In fixing upon a definite and just name for this formidable malady, the same difficulty is experienced as with other diseases of far less magnitude. The predisposing and proximate causes of any disease may be the same; and yet, in the course of its progress and the variety of tissues implicated, conditions of a very different nature may be developed, each of which, according to the prevalent mode of nosological classification, would be entitled to distinct designations. Thus in the disease under consideration. There may be simple mesenteritis, excited perhaps by contiguous inflammation of the bowels, or peritoneum - one or both - or there may be induration of the follicular and mesenteric glands; or hypertrophy of the same, all of which would be mesenteric disease, and possibly all might be dependent on the same predisposing cause, viz., scrofulosis. None of which, however, would justify the use of the term tabes, which signifies in plain English a wasting or consumption of the part to which it is applied. Still, the long continuance of any form of disease of the glands of the mesentery would inevitably result in destruction of nutrition, and a universal wasting of the body, i. e., a tabes, or more properly, marasmus.
Nosological writers have tried hard to find a term that would convey a just definition of the various forms of chronic mesenteric disease, with, however, little success for the reasons already stated. Hoffman termed the disease atrophia mesenterica; Sydenham, febris hectica infantum; Sauvages, scrofula mesenterica; Cullen, tabes scrofula; Good, parabysma mesentericum. Other names have also been suggested with equal satisfaction as, for example, mesenteric fever, chronic mesenteritis, etc. The term tabes mesenterica is most used and, therefore, the best understood, for which reason only is retained in this paper.
Tabes mesenterica although occurring in rare instances in adults, is essentially a disease of early childhood. This fact no doubt led to the solution of such names as tabes infantum, marasmus infantilis, atrophia infantilis, etc., which occur in works of old authors.
The subjective symptoms of tabes mesenterica have been succinctly stated by Dr. Copeland: “distention and, enlarged abdomen; emaciation gradually increasing; irregular and otherwise disordered bowels, and ultimately hectic fever from enlargement and disease of the mesenteric glands,” (Medical, Dictionary). I comprehend in my definition of this disorder all those morbid changes of the glands of the mesentery and enteric mucous membrane, which produce the characteristic derangement of digestion and nutrition. The organic lesions which follow this derangement have been well described by the author just quoted. The glands of the mesentery are hypertrophied. They increase in size to such an extent, in some instances, as to be perceptible to the touch through the walls of the distended abdomen. But the hypertrophy does not stop here. The follicular glands of the mucous membrane, and the absorbent glands throughout the system, become implicated in the same morbid process. As the disease progresses, the mesenteric follicular glands soften and ulcerate, [Watson says they enlarge but never ulcerate. - Practice of Physic] producing peculiar diarrhea and hectic fever. I have myself observed several cases, when there was reason to believe suppurative inflammation existed throughout the entire length of the alimentary tube from the mouth downward. Similar lesions take place in other organs of the body, as the brain, lungs, liver, spleen, pancreas, etc. This form of mesenteric disease is almost exclusively confined to children at the breast, and those in process of weaning.
Another and not less fatal form of the disease is occasionally observed in adults chiefly, and consists of induration, not only of the mesenteric glands, but also of the absorbent glands throughout the system. In cases of this kind the abdomen is sunken and hard. The bowels extremely constipated. The unhappy victim is hypochondriacal and, despite a voracious appetite and its full indulgence, etc., gradually wastes away and dies from lingering starvation. This disease is properly termed marasmus, which it is not proposed to discuss here.
Causes. - In respect to the causes of this formidable malady few will hesitate to concede that a strumous habit of the body is chief among the predisposing causes. Unfavorable locations, breathing impure air subject to a miasmatic atmosphere, privation of light or sunshine, sleeping in low unventilated apartments, personal uncleanliness, difficult dentition, improper and insufficient food, and other depraving, irritating and debilitating influences are also among the predisposing causes. Dr. Copeland and others regard, with questionable propriety, the “epoch of infancy and childhood” as predisposing causes. I am not prepared to admit that infancy or childhood, youth or maturity, has anything to do with producing or disposing to disease of any sort.
