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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,

'ififHJ 0paqUBj 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

^ I )■ of the accidental product; it is decided tubercle with all its other

characters. Moreover, microscopical analysis readily permits its verifi

!/^<- cation.

/ In infants these tubercles very seldom attain a larger size than '. J that I have pointed out; they are seldom observed softened; the

'i c j (i , lungs are seldom perforated by cavities, which singularly modifies the . 'symptoms of the disease. In thirty-six children, from one to fifteen *It H l:"'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, r and very variable in effect according to the intensity of the inflam

matory 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. t ' '•'

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 tuber, culization 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

L; 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

; i * 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 iu thirty-six, or in thirteen per cent.; and the observations of West, which are

based on fifty-four cases wherein tubercle was present in the thoracic viscera, -SuAtA* *

lead to very nearly the same result. Another anatomical peculiarity of the

disease and further illustrative of the acute course of tuberculization of the lungs 0-+4-V"*

iu children, is the great frequency with which yellow infiltration of tubercle is ' (JuUUM

observed iu early Ufe; MM. Rilliet and Barthez having met with it in eighty- ,

eight out of two hundred and sixty-five children, or in thirty-three per cent., AnJLouJii i>

and West in sixteen out of fifty-five, or in just the same proportion. In the

phthisis of children, moreover, cavities in the lungs are rarely observed. Out of CyuxJ^LCK.

two hundred and sixty-five cases that came under the notice of MM. Rilliet « ( . t .

and Barthez, only seventy-six, or 28.6, presented cavities in the lungs, and they l-*t*^*-y

existed in only thirty per cent, of the cases which came under the observation of ^njt(j 11 <

West. Lastly, in the phthisis of children abundant deposit of tubercle is observed '.

in the bronchial glands, constituting an important form of the disease.—P.H.B.] P (HM. 1-1*14'

The phthisis of young children presents itself under two distinct Ci _. . forms; it is acute or chronic.

In many patients the symptoms are very difficult to distinguish, \,luu^J: especially in acute phthisis, -which may be confounded with pneumonia, jli^tjii^f., of which it is, in truth, only a variety known under the name of ., , granular and tuhercular pneumonia. In fact, there may be estab- ,. i lished between the acute phthisis of infants and pneumonia, the same <?/.//>■<••. • relation which already exists between granular meningitis and simple meningitis. This view, actual clinical observation enforces on the judgment.

Acute phthisis, whether granular or tubercular, is very frequent {(ttlU. <» amongst young children, especially at a hospital. It is much less > % %

prevalent in the upper classes of the city. It is everywhere mistaken' ,

and passes for lobular pneumonia. In fact, the symptoms of these ',H,Ui LH. two diseases are very nearly the same, and if the children die quickly, , it is at the autopsy alone that the presence of fibro-plastic granulations ''>■',■ and tubercles in the lung is recognized. Therefore we may refer to / '^ j. the chapter on the varieties of lobular pneumonia, to the article on , . ^ , granular pneumonia, for what relates to the symptoms of acute granular and tubercular phthisis. '" '' ^'""

Chronic phthisis is more rare, so rare indeed that it has been said :, ,n that pulmonary phthisis in the true acceptation of the term does not exist amongst children. If, in fact, by pulmonary phthisis we would '•*'' really understand the consumption which results from pulmonary •<r*r> »'"' excavation by tubercles, as we say when speaking of it in man, then ,vju t :/<"' there is no such thing as phthisis in the infant. But if phthisis, in LttrL 5 , ^ the modern acceptation of this word, represents the acute or chronic *, evolution of symptoms due to the presence of pulmonary tubercles, l ii* !">'''•' then, on the contrary, phthisis is very frequent amongst young children. J. y 5

Chronic phthisis succeeds acute phthisis and lobular pneumonia. • After the usual train of inflammatory phenomena which accompany *> C*IUIpulmonary catarrh and inflammation of the lungs, the child appears <_ ;TS

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h'LaJj.lOu.'*0 recover his strength and to progress towards recovery. But the

convalescence is not realized, the child languishes and daily loses flesh;

'.. '/< l v K*<? the skin becomes thin, wrinkled, and cadaverous; the face contract*,

Cih' and assumes an appearance of premature senility. The fever wears

the child away in a slow, but continuous manner. There is cough,

no expectoration, neither mucus, nor pus, and still less blood.

