COLLECTANEA JACOB]IN EIGHT VOLUMES

VOLS . I , 1 1 AND I l l , PE D I ATR ICSVOLS . IV AN D V , GnNnRAL TH ERA

PBUTICS AND PATH OLOGYVOLS . V l AN D V" , IMPORTANT AD

DRESSE S, BI OG‘RAPH ICAL , AN D HIS

TORXCAL PAPERS , E'

r c .

VOL. V I I I , M I SCELLANEOUS ART"

CLnS, AUTH OR S ‘ AND COM pu ns TOP

ICAL INDBx

DR. J ACO BI’

S WO RKS

COLLECTED ESSAYS, ADDRESSES,

SCIENTIFIC PAPERS AND MIS

CELLANEOUS WRITINGSOF

A. J AC O B I

D. UNIVERSITY OF BONN LL . D. UNIVERSITY OF MICH IGCOLUMBIA YALE HARVARD

oresso r o f In fantile Patho lo gy and Therapeut ics N ew York Med ical Co ll860 Cl in ical P rofessor o f D iseases o f Ch ildr en , N ew York U n iver sidedical Co llege ( 1 865 Cl in ical P rofessor o f Diseas es o f Ch ildr en ,

C o llege o f Physic ians an d Sur geo ns, Co lumb ia U n iver sity ( 1 870 P r ofesso r o f D iseases o f Ch ildr en in the same Emer itus P rofessoro f Diseases o f Ch ildr en in the same Co nsultin g Physic ian t oBellevue, Moun t S ina i , The German , The W oman

’

s In fi rmary,

Bab ies’

, O r thoped ic , M intur n and H ack en sack H o spitals.

mber o f the N ew York Academy o f Med ic in e Med ical So c iety o fity an d County o f N ew York, Med ical So c iety o f the State o f N ew Yo reutsche Med iz in ische Gesellschaft o f N ew York , N ew York Patho lo g icSo c iety, N ew York Obstetr ical So c iety, Asso c iat io n o f Amer ican Physic ian s, Amer ican Ped iatr ic So c iety, Amer ican Cl imato lo g ical Asso c iat io n ,

Co ngr ess o f Amer ican Physic ian s and Sur geo ns, Amer ican Med icalAss o c iat io n , Inter natio nal An ti-Tuber culo sis Asso c iat io n ,

Asso c iat io nfo r the A dvan cemen t o f Sc ien ce ; Asso c iate Fellow o f the Co llegeo f Physic ian s in Ph iladelph ia, So c iété de Péd iatr ie de Par is.So c iété d

'

Obstét r ique, de Gynéco lo g ie et de Péd iatr ie de Par is,Amer ican Academy o f A r ts an d Sc iences ; Fo r e ign Membero f the Gesellschaft fii r Gebur tshii lfe in Ber l in ; Co r r eSpo nding Member Physicalisch -Med iz in ische Gesellschaft o f Wu' r zbur g, Gyneco lo g ical So c iety o f Bo sto n ,

O bstetr ical So c iety o f Ph iladelph ia , Gesellschaft fii rinner e Med iz in und K inder he ilkun de in W ien .

H o n o rary Member Yo nk er s Med ical Asso ciatio n , L ouisv ille Obstetr icalSo ciety, Abingdo n , Va Academy o f Med ic in e, Br o o k lyn M ed icalSo ciety, Med ical So c iety Distr ict o f Co lumb ia , N ew York Obstetr ical So c iety, Med ical and Ch irur g ical Faculty o f Marylan d,Amer ican Laryngo lo g ical Asso c iatio n , Ped iatr ic So c iety o f St.Peter sbur g, Ped iatr ic So c iety o f K iev, Royal Academy o fMed icine, Rome , Deutsche Gesellschaft fii r K inder he ilkunde,Ver ein fur Inner e Med iz in o f Ber l in ,

Royal So c iety o fMed ic in e o f Buda Pesth .

IN EIGHT VOLUMES

EDITED BY WILLIAM J . ROBINSON , M.D.

NEW YORK

1909

CONTRIBUTIONS

ED IATR ICBY

A. JACOB], M.D LL.D.

VOL . I

EDITED BY WILLIAM J. ROBINSON, M.D.

NEW YORK

THE CRITIC AND GUIDE COMPANY12 MT. MORRIS PARK WEST

1 909

COPYRIGHT,1909,

BY MARJORIE MCANENY

AUTHOR ’S PREFACE

To MY READERS—If ther e b e any —I des ir e to givean explanation of, o r an ap ology fo r , the appear ance

of thes e v olumes . Fo r many year s fr iends have en

cour aged me to wr ite my memo ir s . They claimed thatthe Par caa had no t cut the thr ead of my life only t o

give me an opp o r tun ity to r ep or t what I had Obser vedin connection with the histo ry o f the p r ofes s ion o f

the country in a medical p r actice extending over al

mos t s i xty year s , as a public teacher o f medi c ine during

'

fo r ty-five year s , and a member and an officer in

many lo cal, national and inter national as s o ciations .That may be true, but as a memo ir wr i ter I have n otsucceeded in being p r olific b eyond a few chap ter swhich, with o ther s , may o r may n o t r each the eyes of

my fr iends , and enemies , fo r a long time t o come , ifat all. A very go od r eas on fo r that i s intelligible to

every New Yorker . W e hav e no time fo r anythingbut work ; the luxury o f leisur e we do n o t p os s es s ; and

pleasur e i s enj oyed only, o r mostly, by thos e whofind pleasur e in work.

S o n o memo ir s could be wr itten , on account of c onstant , and constantly p r es s ing wo r k . Pegasus wear s

n o har nes s , and I , like most of you, have always been inhar ness . Whether that was always an enj oyment o r

a benefit to other s , I canno t tell you. But I believeI may as sur e my pr esent r eader s that my memo i r s , ifthey ever be wr itten , will pr ove that my p r ofes s ional

7

AUTHOR ’S PREFACE

life,taken all in all, was very succes sful, if not always

lucky o r happy.

To demonstr ate that , a few r em iniscen ces may bep erm itted her e ; they _

may be r epeated, amongst other s ,p osthumously, may be ante

-p o sthumous ly.

The fir st o f my pr ofes s ional suc ces ses was the factthat it to ok my fir s t patient only a for tn ight after mynew shingle began to or nament N o . 20 Howard s tr eet ,t o call on me w ith his twenty—five cent fee . That was

in N ovember , 1 85 3 . I must have had qui te a r eputationat that time, fo r his only ex cus e fo r com ing at all was

that he had heard of me. I think I mus t have gather edmany mor e such fees , fo r after les s than four year s Iwas one of the founder s o f the German dispensary, inwhi ch tr eatmen t was str i ctly gr atuitous . About thesame time of this memor able achievement of m ine, Dr .

Stephen Sm ith, that go od and glo r i ous man , acceptedfr om me a l ong s er ies o f extr acts fr om Eur opean j ourn als and bo oks , mostly on dis eases of chi ldr en , and

Within another year , he was pleased to accep t , what Iam still pleased to call, o r iginal ar ti cles . About thesame time my inexper ience made me try my fir st lectur eon half a dozen suffer ing student s ( in the Sp r ingcour s e, of 1 8 57 ) o f the College of Phys i c ian s and Sur

geon s . I near ly br oke down , mor e o r les s des er vedly.

My subj ects wer e the di seases o f the young larynx and

Iaryngi smus str idulus . N olens volens I exhib ited inmy own p er s on an attack of laryngi smus . W e all survived. A s imi lar exper ience I had thr ee year s afterward when I had been made p r ofes s o r of infantilepathology and ther apeutic s in the New York MedicalC ollege, then lo cated on E ast 1 3 th Str eet . I f s ome

on e wer e anxious t o lear n how I , w ith my kn owledge of

8

AUTHOR’

S PREFACE

pathology and ther apeutics , which indeed was r ather

infantile, became a p r ofes s or , thi s i s how i t happened.

A fr iend of m ine, who has a tablet o f his own in the history o f Amer ican obstetr ics , had taken a chair in ther eo rgan ized s cho ol . So my dear Char les Budd wi shedme to go in wi th him, and came as a comm i ttee to Offer

me a place in the faculty. When I us ed what I hadof common sens e and r ep lied that I did n o t feel c ompetent , he tr ied his gr eat ar t o n himself. He deliver ed

himself, with for cible tongue, o f so many un complimentary r emarks about me, that I ac cep ted his terms at

on ce.

The very next year , the eighth, I made a heap of

money out of liter atur e, which i s r emarkable fo r a medical man , unles s he beWeir Mitchell, o r Osler , o r Holt .It happened thi s way, —perhaps s omeone wishes to

imitate me. Indeed, I believe he should. In 1 8 59, E .

No egger ath and I publi shed a big volume , Co n tr ibu

tion s to the D i seases of W omen and Childr en ,”

at an

expens e to our s elves o f $8 00 ; a few year s afterwardwe s old the edition as waste paper fo r s i xty-eight

dollar s , a clear pr o fit— c ompar ed with nothing.

Thir teen year s pas s ed, and I suffer ed fr om fir e ; s ome

r ar e b o oks and sp ecimens that I could never r eplace

bur ned down w ith the Un iver s ity Medical College build

ing on Four teenth S tr eet . Over the ashes o f my p r op

er ty Tammany Hall was er ected, whi ch r efus es tobur n , at least in thi s wor ld. About the same time Icashed my fir s t big ho sp ital check in the shape of a

petechial typhus , of which I go t well after publicp r ayer s had been offer ed by s ome good o ld ladies .After s eventeen year s , I s cor ed quite a succes s when

I—r efus ing to r es ign—go t mys elf expelled fr om a pub“

9

AUTHOR ’S PREFACE

lic institution fo r p r oving a hundr ed per cent . mor talityamongs t our bab ies , and fo r ins isting up on a farming~

out system . Thus things have been go ing on fo r year sand decades , wi th and without any mer i t o f m ine . Once,only a few year s ago , I had even my s tyle cr itic ized,if not cor r ected. Ther e was a gentleman who had beenwor king fo r a hosp ital thi r ty year s . Then the matr onfound fault with him, and vice versa, and he was toldthat he would be p erm itted to r es ign , if he could notadap t himself to the lady. He r es igned, fo r it i s n oteverybody that p r efer s to be expelled. Ther eup on , and

on acc ount of thi s maltr eatment of a mer i tor i ous officer ,I offer ed my r es ignation , whi ch was ac cep ted becaus ethe ton e of my letter was declar ed to be unpleasant .Such specimens of the p r actical wisdom of other

people I have enj oyed many times . Once in a while Ihad

‘

(like J onathan Swi ft ) to wr ite o r talk fo r the irbetterment , if not fo r their appr oval . Thus fo r ih

stance : In another hosp ital the trustees inter fer ed w iththe mode of electing medical officer s , contr ary to theirown by

-laws , whi ch they m ight have alter ed if they hadwaited only two weeks . But they wer e in such a hur ryto over r ide thems elves and over tur n their do ctor s " So

I had to s end them my message that they wer e n o

longer a par liamentary body, and als o my r es ign ation .

In the cour s e of a long life I have scor ed a cho i ce lo tof success es of that and o ther kinds , but after all, the

defin ition of succes s as under stood by differ ent peoplevar ies very gr eatly.

Still I mus t not for estall my futur e memo ir s , whi chmust be expected to contain many exper iences n ot al

ways o f a pleasur able order . But , at least , they havebeen instructive. I lear n ed fr om them , and the les s on s

1 0

AUTHOR’

S PREFACE

der ived fr om them have benefited me, and as I intendedthey should, perhaps other s . That my methods wer ealways cor r ect o r p oliti c , I do not say. Indeed I am

cer tain that if I had displayed mor e patience in my at

temp ts at imp r oving such c onditions as I found faultyo r defective, I m ight have been mor e succes s ful in car ryingmy p o int s . I trust my mi stakes , s ome of which maybe tr aced in a number o f paper s , may inter es t myfr iends of the gr owing gener ation . They may r emem

ber C icer o , who found that the ear s of the mas ses ar e

dull,” that a truth, when unpleasant, r equir es mor e than

a s ingle p r omulgation . Perhap s the r evolutionarysp ir it of my youth and a warm temper ament whichbo iled at a low temper atur e, made me over lo ok the s lowpace at which r eforms ar e establi shed. R efo rms r e

quir e alter ation s o f op in ions and tenden c ies , and o r

gan ie changes ar e o f slow evolution . Lo oking backwards for ty year s , I can imagine that the very ladiesof the Nur sery and Chi ld’s H osp ital , like the trusteeso f other es tablishment s , impr es sed with their go od intentions and the o r iginality o f their p os iti ons , elatedby the financ ial suppor t fur n ished by the c ity and the

State, but no t accustomed to attend to the actual wor kconnected w ith financial and mor tuary r ec or ds , and ad

ver s e to b e taught by a mer e do ctor who p r oved a mo r

tality in their institution of one hundr ed per cent .

could have been with a cer tain amount of diplomacy,made glad and p r oud of imp r oving b oth their methodsand r esults . My o ld paper s , r ehear sed in one of thesevolumes , will tell a story which has n ot been the onlyo ne s ince . As our system of contr olling public institu

tion s has not met with r adi cal changes , er r or s of ad

m in i str ation s ar e always p o s s ible . I f I have any ad

1 1

AUTHOR ’S PREFACE

vice to give to my colleagues to whommuch i s gi venand fr om whom much i s demanded in thei r connectionwith public affair s , it is to exhib i t mo r e patien ce but n o

les s fir mness .But I forget that thi s i s n o pulp it o r platform . My

following r emar ks may be b r iefer . The fr iends whourged me to r epubli sh Old paper s complained o f their

be ing hidden in tr ansactions and forgotten magazines ,and r egr etted that half of them wer e never r ep r inted,and that such r ep r ints as existed at all wer e n o t acces

s ible , ex cep t in a few large libr ar ies . S ome wer e mor e

c ons ider ate than other s . They wanted me to publi shmer ely a volume o r two of my ther apeuti c paper s . S o

I began a p r oces s of exam in ing and s ifting, and her e

i s the r esult . Ther e ar e a number of hi stor i cal studies .They c ontain facts and r efer ences whi ch may p r oveuseful to thos e who ar e in need Of them . Indeed, ther ear e per s on s who se histor ical inter est s ar e no t lim itedt o what has happened s in ce the beginn ing of the twentieth century. S ome ar e even so lear ned as to quoteother s bes ides themselves and their fr iends . An obj ective r ep or t of histor ical facts should always be welcome .

The hi story of medi cine i s neglected amongst us. Onlyof late we hear of an o ccas ional c our se o f lectur es onthi s most impor tant subj ect , and I kn ow of n o pr o fesso r ship, n o t even lectur eship , on the hi story of medic inein our s chools .

With the ex ception of a s ingl e quar t er ly j ournaldevoted to the hi story of medicine, we have onlyJohn Wats on ’s The Medi cal P r o fes s ion in An

c ien t Times ,”1 8 56 ; The Nose and Thr oat in Medi cal

H i story,

” by J onathan W r ight ; Alvin A . Hubbell ’s“ The Development o f Ophthalmol ogy in Amer i ca,

”

1 2

https://www.forgottenbooks.com/join

AUTHOR ’S PREFACE

Yo r k Academy o f Medicine , the S o c ieties Of the C ityand County, and S tate of New Yo r k, of libr ar ies , andof national and inter national c ongr es ses will al s o be

found alluded to , o r di s cus sed. At all events I beli evethat an attentive r eader will be r ewar ded by much

us eful mater ial . A number of cas es r ep o r t ed dozen so f year s ago , have never lo st fo r me the inter est I to okin them when they wer e fir s t ob ser ved. I hope that mymany talks on the p r inciples of medi cal ethics w illco incide w ith the op in ions o f most o f my r eader s . The

mo r al gr oundwor k of a gentleman’s feelings and be

havio r was always the same , thr ough centur ies man’s

hear t has always been human , only tastes differ and

usually in tr ifles. Whether the pr ofes s ion of Amer icawill always obj ect to a phys i cian taking out a paten tI do not know. They perm i t i t in Eur ope . Whetherwe shall always obj ect to a man p r inting his actualo r p r etended spec ialty on his shingle o r his car d, I

cannot know . They do i t in Eur op e ; but I t rust , weshall always deem i t obj ectionable , as s oli ci ting pr e

sumptuousn es s o r lack of taste. But thes e things showperhap s only absen ce of judgment , but n o lack of hear tand c ons cien ce . But that ther e ar e men in the pr o

fessio n who gi ve o r demand br ibes , take comm i s s ion sfr om apothecar ies , in strument and bandage maker s ,nur ses ,—men and women—manufactur er s , in the shapeof cash o r sto ck, con sultan t s bo th medi cal and surgical -that i s n o longer p r o fes s i onal , no longer eventhe c ompetiti on of an hon est tr adesman : it i s r obbery,whi ch p ollutes the mor al atmospher e of p r ofes s ionallife , and fleeces the con sumer o f your s er vi ces , i . e .the patient .

My vi ews r egarding the p r inciples o f ther apy, both

1 4

AUTHOR’

S PREFACE

hygien i c and medi cinal , I trust ar e agr eeable to tho s ewho live a moder n life, w ithout super stitious beli ef inthings becaus e they ar e o ld, and without faith in thenew stuffs mer ely becaus e they ar e new.

Many pap er s and addr es ses cdn tain my views concer n ing the mos t impor tant and momentous question at

all times and befor e all nati on s , viz : the feeding of ihfan ts. I f the pr oblem wer e s ettled to everybody

’s sat

isfactio n , it would not be neces sary t o speak again at

thi s place . It i s a sati s faction however t o know, thatmoder n phys iology and b iochem i stry have n ot changedthe p r acti cal teaching fur ni shed me by domes ti c and

clin ical obs er vation s these mo r e than fifty year s . Thata number o f men high in our r anks ar e j o in ing mequietly and unostentatiously in gi ving the bab ies a

fighting chance agains t overdon e theor ies and detr i

mental p r actices o f not o r iety- s eeking per s on s , iis a

s our c e of c ongr atulation . Long may they live, Imean the bab ies . Tho s e fr iends of m ine and of all thebab ies ar e not the on es you s o Often meet in connection with inter views , haphazard telephone c onver sationsand r ep or t s of cas es in the daily paper s . They ar e

clever en ough to avo id being called in the publi c column s “ exper t in the dis eases o f childr en ,

” “ famous

p r ofes s o r of p ediatr ics ,”

and what n ot . Indeed thes eshor t-s ighted people p r efer t o make an honest r eputati on o f their own—and they succeed.

In r egard to the di s cus s ion of medical and san itaryp r oblems in the daily p r es s , our views may n ot alwaysagr ee . It i s customary t o exto l it , like the stage, andthe pulp it , as the indi spen sable , omn i s c ient and mo r al

and mos t influential p ower . I mean to j o in in that

pr aisev gf its p os s ib ilities , but I think we could add

1 5

AUTHOR ’S PREFACE

to its indispensab ility, omn is c ience, mor al p ower and

influence, without the neces sary commi s s ion o f manym istakes on the par t of an un info rmed, though everso b r ight news—hunting, r epo r t or ial staff . What Ihave o ccas ionally p r op osed was thi s , that a gr eatpaper should have on its editor ial staff a thor oughmedical man whos e whole o r mos t o f whos e wo r k shouldbe dedicated t o the study and di s cus s ion of p opularmedic ine and san itation in all it s b r an ches . G ive hima large salary and be sur e youwill str ike a cheap bar

gain by paying him well . At that r ate your paperwill s ecur e , fo r ten thousand dollar s a year , a r eliable

r ep or t and s ound cr i tic i sm of what you and your pub

lie i s anxious and entitled to lear n .

A still better plan i s thi s . In matter s o f p oliticaland s o c ial impor tan ce hundr eds o f n ewspaper s havethei r centr al bur eau, the As s o ciated P r es s . The

newspaper s of the c ountry should have their centr al bur eau o f san itati on and p r eventive medi c ine . Letthem spend as much money on this c enter , say thir tyo r fifty thousand dollar s , o r mor e ,—as much as a s inglelarge life insur ance company spends fo r a medical staff,fo r its c ommer c ial pur p oses . At that r ate the paper scan p r o cur e whatever knowledge ther e i s , b oth o ld and

new, and may at once become what they wi sh to be,and wish to be cr edited with, and deser ve to be, —fountains of p opular s cience , teacher s o f the people, founder s of a mor e intelligent , better in formed, and healthiernation . The centr al bur eau should b e fo r all, fur n ishequal information fOr all, bo th fo r the people and i t s

gover nments , without the danger s of gr ave m is takes ,misleading s ensationalism and cor rupting competiti on .

I should add a few wor ds in r egard to myself and

1 6

AUTHOR ’S PREFACE

the edito r of these volumes . Dr . William J . R ob ins on

has been my cri tic and guide . I f I have fault tofind with him i t i s that as a cr itic he was to o len ient .It gave him eviden t pleasur e t o r epublish whateverappear ed to c ontr ibute to the demonstr ation of thelife- evoluti on of a man who s e publi c utter an ces s eemedto him to fur n i sh s ome, though ever so s light , addi

tions to the s cientific, mental and ethical acquis ition sof the medical pr ofes s i on and its s tanding in the

commonwealth. Being a go od c itizen himself, a de

termined adver sary of doubtful o r wr ong p r actices

amongst us, a str enuous fighter against past and p r esent evils a nd in favor o f a r ight-m inded, str i ctly scien

tific and ethi cal futur e, he thought he met in my wr itings a c ongen ial sp ir i t and sympatheti c though modestally. That i s why he, though occup ied w ith the

duties of a medi cal p r acti ce and the editing and p r ae

tical cr eation of thr ee s cientific j our nals— including hisepoch-making CRITIC AND GU IDE —has burdenedhimself with the ar r anging, editing, p r inting, pr oo f

r eading, tr an slating, indexing, b inding, indeed ever v

thing connected with the pr oducti on o f thes e volumes .If ther e be any mer it in them it i s his ; if the b o oks leadto any p r ais ewor thy r esults , the cr edit belongs tohim.

1 9 East 4 7th Street. A. J ACOBI .

1 7

EDITOR ’S PREFACE

I K NOW of n o other man , either among the l ivingo r among tho se who have pas s ed on , who in our c ountryhas had such an imp or tant influence on the development of medi c ine in all its phas es , as has Dr . Abr aham

Jacob i of New York . The adj ective impor tan t i s ,however , not adequate n o r quite sati s factory. An

influen ce may be impor tant , and yet not beneficial ; o rit may be only par tially beneficial , and it i s s ometimesa vex ed p r oblem to determ ine whether a man ’s influ

ence has been mor e beneficial than harmful o r vice

ver sa. No such p r oblem confr ont s us in estimatingthe activity o f Dr . Jac ob i . Fo r his influen ce has been

who lly fo r the go od, fo r the highest go od b oth o f thepr ofes s ion and of human ity. Bear this last word inm ind. Fo r gr eat as Dr . Jacob i i s as a phys ician ,

gr eat as a teacher , gr eat as an inves tigator , he i sequally gr eat as a human itar ian . Not her e i s the place,n o r i s m ine the ab ili ty to s peak of Dr . Jacob i ’s ser

vi ces to medic ine p r op er ; of his s er vices to pediatr i cs ;o f the debt the little childr en the wor ld over owe and

for ever wi ll owe him ; of the thousands o f lives that he

has saved per s onally ; n o r w ill I di late her e up on the

indebtednes s the pr ofes s ion owes him fo r holding aloft“

and lighting it s pathwi th-

thetor ch o f ther apeutic op

timism in the m idst o f the star k—darkness of ther apeutie pes s imi sm and despair ; n o r will I sp eak her eof his s er vi ces in having br ought Amer ican and Eur o

19

EDITOR’S PREFACE

pean medicine clo ser t ogether , his ser vi ces in makingus—tho s e of us who des er ve to be r espected—r espected

abr oad. I hope that all thi s will be adequately and

pr oper ly don e in another place by an abler pen thanm ine . What I want to allude to her e i s J ac ob i , the

phys ician-man . Jacob i belongs to the n oble few who

have per ceived that the di sp en s ing of p ills , p owder s

and decoction s i s n ot the phys ician’s only fun ction ,

n o r even his highest functi on . He belongs to the n oble

few who many year s ago per ceived that many dis eas es

had a s o cial-econ omi c bas is , and that if we wanted to

do any good we had to imp r ove the econom ic and san itary c onditions o f the people . And thi s he p r eached

at every opp or tun ity—even when his p r eaching was

no t welcome. He belongs to the noble few who r egar d

the phys ic ian’s rOIe as s omething mor e than that of a

r el iever of aches and pain s—he per ceived the rOIe of

the phys i cian’s rOle as s omething mo r e than that o f a

san itar ian , a p r eventer , a cr itic, a guide . And whilehe has s ometimes been a s ever e cr i ti c , he has always

been willing and r eady to act as a guide . And his

guidance has always been a safe and r eliab le one .What attr acted me to Dr . Jacob i l ong befor e I had

the pleasur e of his per s onal acquaintance was his stur dyhonesty, his rugged fear les snes s , which o ne could r ead

ily feel in his public s peeches and addr es s es . He neverm i s s ed an o ccas i on to incul cate a wholes ome les s on .

And he was never afr aid o f his audience . Wher e an

other per s on would p our out fuls ome , cloying p r ai se ,he would offer healthy cr itici sm ; wher e another pers on would dispense n othing but taffy, Dr . Jacob iwould p r es ent a

‘

good do s e of E ps om salt ; t o di sp en s eundeserved flattery has always b een as di st asteful to

20

https://www.forgottenbooks.com/join

EDITOR ’S PREFACE

hyp ocr isy, mediocr i ty and commer ciali sm has been

s c or ched by him in n o uncer tain terms . E xcellent as

i s the quali ty o f Dr . J acobi’s wr itings , the ir quantity

no les s ex c ites our adm ir ation . E sp ecially so , when

we r ecollect that he has no t r ehashed any text-b o oksand then published them as his own , and that he hasnever wr itten becaus e o f an unquenchable caco ethes

scr ibendi . No , Dr . Jacob i wr ites only when he has

s omething to wr ite and he speaks only when he has

s omething to say. Unfor tunately many of his es says

and paper s have been hidden away in p er i odical swhich ar e no t r eadily acces s ible , o r in s o ciety tr ansactions which ar e altogether inacces s ible ; s ome o f hisaddr es s es have never been publi shed, and other s havebeen deli ver ed o r wr itten in German . Some o f the ad

mir er s o f Dr . Jacob i , among whom I mos t'

emphati callycount mys elf, have thought it a gr eat p ity to have so

many of his ex cellent, impor tant and even ep o ch—making wr itings bec ome p r actically l o st . They thought itan injustice to Dr . Jacob i and a s in against p o ster ity.

Dr . Jacob i was appr oached on the subj ect . With themodesty of true gr eatness he could n o t s ee i t our way.

He did not think that his wr itings wer e r eally o f such

impor tance , etc. Finally he was p r evailed up on . And

I have been hon or ed w ith the task of selecting,

editing, ar r anging, tr anslating and pr epar ing fo r the

p r inter the enormous mas s o f the mater ial o f whi chDr . Jacob i i s the author . The task s eemed an en or

mous one, but no task i s difficult int o whi ch you puts ome love . H ow I have acquitted myself of thi s lab oro f love, I leave other s to judge.The ar r angement of the matter i s , as far as feas ible ,

both by subj ect s and chr on ol ogi cal , but n o pedantic

22

EDITOR ’S PREFACE

rule has been followed. A mor e o r les s logical ar r angement s eemed to us the bes t .In wr itings extending over a per iod o f over a half a

century, s ome r epetition i s unavo idable . To m in im ize

thi s , the ar ti cles have in some cas es been c ondensed.

Other s have , o n account o f their histor ical value , been

cons ider ed to o impo r tant to adm it o f their abbr evia

tion o r c ondensation in any way. And it was consid

er ed much better to incur the r isk of occas ional r ep e

tition than t o run the danger of elim inating and los inga s ingle hi sto r i cally o r s cientifically valuable s entence .

Fo r the sake of histo r ical fidelity, i t has seemedbest , as a rule , to leave the spelling and the nomen

clatur e as they appear ed o r iginally. W e will ther efor emeet in thes e volumes : anaemia '

and anem ia, haamo r

rhage and hemo r rhage, per itonaeum and per i toneum ,

hypermanganate o f p otas sa and p o tas s ium perman

gan ate, hydr o chlo r ate of ammon ia and ammon iumchlo r ide, ther apeutical and ther apeutic , etc. , etc. The

author has kep t pace b oth with the s implified sp ellingand the constantly changing pharmacopeial n omenclatur e.

May thes e volumes which we trust will r emain a

monument of Dr . Jacobi’s var ied activity aer e per en

m'

us—mo r e p ermanent than br onze— al s o s er ve as an

inexhaustible s our ce of insp i r ation t o the p r ofes s ionof our coun try, the pr o fes s ion whi ch Dr . Jacob i hasloved s o well , the pr ofes si on which in sp ite of it s imper fection s r emain s the n oblest of all p r ofes s ion s "

W ILLIAM J . ROBINSON .

12 MT. MORRIS PARK W .

2 3

CONTENTS

VOLUME I

AUTHOR’S PORTRAIT (Steel plate)AUTHOR’S PREFACEEDITOR’S PREFACETABLE OF CONTENTSINTRODUCTORY CHAPTER

F r om Keating’s Cyclopaedia

.

o f the Diseases o fChildr en ,” Vo l. I .

THE RELATIONS OF PEDIATRICS TO GENERALMEDICINEAddr ess deliver ed befo r e the Amer ican Pediatr icSo ciety at Wiashingto n , D. C., September 20, 1 889.

A r chives“

of Pedi atr ics, No vember , 1 889.

THE H ISTORY OF PEDIATR ICS AND ITS RELAT ION TO OTHER SCIENCES AND ARTSAddr ess deliver ed befo r e the Co ngr ess o f Ar ts andSciences, St . Louis, Mo ., September Amer ican Medicine, November , 1 904 .

THE H ISTORY OF CEREBRO-SPINAL MENINGITISIN AMERICATr ansactio ns of theMedical So ciety o f the State o fNew Yo r k, 1 905 .

CEREBRO SPINAL MEN INGITIS : SYMPTOMATOLOGY AND TREATMENTPar t o f a paper r ead befo re the Deutsche Medicin iScheGesellschaft der Stadt New Yo rk. N ew Yo r ker Medi

cin ische Monatsschr ift, Apr i l, 1905 . T ranslated fr omthe German . The histo ry o f Cer ebr o—Spinal Men ingitis and the mo r tality statistics o f the disease havebeen omitted fr om this ar ticle, as they ar e dealt withadequately in the pr eceding paper .

DIPHTHE RIA : ITS . SYMPTOMATOLOGY AND

TREATMENTF r om “ The Twentieth Century P ractice o f Medicine.

”

THE PATHOLOGY AND TREATMENT OF THE DIF

FERENT FORMS OF GROUP

Read befo r e the Medical Society o f the County o f

New Yo rk. Amer ican Jour na l o f Obstetr ics, Diseasesof Women and Chi ldr en , May, 1 868 .

2 5

CONTENTS

CHOLERA INFANTUMF r om The Twentieth Century Pr actice o f Medicine.”

TYPHOID FEVER IN THE YOUNGRead befo r e New Yo rk State Medical So ciety,October Pediatr ics, Vo l. VI I I , No . 12 .

ANZEMIA IN INFANCY AND EARLY CH ILDHOOD 3 23

Read befo r e Medical So ciety o f the County o f NewYo rk, December 27, 1 880 . A r chives of Medicine,Vo l. V ., N o . 1 , 1 88 1 .

TREATMENT OF INFLUENZA IN CH ILDRENPar t o f a paper r ead befo r e the Medical So ciety o f

the County o f New Yo rk, No vember 26, 1 900 .

Medical N ews, December 1 5, 1900 .

OTITIS MEDIA IN CHILDRENRead befo r e the New Yo rk Academy o f Medicineunder auspices o f the Sectio n o n Oto logy, December , 1 904 . A r chives of Oto logy, N o . 2 , 1 905 .

NEPHRITIS OF THE NEWBORNRead befo r e the Medical So ciety o f the Distr ict o f

Co lumbia, November 28 , 1 895 . N ew Yo r k Medical

Jour nal , January 1 8 , 1 896 .

THE PREVENTION OF TUBERCULOSIS IN SCHOOLCH ILDRENLectur e deliver ed" befo r e Teacher ’s Co l lege, New

Yo rk. Teacher’s Co llege R eco rd, Mar ch, 1905 .

CAUSES OF EPILEPSY IN THE YOUNGRead befo r e the Natio nal Asso ciatio n fo r the Studyo f Epilepsy, No vember 5 , 1 902 . Amer ican ril edic ine,

December 1 3 , 1 902 .

TREATMENT OF ENURESISF r om Keating

’

s“ Cyclopaadia o f the Diseases o f

Childr en ,

”V o l. I I I .

RACH ITIC DEFORMITIES : ETIOLOGY, CLINICALH ISTORY AND LESIONSA discussion at the meeting o f the Amer ican O rthopedic Asso ciatio n at Washingto n, D. C ., MaySten ographi c r epo r t. A r chives of Pediatr ics, September , 1 895.

26

INTRODUCTORY CHAPTER

UPON me has been confer r ed the honor of intr oducingto the medical publi c the essays of all the distinguishedmen contr ibut ing to thi s gr eat work . Though with somehesitation, i t i s with sti ll mor e sati s faction that I complywith this demand. Fo r the very enter pr i s e marks an im

mense p r ogr es s in the hi story of both gener al medical andpediatr ic liter atur e . Indeed, when I began my pr o fes

s ioual li fe,such a collection of monogr aphs as will her e

be offer ed could not have been wr i tten . Now,that dur ing

a Single gener ation ther e should have been such a thor oughchange in the methods o f both medi cal thought and work ,i s a sour ce of the most intense gr atification

,as well to me

as to every other man who has absolute faith in the pers istent evolution of science and the impr ovement of therace .That ther e should be any doubt as to the p r opr i ety o f

a lar ge special wor k on the di seases of childr en,I can

hardly believe in the p r esent stage o f development ofAmer ican medi cal liter atur e . As far as I am concer ned

,

I never obj ected to being found among the adver sar iesof the wildfir e of speciali sm which has been spr eadingamong the gr oups o f medi cal men . On the contr ary, Iam still of the opinion I expr essed eight year s ago whenI opened the fi r s t ses s ion of the Section on Dis eases o f

Childr en,o f the Amer ican Medical Associati on, at its

meeting at New York .

With mor e per tinacity than logic, pediatr ics (compr ehending the anatomy, phys iology, pathology, and ther a

peutics of infancy and childhood) has also been claimedas a specialty. Thi s i s a mi stake

,however , whi ch has

been made mor e fr equently on the con tinen t of Eur opethan with us. I t is ther e that p r actitioner s and author s

This fo rmed the Intr o ducto ry chapter to K eating’s

“Cyclo

paedia o f the Diseases o f Children .

” It has seemed appr opr iateto use it as the intr o ducto ry chapter to the vo lumes o n Pediatr ics.

—E dito r .]2 7

DR . JACOBI ’S WORKS

adver tis e themselves,fo r r easons of their own which would

not be appr oved of her e,as childr en

’ s physicians and“

specialists .”Pediatr ics

,however

,i s no specialty i n the

common acceptation of the term . I t does not deal with an

or gan, but with the enti r e or ganism at the very per iodwhich pr esents the most inter esting featur es to the studentof biology and medicine. Infancy and childhood ar e the

links between conception and death,between the foetus

and the adult . The latter has attained a cer tain degr eeof invar iability. His phys iological labor i s r epr oduction

,

that of the young is both r epr oduction and gr owth. Asthe hi story of a people is not complete with the nar r ationof its condition when established on a solid constitutionaland mater ial bas is

,so i s that of man

,either healthy o r

di seased, not limited to one per i od. Indeed,the most

inter est in g time and that most difficult to under stand i sthat in which a per si stent development

,incr ease

,and im

pr ovement ar e taking place .This appear s to have been felt

,instinctively, fr om the

very beginning . The history of pediatr ics , ther efor e, i sas o ld as that of medicine . Their liter atur es have developeduni formly, fr om super stitious beliefs to empir ical statements and the methodical r esear ches of the pr esent time .The last centur i es

,par ticular ly the last decades

,ar e r e

plete with text-books on the diseases of childr en

,mono

gr aphs on their pathology, physiology, and hygiene, and

j our nals, qui te a number of which ar e now published inthe four p r incipal languages o f the civil iz ed wor ld.

These monogr aphs and j our nals have contr ibuted a gr eatdeal to the amount of medical knowledge . Special r e

sear ches o f the normal condition of embryonic, foetal, and

infant growth, the study of the functions of the or gansin thei r constant development and changes, and anatomicaland clinical investigat ions

,have contr ibuted to pr ove that

pediatr i cs does not deal with miniatur e men and women,with r educed doses and the same class of di seases in smallerbodi es

, but that i t has its own independent r ange and hor izon

,and gives as much to gener al medi cin e as it has r e

ceived fr om it .Ther e is scar cely a ti ssue

,o r an or gan, which behaves

2 8

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

costo-car tilaginous junctur es,ar e exceedingly impor tant, in

asmuch as they explain many o f theO

iso lated cases ofthor acic insuffici ency, phthi s ical habitus, and pulmonary incompetency.

The ner vous system o f the young i s but in a pr epar atorycondi tion . The br ain i s lar ge, but contains a lar ge percentage of water , i s soft, and its gr ay and whi te sub

stances differ but l ittle in color and composition . The

spinal cord has not yet the consi stency of a later per iod ;the anter ior hor ns ar e pr edominant

,and ther efor e mor e

fr equently the seat of pathological changes . The per ipher al ner ves ar e r elatively lar ge, but little excitable, inthe fir st days . The i r excitability gr ows very fast, however ,towards the end of the fir st year , and qui te out of pr o

por tion wi th the slow development of the inhibitory center s .Thus it i s that about that time convulsive symptoms ar e

so very fr equent . Fo r a shor t time after bir th the conducting fibr es between the undeveloped br ain ( it takesthe psycho-motor center s of Fer r i er and Hitzig a monthto exhibi t the fi r st signs of existence) and the pyr amidalfibr es o f the cord per form no functions ; thus the fi r stmovements of the newly b—o r n ar e not contr olled by will

power at all, but subj ect to r eflex exclus ively. After that

time the br ain develops very fast indeed, but far fr omuniformly in all its par ts . I t i s a most inter esting studythus to follow the evolution of the cer ebr al functions intheir dependency upon the anatomical development .The di gestive or gans of the infant exhibit a gr eat many

peculiar ities in thei r anatomy, physiology, and pathology.

The epithelial pear ls ” along the median line of the

palate,and the thinness of the mucous membr anes over

the r oof of the or al cavity and along the gums , give r i s eto ear ly tr ouble, the small si ze and ver tical pos ition of thestomach to a number of abnormal symptoms , the congenital malformations of the intestin e to ser ious danger s ,the abnormal length of the lower par t of the colon to an

unusual form of pr otr acted constipation, the pr evalenceo f polypi in the r ectum to hemor rhages of a kind seldomfound in advanced age. The glands r equir ed fo r the di

gestive p r oces ses ar e but gr adually pr epar ed fo r their

3 0

INTRODUCTORY CHAPTER

functions . The salivary glands ar e but par tially activeat bir th, the pancr eas r equi r es time fo r i ts full development

, the secr etion of lactic pr edominates over that ofmur iatic acid i n the stomach

,the intestinal lymph-bo dies

ar e in par t, par ti cular ly the patches of Peyer , so behindtheir futur e si ze and formati on as to change their functions consider ably. The t ime of dentition adds to the inter est of the per iod, mor e, it i s true, fr om a physiologicaland anatomi cal standpoint than on account of pathological r easons ; fo r i ts alleged causal connection withthe lar ge number of di seases attr ibuted to its mer e occurr ence has been gr eatly exagger ated.

In connection with these br i e f r emarks on some of thepeculiar iti es of the alimentary tr act of infancy, I may bepermitted to mer ely allude to the question o f nutr ition and

feeding. Sever al meetings of the Childr en’ s Section of the

German Association of Physi cians and Natur ali sts, the lastone of that in the Amer ican Medi cal Association

,and the

deliber ations of every medical society in every land, pr oveits impor tance . These questions belong

,as special stud

ies,eminently to pediatr i cs ; phys iology and chemi stry can

teach the gener al pr inciples only, and to clinical obser vation is left the final settlement of the hygiene of infancy.

The r elation of nur se’

s to mother’

s milk, the uti lization o f

cow ’ s milk in all its differ ent forms as one of the constituents of ar tificial foods

,the value of far inaceous ad

mixtur es, the addit ion o f animal foods,the pr opor tions of

salts and water , the quantity to~

be administer ed, the

length of inter val s between meals, the alter ations r equi r edin s ickness

,ar e just so many questions which demand

per si stent study and special industry.

The blood and the or gans of cir culation exhibi t the mostinter esting differ ences in the young as compar ed with the

adult.The young infant (and chi ld) has less blood in pr opor

tion to its enti r e weight ; thi s blood has less fibr in,fewer

salts,less haemoglobulin (except in the newly-bor n ) , less

soluble albumin,les s specific gr avity, and mor e white blood

corpuscles than the blood of advanced age.

Ther e ar e some other differ ences, depending on age, in

3 1

DR . JACOBI’

S WORKS

the composition of the blood, mor e o r les s essential . Thefmtal blood and that of the newbo r n contain but l ittlefibr in

,but vigor ous r espir ation works gr eat changes in that

r espect . Nass e foun d the blood of young animal s to co

agulate but slowly. In accordance with that obser vation,i t str ikes us, in r egar d to cer ebr al apoplexy of the newbo r n

,that the time fo r coagulation of the blood must be

longer than in the adult ; fo r hemor rhages ar e apt to bemost extens ive in the in fant. I n the sanguineous tumor

(kephalhaematoma) o f the newly-bor n, the blood r emainsliquid in the sac fo r many days . In apoplexy it i s apt

to sp r ead all over the hemispher es,and has plenty of

time to per for ate and penet r ate the pia in all dir ections ,destr oy much of the cer ebr al ti ssue, and flow down the

spinal cavity. Thes e occur r ences ar e so fr equent in the

infant,and so r ar e in the apoplectic adult

,that they can

hardly be explained except thr ough the insuffi cient co

agulability of f<Ptal and infant blood.

The si ze and vigor of the newly-bor n hear t offer a r eadyexplanation of the r apid gr owth of the infant body, and

mainly these or gans which ar e in the most dir ect commun icatio n with the hear t by str aight and fai r ly lar geblood—vessels . In thi s condition ar e the head and br ain .

Thus the latter has an oppor tunity to gr ow fr om 4 0 0

gr ammes to 8 0 0 in one year ; after that per iod i ts gr owthbecomes less marked. At seven, boys have br ains of

gr ammes ; gi r ls, of In mor e advanced li feits weight i s r elatively Iess, In the male and

in the female . At the same ear ly per iod the whole bodygr ows in both length and weight . The or iginal length of5 0 centimeter s of the newly-bor n incr eases to 1 1 0 withthe seventh year ; the gr eatest incr ease after that timeamounts to 60 ( in the female 50 ) centimeter s only . Inthe same time the weight incr eases fr om kilogr ammesto in the boy, fr om to in the gir l . Thi sgives a p r opor tion of 1 to 6 o r 7 , while after that timethe incr ease i s but thr ee o r four fold.

The normal r elation of the weight of the hear t to thatof the lungs

,between the second and twenti eth year , i s

1 : 5-7 ; in scr ofula it i s 1 : 8 - 1 0 . That means,the hear t

3 2

INTRODUCTORY CHAPTER

is smaller than normal,in the latter condition . Other par ts

of the system of cir culation exhibi t tr aits of their own .

I t i s par ticular ly in the tor pid ” form of scr ofula that,

by vi r tue o f insuffici ent ci r culation, the lymphatic system

par ticipates pr e-eminently. Thi s fact is the mor e important

,as the s i ze

,patency, and number of lymphatics ar e

quite unusual in infancy. Sappey found that they couldbe mor e easily inj ected in the chi ld than in the adult

,

and the inter communication between them and the gener alsystem is mor e marked at that than at any other per iodo f life . These facts have been confirmed by S . L . Schenk

,

who , mor eover , found the net-work of the lymphati cs evenin the skin of the newly—bor n endowed with o pen stomata,thr ough which the lymph-ducts can communicate with the

neighbor ing tis sue and cells .In rhachitis

, the hear t i s o f aver age size, but the ar ter i esar e abnormally lar ge . Gr eat width of the ar ter i es lower sblood-pr essur e . Thi s allows of the best explanation of themurmur fi r st discover ed by Fi sher , of Boston , over the openfontanelles of rhachitical babies , a very much better o ne

than that p r oposed by J ur asz , who looks fo r their causein i r r egular it ies of the canal is car oticus . Still, i t is a

mistake to believe that these murmur s,audible over the

br ain,belong to rhachiti s only. They ar e found in ever y

condition in which the blood-pr es sur e in the lar ge ar ter i eso f the cr anial cavity i s lessened.

E . Hoffmann discover ed the pecul iar fact that the ar

ter ial pr essur e i s very small in the newly-bor n animal .Even as lar ge ar ter i es as the car otid

,when cut

,do not

spur t as in the adult. Thi s low ar ter ial pr essur e i s oneo f the r easons why cor ds not ligated will often not bleed,with the exception of those cases in which the ar ter ial

pr essur e i s incr eased by a moder ate degr ee of asphyxia,

o r when the lungs ar e n o t inflated in consequence o f in

complete development o f the muscular str ength in the pr ematur ely-bor n foetus .Accor ding to a number of actual obser vations made by

R . Thoma, the post-foetal gr owth i s r elat ively smallest in

the common car otid,and lar gest in the r enal and fem

o r al ar ter i es . Between thes e two extr emes ther e ar e

3 3

DR. JACOBI ’S WORKS

found the subclavian,aor tic, and pulmonary ar ter i es . These

ar e differ ences whi ch cor r espond with the differ ences inthe gr owth of the sever al par ts of the body supplied bythos e blo od~vessels. In r egar d to the r enal ar tery and the

kidney, i t has been found that the s i ze of the former incr eases mor e r apidly than the volume and weight of thelatter . Thus i t ought to be expected that the fr equency ofcongestive and inflammatory p r ocess es in the r enal t issuewill be almost pr edestined by the di spr opor ti on betweenthe s ize of the ar tery and the condit ion of the ti ssue . Mor eover

,the r esi stance o f the ar ter ial cur r ent o fl

'

er ed by the

kidney- substance depends also upon the r eadines s withwhi ch the cur r ent i s permitted to pass the capillar ies .Now

,i t has been found exper imentally that thei r per

meability i s gr eater , and that within a given time mor ewater p r opor tionately can be squeezed thr ough them

,in

the adult, than in the child. This anatomical differ encemay ther efor e be the r eason why r enal di seases ar e somuch mor e fr equent in infancy and childhood fr om all

causes,with the exception of that one which i s r eser ved

fo r the last decades of natur al li fe,vi z .,

ather omatous degener ation .

In the ar ter i es o f medium and small calibr e the elasticmembr ane i s a thin and s imple membr ane ; i t i s only inlar ger ar ter ies that elastic fibr es will also extend i nto, and

mix with,the adj oining layer s . The elastic membr ane is

par ticular ly thin, may even be enti r ely absent,wher e

the br anches ar e given o ff fr om the ar ter ies . It i s her ethat spontaneous hemor rhages ar e most apt to take place .I t i s her e al so that

,in later l ife

,aneur i sms ar e met with,

such as find no r eady explanation by an injury.

The anatomical structur e of the thr ee umbilical vesselsdiffer s fr om that of all the r est of either ar ter i es o r vein sin many points , pr incipally in this , that ther e i s no elasti cmembr ane and no intima in the ar ter i es . Some elast ictissue i s found n ear the umbil icus , and i t gr adually in

cr eases in the abdominal cavity ; but the intima i s not developed in the ar ter i es until they ar e in close pr oximityto the il iac . Thus by the mass ive and power ful development of the muscular layer i t i s explained why ther e ar e

3 4

INTRODUCTORY CHAPTER

so few hemor rhages though no ligatur e has been appliedto the cor d.

The umbilical vein di ffer s fr om the ar ter i es very muchless than i s usual with veins and ar ter ies in any otherpar ts of the body. The muscular layer i s very lar ge and

str ong in the vein . Ther e is no intima. None of the thr eevessels emits br anches ; ther e ar e no vasa vas‘orum and noner ves in their walls .Altogether , the gr owth of the inter nal or gans and the

whole body does not pr oceed uniformly. In thi s r espectthe blood-vessels do not stand alone . What Beneke calledthe mor bid dispos ition of the sever al ages

,i s bes t ex

plained by these var iations in gr owth and power . Thatauthor spent much time and labor on the measur ing ofblood-vessels in par ticular . I t was he that found the ar

teries pr opor tionately wide unti l the per iod of puber ty.

Fr om that time the hear t incr eases r apidly, and the ar

ter ies less . In infancy the r elation of the volume of thehear t to the width of the ascending aor ta i s 2 5 : 20

,befor e

puber ty 1 4 0 : 56, and after puber ty Thus it i sthat the gener al ar ter ial blood-pr essur e of infants is lessand the hear t-beats ar e mor e fr equent .After bir th the pulmonary ar tery is much lar ger than

the aor ta ; after the fir st year the width of the formercompar ed with that of the latter is in the adult

in advanced age I t is eas ily understoo d to what ext ent both the normal development and thediseases of the lungs may be influenced by these r elativesi zes of the ves sels . That the si ze an d str ength of ther ight hear t should have a favor able influence on the cour seof a pneumonia i s an infer ence deser ving of cr edit .The r ever se of the normal o ver sIze of blood-vessel s in

the infant and chi ld i s found in abnormal smallness, par

ticular ly of the ar ter ies . The wo r st,and mostly incur able ,

forms o f chlor osis ar e the r esults of this an omalv . Theyhave been studied by Tr ous seau, Vi r chow,

Sée, and other s ,in connection with a small

, o r normal,o r fatty hear t, and

in their complications with occas ional hemor rhagic diathesis . All forms of per si stent anaemia may depend onthis insufficient development of the ar ter i es : the specimens

3 5

DR . JACOBI ’S WORKS

taken fr om a woman of thi r ty-two year s, who died with all

the symptoms of essential anaemia, ar e i n my possess ion .

To the cons ider ation of the or gans of cir culation I have

given so much pr ominence because of their pr e-eminent

influence in etiology. The changes of per iods of lifeand advancing age ar e mainly occas ioned by the alter ations in the structur e of the walls of the blood-vessels .Thei r or iginal thinnes s and fr agility occas ion hemor rhagesin the newly-bor n

,as does thei r anomalous condition in

senility. N o r i s ther e any or gan whi ch i s not constantlyunder the contr ol of the blood—cur r ent . Thi s chapterwould

,however

,gr ow to undue length

,and encr oach too

much upon the legitimate pr ovince of the special es saysdevoted to the consider ation of the subj ects to which Ishould only allude, wer e I to continue to enlar ge uponthem . A few mor e r emarks

,ther efor e

,may suffice .

Ther e ar e anomal ies and diseases which ar e met with inthe in fant and child o nly. Among thi s class we meet congenital di seases and mal formations

, the affections of theumbilical cord, of the ductus ar ter i osus , and o f the tunicavaginal is of the spermatic cord , atelectas i s and cyanosi s ,the di s eases of the thymus , the anomal ies of the intestinaltr act

,congenital constipation

,as I have called it

,r esult

ing fr om the exagger ation of the n ormal length of thelong sigmoid flexur e, and, finally, rhachiti s .Other dis eases ar e mostly found in chi ldr en , o r with a

char acter i stic symptomatology and cour se . Both acute andchr onic hydr ocephalus , acute eruptive diseases, whoopingcough, and diphther ia ar e mostly found at an ear ly age.

Diphther ia i s very l iable to assume differ ent char acter sin differ ent

_ages ; even the s imple inflammatio ns of the

tonsils vary-in sever ity and natur e accor ding to the amountof tis sue destr oyed o r new hyper plasti c connective ti ssueformed in the cour se of r epeated attacks . Almost all thediseases of the intestinal tr act in chi ldr en have thei r peculiar ities

,and r equi r e the Special study of foods and hy

giene. The maj or ity of cases of intussusception take placein infants

,in locali ti es with symptoms of their own .

Ther e ar e dis eases which affect both the young and the

3 6

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

the gastr ic and intestinal ir r i tation so often obser ved in

the adult .Now

,what has been done to facilitate the acquis ition of

kn owledge on all these points by the student and pr ac

titio ner of medicine ? Very little indeed. Ther e neverwas any systemati c in struction in the di s eases of chi ldr en,by a teacher appointed fo r that br anch of medicine exelus ively, until ( in 1 8 60 ) I established a weekly chi ldr en

’ scli ni c in the New York Medical College, at that time inEast Thi r teenth Str eet. That was the fir st of it s kindin the United States . When the college ceased to exi st

( in 1 865 ) I established a childr en ’ s clinic in the Univer sity Medi cal College and in 1 8 70 in the College of Physicians and Sur geons . In both these institutions, as alsoin the Bellevue Hospital Medical College, such clinicshave existed s ince, and a number o f the medical schoolsof the country have imitated the example .In them

,a s ingle hour weekly, dur ing the r egular cour ses

of the winter,i s given to the student of medicine fo r the

spec ial study of the di seases of childr en, who will , in hisfutur e pr actice, form the maj or ity of hi s patients . In thecour s e of four so -called year s, which the legislatur es ofour States pr onoun ce sufficient fo r the attainment of all

medical kn owledge r equi r ed fo r the welfar e of the country, the student is pr essed very har d fo r time . Ther ear e a number of br anches whi ch he i s taught to deemwor th his while and attention

,by being told that he will

be examined in them befor e obtaining his diploma ; butthe diseases of chi ldr en ar e not now among these . To mykn owledge

,ther e i s no school in the country whi ch lays

the least str ess on that br anch of instruction ; fo r I hopether e i s nobody no wadays, even among the teacher s of medicine, who beli eves that a few di dactic lectur es of the pr ofesso r of theory and pr actice ar e a sufficient pr epar ation fo r the pr eser vation of the childr en of the people.No examination being r equir ed by those to whom the stu

dent looks fo r dir ection and enli ghtenment,he neglects

the study, to find out too late the mistake he has made inso doing.

I t i s no consolation that in Gr eat B r itain the same com

3 8

INTRODUCTORY CHAPTER

plaints ar e made . But a few months ago the chai rman ofthe Section of Di seases of Childr en

,Dr . Cheadle

,spoke

in feeling terms of the neglect in the schools and clinicalinstitutions of Gr eat B r itain of thi s most impor tant par tof pr acti cal medicine

,befor e the B r itish Medical Asso

ciatio n . The continent of Eur ope has made mor e r apidpr ogr ess . Most of both the lar ge and the small univers ities have thei r chai r of the Diseases of Childr en, not acl inical one

,which means the author ity given an en

thusiastic worker to teach as much o r as little as he can inan hour weekly, without r ecognition

,thanks

, o r r ewar d,of a doctr ine not officially r ecognized ; they have hospitalsin which to teach pr actically every day what has beentaught in didactic lectur es and lear ned fr om books

,and

thei r students kn ow befor ehand that they will have top r ove, befor e being permitted to p r actise, thei r acquaintance with what they ar e compelled to lear n of the di s easesof chi ldr en . Thus it is i n F r ance and Italy, i n Germany,Austr ia, and Sweden ; thus i t i s now in Russ ia, but notso in England and in our country.

What can be done to imp r ove thi s state of things ?Every future imp r ovement in gener al medical education

will favor the study of pediatr ics . Ther e will be a timein the -near futur e when the student in medicine will beawar e that he will have to pas s an examination in the sub

jects connected with the physiology and pathology of the

young . Ther e will be another time when the medicalcour ses will be both lon g and numer ous enough to permitof clinical in struction in the diseases of childr en beinggiven thr ee o r s ix times a week, and another in whi ch ther ewill be bedside teaching . Fo r that pur pose it i s thateither special hospital s o r lar ge war ds in gener al ho s

pitals ar e an absolute necess ity. I t i s in them only thatthe student, and the p r ofessional man also

,may lear n under

super vi sion,and without the danger of each having to

fi ll with victims a burying—gr ound of his own, both how

to diagnosticate a di seas e in a child and how to nur seand tr eat a s ick one . In hospitals alone can goo d oh

ser vatio ns be made in r efer ence to the cour se of di seases,and the effects of r emedies and methods of tr eatment .

3 9

DR . JACOBI’

S WORKS

Mor eover , special societi es must be founded fo r the purpose o f studying questi ons connected with pediatr ics, o r

special . sections formed in lar ger and es tablished associati ons. The new Chi ldr en ’ s Section in the New Yor kAcademy of Medic ine, that of the Amer ican Medi cal Association

,and the succes s ful or ganization of the Amer ican

Pediatr ic Society pr ove the intensity o f the inter est theAmer i can pr ofess ion has commenced to take in the sub

jects legitimately belonging to that par t of medical scienceand pr actice .

-Finally, all of the latter , as well as those to which I couldbut incompletely allude

,as all other s suggesting them

selves to the car eful obser ver and thor ough student,must

be the themes of per s istent individual study. Besides,as ther e must be time to lear n other men

’

s obser vations,

so time must be found to contr ibute what i s new and val

uable in every pr ofess ional man’

s li fe . The basi s onwhi ch to p r oceed i s to be fur ni shed by thi s Cyclopaedia,the intr oductory r emarks to which I am kindly permittedto offer . Thi s book bids fair to contain all that i s kn ownat p r esent on the anatomy

,phys iology, pathology, and

ther apeutics of infancy and childhood. May the Amer icanpr ofess ion see to it that this same bo ok, whi le being a

digest both of the labor s of the past and the attainmentsof the p r esent, shall become the solid foundation o f suc

cessful scientific wor k in both the near and di stant futur e .

4 0

THE RELATION S OF PEDIATR IC S TO

GENERAL MEDICINE

GENTLEMEN z—P r ogr es s and success

,in order to be com

plete and unmistakable,r equire centr ali zation of means and

co -oper ation of men . The pioneer in his seclus ion, the

har d-working settlement,the thin population of a county,

the j oining of the di sseminated par ts to form a state,and

the amalgamation r esulting in the establishment of a

power ful and wor ld-moving nati onality, exhibit an exampleof the geometr ical incr ease of str ength re sulting fr om the

combination of for ces . The isolated labor s of the gr eatestmen in the hi story of science never accompli shed anythingbeyond a spasmodic and stationary advance . Twenty centur ies in success ion lived on the unchanged teachings ofHippocr ates

,Ar i stotle

,and Galen .

The establi shment of insti tutions of lear ning in moder ntimes

,mainly s ince the fi fteenth and s ixteenth centur i es,

multiplied the names of men, though none r eached thosethr ee ancients, who , in contact with other s equally dis

posed,labor ed successfully in the inter ests of science.

Par acelsus , Descar tes, Sydenham,Boerhaave

,Van

Swieten ,Haller

,Pete Fr ank

,and Bichat pr omoted science,

par tly thr ough conte st, par tly thr ough co -oper ation withfellow- labor er s . The multiplication of institutions, the

similar ity of aims and ambitions,the establishment of

faculties and lear ned societies, accomplished,thr ough the

co-oper ation and fr iction thus cr eated, a pr ogress mor epr onounced in decades than former ly in centur i es .The best r esults, however , wer e obtained by the vo lun

tary association of scientific men all over the wor ld. In

this century, the German Association of Natur alists and

Phys icians, the B r it ish and the Amer ican Medical Associati on

,the numer ous local and pr ovincial societies, and last,

though by far not least, the Amer ican Congr ess of Phys i

4 1

DR . JACOBI ’S WORKS

cians and Sur geons,with its many special associations and

societi es,have not only encour aged scientific or iginality,

but r ai s ed the aver age standar d o f the p r ofession at lar ge .That i s what the i solated labo r s of individual men never

attained. F r om thi s point of v iew I hailed the pr oposal toform an Amer ican Pediatr i c Soci ety with sati s faction and

delight . Thi r tyyear s ago I contemplated the formation of asection fo r the pur pose of studying the diseases of childr enin the New Yor k Academy o f Medicine, and fai led. Thesenine year s the Amer ican Medical Associati on had i ts section on di seases of chi ldr en, the fi r st meeting of whi chtook place under the p r esidency of S . C . Busey, and the

New Yor k Academy of Medicine has a flour ishing pediat r ics ection under J . L . Smi th. To-day thi s national associationhas convened without difficulties and with all the pr omisesof speedy success . The spontaneity of its or i gin i s a

guarantee of vitality and pr osper i ty. My failur e at thatear ly time did not signi fy that no attention had been paidin the United States to the phys iology and pathology ofinfancy and childhood. I t simply meant that the r elationsof pediatr i cs to p r acti ce and to the other depar tments ofmedicine wer e not yet duly appr eciated. In most countr i esin Eur ope it was the same . In Amer ica the names ofDewees, Stewar t, Eber le, Condie, Char les D. Meigs , JohnFo r syth Meigs, and W . V . Keating ar e st ill holding an

honor able place in the history of pediatr ics . But theirlabor s wer e individual and isolated. Though thei r teachings wer e appr eciated

,the p r ofess ion at lar ge was not

sufficiently advanced to look upon the close and specialstudy of the di seases o f childr en as a necess ity fr om the

twofold point of view under which I began ear ly to cons ider it . I was ever of opinion that no t only had specialoccupation with infant pathology and ther apeutics its r e

ward in its el f, but i ts connection with every other specialdoctr ine aided and foster ed the intimate and pr ofoundknowledge o f other br anches o f medi cal sci ence and ar t.

Thus the futur e connection of thi s society with the T r i ennial Congr ess o f Amer ican Phys icians and Sur geons willpr ove a mutual benefit to all par ties concerned.

In an intr oductory to the Cyclopaedia o f the Diseases

4 2

PEDIATRICS AND GENERAL MEDICINE

of Chi ldr en, edited by John M . Keating,I have tr i ed to

establi sh the claim of pediatr ics to be cons ider ed a specialty. Not that it i s o ne in the common acceptation of theterm . I t does not deal with a special or gan

, but withthe entir e or ganism at the very per iod which pr esen ts themost interesting featur es to the student of biology and

medicine . Infancy and childhood ar e the links betweenconception and death

,between the foetus and the adult .

The latter has attained a cer tain degr ee of invar iabili ty.

His physiological labor i s r epr oduction ; that of the youngis bo th r epr oduction and gr owth. As the history of a peoplei s not complete with the nar r ation of its condit ion whenestablished on a solid constitutional and economic bas is

,so

i s that of man ,whether healthy o r dis eased, not limited to

one per iod. Indeed, the most inter esting time, and the onemost difficult to under stand, i s that in whi ch per s i stentdevelopment

,incr ease

,solidificat ion

,and imp r ovement ar e

taking place .I have tr ied to p r ove that pediatr ics does not deal

with miniatur e men and women,with r educed doses and

the same class of diseases in smaller bodies,but that it has

i ts own independent r ange and hor i zon,and gives as much

to gener al medicine as it has r eceived fr om it . My r ea

soning was that ther e i s scar ce ly a tis sue o r an or gan whichbehaves exactly alike in the differ ent per iods of life . Itr ied to pr ove that as ser tion by a cur sory consider ation o f

the osseous tis sue, the ner vous system, the digestive or gans,

the bloo d and the system of cir culation, and the r equi r ements of gener al ther apeutics in the young . To these expositions I added a few r emarks on the p eculiar char acterof the diseases of infancy and childhood. Ther e ar e anomal ies and dis eases which ar e encounter ed in the inf antand child only. Ther e ar e tho se .which ar e mostly foundin childr en, o r with a symptomatqlogy and cour se peculiarto them ; and those

,finally

,which affect both the young

and o ld,with such var i eties, however , both in symptoms

and cour se, as depend on the s ize o r natur e of the afflictedor gan o r or gani sm

,o r the differ ence in the degr ee of its

ir r itability.

The r elations of pediatr ics to the sever al special par ts

4 3

DR. JACOBI ’S WORKS

of the extensive field of scientific medicine ar e very var ious .Inter nal medicine owes many of its best r esults to the oh

ser vatio ns made on infants and chi ldr en . I t i s in them thatconstitutional and developmental di s eases ar e either best o rexclusive ly studi ed. In this connection I r emind you onlyof scr ofula, rhachiti s, anaemia, and chlor osis . Infectiousdi seases

,such as diphther ia, scar latina, measles, var icella,

par otiti s,per tuss is, and tuber culos is, mainly of the bones

and j oints,o f the glands and per itoneum,

ar e mostly en

counter ed in infancy and childhood. Neoplasms ar e notonly fr equent in young chi ldr en,—mor e than for ty casesof sar coma of the ftetal o r infant kidney alone wer e collected by me fo r the Inter nat ional Congr ess of Copenhagen five year s ago , -but r ouse the most intense inter est,fr om the fact that Cohnheim tr i ed to tr ace every neoplasmof later li fe to its embryonic o r foetal or igin . All the

actual o r alleged disorder s belonging to dentition,most

forms of stomatitis,amygdal iti s , and pharyngiti s, includ

ing later o and r etr o-pharyngeal abscess, many of the mostfrequent and impor tant diseases of the nose with their consequences

,and of the larynx, ar e met with in the young . I t

is in them that catar rhal pneumonia has been studied pr incipally, atelectasi s almost exclus ively. Some of the forms ofdiar rhoea, and still mor e of constipation, ar e exclus ively thepr oper ty of youn g childr en . I t i s in them

,also

,that inter

nal medic ine has lear ned the pathology of muscular pseudohyper tr ophy; fr om them,

finally, that it has impr oved and

incr eased diagnostic r esour ces,fo r nobody can study F in

layson’

s contr ibution to the fi r st volume of the Cvclopmdiawithout finding many of them gr eatly depending on cer tainpeculiar ities of the sever al infant or gans .The sur gery of infancy and childhood i s so peculiar

,its

indications so varying, the number o f cases so lar ge, and

some of the oper ative pr ocedur es so exclus ively o r almostexclus ively adapted to, o r necess itated by, sur gical diseasesof the young, that the tr ansactions of sur gical societies andj our nal s ar e lar gely fill ed with discuss ions on subj ects belonging to the spher e of pediatr i cs . I r emind you of thefr equent occur r ence of congeni tal mal format ions r equir inginter fer ence ; those of the anus and r ectum, har e-lip and

4 4

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

formed at all, and that the motor and sensitive i r r itabil ityincr eases r apidly about the fi fth and s ixth months . Thi s i sthe t ime at which r eflex excitability i s very gr eat . I t hasalso been found that the inhibitory function of the cardiacner ves is but feeble in the very young . The contr action umder the influence of the electr i c cur r ent r esembles very muchthat whi ch i s obser ved in the fatigued animal

,and the

per ipher al ner ves exhibit a s light excitability only. Manyother obser vations can be made on the infant only,—thus,fo r instance

,those concer ning the fir st awakening of per

ception . On the fi r st o r second day of li fe hear ing is active ;s ight suffi ciently developed to be affected by light and dar kness ; taste and smell exist, but ar e feeble, and the senseof touch i s mainly demonstrable on the lips . The per ception of pain i s but slightly developed.

Many such special contr ibutions to the physiology of thener vous system gather ed in the young could be intr oducedher e . I can omit that in the p r esence o f those who know ;but r efer to the special works of Kussmaul, G . Darwin

,and

P r eyer , which tr eat of the psychology of the in fant, and tothe gener al tr eatises on the physiology of the young byAlleix , Vier o r dt, and Vittor io Mass ini .Neur opathology also owes a gr eat many r esults to the ob

ser vatio ns made on infants and childr en . Disorder s of thener vous system ar e very common in the young . Of all thedeaths r esulting fr om diseases of the ner vous system,

eightyseven per cent . take place dur ing the fir st five year s of li fe .Their fr equency i s best under stood by the consider ation ofthei r many causes . Marry ar e inher ited o r acquir ed dur ingfoetal li fe . Other s ar e due to the insufficiency of the pr o tection afforded to the br ain . Thus it i s that any t rauma, the

pr essur e of a nar r ow pelvi s o r the for ceps , a fall -whi ch i nthe very young pr oduces r ather a gener al di sor der than a

local lesion,leads to ser ious consequences . The neighbor ing

or gans,such as the ear , o r the scalp, ar e liable to affect the

br ain ; fo r that r eason o titis and impetigo ar e danger ouspr ocesses . The very anatomical deve lopment, the incr easing separ ation of the two cer ebr al substances

,and the in

competency of the centr es of inhibition and those of co

ordination,lead to morbid pr ocesses . An omalies o f the

4 6

PEDIATRICS AND GENERAL MEDICINE

bones, such as rhachitic softening and,still mor e

,p r ematur e

oss ification,inter fer e with the cer ebr al development o r lead

dir ectly to ser ious o r incur able alter ations . The incom

plete structur e o f the blood-vessels i s another fr equentcause of di sease fr om mer e tempor ary congestion to ser ouseffusions o r to extr avasations . Thus we have an expla

nation o f many of the facts unaccountable to the superficial obser ver only. The number of neur opathi es not dir ectly fatal i s exces sive in the young . Convulsions of everydescr iption

,eclampsia

,chor ea

,tetany, epilepsy (po liomy

elitis) , Fr iedr eich’

s ataxia,gather their most copious har

vest among infants and childr en . And again it i s theseon whom most o f our knowledge of cer ebr o-spinal meningitis and cer ebr al meningitis has been obtained.

Neur ology’

s si ster,psychology, i s indebted fo r much of

its wealth to the study o f the intellectual li fe of infancyand childhood. I t i s sufficient to r efer again to the valuable and influential r esear ches o f Kussmaul

,the younger

Darwin,and W. P reyer . Psychiatry also has lear ned fr om

the mental aber r ations occur r ing at an ear ly age, the mor eso as marry of the causes

.

of mental dis ease in later li femust be tr aced back to embryological data and the morbidchanges of infancy. Asphyxia of the newly-bor n

,with it s

r esulting effusion, extravasations, o r thr omboses,i s a fr e

quent cause o f li fe-long epilepsy, stupidity, o r idiocy.

Di sease s affecting the br ain at an ear ly per iod pr ecludethe format ion of ideas . The absence of inhibitory and

psychomotor . centr es i n the newly-bor n animal pr ecludesthe equil ibr ium r equir ed fo r a n ormal mental or ganization .

The di spos ition to psychi cal disturbance r esulting fr om in

dividual constitution,the influences of her edity, and con

genital neurasthenia can be studi ed at the very ear liestage. The symptoms of fully—deve loped o r

'

imminent o r

future mental di sease ar e mor e r eadi ly studied in the youngthan at mor e advanced age, fo r _

in the young the slighte stdeviations will tell . Such symptoms, which ar e eas ily r ec

ogn ized, ar e waywardness and r estlessness,gr imacing

,con

vulsive twitching and convul s ibili ty, abnormal s leep, r e

tardatio n of gr owth,and excessive masturbation . Wher

ever they ar e found to be not the dir ect r esults of easily4 7

DR . JACOBI’

S WORKS

appr eciated cause s,—as, fo r instance, what I have perhaps

wr ongly called local chor ea depending on chr onic nasopharyngeal catar rh,—psychi cal disturbances may well befear ed. They ar e mor e fr equent than the r eport s of lunaticasylums would appear to pr ove . Fo r ther e are but fewinsane childr en in the institutions, fo r obvious r easons . I tis only those cases whi ch become absolutely unmanageableat home which ar e intrusted to an asylum . Thus it i s thatwe can obtain mor e accur ate stati stics of idiocy than of dementia of ear ly year s . The anatomical symptoms of degencr ation

,leading sooner o r late r to mental disorder s , ar e stud

ied to best advantage mostly in infants and chi ldr en . Ofepilepsy, whi ch mostly star ts ear ly, i t i s not necessary tospeak her e . I shall only allude to the deformities of thecr anium due to gener al o r local pr ematur e ossification ofthe cr anial bones and fontanelles, to the pecul iar ities of theposition of the te eth and ear s

,the r etr aced r oot of the nose,

the asymmetry of the head and face, due either to un ilater al atr ophy o r hypert r ophy, and the shor tened base of theskull . Beside s , ther e is the excessive number of cer ebr aldi seases mani fest at a time when the incr easing gr owth ofthe or gans continues to add to the acquir ed lesions ; alsotr auma and insolation . Finally, the impr ess ibility of the

young is such that the causes of mental distur bance inevery age

—chor ea,hyster ia, epilepsy, anomal ies of the

ear s,nose, and hear t, the pr esence o f helminthes , the par o x

ysms of malar ia, the anatomical r esults of typhoid fever ,rheumatism, erys ipelas, and per tussi s, and the nutr i t ive disor der s r esulting fr om anaemia, chlor osis , and alcohol—havevery much mor e ser ious r esults when occur r ing at an ear lyage . Ther e ar e some causes leading to mental di stur banceswhich ar e cer tainly mor e common in the young, viz . imitatio n

,fear , fr ight, masturbation, and the pr otr acted mis

takes constantly made in r egard to tr aining and education .

The over—worked br ains of our school—childr en have beencomplained of in thi s connection as ear ly as 1 8 0 4 by PeterF r ank, and will yet form the subj ect of a few mor e r e

marks .The history o f the embryo and foetus finds its legitimate

termination in that of the infant and child. Thus embry4 8

PEDIATRICS AND GENERAL MEDICINE

ology, ter atology, and pedology, with pediatr ics, ar e but

chapter s of the same book . The scientific consider ation ofany one of them i s impossible without that of the other s .The theor i es of her edity and consanguinity r efer equally toall. The most impor tant changes and di seases met with inthe young human being cannot be studied without theknowledge of its pr evious history, and the i ntelli gent app r eciation of embryology cannot be attained without theexact knowledge of its final outcome . Excess ive o r de

fective gr owth, ar r est of development, and foetal inflammation ar e the heads under whi ch a lar ge number ofanomal ies of the in fant can be classified. The fr equentoccur r ence of car cinoma

,sar coma

,and lipoma in the young

favor s Cohnhe im’ s theory, acco rdi ng to which those neo

plasms owe thei r or igin to the per s is tence of embryonictis sue . Abnormally inver ted cir culation explains the acardiac monstr osity ; deficiency of bui lding mater ial accountsfo r the absence in many cases of limbs o r par ts of l imbs .The laws of duplication

,including intr afcetation ,

ar e nowwell under stood

,and the gigantic gr owth of limbs o r par ts

o f limbs, akr omegaly and macr oglos sia, ar e as impor tantin the li fe of the bor n as they ar e inter esting fr om the

point of view of embryological development .Many symptoms o f rhachitis

,syphili s, and haemophil ia

cannot be under stood except in thei r embryological connection . The same is valid in regard to congenitally dislocatedand hor seshoe kidney, and tr ansposition of the viscer a.

Insufficient closur e o f embryonic fissur es explains encephalo cele

, por encephaly, spina bifida, bifid uvula and epiglotti s,cleft palate, lips, and cheeks, pharyngeal fistulas, her nia,and the communications between the intestinal tr act and theur o—geni tal or gans, and the per si stency and patency of theur achus .Inflammatory p r ocesses give r i se to spontaneous amputa

t ion, the adhesions of the placenta to the head, to the mostsever e forms of o bstructions and defects in the intestine, tothe stenosis o f the pulmonary ar tery, the aor ta

,and the

atr ioventr icular or ifice .I must not

,however

,multiply examples of the i ntimate

cor r elation between embryology and the mal formations and

49

DR . JACOBI ’S WORKS

di seases of the child. These few instances, I beli eve, willsuffice to show to what extent the most exact and specialstudy of the anatomy, phys iology, and pathology of the childi s a connecting link between , and the safest foundation of,a number o f the most impor tant br anches of medical r e

sear ch. Indeed,if all the teaching obtained fr om pedology

and pediatr i cs could be disj oined fr om those br anches,these latter would be str ipped of their best mater ial .Though the hi story of pediatr ics i s but a br i ef one

,i t can

safely be stated that those specialties have been to a

gr eat par t feeding on and been built up by the obser vationsand investigations o f men specially inter ested in the dis

eases of chi ldr en . You wi ll find, when you look over thepr ogr ammes of the nine associations which now form the

Amer ican Congre ss year after year , that topics which infutur e wi ll be the legitimate pr ovince of the Amer i canPediatr ic Society, have attr acted much of their attention .

Fr om the fir st hour of li fe the in fant r equir es specialstudy. Its di et has been a sour ce o f ever -watchful r e

sear ch ou the par t of many of the best minds . In moder ntimes, Zweifel, Ko r owin , Bieder t, Bouchar d,—not to men

tion A . V. Meigs and Rotch among us,—have deser vedwell of the subj ect . Not only diet

,however

,and indi

vidual hygiene have been studied on the chi ld ; the mostvi tal ques tions of public hygiene ar e also connected withpediatr ics most intimately. Besides such as every thi nking man i s deeply conce r ned in, i t is mainly two topicsthat attr act attention of thos e who take an i nter est inchildr en . I allude to the school and to constitutional diseases . My r emarks to-day can be but fr agmentary; sti ll, Imust not, both in the inter est o f our science and of human society, omit to emphas i ze the fact that it still appear sas i f our schools wer e establishments or ganized to pr oducenear—si ghtedness

,scoliosi s

,anaemia

,and both phys ical and

intellectual exhaustion . Contr ary to the treatment a coltr eceives at the hands of its owner

,human society, o r the

state,permits o r di r ects that the power s of a child should

be r ender ed unfit fo r its futur e functi ons, physical, men tal,and mo r al, fo r these thr ee ar e indelibly interwoven . I tr equir es physical and mental education to fer tilize the soil

50

PEDIATRICS AND GENERAL MEDICINE

fo r the evolution of mor al s . Thus the phys ician, and particular ly he who makes pediatr ics his Special study, i s a

pedagogue by p r ofess ion . The question of school-housebuilding and school-r oom fur nitur e

,the structur e of bench

and table, the paper and type in the books,the number

of school hour s fo r the aver age child and the indi vidualpupil, the number and length of r ecesses

,the hour s and

dur ation o f inter veningmeals, the alte r nation of mentaland phys ical tr aining, the age at which the aver age and

the indi vidual chi ld should be fir st sent,have been too

long decided by school-boards consisting of coal—mer chants,car penter s

,cheap pr inter s

,and un der taught o r over aged

school-mistr esses,not, however , of physicians . The health

and vi gor of the Ame r i can chi ld in ear ly year s seems, aocording to Bowditch, super ior to those of the Eur opean .

Why is the youth and maiden, par ticular ly the latter,so

infer ior ? Why’

is i t that anaemia and neur oses eat the marr ow o f the sland

,and un dermine the futur e of the country

by degener ating both the worker s and thinker s of the commun i ty, and the futur e mother s ? I f ther e i s a country inthe wor ld with a gr eat destiny and a grave r espons ibili ty,it i s our s . Its self-assumed destiny i s to r aise humanitar ianand social development to a hi gher plane by amalgamating

,

humani z ing,and civili z ing the scum of all the infer ior races

and nationali ties which are congr egating under the foldsof our flag. Unles s the education and tr ain ing of the youngis car r ied on according to the pr inciples o f a sound and scientific physical and mental hygiene, neither the aim of ourpolitical institutions will ever be r eached no r the UnitedStates fulfil its true manifest destiny. That mani fest destiny i s not so much the political o ne of excluding Eur opeans fr om our continent, -Nor th o r South

,- fo r indeed

the par ti cipation of Eur opean civil ization in the gr adualwork of r emoving barbar i sm ought to be very welcome,but o f r ais ing the standard of physical and mental healthto possible per fection

,and ther eby contr ibuting to the wel

far e and happiness of the people .Another subj ect in which

,fo r the same r eason, pedology

and pediatr ics ar e pr ofoundly inter ested i s that r efer r ing toconstitutional and infectious di seases . Most of them belong

5 1'

DR . JACOBI ’S WORKS

to ear ly li fe, and ther efor e inter est you in thi s society. The

vast maj or ity of them can be avoided, mor tality gr eatlydiminished

,and ill-health r esult ing ther efr om pr evented.

Ninety-nine cases out o f every hundr ed of rhachiti s neednot ex ist . Befor e we wer e over run with the pover ty-str ickenpopulation of Eur ope, r hachitis was hardly known amongus. Unless the social position of the many be impr ovedand the laws of hygiene unde r stood and obeyed, i t will incr ease unti l we shall be ou a level with I r eland

,Switzer

land,and Nor ther n Italy. Wher e the pr evention of syphi

li s l ie s,o r ought to l ie, we fully know . How we could

avoid dysentery and typhoid, the number of which incr easeswith the s i ze of tenements , the insufficiency of sewer s, withthe number of lar ge summer hotels, and defecti ve dr ainage, we thor oughly appr eciate . Scar latina

,mor billi

,diph

ther ia,whooping-cough

,need not destr oy o r maim hun

dr eds of thousands i f contagion wer e avoided ; and, un

less that be done,mankind, s tate, town, have not per

formed the most rudimentary function of thei r existence .After all, we need not boast of our ‘

civilizatio n , whi ch in

deed r equire s healing and mending both fr om a socialand medical aspect .I f we would but concentr ate our means fo r fight ing pr e

ven table di s eas e and death as they concentrate them in Eur ope fo r the pur pose of pr epar ing fo r , and car rying on ,war s " I f we did

,we should save as many hundr ed thou

sands as they seek to destr oy. I f,besides , but every phy

sician knew and appr eciated his duty and his hon or ablevocation, which consists in p r eventing and cur ing di sease

,

and spending his best effor ts in amelior ating human exi stence " What, _then, shall we say of those of our br ethr enwho do not feel i t below their di gnity to study electr icity,o r to make bel ieve they do , fo r the avowed pur pose of supplanting the hangman ?

Ques tions of public hygiene and medicine ar e both pr ofess ioual and social . Thus, every phys ician i s by destiny a

poli tical being ” in the sense in which the ancients defined the term,

—viz .,a citi zen of a commonwealth, with

many r ights and gr eat r esponsibili ties . The latter gr owwith increased power , both phys ical and intellectual . 1The

52

https://www.forgottenbooks.com/join

THE H I STORY OF PEDIATR ICS AND ITS RE

LATION TO OTHER SCIENCE S AND ARTS

TH E most human of all the gods ever cr eated by the

fancy o r the r eligious cravings of mor tal man was PhoebusApollo . I t was he that gave its daily l ight to the awakening wor ld, flatter ed the senses of the select with mus ic,fi lled the songs of the bards and the hear ts of their hear er swith the rhythm and wonder s of poetry, that inspi r ed and

r eveled with the muses o f the Par nassus,cheer ed the wor ld

with the ar tisti c cr eat ion s o f the fer tile br ains and skilful hands of a Zeuxi s and Phidias .

—he, always he, thatinfl icted and healed war r ior s

’ woun ds and sent and cur eddeadly diseases .In the imagination of a warm-hear ted and unsophis

ticated people it took a god to embr ace and bestow all

that i s most beneficent and sublime—phys ical, mor al, and

mental light and warmth ; the sun , ,the ar ts

,poetry, and

the most human and humane of all sciences and ar ts,

namely, medicine .Ancient gods no longer dir ect o r cont r ol our thoughts,

feelings , and enj oyments , either phys ical o r intellectual.The kinship and cor r elation of hypotheses and studi esexper i ence and knowledge ar e in the keeping of the philo sophieal mind of man , who i s both their cr eator and

beneficiary. To demonstr ate thi s r ational affinity of all

the sciences and ar ts,some far -seeing men plann ed thi s

gr eat Congr es s . The new depar tur e—in the ar r angementfo r ita should be an example to futur e gener al and specialsci entific gather ings . Indeed, some of its featur es wer eadopted by the or ganization committee of the Inter nationalMedical Congr ess which was to take place at St . Loui s,but was given up on accoun t of the limited time at the

di sposal of the gr eat enter pr is e .Congr ess es ar e held fo r the pur pose of compar ing and

guar ding diver s ified inter ests . A fr ee political l i fe r e

55

DR . JACOBI’

S WORKS

quir es them fo r the consulting of the needs of all classes .Scientific congr esses ar e convened to gather and collatethe var ied opinions, exper iences and r esults of many men ,and to cr eate o r r enew i n the young and o ld the enthusi

asm of youth. Thei r number has incr eased with the

moder n differ entiation of inter ests and studies . Specializatio n in medicine i s no longer what it was in o ld Egypt,namely, the outgr owth of the all-per vading spir it of castesand sub—classificatio ns

,but as well the consequence as the

sour ce of moder n medical pr ogr ess . I t i s difficult, however ,

' to say wher e specialization ends and over -specializatio n begins, o r to what extent speciali zation in medicineis the r esult o f mental and phys ical limitation o r of thespir it o f deepening r esear ch ; o r , on the other hand, of indolence o r of gr eed ; o r whether , while special ization benefits medical science and ar t

,it lower s the mental hor i zon

of the individual,and either cr ipples o r enhan ces his use

fulness in the ser vice of mankind. Fo r that i s what medical science and ar t ar e fo r . José de Letamendi i s perhapscor r ect when he says that a man who knows nothing butmedicine does no t even know medicine . What shall weexpect, then, of one who knows only a small par t of med

icine and nothing beyond ?

Congr esses in gener al have been of two kinds . Theyar e called by specialists fo r specialists , o r they meet fo rthe pur pose o f r emoving o r r elieving the danger s of limitatio n . Thi s i s what explains the gr eat success of international and national gather ings

,such as the German,

B r iti sh, Amer i can, and other s , and what has given the

Congr ess of Amer ican Phys icians and Sur geons with itstr iennial Washington meetings its br oadening and chastening influence .No r ar e medical meetings the only attempts at linking

together what has a tendency to get disconnected. Lookat our l iter atur e . The r i s ing inter est in the histo ry ofmedicine as exhibited in Eur ope and lately al so amongus, and individual contr ibutions

,such as Gomper z

’

s gr eatbo ok on Gr eek thinker s ; o r even lesser p r oductions

,such

as Eymin’

s Médecins et Philosophes , 1 90 4 ; o r the important pictor ial wor ks of Char cot

,Richet, and Hollander

,

56

HISTORY OF PEDIATRICS

pr ove the cor r elation of medic ine with hi story, philo so

phy and ar t.

Our special theme is the history o f Pediatr ics and itsr elation s to other specialt ie s , sciences and ar ts . NowF r i edr ich Ludwig Meis sner

’ s Grundlage der Liter atur derPadiatr ik , Leipz ig, 1 8 50 , contains on 2 4 6 pages about

titles of pr inted monogr aphs wr itten befor e 1 8 49

on di seases of chi ldr en, o r some subj ect connected withpedology. Of these

, 2 wer e published i n the fifteenthcentury, 1 6 in the s ixteenth, 2 1 in the seventeenth, 7 5in the eighteenth. P . Bagellardus de aegr itubin ibus

puer o rum,1 4 8 7, and Bar tholomeus Metlinger ,

“ Ein vastn iitzlich Regiment der jungen Kinder , Augsbur g, 1 4 7 3 ,

opened the pr inted pediatr i c liter atur e of Eur ope . Inthe s ixteenth century, Sebastianus Austr ius, de puer o rummo rbis, Basileae, 1 5 49, and Hier onymus Mer cur ialis, demo rbia puer o rum trac tatus,

‘

1 5 8 3,ar e facile pr incipes,

‘ inthe eighteenth, Th. Har r i s

, de mo rbis in fantum, Amstelo

dami,1 7 1 5 ; Loew, de mo rbis infantum,

1 7 19 ; M . Andry,l’

o r thopédie ou l’

ar t de pr eveni r et cor r iger dans les en

fants les difformités du corps, 1 74 1 ; Nils Rosen de

Rosen stein, 1 75 2 ; E . Armstr ong, An Essay of Diseasesmost Fatal to Infants, 1 768 ; and M . Underwood

,Tr eat

i se on the Di s eases of Childr en,1 7 8 4 ; also Hufeland

,

establi shed pediatr ics as a clinical entity ; while EdwardJenner

,1 798 , An Inqui ry into the Causes and E ffects of

the Var io lae Vaccinae,opened the po ss ibiliti es of a r adical

pr evention o f infectious and contagious di seases,the very

subj ect which,a century later , is engaging the best minds

and a host of assiduous worker s in the ser vice of plaguestr icken mankind.

In the Un ited States pediatr ics was taught in medicalschools, o r was expected to be taught

, by the pr ofes sor s ofobstetr ics and the dis eases of women and chi ldr en . The

r eor ganization of the New Yor k Medical College in EastThi r teenth str eet facilitated the cr eation

,in 1 860 , of a

special clinic fo r the dis eases of the young . Instead of theunited gynaecologic and obstetr i c clinics held by Bed

ford, Gilman, and G . T . Elliott in their r espective medicalcolleges, ther e was a s ingle clinic fo r the dis eases o f the

57

DR . JACOBI’

S WORKS

youn g exclus ively. When the C iv il War caused the Co l

lege to clos e its door s for ever , in 1 8 65 , they tr ans fer r ed theclini c to the Univer sity Medical College, and in 1 8 70 tothe College of Phys icians and Sur geons . Meanwhile, othermedical schools imitated the example thus p r esented.

The teacher s wer e classed amongst the clinical p r ofes sor s ;only in those schools which ar e forming par t of univer s ities and ar e no longer p r opr i etary establishments, a fewnow occupy the honor ed pos ition of ful l p r ofessor s ; in a

very few the p r ofessor of pediatr ics i s a full member ofthe faculty.

In the English Coloni es of Amer i ca the ear liest tr eati s eon a medical

,in par t pediatr i c subj ect was a br oads ide,

1 2 inches by 1 7 . I t was wr itten by the Rev . ThomasThatcher

,and bear s the date January 2 1 , 1 677

- 8 . I t wasp r inted and sold by John Foster , of Boston . The t itlei s a br ief rule to guide the common people of New England how to order themselves and their s in the SmallPocks

, o r measles . A second edit ion was pr inted in1 70 2 .

