, and was cured by this operation.-P.H.B.]

APHORISMS.

201. Acute pleurisy, with effusion of serum, is very rare amongst infants and children at the breast.

202. Complete dulness, confined to one side of the chest in a young child, indicates pleurisy rather than a pneumonia.

203. Dulness of the chest, and absence on palpation of the thoracic vibrations at the time of the cries, announce a pleuritic effusion.

204. Pleuritic effusion in young children is a very serious disease. 205. The pleurisy of young children, which passes from the acute to the chronic state, is fatal.

206. A considerable effusion in a young child should be treated by paracentesis thoracis.

CHAPTER IV.

ON THE PHTHISIS PULMONALIS OF INFANTS AND CHILDREN
AT THE BREAST.

We should entertain a very false idea of the phthisis of young children, did we consider it as a diminutive or a reduction of the phthisis of adults. In early childhood, phthisis pulmonalis possesses characters and symptoms which are entirely special; it is only the termination by death which can resemble the phthisis of subjects of a more advanced age.

Book VI, Chap. IV.]

ON PHTHISIS.

341

The phthisis of infants is the result of hereditary influence, improper' artificial nourishment, bad quality of the nurse's milk, premature weaning, cold, poverty, and all the debilitating causes which can act directly upon nutrition. It may equally result from an indirect dis- Mal turbance of nutrition, by the frequent diarrhoeas consequent upon bad regimen. It sometimes appears to succeed acute pneumonia, but

in this case there is always room for inquiring which of the two ritien

affections has preceded the other, if the pneumonia is indeed the

primary morbid state, or if it is not itself a secondary affection. For

my part, I believe that in many cases, amongst predisposed children,

it is the pneumonia which brings on the development of the phthisis;vity

and here I mention a circumstance which I should certainly not state if Опешный it referred to the pathology of man. Phthisis is perhaps, then, in the ' infant, in the granular form, one of the manifestations of hereditary chon syphilis. This is a new question, which my experience authorizes me to state, if not to accept.

The phthisis of children presents several distinct anatomical forms; which sometimes coexist, and which I have studied with our learned anatomist, M. Ch. Robin. There is the granular phthisis, the element of which is nearly always the fibro-plastic granulation, sometimes the epidermic granulation, and there is the tubercular phthisis of which tubercule is the principal element. We thus return to the admission of the researches of Bayle, for a time eclipsed by the genius of Laennec, who has prematurely united two products differing slightly in nature, and which should still remain separate.

In granular phthisis, the two lungs are more or less filled by miliary, semi-transparent, opaline, shining, pearl-like granulations. These granulations vary in size from a pin's head to a hemp seed. They are surrounded by a reddish vascular zone, to the extent of .04 or .08 of an inch, or, on the other hand, which is more rare, enclosed by healthy parenchyma. They are hard and resisting to the finger. They are unequally scattered, but without a decided preference for the apex of the lungs, as is observed in true tubercular pneumonia.

These granulations are composed of particular elements, sometimes of fibro-plastic tissue, sometimes of epithelial cells, but this is exceptional. Al Under this form they remain a long time, and amongst the children who die, there are sometimes no other foreign bodies in the pulmonary parenchyma but the granulations which I have mentioned. Amongst other subjects, they are interspersed in the same lung with tubercular granulations so that the two alterations coexist in the same child. The following is the microscopical analysis of these granulations drawn up by M. Ch. Robin himself:

Fibro-plastic granulations. The constituent elements of these granulations are- 1st, fibro-plastic elements; 2nd, amorphous matter

interspersed with molecular granulations; 3rd, fibres of cellular tissue, generally very rare, and which may be entirely absent, elastic elements of the lung, which are still more frequently wanting; 4th, here and there cells of pulmonary epithelium.

1. The fibro-plastic elements here present themselves in their three varieties-nuclei, cells, and fusiform fibres. The nuclei are the most numerous, and may be ovoid with their characteristic forms; some of them are spherical and smaller than the ordinary nuclei. The Nature of cells are less numerous than the nuclei, and are generally ovoid; some have prolongations of their outline, which render them irregular ; Hive they enclose a characteristic ovoid nucleus; some may contain a spherical Fements nucleus similar to those to which we have just referred. It is not uncommon to discover cells possessing two nuclei, a circumstance more frequent in this state of the lung than in the fibro-plastic productions. The granulations included in the fibro-plastic cells are always very minute and uniformly distributed, and thus this variety of the elements always presents a considerable transparence. The fusiform fibres are less numerous than the preceding elements, they are pale and transparent, slightly granular, of variable length, some of them being short like those of the granulations of peritonitis and of chronic pleurisy. It is not uncommon to meet with them having the extremity truncated close to the nucleus. This last is generally ovoid, but sometimes it is observed of a spherical form.

2. The amorphous matter is rather abundant, and presents a variable consistence, more marked in the small than in the large granulations; it is sprinkled with minute greyish molecular granules, of indeterminable outline, so as to be amorphous. In some granulations the mass of this amorphous matter encroaches on the proportion of the other elements. Some of them are black, like pigment granules. This substance is important in consequence of its density, which very much prevents the separation of the other elements.

3. The fibres of cellular tissue are often absent; when they exist they are united with the above mentioned elements. Fibres of yellow elastic tissue more frequently exist than those of cellular tissue.