The shrunken chest permits all the parts being seen. It resounds

less than natural, and dulness sometimes exists on the summit of the

;UH'£n. apex of the lung, or when the granulations and true tubercles are

surrounded by chronic pneumonia. Sibilant, mucous, and subcrepitant

rales, may be heard on both sides of the chest, sometimes on one

3, tjj side, sometimes on the other, or on both sides at once. Sometimes

a souffle exists behind at the apex of the bronchi, and it might give

i rise to the inquiry whether it is a cavernous souffle, or a bronchial

k 'souffle. But as we are aware that in young children, cavities do not

/ u ( Ithl LU exist of a sufficient size to produce this phenomena, it must be referred

to bronchial respiration, in consequence of chronic pneumonia, or to a

considerable dilatation of the bronchi.

The cry resounds more or less according to the degree of induration of the lungs, and it is never more decided than when a well-characterized souffle exists.

Notwithstanding all these phenomena which indicate an extensive

material affection of the pulmonary parenchyma, the children eat

.'-(. r willingly—it is even difficult to restrain them in this respect. They

digest well; sometimes diarrhoea supervenes and still more exhausts

them, but their appetite is not on that account less manifested, and

'iu lUX '* '8 necessary to give them food in order to avoid scenes of temper

which the parents cannot endure. The abdomen swells, and contrasts

by its size with the thinness of the fleshless and withered limbs; the

l f prostration still daily increases; the wants of the children are infinite;

they must be carried in the arms; it is necessary to walk about with

'* ' '1 <- ^**" them day and night, and all this lasts for weeks, months, and even

'more than a year.

However, one day or other, without cause or reason, the diarrhoea ,< // /. establishes itself, never to cease; the mouth becomes deprived of its epithelium, thrush supervenes, the powers are still more exhausted, and the child, like a lamp ready to become extinguished, raises itself, sinks, oscillates, and at last dies in the extreme state of weakness, languor, and marasmus, or in the midst of unexpected convulsions, which soon put an ',i( i end to existence.

[According to West, the general characteristics of the phthisis of childhood are— 1st. The frequent latency of the thoracic symptoms during its early stages. 2nd. The almost invariable absence of haemoptysis at the commencement of the disease, and its comparatively rare occurrence during its subsequent progress.

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3rd. The partial or complete absence of expectoration.

4th. The rarity of profuse general sweats, and the ill-marked character of the hectic symptoms.

6th. The frequency with which death takes place from intercurrent bronchitis or pneumonia.

Bronchial phthisis is characterized by—

1st. The frequent development of its symptoms out of one or more attacks of bronchitis.

2nd. The peculiar paroxysmal cough which attends it, resembling that of '. j/7 incipient pertussis.

3rd. The great and frequent fluctuations in the patient's condition, and the '2V 7 '." occasional, apparently causeless, aggravation, both of the cough and dyspnoea. ^ «•*/« XV'

In very early infancy phthisis is remarkable for the very frequent latency of the ^y > /, y chest symptoms, which, through its entire course, are often entirely merged in the signs of impaired nutrition. h~ /*i r

The most important peculiarities in the auscultatory phenomena of consumption '/^" in the child are— f J~

1st. The smaller value of coarse respiration, prolonged expiration, and inter- '^J^r rupted breathing, owing to their general diffusion over the chest, and to thehr ,^ / /."/ occasional existence independent of phthisis. L*^i*.