Befor e an d about the same time in which Amer i canpediatr ics r eceived its fir st r ecognition at the hands of theNew York Medical College, Eur opean liter atur e fur nisheda new and br illiant special liter atur e . F r ance

,whi ch al

most exclusively held up the flag of scientific medicine during the fi r st for ty year s o f the eighteenth century, furn ished in C. Billar d

’

s T r aité des maladies des enfantsnouveau-nés, 1 8 2 8

,and in Rilliet

’

s and Bar thez’

s Tr aitéclinique et p r at ique des maladies des enfants

,1 8 3 8—4 3 ,

standar d wor ks which wer e examples of painstaking r e

sear ch and fer t ile obser vation . England,which p r oduced

in 1 8 0 1 I . Cheyne’

s E ssays on the diseases of childr en,

gave bi r th to Char les West ’s class ical lectur es on the dis

eases of infants and childr en in 1 8 4 8 , and F . Chur chil l’ s

tr eatis e in 1 8 50 .

The German language fur nished a master -work in Bednar

’

s die Kr ankheiten der Neugebo r nen and Siiuglinge,1 8 50 -5 3 . A . Vogel and C . Gerhar dt

,both gener al clinical

teacher s, gave each a text-book in 1 8 60 , Henoch in 1 86 1 ;and Steffen in 1 865-70 publi shed a ser ies o f class icalessays .

5 8

HISTORY OF PEDIATRICS

The number o f men inter ested in the study and teaching of pediatr ics gr ew in p r opor tion to the r esear ches andwants of the p r ofess ion at lar ge . That i s why thr ee lar geand influential cyclopedias, the works of many autho r s,foun d a r eady mar ket, namely, C. Gerhardt

’

s Handbuchder Kinder -K r ankheiten, 1 8 77-93 ; John M . Keating

’

sCyclopedia o f the Dis eases of Childr en, Medical and Sur

gical, 1 8 89-90 , and I . G r ancher’

s and I . Comby’

s T raitédes Maladi es des Enfants

,in five volumes, the second edi

tion of which i s being p r inted thi s very year .

The collective and per iodi c liter atur e of pediatr ics be

gan at a compar atively ear ly time . Ther e was a per iodtowards the end of the eighteenth century when the in

fluence of Albr echt von Haller seemed to s tar t a new li fefo r German medical liter atur e befor e it lost itself againin the intellectual dar kness of Schelling

’ s natur al philosophy, fr om which i t took all the power s of F r ench en

thusiasm and r esear ch,and the epoch-making labor s of

Skoda, Rokitansky, and finally Vir chow,to r esuscitate it .

About that ear ly time of Haller,ther e appear ed in Lieg

nitz,1 793 , a collection of inter esting tr eatises on some

impor tant di seases of childr en (Sammlung inter es santerAbhandlungen iiber etliche wichtige Kinderkr ankheiten ) .

F r ance followed in 1 8 1 1 with a collection bear ing the t itleLa Clinique des Hopitaux des enfants, et r evue r etr os

pective médico-chirur gicale et hygiénique . Publiées sousles auspices et par les médecins et chirur giens des hopitauxconsacr és aux maladies des enfants .” Next in order ar e

five volumes o f F r anz Joseph von Metzler ’ s Sammlungauser lesener Abhandlungen iiber Kinderkr ankheiten

, 1 8 3 3

3 6 . Twelve fascicles under the title Analekten iiber Kinderkr ankheiten oder Sammlung ausgewahlter Abhandlun

gen uber die K r ankheiten des Kindlichen Alter s ; la cliniquedes H6pitaux des enfants, Redacteur en che-f Vanier ,Par is, 1 8 4 1 ; and I . Behr end and A . Hildebr andt

,Journal

fli r Kinderkr ankheiten, which appear ed r egular ly fr om1 8 4 3 to 1 8 72 . I t gave way to the Jahr buch fli r Kinderheilkunde, which has appear ed in quick and r egular success ion fr om 1 8 5 8 to the pr esent time . Thr ee

’

ser ies of Austr ian Journals between 1 8 55 and 1 8 76 consisted of a dozenvolumes only. They contain among other impor tant con

59

DR . JACOBI’

S WORKS

tr ibutio ns the very valuable es says of Ritter von Rittershayn, who deser ved mor e r ecognition dur ing his l i fe and

mor e cr edit after his death, fo r his honesty, industry and

or iginality, than he attained.

Special pediatr ic j our nals have multiplied s ince . The

United States has two, F r ance thr ee, Germany five, I talytwo

,Spain one . As long as they ar e taken by the pr o

fessio n we should not speak of over -p r oduction . I at

tr ibute their existence to the gener al conviction that ther eis n o gr eater need than o f the di str ibution of knowledgeof the pr evention and cur e of the diseases of the young.

The liter atur e of pediatr ics seems to pr ove it . Notas befor e 1 8 50

,not even titles of bo oks, pamphlets,

and magazine ar ticles exhaust the number .

Pediatr ic societies have incr eased at the same r ate . The

Amer ican Medical Association and the B r itish MedicalAssociation founded each a section 2 5 year s ago , the NewYor k Academy of Medicine

, 1 8 8 6 . The Amer icanPediatr ic Society was founded in 1 8 89, the Gesellschaftfii r Kinderheilkunde connected with the German Gesellschaft der Aer zte and Natur for scher in 1 8 8 3

,the English

Society fo r the Study of Dis ease in Childr en , in 1 90 0 .

Ther e ar e pediatr i c societ ies in Philadelphia,in the State

of Ohio,in Par i s, Kiew, St . Peter sbur g, and many places,

all of them engaged in ear nest work whi ch is exhibited involumes of their own o r in the magaz ines of the pr ofes s ion .

I f we add the annual r epor ts of hundr eds of public institutio n s, which ar e so numer ous indeed that a lar ge volume of S . H iigel, Beschr eibung sammtlicher K inderheil

anstalten in Eur opa, was r equir ed as ear ly as 1 8 4 8 toenumer ate them ; and an enormous number of text-booksof master s , and of such as ar e anxious to become so

,and

monogr aphs , and es says, and lectur es,and notes p r elim ?

nary and otherwise, which fill the magaz ines that most ofus take o r see, and some o f us r ead—we may form an ideato what extent a topic former ly neglected has taken holdof the conscience and the imagination of the medicalpubl ic .Befor e 1 769 ther e was no institution specially pr ovided

fo r s ick childr en . They wer e admitted now and then to

60

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

by their medical advi ser s, have opened their wards befor efaculti es have consented to open their eyes . At the pr esent t ime

,however

,ther e i s hardly a gr eat medical school

that do es not give amphitheatr e o r beds ide instruction,either in a chi ldr en

’

s ward of a gener al hospital o r in a

special childr en’

s o r babies’

hospital . To a cer tain extentthe teaching of pediatr ics in a gener al hospital has its

gr eat advantages . I t i s not a specialty l ike that of a Spe

cial s ense o r a ti s sue . Fo r the pur pose of study i t hadto be segr egated

, but i t will never be tor n asunder fr omgener al medicine . Vogel and Gerhardt wer e both generalclinicians .The compar ative anatomy and phys iology, hygiene,

etiology, and n osology of pediatr ics have been discussedbefor e you by one of the most p r ominent pediatr i sts ofour er a. It will be my p r ivilege to explain, as far as timewill permit, it s r elation to gener al medicine, to embryologyand ter atology, obstetr ics , hygiene, and pr ivate and publicsanitation

,to ther apeutics both pharmacal and oper at ive,

and to the specialti es of otology, ophthalmology, dermato logy and the motor system,

to pedagogy, to neur ology and

psychiatry, for ensic medicine and cr imi nology, and to socialpoli ti cs .Infancy and childhood do not begin with the day of

bir th. F r om conception to the termination of fe tal li feevolution i s gr adual . The r esult o f the conception de

pends ou par ents and ancestor s . Nowher e ar e the laws ofher edity mo r e per ceptible than in the structur e and natur eof the child . Phys ical pr oper ti es, vir tues and s ins

,and

tendencies to dis ease may not stop even with the thirdo r four th gener ation . Hambur ger and Osler tr ace an

angio-neur o s i s thr ough six gene r ations,the fir s t cas e in

the ser i es be ing obser ved by Benj amin Rush. In manyin stances st ill-bir ths, ear ly di seases

,atr ophy, and un due

mor tali ty of the youn g depend on antenatal happenin gs .The condi tion and di et of the mother influences her o ff

spr ing . The danger o f a contr acted pelvis,

and the

necess ity of pr ematur e delivery may be'

obviated by the

r estr ict ion of the di et, o r even by appr opr iate (thyr oidand other ) medicat ion of the p r egnan t w oman . Exper i

62

HISTORY OF PEDIATRICS

ence and exper iment tell the same story. The co ntinuedpract ice of pr eventing conception causes endometr it is .Alco holi sm causes chr onic placentiti s , pr ematur e co nfin e

ment, o r still-bir th. So doe s chr onic phosphorus and lead

po i so ning . For tunately, however the usual medicationr esor t ed to dur ing labor i s r ar ely danger ous, fo r evenmorphine o r er got doses given to the par tur ient woman onpr oper indi catio ns affect the newly

-bo r n r ar ely,and chlor o

form anesthes ia almost never .

Scanty amni oti c liquor,by the pr eventi on of fr ee intr a

uter ine excur s ions , may cause club—fo ot ; o r close contactof the sur faces o f the embryo and the membr anes giver i se to adhesions of the placenta and the head, to filamen tsand bands whos e pr essur e o r tract ion pr oduces gr oo vingo r amputati on o f l imbs, cohes ion of toes o r finger s , umbilical meningeal, encephalic, o r spinal her ni a ; not inext r a—uter ine pr egnancy only, wher e such occur r ences ar e

very fr equent . Even the maj or ity of har elips and fis

sur ed palates have that or igin . Ar r est s of developmentand foetal inflammation ar e the headings under which mostof the anomali es of the newly-bo rn may be subsumed ;co ngenital di s eases of the ear and o f the hear t may r esultfr om either cause o r fr om both. Obstruct ions of the in

testin es,the r ar e closur es of the (e sophagus, the ur eter ,

and the ur ethr a, with hydr o-nephr os is an d cysti c degencration o f the kidneys ar e pr obably mor e due to excess ivecell p r olifer at ion in the minute or ig inal gr ooves than to

inflammation .

The in suffi cient closur es of normal embryonic fi s sur es o rgr ooves explain many cases of sp in a -bifida

,many of

encephalocele, most of the split l ips and palates , all o fpo r encephalus , bifid uvula and epiglott is

,pharyngeal and

thyr oglossal fistulas, the communicati ons between the in

test inal and ur o-genital tr acts,and the per s i stency and

patency of the ur achus .2

2 J . W. Ballan tyne, in his Manual o f Antenatal Patho logy and

Hygiene, 1 902 , has a. separ ate chapter o n the r elatio ns o f antenatal patho logy to o ther br anches o f study, to general patho logy,to the bio logical sciences, such as anatomy, embryo logy, physio logy, bo tany, and zo o logy, and to the medi cal, in cluding obstetr ics,

63

DR . JACOBI’

S WORKS

Her edity need not show its el f in the p r oduction of a

fully developed disease . I t exhibits its elf normally eitherin equality o r r esemblances, either total o r par tial, of thebody, o r some one o r mor e of its exter nal o r inter nal o rgans . In thi s way i t may affect the ner vous, the muscular ,the os seous, o r other tis sues . That i s why dystr ophies indiffer ent forms , obesity, achondr oplas ia, hyper plasia, o r

atr ophy may be dir ectly inher ited, while in other casesthe disposition to degener ation only i s t r ansmitted.

Her edi tary degener acy i s often caused by social in fluen ces. The immor al condit ions cr eated by our financialsystem make women select not the str ong and hear ty and

the young husband, but the r ich and o ld, with the r esultof having less

,and less vigor ous, childr en . Cer tain pr o

fess ions,the vocations of soldier s and mar iner s, and subor

dimate positions of employees in gener al, enfor ce com

plete o r appr oximative celibacy, with the same r esult . Thenations that submit to the alleged necess ity of keepingmillions of men in s tanding armies

,ar e thr eatened with

a degener ated offsp r ing, fo r not only do they keep the

str ongest men fr om timely mar r iages, but they incr eas ep r ostitution and vener eal dis eases

,with thei r di r e co nse

quen ces fo r men, women, and pr ogeny. War s lead to thesame r esult in incr eased pr opor tion

,fo r tens and hundr eds

of thousands of the sound men ar e slain o r cr ippled, o r

demor alized. Those who ar e infer ior and unfit fo r physical exer t ions r emain behind and pr ocr eate an infer iorr ace ; those who bel ieve with Lord Rosebery that an empir e is of but l ittle use without an imper ial r ace will always , in the inter ests o f a wholesome civilization

,obj ect

to the untutor ed enthusiasm which denounces the weakling,

”and the cr aven cowardice of those who believe

in the steady evolution of peace and harmony amongstmen , and, in sympathy with the phys ical and mor al healthof the pr esent and futur e gener ation

,will p r efer the

cleanly and washed spor tsmanship of an educated youthto that of the mud-str eaked and blood-stained man -hunter .

public health, pediatr ics, medicine, psycho logy, dermato logy, sur

gery, o r thopedics and medical jur isprudence, finally to gynaeco logyand neo -natal patho logy.

64

HISTORY OF PEDIATRICS

A gr eat many diseased condit ions cannot be thor oughlyunder stood unles s they be studied in the evolving being.

Tumor s ar e r ar ely inher ited, but many of them ar e

observed in ear ly l i fe . Lymphoma, sar coma, also lipomaand car cinoma, and cystic degener ation, ar e obser ved at

bir th,

o r within a shor t t ime after , and seem to favorCohnheim

’ s theory, according to which many owe theiror igin to the per s istence in an abnormal location of embryonie cells . Thi s theory does not exclude the fact thatcongen i tal tumor s may r emain dormant fo r year s o r de

cades and not destr oy the young .

So much on some points connected with embryo l0g3/ and

terato logy. The connection with o bstetr ical pr actice i sequally intimate . Thr ee per cent . of all the matur e livingfmtuses ar e no t bor n into postnatal l i fe thi s very day. Tor educe the mor tality even to that figur e, i t has taken muchincr ease o f knowledge and impr ovement in the ar t ofobstetr ics to such an extent that it has become possible byCesar ean section not o nly to save the foetus of a living,but also of a dead mother , fo r the foetus in her may sur vivethe dying woman .

But after all,many a baby would be better o ff, and the

wor ld al so,i f it had died dur ing labor . Ther e ar e those,

and not a few,who ar e bor n asphyxiated on account of

Inter rupted cir culation, compr es s ion of the impacted head,o r meningeal o r encephalic hemor rhage, which destr oysmany that die in the fir st week of li fe . Those who ar e notso taken away may live as the r esult o f pr otr actedasphyxia only to be par alyt ic, idiotic, o r epileptic . Manytimes in a long li fe have I ur ged upon the p r actitioner tor emember that every second added to the dur ation ofasphyxia adds to the danger s either to l i fe o r to an im

pair ed human existence . Besides fr actur es,facial o r

br achial par alys is , cephalhaematoma and haematoma of thester no-cleido mastoid muscle, gonor rhea] ophthalmia, withits danger s to s ight and even life, may be daily occur r encesin an obstetr ician

’

s l i fe . All such cases pr ove the iusufficien cy of knowledge without ar t, o r of ar t without knowledge, and the gr ave r espons ibility of the pr actical obstetr ician . To lose a newly-bor n by death causes at least

65

DR . JACOBI ’S WORKS

dir e ber eavement ; to cr ipple his futur e i s not r ar ely cr iminal negligence .Within a few days after bi r th the obstetr ician o r the

pediatr i st has the oppor tunity o f obser ving all sor ts ofmicr obic infections

,fr om tetanus to hemor rhages o r gan

gr ene, and the intense forms of syphil is . Not an uncom

mon dis ease of the newly-bor n and the very young isnephr it i s . I t i s the consequence, in many cases, of whatappear s to be a commo n j aundice, o r of ur ic acid in far etion

,whi ch i s the natur al r esult o f the sudden change of

metabolism . The diver ticula of the colon, as descr ibed byHir schsprung and Osler , and what near ly 4 0 year s ago

was char acter i z ed as congenital constipation, which de

pends ou the exagger ation of the normally excess ive lengthof the s igmoid flexur e, belong to the same class . Theirdanger s may be avoided when they ar e under stood. Ofthe infectious dis eases o f the embryo and the foetus

,it i s

pr incipally syphili s that should be cons ider ed ; amongstthe acute forms var iola and typhoid ar e r elatively r ar e.

What I have been permitted to say i s enough to p r ovethe intimate interdependence and connection betweenpediatr ics and the diseases of the foetus with embryologyand ter atology, obstetr ics, and some par ts at least

,of

so cial economics .After bi r th ther e ar e anomalies and diseases which ar e

encounter ed in the infant and child only. Ther e ar e also,

common to all ages,though mostly found in childr en,

such as exhibit a symptomatology and cour se pecul iar tothem . The fi r st clas s , besides thos e which ar e seen inthe newly-bor n

,i s made up mostly o f developmental dis

eases—scr ofula,r achit i s

,chlor osis . The actual o r alleged

ailments connected with dentit ion,most forms of stomatitis ,

Bednar’

s so—called aphthae,the ulcer ation of epithelial

pear ls along the r aphe,amygdaliti s, pharyngiti s , adenoid

pr oli fer ations , later o and r etr o—pharyngeal abscesses belong her e. In fectious diseases

,such as var iola, diphther ia,

scar latina, measles, per tuss is, and tuber culosis of the

glands, bo nes, j oints , and per itoneum have been most successfully studied by pediatr i sts o r those clinicians whopaid pr incipal attention to pedology. Meis sner pr ints the

66

HISTORY OF PEDIATRICS

titles o f mor e than 2 0 0 actual monogr aphs on scar let feverpublished in Eur ope befor e 1 8 4 8 . Pleur i sy and pneumoniaof the young have their own symptomatology. Empyemai s mor e fr equent and r equir es much mor e oper ative interfer ence .Tr acheotomy and intubation ar e mostly r equi r ed by the

young, both on account o f their liability to (edema ofthe larynx and to diphther ia, and of the nar r ownessof the larynx . Of invagination, 2 555 occur under o ne

year , sag under 1 0 . Appendiciti s,sometimes her editary

and a family di sease, would long ago have been r ecognizedas a fr equen t occur r ence in the young if it had not been

‘

fo r the difficulty, mainly encounter ed in the young, and

sometimes impossibility of its diagnosis . That i s whatwe have been taught by Hawkins and by T r eves, and latelyby McCo sh. Oper ations on glandular absces ses

,o steo to

mies,and other oper ations on the bones and j oints, par

ticular ly in tuber culos i s , and on malformations,such as

have been mentioned, r equir e the skilful hand of the operating phys ic ian in a gr eat many instances . Omphalocele,exstr ophy of the bladder , undescended testicle, spermatichydr ocele, multiple exostoses, imper for ate r ectum

,atr es ia

o f the vagina, o r an occas ional cas e of stenosed pylorus,belong to that class , some r equir ing immediate oper ation,some permitting of delay. I t is pr incipally in fancy thatdemands r emovals of angioma

,which ar e almost all suc

cessful, and of hygr oma, mostly unsucces s ful,main ly

when situated on the neck and r esulting fr om obstructionof the thor acic duct sometimes connected with thr ombosi so f the jugular vein . Childhood r equi r es cor r ection ofkyphosis and scolios i s

,and oper ations fo r adenoids and

hyper tr ophied tonsils , and fur nishes the oppor tunities fo rlumbar punctur e and lapar otomy in tuber cular per itoniti s ;also supr a-pubic cystotomy, and mastoid oper ations . That

gum-lancing i s n o oper ation indicated o r permissible in

either the young o r adult, and not any mor e so in the

former than in the latter,i s easily under stood by those

who acknowledge its necess ity only in the p r esence of a

morbid condition of the gums o r teeth,and not when the

phys iological pr oces s of dentition exhibit no anomaly. I t

67

DR . JACOBI’

S WORKS

scar cely ever does . Altogether oper ating special ists wouldwo rk and know very much less i f a lar ge maj or ity of thecas es wer e n o t entrusted to them by the pediat r ist, who

r ecognizes the p r inciple that those who ar e best fitted toper form it should be trusted with impor tant medical wor k .

So well is the ser iousnes s and difliculty of oper ative pr o

cedur es, as connected with diseases of chi ldr en , r ecognized

by exper ts, that pages of Gerhar dt’

s handbook ar e

dedicated to exter nal pathology and oper at ions , and thatspecial works , bes ides many monogr aphs by hundr eds ofauthor s

,have been wr itten by such master s as Guer san t,

For ster,B ryant, Gir aldes, Holmes , St . Germain, Kar ew

ski,Lann elongue, K irmisso n , and B r oca.

E ar specialists r ecognize the fact that otology i s mostlya specialty of the young . The newly

-bor n exhibit changesin the middle ear which ar e var iously attr ibuted to the

p r es ence o f epithelial detr itus , to the aspi r ation of for eignmater ial

,o r to an (edema ex vacuo occasioned by the sepa

r ation o f forme r ly adj acent mucous sur faces . Pus i sfound in the middle ear of 7 5% of the st ill

-bor n o r ofdead nur slings . I t contains meconium

,lanugo

,and ver nix .

Ascho fl’ 3 examined 5 0 still—bor n, o r such as had l ived les s

than two hour s ; 2 8 of them had pus in the middle ear sHe also examined 3 5 infants that had lived longer

than two hour s ; 2 4 had pus (70g) . Evidently the latterclas s had been exposed to a micr obic invas ion . The diagnos is in the l iving infant i s very difficult, mostly imposs ible,on account o f the lar ge s ize of the Eustachian tube,which after having admitted the in fection

,allows the pus

to escape into the pharynx and the r est of the alimentarycanal . Many o f the newly-bor n that die with unexplainedfever s per i sh fr om the septic mater ial

, o r its toxins,

absorbed in the middle ear o r the intestines . No r ar e

older childr en exempt . Gepper t ( J ahrb. f . Kind.

,xlv

,

1 897 ) found a latent otitis media in 7 5% of all the in

mates o f the Childr en’

s Hospitals . Both latent and knownotitis i s often conn ected with pneumonia

,o r with pneu

monia and enter iti s . In individual cases i t may be difficult

3 Ascho fi'

, Z . f. Ohr enh. Vo l. xxxi .

68

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

fr equent symptomatic anomalies ar e str abismus and

nystagmus—both of them the r esults o f a gr eat manyand var ious exter nal o r inter nal causes, with sometimesdiflicult diagnoses .The connection of pedology with dermato logy i s mor e

than skin deep ; some of the most inter esting p r oblemso f the latter must be studi ed on antenatal and postnatall ines . The congenital absence of small o r lar ge par ts ofthe sur face i s p r obably due to amniotic adhesions ; s eborrhea and the mild form of lichen, also the furun culos iso f infant cachexia and ather oma, to the r apid development

,in the second half of intr a-uter ine l i fe

,of the

sebaceous foll icles ; ichthyosis, to the same and to a

hyper tr ophy of the epidermis and the papilla: of the

cor ium,sometimes with dilatat ion o f their blood-vessels

and with scler os is'

o f the connective tis sue . Congenitalanomalies

,such as l ipoma, sar coma, naevus pigmentosus ,

open all the question s of the embryonal or igin ofneoplasms ; and the eruptions on the in fant sur faceunclose to the speciali s t the subj ect of infectious diseases .We r ecognize in the pemphigus of the palms and solessyphi lis ; in herpes, gangr ene, in what I have descr ibedas chr onic neur otic pemphigus

,the i r r itable ner vous

system ; in eczema,constitutional disturbances of the

nutr ition ; in erythema, local i r r i tation o r intestinal autoinfection ; in i solated o r multiple forms r anging betweenhyperaamia and exudat ion, the effect o f local ir r itationo r the acute o r chr onic influence of drugs . A dermato logist who kn ows n o embryology o r pedology, a pediat

r i st who knows no dermatology, is anything but a competent and trustwor thy medical pr actitioner .

The diseases of the muscles inter est the pediatr i st, the

sur gical specialist, the or thopaedi st, the neur ologist

,to

an equal extent . Many forms of myos iti s ar e of in fectious or igin . Amongst the special forms of muscularatr ophy i t i s the her editary var iety which concer ns thefir st . The spinal neur it ic atr ophy, the myogenous,pr ogr ess ive dystr ophy, including the so -cal led pseudohyper tr ophy, Thomson

’

s congen i tal myotonia, and atr ophie defects of muscles—mainly the pector al

, but also

70

HISTORY OF PEDIATRICS

the tr apez ius,quadr iceps

,and other s—no matter whether

they ar e p r imary o r myogenous (thi s p r obably alwayswhen ther e is a complication with pr ogr ess ive dystr ophy) ,ar e of special inter est to the neur olo gist . I need not domor e than mention tor ticollis in order to pr ove thatneither the pediatr i st no r the or thopaedi st, n o r the gener alsur geon can r ai se the claim o f sole owner ship .

The r elat ions of pediatr ics to fo r ensic medicine ar e

very close . Nothing i s mor e apt to demonstr ate thi sthan the immense liter atur e in every language oninfanticide and all the questions o f phys iology, phys ics,and chemistry connected with that subj ect . The monogr aphs and magaz ine es says of the last two centur ieswr itten on the value o r the fallacy of the lung test in thedead newbor n would fill a small libr ary. Much attention has been paid by phys icians and by for ens ic author sto les ions and fr actur es of the n ewly-bor n head, and toanomalies of the female pelvi s caus ing them . Appar entdeath of the newly-bor n and the causes of sudden deathin all per iods o f li fe have been studied to such an extentas to r ender negative r esults of police investigation and

of autopsy r epor ts less numer ous fr om year to year .

Most sudden deaths r eceiving the attention of the .

author it ies occur in the young . Ther e wer e (Wm .

Wynn Westcott in B r it . M . J ., Nov. 7 , 1 90 3 ) in

England and Wales dur ing ten year s over lainin fants ; in 190 0 , In Liver pool

,out of 960 inquests

ther e wer e 1 4 3 on babies that had di ed of such suffo ca

tion by accident o r malice afor ethought ; in London, in190 0 , 6 1 5 ; in 190 1 , 5 1 1 ; in 1 90 2 , 5 8 8 . In London theyhad annually o flieial inquests, one o f 1 4 of whichwer e on over lain infants . The etiology of sudden deathswould be far fr om complete

,indeed the most difficult

questions could not be solved except by the facilities furn ished by the obser vat ions o n - the young . For eignbodies in the larynx, beans , shoe—buttons, and playthingsgener ally, even ascar ides (Bouchut) , bo nes and pieces ofmeat aspirated dur ing vomiting, acute (edema of the

glottis, aspir ation of a long uvula, o r o f the r etr acted

tongue, the ruptur e of a pharyngeal abscess o r of a suppu

7 1

DR . JACOBI ’S WORKS

rating lymphoid body into the tr achea, a sudden swelling of the thymus in the nar r ow space between the

manubr ium and ver tebr al column, which at best measur esonly cm .

,even a coryza in the nar r ow nose of a small

infant fi lled o r no t with'

aden o ids—ar e causes of suddendeathThe ner vous system fur nishes many such cases . I t

i s true ther e i s n o longer a diffuse inter st itial encepha

litis,such as Jastr owitz would have it, n o r i s the hyper

tr ophy of the br ain by far so fr equent as H ii ttenbr enn ertaught

, but ther e ar e sudden collapses and deaths by fallson the abdomen, by sudden str angulation o f lar geher niae and other shocks of the splanchnic ner ve . Ther ear e sudden and unexplained deaths in unnoticed attacksof convuls ions , in the fi r st par alytic stage of laryngismusstr idulus, in glottic spasms fr om whatever cause

,in the

par alys i s—o r,accor ding to E scher ich, laryngo

- spasm—o f

what s in ce Paltauf has been denominated status lymphaticus, in cer ebr al anemia

,no matter whether it i s the

r esult o f exhaustion o r , as Char les West taught us 60

year s ago , fr om the mer e change o f pos ition of a pneumonic o r otherwise sick baby, when suddenly r ais edfr om its bed. O r death may occur suddenly (a very fr equent occur r ence ) in the hear t failur e of par enchymatousdegener ation of the hear t muscle as it occur s in and afterdiphther ia, influenza, and other infectious dis eases

, o r inthe acute sepsis o f appendiciti s and other intr aper itonealaffections, whether r ecognized o r not. Fo r the absor bing power

,even of the normal per itoneum

,i s enormous .

Of a very acute infection in fectio acuti ssima Wer

nich spoke as ear ly as 1 8 8 3 .

In gastr oenter it is , the terminating br oncho-pneumonia may destr oy l i fe quite suddenly ; ther e i s a capil

lary br onchiti s of the very young with no cry, no moan,and n o cough, but with sudden death ; ther e ar e inextr eme atr ophy, fatal emboli into the pulmonary, sometimes r enal, mor e often cer ebr al ar ter ies . Ther e ar e the

cases of ur emic convuls ions , sudden, with sudden death,which ar e often taken to be mer ely ‘

r eflected o r“ p r ov

iden tial,” because the fr equency of acute nephr iti s in the

72

HI STORY OF PEDIATRICS

newly—bor n and the infant, with its fever and its ur emia,in spite of the publications of Mar tin and Ruge, Virchow

,Or th

,Epstein

, and my own, i s not yet fullyappr eciated. That is so much the mor e deplor able as

the diagnosis of nephr it is at any age i s r eadily madeby the examination of the ur ine, which i s so easy toobtain in the young . Other suddenly fatal condit ions ,such as the acute o r chr on ic sepsis I mentioned befor e,often quite unsuspected, enter ing thr ough the umbil

icus,the intestine

,o r the middle car

,ar e quite fr equent .

I have been car eful not to mention any caus e of deaththat may just as well be and has been studi ed in the

adult : hemor rhages, the many forms of seps is o f laterper iods o f li fe, poisons, such as car bolic acid . and iodoform

,intense cold o r heat

,insolation

,etc .

,fo r it is my

duty to exhibit the r elation to for ens ic medic ine ofpediatr i cs only. For ensic medicine has to guar d the

inter ests of all. Nothing in all medicine is mor e difficult than the discovery o f the cause of death. The bestknowledge of the advanced p r actitioner , of the pathologist

,of the chemist, of the bacter iologist, of the

obstetr i cian, should be at the ser vice of the people.Every Eur opean country under stands that and acts onthat knowledge . Our own Massachusetts has br okenaway fr om the cor oner

’ s institution,whi ch was a fit

author ity fo r a backwoods municipal ity, but i s so nolonger fo r a cultur ed people of eighty millions . Now and

then,even an exper t, o r a body o f exper ts, does n o t suc

ceed in discover ing the cause of death. What shall wesay of a system which n ow and then do es di scover the

hidden cause o f a sudden death ? When the New YorkState Legislatur e s ix months ago passed a bill abolishingthe no longer competent o flice of cor oner

,our good cul

tur ed mayor , a gentleman and author,vetoed it fo r the

r eason that the new law was not per fect. I t was notp r onounced per fect by anybody, no law i s n o r ever was.

That is why it appear s he pr efer s something that alwayswas and i s

,and always will be per fect, namely, the

absurd incompetency and anachr onism o f the cor oner ’ soffice . That i s per fect . I have not hesitated to expr ess

7 3

DR . JACOBI ’S WORKS

myself str ongly and positively, fo r I have been calledupon to speak to you about the r elation of pediatr ics toother sciences and ar ts—poli t ics included, than whichther e i s no mor e p r ofound p ractical and indispensablescience and ar t. The gr eatest histor ical legislator sunder stood that per fectly well, when they knew how toblend hygiene and r eligion with their social and politicalor ganization .

One o f the gr eatest questions which concer ns at the

same time the pr actical statesman, the humanitar ianand the pediatr ist

,i s that of the excessive mo r tality o f

the young . The Par i s Academy of Medicine enumer

ated in its discus s ions of 1 8 70 the following amongst itscauses : Pover ty and illnes s of the par ents, the largenumber of illegitimate bi r ths, inability o r unwillingnesson the par t of mother s to nur se their offsp r ing, ar tificialfeeding with impr oper mater ial, the ignor ance of the

par ents in r egard to the pr oper food and hygiene, exposur e

,absence o f medical aid, car eles s selection o f nur ses ,

lack of super vis ion o f baby farms, gener al neglect and

in fanticide . I f ther e be anybody who i s not quite cer tainabout the r elationship of sci ences and ar ts

,he will still

be conv inced of the cor r elation and co-oper ation of igno

r ance,indolence, v iciousnes s and death, and shocked by

the shor tcomings of . the human society to which webelong. Most of them should be avoided. For ty per

cent . of the mor tality of infants that die befor e the end

o f the fir st year takes place in the fi r st month. That i smostly pr eventable . A few year s ago the mor tality ofthe infants in the Mott Str eet bar r acks of New Yor kCity was 3 2 5 per mille . Much of it i s attr ibutable tofaulty diet.4

Amongst t hose who believe in the omnipotence o f

4 Measur es taken fo r the purpo se o f obtain ing who lesome milkar e no t quite new. Regulati o ns wer e given in Venice, 1599, fo rthe sale o f milk. Milk and its pr oducts o f diseased animals wer efo rbidden . The Par is municipal ity o f 1 792 enj o ined the farmer sto give their cows healthy fo od. Co lo r ing and dilutio n o f milkwer e str ictly fo rbidden, and in 1 792 they knew in F rance how to

punish transgr esso r s.

74

HISTORY OF PEDIATRICS

chemical fo rmulw,ther e p r evails the op inion that a baby

depr ived of mother’s milk may just as r eadi ly be

b r ought up on cow’ s milk ; that i s eas ily disp r oved. I n

Ber li n they found that amongst the cow’ s -milk-fed babies

under a year the mor tality was s ix times as gr eat as

amongst br east-fed infants . Our own gr eat cities gaveus s imilar , o r slightly smaller , pr opor tions, un til theexces s ive mor tality of the very young was somewhatr educed by the car e bestowed on the milk, intr oducedboth into our palaces and tenements . Milk was examined fo r bacter ia, cleanlines s, and chemical r eaction . I twas ster i liz ed

,pasteur i zed, modified, co oled, but no

cow ’s milk was ever under the laws of natur e changedinto human milk

,and with better milk than the city of

New Yor k ever had, i ts in fant mor tal ity was gr eaterthi s summer than it has been in many year s .That hundr eds of thousands of the newly-bor n and

small infants per i sh every year on account of the

absence of their natural food i s a fact which i s kn ownand which should not exist . Why do we kill thosebabies o r allow them to be killed ? Why i s it that theyhave no br east milk ? A lar ge number o f women wor kin fields

,still mor e in factor ies . That i s why their

infants cannot be nur sed, ar e farmed out, fed ar tificially,with car e o r without it, and die. I t is the mis- rule pr evailing in our social condit ions which compels them towithhold milk fr om the in fant while they ar e workingfo r what i s called br ead fo r themselves and their fam

ilies. Many o f these women, i t i s true, would not havebeen able to nur se their newly-bor n, fo r their ownphys ical condit ion was always incompetent . The samemay be said of women in all walks of li fe . Insufficientfood

,hard work, car e, her editary debility and disease,

tuber culos is, alcoholism of the woman ’ s own father ,modified syphil i s o r ner vous d i s eases in the familyaye, the inability of her own mother to nur se her

babies , ar e ever so many causes why the mother’ s foun

tain should run dry. Stati stics fr om lar ge obstetr icalin stitutions (Hegar ) pr ove that only about 5 0% of womenar e capable of nur s ing thei r offsp r ing fo r mer ely a few

75

DR . JACOBI’

S WORKS

weeks . In the p r esence of such facts what ar e we to say

of the r efusal of well-s ituated and phys ically competentwomen to nur s e thei r in fants ? I do

'

not speak of theI mean the who pr efer their ease to thei r

duty, their social fun ctions to their mater nal obligations,who hir e str anger s to nur se their babies, o r wor se yet,who make-believe they believe the claims of the infantfood manufactur er s

,o r ar e tempted by their own phys i

eiaus to believe that cow ’s milk casein and cow s milkfat may be changed into woman

’ s casein and fat, that

chemistry i s phys iology, that the live stomach i s like a

dead labor atory bottle, that the warmth of the humanbosom and that o f '

a nur sing flask ar e identical, and thatcow ’ s milk i s like human milk when it car r i es the

tr adesmark“

Cer tified,

”o r Modified.

” Phys iologicalchemistry its elf teaches that the phosphorus combinations in woman

’

s milk in the shape of nuclein and

lecithin ar e not contained in cow ’ s milk,and that the

lar ge amounts of potas s ium and sodium salts containedin cow ’ s milk ar e dead weights r ather than nutr i ents ,and par ticular ly the lar ge amount o f calcium phosphateoccur s in a chemical, not in a phys iological, combination . But lately, by no means the fir st time

,Schloss

mann and Mur o (Munch. med. Woch.,190 3 , No .

have again pr oved that the albuminoids of woman’ s

and cow’ s milk ar e essentially differ ent, both in their

lactalbumin and the globulin, and Escher ich and Mar fan,

that every milk has i ts own enzymes .The quantitative and many of the qualitative differ

emees of cows’

and human milk have been known a longtime . No addit ion o r abstr action of salts

,no addition

o f cow’

s fat _will ever change one into the other . But itappear s that every new doctor and every new authorbegins his own er a. Ther e is fo r most of moder n wr iter sno such thing as the history of medicine o r of a specialty,o r r espect o f father s o r br other s . In moder n books and

essays you meet with footnotes and quotations of the

p r oductions of yesterday that look so erudite, but also

with the new discover ies o f o ld knowledge whi ch you

would r ecogniz e i f the quotation marks had not been

76

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

nur se their own infants . In fants ar e the futur e citizensof the r epublic . Let the r epublic see that no harmaccrues fr om the incompetence o r unwilli ngness to nur se .Antiquity did not know of ar tificial infant feeding . The

fi r st information of its intr oduction i s dated about 1 50 0 .

Turks,Ar abs

,Armenians

,and Kurds know of no ar ti

ficial feeding to-day. I t takes moder n civilization toexpose babies to dis ease and extinction . I know o f nopolitical o r social question o f gr eater ur gency than thatof the pr evention of the wholesale murder of our infantscaused by the withholding of p r oper nutr iment . Maynobody, however , feel that all i s accomplished when an

in fant has finally completed his 1 2 months . Societyand family owe mor e than li fe —they owe good health,v ital r es istance

,and secur ity against li fe-long invalidism .

But even willing mo ther s may have no milk . Wer equir e a str onger

,healthi er r ace

,and one that phys ic

ally i s not on the down grade . The nur s ing question i sa social and economic pr oblem like so many other s, likethe childbear ing question,

that confr ont moder n civili zation .

We ar e building hospital s fo r the s i ck of all clas ses,and ins ist upon thei r being super ior to the best pr ivater es idences ; asylums fo r the insane, neur opathies , and

drunkar ds ; nur ser i es and schools fo r epileptics , cr etins ,and idiots ; r efuges fo r the dying consumptives ; and

sanator ia fo r incipient tuber culos is . We ar e bent uponcur ing and upon pr eventing . Do we not begin at the

wr ong end ? We allow consumptives and epileptics tomar ry and to pr opagate thei r own cur se . We have nopunishment fo r the syphilitic and the go n o r rhmic who

ruins a woman ’ s l i fe an d impai r s the human r ace .Man ,

however , must see that his kind shall not suffer .

One-hal f of us should not be des tined to watch, and

nur se , and suppor t the other hal f . Human society and

the State have to pr otect themselves by looking out fo r

a healthy, uncontaminated pr ogeny. Laws ar e r equi r edto accomplish thi s ; such laws as will be hated by the

epileptic, co nsumptive , the syphil i ti c,’

and the vicious .No laws ever suited the degener ates against whom they

78

HISTORY OF PEDIATRICS

wer e passed,and i t i s unfor tunate that while health and

vi r tue ar e as a rule not contagious, disease and vice ar e

so to a high degr ee .Moder n Therapeutics, both hygienic and medicinal,

has gain ed much by the close obser vation of what i spermitted o r indicated o r r equir ed in ear ly age. Sincei t has become mor e humane (r emember it i s hardly a

century s ince P inel took the chains o ff the insane intheir dungeons , and not mor e than hal f a century s inceI was taught to car ry my venesection lancet in my vestpocket fo r r eady use) and mor e scientific, so that whatever i s outs ide o f str ict biologic methods i s no longer“

a system,

”but down r ight quackery—the ter r ible

incr ease of the latter as a wor ld-plague is deemed byr ational pr actitioner s and the sens ible public an appalling anachr onism . I t appear s that the States of the

Union ar e most anxious (and have been part ially suc

cessful) to r id themselves o f it, while some at least of thenations of Eur ope ar e gr eater Si i fl er er s than we . According to the latest statistics , ther e is one quack to everyphys ician in Bavar ia and Saxony ; ten quacks in Ber lin,

with its emper or and other accomplishments, to everyfor ty-s ix phys icians . Its gener al population has incr easeds ince 1 8 79 by the number of phys icians, 1 70 2 70 ;that of the quacks

,1 60 0%

One of the main indications in infant ther apeutics isto fight anemia

,which i s a constant danger in the dis

eases o f the young, fo r the amount of blood at that age

is o n lv one-nineteenth of the whole body weight, whilein the adult it i s o ne-thi r teenth. The newly-bor n ispar t icular ly exposed to an acute anemia. His bloodweighs fr om 2 0 0 to 2 50 gr ammes . I t is over loadedwith haemoglobin which is r apidly eliminated, togetherwith the or iginal exces s of i r on . This lively metabolismr ender s the in fant very amenable to the influence ofbacter ia, and the lar ge number of acute

,sub-acute, o r

chr onic cases of seps is i s the r esult . Besides,the p r in

cipal normal food i s milk, which contains but little i r on .

That i s why pediatr ics i s most apt to inculcate the lessons o f appr opr iate postur e, so as not to r ender the br ain

79

DR . JACOBI ’S WORKS

suddenly anemic,and o f p r oper feeding and of t imely

stimulation befor e collapse tells us we ar e too late, and

the danger s of inconsider ate depletion . The exper i enceaccumulated in pediatr ic p r actice has taught gener almedicin e to use small doses only of potass ic chlor ate ;lar ge doses o f strychnine and alcohol in s eps is, ofmer cur ic bichlor ide in cr oupous in flammatio n s

, of hear tstimulants

,such as digital i s

,when a speedy effect is

wanted,of ar senic in ner vous diseases , of potass ic iodide

in meningiti s ; i t has warned p r actical men o f the

danger s of chlor oform in status lymphat icus ;5 i t has

modified hydr otherapeut ic and balneological p r actice,and the theor ies o f har dening and str engthening accor ding to per iods of li fe

,and to the condit ions of p r evious

gener al health.

The appr eciation o f electr icity as a r emedy has beenenhanced by obstetr icians , pediatr i sts and gener al p r aetitio n er s. It is but lately that we have been told (P .

Str assmann , Samml. Klin . Vo r tr .

,1 90 3 , No . 3 5 3 ) that a

newly-bor n and an infant up to the third week ar e per

fectly insens ible to very str ong electr ical cur r ents . The

incompetency o f mer e exper imental wor k, n o t co r r ected

o r guided by p r actice, cannot find a better illustr ation ,fo r ther e is no mor e power ful r emedy fo r asphyxia and

atelectas is than the cautious use o f the inter rupted o r ofthe br oken galvanic cur r ent .The domain of p r eventive ther apeutics expands with

the incr eased knowledge of the causes of dis ease . Thati s why immunizing, like cur at ive s erums , will play a

mor e beneficen t par t fr om year to year , and why the

healthy condition of the mucous membr ane of the nose,

mouth,and pharynx, which I have been advis ing thes e

for ty year s as a pr evention of diphther ia,has assumed

5 In the meeting o f the So ciety fo r the Study o f Disease inChildr en, May 27 , 1 904 , Mr . Thompso n Walker alluded to theco llectio n o f ten cases with status lymphaticus in which deathhad o ccur r ed at the commencement o f chlo r o fo rm admin istration,o r dur ing it, o r immediately after the Operation . In additio n to

the usual changes, a hyperplasia o f the ar ter ies had been no ted,leading to nar r owing o f the lumen .

8 0

HISTORY OF PEDIATRICS

impor tance in the armamentar ium of p r otection againstall sor ts of infectious di seases .Amongst the pr obabilities of our ther apeutical futur e

I also count the p r evention of congenital malformations ,which, as has been shown, ar e mor e numer ous than isgener ally known o r p r esumed, and often the r esult ofintr auter ine inflammation . In a r ecent publication F .

von Winckel (Samml. Klin . Vo r tr .,190 4 , No . 3 7 3 )

emphas izes the fact that the gener al pr actitioner o r the

pathologic anatomist s ees only a small number , thatindeed the maj or ity ar e bur i ed out of s ight, o r ar e pr e

ser ved in the specimen j ar s of the obstetr ician . The

known number of mal formations compar ed with that ofthe normal newly-bor n var ies fr om o ne to thir ty-s ix, toone to one hundr ed and two o r mor e . They ar e metwith in r elat ively lar ge number s on the head

,face and

neck—altogether in of all the 1 90 cases of mal

formation obser ved in Munich dur ing twenty year s . Anumber o f them is the r esult o f her edity, of syphil i so r other influences . How many ar e o r may be the

r esult of consanguineous mar r iages will have to be lear ned.

In all such cases the tr eatment o f the par ents o r the

pr ohibition of injur ious mar r iages will have to he ins istedupon . The number of those r ecognized as due to amnioticadhes ions o r bands i s gr owing fr om year to year . K iim

mel could pr ove that of 1 78 cases , 29 wer e cer tainly o f

that natur e . Exter nal malformations have long beenascr ibed to them ; pr oximal mal formations, such as

aur icular appendices , har elip , anencephal ia , cyclopia,flatten ing of the face

,anophthalmia

,her editary poly

dactylia (Ahlfeldt'

and Zander , Vir chow’s Ar chiv

,

and lymphangioma o f the neck, have been found to becaused by amniotic attachments o r filaments . I s it toomuch to believe that the uterus

,whose inter nal changes,

syphil itic o r other s, ar e known to_be very acces s ible to

local and gener al medication , should be so influenced bypr evious tr eatment that malformations and fmtal deathswill become less and less fr equent ?

The pr oblem of the health and hygiene mainly of theolder child r efer s to mor e than its food. The scho o l

8 1

DR . JACOBI’

S WORKS

quest ion is in the for egr ound of the study of sanitar ians,health depar tments

,physic ian s, and pedagogues . I ts

impor tance i s best illustr ated by the lar ge conventionwhich was or ganized in Stuttgar t, Apr il, 1 90 4, as an

Inter nat ional Congr ess fo r School Hygiene . Pediatr i sts,pedagogues, and s tatesmen formulated their demandsand mapped out futur e discuss ions . Rational pediatr icswould cons ider the following questions : I s it r easonable to have the same rule and the same daily ses sionsfo r childr en of eight and perhaps of fifteen year s, and fo r

adolescents ? Cer tainly not . The youn ger the child the

shor ter should be the sess ion, the longer and mor e fr equent the r eces ses . Ther e should be no lessons in the

after noon , o r only mechanical occupat ions , such as copying

, o r light gymnastics . Ther e should be no homeles sons .The pr oblem of over burdening was car efully con

sider ed by Lo r inser in 1 8 3 6, and by many s ince . I t dealswith the number of subj ects taught, the str ictness and

fr equency of official examinations , and should considerthe over cr owding of school r ooms . We should try toanswer the question whether neur oses ar e mor e the

r esult o f faulty schooling o r of or iginal debility, her edity,under feeding, lack of sleep, bad domestic conditions , o r

all these combined. In Ber lin schools they have begunto feed the hungry ones r egular ly with milk and br ead.

No compulsory education will educate the star vin g . The

child that showed his fi r st symptom of ner vousnes swhen a nur slin g, the child with pavor n octur nus, o r

that gets up t ir ed in the mor ning, o r suffer s fr om motorhyper aesthesia, pointing o r amoun ting to chor ea, unles sr eli eved instead of being pun i shed by an un informed o r

misanthr opic o r hyster ical teacher , gets o ld o r br eaksdown before the termination of the school term o r ofschool age. Ther e should be separate classes fo r the

feeble, fo r thos e who ar e mentally str ong, o r weak,o r of

medium capacity. All of such questions belong to the

domain of the child’

s phys ician, the physician in gener al . The office of school phys ician i s r elat ively new .

Whatever we have done in es tablishin g it in Amer i ca82

HISTORY OF PEDIATRICS

has been pr eceded by countr i es to which we ar e not inthe habit of looking fo r our models . Bulgar ia and

Hungary have no schools without physicians . On the

other hand, Vienna has none fo r i ts schoolchi ldr en . I t i s r epor ted that the aldermen r efused toappoint one . One of them obj ected fo r the r eason thatthe doctor might be tempted to examine the Viennalass ies too closely. His bus iness would be

,and is, to

lo ok out fo r the healthfulness of the school building, itslighting, warming, cleanliness, the cleanl iness of the

childr en and thei r health,and that o f the teacher s . A

tube r cular teacher i s a gr eater danger to the childr enthan thes e, who r ar ely expector ate, to each other . Hewould take cognizance of the fi r st symptoms of in fectious di seases, examine eyes , ear s, and teeth, and inquir einto chr onic constitutional dis eases , such as r achiti s and

scr ofula i n the youngest pupils . He might under takeanthr opometr ical measur ements an d benefit sciencewhile aiding his wards . He would be helped in all theseendeavor s by the teacher s who must lear n to pr idethemselves on the r obust health o f thei r pupils , as theynow look fo r the accumulat ion of knowledge which maybe exhibited in publ ic examinations .They would soon lear n what Chr i stopher demon

str ated,that phys ical development, gr eater weight, and

lar ger br eathing capacity, cor r espond with incr easedmental power

,j oining to thi s the advice that a phys ical

factor as well as the intellectual one, now en ti r ely r eliedupon

,should be intr oduced in the gr ading of pupils .

(Char les F . Gar diner and H . W. Hoagland, Gr owth and

Development of Childr en in Color ado .—T r ans . Am .

Climatological Ass ’n,

Our knowledge of the phys iology and pathology ofthe n er vous system of all ages would be defective without lessons der ived fr om the foetus and infant . Amongstthe newly-bor n we have

i

oftf

erl to deal with ar r ests ofdevelopment, such as micr ocephalus , o r with thatform of foetal meningitis o r of syphil itic alter ations ofblood-ves sels which may terminate in chr onic hydr ocephalus . When the insufficient development o f r eflex

8 3

DR. JACOBI’S WORKS

action in the newly-bo r n up to the fi fth o r s ixth weekhas passed

,the very slow development of inhibition

dur ing the fi r st hal f year o r mor e , together with the

r apid incr ease of motor and sensitive ir r itability, explainsthe fr equency of eclampsia and other forms of co nvul

s ions . Many of them r equi r e , however , an addit ionaldispos ition

,which i s affor ded either by the normal r apid

development of the br ain , o r the abnormal hypermiaof r achiti s . The last 2 5 year s have incr eased our

knowledge consider ably in many di r ections . Congenitalo r pr ematur e, complete o r par tial, oss ification of the

cr anial sutur es lead mechanically to idiocy, o r par alys is,o r epilepsy ; i t i s a consolat ion

,however , to know that

the victims of sur gical zeal ar e gett ing les s in numbers ince oper ator s have consented to fear death on the

oper ating table,

and thought ful sur geons have come tothe conclus ion to leave bad enough alone . In the veryyoung the fr agility of the blood-vessels

,the lack of co agu

lability of the blood, the lar ge size o f the car otid and

ver tebr al ar ter i es,

the fr equency of tr auma dur inglabo r and after bi r th

, the vulne r abil ity of the ear and

scalp, contr ibute to the fr equency of ner vous di seases ,which befor e the fi fth year amounts to 8 752 of all

the cases o f s ickness . Rapid exhaustion leads tointr acr anial emaciation and thr ombosis , the so -calledhydr o en cephalo id of gastr o-enter itis . The lar ge s ize and

number of the lymph vessel s of the nasal and pharyngealcavities facilitate the invas ion into the n er ve center s ofin fections which show themselves as tuber cular meningitis , cer ebr o-spinal meningitis

,and polio—encephal iti s ,

o r mor e so,poliomyelitis , and as chor ea of so -called

rheumati c mostly str eptococci or igin . Nose and

thr oat special ists,

as well as anatomists , have contr ibuted to our knowledge on these points—another pr oofof the intimate dependency of all par ts of medic ine upono ne another . Now all these condit ions ar e notlimited to ear ly l i fe

, but their numer ical pr eponderance at that t ime is so gr eat that it i s easy to under standthat gener al nosology could not advance without the

overwhelming number of well—marked cases amongst

8 4

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

s ioual pr oximate causes . But cauter i zation of the nar es,and st ill mor e, ci r cumcision, and cl itor idectomy p r ovemor e the helplessness o r r ecklessnes s of the attendantthan the possibility of a cur e . The individual cases ofr ecovery by the r emoval o f clots, bones, o r tumor s, ar e

gr eat and comfor t ing r esults,but i f epilepsy and i ts r ela

t ions ar e ever to disappear , i t i s not the kn i fe of the

sur geon but the appar atus of human for esight and justicethat will accompli sh it . Most of the causes of epilepsyar e p r eventable . To that class belongs syphili s and

alcoholism in var ious gener ations, r achitis,tube r culos is

and scr ofula, many cas es of encephalo-meningitis, and

most cases of otitis . A question is attr ibuted to a r oyallayman, I f pr eventable

,why ar e they not pr evented ?

I f ther e i s a p r oof of what Socr ates and Kant said,namely, that statesmanship cannot thr ive without the

phys ician, it i s contained in the necess ities of epilepsy.

P r evention, p r eventives and hygienic, medicinal, and

sur gical aids have to be invoked,unfor tunately with

slim r esults so far .

The influence of her editary syphil is on the diseasesof the ner vous system has been studi ed these 2 0 year s,both by neur ologists and pediatr ists . Its r esults ar e eitherdi r ect—that means char acter is ti cally syphil itic—o r metasyphilitic—that means mer ely degener ative . Hoffmanncur ed a case of syphil itic epilepsy in a gi r l of nine year sin 1 7 1 2 . Plenk descr ibes convuls ions and other ner voussymptoms depending on her editary syphil is, and NilRosen de Rosenstein descr ibes the same in 1 7 8 1 . The

liter atur e of the later par t of the eighteenth,and of the

fi r st hal f of the nineteenth century i s silent on that sub

j cet, though the cases of affections of the ner vous sy stemdepending o n her editary syphili s ar e very fr equent

(thi r teen per cent . of all the cases,according to Rumpf

die Syph. E rk . d . Ner vensystems , Jull ien (Ar ch.

Gen .,1 90 1 ) r epor ts 260 p r egnancies in 4 3 syphiliti c

matr imonies . Of the childr en,

1 62,r emained alive .

Half of them had convuls ions o r symptoms of men ingiti s .According to Nonne (Die Syph. d. Ner vens .

,1 90 2 )

her editary syphil is differ s fr om the acquir ed form in

8 6

HISTORY OF PEDIATRICS

thi s—that sever al par ts of the ner vous system ar e affectedsimultaneously; and that ar ter iti s, meningitis, gum

mata, and s imple scler os is occur in combination . Simplecer ebr al meningiti s and apoplexies ar e very r ar e .Encephaliti s i s mor e fr equent . P r obably sp inal dis

eases ar e mor e fr equent,according to Gilles de la Tou

r ette,Gasne

,Sachs, and other s . Tabes dor salis i s not

fr equent, but may r ather depend o n an atavistic syphil itic

basi s ; fo r altogether the ner ve syphili s of the secondpr evious gener ation as a cause o f disease in the young i snot very r ar e. (E . Finger

, W. klin . Woch.,1 3

,

What we call neur oses ar e not infr equent in infants andchildr en . Neuralgias ar e not so common as in the adult,but would be mor e fr equently found i f sought fo r . Evenad ipositas dolor osa has been obser ved in chi ldhood.

Hyster ia i s by no means r ar e,and i ts mono-symptomatic

char acter,so peculiar to ear ly age, adds to its nosological

impor tance . Its ear ly appear ance is of gr ave impor t . Itsoften her editary or igin makes it a ser ious pr oblem,

under -alimentation o r ill—nut r ition, r achit is and scr ofula,fr equently connected with and under lying it, may makeit danger ous and a fit subj ect fo r the study of educator s,psychologists, judges , and all thos e whose dir ect office itis to study social and socialis tic p r oblems . Hyster ia i snot quite un known amongst males

,though the large

maj or ity ar e females .Some o f the vaso-motor and t r ophic disturbances ar e

less , other s mor e fr equent, in the youn g than in the

adult. Amongst 1 29 cases o f ak r opar aesthesia ther e i sonly one o f F r ankl Hochwar t in a gi r l of 1 2 year s, and

one of Cassi r er in a gir l o f 1 6 . Scler odermia i s met withmostly in matur e life, but the cases of Neumann at 1 3

days , and those of Cruse, Her xheimer , and of Haushalterand Spielmann, who obser ved two cases in o n e family,all o f them when the in fants _wer e only a few weeks o ld

,

pr ove that the same influences which ar e at work inadvanced age, namely, her editary disposition

, neur opathic fami ly influence, low gener al nut r i tion

,colds

,

tr auma, and so on, may play thei r réle i n infant li fe .No r ar e infant erythr omelalgias numer ous . Henoch

8 7

DR . JACOBI’S WORKS

saw one in a teething infant, Baginsky in a boy of 1 0 ,Heimann one in a gir l o f 1 3

,Gr aves one in a gir l of 1 6 ;

that means thr ee o r four cases below 1 3 o r 1 6 year s ofage, out of a number of 65 collected by Cass ir er inhis monograph. (Die Vasomotor i sch

-tr Ophischen Neu

r osen,Ber lin

,In half a century I have s een but

one that occur r ed in ear ly age, namely, in a boy of 1 2 ,

who got well with the loss o f two toes . On the otherhand

,the symmetr ical gangr ene of Raynaud and acute

cir cumscr ibed oedema of Milton and Quincke, 1 8 8 2 ,

tr eated of by Collins in 1 892 , ar e by no means r elativelyr ar e in infancy and childhood. Ther e ar e a few cases ofthe former that occur r ed in the newly-bor n . Two Ihave seen myself . Ther e ar e those which have beenobser ved at 6 months (F r i edel) 9 months (De F r ance) ,at 1 5 months (Bj er ing) , at 1 8 months (Dick) . In the

year 1 8 89 Mor gan collected 93 cases, 1 3 o f which occur r edfr om the second to the fifth

,1 1 between the fifth and

tenth,

and 1 5 between the tenth and twentieth year s .Amongst the 1 68 cases collected by Cas s ir er

, 20 occur r edunder the fi fth

, 8 between the fifth and tenth, and 2 5

between the tenth and twentieth year s of l ife . Likemost ner vous diseases, these cas es had either congenitalo r acquir ed causes, amongst which a gener al neur opathicconstitution

, and the her editary influence of alcohol,

chlor osis,

and anemia ar e consider ed p r ominent . Ofacute cir cumscr ibed oedema

, 2 8 cases ar e found belownine year s of age in Cas si r er

’s collection o f 1 60 cases, o ne

o f which at the age of one a nd a half months i s r epor tedby Cr ozer Gr iffith, one at thr ee months by Dinckelacker .

Again her editary in fluence is found power ful . Oslercould tr ace the di s eas e thr ough five gener ations .The connection o f pediatr ics with psychiatry i s ver V

intimate . Insane childr en ar e much mor e numer ousthan the statistics of lunatic asylums would appear top r ove, fo r ther e ar e

,fo r obvious r easons

, but few insanechildr en in gener al institutions . I t is only those caseswhich become absolutely unmanageable at home thatar e entrusted to o r for ced upon an asylum . The exampleof the F r ench, who mor e than 50 year s ago had a

8 8

HISTORY OF PEDIATRICS

divi s ion in the Bicetr e fo r mentally disturbed childr en,has seldom o r not at all been imitated. Thus it happensthat though not even a minor ity of the cases of idiocybecome known

,i ts stati stics i s mor e r eadi ly obtained than

that of dementia of ear ly li fe . Some of its physicalcauses o r accompaniments have been mentionedasphyxia with i ts consequences, oss ification and asymmet

r ical shape o f the cr anium,accidents dur ing infancy

and childhood, neur oses that may be the beginning o r

p r oximate causes of gr aver tr ouble . Infectious dis easesplay an impor tant par t in the etiology of intellectualdisorder s . Althaus collected 4 0 0 such cases . Theywer e mainly, influenza 1 1 3

,rheumatism 96, typhoid

fever 8 7, pneumonia 4 3 , var iola 4 1,cholera 1 9, scar latina

1 6, erys ipelas 1 1 . In most of the cases ther e wer epr edispos ing elements, such as her edity and pr eviousdiseases

,o r over -exer tion o f long dur at ion . The over

worked br ain s o f school childr en wer e complained of as

adjuvant causes of lunacy by Peter F r ank as ear ly as

1 8 0 4 . We ar e as badly o ff o r wor se,a hundr ed year s

later .

Ther e i s one ailment, however , that appear s to hur tchildr en less than it does adolescents o r adults, that i smastur bation . Ther e ar e those cases, for tunately few,

which depend on cer ebr al dis ease, and or iginal degencr acy, but in the lar ge maj or i ty of instances masturbatio n , fr equent though it be, has not in the very youngthe same per ils that ar e attended with i t later on whenthe differ entiation of sex has been completed and isr ecognized. Babies under a year , and chi ldren under 8

o r ten will outlive their unfor tunate habit,and do not

appear to suffer much fr om its influence . Whateveri s said to the contr ary i s the exagger ation of such as liketo r evel in hor r or s. The same exorbitant imaginationis exhibited in other statemen ts.

J' What Lombr oso and

his follower s have said of the faulty ar r angement o f the

teeth, pr ognathic skulls , r etracted nose,shor t and

attached lobes of the aur icle, as distinct symptoms of

mental degener acy, belongs to that class, and need notalways be taken as the pos itive signs of insane cr imi

89

DR . JACOBI ’S WORKS

nality. Ther e i s s o much poetical exagger ation and wordpainting in them that Lombr oso and also Kr afft-Ebingar e the pets of the p rur ient lay public . I n its midstther e must be many who ar e anxious to believe wi thLombr oso that br own hair and eyes, br achycephalicheads, and medium siz e of the body char acter i ze the

insane cr iminal,i f only fo r the pur pose o f scann ing the

hair and eyes and heads of their near fr i ends and theirmother -in-law ’s r elat ives .I t i s cer tainly not true that, as Lombr oso will have

it,childr en ar e cruel, lazy, lying, thievi sh, just as l ittle

as according to him all savages ar e like car nivor ousanimals

,and es sentially cr iminal, while other s ar e con

vinced that by natur e they ar e amiable,l ike Uncas, and

vir tuous like Chingaco ok, and have been r ender ed sav

age only by the str enuousness of conquer ing immigr ants .No r i s i t true that the idiot br ain i s mer ely ar r ested at a

stage s imilar to anthr opoid, o r even saur ian development

,fo r i t i s les s ar r est o f development than the influ

ence of embryonal o r foetal disease, bes ide amnioticanomalies that cause the ir r egular ities of the encephalon .

Amongst the wor st causes o f idiocy i s cr etinism, boththe endemic

,and the spor adic . Every cr etin is an idiot ,

not v ice ver sa. The fir st could be p r even ted by Stateinter fer ence which would empty the str icken valleys ;the latter depends on thyr oidism,

with o r without a

shor tening of the base of the skull,

and i s par tiallycurable. The idioti sm o f cr etinism causes a fair lyuniform set o f symptoms ; that whi ch depends on othercauses exhibits var ieti es , though not so many as imbecility, which, too, should not be taken to be the r esult ofa s ingle cause . Osseous and car tilaginous anomaliesabout the nose ar e pointed out by William Hill, chr onicpharyngiti s and nasal polypi by Heller , enlar ged tons ilsby Kafemann in one-thir d of the cases, some pharyn gealo r nasal anomaly in four -fifths by Schmid-Monnard.

Adenoids ar e fr equently found as compl ications . Operations to meet all these anomalies have been per formedwith impr ovement o f the mental condit ion in some

,of

the phys ical in many mor e, mainly when the anomalies

90

HISTORY OF PEDIATRICS

wer e complications only. But after all we should be

war e o f the belief in mi r acles and in infallible cur es .Mainly the tons ils have been puffed up to be the maincauses of many human tr oubles and thei r r emoval a

panacea. According to a moder n wr iter it pr events tuber culo sis, but the pr ophet is a little too bold, fo r he

adds that with the exception of himself ther e ar e veryfew able to accomplish it . Defective o r dis eased br ainsar e fr equent in most condit ions . The former class allowseven imbeciles to excel in some ways . In that class maybe found calculating exper ts, chess-player s, o r mechanicaldr aughtsmen .

Imbecile per sons may be taught sufficiently to pr epar efo r the simple duties of li fe . Ther e ar e

,however , many

tr ansitions between the complete imbecile, the mild im

beeile, and the mer ely slow and dull. That i s why the

condition i s fr equently no t app r eciated. In his school theimbecile child i s s lightly o r consider ably behind his class,and the laughing-stock of the r est: As he i s intellectuallyslow, so he i s mor ally per ver se o r i s made to become so .

He knows enough to l ie and libel, to run away fr om school,and fr om truant to become a vagr ant . I t is true it willnot do to declar e the imbecile per se identical with the

typical cr iminal, but as many of them ar e illegitimate,o r

of defective o r alcoholic par ents,o r maltr eated at home,

o r di seased and deformed,they get, by neces sity, into con

fl iet with or der and the law. Thompson found 2 1 8 congenital imbeciles among 94 3 penitentiary inmates . Knecht

,

4 1 amongst When the imbecile i s once a pr isonerhis condition i s not l iable to be noticed on account of thestupefying monotony of his existence .What i s mor e to be piti ed

,the fate of the immatur e

o r imbecile half-gr own child that natur ally acts differently fr om the normal, o r the low condition o f the Statewhich instead of p r ocur ing separate

—schools fo r the hal f

witted, o r asylums, has nothing to offer but contumelyand pr ison walls

,and incr eas ing mor al deter ior ation ?

Ther e is the stone instead of the br ead o f the gospel .Moder n society has commenced

,however

,to mend o ld

injustices .’

Every civilized country admits ir r esponsibility91

DR. JACOBI ’S WORKS

befor e rthe law below a cer tain age, and gr adually the

mental condition of the cr iminal i s taken into cons ider ation and made the subj ect of study. But still thousandsof chi ldr en and adolescents ar e declar ed c r iminal s befor ebeing matur ed. The establishment of childr en

’

s cour ts i sone of the things

,imper fect though they be, that make

us s ee the pr omised land fr om afar . When cr ime will beconsider ed an anomaly, either congenital o r acquir ed inchildhood, a dis ease ; when society will ceas e to insis t uponcommitting a brutality to avenge a brutality; when selfp r otection will take the place of r evenge, and asylumsthat o f State pr i sons—then we shall be a human

,because

humane, society.

CON CLUSIONS

Pedology is the science of the young . The young ar e

the futur e maker s and owner s of the wor ld. Their physi cal, intellectual and mor al condition will decide whetherthe globe will be mor e Cossack o r mor e Republican, mor ecr iminal o r mor e r ighteous . Fo r their education and tr aining and capabilities, the physican ,

mainly the pediatr ist,as the r epr esentative of medical s cience and ar t

,should

become r esponsible . Medicine i s concer ned with the newindividual befor e he is bor n

,while he is being bor n, and

after . Her edity and the health of the p r egnant motherar e the phys ician

’ s concer n . The r egulation of labor laws,factory legislation, and the p r ohibition o f mar r iages ofepileptics , syphil itics, and cr iminals ar e some of his pr eventive measur es to secur e a p r omising p r ogeny. To himbelongs the watchful car e of the pr oduction and distr ibu

tion of foods . He has to guard the s chool per iod fr omsanitary and - educational points of v i ew

,fo r hear t and

muscle and br ain ar e of equal value . I t i s in infancyand childhood, befor e the danger ous per iod of puber tysets in

,that the char acter i s formed, altruism inculcated

,

o r cr iminality fostered. I f ther e be in the commonwealthany man o r any class of men with gr eat poss ibilit ies and

r esponsibilities it i s the phys ician . I t i s not enough,how

ever , to work at the individual beds ide and in a hospital .In the near o r dim futur e, the pediatr ist, the physician,

92

https://www.forgottenbooks.com/join

THE H I STORY OF CEREBRO-SPINAL MENIN

GITIS IN AMER ICA

NOTH ING i s mor e difficult to ascer tain than the age ofcer tain di s eases

,which by r eason of their distr ibution

and mor tal ity have attained hi stor ical s ignificance . The

most notable in the category i s syphilis . The number ofpeople who believe it to have sprung fr om nihil ity at the

close of the fifteenth century, o r who cons ider it an ar ticleof impor tation by the immor al Indians fr om Indianolaint o bliss ful, innocent Spain, has not diminished. Mostl ikely cer ebr o-spinal meningiti s will far e the same fate .What we call cer ebr o—spinal meningiti s to-day was fir st

descr ibed, with cer tainty, in 1 8 0 5 . Ler sch cites , in a

shor t note, also the year 1 8 0 3 (Vo lksseuchen , but

gives no data of the l iter atur e . In all p r obability thisdi sease existed

,either spor adically o r endemically, at an

ear lier per iod. Mer edith Clymer (Epidemic Cer ebr a

Spinal Disease, Phil . 1 8 72 ) gave expr ess ion to his pr esumption that occas ional cases with a s imilar symptomcomplex had been obser ved in the United States towardthe end o f the eighteenth century.

The malignant fever which Daniel Senner t descr ibes in1 6 1 1 i s mo st likely one and the same disease, and laterwas char acter iz ed as spotted fever , cer ebr o- spinal typhus,cer ebr o-spinal fever and cer ebr o-spinal meningitis . Ac

cording to Webber (Boylston P r i z e E s say in Bo sto n Med.

and Surg. J our . fr om the thir teenth century ou

ward, symptoms descr iptive o f cer ebr o-spinal meningitishave been enumer ated. The accounts have not always beenaccur ate, the pr incipal symptoms have been var iouslydepicted ; i t i s quite likely that our dis ease and exanthe

matous typhus wer e often mistaken fo r one another,l ike

syphilis , which befor e the end of the fifteenth century wasoften

,i f not always, confounded with measles and var iola

95

DR . JACOBI’

S WORKS

(J . K . P r oksch, Beitrage zur Geschichte der Syphilis,

Sir John P r ingle,in 1 7 52 , wr ote, in his obser va

tions on di seases of the army, about a pr i son and hospitalfever in which pus was found on the br ain, and Bascome

in his history of epidemic pestilences, London, 1 8 5 1 , r e

fer s to a local epidemic, in Ro ettingen , Bavar ia, in 1 8 0 2 ,

in which youn g, str ong males , with pain ful stiffness ofthe muscles of the n eck

,died within twenty- four hour s .

The best history of cer ebr o-spinal meningiti s o f all

countr i es i s to be found in the thi rd volume of H isto r ischGeographische Patho l0gie by August Hi r sch, 1 8 8 6 . The

Epidemic Cer ebr o-Spinal Meningiti s and its r elation toother forms of meningitis—a r epor t of the State Boar dof Health of Massachusetts, Boston, 1 898 , by W . T .

Counci lman ,F . B . Mallory and J . H . Wr ight, offer s

valuable contr ibutions . That par t of the s econd volumeof Puschmann

’

s Geschichte der Medicin ,edited by Victor

Fo ssel, i s quite super ficial . The Subj ect Catalogue and

Index Medicus contain natur ally everything desir able, and

much that i s not so .

The gr eat knowledge r evealed in our per iodical l iter atur e i s collected with the aid of a secr etary fr om the abovenamed sour ces , fr om Vi r chow-Gur lt

’

s Jahr esber icht and

other encyclopaediac. Without quoting these works toomuch I will give you a shor t sur vey of the o ccur r ence ofcer ebr o- spinal meningiti s in the United States, which mor eoften than any other country has been invaded by thi s

plague . Hir sch divides its history into four per iods 1 8 0 51 8 3 7 ; 1 8 3 7- 1 8 50 ; 1 8 5 4

- 1 8 75 ; 1 8 76 up to the time that hisbook was published—we may say, with inter ruptions, unti lto-day. In the fi r st, third and four th per iods the UnitedStates was s ever ely affected, wher eas dur ing the secondper iod F r ance bor e the brunt o f the diseas e . I t i s to behoped that the per iod we have been going thr ough s incelast year i s not the p r ecur sor of a fi fth per iod. In 1 8 0 6the dis ease was epidemic in New Hampshir e

, Massachu

setts, Connecticut, New Jer sey and Vermont ; in 1 8 0 7 inCanada ; in 1 8 0 8 in Vir ginia, Kentucky and Ohio ; 1 8 09 inNew Yor k and Pennsylvania ; 1 8 1 4 in Maine ; 1 8 1 4 -1 8 1 6in New England in gener al . The epidemic then gr adu

96

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

Ohio r iver and Wor cester , Massachusetts . In 1 8 50 ther ewas

‘

a sev er e epidemic'

in the negr o quar ter s o f New Or

leans,as we find it among populations who l ive in wr etched

hovels with insufficient nour ishment .F r om 1 8 50 - 1 8 56 the United States wer e fr ee fr om the

dis eas e. In 1 8 56 and 1 8 5 7 we find i t in Salisbury, Nor thCar olina (Dickson in Trans. A. M. in the same yeari t p r evailed in the wester n par t of New York, especiallyin Onondaga

,Chemung and Madi son (Thomas in Tr ans.

Med. So . St. of N . Dur ing the war , 1 8 6 1—1 8 64 , thedisease was far r eaching . In the winter of 1 86 1 - 1 862 itexisted in the Army of the Potomac near Washington ;likewise in a negr o colony quar ter ed by the Confeder atesin Memphi s . In 1 8 62 and 1 86 3 it appear ed in the campar ound New Bern

,N . C .

,with the same clinical and -ana

tomical manifestations which had been obser ved in 1 8 1 0 ;

and also in ‘M'

assachusetts in 1 8 64 and 1 865 . Mas sachusetts then r emained fr ee fr om the disease until it appear ed in Boston in 1 8 72 and 1 8 7 3 (J . B . Upham in R e

po r t o f the State Bo ard 0 7" Massachusetts, I t had

appear ed in Philadelphia in 1 8 63 . Thi s epidemic was descr ibed in 1 8 67 by Alfr ed Stille in a monogr aph which hasretained i ts value

,entitled Epidemic Meningitis .” The

same author published‘

an ar ticle in 1 8 8 5 in P epper’

s System o f Medicine

,which i s still very instructive .

Dur ing the epidemic which pr evailed at Philadelphiain 1 8 63 -1 8 66, the whole city was sever ely affected ; alsoIndiana and Iowa ; and likewise the Confeder ate tr oopsin Nor folk, Va .

,whose camps wer e pitched in swampy

r egions,and those who wer e in hospitals . At thi s t ime the

di sease appear ed fo r the fir st time at the military schoolin ‘ Newpor t, R . I . Mobile

,Ala.

,Illinois

,New Jer sey,

Vermont Z'

alo ng the Connecticut r iver, Connecticut and

Ohio wer e sever ely affected. Ther e wer e bad epidemicsin two hospitals and in the or phan asylum at Washingto n .

F r om 1 8 60 -1 8 74 we find epidemics over the enti r e lengthof the land, especially dur ing the winter and Spr ing .

After 1 8 76 the diseas e showed itself spor adically at far

separ ated points . In 1 893 the disease once mor e becameepidemic in New York (H . Berg in Ar chiv. Ped. May,

98

HISTORY OF CEREBRO-SPINAL MENINGITIS

Thi s author emphas izes the non-contagious natur eof the disease . I t also appear ed in the Layaco n ing Val

ley in Maryland in 1 893 . S imon Flexn er and Lewellys

J . Barker in the Amer . J our . o f the Med. Sc. (Februaryand Mar ch

,1 894 ) descr i be thi s epidemic fr om a pr ae

tical and str ictly scien tific standpoint . Appended to thisar ticle ther e i s a two—page bibliogr aphy of the most valuable essays ou thi s subj ect . In some of thei r cases thepneumococcus was found.

Dur ing these decades the disease did not die out. Occasio nally fo r long per iods the mor tality was low ; thensuddenly i t would r ise . Fo r instance, dur ing many year sonly isolated cases developed in Mon tr eal ; so also in theBoston City Hospital, fr om 1 8 8 0 to 1 896, only 3 9 casesdi ed. But dur ing the fir s t month o f the epidemic of 1 897ther e wer e 4 2 fatal cases . Stille r epor ts but few casesin Philadelphia fr om 1 8 64 -1 865 , and fr om 1 8 72 - 1 8 7 3 .

Pepper car r ies the r epor t along until 1 892 and Abbottbr ings it up to date . How r apidly the mor tality changeswill be seen fr om the following figur es : Philadelphia hadin 1 8 8 4

,1 2 4 deaths ; in 1 893 , 2 3 deaths ; in the succeeding

year s s er iatim,2 2 , 3 5 , 1 8 , 1 7 , 7 , 1 0 ; 2 4 in 1 898 , and in

the fir st 4 months of 1 899, 89 deaths .In New Yor k the dis ease was endemic in 1 867—1 868(B r own, Med R eco rd, Ap r il, Somewhat later ,Ohio and Indiana wer e affected ; between 1 8 69 and 1 8 70

we find the diseas e r eappear ing in Alabama, Pennsylvania,and Vir ginia

,in 1 8 7 1 in Minnesota and Pennsylvania , in

1 8 72 in New Jer sey, the cities of New Yor k and B r ooklyn,Onondaga county, also Illinois

,South Car olina and par t

o f Geor gia. Concer ning Augusta, Ga .,I was kept ln

formed at that time by Dr . Ford. The cas es wer e notnumer ous but fulminatin g, and occur r ed almost exclus ivelyamong the most miser able clas s of negr oes . In 1 8 7 3

Mas sachusetts suffer ed sever elyh ln diana and Michigan toa less extent .Childr en wer e chiefly affected dur ing 1 8 06 in Massa

chusetts, 1 8 4 7 in Tennessee, 1 8 57 in E lmir a, 1 8 63 inPhiladelphia

,1 8 64 in Illinois, 1 8 70 in Vi r ginia. Adults

between 20 and 3 0 year s wer e chi efly affected in 1 8 1 1 in

99

DR . JACOBI’

S WORKS

Milford,Conn .

,in 1 8 4 8 in Montgomery, Ala.

,and in

1 8 5 7 in Br o okfield, N . Y . Out of 2909 cases r epor tedfr om Massachusetts 4 0 5 occur r ed in the fir st nine monthso f 1 897 . Of these ther e wer e 3 1 6 under o ne year , 1 4 6

between one and two year s, 26 per cent .I her ewith p r esent a li st compiled by the New York

Board of Health. In cons ider ing it, the incr ease of pepulation fr om 1 8 66 to 190 4 must be taken into account .

O O O O O O O O O O O O O O

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

O O O O O O O O O O O O O O

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

O O O O O O O O O O O O O O

0 0 0 0 0 0 0 0 0 0 0 0 0 0

O O O O O O O O O O O O O O

O O O O O O O O O O O O O O

O O O O O O O O O O O O O O

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

O O O O O O O O O O O O O O

O O O O O O O O O O O O O O

0 0 0 0 0 0 0 0 0 0 0 0 0 0

O O O O O O O O O O O O O O

O O O O O O O O O O O O O O

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

O O O O O O O O O O O O O O

https://www.forgottenbooks.com/join

DR. JACOBI‘S WORKS

of less than on e mlllio n ) than the 1 0 8 3 deaths of the year1 90 4 with a population of 24 mi llion .

Fo r compar ison I pr esent to you the list of deaths ofthe past thr ee months of 1 90 5 , again fr om the officialfigur es . In 190 5 ther e di ed in Manhattan, not in Gr eaterNew Yor k :

Cer . Sp. Men . Mening. Tub.Men .

94 1 44 40

1 3 9 1 79 3 6

295 259 3 7

You will notice that the alleged incr ease of deaths dueto s imple meningiti s has been doubled in two months . Onecannot but surmise that many of these cases may havebeen those of cer ebr o-spinal meningitis . On the otherhand we must not for get that dur ing an epidemic manydeaths ar e wr ongly attr ibuted to the dis ease then pr evalent .The above figur es ar e incr eased fr om 1 0 to 1 2 per cent.by including all the cases occur r ing in Gr eater New Yor k.

The following list p r oves thi s clear ly:

G reater New Yo rk. Manhattan .

M. F . To tal . M . .F. To tal .201 1 56 3 5 7 1 3 1 1 1 4 245

223 1 7 1 3 94 1 50 1 1 1 26 1

1 74 1 3 2 3 06 1 03 75 1 78

1 52 1 1 5 267 92 8 1 1 73

1 45 120 265 96 78 1 74

1 51 1 20 27 1 1 00 73 1 73

759 642 53 2 4 7 1

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

1 0 2

HI STORY OF CEREBRO-SPINAL MENINGITI S

We find the lar gest mor tality fr om cer ebr o-spinal menin

gitis in Manhattan in the 4 th, 5th, 6th, 7th, 8 th and 1 4 th

wards . These ar e the wards in which we meet, bes idesother social atr ocities, the lar gest number of dar k r ooms,of which ther e wer e two year s ago in Manhattanin B r ooklyn in Queens and in Richmond4 52 .

Of the cases under 1 5 year s of age ther e died of cer ebr ospinal meningiti s in New York :

1 895

1 896

1897

1 898

1 899

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

O O O O O O O O O O O O O O O O O O O O

The pr opor tion of childr en that died compar ed with the

number of deaths in Manhattan is accordingly as 8 0 5 :

1 0 0 3 ; and fo r Gr eater New Yor k as That i sto say that in the bor oughs outs ide o f Manhattan the mo r

tality among adults was higher than among childr en ,Everywher e, however , the lar ge maj or i ty of cases ar e

childr en .

Distr ibutio n . The di sease occur s in the temper ateand '

sub-tr opical zones and i s ther efor e adapted to the

United States . I t is found most fr equently in the winterand Spr ing . .Of 8 5 epidemics occur r ing in No r th 'Amer ica,

ther e wer e 3 7 in the winter , 1 8 in the winter and spr ing;and

’

23 in ’ the spr ing . Low temper atur es and the p r esenceof catar rhal di s ease ar e mentioned. However

,we find the

di sease even in mild winter s , e. i n Connecticut and1 8 66 in Kentucky. Many

"

similar ones ar e r efer r ed to byHir sch (pages 3 98 and On the other . hand, . dur

ing some very cold winter s we find only o n e city o r r egio n,One

‘

class o f people, o r o n e r egiment of soldier s,affected,

According to F r othingham in 1 8 6 1 - 1 862 one r egiment that

1 0 3

In G r eater New Yo rk.

3 0 1

3 26

25 1

221

22 1

225

1 056

DR. JACOBI ’S WORKS

was par ticular ly well quar ter ed was afllicted with meningitis, while other r egiments suffer ed fr om malar ia.

The epidemic character of the di sease has been too fr equently obser ved to be questioned. Occas ionally i t appear s spor adically. About 3 0 year s ago ther e wer e twopar ts o f New Yor k wher e the dis ease was very pr evalent,the neighbo rhood of Chatham Squar e

,James and Oliver

str eets,

and the neighborhood south o f West Houstonstr eet and west of McDougall str eet . At that time I saw

two fatal cases within one week in a r oom in Char ltonstr eet . The one case was a baby of 6 months that di ed in 8hour s

,the other a child of 2 year s that di ed in 20 hour s .

The autopsy in one cas e showed the usually p r evalent fibr inous exudate. Differ ent author s have differ ent v i ews concerning the sp r ead of the disease, especially dir ect contagion . Vieusseux

,who descr ibed the Geneva epidemic of

1 8 0 5 , dclar ed the dis ease to be non-contagious . He gave ashis r eason fo r this belief the fact that when two casesoccur r ed in one family, they developed at the same time .Nor th states in his book of 1 8 1 1 that tr aveler s who camefr om an immune place to an infected one contr acted the

di s ease . He attr ibuted it either to contagion o r to localinfluences . According to Hi r sch, in the fi r st lar ge epidemicin F r anken the di sease spr ead in a r egular cour se fr omnor theast to southwest . Love r epor ts that in 1 8 4 7 onlyone r egiment in New O r leans was affected. One F r enchr egiment

,in which meningiti s was p r evalent in 1 8 4 0 , was

tr ans fer r ed to Algier s . After a shor t time natives alsower e afflicted, the only time that the disease was ever ob

ser ved in Nor th Afr i ca. Dur ing our war meningiti s developed in public institutions after an in fected r egimenthad been quar ter ed in the city. Nowlin in the J our . o fthe Am. Med. Asso c ., 1 891 , r epor ts five cases in Shelby~

ville, Tenn ., of which two developed in one house . Such

occur r ences ar e not i solated. Hence it i s not of much moment when occas ionally an obser ver

, as fo r instance H .

Berg. (Ar ch. Pediatr ics, r epor ts that he never oh

ser ved two cases in one house . I have had no per sonalexper ience of contagion in any of my hosp ital s er vices .However , last week a nur se at the Har lem Hospital, who

1 04

https://www.forgottenbooks.com/join

DR. JACOBI ‘S WORKS

was a l ittle garden in fr ont of each house . Evidently theteacher and the childr en infected the entir e subur b withtheir cultur e. Ther e, in all likelihood

,meningiti s

,i f at

all,will develop equally among the white and color ed peo

ple . In another subur b I saw no gardens, no paint o n the

miserable r eeking dwellings,and no clean linen on the

line . Her e we shall find meningiti s in the futur e .

1 06

CEREBRO-SPINAL MENINGITIS—SYMPTOMATOLOGY AND TREATMENT

SYMPTOMATOLOGYIT i s not wor th the while thi s evening to go deeply into

the symptomatology of the di seas e in gener al . I am notdiligent enough to go thr ough all the

'

moder n j our nalli teratur e and fr om six bo oks compile a new one n o r tocompile a new paper fr om manuals . You know fr om ex

per ien ce how o ne lear ns to di sdain thi s kind o f fame . But

I will,in a few r emarks, r elate what dur ing the last year

and a hal f appear ed sur pr i sing to me and was at var iancewith ear li er obser vations .The usual symptoms wer e headache, tor ti collis, vomiting

in most cases one o r mor e times,o ccasionally convuls ions

and coma, sometimes ear ly but most often towards the end.

Ker ni g ’s s ign was p r esent in all but two cases—in a pa

tient of 2 5 year s and one of 4 year s .Spots wer e not always p r esent ear ly, but at some time

o r another dur ing the cour se o f the di sease ; in a smallnumber of cases str ictly i schemi c but becoming hyper emicafter many minutes and r emaining fo r sever al minuteslonger .

In some cases the phenomena wer e unilater al at fi r stand only gr adually showed themselves 1 0 11 both sides ofthe body. A child of 3 year s had a r ight total hemiplegiathat was distinct fo r weeks

,besides gener al symptoms .

The pupils wer e almost always alike : in the beginningof the dis eases they wer e con tracted as a rul e, and lateron, as coma incr eased, dilated ; in every case they r e

sponded but slowly to li ght and in r ar e instances not at all.What I have just said i s in dir ect contr adi ction to

my obser vations dur ing the epidemic thi r ty year s ago .

Ther e I almost without excepti on found the pupils str ongly1 0 7

DR . JACOBI ’S WORKS

di lated fr om the very begin ning of the disease, with nor esponse

'

o r very little to the influence of li ght ; and thi ssymptom was consider ed as pathogn o n omic fo r the di s ease,and was ascr i bed by me to i r r itation of the cer vi cal ganglion contr olli ng the dilator pupillae. I t i s wor th the

while to exper i ence s ever al epidemi cs of the same infectiousdi sease.I had a s imilar exper ience with the spots . In every

ear li er epidemic they appear ed on the fi r st day with suchr egular i ty that I believed also thi s symptom could be us edfo r differ entiation fr om o ther forms of meningiti s . And

thi s I taught up to a few year s ago , but have sincelear ned better . Ther e ar e very many ways in whi ch toer r .

Among 5 8 cases ther e wer e petechiae in 8 , erythema

with petechiae in 1,papulous eruption in 1

,gener al hy

per emia with pustules in 1, uniform hyper emia i n 1 , and

mottled hyper emia i n 1 case,her pes in a small pr opor ti on

o f the cases,and not at a definite per i od of the disease ;

i f it indicates an attack,i t must be infer r ed that i ts ap

pear ance was belated fo r any length of time up to the end

of the third week .

Appar ently dur ing the p r esent epidemic the skin i s notimplicated as i t was in former epidemics . Such differences ar e noted i n the liter atur e of var ious year s and

differ ent localities . Vieusseux i n his r epor t on the Genevaepidemic in 1 8 0 5 does not mention ski n les ions at all

,

whi le Nor th r efer s to thei r fr equent occur r ence in the

epidemic of 1 8 1 1 . The name “ spotted fever datesfr om that time

,and Upham speaks of the poss ibility o f

confounding the di s ease with typhus .‘

Gener al hyper esthesia was very r ar e,which i s decidedly

at var iance with the gener al behavior of former epidemics .Opisthotonos in a high degr ee was r ar ely pr onounced,

tor ticolli s always ; moder ate r otation of the head was poss ible in many cases, and in a few was even easy and painles s .Nasal catar rh was common last year ( 1 90 4 ) but r ar e

this year

0 8

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

bone,make it appear r eally wonder ful that Weichselbaum

’sdiplococcus

,which was found al so in the conjunctiva by

Schwabach in 1 891 , and in otiti s by Scher er (the samediplococcus that

.

was found by Heubner in 1 896 i n the

subar achnoid fluid) , does not mor e often r each the inter iorof the - centr al ner vous system .

