expansion of lung, the solidified lobules never having been expanded. By an extension of the term, atelectasis is also used to embrace the cases in which lobules become collapsed after having been expanded.

For a full account of the interesting and important researches relating to the imperfect expansion and collapse of pulmonary lobules, the reader is referred to works on morbid anatomy and the diseases of children. The term lobular pneumonitis, as heretofore applied, is pathologically incorrect, and its continued use is therefore undesirable. The condition to which this term has been applied is incidental to bronchitis, and will be noticed in that connection.

Pneumonitis occurs in young children, diffused over an entire lobe, sometimes involving a second lobe, and presenting, after death, the anatomical characters which have been described as belonging to this disease in the adult. It is a much graver disease in young children than in adults, proving fatal in a large proportion of cases. From the absence of the subjective symptoms, and the difficulty of obtaining physical signs, the diagnosis is less easy than in adult life, and the disease is not unfrequently overlooked.

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The attack is sometimes accompanied by a convulsion. This may mislead by directing attention to the head. Dulness, drowsiness, or stupor may accompany the progress of the disease, and these symptoms may mislead in the same way, if the symptoms referable to the chest are not marked. expectoration, being swallowed, cannot be observed in young children. regards marked local symptoms, the disease, may be latent in the child, as it frequently is in the adult. But in a certain proportion of cases, the existence of sharp pleuritic pain is manifested by the expression and also by the cry in acts of coughing, or whenever a deep inspiration is taken. A diag nostic symptom, almost pathognomonic, is a moaning or grunting sound with the expiratory act. Attention to this symptom is especially important, as it points very strongly to the existence of pneumonitis. Increased frequency of the respirations, with dilatation of the nostrils, show the existence of some pulmonary affection, compromising the respiratory function. The respirations, in some cases, are very frequent, numbering 40, 50, 60, and, sometimes, even many more per minute. One or both cheeks may present

a circumscribed flush. If the progress of the disease be unfavorable, lividity of the prolabia and face may become marked. More or less acceleration of the pulse occurs, and the frequency, in some cases, is very great, numbering from 150 to 200 per minute.

When the existence of some acute affection of the chest is declared by the symptoms, the differential diagnosis lies between primary pleuritis, capillary bronchitis and pneumonitis. The first of these affections being extremely rare under five years of age, the problem is usually to decide between the last two. In making this decision, the physical signs are to be relied upon, and the reliance is also upon these for the diagnosis in cases in which the symptoms denoting an acute thoracic affection are not marked. The physical signs are generally available with care and patience, notwithstanding the difficulty of exploring the chest in the young child.

The crepitant rale is oftener wanting in pneumonitis affecting the child than the adult, but it is present in a certain proportion of cases, and is, of course, to be sought after. This sign belongs exclusively to pneumonitis, while the subcrepitant rale belongs to capillary bronchitis. If there be doubt as regards the discrimination between the crepitant and subcrepitant rale, it is to be borne in mind that capillary bronchitis is a bilateral disease,

West, and J. F. Meigs, on the Diseases of Children, may be consulted. See, also, review, by Dr. Gairdner, in Brit. and For. Med.-Chir. Rev., April, 1853.

and the rale will be present in both sides; whereas, in the great majority of cases, pneumonitis in the child or in the adult, is unilateral, and the rale will be limited accordingly to one side. Dulness on percussion is readily determinable in the child, and this is an important point in the differential diagnosis. Bronchial respiration and bronchophony may generally be obtained in the child with perseverence in auscultation, the cry answering for the voice. These signs do not belong to capillary bronchitis. In short, the diagnosis is to be based on the same signs as in the adult, but patient efforts may be requisite to obtain them. As regards primary pleurisy, the signs denoting effusion are available in the child as well as in the adult, and their absence warrants the exclusion of that affection.

The treatment of pneumonitis in children involves the same principles as the treatment of the disease in adults, with those modifications which therapeutical measures require in their application to infantile life. It is questionable whether bloodletting be ever advisable in young children, even when the diagnosis is clear, in the first stage of the disease. As a rule this measure is not to be employed, and the exceptions to the rule, if there are any, are few. Depletion by salines should take its place; antimonial preparations, if given at all, are to be prescribed with great caution, and, in general, other and less depressing nauseant sedatives are to be preferred. The veratrum viride, if given, should be prescribed in small doses, and its effects very carefully watched. Blisters should not be employed. A sinapism or turpentine stupes may be applied to the chest, followed by a poultice or the water-dressing Particular attention should be given to the latter, in order to see that either the entire chest or the whole of the affected side is covered with several thicknesses of flannel and a layer of oiled muslin. The spongiopiline is a good substitute for the poultice or water-dressing. Opium need not be withheld, but must be given with circumspection. Finally, as much depends in severe cases, in the child as in the adult, upon the early, judicious, and persisting employment of supporting measures. In children, as in adults, under certain circumstances, there is a remarkable tolerance of alcoholic stimulants. I have notes of the case of a child of a medical friend (age fourteen months), presenting the utmost gravity of symptoms, the pulse 200 and the respiration 120 per minute, in which brandy was increased to at least an ounce hourly, and under this amount of stimulus the pulse fell rapidly to 124 and the respirations to 50 per minute, the carbonate of ammonia and a little morphia constituting the additional treatment. Recovery took place. This case is cited in illustration of the extent to which, in some cases, the employment of alcoholics may be carried. It does not follow that they are to be generally employed excessively or largely. The same rules are to be observed in treating cases of this disease in children as in adults, with a view, on the one hand, to secure the benefits of stimulants, and, on the other hand, to avoid the evils of their over-use.

