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PNEUMONIA   OF   CHILDREN.
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        By M.  M. RILLIET and  BARTHEZ,

HOSPITAL INTERNES, MEMBERS OF THE ANATOMICAL SOCIETY AT PARIS.
Duo sunt prcecipui medicinal Carolines, Ratio et Observatio: Observatio tamen
    est Alius ad quod dingi debent medicorum ratiocinia.—Baglivi.
TRANSLATED FROM THE FRENCH
By  S.  PARKMAN,  M
v.y
FELLOW OF THE MASSACHUSETTS MEDICAL SOCIETY, AND MEMBER OF THE

         BOSTON SOCIETY FOR MEDICAL IMPROVEMENT.
          PHILADELPHIA:
CAREY    &    HART.
1841. 
aw 
      PREFACE   OF  THE  AUTHORS.


   If we examine most of the treatises, which have been published
 upon the diseases  of children, we shall find the authors  to  have
 attempted a description of those peculiar to childhood, rather than
 of the  common  diseases of humanity, as influenced by that age.
 We  shall find,  in  their works, many dissertations  upon certain
 symptoms created with morbid entities, or upon certain lesions,
 which, by their rarity, attract the attention of all observers, but few
 descriptions of  the diseases  which a  daily  practice  presents.
 Within  a few years, however, authors have begun to study the
 affections of children with particular reference to their pathology.
   Numerous observations, and interesting memoirs, have been pub-
 lished in different  periodical collections; young physicians  have
 taken the subject for their inaugural dissertations.  But  from so
 vast a field, all  has  not  yet  been reaped; many important truths,
 scattered here and  there, have  remained lost  for want of being
 incorporated with the body of science.  A good  book upon the dis-
 eases of children is yet to be written.   Far from us the idea of pre-
 tending to undertake, at the present  day, so great a labour.  We
 leave it to hands more skilful and experienced than  ours.   But
 desirous of walking in the  traces of those, who have preceded us,
 and of profiting by the advantages of our situation, we have thought
 to do something useful in studying this important part of pathology.
 We purpose, (if this undertaking  be favourably  received,) to  pub-
 lish a series of monographs upon the different diseases of childhood.
 A part of our material is already collected, but we wish to confirm,
 by new observations, the ideas we at present entertain.
   Among the diseases of this age, those of the chest are, without
 doubt, both  the  most important, and the  most numerous.   We
 commence therefore  with them.  These present  researches upon
 pneumonia  will form the first part of a series  upon the  thoracic
 affections.
  Before entering upon our labour, we ought to say a few words
 upon the method we  have prescribed to ourselves in the perform-
ance of our undertaking, in  order that the  reader may appreciate
the degree of confidence to be placed  in our assertions.  Situated 
VI                         PREFACE.
as internes at the  hospital  for sick children, we have collected a
great number of facts.  We have, particularly in the latter months
of the year, taken observations upon  all the  patients admitted into
the  wards for acute diseases.  Among these observations there are
sixty pneumonias, the analysis  of which forms the basis of this
work.  We  might have operated upon  a much greater number of
facts, but we have preferred to content ourselves with the analysis
only of those collected after a rigorous and continued examination
of the chests of children in  the normal state.  Being then enabled
to appreciate  perfectly the comparative  resonance of the different
parts  of  the  thorax,  we can  count  upon  the  exactitude of our
pathological researches.1  Each  particular fact has been collected
with all  possible  care;  the autopsies have been  made with the
greatest detail, and the alterations have been minutely described at
the moment  of the  examinations.  Our  observations being  col-
lected,  we have decomposed them into their different elements, in
order to  class, into as many distinct tables, the causes, symptoms,
pathology, &c.; from each of these tables we have  deduced propo-
sitions, the developement of which forms the base of this work.  If
we  have  thought  ourselves obliged  to proceed with rigour,  in  the
analysis of our observations, if the numerical method  has always
served us as a guide,  we will aver, that we have avoided, as much
as  possible,  the filling our pages with figures  and observations,
which would have rendered their reading both irksome and labo-
rious ;  we have rather  preferred to postpone, till  the end of  the
work, both the numerical tables  and the observations, as vouchers
destined  to prove  the  assertions which we have advanced.
  We  have not contented ourselves  with giving merely the result
of  our own  experience, but have read and meditated upon  the
works of authors, who have preceded  us, and  we  have taken the
care to indicate the points,  where their  observations confirm ours,
as well as where they are at variance.
   We would not terminate this  preface,  without tendering  our
thanks to odr masters, Messrs. Bandelocque and Bouneau, for  the
wise counsels  given, and the  affectionate goodness always mani-
fested  to us.

  1 The study of the normal state of the child's chest will form the subject
 of a separate monograph. 
PNEUMONIA   OF  CHILDREN.
                         CHAPTER I.

                           HISTORY.

   No where among the ancients, (as  remarks M. Leger,1) do we
 find a description of the pneumonia of children : they hardly men-
 tion  it, and  if Stoll,  Sydenham, Morten, Rosen, &c, say a  few
 words upon  it, it is only when supervening in the  course of the
 eruptive fevers.
   In 1823 appeared the  first monograph, upon the  pneumonia of
 children, a few years  after the discovery of auscultation, without
 the aid of which its history could not have been given with success.
 M. Leger gave to the disease, he was the first to describe, the name
 of latent, a name deserved before his researches, but  which it no
 longer merits,  since, at present, its diagnosis is among the things
 certain.
   M. Leger,  after a careful examination of the causes, establishes
 the following divisions :
   1.  A latent acute pneumonia, with symptoms more or less well
 defined.
   2.  An acute  pneumonia,  without the usual  diagnostic signs,
 without cough, dyspnoea, &c., but on the contrary simulating some
 other affection, not  of the chest, or a meningitis.
   3.  A chronic pneumonia consecutive to an acute, or primitively
 chronic;  and  lastly,  a pneumonia after  measles.  Twenty-eight
 observations  terminate  this dissertation, being divided into  four
 series, after  the divisions  of the author; the greater part of the
 cases were in children, aged from two to four years.
   This thesis,  although very remarkable, leaves many  wants to
 be supplied,  many assertions to  be corrected.   The symptoms,
principally the  stethoscopic  signs, are indicated rather loosely;
 many are passed over in silence ;  the pathological anatomy is very
incompletely  treated ; the divisions are too multiplied, and the ob-
servations taken with little care.
   After M. Leger,  M.  Lenerx,2 in an inaugural  dissertation, enti-
tled, "The pneumonia of children compared with that of old men,"

      1 Thesis, 1S23,  No. 49.               4 Thesis, 1825.
       16—a                                      ril 1* 
b    RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

spoke of the mamellonated hepatisation peculiar to that organ.  He
described  the granulations  of  vesicular pneumonia  as like the
tubercular, and  he attributed  them to chronic bronchitis.   His
thesis, although voluminous, was not equal to that of M.  Leger,
and, without any greater detail, contained a greater number of
errors.
  M. Leger had laid no great stress on a particular form of hepa-
tisation, as frequent in children, although he mentioned it under the
name of partial splenisation.  Many  pathologists sought to repair
this  oversight :  thus  in  1828,  M. Berton1 drew the  attention of
observers  to the lobular  form presented  by this affection in  chil-
dren.  He described its duration, the incertitude of the symptoms,
insisted strongly upon the frequency of the termination by pulmo-
nary abcess, and endeavoured to establish  the diagnosis, between
tubercular phthisis and lobular pneumonia.
  M. Burnet published, in the Journal Hebdomadaire, (July, 1833,)
some researches on this subject, and laid down the following  pro-
positions.
  1. The non-complication of pleurisy:
  2. The possibility of cure  by induration.
  3. Its attacking indifferently all parts of the lung.
  4. The non-termination by suppuration.
  The thirteen observations, appended  to this memoir, leave much
to be desired ;  most of them  are deficient in detail, the  auscultation
incomplete, and the general symptoms and progress of the disease
very superficially described.
  One year later, M. de la Berge,2 in a  memoir based upon detailed
observations, attempted a complete history  of lobular pneumonia.
He divided the disease into two periods—the sthenic, of short, and
the asthenic, of longer duration.  According to him, the treatment
should  be much influenced by these  periods.   The precision and
exactitude of the descriptions of the morbid alterations of the lung
render  the pathological anatomy the  most valuable  part  of this
work.
  Of the five observations terminating this  memoir, three only are
examples of simple lobular pneumonia, and, in these three, the dis-
ease is very limited, (seven or eight points  only).  Of the  two
others,  there is  a pneumonia of an entire  lobe  in  the  one and a
pleuritic effusion in the other.
   About this time, Dr. Gerhard  published in the American Journal
of Medical Science, (August and November, 1834,) some quite in-
teresting remarks upon the pneumonia of children.
   He divides his patients into  two classes, those over, and  those
under,  six years of age.   He proves that, in the first class, pneu-
monia, taking place in otherwise full  health, is not a grave affcc-
1 Thesis, 1828, No. 64.
1 Journal Hebdomadaire, 1834, p. 414. 
HISTORY.
/
lion :  in forty of his patients, only one died.  He describes with
care the symptoms, and discusses the influence of treatment.
  In  the second part of his  memoir, he treats of pneumonia in
children from two to six years of age, he demonstrates that in these
the disease is never developed in perfect health ; he insists upon the
lobular form of the hepatisation and dwells upon the modification
of the respiratory sound,  and, after a careful  description of the ana-
tomical lesions, he finishes with a few words upon treatment.
   His work, fruit of an attentive observation, and  based  upon an
analysis of  facts, is  without contradiction  the most  valuable yet
published.   The author, nevertheless, treating exclusively of pneu-
monia when perfectly evident, has  neglected its  study, when the
diagnosis, being more obscure, requires, in consequence, all the at-
tention of the practitioner.  Having  laboured in the same field of
observation, we have necessarily arrived at  similar results, but we
have  thought ourselves called  upon to  modify some of his asser-
tions, as well as to supply some of his deficiences.
   M. Boudin,1 in some researches upon the complications of mea-
sles, presented some remarks  upon pneumonia.  His observations
are upon ten children from two to seven  years of age.  and offer
nothing not  contained in preceding publications.   But we cannot
pass  in silence  a very  remarkable omission in this  memoir ;  the
author has neglected entirely  to notice the existence of any peculi-
arity  in the  form of  the  hepatisation, not even mentioning lobular
pneumonia.
   M. Rufz,2 has given,  nearly  verbatim, the memoir of  Mr. Ger-
hard, to the  composition of which he had  assisted, in analysing a
part of the cases.
   M. Berton, in his  treatise upon the diseases of children, has add-
ed nothing to the ideas already advanced in his inaugural disserta-
tion.
   M. Hourmann,3 in a  communication made to the Medical So-
ciety  of Paris, described  succinctly the pneumonia of children from
two to  four years of age.  He states, from  six autopsies, that  the
lobular form is far from  being as common,  as is usually supposed ;
he regards bronchial respiration as normal in children, disputes the
utility of percussion, and terminates with  an observation of reco-
very  in a child, of two years, treated by repeated venesection,.
about a pound of blood having been taken.
   Although we  are noticing  only works upon children from two
to fifteen years of age, we cannot pass in silence a very interesting
memoir, upon the pneumonia of infants,  occupying  one  hundred
and fifty pages in the work, just, published by M. Valleix.4   This  is
the result of an analysis of fifteen observations;  an analysis made


   1 Thesis, 1835, p. 91.
   2 Journal des Connoissances Medico-Chirurgicales, 1835, p. 101,
   3 Revue Medicalc, April, 1835. p. 137.
   4 Cliniqu.e des Maladies des Enfans Nouveau-nes, lSuS, 
8    RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

wilh all the rigour of the numerical method.  There are only three
cases of  simple pneumonia;  in the others, it  complicated other
affections.   The disease commenced  by febrile agitation, heat, and
acceleration of the pulse, followed by  cough, dyspnoea, subcrepi-
tous rale, bronchial respiration, and flatness on  percussion  com-
mencing  at the base of the lung.
  The constitutional symptoms disappeared after a day or two, and
were entirely wanting in the cases  supervening on oedema.
  After death, the hepatisation occupied the two lungs in the great
majority  of the cases.  Ordinarily  more marked in the right,  than
leftside, more frequently presenting the lobar than the lobular form ;
the morbid tissue  was always very  hard and smooth upon incision.
  After attentively reading all these monographs, we see that none
except  that of M. Leger, .presents a complete picture of the pneu-
monia of children, while some treat only of the lobular pneumonia
and of that variety revealed  only by  obscure symptoms; others in
examining only the disease, when idiopathic, neglect entirely those
numerous and important instances  where it  complicates other
diseases.
                        CHAPTER II.

                  PATHOLOGICAL  ANATOMY.

  In the study of the anatomical  lesions, authors have not endea-
voured  to establish the connections between  the different  species
of the pneumonias of children ; on  the contrary, they have given
us descriptions of each individual  species, without attempting their
union under one and the same head, as they would seem to require.
We think also, they  have too much  neglected the examination of
those  alterations  of  the  respiratory  apparatus,  which complicate
pneumonia.
  To present a complete picture  of these morbid appearances, we
shall describe each kind separately, pointing out as far as possible,
its nature, and thus treat, in as many distinct paragraphs, of vesi-
cular  pneumonia or  bronchitis, lobular  pneumonia, lobar1 pneu-
monia, of the state  of carnification, and finish  with a few  words
upon the disease after it has become chronic.   We shall then study
the alterations of  the  bronchial tubes, dwelling: particularly upon
vesicular bronchitis and enlargement of the bronchi.
  We shall endeavour, in  each of these articles, to establish the
connections between these  divers  alterations/and finish this chap-

  1 The term lobar  pneumonia will undoubtedly explain itself as  given to
the disease, invading the whole or part of a lobe, as in the adult. (P.) 
PATHOLOGICAL ANATOMY.
9
ter by a succinct account  of  the concurrent  alterations of other
organs.

                     Vesicular Pneumonia.

  Tn"e lung, externally, is flaccid and soft, collapsing, more or  less,
in proportion to the extent  of disease.  Upon incision, it presents a
number of granulations of  the size of a millet seed, of a gray colour
bordering upon the yellow.  At first sight, these might be mistaken
for crude miliary tubercles disseminated through the lung, as we
often see them in children  : but a more,careful examination shows
a great difference, both in  their  physical qualities and their nature.
   Tubercles form full and  solid bodies: the granulations of pneu-
monia contain  a liquid.   Thus, upon incision, some tubercles.
divided by the knife, present  their cut surface on a level with that
of the  pulmonary tissue, while others, escaping before its edge, pre-
serve their globular forms.   These latter upon incision present the
usual appearance of tubercle.   The granulations of pneumonia, on
the contrary, collapse in giving immediate issue to a drop of puri-
form liquid, and those which have escaped the knife  remain whole
and spherical.
   If these latter be opened with the point of  an instrument, there
escapes the same puriform liquid, and  in the centre we discover,
though often with difficulty,  a small  depressed point, departing
from which, we were, in one case, enabled  to trace a small canal,
a few lines in  length, with a smooth  internal surface, which  was
doubtless a minute bronchial ramification.   There is nothing com-
 mon then to these two alterations, save  their form, general disposi-
tion and colour.
   From this description it appears probable, that the disease is con-
 fined  to  the  extremities of the bronchial tubes, and  that a certain
number of the  pulmonary vesicles, becoming inflamed separately.
are  filled with this  puriform liquid, and  dilated without any in
flammatory participation of the surrounding cellular tissue. Doubt-
less, this appearance of the lesion confined to the pulmonary vesi-
cle hns originated the  name,  vesicular pneumonia ; but  perhaps
this appellation is improper, since  the inflammation  is confined to
 a sina-le element of the pulmonary tissue ;  we would therefore pre-
fer to  call the disease, vesicular bronchitis.
   If it happen, that many vesicles, in  the vicinity of  each  other,
 are  affected,  the connecting tissue  may participate  in  the disease,
 from which results a little mass, sometimes attaining the size of a
 lentil, presenting, on incision, several of the granulations, or seve-
 ral of the depressed points, which appearance, except this modifica-
 tion from the granulations, is the lobular pneumonia to be presently
 described.  There in fact exists,  in such a case, vesicular  bron-
 chitis surrounded by lobular pneumonia.
   In other instances, the pulmonary tissue, surrounding the dilated 
10    RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN-

vesicles, is evidently and generally hepatised, and then we have
vesicular bronchitis surrounded by lobar pneumonia.
  The  bronchi, leading to  the diseased portion of the lung,  are
sometimes dilated, sometimes  healthy ;  the former of which condi-
tions will be fully noticed in a further part of this work.     ,

                      Lobular Pneumonia.

  Lobular pneumonia is an inflammation  occupying one or more
isolated lobules.  It has been  described under the names, mamel-
lonated, partial, disseminated.   Its frequency and its gravity make
it deserving of an attentive examination.
  Externally, the lung is usually soft and flaccid, of a grayish rose
colour, more or less deep, presenting scattered spots of a violet red,
generally clearly circumscribed, projecting, solid to the touch, and
not collapsing like the surrounding portions  of the  lung.   These
spots, usually circular, sometimes elongated, especially from above
downwards, are chiefly situated at the posterior border of the lung,
but they are found, also, in  all parts; sometimes  they are absent,
and nothing abnormal is visible, but the finger detects the presence
of nodosities more or less deeply imbedded in the tissue.
  Upon  incision, we find the  lung marbled, by a rosy gray, and
a deep violet red colour; the  exterior red spots correspond to  the
deep-coloured parts of the interior ;  and these spots, as well as  the
others below the surface, form nodules of engorgement, presenting
the  characters of ordinary hepatisation, viz. smooth  to the knife,
granulated  upon tearing, easily penetrated  by the finger, and sink-
ing in water.  But to establish  this latter characteristic, it is neces-
sary to  isolate perfectly  the diseased portion, and to select espe-
cially the centre.   Upon  prrssure, there  is little or no crepitation ;
and there is exuded a sanious liquid, with small bubbles of air,  but
if we be careful to press only the centre, the  liquid issues  without
the  air, as in common lobar pneumonia.
  We meet with this species of pneumonia at the first, second, and
third  degrees.
  Then, upon incision, we have the pulmonary tissue marbled, of
a red or rosy gray, the red parts more or less  regularly limited  a
little less resistant than the surrounding tissue, still  swimming on
the surface, with whatever care we may isolate them, exuding upon
pressure a liquid entirely penetrated with air, and still  crepitating
under the finger.   This is the first degree.
  The second we have already described.
  The third  presents itself  under so insidious a form, as  without
particular attention, to be easily overlooked  at  the autopsy.  And
as, during life, the physical signs are  frequently absent, it  is easily
conceivable that the disease  may be undiscovered, and considerable
uncertainty be thrown upon the cause of death.
  Thus, when the  points of inflammation are  small  in size, and
have passed entirely from the second to the third degree, the  dis- 
PATHOLOGICAL ANATOMY.
11
eased tissue becomes grayish, and presents very little difference from
the surrounding  portions.   The  reader will  therefore easily con-
ceive, that if it requires a careful attention to establish the exist-
ence of a lobular pneumonia at the second degree, how much more
is necessary to recognise it when  arrived at the third stage, where
the peculiar colour, the most common of the marks, has disap-
peared.
   But if we pay proper attention, we cannot fail of remarking, that
in the track of the  incision  certain lobules are projecting, the vesi-
cles not collapsing as in the surrounding portions, and that pressure
in these lobules gives issue to a liquid, rather  purulent than serous,
after which we may easily establish the existence of the other cha-
racteristic signs.
   This description  of  the three stages of pneumonia, written with
the preparations before our eyes, and which is very nearly a compend
of the opinions of all the authors upon the subject, does not appear
to us, however, to give a perfect idea of the pathological anatomy
and the progress of the disease.   We have  thought that we have
observed  two forms of the lobular pneumonia, the one perfectly
circumscribed, which  we would call mamellonated,  the other not
so cleariy limited, to which  we would give the name of partial.  In
giving these names we would not be understood as  thinking to
describe two distinct diseases ; we consider them only as two forms
of an identical affection, having a common origin, but a  different
progress ; finishing by presenting some modifications of the symp-
toms,  and of which the partial is an intervening stage between the
lobular and the lobar pneumonia.
   The mamellonated  pneumonia forms a nodule of inflammation,
the colour and appearance of which contrasts strongly with tbesur-
roundincr  tissue.   It  is a  point of pneumonia perfectly  limited,
 thrown 'into the midst  of a  tissue nearly or quite  healthy, and its
boundaries are clearly defined, even when  the surrounding  tex-
 tures  are engorged.  It may even happen, as we have seen in one
subject presenting about a dozen of these nodules, that the boundary
is  marked by a circle, or rather by a white resistant spherical cap-
 sule  of about  an eighth  of a line in thickness, and presenting a
fibro'us aspect.   Usually,  the  line of  demarcation, besides the
change of colour, is indicated by the collapse after an incision  ot
 all the surrounding parts.                                 .
   The size of these nodules varies from a hemp-seed to a  pigeon s
 eo-o--  their border  is  generally regular, representing  a sphere, or
 soTne analogous figure, and  their number varies from one in a lung
 to twenty, thirty, or even more.
   The partial pneumonia, on the contrary, is less well defined than
 the mamellonated; its circumference is insensibly confounded with
 the surrouii ling  textures, without any distinct demarcation, either
 bv chancre of colour or protuberance of the  diseased  part ; its vo-
 lume often  greater than in  the mamellonated form, is, however,
 sometimes the same :  its form is not always regular, the inflamma- 
# w
12    RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

tion extends itself in different directions, and is either every where
advanced to the second degree, or the centre is alone so, while the
circumference has only attained the first.
  In this latter case it may happen, that a part of one nodule, still
at the first stage of inflammation, connects itself with several other
points of pneumonia, and we have the whole or the greater part of
a lobe inflamed and presenting the  characteristics of the  first and
second degree, scattered without  any apparent order through  its
substance.
  Upon these considerations, we establish the two forms of lobular
pneumonia, one  resulting from an  inflammation  of one  or  more
individual lobules, without any tendency to attack those adjacent;
while the other is the consequence  of an inflammation developed
in one group of lobules,  gradually involving all  the surrounding
ones.   In  the first case, the inflammation, if we may use the ex-
pression, is centripetal, concentrating itself in the lobules primitively
affected.   While  in  the other it  is centrifugal, tending to spread
and attack  all around it.
  Hence the explanation, why the mamellonated  pneumonia may
suppurate and form an abcess, while the  partial form tends  to be-
come general or  lobar.  But that these are only modifications of
the same form of the disease, is proved by an observation which  we
possess, where one side presented the mamellonated pneumonia at
the stage of suppuration, and the other  the partial form tending to
become general.
   In these two cases, the following is the state in  which we find
the lung affected :
   If  the mamellonated pneumonia have passed into the  stage  of
suppuration and abscess, an incision presents to  us little cavities,
in form and disposition answering to the lobular  hepatisation  at
the second degree.   Their  volume varies from that of a hemp-seed
to that of a large pea.  These cavities are filled with pus. mingled
at times with clots  of blood ;  they communicate sometimes with
the bronchi, and at the point of entrance.of the bronchus into the
cavity,  the mucous membrane  ends abruptly, presenting the  ap-
pearance of a solution of continuity, quite evident to the sight, and
shown by the formation  of strips, if the caliber  of the bronchus
admit of this method of examination.    Many of  these  abcesses,
however, do not communicate with a bronchus, but  are surrounded
by it, in this manner proving that the interior of a bronchus was
not in these cases the point of departure  of the inflammation.
   We insist strongly upon  this latter remark, because it is iTecessary
 to distinguish carefully these abscesses, which are rare, from another
 more frequent lesion, to be hereafter described, the dilatation  of the
 bronchial  extremities.  One character which will aid us in seek-
 ing this distinction, is, that the  parietes of the dilated-cavity are
 smooth, polished, and gradually continuous into the bronchial tube
 whilst in the abscess they present quite  a different aspect,  the bron-
 chus being seen  to open abruptly into the cavity. 
PATHOLOGICAL, ANATOMY.
13
  If the lobular pneumonia, already become general, have  passed
to the third degree, we  observe it as entirely lobar, and an incision
presents an  aspect  which  all will recognise from  the  foregoing
descriptions: those  points which were at the first stage  will have
reached the  second, while  those  at the second will  have attained
the third.   The texture will be marbled, with a mingled red and
yellowish gray.
  There is, however, a difference between a lobar pneumonia and
a partial pneumonia become general, which consists in the different
disposition in the lung at the different stages of the disease.  Thus,
in common lobar pneumonia, the disease, commencing  usually at
the  base  of the lung, advances upwards;  and, whilst the base
passes to the second degree, the parts  above are attacked in the
first, and  thus in succession: while in the other case, the disease,
having commenced in distinct lobules, presents  its  different stages
scattered without order through the lung.
   This consideration may  serve to determine, in the dead subject,
if a pneumonia was primitively lobular or lobar; not universally,
however, as the  pneumonia,  in  becoming  general, may have  re-
mained at the second degree, thus imitating perfectly one originally
lobar.
   But even in this case, as in the preceding, we usually  find in the
same lobe, or in the same  or opposite lung, some distinct  lobules,
inflamed in the second degree, constituting the remains of a defined
lobular pneumonia, cases which  have hitherto  been regarded as a
union of the lobar and lobular pneumonias,—added to all which, a
careful study  of the symptoms during  the  patient's life-time, will
materially aid the diagnosis of the two lesions before us.1
   The anatomical proof of the existence  of a  lobar pneumonia is
 much  rarer  in  children  than adults;  for,  in  general,  before five
 years of age, idiopathic pneumonia seldom exists, and after that
 age the disease is seldom fatal.
   Nevertheless, in cases of death from some complication, we have
seen a sufficient number of such autopsies to convince  us  that the
 lesion is the same at both these periods of life.

