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A \,,aA s ;T NOiasw jo Aavaai f Dimgtisoifs .American Medical Library. i. t the difference of seat; the lesion is sometimes in their course, and at others in their extremities. In the first instance the scissors, instead of entangling themselves in the walls of the bronchi, easily follow the smallest branches and arrive immediately at the surface of the lung. Upon laying open the bronchus in the whole of its length, we see it, from one of the first divisions preserving throughout the same diameter, or even perhaps insensibly increasing it. In some cases the dilatation, ap- pearing suddenly at some point in strong contrast with the volnmn of the bronchus from which it springs, continues so throughout the whole extent. Sometimes the dilatation appears only in the smaller bronchi, which have then but a slight though perceptible increase. We have never seen the spindle-shaped form of dilatation in which a bronchus dilates and contracts again almost immediately, in a manner to simulate a small cavern. Only two cases have presented a thickening of the walls of the bronchus ; in one of these it was tripled, and might have been re- garded as chronic with relation to the concomitant disease. The dilatation sometimes has invaded a large part of the lung; in other cases we observe it limited to a space not exceeding a small In all the cases except one, the dilated bronchi were surrounded by diseased tissue, either hepatisation or carnification ; in one case we found only a vesicular emphysema without any inflamma- tion. If the bronchi be dilated in their extremities, the incision of the mug presents a surface strewn with a number of little cavities, communicating with each other, and with the bronchi of which they appear the continuation. The communication of one with the olher is made through an opening in a simple membranous partition, or by means of a cylin- drical canal apparently a dilated bronchus, and which often fur- nishes branches themselves involved in the same disease. It may happen, however, that these channels of communication are yet in the normal state. The greater part of these cavities are surrounded by the lung, but in some instances existing at the surface they are merely en- closed by the pleura, forming externally a small protuberance, and collapsing immediately upon puncture, in this manner simulating emphysema. These little cavities contain the same liquid as the bronchi, their parietes are smooth, thin, and lined by what is evi- dently a continuation of the bronchial mucous membrane. This is the alteration liable to be mistaken for the little abcesses of lobular pneumonia, but we have already pointed out the diag- nostic differences between the two. We have now to decide if the dilatation of the bronchus be con- sequent or precedent to inflammation of the parenchyma. Although 16—b ril 2 13 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDRE difficult of decision, it has seemed to us that the dilatation haseitier commenced at the same time with the pneumonia, or been d va- ioped in its course, as by the physical signs we have never detect ;d any symptoms anterior to those of the pneumonia. Its formation is, perhaps, entirely mechanical, from the sojourn of an abund i-it mucous secretion in the bronchial tubes. A supposition strength- ened by the absence of any thickening of the parietes of the bron- chial tubes thus affected. Colour—Thickening—Softening. . The alterations of the mucous membrane, as demonstrating their inflammatory state, merit a very peculiar attention. We are not to think, however, that an inflammation can be as easily demonstrated here as in the intestinal mucous membrane. The conditions of the two cases are widely different, for, 1st, th3 simple section of the lung covers the mucous membrane with blood, so as to require a careful washing, to arrive at proper conclusions of the colour; and 2d, the bronchial tubes, becoming thinner and more transparent in proportion as they become finer, allow the sub- jacent tissue to impose its own colour upon that of their niucojs membrane. We are driven therefore to a careful examination of the appear- ances furnished by the formation of strips; now these strips although easily obtained in bronchi of any size, are no longer so when the caliber commences to less;-n, even before it has become capillary. In this case then, the tenuity of the vessel opposes it- self to any elucidation, by this means, of the pathological anatomy. Nevertheless we have thought ourselves justified in admitting the existence of a capillary bronchitis, whenever we have found a redness equally diffused in the mucous membrane in spite of a different colouration of the subjacent tissue, and more especially when the liquid in these bronchi was abundant. We have established, yet but rarely, the softening and redness of the mucous membrane by the aid of the formation of strips ; but in the great majority of cases these lesions have escaped us, and we are compelled to acknowledge that the existence of the capil- lary bronchitis can seldom be proved by pathological anatomy. Liquids in the Bronchi. As yet these have not attracted any particular attention, and although we have made them the subject of a particular study, our examinations upon this point have been by no means com- plete. We find, however, noted in our observations the greater or le?s abundance of these liquids, and the presence or absence of air in ihem ; atoms: but its value as such is much affected, inso- mt i.i often occurred before the other signs of pneumonia couk ) i md to exist. In more than one half of the cases it is noted v .; but in those where it was observed as frequent, it ince, te sensibly in proportion to the progress, and in direct ratio ' . . extent of the inflammation. It diminished, however, witi rgth of the patients, and in the last days of life it was entire! ,i.;ng. Nearly always it was dry, and in eight cases it exis ^ .a paroxysms ; but in five of these there was a complication of hooping-cough and very intense catarrh, and in another a pleu- ritic effusion. Once it was remarkably hoarse, in a child at- tacked with measles, at whose autopsy we found an erosion of the vocal chords. An important fact to be noticed in the history of this symptom, is the period of its appearance. In children from two to four years of age, whatever were the circumstances under which the pneu- monia was developed, and whenever it has appeared under our observation, the cough has always manifested itself at least a week before the decided commencement of the inflammation. In older subjects, in cases of an idiopathic inflammation, the cough, the acce- leration of the pulse, and respiration, marked the opening of the dis- ease, while in the contrary case, when the affection complicated a catarrh, the cough was heard before the signs of the pneumonia were at all marked. The expectoration in our patients, from two to five years of age, was wanting, in the greater number of cases, and has been noted only four times; in one it was sero-spumous, in two others sero- mucous, and in the remaining one sero-mucous, tinged with ver- milion-coloured blood. In those from six to fifteen years it was nearly always present; in seven cases the sputa were coloured and five times tinged with blood : in two cases of idiopathic pneumonia they possessed the rusty tinge peculiar to the disease in the adult. RATIONAL SYMPTOMS. 