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cuously almost every year, and to be somewhat of the samenature as the peripneumonia notha. But finding that it conti-nued to prevail after the beginning of summer-a seasonwhich usually puts an end to all peripueumonic complaints-he felt fully persuaded that a new constitution had arisen, andthat this fever was but the offspring of it. The chief symptomswere, severe pain in the head and limbs, cough, and othersymptoms of a mild peripneumony, sometimes pain in the neckand throat, a tendency to coma or frenzy, but not of that vio-lent kind which is apt to occur in small-pox and some otherfevers, the patient being rather calmly than furiously delirious,and talking ramblingly between whiles. Although the feverwas of a continued type, so generally was there a decidedexacerbation of the symptoms in the evening, that by manyit was regarded, and unfortunately treated, as a species of in-termittent from the very first. In some of the cases, petechiæand purple spots, while in others a miliary eruption, appearedupon the surface. These symptoms were most frequent whena hot regimen and the use of cordials were employed. Theywere considered by our author as " certain signs of a violentinflammation in this and every other kind of acute disease."As to the nature of the fever, he tells us that, taking intoconsideration its symptoms, on the one hand, and, on theother, the mild temperature of the last year (1685) followingupon two very severe winters, and especially of the winterseason, (1685-6,) it appeared to him that it was "nothing elsebut a simple inflammation of the blood, and consequently thatthe curative indications should be entirely directed to repress-ing this inflammation by appropriate remedies." In anotherpassage, he terms it "a peripneumonic fever," doubtless fromthe pulmonic complications which attended it. [Was it notsomewhat of the nature of what is now called influenza ?]

It seems to have continued more or less generally through-out the year 1685 and the following winter, to the summer of1686, when it assumed more of an enteric type, indicated bygriping, diarrhoea, and vomiting. It still retained, accordingto our author, its inflammatory character, and required for itssubjugation a similar mode of treatment. From an accidentalremark in one passage, it would seem that the fever, when itsviolence had been duly checked by bleeding and purging,sometimes assumed the character of an intermittent, andultimately required the exhibition of bark for its completeremoval.So much for the historical portion of my subject. In my next

I shall proceed to speak of the treatment of those epidemicdiseases which have been mentioned in the preceding pages.Fitzroy-square, Jan. 1847.

ON INFANTILE PLEURITIS.BY EDWARDS CRISP, ESQ., M.R.C.S.E.

(Read before the South London Medical Society, Dec. 10th, 1846.)

INFLAMMATION of the pleura has been but slightly noticedby the few authors in this country who have written uponthe diseases of children, and those with whose opinions I amacquainted believe that a correct diagnosis of this disease isunattainable. Underwood, in his work "On the Diseases ofChildren," does not mention it. Evanson and Maunsell* statethat " pleuritis is occasionally discovered upon the post-mortem examination of children; but that there are no dia-gnostic marks which distinguish it from other inflammationsof the chest during life." Dr. Vest, in his " Clinical andPathological Report on the Pneumonia of Children," inspeaking of his table of thirty-seven cases, says:" In twelveof the thirty-seven cases, no traces of inflammation of thepleura were found; in five there existed old adhesions, moreor less extensive; and in twenty there were marks of recentinflammation. In twelve of the twenty cases both pleuraswere affected; in six, adhesions existed only on the right;and in two only on the left side. One of the cases of doublepleurisy might be characterized as slight; in five others thedisease, though slight on one side, was extensive on the other;and in the remaining six extensive pleurisy existed on bothsides. In seventeen cases adhesions between the costal and

pulmonary pleura, and the presence of more or less lymph onthe surface of the lung, were the only signs of pleurisy; butin eight cases there was also effusion of a notable quantity offluid. In three instances this effusion was serous; in theremaining five it consisted of a turbid, sero-purulent, or

purulent fluid."It should be observed that eighteen of these children were

between one and two years of age, and only two of them* Evanson and Maunsell on the Diseases of Children, p. 374.

below the age of twelve months, so that the term infantilewill scarcely apply to these cases. They serve, however, toshow the very frequent combination of pleurisy with thepneumonia of children. Dr. West further observes:—"Itappears probable, indeed, from the researches of M. Ch.Baron,* that the liability to pleurisy is much greater amongchildren above two years of age, than among those who areyounger, since of 3392 autopsies of children from one to twoyears old, pleurisy was found only in 205; and in seventy-ninethe pleura was otherwise unhealthy from some non-inflam-matory cause; or, in other words, inflammation of the pleurawas found only in six per cent., while in 181 autopsies ofchildren from two to fifteen years old, the pleura of 158, oreighty-seven per cent., presented signs of inflammation."