In those cases wher e the di sease is confined to the ner vecentr es, di r ect infection fr om per son to per son must bevery difficult .Fr om an anatomical point of v i ew all cases of menin

giti s ar e

.

cer ebr o-spinal, that i s, the br ain and spinal cordar e affected simultaneously. The ar achnoid and pia

should not be consider ed separ ately. The former constitutes the ser ous sur face connected with the dur a and

one s ide of the subdur al space . The pia r epr esents a

loose connective ti s sue containing lymph spaces and bloodvessels . As the chor oid plexus this total membr ane extends into the ventr icles . In the spinal cord the ser ousar achnoid and the pia ar e separ ated somewhat and form a

r eal subdur al space, but ar e connected by numer ous fibr ous

tr abeculae .I f in meningiti s the spinal cord i s affected mor e pr o

foundly than the br ain,"

and especially i f the pr esence ofthe meningococcus in tr acellular is i s consider ed of etio logi

cal impor tance, we ar e i n the habit of r efer r ing to it ascer ebr o—spinal inflammation . In its epidemi c appear ancethe membr anes of the spinal cor d ar e affected mor e decidedly than at other times

,but the inflammation pr ogr esses

along the cour se of the ner ves and into the substance ofthe centr al or gans . Changes in the tunica intima do notoccur

,however

,in cer ebr o-spinal meningitis . In contr a

di stinction to thi s,in tuber culous meningitis tuber culous

deposits occur along the cour s e of the vessel s and in thefibr in o -purulent exudate . T rue

,the staphylococcus aur eus,

the str eptococcus and the diplococcus lanceolatus pr oduceepidemic cer ebr o-spinal meningitis , but they can be differentiated by thei r behavior in other ti ssues . Finally, thegr eater o r lesser extent, depth and copiousnes s of the exudate

,and the suddenness o r slowness of the intoxication,

1 1 0

CEREBRO-SPINAL MENINGITIS

afford the best explanation of the var iability of the symptomato logy.

TREATMENT

P r eventive measur es cannot positively p r ove to be ef

fective, with the exception possibly as immuniz ing dosesof an antitoxin . Inasmuch as in cer ebr o-spinal meningitisthe invasion pr obably occur s only thr ough the mucousmembr anes

,the o ld rule holds whi ch I have r ecommended

s ince for ty year s in connection with diphther ia,namely:

to keep the nose and thr oat healthy. I cannot under standwhy a moder n autho r r ecommends the par ticular ly mildlyantiseptic bor ic acid as a gener al p r ophylactic .Ther e can scar cely be anything less consoling than a

r esumé of the var ious tr eatments that have been pr oposed.

They seem to have had no influence, positively les s thanthe char acter o f the epidemics

,the mor tality having r anged

fr om 8 0 per cent . to 90 per cent . In my own exper i ence,which extends over sever al epidemics

,the death-r ate has

been fr om 3 0 per cent . to 70 per cent. A summary ofvar ious methods of tr eatment i s given in a paper r eadby Stockton two months ago befor e the State MedicalSociety and s ince publi shed in the Mar ch numbe r of theAlbany Medical Annals. What I have advi sed dur ingfour dozen year s can be found in my Ther apeutics .Let me br i efly r elate what I did myself and what I oh

ser ved. The main thing in every case, whether sever e o r

mild,i s i solation

,r est and moder ate darkness . I deem it

well to keep the head r ai sed, r ather by r ais ing the head end

of the bed than by the use of pillows only. It is essential to give sufficient food

,as the di sease may last fo r

weeks and months and death not seldom sets in fr om in

an itio n o r under symptoms of star vation . Ther efor e everyr emission of temper atur e should be uti li z ed fo r feeding .

I f vomiting be fr equent,small

,oft-r epeated meals must be

given . Such a meal i s occasio nally r etained if 1 o r 2

dr ops of Magendi e ’s solution o r a Q-mg. gr ain ) tabletof mor phine have been put into the mouth a few minutesbefor e, as far backwar d as possible . Once in a whi lefeeding thr ough the stomach tube becomes neces sary, and

1 1 1

DR . JACOBI’

S WORKS

I have it done thr ee o r four times dai ly. Rectal alimen

tatio n i s seldom success ful .Rest at night

,and even also by day as far as pr ae

ticable,should he insi sted upon . B r omides have p r oved

of l ittle avai l,hyoscine useless ; chlor al by enema o n e

'

o r

mor e times a day in doses of to gm . to 531;gr ain ) has sometimes had the desi r ed effect ; the best r e

sults wer e obtained with the opiates—mor phine and mostoften codeine—in not too small doses.

A very up-to -date city colleague claims to have obtainedmar velous r esults with the continued administration o f lar gedoses of mor phine. We will pr obably at an ear ly dater ead an inter view in some paper s " The matter i s ofno fur ther value .The head should be cover ed with an i ce-cap, and i f

poss ible a small bag should also be put at the back ofthe neck

,but the latter application i s difficult and at times

impossible .Occas ionally I applied leeches to the nape of the neck

and the mastoid p r ocesses . Cupping I did not do,n o r

have I r esor ted to bleeding since twenty year s . A pur gative should be given in the beginning of the tr eatment,p r efer ably calomel . What i s ordinar i ly a lar ge dose maypr ove insuffici ent ; i t i s not r ar e to meet with a chi ld 3 o r

4 year s o ld who has taken as much as gm. (7% gr ains )of calomel in hal f a day, without the des ir ed pur gative effect o r any other par ti cular r esul t. Vinegar and waterenemas may assi st the action . Saline pur gatives ar e indicated, but i t i s r ar ely easy to give them . Baths ar e useful,but difficult to employ, because the patients ar e obdur ateand suffer consider ably dur ing the manipulation . Hotbaths I scar cely ever gave . Sponging with alcohol and

water should be pr acticed fo r well-known r easons and hassome effect. Should i t no t have sufficient influence uponhigh temper atur e, small doses of phenacetine may be ad

minister ed, pr efer ably combined with a small quantity o fcaffeine . Antipyr ine I have used in thi s disease but little ;dur ing the many year s that I have known thi s r emedy ithas s eemed to me to fail to exer t its usual action in br aintr ouble.

£ 1 2

https://www.forgottenbooks.com/join

DR. JACOBI’

S WORKS

dr awn o ff o r been able to get mor e than 3 0 cc . In thesecases I have occasionally seen a lessening of the comabut no effect upon the moder ate di lation of the pupils . 1

am of the opin ion that lumbar punctur e i s indi cated inmany cases, whi le I have never seen it have a harmfuleffect in any. I per formed i t in many cases thr ee o r

four times o r even o ftener,fo r our cases as a rule gave us

only too much time fo r its per formance . A chi ld of 4

year s, in" whom constant drainage was kept up, di ed.

Crede’ s ointment I used in two cases ; collar gol I em

ployed per r ectum in doses o f to gm. ( 1% to3

'

gr ains ) di s solved in 1 to 2 tablespoonfuls o f boi led water ,i n two

'

o ther cases fo r weeks, once o r twice dai ly, butwithout demonstr able benefit .In v i ew of the hopelessness of the tr eatment

,I made a

tr ial dur ing the last five o r s ix_weeks also of diphther ia

antitoxin . Dr .

‘Weitzfelder had f avor ed me with information on the subj ect be for e he published his exper i ences or

his views . I take it ‘

fo r gr anted that the method and itstheory as p r opounded by Dr . Wolf of Har tford ar e knownto you. Dr . Wolf di scover ed in his labor atory that ther ewas an antagonism between the antitoxin and cultur es o fthe meningococcus . The doses I employed subcutaneouslyo r

'

by intr amuscular inj ection wer e those r ecommended tome by Dr . Weitzfelder

,namely: 60 0 0 units fo r chi ldr en .

I gave fr om thr ee to six such doses in the cour se of as

many o r mor e days . My r esults wer e negative, as werealso those obtained by my colleagues in othe r divi sionsof Roosevelt Hospital . Quite a number of cases wer etr eated

,without appr eciable effect . I then p r oceeded i n

a manner outlined by Dr . F r ancis Huber , a colleague ofDr . Weitzfelder at the Gouver neur Hospita l and Physieian to the Beth I sr ael Hospital, who had an abundanceof mater ial at his di sposal . I - inj ected 1 50 0 units ofdiphther ia antitoxin into the spinal canal, after withdrawing the usual quantity of fluid.

I ‘ made‘

about 4 0 such inj ections, and the r esults confirmed the o ld story that not all labor atory obser vationscan jbe uti li z ed clinically. My best

‘

case,which will shor tly

be di schar ged as cur ed,

“

did not r eceive ’

any inj ection o r

1 1 4

CEREBRO-SPINAL MENINGITIS

any kind of tr eatment whatever . Sever al o f the inj ectedcases ar e doing very badly, some ar e in a fai r ly goodstate—just like the other cases, r eceiving differ ent tr eatment o r going without tr eatment . Unfor tunately, in in

ter nal medicine many, very many, cases ar e necessary totry out any par ticular r emedy o r method o f tr eatmentand ar r ive at a positive conclusion . Nothing i s‘ mor edeceiving than pr ematur e r epor t s in our j ournal l iteratur e, wr i tten with an enthusiastic desi r e to teachsomething new and useful, but r eally playing into the

hands o f whimsical doubt and even unjustified nihi l ism .

My hospital colleagues did just as I did. The Depar tment of Health placed at our di sposal countless thousandsof units .A few of our cases ar e br i efly descr ibed in the follow

mg:

Man of 2 8 , sudden attack, petechize, coma, high tem

per atur e. units inj ected subcutaneously on secondday, mor e 1 2 hour s later and 8 4 0 0 on third day,making units in all. Di ed on four th day. Sever allumbar punctur es had been made .Man of 1 8

,case s imilar to pr eceding. units hy

podermically on second and thi rd days . Di ed on thirdday.

Child of 8 year s, sever e case . 60 0 0 units subcutane

ously on second, s ixth and s eventh days , 1 50 0 intr aspinallyon eleventh and eighteenth days . Not quite dead as yet.

Chi ld 3 % year s o ld, mild case . Vomiting, deli r ium, to r

tico llis. 60 0 0 units on thir d, fifth seventh and tenth days,subcutaneously, 1 50 0 intr aspinally on twelfth day. Ontwenty—eighth day temper atur e still intermittent but gr adually falling, spinal fluid clear .

Man of 4 1,sever e attack

,only occas ional ly conscious .

20 0 0 units intr aspinally on fifth and seventh days . Di edon eighth day.

Child of 6 year s, sever e attack, unconsciousness, co nvul

sions . 1 50 0 units intr aspinally o n third day. On eighthday still high temper atur e, but conscious .Chi ld of 8 year s, sever e case, with chills, headache, de

lir ium,opisthotonos . 1 50 0 units intraspinally on four th

1 1 5

DR . JACOBI ’S WORKS

day, on seventh 1 5 0 0, on tenth 20 0 0 , on eighteenth 1 50 0

and on twenty-thi rd 60 0 units subcutaneously. On twentyfour th day br ain and spinal fluid clear . Temper atur eintermittent . Deaf.Chi ld of 7 year s, sudden attack

,chil ls

,headache

,vom

iting, tor ticolli s . On thir d and fifth days 1 5 0 0 units intr aspinally. On fi fteenth day temper atur e between 98

°

and

1 0 1°F.

, consciousness r etur ned,neck les s stiff, some

appetite.Chi ld o f 6 year s, mild attack

,convulsions . On four th

and thr ee following days 60 0 0 units each time subcutane

ously. On for ty-eighth day temper atur e still 1 0 1° to 1 0 2

°

F.,pati ent i r r i table and emaciated. Will pr obably die.

Child years o ld, sever e attack . On twelfth and

following five days 60 0 0 units each time . Very emaciated,hydr ocephalus . Will doubtles s die.

Chi ld of 1 2 year s . On sixth day 1 50 0 units intr aspinally, on seventh day subcutaneously. On fifteen th day pati ent conscious . Will r ecover .

Chi ld of 1 0 year s, mild attack . On fi fth day 1 50 0 unitsintr aspinally, on seventh day same . On four teenth daypati ent pr etty well, with acute inflammation of r ight knee .Of th 2 1 cases 9 have alr eady died.

Dur ing the year 1 90 4 we had 2 5 cases in adult s ,1 5 per cent . pr oving fatal ; 2 3 in childr en ,1 0 2 per cent . ending in death. F r om January 1 toApr i l 1

,1 90 5 , we admitted 3 6 cases . Of these 20 ar e no

longer in the hospital, 1 1 childr en and 5 adults being stillher e . Two of the 1 1 chi ldr en r eceived no antitoxin, 6 r e

ceived intr aspinal inj ections o f it (on the aver age 1 50 0

units,one o r mor e times ) , i n 3 i t was inj ected subcutane

ously. One case has r ecover ed,another i s near ly well but

deaf,a

‘

third near ly well but with acute inflammation ofone knee ; 1 case qui ckly r ecover ed without any tr eatment,1 seems to be impr oving but i s doubtful, 1 has impr oved butstill has intermittent pyr exia, 1 has had a r elapse , 2 ar e

exceedingly emaciated, 1 has hi gh temper atur es whi ch in

termit,however

,1 has a low temper atur e with all the

signs of chr onic inflammation . Of the 5 adults r emain ingalive

,1 i s per fectly well, 1 very doubtful, 2 on the way

1 1 6

https://www.forgottenbooks.com/join

DR. JACOBI ’S WORKS

a hall fi lled with cases of epidemic cer ebr o-spinal meningiti s .

POSTCRIPTUM,MAY

,1 909.

Nulla dies sine lin ea. That i s almost l iter ally true inr egard to medicine

,whose p r actical benefits ar eappr eciated

by everybody except the hypocr ites o r fanatics of the

antivivisection cr eed. The hopeles snes s of the v ictimsof the meningococcus i s no longer absolute o r even n ear lyabsolute . Simon Flexner

’

s name has suddenly, and de

ser vedly, become a household word in bo th hemispher es .I listened to him r ecently when he lectur ed at Baltimor ebefor e the Medical and Chi rur gical Faculty of Maryland,(May 1 4 th He was as modest and withal hopefulas always . He is r ather doubtful and cautious when other sar e j oyful and enthus iastic ; but he cannot disclaim the

beneficial r esults o f his an timen ingitis serum . Even to -daycer eb

’

r o-spinal meningiti s i s amenable to tr eatment,thanks

to Flexner,and many who former ly would have died of

the infection,ar e now saved.

When Flexner was in a position to supply patients withhis serum, the New Yor k epidemic was r elenting . That i swhy he does not consider our local exper ience as momentouso r conclus ive

, but p r efer s to r eckon with the bad cases ofa beginning epidemic only. The epidemi cs of the middleWest have been gr ave

, but wer e decidedly influen ced bythe use o f the serum . Of seven cases in the Jeffer son , Mo .

,

bar r acks only two died ; of five in whi ch the diagnosis wasmade ear ly, all r ecover ed with the s erum . In McK inney,Texas

,after four cases had died in a s ingle family,

five other cases,who could be supplied with the Flexner

serum, r ecover ed. The speaker mentioned thr ee r eco v

er ies in five cases occur r ing in the pr actice of Dr . Koplik .

The most conclus ive r esults have been obtained in the

r ecent epidemics of Eur ope, wher e the diagnoses wer emade ear li er and the serum tr eatment r esor ted to in due

time . England,Scotland and I r eland have active epi

demics,and the di sease is decidedly modified by the serum .

The. former mor tal ity of 75 per cent . has been r educed to4 0 per cent . in Edinbur gh, to fr om 2 5 to 3 0 per cent. in

'

1 1 8

CEREBRO-SPINAL MENINGITIS

Belfast . The char acter of the cases has changed ; thepr otr acted chr onic cour se which extended over sever almonths

,ceased abruptly in the hospital wards . F r ance had

a sever e epidemic of two o r thr ee months . Netter had

fifty cases . Of ten childr en under two year s of age thatwer e tr eated with Flexn er ’s serum, he lost one . Calmettetr eated four teen soldi er s in the bar r acks of Lille . Onedied. Thr ee wer e sick outside the bar r acks with no serum .

They all died. Roux expr esses himself as being gr eatlystruck with the r esults of serum tr eatment . And as wego to p r es s we glean fr om the Lancet (May 1 5

,1909)

that the epidemic in F r ance,which i s now on the decline,

has mad e two things per fectly plain : the one is that thedisease is extr emely contagious and the other that theuse o f anti—meningococcic serum is of gr eat value . The

epidemic in the gar r ison at Evr eux, which M . Vaillair e

studi ed with par ticular car e, showed that the contagionspr ead fr om one soldier to another when they occupied contiguous beds in the same r oom . Some r eser vists who hadbeen in bar r acks at Evr eux and who had been sent homewhen

'

the epidemi c br oke out car r ied the infection withthem even i f they showed no signs of the di sease themselves . One o f them

,who was quite well, infected his

wife who di ed ; another in fected four other per sons, ofwhom two died. Examinat ion of the tr oops in bar r acksshowed that in 1 9 per cent . of them the meningococcuswas pr esent in the naso-pharyngeal mucous membr ane .Of 2 4 cases tr eated otherwise than by ser other apy 1 6

died,and of the same number o f cases tr eated with the

serum only four died, the mor tal ity in the one case being

per cent . and in the other per cent . The ear lierthat the serum is administer ed the better ar e the r esultsand ther efor e an ear ly diagnosis i s of much impor tance.

The wor ld does mo ve .

1 19

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

the li ter atur e has s ince gr own immensely. It was veryextensive when I collected i t in my es say on Diphther iain the second volume o f Gerhardt

’ s Handbuch der Kinderkr ankheiten

”I t soon took such dimens ions

that neither in my Tr eati se on Diphther ia (New York1 8 8 0 ) n o r in Pepper ’ s “ Amer ican System of Medicine

(Vol . I .,

n o r i n other publications did I do mor ethan r efer to author ities fo r the elucidation of par ticularpoints . Fo r many year s past it has been the etiology ofthe dis ease whi ch has cr eated a li ter atur e of its own ;so has that par t of the subj ect which tr eats of antitoxinand of intubation . Symptomatology in all its bear ingsand morphology have not r eceived many valuable additions ; fo r clinical obser vations, when cor r ect and cor r ectlyr epo i

'ted,ar e not subj ect to change and at the mer cy of

unkn own factor s, as a gr eat exper imenter has lately said.

On the contr ary, the vast amount of labor , as exhibited inendless j our nal ar ticles and bo oks on special topics

,which

has to be spent on the establishment,’

ver ification,o r r efu

tatio n of a s ingle fact in bacter iology, does not pr ovethat the r esults obtained by exper imentation in the labor atory ar e unambiguous ” to the exclus ion of clinical em

pir icism. Thus i t happens that on the following pages Ishall fr equently r epeat statements (many n ow out ofpr int) which have been found cor r ect in the cour se of time,and give advi ce that wi ll still be found ser viceable thoughi t was offer ed decades ago .

Vir chow di stingui shed between cr oupous and diphther iti cmembr anes. In his opinion the former was fibr in ous withcell p r oli fer ations

,epithelia

,and pus, and was super ficial

on top of the mucous membr ane ; the latter was an exudatio n into the ti ssue of an amor phous, dense, and co agu

lated fibr in which did not always injur e o r implicate thesur face epithelium,

but would necr os e the deeper tis sueand give r i s e to ulcer ation befor e healing . But he ad

mitted that complications between the two wer e very common indeed. Weiger t and Cohnheim wer e of the sameOpinion as far as the mor phological condition and localization of the membr anes wer e concer ned ; the essential p r ocessaccording to them was a combination of necr osis and in

1 22

DIPHTHERIA : SYMPTOMS AND TREATMENT

flammatio n,and thei r causes

,after Recklinghausen and

.

Nassilo ff had assumed the p r imary change to be a micr obicinvasion, wer e bacter ia and toxins .Accor di ng to Wagner the only differ ence between cr oup

and diphther ia membr anes was the fine structur e of and

the admixtur e of pus cells to the former . Both of themhad thei r or i gin in the epithelium

,while Buhl looked fo r

i t in the mucous membr ane itself,in the cells o f which nu

clear o r cystoid pr oli fer ations took place .I cannot detect much differ ence in the theor i es which

have s ince been br ought forwar d,fo r instance

,in those

of Oer tel o r of Heubner . The question i s always one ofdegener ation of epithelia

,of the pr esence of leucocytes ,

an exudation of fibr in, mor e o r less admixtur e of blood,

of hyaline masses, and of new formation of mor e o r

fewer r ound cells in differ ent local ities . Oer tel comes tothe conclusion that, after all the locali zation of the pr ocessi s the final cause o f the form and appear ance of the

pseudomembr ane . Why he should make the effor t of suggesting the differ entiation between a pr imary and a seco ndary membr ane, the former consi sting of dir ect sur facedeposits

,and the latter of membr anous deposits in the ti s

sue which ar e pr oduced by the pr esence of other sur facedeposits in the neighborhood, i s not qui te intell igible except on the scor e of completeness .Fo r some year s i t has become customary to di stingui sh

between those pseudomembr anes which ar e caused, o r ac

companied, by the Klebs-Loefller bacillus, and those whichcontain the pseudobacillus o r staphylococci and pr incipally str eptococci . That these mi cr obes do not establi shany disease by their mer e p r esence, that on the contr arythey ar e met with to an indefinite degr ee in the mouthsand thr oats of the healthy, i s well under stood. That theymay be cons ider ed pathological, o r pathogenic, the p r esenceof pseudomembr anes and t he—p r es ’ence of the micr obesin the pseudomembr anes in some stage of development isrequi r ed. The Klebs—Loefller bacillus is, however , not al

ways found in every stage of the i llness ; i t appear s toper ish quite often towards the macer ation pe r iod. Whenfoun d i t i s located in the super ficial layer s of the pseudo

1 2 3

DR . JACOBI’

S WORKS

membrane only, and not thr oughout it s whole thickn ess ;the coccus, however , per vades its whole substance, usuallyin gr eater number s in the deeper layer s . To explain the

absence of Klebs-Lmfller baci lli fr om these,i t i s assumed

that they ar e destr oyed by other micr obes . Still they ar e

cr edited—in the same way in which they can be pr ovento do so in the labo r atory—with evolving the toxin whi chgives r is e to all the symptoms and danger s of cer tainforms of constitutional diphther ia.

Pseudomembr anes contain ing Klebs-Loefller bacill i ar e

called by almost univer sal agr eement diphther itic, thos ewith pseudobacilli and cocci pseudodiphther itic. Localdiphther ia diphther i ti s constitutional diphther it icinfection, and diphther itic sepsis ar e differ ent degr ees ofthe same di s ease . The fir st may run a fair ly mild cour se,o r be the initial stage o f the second and (o r ) third. Thos ecases which pr esent both baci lli and str eptococc i in thei rmembr ane ar e called cases of mixed in fectio n . I t has beenclaimed that cases of the second class, that of str eptococcusinfection

,ar e of little vi rulence and attended with but

littl e danger . This opinion leads to cruel mistakes inmanagement

,bo th by boards of health and by such medi cal

men as ar e influenced by them. Fo r not only ar e manyun complicated cases very gr ave, but the mixed in fectionsar e the very wor st forms met with in pr actice . Mor eover , the str eptococcus cases ar e contagious

,contr ary

opin i ons notwithstanding . Still,i t i s impor tant to mention

at once that accur ate differ entiation has its gr eat p r acti calvalue

,fo r the r eason that i t i s solely the bacillary var i ety

that can be influenced by the diphther ia antitoxin ( seebelow ) .The par t played by micr obes in diphther ia i s not yet

absolutely clear . The Klebs-Loeffier diphther ia bacillusand a s imilar bacillus that i s not v irul ent ar e found in diabetie and in common tuber culous lungs, in noma, i n em

pyema, on chancr es, in o zaana, and in vaccinia pustules .I t is claimed that ther e ar e differ ences between the two ;the pseudodiphther ia bacillus i s descr ibed as plumper ,shor ter

,and mor e uni form than the genuine Klebs-Laafller ,

but this di ffer ence i s not so str ikin g as not to be denied

1 24

https://www.forgottenbooks.com/join

DR. JACOBI’

S WORKS

of diphther ia does not seem to be settled to the satisfac

tion of all. According to Theobald Smith (Bosto n Medi

cal and Surgical J our nal, August 2 5th, 1 898 ) i t i s onlyclinicians whose voices ar e sometimes r ai s ed against theKlebs—m fler bacillus as the chief caus e of diphther ia ”

;

but Loeffier himself, ,

and C . F r aenkel,and other s

,equally

conscientious, ar e mor e car eful than former ly in expr es sing positive v i ews and ar e les s aver se to r etr acing thei rsteps .Ther e ar e other questions in connection with diphther ia

which seem to be posit ively settled, fo r instance, that ofthe mor phology of the pseudomembr anes . In Gerhardt

’

s

Handbuch and in my T r eati se ” I studied the sub

j ect with a view to elucidate the differ ences in the condition of mor phologically identical p seudomembr anes whenfound i n differ ent locations .1

Marpho l0gy o f Pseudomembranes.—Twenty -five year s

ago Tr endelenbur g infected the tr achea of a r abbit withdiphther i ti c deposi ts which he had r emoved fr om the

pharynx and tonsils,i n the ti ssues o f which they wer e

deeply and fi rmly imbedded. The new deposits, however ,did not take so deep and fi rm a hold on the t is sues as

the or i ginal ones, but adher ed lightly to the mucous

membr ane of the tr achea to which they had been tr ansplanted. Thi s and many other s imilar facts cannot beexplained by the natur e o f the pseudomembr ane

,but by

the hi stological char acter of the mucous membr ane only,which var i es with the locality . Its differ ent elements,vi z .

, the epithelium,basement membr ane, connective ti s sue

interwoven with elasti c fibr es,with blood vessels, with

ner ves fr om the cer ebr osp inal and sympathetic systems ,and fr equently with spindle cells and the papilla: ductsof number less glands , all influence the pathological p r ocessgoing o n upon the sur face .The mucous membr ane of the mouth contains a lar ge

1 These bacter io logical statements and the fo l lowing r efer r ingto the mo rpho logy o f pseudomembr anes are co nsider ed by theautho r necessary fo r the explanatio n o f much that he has to say

o n symptomato logy and tr eatment.

1 26

DIPHTHERIA : SYMPTOMS AND TREATMENT

number o f elastic fibr es mixed with cellular ti s sue and

cover ed by a thick coat of pavement epithelium ; its uppermo st layer contains flat cells the second a lar ger quantity of polygonal cells, and the lowest oval o nes whichassume a perpendicular r elat ion to the mucous membr ane .F r om the mucous membr ane a number of papillae extendinto the epithelium,

and in thi s r espect they r esemblethe papillae of the skin . Acinous mucipar ous glands ar e

fr equent,and most numer ous in the anter ior aspect of the

soft palate . Lymph ves sels ar e very numer ous in the lips,tongue

,uvula

,soft palate

,anter ior and poster ior pillar s

of the soft palate, and cheeks . The uvula contains somany that, i f they be inj ected its cir cumfer ence i s incr eased two o r thr ee fold. They empty into the deepfacial lymph bodi es to which they communicate diphther ia as well as other infections . The lymphatics of theto ngue ar e in intimate connection with the upper layer ofthe deep cer vical, thos e of the flo o r o f the mouth and manyfr om the tongue connect with the submaxillary lymphbodi es . The effer ent vessels empty thei r contents into thesuper ior jugular lymph nodes s ituated in the tr igonumcer vicale super ius, and finally into the fi fteen o r twentyinfer ior jugular (o r supr aclavicular ) nodes which withnumer ous anastomoses form the jugular lymphatic plexus .The to nsils ar e conglomer ations of an indefinite number offollicular bodies

,each of which has a thick capsule whi ch

is of i r r egular shape, and consists of connective tis suelined by mucous membr ane and pavement epithelium . The

connective tissue contains a number of closed follicles ,each inclosing numer ous lymph cor puscles . The follicleshave been consider ed identical with, o r analogous to, thelymph bodi es ; this assumption is pur ely pr oblematical, s inceit has not been possible thus far to ver i fy the existenceof affer ent o r effer ent ducts . The pr actical deductionfr om thi s i s that the tons ils have little connection with the

lymphati c system,and that ad isease l imited to a tonsil i s

not liable to infect the or ganism immediately and intensely .

The mucous membr ane of the nasal cavities i s of varying degr ees of thickness ; it consi sts of connective

-tissue

1 2 7

DR . JACOBI ’S WORKS

fibr es with numer ous nuclei,i s fr ee fr om elastic fibr es

,

but i s supplied with a lar ge number of ner ves and an

abundance o f blood-vessel s ; the Schneider ian membr anepossesses in fact a lar ger number o f blood-vessels thando most of the other mucous membr anes . That i s why,with i ts submucous tissue

,i t fr equently i s the seat of

swellings and hemor rhages,as well in di s eases of di stant

or gans whi ch give r i se to venous s tagnation,as fr om the

slightest local p r ovocation . The inner sur face of the car

tilaginous por tion i s l ined with pavement epithelium ; thelower r egion o f the r eal nasal caviti es , the s

‘

o—called r espi rato ry por tion, thr ough its whole length suppli ed withbr anches of the tr i facial ner ve

,i s lined with cylindr i cal

epithelium and contains a lar ge number of mucous glands .The upper o r so -called olfactory por tion is l ined with ciliated epithelium,

and i s supplied, according to Todd and

Bowman,with long

,str ai ght

,tubular glands . Her e the

lymphatics ar e but po or ly developed, while in the infer iorpor tion they ar e ver y numer ous ; all their openings commun icate di r ectly with the deep facial and poster ior sub

maxillary lymph bodi es . Thus it can be r eadily understood why the sl ightest ir r itation, by a nasal catar rh fo r

instance,in a child pr oduces a tempor ary o r permanent

swelling of the lymph nodes and why the nar es shouldneces sar i ly, by thei r multitude of toxin absor bing lymphfollicles and ducts , be among the most danger ous locali zations of diphther ia.

The epiglo ttis car r i es a lay er o f pavement epithelium ofmm . in thicknes s on its anter ior super ior sur face, that

on its poster ior sur face being fr om to mm. inthickness . The super ficial laver consi sts of spher oidal o rpolygonal cells, the deeper IS of cylindr ical cells ar r angedper pendicular ly to the sur face . Near the inser tion of theepiglotti s

,the polygonal cells di sappear , the cylindr ical

occupy the sur face, and ar e fur ni shed with cilia mm .

in thi ckness . Beneath these ther e ar e r ound and ovalcells in consider able number

,so that the whole epithelial

coating has a thi ckness of mm . Ciliated epithelium isalso found on the false vo cal co rds and in the ventr iclesof the larynx . Polygonal pavement epithelium forms the

1 2 8

https://www.forgottenbooks.com/join

DR. JACOBI ’S WORKS

o r or ganic influences . I t is not pr esent in the mucousmembr ane of the nose, but to a cons ider able amount inthe buccal cavity, i s very abundant in the walls o f thelymph follicles of the tonsils

,and pr edominates in the

tr achea. The influence of these anatomi cal conditions onthe diphther itic p r ocess mus t be very mar ked. I t can

eas ily be demonstr ated that wher e the elastic tissue is pr evai ling

,a r es istance to diphther itic imp r egnation i s main

tain ed fo r a long time, but when it has been for ced to

y i eld,ther e i s a cor r esponding r esistance to r ecovery.

It i s the pavement epithelium that gives the easi est foothold to diphther itic memb r ane . Wher e it i s most abundant, the diphther iti c pr oces s can best settle and develop .

That i s why the tons ils not fr om their pr ominent'

situa

tion alone,but fr om the char acter of thei r sur face also

,

ar e favor able to the r eception and fur ther developmentof an in fection

,and thei r elastic and connective fibr es

,

when at last affected,ar e apt to harbor the pr ocess a long

time . Ciliated epithelium,on the other hand

,i s not l iable

to be invaded. I t occupies a higher r ank in the scale ofanimal formation

,and has a mor e complex fun ction and a

gr eater power o f r esistance ; besides , it expels by its cons tant movements micr oscopic for eign bodi es .The p r esence of a lar ge number of mucous glands 1m

pedes, as a rule

,by the pr esence of the n ormal s ecr etion ,

an extensive destructive action upon the ti s sues . The secr eted mucus as sists in r emoving epithelial masses

,and even

fibr in ous exudat ions,fr om the sur face . The under lying

tissues themselves do not alway s take an active o r pr omimcnt par t in the p r ocess ; the serum of the mucus penetr ates the par ts whi ch ar e the seat of mor bid deposits ,and tends to pr edi spose the latter towar d macer ation , and

the mucous secr etion r ai ses mechanically the super j acentdepos its fr om thei r bed. Thus i t i s that the deposits inthe r espi r atory por tion of the nasal caviti es ar e fr equentlycast o ff thr ough the nostr ils, p r obably because they havebeen p r oduced i n excess ; and in a s imilar manner , themembr anes that have formed in the tr achea ar e ej ected ina semi solid condition thr ough a newly made tr acheotomie ,o r even the natural, outlet . The. lar ge number of mucous

1 3 0

DIPHTHERIA : SYMPTOMS AND TREATMENT

glands in a par t of the lar ynx and in the whole tr acheai s unquestionably the r eason why the lymphatic vesselsof the mucous membr ane, even wher e they ar e pr esent inlar ge number s, ar e not influenced by the over lying loosenedmasses

,and will not absor b ; hence laryngeal an l tr acheal

forms of diphther ia have a decidedly local char acter , and

ar e mostly devoid o f constitutional symptoms .The vo cal co rds form the border s of the nar r owest aper

tur e of the air passages ; they detain o r retain for eignbodies

,whether malignant o r otherwise ; they ar e cover ed

with pavement epithelium which,as has been r emarked

,

i s the pr incipal r esting and br eeding place of the diphcher itic affection . Thev have no defence fur nished bymucipar ous follicles , and ther efor e i f ther e is any par twhich i s pr edi sposed to a local diphther it ic infection i t i scer tainly the vocal cords . That i s why in the beginningo f an epidemic of diphther ia

,o r when it i s dying out,

a local diphther iti c infection can st ill take place, and individual cases occur now and then with an almost in sign ificant power o f infection . Such occur r ences took placepr evious to the ubiquity of diphther ia for ty year s ago ,

and ar e still met with under the same conditi ons , givingr ise to the so -called spor adi c membr anous cr oup .

On the other hand, the absence of acinous glands on thevocal cords must ser ve to a cer tain degr ee as a guardagainst the di sease . Dry, atr ophi c, but at the same timeuninjur ed and smooth condit ions of the mucous membr aneof the fauces tend to war d o ff an attack of diphther ia.

A mor e o r less moist o r vi scid condit ion of the sur face i snecessary in or der that the infecting mater ial may clingther eto . The compar ative dryness of the vocal cords ,however

,consider ed by the s ide of the per petually moist

and uneven sur face of the pharynx would not appear sofavor able to the deposition o f

_foreign —infectious elements.

Thus ther e ar e cer tain conditions pr edisposing to, other santagonizing infection . They demonstr ate

,however , why

laryngeal cr oup i s mor e fr equent in winter than in sum

mer, in di r ect pr opor tion to the gr eater fr equency of lar yn

geal catar rh in winter than in summer . Diphther itic membr anes on the vocal cords ar e not eas ily cast o ff, fo r ther e

1 3 1

DR . JACOBI’

S WORKS

ar e no subj acent mucipar ous glands whose secr etion couldwash them away. No gener al infection can ar i s e fr omthem,

fo r they have no lymphatic vessels which.

couldser ve as car r i er s o f the poison ; fur thermor e, suffocationfr om a local cause occur s too ear ly to enable the fewneighbor ing lymphatics to absor b and tr anspor t the toxinelsewher e

,in case the deposits should finally become mac

er ated.

The compar ative absence of the lymphatics and the

paucity of blood-ves sels.

explain why diphther ia of the

tonsils has so mild a char acter . The lar ge number and

s ize of, as well as the n di r ect communication of the lymphatic ducts of the Schneider ian mucous membr ane withthe lymphati c glands of the neck account fo r the danger ouschar acter of diphther ia of the nose . However

,dir ect in

fecti o n,i .e., the absorpt ion of the poison into the body, i s

not always dependent on the lymphatics, fo r they haveoccasionally neither enough time n o r the oppor tunity touse thei r power . Fo r instance 1n those cases of diphther iaof the nose in whi ch ear ly and slight epistaxi s occur r ed,the poison appear s to have been absorbed dir ectly into theblood-vessels. Then we fail to obser ve the ordinary swelling o f the neighbor ing glands of the neck , but the gener alsymptoms ar e very r apidly developed. Usually, however ,infection r esults thr ough the lymphatics . The fluid contents o f the ti ssues, o r such par t icles o r elements as ar e

suspended ther ein, be they o f a gaseous, chemical , o r par as iti e natur e, ar e conducted to the lymph nodes and intothe ci r culation . Ther e may be, however , two impedimentsin the cur r ent . In the fi r st place

,the for eign mater ial

may be p r esent in too lar ge an amount to ci r culate withease ; the r esult will be stagnation and consequent i r r i tat ion

,either in the fasc ia pr op r ia o r in the substance of

the lymph nodes . By p r essur e, the capillary ci r culationbecomes inter fer ed with, pr oli fer ation ensues, the ci r enlating lymph mingles with the white cor puscles fr om the

lymph spaces , and the r esult i s an abscess in the intr ao r per iglandular tis sue . Or the for eign mater ial i s r e

tained in the inter ior of the fascias,in the connective

tis sue, o r i n the di lated lymph ves sels of the cor tical sub

1 3 2

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

long and give r is e to but few embar r ass ing symptoms, andthat a mild case of diphther ia may, by contagion, p r oducevery ser ious ones, r ender contagion by nur sery maids and

other domestics, by teacher s,seamstr es ses

,sick-nur ses,

wor kmen, factory gi r ls, shopkeeper s, bar ber s, and all otherper sons mingling with the many extr emely easy. The v i~tality o f the diphther ia germs is per si stent

,as is well

kn own,and may extend over year s . They cling to solid

and semisolid bodi es,ar e impor ted in milk

,cling to walls

and floor s,to toys, to cur tains, towels, clothi ng, and bed

ding whi ch i s so often kindly donated to the poor by the

benevolent well—to-do when they wish to get r id of thei rown danger s. They stick to omnibus and car r iage cushions,to car seats

,to the either r eady o r custom made coat on

one ’ s shoulder s near whi ch one’ s baby will nestle—the

very coat that i s sold i n B r oadway palaces after i t hasbeen made in the pest-str icken tenement sweating shop .

The very r estlessness of our people, the fr equency ofmoving into unknown and often infected quar ter s

,i s an

other cause o f doubling the number of cases . Ther e can

be no doubt,besides

,that many animals—hor ses

,chi ckens ,

cows—have and spr ead diphther ia. Thus i t appear s thatwe ought to think twice

,and indeed many times, befor e

admitting among the causes of diphther ia new factor swhi ch cannot be p r oved.

No contagion could be tr aced. That i s the in tr oduction to every wild and unpr oven theory of indigenousspontaneous gener ation . When a case of choler a br eaksout in a vi llage a thousand miles away fr om the coast, 1s

ther e anybo dy in our time who looks after chemical poi sonin a well o r filth on the r oofs ? We look fo r dir ect o r indi r ect contagion fr om a tangible sour ce . Why not so indiphther ia In the N ew Yo rk Medical J our nal of September 2 7th, ,

1 8 8 6, I quoted fr om I samber t the case ofa medi cal as si stant who had nasal diphther ia many months ,and then travelled hal f a year to get r id of the lastr emnants . He fully r ecover ed ; but how many deaths didhe cause—going fr om r ai lr oad car to r ailr oad car

, fr omstagecoach to stagecoach, fr om hotel to hotel ? How manymay have been the physicians who sear ched i n vain fo r

1 3 4

DIPHTHERIA : SYMPTOMS AND TREATMENT

the cause o f the spor adic cases suddenly spr inging up intheir towns, and the epidemics gener ated by them alon gthe r oads on which the luckless wander er after his ownhealth had str ewn out his cur ses ? Nobody suspected the

tr aveller who left days ago , just as nobody may be ableto tr ace every outbr eak of choler a to the unknown per sonwho car r ied i t upon his per son o r in hi s bowels . No r i sthi s an isolated cas e of a long dur at ion o f diphther ia.

Cadet de Gass icour t operated fo r laryngeal diphther iaafter eighteen

,twenty-thr ee and for ty-thr ee days . Sanné

had cr oup pati ents who r ecover ed after twenty- seven,

thir ty-two,

and s ixty days . I know of many cases ofdiphther ia pr otr acted into the second o r even the thi rdmonth.

Golay r epor ted the case of a boy o f five year s who hadthe diphther ia bacillus thr ee hundr ed and s ixty-two days .Dur ing thi s time he had thr ee acute attacks of diph

ther ia and four inj ections of antitoxin . Golay dr aws theconclusions fr om his r epor t (R evue médicale de la Suisse

Romande, 1 897 ) that a fo r tnight’

s i solation after the disappear ance o f the fals e membr ane as advised, i s inadequate ; he does not believe in r ecovery until thr ee o r fourexaminations fo r bacill i made in inter val s o f a week eachhave p r oved unsuccessful . He also finds that the pr esenceof the bacillus in the thr oat does not inter fer e per se

with the gener al health ; also that the bacillus i s apt tor emain a very long t ime

'

unl es s ther e i s a compli catingstr eptococcus infection . In this case he tr i ed many localappli cations (Loefller

’

s included) in vain .

Such facts,pointing as they do to the r eady communi

cability of diphther ia, have influenced my opinion fr omear ly times . I cannot see anything mir aculous in the sud

den appear ance o f a bacillus diphther ia: o r a str epto co ccus

in a per son appar ently not exposed to it. Dur ing an

epidemic ther e i s n o body n o t expo sed to i t, and everybody i ssubj ect to it under favor able cir cumstances . The lattermean a fit condition of the human integument, either cuti so r mucous membr ane

,which makes it liable to become a

r esting-place fo r the germ . That fit condit ion is a slighto r sever e wound

,abr as ion

,denudati on of the sur face . As

1 3 5

DR . JACOBI ’S WORKS

no healthy sur face becomes erysipelatous in spite of erys ipelas being epidemic (

“

erysipela non est sine vulner e,”

Galen ) , as Fehleisen’

s bacillus r equi r es a sor e,so diph

ther ia, being ubiquitous and wai ting fo r a chance,will

stick to a cutaneous wound, a stomatiti s,a pharyngeal o r

nasal catar rh,and will r apidly multiply. A r esected ton

sil will thus be cover ed with a pseudomembr ane within a

day.

I have been quoted as favor ing the sewer -gas or i gin o f

diphther ia,though (with the exception of a car eless ex

pr ession on page 50 o f my“ T r eatis e on Diphther ia ”

)I always, since 1 8 60 , str enuously expr essed my convictio n of the communicability of diphther ia solely by co n

tagion (di r ect o r indi r ect) . Jenner in 1 8 6 1 , Wilks in1 8 7 3 , Thor ne Thor ne in 1 893 , expr essed the same opinion .

I beli eve it i s the latter car eful and most painstaking oh

ser ver whose statements, together with the di scuss ion o n

the subj ect contain ed in the Br i tish Medical J our nal of1 893 and 1 894 , in which Wilks, Davi s

,P r i estley, C . M.

Jessop, and J . Bunting -in oppos ition to Geor ge Johnson ,Parker

,C . N . Al lfr ey, N . G . War r ey, and P . G . Mar

r io tt—favor ed the exclus ive contagion theory, have donemost to establish the latter for ever in the minds of our

B r iti sh br ethr en .

The vitality of baci lli i s r emarkable . It is true thatdir ect l ight ki ll s them after a while ; even diffuse lighthas a s imilar though slower effect . It i s also true thatthey do not live outs ide the body so long as on the hu

man mucous membr ane; and that one obser ver (Spengler )did not find them after o ne hundr ed and twenty days, andother s (Wr i ght and Emer son ) found few only on brushes ,and none on clothing o r on the finger nails . But Abelfound them on chi ldr en ’s building blocks after five months .They r esi st desiccation a long time

,in membr anes (Roux

and Yer sin ,Park

,Loeffler

,Germano ) , in ti s sues (Lteffier ,

d’

Epin e et de Mar i gnac) , and in dust (Reyes, Germano ) .

Rapid desiccation, even by means of sulphur i c acid, doesno t

'

injur e thei r vi rulence, which i s pr eser ved the better

(being pr otected against oxidation) the thicker the sur

r ounding dust . The latter mav be the vehicle of conta

1 3 6

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

and the wor se the odor the les s i s the danger,par ticular ly

fr om diphther ia.

The contr ibuting causes of the latter di sease ar e verynumer ous, and the sear ch fo r the or igin of an individualcase i s often unsuccess ful .I r r itat ion of the thr oat and nasopharynx i s a fr equent

sour ce of local catar rh ; this cr eates a r esting-place fo rdiphther ia germs

,whi ch ar e ubiquitous dur ing an epidemic

,

and thus an oppor tunity fo r diphther ia i s fur nished.

Of the specific germs, those of typhoid fever and

dysentery appear to be the least subj ect to destructionin ces spools and sewer s . These diseases appear to besometimes r efer able to dir ect exhalation fr om pr ivies and

cesspools, but very few cases, i f any, ar e attr ibutable

to the action of sewer ai r .

The imposs ibility o r gr eat impr obability of the infectionof specific di seases

,except dysentery and typhoid fever ,

r is ing fr om sewer s into our houses , pr otected as they ar e,

o r ought to be, by good dr ain s and efficient tr aps, should,however

,not lull our citi zens and author iti es into indolence

and car elessness . Fo r the gener al health suffer s fr omchemical exhalations

,and the vital ity of cell li fe and the

power o f r esistance ar e undermined by them .

SYMPTOMATOLOGY

P r odr omes.—After an incubation per iod lasting fr om

a few hour s to four teen days, pr odr omes may p r ecede thecharacter isti c symptoms of diphther ia fr om a few hour sto several days ; some of them ar e identical with thos e ofgener al malais e

,and nausea ; occasionally vomiting, seldom

other infectious di seases . They ar e lass itude,headache,

diar rhoeag mo r e commonly constipation ; univer sal muscular sensitiveness

,and some stiffnes s of the neck . The

thr oat i s complained of by older childr en as being dry ;the mouth i s eas ily opened, ther e may be no discolor ationof the fauces

,o r a hyperaemia only whi ch, as i f it wer e

traumatic,may be quite local . The tonsils and pharynx

ar e seldom sensitive to the touch, but the swallowing offluids i s r ather difficult. In those cases in which a swelling

1 3 8

DIPHTHERIA : SYMPTOMS AND TREATMENT

of lymph bodi es is noticed near the angle of the lowe r

j aw at thi s ear ly per iod, ther e is pain on pr essur e . The

temper atur e i s seldom r aised except in these cases ; inthem ner vous symptoms ar e obser ved

,such as chills and

convulsions. Ther e i s r ar ely a shor t pharyngeal cough,still less fr equently a hoar se voice

,o r dyspnoea, o r laryn

geal str idor .

SYMPTOMS

The Thr o at.—Most cases of diphther ia begin in the

thr oat . The tonsils being lar ge in the young, and exposed to super ficial les ions occas ioned by catar rhal pr ocesses

,and to injur i es of the epithelium (dur ing deglut i

tion ) , ar e most r eadi ly invaded by bacilli and other micr obes. Ther e may be no, o r a slight

,o r a high elevation

of temper atur e . This differ ence, like all other symptoms,depends on the var ious degr ees of v irulence of the in

vading micr o-or gani sms,on the pr evious immunity, and

on the differ ent power s of r es istance on the par t of thepati ents . When the temper atur e i s hi gh ( 1 0 4

° ther emay be a convuls ion

,o r vomiting

,o r sometimes diar rhoea.

But these symptoms of the initial stage ar e r ar e .The. thr oat i s r ed, all over i n most cases, o r locally ;

mostly on the tonsil,o r near it, ther e i s a gr ayi sh o r

whitish spot,the s i ze of the head of a pin, o r lar ger .

Sometimes the fir st inspection r eveals the p r esence of a

membr ane of the same color o r br ownish. The smallgr ayi sh spot will incr ease within a few hour s o r a dayun til i t gr ows into a membr ane

,o r ther e ar e mor e than

one,four o r s ix o r mor e

,which soon coalesce . The mem

br ane may be thin like a fi lm,o r thick ; lying r ather loose

on the mucous membr ane, o r tightly adher ing so that itsr emoval i s difficult and attended with a little bleedin g ;when it is r emoved i t i s r epr oduced in a few hour s o r

half a day. The gr ayi sh discolor ation i s not always membr an ous ; quite fr equently i t i s caused by an exudationinto the tissue and cannot be r emoved at all. Then itdoes not come away at an y time but under goes a pr ocessof necr os is

,and if it heal s at all does so only by healthy

gr anulations spr inging up on the ulcer ating sur face. The

1 39

DR . JACOBI ’S WORKS

neighbor ing tissues, mainly the uvula when it i s cover edwith membr ane, become azdematous and may swell consider ably. Then deglutition

,r espi r ation

,and ar ticulation

may suffer accordingly. At fi r st the membr ane has noodor . In bad cases

,and after some days, when macer ation

begins, ther e i s some odor , whi ch may be very offensiveand fetid i n septic cases . In the neighborhood of the

membr anes the lymph bo dies will swell, the r egion of thetonsils becomes painful on pr essur e . and ther e i s some

,o r

much,swelling

,which depends in par t on the tumefaction

of the lymph bodi es alone,and in par t on that of the

sur r ounding loose ti s sue . The face i s pale and sallow,

may be bloated even in mild cases and its expr ess ion isliable to be that o f indolence and apathy ; in bad cases ofsepsis and when the veins o f the n eck ar e compr es sed byexudation the color may become livid. Ther e ar e but fewmild cases of uncomplicated diphther ia that do not exhibitsome constitutional symptoms ; the puls e becomes a littl efr equent and small ; in bad cases i t i s very small, veryfr equent, o r very slow . Those cases in which the pharyn

geal diphther ia spr eads into nasopharynx, nar es , o r lar ynxhave thei r own addit ional symptoms ; they will be consid

er ed below,so will be those whi ch terminate in destruction

of tis sue in the thr oat in consequence of deep ulcer ationand gangr ene

,whi ch may even r esult (though that o c

cur r ence be r ar e) in per for ation of the soft palate, o r

its adhesion to the poster ior wal l o f the fauces .The local symptoms of diphther ia may be very indi s

tinct,even absent . As ear ly as 1 860 I descr ibed cases

of diphther ia without membr ane , thi s being absent eitherin the fir st stage only o r altogether . At the pr esent timethe bacter iological pr oof cor ro bor ates what I then had

ample r easo n s to conclude fr om clinical facts . The termcatar rhal diphther ia has been accepted by many since,though it has been combated by other s . That such cases mav

occur in families in other member s of which well-authen ticated instances of diphther i ti c membranes ar e met with hasbeen substantiated by many, among whom I am glad tocount Baginsky. To cal l such cases masked diphther iaappear s unjustifiable, so long as the diagnosis i s made,

1 4 0

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

of the tonsils and pharynx was also descr ibed by me inan ar ticle On Diphther ia and Diphther iti c Affections

,

”

in the Amer ican Medical Times, August 1 1 th and 1 8 th,

1 8 60 , and in C . Gerhardt’ s Handbuch der K inderkr ank

beitem,

” I I .,1 8 77 .

The follicular form of amy gdal iti s (diphther itic o r

o ther ) , caus ing local and small ci r cumscr ibed alter ationsonly, may eas i ly be mistaken fo r a s imi lar c1 r cumscr ibed

deposit whi ch i s not in a tonsi llar lacuna, but on some

other par t of the tonsil . Thi s pun ctuated diphther ia i smostly seen in lar ger childr en, in adolescents

,and in adult s ,

fo r the r eason that r enewed attacks of pharyngeal inflammation so harden and ci catr i z e the tonsillar sur face thatextensive exudations can no longer take place . The br oadstatement i s justified that pharyngiti s cr eates a di spos itionto diphther ia and to the formation of lar ge membr anes inthe very youn g, and r ather destr oy s i t o r causes only smallexudations in advanced age. But whether membr ane o r

do t, they ar e equally contagious . A mild var iety begetsthat whi ch i s mild o r sever e as the sever e form may

pr oduce its like, o r a mild var i ety . This mild var i ety i sthat fr om which adults ar e apt to suffer . I t made mepr oclaim the war ning that ther e is as much diphther iaout o f do or s as indoor s as much out of bed as in bed.

With this var iety the adult i s on the str eet,engaged in

bus iness,i n the schoolr oom

,in the r ail r oad car

,in the

kitchen,and in the nur ser y .

°

With thi s var i ety par ents ,while complaining of slight thr oat t r ouble, which i s notheeded, ki ss their childr en and in fect them (DI

‘

edical

Reco rd, November 2 7th,The confusion in r egar d to the accur ate diagnosis of

an individfial case i s caused by the difficulty of always es

tablishing the tempor ar y pr esence o r absence of the KlebsLmfller bacillus . Having noticed the fr equent identity oflacunar

“ tonsilliti s ” with diphther ia, C . F r aenkel,E .

Czaplewski,and other s believe that baci lli ar e actuallv

mor e common than i s gener ally as sumed,and that numer

ous alleged cases of str eptococcus p seudodiphther ia ar e,

after all,caused by the bacillus , and that, o n the other

hand, un complicated bacillary diphther ia i s quite r ar e .

1 4 2

DIPHTHERIA : SYMPTOMS AND TREATMENT

Another caus e of confusion was the assumption that gennine baci llary diphther ia was the most danger ous formof the di sease . Ther e was a time when the diagnosi s ofdiphther ia was made by the omniscients fr om the ter

mination of the case : i f the pati ent di ed, i t was diphther ia ;i f no t

,not. The advent of the bacillus has changed that ;

the bacillus cas e i s at once made out to be the most danger ons and fatal case . Nothing i s mor e er r oneous . Asa rule the uncomplicated baci llus case is not among thefatal cases ; as a rule the uncomplicated str eptococcus casei s not fatal ; but the mixed case i s ominous . The elimination o r non~appear ance of one of these components i s a

favor able occur r ence . The latest i llustration of thi s factis the r epor t o f Strassbur ger , who states that the lar gemaj or ity of diphther ia suffer er s in Bonn car r i ed KlebsLceffler baci lli which wer e compar atively harmless . Thesemild cases wer e not complicated with str eptococci

,which

wer e pr esent in every gr ave case .Skim—An erythematous eruption, mor e o r les s gener al

,

appear s sometimes on the skin immediately with the in

vasio n of diphther ia,o r after a few days only. It is either

evanescent,scar cely visible fo r mor e than a few hour s

,o r

cover s a lar ge sur face and r emains some days . I t has beenmi staken fo r scar let fever but i s not . gener ally attendedwith a hi gh t emper atur e and with the intense stomatiti sand glossiti s of scar latina ; by the lower temper atur e itis also di stingui shed fr om the erythema which is liable inpr edi sposed infants o r childr en to accompany many feverish di seases .Thi s eruption of diphther ia does not appear to be pr o

po r tio nate to the ser iousness of the i llness . At all eventsit has nothing in common with erys ipelas , whi ch, however ,i s apt to accompany such cutaneous diphther ia as followsabr asions of the skin

,and i s found on tr acheotomy o r

other wounds . Such local depos its of diphther i tic membr anes ar e often found on the local denudations of scr atchwounds, eczema sor es, o r vesi cator i es . They ar e apt tor emain local ; but, on the other hand, in many cases inwhich the fir st localization of diphther ia i s in the skin,it will affect the neighbor ing lymph bodi es and infect

1 4 3

DR . JACOBI ’S WORKS

the whole body. As a rule,however 1t i s amenable to ear ly

and effective tr eatment, and that is why T r ousseau de

clar ed most cases of cutaneous diphther ia to be devoid ofdanger .

In connection with these c'utaneous alter ations may bementioned the mor e o r les s local o r gener al emphysemawhich occur s sometimes dur ing o r after tr acheotomy. Ihad that di sagr eeable exper i ence a number of times

,on ac

count o f my pr efer r ing to oper ate mostly below the thyr oid gland. Ther e the mediastinal ti s sue is sometimes injur ed, and dur ing the intense dyspnoea a local emphysemaof the subcutaneous ti s sue i s the instantaneous r esult . Evenfr om a slight ruptur e of pulmonary alveoli much air willescape and the whole body may become transformed, as i twer e

,into a bulging

,cr epitating balloon .

Exten s ive (edema i s sometimes noticed, even without albuminur ia.

In connection with the alter ations of the skin petechiaa,pur pur a

,and ecchymoses may be mentioned, though, in

deed, they might find their pr oper place also under the

head of the or gans of cir culation . Like scar latina and,

sti ll mor e, measles , and,indeed, all infectious di seases,

diphther ia (pr incipally the mixed baci llus and str epto co c

cus infection ) , mainly when the my ocardium is alter ed and

when blood-ves sels ar e obstructed, will r esult in effus ionand either small o r lar ge extr avasations . Beside the latter in its di ffer ent forms ur ticar ia, erysipelas, and var iolal ike eruptions will be obser ved. Ther e i s, however , noeruption that i s pathognomonic of genuine diphther ia.

The local les ion of the mucous membr anes gives r iseto bloody di schar ges fr om the nar es o r the pharynx .

When sepsi s i s very intens e and gangr ene deeper , actualhemor rhage will occur . The lar ge maj or ity of danger ouso r fatal hemor rhages come fr om tr acheotomy wounds, nowand then

,perhaps

,fr om mer e pulmonary hyper aemia and

apoplexy, sometimes after the loosening of membr anes , o r

fr om er osion of lar ger blood-vessels . Now and then the

pr es sur e of an impr oper tracheotomy tube would cause it,as in Gangho fn er

’

s and in Maas ’ s cases of hemor rhagefr om the innominata, sometimes the septic destruction of

1 4 4

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

those whi ch exhibi t few membr anes, but at an ear ly per iod

a sanguinolent di s char ge . In these not even the lymphbodies may swell, but absor ption will take place dir ectlythr ough the blood-vessels

,which ar e open

,as i s pr oved

by the very pr esence of blood in the di schar ges .So long as the final clinical diagnosis o f diphther ia de

pends o n the p r esence o f the bacillus,i f found, i n the

membr ane o r in the dischar ge, the number les s paper s

strutting about the magaz ines to pr ove either the inn o cu

ousn ess o r the danger ousness of fibr in ous rhin iti s, o r again

the pr esence o r absence of bacill i in fibr inous rhiniti s , o r

its ability o r inability to cause faucial o r laryngeal diphther ia

,ar e super fluous vapor ings of single obser vations .

Whenever nasal diphther ia i s diagnosed in any o f' itsforms

,o r even str ongly suspected, danger should be as

sumed to exi st . In most cases the infection is mixed,ver y

mixed. Edmund Meyer (Ar chiv fii r Laryngo logie und

Rhino l0gie, IV .,1 896 ) found in twenty—two cases of fi

br in ous rhiniti s,

” nine times str eptococci and staphylococcialbi and aur ei

,and thi r teen times Klebs-Loeffier bacilli ;

Guar naccia,i n his cases of caseous rhiniti s

,found Klebs

Lceffier bacill i, str eptococci, staphylococci aur ei and albi,

sar cina lutea, bacillus subtili s, bacillus pr oteus, leucocytescontaining micr obes in their nuclear p r otoplasm

,and

str eptothr ix alba.

The co njun ctiva of the upper (mor e fr equently) o r the

lower eyelid becomes diphther i ti c either p r imar i ly o r seco ndar ily (when the nose and lacrymal ducts ar e p r imar i lyaffected) . Diphther it ic conjunctivitis is not a fr equentdi sease—sometimes I do not see a case in a year ; thi r tyfive year s ago i t was fr equent and destructive . Evidentlythe epidemics differ in r egar d to vi rulence . Usually the

membr ane spr eads r apidly fr om one eyelid to the other ;when the palpebr al conjunctiva i s smooth, dry, and pale,while that of the bulbus i s chemo sed, the whole lid becomesr ed, swells and stiffens, and a membr ane i s fir st depositedin flo ccules, whi ch soon coalesce into solid mas ses . Thesear e so thick as to pr es s upon the cor nea, which speedi lybecomes hazy and ulcer ates . Per for ation takes place, their i s p r olapses, and sometimes the eye i s destr oyed within

1 4 6

DIPHTHERIA : SYMPTOMS AND TREATMENT

a s ingle day. It takes the membrane a few days to beginmacer ation .

The accur ate diagnosi s of the char acter of the membr ane should be made in the usual way ; in many casessimple fi lm p r epar ations to the exclus ion of cultivation

,

ar e suffi cient . I t i s claimed by Mor ay (Annales d’

o culis

tique, Apr il, 1 895 ) and Sydney Stevenson (Br itish Medi

cal J our nal, June 1 8 th, 1 898 ) that quite often the dis

char ge fr om the eye contains only that micr obe which i sthe cause of the inflammation . Ther e i s only one sour ceo f confus ion likely to ar i se

,viz that between Klebs

Loeffler and xer os is bacilli .3

According to Ammann“ the cor nea may be affected bythe Klebs-Lasflier bacillus

,alone

, but i s mostly invadedonly. when str epto and staphylococci ar e pr esent . Oncehe found non-vi rulent baci lli together with the vi rulent .The car i s liable to take par t in the diphther ia of the

nasopharynx . Membr anes may continue into the funnellike aper tur e of the Eustachian tube, which in the youngis r elatively lar ger than in the adult

,o r the specific ca

tar rh (a mer e sur face diphther ia) may extend into the

3 The main po ints o f distinctio n ar e (acco rding to Stevenson)1 . Bo th stain by G r am

’

s metho d, but the.

diphther ia o rgan ismlo ses its gentian vio let, when in alco ho l, much mo r e quickly thanthe xer o sis bacillus. 2 . Klebs-Loef’fler bacilli give r ise to an acidr eactio n when gr own in neutr al bouillo n o r milk

,while xer o sis

bacilli never do . 3 . The latter , when ino culated into guinea-pigs,cause no thing mo r e than a swelling at the site o f the punctur e.

4 The xer o sis bacil lus is believed by Schanz to be identical withthe Klebs-Loeffier . Its micr o scopical featur es vary, but n o t mo r e

so than tho se o f the latter and o f the “

pseudobacillus.

” It dif

fer s in this also that, though it is always combined with str epto co cci, it is n o t believed to be vi rulent, inasmuch as it do es n o t

cause diphther ia. Still, ther e is a case o f vo n H ippel—examinedby C . F r aenkel also—which pr oved the

‘virulence o f the xer o sisbacil lus. It was met with in the co njunctival sac o f a man who

had been operated upo n fo r catar act . I t was found to he veryvi rulent in an imal exper imen tatio n ,

though o n the eye o f the

patient ther e was no kind o f inflammatio n , least o f all diphther ia.

The absence o f diphther ia, however , in the pr esence o f KlebsLceffler bacillus o n mucous membr anes is a fr equent o ccur rence.

1 4 7

DR . JACOBI ’S WORKS

middle ear . Since I collected what l ittl e l iter atur e ther ewas in 1 8 8 0 T r eatise

,p . instances of that kind

have mult iplied. The drum membr ane, the exter nal meatus ,

and the lobes ar e subj ect to diphther ia when the sur faceepithelium has been injur ed. A complication with erysipe

las I saw thir ty year s ago on the exter nal ear of a newlybor n chi ld ; in o lder childr en I have seen that same unfor tunate complication dur ing bad epidemics ; also

,with

out erysipelas, a gangr enous dis integr ation of the cheek,o f the exter nal ear

,sometimes down into the bones, with

all the possibilit ies ar i sing in the var ious forms of otiti smedia and osteiti s . While some died of sepsis

,other s would

succumb to thr ombotic obstructions of a sinus .The kidn eys ar e liable to par ticipate in most infectious

di seases,even in the common forms of pharyngiti s ; in

none mor e so than in diphther ia . no matter whether mildo r gr ave . Evidently the i r r i tation caused by the elimination o f the toxin damages either mer ely the functions o r

the substance of the kidneys. Albuminur ia is s een ear ly,about the thi rd o r four th day , even on the second, in perhaps one-thi rd of all the cases whi le the quantity of theur ine i s r ar ely dimini shed sometimes incr eased. Bloodther e i s very r ar ely, even in septic cases less fr equentlythan in scar latina. U r ea i s pr esent 1n normal o r fairquantities, and the salts ar e n ear lv normal . Cyl indr oids

(mucin ) and sometimes hyaline casts ar e found in thes es imple cases in which the albumin may be p r esent a fewdays o r a week

,without exer ting an influence o n either

the temper atur e o r the other symptoms . Sometimes,after having been quite copious

,it disappear s very sud

den ly.

Actual nephr iti s i s not so fr equent as in scar latina, buti t occur s . Hyal ine casts in lar ger number s , tur bid cell s,small gr anular casts ar e the fir st micr oscopical symptoms,which may be followed by lar ge gr anular casts and o c

casio nally only a few r ed blood cells . The ur ine becomesscanty, the skin mor e pallid, the collapse mor e intense.In thi s nephr iti s o f diphther ia ther e i s less (edema

,les s

dr opsy, les s ur aemia than in that of scar latina o r othercomplications . Convuls ions ar e not even so fr equent in

1 4 8

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

over a mer ely atelectatic ar ea,and the r espir atory murmur s

ar e obscur ed by the tr ansmitted sawing,loud

,laryngeal

sounds . Still when the hither to low temper atur e i s r e

placed by a high one,and the normal long-dr awn inspi r a

tion of uncomplicated lar yngeal diphther ia (cr oup ) givesway to gr eat fr equen cy of r espi r ation

,the suspicion point

ing to pneumonia becomes almost a cer tainty.

Like str epto and staphylococci the Klebs—Lceffier baci llusi s found in tuber culous lungs . I t is eas ily seen that, as

i t i s fr equent on the mucous membr anes of the upper par tof the r espi r atory or gans, it may r eadily appear i n itslower distr ibutions . Whether i t modifies the tuber culousdis integr ation r emains an open question . The influenceo f the str eptococcus on the tuber culous pr ocess i s assumedby all to be power ful fo r evil . Whi le it i s possible and

appear s to be pr oven that the pr esence of str eptococciinter fer es with the g r owth of Klebs-Lcefller bacilli

,other

obser vations have shown that under cer tain ci r cumstan cesthe non-virulent bacilli may become vi rulent under the

influence o r in the p r esence of str eptococci (Schiitz i nthe Ber liner klin ische Wo chenschr ift, Ap r il 1 8 th,The oesophagus r ar ely par ticipates in the diphther itic

affection of the phar ynx beyond a di stance of fr om 2'

to 3 cm. wher e its ti ssue is healthy . I f i t i s not healthy,fo r instance near cicatr i cial contr actions

,membr anes may

be found at auv place . They may be depos ited looselyon the mucous membr ane and eas ily floated

,o r may be em

bedded in the ti s sue, and then lead to necr osi s .The stomach par ticipates in the symptoms of incipient

diphther ia by vomiting, which however,i s not fr equent.

Gastr ic pain and vomiting may p r ecede car diac par alys i s .Membr anes

,however

,ar e found in exceptional cases only.

In one"

I concluded they wer e swallowed befor e death.

The in testinal tract has diphther i t ic (dysenter i c) membr anes in the r ectum and colon, sometimes in connectionwith pharyngeal (and nasal ) diphther ia. Mixed (bacillusand str eptococcus ) infections ar e sometimes complicated bya septic diar rhma with gangr enous fd eto r , and at the sametime with pur pur a, nephr it i s and intestinal hemor rhages .Schwabe has r epor ted the case of a phys ician who di ed

1 50

DIPHTHERIA : SYMPTOMS AND TREATMENT

of a septic diar rhma contr acted by swallowing membranesaspir ated fr om a tr acheotomy wound.

The cases of diphther ia of the bladder , vagina, and

pen is r ecorded by me in my T r eati se of 1 8 8 0,pp . 8 6

90 , do not bear perhaps the p r esent test of bacter iologicaldiagnosi s . But sever al cases, so ver ified, o r diphther ia ofthe vagina, and of cir cumcision wounds have been seenby me since . One of the former was met with i n a cas eo f nasopharyngeal diphther ia, two o f them wer e followedby a faucial affection

,one of thes e was puer per al . The

inguinal lymph bodi es wer e not much affected, but a slight

swelling I never missed. One patient with diphther ia ofa ci r cumci s io n wound, neglected and gangr enous

, diedwith lar ge inguinal adeniti s . N iso t

,Bumm, and J . Whit

r idge Williams (Amer ican J our nal o f Obstetr ics, August,1 898 ) r epor t cases of diphther ia of the vagina (anduterus ) . In the case of the latter the woman was (possibly) in fected by the phys ician . H er new-bor n baby and

several other childr en caught the disease fr om her,and the

baby di ed.

Ther e i s r ar ely a case of diphther ia in which the lymphbodies in the neighborhood of the dis eased locality ar e

not affected. The latter determines the swelling whichis to take place . P r evious r emarks explain why a diph

ther ia limited to the tonsils does n o t cause much swellingof the lymph bodi es, o r why that of the vocal cor ds whenuncomplicated exhibits no secondary adeniti s at all

,and

why a nasal diphther ia with sanguinolent dischar ge fr omopen blood-vessels

,though constituting a formidable va

r iety of the di sease (the toxin being intr oduced dir ectlyinto the blood cir culation ) , should show no tumefied lymphbo di es . These ar e i r r itated by the absor ption fr om the

diseased sur face,the swelling cor r esponding both to its

locality and the gr avity of the case . Bacillary diphther ia,not o r but l ittle complicated with str eptococci , shows lessadeniti s than when the affection i s thor oughly mixed. Simple str eptococcic membr anes yi eld mor e adenitis than a

mild bacillary diphther ia. That is why so many cases ofscar latina in which the complication with str eptococci i smor e fr equent than that with bacilli, have mor e faucial

1 5 1

DR . JACOBI’

S WORKS

and cer v ical tumefacti on than diphther ia. Suppur ati on isless common in the Klebs-m fier affection—LennoxB r owne

’

s opinion notwithstanding—than in the str epto co c

cic o r in the mixed in fection . Lar ge abscesses ar e notfr equent . Though the swellings be ever so immense inmixed infections, they do not abound. Ther e may bemany of them,

but they ar e mostly small . The degenerati on whi ch takes place is r ather a necr osis and gangr enethan suppur ation .

The seat of the adeniti s cor r esponds with that of thediphther ia. The poster i or nar es co r r espond with the deepseated lymph bodi es below and near the angle of the lower

jaw to such an extent that this diphther ia,though no mem

br anes be vis ible,may thus be diagnosticated. In very

gr ave cases the swelling will even extend to the par otid.

The heart i s p r obably affected in every case of diphther ia. In Gerhard

’ s Handbuch der Kinderkr ankheiten,”

Vol . 1 8 77, I mentioned the symptoms with thei r ana

tomical foundation which I char acter i zed as ext ravasations ,cellular and nuclear alter ations (myocar dial) , and endocarditis , fir st mentioned by B r idges . Among 1 7 autopsiesr ecorded by Reimer ther e was fatty degeneration of thehear t in 6 , and ecchymosis of the myocardium in 3 cases .In addi tion to fr equent hyper armia o f the abdominal vi scer a ther e wer e emboli of the l iver in 3 , with capillaryhemor rhages in its per itoneal cover ing in 1

,and emboli

in the spleen in 5 cases .The symptoms do not always cor r espond with the tangi

ble anatomical changes . The r esults of the thousands ofanatomical and micr oscopi cal examinations which have beenmade these for ty year s , though they be insufficient toexplain the phys ical foundations of the mor bid symptoms,do not justify the establishment of a diphther iti c fever .

”

which I r esor ted to in 1 8 60 fo r the pur pose of classi fying just such cases in which the symptoms did not appearto be based on palpable changes Ther e i s no case everso mild appar entlv that will not affect the hear t

’

s functionat once to a cer tain extent . Fr om mi ld cases to the

gr avest ther e ar e gr adual tr ansitions The skin is pale,

yellowish, livid, cyanotic, sometimes the lividity and cya

1 52

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

often watery and dark,at t imes leucocytotic ; the latter

condition was also noticed by Bouchut and Labadi e-Lagr ave . Wunder lich r epor ted two cases of Hodgkin ’ s disease which developed dur ing diphther ia ; Bouchut and Dubr isay found l eucocytosi s wi th cons ider able dispr opor tionin the number of r ed and white cells

,which

,however

,was

not gr eat enough to justi fy the diagnosis of leucocythaemia.

Many examinations of the blood have been made since,

all with s imilar r esults . Thus Gabr itchevsky found hy

per leuco cyto sis in every case o f diphther ia. I t i s gr eatestin fatal cases ; dur ing convalescence and after the inj ect ion of antitoxin i t dimini shes . A p r ogr essive hyper leuco cyto sis in diphther ia justifies a bad pr ognosi s

,and the

analys i s of the blood gives useful information r egardingthe value of tr eatment . Ordinar i ly the white cells vary between and and in fatal cases between 29,50 0 and J . L . Mor se, who quotes Gabr itchevsky,comes to similar conclus ions (Boston City Hospital Repor ts

,1 895 )

The ner vous system i s pr ofoundly affected by diphther ia.

Dur ing the fir st days of a pharyngeal diphther ia the softpalate may so swell as to inter fer e with r espiration and

deglutition . In most cases an impr ovement will take placewith the r esti tution of the tis sues to a fair ly normal si ze,and the local par alysi s will be only appar ent . In othercases thi s appar ent par alys i s may change into an actualone in the second o r third week o r later . Usually, however ,the difficulti es of r espi r ation and deglutition ar e moder ate—indeed

,par alys i s i s liable to follow appar ently mild cases

in pr efer ence to those which exhibit a vast amount ofpharyngeal exudation—and after convalescence has actuallyset in o r pr ogr essed fo r some time a pecul iar ar r ay ofsymptoms will make its appear ance. Usually the par alys isbegins in the thr oat, the uvula appear s elongated

,the soft

palate becomes gr adually immovable, ar ticulation is nasal .deglutition becomes difficult, fluids instead of being swal

lowed may be di schar ged thr ough the nose, o r,when the

muscles of deglutition ar e becoming par alyzed, run downthe larynx and cause cough and pneumonia. Thi s par alys i s of the soft palate is mostly bilater al, sometimes un i

1 54

DIPHTHERIA : SYMPTOMS AND TREATMENT

later al . A week o r two after the beginning of the pharyngeal par alys i s, often whi le it i s getting better , the aecommodatio n of ocular movements becomes faulty in co nse

quen ce of the symmetr ical par alvsis of the ciliary ner ves(Eulenbur g ) . Par alyses of the 1n ter nal and exter nal r ectus ar e less symmetr ical . The pupils ar e not affectedother br anches of the motor ocul i and the abducens butr ar ely. Total ophthalmoplegia has been obser ved in a fewcases only. After thousands of similar obser vations havebeen made

, the obser vations of Scheby-Buch ar e still classical . Of 3 8 clinical cases of par alys i s o f accommodation2 4 r esulted fr om diphther ia ; of these 20 wer e located inthe thr oat

,3 star ted fr om wounds, 1 fr om the vagina

,1

fr om the skin . Ther e was no mydr ias i s, with one exception . Refr action

,which was invar iably dimini shed, and

vision,whi ch was slightly impair ed, became normal again

with the r estor ation of health. This par alys is o f accom

mo datio n was complicated with par alysi s of the palate in1 0 cases

,in 9 cases it was uncomplicated, as in many

other instances noticed befor e and after Scheby-Buch.

Sometimes it would occur sever al o r many weeks after theappear ance of the pharyngeal par alysi s .Next in the usual order i s par alys is of the muscles of

the trunk and of the upper and lower extr emities, fr equently pr eceded by paraesthesia o r anaesthesia of some o r

all the finger s and the palm (and o ther par ts of the hands )and feet

, also of other par t s of the sur face . These af

fectio ns of the sensitive ner ves may be quite local . I havemet with ana sthesia of the trunk . Even the sensoryner ves may become par alyt ic, the or gan of taste in a caseo f Magne ’s ; mor e instances may be found in my Tr eati se

,p . 1 0 1 , in some of whi ch the sens itive changes wer e

such as to cause ataxia. The temper atur e sense has beenfound dimini shed sometimes . The motor par alys is o f theextr emities may incr ease until the limbs ar e entir ely useless fo r weeks ; as a pecul iar mitigation may be mentionedthe compar ative immunity of the finger s in many cases .The sphincter s of the bladder and of the anus ar e r ar ely

affected,likewise the muscles of the larynx and the r espi

r ato ry muscles . When both the exter nal r espir atory mus

1 55

DR . JACOBI’

S WORKS

cles and the diaphr agm ar e mildly taken ther e i s cough,

flapping thor acic r espir ation,

and some dyspncea. Insever e cases the pat ient dies o f apnoea

,sometimes sud

den ly. Per istalsi s is r ar ely par alyzed ; but a single caseof extr eme constipation has come to my notice, and Baginsky, with his ample oppor tunities fo r obser vation

,has seen

a few only. Hemiplegia i s found but r ar ely, and scar celyat all in the very young . One such case has been published by J . W. B r anan . This w r iter says : Ther e ar e

thi r ty-five cases in all r ecorded in medical li ter atur e of

postdiphther iti c par alys is of cer ebr al or igin . Six caseshave come to autopsy; in o ne o f these a hemor rhage wasfound in the inte r nal por tion of the lenticular nucleus , withdestruction of the neighbor ing par t o f the in ter nal capsule . In the other five cases ther e was embolism of theSylvian ar tery. In the total thi r ty-s ix casesther e was complete r ecovery in four , death in seven ; inall the other s ther e was permanent par alysi s of gr eater o r

les s extent .A case of acute dis seminated scler osi s of the spinal cor d,

with neur iti s,in diphther ia has been r ecorded by S . G .

Henschen (Ber lin,The per ipher al ner ves act according to no rule . Some

times the knee r eflexes ar e diminished o r absent ear ly, at

other times late . Reaction of degener ation i s quite commonin advanced cases

, but will di sappear in the cour se of thegener al r ecovery.

In the beginning of a diphther ia the p r ediction that

par alys i s will follow o r not cannot be made . The ver v

wor st cases may be spar ed, mild ones will often be followed by par alys i s ; the latter fact has been substantiatedin cer tain e xper iments made by Heubner . The locationof the diphther itic p r ocess i s indiffer ent in r egard to paralysi s ; i t was found twenty

-five year s ago by Gaytto n .

Scheby-Buch

,and myself, al so by Maingault ( 1 8 5 4 ,

who deser ves the cr edit of having added most (afterBr eto nneau) to our acquaintance with diphther i tic par alysi s

,to be connected with diphther ia of the genital or gans .

The cause of par alysi s i s not local but gener al and toxic .In some seasons and epidemics the per centage of diph

1 56

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

the gr ay substance of the cord voluminous nuclear infiltr ation, in one case extens ive hemor rhages in the spinal men

inges, with nuclear pr oli fer ation in the gr ay substance ofthe cord ; Pier r et found di s s eminated meningitis with per ineur i t i s o f the neighbor ing r oots

,char acter i zed by in fil

tr atio n of nuclei between the ner ve fibr illae; Char cot andVulpian, degener ation of the palati ne ner ves and fattydisin tegr ation of the palatine muscles ; Dej er ine, atr ophyof the anter i or - r oots secondary to a myelitic degener ationof the ganglia of the anter ior hor ns ; al so in two casesliquefaction of myelin and loss of axis cylinder s in in

tr amuscular ner ves .The changes caused by diphther ia in the ner vous sys

tem as descr ibed by one of the very latest wr i ter s on thismuch di scussed subj ect (John Jenks Thomas , Boston CityHospital

,1 898 ) ar e : 1 . Mar ked par enchymatous degen

er atio n o f the per ipher al ner ves,sometimes accompanied

by an inter stitial pr ocess and by hyper aemia and hemo r

rhages ; 2 . Acute par enchymatous degener ation of the

ner ve fibr es of the cord and br ain ; 3 . No changes o r but

slight ones in the ner ve cells ; 4 . Acute par enchymatousand inter stitial changes in the muscles , especially in the

hear t muscle ; 5 . Occas ional hyper aemia o r inflammationo r hemor rhages in the br ain cor d, o r in r ar e cases sever eenough to pr oduce permanent tr oubles such as multiplescler osis o r hemiplegia . The wr iter adds that car diac deathpr obably takes place thr ough the action of the toxin on thecardiac ner ves . It i s ev ident that the last twenty year shave not added much, i f anything, to the findings of theauthor s of decades ago .

To thi s may be added the r esult s of some late exper i

mentation -When B . Mour avieff inj ected diphther ia toxininto the subcutaneous ti s sue o r into the per i toneum ofguinea-pigs

,acute o r chr onic symptoms made thei r appear

ance . Among the former wer e, in the ganglion cell o fthe anter ior columns of the spinal cord, per ipher al chr o

mato lysis and extensive vacuolization , but no anaesthes iano r par alys i s ; among the latter wer e par alysi s and mor eneur iti s than ganglion-cell changes . Extensive per ipher alneur iti s was found only after five o r s ix weeks .

1 5 8

DIPHTHERIA : SYMPTOMS AND TREATMENT

PROGNOSIS

Epidemics differ . In some, mostly on account of thepr evalence of mixed infections

,the mor tality i s high, in

o ther s i t i s low . The last few year s, not thr ough the in~

fluen ce of antitoxin only, have been decidedly favor able,compar ed with many epidemics s ince 1 8 5 8 . The pr ognosi sshould always be consider ed uncer tain

,i f only fo r the

multiplicity and var i ety of poss ible complications .P r evious good health and vigor do not insur e a good

pr ognosi s . Not infr equently a system accustomed to suf

fer ing, o r perhaps immunized against known and unknowninfections

,though the gener al conditi on may seem unfavor

able,will escape destruction

,while a r obust chi ld will

soon succumb . That i s why the r ich suffer at least as muchas the poor . But when the infection is at an end, convalescence i s speedi er and mor e uninter rupted in the vigorous and well-to-do . P r obably the exter nal c ir cumstances

,

better air,change of r o om

,mor e thor ough disinfection of

r o oms i f ther e was a p r ev ious case,have a good deal to

do with that r esult .Very young age i s unfavor able . The mor tality i s gr eat

est below the fir st year o f li fe, very lar ge between the

third and four th,low after the eleventh o r twelfth.

Childr en ar e mor e liable to suffer than adults . Verv

o ld people ar e almost immune ; still I have seen a man ofeighty-six year s who had diphther ia and r ecover ed. Veryyoung infants ar e less subj ect

,though, when they ar e

taken,mor e endanger ed than chi ldr en of fr om one to five

year s ; sti ll in 1 8 8 0 I r epor ted and quoted cases of diphther ia whi ch occur r ed in the newly—bor n . In r egard tomorbidity ther e appear s to be no differ ence as to sex ; mo rtality, however , has always been gr eater in boys . Amonginfants les s than seven o r eight months o ld the maj or ityo f cases occur under the thi rd month.

In the child the mucous membr ane of the mouth, thr oat,and nose i s very soft and succulent ; catar rhal and inflammato ry changes with thei r epithelial alter ations ar e fr e

quent ; the nasal cavities ar e nar r ow ; the tons ils ar e com

par atively large, indeed they ar e but r ar ely cover ed by

1 59

DR . JACOBI’

S WORKS

the anter ior pillar s . Thus invasion and r etenti on of bacilliar e facili tated. The lar ge si z e and number of the lymphvessels pr edi spose to the absor ption of toxins when formed.

Chi ldr en who ar e able to cr eep and to walk do not excelin cleanliness . Thei r finger s ar e equally well acquaintedwith their nar es and thei r mouths as with the dust, dir t ,and par asitic deposits on the floor of the r oom . Theirlips ar e tentacles which examine and lick the crumbs onthe floor

,the toys in the dust, many of whi ch ar e of wood

o r o f felt and harbor er s of dust and micr obes . Thei r facesand hands ar e s eldom clean

, and their handker chi efs and

towels ar e common pr oper ty .

Such babies as cannot cr eep o r walk ar e safer becausethey ar e mostly kept away fr om the floor and in theirbeds ; they ar e not in intimate contact with thei r equalsand possible sour ces of infection

,but ar e nur sed by adults .

Their food i s br east milk, o r when ar tificial it i s boiled.

I t was noticed a long time ago by Home and Canstatt thatbabies at the b r east had but little dispos ition to c r oup .

”

Indeed such infants ar e not so subj ect to any of the contagious and in fectious di seases as older childr en . PerhapsSchmid and Pflan z (Wiener medizin ische Wo chenschr ift,No . 4 2 , 1 896 ) ar e cor r ect in their opinion that woman ’

s

milk contains antitoxic mater ials ; perhaps the immun iz

ing alexins of the blood serum in the newly—bo r n ar e suf

ficien tly power ful to guar d against infections to a cer tai nextent .After the thi rd month of li fe ther e is a copious secr e

tion,s lightly acid

,fr om the mouths of infants . Both its

quantity and its r eaction militate against micr obic invasion ;that i s why at that per iod diphther ia i s less common thaneven in the fir st per iod of life ; even a common angina i snot fr equent unless in cold seasons o r after sudden changeso f temperatur e, o r when or iginating fr om a nasal catar rhwhi ch i s of fr equent occur r ence .The pr ognosi s i s favor able when the affected sur face

i s not extensive and not in very intimate connection withthe lymph cir culation . That i s why uncomplicated diphther ia o f the tonsil s and local cutaneous diphther ia, whichlatter i s very amenable to tr eatment, ar e apt to be mild.

1 60

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

diphther ia—and a gener al catar rhal laryngiti s . A pseudocr oup i s ther efor e liable to set in with a high temper atur e ; a laryngeal diphther ia i s not attended w ith feve rso long as i t i s local and uncomplicated. Still

,an attack

of diphther ia may set in with a high temper atur e—evenconvulsions ar e obser ved

,par tly occas ioned by high tem

per atur e, par tly by toxin—which will fal l with the speedyelimination of the toxin . Low temper atur es do not meana mild char acter of the infection ; on the contr ary, a lowtemper atur e may attend cases of gr eat gravity. Subnormaltemper atur es ar e very ominous ; they accompany astheniao r collapse . I f a moder ate temper atur e be followed bya sudden r i se

,thi s may signi fy a sudden extension of the

disease,but means usually the advent of a complication in

a di stant or gan . A cold. clammy sur face is a s ign of badp r ognostic impor t .The puls e i s very var iable . I t is s eldom p r op or tionate

to the r espir ation,being usually mor e r apid. So long as

i t i s of fair volume, and n o t too much out of pr opor tionto the temper atur e of the body, the hear t i s str ong enough ;as soon as i t becomes r apid and feeble

,and mor eover i r

r egular,the pr ognosis becomes mor e gr ave . Under these

ci r cumstances the most active stimulation is demanded.

In some instances the weak hear t i s not even able to mul~

tiply its beats, and the puls e becomes slow—a most dan

ger ous symptom . I f a fr equent,compr ess ible

,and inter

mittent, o r a slow and intermittent pul s e be met with, together with a puffy, leaden, apathetic

,and cachectic face,

the pr ognosis i s quite bad.

All of these symptoms mean a deter i or ation of the hear t’

saction either by the di r ect effect of toxin on the ner ves—a genuin e cardio—pulmonary par aly s is—o r by the pr esence of clots in the hear t , of my ocar dial dis integr ation ,o r of

_

a r eal ulcer ous endocar dit is . The latter i s,however ,

mor e commonly the r esult o f a str eptococcal than of an

uncomplicated bacillary invas ion .

Affections of the blood-vessel wal ls leading to petechiae

o r ecchymoses imply a bad,but not a fatal , pr ognosis .

The otitis media accompany ing o r depending upon diphther ia i s pr ognostically not so bad as that which i s oh

1 62

DIPHTHERIA : SYMPTOMS AND TREATMENT

ser ved in measles o r scar latina. Though deafness i s notan in fr equent outcome, oper ations ar e not so often de

manded. Meningitis may occur in the contiguity of theti ssue o r by lymph communication ; in either case it o r iginates fr om the pharynx o r fr om the nar es

,and often

passes thr ough the cr ibr i form plate .Pulmonary complications impair the p r ognosi s . B r oncho

o r cr oupous pneumonias, many of whi ch ar e caused byaspir ation of mor e o r less septic mater ial

,pulmonary hem

o r rhages, atelectasi s caused by local impediments, and ner vous incompetency ar e danger ous . The descent of membr ane fr om the larynx o r the spontaneous formation ofmembr ane in fibr in ous (not always diphther i tic) br onchiti sis danger ous .Par alysi s of the laryngeal muscles and the pr esence

o f pseudomembr anes in the lar ynx ar e gr avecomplications . Ther e was a time when almost every pa

ti ent was doomed, vi z .,befor e tr acheotomy was intr oduced

by von Roth, K r ackowizer , and Voss into Amer ican pr actice . Even then the p r ejudice against the oper ation wasgr eat . When I per formed it fr equently after 1 860 a

famous sur geon was known to ask in all ser i ousnes swhether Dr . J . did not cut too many thr oats . Its r esultswer e impai r ed by impr oper p r ocr astination and by the septic char acter o f many of the epidemics . Impr oved antisepsis in tr acheotomy, and O

’

Dwyer’

s intubation, whichhas almost enti r ely r eplaced the former oper at ion , and i tscombination with the use of antitoxin have so much r e

duced the mor tali ty of laryngeal diphther ia that o ld sta

tistics have lost all except their histor ical value .Albuminur ia, which i s often obser ved on the third o r

four th day of the di sease, i s not by itsel f a gr ave symptom .

Lar ge quantities of albumin will sometimes di sappear i na s ingle day o r in a few days—as they will occasionallydo in other affecti ons of the thr oat.

‘

Se'

long as the amounto f ur ine and the per centage of ur ea ar e normal o r near lyso, the danger i s tr ifl ing . But the pr esence of many epithelial cells

,lar ge casts, o r blood, diminished o r absent

mictur ition, and perhaps even gr een o r fecal vomiting, ar e

grave symptoms . The intactness of the cer ebr al faculties

1 63

DR . JACOBI’

S WORKS

dur ing these attacks of nephr iti s should not be taken as

a mitigating sign . In many cases and in many differ entepidemics I have seen consciousness pr eser ved until withina few minutes befor e death. I t i s for tunate that actualnephr i ti s i s not so common in diphther ia as it i s in scarlatina ; altogether diphther it ic nephr iti s i s not fatal to thesame extent as the same di sease when occur r ing in scarlatina.

