case in which he drew off from the head of a child congenitally hydrocephalic, six pints and three quarters of fluid in eight tappings, between the seventh and thirteenth months. It is stated, and deserves to be noted, that "after each tapping the kidneys uniformly acted more freely for several days, more urine being discharged than at other times, even when diuretics were administered." This child, whose life was certainly prolonged by the operation, "fell an easy victim to a simultaneous attack of thrush and hooping cough." Greatwood records the case of a hydrocephalic child fifteen months old, whose head was punctured by falling on a nail, and the fluid escaping, it perfectly recovered. Dr. Conquest has collected nine successful examples of paracentesis capitis, of which four were cases of his own; he having himself operated on nine patients. It is not proper to withdraw too much of the collected fluid at once; twenty ounces is the largest amount reported; nor should the punctures be repeated too frequently. The loose pendulous bones of the cranium, must be carefully sustained by the pressure of strips of adhesive plaster and bandages, properly adapted. Indeed, this gentle and continued compression by strips and bandages, seems, in chronic cases, of itself remedial. Barnard and Sir Gilbert Blane have each recorded a case cured under this treatment; not exclusively employed, however, internal remedies being at the same time administered.

Professor Dugas, of Augusta, Georgia, has published in the valuable journal of which he was the editor, an interesting history of a child, whose life he prolonged by seven tappings. (Vol. i., 1837.)

Mr. Brown, of Haverford West, recites the case of an infant six months old, whose head was punctured eight times. At its death, a large wash basin full of fluid was found in the sac, which was "formed by the unfolded brain."

A most instructive detail of successful treatment by this method. was communicated to the Provincial Medical and Surgical Association, in 1840, by Mr. Kitsell. The subject was his own son, eighteen months old. When he had nearly reached the age of eight months, symptoms of subacute cerebral disease began to manifest themselves. They were preceded, as is usual, by the tokens of abdominal disorder, and irritated bowels, with paucity of urine, furred tongue, occasional vomiting, etc. With the increase of these ailments, the head became enlarged, and the parietal bones separated to the extent of two inches. Then followed the familiar, but most annoying, series of phenomena belonging to the advanced stages of hydrocephalus; "rolling of the head on the pillow, tendency to coma, contraction of the thumbs and feet, stertorous breathing, dilated pupils, strabismus, and lastly, convulsions of the most distressing character numbering fourteen in thirty hours, with opisthotonos, blackened countenance, foaming at the mouth, etc.; each fit threatening the immediate extinction of life." The head was punctured during a convulsion, the trocar being passed to the depth of two inches before any fluid escaped, the puncture being made very obliquely that it might be as valvular as possible. "The instrument was introduced about an inch below the anterior superior angle of the left parietal bone, in the direction of the lateral

ventricle. About 16 ounces of limpid colorless fluid were speedily drawn off, which appeared to act like magic in subduing all the bad symptoms, no convulsions occurring afterwards. Instead of closing the wound with a compressed and retentive bandage, Mr. K. encouraged the discharge of fluid, by occasionally opening and cleansing the puncture, thus allowing it to escape probably as fast as it was secreted; this continued about five days and nights, gradually subsiding, after soaking a large number of napkins, the total quantity being computed at about four pints." Mr. K. attributes the happy result to the large opening, and the slow and constant discharge, which permitted the parts to contract slowly into their natural condition and relations. Four months after the operation, the health and vigor of the child seemed to be completely restored; the head retained its diminished size, the various sutures being closed, and was thickly covered with hair. (American Journal, Jan. 1850.)

SCROFULOSIS-STRUMA-SCROFula.

The primary local origin of all diseases, is a doctrine so strongly insisted on, and so frequently referred to by a large majority of modern writers on pathology and practice, that it cannot fail to have impressed the mind of every attentive student. Of late, indeed, there seems to me some danger that we shall lose sight of a principle of little less importance, the dependence, namely, of local affections, diseases implying lesions of peculiar character, as well as functional disturbance of various organs, upon special conditions of the animal constitution, of unlimited and, indeed, universal influence. There are probably many such vitiations of the general system, predisposing to and productive of local maladies; as examples, it will suffice to refer to gout, cancer, and scrofula, the latter of which I now proceed to make the subject of a brief and comprehensive essay.