43 We arrive, thus, at the same result as Dr. Gerhard, who, in twenty patients, only met this kind of sputa three times. In the young children it was very difficult to assure ourselves of the existence of pains in any part of the chest, both from their want of the power of expression, and the difficulty of the appreciation of their existence by percussion. We have, however, assured our- selves of the presence of this symptom in three cases, in two aged four years, and another five: one of the two former had been attacked at the hospital with the disease, while in tolerably good health: in the remaining two, the inflammation supervened in the course of, or soon after, the measles. In the two former the pain was seated below the nipple, in the latter it was sternal, and, con- sequently, not corresponding with the pneumonia, which was situ- ated antero-posteriorly on the right, and postero-inferiorly on the left side. In patients from six to fifteen it was more often noted, as we have encountered it twelve times. The epoch of the disease, at which the pain appears, is variable: sometimes it is the commencement, and, after a duration of some time, we have found, at the autopsy, old adhesions : at other times, the pain appeared at the end of the disease, or during the last days of life. This thoracic pain was not as characteristic, nor of as long con- tinuance, as in the adult: although really pleuritic, it has never, in our cases, lasted but from one to three days. The thorax in the greater part of our patients was well formed : we have, however, observed in four cases that the chest was con- tracted in front, and compressed on the sides, in a very sensible de- gree : these children were aged twenty months, and two and three years. In two other subjects the chest was remarkably arched in front. Rickets, so frequent in children, is the special cause to which we are to attribute all these alterations of symmetry; but it would be difficult to determine exactly the precise influence of these deformities upon the production of pneumonia. In children from two to five years of age, the decubitus was either on the back, or indifferent; but we must mention that the two patients, attacked with the pleuritic pain, changed immediately after its invasion their mode of lying; thus—before, they lay indif- ferently on one side or the other, but afterwards one preferred the side of the pain, the other the opposite. In the children betvveen five and fifteen years, the decubitus has offered nothing specially worthy of note. The respiration and the circulation were not the only functions offering remarkable disorders. The nervous system, so liable to impressions in the child, presented various lesions in two thirds ot our cases—in all the young patients from two to five years, and in half of those from five to fifteen. In the former, the symptoms consisted most generally in an anxiety and an agitation, sometimes carried to extremes. They showed themselves ordinarily at the commencement, and rarely 44 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN- continued throughout the whole of the disease. In the greater part of our patients this excessive anxiety was very well explained by the extent of the disease, occupying the greater part of the lungs; but in a child of two years, presenting only a few nodules of pneu- monia, it must be referred to the eruptive fever which coexisted with it. Other patients, far from presenting this agitation, offered a re- markable prostration and somnolence: in two of these cases the disease attacked in tolerably good health, and the hepatisation occupied all the lobe of one lung. The children from six to fifteen years, especially the youngest, presented sometimes an extreme anxiety, attended even with deli- rium : in other cases of the disease, complicating other affections, we observed a remarkable depression of the strength, frequent gid- diness, &c. In a young girl, aged fifteen, attacked with the pneu- monia during convalescence from typhoid fever, we observed the return of the typhoid cerebral symptoms at the same time with the development of the new inflammation. In a single case only have we been able to observe those symp- toms on the part of the nervous system, considered by some patho- logists as simulating a cerebral affection. These pseudo-meningites, appearing in the course of a pneumonia, are not so common as they have been hitherto pretended: and if we glance at some of the observations reported as examples of this particular form, we find many of them to be well-marked cases of typhoid fever; for ex- ample, M. Leger's case, (pneumonia of the right side, with enteritis and ataxic symptoms.) Nevertheless, there do exist in the Gazette Medicale two or three examples of this particular form. Finally, in one of our younger patients, (a child of five years,) a pneumonia supervening in perfect health, assumed the typhoid character. Headach was inappreciable in the greater number of our pa- tients. Nevertheless, we have observed it once in the midst, and once at the commencement of the disease, both times in patients aged four to five years: five only of our older patients have made any complaint, nearly always at the commencement, and, at times, during the course of the disease. Of these five, four had idiopathic pneumonias, and the fifth a pneumonia accompanying measles. When the headach did exist, it was frontal, and was of no great intensity. In more than three quarters of the cases the digestive tube was in a more or less abnormal state. Most were attacked with diar- rhoea, slight in some cases, but more abundant in others, and con- stituting one of the affections during which the pneumonia fre- quently developed itself, (chronic enteritis.) The abdomen was without pain, tympanitic, or the contrary: the tongue, nearly always moist, was often covered with a white or yellowish coat. In two children, one aged three and the other four years, there was slight spontaneous vomiting, but only in the first day of the disease. We have seen the appetite persist in some children SKETCH OF THE DISEASE, ITS PROGRESS, &C. 45 attacked with a pneumonia, which progressed very slowly, (it was of the simple lobular form in two of these.) In cases, on the con- trary, where the inflammation was extensive, and assuming a very acute type, the anorexia was complete, and in these also the thirst was extreme, far exceeding any thing of the kind in the adult: thus, we have seen young children swallowing with avidity every liquid that was presented to them, and only desisting from the necessity of respiration. In the older subjects the digestive tube has offered no remarkable symptom; thirst and anorexia have been noted in all the cases, and sometimes there existed vomiting. After thus enumerating one by one all the symptoms presented by the pulmonary inflammation of children, we ought to examine them grouped together, forming a single morbid entity. We should seek to sketch a picture of the disease, showing its diagnosis, and the march of its different varieties. This will form the subject of the following chapter. CHAPTER VII. SKETCH OF THE DISEASE, ITS PROGRESS, &C. Before commencing this description, what shall be the elements of our divisions? Shall it be the pathological anatomy? Shall we describe, as have done all our predecessors, the lobular and lobar pneumonias as two distinct diseases ? Or, imitating the ex- ample of Gerhard, shall we form two great varieties, dependent on the ages of the patients attacked by the disease ? Or, further, shall we divide our patients into two categories, according as the disease attacks in full health, or supervenes upon some other affec- tion, which it complicates? The details into which we have already entered have shown us, that the two forms of pneumonia are confounded by very appreci- able gradations, and that the symptoms of a lobular pneumonia, be- come general through the lung, do not essentially differ from those of the lobar form: consequently, with the pathological