SECTION VI.

PLEURITIS OF CHILDREN.

Pleurisy is common in children of all ages; but is most fre quent in its uncomplicated forms after the age of five years. Anterior to that period it is, in general, associated with pneumonitis and bronchitis. Sometimes it is a sequela of eruptive fevers. During the whole period of convalescence from them, while the functions of the skin are but partially restored, this disease in children is prone to occur.

PATHOLOGY.-Primitive pleurisy in young children does not present any striking anatomical characteristics which distinguish it from the disease in adults, as in the case of pneumonitis. There is, however, one fact in those cases, which points out the affection. It is a want of compressibility in the lung from the liquid effusion. The effect of this is seen in the modification of the physical signs which it produces.

DIAGNOSIS.-Dullness on percussion presents its usual characteristics. But the respiratory murmur, on the contrary, instead of being feeble or absent, assumes a bronchial character, equally as distinct as that of pneumonitis, but far more extensive, accom panying the dullness on percussion, and being often heard all over the affected side, and without crepitation or rhonchus. "This bronchial respiration," says Dr. Swett, "as connected with pleuritis, is the rule, in the pleurisy of young children, not the exception, as in that of adults."

PROGNOSIS.-Pleuritis in children is far more dangerous than in adults; more especially when it occurs as the sequela of eruptive fevers, of pneumonitis, or pertussis. In infants this disease, whether simple or complicated with pneumonitis, bronchitis or whooping-cough, is often fatal. In twenty-four hours, by causing suffocation, it may end in death. In very young children it seldom assumes a chronic form; for in them the later stages of the disease are less liable to occur.

TREATMENT.-Pleurisy in children requires the same measures which are recommended for adults, modified according to age and to the susceptibility of infancy to the influence of remedies. Relaxing enema should be more frequently directed, and the use of the more harsh and debilitating means, more cautiously prescribed. Warm demulcent poultices, instead of irritants or vesicants, should be employed. In the chronic form, the frequent sponging of the surface with warm salt water, as an external application, is excellent. For an internal remedy, the sirup of the iodide of iron, administered in simple sirup of sugar, is sometimes serviceable as a tonic.

Other varieties and modifications of pleurisy are described by some authors. But they are for the most part, unimportant, and their consideration is of no practical utility.

CHAPTER XII.

PNEUMOTHORAX.

The term pneumothorax from the Greek vsupa air and pağ chest, which would, according to its etymology, mean any collection of air in the chest, is at present, used to designate more especially the effusion of aeriform fluids in the cavity of the pleura, whether the air exists alone, or whether there is sometimes a certain quantity of liquid mingled with it. In the first instance the collection receives the name of pneumothorax, in the latter that of hydro-pneumothorax. Notwithstanding the distinctive use of these terms, the name pneumothorax is in general applied to both of these phenomena.

Before the commencement of the present century, it had not been made a subject of thorough investigation. To Laennec belongs the honor of first making it an object of scientific study.

PATHOLOGY.-Pneumothorax is a consequence of lesions of both the lungs and pleura. In most cases it is the result of tubercular disease perforating the pleura pulmonalis, before it adheres to the pleura costalis. The cavity formed by tubercles communicating

with the pleural sac, and at the same time with the bronchial tubes, gives rise to this affection. Sometimes pneumothorax occurs in gangrene of the lungs. A gangrenous eschar may break into the pleural sac, and a communication be formed with the bronchi. It is possible for an emphysematous vesicle in the lung to rupture the pleura covering it, and thus produce a pneumothorax.

Another way by which this has been supposed to be produced, is the secretion of air by the absorbing surfaces of the pleura, or by the decomposition of inflammatory products. A fistulous opening or wounds produced by accident or by the hand of the surgeon sometimes are its immediate cause.

When the air enters the cavity, it compresses the lung and gives rise to the physical signs of this organic lesion. Perforations of the pleura, as we should expect from the more frequent location of tubercles in the left lung, oftener are found on the left than on the right side. Reynaud found in forty cases of perforation, twentyseven on the left lung, and thirteen on the right.

DIAGNOSIS.-General symptoms. These are very equivocal, and altogether insufficient to serve as the basis of a confident diagnosis. Dyspnoea caused by the compression of the lung is a very constant symptom. Its degree depends upon the amount of air and liquid in the cavity of the pleura, upon the rapidity and permanence of the accumulation, and upon the condition of the opposite lung. Cæteris paribus the dyspnoea will be less, when the admission of air or the collection of other fluids, is gradual; because the organs of respiration and circulation, to a certain extent, accommodate themselves to the new condition.

