AN
ATTEMPT
To establish the
ORIGINAL SAMENESS
OF
Three Phenomena of Fever,
(PRINCIPALLY CONFINED TO INFANTS AND CHILDREN),
Described by Medical Writers under the several
Names of
HYDROCEPHALUS INTERNUS, CYNAN-
CHE TRACHEALIS,
AND
DIARRHEA INFANTUM.
By CHARLES CALDWELL,
FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILA-
DELPHIA, &C.
PHILADELPHIA;
PRINTED BY THOMAS DOBSON, AT THE STONE-HOUSE,
N° 41, SOUTH SECOND-STREET.
1796.



AN
INAUGURAL DISSERTATION,
FOR THE DEGREE OF
DOCTOR of MEDICINE;
Examined and approved by
THE MEDICAL FACULTY
OF
The University of Pennsylvania,
AND DULY DEFENDED BEFORE
THE BOARD OF THAT INSTITUTION,
ON THE 17th DAY OF MAY 1796. 



TO THE
PRESIDENT and MEMBERS
OF THE
AMERICAN PHILOSOPHICAL SOCIETY.
GENTLEMEN,
I FLY not to the authority of the Ameri-
can Philosophical Society as a city of refuge from the
strictures of criticism; nor do I supplicate from the
dignity of the Philosophical character the shadow of
patronage to the following publication. My open appeal
ismade, my respectful address is directed solely to that
liberality and candor which never fail to characterize
the truly philosophical mind.
I have ventured to explore a narrow, but in my
view, an important tract of terra incognita in patho-
logical science: I have hazarded a free and a public
declaration of what I there observed. To most, if not
indeed to all practitioners of medicine, my position re-
specting 

vi DEDICATION.
specting the original sameness of the three topical dis-
eases embraced in my dissertation, will be wholly new;
to many it will appear improbable, perhaps erroneous.
A thorough and dispassionate investigation of this sub-
ject is what I most earnestly desire. If my opinions be
indeed unfounded, I am open to conviction on rational
principles; if they be just, I wish to see them more ably
elucidated, more fully confirmed. In neither case can
my views be answered; in neither case can the interest
of science be advanced, save by the talents and atten-
tion of medical philosophers alone—To the magnitude
and difficulty of such a task, mere physicians are
wholly incompetent.
To the medical philosophers, therefore, of the institu-
tion I address, is the following inaugural dissertation
more particularly dedicated. To their liberality it is
recommended; to their perusal and consideration it is
freely submitted. They will examine it with candor,
and judge of it without the bias of prepossession. Their
decision will be the voice of calm conviction, not the cry
of impassioned prejudice. They will think, they will
"speak of it as it is." Their award will be charac-
terized 

vii DEDICATION.             
terized by literal justice, not by severity undeserved,
not by indulgence unsolicited. They will not condemn
from motives of envy, nor will they praise from those of
special grace.
Should the principles and opinions contained in the
following pages correspond to the enlightened views of
such competent and impartial judges, their approbation
will not only afford the highest gratification to my feel-
ings, but will doubtless tend to my farther confirmation
in the truth of those medical tenets I am about to deli-
ver to the world. But should they, on the other hand,
be considered as either doubtful or wholly unfounded, the
strictures and objections of the liberal and learned,
shall, from me, ever meet with a candid reception.
With sentiments of esteem and respect the most pro-
found, I have the honour to be,
GENTLEMEN,
Your obedient and
Very humble servant,
PHILADELPHlA, 
May 4th, 1796.  
The AUTHOR.



Inaugural Dissertation, &c.
SECTION I.
INTRODUCTION.
THE frequent occurrence, the obstinate re-
sistance, and the melancholy effects of those pheno-
mena of fever to which my present speculations are
confined, will doubtless be admitted as a sufficient
apology for every possible attempt to investigate
their cause, to elucidate their nature, or to obviate
with success their worst result.
I have called them phenomena or symptoms, be-
cause I do not consider them as primary diseases; I
shall treat of them as the dependent effects, not as
the original cause of that febrile state of the sys-
tem, by which they never fail to be accompanied.
Without the previous existence of general fever
these phenomena can no more occur, than an effect
B can 

(10)
can, in any instance, take place without the pre-ex-
istence and pre-action of its cause. They shall be
considered then, in the following pages, as the ge-
nuine and destructive offspring of arterial action,
morbid in its nature, excessive in its violence, and by
causes of peculiar tendency determined to the ence-
phalon, the trachea, or the intestines.
I cannot believe, as is alledged by some, that
these phenomena or symptoms of general disease,
even when existing in the most consummate degree,
possess any considerable power as co-operating causes
tending to augment the febrile affection from which
they derived their origin *—They are the imme-
diate result of an evacuating process, which never
fails to diminish the impetuosity and tumult of fe-
* To the extent of this general observation, Cynanche tra-
chealis (that most distressing, and perhaps I might add, most
fatal of all febrile phenomena) may seem indeed to consti-
tute a just exception. Possibly the preternatural membrane,
which here occurs, and invests, as a lining, the parietes of the
trachea, may, by its irritating and painful impression on this
exquisitely sensible tube, co-operate with other causes in con-
tinuing or even augmenting that febrile affection from which
it originally derived its existence. Neither observation, how-
ever, nor yet any practicable effort of speculation has been
able to furnish me with reasons sufficient to convince me, that
that from this cause, so partial and circumscribed, any febrile
affection of importance can probably arise.
brile

(11)
brile action. This process is, indeed, in the pre-
sent case, uniformly attended with more or less un-
easiness and pain; but the stimulant effect of the
pain occasioned by the distension of the arteries and
their consequent effort to discharge their irritating
contents, is perhaps fully counterbalanced by the
powerfully sedative tendency of the simultaneous
evacuation.
But although these phenomena be indeed the ef-
fects and not the causes of that febrile affection of
the system by which they are always accompanied;
yet when completely formed, they become real and
original causes of succeeding symptoms, more alarm-
ing in their appearance, more distressing in their na-
ture, and more certainly fatal * in their final result.
* I would by no means have the reader to suppose, that I
believe hydrocephalus internus, cynanche trachealis, and di-
arrhea infantum to be diseases literally incurable—It is how-
ever a consideration equally painful to humanity, and humilia-
ting to the professors of the healing art, that when once these
local affections have become fully established and firmly root-
ed in their respective organs, they too frequently baffle every
possible attempt to dislodge them, and thus free the system
from that melancholy groupe of symptoms to which they give
birth and duration. Hence, therefore, we infer the necessity
of treating the system, previously to the actual existence of
these phenomena, in such a way, as may most effectually tend
to prevent their complete accession.
B2 Of

(12)
Of these latter symptoms a brief detail shall be
given in subsequent pages of this dissertation.
I have said that those phenomena of fever, to
which my present speculations immediately relate,
are principally confined to infants and children. I
beg leave to state a few observations briefly expla-
natory of the cause, why this tender, helpless, and
innocent portion of the human race, are so exclu-
sively * subjected to such formidable and destructive
maladies.
At the expiration of ten lunar months from the
period of conception, the tender infant emerges into
actual life, with many organs and parts of its body
in a very unfinished and imperfect state. This im-
perfection manifests itself to a degree peculiarly ob-
vious and striking in the bones of the head and
face. Those of the head in particular exhibit nu-
* Exceptions may perhaps be taken to the pointed defini-
tude of the word "exclusively." Many physicians of accuracy
and eminence allege, that they have actually seen adults af-
fected by the diseases now under consideration, more espe-
cially by that of hydrocephalus internum I admit and be-
lieve that such cases do indeed occur; but they are so extremely
rare, as to merit no particular attention in an essay chiefly
confined to general observations and principles, and not in-
tended to treat of subjects in minute detail.
merous 

(13)
merous phenomena of a state extremely immature.
They are unfinished with respect to texture and
firmness (possessing a cartilaginous rather than a
bone-like consistence) and so highly defective in point
of size, that considerable interosseal vacuities are
known to exist in this important part of the infan-
tile system.—As nature seems to delight in a certain
degree of perfection in all her works, such is the
purport, such the uniform tendency of her establish-
ed laws, that these deficiencies in the bones of the
cranium must be gradually supplied—Not to men-
tion the changes which are yet to be effected in the
consistence, the articulation, and the figures of the
upper and lower maxillary bones, these are both, in
subservience to the fundamental and governing prin-
ciples of the system, to be furnished with two seve-
ral sets of teeth. Besides those already specified,
there exist, in the head and adjacent parts of the
infant, various other deficiencies, in degree less ob-
vious, in nature less important.
For certain essential and wise purposes in the im-
portant economy of man, it is necessary that the or-
ganization of the head be brought to ultimate per-
fection at an early period of life. The existing de-
ficiencies are therefore supplied, and most of the re-
quisite changes in this part of the system are usually
effected about the child's arrival at its twelfth year.
B3 During 