Unhappily the exciting causes are numerous enough. — Among the most prominent may be mentioned improper food furnished at unreasonable hours. Too early and too radical changes in diet. Neglected diarrhea and then gastric disorders. Too free indulgence in crude and inapplicable drugs, such, for example, as Calomel, Aloes, Rhubarb, Castor oil, Glauber salts, Nitre, etc., with which over anxious and ill advised nurses and mothers so frequently ply themselves and their little ones. Insufficient clothing, and sudden exposure to cold and inclement weather, by which atonic congestions and inflammations are induced. Scrofulous nurses. Inattention on the part of the nurse to the kind and quality of her own diet, to habits of cleanliness and chastity; in brief, any error of circumstance or condition which tends to irritate her milk and disorder her general system, is a direct and palpable cause of exciting this form of disease in her child.
1. The premonitory symptoms of mesenteric disease are not peculiar. There is obvious indigestion; the bowels are loose; the appetite capricious; the child exhibits considerable languor; throws up its food; is fretful and restless day and night. The doctor says its food disagrees and is not at all appropriate. He recommends, perhaps, farina gruel; or, may be, arrow root; not unlikely malt; and, more than likely, mutton broth, without regard to age or condition. Each is faithfully tried in its turn, but the child grows rapidly worse.
2. The second stage supervenes. The child has fever; its little hands are hot and dry; there is much thirst and manifest hunger, indeed the appetite is rapacious; the bowels move hourly; the stools are lienteric, watery, of deep yellow color, commingled with green; there is much flatulence; the abdomen is bloated and tympanitic. He may have been ill but a few days, and already the disease has made fearful draughts on his strength and flesh. Foolish but well intentioned experiments may have been instituted to nourish the little sufferer, but evidently with no success.
3. The third stage, arbitrarily speaking, finds matters still growing worse. Emaciation and hunger, always characteristic indications of the disease, are now more than ever prominent and ruling symptoms. The skin, owing to the extreme wasting, literally hangs in wrinkles from the limbs; the stools are not less frequent, often fetid, mixed with the ingesta, watery; sometimes amber colored, sometimes white and chalky, at others still, green as grass. Hectic fever, ___olliquative ___ sweats occur, with frequent rigors; restlessness continues; the pulse is frequent, thread-like and compressible; the features are pointed; eyes either dull or glassy. The voice at this low stage of the case is hardly human; its faint whines resembling more the feeble bleating of new born lambs. The bowels may remain swollen to the close, hut not unfrequently they become sunken, and exhibit, in common with other parts, an extremely wasted appearance. Well may Sydenham have designated such cases “febris hectica enfantum.”
When lung complications exist, which is not unfrequent, it is at the later stages they assume the most serious aspect. In addition to the symptoms already noted will be cough; enlargement of the cervical and bronchial glands; ulceration of the throat and the characteristic signs revealed by percussion and auscultation. I have known infants of a few months old afflicted with the disease, cough and raise like old tubercular patients.
It will be observed that I have related above the symptoms, such as will be presented in a case of the disease allowed to run its course unchecked. All cases, happily, do not present this serious phase, because early and effective medical treatment arrests its progress. I always feel proud of my art and satisfied with myself when conscious of having thus arrested the malady and saved the little innocent from a premature and torturing death.
Dr. Copeland writes: “When the disease is clearly manifested, the prognosis is unfavorable; and no hopes of recovery should be entertained when it is associated with tubercles in the lungs, or with chronic peritonitis. On the other hand, when the disease is not far advanced, and before hectic symptoms are established, or the emaciation becomes great, or the stools have assumed a chalky or lienteric appearance, hopes of recovery may be entertained, although, even in these cases, a cautious prognosis should be given. The younger the child the greater is the danger. The causes and complications of the disease should also in some degree influence the prognosis. When these causes admit of removal; when unwholesome food and impure air produce the malady, and may be removed; and when intestinal irritation is the only complication, then, a more favorable opinion may be given than under other circumstances” (Medical Dictionary).
Dr. Good writes; “Yet it is only in recent and uncomplicated cases that we can fairly hope for success, let our medical plan be what it may. In the scirrhous, sarcomatous, steatomatous and, especially, the fungous modifications and, more especially still, where several of these are playing their parts simultaneously, the art of medicine may possibly retard, but can never entirely ward off, the fate that is approaching, with perhaps a slow, unperceived. and insiduous, but at the same time, with a certain and irresistible stealth of footstep” (Study of Medicine; article, Parabysma Mesentericum).
