I do not remember to have met with the phlegmonous form, quinsy, in a very young child.

Treatment. In a robust adult, it may be necessary to bleed freely from the arm. Local bloodletting by leeches is almost always useful. Crampton and others propose to carry them to the inflamed spot.

Emetics are often given in the first stage, and with advantage, if the stomach is oppressed, the tongue foul, and the breath fetid, without vomiting. Cathartics, especially the saline, are almost universally required. They may be combined with diaphoretics, as, at first, ipecacuanha and antimony, and afterwards with the infusion of serpentaria or seneka. When farther depletion is unnecessary, we may reduce the force of the circulation by moderate doses of nit. potass. combined during the day with au antimonial, and at night with Dover's powder. Various local applications are recommended. Velpeau's suggestion of the application of powdered alum has proved very useful. The remedy, he himself says, however, is only of benefit in the superficial pharyngitis; it does harm in the tonsillary or phlegmonous.

I disapprove of all gargles in the early stage, as painful and irritating. The steam of water at a moderate heat may be inhaled, to relax and soothe the parts and procure a flow of saliva and mucus. After a time, the sedative and mildly astringent solutions may be of some advantage, more especially where there is ulceration. Nit. potass., alum, sulph. zinc, acet. plumbi, and the mineral acids are much used. Infus. cinchona and myrrh are among the best. This may require special attention in the case of children, the foul secretions from whose ulcerated fauces it may be necessary to cleanse with a syringe, or a bit of lint attached to a probe.

Where any membranous deposit appears upon the surface, we must resort to the nitrate of silver. A strong solution of 10 grs. to j in an ounce of water should be applied by a sponge or lint freely to the parts affected and repeatedly, until their condition is changed and lymph no longer effused. Many prefer to employ in this way the muriatic or hydrochloric acid. Both Bretonneau in France and Fourgeaud in California ascribe to it a specific efficacy.

The employment of the stimulating gargles, so much in vogue, requires judgment and discrimination. It cannot be denied that there are cases in which, even from the first, the infusion of cayenne is beneficial, but it is difficult to point them out; and it is a good general rule to abstain from the use of these washes until the ulcer has become somewhat indolent and the case assumes a chronic character. In such instances, good is done with the solution of the sulph. cupri, and by touching the ulcerated surface with the nitrate of silver. These cases farther demand the administration of alteratives and tonics. A mild mercurial course, as of blue pill or merc. corros, sub., may be alternated or combined with the use of the bark and the mineral tonics, of which the best is the tinct. mur. ferri.

The uvula is sometimes permanently elongated or relaxed so as to fall upon the back of the tongue, and keeps up a harassing cough, which, in some cases, has been the precursor of phthisis. To prevent this, it should be amputated. When the tonsil is so much enlarged as

to impede the respiration, we must not hesitate to pass a lancet freely into and across it. If an abscess has formed, we evacuate the matter at once; if not, we give relief by diminishing the bulk of the tonsil, and reduce its inflammation by emptying its vessels. If the tumefaction be so great that the patient is in danger of being suffocated, an opening should be made in the trachea until the tumor subsides or suppurates. The tonsils remaining indurated and enlarged, they should be freely scarified in all directions, or completely extirpated.

MALIGNANT SORE-THROAT, Cynanche maligna, may be described as a combination of inflammation of the throat with the lowest grade of typhus fever. Sporadic cases are often met with, but it is apt to appear as an epidemic. Its proportional mortality is frightful. Its subjects are generally young persons and children, from infancy to puberty.