When developed, under the agency of whatever circumstances, scrofula may attack every organ and tissue of the body. The skin, the glands, the bones, and joints, the mucous membrane, the eyes, the lungs-nay, the very heart itself, have been found altered in structure. The lesions which we ascribe to scrofulous predisposition, vary somewhat in the several parts affected, but we infer with sufficient clearness their dependence upon a common source. This morbid state of the system-somewhat obscure in its nature and not easily definable-we speak of technically as "occult scrofula; the scrofulous or strumous diathesis." The liability of the several organs and tissues to scrofulous affections, seems in some degree to depend upon age; thus, in infancy and early childhood, we have a singular irritability of the skin and eyes, and great frequency of cutaneous inflammation and ophthalmia; next we have inflammation of the bones and joints, white swellings and morbus coxarius, or glandular enlargements and indurations, and lastly, phthisis, pulmonary consumption in its worst form. It is to be noted that some subjects go successively through all these ailments, and again, that, in many families, especially when the parents have

been affected with any of these forms of scrofula, some of the children will exhibit one, and others a different local malady of the series above enumerated. I do not hesitate farther to state, that in all such families and in obvious connection with the class of disorders indicated, we shall find a remarkable liability to the production of what is called tubercle and the deposition of tuberculous matter.

Whether, indeed, scrofulosis, or the constitutional tendency to scrofu. lous deposit and inflammation, and tuberculosis, or the constitutional tendency to tubercular deposit with its results, are identical, is a question not yet absolutely settled. They are, however, obviously and closely related, and I shall, therefore, treat of them in connection, so far separating them as merely to bring into strong prominence the circumstances considered characteristic of each. Pathologically regarded, it would be indeed difficult, in the present state of our knowledge of them, either to set them definitely apart from each other, or entirely to confound them together.

The conditions in which we meet with them are, if not positively identical, very remarkably analogous and similar. They may be said to consist in a cachectic state of constitution, the chronic production of the crowd-poison ochlesis, as typhosis is its immediate and acute effect. "Domestication or confinement of the lower animals," says Williams, "always gives rise to scrofula. The stabled cow, the penned sheep, the tame rabbit, the caged lion, tiger, elephant, are almost invariably thus cut off. In Cornwall and Devon, the healthiest counties in England, one-half of the miners, deprived of air and light, die of phthisis pul monalis." (Cyc. Met.)

The deposits which occur in the cachectic states thus spoken of as concurrent and closely associated, are affirmed by Vogel to be histologically undistinguishable. They are described as "an amorphous transparent stroma, with molecular granules, and larger corpuscles, imperfect cells, and cytoblasts. These elements are partly protein compounds, partly fat, and partly calcareous salts, phosphate and carbonate of lime." We shall see, when we treat of tuberculosis, how the same analysis is repeated, and how minute and doubtful are the points of suggested diagnosis. We shall see how divided the best authorities are on the subject; while Legrand urges the existence of definite distinctions, Mandl denies that tubercle presents any specific morphologic or characteristic elements.

Typhosis seems independent of any previous circumstances, and may arise abruptly in any, the most healthy system. It is possible, as we shall by-and-by state, that tuberculosis may be also promptly generated under very special contingencies. But, so far as we know, scrofulosis requires time, and the fostering influence of predisposing causes, for its development.

There is, in the whole circle of pathological discussions, no topic so deeply obscure as the doctrine of predisposition, which involves, as perhaps its most obscure division, the history of latent periods.

The hereditary transmission of inevitable tendencies to special disease, is too clearly obvious to admit of a doubt; gout, which does not necessarily imply, even in those who have been repeatedly attacked by

it, any notable change in the structure or arrangement of any part, is transmitted only in the latent tendency; and we may suppose the offspring of a gouty ancestor to be in precisely the same condition in which his parent would be found during the intervals between his paroxysms of podagra. Thus, also, it is with those who are destined to suffer, like their progenitors, from carcinoma.

The nature of occult scrofula-scrofulosis-this latent but strong predisposition to known forms of local diseases, various in seat and in modes of development, is a subject of very unsettled dispute. A majority of recent writers are disposed to regard the strumous diathesis as essentially connected with, if not dependent upon a certain depraved state of the digestive organs. Of the truth of the assumption I am, however, very doubtful. I see, daily, cases of scrofula of great diversity, where the subjects are totally unconscious of any obstacle or imperfection in the functions of the stomach and bowels.

