and when there is much night perspiration belladonna is by far the most reliable remedy. Twenty drops may be given to a child of four or five at bedtime, or a smaller dose may be added to each dose of any compatible medicine that it may be taking during the day.

I have once seen fatal hæmoptysis in a child of three or four years from an aneurism on a branch of the pulmonary artery in the wall of a cavity. But hæmoptysis is not common. Should it occur, small doses of turpentine-e. g., five or six drops of the oil-may be given with some mucilage of tragacanth, syrup, and dill-water.

CHAPTER XXIV.

PLEURISY.

Pleurisy is a very common disease, and is a particularly important one, if for no other reason than this-that the fluid effused is so frequently purulent. I have notes of 149 cases, gathered from all sources of my own practice. Of these, 71 were simple, 78 were purulent. This can, perhaps, hardly be considered a fair average, for a hospital physician is naturally likely to see the worst side of all diseases.

The subjoined facts may be of interest:

Fibrinous pleurisy affected the right side 28, the left side

43 times; empyema, the right 18, the left 59 times; one case was doubtful.

The large preponderance of left-sided empyema over rightsided, four to one, is worth remembering.

Pleurisy is usually stated to be most commonly a secondary disease, and, if we consider how many causes lurk in diseases of the surrounding structures, we shall not wonder that it is at any rate, not unfrequently dependent upon disease of those parts. Tubercular disease of the lung; acute and chronic pneumonia; bronchitis; dilated bronchial tubes; disease of the bronchial glands; pericarditis; inflammatory conditions below the diaphragm, such as localized abscesses between the liver and diaphragm, or the spleen and diaphragm; general peritonitis; disease of the spine and ribs— these are some of the many affections which may set up pleurisy. Less obvious in their actions, but frequent as causes, must be reckoned scarlatina and rheumatism-the latter of acute fibrinous pleurisy, the former of empyema. The importance of both these affections as causes of pleurisy is, I believe, not fully estimated; but when all is said with reference to the causes of pleurisy, there will remain a large number, in my experience the greater number, in which it has not been possible to assign any cause, and I should therefore be disposed to think that idiopathic pleurisy is not so very uncommon.

Pleurisy may lead to the formation either of lymph, or serum, or pus. It is impossible to make any useful distinction between those cases in which the exudation is fibrinous and those in which it is serous, or, to put it in other words, between those in which there is effusion and those in which there is none, the reason being, that in children the formation of lymph is so active that the presence of fluid is often suspected where the exploring syringe shows the opinion to have been unfounded. In the treatment of empyema, a knowledge of the existence of this excess of lymph is of the greatest importance.

Symptoms. As a rule they are not very acute, even in simple (non-purulent) pleurisy, although there is a definite onset. Pain in the side is common, but it often needs to be inquired for. Fever, wasting, want of appetite, languor, and cough are the more usual symptoms complained of. Headache, vomiting, convulsions, and diarrhoea are also occasional symptoms. The time at which the child has been brought for treatment has been very variable, from two or three days to as many months. This will serve to show that the acuteness of onset is liable to vary considerably; and I would further say that occasionally the onset is so acute as almost to deserve the name of violent-the fever being high, delirium considerable, and the pain in the side. apparently an agony. These cases are quite likely to be mistaken for an acute pneumonia, of which, indeed, it would be impossible to deny the existence in some measure, and they are, in my experience, very likely to be quickly followed by the rapid and copious effusion of pus. The temperature in pleurisy is of no characteristic type-it is often up to 101°, 102°, or 103° in the first day or two (in the very acute cases higher), in the afternoon or evening, and the pyrexia may be prolonged. I have several times entertained unfounded fears for the formation of pus from this prolongation of the pyrexia. It is difficult to get any large number of cases in which the disease has been uncomplicated and watched from the commencement as regards this point. In eleven cases the temperature has averaged not much over 100° after the first onset, although occasionally in several of these making erratic excursions.

In infants, pleurisy is apt to produce a pinched and collapsed condition, like peritonitis in the adult.

When the fluid is purulent, excepting in the very acute cases already alluded to, the onset is still more indefinite than when the products are serous. In this respect, again,

the pleura may be compared with the peritoneum, in which the fibrinous or plastic inflammations are very generally acute, painful, and not to be mistaken; the purulent inflammations are apt to be overlooked, by reason not so much of their lack of symptoms as of the vagueness of those symptoms which occur. Nevertheless, commencing, as the disease often does, in acute pneumonia and other evils, a sudden onset is noticed in many cases. Of fifteen cases, in eight the child was suddenly taken ill; in seven, the onset was indefinite after mumps, or scarlatina, or pertussis. Of general symptoms likely to be present in empyema, emaciation is often rapid and extreme. I once saw a child, a few months old, wasted to the last degree, with a moderate quantity of fluid in the left chest. The wasting seemed to be too extreme for pleurisy alone, and nothing was done to remove the fluid. The child died the next day, and the post-mortem examination revealed nothing but an empyema. There may also be much pallor, and sometimes a puffy appearance of the face, such as suggests Bright's disease. This latter symptom I believe to be sometimes a most valuable one as indicating the existence of fluid in the chest, and, in the absence of renal disease or pertussis, pleuritic effusion should be thought of. Moreover, it is a symptom which indicates a large effusion, and I have seen cases where, except for this sign, the auscultatory and other phenomena were in favor of pneumonia. This symptom is not confined to empyema; it may accompany any large pleuritic effusion.

Here, again, the temperature is not to be trusted implicitly. As a rule, it rises by night; and I have noticed that the suppurative fever is apt to register with particular delicacy the reaccumulation of pus when it has been removed by operation. It is by no means uncommon to find oneself in considerable doubt as to the presence of pus in empyemas