(14)
During the whole of this interesting period of
human life, as well as for several years afterwards,
the head exhibits a size evidently disproportioned to
that of the other parts of the body. To accommo-
date the disproportioned size of this part of the sys-
tem, and also to furnish matter for supplying the
deficiencies and effecting the requisite changes of
which I have already spoken, there necessarily ex-
ists, during the years of infancy and childhood, a
disproportioned determination of blood to the head
and immediately adjacent parts.
That such determination to the head does indeed
exist, more especially in the infantile state, we may
farther infer from the constant and profuse dis-
charges of saliva and mucus, which, during this
state, very generally take place from the eyes, nose,
and mouth; as also from the troublesome and pain-
ful eruptions which so frequently appear on the
heads of children during the two or three first years
of life.—Similar discharges of mucus not unfre-
quently occur in adults, when in consequence of an
obstruction of perspiration, co-operating with a con-
stipation of the bowels, and a diminished secretion
of urine, an undue proportion of blood is forcibly
thrown into the vessels of the head.
During 

(15)
During such a disproportioned afflux of blood to
the head of infants and children, it is obvious that
this part of the system must, from any considerable
encrease of arterial action, be subjected to more or
less danger in consequence of the augmented impe-
tus of the circulating fluid against the very delicate
vessels of the encephalon. When in these young
and tender subjects a violent attack of fever occurs,
with dry skin, costiveness, and a parsimonious dis-
charge of urine, so much is the determination of
blood to the head generally augmented, as to sub-
ject the unhappy patients to the hazard of all the
disastrous consequences of effusion, either from rup-
tures, or from an undue and morbid action, of the
tender vessels of the part—Hence we deduce the
leading cause why hydrocephalus internus, which
consists of a preternatural effusion of a serous or of
an aqueous fluid into the ventricles of the brain, is
fo very generally confined to infants and children.
We may further observe, that such subjects are
much more frequently than adults exposed to inju-
ries of the head from blows, falls *, and other acci-
dents arising out of the nature of their early sports
* When children fall (an incident which often occurs) the
heady in consequence of its disproportioned size and weight,
seldom fails to become a suffering part.
B4 and 
 

(16)
and amusements. These injuries often operate as
exciting causes of morbid and excessive action in the
vessels of the encephalon, thus exposing that im-
portant viscus to the risque of all the dreadful con-
sequences attendant on inflammation * or effusion.
To the foregoing considerations perhaps we may
with sufficient propriety add, that of human subjects
during the earlier periods of life, being more uni-
formly confined to a recumbent or horizontal posi-
tion, than is the case with those whose years are
more numerous, and whose consequent acquisitions
of strength are more considerable. To physicians
at all acquainted with the striking effects of gravita-
tion on the circulation of the blood, it is wholly
unnecessary to observe, that a recumbent position of
the body is highly favourable to a forcible propul-
sion of blood into the tender vessels of the encepha-
lon. The probable consequences which, during a
general febrile affection, may result from such habi-
* It must here be observed, that infants and children are
much less subject than adults to severe attacks of true topical
inflammation originating from general fever. The cause of this
should be sought for in the laxity and extreme irritability of
the exhaling vessels in the former subjects, and the consequent
facility with which they give admission to copious topical effu-
sions. This observation will apply to the vessels, not only of
the head, but also to those of every other part of the system
during the earlier years of life.
tual 

(17)
tual propulsion, are too obvious to call for a parti-
cular specification.
I have thus enumerated some of the principal
causes which seem to co-operate most powerfully in
subjecting infants and children, rather than adults, to
that melancholy affection of the head denominated
hydrocephalus internus. I will conclude my introduc-
tory section by attempting a few observations ex-
planatory of the reason, why the two remaining dis-
eases, namely, cynanche trachealis and diarrhea in-
fantum, are so exclusively confined to subjects of the
same age.
That in infants and children the general volume
of fluids bears a much greater proportion to the ag-
gregate mass of solids than in adults, is a truth with
which anatomists and physiologists have been long
acquainted. That in the former subjects the action
of the arterial system is proportionally more vigo-
rous, and the motion of the blood consequently
more rapid than in the latter, is also a position that
will not be controverted by the medical philosopher.
From these two well known circumstances, taken in
conjunction with the great laxity and exquisite irri-
tability of the minute arterial extremities, much
more copious discharges take place from exhaling
and secreting surfaces in very early than in more
advanced 

(i8)
advanced periods of life. Thus in infants and chil-
dren we observe numerous and plentiful stools of a
soft consistence, often profusely abounding with the
mucus of the intestines; while at the same time fre-
quent discharges of a viscid phlegm by coughing
and vomiting give evidence of a copious secretion
going forward in the esophagus, the trachea and its
ramifications, the bronchiæ.
Nature, as if conscious of these peculiarities in the
infantile economy, not unfrequently attempts to
avail herself of them for the purpose of eliminating
from the arterial system superabundant portions of
fluid, which if retained, might by its stimulant im-
pression prove injurious to health, perhaps even de-
structive of life itself. Thus, for example, when
children are attacked by a fever of excessive ac-
tion *, in which case a diminution of the volume of
* I beg leave in this place to suggest the propriety of dis-
tinguishing between genuine inflammatory fevers, and simple
fevers of excessive action. It is indeed true, that inflamma-
tory fevers are always fevers of too much action; but of this
proposition the converse is by no means equally admissible.
Fevers of too much action do not necessarily possess a nature
truly inflammatory. In order to be, with literal propriety,
entitled to the denomination of inflammatory, a fever should
be always accompanied by a topical affection, where the eva-
nescent extremities of the arteries are themselves brought into
blood 

(19)
blood becomes necessary, an effort of the constitu-
tion most undoubtedly takes place to effect this salu-
tary purpose by an increased discharge from some
excessive action, and where pain is thus generated by over-
distension from fluids in a misplaced situation. In a simple
fever of excessive action, no such local affection, no such stri-
king inequality of arterial exertion appears—In all parts of
the system the larger arteries act with too much frequency
and too much force; but in no part do the minute ramifica-
tions play with such undue violence as to produce either an
error loci, or a preternatural effusion of the circulating fluids.
That such a simple state of fever may, and indeed does, in
some cases, unequivocally exist, we are induced to believe
both from speculative theory and actual observation.—
Thus, for example, should a fever consisting in excessive
arterial action occur in a human subject: where every organ
and part of the system are in perfect equilibrium with regard
to irritability, sensibility, power, and action; in such a case
the production of a topical affection would be wholly imprac-
ticable. That systems of such an exquisite balance may actu-
ally exist, is a position to the probability of which we can be
easily induced to give our assent; and that fevers of such sim-
plicity do indeed occur, is a truth which I trust will not be
denied by physicians of experience and real observation. Be-
tween fevers truly inflammatory and those simply of excessive
action, a very material difference should be observed in point
of practice—In the former both general depletion and topical
applications are absolutely essential; whereas in the latter ge-
neral depletion is alone sufficient.
particular 

(20)
particular part of the system—or, in other words,
an undue determination of blood to some organ or
part of the human body generally occurs. When
this determination is directed to the trachea, cynan-
che trachealis is too often the melancholy result—
when to the intestinal and hepatic systems, the pa-
tient is subjected to an attack of diarrhea infantum.
Perhaps the continued irritation produced by the
tedious process of teething, may co-operate as an
assistant cause in pointing the morbid determination
to the trachea of children; while, on the other
With regard to the three diseases which constitute the object
of my present dissertation, they would be all of a truly in-
flammatory description, were they not forced to assume a dif-
ferent character by certain peculiarities in the systems and
constitutions of those subjects where they generally appear.
Thus, what in infants and children becomes hydrocephalus
internus, would in adults assume the form of genuine phrenitis,
and run on perhaps to actual suppuration; cynanche trache-
alis would show itself in peripneumony or angina inflammatoria;
and diarrhea infantum would be converted into enteritis, or
into an inflammatory affection of the liver.
These propositions will be perfectly intelligible, and will,
I am sure, appear sufficiently probable and satisfactory to
those, who have paid due attention to the numerous and di-
versified modifications of disease, resulting from differences of
age, habit, and constitution.
hand, 

(21)
hand, certain species of food with which these ten-
der subjects are occasionally supplied, may tend to
increase the debility and consequent irritability of
the intestines, and thus aid in predisposing to an
undue determination to that part of the system.
Having thus introduced my subject by a few pre-
liminary observations of a general nature, I will
next proceed to deliver, in brief detail, the most
striking and characteristic specialties of the three
diseases now under consideration—I will attempt to
give a succinct statement of the most usual precur-
sors of each disease, to point out the first pheno-
mena that should occasion serious alarm, to trace
the future changes that commonly succeed, and to
specify such symptoms as most unequivocally an-
nounce the approach of death. After having, in
three several sections, affected in some measure the
accomplishment of these different objects, I will in
my next, attempt the establishment of a parallel be-
tween the three topical diseases, or rather symptoms
of general disease, which constitute the leading ob-
jects of my enquiry: In other words, I will endea-
vour to shew, on the solid and rational ground of
facts and direct induction, that the topical affections
of hydrocephalus internus, cynanche trachealis, and
diarrhea infantum, are in nature very closely allied
to each other, being indeed nothing else than
noxious 