   1 It may be well to mention here a form of pneumonia of children pointed
 out by M'. de la Berge, under the name of the marginal.   It often  happens
 in reality, that we find hepatisation slight in  extent, seated around the base
 or on the anterior border of the lung; these hepatisations perfectly  resemble
 ordinary inflammations in their pathological alterations, and  physical cha-
 racters.  The circumstance of the seat and slight extent of the disease suf-
 fice to attract attention.   Its  symptoms are  inappreciable, and  Ave  may find
 its cause in the feebleness of  the child and the want  of reaction in the pul-
 monary organs; allowing those parts most distant from the centre of the
 circulation to become engorged.  For we are not to think that it is from an
 excess of vitality that the lungs of children inflame—reasoning  thus, the
 lungs of old  men  should have^the same attributes  of superior vital force,
 judging from the frequency of pneumonia ; besides, in children we ought to
 observe it  attack with  preference  the most vigorous and  most healthy,
 whereas the reverse is the more general rule. 
14   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
   To the distinction  of some authors, founded upon the smooth
 surface presented by an incision of the inflamed portion, we attach
 no great importance;  since,  even when the texture is smooth
 under these circumstances, it  is  not the  less granulated upon
 tearing.
   After this description of the different forms of the acute pneumo-
 nia of children, we pause a moment to remark, that all these lesions
 are only varieties of the same affection,  without any special pecu-
 liarity attached to either;  since from one to the other there is but
 a step, and since one can easily transform itself into the other.
   In  truth, commencing with the capillary bronchitis, of which we
 shall  soon speak in detail, we next arrive at the  vesicular pneu-
 monia, or rather bronchitis,  which  is an evident extension of the
 first,  and thence to the true  lobular pneumonia, the transition state
 being in those cases where  the vesicular bronchitis is surrounded
 by a  lobular pneumonia.  Besides, all the authors upon this latter
 species of pneumonia have endeavoured  to establish it as a conse-
 quence of a bronchitis; for this propagation of inflammation from
 one tissue to another is easily conceivable, and by it alone we might
 explain the development  of lobular  pneumonia.   In  reality, the
 final  bronchial ramifications, being independent one of the other.
 we easily conceive how the  inflammation propagates itself by iso-
 lated  lobules;  and the whole, therefore, reduces  itself to this, that
 childhood, more than any age, is disposed to  capillary bronchitis.
 or to  the affections consequent upon it;  and  having before shown
 the passage of the lobular  into the lobar pneumonia, we have com-
 pleted the series of the pulmonary inflammations of children.
   Beginning with  capillary  bronchitis,  advancing to  vesicular
 bronchitis, to lobular,  and finally lobar  pneumonia, we find  the
 only difference  between these diseases to be in the greater or less
 extent of the inflammation.
   We must, however, guard ourselves against too great a general-
 isation of these ideas, involving, as a consequence, the opinion, that
 in the child  all the inflammations of the lung commence by the
 capillary bronchitis, and pass successively through all  the deorees
 above described; it will be shown atalater period of this work^that
 pathological anatomy, on the one hand, does not furnish the means
 of positively recognising the  existence of  the bronchitis; while on
the other, in the greater  number of pneumonias,  especially the
lobar, the bronchitis is not  of sufficient  extent, and the constitu-
tional symptoms appear too suddenly to allow of the supposiiion of
this propagation of the  inflammation from one tissue to the other.
   We would only wish then to establish the existence of these va-
 rieties, the small distance which separates them, and the easy trans-
 migration of one to the other.
   To complete, then, the description of our views  upon the pneu-
 monia of this age, it only remains to speak of two kinds of altera-
 tion of the texture of the lung, distinct, and yet offering, perhaps" 
PATHOLOGICAL ANATOMY.
15
some analogy one with the other: we  refer to carnification of the
lung and chronic pneumonia.


                         Carnification.

   The former of these alterations, though somewhat frequent,1 ha?
never been described by authors, and is merely alluded to in a note
to the memoir of M. Rufz.   The description, given by him, is how-
ever exact, and agrees perfectly with our observations.
   The lung, in this state is, externally, collapsed, soft, and flaccid,
instead of full, hard, and resistant as in pneumonia.  Its colour is
violet, marbled by white lines, disposed in losenges or squares,  de-
fining the lobules, without any crepitation upon pressure.
   An incision presents a  texture of a  red colour, smooth, resisting
the pressure of the finger, so as to be penetrable with considerable
difficulty ; exuding upon  pressure a serous bloody liquid destitute
of air.  Its  appearance very like the close compact fibres of a mus-
cle has given it its  name.
   The .carnification occupies often the circumference of the base of
one of the  lungs, being then marginal, or else some portion of a
lobe: the middle lobe is the only one  we have seen entirely in-
vaded ; whilst at other times it affects the lobular form, appearing
in distinct, and separate circumscribed  masses.
   From this we see that this lesion affects the peculiar seat of each
species of pneumonia, never, however, involving any considerable
quantity of lung.  It exists besides in  subjects  presenting at the
same time the lobar and lobular pneumonias.
   The first idea, presented  to the mind by the examination of  this
tissue, is  the resemblance to  a lung of a foetus which has not yet
respired; the vesicles of which have not yet dilated, under the
'thoracic expansion, to admit  the air  into their interior.  Or we
might think them to have been obliterated  by some disease, an in-
flammation perhaps, the engorgement having disappeared, without
leaving the vesicles the power of returning to their former state of
 dilatation.
   With these views, we might regard the carnification as a sort of
termination of pneumonia or as that disease in a chronic stage.   In
fact we  possess an observation which  would justify this idea ;  it is
of a child, presenting for a long  time  the signs of  a pneumonia of
 the right side, and dying finally of the disease invading the left;
 the autopsy showed a considerable carnification of the right lung,
 at those points where the  auscultation had previously established
 the existence of a pneumonia.

                      Chronic Pneumonia.

   Authors  are by no means agreed upon what we ought to under-
1 See table of the Pathological Anatomy. 
  16   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

  stand by the chronic pneumonia of children, and to show how con-
  fused are their ideas upon this subject, it will be sufficient for the
  reader to know, that some Consider it very frequent, while  others
  regard it as very rare.
    M. de la Berge speaks of the yellowish gray colour  as marking
  the change to  the chronic state; but we  can  regard  this only as
  indicative of the third stage of the disease in children, as is admitted
  on all hands in the adult; and we must  have something besides
  colour to characterise the passage to the chronic state.
    We have never met with any lesion which might be  regarded as
 chronic pneumonia, unless it  be the carnification just described:
 we shall not attempt therefore any description of this affection.

                           Tubercles.

    Tubercles, so common in youth, might naturally be  expected to
 present themselves frequently with the pneumonia of children, never-
 theless they are very rare.1   Our results agree perfectly with those
 of Gerhard and Rufz, although we would not as yet agree with the
: latter in the conclusion that measles ought not to be considered a
 cause of tubercles : the question  merits a  separate attention  and
 does not form part of our subject.
    We  have observed tubercles  in fifteen  of forty-three antopsies.
 In three cases they existed in other organs  besides the lungs, in
 the bronchial or mesenteric glands; in the other cases their number
 was small:  they appeared to select the superior lobe ; and twice
 we found them at the extremity of a dilated  bronchus, and twice in
 the centre of a  lobular pneumonia.
   Here  terminate our remarks  upon  the pathological  anatomy of
 the pneumonia of children ;  we shall  refer hereafter2 to the com-
 parative frequency of each of these affections  in the different ages;
 but we have thought it might be  useful to connect with the pre-
 ceding descriptions some account of many other alterations, which,
 mingling their  symptoms with those of the pneumonia, merit for
 that reason a careful examination.

                     The  Bronchial Tubes.

   We have made the bronchi a subject of particular attention ; we
 have noted carefully their caliber, the  colour, thickening and'soft-
 ening of their mucous membrane, as  well as the liquids contained
 in their cavities.
   Caliber.—Most of  the authors have spoken of the dilatation of
 the bronchi, but without insisting sufficiently, we  think upon this
 lesion,  which  must be  so frequent, since we  have found it in  one

  » We would be understood not to speak of those more frequent cases where
 the tubercles being the principal disease are complicated  by pneumonia  but
 only of those instances where the pneumonia is the primitive lesion.   '
  2 Vide table of Pathological Anatomy. 
PATHOLOGICAL ANATOMY.
17
quarter of the cases terminating  fatally.  The dilatation of the
bronchi affects two  forms, quite distinct and apparently the result
of 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 volumm
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
egg-
   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
lung  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 other 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 
H   RILLIET AND BARTHEZ OX PNEUMONIA OF CHILDRE
difficult of decision, it has seemed tons that the dilatation has either
commenced at the same time with  the  pneumonia, or been d V3-
loped 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  abundant
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 mucous
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 less
 abundance of these liquids, and the presence or  absence of air in
 them;  we find it often remarked, also, that the mucus was orayish
  thin, not viscous, puriform, or else the contrary, viscous, whitish 
PATHOLOGICAL ANATOMY.
19
purely mucous; and these remarks have assisted us in the explana-
tion of certain stethoscopic signs.
  But we would  have wished to  have been able by more detailed
observations  to determine the relations of the different  species of
inflammations, the bronchial dilatation and the abundance of liquid,
with  its  consistence,  its tenuity,  and its mixture with air;  we
would have  wished  to see  if in  the  same lung the mucus were
more abundant where inflammation is seen to  have  existed, than
where, although  the  eye after death  detects no alteration of  the
tissue, auscultation has indicated  the existence of rales during life;
if there  may exist mucus  in the bronchi without pneumonia or
capillary bronchitis, (fee. To  answer these  questions, it would be
necessary to  decide if  the decubitus of the body upon the back de-
termine the gravitation of the fluids to that part. All these details, at
present left incomplete, will  be the object of future  study.
   We may nevertheless endeavour to determine  whether abund-
ance of mucus be a  necessary  proof of an inflammation of  the
bronchi.   Upon this  subject we  are  of opinion, that a  bronchitis
cannot be admitted unless we have the existence of the  mucus;
that its  presence, in  any quantity, however great, by  no means
establishes the bronchitis, for we  have seen the fluid  where it was
impossible to admit an existence  of this latter,—a  fact easily con-
ceivable,  considering the great weakness of children, which prevents
the expectoration of the mucosities, and allows their  accumulation
upon the surfaces normally secreting them.

              Larynx— Trachea—Large Bronchi.

   Inflammation  of these organs in connection  with  pneumonia is
not frequent.  We have twice seen erosions upon the  inferior vocal
chords ;  in one there had been measles with hoarseness, in the other
entire loss of the voice; inflammation  of the large  bronchi is very
rare,  once  only we  have satisfied ourselves of its existence,  we
therefore rest assured that if there is a bronchitis existent with the
pneumonia of children, it is  always capillary.

                     Vesicular Emphysema.

   To complete the series of the  alterations, which we  have  met
complicating pneumonia, we must mention vesicular emphysema,
which we have sometimes observed.
   It  presented,  usually, the following appearances. Occupying
especially the summit and the anterior border of the  lung, the  em-
physematous portions  did not collapse n\>on the  admission of air
into the chest ; they appeared of more than the ordinary thickness
of these  parts, and extended towards, or even  covered  the corres-
ponding  portions  of, the opposite lung.
   The lobules of the  lung  were  protuberant, and  the  pulmonary
vesicles,  more distinct than elsewhere,  were  unequally   though 
20   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILD
slightly dilated, being never seen larger than the head of a ^large
pin.   We have never met with  the  appendices described by M.
L,ouis.  The emphysematous portions felt between the fingers did
not appear thicker than the healthy tissue.   The vesicles  were per-
fectly transparent, and collapsed entirely upon puncture.
  This alteration has appeared due, in some cases, to a rachitism of
the chest, causing such a deformation as to compress  the lung in
certain  parts.  We shall develope  this idea in another work, of
which we have in part the materials.


                            Pleura.

  Authors have said that pleurisy is rare in the child; if by this they
mean, that pleurisy does not complicate pneumonia so  generally as
in the adult, they are right; but they are mistaken if they imagine
pleurisy to be in  itself a  rare disease in children; since it is very
common to  find  in the pleura of this age traces of recent or old in-
flammations. Thus, in forty-three cases, we  have found the pleurae
healthy only ten  times.   Nineteen  times we have met ancient ad-
hesions more or  less extensive, situated especially along the pos-
terior border of the lung.  Sixteen1  times  we  have found recent
adhesions not differing essentially from those in adults.  Thus we
have met with redness, and vivid injection of the pleura, with yel-
lowish,  soft,  elastic, and  at times tuberculous false  membranes,
with gelatiniform adhesions infiltrated with serosity, or with lemon
coloured, clear, or flocculent serous effusions, and finally even with
effusions of a purulent nature.
   Acute pleurisy has been thought especially rare in children from
 two to five  years, (Gerhard and Rufz): but we have observed it in
 a third of the cases at that age. It appears more frequent in females
 than males, and has always  coexisted with a  lobar pneumonia, or
 with the lobular  form become general.
                      Bronchial Glands.

  Often healthy, in other cases however, they were increased in
volume, softened, reddened, or of a paler hue.   Sometimes they
had undergone tubercular degeneration, but in these the existence
of tubercles was almost constant in the lungs:  and even in one case,
where one lung only contained tubercles, the glands of that  side
were alone affected.
  As  to alterations existent  in the organs of other functions their
description does not form a part of our subject, it will be sufficient
to indicate them, that their complication may be appreciated.

  1 These  numbers form a total of forty-five  instead of forty-three two of
the  observations  being doubled, from presenting recent, together with old
adhesions. 
PATHOLOGICAL ANATOMY.
21
                        Pericardium.
  Healthy in all  our patients, containing from one half to three
spoonfuls of a lemon coloured serosity ; one subject, who had suc-
cumbed to hemorrhagic  measles, presented ecchymosishmder the
fold of this membrane  investing the heart; and another presented
an ecchymosis under the serous  membrane lining the fibrous invest-
ment  of that organ, the consequence of pressure  from a rachitic
deformation of the chest.

                           Heart.
  Always found  in  a  normal state, both  in volume and structure.
It contained often  coagula, either black or fibrinous; colourless
in the auricles, and sometimes in  the right ventricle.   In  the case
of hemorrhagic measles, there were no where any coagula.
  The lining membrane was always smooth, polished, and  pale.
The valves, especially of the left side, presented,  rather  often, a
somewhat vivid redness,  being  thus tinged in  one quarter of the
cases, sometimes  on the  right, sometimes on the left, and  at other
times on both sides indiscriminately.

                           Brain.

  Most generally the nervous system was healthy, with the excep-
tion of a subarachnoid  infiltration, somewhat abundant, but neither
more so, nor more frequent than in the other diseases of children.
  Once there was a general hardening  of the substance of the
brain  and spinal  marrow; but  there had been an  existence of
paraplegia, and the child showed some symptoms of asphyxia.

                  Digestive tube.—Stomach.

  Seldom but slightly affected;  this viscus has presented the fol-
lowing alterations:—
  Ten times softening  of the mucous membrane of the grand cur-
vature: ought this to be regarded as cadaveric?
  Redness,  in different degrees, without  softening or thickening,
to be regarded as a slight congestion, but not inflammation,  five
times.
  Once we found thickening, without injection; once ecchymosis;
once linear redness along the grand curvature, with softening  and
superficial erosions:  and, finally, in one case, after  the injection of
a large quantity of Kermes mineral, we found vivid redness in the
small curvature, existing in large bands, small lines, or little points,
with ecchymosis, the softening  having attacked indifferently the
red and the  pale portions.

                       Small  Intestine.

  The lesions we have met in this organ are the following:—some 
 22   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

 arborescent vessels or congestions  more vivid than in the healthy-
 state; thrice a white softening of the mucous membrane in  a con-
 siderable extent; nine times redness and softening in the patches
 of Peyer;  once only any ulceration of these patches.  Every one is
 aware that the glands of Brunner appear in children generally very
 protuberant under the mucous membrane, dotted, or reticulated
 with black, without any actual morbid affection.  We have, how-
 ever, found them sometimes so red, soft, and swollen, as no longer
 to be regarded in the normal state.

                       Large Intestine.

   It is here that we find the most frequent complications of pneu-
 monia.   But we must  remark, that  inflammations of this organ,
 together with  those of the  lungs, are, perhaps, the diceases most
 fatal to childhood.
   The alterations may be classed as follows :—
   1. Colitis, with redness, thickening, and  softening.
   2. Abnormal dilatation of the follicular orifices.
   3. Colitis, advanced to ulceration, with or without false  mem-
 brane.  These ulcerations  have always appeared seated in  the
 follicles, more numerous at the end of the  intestine, and never in
 the caecum.
   4.  Softening, without notable change of  colour, and with a nor-
 mal thickness.
   5.  The easy separation of the  mucous membrane from the sub-
jacent tissue, with or without redness.
   6.  Ecchymosis.
   To give,  in a few words, our conclusions, the digestive tube has
 been the organ most frequently complicating by its affections  the
 pneumonia—hardly can we count nine cases where it was through-
out healthy.  The greater part of these affections, especially of The
 large intestine, was chronic, consequently antecedent to the pneu-
 monia ;  in proof of this, we have the  fact,  that, in the great majo-
 rity,  the pneumonia developed itself in  patients labouring under
some anterior  malady.   The other abdominal  organs  were either
 healthy, or their slight alterations hardly  deserve attention :—we
 may  merely  remark,  however, that in  the case  of hemorrhagic
 measles, the kidneys presented  numerous ecchymoses  with thick-
ening of tho mucous membrane of their pelves. 
MODIFICATIONS OF THE RESPIRATORY SOUND.       23
                        CHAPTER III.


         MODIFICATIONS OF THE RESPIRATORY SOUND.

  The discovery of auscultation, so eminently useful in the thoracic
affections of adults, ought to render double service in the study of
these maladies in a younger age.  In reality, during the first years
of life, the lung most often only betrays its diseases by those signs
which the physical examination reveals: deprived of this precious
aid to our investigation, we should be exposed every day to mis-
take,  or  to overlook the greater part of the diseases of the viscera
contained in the cavity  of the chest: therefore ought we to pay a
particular attention to the numerous modifications of the respira-
tory murmur in this class of patients.
  This subject has not  yet  received all  the care it deserves:  the
character of the rales, their seat and frequency, the changes of one
into another, and, above  all, their respective diagnostic values, have
not yet been pointed  out  in a sufficiently clear and positive manner.
Let us see what the analysis of our facts furnishes upon  this sub-
ject,  in examining  successively the  sonorous,  sibilant,  mucous,
subcrepitous, and crepitous rales, the bronchial respiration, and  the
natural respiration, when rude or obscure.
   The sonorous  and sibilant  rales.—Their  characters are  the
same as  in the  adult, and they are, without doubt, the least  im-
portant of all—their duration is usually very short, (two days at  the
most:) they affect indifferently all parts of the chest, but never in-
volve it in  its whole  extent.  We find them at different epochs,  but
in a third of the cases (especially in the young subjects) before a
full declaration  of the malady.   They precede, therefore, the  ap-
pearance of the bronchial respiration, but seldom immediately, for
usually we hear other rales before this  latter manifests itself: in
the large number of cases they are intermingled with the mucous
crackles, and  the sounds  which replace them are very  variable.
They present hardly any diagnostic value, except in patients from
two to five years, where  the pneumonia usually commences with a
bronchitis, and where the sibilant rale is often the first symptom of
this latter affection. We deduce from this the practical consequence
that,  in a child  of two years, a sonorous  or sibilant  rale should
put the physician upon his guard against the ulterior development
of a pneumonia.
  As to the producing cause, the inconstancy and short duration
of these rales have never allowed its discovery: we can, however,
say, that in no case where  they have been present, have  we  been
able to discover, at the autopsy, in the corresponding part of  the
lung, any  tumefaction of the  mucous membrane  of the smaller
bronchi. 
24   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
   The mucous rale.—This  rale resembles that  in the adult, and
does not present any varieties  from age.   Its bubbles,  sometimes
large, under the form of a crackle, sometimes finer, approach, in
this  latter  case,  the  subcrepitous, with which it  is  easily  con-
founded.
   The  mucous  rale  is  heard usually both in inspiration  and
expiration, in all parts of the chest, always behind, generally on
both sides, and sometimes in front.  It presents itself at all the
various periods, at the commencement, a few days after, or at any
point in the course of the pneumonia.
   We  have remarked nothing constant in the alterations of the
respiratory murmur preceding or succeeding it: we have seen it,
however, succeed to  a  pure respiration  rather oftener than to any
other species.   Its duration  has, in general, been very short.   This
latter remark is especially true  in  children  from two to five years,
for in those from five to ten its progress, sometimes  irregular, has
been more constantly uniform,  and its duration  longer: it has ex-
isted  throughout the whole  of the disease, and  when once its
presence has  been established, it was  rare that we did  not find
it many days in succession  in  the same  place, more or less ex-
fended.  Seven times in thirty it was mingled with a bronchial
respiration, especially in children  from two to five years:  once
even it manifested itself at evening in a point where, on the morrow,
we found a bronchial respiration.
   From what we have said, the value of this rale appears superior to
that of either of the other two : its great frequency, its persistence in
certain cases, and its frequent coexisting with, or preceding a tubal
respiration, render it a most precious means of diagnosis.  It may,
therefore, sometimes be regarded as the generating rale of bronchial
respiration, (only, however, in cases from two to five years.) What
a difference from the mucous  rale of adults, which  is only indica-
tive of a simple catarrh !
   The subcrepitous rale.— What  we have said of the last rale will
apply, in  part, to the  subcrepitous,  since, in  a large number of
cases,  the  passage of one to the  other is  very difficult  to  seize.
Generally, it was heard in both the times of the respiration ; some-
times only in the inspiration,  especially  when  accompanying the
bronchial sound : once only it existed in the expiration alone. Our
remarks upon  this  rale refer  especially  to children from two to
ten years,  for from ten to fifteen we have observed it but five times.
It existed  oftener on both sides than  on one alone: in three quar-
ters of the cases to a greater extent at the base than elsewhere, but
 we have heard it in all parts of the chest.   When existent only on
one side, it was often mingled with a bronchial  respiration: in the
 young subjects, from two  to five years, in half the cases where
 heard, it appeared in points where the  bronchial respiration after-
 wards developed itself;  so that it  may be  regarded  as  one  of its
 generating rales. Observe,  to strengthen  this remark, that it was
 precisely in those cases where  we had ausculted the patients from 
MODIFICATIONS OF THE RESPIRATORY SOUND.      25
the beginning, that this  succession of symptoms was observed;
which would encourage the idea that its absence, in the other cases,
was due to our not having ausculted sufficiently early, rather than
to its  non-existence.
   The duration of this rale was variable—short, three or four days
at the most, when manifesting itself before the bronchial respira-
tion—much longer when  it succeeded it.  In a child of three years,
under these circumstances, it persisted for two whole months.
   Existing sometimes alone, it was more frequently accompanied
by a  bronchial inspiration or expiration:  in  some cases it  was
heard around the tubal sound,  and,  as this latter advanced, the
rtle preceded it to attack the adjacent parts.
   In cases where it disappeared, it was replaced by different altera-
tions of the respiratory sound  presenting nothing constant.
   This rale is of great value in the diagnosis.   The fact that  it so
often  precedes  the  bronchial  respiration,  and  is heard where the
other is soon to appear, establishes,  it would seem, a very important
relation of cause to effect.  The shortness of its duration, when
anterior to the tubal sound, is explained by the rapidity with which
the hepatisation supervenes:  while its length, when succeeding to
this latter, confirms the remark already made, of the tardy  resolu-
tion of pneumonia  in  younger children.   We can  then  establish
the principle, that, when in a  child of from two to  five years, pre-
senting for some days some slight  modifications of the respiratory
murmur,  the sonorous or sibilant rales, for example, we  begin  to
detect a subcrepitous rale with equal and numerous bubbles, there is
strong reason to suspect the immediate invasion of a pneumonia.
   Crepitous rale.—This  rale, pathognomonic of the pneumonia of
adults, does it exist in children?  Gerhard  and Rufz say  never  in
children from two to five  years:  this  appears  to us  erroneous, for
we have observed it in nine of our  patients: and we are quite sure
never to  have mistaken  for it a subcrepitous rale,  as we  find it
clearly mentioned in our  notes as a crepitous rale, excessively fine,
as in the  adult.  With the exception of three  cases, it has always
been mingled with  bronchial respiration :  once it appeared on  both
sides  behind,  and was  replaced  the  next  day by  a subcrepitous
rale:  another time it occupied the whole of the right back.  In this
case,  the child succumbing twelve  hours  after, we found the lower
lobe of a violet colour externally, of a deep red on incision, impene-
trable to the finger, still swimming  upon the surface  of water, and,
when pressed, giving issue to a great quantity of blood, with a  little
air.   This description corresponds  entirely  with the inflammatory
engorgement of Laennec, and, consequently, the lung, in this case,
was in progress towards hepatisation, the  rapidity of the  fatal ter-
mination  alone preventing its arrival there.
   In older children, the "crepitous  rale is admitted by all patholo-
gists.   We have met it eleven times,  always  intermingled  with a
bronchial respiration.  Its shortness of duration is  quite remark- 
26   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
able,  one or two days  at  most,  never reappearing in the  points
where it primitively showed itself.
   The value of this rale is very great, as being a  predecessor of
bronchial respiration ; nevertheless, as compared with the subcre-
pitous, its importance is diminished by its rarity.
   In  closing the history of these rales, we would call the reader's
attention to their duration being shorter, their march less regular, and
their  transformations more numerous in the child than in  the adult.
Our observation confirms,  also, the remark of  M. Guernard, with
regard to the facility with which we cause their disappearance, by
keeping our little patients  a  short time seated,  and  their greatest
distinctness at the moment when the child is raised from  his bed.