Dr. Watson writes: “This (tabes mesenterica) is not only a very common, but a very fatal disease among children and young persons. The glands of the mesentery enlarge and become charged with tubercular matter. * * Their enlargement is commonly connected with scrofulous disease and ulceration of the mucous follicles of the intestines; and the little patients die because the lacteals are no longer able to take up from the food a sufficient supply of nutriment ( ? ) They die starved. But some few cases do recover from tabes mesenterica,” (Watson's Practice of Physic). Dr. Dunglison also remarks, that the prognosis “is usually unfavorable,” (Medical Dictionary).
Such briefly is the allopathic estimate of this truly terrible malady, and the confidence which they repose in their method of treating it. What graver comment could be made against a system of therapeutics than that it were important in the treatment of a disease, or class of diseases, not strictly self-limited, and which by nature tend irristibly to death?
The propriety of rendering a cautious prognosis in so grave a disease as tabes of any kind, is not to be questioned. It is fairly questionable, however, that we are not to hope for success except in “recent and uncomplicated cases,” “let our medical plan be what it may.” Although it is freely admitted that many case will die despite our “medical plan,” from causes and circumstances not within our control, yet when we are able to remove the direct exciting causes of the disease, in other words, to place the patient under favorable relations to life, such as appropriate food, proper clothing, fresh air and sunshine, we should not only hope, but confidently expect, to save our patient, whatever may be the specific predisposing causes which we have to contend against.
The means best adapted to consummate this most desirable result are often difficult of discernment, and when ascertained, frequently, it must be confessed, prove inadequate for the purpose. They consist of:
1. Agents of Hygiene; embracing the natural requirements of the system in health and disease; such, for example, as appropriate food and drink, fresh air, plenty of sunlight, cleanliness, change of location, appropriate exercise, etc.
2. Remedial Agents; consisting principally of Arsenicum album., Baryta carb., Chamomilla, Calcarea carb., Iodium, Phosphorus, Sulphur. Other remedies have been suggested and will sometimes be found serviceable, chiefly as auxiliary aids in the treatment, it is believed, such as Belladonna, Asafetida, Causticum, Cina, China, Hepar, Lachesis, Magnesia, Nux vom., Petroleum, Pulsatilla, Staphysagria, Sulphur, etc.
Hygiene. - The diet and regimen of the patient are of the first importance. Failure in meeting the hygienic demands of nature would compromise the otherwise most skilful treatment. A trifling error in diet, either in quantity or quality, or time of administration, may aggravate an existing intestinal irritation, or produce one where it did not exist previously, and render abortive the most wisely selected remedy. More attention, therefore, to the subject of diet, especially, is demanded of the therapeutist, if he would cure his patients of intestinal and digestive disorders.
What are the indications of diet in this malady? Obviously, the selection or such articles of food as are easy of digestion, and which, at the same time, meet all the circumstances and constitutional peculiarities of the case. This is by no means an easy task. There are, it is true, certain general principles to guide us in selecting the proper food; but even with these, valuable as they are, and must be, much must necessarily be left to individual experiment.
Milk is the only pabulum designed and purposed by nature to nourish the young mammal; and experience proves it best adapted to fulfill the requirements of food for infants, either sick or well. Privation, or insufficient supply of the mother's milk, in a majority of cases of tabes infantilis, is the chief exciting cause; and if the disease be fully developed, and the child very young and frail, no time should be lost in providing for it a full supply. If it be impracticable for the mother to nurse the little sufferer, a wet-nurse, of good condition and appropriate age, should be gotten at once. Do not delay. It were useless to proceed with remedies and leave the indication of diet, so clearly manifested, unheeded. A few days experimentation with rank cow's milk or the milk of goats or asses or raw beef or, still worse, farinaceous preparations and nauseating malt, and the various but inappropriate broths so commonly used, will find the disease far advanced and, may be, beyond hope of recovery from any source. With the restoration of its natural pabulum — that good which Infinite Wisdom expressly provided for it — the chief cause of gastric and intestinal irritation will be removed, and some reasonable ground of hope furnished thereby that the disease may promptly yield to some remedies.
