LECTURE XX.

INFLAMMATORY AFFECTIONS OF THE TISSUE OF THE LUNG-Lobar Pneumonia-More common in early life than has been supposed-Its general characters the same as in the adult--Some morbid appearances deserving especial notice; viz., sub-pleural ecchymoses, pneumonic abscess, and emphysema of the uninflamed portions of the lung. Frequency and causes of inflammation of the respiratory organs-Influence of age-of previous attacks-of various diseases.

BRONCHITIS-ITS SYMPTOMS AND TREATMENT-A more serious disease than in the adult, and why-Symptoms of capillary bronchitis-Illustrative case-Results of auscultation.

Treatment of bronchitis-Change in the epidemic constitution of diseases and inexpediency of very active measures-General rules for treatment-Treatment of bronchitis in its chronic stage.

INFLUENZA-its peculiarities and treatment in early life.

WE were occupied during the last lecture with the examination of some of the results of inflammation of the respiratory organs in early life, and considered more especially those changes which inflammation produces in the air-tubes. You were told on that occasion that the disease does not always remain limited to the bronchi or pulmonary vesicles, but that it sometimes involves the substance of the lung, and thus gives rise to the appearance of a number of small circumscribed patches interspersed throughout its tissue, either red, hard, and solid, or grey from the infiltration of pus; while, if the mischief advance one step farther, it may lead to the destruction of the parenchyma of the organ at these points, and thus produce numerous minute abscesses-a condition which has come four times under my own observation. Cases of this kind, constituting true lobular pneumonia, though somewhat less rare than in the adult, are yet of very infrequent occurrence. It is almost needless to remind you that the contrary opinion resulted from persons not having learned till very lately to distinguish between that solidity of the lung which is produced by inflammation, and that which results from the mere collapse of its air-cells.

The exaggerated estimate of the frequency of lobular pneumonia, and the peculiar character of the field presented at the Hospital

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LOBAR PNEUMONIA-NOT UNUSUAL IN CHILDHOOD.

for Children at Paris, in which the most diligent and most successful students of children's disease laboured, led to an underrating of the frequency and importance of lobar pneumonia such as is met with in the adult; and hence you will find but little said concerning it in many most valuable works of our continental neighbours. Lobar pneumonia, however, is often met with in early life both as an idiopathic and a secondary affection, giving rise to the same morbid appearances as in the adult, and requiring similar treatment.

a very

Not only are the physical characters of the lung in lobar pneumonia the saine in childhood as in adult age, but the three stages of engorgement, of red and of grey hepatization, are observed with much the same frequency at the one period of life as at the other. I find that after rejecting all cases in which pneumonia occurred as a complication of phthisis, or of acute pleurisy, and in which the results might be modified by the disease to which the inflammation of the lung succeeded, I have a record of 94 cases in which the condition of the inflamed lung was carefully noticed. In 15 of these cases the 1st and 2nd stages of pneumonia co-existed.

This result does not differ very widely from that obtained by M. Grisolle, on an examination of 40 cases of pneumonia in the adult.

In 4 cases the 1st and 2nd stages of pneumonia co-existed.

It will be seen, on a comparison of these tables, that the third stage of pneumonia occurs not very much less often in children Traité de la Pneumonie, 8vo. 2nd ed., Paris, 1864, p. 17.

than in adults, having been met with in the former in the proportion of 56.3, in the latter in the proportion of 72.5 per cent.; and the main difference between the two consists in the greater frequency with which all three stages of pneumonia coexist in the young subject. This peculiarity of pneumonia in childhood is probably due to the tendency which the disease then displays to involve a large extent of pulmonary tissue; and to the same cause we must attribute the frequency of double pneumonia in early life, which, in the cases that came under my notice, preponderated greatly over those wherein only one lung suffered. The well-known law, according to which pneumonia of the right lung is more common than pneumonia of the left, holds good in childhood; nor is the frequency of concomitant pleurisy much, if at all, less in the child than in the adult. The contrary opinion arose from the error to which reference has so often been made, of regarding cases of collapsed lung, either with or without bronchitis, as instances of red hepatization of the pulmonary substance.

Instead of inflammation of the lungs being less active in the child than in the adult, there are some facts which would seem to lead to a directly opposite conclusion. Such are the frequency with which, in fatal pneumonia in children, ecchymoses are found beneath the pleura covering the inflamed lung, the more common occurrence of pulmonary abscess in early than in adult life, and the very extensive emphysema which is often observed in those parts of the lung to which the inflammation has not extended.

The sub-pleural ecchymoses appear to result from the rupture of some of the minute capillaries of the lungs in consequence of the great disturbance of the circulation through them. They are usually small, like petechiæ, but occasionally they attain a large size, and now and then they even extend a little way into the tissue of the lung, constituting little spots of pulmonary apoplexy, about the size of a millet seed, or even a little larger. They are most numerous on the posterior surface of the lungs, and especially in parts where the lung has become hepatized, though by no means confined to those situations.