                    Bronchial Respiration.

   Of all the alterations  of the respiratory murmur, this deserves the
most  particular attention : it was present in two thirds of  our cases,
and where it is not in our notes, the lesion was either very limited,
or auscultation had not  been  practised  during the latter days of life!
A remarkable fact, often established by our cases, is, that frequently
this modification of the respiration was only heard  in  the expira-
tion, while the inspiration continued pure, or accompanied by some
rale.  In these cases, the expiration, prolonged and bronchial, mani-
fested its peculiar note in the  little accompanying cry.   We have
observed this phenomenon more generally in the younger subjects,
and at two particular stages of the disease, viz.:  either  before or
after the appearance of the bronchial respiration, when the disease
was beginning to limit itself.
   But why is it that the bronchial respiration was thus  more  fre-
quently heard in expiration?
   In children from two  to five  years,  lobular pneumonias, of  one
kind or the other,  being, without contradiction,  the  most frequent
form of the disease, it is natural  to suppose that this  stethoscopic
phenomenon originates in this peculiarity.  The  little nodules, with
regard to their influence upon the respiratory sound,  have the same
effect  as tubercles.  Now, since Jackson,1 we all know a prolonged
exp.rat.on to be a sign of tubercles scattered in  the pulmonarv pa-
renchyma.   In children from two to five years, as we have already
said, the bronchial respiration was, in  a certain number of cases,
preceded by rales of different natures.  In  the  subjects  more ad-
vanced, it was often ushered in by an obscurity of the  respiratory
sound, and m this  c ass, more frequently than in the other, it was
the first symptom established.                             '
   In children from  two to five years,  it has  always existed pos-
tenony, and most commonly  near the vertebral column
   In those from  five to fifteen, we have, in the great  majority of

             1 The late James Jackson, jr., of Boston.—P. 
         MODIFICATIONS OF THE  RESPIRATORY SOUND.       27

our cases,  found it behind: four  times  only anteriorly, of these
once at the level of the right middle lobe, once at the anterior and
middle part of the two lungs, and, finally, in  the two other cases
under the clavicles.  In the greater part of  our patients, we have
found it for several successive days.
  In children from two to five years, in  cases terminating favour-
ably, the bronchial respiration disappearing, gave place to divers
modifications of the respiratory sound.   In those cases, on the con-
trary, where  death supervened,  it persisted until that event,  and
this persistence, when  it  coexisted with an increase of the general
symptoms, was  considered by us  of very grave  import;  whereas
in a child of nine years, in whom the  disease was developed in a
state of perfect health, the bronchial respiration was heard several
days after the disappearance of the febrile symptoms, and when, to
all external appearances, the disease no longer existed.
  Although generally easy  to hear, we ought to remark, that  the
presence of rales, the  difficulty  of inducing our little patients to
cough, added to their repugnance  to examination, sometimes mask
its character.   But without" regard  to the difficulty of its perception,
can bronchial respiration  in  children possibly be confounded with
any other stethoscopic sign ?  We have no doubt of it.  In a good
number of cases, we have seen  persons  little accustomed  to  aus-
cultation, especially of the  healthy lung of children, mistake the
normal puerile  respiration for the  bronchial;  nevertheless, the  dif-
ference is great, for however puerile it may be, it always gives the
sensation of  air entering a number of vesicles ;  besides, it is only
heard in the inspiration, "whereas the bronchial character especially
manifests itself in  the expiration.
  There is, however, a variety of respiration still more difficult to
distinguish from the  bronchial, viz. a rude  respiration;  and we
even incline to  think that this rudeness is, in some cases, the index
of a pathological condition differing only  in extent from that giving
rise to the tubal sound; we  have observed it only a small number
of times.   More than this it  has offered nothing constant, either in
its duration or in the rales preceding or succeeding it.
  A bronchophony has always accompanied the bronchial  respira-
tion, whenever we have  succeeded in eliciting a few words from
our little patients; in some  cases,  the  resonance  of their plaintive
cry has replaced with advantage the bronchophony which we could
not establish.
  The respiration is sometimes quite obscure: this character  pre-
cedes immediately the bronchial  respiration, or else shows itself
at different epochs of the  disease.  The duration of this state was
generally very short.
  To conclude ;—of all  the signs which  auscultation  gives  us,
the bronchial respiration  is  the  most  precious aid; it is the only
pathognomonic symptom  of inflammation of the pulmonary paren-
chyma, indicating by its extent that of the disease, and  by its per-
sistence, the gravity of our prognosis. 
28   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

                          Percussion.

  As a diagnostic sign, percussion is of much less value than aus-
cultation ; it furnishes no results in the simple lobular form  of the
disease ;  it is only useful where the hepatisation is become general,
or from  the commencement  has  taken the  lobar form.  We find
dulness on percussion signalised in many of our cases, always in
proportion, both in extent and degree, to the  bronchial respiration,
generally developed at the same time with,  never, however, before
it.
  Percussion, to be useful, should be practised with  much care,
and the observer should be perfectly acquainted with  the natural
resonance of the child's chest.  The thorax of the young subject
being naturally very sonorous, the flatness is  seldom any thing
more than relative.   The comparative sonorousness, also,  of the
different parts of the chest is not to be overlooked ; thus, the infe-
rior  dorsal region being naturally the  most resonant,  percussion
has never given but a relative degree of dulness.
  There are even  cases of  greater difficulty, as where a double
hepatisation   has  gained the same  level on the  two  sides, and
where in consequence we have no longer any point of comparison,
M. Hourmann,  who allows  but  little value to  percussion,  insists
somewhat upon important  results obtained  from the application of
the palm of the hand upon the chest.  He thinks that the vibration
of the walls  of the chest, from the cries of  the child, always com-
municates to the hand upon  the diseased side a more decided
vibratory thrill.
                       CHAPTER IV.

THE CONNECTION BETWEEN THE  AUSCULTATION AND PATHO-
                      LOGICAL ANATOMY.

  After the separate study of the alterations of the respiratory mur-
mur, and the pathological  anatomy in this disease,  we come natu
rally to the question of the correspondence between the two.
  To establish a comparison of  this nature, we shall follow the
same steps as in the description of the  pathological anatomy, and
as in  the series of pathological  changes we have  found a chain
commencing with the capillary bronchitis and ending with the
lobar pneumonia;  so, also, we are able  to establish a gradation of
symptoms admitting of a  perfect  parallel.   There is the same dif-
ference  between the stethoscopic signs of the capillary bronchitis at
one end of the chain and those of the lobar pneumonia at the other,
as there is  between  the pathological states of the  luno- in these 
          AUSCULTATION AND PATHOLOGICAL ANATOMY.      29

cases:  and as the intermediate lesions are but the union of the two
extremes in different proportions, so their symptoms are a propor-
tionate combination of those furnished by the same extremes.
  To illustrate our remark, a bronchitis reveals itself by a mucous
or subcrepitous rale ; a pneumonia, by a bronchial  inspiration or
expiration ; and the predominance of either of these in  a combina-
tion of the two, is the index of the like predominance of either of
the affections—inflammation of  the  mucous  membrane or  of the
parenchymatous structure of the lung.
   For these  reasons, and to facilitate our discussions, we  give a
name  to each  of these extremes.   Thus  we shall speak  of the
capillary bronchitis, the bronchial  mucus, and  the mucous and
subcrepitous rales as the bronchial  element,  whilst  the inflamma-
tion of the parenchyma, with the bronchial respiration, will be the
parenchymatous element, the predominance of either making the
excess of its  element in the particular affection of the lung.
   This understood, it remains  to us  to complete the parallel, in
properly estimating and specifying the degree of combination of
the two.  In this we shall support ourselves wholly by our observa-
' tions, and although, with our point  of  departure, we might make a
\ diagnosis from theory alone, we shall avail  ourselves of this latter
 only to facilitate and illustrate our facts.
   We shall first call the attention to the different varieties of pneu-
 monia uncombined, examining afterwards their symptoms when
j united with, or complicating  some other of  the alterations which
: we have described.

               Vesicular Bronchitis or Pneumonia.

   This affection has always occurred to us in connection with some
 other form of pneumonia, or at least a capillary bronchitis; but it
 is easily conceivable that the bronchial element is here the only
 existent one, both as symptom and  pathological state.

                      Lobular Pneumonia.

    It is impossible to study the characters of this inflammation in
"I its state of perfect simplicity, as it is never met with without a co-
^ existent bronchitis, or at least  an  abundant secretion of mucus;
i thus,  instead of finding a pure hepatisation, we have a combination
i<' of our two elements.
»f    But what a variety of circumstances influence the predominance
J( of one or the other?  We have, for example, some scattered points
ii of pneumonia, with an abundant effusion of  mucus; here is predo-
i minance of the bronchial element.   On the other hand, a case pre-
iin sents a slight quantity of mucus, with but thickly disseminated
i points of pneumonia ;  here the parenchymatous is the most declared :
ef the same  difference, if the little nodules be superficial or central,
11 voluminous or small in size. 
 30   RILLIET AND EARTHEZ ON PNEUMONIA OF CHILDREN.

   Hence the great irregularity of the simple lobular pneumonia,
 which has not yet  become general.
   It is always to  be kept  in mind, however,  that the bronchial
 element is  much more  universal than  the other, and, as it were,
 surrounding it, it is the  more easily detected by  the ear.  Thus, in
 all cases, where the autopsy has shown a lobular pneumonia of the
 whole or part of the  lung, we had during  life observed in the cor-
 responding  mucous  or  subcrepitous  rales,  remarkable for their
 persistence, having endured from the commencement of the disease
 until death.  In these cases  the  percussion has furnished us no
 light, for the  resonance  was nearly always equal to that  of the
 opposite side.
   In a small number of our observations we have met with super-
 ficial points of pneumonia in those parts  of the lung where auscul-
 tation had detected a drier and finer rale, surrounded  by the moist
 rale of a bronchitis, and  this we have regarded as the commencing
 development of the parenchymatous element.
   At other times we have heard a prolonged expiration or a very
 rude inspiration  always accompanied by a rale  more or less fine,
 and always at points  where the autopsy revealed  an  assemblage of
 a somewhat large number of  the  little nodules  of pneumonia: in
 these cases, in  fact, we consider  the lobular pneumonia  to play the
 part of tubercles  in producing the phenomena of the auscultation.
   We have also  heard the bronchial sound  in the expiration, and
 even both in expiration and inspiration, in cases  where the mucous
 rale became  less abundant; and these symptoms have disappeared
 upon the bronchi becoming again  filled with fluid.
   This  occurred in  points where  the autopsy afterwards demon-
 strated a lobular  pneumonia.
   Finally, we  are to  observe  that all  the symptoms  of  the paren-
 chymatous inflammation  are more easily  appreciated at the summit
 or middle,  than at the base of the lung; it is there  that we have
 been most sure  of our diagnosis, because there the subcrepitous
 rale is less  abundant, and at times even  absent entirely.   From
 these remarks we may deduce.
   I. Lobular pneumonia is more easy of detection superiorly than
 inferiorly, but as  it  does not affect any particular part  of the lung,
 when we find  it in one  portion we may suppose it to  exist else-
 where, and the manifestation of the slightest symptom of the paren-
 chymatous element authorises us to admit its more general exten-
 sion, especially if the  bronchial element be very welfdeclared, and
 the natural symptoms lead us to suspect a pneumonia.
   2. A single examination does not suffice for a positive  diagnosis,
 but  it should be  repented often  in  the same day, to seize, if there
 be any, the changes from the one element to the other.
  3. Not being able to augment  the parenchymatous element, we
should seek to diminish the bronchial.  Thus, in  all cases it is use-
ful to free the child's  chest of  any mucosities, and in this we shall
have the additional advantage of assisting  our diagnosis. 
         AUSCULTATION AND PATHOLOGICAL ANATOMY.       31

  With these precautions, our  stethoscopic diagnosis will be cer-
tain, if not in all, at least in the greater number of cases ; and if  we
will avail ourselves of the other signs to be hereafter detailed,  we
shall seldom be  found at fault.

         Simple Lobular Pneumonia becoming general.

  In these cases the two elements, the bronchial and the parenchy-
matous,  are  equal, and manifested nearly at the same time, what-
ever may be  the amount of either.
  It is easily conceivable that  the pneumonia must have become
already general  in a certain extent, for these two symptoms to be
constant.
  Thus,  a  bronchial respiration or expiration,  with a mucous or
subcrepitous lale  and  dull on  percussion, are the  peculiar  symp-
toms of this affection ;  we have, however, seen one case where  the
bronchial respiration was not heard till  the evening before death,
although the pneumonia had  become general, and  advanced even
to the third stage in some places.  In  this case, the mucous  rale
was extremely  full and abundant, and  the bronchial tubes were
crowded with mucus.                       #
  When  we can  follow the   march  of a lobular  pneumonia in
progress towards  the lobar form, we find first the  rales, then an
expiration, or a  bronchial respiration,  unequally  disseminated  and
extending little  by little  till it involves a  considerable space.
  And to show  that this is not  merely in the imagination we will
transcribe a portion of one of our observations.
  1st day.—Right back, subcrepitous rale rather rare in both times
of the  respiration ; at the left summit a little sonorous rale.
  2d day. —Abundant subcrepitous rale on both backs.
  3d day.—Behind, at the left  base, and  at the middle of  the right
lung, bronchial  expiration, mingled with a somewhat coarse sub-
crepitous rale, heard above and" below the point  of the bronchial
respiration.
  4th  day.—In  the whole height of the  right back, bronchial expi-
ration, with  a little subcrepitous rale at  the base;  on the left  the
bronchial respiration is scattered here and there.
  5th  day.—Respiration fully declared  as bronchial in  the  two
upper  thirds of both backs; below, fine subcrepitous rale.
  At the autopsy  there was found a pneumonia  originally lobular,
but already become general.
  It remains now to decide if  auscultation can  teach us  the time
necessary for a lobular pneumonia to become general.  Our  ob-
servations offer  us little  assistance upon  this subject; nevertheless,
considering  the  rapidity with which the  bronchial respiration  de-
clared itself after  the catarrhal period in the case just detailed, we
may conclude, that its march, once commenced, is very rapid.   We
shall see hereafter, however, that the rapidity of this progress is 
32   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

subordinate to the nature of the disease upon which the pneumonia
supervenes.

                      Lobar Pneumonia.

  The crepitous or subcrepitous rales, bronchial respiration, bron-
chophony, and dulness  upon percussion are the characters of this
pneumonia as well in the child as in the adult.
  In the younger children, however, the bronchial element always
exists: thus  in those cases, the  rale  is  more moist than in older
subjects, where  the parenchymatous element, on  the contrary,
predominates in the auscultation  as at the autopsy.
  It is only in the lobar pneumonia that we  have a difference thus
made by the age of the patient;  in the lobular form we have been
able to establish no such distinction.

                        Carnification.

  This affection is generally of too little extent to give rise to any
well marked  symptom.   Most generally we have  only noticed a
mucous or  subcrepitous rale, with a slight diminution of the reso-
nance upon  percussion ; and a careful examination of all our ob-
servations leaves us with the general idea that in an  equal extent
of lesion, carnification offers much less an amount of stethoscopic
signs than hepatisation.  Twice, however, in a vast  carnification,
we  found, in ausculting at various intervals, the bronchial respi-
ration.
  Thus far we have the history of the simple cases.  But a com-
plication of the pneumonia with any other disease of the lung must
cause many modifications in their signs.   These complications are
of two kinds : either several species of simple pneumonia are united
in the same  point,  or else there  is joined to it some one of those
lesions, of which we have not yet detailed the symptoms.
  The first  division will detain us but a few moments; its signs
must depend  upon   the mixture,  more or less considerable, of the
two elements ; we  have seen cases of the union of both species of
bronchitis, the capillary and the vesicular, of this latter or perhaps
of both with a lobar pneumonia or carnification.   In  the first case
the bronchial element existed alone;  in the second the parenchy-
matous predominated. We would be understood, however to allow
that auscultation does  not furnish a differential diagnosis' between
these simple and the complicated affections.
  The second class comprehends those cases where a dilatation of
the bronchi,  or  an emphysema  occurs  in conjunction with  the
pneumonia.
  A priori we should be unable to say what  might  be the influ-
ence of  the dilatation of the bronchi upon the  auscultation • for if
on the one hand it  would produce bronchial respiration by the in-
creased size of the  tubes, on the other it must facilitate the mucus 
         AUSCULTATION AND PATHOLOGICAL ANATOMY.      33

rale, rendered more abundant and more  moist by the quantity of
fluid, and the greater space allowed to the formation of the bubbles.
  Facts  show us  that both these circumstances may occur; we
have observations of dilatation of the bronchi in which  the bron-
chial element  predominates, while  in others it is  the  parenchy-
matous.
  But in this  latter case we would suggest the question whether
the mucus was  or was not charged with  air, frr this  appears to
coincide  with a  remarkable  change in the  production of the rsiles.
We judge so by two cases, in  both of which the parenchymatous
element  predominated in  the  auscultation, whilst at the autopsy
the bronchial appeared the more abundant: one was a case of vesi-
cular bronchitis, with a lobar pneumonia, and a very abundant
quantity of mucus ; the other a lobular pneumonia become general
in the first and second degree  with a dilatation of the bronchi, and
also a large secretion of mucus.  In the first case, we had a bron-
chial respiration  with very little subcrepitous rale in  the  same
points: in the second we had a pure  crepitous rale: but in both
these observations, the mucus was not charged with air, or rather
we  found a puriform liquid, which seemed never to  have  been
penetrated by the air, and therefore not to have contributed  to the
stethoscopic sound of bursting bubbles.   Thus in  these cases the
sounds emanated from the parenchyma of the lung.
   To  conclude, we find  only one case of vesicular  emphysem
complicating  the  pneumonia ; this case, one of the most compli-
cated of all, was a capillary and vesicular  bronchitis, with lobular
 pneumonia at the third stage,  dilatation of the smaller bronchi, and
emphysema, showing the bronchial element in excess as patholo-
 gical alteration  and consequently as symptom.  Besides the fun-
 damental symptoms,  we are to regard also a third—the  intensity of
 the respiratory sound.  In  one case, this, in consequence of the
 emphysema, was  nearly nothing, while the resonance  on percus-
 sion was exaggerated. In addition, we had presented to us another
 phenomenonwhich, according to Laennec, may be referred to the
 emphysema as  cause : thus, at any moment of the disappearance
 of the mucous rale, we heard a succession of dry crackles, a sort of
 gross crepitous rale.  These crackles could not be attributed to the
 lobular pneumonia, as they were too large and heard in an extent
 too considerable.
   In this case the emphysema was the  phenomenon clearest cha-
 racterised, and its symptoms were the following:
    Mucous rale  disappearing after  cough, leaving the  respiration
 very obscure, with a  return  of the rale, alternating with the dry
 crackling.  Resonance on percussion much exaggerated.
    In conclusion, the following may be regarded as the stethoscopic
 signs of each of the alterations which we have described :
  ^Capillary and  vesicular  bronchitis :—mucous or subcrepitous
 rales; natural resonance upon percussion; lobular  pneumonia;
 mucous or subcrepitous  rales, mingled at times  with  a rale more
        16—c                                      ril 3 
34   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

dry in its character; a roughness of the respiration ; prolonged or
bronchial expiration ;  resonance  natural.
   This latter species become general :—mucous or subcrepitous
rale, with bronchial respiration scattered or rapidly spreading ; dul-
ness.
   Lobar pneumonia;  crepitous  or  subcrepitous rales, bronchial
respiration, bronchophony, dulness.
   If a dilatation of the bronchi be joined  to  one or the other of
these affections, it  is sometimes  the  mucous or  subcrepitous rale,
sometimes the bronchial respiration  which are  exaggerated.
   In all that  precedes we  have as yet  said nothing of the stetho-
scopic signs  marking the  change of the pneumonia from  the first
to the  second or from  the second to the third degree.  We have
however spoken of one case  where a well manifested pulmonary
engorgement  gave  for symptom a pure crepitous  rale.  As for the
distinction between the second  and third degree, it would appear
impossible to establish it, and  for  this very  simple  reason, that
in all  our cases of gray hepatisation, there existed no considerable
softening of the parenchyma.  Now Laennec asserts that the infil-
tration of pus into the  pulmonary parenchyma affords us no new
sign, as long  as it remains in a concrete state.   But even supposing
the pus to have softened, the mucous rale, which, according to this
author, indicates the change, would  be of no use to us. considering
its excessive frequency in children.
                        CHAPTER V.

                           CAUSES.