In other cases the necessity of woman's milk may not exist. The child is farther advanced in years. There are, perhaps, four, eight, twelve, or sixteen teeth. The period of infancy, with most of its perils, is already passed. In such cases fresh undiluted cow's milk or the milk of goats - rarely even that of asses - may be demanded and prove the great desideratum - easy of digestion and, consequently, soothing to the intestinal disorders. Cases will occur, however, even among children thus advanced, where the milk of those animals disagrees. It makes its appearance undigested in the stools, and solid pieces of curd, frequently of considerable size, are ejected from the stomach. If such disagreement be radical and does not yield promptly to homoeopathic remedies, arrow root may be given instead and will often prove a valuable substitute.
Another valuable substitute for milk, in the treatment of tabes mesenterica and other intestinal disorders of young children, is mutton-broth. I have known children of a few months old, doomed by pitiful circumstances to the bottle, thrive well on mutton-broth, when all other unnatural preparations had proved indigestible and disease producing. - Chicken-broth is sometimes useful, under similar circumstances and conditions; and although not possessed of all the virtues of the broth of mutton, affords the patient an accessible and often agreeable change of diet.
When the disease occurs at a still later period of childhood, numerous other articles of diet are allowable and, indeed, highly serviceable in sustaining the vital powers and improving his condition; such, for example, as the essence and extract of beef, raw beef, farina, rice, hominy and other farinaceous products; toasted bread, baked potatoes, grapes, etc. Where the teeth are developed it is fairly presumable that the digestive powers are so also, and both kingdoms of nature - the vegetable and animal - are free to the patient, from which he may draw his nourishment, that which experience shall have proved best for him.
The regimen in other respects must be judiciously prescribed. The patient should be dressed in flannel and plenty of it. Its sleeping apartment should be elevated, exposed freely to sunlight and well ventilated. Warm water baths to the extent and for the purpose of cleanliness — nothing further - should be given. Allopathic authorities have, with questionable propriety, recommended saline baths. But, what have they not recommended? When one reads over the list of remedies and recommendations which they have suggested for this malady, it seems as if all the devils in pandemonium had conspired with them in the destruction of the infant race. It should be borne in mind that there is far more danger in bathing these patients too much than too little. Exercise should not be neglected, and it must be tempered to the age and condition of the child. If an infant, and the season and state of the weather do not forbid, he should be taken out of doors daily. If he be too feeble to endure the jolt of a carriage, carry him in the arms gently; care being taken in all cases to avoid undue exposure and fatigue.
Change of location, for reasons not clearly understood, is generally attended with good results. The free country air is preferable to the vitiated atmosphere of closely crowded cities. Residence by the sea-shore, inhaling the saline breezes, is, with this, as with many other scrofulous maladies, highly salutary. In older patients, the advantages of a sea voyage must not be underestimated. The disease is thus stayed, and its effects eradicated, many a time when, inland, the medical art seemed unavailing.
Sleep is also highly important; use every means consistent with reason to promote it. Keep the patient free from exciting causes. Make no draft on his mentality. If sleepless do not poison his brain with anodynes, but relieve it by appropriate homoeopathic remedies.
Wet-Nurse. - In selecting a wet-nurse, particular care should be taken that she be sound in body and mind. Avoid one whose secretions are foul. If she have catarrh; habitually, loaded tongue; offensive breath; hacking cough; chronic diarrhea; tumors in the mammae and axillae; copious and excoriating leucorrhea, or either of them, reject her. She is not a proper person to serve any child in that capacity. It is highly proper also that the age of her milk should approximate that of the patient as nearly as possible.
The influence of a wet-nurse over the destiny of the patient is very great. Her conditions, both physical and mental, react upon and modify those of the child. She may undo by erroneous habits, all that our art can do and as fast. She deserves special attention therefore at our-hands.
Her regimen should be strict; her diet generous and regular; she should have sufficient sleep. It will not do to overwork, nor subject her to undue exposure; still she requires, for the patient's sake, plenty of exercise. Care should also be taken of her person - when ill, prescribe for her without delay - an occasional sponge-bath will, I venture to say, not only improve her personal condition, but prove highly serviceable to the health of the one whose very life she supplies.
If the secretion of milk become, from any cause, defective or insufficient, do not allow her ale, whiskey, nor “strengthening” bitters so much in use, with the view of correcting the difficulty. In most cases a diet of bread and milk and beef soup, in addition to the more hearty food, will supply the want. If the difficulty be not amenable to a more generous diet, ascertain its precise nature and remove it homoeopathically.
