with or succeed to each other at various times without any regularity. These variations depend sometimes on the frequency, sometimes on the extent of the respiratory movements, or on the degree of the pulmonary lesion. In most cases, however, there are doubtless many other concurrent causes, of which we are ignorant; for the morbid phenomena that result from the compression of organs by tumours are usually intermittent. "If the bronchial tubercles are softened and communicate with the bronchi, all the symptoms just enumerated do not exist, because the tumours which are generally smaller are situated in the substance of the lung, and are no longer in contact with the vertebral column: hence neither cavernous breathing nor gurgling are any longer audible, unless tubercular cavities exist in the lung itself. "The character of the expectoration is seldom or never of any great service in assisting us to form a diagnosis. "The phenomena which may be observed result almost entirely from the ulceration and perforation of the organs with which the glands are in contact, and in the present state of our knowledge we are not acquainted with anything capable of indicating that they depend on the glands and not on the lung. Thus perforation of the lung occasions pneumothorax, that of the pulmonary vessels furious hemoptysis, and the formation of a communication between the oesophagus and the bronchi or trachea by the bronchial glands, may occasion violent paroxysms of cough whenever the patient attempts to swallow liquids." (Tome iii, pp. 198-201.) The results of percussion vary much perhaps it yields no sign so frequently as increased dulness of the interscapular region, but this so often corresponds with various alterations in the respiratory sounds that it may give rise to a suspicion of the existence of pulmonary phthisis. Two circumstances, however, will generally suffice to preserve from error: first, the fact that in bronchial phthisis the diminution of resonance is permanent, while the results of auscultation differ at different times; and second, the want of correspondence between the indications furnished by auscultation, and the extent and degree of the dulness; so that, for instance, bronchial respiration may be heard in a situation where the resonance is but very slightly diminished. Valuable as these remarks are, they still leave the subject in much ob scurity, though no better rules for diagnosis could be laid down than are contained in the following paragraph: "If we observe cough, emaciation, fever, and sweats occur in a child from three to four years of age, without our being able to detect any physical signs of tubercle in the lungs, or to discover any indication of tubercle either in the brain or the abdomen, we may then suspect its existence in the bronchial glands. This presumption would amount to certainty, if we were to notice an alteration in the character of the cough, such as its occurring in short paroxysms, but without being attended with hooping or vomiting, or its becoming hoarse; if we were to hear large ronchus in the trachea, or very persistent sonorous or sibilant râle, if we were to observe asthmatic attacks, or very marked but intermittent changes in the voice, or oedema of the face, provided that we had ascertained that this latter phenomenon did not depend on some other cause, such as disease of the kidneys. Great attention also ought to be paid to the signs furnished by auscultation or percussion. As has already been mentioned, they are remarkable for their intermittent character. It is especially the changeableness of the signs yielded by the use of the stethoscope compared with the persistence of those elicited by percussion, which must form the basis of our diagnosis. Great importance must also be attached to the situation in which changes of the respiratory sounds are detected. The signs of bronchial phthisis are perceptible almost exclusively at the upper part of the lung, and prin XXXIV-XVII. .2 cipally in the interscapular space, on a level with the root of the bronchi; they are also occasionally, but much less often, perceptible in front. In adults such a distinction would perhaps be of no great service, since in them tubercular deposit occupies almost exclusively the summit of the lung, but this is not the case in the child, but the tubercles are often scattered through various parts of the lung, or if they occupy its upper part auscultation beneath the clavicles will reveal their existence. Whenever, therefore, in a child affected with some chronic pulmonary complaint, the signs of tubercles are discovered in the interscapular space, there will be reason to conclude, if they vary in their degree and fluctuate in their progress, that they depend on tubercular degeneration of the bronchial glands." (Tome iii, p. 204.) PULMONARY PHTHISIS. They next pass to the investigation of tubercle in the lungs of children; and here we may notice a very important remark with reference to the stethoscopic signs of their existence, the truth of which we can fully confirm from our own experience. It will be found that some of those physical signs from which we should without hesitation conclude that tubercular degeneration of the lungs existed in the adult, do not always indicate the same serious mischief in the child. Thus, for instance, that unusually harsh respiration which in the adult is so valuable a sign of the presence of crude tubercle in the lungs, loses much of its value in the child from the circumstance that it may exist even when the lung is perfectly healthy; and that it often is not sufficiently confined to one spot to warrant our drawing any conclusion from it. The subclavicular region is that in which this coarse respiration is most frequently heard, even in children whose lungs are perfectly sound; in the same situation, too, the expiration is often considerably prolonged, without there