2nd. The apparent, and to some extent the real, exaggeration of the signs both sy j 1 J of early and of far advanced diseases of the lungs in some cases of bronchial pbthiais. cQj±-(^ }

3rd. The loss of that information which the phenomena of the voice furnish in""' /

the case of the adult. ./•-'

4th. The small value of inequality of breathing in the two lungs. i/

5th. The difficulty of detecting minute variations in the sonoriety of the chest; /t j / //•../,. and, V*-** '/

6th. The existence of dulness in the interscapular region, together with moderate £^y^ LC ) li-'/ resonance of the upper parts of the chest and tolerably good respiration there, .t . ,

which are characteristic of the presence of enlarged bronchial glands. i.-^JJt^Ll^*'*,'

It would appear from the returns of the Registrar General, that in London in 1849, of 3,318 males and 3,009 females who died from phthisis, 228 males and 236 females were under five years of age.—P.H.B.]

Acute phthisis should be treated, like acute lobular pneumonia, by '*• ■ XA" antiphlogistics, one or two leeches, several times repeated according CLu1*-' ,-'' to the vital energy of the children, by cutaneous revulsives to the chest, and by emetics several times repeated.

Chronic phthisis does not, in any way, require the employment of abstraction of blood. Flying blisters on the chest, frictions with tartar ^ emetic ointment, frictions with croton oil, are infinitely more useful. The employment of these means may be left off" and resumed several times during the duration of the disease.

Internally, pectoral drinks, emollients, draughts of mucilage, juleps, combined with narcotics or opiates, should be given to young children, provided that the distaste for these medicines is not decided.

Cod's liver oil, in the dose of 3 v a day; the iodide of potassium /jUiii-f il . in a julep, three and a half to seven grains; tartar emetic, in the r-' dose of .15 grain; oxysulphuret of antimony, three to three and a U&U .

half grains in the twenty-four hours, have been administered, and may be so with advantage.

The complications of the disease by thrush, diarrhoea, and convulsions, should be treated by means of the medicines which have been indicated in each of these diseases.

CHAPTER V.

ON HOOPING COUGH.

Hooping cough is a contagious, and at times an epidemic, disease, characterized by a convulsive cough, returning in frequent, and more or less prolonged paroxysms. These paroxysms possess a particular character. The expirations, of which the fits of coughing are composed, succeed each other with great rapidity, and are followed by a long, distressing, and sonorous inspiration, which is called the hoop.

History. The term hooping cough (coqueluche) has not always possessed the signification which physicians now apply to it. In the fifteenth century, this name was applied to a species of epidemic catarrh, which Mezeray, De Thou, and Pasquier (Etienne), mention in their works. One of these epidemics, described by Valleriola, does not present any resemblance with the disease, as it is observed at the present age, but was more allied to influenza. Without dwelling any longer on this historical question, which I cannot decide in this work, I shall confine myself to the statement that the Greek and Arabian physicians make no mention of hooping cough. Those authors, then, are quite in the wrong who have pretended to recognize this disease in a passage in the Epidemics of Hippocrates, in which it is simply a question of an epidemic disease of the throat, which was often complicated by '*;'./ .'» inflammation of the larynx.

According to M. Blache, Willis is perhaps the first who, under r IS the denomination of tussis puerorum convulsiva, sujjfbcativa, really appears to have indicated the disease we are about to study. i : ;• L In the eighteenth century only, has hooping cough been described as a distinct disease, and it has been termed pertussis (Sydenham); .■"'.'.'. tussis clangosa (Basseville); hex convulsiva (Good); bronchitis convulsion (Bourdet); affectionpneumo-gastro-pituiteuse (Tourtelle); bronchociphalite (Desruelles); catarrh-conr.ulsif (Laennec); tussis spasmodica, stranjulans, orthopncea, &c. (different authors.)

The etymology of the word coqueluche, generally adopted in France,

is rather uncertain; some derive it from coquelhuchon, a cowl, a sort

'. of hood with which people covered themselves in the epidemics of

1414, 1510, 1557, &c.; others would originate it in the extensive

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