The termination of pneumonia in abscess of the lung is so rare an occurrence in the adult, that Laennec did not meet with it above five or six times in the course of several hundred examinations of persons who had died of inflammation of the lungs. In the child, however, the case is otherwise, for abscess of the lung has come under my observation in four out of the ninety-four

examinations of cases of pneumonia, on which my present remarks are founded. In one of these cases, that of a boy, aged 20 months, who died on the fourteenth day after the commencement of an illness which resembled remittent fever in many of its symptoms, but was associated from the outset with the indications of pneumonia, the following appearances were observed:- The upper and middle lobes of the right lung were connected to each other, and to the walls of the chest, by adhesions which were chiefly recent. Nearly the whole of the upper lobe was solid, and sank in water. It was of a mottled reddish-grey colour, in which grey predominated; it broke with a granular fracture, and was readily reduced to a dirty putrilage. Near the apex was a portion the size of a walnut which was already soft and in a state of quagmire. The upper two thirds of the middle lobe were in the same condition as the upper lobe; the lower third was emphysematous. In the centre of the middle lobe was a cavity the size of a bean, irregular in form, intersected by the remains of some vessels lined by a thin layer of yellow lymph, and surrounded by lung in the third stage of pneumonia; but neither in that lobe nor in any part of the pulmonary tissue was there the least trace of tubercle, and the only indication of phthisical disease consisted in one bronchial gland having become converted into tubercle which had undergone the cretaceous transformation. The lower lobe of the right lung was in the first stage of pneumonia; the left upper lobe was quite healthy; the left lower lobe was in a state of mingled red and grey hepatization. Two cases occurred in children who had suffered for some weeks from hoopingcough, and in both the lungs contained numerous semi-transparent, grey, tubercular granulations. One of the children was a boy, five years old; the other a little girl, aged two years. In the case of the former, the abscess, as large as a walnut, was situated at the lower border of the upper lobe, extending a little into the lower lobe. In the latter it was of the size of an unshelled almond, and occupied a similar position with reference to the right upper and midde lobes. The characters of the abscess were the same in both instances, being situated almost immediately beneath the pleura; from which a wall of lung not above two lines in thickness separated it. Its cavity was partly filled with a yellowish, puriform, very tenacious fluid, like very tenacious pus, and which did not bear any resemblance to softened tubercle. It was not lined by any membrane; there was no appearance of tubercular deposit in the hepatized lung in its

immediate vicinity, which was generally in the second stage of pneumonia, nor was it situated near to, nor in communication with, any large bronchial tube. In the fourth case, that of a boy aged eleven years, who died of pyæmia, consequent on exposure to cold and wet, the purulent deposits were not limited to the lung substance, although they were associated there with general pneumonia, and with several patches of pulmonary apoplexy.

The lung in childhood shows a much greater tendency to pass into a state of gangrene than in adult age. It may be doubted, however, whether this gangrene is the result of the intensity of the inflammation so much as of some peculiar change in the blood which favours the occurrence of mortification. The occasional prevalence of gangrene of the lung and of other parts, as an endemic affection in the Hôpital des Enfants at Paris, favours the latter supposition, with which the only instance of it that has come under my own observation in the child is quite in accordance.

The emphysematous condition of the uninflamed portions of the lung, in cases of fatal pneumonia in early life, scems to be connected with the rapidity of the advance of the disease. It is usually most obvious at the anterior part of the upper lobes of the lungs and at the margin of the other lobes, and always bears a marked relation to the shortness of the patient's illness, and the extent of lung which has been rendered unavailable for purposes of respiration. The cases, however, which terminate most rapidly are not those in which the direct results of inflammation are the most extensive, but rather those in which collapse of a considerable portion of lung has taken place; and the emphysema, which is met with also in many cases of vesicular bronchitis, is consequent less on the inflammation than on the collapse by which it is accompanied. Its occurrence in those circumstances affords therefore an illustration of that modification of the inspiratory theory of emphysema so clearly propounded and so ably supported by Professor Gairdner of Glasgow;* and which regards the overdistension of the air vesicles of one part of the lung as a necessary compensation for their collapse, and the consequent diminished bulk of another part, while the enlargement and the capacity of the thorax during inspiration remain the same, or at any rate are but slightly modified.†

On the Pathological Anatomy of Bronchitis, &c., 8vo., Edinburgh, 1850; and Edinburgh Monthly Journal, vol. xiv.

In the second and third editions of these lectures I stated that the amount of emphysema bore a 'marked relation to the shortness of the patient's illness, and the extent of lung which had been invaded by the inflammation.' A careful re-examina