The aver age case of diphther itic par alysi s permits of a

fair pr ognosis . The pati ent gener ally gets well in fr omsix to eight weeks under p r oper t r eatment . Extensiveneur iti s with fatty degener ation of the myocar dium may

par alyz e the hear t ; par alys i s of the pharynx and of thevestibule of the pharynx may lead to aspi r ation pneumonia ;ciliary par alys is may r emain permanent ; that of the r espir ato ry muscles may cause apnma and death, and that ofthe sphincter s of the anus and of the bladder

,in the r ar e

cases in which they have been obser ved, o r of the spinalcord (tabes, hemiplegia) may last for ever . That i s whythe p r ognosi s in every case of diphther ia should be a

guarded one unti l r ecover y i s found to be complete .

TREATMENT

P r even tive Tr eatmen t. —P r evention i s par tly the bus ines s of the physician, but should be mostly that of the individual, o r of the complex o f individuals

,vi z .

,the town

,

state,o r nation . A chi ld s ick with diphther ia must be i so

lated, though the case appear ever so mi ld, and i f poss iblethe well childr en should be sent out o f the house . I f thatbe impossible

,let them r emain outside

,in the open air

,as

long as; feasible ; let them sleep in the most di stant par t ofthe dwelling with open bedr oom windows dur ing the night,and let their thr oats be examined every day. The watchfuleye of an intelligent father o r mother may discover deviatio ns fr om the norm

,so that the phys ician can be noti

fied. Let the temper atur e of the well childr en be takenonce a day, in the r ectum . The expenditur es o f a few minutes of a mother

’ s time will be r epaid by the, di scovery of aslight anomaly, which may r equir e the pr esence of the phy

1 64

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

issued the following school r egulations , which, i f obeyed,cannot fail to have a good influence and should be adoptedby s imi lar author it ies .

1 . Each day dur ing the pr evalence of infectious disease, after the school is dismissed the j anitor i s to scrubwith warm water

,soap

,and a stiff scrubbing-brush all

par t s of door s, casings, and other woodwor k which can betouched by the hands o f childr en . 1 1 . The floor shouldbe in good r epair and without open cr acks o r cr evices .It should be sp r inkled with clean water daily befor e beingswept . I II . Lead pencils (ther e should be no slates )should every day be immer sed in a five—per—cent . solution

of car bo lic acid and wiped dry. IV . Books whichhave been used by a pupil who i s suffer ing fr om any oneof the commun icable di seases should be destr oyed by fi r eo r they may be tr eated by exposur e to formaldehyde gas.

V. Dur ing each vacation the walls and woodwor k shouldbe wetted with a solution o f bichlor ide of mer cury( 1 : 1 0 0 0 ) and the windows should be kept open to admitgr eat floods of sunli ght and pur e air . VI . Water cooler sar e un clean and unneces sary. They should not be al~

lowed i n school buildin gs . When pr acticable dr inkingfoun tains, consi sting of a j et of water r i s ing fr om the

center of a piece of mar ble,r equir ing no cups

,should be

supplied. VII . Individual s eats and desks should be pr ovided in every school . VII I . Light and ai ry cloakr oomsshould always be pr ovided, and hooks should be so separ ated that the garments of di ffer ent pupils will not comeinto contact .

”

In times of an epidemi c,every public place, theatr e,

ballr oom,dining-hall

,taver n

,should be tr eated like a ho s

pital . Wher e ther e i s a lar ge conflux of people,ther e

ar e cer tainly many who car ry the di s ease with them. The

spitting nui sance should be per s istently suppr essed. Disinfection at r egular inter vals should be enfor ced by the

author ities . Publi c vehi cles must be so tr eated. Thatthey should be dis in fected after a case of smallpox hasbeen car r i ed in them is deemed qui te natur al . Hardly a

livery stable—keeper would be found who would not beanxious to destr oy the poss ibility of infection in any o f

1 66

DIPHTHERIA : SYMPTOMS AND TREATMENT

his coaches . He must lear n that diphther ia i s, o r may be,as danger ous a passenger as var iola. An d what i s validin the case of a hack i s mor e so in that of r ai lr oad car s

,

whether emigr ant o r Pullman . They ought to be thoroughly di s infected in times of an epidemic

,at r egular in

ter vals,fo r the highr oads of tr avel have always been those

of epidemic di sease,and r ai lr oad officer s and their famili es

have often been the fir st victims, o f the impor ted scour ge .Can this be accomplished ? Will not r ailr oad companiesr esist a plan of r egular di s in fection because of its expensivenes s ? Will ther e not be an outcry against thi sdespotic violation of the r ight s of the citizen, and the

independence of the moneybag ? Cer tainly. But that alsohappened when municipal author ities began to compel parents to keep thei r chi ldr en at home when ther e wer e contagious diseases in the family , and when a smallpox patient was ar r ested because of endanger ing the pas senger sin a public vehicle . In such cases

,i t i s not soc i ety that

tyr anni zes the individual ; it i s the individual that endanger ssoci ety. And society begins at last

,even in Amer ica

,to

believe in the r ights of the commonwealth, as compar edwith the exclus ive r ights o f the democr atic enemy of all

the r est . The establishment of state and national boardsof health pr oves that the nar r ow-minded theor i es of thestr ict constructionists have not only di sappear ed fr om our

politics, but also fr om the conscience and intellect of

soc i ety.

As stated above,every case of diphther ia demands i so

lat ion,dur ing the winter on the upper floor o f the dwell

ing ; the windows should be open as much as possible, thefur nitur e of the s ick-r oom r educed to the least poss iblequantity, the r oom changed i f po ss ible every few days,and the bedding r enewed fr equently.

To what extent the infecting substance may cling tosur r oundings i s best shoW

‘

n'

b y'

the cases of diphther iaspr inging up in pr emi ses whi ch had not seen diphther iafo r a long time, but had not been inter fer ed with ; and best,

perhaps , by a ser ies of obser vat ions of autoinfection . Whena diphther itic pati ent has been in a r oom fo r some time,the r oom

,bedding, cur tains, and car pets ar e infected ; the

1 67

DR . JACOBI’

S WORKS

chi ld i s getting better , has a new attack,may again im

pr ove, and i s again str icken down . I have seen some ofthese childr en die ; but al so other s who impr oved immediately after havi ng been r emoved .fr om that r oom o r thathouse . I f in any way poss ible, a chi ld with diphther iaought to change its r oom and bed every few days .The sick

,in cr owded houses and quar ter s ought to be

tr ans fer r ed to a special hospital,which ought not to be

to o lar ge. The Willard Parker Hospi tal of New York,

with its s eventy beds fo r scar latina and diphther ia,estab

lished thr ough the combined effor ts of the medical pr o fession

,

5 i s in that r espect a pr aisewor thy example . The lar geamount o f good i t i s doing would gr ow in geometr i cal pr o

gr essio n i f ther e wer e, as ther e ought to be in a lar ge andambitious metr opolis

,half a dozen institutions of the same

clas s,not only fo r the poor

,but

'

fo r the well-to-do al so,

both towns-people and stranger s . I have advocated, fo rdozens of year s, the er ection of a hospital fo r the accom

modation of infectious diseases br eaking out among the

thousands of str anger s stay ing in New Yor k City at all

times. As long as ther e is no place fo r them to go to,the cases of scar latina, diphther ia, etc ., ar e hidden in theboarding-houses and hotels

,and ar e infecting the popula

tion at lar ge . I t i s but a few year s s ince a movement fo rthe establishment of such an institution was begun ; thehospital fo r scar latina and diphther ia was finally established a year ago .

When diphther ia br eaks out in a house,either pr ivate

o r tenement with no faci lity fo r isolation , and wher e ther ei s no hospital in whi ch to seek r efuge

,the well should be

r emoved to a healthy place ; in lar ge citi es, tempor aryhomes ought to be pr ovided fo r that pur pose, to benefitthe chi ldr en of the poor . I f the r ich would but r ememberthat thei r childr en will be affected thr ough the many l inksbetween them and—the poor ( ser vants, messenger s, schools,dr esses br ought home fr om the tailor o r s eamstr ess, o r purchased - in the stylish and expens ive establishments which

5 8 ce my pr esidential a ddress befo r e the Medical So ciety o f

the State -o f New Yo rk in the T r ansactio ns o f 1 882 . "Vo l. vii o fthe pr esent editio n o f Dr . Jacobi’s Wo rks ]

1 68

https://www.forgottenbooks.com/join

DR . JACOB I ’S WORKS

sity of keeping the mucous membr anes moist, and of pr eventing fissures and dis integr ation of the epithelia. Inthe last two o r thr ee decades the latter advi ce has beenins isted upon by all those who had waked up to the neces

sity of pr evention . Among other s C . G . Rothe ( 1 8 8 4 ) ad

vised besides hygienic measur es the fr equent use by all the

inmates o f a str i cken house of a gar gle consisting of car

bo lic acid,alcohol

,tinctur e of iodine

,glycer in, and water ;

also the use by all chi ldr en of a school of a solution ofthymol ( 1 : and cyanide of mer cury fo r the verymildest affections . In connection with such advice oner emar k will always be in o rder

,vi z that medicinal gar gles

and ir r igations should not be as unpalatable and malodorous as they can possibly be made ; chi ldr en should not bemade to look upon p r eventive measur es as a punishment .I t was not always good-will and intelligence o r knowl

edge that dictated either r easoning o r r ecommendations .Ther e i s J . Renan fo r instance, who in his Diphther i e

,

”

Par is,1 8 89, r ecommended the fr ee use

,among pr eventives,

of sulphur ous acid and tur pentine . Altogether the liter atur e of diphther ia i s not fr ee even fr om r eligious and

political bias . Accor ding to Renan ’ s monar chi stic pr ejudices the in fer ior ity of pr eventive pr actice in (r epublican )F r ance is due to the changeabil ity o f its gover nment .According to that theory Turkey and Russ ia would excelin pr eventive medicine

,fo r—bar r ing occasional assassina

tions—thei r gover nments ar e stable enough.

Fo r its salutary effect on the mucous membr ane of themouth

,chlor ate of potassium o r of sodium, whi ch i s sti ll

claimed by some to be a specific in diphther ia, o r almostso

,i s counted by me among the pr eventive r emedies . I f

it be anything mor e, i t i s an adjuvant only. I t exhibi tsits best effects in the catar rhal and ulcer ous condi t ion ofthe or al cavity. In diphther ia it pr eser ves the mucousmembrane in a healthy co ndition o r r estor es it to health.

Thus it pr events the diphther itic pr oces s fr om spr eading .

Diphther ia i s seldom obser ved on healthy o r appar entlyhealthy ti s sues . The pseudomembr ane i s mostly sur r oundedby a sor e

,hyperaemic, oedematous mucous membr ane, to

which it will then extend. Indeed, thi s hyperaemia pr e

1 70

DIPHTHERIA : SYMPTOMS AND TREATMENT

cedes the appear ance of the diphther i tic exudation in al

most every case . The exceptions to thi s rule ar e formedby thos e cases in which the virus may take r oot in the inter stices, pointed out by Stoehr , between the normaltonsi llar epithelia. Indeed

,many cases of thr oat disease

occur r ing dur ing the p r evalence of an epidemic of diphther ia ar e but cases of pharyngitis which develop onlyunder favor able cir cumstances into diphther ia. Thesethr oat di s eases ar e so very fr equent dur ing the r eign o f

an epidemic that in my fir st paper on diphther ia,while

r epor ting two hundr ed cases of genuine diphther ia,I

mentioned besides one hundr ed and eighty-five of pharyngiti s without a vis ible membr ane .These cases of pharyngitis , and those of stomatiti s and

pharyngitis which accompany the pr esence of membr anes,ar e benefited by the local and gener al effect o f potass icchlorate . When the sur r ounding par ts ar e healthy o r r e

tur n to health, the pseudomembr ane r emains ci r cumscr ibed.

The gener ally benign char acter of pur ely tonsillar diphther ia, which i s apt to run i ts full cour se in fr om four tos ix days, has in thi s manner contr ibuted to secur e to

chlor ate of potass ium the undeser ved r eputation of beinga r emedy, the r emedy, in diphther ia. The dose of the saltmust not be lar ger

,in twenty-four hour s

,than gr . xv .

( 1 gm .) fo r an infant a year o ld,not over gr . xx . o r xxx .

—2 gm.) fo r a child fr om thr ee to five year s . An adul tshould not take mor e than 3 i s s . (6 gm . ) dai ly. Theseamounts must not be given in a few lar ge doses , but infr equent doses and at shor t inter vals . A solution of 1

par t in 60 may be given in doses of a teaspoonful everyhour o r hal f a teaspoonful every half-hour in the case ofa baby one o r two year s o ld.

I t i s not too late yet to r ai se a war ning voice againstthe use of lar ger doses . Simple truths in pr actical medicine do mor e than mer ely

‘

bea—r

' fl

fepetitio n—they r equir e

it . Fo r though the cases of actual chlor ate of potass iumpoisoning ar e no longer i solated, and ought to be gener ally known , fatal accidents ar e still o cur r ing even inthe pr actice of physicians . When I exper imented on myself with half-oun ce doses, for ty year s ago , the r esults

1 7 1

DR . JACOB I ’S WORKS

wer e some gastr ic and intens e r enal i r r i tation . The samewer e exper i enced by Foun tain, o f Davenpor t

,Iowa

,whose

death fr om an ounce ( 3 0 gm .) of the salt has been im:pr essively descr ibed i n Alfr ed Stille

’ s Mater ia Medi ca,

”

fr om which I have quoted in my Tr eati s e on Diphther ia.

”

His death fr om chlor ate of potass ium induced me to war nagainst lar ge doses in my lectur es as ear ly as 1 860 . Inmy contr ibution to Gerhar dt

’

s Handbuch der Kinderkr ankheiten,

” Vol . 1 8 77 , I spoke of a s er i es o f caseskn own to me per sonally. In a paper r ead befor e the

Medical Soci ety of the State of New Yor k (Medical R ec

or d, Mar ch 1 5th, 1 8 79) I tr eated of the subj ect monogr aphi cally, and alluded to the danger s attendi ng the pr omiscuous use o f the drug, which had even then descendedinto the r anks of domestic r emedies ; and final ly, .

,in my

Tr eati se on Diphther ia,

” I collected all my cases and thefew then r ecor ded by other s . S ince that time numer ousin stances have been r epor ted. Death pr obably occur s fr ommethaemoglobinur ia ( as shown by Mar chand

,of Halle, i n

pr oduced by the pr esence of the poi son in the blood,and by consecuti ve nephr iti s . .

The conscientious use of salt water as a pr eventive measur e will p r ove mor e successful—when combin ed with the

daily cold-water bath o r ablution—than all the offensivesmells and tastes which have been r ecommended.

Lar ge tonsils should be r esected and adenoid gr owthsr emoved while ther e is no diphther ia ; fo r dur ing an epidemic every wound i n the mouth i s l iable to become diphther itic

,and such oper at ions o ught to be postponed, i f

feas ible . The sco oping o ut of the tonsils, fo r whatevercause

,I

_have given up s ince I became better acquainted

with theuse, under cocaine, of the galvanocautery. F r omone to four applications to each side ar e usual ly sufficientfo r every case of enlar ged tonsils o r chr onic lacunar o r

deep-seated '

fo llicular amygdal iti s I t i sadvisable to cauter i z e but o n e side . at a t ime, in order toavoid inconvenience in swallowing afterwar ds, and to bur nthe sur face inward. Cauter i zation of the center of theto nsils may r esult in swelli ng, pain, and suppur ation, unless the cautery i s car r i ed entir ely to the sur face ; that

1 72

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

di s ease appear ed to fur nish a contraindication to the in

j ectio ns.

Similar r esults have been obtained in New York and

elsewher e. The dur ation of the immunity so obtained i s,however

,limited. I t has fr equently been obser ved that a

dose of fr om two to four hundr ed units of antitoxin , whengiven fo r immunizing pur poses, appear ed to be successful,until the child was taken with diphther ia thi r ty o r for tydays after the inj ection .

In connection . with the pr eventive measur es detai ledabove

,I now add

,though they be in par t a r epetition of

what has been said, the r egulations o f the New YorkHealth Depar tment which have been in for ce fo r sometime . They ar e clear

,concise

,and to the point .

I f possible,one attendant should take the entir e car e

of the s ick per son,and no one else besides the physician

should be allowed to enter the s ick- r oom . The attendantshould have no communication with the r est of the family.

The member s of the family should not r eceive o r makevi sits dur ing the illness .

The dischar ges fr om the nose and mouth must ber eceived on handker chi e fs o r cloths , whi ch should be at

once immer sed i n a carbolic solution (made by disso lv

ing six ounces of pur e car boli c acid in one gal lon of ho twater

,whi ch may be diluted with an equal quantity of

water ) . All handker chiefs cloths towels,napkins

,bed

l inen,per sonal clothing, night clothes, etc . , that have come

in contact in any way with the s ick per son,

afteruse should be immediately immer sed without r emoval fr omthe r oom in the above solut ion . These should be so akedfo r two o r thr ee hour s, and then boiled i n water o r soapsuds fo r o ne hour .

In diphther ia and scar let fever , gr eat car e should betaken in making applications to the thr oat o r nose, thatthe dischar ges fr om them in the act of coughing ar e notthr own into the face o r on the clothing of the per son making the applications, as in thi s way the disease i s likelyto be caught .

The hands of the attendant should always be thor

1 74

DIPHTHERIA : SYMPTOMS AND TREATMENT

oughly di s infected by washing in the car bo lic solution,

and then in soapsuds, after making applications to the

thr oat o r nose, and befor e eating.

Sur faces of any kind soiled by the dischar ges shouldbe immediately flooded with the car bolic solution .

Plates, cups, glasses , knives forks, spoons, etc ,

usedby the sick per son fo r eating and dr inking must be keptfo r his e special use

,and under no cir cumstances r emoved

fr om the r oom o r mixed with s imilar utensils used byother s

,but must be washed in the r oom in the car bolic

solution and then in ho t soapsuds . After use the soapsuds should be thr own into the water -closet and the vesselwhich contained it should be washed in the carbolic so

lutio n .

The r oom occupied by the si ck per son should be thoroughly air ed sever al times daily, and swept fr equen tly,after scatter ing wet newspaper s

,sawdust

,o r tea leaves on

the floor to pr event the dust fr om r ising . After sweeping,the dust upon the woodwor k and fur nitur e should be r e

moved with damp cloths. The sweepings should be bur ned,and the cloths soaked in the car bolic solution . In coldweather

, the s ick per son should be pr otected fr om dr aughtsof air by a sheet o r blanket thr own o ver his head whilethe r oom i s being air ed.

When the contagious natur e of the di sease i s r ec

ogn ized within a shor t time after the beginning of the

i llnes s,after the appr oval of the Health Depar tment in

spector,it is advi sed that all ar ticles of fur nitur e not neces

sary fo r immediate use in the car e of the s ick per son ,

especially upholster ed fur nitur e, car pets, and cur tains,should be r emoved fr om the sick-r oom .

When the patient has r ecover ed fr om any one of thesediseases the entir e body should be bathed and the hai rwashed with ho t soapsuds and the pati ent should be dr essedin clean clothes (which have _

n o t b een -i n the r oom dur ingthe s ickness ) and r emoved fr om the r oom . Then the

Health Depar tment should be immediately notified, and

disinfector s will be sent to di s infect the r o om, bedding,clothing, etc.

, and under no conditions should it be again

1 75

DR. JACOBI ’S WORKS

enter ed o r occupied unti l it has been thor oughly disin

fected. Nothing used i n the r oom dur ing the s icknessshould be r emoved until thi s has been done .

The attendant,and any one who has ass i sted in car

ing fo r the s ick per son,should also take a bath, wash

the hair,and put on clean

'

clo thes, befor e mingl ing withthe family o r other people after the r ecovery of the patient. The clothes wor n in the sick-r oom should be leftther e

,to be di s in fected with the r oom and i ts contents

by the Health Depar tment.Among the di s infectants employed to advantage in dwell

ings formalin has of late taken a high r ank . A spr ay ofa two-per -cent. solution has been found avai lable . Fr om60 to 70 c .c . of dissolved concentr ated formalin i s beli evedto be sufficient fo r the space of one cubic meter (thir tycubic feet) . One gr am o f formaldehyde evapor ated fr omScher ing

’

s lamp o r other appar atus r ender s the same ser

vice ; o r the substance may be allowed to evapo rate gr adually. Meanwhi le the eyes should be pr otected by glasses,the nose by a mask

,the hands by vaseline . Still , i f

Symansky be cor r ect (Zeitschr ift fii r Hygiene, etc ., xxvi ii .,1 898 , p . even formalin leaves much to be desi r ed.

He claims,whil e mentioning in its favor that i t does not

injur e clothing and fur nitur e, with the exception of changing r ed anil ine dyes into pur ple, that its best effect i s oh

tain ed at high temper atur es and in dry atmospher es,and

that i t has but li ttle penetr ation and destr oys no spor es,and fo r that r eason yields no absolutely safe r esults .

LO CAL TREATMENT

The local r emedies employed have been used fo r the

pur pos e’

of either di r ectly destr oying the pseudomembr ane,such as nitr ate of silver

,car boli c acid

,the actual cautery

o r to dissolve them,such as the alkaline car bonates, the

chlor ides,steam,

papayotin ; o r to act as astr ingents, suchas limewater and the chlor ide and subsulphate of i r on ;o r to di s infect, snob . as the potass ic chlor ate, chlor al hydr ate

,tur pentine

,car bolic acid, mer cury, sulphur , br omine,

iodine, i odoform,chlor ine water

,and per oxide of hydr o

1 76

https://www.forgottenbooks.com/join

DR. JACOBI’

S WORKS

it should be either destr oyed o r di s infected. Fo r that purpose one o r two dr ops of a fi fty

-

per-cent. solution of car

bo lic acid in glycer in may be applied once (not mor e thantwice) a day, o r of the tinctur e of iodine

,o r of a solution

o f 1 par t of the bichlor ide of mer cury in 1 0 0 o r 50 0

par ts o f water , sever al t imes a day. I t i s in these casesthat chlor ine water has been inj ected thr ough the sur faceinto the upper layer s of the tonsi ls . But we should neverfor get that only a small par t of the pharynx is acces sibleto such tr eatment, and that it i s only one clas s of patientsthat can be subj ected to it . In or der to be effective, theapplication must be thor ough. None but adults o r olderchildr en, and of them only a small number

,will submit

to opening their mouths and to the applications . It isthat very clas s of pati ents who can be induced to gar glewith some little

,though very little, success . Smaller chil

dr en wi ll obj ect,will defend themselves

,will struggle .

I t takes many an anxious moment to for ce open the mouthmeanwhi le

,the patient i s struggling, per spir ing, scr eam

ing,and exhaust ing his str ength. One may succeed in

for cin g o pen the j aws,then ther e begins the p r actice of

mak ing applications,of swabbing

,of scr atching o ff the

pseudomembr ane, of cauter i zing, of bur ning . The struggling chi ld will p r event the limitat ion of the applicationto the dis eased sur face . One cannot help injur ing the

neighbor ing epithelium,and thus the mor bid pr ocess will

Sp r ead. Instead o f doing good, we have done harm ; fo r ,indeed

,no local application can do so much good as the

struggles of the fr ightened childr en do mischi ef . I haveseen them die while defending themselves against the at

tempted v iolence, l eavin g doctor and nur se victor ious and

ali ve on the battlefield. I t i s incr edible, but i t i s true,that mor e than one have r ecommended using the electr ocautery o r the thermocautery on the thr oat of the baby,after for cing the mouth open " It i s almost incr edible,fo r the offender s cannot have been ign or ant of the factthat what they can r each with their instruments i s but verylittle besides the tonsil, and they might have known thatit i s just the tonsils that ar e least apt to favor the ad

mi ssion o f sepsi s into the cir culation .

1 78

DIPHTHERIA : SYMPTOMS AND TREATMENT

Ther e is an easy way of using dis in fectants on the

thr oat and mouth, v i z ., to give medicines which ar e at the

same time di s infectants, digestible . and easy to take ; togive them in small doses but fr equently ; to see that whenthey have been given

,no water o r milk i s taken imme

diately afterwards,so as not to wash them o ff fr om the

mouth and thr oat . Such medicines ar e mild dilutions ofthe tinctur e of chlor ide of i r on , o r l ime water , o r solutionsof bor i c acid

,o r of bichlor ide of mer cury, o r of benzoate

of sodium,most of whi ch will act both by thei r consti

tutional and their local effect .Diphther ia i s most danger ous when located in the nose

and nasopharynx . The changes taking place in the nar esmay be an ext ens ive catar rh. besides the diphther itic de

posits . The diphther itic membr anes ar e sometimes verythick

,and contain a gr eat deal of fibr in . Sometimes they

ar e so thick as to clog the nar es and pr event r espi r ation .

Under neath them copious absor ption of toxins may takeplace . In most cases, however , the diphther itic membr anesar e not so thick . Some of them macer ate very r eadily,and the toxin. i s very speedily absorbed thr ough the exceedingly copious lymph ducts

,and seps is is the r esult .

In some cases o f diphther ia however, the membr anes can

hardly be seen . The dischar ge fr om the nose is liquidand acr id, contains small flakes and some blood. Thesear e the cases in whi ch the toxin is absorbed di r ectly intothe cir culation . All o f these forms may lead to necr osi sand gangr ene of the ti ssue and pr oduce a very pecul iar ,sweetish

,nasty odor . Thus

,the inhal ed air i s poisoned,

and, being car r i ed down into the lungs, acts as an additio nal per i l . The most danger ous locality i s the poster iornar es, with their dir ect communications with the lymphbodies below the angle of the lower j aw. The pseudomembr anes

,the lymph ducts, and lymph bodies , swarm with

bacill i and toxin,with str epto cocc i ,—wi th staphylococci, and

lead to immense tumefaction between the ear s and clav

icles,to the formation of multiple small absces ses, to hem

o r rhages, to sepsis . All of these forms of nasal diphther ia r equi r e immediate

,per si stent

,and effici ent local

tr eatment,fo r it i s safe to say that every case of genuine

1 79

DR . JACOBI ’S WORKS

o r mixed nasal diphther ia has a tendency to terminatefatally.

The local tr eatment cons ists in cleansmg and dis infecting . In most cases thes e two ar e identi cal

,fo r if we

s imply succeed in washing out the macer ating mater ial,

that pr oves suffi cient . In order , however , to have thateffect the washing and di sinfecting must be done oftenevery hal f-hour

,every hour , every two hour s, day and

night . In the bad cases, i n which the nar es ar e cloggedwith pseudomembr ane, the cleansing and dis infecting ar e tobe p r eceded by for cing a passage thr ough the nar es with a

pr obe cover ed with wadding and dipped in car bolic acid.

Par ti cular ly i s thi s indication ur gent when ther e i s sopor ,whi ch owes i ts or igin par tly to the difliculty of r espi r ationand car bo nic-acid poisoning and par tly to the septic condit ion . The methods of local tr eatment, bes ides the onejust descr ibed, ar e the (not always success ful ) applications of o inM en ts withi n the nose by means of the brusho r wadded pr obe

,o r the use of the sp r ay o r syr inge o r

ir r igator,o r the use of a spoon o r a nasal cup o r a feed

ing-cup, thr ough which li quids ar e pour ed into the nar es .The indispensabil ity of thes e nasal administr ations cannotbe ur ged too positively. Park thinks that “ when the

str ength i s good and the nostr il s and thr oat ar e ful l o fdischar ge and membr ane

,it i s well to insi st on cleansing

by i r r igation ; when, however , the child i s much pr ostrated,and struggles against it

,i r r igation may have to be omitted

An Amer i can System of the P r actice of Medi cine,”i .,

p . I believe,however

,that in nasal diphther ia local

tr eatment is the v ital indi cation .

In making local applications it i s impor tant that thewhole sur face should be touched ; ther efor e neither ointments n o r instillations fr om a medicine-dr opper ar e avai lable in the aver age cases in which the whole nasopharynxis the s eat of the affection ; n o r as a rule wi ll the atomi zerconvey a sufficient amount of li quid into the cavi ti es tobe of much use. A spoon o r a small feeding-cup, o r bett erone of the nasal cups made fo r the pur pose, the nozzle ofwhich i s nar r ow enough to enter the nose, will do fair lywell

,and will allow the in tr oducti on of liquids into the

1 80

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

1 0 par ts of chlor ide of sodium o r chlor ide of ammoniumin fr om to par ts of water . I t may be usedfr eely.

I f moder ate quantities of a mi ld solution of bichlor ideof mer cury be swallowed whi le being inj ected, no harm isdone . Wher e ther e is a fetid odor

, the nar es ought tobe deodor i zed fr equently by carbolic acid o r cr eolin o r

permanganate of potas sium .

Car bolic acid may be used in solutions of fr om 1 to1 0 : 1 0 0 0 par ts of water , but i t should not be for gottenthat ther e is some danger in swallowing it, because of thenephr iti s to which i t may give r i se . Fo r the same purpose o f deodor i z ing, cr eoli n may be used in one-per -cent.solution . Locfller

’

s solution of alcohol 60 , toluol 3 6 , and

tinctur e of i r on sesquichlor ide 4 par ts,does not act better

than other s,has a bad taste, i s obj ected to very str ongly,

and gives r i s e to exhausting struggles. Permanganate ofpotass ium in solution may be appli ed once or

twice a day to the fetid nar es with a p r obe wr apped i nabsor bent cotton, o r may be used fo r spr aying, fo r inj ection,o r fo r ir r igation in a solution of l z2

,o0 0 many

times a day. Per oxide of hydr ogen is a power ful dis imfectant ; some of its eulogizer s condemn such pr epar ation sas ar e acid

,other s those whi ch ar e not acid. Solutions

which ar e not very dilute will coagulate the soluble albuminof the sur face tis sue with which they come in contact ;form membr anous deposits whi ch ar e fr equently mistakenfo r di phther iti c pseudomembr anes ; give r ise

,when the

membr anous ar tefacts will have been thr own o ff, to localsor es

,which may, and very o ften do , fur nish a r esting

place to new micr obic invas ions . This should be taken intoconsider ati on, and i s true , though one of the manufactur er sof thi s substance once tr i ed to incr ease the v i gor of theadver ti sement of hi s war es by coupling with i t his co nvic

tion o f my ignor ance on the subj ect .Fo r the pur pose of disso lving membranes, papayotin

(not the pr opr i etary medi cine sold under a s imilar name)has been used i n five-per -cent . solutions, as a spr ay, byinj ection

,o r as a dir ect application by means of a sponge

o r brush. Many year s ago I employed i t in gr eater con

1 8 2

DIPHTHERIA : SYMPTOMS AND TREATMENT

centr ation to di s solve the di phther iti c membr anes of thetr achea below

'

the tr acheotomy tube . Its application inpowder does not answer well . Fo r the same pur pose trypsin has been employed in five-per

-cent. solutions,mixed

with bicarbonate of sodium .

The cer vical lymphaden itis, of whi ch I have spoken as

the r esult of nasal diphther ia, must be tr eated per s i stently and effectively. Thi s tr eatment may be pr eventiveand cur ative . The pr eventive tr eatment consi sts in the

nasal inj ections descr ibed. The r apidity with which lar geswellings diminish when ir r i gations ar e made fr equentlyand conscientiously i s often sur pr is ing . When lar ge tumefaction has taken place

,tinctur e of iodine has been ap

plied exter nally ; in that way it i s useles s . Mer cur ial ointments and oleates have been appli ed ; they also ar e useless,either as actual r emedies o r as a means of massage . Anointment o f potass ic iodide and adeps lanae hydr o sus

( 1 1 6—8 ) i s mor e r eadily absorbed and less i r r itating . I ceexter nally i s r ational

,but i t i s useles s so long as the

infection i s not stopped. I have in a number of instancesinj ected iodoform

,in ether

,into the swelled mas s, but it

is too painful and too efficacious,and does not pay fo r the

agitat ion,angui sh

,and exhaustion of the unfor tunate chi ld.

So,indeed, ther e i s no r emedy, bes ides the p r eventive

measur es,except in occasional long and deep incisions into

the immense mass . We should not wai t fo r fluctuationo r even semi—fluctuatio n to become appar ent . A gr eat dealof the swell ing is inside the fascia. Absces ses

,when thev

form,ar e seldom lar ge . The contents consist mor e of

necr otic tissue, whi ch ought to be laid open as soon as

possible and di sinfected. The inci s ion must be a longone—in many cases fr om ear to clavicle . The di sinfectionof the wound may be o btained by applications of subnitr ateof bismuth o r tinctur e of iodine, and by i odoform o r

other antiseptic gauze . No carbolic- "

acid should be usedfo r dis infection

,because of its tendency to give r i s e to

hemor rhages . When a hemor rhage takes place, it willusually stop under pr essur e with antiseptic gauze ; butsometimes

,when a lar ge blood-vessel has been er oded, i t

is very copious . In such cases the actual cautery, acu

1 8 3

DR . JACOBI’

S WORKS

pr essur e, o r sometimes the ligatur e of blood-ves sels has tobe r esor ted to . Chlor ide of i r on and subsulphate of ir onmust never be used on such necr otic sur faces . They giver i se to a thick coagulated scab under whi ch septic abso rption is apt to take place .Sanguinolent di schar ges fr om the nostr ils may usually

be ar r ested by the conscientious application of cleans ingand disinfecting solutions ( in most cases gentle i r r igationworks best) . But the subsulphate o r per chlor ide of i r onshould gener al ly not be employed fo r the r eason abovegiven . The application of a solution of antipyr insometimes 1 : 3 ) by means of a swab o r a spr ay will gener ally p r ove sati s factory i n hemor rhages . I n ur gent casesa tampon satur ated in a solution of antipyr in i s r equir ed ;its styptic pr oper ty i s enhanced by the addi tion of a smallamount o f tannic acid.

Moder ate hemor rhages fr om the thr oat should be tr eatedin a s imilar way, and by ice-bags p r oper ly appli ed. Un

les’

s they be par enchymatous thei r locality should be inqui r ed into fo r the pur pose o f the locali zation of a styptic_ antipyr in, o r the actual cautery. I f ther e be an er os ion .

of a lar ge vess el,such as the car otid ar tery in a case

r epor ted by me in the Tr ansactions of the Association ofAmer ican Physicians nothing shor t of the ligationo f the vessel i s app r opr iate . I f it be the jugular veinwhich i s ruptur ed, either li gation o r compr ession shouldbe r esor ted to .

Local tr eatment has lost its cr edit with some who believe that antitoxin alone should be r eli ed on in all cases ,and fo r all indi cations . That i s a gr ave mi stake

,whi ch

will again be r efer r ed to below.

Fo r the pur pose of softening and macer ating pseudomembr anes steam has been extensively utiliz ed. I ts in

halation is useful in cases of catar rh of the mucous membr anes

,and in many inflammatory and diphther itic affec

tions. On mucous membr anes it will incr ease the secr etionand li quefy i t, and thus aid in the thr owing o ff of thepseudomembr anes . I ts action is the mor e p r onounced the

gr eater the amount of mucipar ous follicles under o r alongside a cyli ndr i cal o r fimbr iated epithelium . Thus it is

1 8 4

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

with alcoholic stimulants should be encour aged. Over a

thor oughly moistened mucous membr ane the pseudomem

br ane is mor e easi ly made to float and to macer ate .To evolve lar ge volumes of steam the slaking of lime

has been r esor ted to . I t i s bo th an o ld and an effective

pr ocedur e . Not only i s the obj ect in view accomplishedby it, but i t i s the best means of br inging lime into contact with the morbid sur face . In a r oom in which l imehas been slaked

,everythi ng is cover ed with it . Thus thi s

method of pr ofiting by the local effect of lime i s decidedlvpr efer able to the almost nugatory effect of lime waterspr ayed into the thr oat .In connection with these measur es

,taken fo r influencing

the mucous secr etions and exudations of the mucous membr anes

,I may her e r efer to some inter nal medication r e

sor ted to with the same obj ect in v i ew . I t was to fulfi lthe same indication of softening the pseudomembr ane

,by

incr easing the secr etion of the mucous membranes,that

pilocarpine o r j aborandi was highly r ecommended (Guttmann ) as a panacea in all forms of diphther ia. Ther ei s no doubt that the secr etion of the mucous membr anesis vastly incr eased by the inter nal admini str ation

,o r by

r epeated subcutaneous inj ections of the mur iate o r nitr ateof pilocar pine

,but the hear t i s enfeebled by its use. I

have seen but few cases in whi ch I could continue thetr eatment fo r a suffici ent time . In many I had to stop i tbecause after some days of per si stent administr ation Ifear ed fo r the safety of the pati ents . Ther efor e, as ear lyas 1 8 8 0

,at the meeting in that year of the Amer i can Med

ical Association at Richmond, I felt r obliged to war nagainst its indi scr iminate use in diphther ia. Thus i t hasshar ed the

” fate of all the hundr eds of r emedies and methods which have been declar ed to be in fallible and havebeen found wanting.

The diphther itic co njunctiva should be ir r igated fr e

quently, every hal f—hour o r every hour , with a mi ld antiseptic soluti on (bor acic acid 1 These i r r igationsar e quite often difficult to make becaus e of the mass iveinfiltr ation of the tis sues . To counter act thi s and its pr essur e o n the eyeball, I saw,

thir ty year s ago , a deep hor i

1 86

DIPHTHERIA : SYMPTOMS AND TREATMENT

zon tal incis io n made thr ough the exter nal angle . In somecases the pr essur e was r elieved in spite of the extensiono f the diphther ia along the wound. I ce applicat ions tothe eye ar e always indicated, par ticular ly at fir st . I f bagswi ll not be tolerated, cloths lar ge enough to cover the

eye should be placed on a lump of ice and applied fr esh,

wi thout pr evious wr inging, every two minutes . These iceapplications should

,however

,be watched. They ar e liable

to incr ease the anaemia caused by the infiltr ation of thetis sues and give r is e to necr osi s . Such occur r ences shouldbe met by warm applications

,whi ch may incr ease the

tendency to macer ation . Abscesses in the lower par t ofthe cor nea should not be opened. Accompanying eczemao r erythema of the cheeks should be tr eated with an

iodoform-vaseline ointment and cellulitis of thesur r ounding ti ssue of the cheek according to the commonpr inciples of antiseptic sur gery.

Ammann tr eated s ix ser ious cases o f diphther ia of theeye wi th r epeated inj ections of antitoxin

,which wer e not

success ful . It appear s its effect i s doubtful when the

cor nea i s affected,and mainly, as i t happened in his cases

,

when diphther itic conjunctiviti s and ker atiti s wer e complicated with the pr esence of cocci .

GENERAL TREATMENT

The dietetic tr eatmen t of a case of diphther ia,either

simple and uncomplicated, o r mixed,o r septic

,should be

guided by ci r cumstances and gener al pr inciples . Solidfood i s r ar ely r eli shed and gener ally r efused, though ther ebe but little pain in swallowing. A child may be permitted to go without food fo r the fir st day o r longer . But

the tendency to leucocytos is, hydraemia, and toxic exhaus

tion demands measur es fo r the pr eser vation and r esto r a

tion o f str ength. Milk in differ ent forms, with and withoutfar inaceous admixtur es, br oths and beef jui ce, eggs inacceptable form

,and alcoholic stimulants at an ear ly time

should be ins isted upon . I t should be super fluous to ur gethe neces s ity, whi le tryin g to r emove the disease, of pr eser ving the pat ient .

1 87

DR . JACOBI’

S WORKS

The medical tr eatmen t of an aver age case of pharyngealdiphther ia can be made to combine the indications o f bo thinter nal and local administr ation . Fo r for ty year s I haveemployed the tinctur e of the chlor ide of i r on . I t is an

astr ingent and antiseptic . I ts contact with the dis easedsur face i s as impor tant as i s its gener al effect ; ther efor eit should be given fr equently, in hour ly o r hal f-hour lydoses

,even every twenty o r fifteen minutes . An infant

of a year may take 3 o r 4 c .c . (3 i .) a day, a chi ld of thr eeo r five year s 8 o r 1 2 c .c . (5 ij . o r I t i s mixed withwater s o as to make the dose hal f a teaspoonful o r a tea

spoo nful ; a dr achm o r two dr achms (4 o r 8 c .c . ) with a

small quantity of chlor ate-

o f potassium (see above) , infour ounces ( 1 20 c .c . ) allows hal f a teaspoonful everytwenty minutes . No water must be drunk after the medicine . As a rule, i t i s well toler ated. Ther e ar e some,however

,who will not bear i t well . Vomiting o r diar rhoea

i s a contr aindi cation to per sever ance in its use,fo r noth

ing must be allowed to occur which r educes str ength. Agood adjuvant i s glycer in, and better than syrups . F r omten to fifteen per cent . of the mi xtur e may consist o f i t.Now and then

,but r ar ely, i t i s not at all toler ated. When

diar rhcea sets in glycer in should be discontinued. Sti ll,thes e cases ar e r ar e ; indeed, the stomach bear s glycer invery much better than the r ectum.

I have s een so many bad cases r ecover under the ad

mini str ation o f chlor ide of ir on,when tr eated after the

method detailed above, that I cannot r escind former expr ess ions of my bel ief in its value . Still

,I have often

been so s ituated that I had to give i t up in pecul iarcases . They wer e those in whi ch the main symptoms wer eof so intense a sepsis that the ir on and other r ationalmethods of tr eatment wer e not power ful enough to pr event the r apid pr ogr ess o f the di sease . Chi ldr en withnasopharyngeal diphther ia,

' large glandular swelling, feeblehear t, and fr equent pul s e, thor ough seps is, and i r r itablestomach bes ides , those in whom lar ge doses only of stimu

lants,gener al and car diac, may possibly br ing any r eli ef

,

ar e better o ff without the ir on . When ' the ci r cumstancesar e such as to leave the choice between ir on and alcohol

,

1 8 8

https://www.forgottenbooks.com/join

J ACOBI ’S WORKS

cent as i t appear s. In many the application exter nallyof cold water o r i ce-bags to the neck i s vastly pr efer able .But in most cases of anaemic and highly ner vous childr enthe latter ar e not tolerated. Constant inhalations of turpentine o r car bolic acid fr om a kettle of boiling waterhave impr essed me as beneficial in a lar ge number of cases .Inhalations

,in a small r oom o r under a tent

,of calomel,

which is subl imated in doses o f gr . vi ij . o r x .

every hour o r at longer inter vals,ar e cer tainly effective .

The patient r emains in bed as much as possible,and

may continue such expector ants as he perhaps took fo r

pr evious catar rhal symptoms ; he may also take diaphor eticsand warm bever ages ; an occas ional opiate to excite diaphor esis and to pr ocur e some r est. The continued use ofchlor ate of potassium,

when the invas ion of the larynxis complete

,i s r ather super fluous . Antipyr eti cs ar e out of

the question unless ther e i s a very high temperatur e depending o n a complication (gener al diphther ia, pulmonaryinflammation s) . Pilocar pine injur es by debili tating the

patient ; the cases which ar e r eally benefited by it ar e

exceedingly r ar e . Mer cur ials have r esulted in mor e actualr ecover i es than has any other internal tr eatment . The

cyanide and iodide have been r ecommended. Fo r near lytwenty year s I have employed the bichlor ide in doses of1 mgm . (gr . % 0 ) o r mor e once every hour . The smallestbabies take one-four th or

'

one—third of a gr ain daily fo r

days in succes sion . Almost never will a stomatiti s follow,and no gastr ic o r intestinal i r r itation, p r ovided the di

lutio n be in the pr opor t ion of at least 1 : 8 00 0 . An o c

casio nal slight diar rhoea may r equir e the addition of a

few dr ops of camphor ated tinctur e of opium . I can

r epeat a -former statement that never befor e the antitoxinper iod (see below) have I seen cases of cr oup getting wellin such number s

,either without o r with tr acheotomy o r

in tubati on, as when under mer cur ial tr eatment . I wouldnot be under stood, however , to limi t the use of mer curyto laryngeal diphther ia r it has equal effects in that ofthe pharynx, and mostly in the str eptococcic and in the

mixed forms of diphther ia. In connection with thi s s tatement I wish to emphasi z e again the necess ity of not r elying

190

DIPHTHERIA : SYMPTOMS AND TREATMENT

on a single method of tr eatment in a disease so danger ousand whimsical as diphther ia. The s elf-complacent nihi lismwhich r elies exclus ively on pathological r esear ch and

labor atory methods has mor e than o nce impeded the medical and social and humanitar ian position of cl inical medicine . I t i s a pleasur e

,ther efor e

,to quote an author who

has won laur els in bacter iology: The giving inter nallyof the tinctur e of the chlor ide of ir on o r of the bichlor ideof mer cury in small fr equent doses has consider able localeffect upon the mucous membr anes of the thr oat and

pharynx (W. H . Park) .

When,in laryngeal diphther ia, internal tr eatment pr oves

unsuccess ful, intubation o r tr acheo tomy should be r esor tedto . A small

,fr equent

,and intermittent pulse

,aphonia

,

cyanosis, and marked r etr action,with every inspir ation, of

the sup r aclavicular fossae and the epigastr ium,ar e most

ur gent indi cati ons fo r the oper at ive p r ocedur e . Theyshould not be allowed to last . I shall not her e be temptedto di scus s the cr iminality of allowing a child to suffocatewithout r esor ting to mechanical r eli ef

,o r to compar e the

two oper ation s with each o ther . I can only say that fo r

year s I have not seen a cas e in which intubation wouldnot take the place of tr acheotomy, and have, ther efor e,not per formed the latter . Intubation takes the place oftr acheotomy in most cases ; in none does it make it imposs ible when r equi r ed in the opinion of the oper ator .

The latter oper ation may be pr efer r ed o r become neces

sary fo r the pur pose of getting at the tr achea and br onchifo r the mechanical r emoval of membr ane and other localtr eatment, r ar e though the cases be in which such pr o

cedur es ar e attended with success . I t i s pr obable that themany secondary tr acheotomies which ar e still per formed inEur ope when in tubation i s alleged to be insufficient willnot be consider ed r equi s ite in the futur e . No r i s it pr obable that Bokai

’

s method of using'

intubatio n as an ad

juvan t to tr acheotomy will be followed long even by thatdistingui shed clinician himself . Since 1 891 his pr acticehas been fir st to per form intubation and then tr acheotomy,r emoving the tube just befor e he makes his incision intothe tr achea.

191

DR . JACOBI ’S WORKS

In the vast maj or i ty of cases o f pseudomembr anouslaryngitis the Klebs-Loefller bacillus i s found ; and all ofthem ar e

, ther efor e, fit subj ects fo r the use of the diphther ia antitoxin . Since i ts intr oduction both gener al andlocal (laryngeal ) diphther ia have been gr eatly benefited.

At its Washington meeting in May, 1 897, the Amer i canPediatr i c Society r eceived the

“ Repor t of its committeeon the collective investigation o f the antitoxin tr eatmento f laryngeal diphther ia in pr ivate pr actice .

” Its sal ientpoints ar e as follows: The number of cases r epor ted during the eleven months ending Apr il l st

,1 897, was 1 70 4

—mor tal ity, per cent . The cases occur r ed in the

pr actice of 4 22 physicians in the United States and Can

ada. Oper ations employed : Intubation in 6 3 7 cases , mo rtality 26 per cent . ; tracheotomy i n 20 cases, mor tali ty 4 5

per cent. ; intubation and tr acheotomy in 1 1 cases,mo r

tality per cent . Number of States r epr esented,2 2

,

besides the Distr ict of Columbia and Canada. Non-oper ative cases, 1 0 3 6, mor tality per cent . ; operatedcases

, 668 , mor tality per cent .Two facts may be r ecalled in connection with these

statements : Fi r st,that befor e the use of antitoxin 90

per cent . of cases of laryngeal diphther ia r equir ed oper ation ; under the antitoxin

,however

, per cent. Second,that the per centage figur es have been r ever sed : former ly27 per cent . r epr esented the r ecover i es ; now,

under antitoxin

,thi s figur e r epr esents the mor tal ity. The committee

expects still better r esults when antitoxin will be administer ed ear lier and in lar ger doses

,and r ecommends that

all patients with laryngeal diphther ia, being two year s o r

over , should r eceive as follows : Two thousand units at

the ear l iest poss ible moment, two thousand units aftertwelve dr eighteen hour s

,unles s ther e be an impr ovement,

and the same dos e twenty -four hour s after the seconddose

,i f ther e be still no impr ovement . Pati ents under two

year s should r eceive one thousand o r fifteen hundr ed units .Dr . Dillon B r own

’ s per sonal exper i ence being unusuallylar ge and car efully r ecorded I add without comment thefollowing figur es r epor ted by him. He divided his intubatio n cases into thr ee clases : P r evious to November ,

1 92

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

discontinuance of thei r gr owth after the inj ection o f an

tito x in ar e the r easons whv Baginsky has since pr efer r edintubation to tracheotomy .

At that ear ly time in whi ch his r esults wer e published.

Heubner per formed 3 3 oper ations in 1 8 1 cases—vi z .

,2 3

tracheotomies with 5 2 per cent ., 1 0 intubations with 8 0

per cent . r ecover i es—a r emarkable impr ovement over the

figur es of the ante-antitoxin per i od.

At the Inter national Congr ess of Moscow Monti madethe statement that in his ser vice cases of laryn geal stenosi swer e apt to get well under the sole influence of antitoxin

,

that an oper at ion was r esor ted to o nly when that tr eatment p r oved unsucces s ful (after some days ) , and eventhen was l ikely to be succes s ful . Without antitoxin, informer times

,his intubations would yi eld a mor tality of

fr om 2 5 to 4 0 per cent ., n ow whi le antitoxin was employed,1 2 per cent . Only in the

“

mi xed” in fections the mo r

tality r ose to 3 3 per cent .It is useless to quote anv mor e exper i ences in r egar d

to the efficacy of antitoxin i n diphther itic stenos i s of thelarynx . In many cases it r ender s oper ations unnecessary ;in those oper ated upon the pr ognos is i s impr oved. Stillmany die ; of those following mixed ” infections manydie . I f ther e be those who shoulder the r esponsibility ofr elying on a sole r emedy ,

which fr equently heal s and

fr equently fails, to the exclus ion of every other helpfulmedication o r contr ivance

,they ar e as shor t- s ighted as

those who still r efuse altogether to acknowledge the gr eatefficacy of antitoxin in diphther ia. The fanati ci sm ofthe one should not be permitted to justi fy that of theother . The sati s faction at having a power ful r emedy likeantitox in should not engender the nihil i sm which begin safter the subcutaneous inj ection of serum . This

"

cannotbe said too often , par ticular ly in r efer ence to mi xedinfections . It i s only the bacillus par t of the malady whi chcan be counter acted by antitoxin . The mixed infections atleast

,with thei r vi rulence and danger

,should not be left

to die without medication beyond inj ection and expectan t neglect .H ear t failur e i s usually developed gradually. I t i s

194

DIPHTHERIA : SYMPTOMS AND TREATMENT

for eshadowed by an incr eas ing fr equency and weakness ofboth hear t beats and pulse, by an occas ional intermiss ion

,

by unequal fr equency of the beats in a given per iod (sayof ten seconds ) , o r by the equali zation of the inter val between systole and diastole, and diastole and systole . Thi slatter condition

,which i s normal in the embryo and foetus ,

is always an ominous symptom ; so i s the too close pr oximityof the second sound (so as to become almost inaudible )to the fir st.Hear t failur e i s due

,besides the influences common to

every di sease and ever y fever,to tis sue changes in the

myocardium,in its ner ves

,in the endocardium

,and to the

gr adual formation of blood clots . These changes may bedue to the malnutr i tion of the ti s sues r esulting fr omevery septic conditi on of the blood, o r to specific alter ations due to the diphther itic pr ocess . Failur e may comeon after hav ing given war n in g, o r i t may be on us withoutany. Thus every case o f diphther ia ought to make usanxious and afr aid. Indeed

,ther e i s no safety and no

positively favor able pr ognosi s until the patient i s quiter ecover ed

, and even advanced beyond the per iod in whichpar alysi s may develop .

Whatever enfeebles must be avoided ; absolute r est mustbe enj oined. The patients must be in bed, without excitemen t of any kind ; they must take thei r medi cineswhich ought to be as palatable as poss ible—and thei rliquid food, and evacuate thei r bowels in a r ecumbent o r

semi r ecumbent position ; crying and wor rying must be pr evented ; the r oom must be kept ai ry and r ather dar k, soas to encour age sleep i f the pati ents be r estless; and r estles s they ar e

,unless they be under the influence of sepsis ,

and ther eby subj ect to fatal dr owsiness and sopor . In nodis ease

,except perhaps in pneumonia

,have I seen mor e

fatal r esults fr om exer tion o n the par t o f the s ick, o r fr omanything mor e fatiguing than a sudden change of postur e .Unless absolute r est be enfor ced, neither physicians n o r

nur ses have done their duty. The latter must avoid all

the danger s attending the administr ation of medicines, in

jectio n s, spr ay s , and washes . P r epar ations fo r the samemust be made out of s ight, every application should be

195

DR . JACOBI ’S WORKS

made quickly and gently. On no account must a patientbe taken out of bed fo r any of thes e pur poses . I knowof chi ldr en dying between the knees of nur ses who calledthemselves tr ained and had a diploma.

The use of pharmaceutical pr epar ations,such as digitali s,

str ophanthus, spar teine, caffeine, bes ides camphor , alcoholand musk

,should not be postponed until feeblenes s and

collapse have set in . Thes e ar e at least poss ible,even

pr obable,and i t i s cer tain that a cardiac stimulant will do

no harm . It i s advi sable to use i t at an ear ly date, particular ly in those cases in which perhaps antipyr in o r

anti febr in (the indications fo r which ar e cer tainly r ar e,

as excess ive temperatur es ar e very exceptional ) i s given .

Bes ides,i t i s not enough that the patients should mer ely

escape death ; they ought to get up, cito , tuto , et jucunde,with littl e los s and speedy r ecuper ation ; a few gr ains ofdi gitali s o r their equivalent—pr efer ably a good fluid extract—may o r should be given

,in a pleasant and digestible

form,daily. When a speedy effect i s r equir ed, one o r two

doses of two to four minims each ar e not too lar ge, and

must be followed up by smaller ones . When it i s justlyfear ed lest the effect of digitali s be too slow, I give, witho r without i t

,str ophanthus

,in doses of fr om o ne to s ix

dr ops of the tinctur e,o r sulphate o f spar teine. Of the

latter an in fant a year o ld should take gr . o r {g (6-1 5mgm .) four times a day as a matter of pr ecaution

,and

every hour o r two hour s in an emer gency.

Of the same impor tance ar e alcoholic stimulants . The

advice to wait fo r positive symptoms of hear t failur e and

collapse befor e employing the li fe- saving appar atus is

bad. Ther e ar e cases whi ch will get well without tr eatment

, but we do not kn ow befor ehand whi ch they willbe . No alleged mild case i s safe until r ecovery has takenplace . When hear t fai lur e has once set in—and i t fr equently occur s in appar ently mild cases—our effor ts ar e

too often in vain . Thus alcoholic stimulants ought to begiven ear ly and often, and in lar ge quantities, thor oughlydiluted. Ther e i s no such thing as danger fr om themo r intoxication in septic di seases—1 0 0 c .c . (3 ii i .) dailymay suffice but I have often seen 3 0 0 c .c . (3 ix .) o r mor e .

196

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

ber of identical ther apeutical indications . These ar e the

sustaining of the str ength of the hear t by digitali s and

other car diac tonics . This is an indication on which Icannot dwell too much. Manv of the acute

,and most of

the chr onic, di s eases of all ages do very much better byadding to other medication a r egular dose of a cardiactoni c . While i t i s a good pr actice to follow the goldenrul e to pr escr ibe simply, and i f pos s ible a s ingle r emedyonly, i t i s a better one to p r escr ibe efficiently.

Besides,ther e ar e some mor e indications : mild pr epar a

tions of i r on, pr ovided the di gestive or gans ar e not interfer ed with ; strychnine, o r other pr epar ations of nux

vomica,at all events ; in o rdinary cases a child of thr ee

year s will take gr . thr ee o r four times a day ( together Local fr iction, massage o f the thr oat

,

of the extr emities,and trunk

,dry o r with ho t water , o r

oil,o r water and alcohol ; and the use of both the inter

rupted and continuous cur r ents, according to the knownrules and the local ity of the suffer ing par ts, find thei rr eady indications . The par alys i s o f the r espi r atory muscles i s quite danger ous ; the apnma r esulting fr om it maypr ove fatal in a shor t time . In such cases the electr iccur r ent used fo r shor t per i ods, but very fr equently, and

hypodermic inj ecti ons of sulphate of strychnine in mor ethan text—book doses

,and fr equently r epeated

,will r ender

good s er vice . I r emember a case in which these,with the

occasional use of an inter rupted cur r ent,and occasional

ar tificial r espi r ation by Sylvester’ s method

,per sever ed i n

fo r the better par t of thr ee days, pr oved effective . In a

few cases of diphther i tic par alysi s the use of antitoxinappear ed to scor e a success . Other forms of par alys i s

(hemiplegia, ataxia) demand a tr eatment l ike the above,

modified by their pecul iar ci r cumstances o r symptoms .Or rho therapy.

—The use of diphther ia antitoxin has

been discussed sever al times on pr evious pages,mainly as

r egards its effect as an immunizing agent and it s actionin laryngeal diphther ia. I t has pas sed i ts exper imentalstage as safely as i f i t had been employed these fifty year s,and has cr eated a liter atur e of its own on which bacter io logists

,chemists

,medical and sur gical clinicians

,pr actical

198

DIPHTHERIA : SYMPTOMS AND TREATMENT

men and theor i sts, fr i ends and enemies have been at work .

No matter what the natur e of its action may be, whetherwhen inj ected under the skin of a diphther ia pati ent itsupplements the antidote cr eated by the toxin of diphther ia in the blood o r the cells o f the patient

,o r whether

it aids the antitoxin into which the toxin i s beli eved bysome to be changed (Buchner , S

'

mirnow, Metchn ikoff) o r

whi ch i s the pr oduct of r eaction (Behr ing, Ehr l iche

) ,this action can no longer be doubted. Di scus sions on thatpoint ar e fruitless . When the inj ection i s to be made, thesyr inge should be ster iliz ed each time, fo r no poison i s en

tir ely safe . A carboli c-acid solution of five per cent ., and

absolute alcohol will suffice fo r that purpose . The inj ectionshould be made into a loose and copious subcutaneous ti ssue, not into the skin, and not into muscles . The abdomenis mor e sensitive than the lumbar r egion and the thigh,and the subscapular o r in trascapular r egion . The lattershould not be selected unles s the subcutaneous ti s sue i squite abundant . According to the sever ity of the cas e s ixhundr ed o ne thousand

,fifteen hundr ed o r two thousand

units should be inj ected. The dose should be r epeatedunless the symptoms—both constitutional and local—beimp r oved within twelve o r twenty-four hour s . Sixty-five

hundr ed units wer e success fully used in a bad case of nomaof the vulva, in whi ch diphther ia and putr efactive bacter iawer e found by Petrushky (Deutsche medicinz

’

sche Wo chen

schr ift, The punctur e should be cover ed with an

antiseptic gauze, o r with iodo form collodion .

A unit i s equivalent to 1 c .c . of what i s called n o r

mal serum . Normal serum is the blood serum of an

immun i z ed animal which was made so efficacious thatc .c . antagonizes ten times the minimum of diphther ia poisonfatal to a guinea-pig weighing 3 0 0 gm . (about 1 0 ounces ) .

The univer sal demand i s fo r ear ly inj ectio n . Ther e i sunanimity in the exper ience that the p r ognosis i s impair edby pr ocr astination . The latest r epor t fr om Vienna i s only

6 Ehr lich thinks the antitoxin is the r esult o f functio nal overexer tio n o f the cell pr o toplasm which has been ir r itated by the

cir culating to xin, and compar es this pr o cess with the hyper tr ophyo f overexer ted o rgans.

199

DR. JACOB I ’S WORKS

a r epetition of what has been known these four year s.

When antitoxin was inj ected on the fir st and second day,only per cent . of all the cases died, on the third 1 9,on the four th 2 3 , on the fifth 3 1

,on the s ixth per

cent.Thi s fact has become so fixed in the minds of many

p r actitioner s who beli eve themselves r esponsible fo r the

welfar e of their patients,that in doubtful cases i n which

the diagnosi s o f“

diphther ia ”o r pseudodiphther ia

has not been made on account of time,and in v i ew o f the

innocuousness of antitoxin when inj ected un neces sar i ly,and believing that whatever discomfor ts ther e may ar i seafter the inj ection do not compar e with the danger of thedisease when not combated i n time, they

“ inj ect the an

.tito x in and settle the question of diagnosi s afterwards ”

(Char les G. Jennings in Medical Age, February 2 5th,In gener al that pr actice i s to be r ecommended in

bad cases and bad s easons, fo r the bacter iological diagnos is can be completed befor e another inj ection i s r equir ed,i f at all.

All forms of diphther ia ar e liable to be benefited byantitoxin

,fr om the s implest to the septic, fr om the um

complicated to the mixed, the latter less than the former .

I t i s this mixed form in which I look upon the neglectof other tr eatment

,both local and gener al

,as simply

cr iminal . The stati stics both of hospitals and of pr ivatepr acti ce have gr own immensely, and ar e daily gr owing ;they ar e the staple ar ticle of our j our nal liter atur e . Iwould ther efor e r efer the r eader to what I quoted i nmy

“ Ther apeutics of Infancy and Chi ldhood,

and wil lconclude with a few of those data whi ch ar e quiter ecent .Of the r epor t of the diphther ia committee of the Clini

cal Society o f London The Lancet (June 4 th, 1 898 ) publishes what follows

Fo r the pur pose o f the i nquiry 8 3 2 r epor ts of caseswer e collected

, but upon examination 199 of them had tobe r ej ected, either because the committee wer e not sati sfiedas to the evidence of diphther ia o r because the amount ofantitoxin administer ed was not stated in normal units,

20 0

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

wer e appar ently due to the antitoxi c serum wer e obser vedin a small number of cases . The per centage of deathswith suppr ess ion of ur ine was found to be p r acticallythe same in the antitoxin and the non-antitoxin ser i es .The gener al r esult of the inquiry showed that in the casestr eated with antitoxin not o nly was the mor tality notablylessened, but the dur ation of li fe in fatal cases was al sop r olonged. The inj ection of anti toxi n may pr oduce r ashes,j oint pains

, and fever ; with thes e exceptions no pr ejudicialaction has been obser ved i n the ser i es of cases investigatedto follow even in cases in which a very lar ge amountof antitoxin serum has been used.

”

According to Buchwald (Mii nchner medicin ische Wo chen

schr ift, 1 898 , No . 1 4 ) of 563 pat ients tr eated withoutantitoxin

, per cent . died ; of 3 1 1 tr eated with i t,per cent . di ed. Tr acheotomi es wer e r equir ed in 5 7

per cent . in the ante-serum per i od,in per cent . dur

ing the s erum time . Albuminur ia was obser ved in

per cent. of all the inj ected cases,par alysi s in 93 cases,

exanthems in 74 , pain in j oints, without swelli ng, however ,in 2 , o to r rhcea in 1 0

,br onchopneumonia in 3 6 cases. Most

o f the latter wer e fatal . Besides antitoxin,good nutr ition,

stimulants,and ir r igation of the nose and mouth wer e em

ployed.

Axel Johannessen communicated to the Moscow Co n

gr ess a r epor t cover ing 1 1 3 1 cases of diphther ia obser veddur ing 1 890 by 7 1 Norway phys icians . Those cases wer etr eated with antitoxin ; ther e wer e 7 3 deaths per

cent ) ; this per centage i s r educible to per cent . bydeducting the cases that came under tr eatment while mor ibun d. F r om 1 867 to 1 893 , befor e the antitoxin per iod,the mor tality was per cent.Escher ich had in P r ague a mor tality of 9 per cent .,

compar ed with 3 6 per cent . of former times .John E . Wal sh (N ew Yo rk Medical J our nal, Jun e 1 8th,

1 898 ) publi shes the following figur es . In 1 895-96 ther ewer e tr eated in the Di str ict of Columbia

Cases with antitoxin, 1 74 ; died, 23 2 1 3 2 per cent.Cases Without antitoxin, 1 52 ; 53 2 3 4 9

20 2

DIPHTHERIA : SYMPTOMS AND TREATMENT

In 1 896-97 ther e wer e

Cases with antitoxin, 285 ; died, 2 1 : per cent.Cases without antito xin, 3 3 5

Of the 2 8 5 antitoxin cases ther e wer e 2 3 8 below twelve

year s, with a mor tality of per cent . ; of the 3 3 5 nonantitoxin cases ther e wer e 2 56 below. twelve year s, witha mor tality of 3 3 per cent . Of 8 6 over twelve year str eated with antitoxi n none di ed ; of 1 1 3 of the same age

tr eated without antitoxin,8 di ed. In the last seven months

pr eceding the publicati on 4 22 cases wer e tr eated : 2 1 1with antitoxin and a mor tality o f 8

,o r per cent .

190 without antitoxin and a mor talityof 65 , o r per

cent .,as in the pr e

-antitoxin per iod. The tr eatment em

ployed in 2 1 cases was unkn own to the wr i ter .

Among the very latest stati stics ar e those of K r onlein

(Z ii r ich) , who r epor ted to the Twenty-seventh Congr es s ofGerman Sur geons (Apr il, 1 898 ) on 1 77 3 cases of diphther ia obser ved in the clinical hospital s o f the univer s itydur ing the year s 1 8 8 1 -97 . A r ecapitulation of the r esultsi s pr esented in the followin g table

PRE-ANTITo xm m o n ANTITOX IN m o n

0

s 2 oa O H

g g S 526 550 E '

7‘ -9‘ 2. T £3

(3

?32 g Eas 8O 0

1: 0-1(1 )

Z

To talDeathsMo rtality

Operatio nsDeathsMo rtality

Cases no t operatedDeathsMo rtality

In all the 4 3 7 cases in the antitoxin per iod the KlebsLcefller bacillus was demonstr ated. Kr énlein

’

s stati stics

20 3

DR . JACOBI ’S WORKS

pr ove the following facts : Whi le the morbidity of thewhole di str ict (city and country) r emained unalter ed inthe anti tox in per iod

, the mor tality decr eased co nsider ablv—mainly i n the sur gical clinic, in oper ated (tr acheotomyo r intubation ) o r non-oper ated cases

,and pr incipally in

the fir st year s of li fe . While pr evious to the institutionof antitoxin tr eatment one-half of all the cases had tobe oper ated upon

,thi s per centage has fallen to per

cent. s ince that time .After the inj ection o f antitoxin impr ovement set in

speedily ; the temper atur e diminished ; the deposits on, andthe membr anes in

,the thr oat and air passages soon

loosened,and the diphther iti c secr etion of the nose be

came speedily less ; the lymphadeniti s of the neck diminished ; the diphther ia pr ocess did not descend into the air

passages ; mild laryngostenosis did not incr ease ; ther e wasno diphther ic infection of the tr acheotomy wound, whichwas obser ved in one-third of all the cases of former times ;and the tube could be r emoved as ear ly as the third

,

four th,

‘

o r fifth day after tr acheotomy.

Dur ing the same per iod albuminur ia was obser ved in

per cent . of all cases of diphther ia, pr onoun ced n e

phr itis in per cent ., and postdiphther it ic par alys is in

per cent . Exanthems of the most var ious forms ,with mild gener al symptoms only, wer e met with in 8

per cent . ; they wer e attr ibuted to the serum . None wasfound after smal l inj ections made fo r the pur pose of immun iz ing healthy per sons .To gainsay, with such stati stics at hand, the super ior ity

o f antitoxin to any other s ingle r emedy known to us fo rdiphther ia i s a foolhar dy under taking . But ther e ar e somedr awbacksmet in its employment which ar e acknowledgedby all

,and exagger ated by some . I r efer to disagr eeable

symptoms with whi ch the admini str ation of antitoxin i schar ged

,and whi ch ar e said to take place in the blood,

on the skin, in the j oints, in the r espi r atory, ci r culatory,ur inary, digestive, and ner vous systems. Even suddendeath has been claimed as one of the r esults o f antitoxininj ections .Dr . James Ewing studi ed the effects of antitoxin on the

2 0 4

https://www.forgottenbooks.com/join

DR. JACOBI’

S WORKS

acid contained in the antitoxin should not be held r e

sponsible fo r the eruption ; n o r can the local i r r itation bechar ged with causing eruptions which take a week o r weeksto develop . Altogether this ur ticar ia behaves l ike the

vasomotor o r neur opathi c cutaneous ir r itations obser ved inpr edi sposed per sons after the use of oyster s, cr abs, o r

str awber r ies .H erpes (nasal, labial, aur al ) has been noticed in a few

instances,notably by Baginsky, and byMya, who obser ved

at the same time a cr it ical ” fall of the temper atur e ofthe body.

Other fo rms of eruptio ns, macular , papular , and erythe

matous,also petechiae with o r without lar ger extr avasations

,

have been r ecor ded. Desquamation is obser ved in pr o

por tion to the degr ee of dermatitis . Some obser ver s speakof many cases, other s of few, o ther s (Rumpf) never saw

any eruption .

W. T . Coues r epor ts fifty cases of antitoxin inj ectionsfo r the pur pose of immunization . A chi ld of five year sr eceived five hundr ed units

,a baby o f o ne day fi fty, those

under s ix months thr ee hundr ed, under a year four hundr ed. The older chi ldr en wer e not affected in the least ;the infants wer e r estles s and cr i ed long after the inj ection . The

“ temper atur e of thr ee infants r eached 1 0 1°

F . five hour s after the inj ection ; the next mor ning it wasnormal . On the mor ning following the inj ections the

youn ger childr en had slight coughs,which passed away in

two o r thr ee days . Ur ticar ia o ccur r ed in 1 4 cases out ofthe 50 inj ected ; a punctated erythema in 2 ° in 1 ther ewer e sor eness and pai n in the r ight knee-j oint, whichpassed o fl

'

in two days (Bo sto n Medical and Surgical

J ournal, July 1 4 th,Abscesses, occas ionally with lymphangitis, have been ob

ser ved by Monti , Var io t, and other s . When they occur r ed,fault was found with the serum whi ch was not co nsider edgerm- fr ee

,o r with the skin which was char ged with not

having been aseptic, o r with the undue thi ckness of the

needle and subsequent infection of the wound, o r withthe per for ation of too many layer s o f tis sue down into themuscles

,o r with the condi tion of the syr inge, which i t i s

206

DIPHTHERIA : SYMPTOMS AND TREATMENT

difficult, no matter whether the piston i s leather o r asbestos,

to r ender absolutely safe . In a few instances symptomswer e obser ved which wer e attr ibuted to the entr ance ofair into a small vein .

Ar thr oparthies wer e noticed with o r without exanthems .Swelling and pain of a knee o r an ankle—j oint wer e noticeda few times, together with ur ticar ia in the second weekafter an inj ection . Thes e lasted a day o r a week o r

mor e. They ar e not fr equent, fo r ther e ar e obser ver s whohave never seen them in any of a lar ge number of cases .I t should not be for gotten that they ar e symptoms whi choccasionally occur in di phther ia not tr eated with antito xin .

Lymph bodies now and then swell after an antitoxin in

jectio n ,but only in connection with an eruption o r an

ar thr opathy.

Antitoxin has been char ged with causing pneumo n ia.

The latter i s so fr equent a complication of diphther ia inall its stages that the attempt to substantiate the char geseems hazar dous . I f antitoxin affects the mucous mem

br anes favor ably i t i s not likely to pr oduce br onchiti s o r

pneumonia. Poss ibly Lennox B r owne fear ed thi s allegedeffect when he co nsider ed the use of antitoxin contr aindicated dur ing the existence of a br onchopneumonia.

I t has also been accused of developing a latent tuberculo sis into one of mor e r apid p r ogr ess . That i s bar elypossible

,inasmuch as every fever , fo r instance after vac

cinatio n,is held to have a similar effect . But it i s very

much mor e pr obable that the invasion of the Klebs-Loefllerbacilli and of the str eptococci of the diphther itic attack

,

according to p r evious statements r efer r ing to thei r complicati ons with tuber cle bacilli

,leads to the outbr eak.

A secondary fever , lasting a day o r longer,has been

obser ved after ten o r four teen days ; it often coincideswith an eruption of ur ticar ia

,and seems to be a legiti

mate symptom o f the latter . In most cases,however , an

other etiology i s mor e pr obable . I t is mor e often connected with the diphther ia than with the antitoxin tr eatment . In many cases ther e may be a new invas ion, mostlycocci ; ther e may be an abscess, a rhin itis

,a tuber culosi s .

2 0 7

DR . JACOBI ’S WORKS

With an absces s,o r still mor e commonly with rhinitis

,

lymph bodi es wi ll swell and the temper atur e will r ise .After an inj ection of antitoxin vomiting and diar rhaea

have been noticed and have been explained as the r esulto f intoxication with a fibr in ferment . On the other hand,Bagin sky i s positive that he has seen those symptoms les soften after antitoxin than in cases of diphther ia not sotr eated. I t appear s not impr obable that the blind co nfi

dence in antitoxin has somethi ng to do with an occas ionalcas e of gastr ointestinal i r r i tation . Fo r with some everyother tr eatment i s neglected

,while antitoxin i s being ad

minister ed,and i t i s qui te poss ible that abundant mem

br anes not r emoved by i r r igation, whi le being r apidlyloosened and thr own o ff, ar e swallowed.

Albuminur ia and n ephr itis ar e not at all met with afterthe inj ection of antitoxin by some obser ver s (Riether innone of 1 4 50 cases ) ; fr equently by other s (Soltmann in72 per They occur wi thin a week . Sii r ensen r e

por ts no albuminur ia when be oper ated with Danish serum,

but many cases after the use of Fr ench serum . That ex

per ien ce would go to show that either the normal hor seserums wer e differ ent, o r that the pr epar ation of the an

tito x in was not identical . The small amount o f phenolcontained in i t should not be accused, fo r i t i s too minuteeven to be di scover ed in the ur ine . What should not beover looked i s the fact that both albuminur ia and nephr iti sar e common occur r ences

,beginning in the very fi r st week

of a diphther ia, sometimes within a few days, befor e an

tito x in i s administer ed o r has had time to take effect .Among 1 8 1 cases of Heubner

’ s of those inj ected on the

fi r st day of the disease five—s ixths r emained fr ee ; on thesecond

, two -thirds ; on the thi rd, one-hal f ; on the four th,one-third. In 52 5 cases of Baginsky

’

s tr eated with antitoxin there was albuminur ia in per cent ., clinicalnephr itis in per cent . . and post-mor tem nephr i ti s in

per cent . However , among 93 3 tr eated without antito x in ther e was albuminur ia in 4 2 per cent ., clini calnephr iti s in per cen t and post-mor tem nephr iti s in

per cent—r ather a favor able showing fo r anti toxin .

In Str as sbur g (Sieger , in Vi r chow’ s Ar chiv, 1 897 ) r enal

20 8

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

and that his exper imen tal ther apeutics i s in conscious opposition to medi cation (German Congr es s fo r Inter nalMedicine

,Jun e

,

Behr ing himsel f explains the occur r ence of undesi rableeffects o f his serum only by the accidental and indi ffer entalbuminoids and salts contained in the serum . They ar e

according to him gr eatly r educed by incr easing concentr ation, even to the dry state which he succeeded i n o btaining . In the concentr ati on the antitoxin i s absolutelyun injur ious

,without poisonous effects in man o r animal

,

healthy o r s ick . According to H . C . E r nst,J . N .

Co o ledge, and H . A . Co oke (J our nal o f the Bosto n So cietyof Medical Science, May, the antitoxic pr oper tyof antidiphther i ti c serum can be r emoved fr om one par tof the serum and added to another by. a method of fr actio nal fr eezing

,the bottom layer s showing gr eater str ength.

By this metho d serum of high potency, mor e o r les s permanent

, can be obtained.

Like Behr ing,Henry W. Ber g (Medical Reco rd, June

1 8 th,1 898 ) attr ibutes undesi r able effects, erupti ons follow

ing the administr ation o f antitoxin,to some

'

or iginalimpur ity. I t i s pr obable

, almost cer tain, that manyo f the eruptions ar e due to a toxalbumin contained in theserum of the hor se which should be str ained thr ough a

fine Chamber land fi lter . Neither the pur e serum ofthe hor se n o r the diphther ia antitoxin loses any of its powerby fi ltr ation .

The adver sar ies of antitoxin have tr i ed to make it r e

sponsible fo r diphther it ic par alysis, without any r eason .

I t i s true that ther e ar e many cases of par alys i s occur r ingin childr en pr evi ously tr eated with antitoxin, but it hasalways appear ed to me that the number was swelled

"

bysome of those who would have succumbed without antitoxin long befor e the per iod o f par alys i s was due. Ap

par ently mild cases of diphther ia ar e followed by par alys i s ; it i s cer tainly true that many a case i s changed intoa mild one by antitoxin .

.I t i s after all better to have

a par alyt ic child with the gr eat p r obability of a fin al r ecovery than a cor pse without even a chance of par alys i s .Mor eover

,I cannot imagine a mor e difficult task than to

2 1 0

DIPHTHERIA : SYMPTOMS AND TREATMENT

calculate statistics on to tallv absent bases . The aver agenumber o f par alyses var i es according to the cases , the sever ity of the epidemics and pr obably to the tr eatmental so . And finally, lar ge number s of cases, like those o fBaginsky, appear to pr ove the contr ary of what hasbeen alleged. Among 993 pati ents befor e serum therapywas intr oduced ther e wer e 6 8 cases of par alys i s, o r

per cent. ; among 52 5 in the antitoxin per iod ther e wer e2 7 , o r per cent. Schmidt Rimpler feels cer tain thathis patients with accommodation paralys is r ecover ed mor espeedily under the use of antitoxin than without i t .Sudden deaths have occur r ed after the inj ection of anti

toxin, the doses being in some instances quite small . The

case of the Langerhans child in Ber lin, who died afterhaving r eceived an inj ection of antitoxin

,i s not explained

in spite o r because of loud vituper ations and vilificatio ns.

Most r epor ter s of cases have been sati sfied with the admitting they kn ow o f no explanation . Belin publi shes oneof the latest cases, and admits that death cannot positivelybe attr ibuted to the influence of the serum . Nifong (Mcd

ical Review, May 7th, 1 898 ) gave a boy of fifteen year s,of sl ight build and with feeble ci r culation

,fifteen hundr ed

units . After ten minutes ther e wer e pallor,numbness of

the extremities,cyanosis, swelling of the face, and vom

iting. Death occur r ed i n thi r ty-five minutes . Two gir l sr eceived the same dose of the same serum obtained fr omthe city chemist of St . Louis without a bad r esult .Rauschenbusch obser ved on his four -year -o ld daughter ,

who had taken thr ee times the dose whil e sick with diphther ia two year s pr eviously , prur itus, ur ti car ia, vomiting,sopor

,and hear t failur e after two hundr ed units inj ected

fo r the pur pose of immunization . I t does not appear thata connection between hear t fai lur e and sudden death onthe one hand and antitoxin on the other has been established in any case, and ventur esome and gener ali z in gspeculations ‘

ar e not able to shed light on obscur e subj ects .At all events

,a s ingle finding

,a suggestion

,o r a suspicion

o f vomi ting and aspir ation o f a solid body into the air

passages , o r of the inpectio n of ai r into a vein,o r excite

ment and fr ight,o r a lymphatic state, o r a lar ge thymus,

2 1 1

DR . JACOBI’

S WORKS

i f at all applicable to an individual case,does no t permit

of a univer sal inter pr etation .

After all, we can well agr ee with the conclusions o f

Di eudonne when he says that the tr eatment of diphther iawith serum is an essential advance in ther apeutics

,that

its effect i s mor e fr equently favor able than that of formermethods , and that accessor y consequences do not outweighthe use ful effects .H . Biggs r ecapitulates many of his pr evious wr itings in

a paper r ead befor e the Society o f the Alumni of Bell evue Hospital, as follows : Since the introduction of an

tito x in tr eatment the mor tality of diphther ia i s r educedto one-hal f

,i ts cour s e is shor ter and milder ; an inj ection

made within the fir st two days r educes the mor tali ty tofive per cent . ; the ear l ier i t i s made the better the r esult.Small quantiti es o f concentr ated serum ar e toler ated by thevery youngest babies . I f antitoxin i s not a specific it iscer tainly the best r emedy in our possession against diphther ia. The genuine (that i s, uncomplicated bacillary)cases

,ar e mor e amenable to its favor able influence than

mixed infections . I t has no secondary efl'

ects o n hear t,kidneys, o r ner ves . Hear t fai lur e and par alys i s wheneverobser ved ar e caused by diphther 1a not by antitoxin .

”

3

0p (Q

https://www.forgottenbooks.com/join

DR. JACOBI ’S WORKS

var iola, erysipelas, typhus and typhoid fever , and influenza.

The anatomical l esions found in per sons who have di edwhile affected with catar rh of the larynx do not alwayscor r espond with the symptoms encounter ed dur ing l ife .The mucous membr ane of the larynx i s so r eplete withelastic fibr es that after death even

, the blood i s squeezedout o f the di lated capillar i es . In very sever e forms ofcatar rh, small apoplexies

,ecchymoses occur now and then

,

and will be found after death,occasionally. The mucous

membr ane i s denuded of the normal vibr ati le cyl indr ical epithelium which forms the uppermost epithelial layer of thelarynx . The mucous membr ane i s r eddened, moist, sucenlent, loose in i ts ti ssue ; the sub—mucous ti ssue i s now and

then oedematous, and sometimes, even in an acute catar rh ofqui te a r ecent date

,smal l super ficial ulcer ations have been

found. Thus the anatomical changes left in the mucousmembr ane of the larynx, after death

,fully cor r espond

with those found i n the mucous membr anes of o ther or gans .Sometimes the tr aces of catar rh ar e clear and dist inct ,sometimes nothing is found in post—mor tem examinations .An example o f thi s fact is the occasional absence of all

and any post-mor tem r esults in childr en who have diedin a sever e attack of gastr o- intestinal catar rh, so

-calledcholer a in fantum . While in some ther e ar e all the tr acesof catar rh

,and i ts sequelae

,fr om simple hyperaemia to

folli cular ulcer ation, ther e i s no alter ation in other s .The acute catar rh of the larynx, as mentioned

,with i ts

capillary inj ection , its thr owing o ff and r apid di s integr ation of the epithelium,

and it s oedematous infiltr ation, i sby no means univer sal in all cases . In some, the epiglotti s,o r the mucous membr ane of the infer ior vocal cords , o r

the Wr isbergian , Santo r in ian,

and arytenoid car tilages ;the aryepiglotti c folds, the true vocal cor ds , o r the in

fer io r par t of the larynx, may be affected either separ atelyo r contempor aneously, with o r without a s imilar affectionof the contiguous r egions between nose, pharynx, and

lungs . The symptoms of the affection will fr equently varyin cor r espondence with these anatomical differ ences .The acute catar rh of the larynx is seldom,

fr om the be

2 1 4

TREATMENT OF GROUP

ginning,a fever i sh disease . The patients feel comfor table,

and the functions of the di seased or gan alone ar e abuormal. Ther e i s a cer tain degr ee of sens ibility in the r egionof the larynx, a bur ning o r i tchi ng sensation . The voiceis alter ed

,becoming indi stinct and hoar se

,in consequence

of the thi ckening of the mar gins o f the vocal cords, whi chthe muscles ar e no longer able to for ce into as many vi

br ations as befor e . Besides the itching and bur ning sensation

,and hoar seness

,ther e is another symptom pr esent,

namely, sever e cough, occur r ing in par oxysms, as if pr oduced by some for eign body touching the mucous membr aneof the larynx . Expector ation i s not COpious ; in the commencement of the dis ease ther e i s n one, o r it i s clear and

ser ous,containing some few cylindr ical epithelia, and a

few fr om the lower layer s . In the other stages of thedisease

,par ticular ly in the cour se of r ecovery, the expec

to r ation becomes mor e cons istent mor e purulent, and yel

lowish In a somewhat advanced age only will childr enr emove thei r expector ation voluntar i ly ; they will swal lowwhatever touches their fauces, and ther efor e it i s ver v

difficult sometimes to obtain any information as to the

natur e of the expector ated substances . Phys ical explor ation by means of the laryngoscope yields, at thi s age,and with the uncontr ollability of most chi ldr en, but fewr esults .The sub—mucous ti s sue i s much swollen in some excep

tio nal cases only, as far as adult per sons ar e concer ned.

Fo r the glottis,and par ticular ly i ts poster i or third, forms

a pr etty lar ge opening in adults,and the entrance of ai r

into the r espi r atory or gans i s n o t p r evented by the tumefaction o f the mucous membr ane . Even chi ldr en do notsuffer very often fr om constant dyspnoea, in consequenceof a s imple laryngeal catar rh. Although in them the glottis i s shor t and nar r ow

, the swollen chor dae vocales, bymeans of the constant and uninter rupted action of the poster io r cr ico-arytenoid muscles, ar e sufficiently di stant fr omeach other not to pr event the entr ance of air . But sometimes childr en

, who have been coughing and hoar se dur ingthe day, without feeling sick, will be obser ved to awakesuddenly in the night, with an attack of suffocation . In

2 1 5

DR . JACOBI ’S WORKS

spir ation i s extr emely difficult and exhausting ; in the ut

most height o f their anxiety and tr ouble, the childr en will

r oll about, str etch thei r necks and gr asp their thr oats ;thei r cough i s hoar se, r ough

,bar king. These attacks have

been and ar e very often mistaken fo r cr oup,have been

and ar e descr ibed as pseudo-cr oup,fals e cr oup

,and usually

disappear without leaving a tr ace, after a dur ation of o n e

o r a few hour s . These ar e the attacks whi ch r eadily disappear after the administr ation of ho t milk

,o r ho t sponges

over neck and thr oat,and by emetics, and which have won

fo r these r emedies the r eputation of being infal lible incr oup, when given in time . You may be cer tain that all

the childr en who ar e r epor ted to have suffer ed fr om cr oupfour

,s ix, and twelve times

,and have always been saved

wer e simply suffer ing fr om attacks similar to those of whichI have just been Speaking . Perhaps the sudden attacks ofsufl

'

o catio n ar e p r oduced by a momentary swelling of themucous membr ane and nar r owing of the glotti s

,which the

muscular action could not counter act, as sometimes a nostr i l i s thor oughly impermeable in consequence of a sever ecold. But i t i s better explained i n the following manner :The suffocative attacks almost always occur in the cour seof the night ; they diminish and disappear

,after the child

has been awake fo r a time,with scr eaming

,coughing, and

vomiting ; and will appear anew after the patient hasagain fallen asleep . F r om this fact i t i s p r obable thatthe cause of the sudden suffocat ive attacks i s due to theexs iccation of a collection of tough secr etion in the laryn xand glotti s . At all events

,the quick oper ation of the above

mentioned r emedies i s best explained in this manner . ThusI always give the advice

,dur ing the fir st two nights of

an acute laryngeal catar rh, not to let the chi ldr en sleepbevo nd a cer tain time . Awake them fr om time to timeand let them dr ink . I pr efer them to cough mor e fr equently and mildly to expos ing them to violent spells o fboth coughing and dyspnoea.

Some have attr ibuted a lar ge par t of the symptoms tospasm ; the affection has even been call ed spasmodi c laryngiti s . Now,

actually every cough, no matter of what sor t,i s a convulsive action, but thi s i s not the meaning of those

2 16

https://www.forgottenbooks.com/join

DR. JACOBI ’S WORKS

faction of the infer ior vocal cords cover ing the inner margin of the super ior ones ; by swelli ng of the poster ior wallof the larynx ; and by an accumulation of secr etion br oughtabout by the impeded function of the congested and oedematous laryn x.

2 . Deficient dilatabil ity of the glotti s, that i s, impededmotion of the arytenoid car tilages, and the true vocal cords ;by swelling of the i nteguments of the San to r in ian and

arytenoid car tilages, and subsequent immobility of thesecar ti lages and the true vocal cords inser ting on the vocalpr ocesses ; and, finally, by par alys is of dilating muscles .When such complete obstruction takes place, the same

symptoms as those of membr anous cr oup, o r for eign bodi es,o r polypous gr owths, o r acute (edema

,obstructing the wind

pipe,will appear

,with the same indications and the same

r esults,unless these indications ar e fulfilled.

As to the cour se,dur ation

,and termination of the milder

form of acute catar rh of the larynx, i t may be added thatusually after a few days the larynx ceases to be as sensitive

,the cough subsides, the hoar seness vanishes , and the

dis ease terminates in r ecovery, after a week o r two . But .

a dur ation of sever al weeks i s not uncommon,and do n o t

for get that the infantile or ganism has a gr eat tendencyto inflammatory affections, and to the exudative p r oces ses ,and that the infantile vocal cords will not bear so wellas those of adults

,a thi ckening of thei r substance and a

cons ider able nar r owing of the r ima glottidi s . The patientmay he appar ently well dur ing the day but tr oubled byattacks of coughing every mor ning and night

,and thi s

state of things may last fo r a long time,until the catar rh

and i ts consequences have become chr onic, and r emovablewith difficulty only. But mor e ser ious consequences mayfollow the slightest dyspnoea, continuing fo r a long time ;a smaller amount of oxygen enter s the blood than is mecessary fo r normal combustion, and fo r a complete and r egularphys iological metamor phosi s of the or ganism . Thi s i sundoubtedly pro ved by the asser tions even of adult pati ents

,

suffer ing fr om slight laryn geal catar rh, who will exper iencesuffocative attacks

,and sur pr i se you by showing a mass

of mucus br ought up after long coughing,dry, hard, some

2 1 8

TREATMENT OF GROUP

times slightly tinged with blood, and exactly bear ing the

outlines of Mor gagni’

s fo ssze between the super ior and in

fer io r vocal cor ds,o r some other par t of the larynx .

