wine, or tincture of squills. Some practitioners recommend astringents, such as alum or sulphate of zinc, and from our experience of them we should say that they are especially useful after a few days' treatment by expectorants, and when the distinctive character of the cough is once fully established. Some authorities give carbonate of potash and cochineal; others have great faith in ferruginous tonics; Sir Duncan Gibb asserts that nitric acid-F. 49-is a specific, though it has not proved so in our hands; many authorities give mercury in alterative doses; in Germany sulphur has a great repute; it may be given in doses of 3 or 4 grs. three times a day to a child three years of age. Some few physicians think it necessary to bleed. It is, however, impossible not to see, as Dr. Todd pointed out, that this affection is not inflammatory, but rather spasmodic and convulsive; consequently, all antiphlogistic measures, as such, are to be discarded. The general nutrition of the patient should be maintained by easily digested food; the chest should be sponged, back and front, once or twice a day with cold water; and stimulating embrocationsF. 159-may be afterwards used to the same part. The best drugs are those known as antispasmodics and narcotics; such as henbane, conium, belladonna, lobelia, hydrocyanic acid, assafoetida, camphor, chloric æther, and chloroform. It need hardly be mentioned that the greatest caution will be necessary in the use of some of these remedies, that they should be given in very small doses, and that their effects should be narrowly watched in the Appendix of Formulæ numerous prescriptions are given, showing the doses, &c., in which they are to be ordered. Of the narcotics there is none which in our hands has proved so useful as belladonna, and we have generally found that there is a remarkable tolerance of this drug in children. For instance we have often given, and with good effect, five, six, and even eight minims of the tincture to a child three or four years of age, repeated three times a day of course the effect of such a remedy must be narrowly watched, and it is only when the paroxysms of cough are frequent and severe that any good is likely to result from it. Hydrocyanic acid we have also found very useful, especially in combination with the dilute nitric acid. Frictions over the chest night and morning with stimulating and sedative liniments, have proved very useful in our hands, the camphor, soap, and belladonna liniment in equal proportions is the form we generally employ. Where the secretion from the bronchial tubes is excessive, it should be checked by astringents; as for example, by alum, which was very strongly recommended by Dr. Golding Bird as

of the greatest value, and has been used with great success by many other physicians; sulphate of zinc, which we have often found very efficacious; small doses of sulphuric acid and infusion of bark, or gallic acid. The ferruginous astringents we have prescribed with admirable results in children of a flabby and enfeebled constitution, in whom there is a tendency to free mucous secretion; where it is thick, ropy, and scanty, an emetic of antimony or of ipecacuanha, will increase and aid its expulsion. Lately, the bromides of potassium and ammonium have been much vaunted, and there is ample testimony in their favour; the proper dose is 1 gr. every six or eight hours for each year of the patient's age. Much larger doses have been given without any evil result, but not apparently with any increased beneficial effects. Of the bromide of ammonium we have not had much experience, but we can speak very decidedly of the value of the bromide of potassium. In many simple cases, when the paroxysms have been severe, benefit sometimes results from sponging the fauces and glottis with a strong solution of nitrate of silver-20 grs. of the salt to water 1 oz. When the case becomes chronic, a cure may often be effected by change of air, and especially by removal to the sea-side. Tonics will also be necessary at this stage, and of these quinine, with or without steel, will be the most useful.

With regard to the treatment of the various complications, we would only advise that remedies of a depressing nature be neither too readily resorted to, nor too actively employed. In other respects, such a course should be followed as the nature of the complication and the condition of the patient may dictate.

VIII. PLEURISY.

Inflammation of the pleura as a primary disease, though comparatively rare during childhood, especially within the first five years of life, is yet probably not so rare as has hitherto been supposed. From the Report of the Registrar-General for 1866, it appears that of 142 deaths from pleurisy which occurred in London at all ages, 85 being males and 53 females, 12 only occurred under five years of age, 3 of which were males and 9 females. In England there were 858 of all ages, 519 males and 339 females; of these 74 occurred under five years of age, 38 being males and 36 females: so that it appears that a larger proportion of cases of pleurisy occur under five years of age in females than in males, thus

3 in 83 males in London.
9 in 53 females

66

And 38 in 519 males in England. 36 in 339 females

66

It is, however, very probable that, owing to the difficulties of diagnosis in children, many cases of pleurisy are in them. overlooked, for there are few diseases more obscure in their origin, or more liable to be mistaken; this is also partly explained by the fact that the symptoms and physical signs differ somewhat in childhood from those observed in adults. Hence the importance of a careful study of the symptoms of pleurisy in children, and it is deserving of attention, moreover, since it not uncommonly occurs as a secondary affection in the course of pneumonia.