being any pathological condition which could account for this phenomenon; and great doubt is thus thrown over two of the most valuable indications of the early stage of phthisis. The occurrence of severe pneumonia in the course of phthisis appears to be more frequent in the child than (judging from the remarks of M. Grisolle and M. Louis) it is in the adult. It may supervene as a complication either of the acute or chronic form of phthisis. In the former case it is sometimes coeval with the earliest symptoms of tubercle, but oftener it does not occur until after such symptoms have existed for some time. In the latter case intense fever and heat of skin, with a full and hard pulse and all the indications of acute inflammation suddenly come on. The cough, previously slight, becomes all at once very frequent, the oppression of the breathing is intense, and auscultation detects moist sounds through the whole posterior part of the lung, or perhaps even bronchial respiration. After these symptoms have existed for some time either the patient dies or a degree of remission takes place in the symptoms, which, however, continue in the main the same. Fever is still present, but the pulse has become small, the face has grown pale, and the child, who before the attack was not all emaciated, loses flesh rapidly. Auscultation continues to yield the same results; moist sounds are present in abundance; the bronchial respiration, dulness, &c. vary in degree, but do not altogether disappear, and the patient dies in two or three months. Sometimes the pneumonia is very extensive from the outset, and then it proves fatal much more rapidly; but usually successive attacks take place, the hepatization of the lung gradually extending with each recurrence of the inflammation till it proves fatal. When pneumonia supervenes on the chronic form of phthisis, it usually terminates in death after a few days, seldom lasting longer than a fortnight. A sudden exacerbation of all the symptoms is observed accompanied often with a tinge of blood in the expectoration, and with pain of a pleuritic character. The moist sounds which before might have been heard over a small surface now become more abundant and more extensive, bronchial respiration is perceived through the whole posterior part and base of the lung, and death ensues after some days. There is besides a latent form which pneumonia assumes in some of these cases, that hardly betrays itself by any symptoms. The patients gradually lose their strength, and become unable to leave their bed, but without any great increase in the fever, cough, or oppression, though the prostration of their strength is very marked. Auscultation is probably neglected from the fear of distressing the patient; and when he dies, after the lapse of a few days, very extensive pneumonia is discovered, the existence of which had not even been suspected. MESENTERIC PHTHISIS. The error which regards the tabes mesenterica as an extremely common disease of childhood is by no means confined to the vulgar. A similar opinion is expressed by many authors, who have not only confounded a number of different affections-as tubercular peritonitis, enteritis, ulceration of the intestines, &c.-under one common name, but have also regarded as morbid the large abdomen natural to childhood. The presence of slight tubercular deposit in the mesenteric glands is, it is true, far from being a rare occurrence, since MM. Rilliet and Barthez found it in half of their post-mortem examinations of tuberculous children. The number, however, in which this tubercular deposit was so considerable as to be of much moment was far smaller, not exceeding one in sixteen. MM. Rilliet and Barthez have satisfied themselves that serious mesenteric disease hardly ever exists in children under three years of age, that the affection is always slight in proportion to the youth of the children, that it is most severe between the fifth and tenth years, and from the twelfth to the fifteenth year is extremely rare in any form, either trivial or severe. The symptoms that attend the disease are by no means definite; for the functional disturbances to which it gives rise are common to it with many other affections, while the general indications of the existence of tubercular disease are often less marked in this than in other forms of phthisis. It might indeed be supposed that the tuberculous mesenteric glands would give rise, by their enlargement, to derangements similar to those which result from the diseased bronchial glands. This, however, is not the case, for the abdominal parietes, unlike those of the thorax, are soft and yielding, and allow the glands to acquire a considerable size and to approach the anterior part of the abdomen without forming adhesions with neighbouring organs. The adhesion, too, of the bronchial glands is favoured by the firm and solid character of many of the organs contained in the thorax with which they are in contact; but no such resistance is offered by the intestines, which, from the ease with which they change their position, constantly avoid compression. Hence, until the glands have acquired so large a size as to be perceptible through the parietes of the abdomen, the diagnosis of the disease is attended with much difficulty. In the early stages of the disease there is no change in the form of the abdomen, and at a later period its increase in size is by no means an invariable occurrence; sometimes, indeed, it is retracted, and shrinks under pressure. It is true that usually as the malady advances there is some increase in the size of the abdomen; but this symptom is common to it with many other affections, and exists, as M. Guersent has remarked, as a natural condition in weak and rickety children. Even when the tuberculous glands have acquired a considerable size it is not always possible to distinguish them through the abdominal integuments. they