mercury, just as you would do in the case of the adult, and diminish or discontinue the remedy on the first indication of their being affected.

The diet of children in the early stages of pneumonia should be sparing; and infants not weaned should have some less nutritious food than the mother's milk, which their thirst will otherwise lead them to take more abundantly even than when they are well. If the pneumonia be severe, it is better to give even the mother's milk with a spoon, rather than to allow the infant to suck, since the very act of sucking is injurious, and taxes to the utmost the respiratory function, the organs of which it is desirable to keep in as unexcited a state as possible.

But though the treatment of inflammation of the lungs requires a strict antiphlogistic regimen in the early stages of the disease, yet in many, perhaps in most cases there arrives a period in which a spare diet is no longer suitable-in which your main efforts must be directed to support the constitutional powers, rather than to subdue the inflammation. If you forget this, it may happen to you to overcome the mischief in the chest, but to lose your patient from carrying too far, or from continuing too long, the very treatment which, within proper limits, was most salutary. No point in the management of the disease is more difficult than the seizing the exact moment when the employment of stimulants becomes necessary; and no general rule can be laid down for regulating their use. If, however, the patient were beginning to be much purged, if the respiration were growing more laboured and irregular, though diminished in frequency, and if the pulse were becoming more frequent, and above all, smaller and smaller, it is high time to resort to their use. Wine is as indispensable in such cases in the pneumonia of the child as in that of the adult; and it may be necessary to give it even to infants at the breast. Ammonia may also be advantageously administered in this stage of the disease, either in a mixture with the decoction of senega, or dissolved in milk, which conceals its disagreeable pungency better than any other vehicle. If diarrhoea do not exist, strong beef-tea or veal-broth is the best form in which nutriment can be given; but if the bowels be relaxed, arrowroot, or the décoction blanche† of the French hospitals, should be substituted for it.

In conclusion, it may be well to offer a caution with reference to the employment of blisters-a measure to which we often have *See Formula No. 12, p. 325.

† See Note, p. 51.

STIMULANTS-BLISTERS.

345

recourse with advantage during the resolution of pneumonia in the adult, but which is not advisable in young children whose lungs have been solidified by the disease. Stimulating liniments* may be employed with advantage; they produce very evident good, and are unattended by the risk that always accompanies making a breach of the surface in a young child exhausted by previous illness. The risk of such sores taking on an unhealthy character appears to be greater after inflammation of the lungs than after almost any other disease; and it may be added, that the risk is still greater in those cases of secondary pneumonia that supervene on measles.

*See Formula No. 11, p. 323.

LECTURE XXII.

EDEMA OF THE LUNGS-Occasionally comes on in the course of scarlatinal dropsyseverity of the symptoms, and their sudden accession-Difference between characters of oedematous and hepatized lung-treatment-importance of venesection-occasional exceptions to its use-Chronic edema, or carnification.

GANGRENE OF THE LUNG-Case illustrative of the disease-is not the result of mere intensity of inflammation-unattended by any pathognomonic symptom. PLEURISY-its symptoms and morbid appearances similar to those observed in the adult auscultatory signs of it, and their changes as recovery advances-it occasionally simulates other diseases, as affections of the head, and of the abdomen-Evidences of auscultation less conclusive than in the adult, and why. Latent Pleurisy-occasional sudden death in these cases-various modes in which pleurisy proves fatal-other terminations of the disease-deformity of the chest from pleurisy, spontaneous opening in chest, its tendency to remain fistulous. Treatment in the acute state, importance of depletion and antiphlogistic measures; management in subsequent stages-Question of paracentesis considered-management of pleural fistula-of deformity of chest after pleurisy.

BEFORE we proceed to the examination of some other forms of inflammatory disease of the respiratory organs, it may be convenient to notice two conditions of the pulmonary tissue, which, though not the direct results of inflammation, yet are closely connected with it. One of these conditions is acute oedema of the lung; the other is gangrene of its substance.

It is unnecessary to occupy your time with any detailed account of that anasarcous state of the lungs which is sometimes met with in connection with general dropsy of long standing, or with some old disease of the heart and great vessels. In such cases, the oedema of the lungs is a secondary affection, and has very little share in producing the patient's death. But it occasionally happens that children are attacked by intense dyspnoea, and other symptoms of disorder of the respiratory organs, which terminate rapidly in death; while it is discovered, on an examination of the body, that the thoracic viscera generally are free from disease, but that the tissue of the lungs is loaded with serous fluid. Laennec refers to

* On the Diseases of the Chest, translated by Dr. Forbes, 4th edition, p. 164. London, 1834.