(22)
noxious and exuberant branches from the same pa-
rent stock *. In a subsequent and concluding section
I will lay down a few general rules relative to the
cure, or rather prevention of these melancholy af-
fections.
SECT. II.
OF HYDROCEPHALUS INTERNUS.†
THIS dreadful phenomenon of fever is, as
already observed, with a few exceptions, peculiar to
infants and children from the early age of six months
to the tenth or twelfth year of life. Neither situa-
tion, climate, nor condition in life can afford secu-
* If the reader would allow me to indulge my fancy in a
comparison equally simple and descriptive, I might say, that
these three infantile diseases, taken in conjunction with the fe-
ver from which they originally spring, resemble a sprig of
our common trisolium pratense, where three kindred leaves
are protruded from, and supported by, one general connecting
or common footstalk.
† Although not immediately connected with the subject of
my present investigation, I am yet unwilling to neglect so fa-
vourable an opportunity of stating a few strictural observa-
rity 

(23)
rity from its remorseless attack. It acknowledges
no distinctions, either in point of rank, wealth, or
merit; but visits alike the families of the high and
tions op an opinion, very generally entertained by practitioners
of medicine, relative to a certain phenomenon attendant on
anasarcous swellings.
It is a circumstance well known, that, during the hours of
repose, while the body is suffered to rest in a posture nearly
horizontal, such swellings are commonly determined to the
face and parts immediately adjacent; whereas throughout
the course of the day, when the body is preserved in a po-
sition more nearly perpendicular, they are removed again
from the superior parts of the system, and uniformly thrown
on the lower extremities, particularly on the ankles and feet.
This metastasis or translation of swelling, is, by physicians, very
generally supposed to be produced entirely through the me-
dium of the cellular membrane.
Between all the different cells of this membrane so uni-
formly disspread throughout the several parts of the body,
there appear indeed to exist communications more or less
open and direct. By the immediate route of these commu-
nications the serous fluid, giving rise to anasarcous swellings,
is supposed to pass from one part of the body to another,
without at all re-entering either the absorbent or sanguiferous
system.
Thus, for example, physicians alledge, that that particular
portion of serous fluid, which, in the morning is lodged in,
and gives distension to, the cellular membrane of the face,
the 

(24)
the low, the rich and the poor, the virtuous and
the ignoble. It occurs at every season of the year,
during the existence of a humid and chilling atmo-
begins its downward course as soon as the body is placed in
an erect position; and, that influenced solely by the principle
of gravitation, it passes slowly onward from cell to cell, till
finally, towards the close of day, it arrives at its journey's
end, and takes up a temporary residence in the cellular mem-
brane of the lower extremities. Such physicians farther al-
ledge, that during the hours of the night, while the body is
suffered to rest in a recumbent posture, this same portion of
extravasated serum begins again to move in  a retrograde
direction, and, thus, uniformly governed by the same prin-
ciple of gravitation, continues to pursue its journey towards
the head, till it finally arrives at, and takes actual possession
of, its former situation in the cellular membrane of the face
and parts adjacent. Thus, is the same individual portion of
serous fluid supposed to distend alternately the cellular mem-
brane of the face and feet; and thus, is this inexplicable web
considered as constituting a medium of easy and simple com-
munication between the two extremes of the system.
To me it has, indeed, been ever disagreeable and painful,
publicly to avow my dissent from medical opinions, sanctioned
by the authority of the most celebrated patrons of physic, and
rendered even holy, in the eye of most physicians, by the cir-
cumstance of their high antiquity. My feelings on this sub-
ject have been still more sensibly affected by the considera-
tion, that the opinions, to the propriety and truth of which I
have been, at any time, obliged to object, were particularly
inculcated on my mind by those characters, to whom I stand
4 sphere;

(25)
sphere; but exhibits itself most frequently about
the close of autumn, throughout the whole of the
winter, and more especially during the variable tem-
indebted for the first rudiments of my medical knowledge.
Though early prepossessed by such powerful motives as these
in favour of the pathological doctrine, just laid down, respecting
anasarcous translations, I am, notwithstanding, obliged to de-
clare, that such doctrine is wholly repugnant to the opinion
which I now entertain relative to this curious and interesting
point of physics. I believe that the metastasis or removal of
anasarcous swellings from the face to the feet, and from the
feet to the face, is effected, not through the medium of the
cellular, but wholly through that of the vascular system. That
such translation is not—that, in common cases, such transla-
tion cannot, be accomplished by means of an extravasated
fluid journeying slowly from cell to cell, as already described,
I would attempt to infer from the following series of conside-
rations.
I. During the earlier stages of anasarca the cellular mem-
brane, in most parts of the body, is as yet in a state consider-
ably found and healthy. Its tone is as yet unbroken; its cells
and their communications are as yet undilated by means of
frequent over-distension. While in such condition, therefore,
this intricate and curious membrane can scarcely be conceived
capable of affording so free and easy a transition to a small
quantity of serous fluid, as to suffer it to pass, in eight or ten
hours, from the one extreme of the body to the other, urged
onward only by the power of its own gravitation. After the
cells and their numerous communications have become greatly
dilated and much relaxed by means of morbid and long con-
C perature              

(26)
perature of the vernal months. Children of sound
health, robust constitutions, full habits, and active
minds, are most subject to be attacked by this ter-
tinued distension, such a transition may be considered as an
event much more likely to occur.
II. Were it indeed true, that this fluid travels from the
head to the feet through the mazy route of the cellular mem-
brane, its progress would doubtless be marked by the follow-
ing phenomena—The subsidence of the face would be suc-
ceeded by a gradual but obvious tumefaction of the neck, in
consequence of the fluid having descended from the cells of
the former, into those of the latter part of the body. Next
would appear some degree of distension in the cellular mem-
brane lying over the thorax; at length the intumescence
would descend to the integuments of the abdomen, and thus
might the fluid be traced through every step of its downward
progress by an obvious distension existing in the place of its
immediate lodgement. But to physicians, who have paid at-
tention to this subject, it is wholly needless to declare, that no
such phenomena as these are ever presented to our observa-
tion.
III. Were the cellular membrane the medium of convey-
ance for the distending fluid, from the face to the lower ex-
tremities, the following effects would doubtless result from
tying a bandage immediately above the knee with such tight-
ness as effectually to compress the subjacent stratum of cellu-
lar membrane, without obstructing at the same time the move-
ment of the blood along the deeper seated veins—The vica-
rious swelling of the foot and leg below the ligature would
rible 

(27)
rible disorder—Those, in particular, of the above
description, who are at the same time inclined to ha-
bitual costiveness, seem designated by nature as its
be entirely prevented, while, at the same time, an intumes-
cence would form above the ligature, extending along the
thigh to a distance in some measure proportionate to the pre-
vious swelling of the face. To such phenomena, however,
I am authorised to say, that such an experiment does not give
origin.
IV. Were the cellular membrane the only medium of the
serous fluid's descent, the intumescence of the face could not
possibly subside without giving rise to a certain degree of in-
tumescence in some other part of the body. This, however
is by no means the case; for by preserving the trunk of the
body erect, and keeping the feet and legs at the same time in
a horizontal position, and moderately compressed by means of
general and equable bandages, we well know that the swel-
ling of the face will often subside throughout the course of
the day, while no fulness or distension will appear in the cel-
lular membrane of any other part of the body.
V. That it is not the cellular membrane which affords a
passage for the distending fluid from the face to the feet, may
be farther inferred from the following consideration. If the
patient sits throughout the day with his knees bent in such a
way as to be elevated above his nates nearly the whole length
of his thighs, at the same time that his feet and legs are suf-
fered to rest in a position nearly perpendicular, these latter
parts will be distended almost, if not wholly as much as if they
had been kept in a right lined direction with the thighs, and
C2 readiest 

(28)
readiest and peculiar prey. Children whose heads
are unusually large appear also to inherit the me-
lancholy birth-right of a strong predisposition to hy-
had both been suffered to remain in an inclined position.
Here it cannot possibly be supposed that the distending fluid
has slowly forced its way through the whole length of the
cellular membrane, urged on by the principle of gravitation
alone: because in a certain, and even a considerable part of
its journey, namely, in passing from the nates, or from the
groins to the knees, it would be necessarily obliged to move
in an upward direction—a direction very different indeed from
that in any case effected by the operation of the gravitating
principle. As, therefore, no cause can possibly produce an
effect in direct opposition to its own immediate principle of
action, the power of gravitation cannot be supposed to give
rise to such a phenomenon, as the ascent of a portion of ex-
travasated serous fluid along the cellular membrane of the
thigh.
VI. Having thus established in some measure, at least, the
improbability of an extravasated fluid passing by the principle
of gravity from the face to the lower extremities, through the
medium of the cellular membrane, while the body is in a po-
sition more or less erect; let us now for a moment attend to
the reverse of this pathological proposition. Let us examine
what testimony exists in favour of a belief, that during the
hours of night, while the body is laid in a posture more nearly
horizontal, a fluid can pass, through the medium of the cellular
membrane, from the feet and legs to the face and parts im-
mediately adjacent? Here we shall find that this fluid, in its
passage from the feet to the head, must necessarily meet with
drocephalus 