I t is a r emarkable incident that just the r ever s e of whathas been pr esumed to be cor r ect

,i s so . The fact that

childr en die of cr oup, who on the post-mor tem table do notexhibi t much anatomical obstruction in the larynx, pr ovesa par alys is r ather than a spasm of the larynx . Animalswhose pneumogastr i c ner ves have been cut

,and whose glot

tis i s par alyz ed in consequence, die with the exact dyspnoeaof cr oup . Mor eover

,let us consider fo r a moment in which

condition the mucous membr ane, the sub-mucous tissue,and the muscles of the larynx may be found. Ther e i ssucculence

,swelling

,(edema. Ther e is in consequence of

thi s condition of the mucous membr ane,oedematous infiltr a

tion and paleness o f the submucous tissue and the muscles .Thus

,to pr ove by analogy, in pleur iti s the inter costal

muscles are par alyzed and bulging out ; i n per itoniti s and

enter itis ther e i s succulence, (edema, and par alys is of themuscular layer of the intestine, by which the absence ofper istaltic motion and the pr evalence of flatulen cy and

constipation must be explained. The same pathologicalfact holds good fo r the sever al constituent tis sues of thelarynx .

Fur ther : the base of the two arytenoid car tilages forming (by str etching forward and inward) the vocal pr ocesses,ar e very lar ge in adults so lar ge, indeed, as to form a

tr iangular sur face,the par s r espi r ator ia ” of Longet.

Thi s par t does not exist in childr en,as the base of the

car tilages i s br t nar r ow,and thus the glotti s fr om anter ior

to poster ior i s but a uni formly nar r ow slit bor der ed bythe vocal cords . Now when the air in the tr achea i s r ar efied and

_a full cur r ent of air falls on the vocal cords ,

and the dilator s of the vocal cords , namely, the poster iorcr ico-arytenoid muscles

,ar e p ar alyzed, the vocal cords ,

oblique in their r elation to each other , ar e appr oximated,o r entir ely closed. By sucking the air out of the tr acheaof a chi ld fr om below,

thi s fact can easily be ver ified inthe fr esh anatomical specimen . Thus when the symptomsof cr oup ar e the r esult of membr anous obstruction of the

2 19

DR . JACOBI’

S WORKS

larynx, both inspir a tion and expir ation ar e impeded ; whenof paralys is, the inspi r ation suffer s mor e ser iously thanexpir ation . Thi s latter i s especially the case

,when the

pharynx is implicated in the cr oupous pr ocess,as in so

called descending cr oup . Fo r i t is the mucous membr aneof the pharynx whi ch forms the integument of the mm .

cr i co—arytenoidei por ti ci , which in normal inspir ation, whenhealthy, enlar ge the glottis .As far as the tr eatment of acute laryngeal catar rh, o r

spasmodic laryngiti s, o r pseudo-cr oup,i s concer ned

,i t i s

better to accustom healthy childr en to the usual causes ofthe affection than to guard them too cautiously. Suchas have been affected befor e, will be most l iable to be takensick again . They ought to be dr essed car efully accordingto the temper atur e of the atmospher e . I f ther e is anything as injur i ous as it i s unaesthetical

,it i s the naked

shoulder and leg of a shiver ing chi ld. But they ought tobe accustomed to inhale fr esh air

,and to the fr ee use of

cold water,r iver and sea bathing. Such will be the most

efficient p r eventives . Common cases o f acute laryngealcatar rh

,p r oduced by atmospher ic influences, r equir e warm

foot baths and mild diaphor etics, ho t tea o r milk, subace

tate of ammonia,tar tar emetic in small doses ; the ir r ita

tion of the skin by ho t sponges, s inapisms, and the application o f cold water to the thr oat ; a sever e attack of suffocation o r dyspnma will now and then r equi r e an emeticipecac in infants

,ipecac with tar tar emetic in mor e ad

van ced age. I state,however

,that I take exception to

the too gener al use of emetics in these so -called cases ofcr oup

,when no other symptoms but hoar seness o r a bark

ing cough show themselves . In cases of ser ious dyspnoeaalone they ought to be administer ed. Thi s much I can

assur e, that not one out of a dozen of the childr en en

trusted to my char ge ar e puni shed to such an extent in thi saffection . Wher ever a complication i s found of pharyngealwith laryngeal catar rh, astr ingent gar gles o r applications,

‘

o r inhalations of tannic acid, o r alum,o r nitr ate o f silver ,

in str ong solutions,o r in substance, ar e use ful . Even '

when not applied to the larynx dir ectly, they will fr equentlypr ove beneficial by contr acting the dilated blood-ves sels

220

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

ipecac, squi ll,‘

senega, tar tar emetic, sanguinar ia, . and id

genus omne . My own opinion of their value i s not verygr eat . I hardly ever pr escr ibe them . As thi s i s so

,I

have to beg your par don fo r swelling their‘

number by twoother s . One i s the oxysulphur et of antimony, s imilar inits chemical composition to kermes miner al

,on the expec

to r an t qualities of whi ch I published an essay in the N ew

Yo r k J our nal o f Medicine, ten year s ago. After the feverof catar rhal affections has subs ided

,and wher e no diar

rhoea i s pr esent,and the power s of the patient not ah

so lutely low,i t may be given, i n doses of fr om one-four th

to two gr ains,fr om four to eight t imes a day. I t does

not exhibit the depr essing n o r the pur gative effect ofother antimonials

,although after a while it will be dis

cover ed i n the passages,unchanged ; and may be given

as a powder , o r in mixtur es , with o r without adjuvants,

o r sedatives . The other i s the hydr ochlor ate of ammonia ,

o r chlor ide of ammonia. The so -called r esolvent,anti

neur algic, anti-rheumatic effects of thi s salt have beenmentioned

,and sometimes extolled, in Gr eat B r i tain and in

our country. I t was sometimes spoken of as a power fulr emedy, undoubtedly because of its being an ammoniacalpr epar ation ; and I have sometimes r ead, and heard of late,of its wonder ful effect

,and the poss ibility of its being a

danger ous drug . The truth is,that its power s of both

injur ing and benefiting have been gr eatly exagger ated.

Fo r decennia, whi le it was compar ativelyunknown, and

sometimes fear ed,in England and Amer ica

,i t was the

common accommodation drug of German pr actitioner s ;In doubtful and plain

'

cases, danger o r not, indi cationo r not, i f no other innocent o r convenient thing wouldstr ike the non - inventive genius of the pr actitioner , chlor ideof ammonia was r esor ted to . It was the squills o r the

calomel of the Englishman . You would find as manyr ecipes with chlor ide of ammonia on the counter s of a

German,as calomel on those of an English drug stor e .

Thus i t may be consider ed pr obable that its str ong o r in

jur ious effects cannot be very marked. What I can sayof it i s thi s : I have no high opinion of its effects except those r efer able to the mucous membr ane

, par ticu

222

TREATMENT OF GROUP

lar ly of the r espir atory or gans . Its effects on the mucousmembr ane of the stomach and intestines ar e far infer iorto those which may be obtained by a judicious use ofemetics, alkalies, and acids, especially the bicar bo nate ofsoda, and the mur iatic

, o r the nitr omur iatic acids,o r the

usual salts o f silver o r bismuth. But its effects on the

mucous membr ane o f the tr achea,larynx, and br onchi ar e

marked, in all such cases, but in those cases only, i n whi chthe liquefaction of a tough

,hard, vi scid secr etion i s r e

qui r ed. In a catar rhal affection,when the fever has

subsided, and expector ation appear s insuflicien t,i t will be

administer ed with marked benefit . Her e,and her e only,

l ies its spher e . It may be given in doses of gr . xx . o r gr .

xl . a day, with o r without a sedat ive to diminsh local ner vous i r r itation, hyoscyamus o r belladonna ; and will be ad

van tageously combined with the same amount of chlor ateof potassa o r a somewhat lar ger dose of chlor ate of soda,in complications with catar rh of the pharynx . I t may begiven thr ough the day, whi le towar ds bed-time

,o r at

nine o r ten o’clock

,a suflicient s ingle dos e of opium,

o r

an opiate,may be administer ed. Such ar e the outlines of

the rules according to whi ch the usual form of laryngealcatar rh ought to be tr eated. Those forms

,however , in

which a complete obstruction,o r an almost complete closure

of the larynx takes place, fr om such causes as enumer atedbefor e

,and i n which the above tr eatment pr oves ineffi=~

cient, r equir e other means to ward o ff the fatal termina

tion by suffocation . These ar e the forms which deser vethe name of catar rhal cr oup,

and r equir e as sound and

quick a judgment as a steady hand. They ar e not fr equent

, but they will occur , in every land and pr actice .Just as sur ely as a case of polypus, o r for eign body in thelarynx r equir ing inter fer ence, may be met with any day,although sometimes not in a dozen year s, a case of catarrhal cr oup thr eatening speedy death

-

fr om suffocation maybe met with. Every phys ician i s acquainted with the

o ccur r ence of acute oedema of the glotti s, and the necessityfo r establi shing an ar tificial entr ance of air into the lungs,and every one may meet with a case of catar rhal cr oup i n

which the omission of tr acheotomy is homicide .“

22 3

DR . JACOBI ’S WORKS

Dr . Kuhn has collected 1 49 cases o f fo r e1gn bodi es inthe larynx, tr eated with tracheotomy, and 1 09 r ecover ies ;7 3 cases o f oedema of the glotti s

,and 5 4 r ecover i es ; 5 2

cases of syphi l iti c laryngiti s, and 3 9 r ecover ies ; 2 8 casesof per i chondr iti s and necr osis

,and 5 r ecover i es ; 4 cases

of angina tons illar is, and 1 r ecovery; 22 cases of epilepsy,and 20 r ecover i es ; ~ 1 1 cases of wounds of the larynx, and

1 0 r ecover i es ; 1 2 cas es of combustion, and 6 r ecover ies ;3 5 cases o f di seases of sur r ounding or gans

,and 5 r eco v

er i es ; 5 cases of polypi , and 4 r ecover i es .Such figur es ar e r eason enough why the name of those

should be r emember ed and blessed who lear ned and taughtto tempor ar ily supply the lungs and blood with thei r es

sen tial nutr iment . We shall soon see that their example isnot o nly val id in cases of walnut shells, bones, copperpennies

,pieces of china, coffee beans, pebbles, and sugar ed

cor n imbedded in and obstructing the ai r -passages,but

in every sor t of air -pas sage obstruction,both accidental

and pathological .Fr om our consider ations of the tr eatment of cr oup, how

ever,non-obstructing catar rh on one side

,for eign bodi es ,

polypi, ulcer ations , with oedematous swelling, as i n typhoidfever

,typhus, syphil i s, tuber culosi s, and spasm of the glot

tis,must be excluded. The diagnosis of t rue cr oup has

fo r a long per iod been thought to be dependent on the

pr esence of membr anes, and consecutively the di st inctionbetween cr oup and pseudo-cr oup, according to their pr esence o r absence

, was cons ider ed unimpeachable . But ther eare a number of cases on r ecord in which tracheotomy was

per formed fo r cr oup, and no membr anes found. Or afterpseudo—cr oup had lasted and been diagnosticated fo r days ,all at once membr anes wer e found in the larynx, withthe exclus ion of the pharynx . Or in other cases the symptoms wer e so ur gent that tracheotomy was per formedfo r what was shown to be s imple catar rh with considerable (edema

,and with o r without pharyngeal membr anes .

And sometimes the membr anous deposit was found in thepharynx alone

,and nothing be side it

,after death. Fo r

these r easons a diphther i tic , a membr anous,a catar rhal

and spasmodic cr oup wer e distinguished. But this much

224

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

aamia of the sur r ounding par ts, o r inter sper sed por tions,depends on compr ession of capillar i es by infiltr ati on, whichmeans new-formed cells and connective tissue ; mor eover , letus not for get that we have for tunately passed by the timewhen the nutr itive disor der called inflammation was al

ways thought to depend on pr evious congestion of the

par ts.

All those forms of change of tissue ar e not found uncomplicated in every given case . When lar ge sur facesar e taken at once, you may see in the mouth a catar rhalpr oli fer ation o r c r oupous condensation of the epithelium .

on the tonsils a diphther i tic deposit imbedded in the ti ssue, o n the larynx and tr achea a plain cr oupous depos it

,

and in the.

br onchi a muco-purulent s ecr etion . And again,

under the same endemic and epidemic influences you willfind a case of catar rh

,a case of cr oup

,a case of diph

ther ia, a case o f folli cular exudat ive amygdal iti s, i n the

same family in the same week . Thus i t appear s that inthe long list o f mor bid conditi ons met with, catar rh onone side, diphther ia on the other

,ar e but the star ting

and terminating points between which all the differ entshapes and forms may be r egister ed according to thei rdignity, their modification depending on individual, local,endemic and ep idemic influences ; the only form which i sperhaps

, but perhaps only, to be excluded, being the necr otiz ing diphther ia. And when we compar e the clinical natur eof the affection we find similar differ ences . The affectionmay be local without fever , o r s imply febr il , o r local andobstructing, o r obstructing and poisonous . In some casesthe pr oces s will not even be confined to the r espir atoryor gans

, but, s imilar to the r inder pest of animals, the di

gestive prgan s’

will par t icipate in the pr oces s,and skin,

kidneys ; spleen, may follow .

Thus gr eat may be found the di ffer ence of the amatomical lesion in cr oup

, but the stenosi s , obstruction of thelarynx, is the common symptom of all forms .After the symptoms of tumefaction, succulence, and in

cr eased secr etion, with thei r par alyz ing influence on the

mobility of the vocal cor ds, and with i ts barking o r soundles s voice o r cough, have passed by, o r without these pr e

226

TREATMENT OF CROUP

monitory symptoms, inspir ation becomes impeded . its dur ation pr olonged

,and its sound s ibilant . The r espi r atory

effor ts ar e incr eased i n consequence ; the levator es alarumnas i active, the muscles of the thor ax over str ained. Ex

pir atio n shor t, no inter val between expir ation and inspi r ation, mouth and nostr i ls open . The super ior por tion of thethor ax flattened, the supr a-clavicle r egions sunk

,ster num

and scr obiculus cord i s dr awn in ; the infer ior par t of theabdomen bulging out ; larynx and tr achea ascend and de

send consider ably with every expi r ation and inspir ation tocompensate fo r the dimini shed amount of air admittedto the lungs . The flushed face becomes pale, now and

then the child i s sopor ous, vomiting will occur spontaneously while emetics ar e los ing their effect

,r espir ation i s

super ficial, attacks of suffocation will alter nate with sopor .

Sometimes fo r a change,entir e r emissi ons

,mostly in the

mor ning,will take place

,and the chi ld br eathe mor e

qui etly and appear mor e comfor table,until with an attempt

at deep inspi r ation, exactly like animals in whom the pneumogastr ic ner ves have been cut, a fear ful attack of suffo

cation sets in .

Par t of these symptoms r esult fr om the abnormal amountof carbonic acid r etained in the blood ; not fr om r etention of the blood in the br ain ; fo r as long as in spir ationalone i s impeded

,blood i s not r epelled into the br ain,

n o r into the integuments, and ther efor e we notice nocyanotic hue, except in a sever e attack of coughing, o r

except toward the fatal termination when the hear t isbecoming par alyzed and the ar ter i es insuffici ently filled.

Then the veins ar e dilated by the ci r culation being im

peded. To the contr ary, when the elastic lung tissue, n o t

sufficiently fi lled with air of normal density, affor ds mor er oom fo r the capillar i es to dilate, when ther e i s les s pr essur e ou the wall s of these lung capillar i es , the r esult i scongestion

,catar rh, br onchiti s, and

’

br oncho-pneumonia inside

,while the exter nal sur face is the paler . Thus br on

chial catar rh and br onchi ti s with it s sequelae—not, however ,cr oupous pneumonia

,whi ch r equi r es other causes—i s the

dir ect effect of impeded cir culation, and ther efor e the

fr equent cause of death even after tracheotomy has r e:

2 27

DR . JACOBI’

S WORKS

lieved the dyspnoea. Cyanos is, and impletion of the veinsgener al ly, i s the r esult bo th of impeded expir ation and

inspir ation,when the larynx i s almost fully obstructed

by membr anes . As expir ation can be attended with gr eate rmuscular for ce than inspir ation

,the blood will effectually

be r epelled into the venous system . Thus will occur dir ectbr ain symptoms not depending on car bo nic acid poisoning ; fr om thi s

,sour ce the immense and danger ous dilata

tion o f the veins o f the neck and thyr oid gland as met within many cases of tracheotomy ; fr om thi s sour ce also

,local

o r gener al cyanosis . With the exception of a very fewcases in which the obstructing membr ane i s for tunatelyexpelled

,nothing else but death can be expected. I t will

ensue fr om gr adual par alys is, o r sometimes fr om suddensuffocation by loose o r near ly loose membr anes obstructingthe glottis .Among the most danger ous symptoms in the final de

velopmen t of the pr ocess,I mention the following as con

sider ably impai r ing the p r ognosi s1 . Emetics administer ed

, and no r eli ef.2 . Emetics administer ed, and no effect .3 . Constant incr ease o f dyspncea.

4 . No mor e r emi ss ions between the attacks of suffo ca

tion .

5 . Feeble,fr equent

,and intermittent r adial puls e

, the

intermission coinciding with inspir ation .

The indi cations fo r the tr eatment of cr oup must mecessar ily be dependent o n its anatomical and phys iologicalchar acter .

The char acter of cr oup is : suffocation by insuffici ento r absent entr ance of air into the lungs in consequenceo f a nutr itive disorder of the larynx .

The obstructing causes ar e either (edematous swelling,o r par alysi s o f vocal cor ds , o r pr esence of membr anes

,o r

two o r all of these factor s . The indication i s to r emovethe one o r all of them bv the p r oper means , and to pr event the morbid pr oces s fr om incr easing . To give a li sto f the r emedies which have been given in cr oup fo r the

pur pose of dr enching the blood and system with a solvent,

” “

antiplastic,

” etc ., r emedy, would be to wr i te a

22 8

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

fication, becaus e it i s not local . You would poss ibly by a

well-di r ected scar ificatio n diminish it, but not r emove it

Even local oedema glottidi s has been known to r equi r etr acheotomy after scar ificatio n s had been fr eely made .Mor eover , the case is mor e unfavor able still fo r a dir ectinter fer ence . The very oedema of the mucous membr ane

(and sub—mucous t is sue ) , of the cr ico-arytenoid folds giving r i se to the par alysi s o f the glotti s i s its elf but secondary, the or iginal cause being almost i n every case the

diphther itic and (edematous condition of the pharynx . Afterall I have said

,i t appear s doubtless that we have to give

up the idea of inter fer ing with, o r r emoving, the par alys i s

o f the glotti s as met with in cr oup,the natur e of the

par alys is itsel f being as much the caus e of thi s impossibilityas the r apid cour se of the mor bid pr ocess . A mild casemay find time to get well, a s er ious o ne will suffocate .The next indication

,in cas e membr anes ar e deposited,

no matter whether of the hard o r pultaceo'

us char acter,

i s to r emove these membr anous depos its .Fo r thi s pur pose ther e have been r ecommended :1 . Inter nal tr eatment .2 . Mechanical tr eatment .The inter nal tr eatment has been mentioned above ; i t

was meant to have its effect according to the laws eitherof physiological chemistry, o r the pathology of neur oses .The latter has fai led. And so is the fi r st sur e to fail,in your minds , i f I shall succeed in pr oving that the sameremedies which wer e thought power ful enough to dis solvemembr anes by thei r pr esence in the blood, ar e en tir elv

power less to dis solve the same membr ane under your eye,

in your bas in, in constant contact with a str onger solutiono r dose o f the r emedy than you would dar e to administerinter nally.

The mechanical o r local tr eatment r ecommended i s themechanical r emoval of the membr anes within r each, withfor ceps , brushes , etc .Appli cat ion of r emedi es expected to di ssolve o r soften

the membr anes, fo r instance glycer ine .Application of caustics

,and astr ingents, alum, tannin,

chlor ide of i r on, miner al acids, nitr ate of si lver , by means

2 3 0

TREATMENT OF CROUP

of gar gles, dir ect local application with the pr obang, the

for ceps, the brush, o r the pulver iz ing appar atus .Removal of membr anes by emes is .The gentlemen ar e sufficiently acquainted with the local

application of nitr ate o f s i lver to the inter ior of the

larynx, inasmuch as par t of the most impor tant liter atur eon the subj ect i s our s . The name of Hor ace Gr een i s mor edeser ving o f the r espect of Amer i cans fo r his local tr eatment of the ai r passages— his tr eatment of cr oup I shouldnot, however , include in his gr eat impr ovements in scienceand ar t—than that of Loiseau of that of the F r ench. Now,

it has been pr esumed that nitr ate of silver would pr ovevery destructive to the laryngeal false membr ane, and

ther efor e has been widely r ecommended. But I wish tor emind you of the r esults of your local application tothe pharynx in cases o f s imple diphther itic deposits . Um

less you take, and ar e allowed,a r ather long time

,to me

chan ically tear up and destr oy the membr anes,with some

efl'

o r t and even v iolence, you will not succeed. The membr ane is even apt to shr ink and harden, i s not destr oyed, itsbase is intact

,and a new cr op may follow . I t is char ac

ter istic in nitr ate o f s ilver that its effect i s so very muchconfined to the exact point it comes in contact with. Ina few minutes I shall have to r elate a fr ightful p r oofo f this fact .Thus the very vi r tue of the agent is a dr awback wher e

youwant extensive destruction and a quick cfl ect. A longcontinued application i s out of the question . I have losta child

,in whose laryn x I oper ated with a satur ated solution

of nitr ate of silver,by instantaneous death. And those

few cases which I have r ead of, and o n e o r two cases thatfr i ends have r epor ted in medi cal societi es , cases in whichthe pr obang with a solution of nitr ate of si lver pr ovedeffective

,pr ove

,in my opinion, nothing fo r the nitrate of

silver, but everything as far as it goes fo r the moi st pr o

bang with its di r ect mechanical effect, and i ts indirecteffect in pr o ducing coughing, etc .We ought not to for get that the local tr eatment of

cr oupous o r diphther iti c membr anes in the pharynx whendesi r able

,i s a gr eat deal easi er than in the larynx . The

2 3 1:

DR . JACOBI’

S WORKS'

faci lity i s gr eater , and the or gan neither so v ital no r sovulner able. And what appli cations to membr anes may beexpected to do , will be seen by the following r esults o fdi r ect exper iments, par t o f which I have had fr equentchances to r epeatLime water r equi r es thi r ty to fifty hour s to di s integr ate

fals e membr anes, and thr ee days o r mor e to entir ely dissolve them . I t r equi r es fr om four to ten hour s to thoroughly li quefy the soft pultaceous diphther it ic depos its .Hydr ates of potassa and of soda

,1 : 5 0 0 , act mor e slowly

than lime water .

Permanganate of potass ium,

dis integr ates fal semembr anes in its outer par ts

,whi le the inter ior r emains

har d and solid,i n ten hour s .

Carbonate o f l ithia and car bonate of soda,

- 1 50,

had the same efl'

ect in the same time . About the sametime i s r equir ed by the constant effect o f chlor inatedwater .

Nitr ate of soda,1 : 20 0 - 3 0 0

,has no effect on membr anes .

Iodine,the o fficinal tinctur e, o r a solution of

shr inks and hardens them .

Nitr ic acid, has the same effect . So has aceticacid

,except on the soft diphther i tic mas ses

,whi ch get dis

integr ated.

The only agent whi ch di s solves membr anes soon , butone which is hardly fit fo r use fo r obvious r easons

,i s

ammonia.

Car bolic acid,applied to a membr ane o r a pultaceous

diphther iti c deposit, shr inks it in a shor t time,making

it r emovable to a high degr ee . The difficulty, however ,of applying it to the laryn x and br inging it into contactwith a suffi ciently lar ge sur face is very gr eat indeed.

To normal ti s sue it i s not without danger . Thus I am

not p r epar ed to say what it may be made to do in cr oupof the larynx, whi le I am pleased with its local effectsin the same affection of the fauces . To act quickly itmust be applied very l ittle, i f at all diluted

,and r equi r es

an exper i enced hand.

Subsulphate of i r on and sesqui chlor ide of i r on act, al

though, perhaps, not so vigor ously, similar ly to carbolic

2 3 2

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

only, i t will alleviate the symptoms, and may be r esor tedto and r epeated. When the obstruction is membr anous

,it

will be of less impor tance,inasmuch as the membr anes ar e

mostly closely attached in the beginning,that i s

,fo r days,

to the larynx, especially in those places which, li ke the fossae Mor gagni, ar e less exposed to the cur r ent of air fr omthe lungs .

'

But the effect o f the emetics i s gr eater thanthat o f the most sever e spell of coughing

,because of the

dilatation of the glotti s whi ch takes place dur ing vomiting .

In this dilatation a lar ger por tion of the larynx is exposedto the cur r ent of air emanating fr om the lungs than incoughing . Thus ther e i s hardly an obj ection to trying theeffect of an emetic in a cas e of membr anous obstructionof the larynx, which will best be diagnosticated by the

expi r at ion being impeded like inspir ation,with a view of

detaching it fr om the walls o f the larynx ; especially i s itindicated when membr anes ar e par tially loosened. Thi scondit ion is sometimes diagnosticated amidst the most urgent dyspnma by a peculiar loud, clashing, flapping sound,par ticular ly in expi r ation . Whenever r elief i s obtained

,it

ought to be r epeated fr om time to time, not otherwise .When the symptoms of gener al par alys i s fr om deficientdecarboni zation of the blood ar e on the incr ease, r eac

tion will cease,

and emetics will withhold thei r effect ,even at a per i od wher e spontaneous vomiting may stilltake place . When such i s the case the most power ful ofall ir r itants

,cold effusions to the head, o r neck, o r the pit

of the stomach,may sti ll r ous e the r eaction of the oh

longated spine and the pneumogastr ic ner ves .Of the r emedi es whi ch ought to be r esor ted to I have

spoken alr eady. I pr efer the sulph. cupr i to any of ther est . The mode of thei r pr oducing emesi s i s the same,and as emesis only i s r equi r ed

,the most r eliable medi ca

ment ought to be selected.

The indi cation of cutting shor t the pr oces s of obstruc

tion,to inter rupt the cour se of the di sease, has appear ed

to many to r equir e the use of diaphor etics , depletion, vesicator i es

,warm applications, o r cold applications .

Diapho r etics.—Their effect i s per ceptible in cases of

simple catar rhal hyperaemia only. The di latat ion of the

2 3 4

TREATMENT OF CROUP

capillar i es o f the sur face is apt to empty inter nal bloodvessels . Thus i t i s r ational to try diaphor etics in casesof catar rh, o r wher ever fo r a li ttle while the diagnos isbetween catar rh and cr oup i s doubtful . While

,however ,

it would be wor s e than unwise to expose the body of thepati ent to cold air

, we ought not to for get that i t is umphysiological and wor se than wasting time to expect ther eduction of a nutr itive di sorder of such an extent fr omthe admini str ation of inter nal diaphor etics

, o r diaphor eticexter nal tr eatment .Local depletion has fr equently been r ecommended.

Leeches wer e to be applied to the thr oat,to the manu

br ium ster ni . The same can be said of them as of dia

pho r etics. They may not be very injur ious in catar rhtheor etically they may even be justified, although the

same end i s better o btained by mor e innocent r emedi es ;they may not hur t r obust and vigor ous childr en whosestr ength i s not so easily consumed. But again

,inflamma

tion and hyperaemia do not always coincide, and exuda

tion i s not p r evented by leeching . To the contr ary, thewell—known fact that the pr opor tion of fibr in in the bloodincr eases with every depletion, ought ,

to make us ver v

cautious indeed. Mor eover, the danger o f local o r gener aldepletion in diphther ia ought to be too well under stood tobe under estimated. Fo r near ly ten year s, in thi s city and

over the wor ld, diphther ia has been pr evalent, with all its

local destructiveness and its constitutional poi son ; the lar gemaj or ity of cases of cr oup have been of a diphther iti cchar acter . The r esult of depletion in such cases i s buttoo often the r apid incr ease of exhaustion, and the formation of diphther itic deposits on the sor e sur face . ThusI consider the use of depletion in cr oup as excusable inbut few cases

,although hardly ever indicated ; in the ma

jo r ity o f cases it i s danger ous .What I have said of depletion 1s also valid fo r vesica

tor ies . I t is char acter isti c fo r diphther ia that not onlymucous membr anes

, but the cuti s too, wher ever i t i s denuded of its epidermis

,will be r eadily cover ed with mem

branes o r pultaceous deposits . Thus eczematous o r im

petiginous sor es will under go this change ; and those who:

2 3 5

DR . JACOBI’

S WORKS

have per formed tracheotomy o r any other oper ation in a

diphther itic individual, o r dur ing the pr evalence of an

ep idemic, have had sufficient r eason to be shocked at diph

ther ia exhibiting its erupti on within twelve o r twenty-fourhour s . I have seen dozens of tons ils r emoved fr om ap

par ently healthy indiv iduals in such seasons, cover ed withdiphther itic deposi ts wi thin a day, and r emember to havelost a cas e of r esection of the head of the femur fr om the

same cause . Thus, bewar e of ves icator i es . Their usualr esult i s not a r elief

, but diphther iti c cover ing o r disin

tegr atio n of the affected par t,and fr equently collater al

swelling . I do not asser t too much when I say that theonly effect I have ever seen fr om their use has been veryunfavor able.Both warm and cold applications have been made to

the larynx, exter nally, fo r the purpose of alleviating the

symptoms, o r inter rupting the pr ogr es s of the disease .Can we expect an effect, by either of the two, on the

formed and deposited membr ane ? No . Thus we cannot,in fact

,expect to influence the fully developed di sease

by either . Or on the collater al oedema and consecutivepar alys i s of the vocal cords ? Exactly the same must betrue . Now

,in inflammatory and exudative p r ocesses in

other or gans and r egions we use bo th warm and coldapplications , but i t appear s to me fo r differ ent indications ,and fo r differ ent pur poses. Ther e i s no doubt that warmpoultices in a cer tain advanced stage o f per itonitis o r

pneumonia will do a gr eat deal to p r omote the absor ptionof exudation

,and the comfor t of the patient ; but abso rp

tion we do not expect in cr oup of the larynx, and comfor t ther e i s none . But wher ever we do have a congestive disease, an inflammation based upon hypermmia, a

dilated condition of the blood-vessels, cold applications ,when the par ts ar e within easy r each

,ar e the only r eason

able means to fall back upon . I f thi s i s true of enter it i s,per itonitis

,o r pneumonia

,i t i s so much the mor e so in

afl'

ections of the larynx with i ts easy access and i ts close

pr oximity to the skin . The only thing I should not liketo di spense with i n the tr eatment of cr oup, i s, ther efor e,ice

,which

,i f anything, i s the most s imple, un exhausting,

23 6

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

'

whi ch they ar e, can’ be made to inhale volun tar ily. Mor e

over , pur e oxygen is not fit fo r r espir ation,on the corr

tr ary, i t causes dyspnoea in the healthy ; the mixtur e inwhich oxygen i s in the atmospher e appear s to be the onlypr oper food fo r the blood

,and alone capable of keeping

up the diffusion of gases thr ough the walls of the pul

monary capillar ies .Fo r the same pur pose Bouchut invented and descr ibed

his“

tubage .”He intr oduced

,so he said

,tubes between

the vocal cor ds, thr ough whi ch the cr oupous childr en wouldimmediately br eathe qui etly and sufficiently. Now

,in a

larynx filled withmembr anous o r other diphther it ic deposits

,thi s i s a plain impossibi lity. Only in cases of par

alysis o f the vocal cords such a pr oceeding could be

thought '

o f. Whether i t can be done o r endur ed, I dono t know. But I do know that Bouchut has not succeededhimself, inasmuch as he asser ts that the childr en intowhose glottides he intr oduced his tubes, expr essed to himtheir

'

gr atitiide, by words immediately after . When r e

por ting on"

this tubage o f Bouchut’

s, Tr ousseau al

ready stated that the hi ther to kn own laws of phys iologywould for bid a chi ld to speak with the vocal cords heldaside, and steadi ed by a solid tube in the r ima glottidis.

'

Fo r thi s pur pose, finally, we per form tr acheotomy ; thatis,we affor d the ai r access to the lungs below the ob

structed point . Thus tr acheotomy i s not a cur e fo r cr oup,i t i s

'

s imply a means to keep the patient fr om sufl o catinguntil the pr oces s above has completed i ts cour se . As soonas the larynx will be per vious again

, you expect to close

your ar tificial opening. Thus tr acheotomy appear s on alevel

, but mor e favor able than these, with par acentesisof the bladder , oper ation fo r ar tificial anus , o r thor aco ;

centes is fo r acute copious effusion . Thus ther e ought tobe no contr aindication when the pr ominent symptom isdyspnma, and suffocation . I cannot imagine any complication of cr oup that would pr event me fr om opening the

tr achea when the child i s dying o f suffocation . Thi s i sso plain to my under standing that I should consider i teven a cruelty to r efuse tracheotomy when I kn ew before~

2 3 8

TREATMENT OF CROUP

hand that the child was sur ely going to die. Whoeverhas seen chi ldr en die of cr oup, fully conscious, gasping,r aving fo r air unti l they ar e slowly str angled in yourarms, un der your eyes , will at least bless a p r oceeding

,

the consequence o f which will in most cases be an easierdeath ; with the exception of those in which solid membr anes wi ll

, after the oper ation,migr ate down into the

smallest r amifications of the br onchial tubes .No r do I acknowledge that tender age, the age under

two year s, ought to be held as contr aindication to the

per formance of the operation .

Now, it i s a fact that the r esults of the oper ation at

thi s age ar e much less favor able than at a mor e advancedper iod. All and every stati st ical r ecord yields the sameevidence . But lately, G ii terbo ck has publi shed one hundr ed cases o f tracheotomy fo r cr oup

,o ne of which was

under a year , one under two year s , both terminatingfatally. As far as the r est i s concer ned of those oper atedupon, between the second and third year the per centage ofr ecovery was 3 3 1 - 3 ; between the thir d and four th year ;4 0 per cent . ; between the four th and fi fth year s, 3 8 8 -1 3

per cent. ; between the fi fth and sixth year , 4 4 4 -9 per

cent . ; between the s ixth and s eventh year , 4 4 4 -9 per cent . ;between the seventh and eighth year , 1 4 2 -7 per cent . ;between the eighth and ninth year , 2 5 per cent .Theor etically, ther e i s no r eason fo r tender age being

an excuse why suffocating infants should be left to a

sur e death. I f,however clin ical exper i ence would sus

tain the contr aindication as such, we mi ght be satisfied withleaving them to thei r fate . But for tunately the case isnot so bad after all. Fo r ther e ar e a number of caseson r ecord in whi ch tr acheotomy per formed on very youngchi ldr en pr oved success ful . I will not ur ge the case ofScoutetten

,er r oneously attr ibuted to Sedillo t lately, who

oper ated on an infant of s ix weeks , as i t has been de~

clar ed to have been a case o f so -called pseudo-cr oup ; ale

though,even i f this was so

,the advisabil ity and possibility

o f the oper ation was clear ly pr oved by thi s very case .But the cases of Baizeau, in an infant of ten months, and

in {sippthcr of fifteen months ; the case of Isamber t, s ix-i

k2 39

DR . JACOBI ’S WORKS

teen months ; Ar chambault, thi r teen and eighteen months ;Royer , nineteen months ; Vigla, s eventeen months ; Potaineighteen months ; Moutard-Mar tin, eighteen months ; Tr ousseau, thir teen months ; Bar thez, thir teen and seven months

,

pr ove the very fact that the gener al indication fo r tr acheo tomy, namely, obstructive dis ease of the larynx, r emainsvalid.

Dr . K r ackowizer’

s ear l iest cas e of r ecovery, in thi scity, was not two year s o ld. He r emoved the tube on thechild

’

s thi rd bir thday, but was compelled to intr oduce i tagain fo r a few days .The r esult o f my own cases of tracheotomy i s as fol

lows : I have oper ated on sixty-eight chi ldr en, sixty-seventimes fo r cr oup , once fo r a for eign bo dy contained in thelarynx . The case was that of an infant of eleven months

,

who had a flat bone seven lines long and one to four lineswide lodged in the larynx whi le being fed. The dangerappear in g imminent, dyspnaaa gr owing fr om minute to minute and r esulting in a gener al cyanotic hue o f the face,and emetics pr oving useles s

,help was immediately sought

fo r and the oper ation o f tr acheotomy per formed about twohour s after the accident . The for eign bo dy was di slodgedfr om below upward thr ough the tr acheal opening withgr eat difliculty ; after i t had been r emoved the dyspnoeawas not entir ely r eli eved and the child did not br eathenormally except thr ough the tube only. I t appear ed that

,

although ther e was no longer a for eign body ins ide the

larynx, it had dur ing its stay ther e worked changes r e

sulting in obstruction . I t was, ther efor e, impossible tor emove the tube, symptoms of laryngit i s showed themselves after a few days, high fever s et in, and the infantdied on the eleventh day after the oper ation

,of tr aumatic

laryngitis. The post-mor tem appear ances wer e : intensecatar rhal inj ection

,intermingled with an occas ional cc

chymo sis of the epiglotti s, cons ider able swelling of the

enti r e mucous membr ane of the larynx, and sloughing ofthe fossae Mor gagni and par t of the vocal cords.

Of the s ixty-s even cases of tr acheotomy fo r cr oup,thir ty-eight wer e made on boys , twenty

-nine on gi r l s . Ofthe s ixty-seven, thi r teen r eco ver ed ; of the thi r ty-eight,

2 4 0

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

a for eign body was located in the larynx, though I r e

luctan tly confess that I believe I have lost lives by los ingtime . A case of thi s descr iption occur r ed but lately. Aboy of a little mor e than two year s was taken with hoar seness and moder ate fever

,and a c r oupy cough. The mes

sage did not r each me befor e the following mor ning,when

I paid my fi r st visi t at 1 0 a. m . Hardly any deposit ona (the left) tonsil, gr eat dyspn tea, but voice not gone,the muscles of the thor ax in thor ough exer tion

, per spir a

tion,pul se of The mother had dur ing the night ad

minister ed chlor ate o f soda, and applied ice water to thethr oat . T r eatment continued

,with an occasional emetic

,

until I should call in the after noon . Vis it at 5 p . m .

Mor e dyspnoea and per spi r ation, dyspnma constant, eya

n o tic hue o f lips and nose,pul s e 1 50 to 1 60 , ir r egular . Still,

I try the effect o f an emetic ; i t takes effect, but gives nor elie f. Then I call on Dr . Chamber lain fo r as si stance inthe oper ation, which i s per formed at 7 p . m . The r eliefaffor ded by i t i s str iking, but below my expectation ; thr eequar ter s o f an hour after the oper ation the r espi r ation i sr ougher

,har sher than normal

,3 6 to 4 0

,pulse 1 24 to

1 2 8,the patient toler ably qui et, but spells of r estlessness .

which,however , do not last very long . At 1 0 p . m . an

occasional cr epitant r i de,4 4 to 4 8 r espir ations

,1 50 pul

satio ns,heat of skin incr eased

,no dull per cussion sound.

I fear a beginning br oncho—pneumonia, and state my um

eas iness concer ning the termination of the case to Dr .

Chamber lain, who kindly accompanied me . At a. m .

I was sent fo r,only to lear n that the child had died soon

after the messenger went fo r me . The post—mor tem exami

nation r evealed,besides the complete membr anous obstrue

tion of the larynx, a few thin and small membr anes co r

r esponding with the fir st five o r s ix car tilages of the tr achea

,intense inj ection and ecchymotic di scolor ation of the

l ining membr ane of the tr achea and br onchi with theirr amifications, a gener al and intense oedema of the lungs ;no pneumonia

,no hemor rhage, no collapse of the lung .

Those who ar e conver sant with the mechanical influenceo f the r ar efaction of the ai r inside the lungs, and the

dispr opor tion between the tension of blood i n the ves

242

TREATMENT OF CROUP

sels and the diminished atmospher ic pr es sur e on theirwall s fr om outs ide

,will be apt to explain the post-mor tem

appearance and the mode of dying . I t has been the onlycase of uncomplicated, fatal pulmonary (edema after cr oupand tr acheotomy which I have seen , and ther e ar e but fewsuch cases on r ecord. The tendency i s much mor e to thedevelopment of an exudative than an effus ive pr ocess , and

while br oncho—pneumonia i s a fr equent occur r ence,un com

plicated pulmonary oedema i s as rar e as i t is instructive .Of my pati ents one was at theage of 1 year 1 month ;

one,1 vear 2 months ; one, 1 year 7 months ; one, 1 year

1 0 months ; five,2 to 21; year s ; nine, to 3 year s ; six

teen,3 to 4 year s, twenty—thr ee, 4 to 5 year s ; seven, 5 to

6 year s ; two, 7 to 8 year s ; and one 1 0 year s .Recover i es took place :

1 at the age o f to 3 year s, 1 out o f 5 operatio ns,= 20 per cent .3

cc3

u4

ul 1 6 u

2 1 9cc

7 4 5 1 23 = 3 0

2 5 6 1 7 = 28 4 -7

The after -tr eatment in some of these cases was pr o

tr acted, and ther efor e the tube had to r emain in some a

pr etty long time ; It was r emoved in two cases on the 1 7thday, one on the 1 8 th, one on the 2oth, one on the 2 7th,

one on the ' 29th, one on the 3 oth,two on the 3 5th

, oneon the 4 2d

,one on the 4 4 th

,one on the 4 6th, and one on

the 5 4 th day.

The cause of the long dur ation of the after—tr eatmentwas in four cases of a peculiar natur e . I t was found thatin the second week fafter the oper ation , the larynx having expelled the macer ated membr anes, would r esume itsfunctions

,and the patient br eathe normally thr ough the tube

and i ts upper fenestr a,and the larynx, the anter ior open

ing of the tube having been closed by a cork . But the

r emoval of the tube fr om the tr achea gave r i se to instantan eous attacks of dyspnma and suffocation , which wer einstantly r emoved again by the r eplacing o f the tube .This occur r ence would take place so r egular ly that thepatients would not admit the r emoval of the tube after

24 3

DR . JACOBI ’S WORKS

ward. The cause of this str ange and unsatis factory cc

cur r ence was found to be the pr esence of polypoid excr escences

,sometimes numer ous

,of the s iz e of a pin ’ s head

to that of a pea and mor e,or i ginating on the mar gin of

the tr acheal wound,i n one case on the lower por tion o f

the sor e larynx itself . I t r equi r ed a gr eat many appli

cations o f nitr ate of s ilver,o r subsulphate of i r on

,to de

str oy them ; their di sappear ance would instantly r elievethe symptoms and allow of the final r emoval of the tubefr om the tr achea. Such i s the case of the boy D

’

Echauf

four , a patient of Dr . H o eber’

s,fo r whom I per formed the

oper ation,at No . 67 Sixth Str eet, whose final r ecovery

was long defe r r ed by such new—formed gr anulations, and

who is still said to suffer now and then fr om sudden at

tacks of dyspnoea, which (although I have not seen the

chi ld fo r some time) may still depend on the p r esenceof small polypous excr escences, giving r i s e to obstructi ono r spasmodi c contr actions, when for ced inspir ations ar e

taking place .Not all of my oper ati ons wer e made on uncomplicated

cases of laryngeal obstruction . In two,br onchiti s had been

diagn osticated in the incipient stages of cr oup,and almost

all the . cases, fr om 1 8 59 to 1 867 , wer e complicated withlocal and gener al symptoms of diphther ia. Seldom haveI oper ated on a case

,without fever attending it fr om the

beginning ; seldom wi thout the pr esence of swelling of theadj oining lymphati c glands . Thos e who have watched thepr evalence o f local di phther ia and gener al diphther ia inthi s c ity fr om 1 8 5 8 up to thi s day, will feel sati sfied thatmy statement is not exagger ated.

Now,while I admit that wi th symptoms of gener al diph

ther ia complicating a case of laryngeal diphther ite calledmembr anous cr oup

,the p r ogn osis o f the oper ation becomes

mor e doubtful, I lay str ess on the very same fact fo r ther eason, that even in such cases, the only indication fo r theoper ation r ests in the local o bstruction . Fo r i t i s easilyun der stood, that while gener al diphther itic poisoning within sufficient obstruction does not indi cate tr acheotomy; i ti s just as plain common sense that suffocation fr om oh

struction of the‘ laryn x complicated with a constitutional

2 4 4

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

my instrument downward i n fr ont of the tr achea i n the

loose cellular ti s sue,I r emoved the dilator and found the

incision co r r ect . I then for ced a si lver p r obe into the

tr achea,and felt some hard mass giving way after some

pr essur e . The p r oblem was then eas ily solved. The

tr achea and br onchi wer e densely fi lled with membr ane, myincision had penetr ated the tr achea but not the membr ane,thus my tube doubled the membr ane inside the tr achea, de~

taching it fr om its anter ior wall ; and thus, the chi ld wasstr angled in the attempt to save her li fe .Carboni c acid poi soning, asphyxia, 6 . Oper ation per

formed too late .Anaemia and exhaustion

,3 .

Gener al diphther ia,8 .

B r onchi ti s, 6 .

B r oncho-pneumonia, 1 5 . Two of these died soon afterthe oper ation ; one, a case of Dr . Blumenthal

’s,in which

the diagnosis o f the complication could not be made befor ethe oper ation, in consequence of the laryngeal sounds covering the auscultator y symptoms belonging to the lungshalf an hour after the opening of the windpipe .Bilater al cr oupous pneumonia

,1 .

B r oncho-pneumonia and gangr ene of the lungs,1 . A

gi r l of ten year s, in 1 5 7 Eldr idge Str eet, in whose neighbo rho od a lar ge number of cases of diphther ia and cr oupoccur r ed at that very time, 1 8 64 , showed the symptoms ofgener al diphther ia on the fir st day after the oper ation .

Every accidental sor e on her skin became cover ed withdiphther iti c membr anes , and the wound assumed a fear fulchar acter . The diphther itic necr osis of the ti ssue cr eptalong the mar gin of the wound, along the intermuscularti ssue, dis sected as i t wer e the s ingle muscles

,destr oyed

par t of them and the whole of the sur r ounding cellular'

tis sue destr oyed par t of the car ti lages until the tr achealwound was mor e than an inch in length

,and one-thi rd of

an inch in width, so that the tube moved fr eely in the lar geaper tur e . On the fifth day extensive br oncho-pneumonia,and on the eighth gangr ene of the lungs commenced to

’

show its fear ful symptoms . The gir l di ed on the thirteen th day.

246

TREATMENT OF CROUP

Uncompli cated pulmonary oedema (the case spoken o f

above) . 1 .

Suffocation fr om the membr anous deposits extendinginto the smallest r amifications of the br onchi

,5 . Four

of them di ed on the third day ; two exactly after_sixty

hour s . One,a pati ent o f Dr . Ranney

’

s,on the fifth day .

All of these cases did appar ently well fo r some time, untilthe exudative pr ocess showed its pr esence far below . Insome the p r ocess did not stop at all after the oper ation,but went gr adually on . In some ther e was a completer est

,o r intermission

,and the chances very good indeed,

thus in Dr . Ranney’

s case fo r thr ee day s . Then at once,the pr ocess would commence anew and not terminate untildeath.

Miliary tubeculo sis,1 . A little gi r l had suffer ed fr om

br oncho—pneumonia some time pr evious ; was r epor ted tohave r ecover ed

,but to have r emained feeble . On the

thi rd day after the oper ation a violent fever set in,with

gener al br onchiti s . She di ed within thi r ty—s ix. hour s after .

The post-mor tem examination r evealed an abscess half an

inch in diameter in the upper lobe of the left lung,and

ci r rhosi s of par t o f the same lobe, and miliary tuber culosi s o f r ecent—date .

“ Exhaustion and pneumonia,1 . Thi s was a very un fo r

tunate case of the following descr iption : A little gi r lof four year s, a patient of Dr . Lev ings ’

, appear ed to dowell after the oper ation, fo r some days . I commencedlocal cauter i zation of the larynx fo r the pur pose o f r e

moving the membr anes o n the second day, and continuedthe same every day unti l the fi fth. I held the solid sticko f nitr ate of silver by means of a for ceps which I intr oduced into the tr achea, end upwar d. With an unex

pected movement o f the child, I lost hold of the caustic,which fell downward and was not r ecover ed. Incess‘antand violent coughing

,day and nightrwith r ar e in termis

sions,was the next, pneumonia the final r esult . The child

died on the ninth day. The post-mor tem examination r e

vealed no tr acheitis,no br onchitis in the r amification of the

fir st order,little inj ection in those of the second. A piece

o f n itrate of’

silver sticking to the inner s ide of the r ight

2 4 7

DR . JACOBI’

S WORKS

lar ge br onchus immediately imbedded in a thick albuminate

,and not enti r ely obstructing the lumen . N 0 inj ection

in the neighborhood of the lining membr ane . Old caseousinfiltr ation by the hundr ed in the two upper , and the mid

dle lobe of the r i ght lung . A r ecent hepatization in themiddle lobe of the r i ght lung

,and in the two lower lobes .

Dr . Lothar Voss has placed at my disposal the statisticso f his oper ations of tr acheo tomy per formed fo r cr oup between 1 8 5 3 and 1 867 . He has oper ated for ty-thr ee times,on twenty—thr ee boys and twenty gir ls . Of the twentythr ee boys, four r ecover ed ; of the twenty gi r l s, six .

How much the pr evalence of gener al diphther ia‘

appear s to have inter fer ed with the r esults—a fact whichhas also been p r oved by my own exper i ence, as I have nocase o f r ecovery fo r instance in 1 8 65—i s shown by the

fact that of his s ix cases oper ated befor e the end of 1 8 5 8 ,five r ecover ed ; while of the r emaining thir ty—seven operated upon between 1 8 59 and 1 8 67, but five r ecover ed. Thr eeof his cases wer e under two year s, namely, 1 year 1 month

,

1 year 8 months, 1 year 1 1 months, all of them gir ls, n oneof whom r ecover ed. The only fatal case in 1 8 58 , the s ixthof the number

,was successful enough as far as tr acheotomy

i tsel f i s concer ned, although it i s counted among the un fav o r able cases

,the tube being r emoved on the n inth day.

The chi ld appear ed quite well, but feeble . Gener al and local diphther ia set in, of which and of the consecutiveanaemia

,the child di ed on the thi r ty-fi r st day after the

oper ation .

The ages of the childr en on whom Dr . Voss has oper ated ar e the following : 1 to 2 year s, thr ee cas es ; 2to 3 year s , fifteen ; 3 to 4 year s, ten ; 4 to 5 year s, eleven ;5 to 6 year s , two ; 6 to 7 year s, one ; and 7 to 8 year s,one .Of those who r ecover ed

,the age was 4 year s 2 months ;

4 year s ; 4 year s 3 months ; 3 year s ; 4 year s ; 2 year s4 months ; 2 year s 6 months ; 2 year s 6 months ; 2 year s6 months ; and 6 year s 5 months .In ' these ten cases the tube r emained 8

, 6 , 8 , 1 9, 1 4,

1 4,8 , 8 , 5

, 6 days . Some delay took place, usually,befor e the wound, which I , in my cases, have found to

2 4 8

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

6 in 1 865, with 1 r ecovery, and 5 deaths.9 1 866,

CC9

3 1 867, 3

The causes of death wer e cr oup and br onchiti s,thi r ty;

infectious diphther ia,thr ee ; scar latina, one ; tr acheal gr an

ulatio ns and attacks of dyspnoea, and exhaustion, 54 daysafter the oper at ion, and 4 weeks after the wound healed,one ; exhaustion and pulmonary oedema

,four ; suffocation

dur ing the oper ation,one. Total

,for ty.

I fur ther,Mr . Chairman, in pr esenting thi s four th list

of stati sti cs to you and the Society, desi r e to pay due homage to the memory o f a deceased phys ician who i s r e

member ed by a number of those pr esent,although over

his accomplishments and expectations the gr ave has beenclosed these last ten year s. Dr . Waldemar von Roth wasthe fir st among us who oper ated extensively fo r cr oup ;and i f he had no other mer it to fall back upon, that wouldbe sufficient that his memory should never die out fr omamong both his pr ofessional br ethr en, and the public. Be

tween August,1 8 5 2

,and January, 1 8 56, he oper ated on

for ty—eight cases, eleven of whi ch r ecover ed. Of the thir tybo ys 9, and of the ei ghteen gi r ls 2 , r ecover ed. He r e

cords in 1 8 52 , s ix oper ations, and two r ecover i es ; in 1 8 5 3,

eleven oper at ions,and thr ee r ecover ies ; i n 1 8 54 sixteen

oper ations, and two r ecover ies ; in 1 8 5 5 , nine oper ations,

and two r ecover i es ; and in 1 8 56, s ix oper ati ons, and twor ecover i es .

‘ My'

last statements have been r ather cur sory, Mr . Chairman ,

as I have been afr aid of taxing your patience toolar gely. If shall consider i t my duty, as thi s subj ect hascome up fo r consider ation

,to pr esent all the stati stics

fr om which I have dr awn to-night, to the medical public.What

,however

,my obj ect has been, in speaking of a

subj ect on whi ch every one has obtained mor e o r lessknowledge, is clear . I meant to si ft vague o r misunder

stood doctr ines, to show that no harm is done by ackn owl

edging the limits of our science and ar t, to pr ove that i t

i s o f mor e impor tance to kn ow what cannot be accompli shed2 50

TREATMENT OF CROUP

he inter nal administr ation o f medicines than to fightferpower ing enemy with r emedi es

,the number of which

rpassed only by their power lessness, and finally, tothe r esults o f tr acheotomy in mor e than two hundr edof cr oup, every one of which would, sur ely, havehed without it . Let those fi fty doomed childr en savedhe oper ation , and let those whose suffer ings wer e at

alleviated,plead befor e you the cause of tr acheotomy.

2 5 1

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

lar ge ; but in many instances the amount o f diges tive fluidi s too small, and thus fermentation i s caused in place ofnormal digestion . Mor eover

,the diastatic effect of the pan

c r eatic juice i s limited at a very ear ly age, and undigestedmater ial i s car r i ed o ff. In thi s way, the movements maybecome quite loose, without the occur r ence of extens ive o r

deep anatomical alter ations . Super ficial changes,however

,

may take place ; they co nsist in the hyper aemi a of the

sur face in r apid tr ansmutation o f epithelium,and the fo r

mation of mucus .“Most cases, however , of actual diar rhoea or iginate in ex

cessive per i s tals is, which may be either local o r'

gener al.

I f it be limited to the small intestine exclusively, the

contents r etained i n the colon may become dry, and the

pr esence of hyper per i stalsis in the former may then bedoubtful . I t may be caused fir stly _

by ir r itatio n of local

( intestinal) or igin, o r secondly by ir r itants furn i shed eitherby the ner vous system o r by the blood.

The fir st clas s embr aces impr oper and indi gestible foods,o r excessive quantities . The abnormal compos iti on ofmother ’ s milk i s an occas ional cause . Mother s who ar e

s ick,o r convalescing

, o r subj ect to str ong emotions,those

who nur se too often, o r suffer fr om tuber culosi s o r

syphiliS‘

o r anaemia,o r ar e pr egnant o r menstruating, do

o r may secr ete an anomalous milk . The colostrum secr etedimmediately after childbir th may cause diar rhoea ; so maymilk which contains too much ‘ either of fat

,o r casein, o r

sugar,o r

'

salts. It i s mainly the casein, whose coagulat ioncauses mo r e intense di sorder s i n the young than the

causes leading to ster cor aceous diar rhoea in the adult . AnexceSS

'

o f fat i s very i r r itating by the formation of acid.

I t i s true that i t i s not the only element of per tur bationin the usual food of the young, vi z ., milk . The milk sugarand

'

albumin,as well as the fat, may give r i se to the de

velopmen t o f acids . In that r espect the albuminoids (caseinpr incipally) ar e not very injur ious, even milk sugar i s butmoder ately so ; but as the oxidi z ing power i s gr eatly r e

duced‘ in gastr ointestinal disorder s, the pr oducts of the

decomposition of fat ar e very active . Together with fat

acids,carbo’nic acid and sulphide of hydr ogen ar e formed.

254

CHOLERA INFANTUM

Thei r i r r itating effect may’

give r is e to hyper secr etion,only, but fr equently leads to catar rh. A similar effect i scaused by pur gatives, mainly by salts either medi cinal o rcontained in fruit o r cer tain abnormal milks . Par as itesact s imilar ly, fr om lumbr ico ids to tr ichomonads o r amoebaa.

I t is true that when pr esent they have not always causedthe liquid stoo ls in whi ch they ar e found—indeed

,in a

case lately obser ved of intestinal ulcer ation of long dur ationtr ichomonads wer e not found fo r months, until at last theyappear ed in incr edible number s

,thus suggesting that i t was

the abnormal condition of the intestine and of its contents whi ch facilitated thei r existence, and not vice ver sa.

But the occasional impr ovement of diar rhaeal di s eases afterthe r emoval of such par as ites allows of but l ittle doubtthat they may be the actual cause o f the liquid and o f

fensive stools in whi ch they ar e found.

The intestines may be i r r itated by changes o f inner vation

,less

,i t i s true

,in in fants and childr en than in adults .

Exper iments on the pneumogastr ic, sympathetic, and

splanchnic ner ves have fur nished ample pr oo fs of theirinfluence on intestinal secr etion and per i stals is

, but i t i smainly clinical obser vation whi ch has established i ts existence. Tr ousseau discour sed extensively on ner vous diarrhtea. The gastr ic and i ntestinal cr ises of tabes dor salisar e fr equent occur r ences ; B

'

eard quoted both constipation and diar rhoea among the symptoms of neur asthenia ;Mobius claims the same fo r migr aine ; the actio n of tobaccoi s of daily exper ience . No r i s it out of place to r ememberthe influence o f r apid changes of temper atur e among themost fr equent causes of diar rhaza, in all seasons, and fo r

all ages . Thus the pr evalence of bacter ia and toxins inour etiological r easonings should not be able to di slodger eflex hyperaemia and secr etion fr om thei r cor r ect placesas causes of di seas e . Like the nasal mucous membr anes ,the intestinal sur face is pr of oundly

'

ae suddenly influencedby colds . Wet feet and exposur e of the per spir ing skinto a cold o r dr aught will convince the most obstinate and

exclusive claimant o f bacter ial r ights of his dependence onother exter nal factor s .Intestinal i r r itation

,with per i stals is and hyper secr etion,

2 55

DR . JACOBI’

S WORKS

is often caused by changes in the blood. P ilocar pine,o r

salines and other pur gat ives inj ected under the skin causediar rhoea. So does ur aemia

,sometimes without any ana

tomical alter ations of the pale mucous membr ane,other

times with catar rhal, ulcer ous, o r cr oupous changes de

pending o n the action of ammonium car bonate . Extensivebur ns of the sur face of the body exhibit s imilar r esults .They ar e also obser ved i n malar ial poisoning . Infections

,

such as those in lobar pneumonia,influenza

,erys ipelas, and

septicaemia, may cause intense diar rhoea, with o r withoutvis ible alter ations . Even typhoid fever may give r i se toextens ive tr ansudations without either catar rh o r ulcer ations of the mucous membr anes . That i s mainly so in a

cer tain number of young pati ents, in whom Peyer’ s plaques

ar e but s lightly developed and but slightly changed. H o

denpyl’

s latest r esear ches pr ove that even without glandularchanges typhoid fever may exhibit all sor ts of typhoidsymptoms . Asiatic choler a, finally, by i ts to xin, which i sabsor bed and r eaches the intestinal glands

,r esults by hy

per secr etio n and fail ing absor ption,in very c0 pious dis

char ges . We shall see that choler a infantum exhibits thesame symptoms .

SYMPTOMS

Choler a infantum may be p r eceded by symptoms ofgastr i c o r intestinal

, o r gastr ointestinal catar rh, but i s fr equently usher ed i n without any p r odr omi . Vomiting and

diar rhea, often diar rhoea without vomiting, with either a

moder ate o r a high elevation of temper atur e,ar e the fi r st

symptoms . Vomiting follows the ingestion of food o r dr inkimmediately, and may be continued without thi s cause . Inthe latter case nothing but mucus and a s er ous fluid, laterbile

,ar e br ought up ; the latter i n small quantity, unti l its

secr etion and elimination stop altogether . The alvine dischar ges ar e copious and numer ous

,fr om hal f a dozen to

two dozen aday. They ar e acr id at fir st,alkaline after

wards, and watery. They contain no bile but lar ge massesof intestinal epithelia and bacter ia. The abdomen is soft .The thir st i s intense, the pulse small and fr equent, thevoice hoar s e o r gone, the fontanelle depr essed

,the skin

256

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

The fir st fun ctional change is albuminur ia. It may be ofno accoun t even when it i s cyclical, and when it makesits appear ance only when the patients ar e out of bed

,

and differ s gr eatly i n its impor t fr om the formation o f castswhi ch depend on morbid pr oces ses either i n the secr etingepithelium o r i n the inter cellular substance . Genuinenephr it i s

,either par enchymatous o r inter cellular , occas ion

ally with shr inking, with hemor rhage, r ar ely amyloid, and

seldom exhibiting dr opsy, r etiniti s, vascular tension o r

car diac hyper tr ophy, i s a very fr equent r esult o f intestinaltoxicity. In a small hospital contain ing little mor e thanfor ty beds, I noticed lately at the same time four caseso f nephr i ti s evolving out of and accompanying pr otr actedcolitis .

PATHOLOGI CAL ANATOMY

When the di s eas e has lasted only twenty-four hour sther e may be few o r no changes in the gastr ointestinal mucous membr ane . When it has lasted longer

,the mucous

sur face i s depr ived of its epithel ium (under the influenceof exces s ive fermentation and secr etion b r ought about bytoxins, ner ve influence, o r ingesta) . Between the gastr icglands r ound cells ar e deposited in lar ge number s in themucous membr ane of the stomach. The gland cells ar e

swollen,and according to Fi schl and Heubner 2 thei r nuclei

ar e stainable only with gr eat difficulty. The same r oundcell pr oli fer ation takes place in the lower par ts of the intestin al tr act ; her e also the epithelium of the vi lli i s thr owno ff. The blood—vessels ar e dilated and filled with blood.

Lieberkiihn’

s glands ar e r ar ely intact ; they exhibit funnellike dilatations and an incr ease of cells

,whi ch i s al so

manifest in other glands . Peyer’ s plaques

,too

,ar e lar ge

and r ich in newly formed cells, which ar e also found between the muscles . Micr obes ar e met with in lar ge num

ber s and in many var i eties . Bacter ium lactis aer ogenesmostly in the upper par t of the bowels , and B . coli commune mostly i n the colon, ar e common . Among them ther ear e str eptococci and l iquefying bacilli which ar e inconstantthough fr equent in all sor ts of diar rhoea. So far as bac

ter ium coli commune is concer ned, it was di scover ed by2 58

CHOLERA INFANTUM

Escher ich in 1 8 8 5 . At that time it was consider ed to beharmless . But i n 1 8 89 i t was found by Lar nette in twocases of per for ation per itoniti s ; its cultur es caused exper i

mental per itoniti s in animals . Since that time it hasbeen met with in many tis sues of the human body, intowhi ch i t has emigr ated dur ing the mor ibun d state o r afterdeath ; but i t appear s also to be settled that it may causeinflammation

,suppur ation, and sepsis in many dis eases , such

as enter iti s,colitis

,typhli ti s, per itoni tis, cystiti s, pyelo ne

phr itis, cholecystiti s, meningiti s angina, pneumonia, endocar dit i s, ar thr itis

,salpingiti s, endometr iti s, lymphangiti s,

panar itium, gas phlegmon, and puerper al fever . Lately a

case of per i and endometr iti s was publi shed by Uhlenhuth

,

3 who claims that in his pati ent the bacter ium coliexhibited thr ee differ ent degr ees of vi rulence .Like E scher ich, Booker found no specific bacter ia in

diar rhoeas,but mixtur es of many ; pr oteus vulgar is was

mostly found in the colon, also in the stomach, least in thesmall intestines . When str eptococci ar e extensively metwith

,they give r is e to symptoms r esembling an i r r egular

typhoid fever , and depending either on str eptococcal in fection o r on the absorption of a toxin . All of them ar e

o r may be the causes o f the palpable changes in the in

testinal sur face ; when they ar e sever e and lead to ulceration

,micr obes may be swept into the ci r culation . In thi s

way the lun gs ar e known to be infected. Still it shouldher e be emphas ized that in testinal ulcer ation does not always r equir e the pr esence and action of bacter ia to any

o r to such a degr ee as in diphther iti c o r gangr enous coli ti s,wher e they ar e mostly in evidence .The contents of the bowels ar e copious and thin, exactly

like those which ar e obser ved in chi ldr en who have died ofconvuls ions dur ing the ho t season . In sunstr oke both the

stomach and the intestines ar e apt to be found in the samecondi tion . Thi s s imilar ity- i s very-

“ suggestive . I t appear sto show that choler a infan tum ,

when fatal on the fir stday, pr oves so by par alysi s exactly as in insolation . Atthat ear ly t ime sur ely choler a infantum i s not yet enter itis .Thi s i s p r imary in the other forms of intestinal over se

cr eti o ns ; in cholera in fantum it is secondary. The kid~

2 59

DR . JACOBI’

S WORKS

neys ar e lar ge and pale,with fatty degeneration of the

par enchyma,and sometimes pus in papillae and calyces .

Bacter ial emboli ar e r ar e,cer tainly much r ar er than in the

lungs . The liver shows the same cloudy swelling of thepar enchyma which i s met with in the kidneys . Other pathologi cal changes ar e the inten se r igor mor ti s

,and the dark

color and defecti ve coagulability o f the blood. The me

n inges and the lower par t of the lungs ar e hyper aemic .These r esults wer e par tly found, and par tly confirmed bv

one o f the most industr ious and car eful of moder n bacter io logists who at the same time i s a clinician

,Booker

,

who spent year s of labor on hi s r esear ches on the bacter ialnatur e o r complications of the differ ent forms of intestimal disorder s, both light and gr ave . He published ninetytwo bacter iologi cal examinations, in all of whi ch he foundthe bacter ium lacti s aer ogenes and coli commun e ; in mostof them also str eptococci and pr oteus vulgar i s . The num

ber of his autopsies was thi r ty-thr ee ; the cases wer e classedby him as acute and chr onic gastr oenter iti s . In the formerthe local alter ations of the intestine wer e but few ; but thegener al in fection

,including that of the lun gs in whi ch bac

ter ia wer e found,and that o f the spleen and kidneys whi ch

wer e mostly affected by toxins, was very i ntense . The

later exhibi ted many alter ations both of an inflammatoryand a degener ative natur e

,which differ ed with the local

izatio n and the destructive influence of the bacter ia. Whenhe met with these same r esults in the living

,the p r ognosi s

depended on the clinical symptoms, whi ch differ ed widelyin individual cases . This obser vation of a pathologi st whois at the same time a clinician pr oves again the insufficiencyof pathological anatomy when confined to the dead-house ,o r of bedside obser vation when not guided by histologicaland bacter iological r esear ch.

The ubiquitous appear ance of a gr eat many var i etieso f micr obes which wer e pr esent in all sor ts and gr ades ofintestinal di sorder s, induced Booker to ventur e upon a classificatio n whi ch i s par tly clinical , and par tly bacter iological .He di stingui shes thr ee forms of diar rhoeal diseases : (Fir st)The dyspeptic diar rhoea, with no inflammation, with no leuct>cytes er epitheli a i n the lumpy acid stools, with plenty

260

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

The temptation to attr ibute choler a infantum to the dir ect influence o f micr obes was combated by the fact thattoo many of the latter wer e found, and that it became difficult to identi fy a s ingle one as the cause of choler a in fantum. Neither Escher ich n o r Bagin sky n o r Booker convinced himself that ther e was a dir ect conn ection betweenthe pr esence of special bacter ia with the symptoms ofcholer a infantum . Baginsky found twenty species o r va

r ieties of bacter ia, mostly sapr ogenous, none of which couldbe claimed as pathogenous . Thus chemi stry, after havinglong been neglected

,had to be called in . Uffelmann and

Seiber t accused the decomposed milk sold in lar ge citi es,

Lesage a poi son pr oduced by some micr obe not specific,Vaughan his tyr o to x ican . The poisonous substance would

,

in the opinion of many of these autho r s, be evolved out ofmilk, even out of br east milk . Differ ence of opinion

,how

ever , became appar ent in r egard to the question whetherthe poison enter ed r eady made with the milk, o r was de

veloped out of it in the alimentary tr act of the infant .Both of these Opinions ar e founded on facts ; in many casesboth r oads wer e found access ible to the poison .

The fi r st stages of choler a infantum do not look alike .Some cases begin very abruptly, other s have a slight gastr o intestinal di stur bance o r pr odr ome . The pati ents ar e

les s than two year s o ld. In the vast maj or ity the feedingis ar tificial

,and with but few exceptions the attacks occur

dur ing the ho t months of the summer , on such days as

fur nish only a slight differ ence between the temper atur es of day and night

,and dur ing the weeks following

them .

Constant heat i s undoubtedly a pr ominent etiologi calfactor . I t appear s

,however , that when and wher e the

babies ar e habituated to a warm climate, they do not sufferlike those who ar e suddenly exposed to excess ive temper atur es . The differ ences of temper atur e, as collated byMeiner t

,between January and July, ar e in Afr ica

C . (6 1° in South Amer ica in Aus

tralia 1 3°

(2 3 4° in centr al Asia and Eur ope

(4 7°

and in Nor th Amer i ca C . F ) . The

sudden heats of the temper ate zones ar e among the pr in

262

CHOLERA INFANTUM

cipal causes o f choler a infantum ; in them it i s most fr equent, though it be found in warm climates .How does heat affect the babies

,indir ectly o r dir ectly ?

Its indi r ect effect is best appr eciated when it i s r emember edthat br east—fed babies do not suffer like those ar tificiallyfed. Meinert

’

s obser vations i n D r esden5 yi elded eighteendeaths among the former

,four hundr ed and s ixty amon g

the latter in eleven ho t summer weeks . Thi s agr ees withwhat every pr actitioner lear ns fr om his own exper ience .That coar se and fermentable food leads to catar rhal ir r itatio n o f the intest ine whi ch may pr ecede choler a in fan

tum,o r to the formation of a toxin o r toxins which cause

i t without a pr evious anatomical les ion,i s eas ily under

stood.

I s ther e anything like a dir ect influence of heat on thebaby with the r esult of caus ing choler a in fantum ? I t hasalways appear ed so to me . In a br ief paper r ead befor ethe Ver ein Deutscher Aer zte in 1 8 5 8—it i s contained inthe minutes of the society—I took that s tand ; and againin 1 8 68 in a paper 6 entitled Concer ning the NeglectedCauses of Infant Mor tali ty in the City of New York.

Twenty year s ago Clark Mill er 7 pointed out the str ikingr esemblance between choler a infantum and sunstr oke . Heclaimed the symptoms belonging to the former as due toparalysi s . Meiner t shar es his opinion to its full extent.Both ar e di seas e of the ho t season, and caused by un

inter rupted heat . Hot days r elieved by cool nights ar ewell toler ated ; i t

‘

i s the constant heat which pr oves dett imental . Constancy i s sti ll mor e danger ous than temporaryexcess . A r elatively lower temper atur e, but r elentlessand moist

,demands most vi ctims . High temper atur es with

wind and dr ought ar e compar atively safe ; absence of ventilatio n is destructive . No wall ventilation takes placedur ing summer ; and in the fir st weeks of the autumn thehouses r emain warmer than the sur r

'

o'

u'

fiding ai r,fo r the soil

r etains the temper atur es soaked in dur ing the summer .

All this i s wor se in lar ge cities, in cr owded str eets, wher ethe buildings ar e high and exclude wind and dr aught, innar r ow flats o r tenement houses, in r esidences with scantywindows looking in one di r ection only. In them the

263

DR . JACOBI’

S WORKS

babies ar e housed, ther e they ar e stifled in thei r beds . Ifthey be br east fed, they ar e now and then taken up and

changed about. I f not, they ar e given thei r bottles in theircr ibs without perhaps changing their positions . Lehmannexper imented on such babies bur i ed in their beds

,and found

that they inhale four times the amount of car bonic acidr eceived by those not so bur i ed. They ar e the ones thatar e liable to suffer , though o r r ather because they ar e notexposed to the sun , fr om i solation ; they ar e the very v ictims of choler a infantum . Fo r in addition they lack whati s most essential to keeping up cir culation and ti s sue metamor phosis, vi z ., water . Swelter ing in their unclean and

ho t bed pr is ons they ar e given the exact food they r eceiveon cool days . The very adults who will sati s fy theirthir st by copious dr aughts of water , will never think of giving an extr a allowance of it to thei r star ving young ones .The br east-fed infant i s better o ff in that r espect also .

The mother o r nur se,dr inking ad libitum, dilutes her milk,

fo r br east-milk i s no unchangeable ar ticle like the GordonWalker o r Gaer tner ; it may change in cer tain l imits itsper centage of constituents every hour of the day, everyday of the week .

The question whether heat causes cholera infantum byits dir ect o r indir ect effects i s ther efor e eas ily answer ed.

It acts in bo th ways . By fermenting and spoiling the

baby’

s food,mainly cow

’

s milk,i t pr oduces deleter ious

ptomains . By par alyz ing its ner vous system it causes thechar acter i sti c gastr ic and intestinal di stur bances, o ver se

cr etion and non—absor ption . Both of these need not coincide with, o r depend on

,catar rhal o r other changes of the

alimentary tr act. But these latter will become appar entwhen the former have lasted mor e than a day.

No single cause will always have a uni form effect . Individual power of r es istance and vitality incr ease o r les senthe acti on of exter nal cir cumstances . A cer tain p r edi sposition is always r equi r ed to make a l iving being submi tto a mo rbific influence . Not everybody suffer s fr om insolation when exposed to p r otracted heat . No r i s the samefood equally danger ous to all. In the foundling hospitalof P rague

,under Epstein

’ s contr ol,the mor tality of the

264

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

fluences which give r i se to all sor ts of di sturbances,vi z .

,

constant solar heat and inappr opr iate feedi ng . Fo r the

pur poses of pr actice an exact diagnosis in di fficult casesis perhaps not always very impor tant . Fo r no matterwhat the case may be called, the indi cations p r esented bythe local changes in the alimentary tr act and by the constitutio nal symptoms exhibited by the patients ar e mor e o r

les s identical . Still the diagnos is of choler a in fantumfr om other forms of gastr ointestinal di sturbances shouldbe made ; in many of the latter the succes s ful tr eatmentdepends on the exact knowledge of the condi tion of thebowels . Ther e ar e sever al forms of diar rhaea which shouldbe known in thi s connection

,viz .

,fat diar rhtea

,catar rhal

enter iti s,and folli cular enter i ti s .

The name of fat diar r hcea was given by Bieder t toa condition in whi ch the normal p r opor t ion of fat in the

infant faeces,which amounts to fr om four to twenty-five,

mostly fr om nine to eleven per cent ., i s incr eased to fr omfor ty-one to sixty-seven per cent . In this form of diar rhma the di schar ges ar e shining and glossy with fat of

yellowish o r gr ay color , sometimes gr eenish, mixed withmucus

,and mostly very malodor ous . The fat molecules

ar e lar ge, in the normal faeces small . I t should be r e

member ed, however , that the per centage of faecal fat i sl iable to be incr eased in every attack of dyspeps ia (Tschernow

,Uffelmann) .

Thi s fat diar rhoea may be‘

pr imary o r secondary. The

fi r st i s the dir ect r esult of the ingestion of an excess offat

,and i s r eli eved by cor r ecting the compositi on o f the

food. Fat should be dimini shed, and sometimes withheldaltogether . Fo r some days the substitut ion of egg water

(albumen beaten up in water o r in bar ley o r toast water ) ,o r o f a thin chicken br oth i s advi sable . Ther e ar e somebabies who fr om the moment of bi r th bear milk, evenbr east milk

,in gr eat di lution only—an illustr ation o f the

justice of my demand of ample di lution of the food givento the newly-bor n and very young.

The secondary form of fat diar rhoea, not dependingsolely on an excess of fat

,i s due to catar rhal condi tions

of the intestin e, o r to di sease of the pancr eas . In autop266

CHOLERA INFANTUM

sies duodenal catar rh, a lar ge size and dry condition of the

pancr eas, a contr action of the or ifice of the choledochusand pancr eatic ducts, par enchymatous pancr eatitis and

fatty degener ation of the liver have been found. A mod

er ate amount of the latter,however

,i s met with under

n ormal conditions o f the baby.

In in testinal catar rh (catar rhal enter iti s ) ther e ar e fever ,diar rhcea

,and pain

,and when the affecti on begins in the

stomach, vomiting also . The babes ar e pale, and dr aw uptheir legs, and when the catar rh descends to, o r begins in

,

the r ectum,ther e i s tenesmus . The evacuati ons in the

beginning contain r emnants of food,and have a str onger

odor than normal faeces, still they ar e not very offensive ;afterwards they ar e li quid

,light yellowi sh o r br own ish in

color , str ongly acid, but later of an alkaline r eaction, withmany specimens of bacter ia (none of whi ch i s char acteristic o f the affection ) , epithelium,

mucus,sometimes pus,

and r emnants of food of all kinds ; the per centage ofwater i s very lar ge, amoun ting to ninety to ninety-five percent.

,whi le in normal faeces of the nursl ing it i s but

eighty-five per cent . and in older childr en eighty to seventyfive per cent . ; par ticular ly i s the per centage of waterlar ge in all those cases of diar rhoea whi ch depend upon ,

o r ar e complicated with,di sturbances o f the ci r culation

br ought on by di s eases of the hear t,the lun gs, o r the

l iver . I f the evacuations wer e fir st odor less,they become

faecal, afterwards acid

,and in pr otr acted cases and so

called follicular enter it is,cadaver i c .

In the beginning of the diseas e ther e i s sometimes herpeslabialis

,and the ur ine i s diminished in quantity, but i s

ent i r ely ar r ested only in the very wor st cases which havea tendency to become choler ai c . In a few cases r ecoveryi s qui te r apid ; in other s the dis ease terminates in so -cal ledfollicular enter iti s

, o r i n chr onic intestinal catar rh.

When ther e i s diar rhoea we have to conclude that theupper par t at least of the colon is affected. Food r emnantswill r equi r e two o r thr ee hour s to pas s fr om the pylorusto the caecum ; until then the contents ar e fluid. Below thatpoint they become r ather dry; not so when par t of thecolon is also in a catar rhal condition . Thus, when they

2 67

DR . JACOB I ’S WORKS

are qui te fluid, an affection o f the upper par t of the colonnecessar ily exi sts and r esult s in undue per i stalsi s .Duodenal catar rh can be diagnosed only when it i s com

pli cated with j aundice, as

,when uncomplicated

,it never

gi ves r is e to di ar rhoea. Catar rh o f the j ejunum and

ileum i s s eldom i solated without the upper par t of the

colon par ticipating in the p r ocess,and i t must be sup

posed that they ar e disorder ed when the stomach i s affectedin a case of diar rhe a. When the faeces ar e fair ly solidand contain conglomer ate masses of mucus thor oughlymixed with the fzecal masses, we make the diagnosi s ofi solated catar rh of the small intestine . Fur ther

,when the

faeces contain a gr eat deal of undigested mater ial we mayalso conclude that we have to deal with a complicatedcatar rh

,involving both the small intestine and stomach ;

this is the condi t ion in which un digested food i s s een inthe faeces lien tery But i t must be r emember ed thatgastr ic catar rh alone

,with anaemia and abnormal per istals i s

of the stomach and upper par t of the small intestine,i s

of itsel f able to pr opel undi gested food with abnormalr apidity.

When ther e i s bile in pas sages of gr een color, yi elding

a di stinct r eaction with nitr ic acid, and attached to themucus and cyli ndr ical epithelium and r ound cells

,we have

also to conclude that the catar rh has its s eat in the smallintestine

,as un der normal conditi ons ther e i s but very

little o r no bi le in the lar ge intestine .I t has been stated that when ther e is consider able per

istalsis and rumbling (audible o r per ceptible on palpation )in the middle of the abdomen and i ts lower par t

,the af

fection is in the smal l intestine ; that they ar e later al andin the upper part

,when the lar ge intestine i s involved.

Still,neither pain n o r locality i s absolutely pathognomonic .

Ther e i s one condition,however , that i s so . When the

mucus i s not thor oughly mixed with the faeces,when the

faeces ar e wr apped up in o r cover ed by i t after evacuation,then the mucus comes fr om the colon, and we have to dealwith catar rh of thi s par t of the i ntestin e ; and when thefzeces ar e still solid, the catar rh has its location in the

lower par t of the colon .

2 68

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

PROPHYLAX IS

Ther e ar e many measur es of a publi c char acter thatwould, and could, be taken in the inter est of p r eventionof choler a in fantum and all other intesti nal diseases in a

mor e advanced condition of public hygiene . The demandfo r mor e air space to the indiv idual

,fo r the separ ati on of

,

and less stor i es in tenement houses,fo r pr otection against

the sun in our str eets,fo r extensive str eet spr inkling

,fo r

str eet cleaning, fo r an abundance of lar ge and small parksand cover ed pier s

,fo r public baths r eser ved fo r infants

and chi ldr en, fo r a close and str i ct super vision of our

markets by the health depar tments, will be compli ed within some di stant futur e when human society and the stater ecognizes thei r r espons ibili ties to the individual in contr adistin ction to the egotism and individuali sm of the pr esent. Indeed many questions of the public hygiene and

welfar e ar e of a social and politico-economic natur e o nly ;and the safety of the individual depends on the sens e ofr esponsibili ty demonstr ated by the state thr ough its lawsand institutions establi shed and managed in the inter esto f all.

P r ivate houses and r ooms should be kept cool in summerand well ventilated. Our windows, whi ch can never beopened mor e than hal f

,ar e badly ar r anged. I f a pr i ze

had been set on faulty construction it would have beenawarded to the man who devised our pr esent ar rangementsfo r li ght and air . The dwellings in the tenements of thepoor

,with windows on one side only, with an imposs ibili ty

of pr ocur ing a dr aught, ar e the main suffer er s fr om thesewindows of whi ch the upper hal f only can be lower ed o r

the lower hal f r aised.

No weaning should ever take place in summer , exceptfo r very ur gent r easons

,and with the possibil ity of pr o

cur ing good substitutes , inclus ive of fr esh o r aseptic milk.To thi s the most car eful attention should be given . Nofamily should be wi thout r ed and blue li tmus paper , tomake sur e of the absence of acidity. Altogether the ruleswhi ch have been . publi shed by the Health Depar tmentof thi s city these thir ty year s, with but slight modifications

2 70

CHOLERA INFANTUM

o f and additions to my or iginal dr aft o f 1 866, have pr oveduseful and successful." Diar rhaaas must not be neglected.

Diar rhcea fr om teething,”i f

‘

i t existed at all,should not

be over looked any mor e than that depending on its usualcauses .

NORMAL FEED ING

The most impor tant p r eventive of choler a in fantum (asof other intestinal di seases o r di sorder s ) i s app r opr iateand di gestible food ; i n the vast maj or ity of cases thi s i s,fo r the poor in fant

,human milk . Whenever that cannot

be had,pr oper substitutes should be pr ovided. Among

them the milk of the goat and that of the cow take the

highest r ank . The former , however , contains too much

The o r iginal draft o f tho se rules, which was but slightly a1

ter ed afterwards,was as fo llows

I f you nur se your baby:

Do no t nur se your baby o ftener than o nce every two o r th reehour s.

Do no t nur se a baby o f mo r e than six mo nths o ftener than fivetimes in twenty-four hour s. When it is thir sty in the mean time,give it co ld water . In very ho t weather o nly, mix a teaspo o n fulo f whiskey with a tumbler ful o f water .

I f you cann o t nur se your baby:

You canno t br ing it up without milk. But the milk (cow'

s

milk) must n o t be given pur e, no r with water .

Bo i l a teaspo o n ful o f bar ley, gr ound in the co ffee-mill, with a

gil l o f water and a little salt fo r fifteen minutes, then add hal fas much bo iled milk and a lump o f lo af sugar , and give it lukewarm fr om a nur sing-bo ttle.B o ttle and mouthpiece ar e always to be kept in water when no t

in use.

Babies o f five o r six months, hal f bar ley water and hal f bo iledmilk, with salt and lo af sugar .

When the bowels ar e co stive, take far ina instead o f bar leyflour .

When they ar e

.

very co stive, take o atmeal gruel ; strain it be

fo r e mixing with milk.

When you have but hal f enough br east—milk use the same fo o d .

Give the fo o d and br east-milk alter nately so that your milk hastime to get fit fo r your baby to take.Youmay give beef tea o r -beef soup mixed with your bar ley o r

27 1

DR . JACOBI’

S WORKS

casein and fat, besides being otherwise incongruous . F r ommany o f my wr itings, and mainly fr om the second editi onof my Ther apeutics of Infancy and Childhood 8 I her econdense the following points :The mixed milk of a dairy i s pr efer able to that of one

cow. Cow’

s milk should be boiled befor e being used. Co n

densed milk is n o t a un iform ar ticle,and i ts use i s pr e

car ious fo r that and other r easons. Skimmed milk obtainedin the usual way, by allowing the cr eam to r i se in the

cour s e of time, i s mostly obj ectionable, because such milki s often acidulated. The caseins of cow ’s and woman ’ smilk differ both chemically and phys iologically. The fo r

mer i s les s diges tible . Ther e ought to be no mor e than one

per cent . of casein in every in fant food. Di lution withwater alone may appear to be harmless in many instances ,fo r some childr en thr ive on it . Mor e, however , appear o nlv

to do so,fo r incr easing weight and obes ity ar e not syn o ny

mous with health and str ength. A better way to di lutecow ’ s milk

,and at the same time to r ender it s casein les s

l iable to coagulate in lar ge lumps, i s the addition ofdecoctions of cer eals . Thei r mechanical efl

'

ect, however ,is not the only one which i s obtained. They add to thenutr i tiousnes s of the food by their albuminoids, and ar e

cer tainly not injur ious because of thei r r elatively small

per centage o f star ch, fo r fr om the very fir st month ofli fe a distinct diastatic effect i s pr oduced by the or al s ecr et ion ; i t incr eases with every month. Even infus ionsof the par otids, pr epar ed at differ ent times after death,far ina o r gruel to babies o f five mo nths and o lder . When ten

o r twelve months o ld, a piece o f r are beefsteak every day to

suck o n .

N o child under two year s ought to eat fr om your table.Summer complain t :

When babies thr ow o ff and purge, give no thing to eat and no thing to dr ink fo r at least four o r six hour s. Af ter that you givea few dr ops o f whiskey in a teaspo o n ful o f ice water now and

then , but n o mo r e unti l you have seen the do cto r .

Stop -giving mi lk at o nce.

G ive no laudanum, no parego r ic, no so o thing syrups, no teas .When you see the do cto r , trust in him and no t in the women.

They do no t know better than you do your self.

2 72

https://www.forgottenbooks.com/join

DR. JACOBI"S WORKS

temperatur e i s high, n o r dur ing a sever e gastr i c catar rh(n o r in dilatation of the stomach r esulting fr om congenitalo r other constr iction of the pylorus ) . In these condi tionsfar inacea (amylacea) ar e taken to advantage, pr incipallybecause the diastatic effect of saliva i s not distur bed.

In anaemia and in convalescence,par ticular ly fr om fever s,

the functions of the stomach ar e impair ed. In them bothpepsin and hydr ochlor i c acid ar e wanting . To incr easetheir secr etion lar ge quantities of water ar e r equi r ed.

Infants’

food ought to be mixed with lar ge quantitiesof water

,not fo r the s ick only, but under ordin ary cir

cumstances. In diseased condi t ions of the stomach the fr eedilution of chi ldr en

’

s nour i shment with water is demandedupon the following addit ional facts . On ly to a cer tainlimit

,i f at all

,will peps in be fur nished fo r digestive

pur poses . P r obably a por tion o f thi s i s not enti r ely uti lized

,becaus e a gr eat quantity of water i s necessary to

assi st in pepsin digestion . In ar tificial digestion albuminoften r emains un changed unti l lar ge quantities of seidulated water ar e suppli ed. Without doubt many distur banecs of digestion ar e to be explained by a deficiency ofwater

,cer tainly many mor e than ar e due to an exces s of

i t,fo r the latter i s speedily r elieved by r apid absor ption .

When metamor phosi s i s gener ally slow, water in abund

ance incr eases the elimination of ur ea and car bonic acid.

When the ur ine is scanty and of too hi gh specific gr avity,water pro tects the kidneys fr om undue ir r itation . I t actson the mucous membr anes as i t does on the exter nal integuments . In laryngitis and br onchi ti s i t liquefies vi scidexpectoration ; in many forms of constipation it acts benefically by incr easing the secr etion of the mucipar ous glandsof the

,intestines. I ce and i ce-water , o r iced car bonated

water,in smal l quantiti es, but fr equent doses, r eli eve hyper

aesthesia of the stomach and stop vomiting . An other r egular addition to the milk food of infants and chi ldr en shouldbe that of sugar . Its per centage in the milk of the womanis lar ger than in that of the cow . Immediately after themilking of the cow the milk—sugar begins to be changedinto lactic acid

.

Thi s pr ocess,after the r ennet of the

stomach has exer ted its co agulating effect, together with

2 74

CHOLERA INFANTUM

the gr adual'

conver s ion of fat into acid, i s the final causeo f curdling . The lar ge amoun t of sugar in woman ’ s milk

,

together with its smaller per centage of casein (aboutone per cent . ) and butter , gives i t the pecul iar bluishcolor and gives to the colostrum of the fir st days afterbir th ( i t co ntains plenty of salts besides ) , its tendency to

loosen the bowels . Thi s pr oper ty becomes manifest, some;times under abnormal cir cumstances . Thus in the milk

'

o i

anaemic women sugar i s occas ionally found to an unusualdegr ee . In their cases the other solid matter s may alsobe diminished, sti ll thi s i s not uni formly so . The infants

,

however,suffer often fr om obs tinate diar rhoea.