Billardt says:" Pleurisy is more common among younginfants than is generally believed; it often appears withoutthe lungs participating in the inflammation. I have seenseveral infants die immediately after birth of this affection."He relates three cases. " The first occurred to an infant twodays after its birth ; the cavities of the chest containedyellow serosity, with albuminous flakes; the lungs floated inwater. The second case took place in an infant ten daysold, and terminated fatally in six days. The lungs were red,and contained much frothy serosity; the posterior border of theright was affected with red hepatization. Two spoonfuls ofserum in each cavity of the chest; the pleuræ spotted red,and the lungs adherent to the diaphragm by tender albu-minous filaments. The third example was one of chronicpleurisy in an infant, three months old, affected with ma-rasmus and uncertain symptoms. The costal and pulmonarypleurae were covered with plastic lymph, and when this wasremoved, the membrane beneath was seen rugous and in-jected. When the lungs were cut transversely, a well-markedred line could be seen at the circumference of these organs,indicating the separation between the inflamed pleura andthe healthy pulmonary tissue."

Billard likewise observes:" As a general rule, it is noteasy to make a diagnosis of pleurisy in young infants; stillits existence may be suspected when we observe muchanxiety, restlessness, difficulty of breathing, painful dilatationof the thorax, quick and more marked contractions of thediaphragm and abdominal muscles; and in the midst of thesesymptoms, if the cry should preserve its integrity, and presentno other alteration than that which arises from fatigue andexhaustion. Percussion and auscultation give but very un-certain signs in this disease; yet if the respiration be notheard at any part of the thorax while the cry is completeand free, and when it would appear as if there existedeffusion without hepatization, the infant, in all probability,is affected with pleurisy : this conclusion will, however, bestill uncertain. I must, on this account, consider the dia-gnosis of pleurisy in sucking children as very difficult, andthat it is very easy to confound it with pneumonia. Happily,this mistake cannot be very prejudicial to the patient, becausethe treatment of one will be the best that can be adopted forthe other."

I have no means of forming a correct estimate of the com-parative frequency of this disease in infants; but on referringto notes which I have taken of forty-one post-mortem exa-minations made by myself of children under two years of age,(the greater number under twelve months,) inflammation ofthe pleura has been found in six instances: in five of these itwas combined with a certain amount of inflammation of thelungs; in one case it was complicated with pericarditis; andin another with peritonitis and hydrocephalus ; in the sixthcase, the pleura alone appeared to be inflamed.

It will naturally be asked, why I have used the term in-fantile ? and how this complaint, when occurring in infants,differs from the same disease in the adult?

Pleuritis in the adult is generally recognised without muchdifficulty,and the patient’s description of the character of thepain, the state of the pulse, heat and dryness of the skin,nature of the cough, quickness of breathing, will for the mostpart afford sufficient indications to enable us to arrive at acorrect diagnosis, without the assistance of auscultory signs.The last, however, combined with percussion, will afford, inmany cases, very valuable information, and by their meanswe can often point out the boundaries of the disease, andmake many nice points of diagnosis which the use of the earwill alone enable us to attain. Although ill the generality ofcases inflammation of this membrane is easily recognised, itmust be admitted, that in some instances, especially when theinflammation is seated in that part of the membrane m con-

De la Plenrisie dans 1’lsnfanec. Paris: 1841. Quarto, p. 52t On the Diseases of Infants. Trauslated by Stewart.