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such an accident as probably accounting for the occasional sudden supervention of extreme dyspnoea in children recovering from measles; but the late much lamented M. Legendre * was, to the best of my knowledge, the first person who clearly proved the connection between the symptoms observed during life, and the state of extreme cedema of the pulmonary tissue after death.

This adema of the lungs, though it sometimes destroys life very speedily, is seldom, if ever, a purely idiopathic affection, but occurs generally as one of the complications of that acute anasarca which not infrequently succeeds to scarlatina; and even then it is not of very common occurrence. M. Legendre records only four cases, all of which were observed in children who were suffering from anasarca after scarlatina; but several instances of it have come under my notice since the publication of his observations, in all of which it supervened during scarlatinal dropsy. In some of these cases it came on while the children were labouring under a great degree of anasarca; while in others the dropsy had greatly abated before the thoracic symptoms appeared. Indications of slight mischief in the chest, such as frequent dry cough, some degree of dyspnoea, with rhonchus and sibilus, or scanty crepitation, preceded the more serious symptoms for two or three days. The patient, in short, had seemed to be suffering from a bronchitis of moderate intensity, when suddenly extreme difficulty of respiration supervened, attended with very hurried breathing, orthopnoea, and most tumultuous and violent action of the heart, though with a feeble pulse. The cough continued, being still short, and quite unaccompanied by expectoration. Auscultation in such circumstances does not seem to give account of mischief sufficiently serious to explain the alarming nature of the symptoms. It may be thought that air enters the lungs less freely than it should do; but the crepitation heard is scanty, bronchial respiration is not perceptible, neither is the resonance of the chest on percussion diminished unless fluid has at the same time been effused into the pleura. Nevertheless, if relief be not soon afforded, the child's sufferings in a few hours amount to perfect agony; the difficulty of respiration and the tumultuous action of the heart continuing; the lips and face becoming perfectly livid, but the intellect remaining clear, and the child complaining of great distress referred to the heart or epigastrium; till at length death takes place suddenly, which it sometimes does within twenty-four hours from the appearance of

* Recherches sur quelques Maladies de l'Enfance, 8vo. pp. 324-352. Paris, 1846.

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CHARACTERS OF CEDEMATOUS LUNG.

these alarming symptoms. At other times the approach of the disease is more gradual, the dyspnoea being augmented in paroxysms, but on the whole increasing with the increase of the general anasarca, and proving fatal in the course of five or six days.

On examining after death the bodies of children who have died of this acute cedema of the lungs, some transparent serum is usually found in the chest, and a few deposits of lymph on the surface of the lung sometimes betoken the existence of slight inflammation of the pleura. The lungs themselves are of a deep red colour, firm, and destitute of air through a great extent of their substance, not breaking down so easily as lung in a state of true hepatization would do, but giving exit when cut into to a most abundant quantity of reddish serum, mixed with very few airbubbles. If the lung be punctured, the fluid will by degrees drain out, and the organ will recover much of its natural flaccidity, while, if the air be blown into the bronchi, the pulmonary tissue will completely resume its light colour, and will crepitate as in a state of health. These experiments show that the fluid is not actually incorporated with the substance of the lung; and M. Legendre explains the sudden occurrence of alarming dyspnoea in some instances by the assumption that it is due to compression of the airvesicles by the rapid pouring out of fluid into the cellular tissue by which they are surrounded. The supposition, however, that the fluid is in these cases entirely external to the pulmonary vesicles does not appear to be well founded, for watery fluids will pass by endosmosis from one part of the lung to another, and will even transude through the pleura. The general effect, however, is the same, whether the chief accumulation of fluid be within the air-cells, or external to them, for in either case the free entrance of air is impeded; while the severity of the symptoms depends upon the rapidity with which the cedema has taken place almost as much as upon its degree. In cases where it comes on towards the close of some chronic affection, there is often no dyspnoea nor any agra vation of the patient's sufferings to mark its occurrence, while, when it takes place suddenly, not only are the symptoms most urgent, but the right auricle and ventricle are found after death enormously distended with coagulated blood-a token of the difficulty with which the heart had discharged the functions to the performance of which it at length became wholly unequal.

In every case of anasarca after scarlatina, the possibility of the

See the remarks and experiments of M. Barthez, in a note at p. 188 of vol. ii. of his and M. Rilliet's work on Diseases of Children.