anatomy tor our sole guide, we should find ourselves obliged to divide very much our descriptions, for the same patient often presents on one side a simple lobular pneumonia, while in the other there exists he same form rapidly becoming general: now, how distinguish in the same patient the symptoms and the progress of these two diseases ? No more should age be the sole base of our divisions, since the study of symptoms demonstrates to us that the form assumed by the disease, and the progress that it follows, depend more upon the conditions n which it manifests itself, man upon the time of life 46 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN- at which it overtakes the patient. Finally, the mere consideration of the anterior state of the health will no better assist us to class under one head all the varieties of the pneumonia of children. Adopting, then, no one of these divisions exclusively, we will lay them all under contribution—and desirous of presenting a complete picture of the disease, of producing the physiognomy and the particular expression of its different varieties; in fine, of giving, in a word, a description which shall enable all, now unacquainted with the pneumonia of children, to arrive easily at its diagnosis, we have thought best to establish the following species—two prin- ciples have served us for basis. The first, that the form of the dis- ease is dependent upon its exciting cause. The second, that the progress it follows partakes of the nature of the affection, in the course of which it is developed : thus, the simple lobular pneumo- nias become general, and the lobar pneumonias supervening upon a long-continued affection, are clothed with the particular attri- butes of chronic disease—while those, on the contrary, which arise in perfect health, or in the course of an acute disease, take to them- selves the acute characteristics. Hence two divisions. 1. Simple lobular pneumonia, the lobular becoming slowly ge- neral, or the lobar form supervening in the course of a chronic affection. 2. The simple lobular, the lobular rapidly extending itself, or the lobar form attacking the patient in perfect health, or in the course of an acute disease. The first species is peculiar to the younger children, supervening generally upon the chronic ententes so common at that age, some- times after the exanthematous fevers, but in these latter long after the disappearance of the eruption. As it thus appears in patients, emaciated and enfeebled by long standing disease, its external symptoms are not well defined. The cough is rare, sometimes even not present: the pain of the chest does not exist, the expectoration is wanting, the skin pale and cold, with oedema of the face and extremities : usually, however, at the moment when the disease tends to become generalised, there ap- pears a movement of reaction, manifested by an acceleration of the pulse and respiration, and an increased heat of the skin. The disease would, however, often continue completely latent, if auscultation, coming to our aid, did not reveal the symptoms of which a former full detail renders the enumeration unnecessary. Despite the diarrhoea often colliquative, the appetite frequently remains in full force and the thirst is not augmented: the skin is covered with ecchymoses and furuncles. Ulcerations arise either on the nates or on blistered surfaces—the emaciation makes rapid progress and the patient succumbs in the last degree of maras- mus. Of all its forms, it is when in the simple lobular state that the pneumonia is most difficult of recognition, but then also its diag- nosis is least important- supervening under the most unfavourable SKETCH OF THE DISEASE, ITS PROGRESS, &C. 47 conditions, and at an epoch when disease has already undermined the powers of life, it adds but little to the gravity of the prognosis. Surely it well merits the name of asthenic, given by M. de la Berge : but this appellation applies throughout its whole extent, without any particular reference to his supposed second period, which we confess has always escaped us. But even if we would establish two periods for the disease, the first should be the asthenic and the latter the sthenic, since, (as we have already explained) the reac- tion takes place in these cases only at the moment of the generali- sation of the pneumonia, and this generalisation is the last period of the disease, the one immediately preceding the fatal termination. 2. The simple lobular, the lobular generalised, appearing in an acute disease, with the lobar species under the same circumstances or in perfect health, assuming an acute form, constitute our second division. They all follow the same course in children from two to five years: in those from five to fifteen they present some slight differences between themselves. The pneumonia of the former age presents two well marked distinct periods, the one, which may be called catarrhal, the other inflammatory. The catarrhal stage presents nothing constant as to its length of duration, but is always appreciable by its cough, generally not intense, slight alterations of the respiratory murmur, the sonorous or sibilant rales, the mucous cracklings, &c, without any accelera- tion of the pulse or respiration : the appetite is preserved, and the child still continues its sports, until finally there appears suddenly and simultaneously an acceleration both of the pulse and respira- tion, (marking the second period :) the skin becomes burning, the alee nasi are widely dilated, and there is an anxious expression of the face: the agitation, sometimes extreme, is replaced in <- mantle disease in the adult. It commences by fever, thirst, an- >;exia, pain in the head, cough, pain in the chest, and sometimes omiling: auscultation discovers a crepitous rSle, bronchial respi- : r.nd bronchophony; the expectoration is often bloody but 'y '^ty ; the acceleration of the pulse and respiration is con- s■... !'-■:■•::. The nervous symptoms are sometimes rather pro- nov; - -• ' ;d Ave observe intense headach with anxiety or even del. .According to Gerhard and Rufz the mean duration of this ;: irteen days. In the few cases we have seen, it has been ..>; Ter; one of our patients quitted the hospital the twenty : v f his disease with the bronchial respiration still present; :■; s ■•••. -uherthe subcrepitous rale, which had succeeded it, endure c ■■>;:■ -s. CHAPTER VIII. l ] DIAGNOSIS. -ition of the symptoms to assist us in the recogni- a of children, let us see if there be no danger t with any other disease of the respiratory organs. After *'r tion of tn of confc DIAGNOSIS. 