Symptoms.-The attack is ushered in with nausea, and sometimes vomiting; there is oppression, restlessness, anxiety; the voice is hoarse or husky, the skin dry and constricted; there is thirst; the pulse is small, compressible, very frequent; there is great languor and prostration. It is not in every case that there is any pain or difficulty in swallowing, but on examining the throat, we find a dusky redness overspreading the whole surface of the pharynx, fauces, tonsil, and uvula. One or more ash-colored ulcers may appear, which spread rapidly, with little or no pain; or, as is much more common, there is an exudation of plastic lymph covering the inflamed surface, to which it adheres pretty firmly. Pieces of this membrane are frequently thrown off, dark-colored and offensive, with a foul discharge from the surface. An efflorescence often shows itself on the skin, but by no means uniformly or even in a majority of cases, as affirmed by European writers, who often confound scarlatina anginosa and maligna with our present subject. As the disease progresses, the inflamed parts may assume a gangrenous disposition, becoming livid or even black, with great fetor. Diarrhoea comes on, and the patient soon sinks exhausted.

The cause of this malignant pestilence is unknown. It is usually epidemic in its prevalence. It is alleged, also, to be contagious.

The prognosis is highly unfavorable. The younger the subject, in general, the greater the danger. In early life there is special liability to the extension of the ulcerous action and effusion of lymph into the larynx, a combination almost always fatal. In older subjects we judge of the degree of risk, as in typhous fevers, with less reference to the local affection.

Treatment. The general management of the patient is similar to that recommended under the head of typhus fever. It is the usual practice to premise an emetic. Ipecac. is, perhaps, the best, but some prefer the antimonial, as more active, and others regard the sulph. cupri as exerting a special efficacy. I see no objection to either. Our permanent reliance is upon the class of stimulating diaphoretics which may be employed in turn; the infusion of serpentaria or seneka, the combination of carb. potass. with the tinct. opii camphorata, the acet.

and carb. of ammonia, the nit. ether with the infus. cinchonæ; a generous and stimulating diet should be allowed, with wine, in proper amount; if necessary, the bowels, in the mean time, being gently acted upon by some mild cathartic. I prefer, to all others, the combination of merc. dulc. with pulv. rhei, in small doses and at proper intervals.

Of local applications, I regard the blister and the leech to be alike of equivocal effect, and prefer mustard or lin. vol. to either. The throat and mouth must be kept scrupulously clean. The ash-colored spots must be touched with the strong solution of nitrate of silver or muriatic acid occasionally, and the foul secretions washed off with the syringe, or, if the patient can use them, with gargles. These should be somewhat stimulating. The infus. cinchon. with myrrh or camphor, with the mineral acids, is much to be confided in. The infusion of cayenne pepper is greatly in vogue, and often does good service. Besides this very useful local application as a gargle, it is, perhaps, our best internal stimulant, and should be administered freely. The infusion should be preferred as strong as the patient can take without suffering, and containing a small proportion of common salt. When its pungency cannot be borne, the pulv. capsic. should be prescribed in substance, made up into pills or covered in capsules of jelly.

Like all other typhoid affections, cynanche maligna is apt to produce or associate with itself some cutaneous efflorescence, which often resembles erysipelatous inflammation, but more commonly is a mere erythema. This is the source of the confusion so often made between malignant sore-throat and scarlatina maligna; and it must be confessed that there are several points in common, presented by the two maladies. But a careful examination will show the absence of many of the specific symptoms or characteristics of scarlatina in the merely anginose cases; and the absence of the ordinary sequelæ, and the subsequent liability to the true exanthem, leave no doubt of the essential difference that separates them.

In Dr. Drake's earliest work, Notices concerning Cincinnati, dated 1810, there occurs the following paragraph: "Angina maligna and scarlatina anginosa. The former of these diseases had an extensive and fatal prevalence in this country eighteen or twenty years since; the latter, probably, has never prevailed generally here." The former, indeed, is of frequent spontaneous origin; the latter waits to be imported and communicated.

SECTION III.

DISEASES OF THE RESPIRATORY
SYSTEM.

NEXT in order we proceed to treat of the diseases of the organs of respiration, under which head we include the larynx, trachea, bronchi, and lungs. Here we shall meet with many of the most destructive, and some of the most rapidly fatal maladies to which the human constitution is liable. The necessity of an adequate supply of atmospheric air, and of its easy and unimpeded access to the cells constructed to receive it, is urgent and absolute. Any affection of the pipe or tube through which it passes to the lung must therefore be distressing and dangerous, in exact proportion to the degree of impediment presented to its entrance and escape, thus presenting an obvious mechanical risk in addition to the general irritation, and other ill consequences, which may arise from the nature and ultimate effects of such disorder.