  After the study of the anatomical lesions in the pneumonia of
children, and the exposition of the physical  symptoms which cor-
respond to them, we come naturally to the question of the circum-
stances favouring the development of the disease under considera-
tion.
  A fact, which  strikes at first view, and which has been noted  by
ail authors, is, that in the large majority the pneumonia supervenes
in the  course of some prior affection.   This has  been  especially
insisted upon in children of from two to five years.  Gerhard and
Rufz go even so far as to say that idiopathic pneumonia does not
exist at that age. This assertion we cannot admit in all  its rigour,
since we possess three examples of children  of five  years, in whom
the disease was developed in the midst of perfect  health • but we
recognise the truth of the general proposition ;  of forty patients be-
tween these ages, only three were in full health at the commence-
ment of the pneumonia.
  Cut  more, it is not solely in  these first  years of life  that the dis- 
CAUSES.
35
ease is rare in an idiopathic form :  it is the same in the succeeding
periods.  Our observations prove this very evidently.   Of twenty
patients from six to fifteen years, six  only were in good health at
the invasion of the malady, the others were attacked with different
diseases: measles, small-pox, typhoid  fever,  hooping-cough, gan-
grene of the mouth, &c.
  From these remarks it results that children may be attacked with
two kinds of pneumonia;  one somewhat rare which may be styled
the idiopathic,  or the primitive, the  other much  more frequent.
which we shall call the complicated or secondary form.
  This fact once admitted, what are the causes exerting an influ-
ence upon the development of this  inflammation.
  Age is one of the most efficient of the predisposing causes, since
from two to five  years the  malady is by far the most frequent.  In
sixty patients, forty were from two  to five years of age, and twenty
between five and fifteen :  and  the real proportion is even greater
than this, as the  number of beds in the ward for the older children
is much the more numerous, and the admissions there consequently
more frequent.
  To corroborate our assertion  we will cite the result of the tables
of pathological anatomy drawn up by M. Haese, who in one hun-
dred and eight autopsies found a  pneumonia seventy-one times in
children between two and five  years,  and  thirty-seven  times Only
between the ages of six and fifteen.
  A<re exerts an  influence not  merely upon  the frequency of  the
disease, but equally upon its particular form.  We are of opinion,
however, that the proposition, that lobular  pneumonia is peculiar
to the younger class of children, is  too general—for although with-
out any doubt it is more frequent at these ages,1 still we possess an
observation of a perfectly  well  marked lobular pneumonia in  the
partial form, in a child of nine  years.  And. in an examination of
facts furnished  by our predecessors, we find, that  the first case of
M.  Burnet, is this form of the disease  succeeding to measles, in a
girl aged eight  years; and his fifth  is of  the same affection in a
child of nine and a half years :  and lastly M. de la Berge's first ob-
servation is in the same category.
  Another fact, tending to limit the influence of early age upon  the
particular form of the disease, is, that from  the observations of MM.
Valleix and Vernois, the lobular form is very rare in infants.
  Sex has not appeared to us to  exercise any well marked influ-
ence upon the development of the  pneumonia in  the first class of
our patients ; neither  has it in the  second  series,  when the disease
complicates some pre-existing  affection :  but according to  Ger-
hard, idiopathic pneumonia from the ages of five to sixteen is more
common in males than females.
  Authors vary upon the time of  the  year most favourable to  the
production of pulmonary inflammations.   M. de  la Berge, reason-
' See table of Pathological Anatomy. 
36   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDRE
ing from the fact of the great number of eruptive fevers in spring
and autumn, advances  an opinion that lobular  pneumonia is more
frequent at these seasons.  M. Leger makes the same observation ;
and Dr. Gerhard assures us that idiopathic pneumonia is the most
common in the months of April and May.
  One of our colleagues, M. Becquerel, having had the kindness to
place at our disposition a list of the pneumonias occurring  in the
service of  acute  diseases, (girls,) during the months of April, May,
and June,  we are  enabled, in uniting his  notes with  ours, col-
lected at the beginning and end  of the year,  to give a complete
table of all the pneumonias observed in this service during the year
1837.  We would observe, however, that circumstances beyond our
control  having prevented the  observation of a few cases, which
occurred in the latter end of March, this month will not enter into
our table of results.  The total of pneumonias in the eleven months
is ninety-four, divided as follows:
  (We have marked  not only the number of the pneumonias, but
also the relative frequency of the idiopathic and complicated.)
Months.	Number.	Idiopathic.	Complicated.
January, February, March,	8 18	1 5	7 13
April, May, June,	8 5 7	1 1 1	7 4 6
July, August, September, October,	13 5 5 9	0 0 1 I	13 5 4 8
November,	11	2	9
December,	5	0	5
      Total,        94            13             81

  Different  consequences  may be deduced from  the foregoing
tables.   1. What we already knew;—the enormous  disproportion
between the frequency of the idiopathic and  complicated pneu-
monia;  2. the rarity of  idiopathic  pneumonia in  the  warmer
months of the year.   We may moreover observe, that  the number
of complicated pneumonias depends  upon the prevalence, at the
time, of those diseases, upon  which they  are liable  to supervene.
Thus if the month  of February  presents the largest number, we
find the cause in the epidemic prevalence  of the grippe at that sea-
son of this particular year, (1837.)
  Taking into account the force of the constitution, we have made
the remark that nearly all our younger class of patients presented
a very  delicate complexion,  while those  from six to fifteen years
appeared generally to enjoy a very good constitution. 
CAUSES.
37
  Different  debilitating causes appear to exert a very manifest in-
fluence upon the pneumonia of children, we refer particularly to
the diseases in the course of which the affection of the lungs su-
pervenes, a  prolonged residence at  the hospital and the continued
decubitus upon the back.
  It will not be uninteresting, to  examine what are the affections
with which  the pneumonia is most frequently complicated, as well
as the comparative frequency of these diseases in the different ages
—a glance at the following table will satisfy us upon  these points :

                    From two to five years.

          Diseases.                                Number of cases.
       Measles,.......11
       Hooping-cough,       .....      3
       Slight catarrh,......2
       Small-pox,       ......2
       Varioloid, or  scarlet fever,     ....    1
       Chronic enteritis,      .....      6
       Gangrene of the mouth,       ....    I
       Rickets,    .......      1
       Hardening of the cellular tissue,    ...    1
       Paralysis of the arm,.....1

                    From six to fifteen years.

           Diseases.                                Number of cases.
       Measles,.......4
       Small-pox,       ......3
       Hooping-cough,    ......    1
       Bronchitis and enteritis,     ....      1
       Typhoid fever,......2
       Gangrene of the mouth,     ....      21

   From this  table it  results, that  from two  to  five years of age
measles is the disease  most frequently  complicated by pneumonia,
then  chronic  enteritis and hooping-cough ; whilst after five years
it is measles, with  small-pox second in frequency.  Although in
our result  gangrene of the mouth only appears  three times, we
can assure the reader, that, of all  the diseases of children, it is the
most frequently complicated by pneumonia;  for we have seen this
inflammation in eleven cases  of gangrene of the mouth ; and M.
Baudelocque's  experience is perfectly in accordance with our own.
   Independently of  the diseases just mentioned, predisposing more
or less decidedly to  pneumonia, we would observe that the cuta-

  1 The tuberculous affection,  ns  predisposing  cause, does not appear in
these tables,  as we have eliminated all the cases of pneumonia supervening
in advanced phthisis. 
38   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

neous system presented different affections (ecchymosis, eczemas,
ifcc.) in one half of our cases.
  The prolonged sojourn at the hospital, and especially the decubi-
tus upon  the back, have been very justly considered by M. Leger. as
prejudicial to young children ; an assertion confirmed by our own
cases, for we possess  observations in which the sole cause, which
could be  considered as productive of the disease, was the long de-
cubitus upon the back.
  The explanation of this  is easy.   The weakness and the diffi-
culty of the expectoration in children, favours, in certain cases, the
stasis of the liquids in the most inferior portions of the lung, where
their sojourn  determines  an  inflammation of the  neighbouring
parts,—we say determines  the inflammation, because, in the great
number  of cases the anatomical changes have  not  appeared  to us
as analogous to  those of the hypostatic pneumonia, and we would
not give  a purely mechanical explanation  either of the lobular or
lobar hepatisation.  We advance here an opinion directly opposed
to that of Dr. Gerhard, who thinks that pneumonia in children
from two to five years of age possesses a very great analogy with
those sanguineous congestions resulting from a mechanical obstacle
to the free circulation of the blood in the lungs.  It seems to us, that
to refuse  to the pneumonia of young children any purely inflamma-
tory character, is to put ourselves in direct opposition to facts.  A
rapid progress, formidable  symptoms of reaction, evident traces of
a;i inflammation in the lung or its dependances—are not these suf-
ficient to characterise an inflammatory affection ?
  Authors have not  contented themselves with the  simple causes
above enumerated, but have wished to ascend higher, and seek in
the peculiar structure of the child's lung, the rapidity of the circu-
lation, the number of inspiratory movements, &c, an explanation
of the frequency of pneumonia at this age.  So far these pretended
causes are to be considered merely as flights of fancy, more or less
ingenious, not as settled and positive facts.
  Latterly MM. Burnet and De la  Berge  have sought  to connect
pneumonia with a cause  more  general  than  any  we have  men-
tioned.   They have  advanced that the lobular pneumonia always
succeeds to an inflammation of the bronchial tubes.   This is a
question  of sufficient importance to receive a special and attentive
examination.
  If our  details, when upon the  subject of the pathological anato-
my, be recalled,  it will be seen that in  many cases  the  most atten-
tive examination of the smaller bronchi did not enable us to assure
ourselves of the existence of an inflammatory lesion of these tubes.
Pathological  anatomy thus affording  no light, we are obliged
to have  recourse, for  a solution, to a careful  examination of the
symptoms.  And what do these teach us?  That in the great ma-
jority of cases, not only in  the variety described by M. dela Berge,
but also  in the diffused lobular species, and even in the lobar form
in the youngest children,  there exist  cough and different altera- 
RATIONAL SYMPTOMS.
39
tions of the respiratory murmur, supposed to be dependent upon a
bronchitis, before the positive signs of a parenchymatous inflamma-
tion have declared themselves.
  Therefore, without denying the possibility of a pneumonia origi-
nally commencing in the parenchyma, in children from two to five
years (for we possess examples  of it) we regard the occurrence as
exceedingly rare.  But very frequently it is impossible to recognise
any connection between the gravity or extent of the catarrh which
precedes, and the pneumonia which follows; so that the bronchitis
ought to be regarded as predisposing to inflammation of the paren-
chyma, rather than as an occasional active cause; and the pheno-
mena to be those of a propagation  of inflammation in continuous
textures.
  Thus, to sum up;—nearly all the causes of pneumonia in children
are reduced to the predisposing; and if a change of temperature, a
suppression of an habitual discharge, a repercussion of a cutaneous
disease, or  the  exanthemas, are capable of its production, our ob-
servations enlighten us very little with regard to the degree of their
influence.  We have, however, thought ourselves to have observed
that sudden changes of temperature had a manifest influence upon
the development  of this  disease.   Thus, in two cases,  we have
imagined that a sudden chill appeared to have been the occasional
cause  of the  appearance of the pneumonia.   In one of these a
young girl, ill with measles, was seized with all the symptoms of a
pneumonia (cough, pleuritic pain, (fee.) after putting her feet upon
the ground, the eruption being in full vigour; in another, a young
boy, going out the eighth day of the eruption of  small-pox, was
taken four days after with cough, dyspnoea, and we discovered from
the day of entrance all  the signs  of a pneumonia at the second
degree.  We  have observed, in young children  labouring under
diseases of the skin or hairy scalp,  the falling off of  the scabs or
the suppression of the discharge, far from being the cause, to be
rather the result of the inflammation, and the affection of the skin
to be sensibly  modified after the full development of the pneu-
monia.
                        CHAPTER VI.

                     RATIONAL SYMPTOMS.

  The pneumonia, once  declared, determines in the organism an
assemblage of symptoms which we must attempt to comprehend.
It  has be"en lately often  repeated,1 that children  manifest in their

  • The authors refer here to the ideas of M. Jadelot, one of the physicians
at the Enfans Malades, upon the lines  of the  countenance as diagnostic of
visceral disease.—P. 
40    RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
 countenances, the signs of the diseases with which they are attacked;
 it has been admitted that certain  modifications of the  lines of the
 countenance correspond constantly with certain thoracic or abdo-
 minal affections:  we have attempted,  in the  larger part of our
 cases, to appreciate the value of these diagnostic signs, and the fol-
 lowing are our results :—
   We have remarked nothing constant in the different folds of the
 skin of the countenance ;  they appeared to us rather as the index
 of a  general  suffering  than as pathognomonic  of disease of the
 viscera,  either of the chest or  abdomen.   We  will  not say the
 same, however,  of the dilatation of the alas nasi, which  we have
 observed in  nearly all our cases, immediately preceding the inspira-
 tion, and lasting nearly the whole period of the disease.  Sometimes
 it was excessive, and  nearly always proportionate to the acuteness
 and  gravity  of  the pneumonia.  In  young children  the general
 expression of the countenance was very various—sometimes pale,
 sometimes coloured, at times  only on a single cheek,  but without
 any  reference to the side affected by the pneumonia;  it offered in
 several  cases, from the  commencement of the  disease, a profound
 and  characteristic alteration, followed by a rapid  emaciation.   But
 it would be wrong to  consider this  facial alteration as peculiar to
 the younger series, for we find  it noted in several of our  observa-
 tions of children from six to fifteen years, in whom the termination
 of the disease proved fatal.
   Paleness and puffiness of face are notes in many of our observa-
 tions, coinciding often with  infiltration of the extremities.
   In  young  children, being unable to establish the existence of a
 chill, we cannot say if the disease commences in this manner ;  but
 we are certain that, after the invasion  of the pneumonia, the heat
 of the skin was sensibly exalted in the larger part of our patients:
 most usually it was great, sometimes  excessive, but almost never
 accompanied with moisture.
   In  older children the disease commences  with a very apprecia-
 ble chill, to which the heat of the skin soon succeeds.
   The  pulse was always  counted—rarely under 120* in  the
 younger children  it varied between this number and 140 to 150,
 and  has been  observed  as high  as  180.  In children from  six to
 fifteen years it was less accelerated,  as it more  rarely attained  140
 to loU, but the day of invasion it was always 120
   In  the greater number of cases after the  commencement it  pre-
 sented no special character: usually full and  regular, but nearly
 always in the younger children, a few days before death, it became
 of an extreme smallness, sometimes nearly imperceptible.  In the
 cases terminating favourably, this smallness of the pulse was never
 observed at any period of the disease.
  The number of inspirations varied between thirty and eighty, in
the children  from  two to  five years; in those from six m fifteen,

nZtedTil*"6"" &nd SiXty-eig,,t-  In the half of *" ""8 ti,e;
presented  nothing particular;  m the other half, at all aoes,  but 
RATIONAL SYMPTOMS.
41
specially in  the  younger series, we observed the following pecu-
liarities:—Sometimes they  were anxious, very full, raising  the
whole chest, or else they were  entirely abdominal; at other times
they were irregular, unequal, and interrupted; in some cases the
inspiration  was normal, the expiration alone  being hard, noisy,
painful, difficult at the  commencement, and seeming to exact an
effort, and to be rather an active than a passive phenomenon.
   A great number of our cases of pneumonia declaring themselves
at the hospital, we have been able to establish the increase  in the
number of inspirations and pulsations at the moment of the decla-
ration of the disease ; we cannot too much insist upon the simulta-
neous appearance of these two symptoms.   But we would be care-
ful to say that it is only on  the first, second, or third day that we
are able to remark this, since later in the  disease, under the influ-
ence of treatment,  or  causes  which  escape our  observation,  the
comparative march of the pulse and respiration becomes often  irre-
gular, and even inverse: that is to say, we find an increase in the
number of pulsations to correspond to a diminution of the  number
of inspirations, and vice versa.
   After this separate examination of the  pulse and  respiration, let
 us see the influence of the extent of the hepatisation upon these two
 symptoms.   When  there was no complication of other acute dis-
 ease, the acceleration of the pulse and respiration has been in direct
 proportion  to the acuteness and extent of the inflammation, with
 the exception of some cases  already alluded to, where the discre-
 pancy was to be attributed  in part to the treatment.
   In the cases of pneumonia co-existing with an acute disease, the
 measles, for example, the acceleration of the pulse and respiration
 was sometimes extreme, although  the inflammation of  the  lung
 was very limited.
    We think, therefore, that we may say,  in general  the intensity ot
 the febrile  reaction depended upon the extent of the inflammation.
 This result, although a rigorous deduction from facts, so  simple as
 to appear to be established  a priori, is nevertheless opposed to what
 has  been written by authors  upon the lobular  pneumonia; who
 state the pulse  and respiration to be always much accelerated.
    An examination, however, of these observations of MM. Burnet
 and de la Berge, shows us, that in all the instances  of acceleration
 of the pulse and respiration, the fever explains itself very naturally
 by the  existence of certain coexisting affections, measles, typhoid
 fever <fcc   Independently  of the extent of the  hepatisation, the
 reaction depends on the nature of the disease upon which  the pneu-
 monia supervenes; we shall have occasion to revert hereafter to
 this latter  consideration.
    When an effusion into the cavity of the pleura complicated the
 nneumonia, we find mentioned  in our notes a collection  of symp-
 toms which in a similar case might serve for diagnosis. We refer to
 the paroxysms of suffocation.  The oppression becomes extreme, the
 inspirations succeed each other with a prodigious rapidity, the face 
42    R1LLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
 is purpled, and these symptoms all disappear, to be in a short time
 reproduced.  In ordinary pneumonia the  difficulty of the respira-
 tion is sometimes very great; but in general its progress is more
 or less  regular, whether  in  the increase or decline, and does not
 show itself thus under a paroxysmal  form.
   In cases where the respiration has  been  irregular or unequal, we
 have not observed these circumstances to  be dependent upon any
 greater or less intensity of the inflammation ; in two cases, one of a
 pneumonia of the whole posterior  part of the lung,  comprising also
 the  whole  superior lobe, and the other only  of the summit,  the
 respiration  was in  both remarkably unequal.  And  finally, in those
 where  it is noted as anxious, raising  the whole  chest, the pneumo-
 nia  was very extended, occupying  even  nearly  the  two entire
 lungs.
   The cough has been wanting twice: another time it was exces-
 sively rare, (lobular pneumonia.)  In regard to the great number
 of cases in which it existed,  it ought to be ranked among the im-
 portant symptoms: but its value  as  such  is much affected, inso-
 much as it often occurred before the  other  signs of  pneumonia
 could be found to exist.  In more than one half of  the cases it is
 noted as rare; but in  those where it  was observed as frequent, it
 increased quite sensibly in proportion to the progress, and in direct
 ratio with the extent of the inflammation.  It diminished, however,
 with the strength of the patients, and  in the last days of  life it was
 entirely wanting.   Nearly always it was dry, and in  eight cases it
 existed in 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-
mihon-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 ot
 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  between
 five and  fifteen years,  the decubitus has offered nothing specially
 worthy of note.
    The respiration  and the circulation were not the only lunctions
 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, orte 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 thelobar form: consequently,  with  the pathological anatomy for
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 the
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 in which  it manifests itself, than 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 decree 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.dela 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
alse nasi  are widely dilated,  and there is an anxious expression of
the face: the  agitation, sometimes extreme, is replaced in other
cases by  a  remarkable somnolence and prostration :  the ausculta-
tor in  the first hours of the disease, recognises an  obscurity of the
respiratory  murmur, or a subcrepitous rale, without appreciable
dulness upon percussion ; later there appears a bronchial expira-
tion, accompanied by the same rale, the bronchial  character finally
extending itself to both times of the respiration together with a no-
table dulness upon  percussion: the general  symptoms preserve all
their intensity as long as the pulmonary inflammation makes  any
progress.
   At last the moment arrives when the  pulsations and respirations
become irregular, the pulse extremely  weak, the face purple, the
extremities cold : the prostration gives  place to an anxiety in the
whole performance of the functions,  the cough ceases ;  the young
patients are attacked with prolonged gapings, uttering deep sighs,
the pulse finally becomes insensible and  death  closes  the scene.
The progress of the hepatisation is sometimes so rapid as to pro-
duce death in two or three days.
   In cases  where the disease is to terminate favourably, the sub-
crepitou'rale begins to  reappear, the bror.chial sound  is limited to 
48   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
the summit of the lung or the root of the bronchi, and the respira-
tory murmur is again heard :  while the local state is thus amelio-
rating, the general symptoms lose their intensity ; thus, the  pulsa-
tions"and respirations are  quickly diminished in number, the heat
of the skin gives place to a pleasant  moisture, with disappearance
of the anxiety, &c. This resolution usually commences the seventh
or eighth day, but even as late as the twentieth  the last traces of
the rSle have not in some cases disappeared.
   These remarks apply specially to children from two to five years.
In those from  five to fifteen the differences in the progress  of the
pneumonia are somewhat important:  it may attack in two circum-
stances,—in the course of another disease, or in the midst of perfect
health.  In the former case if the  malady which it complicates he
catarrhal, we find the two periods much the same as in the younger
class of children.
   If the pre-existing disease be not catarrhal, (typhoid fever, small
pox,) the pneumonia is remarkable for its  insidious approach, a
cough is hardly present, the pain in the chest and the expectoration
are entirely wanting ; and as the pulmonary affection is developed
in the course of a febrile disease, we can with difficulty assure our-
selves of the acceleration of the pulse or respiration.   But there is
one important symptom which may serve to arouse suspicion of the
commencement of the disease—the deep change of the expression of
the face, which we find  noted in all our observations.
   The  idiopathic form does  not differ in a  sensible manner from
the same disease in the  adult.  It commences by fever, thirst, an-
orexia,  pain in the head, cough, pain in  the chest, and  sometimes
vomiting: auscultation  discovers a crepitous rale, bronchial respi-
ration  and bronchophony; the expectoration  is often bloody but
rarely rusty ;  the acceleration of the pulse and respiration is con-
siderable.   The nervous  symptoms  are  sometimes  rather pro-
nounced,  and we  observe  intense headach  with anxiety or even
delirium.  According to Gerhard and Rufz the mean duration of
this form is  fourteen days.  In the few cases  we have seen, it has
been  much  longer;  one of our patients quitted  the hospital the
twenty-first day of his disease with the bronchial respiration still
present; and in another the subcrepitous rale, which had succeeded
it, endured six weeks.
CHAPTER VIII.

   DIAGNOSIS.
  After this exposition of the symptoms to assist us in the recogni-
tion of the pneumonia of children, let us see if there be  no danger
of confounding it with any other disease of the respiratory organs. 
DIAGNOSIS.
49
  For example,  what are the  differences between  pneumonia and
pleurisy, bronchitis and phthisis. * Simple pleurisy is a very rare
disease in children from two to  five years ;  for our part, we have
never met it, for whenever we  have found  a liquid in the pleural
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 after
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 certain that a rapid hepatisation may not
give  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
sfdes 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 idiopathically, 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 4 
50   RILLIET AND BARTHI.Z 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 aisease.
  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
he 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 cough  continues,
that for a month after there  is still heard the  mucous raMe 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, <fcc, what ore 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  general 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 prove 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  <nve 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 l£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
developement of 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, I.  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
general, 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 single case would not induce us to dare to imitate such an ex- 
54   RILLtET 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 effect 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 bleeding 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 160 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 whole 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 the  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
 good health, has the greatest tendency to assume, of itself, a favour-
 able  change.
  In the second, the resolution of the pneumonia appeared only  the
 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 CHILDR
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.

                 Antimonials— 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 hns varied
from  sixteen to twenly-four grains.   In  these  four  patients the

  1 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 manifested 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 litile cause of fear; and. finally,
that this medicament appears to  act more  directly upon the puke
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  general
the amelioration appears from the seventh to  the ninth day, as m
 the cases  treated  by the tartar emetic simply, we  find in  two  or
 three cases an amendment of the symptoms on the  hfih  or sixth
 dav 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 d.s- 
58   RILLIET AND B.VRTHEZ ON PNEUMONIA OF CHILDREN.
 ease at which it was employed.   Three of our  patients were sub-
 mitted to the com'iined 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 the.^e cases not the
 least  accident has  resulted.


        White Oxide of Antimony—Pulvis Antimonialis.

   Eighteen of our patients were treated with this'medicament; ten
 m 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  eiVht,
 the dose per diem  varied between  ten and eighteen grains in Four
 ounces of vehicle, to which was added  3ij. or^iij. of syrup of dia-
 codium  (syrup of poppies.)'  All these children, except one, are
 in our first d.vis.on-that is, pneumonia supervening upon some
 chronic affection.   Two  of these  recovered, but this  cannot be
 attributed to the remedy;  m  one case  it was not commenced till
 the ninth day, when the pneumonia already tended to a resolution,
 wlnls  m 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 eliminate0 two, who, dying the day
after  heir  entrance  of very  extensive pneumon as, took cons*
quently, only one potion of the remedy.  The pulvis anthnomalis
 was administered to children  between two an/five  years ofage

  1 The syrup  of poppies of the London Pharmi,.™™;.,      •     .  ,
United States Dispensatory, resembles the syrup of?dTacnft? ^l  '" ^
to be considered as identical with it.-P   Y  P    diacod'um sufficiently 
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 50, the physical
signs 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 ot 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
antimonial 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,
death  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 commence ;  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 soma  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 was of our first species, and therefore almost necessarily
fatal.  Among  those on the contrary, terminating in  health, are 
TREATMENT.
61
found the idiopathic and  lobar forms, free from all complication,
where, according to Gerhard and Ruf'z, recovery is certain what-
ever may be the treatment.  Besides a certain  number of our pa-
tients have entered  when the disease had  reached its maximum  of
intensity, and when an  amelioration after  the first dose of kermes
is rather to be attributed to the arrival of the disease at its natural
climax.  Thus a child of four years was submitted to our observa-
tion the seventh or  eighth day of an idiopathic lobar pneumonia
with pure bronchial respiration ; he took a grain of kermes and the
next day he had the returning  crepitous rale, and two days after a
diminution of all the symptoms. Is the amelioration to be attributed
to the kermes taken these three days, or to the natural progress  of
the disease? The latter appears to us the more probable.    Observe
in fact, that in all our cases of supposed beneficial effects of reme-
dies, it is always at the same period of the disease that the amelio-
ration  manifests  itself—from  the seventh to the  ninth  day—we
cannot, however, refuse to admit some influence to the kermes,  as
we have  established its  power in diminishing the pulse  and respi-
ration in  several cases, both immediately after the first dose, as well
as after several days of  treatment, in patients gravely affected, and
attacked with complications finally resulting in death.  We possess,
besides, one case of recovery in a lobular pneumonia after measles,
under the sole  use  of the kermes:  and this pneumonia  although
exempt from  any  unfavourable  complication, was not  the less
grave, considering the cause to which it owed its birth.
   In some cases the kermes has been administered at a  very  high
dose, especially  for a child.   Seventeen grains are more than  is
habitually  given to an  adult;  a dose apparently so enormous has
had no unpleasant influence upon the digestive organs ! Here is the
result.of our experience.
   Our patient, who took the seventeen grains,  and who recovered,
presented before the administration  of the kermes, some  symptoms
referable to the digestive tubes—bilious vomitings, diarrhoea, and
abdominal pains.   These symptoms underwent no augmentation
under the increasing doses ; after about  fifteen days  they ceased
altogether, although the patient was then  taking thirteen or  four-
teen grains in the twenty-four  hours.
  In another who took fifteen grains and who died, we observed
before the first dose the same  symptoms connected with  the intes-
tinal canal; but these symptoms increased with the inflammation
of the lung, and at  the autopsy we  found  an inflammation of the
gastric mucous membrane, slight in extent it is true, but very well
maiked,  especially  where there  yet remained a portion of the
kermes.  We have never  observed any other accident requiring a
suspension of this treatment.
  To conclude  the history of  the kermes  mineral, we give a suc-
cinct extract from the observation of one of our patients  treated  by
bleeding, the  tartar emetic  and this latter substance; the reader
may thus judge of the combined action of the three. 
62   RILLIET AND RARTHEZ ON PNEUMONIA OF CHILDREN.

