the symptoms of a well-determined pneumonia, the hepatization was of slight extent, and but little profound; whilst, on the other hand, if the bronchial expiration, the resonance of the voice, and the dulness of the chest are suddenly increased, the pneumonia, to which the pleuritic effusion has just been added, occupies a large extent both in depth and surface. (Maladies des Enfans.)

Upon examination, after death, the appearances discovered are: adhesions of the pleura, more or less recent; the pleura covered, to a greater or less extent, with yellowish lymph, forming, in some cases, a coating of considerable thickness; effusions into the cavity of the pleura of a serous or sero-purulent fluid, or of serum mixed with numerous small flakes of lymph. The serum is, sometimes, perfectly transparent; at others is troubled and more or less opaque. The fluid. secretions usually occupy the most depending portions of the pleural cavity; they are occasionally collected in separate cavities formed by recent false membranes or adhesions of the pleura. The most common lesion met with after death from pleurisy is unquestionably false membranes; they usually cover the costal pleura, often the pulmonary, and frequently both. In some instances the pleura is studded with numerous small red points, arising from ecchymoses beneath the membrane; we have observed this occasionally upon the costal pleura, but more frequently upon that of the lungs. The pleura is not unfrequently thickly studded with minute tubercles, the lungs generally being in a similar condition: we have met with tubercles of the pleura, however, where none existed in the lungs.

The inflammation is most commonly confined to one side of the chest, but may affect both. It is more frequent on the right than on the left side. According to the observations of Rilliet and Barthez, when the pleurisy complicates pneumonia it is more frequently on the left than on the right.

As a primitive disease, pleurisy occurs more frequently in boys than in girls. It is a common complication of pneumonia. In such cases, however, it is often of little intensity, though in others it assumes as serious a character as does the accompanying pulmonary inflamination. It is a frequent complication of rheumatism, scarlatina, and Bright's disease. It is of more frequent occurrence in spring, autumn, and winter, than in summer, or seasons of moderate, equable tempera

ture.

Pleurisy is not, of itself, a very fatal disease, and is readily controlled by an appropriate treatment. We have never seen a case in which the disease terminated fatally in its acute stage. Even when extensive effusion has taken place in the cavity of the chest, this will often be entirely absorbed, if it consists chiefly of serum. When purulent, it frequently produces considerable uneasiness and suffering, and, sooner or later, causes the death of the patient. When extensive adhesions occur between the pleura costalis and pulmonalis, in chronic cases, a very marked contraction of the chest takes place, on the side on which the adhesions exist, productive, when of any extent, of decided deformity.

In cases where copious effusion into the cavity of the pleura has

taken place, the lung is more or less pressed upwards, and its functions impeded. If, after this has existed for some time, a rapid absorption of the effused fluid takes place, the lung not expanding with sufficient celerity to fill the chest, the ribs will consequently close upon the compressed lung, and thus more or less contraction of the chest will be produced. This deformity often disappears during the growth of the child-occasionally it may exist, to a certain extent, throughout life.

Of the treatment of pleurisy but little need be said; it differs in no important particular from that proper in cases of bronchitis and pneumonia. The remedy upon which the chief dependence is to be placed is bloodletting, early employed, and carried to a sufficient extent to produce a decided impression upon the symptoms of the disease. Precisely the same remarks that were made in relation to the employ ment of this remedy in cases of pneumonia, are applicable to the disease before us. In young children, a few leeches to the chest, followed by soft warm cataplasms, will often produce a very decided abatement of the disease. In the commencement of the attack, the bowels should be freely opened by a purgative of calomel, followed by castor oil, or sulphate of magnesia, and kept in a regular condition by small doses of ipecacuanha and calomel repeated daily.

In the latter period of childhood, when pleurisy is most apt to occur independently of inflammation of the lungs, the tartarized antimony, either alone or combined with nitre, will often be found a powerful auxiliary to bloodletting. The tartarized antimony, combined with nitre and calomel,2 is particularly advantageous in cases in which, after bloodletting, the skin remains hot and dry, and the cough short and frequent. Under the same circumstances, the warm hip-bath and warm pediluvia act beneficially.

1 R.-Nitrat. potassæ, 3j.

Tart. ant. gr. ij.

Aquæ, iv.

Sacch. alb. 3ij.-M.