These small details may seem unimportant to many, and it is for that reason, and also because they are so often disregarded in practice, and with too often fatal consequences, that I linger upon them. It should always be borne in mind that judicious attention to diet and regimen, in respect to both nurse and patient, is of the first importance, without which, in severe and fully developed cases, the best remedies will be prescribed in vain.
Remedies. - In attaching so much consequence to diet and regimen in the management and care of this disease, I trust not to be understood as underrating the value of appropriate remedies. I say appropriate remedies. The term appropriate in this connection is used with its full signification; for it were ten thousand times better that the case be left entirely to the beneficent influences of a correct regimen, then that repeated doses of drugs, large or small, be given, the nature and effects of which are unknown, or if known, entirely disregarded. Better do nothing at all than to do the wrong thing. Wait, study the case awhile, and become, if not already, familiar with its essential features. The patient can far better afford to wait a day or two longer, and would no doubt prefer to do so if he was capable of intelligent choice, rather than take the risk of taking inappropriate and incongruous drugs. Having definitely ascertained the disease and its specific counterpart, the remedy, we may proceed with our prescription in the full assurance of, at least, doing no harm.
In this connection Dr. Dunglison's words of advice, himself a venerable allopathic author, and writing for the benefit of allopathic physicians, are singularly pertinent. How many precious little lives would be annually saved if they were heeded! He writes, “The physician exhibits his skill by controlling disease by appropriate regimen, than by administering combinations of whose effects he often knows little, and where much of his practice must necessarily be involved in conjecture. The science of medicine is more demonstrative than is usually imagined, and, when the case is not so, the practitioner had better for the time do nothing. Any experiment may have one of two opposite results; it may do good or harm; and hence a practitioner is not justified in administering a powerful medicinal agent at random. If he be desirous of instituting experiments, he ought to take example from some modern therapeutical inquirers in Germany, and make them upon himself rather than upon his patients” (Therapeutic Materia Medica, Vol. I, p. 24).
If then we would cure these patients, for cure them we must if cured at all, it is obviously necessary, first, that the true nature and seat of the disease be discovered; second, that the exciting and predisposing causes be definitely ascertained; third, the pathognomonic symptoms be fully noted; fourth, that a remedy be selected whose pathogenetic symptoms in their entirely exactly correspond to the totality of the symptoms of the case. When this analysis shall have been made, our medicines can be administered with a positive certainty of doing good.
Clinical Observations. - The following clinical observations must not be regarded as in any sense exhaustive. Such indications only are given as have been repeatedly verified by successfully treated cases in my own practice, and which, for the most part, are justified by the record of trust-worthy provings.
Arsenicum alb.- Great physical prostration and emaciation; skin cool and dry, or dry and burning; abdomen distended and hard; swelling of the mesenteric glands; stools frequent; excited by eating and drinking, mixed with ingesta, green, slimy and watery, offensive or odorless. Inordinate appetite; unquestionable thirst for cold water; nothing seems to satisfy the patient; frets and moans, and tosses about; excessive restlessness; if a child, desires to be carried about constantly, day and night.
Arsenicum is rarely, I believe, indicated, in the beginning of the disorder; neither will it cure it when fully developed. It is capable, however, of mitigating the patient's sufferings and improving his condition generally. It is of great use, nevertheless, in so much that it frequently renders the disease amenable to the influence of other and more appropriate remedies. It seems to be more appropriate to the stage of ulceration than of induration. Hence in the later stages of the malady the drug reaps its best laurels. Even where the disease is beyond the hope of recovery, Arsenicum will often do more to sooth and comfort the last hours of the patient than all the anodynes put together.
Baryta carb. - This drug is more appropriate in children of advanced age, and in cases of induration and enlargement f the glands. The abdomen is tense and inflated; stools loose and pappy, or hard and dry; immoderate appetite; troublesome inflation of the stomach after meals; enlargement and induration of the tonsils; sound of bells in the ears; eczematous eruptions on the face and scalp; dry harsh skin, etc.