(29)
drocephalus internus. Such as are subject to trou-
blesome eruptions of the head are extremely liable
to be attacked by this disease if such eruptions too
suddenly disappear.
difficulties greater—much greater, indeed, than those already
pointed out as obstructing its passage in a contrary direction.
The principle of gravitation is confessedly the only power, by
the operation of which this extravasated fluid is supposed by
physicians to move, while the body is suffered to remain in a
state of entire rest. But the influence of this principle is cer-
tainly in full opposition to the motion of any fluid from the
feet towards the head, while the body is reclined in a bed of
the common form and direction. I need not here observe
that a bed is always made in such a manner, as to have that
end denominated its head somewhat elevated above its foot;
consequently such must be the posture and direction of the
body it contains; the feet must necessarily be depressed below
the head. How then can we conceive it possible, that in a
body laid in this inclined position, a quantity of extravasated
fluid can, by the principle of gravitation be carried upward
from the lower extremities, and finally lodged in the cellu-
lar membrane of the face?—Before such a result can possibly,
in such a situation, take place, one of the essential properties of
matter, together with all its dependent phenomena, must be
either annihilated or completely reversed.
Were I now asked, in what manner this reciprocal alterna-
tion of swelling between the feet and the face is effected? I
would answer, that it is accomplished entirely, not through
the medium of the cellular membrane, but through that of the
sanguiferous and lymphatic systems;—not by the agency of
C3 This 

(30)
This disease is, not unfrequently, excited by an
early and imprudent use of opiates in attacks of
diarrhea accompanied with fever, and also by the
the principle of gravitation, but by the common laws of circu-
lation, exhalation, and absorption.
Thus, for example, during the erect position of the body
throughout the course of the day, the quantity of fluid ex-
haled or effused, from the evanescent arterial extremities, into
the cellular membrane of the face of an anasarcous patient,
is considerably less than that absorbed from the same part, by
the incipient radicles of the lymphatic system. In conse-
quence therefore of this disproportion between effusion and
absorption, the whole of the distending fluid will be at length
removed, first into the absorbent, and thence into the sanguife-
rous system, and an entire subsidence of the face will be thus
effected. On the other hand, the feet and legs are, during
this time, in a depending position. From  this circumstance
an undue accumulation of blood occurs in the lower extremi-
ties, and in this part of the system throws the balance be-
tween effusion and absorption into the opposite scale, giving
thus a decided preponderance to the former process. Of this
superabundant effusion, a morbid distension of the cellular
membrane of the ankles and feet, is the necessary consequence.
When the body is again laid in a recumbent posture, this ac-
cumulation of blood in the lower extremities is removed, and
the process of absorption gains once more, in this part of the
system, an ascendency over that of effusion. The distending
fluid is therefore again removed from the cellular membrane
of the lower extremities, and conveyed through the absorbent
into the sanguiferous system.
operation 

(31)
operation of all such causes as check or diminish the
cutaneous discharge. In the former of these cases,
that portion of stimulating fluid which would have
been eliminated by the bowels, in the latter that de-
stined to be evacuated by the skin, are determined
to the encephalon with so much violence of febrile
action, as to give origin to congestion in, and subse-
quent effusion from, the tender and irritable vessels
of that important viscus.
* Hydrocephalus internus is generally ushered in
by the following gloomy train of precursors. The
But while the evil is slowly declining in one, it is gradually
increasing in another part of the debilitated body; for a re-
cumbent position is highly favourable to a forcible protrusion
of blood into the vessels of the head and face. In consequence
of such protrusion, and its concomitant accumulation, the effu-
sive becomes immediately superior to the absorbing process in
this part of the system, and thus again an undue and morbid
distension of the cellular membrane of the face is generated.
On such simple and well known principles as these, would
I attempt to account for the alternation of anasarcous swel-
lings, between the face and lower extremities.
* If I have been less circumstantially minute in my de-
scription of hydrocephalus internus than Doctors Fothergill,
Quin, and Rush, the reader will readily excuse me for this de-
ficiency, when possessed of the motives by which I am wholly
governed. My view is to give, unmixed, the genuine result
C4 child 

(32)
child becomes uncommonly dull and loses all relish
for playful amusements. Its movements are lan-
guid, its gait slow, and its whole deportment more
than usually grave.—To the native vivacity and
lustre of its eyes, a dull lifeless appearance, accom-
panied by somewhat of a drowsy heaviness, succeeds,
and its whole countenance bespeaks a degree of un-
easiness and distress. Its disposition to cheerfulness
and good humour forsakes it, and it becomes peev-
ish, fretful, and sometimes sullen: even at this early
period of indisposition the undue determination of
blood to the head is often unequivocally pointed
out, by small but repeated hemorrhages from the
nostrils; the temporal arteries are also more than
usually turgid; the eyes are watry and sometimes
slightly pencilled with blood.
of my own experience, observation, and reflection. I rely as
my authority on no one dead—I apply for my information to
no one living—On the credit of my own observation I deliver
my facts, on the anthority of my own speculations I risque
my opinions. As the experience of the authors referred to,
must have been much more extensive than mine, this disease
has doubtless presented itself to their observation characterized
by a proportionally greater diversity and irregularity of symp-
toms. What I have myself seen, that have I given in brief
detail; what I have only read or heard (though impressed
with an entire belief of the truth of each particular) I have
not thought proper to embrace in my dissertation.
The           

(33)
The appetite begins to fail, frequent but transient
fits of nausea appear, and extreme costiveness takes
place; or, if before habitual, becomes now much
more obstinate and troublesome; broken and uneasy
sleep, excessive and morbid wakefulness, but some-
times a propensity to sleep of a profound and coma-
tose nature, exhibit themselves among the precur-
sors of hydrocephalus internus. During the earlier
stages of these several symptoms the patient seldom
or never complains, nor even acknowledges the ex-
istence of actual indisposition. When interrogated
respecting his health he either makes no reply at all,
or answers in a careless and evasive manner.
At length, however, this insidious disease throws
aside its mask, assumes a more open and daring de-
portment, and ventures to appear in all its native
horrors. The system is invaded by a groupe of
symptoms equally distressing in their nature, alarm-
ing in their appearance, and dangerous in their ef-
fects. The patient is arrested by a general and
violent fever; the head becomes a seat of excrucia-
ting pain, and great prostration of all the voluntary
powers succeeds. The pain of the head is some-
times uniformly permanent; but is more generally
marked by temporary intermissions alternating again
with returns the most acute and distressing. So
great is the accumulation of sensibility in certain
parts 

(34)
parts of the system, at this stage of the disease, that
the impressions of light, found, and motion prove
often insupportable. In a case of hydrocephalus in-
ternus lately under my direction, so exquisite was
the sensibility of the optic nerves as to demand a to-
tal exclusion of light; so painfully sensible were the
organs of hearing as to oblige me, when in the sick-
room, to speak in the softest whisper; and so dis-
tressingly acute was the affection of the head, as to
extort from the patient reiterated screams of agony,
and to prohibit me from walking the floor of the
chamber otherwise than with the most flow and cau-
tious step. This stage of the disease, especially in
children of riper years, is oftentimes accompanied
with symptoms of high and fierce delirium, such as
wild, ferocious looks, quick, desultory, incoherent
talking, occasional singing, or sudden paroxysms of
terror unexcited, or of anger unprovoked, by any ex-
isting cause. During the whole of this distressing
and dangerous period, the constipation of the bowels
remains obstinate, and the stomach is strongly dispo-
sed to reject, immediately, every thing, whether
liquid or solid, that is taken in by the mouth.
After the fever has continued, with slight morn-
ing remissions and strong evening exacerbations,
from one to three or sometimes five days, a peculiar
and striking affection of the eyes becomes observa-
ble. 

(35)
ble *. The pupils, which were before contracted
to a diameter unusually narrow, suffer a dilatation
much greater than ordinary: their sensibility to light
(already said to have been, in an earlier stage of the
disease, preternaturally acute) begins now to suffer
a slow, but progressive diminution, so as to sink, at
* I am indeed sorry at being obliged to deny my assent to
the accuracy of that part of the treatise on hydrocephalus in-
ternus published by the learned and ingenious Dr. Quin, where
the author points to the particular stage of disease in which he
alledges the strabismus and dilatation of the pupils occur.
The doctor evidently classes these affections of the eyes among
the first groupe of symptoms that appear, thus making them
nothing else than simple precursors or harbingers of actual dis-
ease. On this subject I must confess that my observations
have furnished me with a very different result. If my me-
mory be not extremely fallacious, and if I have not been un-
pardonably inaccurate and erroneous in notes which I have,
at different times, taken down in sick-rooms to which I
have been called, strabismus and dilatation of the pupils are
affections of the eyes which seldom, if ever, take place till after
the existence of very considerable fever: I would therefore
class them among the second, perhaps I may say among the
third groupe of symptoms characteristic of hydrocephalus inter-
nus. These are phenomena which do not barely portend an
approaching, but strongly bespeak a high degree of actually ex-
isting, disease. They ought not to be viewed as the precur-
sors, but as the melancholy consequences of fever; being the
immediate result of effusion or congestion in the volume of the
encephalon, produced by the impulsive violence of febrile
action.
length,        