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tact with the pericardium, or in that portion of it covering thelower part of the right lung and diaphragm, that the diagnosisis more difficult. If this disease is sometimes undetected inthe adult, how much more likely is it to escape observation ininfantile life, where many of the valuable signs we obtainfrom patients more advanced in age are wanting.The symptoms which I have observed in infantile pleuritis

are, great restlessness, violent screaming at the onset, veryquick pulse, hot and dry skin, glassy eye, dry cough, (this notfrequent,) the head thrown back, and great apparent painwhen the child is placed in the erect position. On the appli-cation of the ear or stethoscope, a dry, rubbing sound is heard,and the lungs appear to move up and down like the piston ofa steam-engine, (" frottement ascendant et descendant.") Thismay appear to be a very inapt comparison, but such wasthe impression produced on my mind in the fifth and sixthcases.

I am aware, that many of the signs I have described maybe present in other diseases, especially in inflammation of thelungs; and that when pleuritis is complicated, as it generallyis, with pneumonia, the difficulty of the diagnosis is greatlyincreased. I believe, however, that when the dry, rubbingsound is heard, with frequent screaming, and apparent in-crease of pain on elevating the head, that the existence ofpleuritis is pretty clearly indicated. If the mucous and cre-pitating rales are likewise heard, and a small portion of theserous membrane only is inflamed, the diagnosis is moreobscure; but even with these combinations, I think that acareful investigation will enable us to recognise the disease.I believe that I have an infant now under my care with pneu-monia, combined with pleuritis, to a small extent, in the rightlung. I shall now proceed to describe the examples of thisaffection which I have met with. In the first four, the pleu-ritic inflammation was not suspected, my attention not havingbeen directed to the subject. The combination of this diseasewith pneumonia likewise rendered it less easy of detection.In the last two cases, where the inflammation was chieflylimited to the pleura, I had no doubt about the existence ofthe disease.

CASE 1.—Dec. 9th, 1833.—I was called to Mr. H ’sinfant, a very fine child, aged six months. I attended it duringan attack of inflammation of the lungs two months since,from which it perfectly recovered. It is now labouring undersymptoms of pneumonia, which made their appearance yester-day ; the respiration is hurried and difficult, cough frequent,skin hot and dry, pulse quick, bowels regular. Ordered, awarm bath, one leech to the chest, and a blister. I lanced the

gums, and gave a dose of ant.. potass. tart. to produce vomit-ing : this was followed by small doses of tartarizod antimony atintervals of two or three hours.

10th.—The symptoms were rather more favourable thismorning; the rale crepitant very distinct at the inferior por-tions of both lungs.20th.-The child died this morning. Since the last report,

the symptoms have at intervals been more favourable: thechild has always taken the breast-milk without difficulty, andretained it upon the stomach; the cough, during the last threeor four days, has been nearly absent; there has been droppingof the upper eyelids, rolling of the eyeballs, and twenty-fourhours before death, frequent tossing of the head. The treat-ment since the last report consisted in the administration ofcalomel and tartarized antimony for three or four days, andafterwards small doses of ipecacuanha wine.

Post-mortem examination.- The inferior portions of bothlungs hepatized; and on pressure a quantity of pus oozedfrom the bronchial cells; a portion of the lung sunk when putinto water; recent adhesions between the pleura costalis andpleura pulmonalis on the left side. I was only allowed toexamine the chest.

CASE 2—March 6th, 1835. Mrs. B—’s child, Walworth,aged eleven months, now cutting the incisor teeth, has beenindisposed for four or five days. This morning, the motherfirst observed a rolling motion of the tongue, which has con-tinued for three or four hours; the papillm raised, and scarlet;the child sensible; pupils natural.

10th.—This peculiar motion of the tongue continued forthree days, and the child died this morning. The pupils hadcontracted readily on exposure to light; the abdomen wastense; and the child was observed, a short time before death,to draw its 1:_,crs up frequently towards the abdomen.

Post- mortem examination.—Vessels of the brain turgid, andabout two teaspoonfuls of water in the lateral ventricles; leftpleura costalis adherent to the pleura pulmonalis with deposit

of lymph; the intestines filled with air, and glued together inseveral places by soft lymph; the cavity of the abdomen con-tained about an ounce of sero-purulent fluid.