4. The pulmonary epithelium cells preserve their normal aspect, and sometimes present vibratile ciliæ, which are derived from the sides of the small bronchi not yet destroyed by the fibro-plastic deposit.

Epidermic granulations. M. Ch. Robin has only observed granulations of this kind four times; twice in children from four to five years old, twice in the adult. In the two young subjects, granulations of the size of a pin's head to that of a pea were found scattered throughout the whole extent of the lungs. Separated from each other by about 4 to 8 of an inch, they were difficult to crush, presenting a considerable consistence and a peculiar friability. These

granulations projected on the incision of the lung; their distinct outline was surrounded by vascular pulmonary tissue; they presented a grey pearl colour approaching a dull white; they were homogeneous in their whole thickness, and their substance expanded in water, like starch becomes swollen in alcohol.

They were composed of the elements of pulmonary epithelium, of cells having a flattened appearance, generally of from four to five sides, otherwise of variable dimensions, but possessing considerable regularity. These cells, nearly quadrilateral, assumed a flattened form, and were ordinarily mixed with cells which, in the normal state, were of a characteristic cylindrical form. The diameter of these cells varied between fifteen and eighteen thousandths of a millimeter, which is one half less than that of the mucous or cutaneous pavement epithelium. Molecular, granulations, presenting nothing unusual, were observed mingled with these elements of epithelium.

In the two other cases remarked in the adult, granulations analogous to the preceding were found distributed in the two lungs, and more abundantly in the inferior lobes than in the superior. Some were confluent, others isolated by about 4 of an inch of pulmonary tissue. From this disposition a particular riddled appearance resulted. Their size varied from a pin's head to that of a large pea. The largest ones were the softest, some appeared softened like what is observed in epidemic tumours of the face. They were of a greyish white colour. Portions which could be easily crushed were observed, and they were composed of irregular cells of epithelium; the molecular granulations were very abundant in all these cells, which contained spherical or slightly ovoid nuclei. Some, but very few, had yellowish grey molecular granulations around the nucleus.

Around these epidermic and fibro-plastic granulations the special alterations of lobular, discrete, or confluent acute or chronic pneumonia, according to the nature of the attack which has terminated the existence of the children, are often observed.

The bronchial glands are always hypertrophied, and they often enclose tubercular matter.

The pleura sometimes presents on its surface small delicate pseudomembranous deposits, or, more rarely, fibro-plastic intra-pleural granulations.

The liver, kidneys, and peritoneum sometimes present similar changes.

[Dr. Sieveking states that the intra vesicular characters of the deposit were satisfactorily and distinctly exhibited in the case of a child in whom an attack of acute tubercularization of the lungs supervened upon rheumatic heart disease and central cerebral softening; he is not prepared to assert that the tubercular deposit is never interstitial, but is inclined to believe that it is never primarily so; and his investigations have led him to the belief independently of any preconceived theory that

it is never effected without those local and molecular changes in the vascular system which are characteristic of inflammatory action, marked on the one hand by enlargement and congestion of the small vessels, on the other by formation of exudative matter in the shape of aggregation corpuscles, or definite exudation cells; but while these forms are found surrounding the tubercular deposit, they are in no way identical with it.-(British and Foreign Med. Chir. Rev.)—P.H.B.]

In tubercular phthisis, both lungs also present miliary, whitish, opaque, sometimes yellowish granulations, scattered here and there in the different lobes, but more usually in the superior lobes. The granulations are the size of a millet or hemp seed, and even acquire that of a cherry kernel. Then there can be no doubt as to the nature of the accidental product; it is decided tubercle with all its other characters. Moreover, microscopical analysis readily permits its verification.

lave

In infants these tubercles very seldom attain a larger size than that I have pointed out; they are seldom observed softened; the lungs are seldom perforated by cavities, which singularly modifies the symptoms of the disease. In thirty-six children, from one to fifteen months old, who died with tubercles, in three cases only did I observe a commencement of excavation, which formed little holes rather than caverns. None exceeded in capacity the size of a cherry kernel.

Around these tubercles, as around the fibro-plastic granulations, the lung presents numerous alterations, very varied according to the subjects, and very variable in effect according to the intensity of the inflammatory action which surrounds each foreign body. The lung presents nuclei of lobular pneumonia, more or less numerous, or on the other hand a pseudo-lobar induration of chronic pneumonia, changes which have been previously described, and to which it is unnecessary to revert.

All the bronchial glands are hypertrophied, and for the most part converted into tubercle. This product may, moreover, be observed in various parts of the economy upon all the tissues, in all the viscera, not even excepting the brain. We can thus well observe that tuberculization is the result of a decided internal diathesis, and it is only amongst children that we can verify the truth of this great pathological law.

[The anatomical character of tubercle in the lung of children present some peculiarities. Grey granulations and crude miliary tubercles frequently exist in the lungs independently of each other and of any other form of tubercular deposit. In the adult, Louis discovered miliary tubercles unassociated with grey granulations only in two out of one hundred and twenty-three cases, or in 1.6 per cent., and grey granulations with miliary tubercles in five out of one hundred and twenty-three, or in four per cent. In the child, MM. Rilliet and Barthez found tubercle without grey granulations in one hundred and seventy-one out of two hundred and sixty-five instances, or in sixty-four per cent., and granulations alone