Most frequently it happens that the entrance of the air is sudden, and as a consequence, dyspnoea quickly becomes severe attended with acute pain, and sometimes with a sensation as if something had given way in the chest. In case the pleural sac is distended with pus, a copious expectoration of a puriform character suddenly supervenes as a result of the opening into the pleura. Sometimes it so happens that the pleural opening is so large as to permit a ready egress of the air admitted into the pleura, in which case the dyspnoea will be less violent. On the contrary, if

the opening be such as to permit the passage of air only one way, like the valve of a pump, then at every inspiration more air is admitted than is expired, until the accumulation is so great as to cause suffocation. Very soon, under such circumstances, death may occur, preceded by the most painful and laborious breathing, intense anxiety and general prostration. When one lung from the effects of the disease is unfitted alone to arterialize sufficient blood to sustain life, and the pneumothorax occurs on the other side, sudden death is almost inevitable.

When communication first takes place between the lung and pleural cavity, there is not only dyspnoea, but also sharp pain and cough, in consequence of the irritation of the pleura. This is sometimes very severe; so much so as to cause a great depression of the vital powers. This, however, is usually followed by reaction, giving rise to the ordinary symptoms of fever. The cause of this irritation, by many, has been supposed to arise directly from the contact of air with the serous membrane, the pleura. Concerning this, there is, however, some doubt. A probability exists, that the acid matter from vomicæ, drawn into the pleural sac with the air, produces much of the effect usually ascribed to another cause. In case liquid exists in the pleura, anterior to the ingress of air, its admission would be very apt to produce chemical changes in the effused substances, and thus secondarily cause irritation. In general, the sitting posture is most agreeable to the patient, or if he lies down, the decubitus, after the pleuritic pain has subsided, is on the affected side.

Special symptoms. Without some more sure means of detecting the existence of pneumothorax than the general symptoms, correct diagnosis could not without great difficulty, if at all, be determined. Of all the diseases affecting the chest, this, though once so obscure, has now become by the aid of the physical signs, the most easily detected. As soon as the air enters the pleural sac, the lung collapses, and consequently less air is inspired. The effect of this, is to lessen the respiratory murmur on the affected side.

Under such circumstances, what does percussion reveal? The pleura distended with gas, and the lung collapsed, afford condi tions which, from reason we should expect to favor the production

of great resonance. And thus we find it to be. On the diseased side, we get the drum-like sound on striking the chest, while on the opposite side we have more flatness on percussion, but a louder respiratory murmur. So that the physical signs on the two lungs, are opposite. On the diseased side there is great resonance, but very feeble if any respiratory murmur. On the healthy lung, the resonance is less than on the other, but the respiratory murmur is more distinct than natural. As the disease advances, and pus collects, or if there is at first water in the pleura with the air, the percussion detects the exact extent of the liquid collection, it draws the line of demarkation between the water and the air. Whenever the patient changes his position, the location of the flatness is likewise changed, and the metallic tinkling is heard when the patient, after lying in one position, suddenly changes it; so that the liquid adherent to the sides of the pleura falls in drops upon the surface of the liquid below. The production of this sound, however, is a matter concerning which there is not among physicians a full agreement. There are according to some two methods by which it is produced; the first by the falling of the liquid drops as above described, the second, by the passage of air, which, entering the liquid in the pleural sac beneath its surface, causes, as it perforates the surface of the liquid, little bubbles to rise, that burst and produce the sound. This bursting of bubbles, makes a sound, which, on being reflected from one side of the cavity to the other, comes to the ear so modified, as to produce that peculiar tinkle, which authors describe.

Sometimes this occurs when there is no liquid in the pleural sac. In this case how can it be produced? Mr. Castelnau's views will explain the phenomenon. The metallic tinkling, according to his theory, may be caused by the bursting of air-bubbles in the tuberculous abscess itself, just at or near the point of perforation, and the sound thus generated resounding in the large air-chamber formed in the pleural sac, changes a rattle which would otherwise be a mucous rale, into metallic tinkling. The metallic tinkling is by no means a constant sign, therefore it should be considered as of less importance than amphoric respiration, and resonance of the voice.

To detect the presence of liquid in the pleural sac, the Hippo