into the hospital during the month of October. It may be here interesting to remark, as showing how dependent this disease is upon thermometric fluctuations, that during a few cold days in the middle of August, three cases of very severe capillary bronchitis were admitted into the wards, two of which ended fatally.

The above are only a few of the more interesting points in the etiology of the disease, and may be classed as predisposing causes. The exact exciting cause is not always such an easy thing to determine in individual cases. Most commonly the child does what is usually called "catching a cold;" and although this is only begging the question, still is very often the only explanation we can give. How a cold is caught, has received many explanations, one of the most plausible being Rosenthal's, whose experiments tend to show that after being for some time in a heated atmosphere the cutaneous capillaries become paralysed and dilated, thus causing a rush of blood to the surface which, in its turn, leads to an increased loss of heat and prevents the temperature of the body from rising to any great height. If now the skin is suddenly exposed to an atmosphere of normal temperature, the vessels still remain dilated, and with the considerable difference between the temperature of the body and that of the atmosphere, much more heat is lost than would be the case if the vessels were in an undilated condition. The blood which was previously flowing through the subcutaneous tissues, is now driven to the internal organs and cools these off much more rapidly than it would do had the body been simply exposed to cold without the previous influence of heat.

If the organs are in a good condition, and not in any way predisposed to inflammation, no harm may result; but in many cases one or other of them is the locus minoris resistentiæ, and so an attack of enteritis, nephritis, hepatitis or bronchitis

occurs.

Perhaps under the heading of exciting causes may be classed the presence of injurious substances in the atmosphere. Just as the lungs of coal-miners, needle-grinders, and stonemasons become irritated by the fine dust present in the air of their workshops, so does the tender bronchial mucous membrane of children become irritated by the foul atmosphere of the homes in which many of them live. In the small ill-ventilated rooms

of the poorer classes, in which, in not a few instances, several families live, eat and sleep all the year round without a window being once properly opened, the air must be teeming with or ganisms of all forms, which, though perhaps unable to act upon the more hardened bronichal mucous membrane of the adults,

finds a convenient soil in those of the younger members of the family. It should be, then, our first aim in treatment to remove them from this vitiated and poisonous atmosphere to the purer air of the hospital.

We now come to the study of the disease itself, of its signs and symptoms, and this may be best done by taking a typical case of simple bronchitis.

Harry W, aged 2 years, was admitted on July 11th, under Dr. Clarke. History of several previous attacks of bronchitis, and there was a family history of consumption. On admission his temperature was 99.8°. He was a delicate looking boy, but there was no sign of rickets. Examination of chest gave no indications of any patches of dullness, but there were bubbling and cooing râles to be heard all over the chest. Dyspnoea was not a marked feature, and there was only a slight amount of retraction of the soft parts of the chest walls on inspiration. There was very free perspiration. The child was given a hot bath and put to bed, and antimonium tartaricum. second centesimal, gtt. ii., alternately with the same amount of phosphorus third centesimal every three hours was ordered. A steam kettle was also used. The next morning the temperature was 99°, and a few coarse crepitations were to be heard over both lungs, but there were no signs indicative of any collapsed or pneumonic areas. A peculiar symptom was present in this case, which is not altogether uncommon. The worst attacks of coughing were accompanied by a spurious kind of crow. It was not exactly of the nature of a "whoop," nor did the child vomit after each attack of crowing. The child progressed favorably, and in six days all the moist sounds in the lungs had disappeared, only a few dry râles being left, and in nineteen days he was discharged cured. During the whole of the attack the pulse and respiration ratio was but little disturbed.

The above, apart from the crow, of which sympton I shall have occasion to speak later on, was a fairly typical case. uncomplicated cases the temperature does not usually reach any great height, in this one it never rose above 100°, F.; the dyspnoea is seldom extreme, and the pulse and respiration ratio is but little disturbed. It is otherwise, however, when the inflammation of the tubes has spread down to the smallest ramifications. In such cases there is often much fever, the dyspnoea is very urgent and the cough is constant; the pulse and respiration ratio is also usually disturbed, and this without there necessarily being any pneumonic complication. Added to these there is more or less cyanosis, and other signs indicative of the hindrance of the oxygenation of the blood.

We will now consider the treatment of uncomplicated cases of bronchitis.

In slight ones, all that is necessary is to put the little patient to bed after having given a warm bath. I think that this latter point should never be neglected, it not only has the effect of making the cough easier, but it also removes the restlessness and uneasiness which, especially in infants, is often such a very distressing symptom. The bath should be about 110°, F.; this carefully given should not tend to produce any collapse or faintness. The patient may be left in the bath from five to ten minutes, and sponged well all over, taken out, dried quickly and put into a flannel gown, or in the absence of this, between blankets. The effect of the warm bath and after application of flannel will be to produce a relaxatian of the cutaneous capillaries which, in about half an hour, will be followed by free perspiration with immense relief to the patient, who will probably fall into a quiet sleep and awake afterwards with all the symptoms much relieved.

Future examinations can be easily made by means of applying the ear to the child's chest without removing the flannels, so as to avoid exposure. One remark about the sleeping coverings of infants and young children may not be out of place here. If you watch one in a restless sleep you will find that in spite of all your efforts to prevent it, the child will invariably get his legs outside the bed clothes, and thus stand the chance of catching a fresh chill. This cannot be prevented, and the best way to prevent any mischief coming of it is to have a flannel combination drawers and vest made for the child, and these should fasten by means of tapes round the ankles and wrists.