49 For example, what are the differences between pneumonia and pleurisy, bronchitis and phthisis. Simple pleurisy is a very rare disease in childreti from two to five years ; for our part, we have never met it, for whenever we have found a liquid in the pleuial cavity, there has always existed an hepatisation of the lung, thus usually confounding the symptoms of the pneumonia with those of the pleurisy. In one case the absence of all respiratory sound, where a bronchial respiration had been heard, immediately aitei the declaration of a pleuritic pain, enabled us to recognise an effu- sion complicating the hepatisation. We may also remark, that the access of suffocation, mentioned in two of our observations, ap- peared of some value as diagnostic of an effusion into the pleura. cavity. But we must not assign too much importance to this symptom, as we are not certaiu that a rapid hepatisation may not jjive rise to the same phenomenon. Among the observations of MM. Constant and de la Berge, we find two of a pleuritic effusion diagnosticated by percussion and change of position. In the older children, simple pleurisy is still a rare affection, dif- fering however in nothing from the same disease in the adult. A bronchitis severe enough to produce constitutional symptoms is certainly very rare in children from two to five years. In the immense majority of cases, when it puts on this form, it is compli- cated with lobular pneumonia, and we have, in speaking of the diagnosis of this latter, alluded to the great difficulty of distinguish- ing these two affections, especially where the bronchial element is predominant. A catarrh in the younger children not determining any symptoms of reaction is characterised by cough, sonorous and sibilant rales, mucous cracklings or even the subcrepitous rale, but this latter is in general of short duration and its bubbles are very unequal. As we have often heard a subcrepitous rale in cases where we have afterwards found pneumonia, we would guard against being understood to assert, a subcrepitous rale heard on both sides of the back to be a pathognomonic sign of bronchitis, such an assertion would be in flagrant contradiction to facts, which we have detailed above. In children from five to fifteen years, a pulmonary catarrh fre- quently complicates other affections, measles, hooping-cough, typhoid fever, &c, but it is also observed idiopathicaily, and then it presents no difference in its symptoms with that of the adult. The tuberculous affection of the lung ; can this simulate a pneu- monia? In speaking of vesicular pneumonia we had occasion to remark that a superficial examination might mistake the granula- tions of inflammation for those of tubercles, and we have thus pointed out their characteristic differences. Inattentive observers also might regard the small abscesses of the lung as tubercular excavations, but in those latter when existing in the parenchyma, the surrounding tissue and the age at which they occur prevent all mistakes of this nature. In fact we all know that in children, of 16—d ril 1 ' j* 50 RILLIET AND BARTHLZ ON PNEUMONIA OF CHILDREN- two or three years, the tuberculous affection is rare, and that in the cases where it is found to occur, the tubercles have never advanced beyond the crude state. In older subjects, phthisis becomes ex- tremely frequent, but its chronic character most generally diagnos- ticates'it from pneumonia. The diagnosis however is often very obscure, especially when we are deprived of an accurate informa- tion of the origin and progress of the disease.—To choose some examples illustrative of this subject. A child" has the skin hot, an intense fever, dulness on percussion, and bronchial respiration un- der one of the clavicles. Is it attacked with pneumonia / We have frequently seen this question decided in the affirmative and a treat- ment, consequent upon such a view, applied to the case ; but ne- vertheless the autopsy has proved these symptoms, in the great majority of the cases, to be dependent upon a tuberculous infiltra- tion of the lung. Besides such a diagnosis might be given a priori. as a glance at our table of the seat of the lesions shows only two cases of pneumonia limited to the anterior portion of the lung, and only one of hepatisation immediately beneath the clavicle. The signs of an idiopathic pneumonia under the clavicle, although rare, do sometimes exist, when this affection is developed in a tubercu- lous subject. And as the young patients are often brought to the hospital for the complication alone, with the very incomplete in- formation we can obtain of the former health, we might easily overlook the original disease, and give a prognosis founded on too favourable a view of the case. In these difficult cases great regard is to be paid to the intensity of the febrile movement, and the pro- gress of the disease. Thus, a persistence of the physical, after the decline of the rational, symptoms is very probably due to a tuber- culous affection. But finally, when the tubercles, surrounded with the pneumonia, exist at the posterior part of the lung, the difficulty of the diagnosis increases greatly, from the doubt created by the seat of the disease. And this is not all ; when the tuberculous affection, instead of being confined to a limited space, is scattered profusely through the whole parenchyma, as is so common in the acute phthisis of children, the diagnosis is far from being clear. Thus, in those cases of equally disseminated tubercles, without any surrounding pneumonia or bronchitis, we have many times found no other phy- sical signs than a rudeness of the respiratory murmur ; and if there be bronchitis or presence of mucus, we have a mucous or subcrepi- tous rale ; very nearly the same symptoms as in the simple lobu- lar pneumonia. Now as this latter affection, as well as phthisis, is the frequent successor of measles, we can, in such a case only form our diagnosis upon the collateral evidence and the final pro- gress of the disease. Suppose, in a case of hereditary predisposition to tubercles, we observe, after measles, that the cou^h continues, that for a month after there is still heard the mucous rale and that the child emaciates with an attack of fever, each evening • with DIAGNOSIS. 51 these symptoms alone we might suspect the existence of tubercles. If, however, after the measles in a healthy well constituted child. there still exists a violent fever, cough, mucous or subcrepitous rales, succeeded by an expiration and then bronchial respiration, we might believe in a lobular pneumonia which has finished by becoming general. We see, therefore, there are many cases where error is easy, and we ought to suspend our diagnosis till after some days' examination. Finally in a last case, the difficulty of the diagnosis depends no longer merely on the combination of the phthisis and the pneu- monia, but lies entirely in the particular form of this latter affec- tion. If, in fact, we recall the particular character given to our first species, we shall recognise in them nearly all the symptoms of phthisis arrived at its last degree. The cough, the colliquative diarrhoea, the extreme emaciation, the paleness of the skin, the infiltration of the extremities, &c, what are these but the collection of symptoms assigned by all pathologists to the tubercular disease, in its most advanced stage. Despite an appearance so deceitful, however, the diagnosis will not be very difficult, since it must be one of two things ; either the pneumonia will be simple, and then, the physical signs bearing no proportion to the gravity of the con- stitutional affection, will indicate that we have to do with a limited affection of the lung, as a tubercular disease accompanied by such grave ceneral symptoms presents ordinarily physical signs indica- ting a considerable alteration of the pulmonary parenchyma, or else the pneumonia will have passed to a generalisation and as- sumed the lobar form, and the stethoscope will inform us that the disease exists at the posterior part of the lung, is double, &c. &c ; in a word, we shall recognise by it all the signs of a pneumonia. The progress of the malady will also present various differences between the two diseases; thus, generally the diarrhoea precedes the cough in the pneumonia, while in phthisis it appears at a period more or less distant from the commencement of the disease. And to conclude with the final difference, we will cite the age at which both the affections are developed. Our first variety of pneu- monia is most often met with in children of two and three years of age, while at that period of life pulmonary phthisis is very rare. CHAPTER IX. PROGNOSIS. The gravity of the prognosis varies with the age and the different forms of the disease. It may be advanced, as a general proposition, that a pneumonia is the more dangerous