The conver s ion of milk- sugar into lacti c acid takesplace very r apidly Under i ts influence cow ’s milk turns'

sour at once .'

Not infr equently i s i t acid fr om the fir st ,it has been found to be so in the udder ; in most cases iti s amphoter i c

,

” neutr al . Thus the quest ion ar ises whatkind of sugar i s to be used as the addition to the food ofchildr en both well and s ick .

Cane-sugar i s not so easily tr ansformed. Indeed,i t i s

uti li zed fo r the pur pose of coun ter acting the r apid conver sion of milk- sugar , and fo r the pr eser vation of ar ticlesof food in general . T r ade i s not so slow in avail ing itselfof the r esult s of or ganic chemistry as the medical pro fess ion . Condensed milk r emains un changed

'

a long time,on accoun t of the plenti ful addi t ion of cane sugar , in spiteof the or iginal p r esence o f milk- sugar i n it . Ther efor e iti s not at all an indiffer ent matter whether milk- sugar o r

cane sugar be added to the fo od of infants and children .

I have always insisted upon the selection of the latter fo rthat pur pose . Bieder t employs cane-sugar in his cr eain

mixtur e .In the sick the absor ption of sugar i s slower than in

the healthy. Besides,dur ing

_most .di seases, par ticular ly

those of the alimentary canal, ther e i s mor e abnormal ferment in the mouth and stomach. Thus but little sugarought to be given

,and never in a concentr ated form.

Gr ape-sugar and dextr in ar e absor bed equally. Cané-sugar ,according to Pavy, i s par tly inver ted into grape-sugar and

par tly absorbed. All appear to be changed, when given2 75

DR . JACOBI’

S WORKS

in moderate quantities, into carboni c acid and water,even

dur in g sli ght fever .

In that form of constipation o f small infants whi ch depends on a r elative absence of sugar and super abundanceof casein in the br east-milk

, the addition of sugar actsvery favor ably. A piece of loaf sugar (a teaspoonful o rless ) di ssolved i n tep id water (o r oatmeal water ) shouldbe given befor e each nur s ing, and will often pr ove theonly r emedy r equi r ed fo r the r egulation of the bowels .The physiological effect of chlo r ide o f sodium i s very

impor tant, no matter whether i t i s di r ectly intr oducedthr ough the mother

’

s milk,o r added as a condiment to

cow’

s milk, o r to vegetable food. Both of the latter contain mor e potass ium than sodium

,and neither ought ever

to be given, to the well o r s ick, without the addition oftable salt . A por tion of that which i s intr oduced may beabsor bed in solution ; another par t i s, however , br oken upinto another sodium salt and hydr ochlor ic acid. Thus its er ves dir ectly as an excitant to the secr etion of the glandsand facilitates di gestion . Ther efor e dur ing diseases inwhi ch the secr etion of gastr ic juice is inter fer ed with, o r

i n the beginning of convalescence, when both the s ecr etingfaculties and the muscular power of the stomach ar e wanting

,and the necessity of r esor ti ng to nitr ogenous food i s

appar ent,an ample supply of salt ought to be fur nished.

The excess of acid which may get into the intestinal canalunites wi th the sodium of the bile in the duodenum ,

and

ass i sts in p r oducing a seco nd combination o f chlor ide ofsodium

,whi ch again i s di s solved in the intest ines and ab

sor bed. I ts action in the ci r culation i s well under stood ;i t enhances the v ital pr ocesses, mainly by acceler ating ti ssue changes thr ough the elimi nation o f mor e ur ea and car

bo n ic acid.

A very impor tant fact is al so thi s : that the addi t ion ofchlor ide of sodium pr events the too solid coagulation ofmi lk by either r ennet o r gastr i c juice . Thus cow

’

s mi lkought never to be given without table salt, and the latterought to be added to woman

’ s milk when it behaves like'cow ’ s mi lk in r egard to solid curdling and consequentindigestibility.

276

https://www.forgottenbooks.com/join

JACOBI ’S WORKS

haps not sufficiently appr eciated. Both excess ive fats and

pr oteids in the milk of the mother may cause gastr o intestinal

,

symptoms in the nur s ing infant ; the former may bereduced by diminishing the nitr ogenous elements in the

mother’

s di et ; the latter by the pr oper amount of exer ci s e .Excessive pr oteids ar e especially apt to cause gastr o in testinal symptoms dur ing the colostrum per iod, and par tienlar ly dur ing that o f p r ematur e confin ement, when their percentage i s higher . Pr ematur e infants ar e

, ther efor e, inpar ticular ly gr eat danger , and thei r food ought to begr eatlymodi fied and water ed.

In connection with thi s question I may also be permi ttedto

‘allude to the indi scr iminate admin i str ation of cr eam and

the? r outine tr eatment with cod-l iver oil in cas e of sicknes s ; even normal di gestion di sposes only of a l imitedquantity of fat (cr eam,

butter , cod-liver oil) ; twenty—fiveper cent. of it in the food, as lately r ecommended,

1 0 i sex ces s ive . One of the pr epar atory stages of its assimi lati on i s the format ion of o lei c acid ; lipan in , whi ch has

.

been r ecommended i n place of cod- liver oil, contains s ixper cent . of that acid

,the phys iological pr epar ation o f

which the body i s spar ed by i ts admini str ation . Ther e may

be very few conditi ons in which the di gesti on i s so slowas

‘not ' to insur e some of the r equi r ed tr ansformation, buti n chr oni c dyspeps ia of differ ent sor ts fat i s badly di

ge sted and absor bed,and lipanin may take its place . A

small amoun t of star ch i s di gested at the very ear li est age.

But c er eals contain ing a smal l per centage of it only ar e

to be p r efer r ed. Bar ley and o atmeal have an almostequal chemi cal compositi on ; but the latter has a gr eatertendency to loosen the bowels . Thus

,wher e ther e i s a

tendency to diar rhoea, bar ley ought to be pr efer r ed ; incases o f constipation

,oatmeal . The whole bar l ey cor n,

gr ound fo r the pur po se, should be us ed fo r small chi ldr en,not only the

‘

center (whi ch i s pr efer r ed becaus e of itswhite 'color ) , because of the pr otein being mostly contained just inside and near the husk . The newbor nought to have its bo i led milk (sugar ed and salted) mixedwi th four o r five times its quantity of bar ley water , thebaby of six months may take them in equal par ts. Gum

278

CHOLERA INFANTUM

ar abic and gelatin may also be utili zed in a s imilar manner .

They ar e not only di luents, but also,under the influence

of hydr ochlor i c acid,nutr i ents . Thus

,i n acute and de

bilitating diseases whi ch fur nish no o r little hydr ochlor icacid in the gastr i c s ecr etion, a small quantity of the latter ,well di luted

,should be pr ovided fo r .

This, my metho d of infan t feeding, whi ch is suited fo rthe stomachs and pur ses of the r ich and poor alike

,i s,

however,not the only one pr oposed and found satisfactory.

No single method, indeed, i s the only one, no r does it suitevery case. I t i s only an occasional chemist who expectsthe or ganic stomach to behave like a chemi cal r eagent ;clinicians, however , admit exceptions to the workin g o f

thei r rules and r egulations, though their conception wer eever so cor r ect and phys iological . Still the endeavor s toimp r ove the diet of the young, and ther eby to r emovethe danger s of intestinal disorder s and the sour ces of ex

cessive mor tality and invalidi sm, ar e going on . Nothinghas been mor e succes s ful in that dir ection than the widespr ead pr acti ce o f ster i li zation and pasteur i zation of cow ’ smilk . Both ar e the logi cal development of the plan oftr eating milk by boiling which I have per s istently advisedthese for ty year s at least, and detai led in my InfantDi et ” 1 1 in Gerhardt ’s Handbuch,

” 1 2 in Buck’

s“

Hygiene

,

” 1 3 in Intestinal Di s eases of Infancy and Chi ldhood

,

” 1 4and in my clinical lectur es del iver ed dur ing mor e

than one—thi rd of a century. Ther e can hardly be a doubtthat i f r aw milk could always be had unadulter ated, fr esh,

and untainted,and as often as i t wer e wanted, i t would

r equi r e no boiling. I t would even contr aindi cate it, fo rhigh temper atur es destr oy not only some of the danger ousbacter ia

,but als o those whose action is desir able fo r n o r

mal digestion . Besides,ther e ar e those who str ongly be

lieve that boi ling causes chemical changes. But such idealmilk canno t be had so long as- co ws'

ar e tuber culous, as

scar let fever and diphther ia ar e met wi th in the housesand about the clothing and on the hands of dai ry men and

women,and as typhoid stools ar e mixed with the water

which i s used fo r washing utensils .Now

,what is i t that boili ng can and wi ll do ? Bes ides

279

DR . JACOBI ’S WORKS

expelling air, i t destr oys the germs o f typhoid fever ,

Asiatic choler a, diphther ia, and tuber culos i s, also the oidiumlactis, which i s the cause of the change o f milk- sugar intolactic acid and of the r apid acidulation o f milk with itsbad effects on the s ecr etion of the intestinal tr act . Somevar i eties of pr oteus and most of bacter ium coli ar e al sor ender ed innocuous by boiling. Thus it pr events manycases of infant diar rhoea and vomiting

, but not all of them ,

fo r the most danger ous bacter ia ar e influenced neither byplain boiling n o r by the common methods of ster ili zation .

Boiling, o r ster il ization,i s not

,however

,a safe pr otection

under all cir cumstances. Aer obic bacter ia. the so -calledhay o r potato bacilli, have very r esistant spor es

,whi ch

develop in time . They ar e found in cow-dung and in thedust of stables, o f the soi l and str eets

, and of hay ; theyr ender the mi lk alkaline and bitter ; they peptoni ze caseinand liquefy it and make the milk sti ll mor e bitter . Theyar e very poisonous ; their pur e cultur e gives young dogsa fatal diar rhoea. I t takes hour s of ster i l ization to killthem ; in some instances it r equir ed five o r s ix hour s .Even the bacillus butyr icus takes an hour and a hal f.But such a pr otr acted ster i l ization

,bes ides being far fr om

cer tain in its effect, i s a clumsy pr ocedur e and one not calculated to benefit the milk . That i s why hay-feeding i s anabsolute necessi ty, fo r the bacilli ar e destr oyed by a sixweeks ’ drying. Besides

,it i s impor tant to keep the stables

scrupulously clean, to avoid dir t and dust, to employ peatinstead of str aw fo r bedding, to wash the udder and tie

the tai ls befor e milking,to thr ow away the fi r st milk

,and

to r emove for eign mater ial fr om the milk by the centr if

ugal machine . But no absolute secur ity can be guar anteed.

Ther efore Flugge adds to his expositions a war ning againstsome wholesale manufactur er s who , always anxious aboutsomebody

’ s—their own—welfar e, wer e (ar e ? ) kn own toconceal the changed condition of the milk and the separ ation of butter par ticles by co lor ing the glass of theirbottles .Whatever I have her e br ought forward i s cer tainly not

to dispar age the boiling of the milk ; i t i s meant to pr ovethe danger of r elying on a s in gle pr even tive when the

2 80

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

natur e of thi ngs they cannot know the condition of theirwar es .Another alter ation o f a less danger ous char acter

, but far

fr om being desi r able,i s the spontaneous separ ati on of

cr eam fr om ster il i z ed mi lk which i s pr eser ved fo r sal e .Renk 1 5 foun d that it took place to a sli ght extent dur ingthe fir st weeks

, but later to such a degr ee that per

cent . of all the cr eam contained i n the milk was eliminated.

Ster ili zation has been claimed to be no unmixed bo onbecause of its changing the chemical constitution of milk .

Still,opinions on that subj ect vary to a gr eat extent

,the

occur r ence of changes being bo th asser ted and denied byappar ently competent judges . But what I have said a

hundr ed times i s still true and bor ne out by facts—vi z .,that no matter how beneficial boili ng, o r ster il ization

,o r

pasteur i zation may be, it cannot tr ansform cow’s milk into

woman’

s mi lk,and that it i s a mi stake to believe that the

former,by mer e ster ili zation, i s a full substitute fo r the

latter . I t i s true that when we cannot have woman ’ smilk we cannot do without cow

’

s milk . Ther e i s no al

leged substitute that can be had with equal facility o r insufficient quantity. But

,after all

,it i s not woman ’ s milk .

Babi es may not succumb by us ing it, and may but seldomappear to suffer fr om it ; indeed, they will mostly appear tothr ive on it ; but i t i s a makeshi ft after all and r equi r esmodifications . Hammar sten was the fir st to pr ove the

chemical di ffer ence between the casein of cow’ s and wo

man ’ s milk . Whatever was known on thi s subj ect at thattime I collated in Gerhardt

’

s Handbuch ” 1 2 The caseinof woman

’

s milk i s not so eas ily thr own out by acids o r

salts as that of cow’ s milk

,and i s mor e r eadily di ssolved

i n an excess of acid. But lately Wr oblewski demonstr atedthe differ ence in solubili ty of the two milks . Woman ’scasein r etains, dur ing peps in di gestion, its nuclein (pr oteid r ich in phosphorus ) in solution, i t is fully di gested ;in cow ’s casein the nuclein i s not fully digested, a par anuclein ” i s deposited un dissolved and un digested . Be

s ides,woman ’ s casein contains an additional albuminoid

which i s not identical with either the known casein o r

album in (H . Of the albumin oids in woman’

s

2 8 2

CHOLERA INFANTUM

milk s ixty-thr ee per cent. i s casein, thi r ty-seven per cent .lacto-albumi n (Schlo ssmann ) , whi ch being di r ectly absor bable constitutes an essential differ ence fr om cow ’ s milk ;all of the latter has to be tr ans formed dur ing the digestivep r oces s befor e it can be ass imilated. Bes ides

,ther e is

(Wr oblewski ) in the human mi lk another pr oteid r i ch insulphur , poor i n hydr ocarbon, and

,according to sever al

author s,in albumoses and peptones .

K . Wittmaack and M . Siegfr ied 1 7 publi shed lately thei ressays on nucleo n (the phosphor i c acid of muscle) in themilks of cow

,woman

,and goat

,and on phosphorus in the

milks of the cow and the woman . Their conclusions ar e

accepted by E . Salkowski as cor r ect,which

,I should say,

pr oves them to be so . Cow’

s milk contains goat’

smi lk and woman ’ s mi lk per cent . nucleon . Incow ’s mi lk the phosphorus of the nucleon amounts to s ixper cent . of the total amoun t of phopho rus contained inthe milk ; i n woman

’

s milk per cent . That means thatin cow ’ s mi lk not one-hal f of its phosphorus i s in the o r

ganie combin at ions of casein and nucleon ; in woman’

smilk almost all of i t i s . In cow

’ s milk the phosphorus notutili zed fo r o r ganic combinations is contained in the in fer iorphosphates . E . Salk owski adds the following r emarksThese conditions ar e evidently of the gr eatest momentin the _ nutr iti on of the nur sli ng . As the development ofbones i s mor e r eadi ly accomplished in nur slings fed onwoman ’ s milk than in those fed o n cow

’

s milk, the p r obableconclusion i s that nucleon has an impor tant par t in the

absor ption and ass imilation of phosphorus .”

The sameshould be said of calcium,

which also combines with nu

cleon . Though woman’ s milk co ntains less calcium than

cow’ s milk,mor e calcium is uti li zed out of the former , and

the nucleon i s evidently an impor tant factor i n its ah

so rptio n a lso .

E r go,cow ’ s mi lk i s not woman ’s milk . I t is not iden

tical with it . Ster ili zation does not change its char acter ;it mer ely obviates such danger s as r esult fr om the p r esence . of most pathogenic germs and fr om p r ematur e acidulatio n . The substitution of cow

’ s milk o r_

o f ster il izedcow ’ s milk fo r woman

’ s milk as the exclusive in fant fo od

2 8 3

DR . JACOBI ’S WORKS

is a mistake . Exper i ence teaches that digestive di sorder s,such as constipation o r diar rhea, and constitutional der angements, such as r achi tis

,may be p r oduced by its per si stent

use,and it appear s to be mor e than an occasional (at

least cc-oper ative) cause of scur vy.

S ince the advi sability of finely dividing and suspendingthe casein of cow

’

s milk and of adding to the nutr itiousnesso f the latter caused me always to advi se the admixtur e ofcer eals with i t, even in the very fi r st days of infancy,the subj ect of infant feedin g has never been lost sightof by medical men, scienti sts, and tr adesmen . No subj ecthas been tr eated mor e extensively, mor e eager ly, sometimeseven mor e spitefully, than that of infant feeding . The

philosopher ’s stone has not been so anxiously sought fo rn o r so often found as the cor r ect infant food and the

appr opr iate tr eatment of cow ’ s mi lk in medical j our nals ,books

, and societies .The debilitating influence of per s istent summer heat may

be counterbalanced by impr oving the v itality and r esi sting

power o f the young . I t is true no newbor n baby shouldbe bathed in cold water , but the gr adual diminution o f thetemper atur e of the water used fo r ablutions may go onunti l after a few weeks o r months the healthy infantbear s washing and fr iction with cold water per fectly well .In the heat of summer it should be so tr eated sever altimes a day. The clothing should be qui te thin ; thosewho per spir e fr eely should have no linen next to theirbodi es ; altogether

,cotton o r thin flannel, bo th of whi ch

gr adually absor b and give o ff per spir ation, ar e p r efer able .In very warm weather a s ingle loose gown should be suf

ficien t . No feather beds o r pillows should be permitted.

Sur ely; the baby would be better o ff in a hammock, thehead being suppor ted by a hair o r air pillow . Babies inbed should have their positions changed fr om time totime.

The mouth of the newbor n infant r equi r es the utmostcar e . It i s a fr equent inlet of micr obes and toxins, and

when its mucous membr ane i s injur ed, i t adds a new element of danger to the differ ent forms of intestinal and

septic di sturbances which ar e not at all uncommon at the

2 84

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

and their like ar e always the same, day in and day out ;br east milk

,however

,may change . The main danger at

tending the uniformity o f food i s,in ho t weather

,the in

sufficient amount of water,of which our babies do not r e

ceive enough. Casein,sugar

,fat

,and salts should not

only have their due aver age admixtur e of water,but the

latter should be given in extr a doses dur ing ho t weather .

Pe r spi r at ion thickens the blood,hinder s the ci r culation

,

and may even lead to thr omboses ; it i s good pr actice,ther efor e

,to give br east-fed childr en a dr ink of water

which should be boiled and ther eby ster i li z ed—befor e eachnur s ing ; and to di lute the ar tificial food given to thos ewho ar e br ought up on the bottle, and to let them all

have water between meal s to their hear t’s content .

TREATMENT

The most per ceptible symptoms of choler a infantum ar e

vomiting and diar rhoea,both of whi ch ar e in the lar ge

maj or ity o f cases—to say the least—the effects of i r r itation o r par alys i s caused by bacter ia and toxalbumins .Whatever i s s till within r each and active

,should be r e

moved by ir r igation . I f ther e i s r eason to suppose thatthe stomach sti ll contains for eign mater ials, it shouldbe washed out

,no matter whether the attack i s attended

wi th fever o r not . Both bacter ia . and toxalbumins maypr ove fatal wi thout much incr ease of temper atur e ; indeed,many attacks o f choler a in fantum behave in thi s r espectlike diphther ia

,puer per al fever

,o r other septic pr ocesses

,

the wor st forms of which ar e often accompanied with lowtemper atur es . A mouth gag i s not always r equir ed fo r

the pur pose of i r r igating the stomach, but in most cases

it facilitates the pr ocedur e ; a cor k firmly planted betweenthe alveolar p r ocesses will gener ally suffice to enable thefinger s to per form their work . No solid stomach tubesshould be employed. Soft elastic catheter s

,Nos . 1 6

'

to3 0 F r ench

,according to age, will suffice . The baby,

wr apped up in a blanket and s itting on the lap and be .

tween the arms of an attendant,i s sati s factor ily immo

bilized,and its head i s suffici ently fixed and bent forwar ds

2 86

CHOLERA INFANTUM

so as not to'

nar r ow the space between tr achea and ver tebr al column . Ther e ar e but few cases in whi ch the (esoph

agus i s missed at the fi r st attempt ; when the tube hasonce enter ed, the slight contr action behind the larynx i seas ily over come, and the catheter slides down . By meansof a glass tube and an india-rubber tube attached to it,the connection with a funnel

,thr ough which tepid water

is slowly pour ed in , i s easily established. The flow i sgr aduated by the elevation of the funnel . When a fewounces have been allowed to fill the stomach

, the funneli s lower ed and the l iquid run s out. The same pr ocedur eis r epeated

,while the amount of liquid i s incr eased

,until

the water r etur ns clear . Vomiting alongside the tube i s notharmful . The fountain syr inge in common use amongus will answer every purpose . In individual cases

,when

the indication of dir ect di s infection appear s ur gent, thetepid water (o r per cent . salt solution ) may containr esor cin (one per cent .) o r thymol per cent .) o r

permanganate of potass ium per As a rulethese addit ions will not be r equi r ed ; n o r i s the i r r igationof the stomach indi spensable when the patient i s seen sometime after the vomiting has ceased. In bad cases, however ,any doubt in that r espect should be dismissed in favor ofir r igation . I t will not often be r equir ed asecond time .The next step in the tr eatment of choler a infantum is

the washing out of the intestinal tr act as far as i t i s ac

cess ible . The fluid to be intr oduced i s the same as above .In a number of instances when ther e seemed to be intens epain o r tenesmus, I have mixed subcar bonate o r subgallateof bismuth with the water . The baby should be placed onone s ide, the nozzle of the fountain syr inge intr oduced a

few inches,and the instrument suspended a foot o r two

over the anus . To facilitate the flow,the hip s should be

somewhat r aised ; in some instances the gentle manipulationof the abdomen answer s the ‘

same’

purpo se. To intr oducea long tube in order to r each the colon i s either unnecessary o r contr aindi cated. Fo r in the infant the sigmoidflexu

’

r e i s so long that no tube passes the convolutionswhich ar e apt to cover one another , and sometimes r eachto the opposite s ide of the upper pelvis . When the tem

2 8 7

DR . JACOBI ’S WORKS

per atur e o f the body is hi gh, the inj ection should be cool ;when ther e is collapse

,i t should be ho t. In the latter

case, a small amount of alcohol (one per cent .) o r goodbrandy o r whi skey (two o r thr ee per o r coffeeshould be added to the inj ection . These i r r i gations shouldbe continued until the fluid r etur ns clear ; they should ber epeated when the diar rhoea r etur ns

,and par t icular ly when

the stools ar e offensive . That all the inj ected fluid shouldbe expelled i s not neces sary ; on the contr ary, as the lossof or ganic water has been gr eat

,and some of the danger s

of choler a in fantum depend on that very los s, it i s des ir able that the intestine should r etain and absor b somefluid. That los s i s so ser ious indeed that the intr oductionof water becomes an ur gent necess ity. To fulfil thi s indicatio n in emer gency cases, subcutaneous infus ions of saltwater (6 : with o r without the addition of sodiumcar bonate ar e r equir ed. The water

,however

,

should be ster ili zed, and the whole p r ocedur e must beaseptic . I t i s true that many of the cases which indicateit will die ; but i t i s not the infus ion, but the diseasethat ki lls. I feel cer tain that ‘

a few of the pati ents Ihave seen the last hal f-dozen year s wer e thus saved.

In connection with the question to what extent disimfectan ts added to the ir r i gations destr oy bacter ia o r othertoxins

,I should state her e that thi s effect need not be ao

compli shed and still salutary action may be obtained. Manyyear s ago P rudden p r oved that a one-twentieth of one

per cent . solution of car bolic acid annihi lates the action o fbacter ia

,not indeed by killing but by par alyz ing them .

To p r event them fr om evo lving toxins i s as beneficial asto destr oy them .

The .same r emar k should be made in r egard to thoseinter nal r emedi es whi ch appear to be indicated, mainly i nthose cases whi ch owe their or igin to, o r ar e evolved out

of any of the forms of p r odr omal enter i ti s o r enter co li

ti s,fo r the pur poses of di s infection . Vaughan believes

that much harm and no good can be obtained fr om them,

but every clinician knows that the eminent bacter iologisti s mistaken . I t is true that calomel, naphthol, naphthalin,salol

,and camphor in medicinal doses do not dimini sh the

2 8 8

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

these mor e than twenty-five year s, will often be foundpr ofitable . The method i s to mix 2 c .c . of dilute hydr ochlor ic acid with a pint of water and to add ther eto a

quar t of milk . Thi s i s to be boiled. I f ever ther e becoagulation

,i t mer ely pr oves that the acid was mistakenly

used in excess .Inter nal medicinal tr eatment i s mainly indicated in

those cases which developed on the basi s of a dyspeptic,catar rhal

, o r foll icular enter iti s . As ir r i gations o f the

r ectum act on the lower par t of the bowels only, the smallintestines may be clear ed by a pur gative . I f castor oilbe r etained

,it will have a good effect . To mix it with

tinctur e of opium is unwise at that stage in whi ch the

emptying of the tr act o f injur ious masses i s the main indication . Calomel may take its place, and will be welltoler ated in fr equent (hour ly) doses of 4 to 5 mgm. (gr .

to It should be continued until the stools showits effect

,whi ch they will do though the r emedy r emain

in the mouth and be ther e absor bed after having beentr ansformed into a mer cur ial albuminate . I f ther e be an

excess of acid (lactic, aceti c, o r butyr ic) in the stomach,

calomel should be combined with an alkal i,mainly chalk,

the car bonate and phosphate of which have the additionaladvantage of forming with the fat an insoluble combination which acts as a pr otective cover to the sor e mucousmembr ane . Doses o f fr om 5 to 1 0 cgm . (gr . i .-is s .) maybe given every two hour s. The subnitr ate, the subcar

bonate,o r the subgallate of bismuth in doses every two

hour s of fr om 1 5 to 1 0 0 mgm . (gr . i—i s s .) acts as a dis

infectant,par tly by binding sulphide o f hydr ogen, and

pr otects the sor e sur faces . Salol should not be given inlar ger doses than fr om 3 to 1 5 cgm . (gr . ss.

-1 1ss. r e

sor cin fr om 1 5 to 3 0 mgm . (gr . These ar e p r eferable to many other s because o f thei r indiffer ent taste .When the time has ar r ived fo r astr ingents

,nitr ate of

silver in solution, 2 to 4 mgm . (gr . in a tea

spoonful of water , o r gallic acid in doses of fr om 5 to 1 5cgm . (gr . i . o r tannalbin o r tannigen

,i n doses of

fr om 3 to 1 2 cgm . (gr . ss.—i i .) —all of them in inter vals of

two hours—may be administer ed.

290

CHOLERA INFANTUM

Ar e ther e any indications fo r opium, o r i s it totallycontr aindi cated ? I t cer tainly limi ts s ecr etion and hyperacidity better than mor phine Its effect i s slower thanthe latter

,and ther efor e safer and local . I t also di

minishes hyper per i stals i s ; i t i s, thr ough its effect on the

sensitive ner ves o r on the ganglia,a sedative

,and an in

hibito ry agent thr ough str engthening the splanchnic . Fi

nally it r eli eves pain . Thus it i s r eadily seen that in theincipient stages of dyspeptic and ster cor aceous diar rhoeas itfinds no place

, but when the bowels ar e emptied,it ful

fils i ts indication of r eli eving pain and hyper s ecr etion and

of stimulating—in small doses—the hear t . Under thesecondit ions a baby of six months may take fr om four toten dr ops of the camphor ated tinctur e of opium, o r an

equivalent,every two, thr ee, o r four hour s .

Gr eat sensitivenes s of the abdomen may also be r elievedby warm fomentations , with water , o r with poultices .They should be cover ed with oiled silk, o r an india—rubbercloth and flannel . Car e should be taken lest the clothingand bedding get moist . Warm bathing may occas ionallytake thei r place . In cas es of collapse the temper atur e offomentations o r baths may be r aised a l ittle beyond the

normal temper atur e of the blood. When ther e is gr eat

pain combined with high temper atur e of the body, coolapplications to the abdomen ar e indi cated. The clothwrun g out of cool water

,secur ed and pr otected as above,

should be changed when it becomes ho t.Gr eat car e should be given to the r eli ef of the ex

hausted and par alytic condition of the pati ent . Ther e ar e

those cases whi ch r equir e stimulation at once . I t i s indicated when the fontanelle i s depr essed at an ear ly time,the pulse very small and fr equent ( 1 50 -220 ) and hardlyper ceptible at the wr i st

,and the complexion ashy. To

r ely on inter nal stimulants i s out of the question ; ther ear e

,however

,many oppor tuniti es f or —subcutaneous appli

cations o f the sal icylate (o r benzoate) of sodio caffein e,

o f the sulphate of strychnine, of camphor , o r of whi skey.

The fir st may be employed in dos es o f fr om thr ee toeight dr ops of the satur ated solution the second indoses of fr om to 1 mgm . (gr .

IAN the thi rd in

29 1

DR . JACOBI ’S WORKS

doses of fr om four to ten dr ops of a solution of fourtimes its weight of sweet almond oil ; of the last fr omfifteen to twenty-five dr ops may be inj ected. All ofthes e administr ations may be r epeated accor ding to indications . The same r emedies may be used inter nally i fthe condition of the stomach permit . The very best stimulant i s S iber ian musk

,of whi ch fr om 3 to 1 0 cgm . (gr .

ss.-i s s .) may be given every hal f-hour

,until fr om thr ee

to s ix doses will have been taken .

B IBLIOGRAPH ICAL REFERENCES

' 1 . B iedl und K r aus: Zeitschr i ft fur Hygiene und In fektionskrankheiten , xxvi ., p. 3 76, 1 897.

2 . F isch l und Heubner : Zeitschr ift fur klinische Medicin,

xxix., 1 896 .

3 . Uhlenhuth: Zeitschr ift fur Hygiene und Infektio nskr ank

heiten, xxv., p. 4 76, 1 897 .

4 . Bo oker : Jo hns Hopkins Ho spital Repo r ts, vi ., 1 896 .

5 . Meiner t : Medical Annual, 1893 .

6 . Jacobi : Medical Reco r d, December 1 8 , 1 8 68 .

7 . Clarke Miller : Amer ican Jour nal o f Obstetr ics, 1 8 79.

8 . Jacobi : Ther apeutics o f In fancy and Childho o d, -2d cd.,

Philadelphia, 1 898 .

9. V. and I . S . Adr ianee: Ar chives o f Pediatr ics, 1 897 .1 0 . Ber liner k lin ische Wo chenschr ift, June 1 4, 1 897.

1 1 . Jacobi : In fant Diet, New Yo rk, 1 8 74 .

1 2 . Jacobi : Die Pflege und E r nahrung des K indes in Ger

hardt’

s Handbuch der K inder heilkunde, vo l. i ., 1 877 (2d cd.,

1 3 . Jacobi : In fant Hygiene in Buck’s Hygiene, New Yo rk,

1883 .

1 4 . Jacobi : Intestinal Diseases o f Infancy and Childho od,Detr o it, 1 887 .

1 5 . Renk : Ar chiv fur Hygiene, xv1 1 ., 1 893 .

1 6 . H . HOplik : New Yo rk Medical Jour nal, Apr il 1 3 , 1 895 .

1 7 . Wittmaack und S iegfr ied : Zeitschr ift fii r physio logischeChemie, xxii ., 1 896-9 7.

18 . Bo ok Review in The Amer ican Ther apist, June, 1 894 .

292

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

been dry fo r months ; in the soi l and in clothing afterone o r two months . Into water and into the soil i t i sintr oduced with typhoid di schar ges whi ch car ry contagionthough they have been in contact with putr id mater ial .Thi s exper i ence explains i solated cases and those attr ibu

table to the influence o f sewer s and pr ivi es,and the tr ans

miss ion t hr ough the atmospher e . Flies have been char gedwith car rying the poi son . Infected water that i s used fo rdr inking o r fo r washing the bottles and cases in whichmilk is kept

,i s r esponsible fo r hundr eds of epidemics .

Contagion fr om patient to patient in a hospital o r in a

tenement,by bedding, by the hands of the attendant

,by

the use of the same unwashed thermometer fo r the typhoidand non-typhoid ar e sur ely either possibil iti es o r facts .The fetus and newly bor n may obtain their typhoidsthr ough the blood of the mother s ; contagion thr ough the

milk of the mother i s not impr obable,though in most of

such instances the suspicion may be di r ected to othersour ces of the malady. Small in fants have a gr eat ad

vantage in thi s that their typhoids ar e not fr equentlyattended with char acter isti c stools

,and that fo r thi s r eason

a hospital case i s not so danger ous to its neighbor s ; thatthey ar e not r oaming about the floor s wher e older childr enpick up infection, and that the water they dr ink o r eat

i s almost always boi led. The latter fact alone explainsthe r elative absence of typhoid fever fr om the fi r st year ofli fe.

SYMPTOMATOLOGY.

Temperatur e.—The sever ity of the i llness need not co r

r espond with the body temper atur e . A gi r l o f 9 year s ,whose case is r epor ted by Ger lo czy, in D . Med. Wo ch

No . 1 5,1 892 , had unconsciousness, diar rhea, very fr equent

pulse,univer sal hyper esthesia, r oseola

,abscesses

,and br on

chial catar rh,and got well after thi r ty-nine days . Dur ing

all thi s time ther e was no incr eas e of her body temper atur e .I t appear s that very sever e cases of typhoid fever whenexhibiting bad cer ebr al symptoms ar e liable to have lowtemper atur es on account o f the thor ough sepsi s p r evail ing .

I f so,the pr ognosi s i s very had.

294

TYPHOID FEVER IN THE YOUNG

Belei Medvei ( Inter n . Klin . Rundschau,1 891 , No . 3 5

and 3 6 ) obser ved a gir l o f 1 2 year s that was taken sickwith sever e headache

,r estlessnes s, chill, pain in neck, um

consciousness,miosi s

, unequal pupils, r apid r espir ation,and

a temper atur e fo r four days fr om 3 6 8° to C .

°

Thenthe temper atur e r ose and the typhoid symptoms of spleenand cecum

,and diar rhea made their appear ance .

Thi s absence of high temper atur e does not astonish thosewho see a go od deal of sepsi s and of sickness complicatedwith weak hear t . Temper atur e and danger need not co rr espond. The very feeble ar e not as a rule subj ect to hightemper atur es any mor e than the very o ld ; and quite oftenthe wor st cases of seps is ar e thos e which exhibit low tem

per atur es. That i s a fact best known to those who seemuch diphther ia o r much puer peral fever .

Obser vations o f high temper atur es pr evious to the ap

pear ance and r ecognition of the symptoms ar e not fr equent . While an adult would be about his work, the infan to r child i s seldom consider ed sick enough to claim attention and attendance . That i s why chilliness and chill s ar er eadi ly over looked ; indeed, the latter ar e not marked

.

as

a rule in any illness o f the young . The r i se of the temper atur e in the typhoid of the young is mostly gr adual ; i t i shi gh in the second stage with slight r emiss ions and gr aduallvfalls toward the end of the disease . This rule, i f i t can becalled so

,i s,however

,subj ect to many exceptions . The

temper atur e of small in fants may be very i r r egular , i s i nmany cases r ather low and uni form,

in other s hi gh withfew and shor t r emiss ions . I r r egular ities

,mor eover

,often

depend on complications . After all,neither those ar e al

ways r ight who consider the typhoid o f the nur sling and

infant as a uniform sever e di sease, like Baginsky and

Roemheld,n o r those who make light of it . The degr ee of

individual infection,and the natur e of the epidemic ar e

factor s that have to be consider ed.

Complications which distur b the r egular ity of the tem

per atur e cur ves ar e,fo r instance

,otiti s, which i s quit e

fr equent . In connection with i t we should not for get thatthe otiti s media of the infant need not terminate in perfo ratio n of the drum membr ane ; fo r the pharyngeal end '

295

DR . JACOBI ’S WORKS

of the Eustachian tube is so lar ge a funnel at that ear lyage as to permit the dischar ge of pus fr om the middleear . An occasional compli cation i s scar latina ; in the lasttwo year s malar ia was a mor e fr equent complication oftyphoid than I have ever kn own it to be . Suppur atingar thr iti s

,diphther ia of the thr oat o r of the vulva, both

bacillary and str eptococci c,ar e detr imental in the same

way. Constipation i s also an occas ional cause of the r i seof temper atur e ; the r egular vi s iting hour s of hospitals ,even without clandestine feeding

,ar e apt to incr ease tem

per atur es. Now and then ther e ar e two r egular dailycur ves . That i s another r eason why the r ectal temper atur eshould be taken at least four times in twenty-four hour s .Digestive Organs.

-The condi ti on of the li ps,the tongue

and the mouth may depend on pr evious catar rh, angina, o r

the pr esence of adenoids ; otherwise on the sever ity of thetyphoid, and exhibi ts the same sur face changes of the

epithelium and mucous membr anes that ar e obser ved i nthe adult . The l ips ar e fr equently dry, the tongue mostlymoist

,i ts epithelium accumulated in the centr e

,the edges

r ed, o r the whole tongue r ed and dry, cover ed with dryepithelial scabs

,tor n o r ulcer ated. Lar ge ulcer ations ar e

mainly noticed dur ing unconsciousness, smaller ones maybe quite numer ous on the hard and soft palate in everysever e case . Ther e i s no her pes . The thr oat shows angina

,

the tonsils ar e swollen , in exceptional cases cover ed with a

pseudomembr ane whi ch once, in a boy of 9 year s, continuedthr ough the whole length of the esophagus to below the

cardia. In bad cases o f older childr en , o r in the few thatoccur in the nur sling when the mouth i s kept open becauseof the nar r owness in the naso-pharynx, of indolence o r

un consciousness , thrush i s met with as it i s in the wor stcases of adult typhoid, o r i n mor ibund phthi s is . Stomacaceis less fr equent, noma still less so ; the latter i s obser vedonly toward the end o f the i llness

,o r dur ing appar ent

convalescence . For tunately, dur ing near ly fifty year s Imet with hal f a dozen cases only, one in a baby o f 8

months,one in a gi r l of 1 1 year s , all fatal . Baginsky,

however,r epor ts a case of noma that r ecover ed. It may

be added that noma i s not quite so fr equent after typhoid

296

https://www.forgottenbooks.com/join

DR . JACOBI’S WORKS

develop toward the end of the fi r st o r dur ing the secondweek

,while

,on the other hand, diar rhea may be obser ved

among the pr odr omi o r in the fir st week,and be r eplaced

by co nstipation .

Almost in all cases of typhoid, in the young and in theo ld

,intestinal ulcer ations ar e common . But exceptions to

thi s rule ar e met with,

S . Flexn er and N . M . Har r is (Bull.'

J ohns HopkinsHospital

,December

,1 897 ) detail the case of a man of 68

year s who had typhoid fever with bacill i in many or gans,but n o intestinal lesions ; Al G . Nichols and C . B . Keenan

(Mo n tr eal M . J our ., January, 1 898 ) one with positive Widal test, and tumefied

’

spleen and mesenter ic lymph nodes ,and no intestinal les ions ; E . H odenpyl, one that died on theseventeenth day of illnes s with ulcer ations in the lar ge intestine , but none in the small . This absence of intestinalles ions i s rar e indeed in the adult ; in the young, mainlyin the very young, it seems to be les s r ar e . As a rule,i t may be stated that the i ntestinal tr act suffer s mor e inadvanced age, the blood mor e in the ear ly.

Accor ding to B ryant (B r it.Med J our nal, 1 899, L , p .

766 ) fi fteen cases of typhoid fever ar e known to haveexhibited no intestinal les ions . His case was that of a

boy of 1 year and 9 months ; i t occur r ed in a family inwhich ther e wer e other

’

cases of typhoid fever . Ther e wasa char acter i stic fever cur ve

, diarrhea, tympanites, tumefaction

'

o f the spleen , and a pos itive Widal r eaction . At theautopsy ther e wer e pur e cultur es of bacill i i n the en

larged mesenter i c glands, but no intestinal ulcer ation .

In one of his autopsies Henoch found but one'

Peyer’s

plaque that was slightly swelled.

In N . Y. Med. J our nal of July 29th, A . J . Har tigan,

assi s tant in the Bender Labor atory of Albany, N . Y.,

r epor ts two cases of typhoid in fection without any intestinalles ions . Of the older liter atur e of such instances he quotesLoui s

,mor e than hal f a century ago , and Litten

,Moor e

,

and Chur ch between 1 8 8 0 and 1 8 8 2 . He then continuesThe bacter i ological er a in the investigation of these formsbegins with Banti

,i n 1 8 8 7 . In his case death took place

on the twenty-eighth day of the disease . No intestinal

298

TYPHOID FEVER IN THE YOUNG

les ions wer e found, but the spleen and mesenter ic glandswer e swollen ; in them bacilli mor phologically s imilar tothe bacillus typhosus wer e found.

”He

”

quo tes seventeenauthor s

,and adds his own cases

,without

,however

,men

tio n ing H odenpyl.

I t'

should, however , be stated that the statistics of intestinal ulcer ations with per for ation ar e not co nclusive ; ~manyar e obser ved in pr ivate pr actice

,not counted

,not r epor ted

,

and for gotten . Now and then,again

,a case i s r epor ted

as a cur ios ity without r efer ence to the number of casesobser ved and other

.impor tant points . Bar r i er met withtwo per for ations in 2 4 cases, a very unusual p r opor tion .

Mo ntmoullin r epor ts seven cases in which per for ation wasdiagnosticated

,thr ee of w hich r ecover ed—a pr opor tion of

spontaneous r ecover i es able to ar ouse the j ealousy of anyoperator .

Bar r ier and Bouchut made long ago similar obser vat ionson the adult, so that they concluded that the anatomicalalter ations of the intestine may be absent . Chiar i (Z . f.H eilk .

, 1 897 ) while finding les ions in the stomach, and

bacilli in differ ent or gans,and septic symptoms, found no

intestinal lesions . In nineteen co llected cases , whi le the

Widal test was positive,the same absence of intestinal

lesions was marked. So the latter i s not conclus ive . The

last case of the same natur e was published by A . Me.

Phedr an in the October i s sue of the Phil. Mo n thly Med.

J our nal

Gur gling in the i leo-cecal r egion, both with and withoutpr essur e

,is common in intestinal catar rh, both infectious

and non-infectious ; that i s why, under ordinary cir cumstances

,it should not be held to be char acter i st ic of typhoid

fever . I t would be mor e so,i f complicated with constipa

tion,and with some of the mor e fr equent symptoms of

typhoid fever .

Incontinence of the sphincter am when met with i s notso much the local r esult of the infection as of unconsciousness ; when it occur s dur ing convalescence, it depends onhyper per istals is , mostly combined with colic .Tympanites i s usually very moder ate, fo r extensive per i

to n itis i s very uncommon, except with per for ation . Sensi

299

DR . JACOBI ’S WORKS

tiven ess of the abdomen is fr equent, without the diagnosiso f local per i toniti s being always within easy r each. Thi slatter form is , however , quite fr equent, fo r in the autopsiesof childr en

,o r of adults who di ed of other di seases , local

discolor ations and thickenings,of a gr ayi sh white, o r yel

low color,ar e often found on the per i toneal layer of the

intestine,above

,near o r below the cecum . They ar e the

r esul ts of pr evious local per i tonit is cor r esponding with thelocal ity of ulcer ations dur ing typhoid fever , o r any of theforms of enter i ti s in former year s. Unexpected per for ations of the intestine, occur r ing in advanced year s, dur ingappar ently per fect health, ar e the final r esult s of such localper itonitis.

Hemor rhages in the very young ar e exceptional,and

mostly mild in childr en of mo r e than four years. I haveseen it mor e than a dozen t imes . In a gi r l of 1 0 year s,the loss of blood was such, ther e being sever al hemor rhagesin the cour se o f the third week, that I attr ibuted the superven ing hear t fai lur e to exhaustion only. Both the numberand sever ity of the hemor rhages appear to depend on thechar acter of the epidemic ' o r on the s eason . In the veryyoung, I sometimes saw no tinge of blood in five year s,and in a s ingle season eight year s ago I met with two

,

not fatal,cases of hemor rhage

,in gir ls o f 5 and 7 year s .

This very autumn I have seen four cases of typhoid feveri n chi ldr en of fr om 5 to 9 year s, i n which mild hemo r

rhages occur r ed. Of Henoch’s n ine intestinal hemor rhages,

five wer e quite mi ld.

Cir culato ry Organs.—The or gans of ci r culation ar e not

affected to the same extent as in adults . The aver agehear t of. the young i s str onger , an d less di seased. Endoand per i car diti s

,embo lisms and thr ombr o ses ar e r ar er than

in advanced age, except in very bad and pr otr acted cases,

in which the myocardium was deter i or ated by the bacillarytoxin . Fo r the same r eason complete adynamia j s not sofr equent at least in the fi r st week o r weeks . Dur ing incr eas ing inanition

,however

,the cir culation i s impair ed

,as

best shown by the coldness o f the feet . The gums bleedbut r ar ely, the nose not so often in infants , and the veryyoung, as i n older chi ldr en . The pulse

,mainly dur ing the

3 00

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

which scar ification of the inter ior of the larynx was unsuccess ful—the chi ld was saved by the oper ation . The

other tr acheotomy was made dur ing convalescence on a boyof ten year s, because of an abscess developing over and

behind the manubr ium ster ni . He died after many weeksof pyemia, the main sour ce of whi ch was found about thelowest r ings of the tr achea

,and the mediastinal lymph

nodes . B r onchial catar rh i s fr equent, without much cough,as long as the r espir at ion i s shallow ; with cough on deepr espi r ation ; catar rhal pneumonia is not r ar e

,and mostly

bilater al ; cr oupous pneumonia i s also apt to be bilater al .The mor e fr equent form of pneumonia, however , in the

p r otr acted cases of feeble patients , i s hypostatic, with a

tendency to become bilater al at once, and to extend.

Pulmonary gangr ene i s exceptional, but should be fear edi n every case of infectious broncho-pneumonia, complicated wi th a weak hear t .Pleur itis i s compar atively r ar e

,purulent in exceptional

cases only, sometimes sanguinolent, though ther e be nocomplication with tuber culos i s .Complicati ons with diphther ia of the baci llary var i ety

(nasal, pharyngeal, o r laryngeal ) , ar e not common . Whenthey occur dur ing the pr evalence of a diphther ia epidemi c,they ar e gr ave accidents .Ur inary Organ

s

.—The ur ine is mostly of a high color

,

contains in the beginning much ur ea and ur ic acid, les schlor ides than normal

,indican sometimes, albumin fr e

quently at an ear ly per iod and mor e so dur ing the heightof the dis ease, r enal epithelia

,blood

,thin gr anular casts

,

and occasional bacilli . The r enal i r r itation exhibited bythe mi cr oscopic appear ance i s that which i s usual in mostinfectious di seases

,and i s due to the effect of the toxin

while being eliminated thr ough the kidn eys , Symptoms connected with thi s elimination need not be very marked and

need not lead to nephr iti s . Still,the latter may follow.

Even pyur ia has been found, fo r instance, by G . Blumer,

in chi ldr en,one o f 1 3 and one of 1 0 year s (Johns Hop

kins Rep .

,Vol . V ) .

Retention of ur ine i s r ar e in childr en, but occur s when

ther e i s coma o r much per i tonitis . In that case,and when

3 02

TYPHOID FEVER IN THE YOUNG

ever i t i s impor tant to secur e ur ine fo r exami nation, catheter izatio ns should be r esor ted to . I t is mor e easily per

formed in the young than in the adult and mor e r eadi lyin boys than in gir l s . Under or dinary ci r cumstances, whenthe catheter i s not employed fo r some r eason o r other a

big ball of absorbent cotton will collect ur ine enough fo rthe usual examinat ion o f the ur ine . Polyur ia i s seen during convalescence when much water is drunk . In thatper iod dr opsical effusions may be obser ved with o r wi thoutalbumin ; i t should also not be for gotten that salicylic acido r antipyr in when employed may cause edema ; and

,fur

ther,that ther e may be nephr iti s without albuminur ia ,

The

Diazo test is mostly positive towards the end‘

of the fir stweek

,and r emains so unti l the middle of the thi rd

,some

times very much longer . At all events,however

,its absence

is no p r oof against the pr esence of typhoid fever . Roemheld missed it altogether in many cases .The obser vations made by Lafleur and other s

,that the

ur ine voided after cold bathing exhibits a high degr ee oftoxicity, would r ather speak in favor of that tr eatment ;fo r the mor e toxic the ur ine and danger ous to the labor atory animal

,the less toxin ther e i s left in the patient .

Elimination, as speedilv as possible,i s what should be

aimed at . And whatever diur etic effect ther e is in cold bathing

,as i n other r emedi es

,i s welcome as long as the con

dit ion of the pat ient permits it. H ow r ar ely that i s so,will be seen in t he r emarks I have to make on ther apeutics .Skim—The tendency of the ski n is to be dry; that i s

why chr onic eruptions ar e liable to disappear dur ing thei llness and to r etur n when r ecovery i s complete . Thi s dr yness is also the cause of the tr ansver se fissur es under theknee which Koebner explains by the co -oper at ion of theli feles s epidermi s, the v igor ous gr owth of the extr emitiesand the flexed postur e of the knee ; i t also causes the extensive desquamat ion befor e an d dur ing convalescence .The char acter i sti c r oseola exhibits the same pecul iar ities

that ar e noticed in the adult ; it i s absent in perhaps 2 0 percent. Mor se collected 67 ] cases , in 4 0 6 of which i t waspr esent ; Henoch found i t 3 62 times in 3 8 1 cases . I t is n otUBQOIDLHOD in the Very young . I found a few spots on the

3 0 3

DR . JACOBI ’S WORKS

epigastr ium of a newly bor n that di ed on the sixteenth dayo f its l i fe ; Gerhardt (Handb. Vol . I I

,p . 3 7 3 ) met with

r oseola (and a tumefied spleen ) in a baby of thr ee weeks .I t may appear as late as the eleventh

,even the fifteenth

,

o r seventeenth day, i s mostly not so copious as it i s inthe adul t

,and occur s p r efer ably on the chest and abdomen

,

but also on the back and on the extr emities . When the

temper atur e is hi gh at an ear ly date, r oseola may appearear ly,on the thi rd o r on the four th day, and new cr ops mayoccur afterwards . In r elapses it i s mor e fr equently mis sedthan in the pr imary attack

, but a new cr op in the four thweek means a r elapse . Petechiae ar e not fr equent, but dooccur i n childr en of mor e than seven o r eight year s, also inthe very young ; when complicated with extensive pur pur i cextr avasation they ar e ominous .Miliar ia i s sometimes obser ved when ther e i s exceptional

per spir ation ; and erythema dur ing the height o f the diseas e when ther e i s much intestinal disorder and coma as the

r esult of di r ect tox ic, o r o f auto- infection . Eczema is ther esult o f uncleanlines s only ; gangr ene, absces ses , furuncles,and pustules ar e fr equent occur r ences , but in the laterper iods of the disease only.

In bad cases,and mainly when the hygiene of the skin

was neglected,abscesses will appear in i t and in the sub

cutaneous ti ssue, pr efer ably o n the head, face and chest .Sli ght i r r itations ar e sufficient to act as p r oximate causes .A chi ld o f two year s developed the fir st absces s on the

epigastr ium in consequence of a subcutaneous inj ecti on ofquinin . Mor e followed

,mainly on the hands, finger s

,and

feet,mor e than sixty wer e incised in the cour se o f a few

weeks,until , finally, r ecovery set in .

In a child of two year s I saw copious hemor rhages aboutthe ear,gr oins, and neck with consecuti ve gangr ene ; i n a

boy of nine, extens ive destruction of the skin over mor ethan one-hal f of the abdomen ; in both cases with final r eco very.

The desquamation of typhoid fever may be qui te copiousand r esemble that of measles o r even of scar latina . Onthe other hand, some of the eruption of the two latter mayr esemble the r oseola o f typhoid fever . That i s why the

3 04

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

r ar e,and those in bed often demand permission to get up,

expr es sing the most complete sati s faction with their condition

,whi le their temper atur e r anges at o r above 1 0 4 .

Other childr en ar e apathetic,o r somnolent

,o r peevish, and

r estles s . The“ typhoid state

” should not by i tself betaken as a symptom of typhoid fever . It may be absentaltogether , and i s found now and then when ther e i s notyphoid. Headache is fr equently complained of o r i s betr ayed by ver t ical wr inkling ,

Hear ing may'

be bad, theconjunctiva inj ected and the cor nea cloudy under the in

fluence of the toxic disturbance of the tr ifacial ner ve .Gr inding of the teeth, sopor , o r delir ium

,and vehement

scr eams r esembling those of meningiti s,ar e occas ionally

met with. Such symptoms, though ever so sever e , neednot cor r espond with the elevation of the temper atur e at

all ; the latter may be r ather low,while the intoxication

is quite pr onounced. Not every case of seeming cer ebr al o rmeningeal symptoms should be attr ibuted to cer ebr al af

fectio n only ; still, contr actur es, o r convuls ive movementsmay occur when ther e is an effus ion fr om the pia mater .

Such complications of genuine meningitis with typhoidfever cer tainly occur , and not only after the eighth o r

tenth year when gr adually the typhoid fever in the youngr esembles mor e and mor e that o f advanced age. Ker nig ’ ssymptoms may be employed to clear up the diagnos is ofgenuine meningit is .Some of the symptoms common to both may be explained

differ ently. Vomiting may be due to the toxic degener ationof the cer ebr al substance

,o r to meningiti s, o r to the ah

normal condit ion o f the stomach,o r even of the pharynx , o r

to nephr it i s . Coma o r delir ium I have s een in typhoid inmeningi ti s, al so in cinchoni sm

,and under the i nfluence of

sali cylic acid.

As a consecutive symptom aphasia was found twentytimes by Henoch ; hal f a dozen times I have seen it in thecour se of many year s ; with the exception of one that sudden ly died

,pr obably of myocardial degener ation, all of

them got well . Polyneur iti s i s n o t r ar e . In sever e epidemics i t i s fr equently s een, usually with a favor able termination ,

I t i s due to ti ssue alter ations,occasioned by

3 0 6

TYPHOID FEVER IN THE YOUNG

the influence of the bacillary toxin . Hemiplegia i s r ar elyobser ved ; a case of cer ebellar ataxia in a boy o f Seven ,which terminated in r ecovery, was r epor ted by Lui gi Co ncetti, in La Pediatr ia, No . 8 , 1 898 .

Par aplegia i s mor e fr equent, and stil l mor e so i s localpar alys i s, under the influence either of the toxin, o r o f a

hemor rhage, o r of an embo lus. Amongst them ar e par alysi s o f the glottis, which necessitated a tr acheotomy in a cas<

of Behn ’ s,and of the abducens (which I have seen in

quite a number o f cases , most of which wer e obstinate,some permanent) and of the accommodation muscles of theeye. Par alys i s of the sphincter o f the bladder i s not infr equent .Psychical disturbances ar e seen as the sequelae of every

infectious fever , mainly scar latina and typhoid. Four suchcases wer e r epor ted by S . S . Adams to the Amer i can Pediatr ic Society in 1 896 . They may r esult fr om inanition

,

o r fr om the par enchymatous ti s sue changes caused by the

toxin,o r fr om meningitis . Mania and melanchol ia ar e

the two forms mostly met with, Not all o f them terminate favorably. Two o f my ear ly cases di ed in lunati casylums in r ather advanced year s . The motor di sturbancesnot par alytic, which follow typhoid, par ticular ly chor ea,have all got well in my r ecollection

,a few only with r e

lapses . It struck me that post-typhoid chor ea was les ssubj ect to r ecur r ences than other forms .I now give the par ticular s of two sets of obser vations,

which will pr ove that the symptoms, cour se and complications of the typhoid fever of the young may gr eatly difl

'

er

fr om one another,o r fr om any aver age descr iption of its

nosology. One I published in the Ar ch Ped., Mar ch,1 8 8 5 .

The number of typhoid fever cases tr eated in the Childr en ’ s Pavilion of Bellevue Hospital, fr om October , 1 8 8 2 ,to September

,1 8 8 4

,was 2 5 . Of these 1 1 wer e males , 1 4

females ; 1 7 r an a s ingle cour se,—5 ’ had r elapses , 3 wer e

sick over a per iod of fr om four to six weeks, without permitting the second attack to be di stingui shed fr om the

fir st by an allev iation of the symptoms . In seven casesa distinct chill was mentioned as usher ing in the illness ;in half a dozen mor e sever al attacks of chi llines s wer e

3 0 7

DR . JACOBI ’S WORKS

noticed. The ages of the patients r anged fr om 2 to 1 4

year s , the aver age 9. Pain in the i leo-cecal r egion wascomplained of in four teen cas es, diar rhea was noticed infifteen

,bloody stools not amounting to hemor rhages in

thr ee ; in thr ee constipation was mentioned as a notablefact ; in the fir st week of six epistaxi s was obser ved. Tumefaction o f the spleen was noted i n sixteen ; r oseola was

obser ved in four teen cases . I ts fir st appear ance was noticed between the fifth and seventh day ; it lasted fr omfive to ten days . P r emonit‘ory symptoms wer e r epor ted innine cases ; in four they lasted two weeks . They consistedin lass itude, los s of appetite

,change of temper

,and in

some few cases,diar rhea set in a week befo r e the initiating

chill o r chillines s . Five of my cases died ; one r emainedstupid and har d of hear ing fo r sometime, but r ecover ed.

Contr ary to my exper ience, as expr essed i n a lectur e ontyphoid fever (Medical Reco rd, Nos . 1 7 and 1 8

,

in whi ch I claimed a mild type and a low mor tal ity fo r

the typhoid fever o f in fancy and ear ly childhood,this

Bellevue ser vice of mine had a mor tality of 20 per cent .—s imilar to that of (E ster len,who estimated i t at 22 per

cent ., and F r i edr ich,who r epor ted 2 3 per cent ., in chi l

dr en under five year s of age.

In 1 8 8 2 and 1 8 8 3 we had a bad epidemic of typhoidamongst all classes and ages . The guests of summer hotelsand boar ding houses impor ted hundr eds o f cases

,and the

whole population suffer ed in consequence,infants and hal f

gr own chi ldr en as much as the r est,and the mor tal ity all

over the city was hi gh. The hospital s have always mor ethan their shar e, however , and their stat istics must n ecessar ily be er r oneous . E r r or s ar e occas ioned by the factthat with us at least hospitals do not contain the averagecases

, but as a rule those only who far e badly and pr omisebadly. A poor family will nur se their childr en, while theyr equi r e but little car e ; only that one whi ch i s ser iouslv

i ll, and gives a gr eat deal of tr ouble and a bad pr ognosis,

is sent to the hospital . Of that class,many will die.

That i s why the mor tal ity of a hospital does not indi catethe gener al char acter of the epidemic . That i s al so whythe general pr actitioner , s ingly o r collectively, i s the better

3 0 8

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

one,with consider able dilatation of the stomach dur ing

convalescence ; aphas ia in five ; or chit i s of the left s idewithout suppur ation

,o ne ; and meningit is

,thr ee ; two of

the last terminated fatally. All these cases looked verymuch l ike cer ebr o- spinal meningi ti s ; still ther e was the

tumefied spleen, and no herpes . In other cases ther e wer emilder cer ebr al symptoms, such as dy sphagia, par tial convulsio n s, aphas ia

,and i nequality of the pupils, without

strabismus,o r vomi ting.

AGE , MORTALITY

Fr iedleben placed the gr eatest fr equency of typhoid i nchi ldhood between the 5th and 8 th year , Gr iesinger be~

tween the 5th and 1 1 th,Loeschner and F r i edr ich between

the 5th and 9th, Billi et and Bar thez between the 9th and

14 th,Bar r i er between the 5th and 1 5th year , and Faucon

net between the l oth and 20 th year . A few other figur escontained with the above in Gerhardt’s H andbuch, Vol . I Iar e as follows : Mur chi son noticed that 20 per cent . of all

the inmates of the fever hospital wer e les s than 1 5 year s,Von Fr anque collected all the typhoid cases of the p r ovinceof Nassau

,and found 20 2 1 of to be les s than 1 0

year s , Gaultier gather ed many F r ench statistics, and r e

por ted 3 1 per cent . below 1 5 year s . In a small town ‘

Baginsky counted sixteen cases under 1 0 year s out of a

total of 50 , Rosenthal 2 8 in 1 1 5 , Schazdler 1 1 in 1 4 4 .

Holt (Textbook, p . 1 0 0 8 ) quotes 970 cases fr om eightauthor s ; 8 per cent . wer e under 5

,4 2 per cent . fr om 5

to 1 0,50 fr om 1 0 to 1 5 year s o ld. Mon tmoull in (These de

Par is, 1 8 8 5 ) r epor ted fifteen cases under two out of ' a totalof 295 under 1 5 year s . Schavo ir

,in Stamford

,Conn .

,

collected'

4 06 cases of all per iods of‘

li fe ; of these 68wer e under 5 year s, 72 between 5 and 1 0 year s . Mor s er epor ts 2 8 4 cases in the Bos to n City Hospital ; 3 wer eunder 5 year s , 77 fr om the fifth to tenth

,and 20 4 fr om

the tenth to the fifteenth year . He also concluded thattyphoid i s unusual in infancy, because the Widal r eactionwas negative in two cases of s imple diar rhea

,for ty—five

cases of fermental diar rhea,and thr ee o f i leo-col iti s

,with

the exception of one whose mother had typhoid fever year sbefor e . I t will be seen, however , that in none of these

3 1 0

TYPHOID FEVER IN THE YOUNG

cases the diagnosis of typhoid fever was made o r suggested.

As ther e was no typhoid ther e was no Widal .All these figur es and r esults ar e in confirmation of the

ear l iest obser vations . Gr ies inger,fo r instance

,wr ote in

1 8 5 7 (Vi r ch. H andb., I I ., 2

,Typhoid fever i s

very r ar e in the ear li est infancy ; i t i s only fr om the seco nd to the thi r d year that the dispos ition becomes gr eater ;after that time it gr ows r apidly, so that typhoid fever i squite fr equent amongst us.

”

(Germany. ) Bouchut deniesthe occur r ence of typhoid in the newbor n . Accordin gto him i t occur s fir st between the fi r st and s econd y ear .

Ther e ar e,however

,well obser ved cases of typhoid fever

in the newbor n . Gerhar dt quotes Char cellay who saw

i t in a child o f eight days ; Bednar , five days ; Necker ,thi r teen days, and r epor ts a case of his own at thr eeweeks . I had a case

,the mother having typhoid fever when

the child was bor n . In the latter I diagnosticated the

di sease on the ninth day. Ther e wer e a few spots on theepigastr ium on the s ixteenth day, a lar ge and soft spleen,and Peyer

’ s plaques swollen and r ather soft,not yet ul

cer ated. The in fant di ed on the s ixteenth day of herli fe . C . P . McNabe (N ew Yo rk Medical J our nal, Feb .

lgth, obser ved typhoid fever , complicated withwhooping cough and pneumonia in a baby a few weekso ld.

The poss ibi l ity of the tr ansmi ss ion of typhoid fever tothe fetus is beyond any doubt . Clinical exper i ence pr ovessuch "

a tr ansmiss ion fo r typhoid fever , malar ia, measles ,scar latina

,var iola and syphili s ; also in erys ipelas, r elaps

ing fever,tuber culosi s and sepsis . In young sheep anthr ax

was found as ear ly as 1 8 8 2 ; chi cken choler a and glander sar e tr ansmitted in the same way. But i t i s poss ible thatthe epithelium of the placenta i s a fr equent bar r i er , and

the suggestion of Malvo z’

s that the transmi ssion -o f an

infectious disease fr om the mother t o’ the fetus takes placeonly when the v illous epithel ium is injur ed, I have alway sconsider ed to be cor r ect . He emphasi zes the fact that oftwins one may be affected while the other goes fr ee . All

these points ar e di scussed by W. Fordyce in the B r it . M .

J our ., of Feb . lgth, 1 898 . The typhoid fever of the

mother may destr oy the fetus, may allow it to be bor n

3 1 1

DR . JACOBI’

S WORKS

al ive but weak,o r al ive and vi gor ous . Which of thes e

r esults occur s depends on the amount of bacillary toxintr ansmitted o r on cir cumstances unknown to us in an in

dividual cas e . But the facts ar e firmly established. The

fetal intestine was found diseased by Manzoni in 1 8 4 1 ,

Char cellay in the same year , Weis s in 1 8 62 . Bacill i wer efound in , the fetus by Reher and Neuhaus in 1 8 8 6 ; inthe blood by Eber th i n 1 893 ; and the same r esults wer eobtained by Fr eund, Levy, E r nst, and Dur ck . Other goodobser vations wer e made on the living child. The Widaltest was .found positive in a healthy in fant 7 weeks o ld,that was bor n when the mother was in the thi rd week oftyphoid fever , by Cr oz ier Gr iffith (Med. N ews, May 1 5th,

and by Mosse (P r ogr és Méd., Mar ch 1 3,1 897 ) in

a newly bor n, whose mother had typhoid fever when inthe sixth month of her pr egnancy, and whose milk and

placental blood gave the same positive r eaction . Perhapsthe case o f Landouzy

’ s will al so p r ove the possibility o f

tr ansmi s s ion though not thr ough the placenta (Soc . deBiol . Nov . 6 , A healthy baby showed a pos itiveWidal test

,whi le the woman had typhoid thr ee months

after confinement . As the baby had no other symptoms oftyphoid fever , i t i s fai r to suggest o r to be li eve that tr ansmission to a suflicien t degr ee took place thr ough her milk.

The tr ansmi ss ion of typhoid bacilli into the fetus i s demo nstr ated by a case r epor ted by Etienne (Gas. hebdom

1 896, No . A woman of 1 8 year s expelled on the

twenty-ninth day of her typhoid fever a fetus in the

fifth month o f uter ogestation . In its blood taken fr om the

r ight hear t, the spleen, the liver and the placenta were

typhoid bacill i, but no chan ges in the other or gans . I t appear s that the death o f the fetus r esulted fr om the toxinwhi ch acted so r apidly that the or gans had no time topar ticipate in the pr ocess .I f

,however

,typhoid fever has been found by some in the

fetus , in the newbo r n in the nur sling,ther e ar e those

who never saw it at that age, and ther efor e ar e incl inedto deny its occur r ence .In the Ar ch. Ped.

,1 895 , p . 91 6, Dr . W. P Nor thrup

speaks of the r esults o f autopsies in chi ldr en under

3 1 2

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

Accor ding to these figur es the lar gest mor tality occur r edbetween the tenth and fifteenth year ; the mor tality ofchildr en below 5 o r below 1 0 year s equalled that of adult sbetween the for ti eth and fiftieth year .

H . Cur schmann (N o thnagel, Spec, Patho l. u. Therap.

II I .) r epor ts on 4 5 1 childr en (2 50 male and 20 1 female)obser ved with typhoid fever in the Hambur g Hospital between 1 8 86 and 1 8 8 7 . Of these

,seven wer e 2 ; nine wer e

3 ; s ixteen, 4 ; eighteen, 5 ; thi r teen, 6 ; twenty-two, 7 ;twenty-seven, 8 ; for ty-four , 9 ; fifty, 1 0 ; fifty, 1 1 ; sixty,1 2 ; seventy—one, 1 3 ; and s ixty—four 1 4 year s o ld.

Of Br ouar del’

s cases obser ved between 1 8 80 and

1 8 89, 3 6 wer e 1 year and under,

under 5,

fr om 6 to 1 0 , and fr om 1 1 to 1 5 year s o ld.

According to an excellent r epor t published by Dr . I .Budi sch

,in the Moun t Sinai Hospital r epor ts o n

974 cases of typhoid fever , which occur r ed fr om 1 8 8 3 to1 898 , 1 2 4 occur r ed in childr en below ten year s, and 90

between the eleventh and fifteenth ; a total of 2 1 4 cases .Of thes e one was s ix

,another ten months of age. Ther e

wer e altogether below five year s 3 7 cases, s ix of whichdi ed per cent ., and 8 7 between the s ixth and tenth,7 of which di ed : per cent . The exact figur es fo rthe fir st year wer e 5 cases with 3 deaths

,fo r the second

6 with no death, the third 5 with no death,the four th 1 0

with 1 death, the fifth 1 1 wi th 2 deaths

,the sixth 1 6 with

2 , the seventh 2 0 with 1, the

' eighth 1 1 with no death,the

ninth 24 with 3 , the tenth 1 6 with 1, and fr om the eleventh

to the fifteenth 90 cases with 9 deaths .One o f the pr incipal points made by Dr . Nor thrup i s

that the ulcer ations claimed fo r typhoid fever ar e notchar acter i stic at all ; that, indeed, they ar e found i n com

mon intestinal di s eases of non-infectious natur e . That i swhat Her vieux contended thir ty year s ago , when he saidthat folli cular swellings and super ficial ulcer ations in theintestines

,and swelling of the mesenter ic lymph nodes

wer e found without any specificity in the morbid pr ocess .Thi s obser vation

,and the as sumption of uni formity in

the natur e of these ulcer ations,was indeed the r eason why

in F r ance fo r a long time the terms typhoid fever and

3 1 4

TYPHOID FEVER IN THE YOUNG

do thienen ter ite wer e synonymous . But as ear ly as 1 8 77C. Gerhardt emphas iz ed the fact that the peculiar typhoidmarkige infi ltr ation an d the formation of scur fs

,

which ar e mentioned now and then ar e distinctively differ entfr om the ulcer ations of follicular o r other enter itis . I t i strue

,however

,that in many cases ther e is a differ ence be

tween the youngand the adult. The changes in the plaquesof the former ar e mor e hyper plasti c (they ar e

' not so inenter iti s ) , of the adult mor e n ecr obiotic . Nowadays thepr esence of the bacillus typhosus in and about doubtfululcer ations would fur nish another positive diagnostic s ign .

D IAGNOSIS

I t i s determined by the symptoms enumer ated aboveand whi le i t i s mostly easy in the adult

,becomes mor e

difficult in the very young . I choose to take it fo r gr antedthat in doubtful cases the diagnosi s of den titio n '

and wormsis nowadays confined to a cer tain clas s of illiter ate womenand obsequious pr actitioner s only ; but the differ ential diagnosis of the typhoid in the very young fr om a catar rhalfever

,o r influenza

,o r glandular fever

,even fr om an in

testinal auto- infection may r emain difficult thr ough manydays—even fo r the skilled and thinking . The fever cur vei s very apt to be i r r egular , mainly i n enfeebled childr enand in the pr esence of one of the many complications .Ther e ar e even some cases in whi ch the di sease sets insuddenly with a high temper atur e ; ther e ar e those

,how

ever,in which a high temper atur e i s apt to be deceptive,

fo r I believe with A . Fairbar n (J our . Am. Med. Assn, Apr i l1 2

,1 897 ) that the fir st symptoms may be over looked fo r

many a day. A cer ebr al pneumonia may exi st hal f a weeko r mor e without being r ecognized

,until the development of

the di sease and car eful examination clear s up the diagnosis .Influenza may assume the char acteri stics of typhoid to a

cer tain extent . Meningiti s may be r ecognized,i f by no

other symptoms, by means of a lumbar punctur e and examination of the cer ebr o-spinal fluid. Altogether a r atherslow pulse when not in pr opor t ion to the height o f the

temperatur e,the condition of the tongue, the swelling of

3 1 5

DR . JACOBI ’S WORKS

the spleen,and the pr esence of r oseola r ender the diagnosi s

secur e even without the Diazo and Widal tests. In otherinstances

,however

,we ar r ive at a r esult by exclusion only.

Ther e i s hardly a s ingle clinical symptom which alonepr oves the pr esence of typhoid fever ; the s imultaneouspr esence o f many i s a mor e per fect guide . The diazo testi s near ly conclus ive when tuber culos is and pneumonia maybe excluded ; i t may be expected to be positive in 90 per

cent . of all the cases between the end of the fir st and the

middle of the third week . The gr eatest difficulty i s metwith in those infants that yi eld few o r no local symptomsexcept those of a septic infection only. Lymph nodes ar e

sometimes found tumefied ; their swelling in the inguinalr egion

,however

,fr om other causes i s so fr equent that,

when found alone it should not’

count . The pr esence ofher pes should gener ally be taken as pr oof of the absenceof typhoid fever . The pr esence of the bacillus in the

di schar ges would be the best symptom if we commanded a

r eadi er pr actical method fo r i ts discovery, pr ovided ther ebe other symptoms which make the case suspicious of being typhoid fever .

Much i s natur ally made of the pr esence o f bacilli in thedischar ges o f doubtful cases

,and quite often the diagnosi s

had to depend on it . To what extent i s that justified ?Ther e may be cases in which I should utter ly r efuse to ao

cept the diagnosi s o f typhoid fever unless ther e be someone o r mor e adjuvan t symptoms, fo r the same r eason thatmakes me r efuse the diagnosi s o f diphther ia when ther ei s nothing but the pr esence of Klebs—Lo effler bacilli

,o r

that of tuber culosi s when bacilli ar e depos ited on somemucous membr ane .

PROGNOSIS

The char acter and the mor tali ty of typhoid fever ar e

apt to vary according to seasons and epidemics. Baginsky places the mor tality at 9 per cent ., Mo n tmoullin at

Stefl'

en at Henoch at Wo llberg at In ho s

pitals it i s liable to be gr eater than in gener al p r acticefo r the r eason that as a rule bad , cases only ar e sent topubli c institutions . Still

,in the Chi ldr en

’ s Hospital of

3 1 6

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

after sever e cases, without o r with er r or s in hygiene o r

di et ; when ther e was apyr exia, they wer e mostly of a

shor ter dur ation than when the fever r emain continuous , o rexhibited a slight r emission only.

TREATMENT

The food should be liquid. My invar iable rule i s , withadults also

,to ins i st upon that demand until apyr exia has

lasted ten days . The patient should be encour aged to dr inkwater fr equently ; the admixtur e of fr om eight to twelvedr ops of di lute hydr ochlor i c acid to a tumbler full of water ,o r sweetened water , i s a pleasant and dis infectant dr ink .

Of albuminoids,peptones

,and pepton o ids,

”and of beef

juice, only a cer tain quantity i s digested o r absor bed ; thegood that i s to come fr om them is not fr om swallowing,but fr om digesting. The l ips and tongue should be keptclean . Older chi ldr en will wash and gar gle . When the

tongue i s r ed and dry, and fissur ed,one o r two daily ap

plications may be made with a clean camel-hair brush,of

a one o r two per cent . solution of nitr ate of silver . The

nose should be kept clean,washed out with normal salt

solution in ur gent cas es . To guard against hypostas i s ofthe lungs and the cord, the postur e in bed should bechanged fr om time to time .A pur gative dos e of calomel in the very beginning will

act beneficial ly not so after the second hal f of the fir stweek when diar rhea and hemor rhages may be caused by it .Constipat ion r equir es warm water enemata dai ly ; diar rhea,fr equent ir r igations with water

’

of fr om 95 to 1 0 0° F .

When the di schar ges ar e offensive,thymol, o r perman

ganate of potass ium may be added in a p r opor tion of0 0 0 Inter nal ly, bi smuth, sulpho-carbolate of z inc,salol, naphthalin ar e indicated. B r onchial catar rh demandsno special tr eatment in most cases ; i f the secr etion i sviscid

,and dyspnea pr esent fr om that cause, camphor i s

s er viceable . Collapse r equi r es str ong stimulants,by mouth

and sub-cutaneously ; diluted alcohol,camphor in sweet al

mond oil and the sali cylate o r benzoate o f sodiumand caffein, so luable in two par ts of water

,answer best

3 1 8

TYPHOID FEVER IN THE YOUNG

fo r that pur pose . Insomnia,gr eat excitement

,and con

secutive psychoses may r equir e chlor al hydr ate . When thehear t i s feeble, cr oton chlor al should be selected instead.

When these symptoms ar e accompanied with heat of thehead, cold applications to the head, i ce water , i ce bagsar e soothing . The head should, under such ci r cumstances,be kept as high as comfor t permits . Sopor o r coma shouldbe tr eated with cold affus ions

,while the body i s submer ged

in water of 90 o r 95 degr ees .I s i t desir able to r esor t to antipyr etic tr eatment ? I f

so,in what clas s of cases, mild, medium o r gr ave ? Thi s

latter classification, however , should not exist, fo r the ap

par en tly mi ld case may tur n out to be a grave one . Or i sit des ir able to allow high temper atur es to per sist ?

The vi s medi catr ix naturae has been eulogized in in fectious fever s . However

,the wholesome influence of intense

body heat on bacter ia and toxins has become very doubtful, and good obser ver s like Fliigge deny the new gospelof the incr ease of phagocytosis by high temper atur es ah

so lutely. No r i s the dis integr ation of ti s sues by heat alonesuccessfully contr adicted. Thus

,after all

,we need not en

j oy the pr esence o f high temper atur es as a blessing,dis

gui sed o r undisgui sed, and should r educe them . Thi smuch i s cer tain

,that the comfor t of the patient is enhanced,

and gr ave ner vous symptoms alleviated,when the ho t

,dr y

skin becomes cooler and moi st in pr opor tion to the r eduetion of the gener al temper atur e .Which ar e the means by which we can effectually obtain

it ? The number of an tiferbr ile medi caments has gr ownimmeasur ably ; the caut ious pr actitioner will do well, however , not to embar k in the dar k sea of unknown ter r itor ies ,guided by nothing but the flashlight adver ti sements of thedrug manufactur er . Some of the new r emedi es ar e actualdanger s . Acetanilid i s a poison like all anilins ; it changeshematin into methemoglobin ,

_and—thus~ cause the cyanosisthat i s so fr equently noticed. Antipyr in is perhaps thesafest ; sodium salicylate annoys the stomach and the k id

neys, which ar e very l iable to suffer fr om the typhoid toxinalone. Quinine acts well dur ing intermi ss ions and r e

miss ions,not however when hi gh temper atur es are continu

3 19

DR . JACOBI’

S WORKS

ous. The cardiac stimulants—digitali s, str ophanthus, spartein

,camphor

,alcohol—which impr ove the gener al and cu

taneous cir culation , and ther eby the r adiation of heat fr omthe skin

,ar e mighty weapons in the hands of the in telli

gent medical advi ser,who mor eover need not limit himself

to the few r emedies I mentioned.

All of these r emedi es,however , do not exhaust our r e

sour ces ; indeed they ar e only of minor impor tance . Without knowing all of it the o ld poet exclaimed hudo r ar is

to n ,

”the water i s the best. Cold water and warm water

ar e our most r eliable and at the same time the safest antipyr eti cs . Str ess should be laid on the latter title, becausemany of the very apostles o f hydr other apy, perhaps influen ced by shaky phagocytosis and toxin theor ies

,belittle

i t in compar ison with the ner ve stimulating power s ofwater . Now,

cold bathi ng i s fr equently contr aindi cated ; iti s not bor ne when the hear t is feeble fr om whatsoever cause ;fo r instance, long dur ation of the di sease, complicationswith pneumonia, per i tonitis , o r hemor rhages

,p r evious bad

health o r,in the adult

,exces ses . No stimulant given befor e

o r dur ing the pr ocedur e is cer tain to counter act the paralyzing effect on the per ipher al ci r culation . When aftera cold bath the feet r emai n cold and the pul se small,the bath was contr aindi cated

,and did harm . The patients

in public hospi tals ar e quite often of a low vitality, and

feel the cold bath as a shock ; at all events,most of those

who ar r ive in the hospital after a week o r two have passedthe time when the cold bath might have done good. Ofthi s natur e i s the latest exper i ence of I . Budisch in the

Mount S inai Hospital (Mt . S . Rep .,Vol .

,He says :

The B r and tr eatment r educed the mor tal ity a little over2 per cent . Thi s r eduction occur r ed in the cases whi chhad been sick two weeks o r longer

,outs ide the hospital .

Since the intr oduction of the B r and tr eatment ther e hasbeen an incr eas e i n the number o f cases of pneumonia and

phlebiti s,and a decr ease of those of furun culosis and

nephr i tis . Relapses have incr eased per cent . The

death r ate in the r elapse cases befor e and since the in

tr oductio n of the B r and tr eatment i s pr actically the same .I t has not r educed the number of complicated cases as a

3 20

https://www.forgottenbooks.com/join

ANAEM IA IN INFANCY AND EARLY CHILD

HOOD

PATHOLOGI CAL pr ocesses ar e but the utter ances of physiological fun ctions per formed under abnormal c ir cumstances .Those functions depend on the anatomical condition o fthe ti ssues o r or gans . While thi s r elation has long beenestablished in the minds of medical men

, the former,

though acknowledged theor etically, i s fr equently n ot

heeded. As a rule, the pathological anatomy of a dis

eased or gan i s stated, in connection with the hi story o f

a case,o r the descr iption o f a class of cases

, but the

refer ence of an anatomical pr edi sposition of tis sues o r

or gans to special mor bid pr ocesses is mostly neglected.

It is mainly Beneke who has studied disease fr om thispoint of vi ew

,and i t i s fr om his var ious essays and works

on kindr ed subj ects that some of the exact data to belaid befor e you ar e taken .

By r ights,every tr eati se, essay o r paper on a patho logi

cal subj ect ought to commence with the normal anatomicalcondition of the or gan o r tissue to be dealt with. Thus,only, an intelligent appr eciation of the facts becomes possible

,and thus

,only, when every case is vi ewed in thi s

light,the pr actice of a medical man i s r aised above the

level of r outine and drudgery.

When,some time ago , Mr . P r esident

,I had the honor

o f r eading befor e our Society a paper on infant diar rhoeaand dysentery, I emphas ized the fact that healthy infantshave a normal tendency to loose l iquid o r semi-fluid evacu

tions fr om the bo wels . The causes/

1‘

stated to l ie par tlyin the condit ions of the in testinal tr act, and par tly in thenatur e of the normal food, vi z ., br east milk . The latterdo not concer n us now, but the former I r epeat mer ely fo rthe purpose of establi shing, in a few examples, the closeconnection between anatomical structur e and phys iological

3 2 3 .

DR . JACOBI ’S WORKS

and pathological conditions . The per istaltic movementsin the infantile intestine ar e very active ; the young bloodvessels very permeable ; the tr ans formation of sur face cellsis very r apid. The per ipher i c ner ves lie very super ficially,mor e so than in the adult

,whose mucous membr anes and

submucous ti s sues have under gone thickening by both n o r

mal development and mor bid pr oces ses . In the infant,

the per ipher ic ends of the ner ves ar e lar ger in p r opor tionthan in the adul t

, the anter i or hor ns of the ner ve centr es mor e developed than the poster ior ones . Thus, thegr eat r eflex i r r itabili ty of the young, under intestin al andother influences, i s eas ily explained. Besides

, the actionof the sphincter an i i s not quite power ful, the fwces

ar e not r etarded in the colon and r ectum,and no time i s

afforded fo r the r e—absor ption of the li quid o r di ssolvedconstituents of the faeces . Mor eover

, the fr equent occurr ence of acids

,sometimes in normal conditions

,in the

small intestines,gives r is e

‘ to the formation o f alkalinesalts with pur gative pr oper ties .On the other hand, constipation in the very youn g i s

sometimes the r esul t of gr ossly anatomical conditions ofthe intestinal tr act . I should not have to allude to thefact at the pr esent time if it wer e not fo r the followingr easons : Fi r stly, thi s form of constipation illustr ates exceedingly well the connection between anatomy and function ; s econdly, the r outine tr eatment of constipation bythe administr ation of pur gatives would be very danger ousin just such a case ; and lastly, what I have published aboutthe subj ect mor e than ten year s ago , and r epeated inthe tr eati s e on hygiene, edited by Dr . A . Buck, appear snot to have been n oticed to such an extent that the suf

fer ing infants can be suflicien tly benefited. At least, in an

es say on constipation, publi shed but lately and pr esumablyconsider ed complete in its etiology, thi s impor tant causeof the most obstinate form of constipation in the veryyoung is not mentioned at all.

It ther efor e bear s r epetition ; i t i s, in a few words , as

follows : Until the four th o r fi fth months of fcetal li fe,ther e i s no colon ascendens

,and it i s still shor t at bir th.

Notwithstanding that fact, the lar ge intest ine at bir th

3 24

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

cho lestear in,the impor tance of which

,in the establi shment

of a hyper plastic condition of car tilage cells and tissueelements i n gener al, has long been r ecognized. Thus, ossification becomes ir r egular and defective

, and the rhachiti

cial bone contains an abnormally lar ge quantity of fat, incontr as t with the defici ent per centage of lime

,which

,either

i s n o t intr oduced o r not ass imilated in consequence of thefaulty natur e of the pr eliminary stages o f osseous developmen t.

Some other pecul iar ities ar e found in the condition whichhas been called scr ofula. The normal r elation of the hear tto the lungs

,between the second and twentieth year s, i s

1 : 5-7 in scr ofula i t i s 1 : 8 - 1 0 . This cir cumstance,coupled

with an acquir ed debility of the ner vous system,r esults in

an insuffi cient supply of blood to both lungs and or ganism,

and defective oxygenation, par ticular ly in thos e cases whichby common consent have been called torpid scr ofula. Iti s mainly in these that the lymphati c system pre

-emiuently par ti cipates in the symptoms . The si ze and numberof the lymphatics ar e very gr eat in infancy. Sappeyfoun d that they could be mor e eas ily inj ected in the childthan in the adult

,and the i nter communication between

them and the . gener al system i s mor e mar ked at thatthan any other per i od of li fe . These facts ar e but latelyver ified by S . L . Schenck, who , mor eover , found the networ k o f the lymphatics in the skin of the newly

-bor n en

dowed with open stomata, thr ough whi ch the lymph-ductscan communicate with the neighbor ing tissues and cells,and vice versa (Jacobi, Tr eat . on p .

The blood of the newbo r n differ s gr eatly fr om thatof the i nfant at a per iod but little advanced. The basmoglobulin in the umbilical ar tery amounts to per cent .o f the whole solid const ituents, whil e in the venous bloodof the mother it i s but per cent. The fi r st to pr ovethis high per centage was Deni s, in 1 8 3 0 , who found the

cor r ect p r opor tions by determining the quantity of ir oncontained ther ein . Poggiale found a s imilar pr opor tion ofthe haemoglobulin in the newbor n and the fully-gr owndog, v i z .

, per ,

cent .,and Wiskeman ’

s r esultsar e s imilar . The total amount of the blood contained in

3 26

ANE MIA IN CHILDHOOD

the newbo r n is, however , smaller than in the adult, ther elation of its weight to the total weight of the body beingin the former , 1 : in the latter

,1 : 1 3 .

These conditi ons, however , ar e being changed soon . The

high per centage of haemoglobulin commences to decr easeinstantly. Young animals have les s than o ld ones ; in the

calf and oxen the pr opor tion isDenis found i t to diminish un til the age of six months,

and a very slow incr ease up to the thir tieth year . Leichtenster n found the following pr opor tions : i f the blood ofthe newbor n contains haemoglobulin 1 00 , that of a childof fr om six months to five year s contains 5 5 ; of fr om fiveto fifteen year s 5 8 . At the age of fr om fifteen to twentyfive it i s 64 , 2 5 and 4 5 -60 it is 63 . Subo tin alsofound less in young animals than in o ld ones ; also lesswhen the amount of nitr ogenous food was r educed. Leichtenstern found the per centage of haemoglobulin to decr easein the very fir st two weeks .

‘

I t was lowest at the age

o f fr om six months to s ix year s ; after that time a slow incr ease takes place . But even in the very v igor of li fe, inthe third and four th decennia

,the per centage of haemo

globulin is smaller than in the newbor n .

Ther e ar e some mor e differences in the composition ofthe blood of the young, mor e o r less essential in char acter .

The foetal blood and that of the newbor n contains butli ttle fibr ine, but vi gor ous r espir atio n works gr eat changesin that r espect . Nasse found the blood of young animalsto coagulate but slowly. How thi s i s in the infant cannotbedetermined until mor e and better obser vations will havebeen made . Ther e ar e les s salts in the blood of the young,and acco rding to Mo lescho tt, mor e leucocytes . Its specificgr avity in the young is 1 0 4 5-1 0 49 ; in the adult, 1 0 5 5 .

Thus,letting alone the newbor n, the r esult fr om the

above figur es i s thi s : The infant and chi ld has and r e

quir es mor e blood in pr opor tion to i ts entir e weight, butthi s blood has less fibr ine, less salts , less haemoglobulin ,

less soluble albumen,mor e whi te blood corpuscles, and

less specific gr avity.

The lar ge ar ter ies in the newbor n and the infant ar e

wide, and consequently the blood pr essur e is but low. This

3 27

DR. JACOBI S WORKS

is mainly so in the fir st five year s, i n the subclavian andcommon car otid. Thus the br ain has a chance to gr owfr om 4 0 0 gr ammes to 8 0 0 in one year ; after that per iodits gr owth becomes less . At seven

,boys have br ain s of

1 1 0 0, gi r ls of 1 0 0 0 gr ammes . In mor e advanced li fe its

weight i s r elatively less ; 1 4 2 4 in the male,and 1 272 i n

the female . At the same ear ly per iod the whole bodygr ows in both length and weight. The or iginal 50 cm .

o f the newly—bor n incr ease up to 1 1 0 with the seventh

year ; the gr eatest incr ease after that t ime amounting to60 ( in the female

,50 ) centimetr es only. In the same

time the weight incr eases fr om ki lo . to in the

boy; fr om to in the gi r l ; a pr opor tion of 1 to6 o r 7, whi le after that time the incr ease i s but thr eeo r four -fold.

As the or gans gr ow,so do the per ipher ous blood-vessels .

Thei r si ze i s in p r opor tion to the lar ge blood-vessels .Only the hear t gr ows towar d the seventh year , perhaps,only becaus e i t r equi r es an over -exer tion to over come thesluggishness in the cir culation o f the lar ge and smallblood-ves sels . I t is smallest

,with lar ge ar ter i es

,in the

fi r st year (par ticular ly i n the second hal f) at the sametime that the gr owth i s most intense . Thus it appear s thatthe gr owth and physiologically low blood p r essur e gohand in hand.