2 R.-Nitrat. potassæ, 3j.
Tart. ant. gr. j.

Calomel, gr. iv.-M. f. chart. No. xij. One to be given, mixed in sugar and water, every three hours.

A teaspoonful to be given every two or three hours, according to the age of the patient. As soon as the violence of the disease has been subdued by direct depletion, a blister to the chest, as directed in cases of pneumonia, will, often, very promptly relieve the cough, pain, and dyspnoea. Under the same circumstances that blisters become proper, considerable benefit will be derived from small doses of the compound powder of ipecacuanha, particularly in the evening. When well-timed, nothing will be found more effectually to relieve the cough and restlessness, and promote the healthy action of the cutaneous exhalants, particu larly if, at the same time, a warm pediluvium be employed.

When effusion to any extent has occurred within the chest, and the fluid is not speedily removed, after the inflammation of the pleura bas been subdued, its presence being indicated by auscultation as well as by the inability of the child to assume a recumbent posture without experiencing more or less dyspnoea and cough, small doses of calomel, squill, and digitalis, given every three or four hours, will often cause

4

the effused fluid to be absorbed. In some cases a combination of digitalis and bi-tartrate of potassa, or a mixture of the syrup and oxymel of squill,' with sweet spirits of nitre, will prove highly effi

R.-Bi-tart. potass. 3iij.

Digitalis, gr. iij.-M. f. chart. No. xij.

f. chart. No. xij. One to be given every three or four hours. R.-Syrup. scillæ, 3vj.

Oxy. scillæ, 3ij.

Spir. æth. nitr. 3vj.-M.

Dose, twenty-five drops, three or four times a day.

The same rules are to be observed in regard to diet as were directed in pneumonia.

In chronic pleuritis, our chief remedies are a mild unirritating diet, composed principally of the farinacea and milk, counter-irritants to the parietes of the chest, and internally, calomel in small doses, combined with some of the diuretics, of which, perhaps, digitalis and squill are the best. Occasionally the tincture of Sanguinaria Canadensis will be found a very valuable remedy in these cases, in the dose of from two to ten drops, according to the age of the child, repeated three times a day. In some cases mercurial inunction, employed in the same manner as was directed in pneumonia, will produce a beneficial effect. The bowels should be kept open by mild laxatives, or purgative enemata. Iodine, both internally, and externally, may, in some cases, be productive of benefit.

When effusion of pus has taken place in the pleura, the case, as we have already remarked, is generally hopeless; nevertheless, we are assured by Herpin, that the pus has been evacuated, by an operation, even in a child only seven years of age, and entire recovery thus secured, with the exception of a slight contraction of the chest on the affected side.

The operation has been performed several times with success, by Heyfelder, in children of from six to eight years of age. Trousseau has also insisted upon the utility of the operation in children. Dr. Hughes (Guy's Hospital Reports, 1844) states, that of twenty-five cases in which it was performed, in some repeatedly, thirteen may be fairly said to have recovered. The colleague of Dr. Hughes, Dr. Addison, considers, however, the operation to be one of the worst and most deceiving in general practice. (Lancet, Nov. 1855.) Dr. Henry Bennett (Lancet, Dec. 1843) records six successful cases out of nine, in which the operation was performed by Dr. Davies, and several in the practice of Dr. Hamilton Roe.

During convalescence from chronic pleuritis, change of air will often be advisable, especially the removal from a cold, damp, and variable climate, to one warmer and more equable.

If we take into consideration its frequency, the rapidity of its progress, the distressing and painful symptoms by which it is accom

panied, and the amount of mortality produced by it, tracheitis or croup must be regarded as one of the most formidable of the diseases peculiar to infancy and childhood. In Philadelphia, during the ten years preceding 1845, there occurred 1150 deaths from croup, being an average of 115 per annum; in London, during the five years from 1845 to 1849, both inclusive, the deaths from this disease amounted to 1543, being an average of 309 nearly, per annum. In 1840 the deaths from croup throughout the whole of England, were 4336. In Paris the deaths from croup for three years, from 1838 to 1840 inclusive, were 799, being an average of 266 per annum.