can be distinguished they will always be felt in the neighbourhood of the umbilicus, forming a tumour, whose surface, more or less irregular, is evidently composed of several masses agglomerated together. Their situation sometimes appears to vary, owing to the varying tension of the walls of the abdomen, according as the intestines are full or empty. The state of the tongue and bowels, the appetite, &c. and the pain which is present in the abdomen are not peculiar to tabes, and, consequently, render us no service in forming a diagnosis. An exception to this statement perhaps should be made with reference to the enlargement of the superficial abdominal veins, which, if there do not exist enlargement of the liver or chronic peritonitis, must at once lead to the suspicion of tubercle of the mesenteric glands. The preceding remarks show how obscure are the local symptoms of mesenteric disease. Nor are the general symptoms less so, they being those of tuberculous disease in general, but of a rather mild character. The course of the disease is probably slow, but the obscurity of the early symptoms renders it difficult to fix the date of its commencement, and in its course it almost always becomes complicated with other forms of tuberculous disease, or else some intercurrent inflammation, as peritonitis, accelerates the fatal issue. Nearly allied to tabes mesenterica, and not unfrequently confounded with it, is the tubercular disease of the peritoneum. Like it, too, the symptoms that betoken its existence are usually obscure. The summary of them given at p. 389, of vol. iii, we had purposed extracting, but we are prevented by want of room. In its present form we can conscientiously recommend MM. Rilliet and Barthez's work to all who, possessing a tolerable familiarity with children's diseases are anxious to perfect their knowledge, and who will not be deterred from seeking truth by the labour of some digging to arrive at it. The book wants something, however, besides mere condensation, before it will be altogether suited for beginners. The most elaborate analysis of symptoms does not suffice to convey a correct impression of the nature of any disease. It is the talent of combining details so as to produce a vivid portraiture, that is most needed in a work intended to teach the beginner. In this, the writers have not been so successful, but we believe them to possess every qualification for the task, and we hope before long to congratulate them on having achieved it. ART. II. 1. Statistical Reports of the Sickness, Mortality, and Invaliding among the Troops. Compiled by Major TULLOCH, and presented to Parliament, 1838-41. 2. Statistical Reports on the Health of the Navy from 1830 to 1836. Compiled by Dr. WILSON, and ordered by the House of Commons to be printed, 1840-1. ON various occasions we have brought under the notice of our readers the valuable statistical reports on the health of the army and navy, and have reviewed in detail the leading facts which they tend to establish. We now propose to institute a comparison between the sickness and mortality in these two branches of the public service, and to investigate the causes to which any remarkable difference in this respect is likely to have been attributable. As a preliminary to this comparison, however, it is necessary to examine those peculiarities in the condition of the soldier and the sailor, by which their health is likely to be affected. Of these the first, and perhaps the most important, is the duration of service. The soldier must enlist for life, or until he is by age or disease unfit for military duty, while the sailor engages only for a limited period, and as ships are generally paid off after being about four years in commission, he is then at liberty to terminate his engagement.* The system of unlimited service exerts, we have no doubt, an injurious influence on the health of the soldier, by depriving him of the hope of returning, at a definite period, to his native land, a hope which would probably have the effect of preventing many of those reckless excesses into which he is occasionally led, and would remove that nostalgic depression, which, in the hour of sickness, frequently renders the best efforts of the medical officer unavailing. It follows as a consequence of the limited duration of the sailor's service, that he is more subject than the soldier to frequent medical examinations, at which unhealthy and ineligible men are rejected. When a ship is about to be paid off, the sailors are allowed to volunteer into another without a certificate from the surgeon being required, but they very often, particularly after a long cruise, prefer having their "lark" on shore, and when their money is spent, if they again wish to enter, they must, in the first place, be examined by him and reported fit for service. Thus an opportunity is afforded of getting rid of many men who have become, or are becoming, inefficient, and though all are not necessarily subject to this re-examination, there is reason to believe a very large proportion undergo it. The advantages arising from a selection of lives have been fully ascertained by the experience of assurance offices, and although the same strictness cannot probably be exercised in the selection of seamen, the influence of these repeated examinations must be considerable. In respect of diet, also, the navy has many advantages over the army. Deputy-inspector-general Marshall says,† The ration of the seaman is not only ample for three meals a day, but these meals may be varied in no small degree, according to the option of individuals, .....the ration of a soldier (in the colonies) will only furnish him with two comparatively scanty meals daily;" and again, "in this country the dinner (of This remark applies to the present period of peace. The case was different formerly, + United Service Magazine for April, 1842, p. 538. |