PLEURODYNIA AND INTERCOSTAL NEURALGIA.

A brief consideration of these affections is included in this chapter, because, from similarity as regards pain, they are liable to be confounded with either acute pneumonitis or pleuritis. Prior to the employment of physical exploration, this mistake was by no means uncommon, and it is still made by those who depend on symptoms alone. The term pleurodynia is applied to a rheumatic affection of the muscles entering into the composition of the thoracic walls. Intercostal neuralgia denotes a neuralgic affection of the intercostal nerves.

Both affections may be characterized by pain resembling that of acute

pneumonitis or pleuritis; that is, lancinating, and felt especially in the act of inspiration. They may be accompanied by a dry cough, which is acutely painful. In cases of pleurodynia there may be febrile movement, and this may accidentally exist in cases of intercostal neuralgia. How are these affections to be discriminated from inflammation of the pleura, either primary or occurring as a complication of inflammation of the pulmonary parenchyma ? Intercostal neuralgia, as a rule, is not accompanied by febrile movement. But this affection has a diagnostic criterion which is readily available. It consists in the existence of tenderness usually in three isolated points, viz., behind near the dorsal vertebræ, laterally in one, two, or three intercostal spaces, and anteriorly in one or more intercostal spaces near the sternum or over the epigastrium. Sometimes tenderness exists in only two of these situations. The tenderness is frequently confined to a very limited space in each situation, a space perhaps small enough to be covered by the finger. On the opposite side of the vertebræ, and between the tender points in the three situations, pressure or percussion is well borne. In addition to this diagnostic test, physical exploration fails to discover the evidence of either pleuritic or parenchymatous inflammation, viz., in primary pleuritis a friction murmur in some cases, and the signs denoting pleuritic effusion, and, in pneumonitis, the crepitant rale and the signs of solidification. The affec tion occurs much oftener on the left than on the right side. Both sides may be affected, but this is extremely rare.

Pleurodynia lacks a similar positive test, that is, the tenderness is not limited to isolated points, but is more or less diffused. The diagnosis, therefore, must rest on the exclusion of intercostal neuralgia by the absence of the evidence just stated, together with the absence of the signs of both pleuritis and pneumonitis. Pain in pleurodynia and intercostal neuralgia is more marked, as a rule, in movements of the body than in the respiratory movements, the reverse being true of the pain in pleuritis and pneumonitis. This remark applies more especially to pleurodynia. The tenderness in both affections varies, being sometimes slight and sometimes exquisitely acute.

Of the two affections pleurodynia is much the less frequent. Before the diagnostic criterion of intercostal neuralgia had been pointed out by Bossereau and Valleix, cases of this affection were doubtless often considered as rheumatic, and, hence, cases of the neuralgic affection have apparently increased of late at the expense of pleurodynia. Intercostal neuralgia is of frequent occurrence. Cases are numerous both in private practice and among patients treated at hospitals and dispensaries, but more especially the latter. The poorer classes are more liable to it than those in comfortable circumstances. It occurs oftener among females than males. Persons affected are frequently anæmic. It is apt to be developed during the progress of pulmonary tuberculosis. It occurs especially as a sequel of intermittent fever. It prevailed very extensively among the Northern troops who had lately returned from the peninsular campaign in Virginia in 1861, where they had suffered much from malarious disease.

The degree of suffering from these affections varies much in different cases. They are sometimes so slight as merely to occasion annoyance, but in some cases the pain is sufficiently severe to shorten the inspirations, thus rendering the respirations frequent, as in acute pleuritis, and occasioning great distress. In the neuralgic affection exacerbations of pain are frequently experienced. They vary greatly in different cases as regards duration, occurring sometimes as transient affections, but in some cases persisting for a long period. In some of the cases just referred to, which I have met with among soldiers, intercostal neuralgia has lasted for weeks and months, proving rebellious to divers plans of treatment. Pain and soreness in the chest

are sometimes assumed by malingerers, but a ready proof of the reality of the affection is the diagnostic test, viz., the limitation of the tenderness to the three points on one side of the chest. This proof is reliable unless the malingerer have had shrewdness enough to discover that this test is relied upon for the diagnosis.

The treatment of both affections embraces measures to relieve pain if it be severe or considerable. Opium may be required internally for this object. Local applications may suffice if the pain be slight or moderate, for example liniments containing chloroform or aconite, or the belladonna plaster. In cases of intercostal neuralgia, I have found quinia an effective remedy, whether the affection be a sequel of intermittent fever or not. If anæmia exist, this condition claims appropriate treatment. The citrate of iron and quinia or the tincture of the chloride of iron may be prescribed with reference to this condition. In obstinate cases flying blisters are useful. Valleix considers these as most likely to prove effective. The application of dry cups will sometimes afford relief. Hypodermic injections of Magendie's solution of morphia, or a solution of aconite, may be resorted to if the pain be severe, or morphia may be sprinkled upon a blistered surface.

