A little girl, aged fourteen months, with eleven teeth, was said to have been a fine child until the age of ten months. At that time she had begun to suffer from a cough which was called whooping-cough by the medical at tendant. The child was brought to the hospital for the cough, which had continued for four mouths, and for general wasting of two months' stand ing. On examination, although there was no obvious contraction of the right side of the chest, the respiratory movement of that side was seen to be impaired. The lower intercostal spaces, however, sank in fairly well, although less deeply than on the opposite side. On percussion, complete dulness with increased resistance was found over the greater part of the right side. It extended over the whole posterior region, and reached up wards in the axilla to the second rib, and in front to the third. Towards the spine behind the note had a wooden quality. Posteriorly and laterally the breath-sounds were cavernous with abundant crisp, clicking sounds. In front the breathing was bronchial. The resonance of the cough was abnormally strong.
On the left side there was no dulness, but the breathing was blowing towards the apex, and some clicking rhonchus was heard all over the left back. The heart's apex was in the fourth interspace slightly to the outer side of the left nipple line. The edge of the liver could be felt one inch below the ribs.
The chest was twice explored with a fine aspirating syringe, but no fluid could be detected. The child eventually died. Her temperature until shortly before death was normal.
On examination of the body the right lung was found to be much shrunken and to be universally attached by old but readily separable ad hesions to the chest-wall. It was almost entirely non-crepitant, and felt very tough and firm in texture. Inflation only partially succeeded in dilating the condensed tissue and much force had to be employed. On section the texture of this lung was found to be throughout excessively tough and firm. It was thought there was some slight dilatation of the bronchi. A few nod ular caseous masses were found scattered over the parenchyma. The left lung was generally emphysematous, with the exception of the inferior part of the lower lobe, which was collapsed, but could be reinflated with the blow pipe. This lung passed across the middle line of the chest and encroached largely upon the right pleural cavity. On section it was pale and contained little blood. The kidneys looked fatty. The heart and other organs appeared to be healthy.
This case had been, no doubt, one of pleurisy in which the effusion had become absorbed, leaving the lung in a state of condensation and collapse, similar to the gray induration described by Addison. The physical signs
were very similar to those of fibroid induration of the lung ; indeed, this was the opinion expressed as to the nature of the case, in spite of the tender age of the patient. • Diagnosis.—When the collapse assumes the lobular form, the diagnosis has to be made without the aid of physical signs. In a well-marked example, however, the symptoms are so characteristic that an accurate opinion can be formed without much hesitation. Our conclusion is based upon the fact that in the course of a pulmonary catarrh signs are suddenly observed in dicating feebleness of inspiratory power and deficient aeration of the blood. Thus, a weakly or rickety infant, who has been noticed to cough for a day or two, all at once begins to exhibit signs of restlessness and distress. His cough ceases, his cry is replaced by a feeble whimper or a mere distortion of the features without sound ; the eyes are hollow ; the complexion is livid ; the Dares act ; the breathing is shallow and is hurried out of proportion to the pulse and the temperature is low.
If pulmonary catarrh attack a feeble infant, we must always be prepared for the establishment of collapse, and the sudden occurrence of the symp toms enumerated, combined with a low temperature and the absence of all physical signs connected with the chest, leaves us no other explanation of the child's condition. The only other disease which would be accompanied by a similar train of symptoms and an equal perversion of the pulse-respi ration ratio, without any abnormality of the physical signs, is acute bron chopneumonia. In this disease, however, the temperature is high, the breathing very laborious, and the cough loud and hacking. In pulmo nary collapse the temperature is normal, or even below the natural level of health ; the cough is feeble or suppressed, and the breathing is shallow , for even if there is recession at the base of the chest from rickets, there is no laboured movement of the shoulders or upper part of the thoracic wall.
A difficulty sometimes arises from the slightness of the pulmonary catarrh. The cough may be unnoticed by careless attendants, and the occurrence of such symptoms without being preceded by any history of cough may excite some surprise. It is necessary, therefore, to remember that atelectasis may be the consequence of a very slight catarrh, and that, we are justified from the symptoms alone, and without the presence of physical in drawing the conclusion that the child is suffering from collapse of the lung.