(36)
length, far below its common and healthy state;
while, at the same time, there supervenes a conti-
nued rolling of these globes in their orbits, together
with a strabismus or permanent perversion of the
direction of their axes. These affections are some-
times confined to one, but more generally extend to
both of the visual organs.
In proportion to the advancement of this last
groupe of symptoms, the pulse itself has been under-
going a gradual but very perceptible change. From
having been considerably full, strong, tense and fre-
quent, it has now become rather weak, soft, slow,
and generally irregular, oftentimes intermittent.
The intensity of the pain in the head ceases, and
the less acute sensations of fulness and heaviness suc-
ceed; the disposition to vomit disappears; a con-
stant tendency to coma takes place, while the pa-
tient when roused from his death-like slumbers swal-
lows down drink, and often devours food, if offered,
with an appetite of the utmost voracity: The eyes
begin at length to suffer a very visible protrusion
from, or rather an elevation in, their orbits; and in
the heads of infants a tumor more or less prominent
is formed at the scite of the fontanel. These two lat-
ter symptoms evidently re=sult from the mechanical
effect of a quantity of fluid effused and lodged in
the ventricles of the brain.
This 

(37)
This latter groupe of symptoms continues to in-
crease in degree, while the strength of the patient
hourly fails. As the pulse declines in force, it rises
in frequency of action, till it may be said at length to
flutter rather than pulsate. The growing insensibi-
lity of the system to impressions of every kind be-
comes gradually more and more confirmed; fright-
ful distortions of countenance supervene; sudden
twitchings or involuntary contractions of the mus-
cles become frequent, and general convulsions at
length coming on, put a period at once to wretched-
ness and to life.
SECT. III.
OF CYNANCHE TRACHEALIS.
THIS topical disease is uniformly accompa-
nied by general fever in a higher or lower degree.
When completely formed, it consists of a preterna-
tural membrane * considerably tenacious and firm,
* Some writers speak of a stridulous suffocation originating
from a simple spasm of the muscles of the larynx, or from a
spasmodic affection of the trachea itself. As such a disease,
however, has never fallen under my observation, and especially
investing 


(38)
inverting  the whole  or part of the trachea, toge-
ther, frequently, with part of its bronchial ramifica-
tions. This membrane may be said with propriety
to possess a nature sui generis. It is different from
common mucus; different from coagulable lymph;
and different, indeed, in some measure, from all ani-
mal substances which I have seen subjected to the
test of experiment.
Cynanche trachealis is principally confined to in-
fants and children of a description similar to that
already given of those particularly subjected to at-
tacks of hydrocephalus internus. Like the latter
disease it occurs at all seasons of the year, but ap-
pears most frequently about the close of autumn,
throughout the months of winter, and during the
variable temperature of the spring. No climate nor
situation is wholly exempt from the ravages of this
distressing and dangerous malady; but it appears to
be, in some measure, endemic in places uniformly
subjected to a moist and chilling atmosphere. Hence
its frequency in the immediate vicinity of lakes, ri-
vers, marshes, arms of the sea, and other extensive
bodies of water.
as its very existence is with me a position somewhat pro-
blematical, it will engage no part of my attention throughout
the present dissertation.
The 

(39)
The preternatural membrane which constitutes
this truly formidable disease, I consider as a product
of febrile action, particularly determined to the as-
pera arteria. Whether this membrane be produced
by the immediate action of the mucus follicles of the
part, or by minute arterial extremities which, du-
ring health, exhale a more attenuated fluid, is a
controversial point on which I do not mean to ha-
zard an opinion.
This disease makes sometimes a very sudden and
violent attack, but for the most part invades the sys-
tem in a slow, gradual, and insidious manner. Its
earliest precursors are nearly the same with those of
hydrocephalus internus. They are such as unequi-
vocally bespeak a general febrile affection of the sys-
tem. The topical affection of the trachea is by no
means among the earliest symptoms that appear. In
all those cases where I have had an opportunity of
making minute and accurate observations, slight
symptoms of febrile indisposition existed at least for
several hours, in most of them several days, before
the peculiar hoarseness became at all perceptible.
The reason why this affection of the trachea has
been so generally considered as the earliest symp-
tom, and therefore the original cause of all the sub-
sequent train of evils, must doubtless be sought for
in the inattention and inaccuracy of parents, nurses,
and

(40)
and physicians, relative to the slighter phenomena
of disease. In the present, as in most other instances
of general fever, costiveness seldom fails to appear
among the earlier precursors.
These moderate symptoms of general fever having
continued for a period of time, subject, in different
cases, to great variety with respect to its duration,
a cough and hoarseness, accompanied by more or
less difficulty of respiration, at length occur, which
may be considered as the sure harbingers of ap-
proaching danger *. The cough attending cynanche
* A few cases of this disease I have seen accompanied by a
temporary efflorescence or scarlet-like eruption on different
parts of the body, which, during its continuance, seemed to
afford a certain degree of alleviation to the symptoms of gene-
ral fever.
I would here beg leave to observe, that the principles and
laws of the translation of real febrile action from one part, or
perhaps I may say, from one system of the body to another,
would indeed form a subject of investigation equally curious,
interesting, and important. Thus, for example, in small-pox
and measles the cuticular eruption is nothing else than a genu-
ine translation of fever from the arterial system to the skin;
that is, from a deeper seated to a more superficial part; hence
the evident abatement of the symptoms of general fever on
the complete occurrence of a general eruption. Thus again
the cutaneous eruption in what is called the rash fever appears
4 trachealis 

(41)
trachealis is accompanied by a very shrill and pecu-
liar found, which has been said by different authors
to resemble the voices of several different animals.
For my own part I do not think I have in any in-
stance heard this morbid sound more nearly imita-
ted, than by a harsh, disagreeable note, sometimes
emitted by our common fowls in attempting to dis-
charge from their throats a grain of corn, or some
other obstructing body of considerable magnitude.
Soon after the symptoms of cough and hoarseness
have become evident, the disease begins to assume a
much more alarming and formidable appearance.
The phenomena of general fever remain no longer
latent or equivocal even to the most superficial ob-
server, but openly assail the prostrated system with
to be nothing more than a translation of febrile action prin-
cipally from the stomach to the skin; hence the obvious relief
given to the former by the appearance of an eruption in the
latter part of the system; and hence the re-attack made on
the stomach if, in consequence of imprudent exposure to cold
or moisture, the cuticular eruption prematurely disappear.
Thus, in like manner, in the erysipelas of the face, the rose-like
efflorescence is doubtless an unequivocal translation of fever
from the vessels of the brain to those of the skin; hence the
comatose symptoms, that seldom fail to characterize the ear-
lier stages of this disease, are so uniformly relieved on the ap-
pearance of the efflorescence and swelling; and hence the re-
attack so frequently made on the vessels of the brain when
the cuticular affection too suddenly retires.
D high             

(42)
high degrees of violence. Respiration becomes uni-
formly and permanently more difficult and labori-
ous; but this difficulty is so much increased by oc-
casional paroxysms, that the patient is in the utmost
danger of death from actual suffocation.
At this period of the disease the countenance is
sometimes pale, marked by frequent but transient
flushings, and sometimes full and rather livid, in con-
sequence of a partial stagnation of the blood. I
have frequently seen the patient disposed to a coma-
tose state, had not such quietude been prevented by
the perpetual irritation of the membrane in the tra-
chea, and by the necessary and increasing violence
of respiratory efforts. In consequence of the uni-
form reiteration of such efforts, together perhaps
with the small quantity of air taken into the lungs
at each act of inspiration, the excitability of the sys-
tem is gradually diminished, the voluntary powers
are greatly exhausted, and every symptom of danger
and distress is evidently augmented: the business of
respiration grows more and more difficult and labo-
rious; exertions of coughing are too arduous to be
any longer effected; the pulse becomes weak, op-
pressed, and trembling; the eyes are suffused by a
glairy pellicle; the system is invaded by occasional
convulsions, till, finally, after a painful struggle of
actual strangulation the miserable patient expires.
SECT.

