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emphysema is not uncommon in the child. As an acute lesion it is of frequent occurrence, arising in the course of various forms of pulmonary disease. It is then of little consequence, is accompanied by few symptoms, and usually subsides when the primary complaint has disappeared. As a chronic affection emphysema is met with much more rarely in early life ; but a child so afflicted presents all the symptoms common to the adult sufferer, and may have his health permanently in jured and his life considerably shortened by this condition of his lung. The lesion may be seen both in the vesicular and interlobular forms, and has been found at all periods of childhood, even in new born infants.

Causation.—Pulmonary emphysema is always a secondary disease, and appears to be mainly due to forcible distention of the air-cells in the act of coughing. It is found in various forms of lung disease, especially in whooping-cough, bronchitis, and catarrhal pneumonia. Of these the vio lent cough of pertussis and catarrhal pneumonia produce the lesion with the greatest certainty, and emphysema is a constant complication of every severe attack of these two diseases.

It seems probable that over-distention of the air-cells in these cases may be effected both by inspiratory and expiratory mechanism. In whooping-cough and bronchitis many air-vesicles are rendered impervious by patches of disseminated collapse. In lobular pneumonia considerable portions of lung may be closed to the entrance of air. Iu all these cases the diminution in the respiratory surface necessitates increased energy of inspiratory movement, so that the air-vesicles which remain pervious are over-distended. Again, a serious strain upon the air-cells is induced by strong expiratory efforts made when the glottis is closed, as when the patient is preparing to cough. Such efforts drive the air into the parts of the lungs which are the least supported, and dilate to excess the alveoli in these situations. In pertussis, especially, where the child strives with all his might to repress the cough, the strain is often very severe and long continued. Marked emphysema of the apices and anterior margins of the lungs fray be excited by this means, and if the over-stretched walls of the air-cells have been injured by the distention, the lesion may be a per manent one. Usually the alveoli return to their normal size when their

walls cease to be distended. It is only when the dilatation has been carried to an extreme degree, so as to impair the elasticity of the alveolar parietes, that the distention continues as a permanent condition.

Besides the diseases which have been mentioned, any complaint of which cough is a symptom may give rise to emphysema, ; as phthisis, where the alveoli at the bases often become distended ; pleurisy, where the air-vesicles of the sound lung are often temporarily over-dilated ; also stridulous laryngitis, if prolonged, and membranous croup. In advanced rickets, where there is marked grooving of the sides of the chest, the sternum is forced forwards at each inspiration, and the anterior borders of the lungs become over-distended with air. The mechanism of this form of emphysema is referred to elsewhere (see page 134). The tendency to perpetuation of the vesicular dilatation appeals to be influenced by the scrofulous diathesis. It may be that in that constitutional condition the elasticity of the alveolar walls is more readily impaired ; or it may be that the susceptibility to catarrh of the pulmonary membrane and other mucous tracts, inseparable from the strumous habit, induces a more frequent and persistent strain upon the air-cells. In any case the subjects of chronic emphysema in early life are usually found to be well-marked examples of the scrofulous diathesis.

Pulmonary emphysema may be found at all ages. It is not uncommon even in infants recently born. Thus, out of thirty-seven cases collected by Hervieux, nineteen occurred in infants under twenty days old, and of these one had lived no longer than two days. So, in a child who died of tetanus under my care in the East London Children's Hospital, aged fifty hours, the lungs after death were found to be emphysematous along the anterior margins, and also in spots over the surface. There were some solid patches of unexpanded tissue in each lower lobe.

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