The s i zes of the lar ge blood-vessels do not gr ow equally,no r do they exhibit the r elat ive pr opor tions to each otherof the normal development of the adult . The pulmonaryar tery i s

.

fr om two to four centimetr es lar ger than the

descending aor ta. That means fo r the lungs mor e activework

,but al so mor e tendency to di sease, par ticular ly as,

s ince,the closur e of the ductus Bo talli, the aor ta

,fr om

which the br onchial ar ter ies ar e sent o ff, assumes co n

sider able pr opor tions within a shor t space of time .At thi s t ime the lungs begin to r ival the liver , whi ch in

the fir st days of li fe was twice as lar ge as both lungscombined. At thi s time, the amount of car bonic acideliminated by the lungs is incr easing steadily to r elativepr opor tions not known

_

in the adult, in the same manner as

the amount of ur ea eliminated i s r elatively lar ger than in

3 28

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

o f the o ld. Thus the normal oli gaemia of the child i s inconstant danger of incr eas ing fr om normal phys iologicalpr oces ses . The wor k befor e a baby has to be per formed,under the most favor able cir cumstances

,with

,so to speak,

a scar cely sufficient capital . The slightest mishap r educesthe equil ibr ium between that capital and the labor to beper formed, and the chances fo r the diminution of the

amount of blood in possess ion of the chi ld ar e very fr e

quent indeed.

Thus, the vuln er abil ity o f the young being gr eat, and

dis eases in ear ly infancy and chi ldhood so very' fr equent,

cases of anaemia ar e met with in every day’s pr actice

,and

in every form,complicated and un compli cated

,with gr eat

emaciati on o r without it, and either cur able o r not . Acondit ion so fr equent, so var iable, so danger ous, deser vedto be tr eated i n monogr aphs by the best men amongstpr actitioner s and wr iter s, and still ther e ' i s scar cely anytext-book

,any.

j our nal,in whi ch a competent and comp r e

hensive vi ew of the subj ect can be found. Ther e i s butone notewor thy exception to thi s fact . Dr . Fii r ster

,of

Dr esden,contr ibuted two year s ago a valuable essay on

the subj ect in one of the most pr ai s ewor thy liter ary undertakings o f moder n medical author ship . Ther e ar e twogr eat wor ks in pae diatr ic li ter atur e r ecognizable as landmarks . The fir st wer e the thr ee volumes o f monogr aphspubli shed by Billi et and Bar thez . The second i s the gr eatmanual on di seases of childr en, edited by C . Gerhardt . Inits third volume Dr . Fiir ster

’

s art icle has been published.

Like other s befor e him,he makes a distinction between

idiopathi c and symptomati c anaemia.

The former diagnosi s i s made when ther e is no tangiblecause at all

,o r none whi ch still per s i sts ; the latt er when

the change in the blood, with all its consequences, i s at

tr ibutable to a pr evious o r pr esent sickness . Perhaps it isidle to cons ider the question at all, whether ther e can bea genuine

,pr imary idi opathi c anaemia. When we s i ft the

matter,we shal l come to the simple conclus ion that every

thing has its cause, is' but a r esult, and secondary to some

thi ng else . F r om this point of view,and str ictly speaking,

obj ection could be r ais ed to the term idiopathic pneu

3 3 0

ANZEMIA IN CHILDHOOD

monia, per itonitis, o r meningitis . When we make use ofit, we mean to state only that the local affection is nolonger complicated with any other that could be diagn o sticated, and, possibly, r emoved.

In thi s sense ther e ar e cases of idiopathi c anaemia,in

whi ch the or iginal infant di sposition to it,of phys iological

char acter,has been r ais ed to a pathological dignity. But

the lar ge maj or ity of cases ar e of mar kedly secondary character , and cannot be appr eciated o r tr eated r ationally without the r ecognition o f the or iginal causes . They ar e ofthe most var ious char acter . In fact every di sease occurr ing in infancy and childhood may give r i se to anaemia.

Very few di seases when they have run their full cour seand terminated in what we ar e pleased to call r ecovery,leave the or ganism o r the affected o r gan in as per fectlya normal condition as pr evi ously. The fr equent r ecurr ence of simple di seases such as pneumonia points to thefact that changes have been worked which cr eate a constant pr edi sposition to pathological pr ocesses in the sameor gan . Thus

,in most cas es of anaemia the diagnosis

of the whole cas e must extend to the or gan fir st affected,and the tr eatment

,while i t may be di r ected against the

r esult, is incomplete unless the causal indicat ions be fulfilled.

Hemor rhages r esult in anaemia in a number of instances .They ar e of differ ent char acter and impor tance . Ther e istrue melaena ; umbili cal hemor rhage ; hemophilia ; pr imaryo r secondary pur pur a ; inter nal hemor rhages of the newbor n ; cephalhaematoma ; hemor rhages fr om r ectal polypi ;epistaxi s depending on coryza ; epistaxis at a mor e ad

vanced age fr om hear t disease and abdominal stagnation ;hemor rhages in diphther i t ic angina ; and such as take placedur ing o r in consequence of oper ations fo r har e—lip o r

r itual cir cumcision . Death may r esult fr om many of them,

such as melaena, hemophil ia, pharyngeaf hemor rhages, o r

cir cumcision ; other s ar e of but little gr avity, such as the

sanguineous tumor of the newbor n ; other s ar e apt tor esult in permanent ai l ing . As a rule, however , an acuteanaemia i s mor e eas ily over come than one that i s of a

mor e chr onic natur e, and ther eby undermines the vitality3 3 1

DR. JACOB I ’S WORKS

and str ength of the or gans while it slowly r obs them ofthei r nutr iment. Infants who ar e thus str icken r ecoverbut slowly o r not at all. Young animals r esist star vationto a less degr ee than o ld ones . A dog of two days bor estar vation in Magendi e

’

s labor atory but two days ; a dogof s ix year s, thi r ty. Similar r esults wer e obtained byCho ssat in his exper iments on pigeons . Thor oughly anaemicand delicate babies seldom r ecover entir ely, like star ving

young animals which never attained their normal condit ion though they wer e car efully fed afterward. The

r ecruits of the P russ ian army bor n in the star vation year sof 1 8 1 6 and 1 8 1 7 wer e of a very infer ior char acter physically. To thi s clas s also belong the childr en bor n pr ematur ely and of del icate par entage

,though ther e wer e n o

r ecognizable constitutional dis ease, and of mother s afllicted

with a di sease of the uterus o r placenta,inflammatory,

syphi litic, o r o therwise ; o r of such as suffer ed muchdur ing pr egn ancy o r lactation ; al so those bor n with congenital diseases

,cyanosis, o r neoplasms, whi ch ar e by no

means so r ar e as has often been believed and said,o r the

peculiar smalln ess o f the hear t, and pr incipally the ar

ter ies, to which Vi r chow attr ibutes many cases of chlor osi s .I have met with hal f a dozen of such cases , in whichthe supply of blood to the body was diminished by thi sanomaly, and Dr . Skene r epor ted a case of pr obably the

same natur e whi ch was published in the J our nal of Ohstetr ics and Diseases of Women and Childr en , Get

,1 8 76 .

Besides the di seases and afl ectio n of the newbor nther e ar e other s which develop in later li fe and lead to thesame r esults . I t i s often acqui r ed in endocar diti s, fo rinstance ; acute inflammatory rheumati sm,

whi ch i s veryfr equent, yi elds in most cases but l ittle swell ing of thej oints

,

“

comp r is es most cases of so -called gr owing pain,and has a much mor e mar ked tendency to the pr oducti onof an endocar diti s than the same afl

’

ectio n in the adult .P r otr acted diar rhma injur es to a gr eater extent than con

stipatio n . I t acts not only by dir ect and immediate lossof serum

,thr ough which i t can pr ove fatal in a shor t

t ime,but mor e fr equently by its consequences . The

mucous membr ane of the intestinal tr act becomes thick

3 3 2

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

its curvatur e of the spine,and compr ess ion of the lungs

and hear t ; fatty liver ; enlar gement of the lymphaticglands, mesenter ic, br onchial o r otherwise ; the complexof symptoms compr ehended un der the gener al head ofscr ofula ; dis eas es of the bon es of the most var i ous kinds ,fr om congeni tal o r p r ematur e oss ification of the costalcar tilages, with its consecutive contr action of the chest andcomp r ess ion o f its contents

,to the chr onic o r subacute

osteiti s of the ver tebr al column o r any of the other par tsof the skeleton

,with its final termination in amyloid de

gener ation o f the v i scer a ; and finally, to conclude with,di seases of the lungs and pleurae

,caseous deposits, cir rhotic

indur ation, emphysema and empyematic deformity.

In anaemia both the skin and the mucous membr anes ar epale

,of a yellowish hue

,thin and flabby. A cer tain

degr ee of appar ent elasticity of the skin and subcutaneousti ssue i s noticed only in cases of oedematous efl

'

usio n .

Those or gans o r tis sues which ar e least in use emaciatefir st ; that i s, in ver y young chi ldr en, fat and muscle .But ther e ar e cases in which fat i s per si stently r etained,and in which it i s o ften incr eased in quantity. Fo r , whenthe r ed blood globules ar e destr oyed, ther e i s scar city ofoxygen, and fo r that r eason the combusti on of the al

bumin ous substances becomes incomplete, and fat,the

phys iological r esult of thi s incomplete combustion, i s depos ited in lar ge masses . Par ticular ly i s thi s the casewhen anaemia i s either complicated with o r i s the r esult ofgener al rhachi tis—when at the same time the glands and

the chest ar e sufl'

er ing fr om the r esults of the rhachitic

pr oces ses . An illustr ation of thi s pecul iar occur r ence,which i s by no means r ar e

,i s also seen in the peculiar

appear ance o f acardiac o r acephalic monster s,whi ch con

tain a lar ge amount of oedematous fat, in consequence ofthe exclus ively venous char acter of their ci r culation .

In consequence of the i ll nutr ition and the emaciation o f

the muscular ti ssue these infants and chi ldr en ar e eas ilyfatigued. In gener al

,the functions of all the or gans suffer

consider ably. And with such debility, i r r itabi lity goeshand in hand. The ner vous system is less affected thanany other, because of the r apid gr owth and development

3 3 4

ANAZMIA IN CHILDHOOD

which i t under goes at that per iod o f li fe. Not in fr equently, babies who ar e anaemic and emaciated ar e in the

very best of spir its, because their br ains ar e compar ativelyin good conditi on . A cer tain amount of emaciation can

be eas ily r ecogni zed by the depr es sion of the fontanellesof babies under one year o ld o r even later ; but the emaciation o f the br ain does not incr ease at a r ate whi ch co r

r esponds with the loss in weight of the other or gans and

ti ssues of the body. In addition,the very s inking in of

the fontanelles , which allows us to estimate the amountof emaciati on that has taken place inside of the cr anialcavity, leads us to the fair conclus ion that the emaciationof the r est of the body has taken place to an unusual extent ; and any baby with consider able depr ess ion of thefontanelles must be consider ed in danger fr om the degr eeof inaniti on pr esent .Murmur s in the jugular veins ar e not very fr equent in

infancy and ear ly childhood. Murmur s in the car otidsand over the lar ge fontanelles, however , ar e not at all

r ar e . It i s not true that these murmur s,audible over the

br ain,belong to rhachiti s alone . They ar e found in every

condition in which blood pr essur e in the lar ge ar ter ies ofthe cr ani al cavi ty i s lessened.

The hear t itsel f seldom exhibits functional murmur s .Whenever they ar e pr esent, it i s safer to attr ibute themto or gani c di sease than to mer ely fun ctional di sorder . Be

sides,it i s now well known that acquir ed endocardit is i s

by no means r ar e, and,mor eover

,that i t occur s even mor e

fr equently i n the ar ticular rheumati sm of the youn g, bei t ever so slight

,than of the adult . Although the brain

be not so liable to suffer fr om emaciation, dependent uponanaemia

,as other or gans

,sti ll ther e ar e a number of cases

in which headaches , attacks of syncope, sleepiness, etc ., o r ,on the contr ary, sleeplessnes s and hyster ical attacks, ar e

the r esult of anaemia alone, and disappear when this corrditi on i s r elieved. Not a few

—of the babies and childr en

who cry the gr eater par t of the night have no other ail

ment besides gener al anmmia, and such childr en ar e fr e

quently r eli eved by a meal o r some stimulant befor e theyare put to bed, - o r given dur ing the inter ruption of their

3 3 5

DR . JACOBI’

S WORKS

sleep . The pul s e of such childr en i s sometimes very muchacceler ated ; sometimes, however , i t i s slow, and sometimesir r egular . I have known such chi ldr en

,in whom fo r

mo nths, and occas ionally fo r year s, I have'

fear ed the de

velopment of cer ebr al affections fr om the very fact thattheir puls e was both slow and weak ; and yet, when thei rgener al condi tion was impr oved both the r egular i ty and fr o

queney of the puls e wer e incr eased.

The puls e, however , i s, perhaps, amongst the symptomswhich ar e most unr eliable at thi s age. In the baby i t i sbest counted dur ing sleep, and better over the fontanellethan upon the r adial ar tery. I t will change very fr e

quently, not only with alter nate sleeping and waking,

with r est and r estlessness,but sometimes without appar ent

p r ovocation . A slight amount of muscular action willchange its char acter mor e o r less

,and fr equently consid

er ably. Physiologically, the pul se i s very apt to be mor efr equent at the age of two and a half o r thr ee monthsthan ear lier o r later , because it i s at about that age thatmuscular movements ar e actually developed.

Very few anmmic chi ldr en have a good appetite exceptat the beginning . The influence of anaimia i s gener al inr egard to all or gans of the body. Ci r culation i s deficient,and the normal s ecr etions ar e defective o r deficient i n consequence . That i s, both appetite and digestion ar e im

pair ed, and sometimes destr oyed, and cannot be r estor eduntil the gener al condition of the chi ld i s impr oved.

The slowness of the cir culat ion and i ts insufficiency, andthe watery condit ion o f the blood, ar e apt to give r i s e tocatar rh of the pharynx and larynx and the r espir atoryo r gans in gener al . Bes ides

,the walls of the blood-vessels

ar e known to suffer in anaemia. They become thin, and

under go fatty degener ation, which Po nfick has found inthe hear t

,and in the intima of the lar ger blood-vessels

and in the capillar i es . In consequence of the thinnes s ofthe blood and the ' changed conditi on of the blood

-vessels,ser ous tr ansudation, and, now and then, extr avasations willtake place . The same occur r ence is noticed in the adult inconditions of anaemia. I t not infr equently occur s thatthos e who have least blood lose it most easily. Anaemic

3 3 6

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

ing heard in the night amongst the tenement-house population, and sometimes in the bette r -s ituated classes, too,comes fr om star ving babies. After a whi le the yellingtur ns into a whining

,and any slight di sease terminates the

baby’

s suffer ing . Thi s condi tion i s r ecogni zed by the ah

sence of local di sease anywher e, by the gr adual emaciation, and i s char acter i z ed by the paucity of otherwise n o r

mal faeces. Many a case of alleged constipation i s one ofstar vation . Wher e ther e was no food, ther e ar e no evacuations, and when a baby i s r epor ted as having but o ne n o r

mal passage a day, o r even less, the suspici on is that it hasnot enough to eat. The r emedy i s eas ily r ecommended

,

fo r i t consists in nothin g but a sufficient quantity ofpr oper food.

Impr oper food is a much mor e fr equent cause. A few

r emar ks must suffice her e,fo r i t i s imposs ible to go over

the whole gr ound of infant hygi ene in a shor t paper whichi s mor e meant to suggest than to teach. A few points,however

,I must not omit, because of the fr equency of the

s ins committed. The contr aindicat ions to a woman ’s nur sing a baby must be obeyed. Nur sing dur ing pr egnancy,o r extended over too pr otr acted a per iod

,must be forbid

den . The latter i s,i f pos sible

,mor e ser i ous than the

former . Many a case of rhachi ti s o r anaemia owes i t or iginto the baby being nur sed into the second year . A babywhose development i s not normal, fo r instance, whose fi r sttooth does not appear at the r egular age of seven o r

eight months,i s either suffer ing fr om a pr evious di sease

of it has insufficient o r impr oper food. I f nur sed, ther efor e

,it ought to be weaned, o r par t ially so . Many a

flabby chi ld at the br east will thr ive when weaned at last,and good bar ley and cow

’

s milk will make better muscleand teeth than po or mother

’ s milk . An inher ited o r in

her itable o r communicable di sease on the par t of the

mother o r wet—nur se,such as consumption, r ickets, syphi l is ,

ser ious ner vous di seases, intens e anaemia forbid nur sing .

In not a few cases the individual milk of mother o r wetnur s e does not agr ee with the baby. When such i s thecase

,unles s the fault can be detected and r emedied, wean

ing is r equir ed. In most cases it i s poss ible to tr ace the

3 3 8

ANZEMIA IN CHILDHOOD

indigestibility and .insufficiency o f a mother ’ s milk to theabsence o r p r evalence of a special constituent

,mostly

either sugar o r—and mainly so—casein . A “beauti fuli llustr ation of this fact was but lately exhibited by a babypatient of Dr . A . N . Smith. The mother ’s milk was umdoubtedly too white and too casein ous. The baby

’

s digestion was faulty, his assimilation quite defective . The ad

dition o f some far inaceous decoction to each meal fr omhis mother

’

s br east—a few teaspoonfuls given befor e eachmeal—r emedi ed the evil somewhat

, but the pati ent’ s l i fe

was finally saved by nothing but weaning and exclus ivear tificial feeding . I t is impossible

,however , to cons ider

now the question of infant food to any extent . Suchpr inciples as I have laid down i n Buck ’ s Hygiene, and

very br i efly i n my paper on infant diar rhoea and dysentery,have guided me thr ough the better par t of my l ife . I shallnot, ther efor e, tir e your patience by r epeating them.Ther e ar e

,however , a few simple wor ds which I cannot

r epeat too often . Avoid solid food.in the car e of an . in

fant . Avoid cow ’ s milk either undiluted o r diluted withwater only. Avoid condensed milk diluted with wateronly. Use no mi lk without the addition of somegelatinous o r far inaceous decoction

,bar ley, oatmeal, gum

ar abic,gelatine . In anazmia add beef soup to the uniform

infant food dai ly. Give solid food,that i s a small piece

of meat,a crust of br ead

,hal f an egg

,about the end of

the fir st year . Keep up thi s s imple diet fo r another year ,and add slowly such ar ticles of food as phys iology and

exper i ence permit . P r ohibit bad habits, such as i r r egularand fast eating, cold feet and hi ghland-fashion legs, and

enfor ce out-door exer cise ; childr en befor e and after an

out-door play ar e differ ent beings . Avoid cr owded schoolr ooms and the excess of pr ivate lessons . A child sleepingafter a healthy exer ci se o f his muscles and lungs willfinally, besides being str onger 4 1 nd

' healthier , lear n mor ethan o ne who hangs his pale cheeks, sleeping over his

books . We have laws to pr otect childr en fr om being sentto work in factor i es, o r to be employed on the stage, butwe have none to pr otect them fr om the equally destructive,incessant schooling in close r ooms . without ai r o r exer cise.

3 3 9

DR . JACOBI’

S WORKS

Ther e ar e too many bo oks bought fo r Chr istmas and toofew skates .Amongst the medi cinal agents i r on has long been the

main r esor t in anaemia and chlor osi s . This was so evenbefor e the time when hemoglobin was i solated and foundto contain all the ir on of the blood. As it was found tobenefit the cases of anaemia and chlor osis

,in which the

r ed blood corpuscles wer e undoubtedly diminished, i t wasbelieved that i r on had the abili ty to dir ectly incr ease thenumber and the quality o f the r ed blood globules . But

the question whether i t i s r eally the i r on which pr oducesthi s effect has not been answer ed to the sat isfaction of all,fo r a gr eat many of the cases get well whi le no i r on whatever i s given

,and in consequence of change of diet and

the secur ing of r est and a better gener al condition . Be

s ides,ther e ar e a number o f cases in which the administr a

tion o f i r on i s absolutely unavai l ing. Mor eover,ther e i s

plenty of i r on in almost every ar ticle of food. Boussain

gault found that thus eight o r nine centigr ammes (gr .

iss .) o f i r on ar e dai ly taken into the body. The samequantity has been found by Fleitmann to be eliminatedby the kidneys and the intestinal canal . Thus

,ther e cer

tainly ar e cases o f chlor osi s which have 'not been causedby the absence of i r on ; and it cannot

,ther efor e, be said

that the i r on, by supplyi ng this lack o r by r emoving thisabsence, cur es chlor osi s .But it i s sti ll a question whether the i r on thus given ,

under cir cumstances which ar e entir ely abnormal,does not

impr ove the chances of r ecovery i n just these condit ions .The doses given would cer tainly be too lar ge, when com

par ed with the ir on contained in the food and with the

amount of i r on pr esent in the whole quantity of ci r culatingblood

,three gr ammes and no mor e .

Compar ed with thi s small quantity, the doses we ar e ac

customed to administer ar e cer tainly lar ge . Speedy elimi

nation,too

,takes place, thr ough which the whole o r near ly

the total amount of the ingested i r on i s r emoved. But ithas not been found whether the i r on does not act in someo ther way besides incr eas ing the amount of the metal con

tained in the hemoglobin .

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

mal childr en, and almost cer tain to take place i n childr enWhose cir culation has been di sturbed o r whose gastr ic se

cr etions ar e cer tainly below their normal amount in couse

quen ce of a defici ent supply of blood.

The subcar bonate of ir on is a very mild pr epar at ion,eas ily di gested, and pr oper ly combined with a number o f

drugs, such as bismuth o r bicar bonate of soda,is of con

sider able value when,in slow convalescence o r p r ogr essive

anaemi a, thi s gastr ic catar rh thr eatens to inter fer e with theimprovement in the gener al condi tion . The doses may belar ger than thos e o f any o f the other pr epar ations . Achild two year s will eas ily hear fr om 2 5 to 50 centigr ammes daily. This quantity, combined with twice o r

thr ee times as much subcar bonate of bismuth,and, i f meces

sary, thr ee o r four times that amount of bicar bonate ofsoda

,is a very pr oper r emedy to be used i n the conditions

alluded to .

The tinctur e of the chlor ide of ir on,when neutral, i s a

pr epar ation which i s also easily di gested. Dos es of a

gramme dai ly, o r mor e,ar e very r eadily digested, and

pr ove beneficial . This can be easily combined with the

bitter tinctur es,stomachics

,etc . The tinctur e of the mur i

ate o f i r on is the one, amongst the fer ruginous p r epar ations

,with the exception of those par tly composed of ether ,

the acetate,fo r instance

,which must be r egarded as a vas

cular i r r itant,and wher ever the action of the hear t is

lower ed and blood p r essur e i s dimini shed, i t i s the pr epar ation which will be foun d most beneficial .In a number of cases

,the choice among the s ever al

pr eparations o f ir on i s an indiffer ent matter , at least, s o itappear s to be. Sti ll it has s eemed to me that, in thosecases in whi ch I have had to deal with anaemia attendedby gastr ic catar rh and digestive incompetency in the upper por tion o f the small i ntestine, the pyr ophosphatepr oved very satisfactory. I have employed the compoundhypophosphates and phosphates a gr eat deal, which combine ir on

,potassa, lime, and soda, and

,although it i s

well known that the elimination of thes e metal s and

metalloids i s almost as r apid as thei r ingestion, still i t appear s that the effect pr oduced by such combinati ons i s a

3 4 2

ANEEMIA IN CHILDHOOD

very happy one in just such conditions as those of whi chwe have just spoken .

All these pr epar ations ar e of special value in chr onicanaemia, which is by far the most common affection . Acuteimpover i shment of the blood

,such as that caused by sever e

puerper al hemor rhage o r hemor rhage fr om the bowels, isfor tunately very r ar e in infancy and childhood. Ther efor e

,

the oppor tunity fo r tr ans fus ion of human blo od i s s eldomoffer ed, even to those who ar e most fond of that par ticularoper ation .

The doubtful r esults of tr ans fusion upon a lar ge scalehave induced a moder n wr iter to make a number of smalltransfusions by means of the hypodermic syr inge. He

would withdraw blood fr om the vein of a healthy per sonand intr oduce it dir ectly and immediately into the veins ofthe s ick child

,and he states that he has done so wi th

favor able r esults . It seems to me that the plan is r ationalenough, but the futur e must decide whether the r esult swi ll be as favor able as they have been r epor ted

,and

whether ther e will not be gr ave obj ections to what i s descr ibed as a very tr ifl in g oper ation . If it be success ful,it would cer tainly, under equal cir cumstances, have the

pr efer ence over the slow pr ocess of gastr i c, o r of r ectalalimentation

,no matter whether inj ections of defibr inated

blood o r other nutr i ents ar e used.

In cases of chr onic anaemi a I have fr equently used ar

sen ic ; o ne o r two minute doses daily, after meals and welldiluted with water

,and with benefit . Of one thing ther e

is no doubt,and that is that ar senic does good in a pe

culiar torpid condition of the stomach whi ch will not digestand ass imilate in consequence of the absence of both ner vepower and gastr i c juice . Both i n adult s and in childr en,I have given it fo r the pur pose of impr ov ing gener al nutr ition , and I have not seen in chi ldr en what very fr e

quently occur s in adults when ar senic / is—given fo r ner vousdi sorder s

,namely, gastr ic der angement . With ir on, with

o r without stomachics,I have seen the appetite impr oving,

the mucous membrane filling wi th blood, and vi gor r etur ning under its r estor ative influence . Doses : fr om two tofive dr ops daily, of Fowler

’

s solution .

3 4 3

DR . JACOBI’

S WORKS

In this connection, I will state that strychn ia, in myhands, has pr oved very beneficial as an adjuvan t to eitherar senic o r i r on . To a chi ld two year s o ld a dose ofof a gr ain may be safely given daily, and this dose maybe continued fo r a long time . I ts action i s well known in

cases in whi ch the di gestion and the entir e ner vous powerof the patient ar e s imply lower ed, and a few weeks ’ ad

min istr ation, together with pr oper food and either i r on o r

ar senic, has changed the condi tion of the anaemic chi ldconsider ably.

Phosphorus,in about the same doses as strychnia, has

also p r oduced very happy effects . They may be br oughtabout by the influence of phosphorus upon the ner voussystem,

o r they may be explained by the effect which the

r emedy pr oduces when given in diseases of the bones .Some ten year s ago , Geor g Wegner found that the fr actur ed bones of r abbits fed upon minute doses of phos

pho rus, would unite much mor e r apidly than the fractur ed bones of those animals whi ch wer e l eft to themselves .Since that time I have been in the habit of giving phos

pho rus in cases of acute and chr onic dis ease of the bonesof an inflammatory char acter , and in car i es par ticular ly,and my impr ess ion i s that the lar ge maj or ity o f cases dovery much better when small doses of phosphorus, sayto of a gr ain dai ly, ar e given, than when the dis

ease i s left to pur sue its cour se without the use o f thi sr emedy. I t i s true that the time r equir ed by such a

pr oces s as car ies i s long under any ci r cumstances , but i thas seemed to me that even car ies of the ankle j oint andthe metatar sus was apt to pr ogr es s very favor ably in thecour se of a number of months when phosphorus was used,wher eas year s wer e r equir ed in other cases which had notr eceived the same tr eatment .I do not know that i t has been used extensively in

rhachiti s , but i t i s not imp r obable that the good effectwhi ch phosphorus pr oduces in anaemia, mostly of rhachiticial childr en, i s par tly due to the fact that the bonesespecially show an incr eased tendency to normal development.In many cases cod-l iver oil i s very servi ceable ; I need

3 4 4

https://www.forgottenbooks.com/join

TREATMENT OF INFLUENZA IN CHILDREN

P r ophylax is.—I s ther e anything like a p r eventive of in

fluen za ? Ther e is,contr ary to Ber ger (Die Infections

Kr ankheiten, and other s, no infectious di sease ofequal communicabili ty, either dir ect o r indir ect . Underextr aordinary cir cumstances only i s there a possibil ity ofavoiding contact . Influenza may be p r evented fr om en

ter ing a ship coming fr om di stant por ts,o r a ship car ry

ing it may be quar antined with r ather mor e theor eticalthan pr actical effect . Influenza may be kept out of a

monastery o r a pr i son o r out of an insane asylum o r bar

r acks i f ther e is no inter cour se with the r est of the wor ld.

It should be kept out of a sanitar ium fo r lung diseasesby str ict i solation dur ing an epidemic . Indeed

,I know of

no infectious disease that cr eates a gr eater di sposition totuber culosis than influenza. To close a school is unavailing,fo r the childr en will contr act the disease outside . Ex

pecto r ated mucus and the r esult of sneez ing should,i f

possible,be caught and dis infected o r destr oyed ; tools,

toys, towels, handker chi efs, and linen should be tr eated,i . e., washed and dis infected as in other contagious maladies. To p r otect the childr en of a household the patientshould be isolated on the upper floor of the house

,a de

mand with which i t i s impossible to comply in the lar gerpar t of our population . Nur slings

,i f thei r mother s be

sick, should meet them fo r nur s ing only. Sick and wellchildr en should use dis infectant mouth-washes . I thinkwater sli ghtly acidulated with hydr ochlor i c acid will dobest. Dr inking-water should also be acidulated in the samemanner and may have the same favor able r esult that i sobtained in Asiatic choler a. The i r r igation of the noseshould be a matter of cour se in the well and in the si ck,fo r the same r easons that have been ur ged by myself and

very per s istently and for cibly by Dr . C . A . Caillé against

3 4 7

DR . JACOBI’

S WORKS

and dur ing diphthe r ia. In thi s way mucus, which according to Ruhemann catches bacill i as i n a net

,i s r emoved and

'

the mucous membr ane i s kept in a healthy condition . Inwhich way the bacillus enter s i s not enti r ely clear ; i f itinvades thr ough the mucous membr ane li ke the pathogenousbacilli of tuber culos is o r diphther ia o r choler a

,the mor e

normal the condition of the mucous membr ane, the gr eateris the pr otecti on .

Medicinal pr eventives have been r ecommended—cod

liver oi l by Ollivier ; calcium sulphide by Gr eene ; quinineby many. Tr ial s with it made on r egiments of soldier sunder contr ol in their bar r acks wer e equally positive o r

negative . My exper i ence with pr eventives i s very small.Quinine appear ed to cause headache and nausea.

Tr eatment.—Ther e i s no Specific fo r influenza l ike quinine fo r -malar ia o r sal icyli c acid fo r rheumatism . Innocent mur iate of ammonium,

also c ar bonate .o f potass ium,

sulphocar bolate o f sodium,carbolic acid, ichthyol, and other

remedies have been so recommended without the expectedsuccess. Thus, r ational, hygienic and symptomatic and sus

tain ing medicinal treatment only can be consider ed. Apur gative dose of calomel should be given in or der to clearthe bowels of micr obic and toxic ingesta

, the bowels appear ing to be the pr in cipal point of attack in young chi ldr en . The patient should be kept in bed, the temper atur eof the r oom at 70

° F . o r mor e at fi r st,the diet should be

scanty and fluid at fi r st—mi lk, cer eals, far inacea, water ,lemonades

,and br oths . The fur ther development o f the

case will gr adually indicate eggs, and perhaps—in a fewselected instances only—alcohol in addition to other medi cinal stimulants . I t is mor e, however , a slow convalescencethat r equir es it than the cour se of the dis ease itsel f. Inthis r espect it appear s to differ somewhat fr om other in fectious dis eases

,par ticular ly typhoid fever and diphther ia.

In the latter the doses of alcohol should be high fr om the

beginning .

I f ther e be a high temperatur e,cold water is not indi

cated e i ther as a bath o r as a pack . The i r r itating coughwhich often r equi r es opiates is r ather incr eased thansoothed by it ; the char acter i stic br onchi tis of influenza does

3 4 8

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

of the enema, but though water alo n e wer e inj ected i t wouldadd to the ci r culating fluid. That i

s why even a lar geenema given fo r the purpose of clear ing the bowels mayadd to nutr iti on and str ength by such of the inj ected wateras i s almost invar iably r etained. Thus

,seve r e vomiting

should be tr eated with r efus ing to feed thr ough the stomach. The best r elief i s given by mor phine, r ar ely by ice,either inter nally o r exter nally. I t i s not necessary to sendmor phine down to the stomach ; absor ption i s easy and mor er eadi ly accomplished in the mouth o r thr oat . A tablet ofone milligr am may be thr own into the mouth of a chi ldof two o r four year s, ther e to be absorbed

,o r hal f a dr op

o r one dr op of Magendi e ’ s solution may be administer ed inthe same manner without dilution .

The indications fo r the tr eatment of influenza may besever al

,the high temper ature i n many cases, the gr eat dis

comfor t,the r estlessnes s

,and the r apidly incr eas ing ex

haustion . In the tr eatment of many fever s it i s the ir causesthat r equir e cons ider ation ;

2 in other s,however

,thei r r ela

tions to, and influence o n , the body ar e the main cons ider ations . When the condit ion of the latt er i s fair

,and no

danger i s incur r ed on account of the fever , i t should be“

left alone ; when the r i se of temper atur e,however , by itself

is injur ious,i t should be inter fer ed with. At all events

the tr eatment of the symptom fever gives us no hopeof shor tening the disease in which i t occur s o r of whichi t forms a par t ; on the other hand, it i s a sati s faction toknow that

,whi l e we incr ease the comfor t and diminish the

immediate danger s, the natur al healing pr ocess i s not disturbed. In thi s way both the justification and the limitation of the so—called expectant tr eatment become evident .To allow a hi gh temper atur e to deter ior ate tis sues and exhaust the hear t o r br ain, i s as injudicious as is the customof emphas iz ing the number of degr ees of Fahr enheit as theonly valuable par t of a morbid pr oces s . To be satisfiedwith dep r ess ing temper atur e is a gr ave mistake

,but to

allow pneumonia to run its deleter ious cour se of high tem

2 Jacobi, A. Fever s and Fever Remedies, Albany MedicalAnnals, May, 1 900 .

3 5 0

TREATMENT OF INFLUENZA IN CHILDREN

peratur es unchecked with their full influence on the r apidity of r espir ation and the action of the hear t and on theincr ease of waste, i s equally injudicious .In their injur ious influence on nutr ition pr otr acted in

fectious fever s act, fir st, like dir ect losses o r like star vation,and, secondly, as immediate poisons . The younger the patient

,the gr eater i s the danger fr om that sour ce . That

i s why a hi gh temperatur e without any o r with a tr ifl ingr emiss ion should not be allowed to last

,though its imme

diate effect may not appear very ominous . When a hightemper atur e r esults in a convul sion we never hes itate tor educe it ; her e we admit ther e i s a vi tal indi cation . Why,then

,not r educe it while ther e i s the danger of a possibility

o r pr obability of its occur r ence ? Add to these facts thedi spositi on of the young to inanition which i s caused by twomain factor s . The fir st is their r apid metabolism

,the sec

o nd and pr incipal one i s the r elative,almost univer sal

,

insufficiency of the young or gani sm.

Mor eover,we should not for ge t that most o f our antipy

r eties ar e at the same time ner vines,analgesics and dia

pho r etics, thus impr oving comfor t and metaboli sm . Theyar e sur ely indicated when bathing i s not sufficiently effi

cient o r when baths ar e contr aindicated ; in that case theymay act as adjuvants

,as combinations

,and pr ocur e sleep

and r emi ss ions . I f I add that ther e ar e, however , contraindications to the use of medicinal antipyr etics because ofposs ible idiosyncr asies and of the debilitating efl

'

ects whi chmany of the antipyr etic drugs are apt to exhi bit, I mer elysay what all have exper i enced, and what everybody shouldr emember

, viz ., that no degr ee of Fahr enheit and no Gr eekname of a morbid pr ocess ar e the subj ects of our medicati on

, but an individual patient . F r om these points ofview our fever r emedi es should be judged.

In my paper of 1 8903 I said that acetanil id ought to

be pr efer r ed among the po or because nf its low pr ice, antipyr in mainly wher e gr eat solubility was r equir ed fo r thepurpose of its administr ation i n r ectal and subcutaneousinj ections

,and that phenacetin was pr efer able to either

8 Jacobi, New Yo rk Medical Reco r d, 1 890.

'

3 5 1

DR . JACOBI’

S WORKS

when it could be given by the mouth, because of its les suncomfor table effect on the br ain, the hear t, and the skin .

Thi s opinion I have to modi fy to a cer tain extent,not

that I obj ect to what I said of phenacetin, but acetanilid

should never have an oppor tunity to show what good qual ities it may have, in the r ich o r poor . I t should not be usedat all

,under any cir cumstances, not even in the quack

pr epar ations which now and then I know to disfigur e thepr escr iptions o f ' r egular pr actitioner s . Being a der ivativeof anilin

,acetanilid i s poi sonous . Not only has it a seda

tive o r r ather par alyz ing effect on the centr al ner vous sys

tem,but it destr oys the blood and causes anemia by chang

ing hematin into methemoglobin,though given sometimes

in small doses . That i s what gives r ise to cyanosis so oftenobser ved

,mor e often than after the administration of any

other o f our moder n analgesics and anti febr i les .,The poi

so n ous effect is even noticed when the drug is used externally, mainly on the young. Examples of such cases wer er epor ted at the meeting of the Philadelphia Pediatr i c Society, Apr il 1 1 , 1 899.

Antipyr in, when employed dur ing normal conditions, incr eases the tens ion of the pulse and blood pr essur e—ther efor e it is contr aindi cated in hemoptys is—and pr oduces perspir ation . I t works mor e on the gene r al centr al ner voussystem than on the center o f cir culation, that i s why i tacts—while being antipyr etic—as a sedative and analgesic .But i t should not be consider ed as a ner vine

,fo r its action

appear s to be usher ed in thr ough the mediation of the bloodand blood-vessels . The body temper atur e begins to decr ease within fifteen o r twenty minutes after the fir st dose ;to r ender its antipyr etic effect mor e tangible and per s i stent,it should be followed by a second within two hour s .

,Thi s

rule, however , does not hold good when the drug is givenfo r i ts s edative o r analgesic o r fo r its sl ight anti-rheumaticefl

'

ect. Its gener al effect is mostly good, but its undesi rable effects ar e many. Otto Sei fer t 4 quotes eighty author sof note who r epor t disagr eeable effects of antipyr in ; they

4. Seifer t, Otto . W’

ii r zburger Abhandlungen aus dem Gesammt

gebiet der pr akt . Med., 1 900 .

3 52

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

To what extent stimulants should be given in the average o r in the grave cases depends on the gener al condi tionof the patient, and on his medical adviser

’ s knowledge ofhis former health and his r esi sting power . I t i s pr obablethat in most cases some daily doses of sulphate of spar tein,five centigr ams (gr . 5 6 ) fo r a child of two year s, will havea favor able effect . The caffein pr epar ation I mentionedmay be given in doses of fr om two to six decigr ams (gr s.

iij -x ) dai ly. When it appear s to act as an excitant on thebr ain

,it should be r eplaced by camphor in daily doses of

fr om one to four decigr ams . All these doses, however ,should be much incr eased when str ong stimulation i s r e

quir ed,and in an emer gency subcutaneous inj ections of

the same drugs should be used, caffe in being soluble in twopar ts of water and camphor in four par ts of sweet almondoil .One of the best st imulants, useful in the gr avest of all

cases whi ch ar e attended with collapse and hear t failur e,i s sadly over looked among us

,viz ., Siber ian musk . I know

of nothin g better in the most ur gent of cases . A childo f two year s should take of the 1 0 per cent . t incture fiveto ten minims every hal f hour until hal f a dozen o r a

dozen doses have been taken . Musk, together with lar ge,ho t enemata

,has led me over many a difficult pas s

,and I

again offer thi s exper ience of mine,whi ch now extends

over fi fty year s, as a contr ibution to your aid in dir e distr ess, always, however , r eminding you o f the fact that allthese measur es ar e not exclus ive to influenza

,but to all

condit ions of ner ve exhaustion,no matter fr om what cause .

At last,let me allude to a s ingular exper i ence which

was publ ished ten year s ago , I do no t know that it hasbeen r epeated since .“5 Goldschmidt 6 r epor ts as followsAbout New Year

’

s,1 890 , a lady suffer ing fr om influenza

landed in Madeir a and di s seminated the di sease in a shor ttime . Two months pr eviously ther e had been an epidemic

5 In the discussio n fo llowing the r eading o f this paper Dr .

Ho lbr o ok Cur tis r efer red to the inter nal use o f vaccine virus ‘ byhimsel f and o ther s. A. J .

6 Go ldschmidt. Immuni ty Thr ough Vaccinatio n, Ber l. klin.

Woch., 1 890 and 1891 .

3 542

TREATMENT OF INFLUENZA IN CHILDREN

of smallpox and numer ous vaccinat ions and r evaccinationswer e per formed. Now, i t so happened that all those whower e success ful ly vaccinated—1 1 2 all told—r emained fr eeof influenza. Of 98 who wer e vaccinated unsucces sfully,only 1 5 took sick . The autho r concludes fr om thi s ex

per ience that success ful vaccination i s a pr eventive againstinfluenza. But as yet ther e is not enough known to justifyany such conclusion with anything like cer tainty. Still

,

i t suggests the possibili ty of a futur e ser other apy fo r influen za and its very ser ious consequences .

3 55

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

ology. What we have to r emember i s the fact that the samesymptoms and extent of local changes do not belong toall cases equally, and that the same ther apy i s not adaptedto every case .Purulent otitis i s fr equently found in autops ies . P r ey

s in g foun d in those made on 1 0 0 infant s that died of a

var i ety of dis eases, 8 1 affected with otiti s medi a. Only8 wer e unilater al, so that ther e wer e 1 5 4 diseased ear s among1 0 0 dead infants . No r ar e older childr en exempt . Gepper t found a latent otiti s media -in 75% of all the inmatesof the childr en

’ s hospital s he - examined. Thes e ar e the

same r esults which ar e obtain ed by pr evious and succeedingobser ver s of the same di s ease when occur r ing at differ entages . School-childr en have been examined in that dir cetion a gr eat many times, but I give only two instanceswhich

,so far as I know

,have no t been copied in our

j our nals . Dillner found among 3 8 childr en that had tobe excluded fr om their schools on accoun t of incompetence9 still suffer ing fr om inflammatory ear dis eases ; Kalischer ,among 2 5 5 childr en excluded because they made no pr ogr ess and hinder ed their class-mates, 8 0 with pr ev ious o r

still per s i stent middle-ear inflammmation s.

Pyogenous micr obes enter the middle ear mainly fr omthe naso-pharynx, which, according to R . O . Neumann,

1

contai ns even in its normal condi tion a lar ge number o f mi

o r obes,mainly micr ococcus pyogenes albus in fr om 8 6 to

90% and the bacillus pseudo-diphther iae in 98% of all

cases . In nasal catar rh ther e i s a r elative incr ease ofthe bacillus pneumoniae of F r aenkel and F r iedlander , ofstr eptococcus pyogenes, and of the bacillus of diphther ia.

These latter may cause nasal catar rh, while the bacillus

pseudo~diphther iae i s a sapr ophyte only. Thus my fr e

quent statement that many cases of nasal catar rh dur ingan epidemic o f diphther ia wer e diphther itic—fi r st based onclinical obser vat ions published in the Amer ican Medical

Times, of August, 1 860 ,—i s confirmed by the most r ecentbacter iologic r esear ch.

2

1 “Zeitschr . f. Hyg. und In f. 1 902 , vo l. 40 .

2 “ Ther apeutics o f In fancy and Chi ldho od,” 3 d edition, p. 407 .

‘

3 5 8

OTITIS MEDIA IN CHILDREN

Micr obes get into the middle ear in the contiguity of thesur face of the mucous membr ane pr ogr ess ively, not n ecessar ily in every case of diphther ia, scar latina, o r other cruptive di seas e

,but still fr equently ; o r they ar e thr own in

dur ing coughing,vomiting

, o r sneez ing . That i s ‘ mainlyso when the nar es ar e obstructed by catar rhal swelling, o r

by the p r esence of mucus o r of a membr ane, o r by a highdegr ee of congeni tal deviation . Nur slings ar e in dangerdur ingsuckling and deglutition—the mor e so the lower thei rvitality and the mor e fr agile their ep ithelia, the feeblertheir

.cir culation and the gr eater their emaciation . I t i s inthese condit ions that micr obes

,mainly cocci, which ar e ubiq

uitous in the access ible cav ities,will enter the tube with

gr eat facility and meet those whi ch ar e p r eviously in

habiting it, and which become very effective by the cir

cumstance that under the influence of ill nutr ition,atr ophy,

and colds, the vibr ating epithelia become par alyzed. Thi s

latter condit ion i s eas ily p r oduced, on accoun t of the n o r

mally slow air cur r ent in the Eustachian tubes and in themiddle ear . A very di r ect caus e of otiti s media i s found inthe p r esence of naso-pharyngeal diphther ia o r str aightfo r

war d nasal ” diphther ia, which in its mild o r gr ave formis by no means so uncommon as a very moder n author seemsto believe

,who thinks it wor th while to publish, in thr ee

long ar ticles,thr ee new cases of p r imary nasal diphther ia.

It is true that in this paper ther e is a display of such erudition as i s apt to be exhibited in quotations . The author ’ sliter atur e goes back to antiquity, and that antiquity to 190 0 ,aye to 1 890 . I admit that i s uncommon r esear ch in our

over—pr oductive j ournal l iter atur e . But ther e i s still mor eancient liter atur e on the subj ect . 3 In nasal and nasopharyngeal diphther ia, otitis media i s quite fr equent, perhaps, however , not quite so fr equent as we might expect i f

3 The contr ibutio ns to diphther ia, published in the Jour nalo f Obstetr ics, February, 1 8 75 ; _ the _ ar tiele o n Diphther ia,

” in

the seco nd vo lume o f Ger har dt’s H andbo o k, 1 877 ; and the

Tr eaties on Diphther ia, published by Wm. Wo od 8: Co ., 1 880 ;

even the sever al editio ns o f the Therapeutics of I nfancy and

Childho od—all o f which r efer ences ar e in our own libr aryco ntain what would have facilitated moder n r ediscover ies.

3 59

DR . JACOBI ’S WORKS

we over looked the cases in which the membr ane i s solid and

firmly closes the or ifice of the Eustachian tube . I t is mostlyobser ved in those cases of nasal diphther ia in which the

membr anous depos its ar e very l ight and flo cculen t and

the secr etions copious and acr id. I t is p r incipally thi sclass of cases in which the nasal inj ections o r i r r igationsintr oduced by me mor e than for ty year s ago pr ove li fesav in g, and

,as to ear s, pr eventive .

In diphther ia of the thr oat,a s light swelling of the mu

cous membr ane o r,as I have said

,a moder ate diphther itic

deposit may close the Eustachian tubes, and hard-hear ingmay be the r esult. In thi s clas s of cases the patient complain s not infr equently of intens e pain behind the angleof the jaw and in the ear

,and in some cases the diphther

it ic membr ane i s cont inued into the tubes, and gives r i s e tootitis inter na and media, which finally terminates in per

fo r ation of the drum membr ane, and occas ionally in car i esof the bones . VVr eder “ collected 1 8 cases of diphther iao f the middle ear in scar latina

,complicated with the same

affection of the fauces and nar es . One child with diphther ia of the mouth and pharynx had also diphther ia ofthe inner ear . Kuepper saw diphther ia o f the middle ear

and Eustachian tube, and Wendt once in the tubes,and

,

amongst 8 4 cas es of var iola,twice in the middle ear

,to

gether with the same affection in the naso—pharyngeal cavity.

5

A fr equent cause of otiti s media i s s car let- fever , withi ts coccic o r bacillary thr oat affection . In mild o r s ever ecases ther e may be per for ation of the drum membr ane,necr osi s o f the drum membr ane and of bones, pr ogr es s ofthat p r ocess to the antrum and the cells of the mastoidpr oces ses and to the s inuses and meninges, with the r esult sof pyaemia, br ain abscess

,o r s epticaemia. In some of

these cases of scar latinal ot itis media ther e may be, withoutmany appar ent local symptoms , fever , delir ium,

diar rhoea,o r br onchiti s . Many such cases while yielding no painfr om p r es sur e on the mastoid pr oces s exhibit fever

,not

4 Monatschr . f. Ohr enh., x ., 1 8 68 .

5 Quo ted fr om my Tr eatise o n Diphther ia, 1 8 80 .

3 60 .

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

tube dur ing coughing o r sn eez ing. Secondar ily, it depends o n invas ion thr ough the Eustachian tube in cases ofpharyngeal, laryngeal, o r pulmonary tuber culos is, o r thr oughthe cir culation . Thi s happens mostly dur ing the glandular and bone tuber culos is of the young, and in miliarytuber culos i s . Altogether the r epor ts differ in r egard tothe fr equency of tuber culosi s otiti s media. Bezold foundonly 1 27 cases amongst ear pat ients . Amongst thechr onic absces s es of the middle ear ar e tuber culous .Few of them occur in infants and children

,that i s only

of the who le number,while the r emaining belon g

to advanced age (Habermann ) . Absces ses of the inter nalear though they be in tuber culous childr en need not r e

sult fr om o r contain tuber cle bacill i, though accordingto o ne stati stical r epor t 9% of all the abscesses wer e saidto have been foun d in tuber culous childr en

,and a few o f

them had miliary tuber culos i s . The otiti s media dependedin almost every case on pneumococci .In cer ebr o-spinal meningit is the ear i s often affected,

mor e, i t appear s, in some epidemics like that of thi s year

( 1 894 ) tha n in other s . I never saw a case of deafnes s andconsecutive deafmutism or iginat ing in cer ebr o-spinalmeningitis that r ecover ed. Whether p r eventive measur esmay r educe thi s un toward exper ience r emains to be seen .

Fo r nasal affections ar e fr equent . In almost every caseof mine

,obser ved thi s year , ther e was catar rh ; in all that

wer e examined fo r it, diplococci men ingo—inter cellular eswer e found i n lar ge number s . This nasal affection mayand does lead to otiti s media. The labyr inth deafnessoccur r ing dur ing the height o f the disease has thus farpr oved very unfavor able.Inflammations of the inner ear ar e r ar e

,only two in

Pr eysing’

s 1 97 cases . Perhaps the maj or ity depend oncer ebr o-spinal meningiti s . In one of these cases the tr ansmiss ion was not even dir ect, fo r the fi r st r esult of the

otitis media was a purulent meningiti s , in the cour se ofwhich the inner ear o f the oppos ite s ide became diseased.

Menier e’ s symptoms, namely, disturbance of the equilibr ium,

nausea, and vomiting, ar e not often obser ved. They willalways get wor se after quinine o r salicylic acid.

3 62

OTITI S MEDIA IN CHILDREN

The contents of the middle ear may be v is ible thr oughthe drum membr ane o r not ; the latter may bulge o r not .That is why in very many cases otiti s media may not beaccess ible to a diagnosi s

, and per for ation of the drum mem

br ane is not so common as might be expected. I t happenedin only nine of Pr eysing

’

s 1 54 diseased ear s . Thi s infr e

quen cy of per for ations i s believed to be due to sever alr easons.1 . The gr eater r esistance of the drum membr ane in the

young, the exter nal cutis layer being often thicker than inthe adult, the median connective—ti s sue membr ane very solid.

and the inner mucous membr ane with its pavement epithelium at least as normal as in advanced age.

_2 . In the young the Eustachian tube i s shor t but wider ,both at the i sthmus and at the tympanic or ifice, and the

dir ection of the canal almost hor i zontal . In the foetus theopening of the tube i s below the level of the hard palate ;at bir th i t r eaches that level ; in a child four year s o ld it i sabout 3mm above it.6 That i s why P r eys ing denies theeasy ex it of the pus int o the pharynx . He claims

,what is

true, that the pus i s mostly thick, and that pus wouldr ather

,while the baby i s on its back, run into the mastoid

antrum than thr ough the tube . But the r ecumbent position is not always kept up, so long as the baby i s not yeton the autopsy table . Beds ide and nur sery obser ver s willappr eciate this

,and pathologist s might .

I t should be r emember ed that most of the figur es quotedar e taken fr om poor ly developed, emaciated, even atr ophi chospital cases . Now

,atr ophy afl

'

ects the mucous membr aneo f the Eustachian tube as well as the r est of the bodyand adds to the width of the tube, which i s thus wider inthi s clas s of patients than in the healthy and well-nour ished.

In thi s latter , per for ation of the drum membr ane is not sovery r ar e, though indeed many a case of otiti s media in thi svery clas s o f patients, after fever , sens itivenes s on pr essur e,and meninge’al symptoms have been di stinctly noticed, willrun a mild cour s e without per for ation . Whatever pus doesnot find its way into the pharynx

—no per foration having

0 T. Mark Hovell, 2d edition, 1 90 1 .

3 63

DR . JACOBI ’S WORKS

occur r ed—is,o r may be, absor bed

,while the inner mucous

membr ane, including that which cover s the drum membr ane,will become thi ckened and give r is e to hard—hear ing o r evendeafmutism . Still ther e i s another po ssibilty, and indeedone o f fr equent occur r ence . The copious net of lymph vess els in the youn g is always very active

,in the emaciate and

atr ophi c very gr eedy, and the absence (caused by the disease) o f the pavement epithelium of the drum membr aneand o f the cylindr ical and vibr at in g of the inter ior permitsmor e r apid absor ption . This condit ion is a sufficient explanation of the r eadines s with which absor ption may takeplace fr om the inter ior of the ear into the lymph and bloodci r culation

,and lead to deposits in distant or gans, to mild

o r ser ious sepsis,to per s i stent exhibitions of temper atur e

with no tangible cause,to death

, o r to slow r ecovery. Mor eover , P r eys ing found on the inflamed sur face, as the r e

sult o f copious leucocyte migr ation, gr anulation globuleswith mi nute blood-ves sels, without epithelia, r esembling inshape small tuber cles , and sur r oun ded by s light hemo rrhages and a nar r ow r ing of beginning or ganization .

These little gr anulomata,with their small bloo d-vessels,

may also favor absor ption .

The pneumococcus which is found in otiti s i s r atherubiquitous . As we find i t in pneumonia

,meningitis

,per i

carditi s,per itoniti s, and so on, we need not be sur pr ised at

meeting it in connection with the otiti s of the young, with a

pneumon ia, o r with an enter iti s,and their r esult . Pada

t r ophy and otitis have been known to combine,mor e than

hal f a century. I was taught their clinical cotempor aneousn ess when a younger student of medi cine than I am to

-day,fi fty

-five year s ago . Which of these complications,—otitis

,

pneumonia, enter iti s, o r meningiti s,—i s the pr imary one is

difficult to say in most cases . To my mind, none of them is,in many a case

,the pr imary caus e o f the gener al infection .

Pneumococcus, being pr esent on every healthy mucousmembr ane

,will enter the cir culation fr om any poin t, par

ticular ly fr om the nose, on which, by accident o r disease,the

'

epithelial cover i s r emoved o r on whi ch i t i s disin tegr ated. Thus a meningitis may be the fi r st symptom of a

gener al pneumococcus invas ion . I t may be followed by

3 64

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

no t inj ectio ns—suffice f o r that pur pose . Adenoids whensmall will get well without operation when these i r r igations ar e gently and r egular ly made . Spr ays o r the use

o f dr opper s cannot take the place of i r r igations . A spr ay.

of a .5 per cent . solution of s ilver nitr ate thr ough the nar esonce a week will wor k well . Thi s application should bemade s everal weeks in succes s ion .

TREATMENT

A child with an acute otiti s media should be in bed,the head and trun k r aised. The r ais ing of the head alonemay lead to annoyance of the cir culation of the neck .

No feather pillows under the head. Symptoms will beamelior ated by a mild antipyr etic, a nar cotic

,a pur gative .

Politzer and Valsalva ar e not adapted to the acute stage .Sever e pain may be r elieved by a few dr ops of cocaine solut ion instilled into the ear

,occas ionally by a leech on the

mastoid pr ocess . Warm fomentations with spongiopiline,o r s imple warm wet cloths without o r with antiseptic solut ions should be tr i ed. When pus forms the poster ior hal fof the membr ane bulges fir st ; at its edge the hammer i sdist inguished. When an incis ion i s r equir ed i t should bemade poster ior ly and in fer ior ly. The expuls ion of the

pus thr ough the incised wound can be facili tated by Politzer ation , but thi s pr ocedur e may dr ive pus into the cells .Inj ections into the exter nal canal should—if at all, be madetowar d the wall o f the canal . Their advisability i s favor ed and denied in equally str ong terms . I do not usethem . Mor e than a dozen year s ago I lear ned fr om myspecialist fr iends the use of bor ic acid. After the ear has

been wiped out with absor bent cotton i t i s filled looselywith bor i c acid. When thi s i s softened with pus, the ear

i s again cleansed and the pr oces s r epeated. Thi s pr ocedur e has pr oved so success ful that I r emain true to the ad

vice o f my fr iends . I have often been told s ince that themethod i s bad and that inj ections into the exter nal canalshould be pr efer r ed, but I have r ead o f deaths that haveoccur r ed after inj ections in the p r actice of .such men as

Tr o eltsch, F r aenkel, and Katz, and I cannot help appr e“

3 66

OTITIS MEDIA IN CHILDREN

ciating the fact that enough people die without our ag

gr essive co -oper ation .

To what extent sepsis depending on otiti s media,pur e

o r complicated, can be benefited, i s uncer tain . Antistr eptococcus serum is of very doubtful efficacy. Cr edé

ointment may be used with a cer tain amoun t of confidence .

I t should be applied once o r twice a day. The inunctionshould last hal f an hour

,and absor ption facilitated by the

addition of a few dr ops of water to the ointment . Co l

largo l acts mor e r apidly when di s solved in ster ile waterand inj ected into the r ectum . Lar ge quantities of water ,drunk, inj ected into the r ectum

,o r under the skin in the

usual cautious way, ar e known to cause co pious eliminationfr om the blood, and deser ve all the pr ais e which has againbeen bestowed upon them by B . Alexander Randall in an

ar ticle on The Tr eatment of Otitic Septiczemia, whichappear ed in the J our nal of the Amer ican Medical Asso cia

tio n of November 26, 190 4 . Nuclein may be tr ied internally.

A . B r onner,o f B r adford

,England

,

8 publishes his opinion on the local tr eatment of some forms of non—suppur ativecatar rh of the middle ear by compr essed air and a nebul izer ,r ecommending fo r the purpose the compr essed-air appar atuses used in Amer ica. He is car eful enough to add whathe takes to be a fact that many cases of so -called drycatar rh of the middle ear ar e not due to any affection of themucous membr ane at all, but to a pr imary disease of theosseous labyr inth. In these cases the use of the cathetercan do a gr eat deal of harm . I f sudden gr eat pr essur ebe applied

, the hear ing and tinnitus may become wor se .In dubious cases he uses the catheter with an iodine spr ayunder very low pr essur e . It seems pr obable that in manyof these cases we have after all to deal with the r esultsof former inflammatio ns that r esulted in thickening of themucous membrane . I t is in _ these cases, though they beno t syphil itic, that the inter nal use of an iodid o r of mixedtr eatment may be expected to do good. But as a

rule, and that I emphas iz e mor e than anything else, chr onic

fiBritish Med. Jour nal, November 5, 1 904 .

3 67

DR . JACOBI ’S WORKS

diseas e of the mucous membr ane of the ear will never getpermanently cur ed unles s the chr onic catar rh o f the nasopharyn x r eceive constant attention . After all

, the tr eatment of n o n-suppur at ive diseas e of the middle ear is r atherineffective . Nothing i s mor e cor r obor at ive of this o ld ex

per ience than the discuss ion lately held in the B r itishMed

ical Asso ciatio n by eighteen gentlemen, well—kn own in their

specialty and liter atur e, a few o f them our own fellowcountrymen .

9 The latest paper on“

The P r esent Statusof the Tr eatment fo r Deafness Due to Chr onic Catar rhalOtiti s Media,

” published by Dr . Philip D. Ker r ison in the

J our nal of the Amer ican Medical Asso ciatio n , November1 2 , 1 90 4 , expr es ses itsel f in the same strain .

9 B r itish Med. Journa l, November 5, 1 904 .

3 68

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

danger ous n o r of long dur ation . But ther e is none ofthem but may lead to a sever e form

,with possibly a fatal

termination . Ther efor e,the fr equency of infectious dis

eases in infancy and childhoo d ought to fix our attentionconstantly in the dir ection of the kidneys . I t i s true thatsometimes we ar e unable to find anything but albuminur ia,which

,in the absence of kidney elements under the micr o

scope,we ar e liable to dismiss as transient and of little

account . But in thi s we ar e very apt to be mistaken .

My cases of uncomplicated and tr ansient albuminur ia havebecome wonder fully scar ce since I invar iably employ fo r theexamination of the ur ine the centr i fuge . Among twentysuccess ive cases wher e the verdict i s tr ace of albumin Iam cer tain to find in the centr i fuged depos its of nineteen,within a few minutes

,the almost un ifo rm '

r esult—bloodcells

,hyaline casts, hyaline casts studded with epithel ia, o r

finely o r coar sely gr anulated casts .Many of these forms of nephr iti s ar e, as I said, shor t

lived. Qui te often will they disappear within a week o r

ten days . But thi s happy termination is far fr om beinguniver sal . There i s nobody her e but has been sur pr ised ina child of advanced age o r i n an adolescent by an attack ofuraemic convuls ion

, the cause of which could be tr aced to a

scar let fever whi ch,s ix o r ten year s ago , terminated in ap

par ent r ecovery. The same exper i ence is had with nephr iti sfr om other causes ; fo r , unfor tunately, we know by this timethat besides scar latina, measles, var ioloid, and var icella, evenvaccinia

,acute local di seases o f the skin

,e rysipelas , rheu

matism,typhoid fever , acute and chr onic intestinal di seases

may be complicated with o r followed by nephr it is . Fo r

thi s r eason nephr iti s i s very common in infancy and childhood

, and ought to be sear ched fo r whenever the or i gin ofpr ominent o r danger ous symptoms i s not at once clear .

For tunately, it i s easy to obtain a specimen of ur ine, fo rcatheter i zation is mor e r eadily succes sful in the child thanin many adults . Thus it will fr equently happen that a ne

phr itis i s found when the pr ominent cer ebr al symptomssuggested the diagn os is o f encephalitis o r meningiti s . Ofthe many cases of this natur e which I have met with, thefollowingwill fur nish an illustr ation

3 70

NEPHRITIS o r THE NEWBORN

A boy of five weeks who had appear ed to be in fairhealth was taken with high fever and convuls ions . The

case occur r ed in a family living in ve ry moder ate cir cumstances, ther efor e, the medical man had good r eason to suppose that the infant had been ail ing some days befor e itwas considered necessary to call him in . The temper atur ewas 1 0 4

0 to 1 0 5°

F.,the pul se almost uncountable

,and the

convuls ions had not been fr equent when I saw the p atient .Ther e was some cyanosis and per spir ati on over the upperpar t of the body ; the legs and feet wer e cold

, the headwas very ho t. Ther e was n o oedema. The pupils wer eequal, fair ly dilated, contr acted a very l ittle, but sluggishly, under the influence o f a str ong r ay of light, and

under the same light dilated again and contracted withi ncer tain limits . The equality of the pupils, combined withthat pecul iar float ing condition of the i r is

,made me think

of uraemia as the cause of all the cer ebr al symptoms . The

ur ine was known to be scanty, but that i s what it also i sin meningitis

,and in every child that has not been supplied

with a sufficient quantity of water . For tunately, ther e wassome in the bladder . Boiling almost solidified it, and the

micr oscope r evealed blood-cells, epithelial and gr anularcasts, the latter both fine and coar se . The child died ; noautopsy could be had. No clew could be found to thecausation of the fatal di s ease ; and still, the baby was so

young that in all pr obability the or igin of the fatal n e

phr itis might have been found in some occur r ence of thefir st few days of life .

I t i s this per iod of ear ly li fe to which I mean to dir ect

your special attenti on to-night by r epor ting a few of themany cases of nephr itis met with within a few days o r

weeks after bir th. Some ar e pr imar ily r enal diseases, somear e secondary. To the latter clas s be long those nephr itideswhich ar e complicated with o r dependent upon intestinaldiso rder s. Thi s connection is quite fr equent . In manyinstances diar rhoeal di sorder s ar e the r esults of nephr itis,but quite fr equently both acute and chr onic intestinal diseases appear to be the causes of nephr itis, which may be

quite ominous ; fo r indeed i t is her e as in other dis eases,3 7 1

DR . JACOBI’

S WORKS

many of which ar e li able to terminate fatally by their r enalcomplication . Every pr actitioner loses many a cas e ofpneumonia

,not thr ough the sever ity of the pulmonary

lesion,but on account o f the accompanying nephr itis . In

thi s way the enter o-coliti s of the newbor n is quite apt todestr oy li fe thr ough nephr itis . In a highly cr editableessay (Ar ch. f. K inderk 1 894 , xv1 1 , p . 222 ) Felsenthal andBer nhar d have studi ed the connection of nephr iti s withacute and chr onic intestinal disorder s of infancy and childhood. They have also collected the l iter atur e on the subject. Par r ot met with i t in the_ atr ophy athr epsia o f

young infants ; Kjellberg, Fischl, Sti ller , Baginsky, Hir schsprung

,Hagenbach

,Henoch

,Epstein

,and other s have

r ecorded cases of nephr i ti s accompanying in testinal disorder s . The cases of this descr iption ar e by no means r arein the fir st week of li fe . When I look over the l ist of thenumer ous cases o f the kind I have pe r sonally seen, i t al

most seems to me super er ogation to r ecord a case ; and stillI know that many of my colleagues with whom I saw the

cases appear ed to be sur pr i sed at r ecogniz ing both the

pr esence of nephr iti s in such cases and the facility withwhich the diagnosi s could be made .The l iter atur e on the subj ect i s but scanty. I have,

however , r eason to believe that even those who have knownthe connection between intestinal dis eases and nephr iti squite well have not published thei r exper ience . I t has happened to me per sonally that my chapter s on catar rh and

ulcer ation of the bowels in my I n testinal Diseases o f I nfan cy and Childho od, 1 8 8 7, ar e s ilent on that subj ect byan over s ight of my own . But in the discuss ion on TwoCases o f Acute P r imary Nephr iti s in Infancy, by L . Emmett Holt, one of which was perhaps caused by intestinalseps is without that explanation being suspected

,I took

occas ion to say (Trans. of the Am. Peed. So c., 1 891 , vol .ii i, p . 2 3 3 ) Ther e ar e cases of nephr iti s which complicate intestinal di seases. I t i s true that many spells ofvomiting and diar rhoea ar e mer ely symptoms of nephr itis .A number of cases supposed to be choler a

,even Asiatic,

ar e found to be acute nephr iti s . On the other hand, wher ewe have to do with an acute o r subacute intestinal catar rh,

3 72

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

invas ion of a str eptococcus, o r of the bacter ium coli, o r one

of the other forms of micr obes detailed by Booker and byJeffr ies in the Transactio ns of the Amer ican Paediatr ic Society of 1 8 89.

Thei r absor ption i s faci litated by some peculiar anatomical condit ions .The muscular appar atus of the intestine of the fmtus

and of the newbo r n i s but slightly developed. Dur ingfoetal li fe its function is but tr ifl ing, and its contents movebut slowly. Immediately after bir th that muscular debilitypr edi sposes to coli c, as air which i s swallowed ; and gases,both innocuous and putr id

,which ar e developed in the tract,

ar e expelled with difficulty. Besides,the infantile digest

ive tr act is un expectedly long . According to Beneke, thepr opor tion of the length of the body to that of the smallintestine is in the adult 1 0 0 to 4 50 ; in the newborn

,

however,1 0 0 to 570 ; in the second year , 1 0 0 to 660 .

Mor eover,the villi ar e gener ally numer ous and lar ge ; some

asser t they sur pass in si ze those found in the adult intestine ; the capillar ies o f the v illi, it i s claimed, have gr eaterabsolute s ize

,so much so that their diameter i s lar ger than

that of the same vessels in the adult .1 All this tends toshow that both the accumulation of septic mater ial in, and

absor ption fr om, the inter ior o f the intestines is r ender ed

very easy. The access of micr obes to the intestinal tr acto f the newbor n is by no means difficult. How they en

ter,thr ough the mouth, the anus

,o r the blood, I have but

r ecently discussed in the fir st number of Paediatr ics. Af

ter all, i t s eems that the nephr i ti s or iginating fr om in

testinal infection i s of a s imilar natur e to what we oh

ser ve in typhoid fever o fl any of the o ther infectiousdi seases.

Nephr iti s in typho id fever of the newbor n I have seenbut once, fo r the s imple r eason that I have obser ved butthi s one case of typhoid fever ‘ in one so young. I t wascur sor ily mentioned on page 29 of my Tr eatise o n Diphthe

r ia, 1 8 8 0 . The baby di ed on the s ixteenth day of its l i fe,

1 A. Jacobi. I n test. Dis. of I nfancy and Childho od. Geo rgeS . Davis, 1 88 7. Chapter o n Intestinal Digestio n .

3 74

NEPHRITIS OF THE NEWBORN

twenty-two year s ago . The mother r ecover ed. Its kid

neys wer e much congested, the two substances hardly discer n ible fr om each other , an d blood oozed fr om the cut

sur faces. Ther e had been anur ia fo r two days, and no ur inewas found in the bladder after death.

In one o f the thr ee cases of diphther ia in the newbor n

,r epor ted on page 3 0 of my Tr eatise, I was favor ed

with an autopsy. The baby was taken seven days afterbir th and died on the ninth. The kidneys wer e in the

condit ion descr ibed in the pr ev ious case . No micr oscopicalexamination of the ur ine could be had.

In connection with thi s subj ect I now pr esent the caseof the youngest patient I have seen destr oyed by po tassicchlo rate.

B . C .,a boy of nine days, was sei zed, January 1 5

,1 8 8 2 ,

with convuls ions,after not having voided ur ine fo r sever al

hour s . The last time,when a teaspoonful was passed

,it was

of a dar k color,stained the napkin

,and seemed to give pain

dur ing the di schar ge . Ther e was constant re ctal tenesmus,with some pr otrus ion of the bowels

,some five o r s ix hour s

befor e the convulsion . Dur ing all this time the complexionwas sallow, and the lips and finger and toe nails were blue .I saw the infant after the convulsions, with hardly a pulse

,

bluish lips,br ownish complexion

,the sclerae still yellow and

lar gely ingested with dilated blood-vessels . Hear t beats fr om2 0 0 to 2 20 a minute

,scar cely per ceptible . Within an hour

after my vis it he died. The blood in the whole body was ofan intensely dar k color , the hear t of normal si ze and struetur e

,ductus Bo talli near ly closed, ductus venosus Ar anti i

sti ll open . Lungs and spleen wer e engor ged and purplish, sowas the liver . The kidneys wer e lar ge ; a number of bloodpoints—small haemor rhages—wer e vis ible on the longitudinal section ; ther e wer e, besides, a number o f dark str eakscor r esponding with the ur inifer ous tubes, and the differencebetween the two r enal substances was, almost extinct . Theircolor was unusually dark

,and they offer ed a str ongly

marked e lastic r esistance to the touch. What litt le ur ine

(about two cubic centimetr es ) was taken fr om the bladdercontained much pelvic epithelium,

and consisted almost exelusively of decomposed blood

-cells .

3 75

DR . JACOBI’

S WORKS

The great r esemblance of thi s form of nephr iti s to what Ihad descr ibed in the third volume of Gerhar dt

’ s H andbuch

der K inderkrankheiten , ar ticle Diphther ia, in 1 8 77 , and in apaper on The Remedial and Poisonous E ffects of Chlor ateof Potas s ium

,published in the Medical Reco rd of Mar ch

1 5,1 8 79, made me inquir e r ather scrupulously into the his

tory of the dead baby. The mother had suffer ed fr om copious vaginal dischar ge dur ing the last few months of herpr egnancy. Neither she n o r her sur r oundings wer e of thecleanest . The fi r st few days of the infant

’ s li fe wer e n o rmal. On the third and four th day sprue developed and

cover ed lips and cheeks with thi ck deposits . The midwi fein char ge called no phys ician . She knew the best thing fo rsp rue and infl icted it . She brushed the mouth with a satur ated solution o f potassic chlor ate

,as she pr oudly asser ted,

quite often, and fr equently gave a few dr ops to dr ink . Icould not lear n the str ength of her solution . She alwaysused it and i t had a power ful effect

,she said. As far as

I was permitted to lear n,she dis solved a tablespo onful in

a tumbler ful o f water ; I still found a sediment of the saltin the bottom of a tumbler .

A case o f nephr iti s after vaccinatio n was r eported byPer l in the Ber liner klin ische Wo chenschr ift, 1 893 , No .

2 8 . I t behaved exactly as nephr iti s in infecti ous fever s .The child

,two year s and nine months o ld

,became very

r estless about the usual time of the onset of a vacciniafever—vi z .

,fr om the four th to the fi fth day ; at the same

time ther e seemed to be abdominal and lumbar pains .Within a day after

,s imultaneously with the appear ance of

s ix vaccination vesicles,ther e was albumin in the ur ine to

the amount of one hal f of a per mille ; also haematin,blood—cells, and some leucocytes . The casts wer e either

pur ely hyaline, o r hyaline studded with epithelium . The

child was well on the twelfth day. The whole mor bid pr ocess r an its full cour se in s ix days, with no ser ious symptoms at all.The following i s a case of a s imilar descr iption in a

very young infantIn an immigr ant hotel of Gr eenwich Str eet

,New York, I

saw with Dr . John Bishop,Apr il 4

,1 8 77, two childr en, one

3 76

https://www.forgottenbooks.com/join

DR. JACOBI ’S WORKS

evidently bilater al nephr iti s . Both the kidneys wer e lar ge,intensely congested, and blood pour ed out of the cuts ;the differ ence between the two substances could not be distinguished. With him I saw no mor e such cases

,fo r I sug

gested the pr obabili ty that the cold bathing of the newbor n fur nished us the specimen . But the more I have seenof similar cases in the adult, the mor e do I feel that I wascor r ect in my char ge . Fo r acute nephr i tis

,inter stitial

,

sometimes haemor rhagic, i s an occas ionally unavoidableoccur r ence in sudden suppr ess ion of cutaneous cir culation .

Who has not seen death occur r ing fr om nephr iti s,not pr e

ceded by a chr onic afl'

ectio n , in per sons who have been r e

suscitated fr om dr owning in an ice-cold r iver, o r have been

exposed to a dr iving r ain storm while exer ting themselvesto get under shelter

,o r to cold and sleet in an o pen slei gh ?

What the slow influence of cold can not accomplish in thehealthy and vigor ous

,what not even a nephr ectomy can ac

complish in the r emaining kidney, its sudden cfl'

ect on thefeeble

,o r fatigued

,o r even the v igor ous, will easily br ing

about . No matter whether the r easons ar e to be soughtfo r in an antagonism of the skin and kidneys, o r the en

for ced elimination o f cutaneous excr ements thr ough the

kidneys, the facts ar e actual . Mor eover,dir ect exper imentsmade by Lassar unmistakably p r ove the causation of interstitial inflammation by sudden r efr iger ation .

Like excess ive co ld, heat may lead to nephr iti s and

death. Only once have I seen a newbor n sacr ificed inthat way thr ough his fir st bath. The midwife evidently hadanaesthesia o r analges ia. Bystander s noticed the steaming ofthe water in the bath tub, the suffer ing of the suffocatingbaby, his livid appear ance ; and the r ai s ing of lar ge blister s on the sur face told the story. The baby died withina day, having lost some blood mixed with meconium and

passed no ur ine . Even the bladder was empty at the

autopsy, and deeply congested. The kidneys wer e lividand succul ent ; blood oozed out of the cut sur faces . Bloodwas also extr avasated under the capsules . I f the case hadrun a longer cour se , in all pr obabi lity haamoglobinur ia,pr oduced by dis solution of blood-cor puscles

,would have

shown itsel f,as in the exper imental r esear ches of Po nfick

3 78

NEPHRITIS OF THE NEWBORN

and of Wer theim . Changes in the gene r al ci r culation neednot

,however

,be of thi s sudden and violent type, and sti ll

r esult in some injury.

Indeed, the albuminur ia of the newbor n i s fr equently

due to the insufficiency of cir culatio n , and passes o ff whenthe latter is fr eely established ; just as the venous obstruction caused by hear t o r lung disease r esults in tempor aryalbuminur ia in the adult. In a cer tain number of thesecases of almost congenital albuminur ia ther e i s no bloodunder the micr oscope, in other s ther e is, in other s ther e i smor e -vi z .

,nephr itis . I t i s pr obable that after most cases

of pr otr acted asphyx ia of the newbo r n albumin will befound in the ur ine, with o r without blood. Thus the kidneys r epeat but the p r oces s whi ch has been so much better studied in the br ain by Langdon Down2 and also byme .

3

Indeed,in thr ee cases of nephr itis

,two of which pr oved

fatal,obser ved within five weeks after bi r th, no aetiology

except that of pr evious long-continued asphyxia could beelicited. I t was in those two that gr anular and coar secasts wer e in the maj or ity; in the o n e which sur vived,ther e was still after weeks blood and a few epithelial andfinely gr anular casts .In co ngen ital hear t diseases with cyanosis, albuminur ia

is quite common . Agai n I war n against the facility ofover looking it . Time and again I am told ther e i s noalbumin in a specimen ; time and again ther e i s in suchcases a trace

,which i s called only a t r ace,

”but yi elds

fields full of differ ent casts in the centr i fugal specimen .

Thi s very trace is sometimes not discover ed unless the testtube be looked at thr ough water , and unless some littletime i s given fo r the coagulation to become visible . Ne

phr itis does not always wor k with heavy loads of albumin ;that the last stage of chr onic nephr iti s of any per iod ofli fe may be without albuminur ia fo r weeks in success ionneed not be r etold.

0

I once saw a baby of four months, who had spina biflda

2 Tr ansactio ns of the Obstetr ical So ciety, Lo ndo n , 18 76 .

3 Amer ican Jour na l o f Obstetr ics, wxiv, 1 891 , No . 6 .

3 79

DR . JACOBI ’S WORKS

and consecutive par alysi s and contr actur es of both lowerextr emiti es

, die with nephr itis . We seldom see our patientswith spina bifida when they br eathe the ir last ; fo r , until abr i ef time ago , most o f them wer e left to die without an

attempt at r elieving them,and a neighbor ing medical man

was called in at the last minute so that a cer tificate of deathmight be obtained. The same oppor tunity of obser vin g a

fatal case of nephr iti s in a little gir l of thr ee mo nths I hadabout the same time . The patient had . a par alysis of bothlower extr emities

,dating fr om bir th

,and occasioned,

p r obably, by an intr aspinal haemor rhage _ caused dur ingdifficult extr action in br eech pr esentation . Maybe I am

cor r ect when in both cases I attr ibute the r enal changes,

chr onic in char acter,to the fact that the cir culation being

impeded by the muscular inactivity of a lar ge par t of thebodywasmor e dir ected towar d the inter nal or gans . Maybe,however

,thi s suggestion does not appear acceptable

,

4 fo r

i t i s poss ible to assume that the same v iolence whi ch causeda spinal haemor rhage and par aplegia was sufficient topr oduce the same effect in the kidneys .In the newbor n we o bser ve not only the adver se r e

sults of the sudden changes fr om foetal to post-natal cir culation

, but also lesions depending upon the peculiar struc

tur e of the blo od-vessels. The newbor n is r emovedfr om the embryo and foetus by a s in gle station only. Itsti s sues ar e in par t still embryonic, and endowed with les ssolid structur e . This i s why haemor rhages ar e so veryfr equent in the newbor n . Meningeal haemor rhages ar e

most fr equent dur ing the fi r st week,and the slight co agu

lability of the blood of the newbor n adds to its danger s .In r egard to the br ain, I have consider ed this question

year s ago , and fr equently s ince, mostly in connection withasphyxia in the newbor n . A lar ge number of cases ofidiocy, epilepsy, par alys is, and insanity in the very youngar e due to meningeal haemor rhage of ear ly days often usher ed in by asphyxia. Similar occur r ences take place in

4 As above stated, no t even the r emo val o f a who le kidneyr esults in a neph r itis o f the o ther .

3 80

https://www.forgottenbooks.com/join

DR. JACOBI’S WORKS

be ass igned to the lower par t of the intestinal tr act . The

baby appear ed to r ecover a little fr om the sudden shock ofthe los s of blood, when, on the next day, slight tr aces ofblood appear ed in the ur ine . Par t of the blood cells wer etoler ably normal . Within another day the quantity ofur ine diminished gr eatly and assumed a smoky hue. The

micro scope still r evealed blood cell s,but also blood casts,

a very few epithelial and many mor e finely gr anular casts.

The baby di ed and the kidneys wer e r emoved. Both ofthem wer e markedly congested . On the wall s o f the pelviswer e super ficial haemor rhages ; sections r evealed a numberof r ather fr esh blood points . Ther e was no doubt in the

minds of all those p r esent that the nephr iti s in thi s casewas due to the ir r i tation set up by the local haemor rhages .Another case dates twenty-si x year s back . After a

pr otr acted labo r a boy was bor n in br eech pr esentation .

Ecchymose s over the abdomen pr oved the difficulty of

par tur ition and the summary pr ocedur es o f the midwife inchar ge . Almost the fir st ur ine voided by the infant wasbloody, and the diagnos is of tr aumatic ' r enal haemor rhageappear ed justified. Within a day the blood disappearedalmost enti r ely, and ur ine became suppr essed. The babydi ed on the four th day, and was subjected to a cor oner ’ sinquest . Ther e was a moderate amoun t of blood clot underthe per itoneal cover ing of the liver

,the liver was tor n to a

di stance of about thr ee centimetr es,the per i tonaeum slightly

tor n, and blood had escaped into the abdominal cav

ity. Both kidneys wer e lar ge, dar k, an d blood-stained onsection ; the two substances hardly differ ed fr om eachother .

These wer e extr eme cases, and their diagnosis was in a

shor t time followed by death. How many there may occurin which extr avasation i s but moder ate

,and the amoun t of

local o r perhaps unilater al nephr iti s i s not immediatelyfatal, perhaps even incl ined to get well, i s difficult to say.

Lar ge mater niti es, however , and foundl ing institutions ar e

better pr epar ed fo r obser ving such occur r ences than the

practi tioner engaged in p r ivate o r consulting work .

Fr equent causes of nephr iti s o f the newbor n ar e ur ic

acid infar ctio ns. They occur fr om the second to the

3 82

NEPHRITIS OF THE NEWBORN

twenty-thi rd day, but also befor e bir th.

5 They ar e of differ en t var i eties . In a par t o r in all of the str aight ur in ifer ous tubes there ar e found yellowish—r ed o r br ownish

,

spher ical o r angular bodies in such quantities as to formcons ider able deposits and

, when they ar e dischar ged during life

,to cause lar ge stains of mor e o r les s solidity in the

napkins . They ar e in r ar e cases accompanied with blood.

They consist of ur ic acid and of ammonium ur ate . The

latter i s r eadily soluble in aceti c acid,fr om whi ch ur ic acid

crystalliz es in rhombic shapes . In one case Ebstein met inthe tubuli contor ti with yellow globules consisting of ur i cacid and an o r ganic str oma whi ch contained no mucus , butcons isted of albuminoids whi ch were soluble in acetic acid

,

and exhibited either a concentr ic structure o r i r r egularlayer s . At once the question r ises in our minds as to thenatur e of thi s or ganic str oma. I t must str ike us that it canbe of either of two or igins . I t i s either depending on a

cause not connected with the pr esence of the ur ic-acid infar ctio n

,o r i t i s the direct consequence of a local ir r itation

caused by the depos it—viz .,secondary exudation . I n this

manner that form of infar ction would,by itself alone

,ex

bibit a mild degr ee of nephr itis .A second form of r enal infar ctions is of a hwmo r

rhagic and pigmento ns natur e . They look very much likethos e alr eady descr ibed, and ar e found in the same localities . They ar e gr anular

,spher ical

,o r i r r egular conglomer

5 Vir chow’s o r iginal opin io n, acco rding to which the presenceo f ur ic-acid in far ctio n r equir es a cer tain dur atio n o f li fe, hasbeen to a cer tain extent r escinded by the pr o o f fur nished by a

pr emature and stillbo r n foetus which co ntained ur ic acid in its

its ur ine and ur ate o f ammo n ium as sediment. Mo reo ver ,well-developed ur ic-acid infar ctio n s wer e observed by Mar tin

(Jenaische Ann,1 850 ) in a foetus bo r n in the unruptur ed mem

br anes after an unsuccessful attempt at r espir atio n . Ho ogeweg(Casper , Vier telj ., 1 855 ) met -with - them" '

in an in fant who sehear t ceased to beat thr ee quar ter s o f an hour befo r e delivery.

B ir ch-Hir schfeld has a simi lar case, and Ho fmann (Ger ichtl.Med., fifth cd., 1 891 , p. 748 ) published the cases o f two in fants,o ne o f whom lived but twenty-th r ee hour s, the o ther o nly fifteenminutes

,who exhibited ur ic-acid in far ctio ns in full development.

3 8 3

DR . JACOBI ’S WORKS

ates, which contain crystals of haemo to idin . They ar e the

r esults o f small extr avasations or i ginating in gener al hyperaemia o f the canaliculi

,and depend on var ious causes

,to

the pr incipal of whi ch I shall r etur n . The usual changesof hwmatin alter the color of these deposits

,which contain

no crystals o f ur i c acid o r ammonium ur ate, and ar e notaffected by acetic acid.

6

Calcar eous depo sits ar e also found in the newbor n .

They occur mainly in the lower end of the straight canalicul i

,near the papillae

,ar e of a whitish color

,and may,

ther efor e, be mistaken on inspection fo r inter stitial indur ations . They ar e mostly either carbonate o r phosphate ofcalcium

,but r ar ely tr iple phosphate, and ar e soluble in

dilute hydr ochlor i c acid. They ar e,under favor able cir

cumstan ces,deposited into and upon the epithelia.

Which ar e these favor able cir cumstances ? Both phos

phates and car bonates of calcium ar e known to be depositedfr om the blood whenever cir culation i s r etarded o r im

peded ; fo r instance, in the older baby in the latter stagesof epiphyseal rhachitis . I n the newbor n the cir culationi s r etarded o r impeded by congenital (o r r apidly acqui red)hear t disease, by gener al debility, o r by asphyxia. As ear lyas 1 8 8 3 Vir ch. Ar ch.) Litten counted among such favorable conditions a coagulation necr os is occasioned by the

inter ruption of cir culation . Thus these forms of r etarded

6 Crystals o f haemato idin (: bilirubin ) wer e found by Vir chowas ear ly as 1 84 7 (Verhandl. d. Ges. f. Gebur tsh. in B er lin , vo l. ii )in the ki dneys, the tissues, and the blo o d o f infants who died whilesuffer ing fr om icterus neo nato rum. Their main lo catio n is in

the r enal epithelium and in the ur in ifer ous tubes, but r ar elyin the ur ine. They ar e also found in the fibr inous co agula o f

the heat, in the par enchyma o f the l iver (O r th ) , and in theadipo se tissue o f the omentum (Neumann ) . Even in macer atedfcetuses they wer e met with by Neumann and Ruge. It appear s,ther efo r e, that at the time o f bir th, and so o n after , bilirubinexists in the blo od and tissues (with o r without jaundice ) in a

sufficient quantity to permit its getting fr ee in crystalline fo rmeven after death . The pr esence o f genuine ur ic-acid in far ctio nsis no t influenced by this phenomenon , and they and bilirubin mayo ccur simultaneously o r separ ately.

3 84

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

In r egard.

to the danger s attending the pre sence of ur icacid in the kidneys I have mor e to say on pr eventives thancuratives . When we deal with gr avel and stone in the

kidneys of adults our effor ts ar e dir ected to the solution ofthe depos its . Plenty of water , alkaline miner al water s

,

alkalies, mainly potass ic salts, l ithia, piper azine, an’

d lys idine ar e pr es sed into ser vi ce . In the newbor n

,in whom we

must,as in far ctio ns ar e the rule, except the pr esence of the

danger,we ar e in the habit of doing absolutely nothing,

though pr evention be within easy r each. Water i s,i f not

the panacea,at all events the indicated r emedy. But in no

per iod of l i fe i s water mor e withheld fr om the helples scr eatur e than in the fi r st few days . Mother ’ s milk is notfor thcoming unti l a few days have passed by, and then itappear s in small quantities only. Even the exper ience thatthe newbor n lose weight by being star ved i s char gedagainst P r ovidence, whi ch has willed i t so fr om times antedi luvial . I f water wer e given plenti ful and as methodicallyas syrup of figs o r castor oil, much harm could be avoided.

And her e permit me a few words pr o domo . In r egar d tofeeding the newbor n, I have pr actised these for ty year s,and taught thir ty-five

,not only that the very young infant

must be fed, but that its ar tificial food must be gr eatlydiluted. In those ear ly times I knew on ly that the babywould best bear gr eat dilutions

,and I mixed a par t of boiled

milk with four o r five par t s of water , o r r ather of a thi ncer eal decoction . The latter have at last been r ecognizedas cor r ect, even by Heubner , whose main labor s fo r

~

year s

have been spent on studying and discuss ing the questionof ar tificial in fant fo o d. But he sti ll s ets his face againstwhat he calls J acobi

’

s exor bitant dilutions .” In the light

of what I have had the honor of saying to-night, I pr ofessto have even in those r emote times taught better than Ikn ew . At those times I consider ed the question o f digestiononly when I r ecommended lar ge dilutions . I t i s only a

dozen year s ago , perhaps , that I began to consider the quest ion of hi gh di lution of the food of the newbor n fr om the

point of view of its beneficence in r enal in far ction and its

consequences . In 1 8 87 I spoke of its indi cation fo r the pur

3 86

NEPHRITIS OF THE NEWBORN

pose of di ssolving and eliminating ur i c-acid infar ctions inmy I ntestinal Diseases of I nfancy and Childho od. I can

assur e, as I said then, that s ince my advice of greatly diluting the food of the newbor n, and giving plenty of waterfr om the beginning

,has commenced to be minded

,I am

sadly depr ived of the many cases o f gr avel, dysur ia, shr ieking spells

,and consecutive nephr i tis which wer e so common

in former times .The connection of icterus of the newbor n with local

changes in the kidneys i s of vital inter est . In the adultthi s intimate dependency upon each other i s r ar e

,though

many gr os s anatomical changes ar e equally found in all

ages . To that class belong septic infection, syphi lis of theliver

,cir rhos i s of the liver of whatever or igin, obliter ations

of the bil iary ducts,thr ombos is o f the por tal vein, and

catar rh of the duodenum and choledochus duct .In the newbor n many un doubted cases of icterus ar e

due to the destruction of r ed blo od—cells in the fir st fewdays, and to the tr ans formation of haematin into haematoidin

( identical with bilirubin ) . Some of the latter comes fr omthe many ecchymoses and stagnations, both in the skin and

the subcutaneous ti ssue,due to the pr oces s of par tur it ion .