CASE 3.—January 3rd,] 1838, I visited D’lrs. B—’s infant,Walworth, aged fourteen months. The child liad been unwellfor several days, with cough and difficulty of breathing, andon the 2nd had been taken to a gentleman practising as aphysician, who had ordered a mixture of syrup of poppies,oxymel of squills, with tincture of hyoscyamus and digitalis,five doses only of which had been taken. The countenance isnow very anxious, face pallid; skin hot and dry; pulse about130 or 140 ; breathing very frequent, and no respiratorymurmur is heard below the upper lobes of both lungs; slightcough and inability to cry, (three molar teeth nearly throughthe gums.) I lanced the gums, ordered a warm bath, and agrain of calomel every three hours.

4th.—Much the same as yesterday. Repeat the powders.5th.-Not quite so well.6th.-Died at two P.M.

Post-mortem examination, forty-nine hours after death.—Onremoving the sternum, the pericardium was seen much dis-tended, and on cutting into it, about two ounces of yellowserum was found. A layer of coagulable lymph, about thethickness of a shilling, lined the interior of the pericardium,and extended over the heart; which organ was otherwise in ahealthy state; the left lung was hepatized throughout, withthe exception of a very small portion at the apex; the pleuraadherent, and the lower half of the right lung hepatized, andthe pleura pulmonalis covered with coagulable lymph. Abdo-minal viscera healthy. Drain not examined.

CASE 4.-December 24th, 1839. On the 6th of this month,Mrs. V ’s infant, Walworth, was attacked with coughand difficulty of breathing, and the child died on the 23rd.The symptoms under which it had laboured were, frequentcough, quick pulse, hot skin, anxious countenance, respirationpuerile at the upper part of both lungs, indistinct at the lowerpart. The child took the breast-milk well from the com-mencement of its illness, and retained it on the stomach.The treatment consisted in the administration of calomel andtartarized antimony, with a blister to the chest, and warmbaths.

Post-mortem examination, twenty-nine hours after death.—Onremoving the sternum, the pleurae and pericardium were seencoated with soft yellow lymph, about two lines in thickness;this extended over the costal and pulmonary pleurae. Theleft cavity of the chest contained about four drachms of sero-purulent fluid; the upper portions of both lungs were healthy;the lower portions were in a state of grey hepatization, andon pressure a quantity of pus escaped from various parts. Theheart and abdominal viscera healthy. Head not examined.As I have before stated, pleuritis, in the above cases, was

not recognised during life.CASE 5.—Nov. 18th, 1845, I was called to -Nlrs. F—’s

infant, Walworth, aged ten months; about five weeks since,I attended it for an attack of infantile erysipelas of the natesand thighs, from which it recovered in ten days. The childhas been indisposed for several days, and now labours underquickness of breathing, short cough, hot and dry skin, greatrestlessness, quick pulse, and inability to cry loud, (although,two days prior to this, the mother states that it screamedviolently at intervals, and appeared to suffer great pain.) Arubbing sound is heard on both sides of the chest, especiallythe right; the head is thrown back, and when brought intothe erect position, the pain appears to be much increased.The symptoms gradually became more unfavourable, anddeath took place on the 22nd. The treatment had been asfollows:—Warm baths, lancing the gums, leeches to thechest, followed by a blister, with calomel and tartarizedantimony, every four hours, for the first two days; thensmall doses of ipecacuanha wine, with calomel and tartarizedantimony at night.

Post-nortem examination, twenty-six hours after death.-Iexamined the body with my brother, Mr. F. Crisp.-Chest: Alarge deposit of straw-coloured lymph on the right pulmonarypleura; on the anterior and lower part it was one-sixth of aninch in thickness; and posteriorly and laterally, the costaland pulmonary pleurso were slightly adherent; no fluid inthe pleural cavities.-Left side: The lymph less abundant onthis side, but the upper and posterior part of the lung was ina state of red hepatization. The remaining portions of thelungs healthy; abdominal viscera normal. Brain not ex-amined.