  It is the case of a child aged ten years, at the fifth day of a pneu-
monia of the lower half of the left lung, with bronchial respiration,
absence of rale, and dulness  upon percussion.  Infusion of mallows,
syrup of gum, with gr. ij. tartar emetic, looch,1  bleeding to eight
ounces, diet.  The tartar emetic thus administered produced fre-
quent vomiting, and on the morrow the pulse  had augmented from
122 to 152; the inspirations had  diminished from 82  to 62, the
bronchial respiration  had extended a little superiorly, but a crepi-
tous rale was heard after cough inferiorly.   This first prescription
had at once augmented and ameliorated the gravity of the  symp-
toms.  (Infusion of mallows, syrup of gum,  looch, with kermes gr.
ij. the  half of an emollient enema, diet.)
  The day after  this first  administration of the kermes, seventh
day of the disease, diminution of the bronchial  respiration,  more
abundant rale, the inspirations have fallen from 60 to 36, the pulse
from 132 to 96.  The treatment is continued with the addition only
of a bouillon.  But on the eighth day the rale had disappeared, the
bronchial respiration  was in the same extent, the  pulse was,,150,
the respiration 36. (Emetised whey, gr. ij.; blister to the legs.)
  The following day the bronchial respiration  had extended, but
there was but little ia!e ;  respirations 50, pulse 132.   This day the
kermes was resumed in a dose of two grains, with one half an ounce
of syrup of poppies.  The disease continued  augmenting,  till the
thirteenth day, when the patient took five grains of kermes.   But
the fourteenth day, the bronchial respiration was less, the crepitous
rale of return again appeared every where.
  From this moment the  patient continued improving until com-
plete convalescence, and on  the nineteenth day the  respiration was
pure on both sides.  The kermes was continued a few days after
this happy result.   We see, in this case, only a  dubious salutary
influence of  the bleeding and  tartar emetic, as it was only on the
seventh  day of the disease that an amelioration took place; the
kermes was not sufficient to continue this  improvement, and a re-
lapse was the consequence.  The tartar emetic was again  given,
with a similar result, and it was only on the fourteenth day of the
disease, the  sixth of the relapse, that the patient was definitively
better under the influence of the kermes.  Should  we in this case
attribute the cure to the remedy, or shall we think that the disease
has followed its own course  without any regard to its influence?


             Derivatives to the skin— Vesicatories.

  Vesicatories have been employed in conjunction  with the other
remedies and nearly always  at  an  advanced period  of the disease.
They have  been applied either to the diseased  side  or to the ex-
pulsion of almonds and sugar containing some gum traza-
ly demulcent.— P. 
TREATMENT.
63
tremities.   They have  not  appeared to modify the course of the
affection, and they have caused the patient such inconvenience, as
ought to proscribe their employment.  In fact  the skin of the pos-
terior part of the  thorax, in contact with the soiled  linen, com-
pressed  by the projecting ribs, excavates and ulcerates, in a manner
very painful and  difficult to heal,  and adding still more  to the
gravity  of  the prognosis.   It is  especially with regard to the pa-
tients in our first category that we have made this remark,  which
besides has not escaped  M. de la Berge.
  These remarks  upon blisters are equally applicable to the Bur-
gundy pitch plasters sprinkled with  the tartar emetic,  which have
been applied to some of our patients.
  We should not forget among the revulsives, the cupping glasses
which we  have seen  applied in  some cases.  Ordinarily dry cup-
ping only is employed in the younger children ; in the older, how-
ever, the scarificators were  added, thus answering the indications
of a local bleeding, and a derivative.   The cases of the employment
of these means  are too few to estimate their therapeutic value.
  In concluding this history of the different active agents put in
force against the pneumonia of children, we will still revert to a
general  remark upon which we have always insisted, viz : that the
first signs of amelioration appear in nearly all the cases, at the same
period of the disease, from the seventh  to the ninth  day, whatever
be the  treatment employed.  This fact tends to lessen  greatly the
influence of remedies, not upon  the  termination (we put aside this
view of the question)  but upon the course of the disease.  It proves
also that pneumonia  has  a period of increase which it must fulfil,
and that the different medications directed against  it are perfectly
powerless in  arresting its ascending progress :—the proof of this is
in the fact, that in cases where no  treatment  has been employed,
an amelioration has not been the less manifest at  this same period
of the disease.  Of this we have one remarkable example.
  The  second  part of  the  treatment now requires our attention.
consisting of emollients, sedatives,  and at times  of tonics.  The
usual beverage was  infusion of mallows sweetened with syrup of
gum; in addition,  usually, julaps containing  from 3ij to  gss  of
syrup of poppies.   When the child was debilitated by a preceding
disease, or when the constitution was feeble and delicate, there was
added §ss  of syrup of cinchona.
  Whenever any  other disease, complicating the  pneumonia, pre-
sented any pressing indication, it was combated by the appropriate
rpmf*diGS
  The  young  patients were rarely submitted to  an absolute diet.1
In those of the first  category, whenever there was appetite, food
was granted.   In  the younger patients attacked with  acute pneu-
monia,  the anorexia being usually complete, all aliment was with-

  ' The  French dicie is here and in  all other  places  rendered literally,
as meaning the deprivation of all nourishment of whatsoever species.—P. 
64    RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
 held for the first three or four days of the disease—but immediately
 on any appearance of appetite, the light soups, milk, and bouillon
 were prescribed.  Young children support badly an absolute diet,
 and the disease is aggravated by many successive days' deprivation
 of nourishment.   Older children  were dieted, but as soon as any
 amelioration appeared, they were allowed bouillon and soup.
   It is  very difficult to lay down general rules  in therapeutics-
 nevertheless if it be allowed to us to point out a plan of treatment
 for the pneumonia of children, we would recommend the following
   1. In a  pneumonia supervening  upon a chronic affection, and
 assuming itself the character of a chronic disease, no active medi-
 cation should be directed against it, but an attempt made to modify
 the general health.   Particular attention  should  therefore be paid
 to hygienic precautions, avoiding the continued decubitus of the
 child upon the back—prescribing the most absolute cleanliness, &c.
 As general treatment  we would advise the use of light tonics inter-
 nally—and, above all, (the appetite still remaining in most cases,)
 we would prescribe fortifying and nutritive aliment" in a small com-
 pass.   The diarrhoea is not to serve as counter-indication, for the
 diarrhoea of children  by no means always depends upon an inflam-
 mation of the digestive tube : most generally it is dependent upon
 a  softening of the mucous membrane, which has more analogy
 with anaemia than inflammation.   As a tonic externally, the sul-
 phur bath  might be prescribed, from which M.  Jadelot  thinks he
 has obtained some success.
   2. If the pneumonia be present as complicative of a pre-existing
disease,  we  would not have recourse to the subtraction of blood of
which we have already demonstrated the want of success—we should
prefer the treatment by the tartar emetic, since in a certain number
of cases recovery  has followed  its employment.   We should not
fear to carry this remedy to a very high dose  proportionate to the
intensity of the inflammation, and despite any slight contra-indica-
tions on the part of the intestinal canal.
   3. And finally, if the  pneumonia were idiopathic, we would em-
ploy the combination of bleeding and the tartar emetic: we would
however, not carry the  loss of blood to any great extent, always
proportioning it to the gravity and extent of the inflammation 
OBSERVATIONS AND TABLES.
65
OBSERVATIONS AND TABLES.
  We at first intended to append at the end of our work the greater
part of the observations, which have  served for  its basis:  but this
project we have abandoned, as giving to our little  undertaking a
volume too considerable.   We have prefered to give only facts suf-
ficient to prove the principal assertions we have thus far advanced.
Thus, there will be found, in the following  pages, examples of the
different forms, which the pneumonia assumes, of the two periods
observed in it,  of the different alterations of the respiratory sound,
of the numerous lesions of the pulmonary parenchyma,  &c. &c.
If we have  not quoted an example  of idiopathic  pneumonia  in
children from five to fifteen years of age, it is because the periodical
collections abound with cases of this  nature, and we are  desirous
of pointing out only facts the least  known.
  At the end of our observations, we have placed two tables of the
pathological anatomy,  representing the comparative  frequence of
the  different forms of the  pneumonia, as  well as of the  different
other lesions of the lung,  which most usually complicate the in-
flammation of the parenchyma.
OBSERVATION I.
 Child set. three years.  Constitution not strong. Acute pneumonia.  Two
  well marked periods.  Treatment by the tartar emetic.  Effect upon the
  pulse and respiration.  Amelioration of the local state on the seventh day.
  Final convalescence the twelfth.  Disappearance of all rale the twenty-
  fifth day.

  Vaillant (Eliza) 8et.  three years, has been under treatment for
 more than a month  in  the ward  St.  Genevieve,  for  a  diffused
 chronic eczema of the  trunk.   Ten days before entrance  into the
 acute ward, she  had commenced to cough, but her catarrh was so
 slight as  not to  oblige her to take to her bed.   Oct.  12, she  was
 suddenly  attacked with fever and increase of  cough.  The 13th,
 she was brought to No. 2, ward St. Anne, where we  saw  her at 3
 P. M., in the following state :—
  Constitution not strong : remains of the eczema on various parts
 of the  body ; chest well  formed.  Decubitus dorsal,  eyes  closed,
 cheeks coloured, skin burning, pulse 160, full and regular   Inspi-
 rations  64, without dilatation of the ala nasi: the child is re-
markably somnolent.  In front, on both sides, the respiration is
       17—a                                       rii 5 
66   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

strong and pure.  Behind pure, in the whole of the left side and
the summit of the right;  but in the middle part of the right side it
is obscure, and below, in two fingers' breadth, bronchial—the bron-
chial character is especially marked in the slight  cry that accom-
panies the expiration.  The resonance on percussion is diminished
at the  right base;  it is normal in the left.  The cough is rare, with-
out expectoration ;  the tongue is quite  moist, with a slightly white  j
coat:  abdomen  distended and tympanitic : no stool since entrance.
   Prescription.—Sweetened infusion of mallows for drink.

     Take of Tilleul1 water, 3iv.
            Syrup of poppies, ^iij.
            Tart. ant. and potass,  gr. iij.
            Syrup, gj.

   This prescription, given  by spoonfuls,  determined no vomiting,
but three or four loose dejections, and it was  all  taken on the 14th,
at three P. M.  Up to this time the febrile symptoms continued
unabated; pulse 160, respiration 64.   The hepatisation appears to
have advanced.  The percussion is  flat in  a greater extent than
yesterday;  the  respiration  is obscure on the right in the two in-
ferior  thirds: in a  strong  inspiration,  a bronchial respiration is
heard in  various scattered points of the inferior third.   The skin
is excessively hot.  The prescription is continued, with an increase
of the tartar emetic by one  grain.  The  next day, (the 4th,) three
quarters had been taken  at noon without vomiting.  The skin is
less warm than yesterday; pulse  144, respiration 36.  The child
opens her eyes, commences to speak, and asks to sit up in bed; the
tendency to somnolence has disappeared.   This  amelioration of the
general symptoms, however,  is unaccompanied  by any propor-
tionate change in the physical  signs, as the respiration continues
clearly and distinctly bronchial in the two lower thirds of the right
lung,  with flatness  in the  same space, and  a subcrepitous rale at
the summit.  The same  prescription is continued ; the tolerance is
perfect, and the 16th the child's state is stationary.  The  17th, the
child  has now taken in all  fifteen grains of the  tartar emetic, with-
out any vomiting; the pulse is 120,  the respiration 36. The bron-
chial  respiration is present in the whole of the right lower lobe,
and at intervals, after cough, there  are  heard some explosions of
crepitous rale excessively fine.  To-day the tartar emetic is omitted,
 being replaced by a julap  of poppies.   The 18th, at seven A. M.
 the child is in a peaceful slumber; pulse 120, respiration 40, equal.
 The bronchial  respiration ceases to be heard, except at the inferior
 angle of the scapula; below this point, after  cough, there exists the
 crepitous rale,  excessively fine.  19th, pulse 126, respiration 28;
 same  physical  signs.   20th, pulse 116, respiration 28;  the  bron-

   1 Tilleul is the Tilia Europea: no corresponding preparation is found in
 the American Pharmacopoeia.   Its  real nature is unimportant, bein* merely
 used as a  pleasant vehicle.—P. 
OBSERVATIONS AND TABLES.
67
 chial  respiration has entirely disappeared, together with  the  rale,
 only the respiration is accompanied by a sonorous rale posteriorly
 and interiorly on the right, and the percussion is a little less reso-
 nant than in the correspondent parts of the left lung.
   23d.  All trace of the flatness has disappeared f pulse  104, but
 there  exists posteriorly  a somewhat abundant  subcrepitous  rale.
 This rale persisted until the 5th of November;  but the convales-
 cence may be considered as established on the 23d of October.
   Remarks— This observation is  a fine example of acute pneu-
 monia in a child of three years.  With the exception of the expec-
 toration, there  existed the greater part of the  symptoms of the
 adult—acceleration of the pulse and respiration, the stethoscopic
 signs, and flatness on  percussion.  The two periods which we
 have signalised in the pneumonia of children,  from two to  four
 years, are here well defined.   Our young patient had coughed for
 ten days, but  this  slight apyretic catarrh did  not prevent his  run-
 ning about all the day in the  wards; when suddenly and simulta-
 neously  there  supervened the acceleration  of the  pulse  and the
 respiration, which  marked the transition to the  second  period.
 Thirty hours after the commencement of the disease, the bronchial
 respiration had already manifested itself, but in a limited space.
 After this it was heard from the base to the summit of the lung,
 and followed the same course as in the adult.  In this  case, there-
 fore, we  have, very probably,  had to do with a pneumonia of the
 lobar form. The bronchial respiration offers the character common
 to that of children, viz. especially marked in the expiration.  The
 tartar emetic appears here to have had a manifest  influence upon
 the pulse and respiration. The fourth day, after the administration
 of six grains,  the pulse was diminished by 16, and the  respiration
 by 28. The sixth day, fifteen grains had been taken, and the pulse
 was still further diminished  by 24; and, finally, on the seventh
 day we establish a manifest amelioration of the local state, and on
 the ninth the bronchial respiration had  entirely disappeared.  Our
 patient might be regarded as cured  on  the  twelfth  day  of the dis-
 ease, although it was not till the twenty-fifth that the last traces of
 the rales had disappeared.

                        OBSERVATION II.

 Child of  two years.—Generalised lobular pneumonia  on  the left, with  a
  pleuritic effusion.—Simple lobular pneumonia on the right.—Two well-
  marked periods.—Duration of the catarrhal period one month.—Of the in-
  flammatory five days.—Access of suffocation, with the supposed appear-
  ance of the pleuritic effusion.

  Aliot, (Irma,) aet. two years, entered  24th November, 1824, the
Hospital  of Enfans Malades,  and was  placed  No.  2, ward Saint
Anne.                               , ,     1     r    • ,  ,
  The persons who brought her, stated her to have been sick three
weeks, with anorexy, a slight  diarrhoea, and cough.   Submitted to 
68   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
our observation November 25th, we  found the following :  Consti-
tution feeble, skin delicate, eyes black; impetigo of the hairy scalp.
The dentition is not complete, the canines of the lower jaw are still
wanting;  the child is always with her fingers in  her mouth, as if
suffering  with  her teeth;  countenance  natural;  skin not hot;
respiration 28, pulse  112.   Percussion every where resonant.  Be-
hind and  before there is heard a combination of the sonorous and
large mucous rales ; the cough is rare; the expectoration nothing.
Tongue moist, abdomen a  little distended,  but  indolent;  no  di-
arrhoea.
  Until November 30th, the state of the  child  remained the same.
Auscultation, practised every day, gave nothing but the same rales,
and  there were no symptoms of reaction.   The 30th, in the morn-
ing,  the  pulse was found accelerated  as  well  as  the respiration;
pulse 160,  vibrating; 52  inspirations.  Persistence of the same
rales on both sides posteriorly, but more especially on the left. Per-
cussion less resonant at the left than  right base.
  December 1. Skin hot, pulse trembling, 180; respiration  60, un-
equal, with dilatation of  alas nasi.  Posteriorly, in the two inferior
thirds of the left lung, bronchial respiration, with percussion still
less resonant than yesterday; on the right, persistence of the mu-
cous rales, with diminution of the resonance, (julap of poppies, 3ij.)
  Dec. 2.  Pulse 164, still small and trembling;  respiration 60, irre-
gular.  The respiratory  murmur  is  not sensibly  modified since
yesterday; however, the  mucous and sonorous rales,  heard in the
right back,  are  replaced  by a subcrepitous rale in the expiration:
the inspiration is rude at the summit, (tartar emetic, gr. iv.;  dry
cupping on  the left side.)  At four P. M. the child was found at-
tacked with an access of suffocation,  the face purple, the oppression
extreme, and death appeared imminent.
  On the  morning of the 3d, our young patient was, however, still
alive;  pulse and inspirations as  yesterday ; countenance pale, skin
of the body moderately warm, of the extremities cold.   The bron-
chial respiration has  extended to nearly the whole of the left back.
The flatness on percussion is complete; on the right, at the  level of
subspinal  fossa, very distinct resonance of the cry, without  any
bronchial  respiration ; inspiration rude, subcrepitous rale  in the
expiration, percussion resonant.  The cough  has ceased ; three
quarters of the potion already taken have  produced  no vomiting,
but two or three loose dejections. In  the course of the day the con-
dition of the patient continued to aggravate, and he succumbed the
4th of December at midnight.

  Autopsy thirty-four hours after death—weather fine and dry.

vibkesema%'~BOdy Wdl f°rmed;  "° cadaveric  stiffness;  no
  #earf.-Calvaria strongly adherent  to  the  dura mater-  arach-
noid smooth, transparent.  Considerable quantity of Terosityln the 
OBSERVATIONS AND TABLES.
69
subarachnoid  tissue ; cerebral veins injected;  the brain, except a
somewhat excessive quantity of  the bloody points upon incision, is
in the normal state.
  Neck.—Larynx and trachea healthy.
  Chest.—The right lung presents at the base some loose cellular
adhesions. The left pleura contains a glassful  of purulent serosity,
and is covered with false membranes, soft, yellowish, and of about
an eighth of a line in thickness.
   The right lung is supple, rose coloured in  its greater part, but
in its middle posterior third, (base of the superior, and summit of
the inferior lobe,) it is violet coloured  externally,  and  an incision
reveals the presence of a considerable number  of scattered points of
a variable size, where the tissue of the lung is red, friable, and sink-
ing when  placed in water, (lobular pneumonia.)  The rest of the
lung is healthy, except the summit, which contains a tubercle the
size of a small nut.   The bronchi of this lung contain a spumous
liquid, and are a little red, without,  however, any alteration  of
texture.
  Left lung.—The upper lobe is supple, rose  coloured, containing
neither tubercles, nor points of hepatisation  ; the lower lobe violet
coloured externally, marbled red and  gray  in  an incision which is
smooth, friable, granulated upon tearing, not floating upon the sur-
face of water,  either in separate pieces or in totality. This alteration
occupies the whole lobe, and no  single lobule remains unaffected
in the midst of the general disease.   The bronchi of this lobe are
of rather a vivid red ; not dilated.
   The pericardium  contains no serosity.  The heart, carefully
measured, is of normal dimensions;  the  auricles contain numerous
yellowish coagula.
  The abdominal organs, examined with the minutest care, present
no appreciable alteration, except a slight injection of ten or twelve
of the patches of Payer, without softening.
  Remarks.—We  find, also, in  this observation our two  periods of
the disease well marked.  After a catarrh of about a month's dura-
tion, the symptoms of which we were enabled to appreciate, the
disease commenced by a rapid acceleration  of the pulse and respi-
ration, and what is very remarkable, the percussion revealed to us
the sio-ns of a pneumonia before the auscultation had thrown any
light upon the affection.   The access  of suffocation,  taking  place
thirty hours before  death, appears to us to have coincided with the
effusion.   In probable proof of which, there is, on the one hand,
the increase of the dulness, which, from being only relative, be-
came complete ; and, on the other, the  lung was not found flattened
ao-ainst the spine, as if the pneumonia  had  been anterior to the
pfeuritic effusion.   We must not forget,  also,  the resonance of the
cry  the  subcrepitous rale, and  the  rudeness of the  respiration,
which put us upon the diagnosis of a lobular  pneumonia of the
rio-ht side,  which was confirmed by the autopsy.   And, finally, we
relnark, in the left lung a well characterised generalised  lobular 
 70    RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

 pneumonia, a tissue marbled with gray and red, the rapidity of the
 hepatisation having almost destroyed any isolated hepatised lobules;
 the lobules of disease which we met in the right lung are sufficient
 to justify this idea.

                        OBSERVATION III.

 Child of eighteen months. Lobular pneumonia slightly generalised, super-
   vening on a chronic enteritis. Absence of constitutional symptoms nearly
   complete.  Death in the last degree of marasmus.  At the autopsy, a
   generalised lobular pneumonia of the right, simple lobular of the left lung.
   Dilatation of the bronchi.

   Haering, aet.  eighteen months, was brought to the  hospital, Oc-
 tober 9, 1838.  Born of healthy parents,  she was put to nurse im-
 mediately, where she remained till the age of eleven months, when
 she was returned in  perfect health.   Two months before her en-
 trance at the  hospital she was attacked with diarrhoea and vomiting.
 Admitted into the wards in the middle of  September, she went out
 after a short stay, but returned in October for the same complaints.
   October 10, she was in  the following state:—
   Eyes  blue, hair blond, constitution feeble, dentition  incomplete,
 the  canines wanting.  Countenance natural, sitting up in bed. The
 cheeks are cool and moist, the extremities cold and purple;  40 un-
 equal inspirations, pulse with difficulty counted.   The respiration
 is perfectly pure, and the percussion  resonant in front and behind;
 the  thirst extreme, the  tongue moist; the surface of the abdomen
 purple,  tense, resonant,  indolent;  abundant yellowish diarrhoea;*
 appetite  still  preserved.   No cerebral symptoms.  Until the 2d of
 November there appeared  no change,  except  a constant and great
 emaciation.   The diarrhoea is as abundant, and the respiration re-
 mains perfectly  pure ; (the auscultation was daily.)
   November 2.  In the  right back  the respiration is  a little more
 feeble than in the corresponding parts on the other side; here and
 there are heard  some slight cracklings; no symptoms of constitu-
 tional reaction.
   Nov. 5.  On the right back, large, moist, and mucous rales at the
 summit; below, respiration obscure, and percussion a little less re-
 sonant at the base than  on  the opposite side.   Pulse 140,  skin
 slightly  warm,  no dilatation  of alas  nasi;   for the first time a
 slight cough.  From the 5th to the 10th no change.
   Nov. 10.  The cough is increased, the pulse insensible,  respira-
 tion  52 ;  at the right base, for  the width of two fingers, bronchial
 respiration in  the little dry expiration succeeding the  inspiration;
 above, respiration strong;  on the left,  expiration  exaggerated;  the
 percussion is not resonant at the right base.
   Nov. 13.  Pulse still  insensible,  respiration 32, without dila-
tation of alas nasi; in  the whole  right back moist  subcrepitous
rale,  resonance of the cry at the base; on  the left,  sonorous rale • 
OBSERVATIONS AND TABLES.
71
same state of the percussion.  The face is yet paler than  before ;
the emaciation  extreme;  abdomen and  limbs are covered with
ecchymoses, and the extremities oedematous; diarrhoea still persists;
the cough is rare, and only when the child is made to sit up.
   Nov. 14.  Pulse still insensible ; pulsations of heart distinct, 120;
respirations 32;  in front, the respiratory murmur is strong and
pure;  on the right back subcrepitous rale very moist in  the inspi-
ration ; bronchial expiration ; dulness in the inferior quarter, in-
creasing as we approach the base.
   Nov. 15.  The skin is warm; pulse can be counted, 144, very
small,  respiration 36, without dilatation of alae nasi;  on the right
back persistence of the  same physical  signs; on  the left, the  sub-
crepitous rale  is  heard throughout;  diarrhoea still colliquative;
paleness and emaciation extreme.
   16th.  In the morning same state, and  death supervened in the
evening.
   The treatment consisted of julaps of poppies, and a few grains of
diascordiurn;'  the pernitrate of iron  (gutt. vi.) was exhibited for
the diarrhoea; on the 11th, also, a blister was applied  to the right
back;  and the appetite  being partly preserved, the  child took milk
and bouillon.

