BIRMINGHAM GENERAL HOSPITAL

A raxa, sickly, ill nourished female infant, 4* months old, whose father was under treatment for phthuisi, was brought by its mother to the above institution between two and three months ago, with the following history. The child appeared quite healthy at its birth, and remained so until it was two months old. About this latter period, however, its breathing ve gradually altered in character, becoming catching, noisy, and difficult, especially upon movement. During sleep, respiration was performed writh compaatively little embarrassment. Shortly fterdsspasmodic cough supevened; and several sudden and severe paroxysms of dyspncea and general convulsive movements would occur in the day, threatening suffocation. It was particularly remarked that the child's indisposition did not begin with, or in any way resemble, a common cold. Upon examination, the child was observed to be very pllid, the surface cool, and breathing with difficulty, noisily, almost stridulously. Several severe fits of coughing came on while attempting the exploration of the chest, terminating with a hoarse peculiar cry. This mode of repiration was succeeded by intervals of quiet. During the pculiar convulsive respirations, the upper pat of the right side of the chest seemed to fall in. Percussion elicited a modified note over this portion of the chest. It was difficult to arrive at any definite result from auscultation. The breath sound seemed generally exaggerated, and attended with sonorous rile over the apparently affected portion. No additional phenomena of importance were noted during the subsequent progress of the case, excepting that, during the last three or four days of life, the temperature was somewhat increased, and the child semed gradually to sink into an unconscious state. Death occurred two months after the first examination. The case was constantly under observation during its progress. The child was brought up exclusively at the mother's breast, and swallowed without apparent difficulty. The autopsy was made sixteen hours after death, by Mr. H. Wilkin. The body was withered and emaciated; the abdomen not distended. Upon opening the chest, the whole of the left lung, and the middle and lower lobes of the right lung, appeared to be unusually large. They were pale, distended, and presented rounded and prominent edges. Thie upper lobe of the right lung, of flesh colour, as seen beneath the perfectly transparent pleura, was shrunk, dense, and non-crepitnt, affording a remarkble contrast to the middle and lower lobes, which, as I Eave just described, were unally pale and greatly distended. The upper edge of the middre lobe of the right lung consequently bulged forwards, with a defined rounded border, in front of the collapsed upper lobe. Division of the substance of this last named portion showed a perfectly smooth, non-granular face, resembling ordinary muscular fibre, bloodless, without any form of exudation, and intersected by compressed bronchi resembling threads. This lobe was subsequently found to be incapable of inflation. Detached portions readily snk in water. Upon. further dissection, a large mass of tuberculated bronchial glands, filled with yellow material of caseous consistence, was discovered, part of which had completely flattened the principal bronchus of the upper lobe of the right lung. Aother portion of this m furthermore extended beteen the trachea, large vessels and nerves evidently exercising undue pressure upon these structures. Some few scattered miliry tubercles were felt, but not visible, over the remaining portions of lung; but the collapsed lobe remained Uefaatly fre from these FOUt Ca r boearsrt capilrv njeetion exsted over the right ventricle of the qhei oT c aurile W vy grey di d e formeng orve the correpndmi ventriclei sins, The foramen obae not perfec closed, a large fune shaped orifice being left. cavity of the left ventrice was decidedl enwalls waer somewhat thickened. The chamb of the heart contained only black fluid blood. Rzxrns. Although it is far from rare to find tubrculated bronchial glands in children comprssing the air. tubes, vessels, and nerves, to a crtin extent, yet such an amount of pressure as to render an entire lobe utely inca pablo of sufflation, and therefore completely devoid of air s unquestionably unfrequent. The case detailed affords a good illstration of a very common affection-acquired atelectasis-one which, i former times, would have bee confounded with lobar pneumonia. Although the actual pathology of ateleets, congenital and acquired, has been most fully and ably illustrated by Jorg, Legendre, and Bailly, K5stlin, Friedleben, Cohn, West, Gairdner, and others, it is but just to Adral to state that this latter condition had not escaped his observation. In the CtiniSue .Eddicak he points out the distinction between this cf ge (atrophy of the lung, as he terms it) and pneumonia, and relates the dissection of a monkey by himself and Reynaud, in which the lung was atrophied through the compresson of the bronchus by a tuberculous cyst developed around it. In the case I have narrated, however, the sudden and alarming attacks of suffocative dyspnome, terminating with the hoase cry,presents a diagnostic symptom distinguishing this case from one of ordinay pneumonia. These symp toms at one time appeared to justify the suspicion that some foreign body had entered the air-passages, the physical effect in this case being nearly identical with that arising from such body in the right upper bronchus.