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CASE 6.-January 6th, 1846, four P.M., I saw Mrs. W-’sinfant, Vauxhall-road, aged four months. The child hadbeen strong and healthy from its birth, and no appearance ofindisposition was observed until last evening, when, whilst.lying on its mother’s lap, it suddenly uttered a shrill scream."Mrs. W— compared it to the whistle of a steam-engine."After this the child began to cry, and then again screamedviolently, with short intervals of quietude, for nearly twentyhours. I was not sent for before, as the pain was supposed toarise from flatulence. The symptoms are now, hot skin,quick pulse, short dry cough, breathing very quick, eyes glassy,bowels confined, head thrown back, and the pain apparentlymuch increased when the head was moved forwards, and adry rubbing sound is indistinctly heard over both sides of thechest. I lanced the gums, and gave a teaspoonful of tartarizedantimony wine, ordering it to be repeated, in half an hour, ifthe symptoms were not relieved. One grain of calomel, withone-twentieth of a grain of potassio-tartrate of antimony,every five hours; one leech to the chest. (A warm bath hadbeen resorted to before my arrival.)

7th.—The child has been much quieter since last evening,. and slept two hours during the night. The countenance,however, has an unpromising appearance, eyes sunk and dull;pulse rather feeble.

8th.—The symptoms gradually became more unfavourable,and death took place this evening.

Post-mortem examination, ten hours after death.-I examinedthe body, and found both pulmonary pleuræ covered withsoft straw-coloured lymph, uniting these to the costal pleurae.The external surface of the pericardium was also coated withlymph; no fluid in this or the pleural cavities. The posteriorportions of the lungs congested, but their structure healthy,as were also the abdominal viscera. Heart normal; brain notexamined.

Treatment. - Fortunately, the only diseases with whichpleuritis in the infant is likely to be confounded-viz., pneu-monia and pericarditis-are of an inflammatory nature, and willdemand nearly the same treatment. I would, however, inpleuritis, if seen in the first stage, have recourse to more activemeasures than in pneumonia; but this disease is, unfortunately,so rapid in its progress, that medical aid is seldom sought for,until such an amount of mischief has taken place that alltreatment is unavailable. If, however, the case is seen early,there is no reason why the disease may not be arrested and thelittle patient cured. I have attended an infant, recently, inwhich I had reason to suspect, from the symptoms, the exist-ence of pleuritis. The child was seen at the commencementof the disease, the gums were lanced, the warm bath used,leeches applied to the chest, and calomel and tartarized anti-mony given at short intervals, and the child is now conva-lescent. The subjoined case I also believe to have been oneof pleuritis arrested in its first stage:-April 3rd, 1842, I wascalled to Mrs. P--’s child, Walworth, aged two years and ahalf. The child yesterday was in good health; it, however,fell down stairs, but did not appear injured by the fall;early this morning, the mother first observed its breathing tobe hurried and difficult.-Nine A.M.: The child is restless,breathing quick, with dry cough; pulse rapid; skin hot anddry; countenance anxious. Two-fifths of a grain of potassio-tartrate of antimony directly; two leeches to the chest, and apowder, consisting of a grain of calomel and three-fourths of agrain of ipecacuanha, every four hours.-Six P.M.: Much thesame as in the morning, breathing still very rapid; pulsequick, with bruit de frottement very distinct in both sides ofthe chest; no crepitating râle present. The antimonial powderdid not act as an emetic. The gums to be lanced, and powderscontaining half a grain of calomel and one-tenth of a grain ofantimonial powder to be given every three hours.

4th.-Breathing very quick, but the child is altogetherbetter; bruit de frottement still very distinct. Continue themedicine.

5th.-Better; the rubbing sound less audible.8th.-Convalescent.20th.-The child appears to be tolerably well.My object in this communication has been, 1st, to show that

pleuritis in infants is not so rare a disease as is generally be-lieved ; 2ndly, that when the inflammation is confined chieflyto the pleura, it may be easily recognised, and that even whencomplicated with pneumonia, attention to the auscultory signsmay enable us to detect its existence; 3rdly, that whetheraccompanied by pneumonic inflammation, or occurring alone;it is a disease of great danger, and that unless remedies areearly applied, it is but little, if at all, amenable to medicaltreatment.