(43)
SECT. IV.
OF DIARRHEA INFANTUM.
THIS disease, called by some writers Cho-
lera infantum, is, as the name itself imports, princi-
pally confined to infants and children of an early
age. From the termination of the first six months
of life, to the close of the third year, children are
most subject to be attacked by this painful and dan-
gerous disorder. After the expiration of the fourth
year its occurrence is by no means frequent. In
children, however, of a weak constitution, and of a
lax and irritable habit of body, this disease some-
times appears as late as the ninth or tenth year of
life. In instances of the latter description its symp-
toms are less distressing, and its consequences much
less dangerous, than when it attacks subjects of an
earlier age. It never fails to prove troublesome,
and is too often attended with absolute danger,
when it assails children during the tedious and pain-
ful process of dentition.
Happily for the weak and tender part of the hu-
man race, diarrhea infantum is much more under
the influence and controul of temporary and local
circumstances, than either of the diseases just de-
described. It is more limited as to the season, it is
D2 more 

(44)
more peculiarly restricted as to the place of its gene-
ral occurrence. It prevails only during the summer
and the earlier part of the autumnal season; and sel-
dom appears save in the foul and heated atmo-
sphere of a crouded city. The pure and breezy
air of country situations, remote from marshes or
other large bodies of stagnant water, so far from
giving origin to this melancholy disease, affords the
most efficacious remedy to such children as have al-
ready become the unhappy subjects of its violence.
Diarrhea infantum may be therefore considered
as a genuine endemic of large and populous cities.
Most infants and children of  the age already men-
tioned, who pass the whole of the summer months
in the city of Philadelphia, are subjected to more or
less inconvenience and pain from the unwelcome
visits of this troublesome disorder. During the
months of July, August, and September it usurps
the empire over all other infantile diseases, and
reigns for the most part without a contending rival.
Diarrhea infantum may be defined, a disease con-
sisting of frequent and copious discharges by stool,
of a muco-bilious matter *, sometimes coloured by
* The stools of children affected by the disease now under
consideration, possess, for the most part, more or less of a green-
admixtures 

(45)
admixtures of blood, and always accompanied by a
fever of excessive action. As in the diseases of hy-
drocephalus internus and cynanche trachealis, so
here, likewise, I consider fever as the primary affec-
tion, and the bilious diarrhea as nothing else than a
necessary result of febrile action unduly determined
to the liver and intestinal canal.
Infants and children of every description of con-
stitution and habit of body, are liable to be arrest-
ed by this troublesome and painful disorder. Ac-
cording, however, to the result of my observations
on this subject, such as are considerably robust and
fleshy are in more immediate danger of suffering
from this scourge of early life. Such children as
we would judge most strongly disposed to hydroce-
phalus internus or cynanche trachealis, during the
winter and vernal months, are most frequently at-
ish tinge. This colour results, most probably, from a recipro-
cal action of acid and bile on each other. For besides the
evident propensity of the hepatic system to generate, in this dis-
ease, a preternatural quantity of bile, we have evidence sufficient
to induce us to believe, that the stomach is also strongly disposed
to secrete, by its morbid action, a superabundant quantity of
an animal acid. Of these two fluids a conflux and intimate
mixture take place in the course of the small intestines, where
by their joint chemical action on each other they bellow on
the contents of these viscera the above greenish cast.
D3 tacked 

(46)
tacked by diarrhea infantum in the course of the
summer, or about the commencement of the autum-
nal season.
The precursors or earliest symptoms of diarrhea
infantum are very nearly the same with those that
usher in the two diseases already described in the
preceding sections. They are such as unequivocally
announce the existence of fever. The child grows
heavy, dull, inactive, and peevish; loses its keen re-
lish for all the frolic amusements of its age, or be-
comes very soon fatigued and disgusted in their busy
pursuit: fretfulness, loss of appetite, and occasional
fits of nausea succeed. A diarrhea comes on, mo-
derate indeed at first, but accompanied with gripings
more or less severe, and with a considerable dis-
charge of status from the interlines. The skin is for
the most part rather parched and dry, except du-
ring temporary fits of nausea or perhaps of vomit-
ing, when a plentiful moisture appears on the face,
and sometimes on other parts of the body. Chil-
dren of three or four years old complain frequently
of pain in the head and back, or of troublesome
shooting stitches in various other parts of the sys-
tem.
All the febrile symptoms are gradually, sometimes
more rapidly, augmented in violence. Thirst more
or 

(47)
or less troublesome and distressing supervenes; the
pulse becomes frequent, quick, and sometimes con-
siderably full, tense, and hard. The diarrhea grows
more profuse, the gripings more severe, and the
stools are occasionally tinged with slight effusions of
blood. This disease, like most other complaints of
the summer and autumnal seasons, is marked with
evident morning remissions and very considerable
evening exacerbations. During the earlier hours
of the night repose is much interrupted, sometimes
entirely prevented, by the frequency of the calls to
intestinal evacuations, together with the pain by
which they seldom fail to be accompanied.
For a period of time extremely different in differ-
ent cases, and which cannot therefore be specified
with any degree of definitude, these symptoms con-
tinue to pursue their course, suffering little or no
variations save such as result from the increasing de-
bility of the patient. By degrees, however, a very
striking change is at length effected; every symptom
of danger grows more and more alarming; the child
becomes much emaciated and extremely reduced in
point of strength; the stools grow more frequent,
watry, and offensive; sometimes an abundance of
small worms are discharged; at other times the ali-
ments taken in are evacuated without much visible
alteration.
D4 About

(48)
About this period of the disease superficial ulcera-
tions of the lips, mouth, fauces, and about the ter-
mination of the intestinum rectum appear, and are
probably continued throughout the whole tract of
the alimentary canal; the eyes retire deep within
their orbits; and the general shrivering and contrac-
tion of the countenance exhibit, for the most part,
a very high degree of what is denominated facies
hippocratica. As the bones themselves give now to
the face its general configuration and appearance,
unmodified by muscle or adipose substance, it is at
this period of the disease that children are often said
with propriety and truth to resemble some of their
ancient relations.
Strength, both muscular and arterial, being greatly
expended, locomotion is no longer practicable, and
the action of the arteries is little more than barely
perceptible; the whole volume of fluids being almost
exhausted, the plenitude of intestinal evacuation can
be no longer continued. The stools are therefore
much less frequent and copious than before. I have
seen children in this complaint but little troubled
with diarrhea for several weeks immediately previ-
ous to their death. General debility, however, still
continues to make gradual encroachments; and so
extremely imperceptible are its advances, that the
patient is often surrendered into the arms of death
without the faintest struggle of resistance.
Thus 

(49)
Thus insidious, in most cases, is the original at-
tack; thus slow the subsequent progress; and thus
gradual the final termination of diarrhea infantum.
It is necessary, however, to observe, that its pheno-
mena and movements do not at all times exactly cor-
respond to the preceding description. It sometimes
assumes a more daring appearance, and runs its
course with swifter steps. After having, for a few
hours, or perhaps not more than a few minutes, ex-
hibited itself in the form of general fever, considera-
bly violent in degree, it assumes on a sudden the
more alarming appearance of genuine cholera. The
natural contents of the stomach and intestines are
first evacuated; after which profuse discharges of
bile, mucus, and perhaps acid, occur both by stool
and vomit. Sickness the most distressing and deadly
prevails; an entire prostration of strength super-
venes; general convulsions often ensue; and, unless
supported by the most speedy and effectual aid, the
patient soon falls a victim to the impetuosity of the
disease.
SECT. 

(50)
SECT. V.
OF THE ORIGINAL SAMENESS * OF HYDROCEPHALUS
INTERNUS, CYNANCHE TRACHEALIS, AND DIAR-
RHEA INFANTUM.
ON this part of my subject, in particular, I
wish to be clear, explicit, intelligible. I would not
have my opinions on this important point of patholo-
gical doctrine in any degree misrepresented, in any
degree misunderstood. The reader will therefore
indulge me in an attempt to develope my precise
meaning with all possible clearness and definitude,
previously to bringing forward any thing in illustra-
tion and support of my opinions.
I do not contend that the local affections of hy-
drocephalus internus, cynanche trachealis, and diar-
rhea infantum are, when completely established in
* To simplify the theory, and consequently the treatment,
of diseases; to direct the attention of physicians to general
principles, not to topical phenomena; and thus induce them
to prescribe to original causes rather than to subsequent symptoms,
are doubtless very important desiderata in the science and
practice of medicine. An earnest wish to aid in the accom-
plishment of ends so favourable to science, so interesting to hu-
manity, constituted indeed my principal motive for engaging
in the present investigation. How far I may be successful in
my attempt, can be ascertained only from the reception with
their

(51)
their respective organs, the same individual com-
plaint. I well know that an aqueous or a serous
effusion into the ventricles of the brain, is widely
different from a mucoid effusion into the aspera ar-
teria, and that a muco-bilious effusion from the liver
and intestinal canal is a morbid phenomenon differ-
ent from both. I only contend that these topical
affections are nothing else than kindred phenomena
or effects resulting from the operation of the same
general cause. These three local diseases I consider
as a truly fraternal offspring descended from fever
as their common parent. This febrile action, when
determined with disproportioned impetuosity to the
vessels of the encephalon, begets hydrocephalus in-
ternus; when to those of the trachea, cynanche tra-
chealis; and when to those of the intestinal and he-
patic systems, diarrhea infantum. I will farther
add, that when this same febrile impetuosity attacks
the pleura or membrane lining the thorax and lungs,
a peripneumonic affection is the painful but neces-
ary result. For I consider the general affection
from whence originate the three infantile complaints
in immediate contemplation, as a fever of excessive
action. This, when determined to any part with
force sufficient to produce a topical inflammation,
which my opinions will meet, among the professors and prac-
titioners of the healing art.
becomes 