in proportion to the youth of the patient. Our tables very manifestly prow this, and the re- 52 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN- searches of MM. Valleix and Vernois, at the Hospital of the Enfans- Trouves, give a further weight of evidence to this assertion. As to the influence of the different forms, the pneumonias of our first species are grave in consequence of the disease which they com- plicate. They are, in fact, nearly necessarily mortal. Grounding upon the experience of our predecessors, and upon our own in par- ticular, we would call them always fatal, if it were not for a re- markable case before us, of recovery in a child placed under the most unfavourable circumstances. The secondary forms of pneumonia are, at all ages, of an ex- treme gravity: thus, of eighty-one pneumonias, complicating very various diseases, observed in our service in 1£37, seventy-seven have terminated fatally. The pneumonias in the youngest chil- dren, supervening upon a good state of health, or merely upon a slight catarrh, most usually recover: eight patients, from three to five years of age, have recovered from the disease under these cir- cumstances. And, finally, the inflammation of the lung, in children from five to fifteen years, occurring in good health, arrives, in the immense majority of cases, at a happy issue. All the patients of this latter category have recovered: this result, based on so few facts, might be contested, if other observers (Gerhard and Rufz) had not arrived at the same conclusion, after an examination of a much larger number of cases. A general prognosis from the study of the circumstances of the developementof the disease being thus established, it remains to en- quire if particular symptoms indicate, in any positive manner, a greater or less gravity of the affection. The state of the pulse is one to afford us the greatest aid. Its acceleration is generally in a direct proportion to the intensity of the disease: but, in addition, at an advanced period of the malady, we have observed a character already mentioned, but upon which we would especially insist in this connection, viz: the smallness of the pulse. Every time, when this has been noted, death has not failed to appear in a few hours, or a couple of days at the utmost. The cessation of the cough, the chilliness of the extremities, the purple hue of the face, coincide ordinarily with this smallness of the pulse, and announce a speedy dissolution. CHAPTER X. TREATMENT. The therapeutical is, without dispute, of all parts of a monograph, the one meriting the most serious attention. The final end of all medical research, it constitutes the only portion really practical. TREATMENT. 53 Therefore, in the study of the treatment, we have not confined our selves solely to our own observations, but have laid under contri- bution those of our predecessors. Unfortunately, too often their assertions are contradictory, and their opinions without proof. In the hope that an examination of particular facts might throw some light upon this present question, we have analysed, with a special care, nearly ninety observations, inserted in different jour- nals of medicine, or in the different monographs already alluded to: but we have to regret the little fruit of our labour, in consequence of the lamentable deficiency of detail. In the interpretation of facts, as also in the estimation of the the- rapeutic value of our observations, we have adopted the following method:—after as complete as possible an assurance of the proper ad- ministration of the remedy, we have endeavoured to appreciate its influence upon the progress of the disease, and we have laid parti- cular stress upon the period at which the treatment has been com- menced. The comparative variations of the pulse and respiration, together with the physical signs, have served us to denote the increase or decrease of the disease. We have, besides, examined the action of the remedy, considered both in the first dose, and after a continua- tion of several successive days. And, finally, in the appreciation of the final result, (death or recovery,) we have taken into the ac- count, as an essential element, the nature of the pneumonia which we had had to treat; for, if our details upon the subject of prog- nosis be remembered, the reader will recollect the immense influ- ence upon the termination of the disease exerted by the conditions of its development. With the exception of some particular medication, exacted by special indications, the treatment has always been composed of two parts: one common to all diseases, (hygiene,) the other special to the disease before us: we commence with this latter. The principal measures directed against the inflammation have been, 1. Bleeding; 2. Antimonials; 3. Derivatives applied to the cutaneous system. We shall first examine the effects of the separate employment of each of these remedies, and then the influence of all combined. Bleeding. Opinions of authors vary much as to the influence of bleeding in the pneumonia of children. Thus, some proscribe it absolutely, while others make it the basis of their treatment. Some prefer o-eneral, others local bleeding. It should be remarked, that those employing the bleeding, dread to carry it too far, lest the patient may never recover from the collapse. We have cited, however, an observation (perhaps unique in science) of a child treated by the formula of repeated venesection. A favourable issue, however, in this sino-le case would not induce us to dare to imitate such an ex- 54 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN. periment. It must be remembered, however, that the child, though only aged two years, was in perfect health at the commencement of the disease, and, therefore, in the most favourable situation : and further, when we scrutinise the details of the case, we find the amelioration to have commenced only the seventh day from the invasion, that is to say, the bleeding does not appear to have sen- sibly advanced the epoch of the usual resolution of the hepati- sation. Having just said that practitioners did not push very far the loss of blood, we give here their usual method. In children from two to four years, local bleedings are generally alone employed, either by leeches or cupping glasses. At this age, twelve or fifteen leeches, three or four times repeated, are the usual extent. In older child- ren, they employ bleeding from the arm proportionate to the age of the child and the intensity of the disease ; thus, in a child from five to eight years, four to eight ounces of blood at once: in those from eight to fifteen, eight to twelve ounces. In some particular observations, this moment under our eyes, (Gazette Medicale,) we noticed bleeding to nine ounces, repeated twice, thrice, and four times in children from twelve to fourteen years. After this general indication of the methods of different prac- titioners in the employment of this remedy, we will discuss the efficacy of such a treatment. Here we shall find a wide difference between the idiopathic and the complicated pneumonias. Ger- hard thinks copious bleedings may be of advantage in the idio- pathic pneumonia of children from six to fifteen years. He has remarked the immediate ettect to be a diminution of the intensity of the general symptoms, (headach, agitation, oppression, &c.,) with- out, however, any appreciable influence upon the duration of the disease. The analysis which we have made of different observations does not comprise all these results: we find in many the bleedings, even copious, to have had not only no appreciable effect on the pulse or respiration, but also none upon the patient's general condition. Thus, M. Blache has inserted, in the Archives de Medecine, (1837,) several cases of pneumonia, in which no amelioration whatever followed the loss of blood. Besides, we may make this general remark, that the amendment in the symptoms succeeds rarely to the first bleeding, but follows only the second or third, at a time corresponding to the seventh and ninth days of the disease. We may, therefore, establish as a principle, that, although of some ad- vantage in idiopathic pneumonia, the utility of bleedino- appears restrained within very narrow limits. If, now, we attempt an appreciation of its influence in the com- plicated species of the disease, we shall be struck with its want of influence not only upon the termination, which is nearly always fatal, but also upon the progress of the disease, which undergoes no sensible modification. If proofs are sought, we have only to^o-lance TREATMENT. 