 Autopsy thirty-eight hours after death—weather cold and damp.

   Last  degree of  marasmus; numerous ecchymoses upon trunk
 and extremities.
   Arachnoid healthy,  with considerable serous  effusion under-
 neath  ; pia mater not injected;  three  or  four spoonfuls of serosity
 in the ventricles; brain normal.
   Larynx, trachea, and bronchi are but just tinged with red.
    The pleural, smooth and polished, contain neither false mem-
 brane  nor serosity.
    Right lung.—-At  the anterior part  of the superior lobe  there are
 seen some  projecting,  pulmonary lobules; the vesicles are visible
 to the naked eye, and there are also visible some considerable bub-
 bles of air in the interlobular cellular tissue.  At  the summit, be-
 hind,  a space,  the size of  a small egg, the parenchyma is red,
 friable  and does not float upon water; an incision gives issue to a
 yellowish purulent  liquid,  perfectly  analogous  to what is evolved
 in the bronchi, and which escapes from the little cavities formed
 by their dilatation.  The lower lobe  is purple externally, upon in-
 cision it is a red colour marbled with gray; is friable, and sinks in
 water-  in many points there are small cavities anologous to those
 of the 'upper lobe ; the scissors  penetrate easily into the interior,  on
 incising the bronchi, the mucous membrane of which appears con-

    i Diascordiurn is an electuary comprising a great quantity of ingredients
 of tonic, with some sedative properties. — P. 
72   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
  tinuous with that uniting the above cavities; the  bronchi of this
  lobe are of a vivid red, and contain a yellowish purulent liquid.
    Left lung.—Upper lobe perfectly healthy; lower lobe  is purple
  in its posterior and inferior third ; an incision reveals the existence
  of a considerable number of points, varying from the size of a pea
  to that of a filbert,  red  and  friable, (lobular  pneumonia;) the
  bronchi of this part are slightly reddened but not dilated, con-
  taining a moderate quantity of spumous liquid.  The remainder of
  the lobe is healthy.
    The pericardium enclosed a  spoonful of serosity; the tissue of
  the heart is of good consistence; the auricles contain  some gela-
  tinous coagula.
    Abdomen.—The mucous membrane of the stomach  is thin and
  softened in the great curvature.
    The mucous membrane of the small  intestine  is  remarkably
  white, giving no strips, and its tenacity is extreme.
    The large intestine is of a vivid red in various  points: its mu-
  cous membrane is softened in the red points, and offers a consider-
  able number of dilated, follicular orifices.
    The  liver is pale, yellowish, and greases the knife;  the spleen
  and kidneys are normal; no tubercles any where.
    Remarks.—We find, in this  observation, a type of that variety
  of pneumonia which  assumes the aspect  of chronic disease.  As
 the pulmonary inflammation commenced  under our eyes,  we had
 the opportunity of following it in  all its phases, and appreciating its
 duration.   It is in a case like  this, we  have  to felicitate ourselves
 for our daily and exact  auscultation of all our young patients, with-
 out which precaution  the half  of our pneumonias would  have
 escaped us.  The symptoms of reaction were nearly inappreciable ;
 the acceleration of the respiration, however, and the results of the
 auscultation have clearly indicated the  progressive  increase of the
 disease.  The extreme moisture of the subcrepitous rale had made
 us suspect a dilatation of the bronchi, and the autopsy confirmed
 our supposition.


                        OBSERVATION IV.

 Child of four years.  Measles followed by chronic enteritis.  Marginal and
   lobular pneumonia  Ddatanon of the bronchi.  Complete absenfe of re
   aCnat0omy.     '      ' aUSCultati^ si^« explained'by the pathological


   Perrin, (Clemence,) a3t.  four years, entered September 20 and
 was placed No. 11,  ward St. Anne.              *         U' and
   This young patient, of delicate constitution, subject to diari-h™
 and eruptions upon the  hairy scalp, entered  for the first  time in
 September: she was then convalescent of measles, of wh ch  the
 marks were still present.  At this time  we discovered  !!
there existed a cough, the respiration to be pure and\Z^percussion 
OBSERVATIONS AND TABLES.
73
resonant.  She left  the  hospital the 14th, to enter again the 20th,
attacked with a diarrhoea which had existed since her departure.
   Sept. 21, she was as  follows:—Hair  chestnut, eyes blue, face
pale, emaciation advanced, constitution delicate; countenance na-
tural, lips pale, skin  not hot; pulse 96, respiration 32;  percussion
resonant before and  behind; respiratory murmur perfectly pure ;
pulsations of the heart regular, strong, distinct, and heard  in the
whole of both  backs.  A little cough,  no expectoration, tongue
moist, a little grayish ; appetite still present; abdomen supple ;  no
oedema of extremities ; no cerebral symptoms.
   Oct. 5. The child complained  of pains around the umbilicus,
and some inequalities were felt in the  abdomen at this spot.  The
following days the cough augmented, and  there were  heard some
mucous  cracklings,  especially at  the  left  base, which  afterwards
disappeared,  leaving  the  respiration pure.  The cough, however,
persisted; and, Oct. 7, there  were heard some  bubbles of mucous
rale in the right back: but not  only were there no  symptioms  of
reaction, but  the  pulse  was below the standard; pulse  64 ; the
hands are cold ; the face  extremely pale ; the extremities oedema-
tous, and the diarrhoea persists.
   Nov. 3. Same general state.   Percussion every where resonant;
the respiratory murmur is more rude at the right than the left side,
but without rale. The pulse is nearly insensible ; still  a little cough.
   From the 3d to the 6th November, the day of death, our patient
continued in much the same  state, with the diarrhoea still colliqua-
tive : despite of which, however, the appetite was still preserved.
   Nov. 4. There are observed some aphthae upon the tongue and
lips; the pulse  continuing insensible,  the respiration  not accele-
rated, the feebleness too great to allow the patient to  sit up for aus-
cultation, and she died Nov.  6, at seven P. M.

   Autopsy thirty-six hours after death—weather cold and dry.

   No cadaveric stiffness ; last degree of marasmus ;  cedema of ex-
tremities.
   Head.—Fontanella half ossified;  arachnoid smooth,  transpa-
rent ; no glands of Pacchioni; considerable subarachnoid infiltra-
tion of serosity; the cerebral veins contain no blood; the cerebral
substance pale, of good consistence,  containing  three  or four
spoonfuls of serosity  in the ventricles.
   Neck.—Larynx  healthy ; trachea and bronchi contain a large
quantity of purulent liquid, but their mucous membrane is healthy.
   Chest.—The pleurae are smooth, polished, and  contain neither
false membrane nor serosity.
   Right lung.—The middle, or small tongue-like portion of the
lowert and  the lower part of  the superior lobes,  are  purple  exter-
n a 11 y__penetrable  by the  finger, upon incision very finely granu-
lated.  Pressure causes to exude from the affected parts an infinity
of small  drops of a liquid like  that in  the bronchi, whitish,  not 
74   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

spumous, and lodged in the little cavities formed by the dilatation
of the bronchi, which is so great that  their extremities are double
in diameter the parent bronchus.   The  mucous membrane of the
bronchi receives  its coloration from the subjacent  tissues.  In the
remaining lobes, which appear healthy externally,  an incision re-
veals a large  number of indurated points, where  the  pulmonary
tissue is red and friable,  (lobular pneumonia.)  Their volume va-
ries from a filbert to the head of a large pin.   Finally, in a large
number of points, and especially along the anterior border, the pul-
monary  tissue is projecting, and  presents a kind of  thickening,
where the pulmonary vesicles are clearly distinguished, greater  in
volume than in other parts of the lung.
   Left lung.—The tongue-like  portion which  is  in front  of the
heart, and the part of the lung lying upon the diaphragm, in about
an inch of  the elevation, present an alteration of  the  parenchyma
and  bronchi similar to that of the right lung.  At the summit of the
inferior lobe there is a cavity capable of containing a large  filbert,
having its external wall formed by the pleura, and a communication
with a  single bronchus, whose  mucous membrane appears to  be
continued into its interior.  The liquid contained in this cavity is
white, not spumous, analogous to that in the smaller bronchi. The
remainder  of the parenchyma  is  healthy, with the exception  of
some scattered points of lobular pneumonia.
   Neither the lungs  nor the bronchial glands contain any trace of
tubercles.
   The pericardium encloses a spoonful of serosity:  the  heart has
its ordinary volume ;  the valves are pale, with some coagula in the
auricles.
   Stomach.—Mucous membrane rose coloured in the great curva-
ture ; gives no strips at this part.
   Small intestine.—Mucous membrane pale, very thin,  affording,
however, strips of two or three  lines.
   Large intestine.—In the last  foot the  mucous  membrane is
thickened,  red, softened, &c.
   The  mesenteric  glands  are  tuberculous, and many of  them
softened.
   The other abdominal organs present no appreciable alteration.
   No active remedies were employed  against the  pneumonia;  the
diarrhoea was merely combated by enemata of starch and poppies.
   Remarks.—Here  is  another very remarkable example of those
pneumonias of a chronic form, which constitute  our first variety.
In this  case the  pneumonia was not generalised, and the symptoms
of reaction  were entirely wanting.  As to the auscultation, it gave
only negative results, in spite of the existence of the bronchial dila-
tation.   But the absence of  many of the physical signs may easily
be explained by the nature of the lesions found at  the autopsy: 1.
The absence of the bronchial respiration is very well explained by
the slight extent of the pneumonia: if, however,   the auscultation
had been as constantly practised in front as behind, we should have 
OBSERVATIONS AND TABLES.
75
 probably detected it on the level of the middle  lobe : 2. The ab-
 sence of rale, in the last days, is as easily conceivable,  upon reflec-
 tion  that the purulent fluid  filling the  bronchi was not penetrated
 by air.
   If the explanation of the absence of certain signs is easy, it is no
 less so to account for  those in reality present. Thus, the roughness
 of the respiratory murmur in the right back is naturally explained
 by the existence of the numerous  points  of  lobular pneumonia
 which the autopsy revealed.


                         OBSERVATION V.

 Child of three years.  Lobular pneumonia appearing at the same time with
   an  imperfectly  marked  measles,  in the course of a chronic enteritis.
   Pneumonia becoming slowly general.   Resolution still more slow.  Last
   degree of emaciation.   Death imminent.   Amelioration six weeks  after
   the commencement.  Final recovery.  No active treatment.

   Brerige, ast. three years, was brought to the hospital September 12,
 and placed No. 9, ward St. Anne.  Very little information as to her
 previous health;  but we learned that three  weeks before, she was
 attacked with fever, cough, and  an eruption of red spots  over the
 whole body, (measles.)  Since, she had suffered with diarrhoea and
 oedema of the extremities.
   Sept. 13th. Constitution frail  and delicate;  hair  blond, scanty;
 eyes blue, impetiginous scabs upon the  lips ; upper and lower ex-
 tremities cold and purple, with a sensible cedema; abdomen full,
 but no fluctuation; pulse regular,  112,  inspirations 22; in both
 backs percussion resonant, and respiration perfectly pure; same in
 front; pulsations  of the heart not loud, but distinct; tongue moist;
 diarrhoea abundant, like beaten eggs; thirst great;  the child is
 very plaintive.
   From Sept. 13th to  Nov. 8th, the diarrhoea remained the same;
 the emaciation advanced rapidly, but the cedema disappeared almost
 entirely.  The respiration during all this time  remained perfectly
 pure,  and the percussion resonant. Auscultation had been  practised
 every day.
   Nov. 8th.  There supervened  three or four vomitings, without
 any symptoms of reaction.
   9th. the  skin is hot; pulse 160, respirations 44, without dilata-
 tion of the  alee nasi; slight cough for the first time since entrance;
 in the whole of right  back  subcrepitous rale, with inspiration and
 expiration ; on  the left  the  respiration  is strong and  pure ; per-
 cussion every where resonant; on the thighs,  legs, and  abdomen
 there  exist  little red irregular papules of the size of the head of a
pin, disappearing  under pressure ; no trace of eruption in the rest
of the body; diarrhoea still abundant.
   10th. The eruption  has faded,  having been confined to the lower
half of the  body.  The pulse is imperceptible; respirations 30; the 
76   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDRE
warmth of the skin has disappeared; in the right back subcrepitous
rale ;  in the left some rare crackles.
  11th. The eruption has disappeared ; pulse 130, respirations 36;
same phenomena of auscultation.
  12th. No change.
  13th. Skin warm; pulse  128,  respirations  40; in the whole
right  back a subcrepitous rale  heard at intervals ; no vesicular
expansion at the  base ;  percussion less resonant relatively to the
opposite side.
  14th. Skin  warm; pulse  156,  respirations  48,  elevating the
whole  thorax, not anxious; slight dilatation of the  alee  nasi; in
the whole right back subcrepitous rale,  in  the lower third  with
bronchial  expiration ; percussion but slightly resonant at the  right
base ; respiration  pure on the left side.
  Until November 25th, there appeared no change, except a  con-
tinued increase of the emaciation.  The face is  extremely pale, the
diarrhoea persists, the symptoms of reaction have disappeared  ; the
same  subcrepitous rale,  dulness, and bronchial expiration in the
right back—but the abundance of the rale frequently overpowers
the  bronchial sound.
  From Nov. 29 until Dec. 20, the child was examined every day,
and each examination gave very nearly the  same results, the sub-
crepitous rale in the right back, dulness  in percussion at the  base,
but without  the  bronchial expiration.   The emaciation  is at the
last degree.
  Dec. 20.  There  exists a little  amelioration  ; our patient  very
cross  and  plaintive  hitherto; has become more  pleasant; she is
seated in the bed; the  countenance  is a little  better; the pulse is
116;  the appetite  has returned; the  rale persists, but the dulness
no longer exists.
  From  Dec. 20 till Jan.  15, the amelioration  continually pro-
gressed.  The  appetite  is good, despite  the diarrhooa, the tongue
moist, the emaciation commences to disappear and  the strength to
return.  The rale, however, persisted until Feb. 5, when it entirely
disappeared.  The  amelioration was not interrupted  during the
remainder  of the  stay at the hospital.
  No active  treatment was directed against the pneumonia ;  some
slight astringents for  the diarrhoea (syrup of ratanhia,) some ene-
mata  containing  a small quantity of laudanum, as well  as  some
julaps containing syrup of poppies  giij, were  likewise exhibited.
For two days gr.  xij. of the white oxide of antimony were added to
the potion of gum.   The diet was at no  time rigid, as our patient
preserved her appetite throughout the disease.
  Remarks.—This  observation merits a very particular attention
in consequence of the termination of the disease.  The pneumonia
appears under the most unfavourable circumstances at a time  when
the child was reduced to the last degree of emaciation—and  yet
recovery followed.  But  for the final  resolution of the pulmonary
engorgement, how  long  were we obliged to wait!  The eruption 
OBSERVATIONS AND TABLES.
77
occurring at  the  same time  as  the pneumonia, appeared to have
more the characters of a simple erythema (erythema simplex) than
of the measles.   This opinion is confirmed by the fact that the pa-
tient had already  been attacked by the eruptive fever, which  rarely
appears twice in the same individual.  The form of the pneumonia
places it in our first  species; the concomitant eruption, whatever
its character, appeared to impart to the disease symptoms of more
than usual reaction ; an acceleration both of the pulse and respira-
tion decidedly  marked  the commencement of the disease.  The
results of the auscultation deserve careful meditation, as this single
history furnishes several examples of the different transformations
of the respiratory murmur.
OBSERVATION VI.
Lobular pneumonia supervening in good health, in a child of two years,
               accompanied with cerebral symptoms.

  SineL,  (Pierre-Victor,)  ast.  2 years,  No. 8, ward  St. Thomas,
entered Nov. 11, and died in the night of the 17th and 18th.
  This child, born at the full term in perfect health, has, however,
never continued in the  enjoyment of it.  A few days after birth, he
was attacked with a  purulent  ophthalmia, to which  succeeded an
impetigo of the hairy scalp, followed by frequently repeated colds.
These°different affections so retarded his developement, that at pre-
sent he walks with difficulty, speaks but a few words, and dentition
has commenced  only within  five months, at which time he  had
slight convulsions and  a diarrhoea lasting some days.
  Nov. 3, being in tolerable health, he  was attacked with a violent
cough attended with  fever: on  the morrow, during twenty-four
hours, he had convulsions lasting from ten minutes to half an hour,
and returning  about every hour;  attacking the limbs, face,  and
eyes.   The cough and fever have persisted since, and the child has
remained pale, bloated, somnolent, without appetite or diarrhoea.
   Nov  12. Patient lying on back, face  slightly coloured on the
left side  the alaa nasi dilate considerably, the skin is slightly warm,
the left 'foot is, however, a little colder  than  the right, and the con-
trary is evident with regard to the  hands.   Pulse  small, frequent,

   The oppression is considerable. Respiration 76  to 80, irregular,
sometimes  less,  sometimes more in number.  The resonance on
nercussion and the respiratory  murmur are every where good.
Lips dry, tongue moist, gums a little swelled and red  the incisors
are hardly projecting.   Abdomen somewhat large, full of gas, but
supple and not painful; no  diarrhoea. (Infusion of mallows with
 honey, calomel gr. vi.  emollient enema. Bouillon.)    ...
    13  Fever and agitation all night—calomel has produced no de-
jections (same prescription except the calomel.)
  14. Night as the former—cough a little hoarse and strong-
-no 
  78   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

  diarrhoea.   The face is pale, lips dry and encrusted ;  the patient is
  very irritable, crying whenever  he is touched  and hardly allowing
  an examination.  50 irregular inspirations,  difficult,  with a hard
  noisy and painful expiration.  Impossible to count the pulse. Aus-
  cultation is  almost impracticable, nevertheless, despite the cries, we
  thought we heard a mucous rale on the right side. (Same prescrip-
  tion, calomel gr. vi. laxative enemata.)
    15. Some agitation throughout the night,  day somnolent,  his
  sleep is tolerably tranquil, permitting  us to count 30 irregular in-
  spirations and 114 small pulsations.   As soon as he is awakened,
  he becomes immediately very irritable, and only a superficial  ex-
  amination can  be made.   Our patient  is bloated, with his eyes  en-
  crusted,  as  also  the nose  and lips.  Abdomen tense and  pain-
  ful ; one dejection after the calomel; a slight cough still continues.
  (Infusion  of mallows  with honey.  Magnesia gr. 12.  Emollient
  enema.   Bouillon.)
    17. Slight stiffness of the upper extremities: the fingers are bent
 upon the hand and the hand upon the wrist ; they can be straight-
 ened but not without causing pain ; the feet are slightly flexed ; the
 sensibility is preserved but  slightly diminished equally  on both
 sides; pupils dilated but movable.   The head  is quite movable;
 these symptoms were not noticed by the attendants prior to the visit.
   The face presents sudden alternations of pallor and redness, the
 oppression is extreme ; the  dilatation of the  alae  nasi considerable.
 There are still the accesses of irritability, even when not touched.
 Consciousness is  still  present,  and  drinks are swallowed  with
 avidity.   (Mallows, syrup of gum; magnesia, and calomel,  aa. gr.
 iv. demi emollient enema.   Bouillon.)
   During the day our patient had well marked  convulsions in  all
 the limbs for about half an hour. At the evening visit he is more
 tranquil.  Pulse  148, respiration 58, unequal.   The head is drawn
 backward, but without stiffness ;  pupils less dilated ; the limbs are
 the same as  in the morning; sensibility the same; skin hot with
 momentary perspirations.
   Our patient remained in this tranquil state, in full consciousness,
 and asking frequently for drink until the middle of the night, when
 he  was again taken with convulsions lasting for a short lime, and
 he died quietly about 5 o'clock.

 Autopsy thirty hours after death—xoeather mild and slightly moist.

  The body  loaded  with fat, presents a slight  swelling of the ex-
 tremities, which have remained flexed as during life.  The thorax
 presents modosities at the union of the cartilages and ribs.
  Brain.—Cranium very voluminous and its walls are very thick
 in various points, and thin in others ;  the anterior fontanelle is not
 ossified. Dura-mater very adherent to the bone but appears healthy.
 The arachnoid smooth, transparent, presents a  few of Pacchioni's
glands.  In the pia mater there is an abundant  serous infiltration
without any granulations, or traces of inflammation.  The simuses 
OBSERVATIONS AND TABLES.
79
contain numerous coagula, some coloured, others discoloured : the
central veins are slightly congested.
  The consistence of the cerebral substance is everywhere good.
The cortical portion is slightly rose-coloured, the medullary is only
slightly marked with bloody points upon incision.   Ventricles con-
tain three to four  spoonfuls of transparent serosity; their walls are
healthy.
  The spinal marrow  presents no  alteration in colour or consis-
tence.   There  is  only remarked rather  an abundance of sub-
arachnoid fluid, and an infiltration, more considerable than usual,
between the bones and  dura-mater.
   Thorax.—The right pleura has some recent adhesions, which
are soft, gelatinous, and  infiltrated with a yellow coloured serum.
The lung of the same side does not  collapse upon the opening of
the chest.
  The whole of the superior lobe hepatised in the second and third
degrees,  is gorged  with a  great  quantity of  a  sanious  grayish
liquid.  At its external and middle portion there  is a little cavity
of the size of a filbert, filled with sanguinolent fluid, not communi-
cating with the bronchi.
  The middle and lower lobes are hepatised in the second degree,
nearly throughout, but especially behind and in the upper part:
the tissue is dense red,  smooth  upon incision, granulated upon
tearing, and  easily penetrable  by the finger.  The anterior part o?
the base alone remains unaffected and floats upon the surface of
water.  The healthy portions present  some vesicles more volumi-
nous than the others, apparently emphysematous.
  The small bronchi appear reddened  from the colour of the sub-
jacent tissues, and containing liquid mucus, not bloody.
  The left lung and pleura are perfectly healthy, and contain but
very little liquid.
  The larynx and the  large bronchi are healthy.
  There are no tubercles in any of the thoracic organs.
  The heart without any alteration, and of good  consistence, con-
tains numerous coagula in all  its cavities.
  Abdomen.—The mucous membrane of the digestive tube pre-
sents no notable  alteration.  Throughout its whole extent it fur-
nishes strips of five and  six lines, except at the great curvature of
the stomach, where the strips are only two or three lines.   The
colour is a gray rose, and at intervals  there is  an injection, but
limited in extent.
  The other abdominal organs are in the same heathy state.
   Remarks.—This observation is  an  example of pneumonia ac-
companied with cerebral symptoms ; we observe at the  first view.
that the thoracic disease has not been  entirely masked by the phe-
nomena of cerebral reaction.  The first symptom was cough, with
an  oppression, which  was always  considerable,  and  these two
symptoms have persisted until death, although they diminished in
intensity, and presented very considerable variations at different 
80   RILLIET AND BARTIIEZ ON PNEUMONIA OF CHILDREN.
  times.  The auscultation  was never  properly  practised;  we are
  sure, however, that  six days  before the death the respiration ap-
  peared  pure, and nevertheless we found the hepatisation advanced
  to the third degree.
    It  is  impossible to believe that so considerable a  hepatisation,
  should  not be  revealed  by auscultation if properly practised; we
  must only think that there are pneumonias,  which,  by sympathy
  reacting upon  the brain, give rise to cerebral  symptoms, which,
  absorbing the attention of the  observer, mask the symptoms of the
  thoracic affection.
   In the present case, the cerebral symptoms showed themselves at
  the beginning and end of the disease  and are analogous to  those
  described  by M. Tonnelier, in a memoir in the Gazette Medicale.
  The author of this memoir asserts that this assemblage of cerebral
 symptoms exists in  children,  without  any lesion  of"the nervous
 centres,  but of different thoracic or abdominal organs.
   Finally, to conclude, we must notice the form of the  hepatisa-
 tion, which  is  lobar,  and occupied only one  lung, a fact in direct
 opposition with the opinion  of Dr. Gerhard, who affirms, in  chil-
 dren from two  to five years, pneumonia to be always double and
 lobular  in its form.   This  case, moreover, is not the  only one,
 which contradicts the assertion of the American pathologist.1

                       OBSERVATION VII.

