CAUTION—The only Pil. Cascara Cathartic prepared according to Dr. A. G. Hinkle's formula as suggested by him is that made by W. R. Warner & Co. To get full therapeutic effect it would therefore be well to specify "W. R. Warner & Co."

Armour's Soluble Beef

In the form of a broth, at frequent intervals, nourishes, strengthens, sustains, and restores.

SOLUBLE BEEF is soothing to the mucous membrane of the stomach and bowels, and being free from irritating properties, commends itself when other foods cannot be tolerated.

Sold by All Druggists
Samples to Physicians on Request

Armour & Company, Chicago

The object of this paper is to call attention to the necessity for great watchfulness during the course of the zymotic diseases of childhood, in order to detect at the earliest possible moment evidences of broncho-pneumonia; and also to point out some of the difficulties occasionally experienced in determining the diagnosis of lobar pneumonia in children.

It will not be necessary to review the classical symptoms of either disease. Broncho-pneumonia, while frequently occurring as a primary disease, is usually secondary to bronchitis and diseases in which bronchitis is a symptom, as whooping cough, measles, influenza, and other acute infections. The symptoms indicating the invasion are usually not marked, being those of an ordinary bronchitis. The child is apt to be less than three years of age. In a young child convalescent from or during any of these diseases, the appearance of any symptom, no matter how slight, fever, increased respiratory movement and pulse rate, indicating a retrograde movement, requires a most painstaking physical examination, although it must be admitted that, even when the disease is well developed, the physical signs are not always characteristic.

The difficulty in making a satisfactory examination of children. is often very great. It is well, therefore, to make it a rule in all cases to have the patient stripped, and an effort made by the nurse to distract its attention until the chest is completely gone over. In some cases it is easy to entirely overlook sounds that are distinctly characteristic, if every part of the chest is not noted.

* Read at the Central Wisconsin Medical Society, Beloit, April 26, 1904.

At the rear and lower portion of the chest are most apt to be found the characteristic subcrepitant râles.

Pepper observed that "the sounds of broncho-pneumonia are in no sense characteristic; but when to the râles of bronchitis there are superadded fine subcrepitant râles, with harsh or blowing breathing, and areas of even indistinct impairment of resonance at the postero-inferior portions of the lungs, the evidence, so far as physical examination is concerned, is fairly clear." Percussion will occasionally show points of dullness, and often it will not.

Antedating the appearance of fever and increased respiration, for a few days, there may have been constipation and green stools, calling attention to the digestive tract rather than to the respiratory.

If a cough were always present with the accession of fever, little difficulty in diagnosis would be experienced; but it not infrequently happens that little or no cough is present at the beginning of these cases.

There is one early symptom quite constantly present in acute pulmonary affections which is immediately suggestive, that is an increase in the frequency of respiration. With this will usually be found some fever. We have all observed cases in which no symptoms were present for several days, beyond increased respiration and a little fever, which then developed the characteristic symptoms. This is due to the bronchitis so often preceding the actual development. We have also seen young children convalescent from whooping-cough suddenly develop a very high temperature, increased respiration, and green bowel movements, with absolutely no cough or characteristic chest sounds for several days. The occasional absence of cough is very misleading, but the increased respiratory movement is very significant.

There is a form of broncho-pneumonia occurring in new-born infants, which, from its insidious onset and rapidly fatal termination, is apt to leave the physician in doubt as to what ailed his patient. The child may have manifested evidences of a slight cold, when suddenly it is seized with convulsions which may be frequently repeated, accompanied by diarrhea and enteritis. This may occur without much fever or cough; but, as a rule, the respirations are decidedly increased, and it is unusual that a trifle. of cyanosis is not present.

It is well to observe, in passing, that cases of broncho-pneumonia making an unusually slow convalescence may have tuberculosis as a primary cause, affecting the bronchi or lungs, since intercurrent attacks of broncho-pneumonia are not infrequent in pulmonary tuberculosis of children.

The evening temperature of broncho-pneumonia is usually higher than the morning temperature. I recall a case, occurring a few years ago, in which there appeared considerable excitement and intestinal disturbance, with this evening elevations of temperature, which confused a noted diagnostician for five days, owing to the absence of characteristic lung sounds; the case presenting an excellent counterfeit of typhoid fever.

To-day the early signs of pneumonia rarely need be confused with typhoid, even in the absence of distinctly objective symptoms, when it is remembered that a blood count in either form of pneumonia almost always shows a decided leucocytosis, while in typhoid there is rarely an increase; in fact, there may be a diminution in the number of leucocytes early in the disease, and usually before a Widal reaction could be looked for.

Both primary broncho-pneumonia and the lobar form may, owing to their sudden development, be confused with other diseases in much the same way; and they are much more apt to be confused with diseases entirely remote from the lungs than secondary broncho-pneumonia.

Fortunately, lobarpneumonia in young children is not nearly so fatal as broncho-pneumonia. Children attacked with this disease are usually, though by no means always, over three years of age, previously vigorous and robust in health. Some writers. assure us that lobar pneumonia is almost as common in infancy as it is after the third year. In my own work I have seen very few cases of lobar pneumonia in young children.

So many cases of lobar pneumonia in children are inaugurated with pronounced pain that our attention is entirely absorbed by the distress remote from the seat of disease. Pneumonia beginning with severe abdominal pain, either localized or general, high fever, constipation, vomiting, rapid breathing, and anxious facial expression, might very easily pass for a case of appendicitis, until the development of pulmonary sounds indicates the disease in hand. These indications, unfortunately, are often late in appearing.

The importance of an early diagnosis between appendicitis and pneumonia is obvious. Let the physician invariably interrogate the lungs at every point and allow no surgical interference in these cases until he has demonstrated the lungs to be sound. Pain in the side, cough, or an expiratory grunt, no matter how infrequent, is suggestive. A leucocyte count in these cases is not helpful, since it is usually high in both diseases. In adults, pneumonia in the upper lobe is rare; but in children it is of very frequent occurrence. In these cases resembling appendicitis, however, the disease is most apt to be found at the base, rather than at the apex, on the right side. The fever in pneumonia will usually be found much higher than in appendicitis, and it is apt to remain steadily high until defervescence. Respiration is rather more rapid in pneumonia, and close inspection often discerns a slightly restricted movement on the affected side. The abdomen may be tympanitic, tender on the right side, in pneumonia, and even the right rectus muscle rigid, but it has been observed by Barnard that the gentle but firm pressure of the flat hand will detect a light relaxation of the abdominal walls between each respiration in the case of pneumonia, which is not the case in appendicitis.

The crepitant râle is most surely heard during deep inspiratory efforts and coughing, and only after the most diligent and frequent search should it be considered absent. Too much importance, however, should not be placed upon its absence, as it is often not heard in children; neither is the dullness on percussion so pronounced as in adults.

If convulsions occur at the beginning, it is pretty good evidence that the case is not appendicitis. The finding of the pneumococcus of Fraenkel would point strongly toward pneumonia; but unfortunately sputum is rarely obtainable from children.

Cerebral symptoms may so predominate in a case of pneumonia at the beginning that some difficulty may be experienced in eliminating meningitis. Convulsions, vomiting, headache, general hyperesthesia, and high fever may be present in either, and some time may elapse before there are characteristic developments.

The usual respiration-pulse ratio of 1 to 4 is more apt to be maintained in meningitis than in pneumonia, where it often reaches I to 2. Respiration is not usually so rapid in meningitis, nor will there be present that appearance of breathlessness, expansion of