55 at the observations, by M. Blache, of pneumonia complicating hooping-cough, to read the reflections of M. Baudin on the treat- ment of the disease after measles, or consult many other observa- tions scattered in the different periodicals, and we shall be terrified with the immense proportion of the mortality, and the complete In efficacy of the subtraction of blood. We may add, in confirmation, that M. Becquerel, who made his observations in a service where this mode of treatment was solely employed, has never seen a case of recovery in the disease, com- plicating a pre-existing affection. To give some idea of the action of bleeding, we will report suc- cinctly the history of three of our patients, the only ones submitted to this treatment. Their ages were two, five, and six years: in the first two the disease was developed in tolerable health, in the third it complicated a hooping-cough. In the first, (the child of two years) on the sixth day of the disease, five leeches were ap- plied to the right side, the bites of which furnished an abundant quantity of blood. On the morrow there was a sensible ameliora- tion, the pulse had fallen from 1G0 to 120; the bronchial respira- tion' and the dulness on percussion, which before occupied the whole of the inferior lobe, were much scattered ; the coloration of the countenance gave place to paleness ; a calm succeeded to the agitation, &c. ^The child of five years was bled, the sixth day., to six ounces, when the pulse was 140, the respiration 36, and a bronchial respi- ration existed in the middle third of the right lung: the morrow, seventh day, the respiration was bronchial in both its times, the percussion but slightly resonant in these points, the pulse 120, respirations 44. Six leeches were applied to the right side. The eighth day the pulse was 120, the respiration 34, and the bron- chial respiration was heard in the wholf height of the lung. The ninth day, pulse 120, respiration 34, bronchial respiration limited to the summit, with subcrepitous rale beneath. The tenth day, pulse 100, respiration 28, bronchial respiration at the summit, &c. In these two cases there appears to have been some influence exerted upon the progress of the disease. But it should be remarked that if, in the first, the amelioration succeeded immediately Oie ap- plication of the leeches, it was only definitive on the seventh day, that is to say, at the very time when the pneumonia, supervening in aood health, has the greatest tendency to assume, of itself, a favour- able change. . In the second, the resolution of the pneumonia appeared only tne ninth day, despite the bleedings of the sixth and seventh. And as to the final result, (recovery,) we must recollect that our patients were both placed in very favourable circumstances, and in a class of the disease nearly always terminating in health. Our third child was not in the same condition : the pneumonia appeared in the midst of a hooping-cough, or rather of a catarrh, with very intense paroxysms, and the disease had already deter- 56 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN. mined a formidable constitutional reaction when the inflammation of the lung was developed : so great a loss of blood, (one bleeding of six ounces, and twenty-two leeches applied at different times,) exerted no influence upon the pulse, respiration, or march of the disease. Autimonials— Tartar Emetic. In the examination of the effects of antimonials, and of the tartar emetic in particular, we were obliged, from the complete want of published facts, to have recourse solely to our own observations. We find, it is true, many cases in authors, entitled cure of pneu- monia by tartar emetic, but in nearly all, bleeding has been em- ployed in concert, constituting the mixed method, of which we shall soon have occasion to speak. Nine of our patients took the tartar emetic carried to a high dose. Six of them were aged from two to six years, three from eleven to fourteen. The portion given to the youngest contained three and four grains,1 in five ounces of the vehicle ; for the older, the dose was five to six grains. They took a spoonful every two hours, and when the first produced vomiting, they delayed the following doses: in general, a tolerance was quickly established, though sometimes we had to encounter vomitings, and, in one case, a somewhat pro- fuse diarrhoea, lasting several days. The vomitings seldom endured after the first dose, or, in general, they were not numerous, and ceased sometimes even under an in- creased dose of the remedy. We have never seen any accidents from this medicament, except in two cases of a pustular inflamma- tion of the fauces. This inflammation, due entirely to the local action of the remedy, and so frequent in the adult, has been ob- served in nearly all the patients of this year, treated with the tartar emetic: it presents no particular gravity, and yields usually in young children, as well as in older subjects, to the simple emol- lients. What has been the influence of the tartar emetic upon the termi- nation and the principal symptoms of the disease? Of nine patients four have recovered, and two of these under rather unfavourable circumstances: thus, one had a pneumonia after small-pox, the other a double pneumonia, complicating the measles. Our third was a child of three years, attacked from the commencement with a slight catarrh and a chronic eczema : and, finally, the fourth case of recovery is a young girl of eleven years, of a scrofulous consti- tution, but otherwise in good health at the commencement. Two of these commenced the treatment the first day, the other two at the sixth day only. The whole quantity taken by each has varied from sixteen to twenty-four grains. In these four patients the ' In giving the amount of doses of medicine, the quantity per diem is in- tended, this being the form of prescription in the Parisian hospitals__P TREATMENT. 