Symptoms.-The chief symptoms, as well as the physical signs of inflammation of the investing serous membrane of the lungs, are of course in the main the same in the child as in the adult, though, as we shall see, there are some important differences. The disease is usually but by no means universally ushered in with rigors followed by fever, and an acute lancinating pain in the side, called a stitch, which pain is aggravated by the expansion of the lung in inspiration, by coughing, by lying on the affected side, and by pressure: in the adult all these symptoms are well marked, not so in the child; sometimes the pain is referred to some other part, or there is only a feeling of general uneasiness, and it is only by closely scrutinizing the respiratory movements that anything wrong is suspected there; there is also a short, harsh, dry cough, which is often at first mistaken for what is called a "stomach cough," but it may be distinguished from the latter by the accompanying pain in the chest, and by the greatly increased frequency of breathing which is partly owing to the instinctive avoidance of pain; the skin is hot and dry, the cheeks flushed, the pulse hard and quick, and the urine is scanty, high-coloured, and of high specific gravity; occasionally there is albumen in it, and rarely some casts. Besides all this, there is one symptom which is not unfrequent in children, but, though it possesses no diagnostic value, is seldom present in adults,-viz., vomiting, the ejected matter being principally bilious. If we listen to the painful part of the chest at this period, we may sometimes be fortunate enough to hear the dry, inflamed surfaces of the pulmonary and costal pleuræ rubbing against each other, and producing a friction-sound; and if the hand be placed on the corresponding part of the thorax this rubbing may also occasionally be felt as a kind of fremitus. The friction sound, however, which is at all times very difficult of detection in children, soon ceases; for either the inflammation terminates in resolution and recovery, or the roughened surfaces becomes adherent, or they are separated by the effusion of serum, and a kind of dropsy results, known as hydrothorax.

If the pleurisy has been severe, the effusion probably becomes excessive-varying from one to many ounces; and the fluid accumulating in the sac of the pleura compresses the yielding lung and suspends its functions, displaces the heart, producing a bulging of the intercostal spaces, and somewhat distends the thoracic parietes on the affected side. When the serous fluid is mixed with pus, the disease is termed empyema, and according to Dr. Hillier the formation of pus occurs much more frequently and much earlier in children than in adults.

If we listen to the chest when fluid is in it we shall find the respiratory murmur is enfeebled in proportion to the quantity of fluid present; where this is excessive and the lung is compressed backwards-flattened almost against the spinal column -no vesicular breathing at all will be heard, but we shall hear instead the air passing into the large bronchial tubes, the condensed lung and the layer of fluid acting as conductors of sound; we thus get bronchial respiration, and with it bronchial voice, or bronchophony. Bronchial respiration, is one of the earliest physical signs, but it is also one which is most likely to lead to error in diagnosis, as suggesting pulmonary consolidation from pneumonia, &c., and this liability is enhanced by the fact that increased vocal resonance frequently coexists with it, whereas in the adult this sign is usually wanting. The bronchophony may be accompanied by a tremulous noise, resembling the bleating of a goat, which is termed ægophony; this sound is usually heard only at the upper edge of the fluid. If the lung be completely compressed, so that no air can enter even the bronchial tubes, then no sounds of any kind will be heard; but on the healthy side the respiration will be more distinct than natural-will be very loud, or puerile. There will also be dullness on percussion all over the affected side, if the pleura be full of fluid; if it be only partially filled the dullness will be proportionately indistinct; sometimes we can judge of the quantity of fluid present in the chest by placing the patient in different attitudes; for the fluid naturally gravitates to the most dependent part of the chest, and will carry the dull sound with it. This is one of the most valuable signs of the existence of fluid, when once it is clearly made out, but in children this is often a matter of extreme difficulty. Sometimes we can judge of the amount of effusion by the attendant dyspnoea, which will, of course, be more urgent the more the lung is compressed. At this time also the child is frequently unable to lie on the sound side, because the movements of the healthy lung are impeded by the incumbent weight of the dropsical pleura; the pain, moreover, no longer prevents his lying on the diseased

side. If we measure the two sides of the chest, the side containing the effusion will often be found larger than the other. We must remember, however, that in many persons the right side of the chest is naturally somewhat larger than the left. On inspection there is seen to be diminished mobility of the affected side.

After a time the symptoms begin to decrease, and absorption of the effused fluid commences. Supposing the lung to be bound down by adhesions, it will not expand in proportion to the absorption of the fluid; the affected side then falls inwards, and instead of being larger than the sound side, will become smaller.

Causes. The most common causes of pleurisy are exposure to cold and wet, and mechanical injuries. In children it is most frequently produced by the extension of inflammatory actions in pneumonia. The jagged ends of a fractured rib will often excite it, and if they wound the pulmonary pleura, air will escape from the lung into the pleural cavity. The escape of air into the pleural sac may also arise from an external wound; or from ulceration extending from a tubercular cavity. When the pleura contains air alone, we say there is pneumothorax; when, as generally happens, there is liquid with the air, we call the disease pneumothorax with effusion. The physical signs of pneumothorax are, great resonance on percussion, with indistinctness of the respiratory murmur on auscultation; the patient's breathing, cough, and voice, giving rise to a ringing metallic noise, like that produced by blowing obliquely into an empty flask, and is hence called amphoric resonance. When there is also liquid with the air, we obtain in addition, on practicing succussion, a sound known as metallic tinkling, which results from a drop of fluid falling from the upper part of the cavity, and causing a little splash. This, though not infrequent in the pleurisy of adults, is extremely rare in children.

Diagnosis. The signs of inflammation of the pleura are usually sufficiently characteristic to prevent any error. Sometimes there is a difficulty in diaphragmatic pleurisy; owing to the pain at the commencement being referred to the abdomen, being increased on pressure, and being accompanied with vomiting and purging. The urgent dyspnoea, however, which is generally one of the very early symptoms, the dry cough, the diminution of the vesicular murmur at the base of the lung on the affected side, with attention to the general symptoms, will generally remove the doubt; moreover, the tenderness is not to be compared in severity with that which is produced by peritonitis.