ON THE EFFICACY OF PYRO-ACETIC SPIRITIN GOUT AND RHEUMATISM.

BY JOHN HASTINGS, M.D., London.IT is nearly four years since I called the attention of the

profession to the remedial powers of pyro-acetic spirit, or me-dicinal naphtha,, in plxthisis. It occasioned a great deal ofdiscussion at that period, and many who questioned its valuethen have since acknowledged the truth of my views; and Ibelieve many more would have done so, but unfortunately thesymptoms of early phthisis are not sufficiently precise tosatisfy the minds of those disposed to be sceptical. Theopinions I then advanced I have had frequent opportunities ofconfirming.However, it is gratifying to perceive that it is attracting

attention on the other side of the Channel; and I also findthat a book has been recently published by Renshaw,* writtenby an M.R.C.S., on the treatment of this disease, in whichpyro-acetic spirit is put forth as the great curative agent; butthis is without a single mention of my name in its pages.

I have now to deal with another class of diseases, about thediagnosis of which there is no room for either cavil or doubt:I mean, gout, acute and chronic rheumatism. For upwards oftwelve months I have employed pyro-acetic spirit in theseaffections, and my treatment has been attended with a successquite extraordinary, far exceediug the results usually obtainedby colchicum &c. I have not yet seen a case of gout or acuterheumatism which has not rapidly disappeared under its use,at the same time that it brings about a very improved conditionof the general health. Chronic rheumatism requires a morelengthened treatment for its removal ; indeed, it has lesspower over this affection than the two preceding.

I should have forwarded a report of cases, with further ob-servations on this treatment, but from my conviction of itsvalue, I thought it better to make this general statement, andalso to assert my claim to having been the first to employ thisagent in a class of diseases hitherto so intractable, and deferthe other for a future occasion.

Albemarle-street, Dec. l8-t6.

CASE OF

GUNSHOT WOUND OF THE LUNG,WHERE THE BALL LODGED FIFTY YEARS.

BY EDWARD MOORE, M.D., F.L.S., Plymouth.THE generally fatal character of wounds of the lungs

renders an exception to that rule a matter of interest to themedical profession, and especially so where, as in the presentinstance, the individual survived for a period of nearly fiftyyears; and the case also being otherwise attended with somevery singular circumstances, may be considered as peculiarlyworthy of record.The subject of this communication, Mr. John Lennon, was

celebrated, during the last war, for his bravery and energyduring many eventful periods of its continuance. Originallya midshipman in the Royal navy, he quitted the service in1796, and took the command, at Martinique, of an armedschooner, " The Favourite," letter of marque, of six guns andtwenty men. On his first cruise, in December of that year, hefell in with three privateers, two Spanish and one French, thelatter having eight guns and sixty-five men, when, after an en-gagement of one hour and a quarter, he was wounded in the backby a musket-shot, which entered about the right fifth rib,midway between the spine and scapula. He fell, and his crewmade no further resistance to so superior a force. lie wastaken into Carthagena, whence lie was conveyed in theSpanish frigate " Helena" to the hospital at the Havannah,and after four months he was exchanged by cartel to Ber-muda. Mr. Lennon detailed, that on receiving the shot, hefell, and presently became faint, and experienced a sensationof suffocation, accompanied with bloody expectoration. TheFrench captain examined the wound, and finding blood issuingfrom it in large quantities, he stuiled some cloth into it, andbound a sash round the chest. This gave instant relief, par-ticularly to the faintness and difficulty of breathing—probablyby restraining hæmorrhage from the intercostal artery. Hefurther related, that on arriving at the Havannah, he wastormented with a sensation as if the ball was lodged in thediaphragm, about the anterior end of the osseous portion of

* La Phthtsie et les autrcs Maladies de la Poitrine traitées par les Fumi-gations de Goudron et le Medicinal Naphtha. Par le Dr. Sales-Girons.Paris: Labi, Libraire de la Faculté tic Mcdecine, 4, Place de I’Ecole de Mé-decine, 1846.