(52)           
becomes a genuine inflammatory fever *. Thus, for
example, if inflammation be excited in the volume
of the encephalon, the disease is denominated phre-
nitis; if in the liver, hepatitis; and rheumatism when
the inflammatory affection is thrown on the joints.
For the sake of more entire perspicuity, I shall
here take the liberty of condensing into the brevity,
and modelling into the form, of an aphorism, the
general position which I would wish to establish re-
lative to the present point of pathology.
The three topical complaints of hydrocephalus in-
ternus, cynanche trachealis, and diarrhea infantum,
may be considered as equally the result of a general
* I have already suggested my opinion of the propriety of
distinguishing between a simple fever of excessive action, and
that more complex state of disease, with justice entitled to the
denomination of a truly inflammatory fever. At present I would
beg leave further to observe, that fevers of excessive action
may in many respects deviate from their simplest form, with-
out justly acquiring the name of inflammatory. Thus, for ex-
ample, a fever of too much action may be accompanied with
an undue determination to, and a considerable pain in, the head,
while at the same time no inflammatory affection exists either
in that or in any other part of the system. A similar obser-
vation may be made relative to the three infantile diseases of
which I at present treat. In neither of these can the original
fever be said to assume and preserve the simplest form; and
febrile 

(53)
febrile affection; and the same precise species of fe-
ver, namely, a fever of excessive action, appears to
give origin to the whole. The truth of this inter-
esting and important point of pathological doctrine,
I would endeavour to establish by the following
series of proportions.
I. That the diseases in question are indeed origi-
nally of a general, and not of a local nature, we
would presume to infer from two considerations the
most obvious and direct; namely, that the causes,
from which they originate, are general, and most
probably therefore productive of a general, not a
partial result: and that these causes operate always
on the living system at large, not exclusively on any
particular part. Reasoning a priori, therefore, we
must necessarily infer, that the system at large is ori-
ginally affected.
II. In all cases of these complaints that have ever
fallen under my observation, the topical affections
were preceded by the existence of general fever,
with as much uniformity as an effect can, in any in-
stance, be preceded by its immediate cause. This
febrile affection was evidenced by symptoms so direct
yet in very few cases do we discover the existence of actual
inflammation.
and 

(54)
and unequivocal as, with every unprejudiced mind,
to establish the truth of its pre-existence beyond the
faintest shadow of a doubt. In no case to which I
have ever attended did either of the local effusions
first occur, giving birth to general fever of a sub-
sequent date. Nor indeed do these effusions strike
me as causes either adapted in their nature, or per-
haps I may say, adequate in their magnitude, to give
origin to the degrees of fever by which they are ge-
nerally accompanied. As, therefore, general fever
is an uniform concomitant in each of these three
complaints—as it never fails to precede the existence
of topical effusion—as its violence is always more or
less reduced by the occurrence of such effusion—but
more especially, as a timely and complete reduction
of fever will (as shall be shown hereafter) effectually
prevent effusion from taking place, we are certainly
authorised by the most chaste and correct principles
of analogy to conclude, that in such cases fever is
indeed the original cause, and effusion nothing more
than the subsequent effect.
III. The sameness of the febrile affection from
which hydrocephalus internus, cynanche trachealis,
and diarrhea infantum derive their existence, we
would infer from the following consideration. These
diseases are more especially confined to infants and
children similar in age, similar in constitution, and
considerably 

(55)
considerably alike in all their general habits. Hy-
drocephalus internus and cynanche trachealis occur
in the same seasons, in the same situations, and ap-
pear to be brought on by the operation of the same
remote and exciting causes. This latter observation
does not so directly embrace diarrhea infantum, that
disease occurring only in the summer season—a sea-
son which by means of atmospheric warmth, of im-
pure air, of some peculiar gas *, or probably by the
joint co-operation of these three agents, produces
indeed a very striking, and perhaps I may add, spe-
cific effect on the intestinal and hepatic systems.
IV. These complaints are known not very un-
frequently to suffer a reciprocal alternation with
each other. Thus, what practitioner of experience
and observation has not seen sometimes hydrocepha-
* From a series of late experiments it appears, that inflam-
mable air, (denominated by the French chemists hydrogenous
gas) possesses qualities capable of producing a specific deter-
mination to the hepatic system. Does not such a discovery
give us reason to suspect, that a superabundance of this subtle
gas, with which the summer atmosphere of large and popu-
lous cities may be impregnated, acts, at least, as an auxiliary
cause, in giving birth to diarrhea infantum? And might not
a course of well conducted experiments on this subject, lead on
to future discoveries, equally favourable to the interest of hu-
manity, and to the farther advancement of medical science?
lus 

(56)
lus interims, and sometimes cynanche trachealis,
produced by imprudently checking the intestinal dis-
charge in diarrhea infantum previously to the neces-
sary reduction of the existing fever? As instances
of such mutation or rather translation of disease must
doubtless have occurred to other physicians as well
as to myself, I rely for support, at present, on their
own recollection and candor, and forbear to trouble
my reader with the disagreeable prolixity of minute
details. In a case lately under my direction, the pa-
tient (a child nearly three years old) was first affected
with evident symptoms of approaching hydrocepha-
lus internus. These were, by early and proper atten-
tion, all subdued in the space of about three days.
Four days afterwards febrile symptoms again re-
turned; cough and difficulty of breathing occurred;
true cynanche trachealis supervened; and notwith-
standing every opposing effort I could possibly make,
my patient fell a speedy victim to the uncommon
violence of the disease.
V. The morbid processes by which these local dis-
eases are immediately effected are doubtless of a na-
ture truly evacuant—All evacuations evidently pro-
duce on the system effects unequivocally sedative;
but all sedatives certainly operate to the prevention
or removal, and never to the production of general
fever. We may therefore safely conclude on such
2 principles 

(57)
principles as these, that the local diseases, in imme-
diate contemplation, cannot possibly act as the cause
of that febrile affection by which they are uniformly
accompanied.
VI. No instance I believe can be given in which a
morbid and preternatural discharge of any fluid from
small vessels of the system, is of long and dangerous
duration, unless such discharge be kept up by the im-
petus of the blood subjected to a certain degree of
febrile action *. Thus, for example, hemorrhages
from the nostrils, unless generated and nourished by
pre-existing fever, are generally so slight and tran-
fient as seldom to become objects of medical atten-
tion. The same observation may also be made, re-
lative to occasional attacks of hæmoptysis brought on
solely by violent exertions of coughing. In like
manner, the catamenial discharge in females is gene-
rally regulated, both as to its quantity and dura-
tion, by the degree and continuance of concomitant
fever. When the febrile affection is slight, the eva-
cuation is proportionally moderate; but when the
* Although it be true that hæmorrhages are by surgical
writers divided into active and passive, yet I must confess, I
have very seldom, if ever, seen a case of hæmorrhagy truly
passive, in which either the excess or obstinacy of the evacu-
ation was such as to call for any high degree of medical atten-
tion.
E former 

(58)
former is considerable, the latter is, for the most
part, profuse and troublesome. Now as the morbid
evacuations immediately in question, particularly
those of hydrocephalus internus and diarrhea infan-
tum, are both considerable in quantity, and obsti-
nate in continuance, we may by accurate analogy
with the preceding positions conclude, that they ori-
ginally result from, and are subsequently kept up by,
an excess of action in the arterial system.
VII. The last argument I shall attempt to advance
in favour of the original sameness of hydrocephalus
internus, cynanche trachealis, and diarrhea infan-
tum, is derived from the most successful method of
treating these three truly dangerous and melancholy
diseases. I must here beg leave to observe, that
when exhibited at a period sufficiently early, the
same individual remedies are found to prove equally
efficacious in each. In a former part of this disser-
tation, it has, I flatter myself, been in some measure
established, that the three topical diseases of which
I treat, make their first appearance in the system un-
der the form of a general fever of excessive action.
It has been also just observed, that this fever may,
in all cases, be moderated and reduced by precisely
the same mode of medical treatment. Have we not
then sufficient testimony to warrant us in conclu-
ding, that in their original and febrile state, these
melancholy 

a(59)
melancholy diseases are unequivocally the same?
But a brief detail of the most successful method of
cure shall constitute the subject of my concluding
section.
SECT. VI.
OF THE TREATMENT OF HYDROCEPHALUS INTER-
NUS, CYNANCHE TRACHEALIS, AND DIARRHEA
INFANTUM.
I HAVE finally arrived at the most import-
ant, and therefore the most interesting part of the
present dissertation—that part which alone relates
immediately to the practice of the healing art—that
part which alone is directly applicable to the allevia-
tion of human misery. How extremely happy would
I account, how peculiarly fortunate would I consi-
der myself, could I with equal propriety add, that
part on which I am able to speak with the fullest
confidence in the truth of my principles and opi-
nions! But a melancholy want of success in several
cases, where at first my prospects were the most fair
and flattering, and consequently my expectations
sufficiently sanguine, has furnished me with a degree
of professional humility, and taught me, at least, to
doubt respecting the final result of medical remedies.
E2 I have 

(60)
I have already intimated that it is not my inten-
tion to speak, under the present head, of the cure
of the three preceding diseases after the topical effu-
sions have actually taken place. My observations
shall be confined entirely to their prophylaxis or pre-
vention. This desirable end can be accomplished
only by paying early and due attention to the pre-
existing fever from which alone these topical affec-
tions derive their existence.
I have in a former part of my dissertation ob-
served, that I consider the three diseases in question
as resulting from an entire unity of fever, namely, a
fever of excessive action. Effectually to reduce this
febrile affection, and by that means prevent the se-
rious and fatal consequences that might otherwise
ensue, should constrtute the sole object of the phy-
sician when called in at an early period of disease.
Thus, for example, if called to a child recently at-
tacked by a fever of excessive action, accompanied
with violent pain in the head, with cough and diffi-
cult respiration, or with frequent and copious evacu-
ations of bile from the intestinal canal, although I
might be led to apprehend the approach of hydroce-
phalus internus in the first case, that of cynanche tra-
chealis in the second, and that of diarrhea infantum in
the third, yet my whole attention, instead of being
directed to the possible occurrence of either of these
topical 