The functions of this set of organs are complicated as well as delicate, in a peculiar degree. Some chemical changes evidently occur from the admission of air, and its contact with the blood diffused over the pulmonary tissue; these are cognizable to the senses, both as regards the blood and the air. But these constitute only a portion of the results; certain other changes, of a vital and undefined character, are inferred with little less clearness, although they cannot be made the subject of experiment and calculation. I allude to the animalization-the assimilation of the chyle, which is now conceived to be in great measure effected during the passage of the blood, with which it has just been mingled, from the right to the left ventricle. This blood is found to be not only redder from its loss of carbon and union with oxygen, but more highly vitalized and better fitted in every way for the support and nutrition of every part of the organism. Diseases of the respiratory organs may then become fatal in three modes, of which we shall meet with examples; 1. By their general influence upon the constitution, depending upon their nature and the sympathies which they excite, and analogous to the effects of similar derangements located elsewhere. 2. By impeding or impairing the ultimate assimilation of chyle, and thus depriving the blood of a due supply of its nutritive and stimulating materials, whence emaciation, exhaustion, and fatal debility. 3. By impediments offered to the passage of air in the airtubes, producing mechanical suffocation.

Of late years the exploration of the thorax has claimed the special attention of the practitioner, and has been made the source of important

aud definite inferences concerning the actual state of the organs contained in its cavities.

1. When there is nothing to prohibit the exposure of the upper part of the body, the patient should be stripped and carefully examined with the eye and hand. Any want of symmetry of form, any inequality of, or difference between the two sides of the chest, must be carefully noted. Observe if the whole structure is heaved and elevated regularly by the motions of respiration; making the subject respire slowly and deeply, and rapidly. Note the relative position of the sternum and the arch of the cartilages, and examine the spine. There are some deformities which seem consistent with the enjoyment of health, such as the one-sided projections of the cartilages and sternum denoted by the phrases "cuirass," and "pigeon breast," and so on.

2. It is next proper to inquire into the capacity of the thorax. Unless in extreme cases, it is perhaps right to acknowledge that no great stress is laid on this method, considered absolutely; but in a comparative point of view, it is of great value. If the capacity of the lungs to admit air diminish sensibly from time to time, it is evident that the situation of the patient must be getting worse; on the contrary, we draw the most favorable inference from the fact that his inspirations are becoming fuller and deeper. It should be farther admitted, that none of our methods of examining into this question of thoracic capacity are very definite. There are three modes proposed. The first is a careful measurement externally. This being done accurately at proper intervals, we shall know if the flattening of the chest on either side increases or diminishes. The second is, by the use of some spirometer. The subject may breathe into a gas-holder or bell-glass, or common large bottle filled with water and inverted over a trough or basin. It is easy to mark how much water is thus displaced, and to compare this quantity at different periods in the progress of a chronic case. The third is often intuitively resorted to by patients for their own information. A subject whose lungs are capable of containing a large amount of atmospheric air may retain his breath a greater length of time than one who labors under any disease which renders the lung contracted in its capacity. The latter must breathe oftener to supply the demand for the depuration of venous blood sent into the pulmonary vessels. There is scarcely anything which annoys a patient more than the quick panting to which he finds himself a prey; it distracts and fatigues him. The extent of capacity differs in different individuals-some divers remain under water a full minute or even more—but to retain the breath or inspire slowly from thirty to fifty seconds, is good proof, I would say, of average capacity. Of course, we are better satisfied with comparative than with absolute inferences, yet the comparison must be fairly made. We must allow for the contingencies of accelerated circulation from fever or muscular action, which hurry the breathing greatly; and for the diminished cavity of the thorax after a full meal.

3. Of the Hippocratic succussion I shall say little. It is not in every case of thoracic effusion that this sort of agitation will detect the anticipated sounds. No result will follow the most abrupt movement or