CHAPTER VI.

BRONCHITIS.

Acute Bronchitis affecting the larger Bronchial Tubes-Anatomical Characters-Clinical History-Pathological Character-Causation - Diagnosis-Prognosis-Treatment--Subacute Bronchitis Acute Bronchitis in young Children-Capillary Bronchitis-Epidemic Bronchitis Bronchitis with Exudation of Fibrin-Circumscribed Bronchitis-Chronic Bronchitis.

THE preceding chapters have been devoted mainly to the consideration of inflammation affecting the serous covering of the lungs and the lining membrane of the pulmonary cells. It remains to consider inflammation seated in the lining membrane of the bronchial tubes. Inflammation in this situation constitutes the disease called bronchitis. This, in its ordinary form, is the most frequent of the pulmonary inflammations. Ordinary bronchitis is a very common affection in all parts of the globe. A highly important variety of the disease is based upon the section of the bronchial tree affected. In ordinary bronchitis, the inflammation is limited to the larger bronchial tubes. An infrequent and much graver form of bronchitis is developed when the inflammation affects the smaller tubes. The latter form is generally, but, as will be seen, incorrectly called capillary bronchitis. Inflammation of the bronchial mucous membrane may be acute, subacute, or chronic, and varieties of the disease are based on these differences as regards the degree and duration of the inflammation. Bronchitis may be primary or secondary, as regards other pulmonary affections; that is, it may be developed as a complication of certain diseases, such as pneumonitis or tuberculosis, or it may not be preceded by any disease of the lungs. As a complication of other pulmonary affections, it is more limited than when it is the primary affection, and may be distinguished as circumscribed bronchitis. A form of the disease is characterized by the exudation of lymph, and may be denominated diphtheritic bronchitis. Finally, bronchitis occurs as an epidemic, and is then

commonly known as influenza. These several varieties of the disease will claim separate consideration, after having considered the ordinary form, viz., bronchitis affecting the larger bronchial tubes. The term catarrh has been used to denote inflammation of a mucous structure, accompanied by an abundant secretion of mucus. As this term expresses neither more nor less than bronchitis, and relates to a feature by no means distinctive of a peculiar form of inflammation, it is superfluous and may be dispensed with. Proceeding to treat first of ordinary acute bronchitis, it will be considered as occurring after infantile life, and afterwards, certain points relating to the disease as it occurs in young children will be briefly noticed.

ACUTE BRONCHITIS AFFECTING THE LARGER BRONCHIAL TUBES, OR ORDINARY BRONCHITIS.

ANATOMICAL CHARACTERS.-The opportunity of observing the appearances after death is not often offered, as this form of bronchitis does not in itself prove fatal. The mucous membrane differs from serous membranes and the lining membrane of the air-cells in being thicker, softer, much more vascular, and containing follicles which secrete mucus. Owing to these points of difference, the anatomical characters of inflammation differ from those which belong to the inflammatory affections already considered. The accumulation of blood takes place in the membrane itself, whereby it is reddened and swelled. The redness and swelling after death may be found to be uniform through the affected tubes, or more marked in patches or zones. The redness here, as in other situations, found after death, is not to be considered as evidence of the condition, as regards accumulation of blood during life, for in parts which are open to observation, for example, the conjunctiva, mouth, and throat, redness marked during life is found to diminish or even disappear after death. The inflamed membrane is more or less softened by inflammation, and the affected tubes are likely to contain more or less of the inflammatory products which were expectorated during life, viz., muco-purulent matter, with predominance of the characters of either mucus or pus. Inflammation below the trachea very rarely leads to ulceration.

In ordinary bronchitis, the inflammation, as already stated, is limited to the large bronchial tubes. Probably in many cases it does not extend beyond the bronchi exterior to the pulmonary organs, but in cases unusually severe, the larger divisions within the lobes may be involved. The tubes on both sides are equally affected, provided the affection be not incident to an antecedent pulmonary disease. With this exception, bronchitis exemplifies the law of parallelism; it is a bilateral or symmetrical disease. In this respect it differs from pleuritis and pneumonitis.

CLINICAL HISTORY.-Acute bronchitis is generally preceded by inflammation of the mucous membrane of the nasal passages or coryza The inflammation commences in the nostrils and travels downward, either affecting or passing by the pharynx and larynx in its passage to the bronchial tubes. The period occupied in the passage varies from a few hours to one, two, or three days. In a certain proportion of cases, the bronchial tubes are attacked at once without any affection of the air-passages above.

The symptoms offer marked points of contrast with acute pleuritis and pneumonitis. Pain is not a prominent symptom, but the patient experiences a sense of constriction or tightness, with a feeling of soreness or rawness. These painful sensations especially accompany acts of coughing. The pain is of an obtuse or contusive character, and is situated beneath the sternum.