The destruction of blood—cell s in the newbor n i s a

normal occur r ence . According to Hayem and Helot theblood-cells of the newbor n ar e subj ect to r apid disinte

gratio n . Accor ding to H o fmeier the normal congr egationof the blood-cells i s absent ; they exhibit a gr eater r esistance to salving liquids ; the number of leucocytes is verychangeable

,and the s ize of the blood-cor puscles is very

var iable . Silbermann found many blood-cells pale, other s

of normal color in thei r per iphery only ; many o f var iouss izes—macr o and micr ocytes . He also met with nucleatedblo od-cells in the liver

,the Spleen

,and the bone mar r ow ;

with cells of the l iver,sometimes also of the spleen, and of

the bone mar r ow containing blood ; with r ed bodi es of theclub and biscuit form

,evidently changed blood

-ce lls ; andfinally an incr ease of leucocytes . All of these obser vati onsappear to p r ove the destructibi lity of the blood of the new

bor n,which is only equaled, o r pe rhaps even sur passed,

3 8 7

DR . JACOBI ’S WORKS

by the effect of chr onic poi soning, in par t obser ved fo r

exper imental pur poses .7

By many the j aundice of the newbor n i s'

attr ibutedto absor ption of bile into the blood dir ectly fr om the biliary ducts into the small vessels of hepatic ci r culation .

By other s a congenital nar r owness of the choledochus ducto r an accumulation of mucus in the bil iary ducts, o r (Edemaof the per ipor tal connective tissue, o r venous obstruction inthe liver andf consecutive compr ession of bil iary ductswer e claimed as the causes of j aundice . Quin cke explained i t by the patency of the ductus venosus Ar antii ,and by absor ption of bil e fr om the meconium of the intestines .Meconium is r i ch in bili rubin . The latter i s stor ed in

it dur ing and after'

the third month of intr a-uter ine li fe .Biliver din accompanies i t to such a lar ge amount thatSimon (Ar ch. f. Gync

’

ik., 1 8 75 ) met with four per cent .of it .This bil irubin and bil iverdin ar e very liable to be ab

sor bed thr ough the open ductus venosus Ar antii,which r e

mains patent in seventy-seven per cent . of all the newbor n until after the fi r st week of thei r l ives . I ts cir culation is fr ee

,i ts blood liquid, and ther e i s a dir ect communi

cation fr om the intestinal ci r culation with that of the venacava.

8

7 To luylendiamine, acco rding to Afanassiew and Stadelman,exhibits the fo l lowing r esults: Disso lutio n o f r ed blo o d—co rpusclesand co nsecutive haemoglobinur ia ; incr ease o f the co lo r ing mattero f the bile ; anaemia ; moder ate fatty degener atio n o f the largeglands ; acute par enchymatous nephr itis ; destruction o f r enalepithelia. At the same time the epithelia o f the spleen and

l iver are ser iously damaged either directly by the (exper imental)po iso n o r by the circulatio n o f an alter ed blo o d. The ur ine co ntains copious co nglomer ate crystals, which pr obably ar e no t

o rganic, but co nsist o f calcium sulphate.8 Some commun icatio n o f the same kind, with the same effect,

is br ought about between the haemo r rho idal plexus o f the r ectum(thr ough the hzemo r rho idal vein ) and the vena cava, thus cir

cumventing the liver . Still, i t must be r emember ed that lessabso rption takes place in the r ectum than in the r est o f the

3 8 8

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

they will cause albuminur ia,which is often found in i ll

nour i shed i cter i c babies . When ther e is enough to causethr omboses, which ar e qui te common in the capi llar ies ofthe por tal system,

and obstruction of cir culation, theygive r i s e to haemor rhages o r to inflammation . As far as

the kidneys ar e concer ned,ther e is a pecul iar anatomical

r eason why nephr i tis i s very liable to appear in the veryyoung.

The post-fmtal gr owth of blood-ves sels and ti ssuesvar ies consider ably. I t i s least in the common car otid,lar gest in the r enal and femor al ar ter ies . The r enal ar teryand the kidneys, however , do not develop pr opor tionately;the tr ansver se section of the former increases out of pr opor tion to the volume and weight of the latter . Thus its eems that this disp r opor tion between the s ize

,of the

ar tery and the condition of the r enal tissue establi shes a

pr edi sposition to congestive and inflammatory conditions ofthe or gan . Mor eover

,the r esistance in the capillary net of

the young kidney is unusually gr eat . Exper iments pr ovethat the permeability of the capillar i es i s gr eater , and thatwithin a given time a pr opor tionately lar ger amount ofwater can be squee zed thr ough them in the adult than inthe young. This anatomical differ ence seems

,ther efor e

,to

be an additional r eason why r enal ‘ diseases ar e so muchmore fr equent in infancy and childhood

,fr om all causes,

with the only exception of that which i s r eser ved fo r thevery last decades of natur al li fe -vi z .

,ather omatous de

gener ation .

9

In conclus ion, Mr . P r esident,permit me to r ecapitulate

in a few wor ds the main points of this paperNephr iti s i s a fr equent di sease o f infancy and chi ld

hood and by no means very r ar e in the newbor n . Whatwas former ly consider ed mer e albuminur ia

, o r a tr ans ientform of it

,we have been taught by impr oved methods of

investigation,mainly by the use of the centr i fuge, to r ecog

nize as nephr itis . A pr edi spos ition to nephr iti s in the

young i s caused by the fr agili ty of the blood-ves sels in the

9 Hear t and B lo od—vessels in the Young. By A. Jacobi, M. D.,

Br o oklyn Med. Jour .,Mar ch, 1 8 88 .

3 90

NEPHRITIS OF THE NEWBORN

newbor n ; by the r elative imper viousness of the youngr enal capillar ies compar ed with the lar ge size of the r enalar ter ies ; by the feebleness o f the young intestinal muscle,which pr oves insufficient to expel toxic contents ; by the

extensivenes s and si ze of the young intestinal blood-vesselsand lymphatics and the lar ge size of the vi lli, all of whi chfavor the absor ption of toxines .F r om an aetiological point of Vi ew

,nephr iti s in the new

bor n may be :1 . Co ngestive (fr om feeble ci r culation, congenital hear t

di s ease,asphyxia, o r exposur e to low temper atur es) .

2 . Obstructive ( fr om the phys iological r apid decompo

sitio n of the blood of the newbo r n ; the formation ofhazmato idia ilirubin ; j aundice ; the pr oduction of m-etheamoglobin by chemical poisons, such as potas s ic chlor ate

,o r

by excess ive heat ; o r the pr esence of blood in the ur in ifer ous tubes) .

3 . I r r i tative ( fr om the p r esence of ur ic-acid infar ctionso r haematoidin in far ctions

, o r pur pur i c o r other inter stitialhaemor rhages

, o r of 'micr obes and toxines in the numer ouseruptive and infectious maladies and in enter iti s) .

3 91

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

r equi r ed when you mean to instruct a child,and thr ough

the child,i ts family. You have o r will have to deal with

the young at a time when his mind i s most r eceptive and

his tongue most commun icative . That i s why a number ofplain rules ar e r eadily grasped and under stood by a child

,

and the child taught by youmay pr ove a teacher at homefo r his father and mother , who have not the time to r ead,though some of them may have mor e liter ary mater ial thanmer e s ensational newspaper gossip . In this way the kn owledge of the natur e and the pr evention of tuber culos is maybecome di s s eminated

,and the di sposition to the dr ead

scour ge may be r ecognized and gr adually extinguished.

Every educated per son, cer tain ly every one of you, knowsper fectly well that tuber culos i s i s the di r ect r esult o f thepr esence in lar ge number s of a minute micr obe

,the bacillus

of tuber culosi s,o r its toxin (o r vi rus ) in the body of the

pati ent . I ts influence need not be immediate . I t may bebur i ed away in some par t of the or ganism fo r a long timewaiting fo r its chance . That chance will come when someother disease

,par ti cular ly one of an inflammatory char acter ,

br eaks out,o r when such micr obes as ar e the caus e of o r

connected with suppur ation,in small o r lar ge abscesses

,

combine thei r for ces with those of the baci llus . In sucha cas e the outbr eak is apt to be a very sudden one and

we have an instance o f so -called acute tuber culos i s o r r apid,o r flor id

, o r hasty consumption .

Of the location and the fr equency of tuber culos i s in thevery youn g I spoke a year ago at another place . In theinfant and the very young chi ld, wher e youper sonally havefew oppor tunities of close obser vation, tuber culos i s may befound as a chr onic di sease, in the end of a bone

,o r in a

gland ; also in the pleur a and per i toneum ; in its acute statemostly in the br ain and a number of other or gans wher e iti s almost invar iably fatal . In your pr ofes sion youhave todeal wi th childr en after the s ixth o r s eventh year s and withadolescents

,in whom tuber culosi s is very apt to follow the

same cour se and exhibit the same symptoms which ar e met

in the adult . Her e you find i t mostly in the lungs . In nota few cases tuber culos is may be eas ily r ecogni zed, o r at

least suspected. When you have to deal wi th a chi ld that

3 94,

PREVENTION OF TUBERCULOSIS

is unusually pale, o r of low weight,eas ily exhausted, with

glandular swell ing about the neck and nar r ow chest,tuber

culo sis should be suspected and pr oper car e should be taken,fo r it should never be for gotten that tuber culosi s may healo r be made to heal .As a modification, o r as suspicious or incipient symptoms ,

youwill not infr equently notice the symptoms of what hasbeen called scr ofula. Scr ofula i s obser ved in two forms .Ther e ar e a number of chi ldr en

,usually brunettes, with dark

hair,flor id cheeks

,br ill iant eyes, low weight, quite fr e

quently with good mental capacity, who di splay di seases ofthe mucous membr anes ; their eyes ar e fr equently sor e, someof the glands of the neck

,perhaps many, ar e consider ably

swollen . The other form of scr ofula is a mor e sluggisho r tor pid one . The childr en ar e r ather heavy, flabby, mostlypale

,with lar ge and r ather hanging cheeks

,and big l ips ,

and ther e i s swelling of the nose and consider able tumefaction of glands about the neck, with not infr equentlysor e eyes , ear s, and skin . Thi s i s the usual form,

and the

o ne which i s apt to lead into tuber culos is dur ing schoolage. That i s why I wish to dir ect your special attentionto thi s form of disease . Of gr eat impor tance in connectionwith it i s the p r esence of those glandular swellings r oundthe neck, and i t i s to thi s that I ask your attention fo r a

few minutes .Youkn ow that the cir culation in the animal body i s two

fold—fi r st,that of the blood ; second, that of the lymph.

The lymph is di sseminated thr ough the body in every or gan ,

but par ticular ly in and below the mucous membr anes . The

absor ption of chyle as fur nished by digestion takes placefr om mi llions of small glandular bo di es

,many of them of

micr oscopic s ize only. They ar e dis seminated over the intestimal mucous membr anes

,whose contents they absorb and

car ry o ff into lar ger vessels,and fr om them into lymph

bodi es o r so -called glands of -the' mesentery, in the im

mediate neighborhood o f the intestines . They ar e verynumer ous all over . Fr om them the cur r ent goes on intostill lar ger vessels until finally they terminate in a lar geduct, the thor acic duct, which dischar ges its contents intothe cir culation o f the blood. That cir culation in the lymph

3 95

DR . JACOB I ’S WORKS

i s very extens ive and copious . It has been foun d that anar ti ficial opening made into the thor acic duct o f . a youngdog fur nished lymph to the amoun t o f between one- sixthand one-tenth of the weight of that dog within one day,while an adult dog fur nished lymph amoun ting to onlyone-tenth to one-s ixteenth of the body weight . In the sameway the lymph appar atus in a young child up to advancedchildhood and adolescence is very much mor e active than itis in the adult.That i s why the condi tion of the lymph glands in the

youn g is of such impor tance . Whenever ther e i s any in

fectio n of the mucous membr ane, the infecting poison i scar r i ed o ff to the next gland wher e ther e is a stoppingplace . That gland will become the seat of i r r itation o r

swelling . That i s why —to give you an example—whenever ther e is only a sli ght diar rhcca, no matter fr om whatcause

,over -eating

,impr oper food, medicines, typhoid, colds—never fr om dentition

,fo r ther e i s no such thing as diar

rhcea fr om teething in a healthy chi ld—the lymph bodi esin the neighborhoo d will swell . Unles s such a diar rhoeai s soon stopped the ir r i tation will continue, congestion , inflammation

,and swelling of the glands will ensue, and the

structur e of these neighbor ing glands will be changed.

When such an inflammation of the gland has lasted a longtime and new ti ssue has been formed in it, i t may o r willr emain unchanged and unalter able, no matter what youmaydo fo r i t.The same takes place about the lungs . Whenever a baby

o r adult has catar rh with some cough and mucous expecto ration

,the neighbor ing glands in the chest—br onchial o r

mediastinal—will swell,and unless such catar rh is br oken

up the swelling may go on until the glands ar e hardenedo r under go other changes , Sometimes they will form ab

scesses and br eak up. Whenever ther e is in a chi ld o r inan adul t

,par ticular ly i n the young of the age with whi ch

youhave to deal, a catar rh of the nasal mucous membr ane,the glands about the neck will immediately swell . Thisswelling will pass o ff when the nasal catar rh passes o ff .

When it lasts long,when it becomes a chr onic catar rh

,the

swelling of the glands r emains ; they become hardened, they396

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

The in fection of the glands of the neck does not dependon a morbid condi tion of the mucous membr ane of the 'nosealone ; the vast ar ea of the mucous membr ane extendingdown to the pharynx and upwar d to the nose may be af

fected. Ther e i s no mucous sur face that i s cover ed and

penetr ated with small lymph bodi es to such an extent as

that of these or gans . The lymph bodies in the hind par to f the nose form

,when they gr ow,

what has been cal ledadenoids . They sometimes r each such a si z e as to obstructnasal r espi r ation

,compel the patient to have the mouth

open to br eathe,and cause him to hear and to sleep with

open mouth,incr eas ing the danger of infection on account

of the wide access given to micr obes floating in the air .

In that condit ion the night i s the most danger ous time .Adenoids and the whole mucous membr ane have fr equentlybeen found to be cover ed with tuber cular bacilli

,mor e so

than perhaps the tonsils .When the bacilli ar e absorbed, their next lodging-place

i s,as I said

,the neighbor ing glands . These glands about

the neck form thr ee tier s all the way down to the clavicle .F r om ther e the lymph cur r ent goes downward into the

chest and into the axilla ; thus the lymph bodies o r so -calledglands swell in the axilla and in the chest. These lymphbodi es in the chest ar e in di r ect contact with the mucousmembr ane of the lar ge wind—pipes, and i n that way withthe smaller wind-pipes and with the lungs . That i s quitefr equently the way in which bacilli and other v irus enterthe lungs. I t i s often the pr oces s in the adult and in theadolescent and in the gr owing chi ld.

When you under stand that, you see how impor tant it i sthat the mucous membr ane of the nose and of the mouthshould be taken car e of in the very young and in the gr owing chi ld“ A gr eat many cases of tuber culos is, diphther ia,and other contagious and infectious diseases could be pr evented if ther e wer e no di seased mucous membr ane gr eedyafter infecting mater ial . That i s why i t should be a rulein every family wher e ther e i s the slightest tendency to

nasal and thr oat catar rh to i r r igate the nose and the thr oatat least o nce a day, better twice a day, with warm water inwhich a very small dose of common table salt is .dissolved.

‘ 3 98

PREVENTION OF TUBERCULOSIS

Thi s so -called saline solution contains fr om six to sevenpar ts of salt to one thousand of water . A good p r opor tionfo r practical pur poses is hal f a teaspoonful of table saltto a good tumbler ful of warm water . Par t of thi s shouldbe fil led into a common nasal cup, the head should bethr own back, and small quantiti es should be allowed torun down the nose into the thr oat. I f it be swallowedther e is no harm, but childr en will lear n very r apidly howto br ing up the salt water . In thi s way the mucous membr anes ar e kept intact

,and nobody can tell how many

diseases ar e kept away by thi s very simple method. Ican pr ove that i t does have that effect

,fo r you will in

var iably notice that whenever you have a catar rh of thenose

,o r even when you see a very sever e case of diphther ia

of the nose (one of the most danger ous forms of thatdi sease) , the lar ge swell ings of the neck will be r educedin a very shor t time by doing nothing whatever except following the rules just laid down . No medicine

,no iodine

,

no mer cury is r equir ed,simply the washing out—in an

acute di sease like diphther ia very o ften—every one o r

two hour s . In common nasal catar rh,twice a day i s suffi

cient to r educe fr om day to day, o r even fr om hour tohour , the s iz e of the glands, un less it have lasted weekso r months . Sometimes

,even when i t has lasted weeks, and

not infr equently when it has lasted months, the cor r ecti r r igation of the nose twice o r thr ee times a day will gr adually, within a few weeks o r a month, not only r educe, butr emove

,the swell ing that had been annoying fo r many

months o r even a year . In thi s connection I may say thatnothing but i r r igations should be used under or dinary cir

cumstances,and no inj ections . No syr inges should be used

unless order ed by the phys ician in very bad cases o f diphther ia

,wher e it i s impor tant to r emove a gr eat many of

the accumulated membr anes in as shor t a time as possible.I will add

,too

,as a pr actical rule, -that spr ays, which ar e

so fr equently used, ar e not so effective either in disease .o r

in compar ative health. The washing out of the nose can

be better accompli shed by ir r i gations than by mer ely spr aymg.

What I have thus far said would settle in your mind the

3 99

DR . JACOBI ’S WORKS

question whether scr ofula and tuber culosi s ar e identical .They ar e not identical

,but they may become so . Imagine

the or iginal catar rh of the nose and thr oat, br ought on byexposur e

,a dr enching r ain

,cold feet

,dr afts in a tr olley

car,exposur e of the per spir ing skin, met with bacill i which

had been innocent tenants on the mucous membr ane ; thenthese tenants of the sur face would enter thr ough the opendoor

,and a r eal infection would take place . In that case,

not otherwise,the scr ofula o r the alleged scr ofula of the

glands would tur n out to be tuber culosi s . Thus wher everther e ar e swelled glands

,wher ever ther e i s “ scr ofula

,

”

there i s not necessar i ly at the same time tuber culos is,but

ther e i s danger of tuber cular invasion . Scr ofula,when

fully developed in a child, as obser ved by you, will show a

number of symptoms that ar e not found,as a rule, in

tuber culosi s . You have Sor e eyes , sor e ear s, swollen lips,and nose ; youhave the glands, you have the eczema of theskin ; i f all that wer e always tuber culos i s ther e would beno poss ibili ty of r ecovery. The scr ofulous disposition i swidespr ead ; i t ext ends over the skin, over the mucous membr ane

,and may show itself even in the bones ; i t i s char

acter ized by the fact that whenever ther e i s such an“

infectio n

,whenever ther e i s scr ofulous i r r i tation at least it

i s n o t apt to heal. Scr ofulous inflammation and ulcer ationar e very obstinate . I f all that wer e tuber culosi s the patientwould be doomed ; but tuber culos i s invades the body pr i

mar ily i n a cer tain limited locality. I t may r emain in thatlocal ity; it may r emain in the end of a bone

,i n a number

of glands,in a smal l par t of the lung, and ther e may heal

up. In the beginning, ther efor e, scr ofula i s a widespr ead

gener al‘

di sor der and in the beginning tuber culosi s i s a

lo cal di sease . That i s why on the autopsy table we fr equently find tuber culosi s in a body wher e i t was not sus

pected at all, We find deposits,small o r lar ge nodules

,

part icular ly in the upper par t o f the lung, usually the r ightlung

,that ar e cases either o f dormant o r of r ecover ed tuber

culo sis. No such thing i s foun d in scr ofula. When scr o f

ula heals,the whole body is changed fo r the better . When

tuber culosi s heals,i t i s found that i t was a local disease .

The invasion of tuber culosi s into the human body maytake place by inhalation o f the bacill i, o r by feeding, with

4 00

https://www.forgottenbooks.com/join

DR. JACOBI ’S WORKS

often affected than the mucous membr anes of the intestines .The pr incipal mode of entr ance of tuber culos is i s that ofinhalati on, which may be twofold : either that of the drybacill i contained in the dust of the str eet, o r of a r oomo r public place ; o r of the moist par ticles of expector ationwhi ch ar e thr own about in a coughing spell and float inthe ai r of a ro om hour s befor e they ar e deposited on thefloor . As far as the dry bacill i ar e concer ned, it may taketime and some for ce to r emove them. A moder ate air cur

r ent is not sufficient fo r that pur pose . Wher ever they ar e

deposited they ar e waiting fo r thei r chance . Dusting,sweeping of the dry mater ial, will fill the air with baci lli .Chi ldr en ’s r espir atory or gans, being near er the floor thanthose o f the adults

,ar e most exposed. That i s why the

per centage of tuber cular school childr en gr ows in dispr o

po r tio nate r apidity with every year of thei r lives .Now, i t may be wor th your while to consider the final

location of the inhaled baci lli ; do they r each the finestr amifications of the br onchial tubes and the air cells ? It isnot p r obable

,fo r in the advanced chi ld and the adult the .

pr imary location of tuber culos i s i s not at all, o r very r ar ely,in these distant par ts . I t i s much mor e probable thatdur ing inhalation the danger ous inhalation is deposited i nthe poster ior par t o f the nose and in the thr oat. Ther ear e those

,however

,who attr ibute to the tonsils the pr in

cipal, aye, even. the only r ole in the invasion of tuber clebacilli . A late author goes so far as to build his planof pr eventing o r combating tuber culosi s on the total exci s ionof the tonsils . That i s an exagger ation . He claims theoper ation must be made according to a cer tain method,and

, unfor tunately, he suggests that ther e ar e but few except himself who can per form it so as to be effective .Mor eover

,it i s not true that the tons il absorbs as r eadily

as the other thousand of lymph folli cles of the nose and

thr oat . In my s tudies on diphther ia, befor e and in 1 8 74

and in 1 8 8 0 , I found that when the tonsil alone was af

fected,the case was a mild one, and not accompanied by

much swelling of the neighbor ing glands ; that these latterswelled pr incipally when the diphther itic membr ane r eachedbeyond the tonsil ; and that when the mucous membr ane o f

4 0 2

PREVENTION OF TUBERCULOSIS

the n ose was the seat of the diphther itic membr ane,the

case was so gr ave that befor e those times and befor e thesuggestion of local tr eatment, every case of nasal diphther ia was pr onounced fatal by a gr eat Fr ench author ity ofthat per iod

,Roger . I showed that the r eason fo r the

r elative innocuousness of the tonsil i s anatomical . Thoughits structur e i s s imilar to that o f the smaller lymph follicles dis seminated in the neighborhood, it i s sur r ounded bya fi rm fibr ous membr ane whi ch, to a cer tain extent

,shi elds

the system against a r apid absor ption of poi sonous sub

stances which have enter ed the tonsils .Other modes of entr ance of bacill i into the system ar e

the following : The finger nail s of babies,like those of

the adults, ar e unclean . Though they do not exhibit theunappeti z ing spectacle of a mour ning r ing

,they ar e al

ways unclean and har bor micr obes,both uninjur ious and

injur ious . A few year s-

ago ther e was a r epor t of a NewYor k mother whose check was slightly scr atched by her

playful baby. The baby had erys ipelas micr obes under'

itsnai ls

,and the mother died of erysipelas . Thir ty year s ago

I lost a warm fr i end,a

‘ gr eat phys ician, who ,'

while inquiet thought

,scr atched a small pimple on his cheek . H is

erysipelas or iginated in that very spot . Two Germanauthor s (Pr eisn itz and Schutz ) published in 190 2 theirobser vations on the finger nail s of childr en o f fr om sixmonths to two year s of age. They p r oved that four teenout of sixty-s ix had tuber cle baci lli under their finger nai ls .No fixed star i s mor e immovable than the fact that everyone of thes e young ones had thei r danger ous pr etty finger sin thei r noses and mouths . Now

,tuber culosi s will r ar ely

make its appear ance suddenly. Year s may pas s befor e theinvalid lymph glands o f the thr oat and neck give uptheir captive micr obes and allow them to tr avel downwards .That i s the time when your pupils develop their tuber culo sis

,no matter whether they _ impo r ted it fr om the flying

dust of the str eet o r the dry sweeping of the r ooms,fr om their own nails

,fr om the crumbs they picked up, o r

fr om their intimate comr ades,the toys .

Now,ladi es and gentlemen, I have r epeatedly spoken of

the fact that micr obes, no matter in what number s, mav

4 0 3

DR . JACOBI ’S WORKS

invade the nose and thr oat and ar e devoid of danger as

long as the mucous membr ane cover ed by them i s healthy,but that they pr ove, o r may pr ove, danger ous when a

catar rh destr oys the fine film of epithelia whi ch pr otectsthe sur face . That i s why a cold i s always enumer atedamongst the causes of tuber culosi s

,of diphther ia

,of rheu

matism,even of erys ipelas o r of scar latina. As practical

people and bent upon car ing fo r your selves and other s,

you will ask me fo r the methods of keeping the mucousmembr anes in a sound condition, and thus p r eventing disease . That can be done by attending to the gener al health

,

and mainly by the har dening pr ocess .Much has been said about harden ing. What does i t

mean ? Nothing but this:° that the r es istance of the childto the effect of exter nal influences should be str engthened.

I s ther e a uni form metho d applicable to every child, nomatter o f what age o r constituti on ? Cer tainly not . But

ther e i s one obj ect which should be accomplished i n everyinfant and chi ld

,vi z .

,the invigoration of exter nal c ir en

lation . The sur face of a child fr om two to ten year smeasur esfr om thr ee to ten squar e feet . In and under thatsur face ther e i s a lake of blood. In vigor ous health thisblood i s in constant and r apid ci r culation ; within

'

two minutes it enters and l eaves the sur face

,comes fr om and leaves

the center of cir culation—the hear t . Slow cir culation inthe sur face r etards the flow of blood i n the whole body,and impai r s the nutr it ion of the hear t and every or gan ,caus ing congestion and insufficient function

,and dis eas e .

Rapid cir culation in and under the skin,causing r apid

cir culation everywhe r e, pr opels the totali ty of the bloodin the child

’ s body (fr om two to six pounds accordingto age

—fr om two to twelve year s ) into and thr ough the

lungs,in which the contact with and the absorption of the

oxygen of the atmospher e take place . Now,the best stim

ulant of the cir culation in gener al i s,besides muscular

exer tion (exer ci se ) , the stimulation of the skin by coldwater and fr i ction . A child of two o r thr ee year s shouldhave a daily cold wash, either after a warm bath

,o r

standing in warm water whi ch cover s the feet, o r lyingon the attendant

’ s lap, o r on a mattr ess . A br i sk rubbing

4 0 4

https://www.forgottenbooks.com/join

DR. JACOBI ’S WORKS

r ecesses, and obj ected to over cr owding of the cur r iculum,

and to the vanity o f incompetent schoolmaster s and mis~

tr es ses, who uti li ze the poor v ictims in behal f of exhibitions .Mostly in vain thus far . In r egard to the exhibitions

,and

the examinations pr eceding them,I am sur e Dr . Weir

Mitchell has struck a keynote . Only last week in a publiclectur e deliver ed in Philadelphia, he expr essed himsel fstr ongly in r egard to the influences exer ted by the wor ryand fear and over—exer tion connected with school examinations . I t i s true enough. that wi thout some sor t of exami

nations the standing o f the pupils in lar ge schools i s hardto determine

,but

,on the other hand

,whoeve r has seen

much of childr en o r young people about the time of examinations must be fully satisfied that some modification o r

other must be di scover ed.

Now,as to school hour s . A chi ld of seven o r nine year s

should not have mor e than two o r thr ee hour s daily inschool

,one of which should be spar ed fo r an intermediate

r ecess . Fr om nine to twelve year s the school hour s shouldbe thr ee o r four ; after that age, not mor e than five hour s,with fr equent and ample r ecesses . The best exer cis e dur ingr eces ses i s play in the open ai r . Compulsory gymnasticsin badly ventilated localities cannot take its place successfully and may add to exhausti on and i ll-health. I t i s an

un fo runate fact that, when the claims of physical development wer e ur ged upon school author i ti es, gymnastics wer eadded to the over cr owded cur r iculum as a matter of busines s inter est o r of conviction

,not always will ingly o r

intelligently.

The summer vacations of school childr en ought to befour weeks longer than they ar e. The publi c schools oughtto be closed about the middle of June and r eopened inOctober . Many year s ago the Har lem Medi cal Association and the Medical Society of the County of New Yor kr equested the Board of Education of the city to open the

public schools on the thir d in place of the first Monday inSeptember . The soundness of the pr inciple was appr eci

ated and the necess ity fo r such a change was acknowledgedby the author ities

,and the seco nd Monday of September

was selected fo r the beginning of the school s eason, so as

4 06

PREVENTION OF TUBERCULOSIS

to afford the chi ldr en an extr a week’ s br oili ng in the city’

ssun and an oppor tunity to lose, as they did former ly, thebenefit der ived fr om the summer vacation . The sanitaryr eason of thi s los s of a ben eficen t oppor tunity was said tobe the anachr onistic convi ction of an eighteenth-centuryschoo l super intendent, who said he p r efer r ed the influenceof the schoolr oom to that of the New Yor k str eets fo r theNew Yor k boy.

Teacher s ar e pr incipally concer ned with questions connected with the condition of the school bui ldings . Theyshould be ample and sunny and not moist ; they should beexposed to fr esh air , have ample . light and sufficientlylar ge r ooms . All that appear s to be under stood, but in thi svery New Yor k we know that not everything is donethat could o r should be done in r egard to all these postulates. Ther e should be ample light

,not only fo r the pur

pose o f being enabled to see the dust wher e it accumulatesand the mud

,but light i s a r emedy in itself . It i s true

that only in the last very few year s has i t been uti liz edfo r the dir ect cur e of gener al and par ticular ly of localdiseases

, but i t was known pr ev iously that disease—givingmi cr obes that live a long time in dar k places will bespeedily destr oyed under the influence of light .Air space should be ample . I t i s diflicult to say exactly

how many cubic feet ar e the pr oper supply. The amounto f cubic feet in a school r oom

,which i s occupied a number

of hour s only, need not be what it i s in a living-r oom, in a

bedr oom o r in a hospital . In the latter mor e than 1 0 0 0

cubic feet fo r a per son i s the l east that should be demanded. We all know that ther e ar e few per sons . com

par atively speaking,in New York

,with its immense

tenement—house po pulation,that have as much air supply

as that, but we all know how thei r health suffer s fr om thatr eason . A schoolr oom that is occupied only a shor t t imemay perhaps fur nish about 20 0 cubic feet fo r a child. Ar oom of 3 0 by 2 5 feet an fi Q

‘

feEt'

high, containing 90 0 0cubic feet o f air

,should not harbor mor e than 50 chi ldr en .

At best that would give 1 8 0 cubic feet fo r each child. I '

have known of a schoolr oom,indeed, of many school

r ooms,that wer e meant fo r 60 childr en and contained fo r

4 0 7

DR . JACOBI ’S WORKS

a long time an exces s of 1 3 0 . I t i s natural that a gooddeal o f s ickness must be the r esult among teacher s and

pupils .Everybody i s theor etically convinced that the blood can

not be fully a'

er ated,and that the health must suffer , um

less the ai r we inhale i s pur e . The young or ganism suf

fer s in this r espect mor e than the o ld,fo r i t r equir es mor e

oxygen , compar atively. Unless a suflicien t supply of oxygeni s kept up and the per centage of car bonic acid containedin the air i s below seven-tenths of one per cent . good healthis imposs ible . The deter ior ations you have to fight in theai r of your schoolr oom ar e as follows : I t i s too dry underthe influence of our heating appar atus . Fur naces and mostother heater s fur nish a dry air which impair s the sur faceof the mucous membr anes in the nose, the thr oat, and the

lungs . Ther e i s no mor e vor acious oxygen eater than the

gas stove . Carbo n ox id i s the r esult of imper fect combustion

,and a very fr equent deadly poi son . So ar e the

chlor ine gas and the nitr i c and sulphur ic acid contained inour coal supply. They ar e liable to change former healthr esor ts, on accoun t of the incr ease of factory chimneys ,into questionable o r danger ous localities . Add to thi sand you cannot exclude them- the dust of the houses and

str eets with all i t contains,par ticles of stones

,metals

,

vegetable r emnants,and micr obes

,and

,fur ther , the poi s

o n ous exhalations of the skin and intestines such as sul

phides, and you will no longer wonder why ther e ar e somany cases o f catar rh, br onchiti s, penumon ia, infectiousfever

,and tuber culosi s .

The heating should be cons ider ed one of the most im

por tant factor s of health o r dis ease. The fir st r equir emento f a good heating appar atus i s to give no dust and not tor ender the air mor e dry than it natur ally i s . Our wind inNew York is mostly west wind, that deposits all the moistur e befor e it r eaches us. That i s why, as a rule, our ai r

i s very dry ; that i s why our buildings dry out so r apidlythat theymay be inhabited as soon as finished

,and our linen

,

exposed to the air,dr ies in a few hour s ; and that i s why

our heat ing apparatus should supply us with a cer tainamount of vapor . Our fur naces fur nish a dry heat ; so

4 0 8

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

ence . Faith belongs to the r ealm of r eligion,not of science

—o f the other,n o t of thi s wor ld. Now

,the pr ofessions of

doctor and teacher ar e least apt to be caught by glitter ingimpr obabiliti es o r impossibilities. We teach the r eali tiesof both the phys ical and the intellectual wor ld. That i swhy it has given me intense pleasur e to speak befor e

you, though well awar e that in a br i ef time I could pr esent to you but

‘ little that i s for eign to you, o r too li ttleof what you had a r ight to expect . In what I have saidther e may be, however , a few p r actical points of value .In your pr ofess ional work, and in your social contact withthe little and the big ones, you will have ample oppo r

tun ity, I hope, to put them into effect.

4 1 0

CAUSE S OF E PILEP SY IN THE YOUNG

TH E two ser ies o f the Index Catalog of the Sur geonGener al

’ s l ibr ary contain 1 2 5 columns filled in close pr intwith the titles of bo oks, pamphl ets and magaz ine ar ticleson epilepsy. In the pr esence of such a moun ta in oferudition

,I felt I could do no better than to r efer the

anxious litterateur to thos e wonder ful volumes, the pr ideand honor of Amer i can medicine, and confine the few minutes at my disposal to the elabor ation, in as few and as

plain words as poss ible, of some per sonal exper iences , beliefs

, and cr itici sms connected with the causes of epilepsyin the young. I take it that meet in gs l ike these should add

to the lear ning collected in libr ar ies the inspir ation of personal inter cour se .The pr edispo sitio n to epilepsy may he inher ited

,o r

acquir ed dur in g intr auter ine, o r dur ing extr auter ine li fe .Intoxications of the par ents by mor phin, lead,

'

o r alcohol,

their in fection with syphili s o r tuber culos is, their co n stitu

tio nal anemia,gout

,o r diabetes, o r a local degener ation

of either testes o r ovar i es may not caus e in the offspr ingthe identical di sease o r anomaly, but only a gener al debility of the tis sues o r their inner vation . A var i ety of causesmay have the same r esult, and a var iety of r esults may follow an identical cause . Quite often the unexpected i sthe rule, and a gener al neur opathy i s mor e fr equently oh

ser ved than a dir ect inher itance . Still, epilepsy appear sto be mor e dir ectly inher i ted than any other cer ebr al disorder . In Echever r ia

’

s 5 3 3 cases, showed a di r ectinher itance fr om an epileptic par ent ; Gower s has a per

centage of 3 5 ; according- to—Spr at lin g, 66% of the epileptic

childr en have epilepti c par ents . Whether , and to whatextent

,matr imo ny between r elat ives contr ibutes to men

tal disease o r degener ation i s by no means p r oved. Fr omtheor etical r easoning, fr om per sonal exper ience, and fr om

4 1 1

DR . JACOBI ’S WORKS

the incompetence of statistics, which ar e amenable to a

contr adictory var i ety of conclusions when handled by differ en t r eviewer s with differ ent hor i zons and standpoints, Icannot admit that two healthy per sons, be they ever soclosely r elated, must, fo r the r eason of consanguin ity,have a dis eased child. But to what extent the state of thefutur e will inter fer e with the mar r iages of insane o r epileptic people

, as also with those o f car cinomatous o r thoroughly tuber culous, r emains to be seen . I can imagineand believe that the offspr ing of the intellectually and

mor ally healthy couple will—other things being equal andbar r ing the accidents of pr egnancy and bir th—ser ve theimpr ovement of the r ace

,whi le that o f the abnormal must

impair i t. F r om that point of v i ew we should look fo rward with hopeful expectations to a little mor e pater nali sm in our gover nment . Ther e is no country in the wor ldin which a monar chy i s les s pr obable, and the gover nmentof, fo r and by the people is mor e cer tain to come than inour s ; fo r ther e is none in which the or ganization of capitaland the or ganization of labor ar e making such r apid str idestowards a peaceful evolution of social ism as in our s . Thati s why the younger men among us will l ive to see the timein whi ch the sanitation of the country and people

,guided

by the legislative influence of the medical pr ofes sion, willr ender impossible the per petuation of deter ior ating o r loathsome di s eases .It i s pr obably impossible ever to ascer tain the exact

number o f infant o r young epileptics . Neither public institutio ns n o r specialists ar e in a pos ition to gather exactstatistics . Very few ar e as favor ably s ituated as Gower s,Binswanger , and other s . Institutions ar e filled withpatients in advanced year s , specialists see them mostlyin the same way. Many an epileptic infant o r child diesbefor e being obser ved o r tr eated, o r even diagnosticated ;fo r a gr eat many cases of petit mal

,ver tigo

, dr eam- likestates and somnambul ism, fainting, even hyster ic Spells

,

ar e over looked. They ar e n eglected o r car ed fo r at home,

and the seizur e i s taken to be an eclamptic attack . Anexample of the kind i s now in my hospital war d ; a childwith nephr itis after scar latina which r an its cour s e four

4 1 2

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

nasop haryngeal gr owths ; vesical and r enal calculi ; helminthes

,fr om taenia to oxyur i s ; in older childr en delayed

menstruation,ar e so many differ ent causes of epilepsy.

I t i s,ther efor e, only the most painstakin g examination of

all the or gans and the whole sur face of the body whichgives a pr omise of finding the cause of the dis eas e as wellas the indications fo r r ational causal tr eatment .J ackso n ian epilepsy affects a locali z ed gr oup of mus

cles,and always the same ; the spasm i s mostly clonic and

painless,and when it becomes gener alized the attack be

gins in the same order . I t i s fr equently, perhaps mostly,the r esult o f a coar se les ion

,a detached bone, a tumor ,

an absces s,a localized patch of meningiti s , a hematoma,

a cyst, a cicatr ix, o r a for eign body which by ir r itation

s ets up a ser i es of epileptic convuls ions . A (br achial)Jacksonian epilepsy was cur ed by the r emoval of a fo r

eign body fr om the ear by~Mon flier . But thi s r elation

between a J ackso n ian epilepsy and a local disorder can

not always be pr oved. Exceptions ar e very numer ous ;only lately Z . B r egman and N . Odefeld 1 came to the conelus ion that a tumor occupying a lar ge par t of the sur

face of the fr ontal lobe may look like a les ion of the central convolution . A per s istent par alys is of monoplegicchar acter and suggesting localization in the cor tex withsymptoms of Jacksonian epilepsy need not p r ove a les ionof the motor zone . Finally, ther e may be an extensiveles ion of the fr ontal lobe without cor r esponding symptoms .

”

I may add fr om my own exper ience that many‘

a case ofJackson ian epilepsy, when examined postmor tem exhibitedno tangible cause . That i s also why many an operationunder taken fo r r elief was futile .Intr auter ine influences , both inflammations and intoxica

tions,ar e cer tainly power ful as occas ional causes of epi

lepsy. Her editary syphilis i s consider ed a fr equent causeof epilepsy, both Jacksonian and univer sal . The formerr esults fr om the localizat ion of an or ganic diseas e of thebr ain, either meningiti s, o r encephal iti s , o r softening

, o r

gummatous infiltr ation . In accordance with their extent

1 Gr enzgeb. Med. Chir ., 1 902, p. 51 6 .

4 1 4

CAUSES OF EPILEPSY IN THE YOUNG

o r locali zat ion ther e ar e symptoms o f either paralys is o r

ir r itation . When epilepsy i s univer sal o r genuine, no suchlocalization o r local symptoms ar e met with. These casesshow the fate of all thos e which 'permit of nothing but theassumption of an unr ecognized cor t ical alter ation . Whenchildr en of five o r seven year s ar e suddenly attacked withepilepsy, syphili s should be suspected. These childr en ar e

gener ally under s ized and puny, such as Four nier has pictur ed as par asyphilitic . I have often seen and di scussedthem fr om that point of vi ew

,but must confess that though

in the maj or i ty no ser ious ner vous di sorder s seemed to mar ktheir appear ance, in many, however , though no hi story ofsyphi l is of the par ents could be elicited, viscer al les ionswer e found in autopsi es . No r ar e other ner vous diseasesof ear ly age exempt fr om syphilis . In hydr ocephalus iti s fr equent, in polioencephal iti s r ar e . I n 20 0 cases of thi sform of par alys i s, Sachs found only 2 that were attr ibu

table to her editary syphili s . Fr om a s imilar point of viewmostly, the whole subj ect is thor oughly tr eated in a class ical book on Syphili s and the Ner vous System,

”by Max

Nonne,Ber lin

,1 90 2 .

The conclus ion should be that ther e ar e not many caseso f epilepsy that can be dir ectly attr ibuted to syphili s .But a gr eat many epileptics exhibit symptoms that makethem very suspicious . Such ar e ear ly imbecili tv o r idiocy,glandular swellings, chr onic per iost iti s, and anomalousteeth. Not infr equently I found in a family sever al cases,one case o f epilepsy and other s of differ ent cer ebr al disor der s . It appear s

,therefore , that the syphilitic virus,

mor e o r less modified, acts on the germ fr om the beginningo f embryonal li fe with differ ent r esults .In thi s r espect i t r esemble s other influences which -con

tr ol the pr edispos ition to epilepsy, gout, diabetes, hyster ia,o r insanity, whi ch ar e pr evalent in a family in one of thetwo pr eceding gener ations .Many intr aute r ine influences exhibit themselves imme

diately o r soon after bir th. Among them I may be permitted to speak of hyper tr ophy o f

_the br ain

,pr ematur e

ossification of the cr anium, and spur ious meningocele .Genuine hypertr ophy of . the brain is not fr equent

, but

4 1 5

DR. JACOBI’S WORKS

I have seen it once with epilep sy that began when the childwas a year o ld and per s isted until the autopsy was madethr ee year s later . The cr anium was of normal thickness ;20 teeth had pr otruded. The dur a mater was tightly ad

her ent to the cr anium,pale and tense . When it was in

cised the solid cer ebr al substance bulged thr ough the ia

cisio n . The br ain sur face was pale and flattened and the

cor tex of fair diameter ; the ,white substance pal e, hard,

mass ive ; the ventr i cles small, with no serum . As ear ly as

1 8 0 6 2and 1 8 2 8

3 Laenn ec r epor ted that in s ever al casesdiagnosticated by him as hydr ocephalus he found no serum,

but the flattened convolutions of a pale,compr es sed, elasti c

br ain . . Hufeland ( 1 8 2 4 ) admitted to have made the samemistake . I t was he who fir st descr ibed the bulging of theelastic br ain thr ough the incision of the dur a mater . Hiscases of thi s r eal cer ebr al hyper tr ophy—that i s, a lar gebr ain within a normal skull—and those of other olderwr iter s ar e r efer r ed to in E . No egger ath and A . Jacobi

’

sContr ibutions to Midwifery and Di seases of Women and

Chi ldr en,New York

,1 8 59, p . 8 4 . Altogether

,however

,

these cases of abnormal hyper tr ophy of the white substance

appear to be r ar e ; they should be car efully distinguishedfr om the lar ge br ains of Byr on, Cuvier , Turgen iefl

’

,and

Cr omwell, that wer e symmetr i cally lar ge . I think I am

pr epar ed to say that the epilepsy in my case r esulted fr omthe hyper tr ophy of the white substance and the compr ess ion o f the cor tex . Ther e was no other tangible hypertr ophy. Poss ibly it was the latter alone that caused i t, fo rhypoplas ia of the cor tex i s r epor ted as the condi tion of a

young man who di ed in an epileptic attack, by Ziegler in

the second volume of his Pathological Anatomy.

”

Hyper tr ophy o f the br ain, that i s an abnormal and ab

normally lar ge br ain enclosed in a normal skul l,must be

di stinguished fr om pr ematur e ossificatio n o f the fontanellesand sutur es. In this inter esting condition we have to dealwith an or iginally normal br ain tightly enclosed in an ah

normal cr anium . In the book I quoted and in the J our nal

2 Journal de Méd. Chi r . et Pharm., p. 669.3 Revue Med.

4 1 6

https://www.forgottenbooks.com/join

DR . JACOBI’

S WORKS

of such oper ations notwithstandin g. I have not changedmy conviction on that subj ect expre ssed in my Romanaddr es s non nocer e ” of 1 894 . Their per formance byenter pr is ing oper ator s in cases of undiagn o sticated o r mistaken micr ocephal ia—no matter whether the fontanelle i slar ge o r small, o r the bone i s thin o r fi rm—i s no longer a

medi cal question . Wher e natur e made a mistake the do cto r must not believe he can cor r ect it by a cr ime .The diagnosis is not difficult. When the case is one of

oss ification at bi r th it i s only the exagger ation of what may

be obser ved to develop slowly after bir th. In thes e casesthe cr anial bones har den

,the fontanelle decr eases in s iz e

instead of its normal enlar gement up to the eighth month.

They may close at the thir d, s ixth, tenth month. All theconnective ti s sues of the cr anium develop at the same r ate .Many such in fants begin to use their l imbs ear ly. The

teeth appear ear ly and not,as in occasional cases of rhachi

ti s, i n long inter vals, but in r apid success ion . The fi r stteeth to appear ar e not

,as in the healthy, the lower in cisor s,

but the upper . These symptoms, together with the shape ofthe head as descr ibed befor e

,justi fy your _

diagn o sis. Aftera whil e the general development i s distur bed by the in

cr eas ing pr es sur e, o r ir r itation, by the inter fer ence with

intracr anial c ir culation,

and by the addit ional dangercaused ther eby to every occur r ence of a slight o r ser iousai lment. Dur ing such a compli cation the fir st convuls ionmay take place . Often it occur s without any pr emonitorysymptom,

and will r etur n in i r r egular inter vals . Casesin which epilepsy of later year s i s due extens ively to thecompr ess ion of an or i ginally normal br ain in an abnormallycompact and un i formly contr acted skull I have seen . But

mor e ar e due to o r connected with a pr ematur e par tial synostosis . Ther e ar e but few normal heads

“

and br ains inthe well absolutely symmetr ical ; but it i s the fate of a gr eatmany epileptics to have a compar atively small cr anial ci rcumfer ence and an absolutely asymmetr ical shape .Savage nations 5 have made obser vations which show their

5 A. Jacobi : The Intestinal Diseases o f Infancy and Chi ldhood, Detro it, 1 887, p. 1 03 .

4 1 8

CAUSES OF EPILEPSY IN THE YOUNG

fear of such an occur r ence . The Makalaka of SouthAfr ica ar e always anxious to look fo r the location of thefir st teeth

,whether in the upper o r lower j aw. In Bohe

mia i t i s a popular belief that the child whose upper inciso r s come fi r st will soon die. David Livingstone and

Fr itzsch r epor t that some nations in Central Afr ica killthe in fants whose upper incisor s pr otrude befor e the lowe rones .Men ingo cele spur ia means a fissur e of the cr anium and

of the tightly adher ent dur a mater un der an intact scalp .

It i s the r esult of a for ceps operation,of a fall o r some

other tr auma,o f car i es

,o r of syphil i s . When the fissur e

i s super ficial it need not inter fere with the developmento f the br ain

,fo r ther e is not even a permanent loss o f

cer ebr ospinal liquor,but when it i s injur ed down to a

later al ventr icle it r esults in porencephalia. Rhachti s ofthe cr anial bones

,and the interposition of br ain substance

between the fissur ed bones pr events spontaneous r ecovery.

A practical recovery without oper ation may take place bythe inter position of the membr ane s and o f some per iosteum .

Thi s spontaneous pr ocess may pr oceed kindly, but ir r itation of the comp r essed par ts may cause meningiti s and

epilepsy. I made the autopsy, 20 year s ago , of a child 5

year s o ld.

I had seen her once when she was a few mo nths o ld, with Spur ious meningo cele attr ibuted to a fo r ceps Oper atio n . When she

was about a year o ld she had a vio lent co nvulsio n pr eceded bynumerous Spells o f petit mal. Befo r e She died these wer e num

ber less ; sever e epileptic seizur es ther e wer e n o mo r e than hal f adozen all to ld. She had a moderate amount o f liquo r in the lateral ventr icles and some oedema and thickening o f the cho r o idplexus. Round the fissur e o f the r ight par ietal bo ne, which wasclo sed by interpo sed cicatr icial and hard tissue, ther e was inside apale, hard pachymeningitis, the alteratio n extending over 3 cm.

in every directio n, and a thickened pia, pale near the o r igin o f

the affectio n, hyperaemic with large v eins to a distance o f 1 0 cm.

o r 19 cm.

It appear s that with the possibil ity of its r esulting inepilepsy even a spur ious meningocele should not be leftalone. A r ecent case demands the r ais ing of the depr essed

4 19

DR . JACOBI ’S WORKS

bone and either bone o r per iosteum sutur e . Older cases,i f

pr onounced inoper able,should be pr otected by a pad ;

iodine inj ections have pr oved success ful ; dr opsical later alventr icles may be dr ained.

In the for egoing r emarks I have dir ected your attentionto the unpr omi sing r esults of intr auter ine influences . Letme tur n to another subject

,in

”

order to show that ther ear e other power ful influences fo r bad

,the r esults of whi ch

may be mor e fr equently pr evented than cur ed.

A fr equent cause of epilepsy i s asphyx ia of the newbor n

,fr equently the fi r st bor n—no matter fr om what cause :

moder ate o r ser ious compr es s ion o f the fetal head, compr ess ion o r p r olapse of the cor d, in tr auter ine r espir at ionand aspi r ation of liquor amni i o r meconium

, placentar de

tachmen t, mor phine o r chlor al poisoning by the mater nalblood, mal formations of intr athor acic o r intr acr an ial o r

gans,etc . The anatomical r esults in the cr anium ar e ex

cessive hyperaemia, tense veins, sanguineous effus ion, extr avasatio n ,

and thr ombosis . When the baby l ives at all,a meningiti s o r meningoencephalitis may follow, and par

alys i s in many cases ; in many mor e, idiocy o r epilepsy o r

both ar e the final r esults . In o ne-third par t o f the cases

of idiocy ther e i s a combinat ion with epilepsy. In a longli fe I could tr ace the cause of the two latter to asphyxiain hundr eds of cases . Without any suggestions, my quest ion, Did the baby cry when bor n, o r did the baby l ivewhen bo r n ? i s answer ed that it did not ; that the

doctor worked o ver the baby minutes o r quar ter hour sbefor e it was r esuscitated, and that the baby neverwas l ike other in fants, never smiled at the usual time,took little

'

o r no notice,and had gener al convul s ions some

times beginning on one s ide, quite often . Hundr eds ofsuch cases

'

I had oppor tunities to p r esent at my clinics ;never wi thout the war ning to my classes that the par amoun t duty o f the p r actitioner i s to Shor ten asphyxia, and

that ther e is nothing connected with the management of a

cas e of labor so vi tal as the p r evention o r shor tening ofasphyxia, the attendance upon the mother

,though ever so

ur gently demanded, not excepted. A single moment mor eo r less of the asphyxiated condition may decide the futur e

4 20

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

what caused the convuls ion—intestinal ir r i tation by un

digested food o r he lminthes,acute intoxication by alcohol,

cocci o r bacilli o r their toxins, in scar latina, typhoid o r in

fluenza, ur zemia, inanition, whooping cough o r laryngismus .Two cases of epil epsy I r emember dist inctly that wer ecaused by the convulsions of whooping cough. Another wasdue to an apoplexy in an adult . The un for tunate youn gman suffe r ed fr om unmanaged constipation . I was called4 0 odd year s ago to see him in a fit o f what was called a

fain ting spell . I foun d him on the water closet with an

apoplectic attack that soon terminated in hemiplegia of ther i ght s ide . A year afterward he had his fi r st attack ofepilepsy, which was followed by a gr eat many mor e unti lhe di ed

,long after fr om what

,acco rding to the r epor t of

the case,appear ed to be a second attack of cer ebr al hemo r

rhage. Cases of cer ebr al hemor rhage occas ioned by a convulsio n in a chi ld can be tr eated

,but r ar ely cur ed ; but many

may be pr evented by the speediest pos s ible inter fer ence withthe attack . No cas e of eclamptic convuls ion should be leftalone . I t r equir es chlor oform

,no matter what other in

dicatio ns p r esent themselves . Shor tening o f a convul s ionfr om any sour ce, cer ebr al o r r eflected

, by a s ingle halfminute

,may just be in time to pr event a hemor rhage and

subsequent death, o r what i s wor se,par alys i s, Spasti c

encephalit is,idiocy, o r epilepsy.

The causes of co nvulsio ns i n infancy and ear ly childhood ar e so numer ous and their dange r s so many that itmay be wor th our while to spend a few minutes in the

consider ation of at least a few o f them,with the obj ect of

facil i tating an ear ly di agnosi s and the possibility of immediate and cor r ect treatment . They ar e so many, some ofthem not gener ally appr eciated, that it will pay us to eliminate one at least that i s cr edited with mor e mischief thanit i s gui lty of. I mean dentitio n .

.William Phi lip Spr atling 6 expr es ses himself as followsNext to her edi ty, it is my fi rm conviction that denti ti on,when sever e, and when acting o n an o rgan ism that bear s the

impr ess of transmitted weaknesses, plays the most important

6 Medical News, September 1 5, 1 894 .

4 22

CAUSES OF EPILEPSY IN THE YOUNG

r6le in causing epilepsy in ear ly l ife. Indeed, I ful ly bel ieve that the impor tance o f teething in thi s r espect hasnot been accorded the car eful attention it deser ves . Dr .

Spratling fo r tifies his position by quotations fr om Gower sand fr om r eplies r eceived to a cir cular inquiry. F r omamong the latter he p r ints quotations taken fr om letter swr itten by me, Dr . G . Elder Blumer

,Gr aeme M . Ham

mond, F r eder ick Peter son, and T . S . Clouston,of Edin

bur gh. F r om Gower s the following words ar e quoted : Ofall the cases that commence in infancy, at least thr eequar ter s date fr om infantile convuls ions ascr ibed to teething . I wish you to note that the words ar e ascr ibedto teething

,

” not due to teething ; I have no doubt he meantto say

“

. ascr ibed to teething by the men who sent me thecases and thei r hi sto r i es . Gower s7 says, l iter ally: ‘ The

influence of the pr ocess of the eruption of the teeth i sr elegated to its p r oper place, as mer ely a possible excitantin '

a few cases . Fr om my letter Dr . Spr atl in g quotes asfollows : Every convuls ion, ever so slight o r shor t, maypr oduce cer ebr al hemor rhage

,with all the poss ible r esults

epilepsy, idiocy, par alys i s, and insanity. Such cases ar e,

unfor tunately, fr equent .”

You will notice that teethingis not mentioned by me . I cer tainly did not believe, n o r

did I mean to infer,that the convuls ions spoken of wer e

due to dentition . Dr . Blumer expr esses his belie f thatther e is no such thing as a convuls ion due to dentitionpur e and s imple and uncomplicated.

”Dr . Spr atling him

self emphasi zes the r equir ement of the imp r ess of tr ansmitted weaknesses that one must go back of the dentition and r egard the di sturbance of this pr ocess as the

mer e existing cause of the explos ion .

”Dr . Hammond

has r ecords of sever al cases in which convuls ions, due todentition

,wer e followed by true ep ileptic convuls ions .

”Dr .

Peter son can r ecall a number of cases of _ ep ilepsy due tothe convulsions of den tition L

’

L/ Dr . Clouston is mor e positive than any of the thr ee mentioned cor r espondents. Heasser ts that he has seen the convuls ions of dentition followed by pr olonged delir ium ending in idiocy, o r in true

7 Clinical Jour nal, September 1 894 .

4 2 3

DR . JACOBI ’S WORKS

epilepsy, o r insanity of adolescents . I again state that theconvul sions giving r i s e to such cases o f epilepsy ar e calledby the last named thre e author ities convuls ions due to

dentition .

” Neither Dr . Blumer n o r mysel f go that far .

I speak of convul s ions only, no matter fr om what cause, andam

,ther efor e

,quite pr epar ed to accept what I think I al

ways knew and p r oclaimed to-day, and what Dr . Sp r atlingexp r es ses in a concluding r emark,

“ that the spasms and

convulsions of infancy ar e ser ious manifestations,and i f

allowed to go unchecked,may lead to explos ions of genuine

epilepsy, and later on to insanity.

Now what i s dentition, and what its per iod ?I t begins dur ing uter oges tation . The dental sacs of the

20 milk teeth under go ossification in the fi fth month ofpr egnancy. Behind them ar e the sacs fo r

_the permanent

teeth. Thei r separ ation fr om the former i s not completedunti l the fetus i s bor n . Befor e and after bi r th ther e i s a

constant gr owth, the car tilage of the wall o f the dentalcavity and of the gums di sappear s gr adually. The twolower incisor s make their appear ance between the seventhand eight months

,the upper incisor s between the eighth

and tenth months , s ix mor e teeth between the twelfth and

fifteenth months,four bicuspids between the e ighteenth and

twenty-four th months, the four second molar s between thetwentieth and thi r ti eth months . The s econd v is ible dentition begins about the fifth o r s ixth year . I n the twelfth

year four molar s make their appearance,the last o f the

whole set,with the exception o f the wisdom teeth

,which

pr otrude between the s ixteenth and twenty-four th year .

Thus the per iod of dentition begins about the middleof intrauter ine l i fe, and ends v i s ibly fi r st with the thi rtieth month

,and secondly with the twel fth year . I t i s

pr incipally the fi r s t which is char ged with causing o r beingattended by convuls ions .Convuls ions occur almost univer sally between bir th and

the thi r tieth month ; thi s happens to be the per iod of dentition . But i t i s also the per iod of defective inhibition , ofnephr itis, o titis, pneumo n ia, en ter itis, and infectious and

cer ebral diseases. All of these ar e fruitful causes of convulsio ns ; dentition goes on dur ing that per iod, like the

4 24

https://www.forgottenbooks.com/join

DR . JACOB I ’S WORKS

very apt to become pathologic on slight p r ovocations, themor e so as the embryonal char acter of the br ain tissuechanges only gradually in the cour se of a few year s . Thes ear e no new facts . Even in a book on Dentition and I tsDer angements, New York, 1 8 62 , I could utilize a gr eatmany anatomical data, confirmed and added to s ince

,when

trying to find fo r dentition its exact place in etiology. Myconclusions of 4 0 year s ago I can still r epeat . Ther e is acer tain amoun t of itching, even p rur itus of the gums ; ther eis a vasomotor distur bance in the shape o f o n e o r two flushedcheeks ; now and then a slight muscular twitching ; nowand then a r olli ng of the eye caused by the incompetenceof the muscles of accommodation met with in every infantto such an extent that str abismus i s common in healthybabies ; but when I said in 1 8 8 7

8 that I never in 1 0 year ssaw a convulsion due to dentition alone I her e r epeat thestatement as valid fo r additional 1 5 year s . No r is diar rhmaa symptom of dentition, fo r infants either at a healthybr east o r on well- selected ar tificial food have no diar rhoea.

Do youwish another instance of the complete disappear anceof dentition fr om the etiological hor i zon ? When all of uswer e 50 year s youn ger did we not hear of dental ” par al

ysis ? Nowadays we do no t even permit the term ofes sential ” o r

“ infantile ” par alys is . Poli omyeliti s doesnot fall back upon dentition as a cause . And what i s co rr ect in the case of par alys i s i s so in convuls ion . Whena convuls ion

,the fir st appear ance of

, o r r ather the causeof consecutive epilepsy o r idiocy, i s attr ibuted to dentition,the hi story of the case as submitted to us i s incomplete,o r our own diagnos is i s at fault.The high estimation in which dentition was held fo r

mer ly has assumed smaller pr opor tions, even among the

mater nal public . They do not insi st any mor e as they didwhen you and I wer e 4 0 o r 50 year s younger upon havingthe baby

’

s gums lanced over conspir ing poor little teeth, justas li ttle as they ar e clamor ous any mor e fo r worm medicinesfo r their pets to the former extent . The doctor s who knowhow to make a diagnosis of a br onchi ti s

,pneumonia

,nephr i

8 Intestinal Diseases o f Infancy and Childho od, Detr o it, 1 887.

4 26

CAUSES OF EPILEPSY IN THE YOUNG

ti s, otiti s, o r a toxi c infection ar e getting too numer ous,

and the diagnostic atmospher e is gradually becoming pur i'

fied.

Stil l, i t is claimed that i t i s difficult to ar r ive at a diagnosis of the occult di s eases o f infancy. I f the difficultyis,o r wer e, actual

,ther e i s a r emedy. See to it that the

clinical advantages of our medical schools be so numer ousand s o per fected that no young o r o ld doctor i s in a positionto accumulate mor e ignor ance than knowledge . Co nvul

s ions in the young ar e of fr equent occur r ence in everypr actitioner

’

s r ounds . To tr eat it i s something ; to pr eventit i s better . Thi s very day the number o f infectious diseases

,with their hi gh temper atur es and their toxins ; the

many intestinal disorder s , with their ner ve r eflexes , ar e st illall-power ful . Ther e ar e still some meningeal affections thatar e not always fatal, but highly danger ous in their r esults .All this i s well under stood. But ther e i s a clas s of diseases whi ch leads as often to convul s ions as any other ; thati s nephr i tis . I cannot help emphasi z ing the fact that it i scommon in the newly bor n and the very young infant ;that infar ctions and j aundice are a fr equent cause ; enter iti s

,with its indican and i ts toxins

,engender s legions of

cases ; coal-tar medication is a fr equent sour ce of evil ; ex

po sur e causes some ; infectious dis eases, fr om mild var i cellato influenza o r diphther ia o r scar latina, a gr eat many. Asthe diagnosis i s easy to make, r equir ing the examination ofr eadily attainable ur ine only, I admi t that the failur e toar r ive at a diagnosi s i s a constant sour ce of sur pr i se to me.

Convuls ions fr om that sour ce are very fr equent, and the

vast maj or ity of them,with their possible dr eadful couse

quences, could be avoided. Many a case attr ibuted todentitio n could easily be r ecognized as nephr itic .Among the impor tant constitutional di seases that have a

gr eat tendency to convul s ions is rhachitis, not, as Gower ssays, on account of the late gene r al development causedby it, but fo r other r easons . His own wor ds ar e as follows :I t i s impossible to doubt that the dentiti on convuls ions

ar e a definite element in the caus es of epilepsy. So constant, mor eover , i s their association with the defective development which we call r ickets that it is imposs ible to

4 27

'

DR . JACOBI ’S WORKS

doubt that the p r evention of r ickets would have a considerable in fluence in the p r evention of epilepsy. .In the fur thercour se of his r emar ks he defines as defective developmentmainly i ts r etardation of the gr owth of the bones, empha

s i z ing much les s its influence on muscles, lymphatic s and

the lar ge viscer a.

The r etardation of development hurt s mostly bone and

tooth formation . But nobody ever claimed that when a

tooth i s formed and p r otrudes late, i t is fo r that r eason a

sour ce of i r r itation and convulsion . The minor o r maj orattacks of convul s ions in rhachit is ar e always of centralor igin . They always mean the hyperaemia o r (edema ac

companying the rhachi tical soften ing of the cr anial bone s .When r hachit i s i s l imi ted to the cur vatur es of the extr emi

ties, o r the development of a r osary o r Har r i son

’

s gr oove,with ever so much deformity, comp r ess ion of lun gs, .annoyance of the hear t , and dislodgment of the l iver and spleen,ther e is no convuls ion . I t occur s in craniotabes which

,after

a per i od of r estles s, cephalic per spi rat ion and o ccipi tal baldn es s

,begins with the thi rd o r fifth month o f l i fe .

It i s attended by hyperaemia and (edema of the galea,skull

,

dur a and pia mater and br ain,not infr equently with effusion

into the ventr icles . Thes e centr al changes cause manycases of tetany, almost every one o f laryngismus str idulusand a gr eat many of the attacks of convuls ions . Oncestar t ed they r eturn at uncer tain times

,and gener ally disap

pear with the r ecovery fr om rhachi tis,pr oduced by p r oper

food and hygiene, fr esh air and phosphorus . As long as

they last they Shar e the danger s o f every attack of eclampsia, vi z .

, (edema, thr ombosis, hemor rhage . Not infr equentlythey last longer than the rhachit is that caused it . I donot car e to speak of a convul s ive habit and to explain thesubsequent epilepsy by thi s habit ; that would be no explanation

,but another wor d only fo r the fac t . The r eal

explanati on is afforded by the obj ective changes in the

structur e o f the intr acr anial contents caused by the convulsive inter fer ence with the cir culation of lar ge and smallves sels .The local i r r itation of phimosis, congeni tal o r acquir ed,

complicated o r not with balaniti s,r esul ting fr om the changes

4 2 8

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

lupulin, camphor , and other r obor ants,continued fo r year s .

Infants and young chi ldr en ar e not so pun i shed,except ap

par ently in thos e cases in which masturbation itself i s ther esult of a centr al di sease . Goltz places the er ection centerin the cord about the four th lumbar ver tebr a, other s in thepeduncul i’ cer ebr i o r the medulla oblongata. I t is quiteposs ible that in such cases in which epilepsy follows masturbation , both may be of the same centr al or i gin . Theyar e both pr obably incur able, and neither a tr eatment dir ected to the center , n o r ir r itating vesicator ies o r brutaland vulgar clitor idectomy can possibly be expected to havean effect. Such cases of mastur bati on ar e as incur able asthe vast maj or i ty of centr al epilepsy. What I expr ess asmy opinion of clitor idectomy is also valid in r egar d towor se methods . Baker B r own is dead

,Ever ett Flood

,of

Baldwinvi lle,Mas s .

,appear s to be very much alive .9 He

eulogiz es castration and ci r cumcision . The former was performed on 20 males and two females . The cases were r e

por ted at the meeting of the Ame r ican Medical Associationat Atlanta. He admits that castration has “ bitter op

po nents of the same clas s that is howling againstvaccination .

” I do not howl against vaccination . To me

i t i s a wonder that the cr iminal law of Massachusetts hasnot yet inter fer ed with these attempts at deal ing withmasturbation and epilepsy, both of which r ender the consent to be mutilated an impossibility on the par t of ir r espons ible

,unfor tunate suffer er s .

9 Atlantic Med. Weekly, October 24, 1 896 .

4 3 0

TREATMENT OF ENURESIS

TH E incomplete development of the sphincter s , in the

infant, r esults in the involuntary emiss ion of ur ine and dis

char ge o f faeces . This condition pr evai l s a year o r two,

and i s not attended with any subj ective sensation, o r sensitiven ess. The sphincter am is the fir st to gain sufficientstr ength to r etain the contents of the r ectum ; debilitatingdiseases occur r ing in later year s may r estor e it to its or iginal incompetency. The sphincter of the bladder attainsa satisfacto ry power towards the end of the second year .

When,however , its infantile condition per si sts beyond that

per iod, both the ur ine and the genito-ur inary or gans beingfair ly normal, the involuntary emission of ur ine continues,par ticular ly dur ing sleep (enur esis no ctur na) , not in fr equently thr ough the day (enur esis diur na) , o r both in thenight and dur ing the day (enur esis co ntinua) . Many ofsuch cases get well spontaneously about the per iod o f

puber ty, when the whole genito—ur inary appar atus undergoes a r apid development. In some the functional weakness

,however

,per si sts long beyond that time . Not long

ago I had to r elieve the case of a young lady of eighteenwho was getting r eady to mar ry. Most cases ar e obser vedbetween the third and the tenth year in bo th boys and

gi r ls, but the maj or i ty of the pati ents between the eleventhand the thi r teenth year , also of those who suffer in mor eadvanced year s, ar e males .The muscular debil ity o f the neck of the bladder and the

inter nal Sphincter (in fact, identical or gans) is sometimesbut a par t of a univer sal muscular incompetency, whichi s found among differ ent classes of childr en . Some ar e

slow,dull

,and stupid, and lacking in gener al inner vati on ;

other s ar e s imply'

anaemic,ill developed, and gener ally

feeble ; ther e ar e some whose whole vitality appear s to beexpended upon their intellectual spher e : they ar e smar t,(wick; Spirited, excitable, mentally vigor ous though eas ily

4 3 1

DR . JACOBI’

S WORKS

exhausted ; but thei r muscles ar e thin , sensi tive . and in

continence o f ur ine i s fr equent. In many such cases thesexual and ur inary or gans ar e quite small . Ther e ar e

other s,however

,who exhibit no par alleli sm of debility

in the ur inary muscular appar atus and the muscle-supplyof the whole body. In them ther e may be gr eat musculargene r al do velopmen t, and the neck of the bladder aloneseems neglected. On the other hand

,ther e may be gr eat

muscular power about the sphincter i n an otherwise feebleand an iemic body. Thus, no cer tain rul e can be establi shed,and the diagnosi s o f the exact condi t ion o f things may be

come quite difficult . Still,ther e i s a class o f pati ents in

Whom the complication of enur esi s with general muscularin suffic iency i s very appar ent . Indeed

, young men who

after mode r ate vener eal exces ses suffer much fr om n o ctur

nal o r diur nal s eminal emissi ons (with o r without incontinence o f ur ine) ar e fr equently thos e who have a

positive hi story o f incontinence dur ing thei r chi ldhood.

In them the whole muscular appar atus was defective ; andthe poster ior par t o f the ur ethra

,when nar coti zed

,as i t

wer e, dur ing sleep, gives way befor e the gentlest pr es sur e

on the par t of the expelling muscle of the bladder .

Insufficient inner vation has been alluded to as a causeof incontinence . Childr en who pas s ur ine whil e engagedin eager play may suffer either fr om debil ity o f the

sphincter o r fr om want of mental contr ol . Par ti cular lyi n di s eases of the ner ve-center s, with sopor and Slow mental acti on

, and wher e the development o f the r eflex apparatus i s slow and defective

,the sphincter

,whi ch con

tracts normally while the bladder i s fi lli ng up, loses itscontr ol . P r ofound sleep i s said to p r omote incontinence ;still all chi ldr en have that pr ofound sleep

,and but a small

pe r centage ar e afflicted with incontinence . Such gener alconstitutional disor der s as scr ofulos i s and rhachi t i s havebeen char ged with p r oducing incontinence, but the vastmaj or ity of scr ofulous and rhachitical childr en do not suffer fr om it . Slow car bonic-acid poisoning i s al so cr editedwith r esult ing in incontinence ; thus i t i s that G . W .

Maj or and Z i em explain the incontinence o f mouth-br eathing childr en, and E . Bloch the ner vous disposition, r est

4 3 2

https://www.forgottenbooks.com/join

DR. JACOBI ’S WORKS

same effect on the bladder , and diabetes mellitus operatesby both the lar ge amoun t of ur in e and the alter ati ons ini ts chemical compositi on . Cystitis in all i ts forms adds

to the i r r itabi lity of the detrusor : it i s a fr equent cause ofincontinence when thi s makes its appear ance in chi ldr enwhose mictur ition was normal befor e . Stone i n the bladder has the same effect . Phimosi s and tight adhesionof the pr epuce may p r oduce incontinence, par ticular ly inthose boys who ar e subj ect to fr equent er ections . The

r est of the ur inary or gans exhib it the same influence . Thusin every cas e of enur es is with uncertain diagnosi s n ephr i

tis,pyeliti s, r enal calculus, and vaginal catar rh must be

sear ched fo r . As a r esult o f incontinence of ur ine thebladder i s apt to be very much contr acted : it holds butlittl e

,and thus what was or i ginally the r esult o f inco n

tin en ce becomes an additional cause .Mastur bation i s not an un common caus e of incontinence

of ur ine . I believe that my paper on the subj ect of mas~

turbation and hyster ia in infancy and childhood1 has dir ected the attention of the p r ofession to the fr equencyof the habit o f mastur bation, with all its consequences .Now

,in the youn g the caput gallinagini s i s quite lar ge

,

and Cowper ’s gland and the vesiculae pr os tatica: ar e suffi

cien tly developed to r esult in er ections . The constant ir r itation of the par t by self-abuse leads to a chr onic inflammation of the whole pr ostatic por tion and the neckof the bladder

,which i s very Sens itive . Infants addi cted

to the habit ar e very apt to escape fo r year s its couse

quences as exhibited in somewhat advanced chi ldr en ; thesesuffer fr om gener al malai se, dull headaches, alter ation oftemper

,and somnolence . The genital or gans ar e mo stlv

changed. The exter nal par ts—the vulva, the scr otum,and

par ticular ly the glans penis—ar e r ather enlarged

,and the

ur ine i s sometimes alkaline, and often slightly opaque withmucus, leucocytes, and spher i cal and oval epithelia, sometimes even Spermatozoa.

The condition of the r ectum must becar efully examined

1 Amer . Jour . of Obstetr ics and Diseases of Women and Chil

dren ,

’February and Jun e, 1 8 76 . See also Vo l. I I I o f this wo rk.

4 3 4

TREATMENT OF ENURESIS

in every case . The plexus pudendus contr ols both i t andthe neighbor ing or gans ; the pudendal, per ineal, and middle and infer ior hemor rhoidal ner ves ar e di sturbed overthe lower por t ion of the bladder and the vagina. Thusa r ectal i r r itation pr oduced by the r etention of faeces

,

the pr esence of a fissur e, which i s much mor e fr equentin infancy and chi ldhood than is generally supposed, and

the effect of worms (mostly oxyur i s ) in the lower end ofthe intest inal tr act, ar e among the mor e common causesof incontin ence .Ser ious di sorder s of the ner vous system,

such as epilepsyo r night-ter r or s, ar e also among the causes o r complications of incontinence . They, however , and par ticular ly thelatter , need not be taken as causes only; in many casesthe night-ter r or i s but a r esult

, co -ordinate with inco n

tin ence, o f some distant, fr equently digestive, disorder .

TREATMENT.—The gr eat var i ety o f the causes of in co n

tinence of ur ine r equir es tact and di scr imination in the

selection of r emedi es . Gener al anaemia and muscular debility indicate a diet car efully selected fo r its nutr iti ousnes s and di gestibility. Gentle massage o f the whole body,sponging with alcohol and water o r with water , andefficient fr iction with thick towels

,sea-bathing, and the

use of medi cinal r obo r ants, such as ir on o r ar senious acid,will always pr ove beneficial . The elixi r peps . bism. et

strychn . of the National Formulary i s a good pr epar ationfo r use in insufficient gastr i c di gestion, with atony of thestomach ; a child of thr ee year s may take a teaspoonfulthr ee times a day.

Attention must be paid to the capacity of the bladder .

In ever y case, par ticular ly in the evening, the quantityof fluid must be r estr icted. The sigmoid flexur e and the

r ectum must be empty in the night, and patients shouldbe encour aged to evacuate both bladder and r ectum befor er eti r ing. After a few hour s ’

“

Sleep the childr en ought tobe taken up and r oused sufficiently fo r both pur poses .Muscular debility of the neck of the bladder (sphincter )

r equi r es gener al and local stimulation . Strychnine o r otherpr epar ations o f nux vomi ca pr ove effective to a cer tainextent by impr oving both the gener al inner vation and the

4 3 5

DR . JACOBI ’S WORKS

appetite ; in desper ate cases an occas ional subcutaneous in

j ectio n into the per ineum (gr . has r ender ed goodser v ice ; an ointment of o ne par t of extr act o f nux vomicain fr om ten to s ixteen par ts of fat, intr oduced into ther ectum (si z e of a coffee o r Lima bean ) sever al times dailvwill also act well and can be continued fo r some time .The same indi cation i s fulfilled by er got, the fluid o r the

solid extr act of which may be employed inter nally. The

inter rupted electr ical cur r ents i s perhaps the most powerful local stimulant ; one of the eletr odes must be appliedto the per ineum,

the other to the hypogastr ium o r the

lumbar r egion . The advice to apply the negative pole tothe inter ior of the ur ethr a o r bladder and the positivesomewher e exter nally i s bad, because of the danger ofur ethr i t is and cysti ti s .Whenever ther e is oxal ic acid o r sugar o r an exces s of

ur ates and phosphates in the ur ine, the sour ce of the disturban ce must be attended to . The digest ive di sorder sforming the sour ce o f the anomalous condi tion r equi r ea cor r esponding change in the diet (dimi nution of nitr ogenous food) o r cor r ection of the functional disorder s o fthe stomach and l iver . Until that obj ect can be aecom

plished the p r ognosis i s very uncer tain . Vesical catar rh,nephr iti s

,and the pr esence of a calculus in either the

kidney o r the bladder have their own indications ; thecons ider ation of whi ch, as they ar e tr eated in other par tsof thi s volume, i s her e omitted. The hyperaesthes ia of thebody o f the bladder

,complicated o r not with catar rh

,

it i s often.

found without it,—r equir es belladonna o r i tsalkaloid. Both belladonna and atr opine ar e toler ated inmuch lar ger doses by childr en, in pr opor t ion to their s izeo r age, than by adults. In many cases a s ingle eveni ngdose of extr act of belladonna (gr . i—i—l ) o r sulphate ofatr opine (gr . answer s well, sometimes to an unexpected degr ee . B r omide of potass ium (gr . vi—xxv ) , camphor (gr . i i-v) , extr act . humuli fluidum (min . iv—x ) , o r theelixir humuli of the National Formulary i n teaspoonfuldoses, given at bedtime

,answer a simi lar pur pose .

Causes of r eflex contr action located in the vagina, peni s,o r r ectum r equir e local cor r ection . Vaginal catar rh i s as

obstinate because of its inaccess ibili ty as i t i s fr equent.

4 3 6

https://www.forgottenbooks.com/join

RACHITIC DEFORMITIES : ETIOLOGY,CLIN I

CAL H ISTORY AND LE SIONS

I RISE with much diflidence,fo r I am to di scuss a sub

j cet with which you ar e fami liar i z ed fr om day to day.

You see these r achitic deformities so fr equently that I am

afr aid I shall r epeat, fr om my point of vi ew,thi ngs which

ar e to youmatter s of daily obser vation and exper ience .Our subj ect is the etiology and the lesions of r achiti c

deformities . By way of intr oduction, I would say thatrachitic deformities ar e something new in our coun try.

You have seen so many of them that undoubtedly the

younger men her e do not r emember the time when ther ewer e no r achitic deformi ties in thi s country. Thir ty year sago ther e was no r achitis

,except very r ar ely a str ay case .

At that time,when I spoke of r achitis and endeavor ed to

demonstr ate a case in my clinic, I had to hunt considerably fo r mater ial to i llustr ate thi s condition . When, twentytwo year s ago , I wr ote a paper on the fir st cases of cr aniotabes I had seen in New York

,i t was

,with the exception

of o n e by Par ry, of Phi ladelphia, the fir st paper on thissubj ect ever wr itten in our country. The subj ect of r achiti s

,ther efor e

,i s a compar at ively novel one. Since that

time,immigration has be en going on, and the pover ty

str icken people fr om the slums of Eur ope have been ac

cumulat in g her e . As with the gr eater facilit ies fo r tr ans

po r tatio n science has been equal i zed all over the globe,so pover ty, bad air

,and want of every descr iption have

equally spr ead constitutional diseases her e .' Since then

we have seen much r achi ti s her e . Thus i t i s that thetr eatment of r achiti s in

“

the? ffitui' e, although i t will al

ways r emain medical, will also be a social question .

The pr incipal causes of r achiti c deformity ar e numer ous—the r apid gr owth

,the thick epiphyses, the soft diaphyses,

the condition of the ossification car tilage, the tr action of

4 3 9

DR . JACOBI’

S WORKS

the muscles,the debi lity of the muscles, and the pr essur e

of the atmospher e . The locali ty wher e the deformitiesar e foun d depends lar gely upon the intensity of gr owth.

Gr owth i s most intense in the young child in the

cr anium ; (2 ) in the chest ; and lastly only in the extr emities . I r ecapitulate only what you all know when Ispeak of the r achi ti c head

,with the thin skin, the dilated

veins,and theopen sutur es and fontanelles fo r two, thr ee,

four,o r even nine year s, as I have seen it . The edges o f

the sutur es ar e i r r egular . Such a head i s usually lar geactually lar ger than the normal head

—r elatively it i s verymuch

'

lar ger when compar ed with the fr equently smallbody. I t i s so lar ge that i t r esembles sometimes

‘

the

hydr ocephali c head. Indeed some of these heads ar e to a

cer tain degr ee hydr ocephalic ; some ar e entir ely so . Mostof them ar e br achy—cephali c, quadr angular , with depr es

s ion on top . In a peculiar class of cases,fi r st studied by

Virchow, that of the cr etins and semi—cr etins,r achiti s i s

combined with a p r ematur e'

o ssificatio n of the occipitosphenoidal synchondr os is . In this condit ion the base ofthe Skull i s shor tened. At the same time ther e i s a deepgr ooving of the r oot o f the nose

, the eyes ar e widelysepar ated fr om each other

,ther e i s shor tening of the

vomer,and the flat palate so char acter i stic of cr etinoid

condit ions . Not infr equently the occiput i s slightlyflattened

,and the oblique diameter s ar e sometimes not

equal,so that one side may appear to be enti r ely flattened.

Thi s i s par ticular ly the cas e when we deal with r icketysoftening of the cr anial bones—c r aniotabes . In suchcases ther e i s much per spir ation, with loss of hai r on theocciput ; the veins ar e mor e di lated

,the skin thinner and

paler than in the aver age head. In these cases of cr aniotabes 'one s ide may be flattened and the other s ide bulging. The headmay even appear to be tr iangular . Wher eone side bulges out

,and one side i s flattened fr om pr es

sur e,the for ehead i s very pr ominent, sometimes even fr om

thr ee to five times its normal thickness,because of an im

mense amoun t of new per iosteal soft gr owth between theper iosteum and the bones

,which pr oduces a mar ked de

formity of the for ehead. Thi s i s not always a temporary4 4 0

https://www.forgottenbooks.com/join

DR . JACOBI ’S WORKS

thi rd and four th r ibs,and the anter o-poster ior diameter

is lengthened. The r ibs ar e pr omi nent at the os s ificationpoint . On the car tilages ther e ar e fr equently nodulations ;a complete r osary may be developed quite .ear ly. I haveseen it

'

at the age of two months, and a case has been published i n which ther e was a complete r osary in a baby ofonly thr ee weeks . In these extr eme cases the ster numis flat

,and the manubr ium stands out ; fr equently it i s

pr essed down above so as to stand out at an angle at i tslower end ; the lower end of the ster num may be r etr actedwhi le the ensi form pr oces s pr otrudes .Kyphosis i s very fr equently seen in these cases . It i s

often but an exagger ation of the normal cur vatur e . Sc'

olio sis has mostly i ts convexity to the r ight with compen

sation above and below . The spinous pr ocesses ar e veryfr equently dir ected to the concavity. The inter costalspaces ar e very nar r ow on the left s ide, because ther e i sless cur vatur e of the r ibs

,and the r ibs ar e bent out

,

In the gr own-up woman the anter o-poster ior diameterof the pelvi s i s shor tened. Thi s i s not seen to the sameextent in the babe . In the normal baby the pelv1s 1 3 smalland the sacrum very steep, not concave as in the adult.Ther efor e

,when compr es s ion has taken place because of

softening,i t i s still smaller so that often it i s quite diffi

cult to examine the pelvi s sati sfactor ily; the sacrum maybe so changed as to give r i se to a convexity inward and

contr action of the two s ides . This nar r owing may be dueto the mer e fact that the softened bones ar e compr essedon the pillow,

o r by the arms of the nur se,a pr essur e

which i s sl ight,it i s true

, but qui te suflicien t. In very mildcas es the symphys is i s changed but littl e . In a numberof instances, however , i t will be found to be bent forward,and thus i n very ear ly r achit is

,the r achitic pelvi s i s very

similar to the pelvi s deformed by osteomalacia. Thi s i scontr ary to the usual descr iption in the books on oh

stetr ics.

The extremities suffer in differ ent ways , in all theirpar ts—the epiphyses and diaphyses, the per iosteum,

and

the epiphyseal car ti lages . The epiphys i s i s fr equentlythi ck and painful, par ticular ly on the for earm and tibia.

4 4 2

RACHITIC DEFORMITIES

A number o f cases of so -called gr owing pains ar e

simply instances of r achiti c epiphysitis . Sometimes thethi ckening is very consider able ; in most cases it i s un iform

,but in some it i s mor e developed later ally. This

is par t icular ly the case on the upper par t of the thigh.

The diaphys i s is usually bent . Semi—fr actur es take placein the arm

,clavicle and legs fr om a very tr ifl ing applica

ti on of for ce . The per iosteum, however,being soft

,

always acts as a shi eld to the inflamed bone when exposedto the danger of fr actur ing. In all those cases in whi chther e i s much cur vatur e

,par ticular ly in the lower ex

tr emity, the concavity i s inward, and on the for earm and

thighs it i s very often anter ior ly. The differ ence in thedi r ection of the cur vatur es depends on the influence of themuscular tr action, o r of the weight of the body. In thevery young the concavity of the lower extr emity i s inward because of the effect of the flexo r muscles. Whenthe bones become o r r emain soft in those who attemptto walk

, the weight of the bo dy r esults in outward cur vatur es

,and les ions of many kinds .

The ligaments ar e very flabby, and give r i s e to flat-footin childr en that stand up and attempt walking . The per io steum suffer s a gr eat deal, and in di ffer ent ways . I t i ssoftened and exhibits a thick layer of r achit ic deposit . Cal

cificatio n occur s in time, and then the diaphys i s will bemuch thicker and harder than in normal condi tions . The

bones o f rachitic pati ents,when r ecover ed

,ar e solid and

able to stand a gr eat deal of hardship in later li fe .In the r achi ti c per iosteum ther e may be haemor rhages .

Not infr equently i n bad cases of r achitis, and in thos ecases whi ch in the cour se of general illnutr itio n developpur pur a

,ther e ar e haemor rhages under the per iosteum in

the lower and upper extr emities . Many such cases ofdecided r achitis , and those which exhibit s imilar hazmo r

rheges without being mar ked by r achitis,have been thr own

together under the heading of, in this country, scur vy,and abr oad, acute r ickets .” In all of these cases, thechi ldr en ar e ill-fed ; ther e is a gr eat deal of pain in the

lower extr emities and feet, sometimes with and sometimes without per iostitis . The haemor rhages will heal and

4 4 3

DR. JACOBI ’S WORKS

leave a thicken ing in par t .o f the cases . Haemor rhage ofgums i s not -a requi s ite fo r the diagnosis ; it may be absent :

in tho se who have . n o teeth,o r who have ; and pr esent

even wher e ther e ar e no teeth..

Finally, deformities consisting of shor tening of the

whole limb ar e due to the ear ly. calcifications of the epiphyé

seal car ti lages . I t is on thi s physio logical . function thatthe length o f the diaphysi s . depends . When calcificationis complete

,the gr owth of .the bone

,and that . o f the limb

ceases .I wish to r emind you that .r achit is is a , gener al co n stitu

tio nal di sease . In it we have to deal not only with the

gener al system,par ticular ly with another par t of the loco

motor system—the .muscles. The .muscles sufl'

er just as

well as the bo nes'

in r achi ti s,and give r i se -to cer tain de

fo rmities. Both voluntary and invo lun tary . muscles ar e

affected. What has been called r achitic pseudo-par alys i s i s not par alys i s ; i t is s imply a weakness of the musclesand nothing else. . We .should have been . spar ed thi s newterm . The muscles ar e s imply poor ly developed

,and in

consequence they are easi ly fatigued. The involuntarymuscles suffer i n the same way.

Whi le the muscular tis sue i s po or ly developed,fat i s

liable to , be ample . Rachi tic childr en, unless emac iatedby pulmonary .o r . in testinal di seases

,ar e apt to be heavy

and r otund, and . thei r weight and appear ance ar e o ftenmistaken fo r healthy development . But they ar e flabby,anaemic

,and not capable of r esisting attacks of ordinary

di s eases like well childr en . They pr ove, mor eover , thatweight alone is. not . the measur e fo r healthy and steadyevolution .

The muscles in such. subj ects ar e flabby, and couse .

quently the stomach i s apt . to .be dilated,and the muscu

lar layer s of . the intestine ar e apt to , yield, thus givingr i s e to lar ge, flabby abdomens filled with gas, o n -the sur

face o f whi ch ar e di lated veins .The expansion of the intestines

,owing to

'

the weaknessof the muscles, gives -r ise to constipation . This constipationis char acter i stic . Rachitic chi ldr en become constipatedvery ear ly. I t i s sometimes the fir st symptom o f r achiti s

,

4 4 4

https://www.forgottenbooks.com/join