57 emetic tartar appeared to exert some influence upon the pulse and upon the respiration, but this influence has not been in all the cases durable, and in three of the cases it nuuiifested itself nearly at the same epoch in all, viz: from the seventh to the ninth day of the disease. As to the patients who succumbed, they were placed in the most unfavourable circumstances: three were already attacked with measles and with typhoid fever, and the remaining one was a child of two years, with a double pneumonia complicated with a pleuritic effusion. We have, however, been able to remark a de- cided influence upon the pulse and respiration, even in those of the fatal cases, where the dose was a little elevated : but there was no decided effect upon two patients who took only six grains. If we sought to draw any general conclusions from this small number of facts, we should say, but with reserve, from the small- ness of our numbers, that the tartar emetic may be employed with success in the child ; that there is no danger in a somewhat ele- vated dose; that the tolerance is generally easily established ; that the gastro-intestinal accidents give little cause of fear; and. finally, that this medicament appears to act more directly upon the pulte and respiration than upon the hepatisation itself. The combined Method of Treatment, Bleeding and the Tartar Emetic. After this attempt at a separate estimation of the value of bleed- ing and the tartar emetic, we will examine their combined influ- ence upon the disease before us. We have discovered in various authors thirteen cases, giving somewhat circumstantial details upon this mode of treatment. In all these cases the tartar emetic has been given after more or less copious bleeding, and at some dis- tance" from the commencement of the disease. All the patients thus treated and attacked with idiopathic pneumonia, (aged from nine to twelve years,) have recovered, with the single exception of one, who succumbed, with a gangrene of the mouth supervening upon the pneumonia. Two children, in whom the pneumonia was developed around a tuberculous affection, have died, although in one of them there look place a very sensible amendment of the symptoms after the first dose of the antimony. As to the influence of this method of medication upon the progress of the disease, it has appeared to us, after an attentive perusal of the foregoing ob- servations, that the combination of the two methods exerts a more decided influence upon the general and local symptoms than the employment of either one separately. Thus, although in genera! the amelioration appears from the seventh to the ninth day, as in the cases treated by the tartar emetic simply, we find in two or three cases an amendment of the symptoms on the fifth or sixth day • and more than this, in all the cases, even in those terminating fatally, a diminution of the pulse and respiration succeeded the first dose of the medicament, whatever was the period of the dis- 58 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN. ease at which it was employed. Three of our patients were sub- mitted to the combined treatment of bleeding and antimonials: all three were bled once or twice, and took besides, one the tartar emetic, another kermes mineral, and the third both the tartar emetic and the kermes. The tartar emetic was always given in the dose of one or two grains in a large quantity of water as vehicle, and determined numerous vomitings. The three patients submitted to this treatment recovered, but the pneumonias were all idiopathic, and the amelioration took place from the seventh to the ninth day. The facts already published are by no means sufficiently nume- rous to decide the grand question of the mode of action of the tartar emetic. Is it by absorption, or does it merely determine, by the vomitings, a salutary revulsion upon the digestive canal? Both these hypotheses are, perhaps, just; in some proof of which, on the one hand, the emetic tartar carried to a large dose, without vomiting, ap- peared to have exerted a happy influence upon the disease—while, on the other hand, a rapid amelioration followed its employment in doses producing vomiting in two or three patients, whose cases are now before us. In several of these cases, the analysis of which forms the basis of this article, we see that the dose of the emetic was sometimes carried to a great extent—thus, a child of fourteen years took, in all, one hundred grains, and even as high as ten grains, in the twenty-four hours; another, aged nine years, took daily from six to eight grains, &c. &c. In all these cases not the least accident has resulted. White Oxide of Antimony—Pulvis Antimonialis. Eighteen of our patients were treated with this medicament; ten in large doses, and eight in small. We have but little to remark upon these latter cases, as the remedy was never given at the com- mencement, nor throughout the whole disease. In these eight, the dose per diem varied between ten and eighteen grains in four ounces of vehicle, to which was added 3ij. or 3 i i j. of "syrup of dia- codium, (syrup of poppies.)' All these children, except one, are in our first division—that is, pneumonia supervening upon some chronic affection. Two of these recovered, but this cannot be attributed to the remedy ; in one case it was not commenced till the ninth day, when the pneumonia already tended to a resolution, whilst, in the other, (a child of eleven years, attacked with small- pox,) it was administered for only a single day. Of the other ten, we must eliminate two, who, dying the day after their entrance of very extensive pneumonias took conse- quently, only one potion of the remedy. The pulvis antimonialis was administered to children between two and five years of a°-e. ' The syrup of poppies of the London PharmacopcEia, as aiven in the United States Dispensatory, resembles the syrup of diacodium sufficiently to be considered as idenlical with it.—P. ' TREATMENT. 59 One other, aged six and a half years, who was attacked with a general capillary and vesicular bronchitis, cannot, consequently, be included among the pneumonias. The powder was given in emulsion or mucilage, in the dose (for children of two and three years) of half a dram in the twenty-four hours, carried as high as a dram and a half, or even two drams. Children of four and five years took from one up to three drams, or even half an ounce. Of these eight patients only one recovered, who had a lobar pneumonia involving the whole lobe. Of the others there was, perhaps, only one susceptible of recovery, judging from the pro- gress of the disease, the pathological anatomy, and the absence of complication. The influence of this medication has appeared al- most nothing upon the pulse and respiration, whether after a single dose, or many days' employment: if sometimes the pulsations did diminish in number, at others they increased, or remained the same. The same remark applies to the respiration, the variations of which presented no accordance with those of the pulse. But, upon the progress of the disease its influence was still less—in almost no case was there a sensible amelioration. In the only patient who recovered it was after the sixteenth dose, (the eighth day,) that the alteration for the better manifested itself, and the disease lasted, in all, eighteen or nineteen days, which would seem to indicate no abridgment from the pulvis antimonialis. However, the following happened in one of our patients : after the first dose, the pulse in- creased from 120 to 150, the respiration from 46 to 5<\ the physical sio-ns remaining the same; but, after four days of its administration, an amelioration was declared in all the symptoms, the pulse fell 30 beats, and the inspirations instead of 50 were 44: and the aus- cultation confirmed this great amelioration. The dose of the powder was diminished, and the next day all the symptoms re- appeared as violent as ever. It was increased again, the pulse fell to 100, the respiration to 34, without any sensible amelioration in the physical signs: the amendment, however, did not continue; all the symptoms were soon aggravated; and death did not delay- its appearance. , In this case, if the pulvis antimonialis really did exert no mani- fest influence, at least the coincidence between the administration of the remedy and the amelioration of the symptoms is a little re- markable. . , We have never observed any action of this powder upon the digestive tube, nor any accident from its employment, It must be allowed to have the power of slightly exciting the gastric mucous membrane, since in two of our patients treated the one with high and the other with small doses, and in whose stomachs, at the autopsy, we found some of the powder, there existed patches of red- ness, more or less vivid, at those points where it was in contact with the mucous membrane. 