Croup is, strictly speaking, an inflammation of the mucous membrane of the larynx and trachea, the former being, in the great majority of cases, the part first affected. The peculiarity of the disease consists in the early occurrence of an exudation upon the surface of the inflamed parts, forming, in many cases, a pseudo-membrane, which extends often from the larynx throughout the larger, and even sometimes into the smaller divisions of the bronchi. It has been supposed by Blaud, Dugés, and others, that in certain mild cases, of frequent occurrence, unattended with fever, and readily cured by simple. means, the pseudo-membranous exudation does not take place. These cases of simple laryngeo tracheitis have been denominated by Guersent and Bertin spurious, and by others catarrhal croup; they are evidently cases of spasmodic laryngitis.

The distinguishing symptoms of croup are: dyspnoea, a peculiar hoarseness of the voice, a loud ringing cough, sibilant inspiration, and fever.

In the majority of cases the disease is preceded by symptoms of catarrh or bronchitis. The patient is affected with more or less chilliness, succeeded by increased heat of the surface, lassitude, loss of appetite, and cough. These symptoms vary in intensity and duration; in some cases presenting simply the characteristics of a slight catarrh for several days; while in others, the tendency to croup is exhibited from the commencement of the attack.

It is usually during the night that the proper symptoms of the disease are developed. The child, after retiring to rest, suddenly awakes from his sleep with difficult and wheezing respiration, and frequent paroxysms of a loud, ringing cough; his skin is intensely hot, his face flushed, and his voice hoarse and indistinct. Frequently he complains of a sense of constriction in the throat, and sometimes of pain about the larynx. In general, these symptoms, after a short period, gradually abate, the respiration becomes more free, the patient falls again into sleep, and on awaking in the morning, with the exception of some degree of hoarseness and a slight cough, presents no symptoms of any serious disease:-the pulse, however, will, in general, still be found to be more frequent than natural, and the cough more hoarse and resonant.

On the ensuing evening the respiration becomes again suddenly difficult, loud, and wheezing, and the cough convulsive and ringing; the patient experiences a sensation of impending suffocation, and often carries his hand to his throat, as if to remove the cause of bis

suffering. His face becomes swollen and flushed, his pulse hard and frequent, and his voice hoarse and almost inaudible. The cough is unattended with expectoration, or causes the discharge of only a small amount of glairy mucus, streaked with blood. The violence of the foregoing symptoms may, after a time, moderate; but if so, soon again increase in violence, and usually continue, with slight remissions, and exacerbations of augmented severity, during the night. Unless the disease be arrested by an appropriate treatment, the symptoms constantly augment in intensity, and the remissions become slighter and of shorter duration; the cough loses, however, its acute ringing sound, while the loud wheezing respiration of the patient is heard even beyond the apartment he occupies. The dyspnoea becomes excessive, the patient is in a constant state of agitation, his face swollen and livid, his lips purple, and his forehead covered with large drops of perspiration. The skin becomes cool, and the pulse small, feeble, and extremely rapid. The thirst is often excessive, and not the least difficulty is experienced in swallowing the fluids presented. There is often expelled by the cough, or by vomiting, at this period, a quantity of thick, ropy mucus, sometimes mixed with fragments of a membranous appearance.

These symptoms may continue for a longer or shorter period according to their intensity. The voice, however, soon becomes extinct, the respiration short and convulsive, and the patient is every moment in danger of suffocation. His face becomes pale or livid, his eyes dull and inanimate, and his head, face, and neck are bathed in a cold, clammy sweat. There is now but little, if any cough or expectoration, the pulse is feeble, irregular, and intermittent, and the patient at length ceases to breathe-the intellect being, in general, unaffected throughout the attack.

In other cases, however, the disease commences much more abruptly, and proceeds with greater rapidity and violence. The patient, who retired to bed apparently in perfect health, is suddenly awoke from his sleep with a violent fit of loud, ringing cough; his respiration is loud, wheezing, and oppressed, and attended with a feeling of immediate suffocation; there is the utmost anxiety and restlessness; the face is tumid, and of a dark red color, the eyes injected and protruding, and the pulse frequent and hard. These symptoms present not the slightest remission, but increase in intensity, the patient in the midst of the most frightful agony, perishing as though from actual strangulation. In these extreme cases, death may occur in a few hours, or the attack may be prolonged for one or more days.

Between the two forms of the disease we have described-that in which it is gradually developed and of some duration, and that in which it occurs suddenly, with symptoms of the utmost severity, and runs a rapid course-croup may present very various shades of intensity.

Its duration will vary in different cases, according to the severity of the disease, the age and constitution of the patient, and the nature of the treatment pursued. When attacked in its early stages by appropriate remedies, even in the more violent cases, the disease will