 Measles.  Lobular pneumonia generalised  in the second and third stages.
   Mucous rale.  Masking for a long time the bronchial respiration.  White
   softening of the mucous membrane of the  large intestine.

   Delaforte  (Theophila  Alexandre),  aet.  two  years  and a  half,
 was brought to  No. 2, ward St. Thomas, without any other infor-
 mation than  that he had had the measles six weeks previously and
 had been sick ever since.
   Upon  entrance Nov. 30, we saw  him in  the following state-
 complexion blond, skin fine and pale a little rough and scaly upon
 the extremities,  giving the sensation of  a dry  heat, the face  is ane-
 mic, infiltrated,  colour of  wax, the nasal line  is very pronounced
 the eyes are encrusted, the  lips dry, sticking together and pale!
 lne alae nasi dilate  considerably immediately preceding the in-
 spirations,  the pulse  is small  and  frequent,  impossible to  count
 from the patient's restlessness.
   On opening the mouth there are found only the incisors and one
 molar; the gums are  neither  red, nor swollen, and do not appear
 painfu;  the  tongue is moist and pale; the abdomen is large and
 soft, although filled with gas, without  any tumour ; the live? how-
ever projects a little below the ribs.   Pressure  especially upon the
right side  appears painful, augments the nasal line and causes a
knitting of the eyebrows.  Dejections frequent, loose and yellow.

              1 See the table of Pathological Anatomy. 
OBSERVATIONS AND TABLES.
81
  The cough is moist, not frequent; the chest resounds moderately
well in  its whole extent;  every where  except  in the left part and
axilla, there is heard a large abundant mucous  rale in both the ex-
piration and inspiration, more  abundant  at the summit than the
base of the lung.   It is fine and subcrepitous in the  front of right
base, (white decoction,1 julep with oxide of antimony 3ss. syrup of
poppies gss. demi emollient enema: bouillon.)
  Dec.  1. At first sight our patient appears moribund, he is so pale,
feeble, and  nearly motionless.  The symptoms, however, are  the
same as yesterday, except a slight forward movement of the lower
jaw.  The  cough is less abundant, the rales still persist. (Same
prescription.)
  Dec.  2. Same general aspect.  Our patient utters  at moments a
singular plaintive cry.  Behind, the rale  is  the more abundant at
the right base;  there is a bronchial expiration in  the sub-spinal
fossa and here the percussion is dull.  Persistence of the diarrhoea
—pulse small, frequent, cannot be  counted—(oxide of antimony,
3j.)  Death in the evening of this day.
  Autopsy forty-four hours after death—weather cold and dry.
  Chest.—The pleurae present old adhesions posteriorly.
  Right lung.—Deep red externally, especially posteriorly ; volu-
minous, not collapsing.  Its superior lobe  upon  incision resembling
the liver, is of a yellowish gray and red ; upon scraping it furnishes
a sanguinolent, sanious liquid ; upon tearing, it  appears granulated,
and the finger penetrates  without difficulty.   This  lobe  sinks in
totality to the bottom of water.
  The  inferior  lobe presents the same characters,  with a  redder
colour, but only in the posterior portion.  It floats only by the an-
terior portion of its base, which however presents some  points of
hepatisation.  The middle lobe, equally  hard  and  large, presents
some points of hepatisation, and floats in  totality.  The nodules of
separate engorgement, small in number, vary in size from a pea to
a filbert.
  The  mucous membrane of  the smaller  bronchi  transmits the
colour of the subjacent tissues : where the bronchi are sufficiently
large to furnish strips, there is neither thickening  nor softening.
They contain also a tolerable quantity of mucus.
  Left lung.—Externally marbled  gray and  red, but in general
the colour  is  not deep—it floats in  totality  and in   parts, except  a
very small portion of the base  which is hepatised.   It contains ra-
ther an abundant quantity of a spumous  liquid, and is  a little less
resistant than a healthy lung.
  The small bronchi of this lung are redder than those of the other,
owing to the more vivid redness"of the subjacent tissues; the mu-
cus is also abundant.                         ,- .  i   j    i    •,
  The bronchial glands  are  small  and  but  slightly  developed;

                  1 Principally mucilaginous.—TV.
        17—b                                       ril 6 
 82   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN-

 there are no where any tubercles.   The trachea  and the  large
 bronchi are of a grayish red and perfectly healthy.
   Abdomen.—Mucous membrane  of stomach and small intestines
 of a  normal colour and thickness, giving strips of from three to
 five lines.   The patches of Peyer red and somewhat developed are
 neither softened nor ulcerated.
   The large intestine  is gravely affected :  throughout its  whole
 length, the'mucous membrane of a pale white is very thin and does
 not give strips in any of its parts.  This intestine is filled with a
 yellow mucous substance, in large quantity.  The mesenteric glands
 are small, numerous, not softened.
   The other abdominal organs  are normal.
   Brain.—No  alteration save a somewhat considerable subarach-
 noid  infiltration.  The ventricles contain  four to five spoonfuls
 of serosity, without softening of the walls.   The cortical substance
 is  slightly rosy, and the medullary presents no bloody points.
   Remarks.—This is an observation of lobular pneumonia gene-
 ralised, agreeing entirely with our  description of the  passage of
 this pneumonia to the third degree.
   It   shows that in  young children,  and in this  kind of  pneu-
 monia especially, the abundance of the  rale may mark the patho-
 gnomonic signs of the pneumonia itself.
   The general  state of the  patient and the concomitant lesion of
 the large intestine permit us to rank this case in our first category;
it must be, however, regretted that the previous history of our pa-
tient  was so incomplete, as  well as the  succession of symptoms
from the  commencement.

                      OBSERVATION VIII.

 General and  capillary  bronchitis.  Mamelonated and partial pneumonia.
      Hepatisation and carnification, with dilatation of the bronchi.

   Fariol, (Jules,) aet. five years, entered  ward St. John No. 6, De-
cember 22, 1837, and died January 5, 1838.
   We have had but few details  of the  previous history of this
patient, as his parents had him at home  only a month before his
entrance.
   At  that time he coughed much, had a catching pain in the  right
side,  but  only at the moment of the cough : he was slightly bloated,
 had a violent fever, especially at evening, without  any diarrhoea.
 Since that time, persistence of the fever  and couo-h, which has re-
curred in paroxysms, with  blowing inspirations* followed by an
abundant serous expectoration, and even vomiting.  The pain in
 the side disappeared, to return  again; the oppression was always
considerable: the appetite was  preserved, however,  and there was
 no diarrhoea.
   Present state, (Dec. 23.)  Eyes and hair brown ;  skin white and
delicate: face a little bloated, especially  the upper  lip, which is 
OBSERVATIONS AND TABLES.
83
pale and encrusted ;  the  nasal  line is very pronounced;  the alae
nasi are widely dilated a little before  each inspiration.  The skin
is moist and warm ; pulse 136, rather small.  The tongue is moist
and clean ; the abdomen  supple, a little tumid, not painful^ two
semi-liquid dejections since yesterday.   Respiration difficult, but
regular, 56;  the  cough manifests itself in paroxysms of hooping,
lasting several minutes.  In front, percussion gives a good resonance
on both sides; on  the right there  is heard a very loud sonorous rale
both in the inspiration and expiration.  At the top of the lung, in
addition, there is a  prolonged expiration ; on  the  left, the' same
sonorous rstle exists during the inspiration only, while  the  expira-
tion is very rough and  hard, especially at the  summit.  Behind,
the resonance is  good and equal  on  the two sides: every where
there is heard in the inspiration a mucous,  mingled with a sibilant
rale.  In the two interscapular  spaces, but especially in  the left,
there is heard a well-marked bronchial expiration.  Very abundant
sero-mucous expectoration.  (Mallows, infusion, looch, with oxide
of antimony  3j.;  syrup of cinchona gj.;  soup.)
  Dec. 24. General condition much the same ; pulse 140; respira-
tion  60 ; skin of hands warm and moist, of the body  dry and burn-
ing.   Behind, the physical signs remain  the same.   In front, the
sonorous is replaced  by a mucous rstle on  both  sides.  (Same  pre-
scription, oxide of antimony, 3ij., milk.)
  25th. Has  had  a slight sleep in  spite of an abundant diarrhoea.
Lips  are now  a  little less swollen;  the  bloated appearance has
diminished ;  the dilatation of the alae nasi is  less ; there are no
facial lines, and almost no heat of the skin ; pulse 130, respiration
50, nearly  entirely abdominal.  Physical  signs nearly the same,
except the  mucous rale, which  is, perhaps, less abundant, and at
the middle of the right side it  is more dry and crepitous.  The
expiration in the interscapular  space is still heard.  (Same  pre-
scription.)
  27th. Skin dry and warm;  pulse only 120, soft, full, and regu-
lar;  the diarrhoea  has ceased;  same  results  from auscultation.
(Same prescription ;  oxide of antimony, 3hj.)
  28th. The swelling of the nose and lips has reappeared, with the
bloating of the face, and the nasal line.  The countenance is pale,
indicating prostration ; skin hot and dry ;  pulse 144, soft, tolerably
large : respiration 44 ; tongue moist, rosy coloured, and trembling;
abdomen, although  supple, is tympanitic,  and  generally painful  ;
there is an abundant yellow diarrhoea  The chest is sonorous ; the
mucous rale, always  very abundant,  masks a little  the bronchial
expiration.   Expectoration the same.  (Same prescription ; oxide
of antimony,  gss.; semi-enema of flaxseed and poppies.)
  29th. The general condition was considerably aggravated ; pulse
146  small; respiration 56; abdomen continues  painful,  and the
diarrhoea persists. The mucous rale is heard throughout the chest
more abundant than ever;  the bronchial expiration  has disap-
peared. 
84   RILLIET AND BARTHEZ ON PNEUMONIA OF CHIL
   From this time the state of the patient  continued  to  aggravate,
with delirium constant up to the moment of death.   From his ob-
stinacy  in scratching his nose it was covered with bloody scabs,
and the cheeks became of a violet red.  Death, however,  did  not
arrive till  the night of Jan. 4.  During these six days, the collapse
and feebleness prevented all  careful auscultation :  the mucous rale
was always heard  quite abundant; and,  in  the latter days of life,
there was added the tracheal.

 Autopsy thirty-six hours after death—weather cold and  damp.

   The body is thin, without stiffness,  and presents a slight putre-
faction of the abdominal parietes.
   Thorax.—The  mucous  membrane  of the trachea and  large
bronchi display fine points  of a rather vivid redness,  and even
appear  softened.   The  right pleura  offers  solid  adhesions, with
some false membranes, which are soft, vascular, and strown with
little tubercular  granulations.  The lung is heavy,  and marbled
red and violet in separate lobules, and floats in totality; upon inci-
sion, a part of the  lobules appear of a clear red, containing air and
a sanguinolent serosity:  others, of a  deeper  colour,  are  hepatised,
breaking up under the pressure of the finger, and are surrounded by
little collections of  miliary tubercles.   These collections are scat-
tered through the  three lobes, but in  small quantities;  the  same
lung contains also lobules  of hepatisation,  perfectly isolated one
from the other, which sink  in water,  and  yield, upon pressure, a
sanious fluid not containing air.
   At the anterior portion of the middle lobe there is found a portion
of tissue,  the size of a nut, collapsed, flaccid, externally of a livid
red, internally a little less  deeply  so; hard and  resistant to  the
pressure of  the finger, and sinking when thrown into water.  The
bronchi of this part preserve the same calibre from their arrival in
this tissue until they reach the surface of the lung  ; some even are
a little dilated; they contain an abundant puriform fluid, and their
mucous membrane, after being washed,  is too  much softened to
permit of  the making of strips.
   The smaller bronchi of the other parts of the lung are not dilated,
but are generally  reddened,  although the subjacent  tissue is  not
uniformly so; they contain  an abundant  quantity of mucus filled
with air.
   The left pleura offers some weak adhesions : the  lung of this side
presents externally clearly marked lobules of a violet colour, pro-
jecting and  solid under the  finger:  upon incision, these portions
appear hepatised and congested, and there issues an abundant sero-
spumous  fluid, which is in some parts sanious,  and  contains  air.
The hepatised lobules,  being well isolated, sink to  the  bottom of
water, but considerable attention is  necessary to obtain this result
they are  so  enveloped  by,  and insensibly confounded  with  the
simply engorged tissue.   These lobules of hepatisation are nume- 
OBSERVATIONS AND TABLES.
85
rous, and exist equally in the two lobes.  At the anterior portion of
the lower lobe there is found a portion of hepatisation the size of a
filbert, presenting, upon incision,  little cavities, the size of a lentil,
communicating with each other by dilated bronchi, and filled with
a puriform  liquid ; they are lined by a smooth thin membrane, ap-
parently continuous with that of the bronchi.
  The small bronchi of the other parts are like those of the oppo-
site side.  In this lung there are no tubercles.
  The bronchial  glands, voluminous on both sides, are tuberculous
on the right; red,"soft, and without tubercles in the left.
  All the cavities of the heart contain coagula, both coloured and
the contrary, with a slight quantity of liquid  serous blood.  The
border of the mitral valve is a little red and  thickened; the heart's
volume is not increased.
  Abdomen.—No abdominal organ presents any notable alteration:
the mucous membrane of  the intestines is every where of a good
consistence, and furnishes strips of five and six lines.  The colour
is generally pale,  except some arborescent deep redness  scattered
in a small extent  over the large intestine.
  The liver, of the usual size, and containing the usual quantity of
blood, offers a great number of gray demi-transparent granulations
in the interior of  its tissue and under the serous membrane.
  The  spleen contains one  crude tubercle of the size of a hemp
seed.
  Brain.—Arachnoid smooth,  transparent, offering however  a
slight opacity about the glands of Pachioni,  which are very nume-
rous ; the ventricles contain but little fluid. The cerebral substance
is every where of good consistence and colour.
  Remarks.—This observation is of great interest from the nature
of the anatomical lesions,  as well as from the results  of the auscul-
tation.   We find  united here examples—1. Of mamelonated pneu-
monia, that is, lobular pneumonia perfectly circumscribed, without
any tendency to attack the  neighbouring portions.   2. Of partial
pneumonia, that is,  of  lobular pneumonia, with a  tendency to the
surrounding  tissue.  3. Of limited carnification and hepatisation
surrounding our two species of bronchial dilatation.  4. Of a gene-
ral  and  capillary bronchitis, proved  at the autopsy.   All these
lesions were consequent upon the hooping cough.
  As for the  symptoms from the auscultation, we should remark
that the separate  nodules of hepatisation gave  a  bronchial expira-
tion, which, at the end of the disease, was masked by the mucous
rale,'the result of the  constant accumulation of mucus, the conse-
quence, without doubt, of the feebleness of the  child. 
86   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDRE
                       OBSERVATION IX.

Vesicular bronchitis.  Simple lobular pneumonia. Dilatation of the bronchi.
           Bronchial expiration masked by the mucous r&le.

  Androit, (Edmund.) ast. nine years,  entered  Dec. 19, 1837, died
Jan. 2, 1838.
  This boy, of a naturally good constitution and  health, was  at-
tacked with measles about eight days before  his arrival at  the hos-
pital,—the eruption having, by report,  gone through all its  periods;
the fever and the cough  continued, with epistaxis,  diarrhoea, nau-
sea, pain in the abdomen, and sore throat.
  Upon  entrance, patient very well developed,  not emaciated, is
nevertheless considerably prostrated.   The face, livid  in  spots, is
covered  with  an  abundant furfuraceous  desquamation ;  the alas
nasi dilate a little, and the edges of the nostrils are surrounded with
red scabs, in consequence of a slight epistaxis ; the  lips are dry, not
encrusted, and there is no facial line.  The  skin is slightly warm
and dry;  pulse 114, large and soft; no  cephalalgy; the tongue is
moist, loaded at the base, red at the tip, and  there  are some white
patches upon the upper and lower  gums.   The patient complains
of a slight pain in the region of the larynx; the tonsils are a little
red and swollen.   The abdomen, generally painful, is a little less
so at the umbilicus, and  is soft, supple, without  gurgling, rose
spots, or eruption, but covered with some furfuraceous scabs.  Last
night there was  a  bilious  vomiting, and  numerous  liquid  dejec-
tions.
  The respiration is regular, 48 ;  the  cough moist,  frequent, and
still  preserving the character  peculiar to  measles : the expectora-
tion  is sero-mucous: decubitus upon  the back, but possible upon
either side.  The form of the chest is  good, without emaciation, or
an excessive quantity of  flesh.   In front the  resonance is good  on
both sides ; on the  right there is  heard a mucous rale occupying
the whole side, more abundant, drier,  and  finer in the middle  re-
gion, ordinarily heard during both times of the respiration, but
sometimes in the expiration only : on  the left, the  mucous rale is
less abundant, and sometimes is entirely absent.  Behind, the reso-
nance is  moderate,  but equal  in both sides; in the right, subcre-
pitous rale nearly to the summit, but more especially at the base:
at the summit there is united with  it a little  prolonged expiration.
The rale exists in the inspiration,  and at  times  there  is a sibilant
rale in the expiration.  On  the left  the  respiration is strong and
rude, with an expiration  at the summit, and a slifrht  mucous rale in
the  whole height of the chest.
  (Mallows, syrup of gum,  looch with kermes, gr. ij.  ; semi-emol-
lient enema, sinapisms, bouillon.)
  Dec. 21. The prostration and fever are greater; persistence of
the  vomiting and diarrhoea ; the chest  is in the same state.  (Same
prescription ; kermes, gr. iv.)                              ^ 
OBSERVATIONS AND TABLES.
87
   Decern.  22.  Slight  epistaxis ;  the face is more purpled, and
asphyxia appears  imminent;  the prostration is more considerable;
pulse still 144, but less  full, respiration 50:  tongue a little pointed,
red at the tip, white at  the base; profuse yellow diarrhoea :  other
symptoms the same.
   The auscultation gives nearly the same  results as before, with
only the following differences : Subcrepitous rale in the whole right
back, but finer and drier in different  points : there  is a little expira-
tion at the summit, where the  rale  is less : on the left,  the rale is
still less at the summit, where is a considerable bronchial  expira-
tion ;  below there  is an abundant  mucous  rale.   (Same prescrip-
tion ; kermes, gr. v.)
   Dec. 23. The colour  of the face is more vivid ; the prostration
is less, there has been a slight epistaxis; the nose continues red,
and covered with scabs : the lips are dry, the tongue white and
moist, the abdomen is not painful;  only one dejection  since yester-
day ;  has taken soup with  a relish.  Persistence of the febrile re-
action and prostration.
   The auscultation  continues the same in  front,  except that  the
mucous rale has become subcrepitous in nearly the whole extent,
instead of merely in the middle portion.  On both  backs, abundant
subcrepitous rale  throughout,  with strong bronchial  respiration at
the left summit, and a  slight expiration at the right, in the  same
point.  (Same prescription ; kermes, gr. vi.)
   Dec. 24. Agitation throughout night; prostration this morning.
The sore throat and diarrhoea have returned.   Otherwise, persis-
tence of the same symptoms ; desquamation of cuticle continues ;
(same prescription, kermes gr. vii.)
   Dec.  25.  Sleeplessness,  agitation,  and diarrhoea  throughout
night. The eyelids are red and encrusted, there is a slight  nasal
trait, and the  alae nasi  dilate  considerably.   The  face is coloured,
especially the left side.  The lips are dry, tongue moist, and yellow
at the base; continual pain in the situation of the larynx, which
does  not however embarrass  deglutition.   The abdomen, slightly
tense  and tympanitic, is painful in the  epigastrium and right iliac
fossa.  Pulse 120, regular, with heat and dryness of the skin. The
oppression continues the same ; same cough, same expectoration.
   In the whole of both  backs,  there is heard a mucous rale, during
both inspiration and  expiration ; the bronchial expiration has dis-
appeared.   In front, same mucous  rale, equally  strong on  both
sides. (Mallows, syrup of gum, looch, kermes gr. viij. syrup of pop-
pies, gss. semi-emollient enema, bouillon.)
   Dec. 27.  Prostration extreme, heat of skin.  Pulse small,  130.
The cheeks are livid in spots,  the nose is encrusted, bleeding,  same
physical  signs, only the raMe is perhaps a little more fine and sub-
crepitous on the right.  The face  presents two or  three vesicles of
varioloid, none on any other part of the body.  (Same prescription,
kermes gr. xi.)
  From this time till the day of death on the morning of the second 
88   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

of January, (five days after,) our patient's state was continually
worse and  worse, prostration extreme, hardly allowing the  sitting
position necessary for the auscultation, which gave always the
same result, mucous  or subcrepitous rale wherever possible to place
the ear; the skin was dry, except during  the two  or three  latter
days, when it was bathed in copious  perspirations ; the counte-
nance by degrees lost entirely its expression, the patient could with
difficulty articulate;  the  pulse was augmented to 160, preserving
the same smallness,  and the  inspirations to 60; the abdomen con-
tinued painful, and there was an abundant, frothy, yellow diarrhoea.
   The same treatment was pursued in carrying the kermes as high
as fifteen grains.

Autopsy thirty-three hours after death—weather moist and warm.

   The body presents no stiffness, vibices, nor any  trace of putre-
faction.
   Thorax.—The  right  pleura  presents some redness and  arbo-
rescent vessels without any adhesions.
   The right lung heavy, but flaccid and crepitating, collapsing but
little, red posteriorly, of a gray rose colour  in front, is gorged with
a  quantity of sero-sanguinolent liquid, and penetrated  with air.
The incised surface,  of a gray rose colour, presents  the projection
of the bronchi filled  with mucus, together  with a number of small
yellow granulations  projecting from  the surface, about the  size of
millet seed and filled with the same mucus ;  the tissue of the lung
is more friable  than  normal,  but  it still floats upon  the surface of
water.
   The anterior portion of the middle lobe presents  some engorged
nodules, red, hepatised, easily torn and sinking in water; they are
well isolated from the surrounding tissue, which is rose coloured
and have a size from that of a lentil to a large pea.
   The small bronchi are  red, filled with mucus, and are either aug-
mented, or preserve the same size from their origin  to the surface;
their mucous membrane does not appear  softened  ;  they are also
dilated in all the points where the granulations exist,  that is to say,
in nearly all their extent, especially posteriorly.
   The left pleura red, and   containing some arborescent vessels,
presents posteriorly some gelatinous, soft, and recent adhesions.
   The left lung is of a deeper red, swimming in its  totality upon
the surface of water, presenting red, projecting spots, scattered un-
equally over its surface.  The incision is marbled with a violet and
a clearer shade  of red ; the lobules are well defined, and  separated
by their colour and projection from the  healthy tissue ; the deeper
coloured ones, which are the more projecting, are granulated upon
being torn, easily penetrated by the finger and sink in water.  The
lower lobe  presents the same disposition  ; the hepatised points how-
ever are smaller and  more numerous; one of them has suppurated
with  the formation of a small abscess, which does  not however 
OBSERVATIONS AND TABLES.
89
communicate with  the bronchi.  These latter are redder than on
the other lung, but contain less liquid, and are not dilated.
  The large bronchi and the larynx, slightly red, contain a small
quantity of liquid mucus penetrated by air.
  The bronchial glands are red, voluminous and softened.  There
are no tubercles any where.
  There is nothing remarkable in the heart or large vessels.
  Abdomen.—The   stomach contains mucus and some of  the
kermes.  The mucous membrane is of a vivid red, in large bands
in the smaller curvature, elsewhere in small lines and points with
occasional  small  ecchymoses;  its thickness appears great,  espe-
cially towards the cardiac orifice and the great curvature.  Its con-
sistence  is variable in  points close  to each other; the strips  are
sometimes  from one to two lines, or from half an inch to an inch,
indiscriminately in the parts which are reddened  as in those which
are not so,  in the great curvature as in the smaller.
   The small intestines  present no notable alteration ; the mucous
membrane with a few arborescent vessels at the upper portion is
gray and pale in the greater part of its extent, its  thickness is good,
and gives  strips  from three to  five lines; in the duodenum the
strips are only from two to three lines.
   At the lower  portion there are some reticular patches, similar to
a newly shaved beard, but neither tumid nor ulcerated.
   The large  intestines  are generally  healthy, with a good  colour
and consistence of  the mucous membrane;  the  rectum, however,
presents some vivid red spots, where the mucous membrane breaks
under the forceps, giving strips of from two to  three lines only.
   The mesenteric glands are slightly reddened, but not softened.
   The other abdominal organs  perfectly normal, are all, however,
except the  spleen, gorged with a considerable quantity of blood.
   22,-am.—Arachnoid, smooth and transparent nearly throughout,
is a little dry, and presents along the grand fissure as well as at the
vermiform process,  a considerable quantity of the glands  of Pa-
chioni, surrounded  with a slight opacity of the membrane.
   There is no  sub-arachnoid infiltration,  but  all the small vessels
of the pia mater are distended with blood, and there are even some
small ecchymoses, which  the scalpel  moved over the surface does
not push before it.
   The cerebral veins and the sinuses contain much blood.  The
cortical  substance  presents  a little  redness,  and the  medullary
a considerable number of bloody points.  The consistence is every
where good, and the ventricles contain  from one to two spoonfuls
of serosity.
   This  observation is important as proving the truth of many ot
our ideas  already emitted.   We find first a  well marked simple
lobular pneumonia, in a child more than six years of age ;  we see
besides an abscess of the lung, a vesicular pneumonia  and dilata-
tion of the bronchi.  The first of these four lesions is so perfectly
distinct  from the others, that the symptoms  appertaining to each 
 90   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

 may be perfectly appreciated.  And  finally we  observe  a com-
 mencement of pleurisy with simple lobular pneumonia.
   The whole of this  disease has  been developed  after a measles,
 the desquamation of which we have been able to see.
   The lobular pneumonia was manifested by the characters which
 we have attributed to it.   In the right front, a drier and finer rale,
 surrounded by one coarser and more moist, which finally entirely
 prevailed over the former; on the  left back, bronchial expiration at
 the summit, mucous or subcrepitous rale every where else, finishing
 by masking the parenchymatous  element,  in proportion  as  the
 strength of our patient declined.
   We must now explain the existence of the same  expiration at
 the summit of the right  back, where the autopsy has  not revealed
 the existence of a hepatisation ; first,  however,  we must  remark
 that perhaps there really did exist one of those lobular pneumonias
 at the third degree, which so easily escape detection at the autopsy,
 the existence of which  may be expected here from  the physical
 signs.  Unless this be the case, why this remarkable discordance
 between the lesions?  The  tissue, more penetrable  than  usual,
 floats nevertheless in water, and its  colour is a gray rose; if we had
 examined more closely, perhaps, we should have found the vesicular
 granulations  surrounded by points of  pneumonia at the  third
 degree.
   But even if this explanation  be  rejected, another  may  still be
 found in the dilatation of the bronchi: we know, in fact, from other
 observations, that this alteration may, in certain  cases, produce the
 symptoms for which we  are endeavouring to account.   Finally, it
 must be noticed, that here, as in the other lung, the  bronchial
 sound was marked by the mucous rales  increasing with the accu-
 mulation of mucus in the bronchi.
   The symptoms of hepatisation were manifested in the upper part
 of the lung, and only during the time  when the  mucous rale  was
 least abundant, a fact which proves that a mucous rale  may mask
 the bronchial  respiration, almost immediately, or from one day to
 another.
   We have spoken elsewhere of the result of treatment.

