Contents.

Diseases of the Respiratory Apparatus,

Lobular Pneumonia,

ROBT. N. TOOKER, M.D., Chicago, Ill.

MARTIN DESCHERE, M.D., New York City, N. Y.

The Respiratory Tract During Dentition,

Asthma in Children,

Croup,

Pertussis,

Acute Laryngitis,.

C. D. CRANK, M.D., Cincinnati, O. LEILA G. BODELLE, M.D., Chicago, Ill. MILLIE J. CHAPMAN, M.D., Pittsburgh, Pa.

CHAS. W. ENOS, M.D., Jerseyville, Ill.

. A. A. WHIPPLE, M.D., Quincy, Ill.

Discussion.

DISEASES OF THE RESPIRATORY APPARATUS. By ROBт. N. TOOKER, M.D., Chicago, Ill.

GENERAL CONSIDERATIONS.

The subject which has been selected for discussion at the present meeting is, "Diseases of the Respiratory Apparatus in Infancy and Childhood," and I am sure that no more interesting and important one could have been chosen. In its wide range of topics it includes some of the most frequent and rapidly fatal of all the diseases which especially menace the life of the young, among which are certain highly contagious and epidemic affections, such as diphtheria and whooping-cough, about the cause and nature of which physicians of all schools everywhere are at the present time in doubt.

It includes other less dangerous and yet, perhaps, not less, important diseases, which involve problems of a sanitary and hygienic nature, as, for instance, colds, catarrhs, pneumonias, etc., and how far bad ventilation, improper clothing, bathing and feeding may enter as factors in their causation. While these latter affections may not always imperil the life of the infant directly, they are very liable to prejudice to a greater or less extent, its future healthful career.

The subject also gives us a wide range for clinical experiences which cannot fail, I am sure, to be of interest, and of permanent value as well.

With my understanding of the duties which devolve on me as chairman of the bureau, I shall only attempt, in this open

ing paper, a brief preface or prelude to the more elaborate papers which are to follow, and suggest the line of thought which I trust the discussion will take after the papers have been read.

According to West, whose deductions are based on a long series of reports made by the Registrar General of England, nearly one-third of all deaths under five years of age are due to affections of the respiratory organs, while not above one child in four dies under that age from diseases of the nervous system, and not above one in seven from those of the digestive system.

While the causes of some of these diseases properly classed as "respiratory" are obscure or entirely unknown, there are others whose etiology is so obvious that they might well be classed among the so-called "preventible diseases," since only gross carelessness or grosser ignorance is responsible for them.

If we realize, as we should, the double function of the lungs, that the lungs are at one and the same time depurative and vivifying, and that we can live very much longer without food than we can without oxygen, we shall not question the somewhat startling statement of Dr. Clark, that in 1782 he almost immediately suspended the enormous mortality which had prevailed among the young infants in the Dublin Lying-in Hospital, by insuring a free circulation of pure air through its various wards.

Medicine is more than a hundred years older than it was when Dr. Clark let fresh air into the Dublin Hospital, but do we yet fully realize the true function of the lungs and how best to conserve it? Most if not all of our children's hospitals are better built and better ventilated than they were one hundred years ago, and such a state of things as found by Dr. Clark would, at the present day, lead to criminal prosecu

tion.

But almost any day, in the city in which I live, you may see infants in the street cars, in perambulators and carried in arms undergoing a sure process of partial asphyxia by being heavily veiled or swathed in shawls or blankets, that must in the nature of things exclude fresh air, vitiate the blood and

defeat the very object for which the infant is out of doors. Moreover, I think it safe to assert that in three-quarters of the private homes throughout the land, the matter of proper ventilation and pure air is practically ignored, or but poorly provided for in that portion of the house set apart for the

nursery.

As pathology is only perverted physiology, in any consideration of the diseases of the respiratory apparatus, we must not fail to note first those physiological peculiarities which are nowhere else in the economy more marked than here.

At the moment of birth the changes which take place in the lungs are most remarkable. From being previously almost impervious to air and functionally dormant, they suddenly expand and commence their ceaseless round of contraction and expansion without which life can be maintained but a few moments.

During early infancy normal breathing is very different from what it is afterwards. It is from two to three times as rapid as it is in adult life, and this increased rapidity is subject to many more temporary fluctuations from causes exceedingly trivial.

While the normal number of respirations per minute average in the adult some 14 to 17, and any material increase from this number indicates serious disturbance somewhere in the economy, this is not always true of the young infant. Very slight and insignificant causes, entirely independent of a pathological condition, may temporarily increase an infant's respiration from the normal average, viz., 30 to 35, to 50, 60, or even 80.

Whether this fact, which has been noted by all careful observers, is due, as held by West, to feebleness of the respiratory muscles, or "to the as yet imperfect education which is seen in all the muscles, whether of speech or of voluntary movement," as Goodhart avers, is hardly worth much controversy. The fact stands that the young infant may and does breathe paroxysmally, irregularly and asymmetrically, without being in any way sick.

The recognition of this fact is every way important to the diagnostician, for without it he might be led far astray. It emphasizes the necessity of taking ample time for our examinations in suspected chest troubles; of comparing the two sides of the chest and of taking the temperature in all cases involving doubt. Simple irregularity does not involve danger, nor does temporary increase of the normal frequency; but when both of them are conjoined, or when either or both are associated with a disproportionate pulse ratio, and especially with an elevated temperature, we may feel sure that there exists somewhere in the respiratory tract a pathological condition. In other words, increased rapidity of breathing, like increased frequency of pulse, is of no great significance as a symptom when it stands alone by itself. But the ratio which the two bear to each is far more important.

The normal ratio of respiration to heart beat is 1 to 3, or 3 to 5, and if this proportion be greatly perverted so that we have one respiratory movement to two beats of the heart or less, we may safely infer that we have pneumonia or capillary bronchitis to deal with, and that great danger exists of pulmonary collapse.

When the respirations reach as high as one hundred and the pulse is two hundred or uncountable, there exists great danger of heart failure. Again, the respiratory murmur is scarcely audible in early infancy, but in the succeeding period of childhood it is louder than it is in maturity, and so distinctly so as to be known the world over as "puerile respiration." Another interesting fact is that infantile respiration is normally diaphragmatic; the thoracic muscles taking but little part in the process.

These are the principal but not all of the physiological peculiarities which characterize the breathing of the infant as compared with that of the adult.

In the sphere of pathology we shall find peculiarities equally marked. In all morbid conditions of the infantile organism there is a tendency to insidious extension to adjacent parts, surfaces and organs. This is especially true of