Calcarea carb. - Applicable to all ages of the patient and in in all stages of the disorder, except, perhaps, the very last, Calcarea carb., is one of the chief and most successful remedies against the disease. Given early, in sufficiently high potency, in cases to which it is truly homoeopathic, and the malady need never put on its serious phases. In cases fully developed I believe it not incapable, frequently, of meeting every requirement singly and alone. The chief symptomatic indications are: scrofulous and cachectic children with tumid abdomens and tendency to emaciation: appetite voracious; morbid craving for indigestible articles; milk disagrees; the child is uneasy from flatulence and colic; loose stools of creamy color and consistence, fetid and frequent; sometimes watery and calcareous and mixed with undigested substances; worms; wetting the bed; difficult dentition; nocturnal perspiration; loose cough; heat at night; hardness and swelling of the glands of the neck; great bodily weakness; the mind, however, is clear and often precociously developed.
Chamomilla vulgaris. - Mention of this remedy is made here only to remark that its early and judicious administration to children at the breast, will in many cases remove the existing causes of the disorder, such as offensive diarrhea and indigestion so peculiar to infants, and thus prevent the development of the malady.
Iodium. - This remedy is highly valued by allopathic physicians in the treatment of tabes of every form and variety. And the study of its pathogenesis would lead one to believe the confidence reposed in the drug by them, well-founded. The pathogenetic symptoms rendered by Jahr, closely ally it with Calcarea carb. and Sulphur in the treatment of mesenteric disease. I regret to say, however, that in my hands it has not yielded the results which its pathogenetic symptoms had led me to expect. Has it in other hands?
Sulphur. - This drug should stand at the head of the list in scrofulous affections. There is, probably, no remedy in the Materia Medica Pura, whose sphere of usefulness can compare with Sulphur. Well might the eccentric Paracelsus have declared it one of the three great types of remedies, Mercury and Salt being the other two.
Sulphur is applicable in all conditions and stages of the disease. Unlike most other remedies, in cases to which it is truly homoeopathic, it fulfils all the indications of treatment from the beginning to the end. It resembles Calcarea carb. in that respect. It is superior to the latter remedy, however, in other particulars. It is more prompt in its action, and possesses superior range of virtue. It is, moreover, more generally appropriate to desperate stages of the malady under consideration.
It should be observed that Sulphur possesses prophylactic virtues against mesenteric disease. In young children of scrofulous mothers, especially if the teeth develop slowly, and with constitutional irritation; if milk disagrees, and there be colic and distention and soreness of the abdomen, fetid and frequent stools, Sulphur given in high potency will often afford prompt and permanent relief. When the disease is complicated, and the indications of treatment obscure and ill-defined, Sulphur may be given cautiously, if an exception may be allowed to a former remark, until a more complete individualization of the case be obtained.
Phosphorus. - This remedy ranks with Sulphur in tabes mesenterica. In later stages of the malady, and when the disease is complicated with phthisis pulmonalis, the drug has its superior only in Sulphur. In phthisical adults, with mesenteric disease superadded - a complication frequently met with in practice - presenting the following symptoms, Phosphorus will be found an invaluable remedy:
“Great weakness and paralytic lassitude, which sometimes come on suddenly, especially in bed in the morning, or after a short walk. Fainting fits. Inability to remain in the open air especially when it is cold,” and great tendency to take cold. Atrophy of the lymphatic glands, and of the whole body. Sharp ringing cough, day and night, mostly dry. Soreness and painful dryness of the throat. Dainty appetite. Any excess in eating is followed with increased diarrhea. Bowels sunken. Periods of accession and decline of the cough alternate with diarrhea. Stools from six to eight daily, occurring both day and night. Serous stools, of greenish or grayish color, offensive and mixed with the ingesta. Painless stools, followed with lassitude, and aggravated by eating and drinking. Great desire for cold drinks - especially cold water — which seem to produce less inconvenience than warm fluids. Night sweats.
Rapid wasting of the flesh, and great exhaustion. Mental activity. Sleeplessness. Voracious appetite. Engorgement of the glands of the mesentery, neck, throat and groins. Tumid, or “tub-shaped” abdomen. Stools frequent, lienteric, watery; greenish, or amber color; attended sometimes with griping, at others, entirely painless; offensive or odorless. Milk produces colic. Coldness in the morning, and fever in the afternoon. Copious and exhausting perspiration, chiefly after sleeping. Pulse frequent, thread-like. Dry hacking cough. Shortness of breath. Respirations greatly accelerated.
|The American Homoeopathic Review Vol. 06 No. 08, 1866, pages 291-297, pages 334-341, pages 383-383
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