                       OBSERVATION X.

 Generalised lobular pneumonia at the  first and second degree.  Dilatation
                 of the bronchi into small cavities.

  Fifrelin, (Joseph-Francois,) aer.  2  years, entered at  No. 8, of the
 ward St. Thomas, the 29th and died the 31st of October.
  His father, (a German) speaks no French. Any history therefore
 of the previous health or  of the commencement of the present dis-
ease is entirely out of the question.
  Oct. 30.  This child, of a  dark  complexion, and very little de-
 veloped, has so small a pulse as hardly to allow of its being counted. 
OBSERVATIONS AND TABLES.
91
There is, however, no febrile reaction, and the patient is cold and
pale.   The alae nasi do  not dilate, the respiration is oppressed, 40,
unequal, with at times an appearance of stoppage and difficulty in
the expiration, which is  noisy and painful in the commencement.
No cough.
  Resonance of the chest every where good except in the two lower
thirds  of the left back,  where it is diminished.  Here is heard a
very  fine  crepitous rale,  very abundant, without any  bronchial
character.  Same in the axilla  of  this side.  Right  back coarse
mucous rale not abundant,  existence of the same in the two fronts.
   The lips  are dry, encrusted and cracked ; the tongue is moist
and of a rose  colour ;  the  nose  is encrusted; the abdomen is soft,
flaccid, and does not appear painful; diarrhoea very slight.
   Oct. 31.  Our patient is moribund and will  not permit  an ex-
amination ;  no  cough ; 58  to 60 inspirations ; same aspect  as yes-
terday.  The  crepitous rale of the left side is more abundant, and
very  well marked.  Mucous  rale on the opposite side ;  diarrhoea
slight; death the same day, two  hours after this examination.

Autopsy twenty-eight hours after death—weather cold and damp.

   Left pleura healthy.
   Left lung, the lobules of which are very well marked, but the
vesicles of which do not appear dilated, presents along its posterior
border large and flattened bullas, formed by the pleura solely, and
having the appearance of interlobular emphysema.  Upon incision
of these there exude  small drops of grayish  mucus, not containing
air, puriform, and issuing from little round cavities, the size of a
lentil.  These  cavities  communicate with  the  bronchi  of which
 they are the continuation.  Some exist at the surface of the lung
and correspond to the bullas  already mentioned ; others in the in-
 terior of the lobe are so closely situated as to form a species of cel-
 lular tissue being only separated  in  some cases by an imperfect
 partition : others "are united by tubes of communication,  apparently
 dilated bronchi, and which give off numerous branches, themselves
 dilated.  All these are filled with the same fluid as  the  little cavi-
 ties.   Their mucus membrane, not thickened, but coloured red by
the subjacent  tissues, is smooth, polished and continuous with that
 lining the  cavities.  At the extremity of one of the bronchi there
 exists a tubercle, situated apparently in the very interior of the
 bronchus.                                               .
   The surrounding pulmonary tissue is easily torn, and  is gene-
 rally red, some parts of it float upon the surface while  others sink
 to the bottom, without any  apparent difference of their physical

   This description  applies to the whole extent of the  lower lobe.
 The upper lobe presents some  projections  due to the interlobular
 emphysema ; there are none  of the little cavities internally and the
 pulmonary tissue is slightly engorged. 
 92   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

   The mucous membrane of the larger bronchi, of a slightly vivid
 red, possesses a good consistence.
   The right pleura presents some rather finer and solid adhesions.
   The right lung, generally crepitating, but slightly reddened, pre-
 sents, in the middle of its inferior lobe, two nodules of hepatisation
 of the  size of a filbert,  in the  middle of which are two cavities per-
 fectly similar to those of the opposite side.
   All the other small bronchi, not dilated, contain mucus perfectly
 penetrated by air.
   The subject was taken from us before we could possibly examine
 the other organs.
   Remarks.—Although this observation is  doubly  incomplete,
 from the want both of the anticedents of the history, and the re-
 mains  of the autopsy, we cannot help inserting it from the import-
 ance of the details above mentioned.   Besides every thing directly
 relating  to the pneumonia is complete  both  in the  pathological
 anatomy and auscultation.
   We  see here a remarkable example  of our two kinds of bronchial
 dilatation, and which appear to be  seated  either in the course, or in
 the extremities of these tubes.
   We  can establish the difference between these cavities and the
 smali pulmonary  abscess.   Around the bronchial dilatation there is
 found a lobular pneumonia on  the point  of becoming general, the
 hepatised portions being already united by an engorged tissue: the
 only difference between the portions of the left lower lobe lies in
 the circumstance  that  some  of them float  on the surface, while
 others  sink to the bottom of water—in  both  cases there was the
 same colour, and  the same  friability:  there existed here evidently a
combination of points of pneumonia in the first and second degree.
This opinion, moreover, is confirmed  by the lobular pneumonia of
 the opposite lobe.
  The symptoms are not less remarkable : we have, however, but
a few  words to say  upon  these, having  already strongly insisted
upon them in the course of the observation.  This child," aged only
two years, has presented a well-marked example of crepitous rale.
  The  existence  of this rale appears somewhat  contrary to the
lesions which we  have found  after  death,  but we  find a  ready ex-
planation in the fact that the  bronchial-mucus was  not penetrated
by air,  and,  therefore, could not give to  the ear the  sensation of
bursting bubbles.   In  these circumstances the inflammation of the
lung was manifested  by physical signs, belonging to the  degree of
the disease. 
OBSERVATIONS AND TABLES.
93
                       OBSERVATION XI.

Lobular pneumonia after measles. Numerous abscesses of the lung. Double
                            pleurisy.

  Lefevre, (Antoine,) vet. four years,  entered Oct.  2, No. 35, ward
S:. Jean.  Mother healthy ;  the father, within three months, has
considerably  emaciated  under a cough,  haemoptysis,  and night
sweats.   Nursed  by his mother, this child was weaned at four and
a half months ;  has never had any cutaneous disease, nor swelling
of the glands :  first dentition was easy.  Had  the  small-pox eigh-
teen months,  and the measles two months since :  this last was fol-
lowed by cough  and expectoration;  has been in  bed for fifteen
days, and has much emaciated; the  appetite  has  been preserved,
and there has never  existed  any complication of intestinal  dis-
order.
  Oct. 3. Hair blond, emaciation extreme, face  pale  and a little
bloated, marked by the small-pox ; skin hot and moist; pulse  120,
small, with some softness : the tongue  is clean,  the abdomen simple,
and not painful;  thirst, some appetite, slight diarrhoea ; oppression,
slight dilatation of alae nasi;  46 regular inspirations; cough slight,
not abundant, loose ; expectoration  sero-mucous.
   Behind, good resonance at the upper part of both chests, dimi-
nishing sensibly at the lower part, but descending a little lower  at
the right than left.
   Behind, mucous rale in the whole of both lungs, existing in  both
times of the respiration—sometimes, however, in the expiration
solely, intermingled with sibilant rSle ; bronchial respiration, espe-
cially in all  the"  lower  portion, and  slightly  in  the interscapular
space.   On both  sides, in front,  resonance good and equal; coarse
mucous rale, mingled with the sibilant, in the  whole front chest.
   (Mallows,  syrup of  gum, looch,  oxide of antimony 3J-,  semi-
emollient enema  ; bouillon.)
   Oct. 4. Pulse 150, respiration 50;  no  diarrhoea.  The physical
signs vary only as follows: Right back, no bronchial respiration,
except in the middle portion ; elsewhere, mucous rale more abundant
at the base.   In left front sibilant rale at  the  summit, mucous rale
at the base :  at the right summit respiration  rude, with but  little
sibilant or mucous rale.  (Same prescription: oxide of antimony,
3iss.)
   Oct. 5. Same state ; (oxide, 3ij.)
   Oct. 6. Sensible amelioration ; pulse 120, respiration 44;  sub-
crepitous rale small in  quantity in both  backs, a little more in the
right; resonance and percussion good, and equal on both sides.
   In front, a little mucous rale on both sides,  especially at  the base
of the lungs.                                        .
   Three liquid  dejections; no abdominal pains; appetite.  Same
condition during two days.  (Oxide of antimony,  3j.;  soup.) 
 94   RILLIET AND BARTHEZ ON  PNEUMONIA OF CHILDREN.

   Oct. 9. Prostration, diarrhoea, loss of appetite; pulse 150, small;
 respiration 48.
   Right back, dulness on  percussion in middle portion, with cre-
 pitous rale and bronchial respiration. Below, and to the outside, mu-
 cous and unequal crackling ; at the summit, some mucous bubbles
 at intervals.
   On  the left side, less resonance on  percussion at the base, ex-
 tending round to the  side.  Rather large mucous rale, with a slight
 expiration at intervals.
   This falling off, however, was not followed by  any long-continued
 reaction.  (White decoction, syrup of poppies, §ss.)
   Oct. 12.  Fever slight;  pulse 96, respiration 34;  tongue  clean,
 diarrhoea less: the amelioration in the  local symptoms, however,
 not great.
   In the right back the resonance is returned  in a  slight degree,
 but there is still a  persistence of the crepitous  rale  and  the  bron-
 chial respiration : at  the top of the same side there  exists a slight
 prolonged expiration, with a rather abundant mucous  rale after
 cough.
   On the left, at  the summit, the  respiration is  strong : at the base
 it is obscure, without rale ; dulness on  percussion  the same.  In
 front, respiration  pure.  (Oxide of antimony,  3iss.)
   Oct. 18. The disease has continued stationary up  to this  time:
 the diarrhoea is a little less, but the cough is increased ; paleness
 and  prostration :  the  flies commence to gather about the nose, eyes,
 and  mouth ; skin  hot; pulse  150, with  an intermitting stroke;
 respiration 56; oppressed, thirst excessive.
   Continuance of the dulness on left back, from the angle of sca-
 pula downwards, with subcrepitous rale and  bronchial respiration,
 under  and to the  outside of the angle of the scapula:  at the summit,
 mucous rale at intervals.
   On the right side, same state as  before. In front, respiration pure
 on both sides.
  Same prescription.
   Oct. 19. Notable aggravation of local symptoms. On  the left, the
 flatness extends to the top of interscapular region.   In the whole
 extent  of this there is bronchial respiration and subcrepitous rale:
 at the base the rale is  drier and more crepitous :  at the base of right
 back little resonance  upon percussion, with subcrepitous rale and
 bronchial respiration.   At the summit, mucous rale, both in the in-
 spiration and expiration,  disappearing after cough, whilst, on the
 contrary, all the other rales are augmented by  it.   In  front, very
abundant mucous rale throughout  the right side, especially under
the clavicle.   (Oxide  of antimony, 3ij.)
  Oct. 20.  Severe pain under right nipple; and there are heard at
this point explosions of a subcrepitous rale during both the inspira-
 tion  and expiration.   Further than this,  same local  conditions as
yesterday ; skin warm ; prostration more considerable.
  Oct. 21.  The pain of the side has diminished.  Behind the dul- 
OBSERVATIONS AND TABLES.
95
 ness continues, but there appears more respiratory sound, unless it
 may be that we hear a very distant  bronchial respiration.  At  the
 summit some mucous bubbles.
   Oct. 22.  Oppression extreme, respiration 66,  dilatation of alae
 nasi considerable ; pulse 150, small,  hurried, a little irregular;
 thirst excessive.
   The left side appears still a little painful.   On  this side,  behind,
 under the axilla, and even in front, the dulness on  percussion is
 considerable.  The respiration is inaudible in the whole lower part;
 heard  only at the summit behind, and there it is bronchial:  persist-
 ence of the same symptoms in the right side.
   Oct. 23. Death at 8, A. M.

  Autopsy thirty-two hours after death—weather cold and  moist.

   Emaciation extreme, with flaccidity of the flesh ;  no stiffness, no
 vibices ;  putrefaction  somewhat advanced upon the abdomen.
   Chest.—The  left pleura—filled with an  immense quantity of
 a serous liquid, containing floating  flocculent albumen, lined in
 some parts with soft and not thick false membranes—is in itself red
 and injected. The left lung, compressed  upon the vertebral column,
 is red and solid, and sinks immediately in water.  On incision it is
 smooth and  red, and presents the projecting orifices of a number of
 bronchi.   The texture, granular  when torn, is  easily penetrable
 by the finger, but rather less so than  in the usual hepatisation, due,
 without doubt, to the compression by the effused liquid.
   In its interior are discovered a great quantity of small cavities,
 varying in size from that of a hemp-seed to  a large pea, and filled
 with pus, mixed with coagula of blood.  Some  of these cavities
 communicate with the bronchi,  the  opening of which are easily
 distinguishable.   At the point where the bronchus opens into the
 cavity, the mucous membrane appears cut short off, and presents a
 visible solution of continuity, which may, in some instances, be de-
 monstrated  by the formation of strips.   These  bronchi, slightly
 reddened in  fine points, and containing a little spumous  mucus, do
 not appear dilated : a considerable number of these cavities do not
 communicate with the bronchi, but  appear  rather surrounded  by
 them.  These abscesses, so numerous that no attempt was made to
 count them,  do not communicate one with another.
   No tubercle any where in this lung.
   The right pleura presents the same alterations as the left, except
 that it  contains only a few spoonfuls  of serosity.
   The right lung, not solid like the left, floats in  totality upon the
 surface of water.  The finger, passed over its surface, detects small
 hard bodies, which answer to engorged  portions of a deep  red, of
 the same size and form as the abscesses of the opposite side.  These
 portions are  solid, and easily broken down under  the  finger:  they
sink also to  the bottorn of water,  provided they be properly isolated
from the surrounding tissues.  Some of these points of pneumonia 
96    RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.

are traversed by bronchi, which do not change their natural aspect.
The  bronchi generally exhibit a small number of red  points in
their  mucous membrane, and are filled with a spumous mucus.
  The surrounding tissue, red upon incision,  abundantly gorged
with blood and a spumous serosity, floats upon the surface of water,
and does not break  under the pressure of the finger.
  A small part of  the base of the  inferior lobe is reddened, filled
with a sanious fluid, breaks down under the  finger,  and sinks to
the bottom  of water; the remainder of this lobe, containing  no
hepatised  portions, is merely much engorged.
  No tubercles.
  The bronchial  glands, large,  red, and softened, are not  in the
least tuberculous.
  The heart, filled with coagula, some coloured and others the
contrary,  presents nothing but a  hard and thickened adhesion of
the aortic valves,  which prevents  their application against the
aorta.
  Abdomen.—The  mucous  membrane of the stomach, containing
a few arborescent vessels, is, however, normal in its thickness, and
affords strips of several lines.
  The mucous membrane of the small intestines, of a  gray rose
colour, is  healthy, and presents at its inferior portion some  nume-
rous reticulated patches, slightly thickened, but not softened.
  The mucous membrane of the colon generally of a  rosy red,
slightly thickened, furnishes no strips.
  The liver of a normal size  is generally red, but  the  two sub-
stances are distinct.
  The kidneys contain much blood,  but are healthy.  The bladder
contains urine which is troubled and deposits a  sediment.
  The pancreas are red and gorged with blood.
  The spleen, not congested is of its usual  size.
  The peritoneum  is of a rose colour, the subperitoneal vessels are
gorged with blood ;  in a word, all the abdominal organs except the
spleen contain a considerable quantity of liquid black  blood.
  Brain.—The dura mater, very thick, is adherent at the anterior
fontanelle  which is  ossified.   The arachnoid slightly opaque along
the longitudinal  fissure, presents a  large number  of Pachioni's
glands, disposed in  groups : there are some of these also  along the
superior  vermiform process.  The  cerebral  veins are   distended
with  blood  and  the superior  longitudinal sinus contains a firm
coagulum.  The  pia mater is infiltrated with a moderate quantity
of serosity.   The ventricles not dilated contain very little serum.
The cerebral substance is generally soft.   The fornix is sensibly
softened as  also the tubercular quadrigemina upon  their surface
and the anterior  peduncles.   All these softened parts are white!
The medullary substance presents but few red  points, the corticai
is generally rose coloured.
  In no organ were there found any  tubercles.
  Remarks.—The  first impression from the reading of this obser- 
                 OBSERVATIONS AND TABLES.               97

vation, is that our patient was attacked with a general tuberculisa-
tion ;  for it is precisely in similar circumstances that this lesion is
found in children.   We have already spoken of the diagnosis in a
case of this kind.  But instead of tubercles, we find a lesion much
more  remarkable for its rarity: viz. abscess of the lung.  We have
already spoken sufficiently of this termination of lobular pneumonia
not to be obliged to  return to it.
  In this case the lobular pneumonia of  the right side was mani-
fested by the bronchial expiration at the summit of the lung, and
this symptom was finally masked by the  mucous rale.  The alter-
nations of abundance and rarity presented by this rale, explain the
irregularity of the other physical signs;  we must, however, admit
the existence at one time of a more extensive  pneumonia of the
right side terminating in  resolution ;  the bronchial respiration and
the dulness upon percussion recognised at the commencement, the
engorged state of the lung at the autopsy  after the disappearance of
these physical signs  are proof of this.  Finally, in this same right
side there was developed a grave pleurisy, although there had only
existed in this lung a lobular pneumonia. 
98   RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
              PATHOLOGICAL ANATOMY.
                      FIRST TABLE.
 Relative frequency of the different species of Pneumonia at the
                different ages.  43 autopsies.
b o Eja 3 U — a « o Sis — <— o o <* B IB w a •|s o o E O O	Capillary bronchitis, 1 Lobular pneumonia, 2d degree, 1 " " 3d degree, 1 Lobular pneumonia, ] Carnification, 1 5	Vesicular bronchitis and emphysema, 1 Vesicular bronchitis of a single side, the pneumonia being double, 1 Limited marginal carnification, 2 Limited marginal pneumonia, 1 Tubercle occupying the middle lobe with a slight surrounding hepatisation of the side opposite the lobular pneumonia, 1 Emphysema and bronchial dilatation, 1 Tubercles, 1 8	Carnification, 2 Emphysema, 2 Very bad tubercles, 2 6	Vesicular bronchitis, 1 Carnification, 4 Carnification, bronchial dilatation and tubercles, 1 Tuberculous infiltration, 1 Tubercles, 3 10
a> o		1st and 2d degrees, 2 2d degree, 4 2d and 3d, 1 3d degree, 1 3d degree with sup-puration, 2 10	1st and 2d degrees, 1 2d degree, 10 2il and 3d degrees, 2 3d degree, 1 14 In two cases abscess of the lung.	1st and 2d degrees, 3 2d degree, 7 2d and 3d degrees, 2 3d degree, 2 14
at	Lien lower lobe, 2 Right " •' 1 Whole of a lung, 1 Both lungs, ] 5	Double, 7 Right lower lobe, 1 Left " " ] Middle portion right lung, 1 10 In the cases where the pneumo-nia is not noted or double, there were nevertheless found some few points of lobular pneumonia in the opposite side.	Double, 6 Left lower lobe, 3 Left mid. and post, third, 1 Right lung, 1 Right lower lobe, 3 14 In all these cases there existed points of lobular pneumonia in the opposite lung.	Double, 4 Right lung, 1 Right lung, esp. the top, 2 Right summit, 1 Lower portion of right middle lobe, 1 Left lower lobe, 4 Left lower lobe hepatised ; the right at the first stage only, 1 14
bo -<	ii yrs. J 4 1-2 3 5 1-2 1 6 1-2 1 9 1 S	2 yrs. 1 2 yrs. 4 mos. 1 3 1 4 2 4 1-2. 2 5 1 9 1 13 1 10	11-a yrs. l 2 5 2 1-2 1 3 3 3 1-2 2 4 2 14	lyr. 8 mos. 1 2 2 3 1-2 1 4 1 5 1 6 1 7 2 n i 12 1 13 1 14 1 13
u c a> 3 5< O fa	«	o	*»>	s
5 5.2	■a§	.5 ni 3-S x> a o o .So, m	Generalised lobular Pneu-monia.	3 CD a . a. a >" 1 °» S -a O J 1
 
OBSERVATIONS AND TABLES.
99
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E J3 a> .a o <u a a> •3 a CD 1 O o a o O	Lobar pneumonia, 5 Oeneralised 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 pleuiitic affection in one side only, although the pneumonia was double.	Carnification, 5 Generalised lobular pneumonia, 4 Marginal pneumonia, ] Lobar pneumonia, 1 Vesiculai bronchitis, emphysema, and lobular pneumonia, ] Emphyseini, 1 Tuberculous infiltration, 1 14 The cases are 14 instead of 13, as one sub-ject presented the dilatation with hepatisa-tion and carnification.
o fa 1 fc-3 _o "o o	v. a.' a 2 .2 m ■5 4> 2S a> •— — ai cd a 32; Si . U a 3 Ml so u	Form of the dilatation. Preservation of caliber, 3 Insensible increase, 4 Sudden increase, 1 Increase of three small bronchi, ] Dilatation of the bronchial ex-tremities, G 15 The cases are 15 instead of 13, as two of the subjects presented the alteration under a double form.
S a> CO	Double portion of the lower lobes of both lungs, 1 Marginal double, 2 Right middle lobe, 4 Lobular, right, ] 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
oS to <	M « Ifl lO CO	1 1-2 yrs. 1 2 3 3 2 4 2 4 1-2 1 a 2 5 1-2 1 7 1 13
a a> 3 O" o> fa	-	m
ft cd ■z	a 0 <a a cd 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 pueumonias 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.
  7. 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,..............   5
Pathological Anatomy,  ...........8
Modifications of the respiratory sound,     ........  23
The connection between the auscultation and pathological anatomy,     .    .   28
Causes,   -  .   .   .   .    .    .    .    .    .    .    .    .   .   .34
Rational Symptoms!,     .......    ....   39
Sketch of the disease, its progress, &c.     ........  45
Diagnosis,     .............   48
Prognosis,   .   .   ...    .    .    .    .    .    .    .    .   ,   .51
Treatment,    ........    .....   53
Observations and Tables,...........65