With the above precautions no harm will come from keeping the window open day and night, for I consider this another important item. The fresh air will never do harm provided the temperature of the room be kept at about 68°, F., by means of a fire. Of course the cot should not be placed directly in the line of the draught from the window. A thermometer should be hung in the room to ensure the maintenance of the equable temperature. In tiny children a swing cot with head curtains is of great advantage, and the thermometer may be hung at the cot's head.

In all but the mildest cases, but most especially in those in which there is either an absence of secretion from the bronchial tubes as shown by the dry cough and dry râles, or in which the secretion is tenacious and difficult of expectoration, I do not mean actual expectoration from the mouth, for children under five nearly always swallow their sputa, but when the mucous seems to hang about the bronchial tubes one or other of the

various kinds of steam bronchitis kettles is of great service. By the use of this, the air around the patient will be kept moist, and at an uniform temperature, and this will not only have the above-mentioned effect upon the secretion, but will also tend to relieve any spasm of the tubes which may be present.

Spasm of the tubes in the course of an attack of acute bronchitis is much more common than is supposed, and it may appear even when the attack is slight, making it, for the time, appear to be of great severity; indeed, it is the more or less sudden occurrence of this spasm which often leads mothers to bring their children to the hospital for the relief of a bronchitis, which would otherwise have been left to take its own course at home untreated. We constantly meet here with cases of the following type: The child has had a slight cough for a few days; suddenly for some unknown reason the breathing becomes difficult and perhaps attended with crowing, for the spasm may affect the glottis as well as the tubes themselves. The child soon becomes cyanosed, and it may seem as if suffocation were impending. On examination one expects to find marked capillary bronchitis with possibly one or other lung complication, but instead of this only a few dry râles are heard, the breath sounds being very feeble. These are just the cases in which a hot bath will remove all the difficulty and speedily set matters to rights, and more especially if it be followed by a dose of aconite or spongia.

With regard to the medicinal treatment of an uncomplicated attack of bronchitis, no drug seems to succeed so well as antimonium tartaricum. The majority of cases treated here had this medicine, though some had aconite in alternation. For myself I prefer the former alone unless there is great restlessness, quick pulse and high temperature, when the alternation may be beneficial. No other medicines are, as a rule, required unless some complication sets in, and I now propose to take up a few of the most common, and the one to which most of you would give the first place is the spreading down of the inflammation to the minuter tubes, and the supervention of patches of catarrhal pneumonia.

One of the worst cases of this nature I have seen in this hospital was that of Albert P——, aged nineteen months, who was admitted under the care of Dr. Blackley for a very extensive and disfiguring nævus of the left ear and temporal region, which had received great benefit from repeated application of the galvano-cautery. Just before the child was to be discharged he developed an attack of measles. The usual catarrhal symptoms appeared at the commencement of the illness, and remained of only slight character for the first week. But as the rash was

disappearing the cough became worse, and the temperature, which had not gone above 101.4°, suddenly rose to 104.8°. By physical examination patches of dulness with minute crepitations were found at the back of the right lung and catarrhal pneumonia was diagnosed. Aconite 1x gtt.i, every half hour was ordered. The temperature still rose, and the next day was 106.6°. The same evening it fell to 103.6°, and finally rose to 105.8° and remained about this height for the next few days, when the child died. On post-mortem examination extensive pneumonia was found in both lungs, more especially in the right, the lowest lobe of which was solid, so that isolated portions sank in water.

In this case there was practically no difficulty about the diagnosis. The physical signs, together with the sudden rise in temperature, were sufficient to establish the diagnosis of catarrhal pneumonia. Many cases, however, are not so easily determined as this. The commonest sign of pneumonic consolidation is stated to be a sudden rise of the temperature, with aggravation of the symptoms, the temperature afterwards often showing an evening rise and morning fall so long as the condition lasts, but I have seen not a few cases in which physical signs alone were the only guide to the diagnosis.

Such a case was that of Daisy W—, aged eight weeks, admitted under Dr. Blackley with rather severe bronchitis, which had invaded the capillary bronchi, and in whom Dr. Blackley and I both diagnosed, a few days after admission, pneumonic patches at the left base from the following signs: retraction of the soft parts of the chest walls on inspiration, with rapid breathing and marked dyspnoea. A patch of comparative dulness at the left base with harsh breathing and small crepitations to be heard with inspiration; added to this there was increased vocal resonance at this spot whenever the child cried, and the heart's sounds were abnormally conducted to this area, and yet with all the above signs present, which in themselves were pathognomic of catarrhal pneumonia, the temperature never went above 101°, and I have seen few other similar cases. So, in my own mind, the changed physical signs are the only reliable indications upon which to diagnose the presence of patches of pneumonia.

To pass on to the treatment of this condition. Except the child's temperature on admission be very high, there is no reason why it should not have a hot bath. The child should then be put into a tent cot, and a steam kettle used to moisten the atmosphere, and this is kept working day and night until all the signs have passed away and the child is well over the attack.

If the patient is not below one year of age a jacket poultice