60 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN. The different observations published upon the employment of the antirmnial powder in the pneumonias of children do not at all con- tradict the results at which we have arrived. In many of them we can discover no influence of the remedy upon the pulse, respiration, or the inflammation itself; and in many, where its influence upon the progress of the disease is vaunted, it would seem impossible to decide whether the amelioration was due to the remedy, or whether nature herself had not performed the cure, the precise period of the commencement of the disease not being indicated in the observa- tions. It must be remembered that all our patients except in the case of recovery, were in the first category, that is, of pneumonias ac- companying some other grave disease, which are very universally fatal. Precipitated Sulphuret of Antimony.—Kermes Mineral. We have no where found any detailed observations upon the use of the kermes mineral in the pneumonia of children ; we must therefore have recourse solely to our own observations. Fifteen patients were treated by this medicament: of these we must elimi- nate four, to whom it was given in a small dose, as adjuvant merely, and not forming the basis of the treatment, and three others, in whom the disease was already too advanced to hope for any relief, de.ath supervening the day of the commencement of the treatment. The remaining eight patients were aged between four and four teen years, embracing therefore pneumonias of all the ages and species. The kermes was administered in doses of one and two grains to comvnence ; and was carried successively to twelve, fif- teen or even seventeen grains in the twenty-four hours, augmenting a grain about every visit; of these eight patients, three recovered, from an inflammation of- all one lung, or a lobular pneumonia. Among the other five, there was only one perhaps capable of re- covery, since he alone had no primitive grave complication : his pneumonia was well marked lobular, but so extensive at the day of entrance, that a fatal termination was prognosticated from the commencement. If now we attempt to seek the influence of the kermes upon the pulse, respiration, and stethoscopic signs, we find these three symptoms in soni3 cases increased, in others diminished, and in others remaining stationary. The general idea, however, which remains after an examination of the result of the treatment in all these patients, is that the kermes has exerted a favourable influence more often than otherwise, and therefore that it is a tolerably effi- cient remedy. But if we come to the analysis of each separate fact, we find that the cases, where the symptoms were aggravated after several days of treatment were precisely those, where the pneumonia w-© 0 AC C-5 ft. ft, h. 0 •- 3 J "3 '5 n..o a C cs 0 0 as OiJ JO ■e, S<2 S 2^3 = ^=lc32'a3'S ^•§s£5^o| « « a S">.5"5 c e-°.~.= eg 41 g ootf2f>ju>3S»;a ft. >- o g E 0« o-F » "3 3 3 4) 5 «.Sf Q >,o oo4i»;t;i;,:-4ij=ft. i s B 00 c-i=h 0» •* r-i r-c Cl 1 0 -oein 1 -r 0 «r-(NiN j tt a. 4) 3 X Ott s ■ £ OQ* - 4) S js 41 01 41 0 =3 ft. bo *^ bo 41 Z -3 > » bo bo 41 Sf *> 0) 41 41 Q ?5 oTS aT 41 0 c bog bo boo •3 "3 03 - ,-S ^ 41*-3 J ^ 41 C^ 41 ™ 41 3 41 a-3 £3-3 | b> — 3 "■§ eo^T3 3 m-3T3T3TS —' CI CN C2 Co **5 5 -a HS52 ""1 X *C T3 -a — ?i ^» c. Wnnrl | V5 """Ig 6 2:* = §.»!§ on-i-c 1^ — = 1 i 4; ■-.2 3 * ■--' 0 T — G1 <— 1—-v p- IT T3 — ■3 IS £ E 4 3 E 5. - S ^° 2 Z •-■? 3 4» Cud «j 0 ^ gft. . 5 "E §•" 02 »r «5 £~ 5 0 3. 41 <« bo S - 0 s O 41 J2 S bo.C ♦* «J~S O -50SISCC ( 2. '= ll S|^ 41 " C3 _ ft- — " -O * 4> C 4> ° O 4>— a> xs c 0. O.- 0)2 H « 41 ■- 01 .0 aJ *■£" "§ ft, at bo 4) -£S = 0 «og-- 5 "S «.5P.SP 3 j josas' a td bo C3S 41 j=^: n 0 41—41 ■° " "0 § 73-& c c c "0 •*! 0 '5.2 — ° ^ tceiE ^ >-7 -. = = = a lis = botcbcg Ci-C--0 ■—.-..-, C — 41 41 ft-Q«B5Cift4 JJ -"""- 1*° ' - i-« 1-1 (N 0 E 0 bo < t" 5 s gsjcjej 5 2 °? = < o» e» ° °? >,rt« A >.>. - f .A r- wn^tso^^wnt N *t"l/5 c 1 ci m •&•*• u> o>-■1 1 (N (N CO « v u a 3 >o 0 -W ^*< 3" V hi fc, ^ .2 5 « 3-2 0 0 a ■3 « 3 41 c . 01 ^ 41 .2 ll ra ft. -S5.2 « £ ° E.= C 3 s « E ja 0 ■z >M in 41 Ja 0 OJ2 S J OBSERVATIONS AND TABLES. 99 O CO a o S 3 CD C Q- 03 *j fan !* s o ;j2 Eh s o < . £ >-i o < >. «j r-J H c < Q 3 o rf £ h T3 £3 03 a, a fafl c bo s 3 41 O 41 eg 41 ■3 e 03 ■ E o u s o O Lobar pneumonia, 5 Generalised lobular pneumonia, 2 Simple lobular, 2 Vesicular bronchitis, 1 10 Ten cases of carnification were compli-cated by the above diseases: a last case was complicated by a pleuritic affection in one side only, although the pneumonia was doubie. Carnification, 5 Generalised lobular pneumonia, 4 Marginal pneumonia, 1 Lobar pneiinionia, 1 Vesiculai bronchitis, emphysema, and lobular pneumonia, 1 Emphysenii, 1 Tuberculous infiltration, 1 14 The cases are 14 instead of 13, as one sub-ject presented the dilatation with hepatisa-tion and carnification. S o 3 o o u M 41 a 2 .2 2E 41-— 01 COg oi ° S« o* 3 2J O OT 1-ift= 2 V 3 Form of the dilatation. Preservation of caliber, 3 Insensible increase, 4 Sudden increase, 1 Increase of three small bronchi, 1 Dilatation of the bronchial ex-tremities, 6 15 The cases are 15 instead of 13, as two of the subjects presented the alteraiicm under a double form. C3 41 to Double portion of the lower lobes of both lungs, ] Marginal double, 2 Right middle lobe, 4 Lobular, right, 1 Marginal, right, ] Root of left lung, 1 Left lower lobe, 1 11 Marginal, double, 2 Right upper lobe, 3 Right middle lobe, 1 Right lower lobe, 2 Root of right lung, 1 Ant. and inf. part of right base, 1 Right upper and lower lobes, 1 Left lower lobe, 2 13 41 bo < 2 yrs. 3 3 2 5 3 5 1-2 2 6 1 11 i-icommhcihf. \m a 41 3 3" 4> £ s m 41 J3 o | _ «J £ 4) 5s B o a CO O Dilatation of the Bronchi. Several very interesting consequences may be deduced from these tables: 1. Vesicular bronchitis does not exist in the simple state. 2. The lobular pneumonias free from all complication are very rare. ( 100 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN. 3. From eighteen months to five years the most frequent pneu- monias are the simple and generalised lobular ones. 4 Under this form the "pneumonia is always double; conse- quently it is the form of the disease rather than the age of the patient, which makes it double or simple. In proof of this, the lobular pneumonias which are far from rare between two and five years, ordinarily occupy only a single lung. 5. After the age of five years the lobular pneumonias are rare. 6. In the idiopathic pneumonias, the right lung is the most usu- ally inflamed: it is not the same in pneumonias complicating other diseases. r. The lobar hepatisations are more frequent in the lower lobes. 8. Carnification is a frequent lesion : we have never met with it after seven years. It exists rarely uncomplicated. 9. Bronchial dilatation is seldom met with after the age of five years. Very rare in the uncombined state. And is found indif- ferently in all parts of the lung. CONTENTS. PAGE. History,..............* Pathological Anatomy, ...........° Mortifications of the respiratory sound, ........*« The connection between the auscultation and pathological anatomy, . • 28 Causes,..............*J Rational Symptoms,...........y Sketch of the disease, its progress, &c.........™ Diagnosis..............« Prognosis, .....••■•••••• ^J Treatment,.............^3 Observations and Tables,..........."* ~^f\ //• t ' :* *:* .m if *Jm* i. .«& v^:-^.:\"^..?^ yflfv^ »> 'V '«**»-•*. 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