(61)
topical affections, at a future period, would be con-
fined entirely to the state of general fever already
existing. Instead of resting satisfied with topical re-
medies directed only to the head, throat, or alimen-
tary canal, my attention would doubtless extend to
the condition of the system at large. All my views
would be instantly pointed, and every possible effort
would be immediately directed, to the complete re-
duction of the existing fever; from an entire convic-
tion, that by the accomplishment of this end, all its
present symptoms would certainly disappear, and all
its troublesome consequences be effectually pre-
vented.
As uniform experience has long since directed le-
gislators to the propriety of attempting the preven-
tion of approaching evils by means of salutary and
wise institutions, rather than of hazarding the dis-
agreeable and perilous alternative of eradicating
vices already existing, by laws of a sanguinary spirit,
a similar maxim of prudence ought doubtless to be
adopted by practitioners of medicine. They should
ever bear in mind that it is not only a matter of
more ease to themselves, but also of more comfort
and safety to their patients, always, if practicable,
to prevent diseases of every description from be-
coming fully established, rather than to risque the
experiment of removing them from the system after
E3 they 

(62)
they have acquired a confirmed existence. This is
more particularly the case with regard to the topical
diseases embraced in the present dissertation. If
treated with sufficient boldness and propriety at an
early period, daily observation bears testimony that
they may be very generally prevented; whereas, on
the other hand, if suffered fully to form and thus
gain unmolested possession of their respective situa-
tions, it is indeed a truth equally humiliating to the
baffled practitioner, and alarming to the afflicted pa-
tient, that they too frequently bid a safe defiance to
every possible expedient and effort of the healing
art.
From repeated experience and observation I am
finally persuaded, that this pre-existing state of fe-
ver, (which should be considered as the threshold to
the local diseases immediately in question), may, in
general, be most speedily and certainly subdued, by
attentively pursuing the two following principles, or
general indications of cure.
First. By securing the body, as far as possible,
from the access and operation of all external and ad-
ventitious stimuli.
Secondly. By diminishing, to a certain extent,
the quantity and impression of those internal and
more 

(63)
more essential stimuli, to the action of which the sys-
tem is always subjected.
The first of these general indications is to be an-
swered only, by pursuing, to a proper length, what
medical writers have denominated the antiphlogistic
regimen. The temperature of the chamber must be
equable and moderate, not exceeding the sixtieth
degree on the scale of Fahrenheit; and the atmo-
sphere of the sick-room must be frequently changed
—perfect rest should be enjoined—light should be,
in a great measure, excluded—conversation and
noise should be strictly prohibited—the mind should
be zealously guarded against passions and emotions
of every kind; for in all cases of violent febrile af-
fection, it is indeed an important desideratum that
the patient's mind should be suffered to remain in a
state of the most unruffled tranquillity *: All food
* Much has been said by medical writers respecting the sa-
lutary effects of fear and other debilitating passions of the
mind in cases of general fever. That such mental affections
might be rendered useful in the treatment of febrile diseases, I
was taught to believe as one of the essential articles of my me-
dical creed. Were I to rest satisfied with speculation alone
on this subject, I would still subscribe to the plausibility of the
same opinion; for it is doubtless a favourite child of hypo-
thesis. But as it is highly unphilosophical to admit, as deci-
sively certain, any medical tenet which we have not seen sanc-
E4 of 

(64)
of a highly stimulating nature, even if mailed for,
should be carefully withheld—aqueous and subacid
liquids may be used in considerable quantities; but
both drink and aliment should be administered cold
rather than warm. By a steady and uniform adhe-
rence to such directions as these, the fever may be,
if not moderated, at least prevented, in most in-
stances, from acquiring any additional violence.
The second indication of cure shall be now made
the subject of a few general observations. This can
be fully and satisfactorily answered in no other way
than by a free and judicious use of that class of re-
medies denominated sedatives.
I. Of this class the first, and by far the most pow-
erful is the evacuation of blood-letting. Of this re-
tioned by the test of experiment, this position respecting the
utility of such affections of the mind, in the cure of fevers,
must as yet remain, with me, a problematical point. Were
physicians, however, more intimately acquainted with the na-
ture, but, particularly, had they at command a complete regu-
lation, of the human passions, they would then be certainly
able to render them in some measure subservient to the alle-
viation and removal of general disease. In particular cases of
dropsy and of what may be denominated sthenic insanity, fear
and terror have been known frequently to produce effects the
most striking and salutary.
medy 

(65)
medy the repetition and extent must be submitted en-
tirely to the discretion of the practitioner—They can
be duly defined and regulated only by the existing
circumstances of each particular case. It may not
be improper however to observe, that I have al-
ways, in febrile affections, derived the most unequi-
vocal and striking advantage from this evacuation,
by having it performed near to the commencement
of their evening exacerbations.
II. The next remedy to be mentioned is that of
purgatives. Too much attention cannot possibly be
paid to evacuations by stool, particularly in those
cases of fever in children, where there exist evident
symptoms of an undue determination to the head or
aspera arteria. In such instances purgatives of con-
siderable activity are found to be greatly superior to
those that are more lenient and mild.
III. SUDORIFICS. If a free, copious, and gene-
ral perspiration can be brought on by the use of an-
timonials or other remedies that do not rouse the
system to an increase of febrile action, it seldom fails
to be productive of a salutary effect.
IV. DIURETICS. Respecting this class of reme-
dies I have indeed but very little to advance: I
think 

(66)
think  however that I have sometimes seen an in-
creased flow of urine excited, and thus a partial re-
duction of fever effected, by means of squills, as well
as by certain combinations of digitalis and nitre.
V. SIALOGOGUES. I have certainly, in a variety
of instances, seen truly alarming affections of the
head, together with considerable degrees of conco-
mitant fever, greatly alleviated by means of a slight
mercurial ptyalism. In most cases therefore of im-
pending hydrocephalus internus, more especially
where recourse has been had in vain to other eva-
cuations, I would judge it expedient and proper to
exhibit mercury in such quantity and under such
form, as may be best calculated to produce a speedy
discharge from the salivary glands.
VI. The last sedative evacuant I shall here recom-
mend is that of cold, applied directly to the head,
and occasionally to other parts of the body. Let
not such orthodox physicians as are accustomed to
view objects only through the medium of an esta-
blished system, be startled at my novelty in classing
cold among those remedies denominated evacuants.
As a real evacuant I consider, as a real evacuant I
use, this remedy in my practice as a physician, and
as a real evacuant I trust it will appear to  every un-
prejudiced 

(67)
prejudiced mind, from a view of the following suc-
cinct explication.
Heat is a fluid known to be as natural, as essen-
tial to the living system of man, as the chyle that
moves in the lacteals, or the blood that circulates
through the arteries and veins. During the exist-
ence of general fever a morbid accumulation of heat
supervenes: The elimination of the superabundance
of this fluid from the system must be effected by a
process equally evacuant with that which conveys
off a portion of the blood. But this process can be
in no other way directly accomplished than by sub-
jecting the system to the immediate influence and
action of cold. Here then the remedy of cold ope-
rates as the efficient cause of a literal evacuation;
and hence may be considered as the real and specific
evacuant of heat.
Should any topical pain or uneasiness still exist,
even after the fever has been thus reduced by a due
perseverance in the general indications of cure, local
remedies, such as cupping, blistering, &c. should be
immediately applied.
I have thus in a very brief, general, and I am
sorry to add, superficial manner, delivered the result
of 

(68)
of my experience and observation relative to the
history, the nature, and the early treatment of cer-
tain diseases peculiar to infants and children.
But to close my dissertation without paying a tri-
bute of general acknowledgment to the medical pro-
fessors of that institution, under the auspices of which
I have pursued my studies with equal pleasure and
advantage, and from the authority of which I am
now about to derive the highest honours of my pro-
fession, would indeed be an act of high injustice to
my own feelings, and of criminal ingratitude to
those, who have been long my public patrons, and
long my private friends.
To you, gentlemen, my obligations are numerous;
to you my best acknowledgments are due—Accept
the latter; the former no acts of mine can ever can-
cel, no possible combination of circumstances can
ever wholly annul: Deep in my memory are your
offices of politeness and attention imprinted, never to
be effaced by reverse of fortune or by lapse of
time.
I trust, gentlemen, that my future conduct as a
fellow-citizen, as a fellow-practitioner, and as a fel-
low-member of various literary institutions, shall ever
2 furnish 

(69)
furnish the most ample and indubitable testimony of
the sincerity and truth of what I now declare.
Impressed with the most cordial wishes for a long
continuance of your utility and same in public, and
of your individual respectability and happiness in pri-
vate life, I now bid you, as your pupil, a lasting and
an affectionate adieu.
THE END.