That the nutritive or assimilative functions are impaired, or perverted, is, on the other hand, very evident. It is probable that the original germ is often ill-developed. Thus, besides the diseased appearances above described, the infants of scrofulous parents are often born hydrocephalic, or fall into hydrocephalus soon after birth, or become subjects of rickets or marasmus. The causes which give rise to this peculiar state of constitution seem calculated, indeed, to affect the assimilative function specially, though, perhaps, not exclusively. John Hunter attributes scrofula to "dampness and cold, alternating with heat, and any agents which debilitate the system;" and adds, "that it prevails chiefly in latitudes above forty-five degrees." Parr declares roundly, that "it is not only hereditary, but, in low, damp situations, endemic." Mr. Lloyd considers "the simple or combined operation of cold and variable temperature, with excessive humidity and impurity of the air," as capable of originating a scrofulous state of the system. All agree in ascribing its production to the impure air of crowded manufactories; residence in narrow, ill ventilated lanes, low, damp houses-such as the hovels of the poor in large cities; a foul, neglected state of the skin and the clothing; imperfect shelter from the changes of atmosphere; innutritious, indigestible, insufficient diet; intemperance, indolence-which all tend to lower the degree of animal vigor, and deteriorate the physical condition of those subject to their influence. It is, as I have above stated, the chronic effect of moderate and persistent exposure to the crowd-poison, ochlesis, as typhosis is the acute result of intense and concentrated application of the same poison.

Children of parents existing under these circumstances, must be endowed with an inferior kind of vitality, and must be born diseased, or liable to the easy invasion of disease; and experience and observation have shown that certain modes and characters of morbid affection are peculiarly or inevitably apt to develop themselves. That these have a common cause in the ancestral condition of constitution, is farther shown by their occurrence in several children of the same parents, if not in all; and in their passing down, tenaciously transmitted, even after the original causes above enumerated may, for some generations, have ceased to act, or their influences have been notably coun

teracted. That they are also linked together proximately, by similarity or morbid identity, we infer, from the fact that they occur successively in the same individual, or promiscuously in the several children of the same parents. Thus, we shall see in the family of a scrofulous father or mother, one child suffering from cutaneous affections of a definite character, another with ophthalmia, a third with rickets, or marasmus, or dropsy of the head. As the same family advances in age, we shall see white swelling of the knee-joint in one, a second deformed with morbus coxarius, and a third with the cervical glands swollen, suppurating and ulcerating into ugly sores; and, in process of time, the whole generation becoming extinct, from the desolation of tubercular phthisis. These conclusions, I say, are irresistible from the daily repeated coincidence of the facts from which they are deduced, and we may safely and logically regard them as established beyond reasonable dispute.

While scrofula is occult or latent, we have no positive indications from which we can infer the presence of strumous predisposition, or the existence of a morbid state of constitution. There are, however, certain external marks, or physiognomical appearances much dwelt on, as exhibiting the internal tendencies. Thus, a child descended from scrofulous parents will usually present, it is said, a soft, fair, flaccid skin, a blue eye and light hair; the outlines of his figure and his countenance will be rounded, and his upper lip full, tumid, and divided in the centre by a deep fissure. As my own opportunities for observation have been extended, I have been less and less disposed to place confidence in this scrofulous physiognomy, having met with very numerous examples of the disease in subjects of dark complexion, black hair and eyes, and coarse skin.

It is easy to account for the belief in the concurrence of the first set of signs in the case, when we remember that they describe the national or tribal characteristics of the Teutonic or Anglo-Saxon races, from whom we have taken the description, and who, from climate and national occupations, and modes of living, have been widely afflicted with scrofula. No region or nation, however, in the world, is free from it. Among us, its undisputed ravages, especially in the melancholy form of phthisis, are becoming more frequent in every successive generation, and although the negro is by no means free from its attack, the mixed race of mulattoes exhibit a special liability to it.

I have alluded to its successive developments, as somewhat connected with the age of the subject. Tubercle, of which I will by-andby speak more in detail-tubercular formation may occur at any period; during the foetal state, or as late as the sixtieth year of life. Cullen declares that "scrofula rarely makes its first appearance after the age of puberty," and I am much inclined to subscribe to the cor rectness of the remark; at any rate, if a child had evaded every development of the diathesis so long, I would indulge a strong hope that, with prudence, he might escape its influence altogether. The nature and phenomena of the local changes which thus occur in scrofulous subjects, have been carefully examined, and repeatedly described. The cutaneous eruptions appear earliest, usually at first