THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES COLLECTANEA JACOBI IN EIGHT VOLUMES VOLS. I, II AND III, PEDIATRICS VOLS. IV AND V, GENERAL THERA- PEUTICS AND PATHOLOGY VOLS. VI AND VII, IMPORTANT AD- DRBSSES, BIOGRAPHICAL, AND HIS- TORICAL PAPERS, ETC. VOL. VIII, MISCELLANEOUS ARTI- CLES, AUTHORS' AND COMPLETE TOP- ICAL INDEX DR. JACOBTS WORKS COLLECTED ESSAYS, ADDRESSES, SCIENTIFIC PAPERS AND MIS- CELLANEOUS WRITINGS OF A. JACOBI M. D. UNIVERSITY OF BONN (1851); LL. D. UNIVERSITY OF MICHIGAN (1898), COLUMBIA (1900), YALE (1905), HARVARD (1906). Professor of Infantile Pathology and Therapeutics New York Medical College (1860-1864); Clinical Professor of Diseases of Children, New York University Medical College (1865-1869) ; Clinical Professor of Diseases of Children, Col- lege of Physicians and Surgeons, Columbia University (1870-1899) ; Pro- fessor of Diseases of Children in the same (1900) ; Emeritus Professor of Diseases of Children in the same (1903); Consulting Physician to Bellevue, Mount Sinai, The German, The Woman's Infirmary, Babies', Orthopedic, Minturn and Hackensack Hospitals. Member of the New York Academy of Medicine (1857), Medical Society of the City and County of New York, Medical Society of the State of New York, Deutsche Medizinische Gesellschaft of New York, New York Pathological Society, New York Obstetrical Society, Association of American Physi- cians, American Pediatric Society, American Climatological Association, Congress of American Physicians and Surgeons, American Medical Association, International Anti-Tuberculosis Association, Association for the Advancement of Science; Associate Fellow of the College of Physicians in Philadelphia, Societe de Pediatrie de Paris, Societe d'Obstetrique, de Gynecologie et de Pediatrie de Paris, American Academy of Arts and Sciences; Foreign Member of the Gesellschaft fiir Geburtshulfe in Berlin; Corre- sponding Member Physicalisch-Medizinische Gesell- schaft of Wiirzburg, Gynecological Society of Boston, Obstetrical Society of Philadelphia, Gesellschaft fiir innere Medizin und Kinderheilkunde in Wien. Honorary Member Yonkers Medical Association, Louisville Obstetrical Society, Abingdon, Va., Academy of Medicine, Brooklyn Medical Society, Medical Society District of Columbia, New York Obstet- rical Society, Medical and Chirurgical Faculty of Maryland, American Laryngological Association, Pediatric Society of St. Petersburg, Pediatric Society of Kiev, Royal Academy of Medicine, Rome, Deutsche Gesellschaft fiir Kinderheilkunde, Verein fur Innere Medizin of Berlin, Royal Society of Medicine of Buda Pesth. IN EIGHT VOLUMES EDITED BY WILLIAM J. ROBINSON, M. D. NEW YORK 1909 CONTRIBUTIONS TO PEDIATRICS BY A. JACOBI, M.D., LL.D. VOL. I EDITED BY WILLIAM J. ROBINSON, M.D. NEW YORK THE CRITIC AND GUIDE COMPANY 12 MT. MORRIS PARK WEST 1909 COPYRIGHT, 1909, BY MARJORIE McANENY Biomedkal Library to 7 in of grpal anb gnni mrn long of a IjnBpttabl? rotmtrg for rontb00 faunra at tlje t|anb0 of r 0ortrii?0 anb burtng Ijalf a rrnturg. A. 3laroht 809754 AUTHOR'S PREFACE To MY READERS If there be any I desire to give an explanation of, or an apology for, the appearance of these volumes. For many years friends have en- couraged me to write my memoirs. They claimed that the Pares had not cut the thread of my life only to give me an opportunity to report what I had observed in connection with the history of the profession of the country in a medical practice extending over al- most sixty years, as a public teacher of medicine dur- ing forty-five years, and a member and an officer in many local, national and international associations. That may be true, but as a memoir writer I have not succeeded in being prolific beyond a few chapters which, with others, may or may not reach the eyes of my friends, and enemies, for a long time to come, if at all. A very good reason for that is intelligible to every New Yorker. We have no time for anything but work ; the luxury of leisure we do not possess ; and pleasure is enjoyed only, or mostly, by those who find pleasure in work. So no memoirs could be written, on account of con- stant, and constantly pressing work. Pegasus wears no harness, and I, like most of you, have always been in harness. Whether that was always an enjoyment or a benefit to others, I cannot tell you. But I believe I may assure my present readers that my memoirs, if they ever be written, will prove that my professional 7 AUTHOR'S PREFACE life, taken all in all, was very successful, if not always lucky or happy. To demonstrate that, a few reminiscences may be permitted here ; they may be repeated, amongst others, posthumously, may be ante-posthumously. The first of my professional successes was the fact that it took my first patient only a fortnight after my new shingle began to ornament No. 20 Howard street, to call on me with his twenty-five cent fee. That was in November, 1853. I must have had quite a reputation at that time, for his only excuse for coming at all was that he had heard of me. I think I must have gathered many more such fees, for after less than four years I was one of the founders of the German dispensary, in which treatment was strictly gratuitous. About the same time of this memorable achievement of mine, Dr. Stephen Smith, that good and glorious man, accepted from me a long series of extracts from European jour- nals and books, mostly on diseases of children, and within another year, he was pleased to accept, what I am still pleased to call, original articles. About the same time my inexperience made me try my first lecture on half a dozen suffering students (in the Spring course, of 1857) of the College of Physicians and Sur- geons. I nearly broke down, more or less deservedly. My subjects were the diseases of the young larynx and laryngismus stridulus. Nolens volens I exhibited in my own person an attack of laryngismus. We all sur- vived. A similar experience I had three years after- ward when I had been made professor of infantile pathology and therapeutics in the New York Medical College, then located on East 13th Street. If some one were anxious to learn how I, with my knowledge of 8 AUTHOR'S PREFACE pathology and therapeutics, which indeed was rather infantile, became a professor, this is how it happened. A friend of mine, who has a tablet of his own in the his- tory of American obstetrics, had taken a chair in the reorganized school. So my dear Charles Budd wished me to go in with him, and came as a committee to offer me a place in the faculty. When I used what I had of common sense and replied that I did not feel compe- tent, he tried his great art on himself. He delivered himself, with forcible tongue, of so many uncomplimen- tary remarks about me, that I accepted his terms at once. The very next year, the eighth, I made a heap of money out of literature, which is remarkable for a medi- cal man, unless he be Weir Mitchell, or Osier, or Holt. It happened this way, perhaps someone wishes to imitate me. Indeed, I believe he should. In 1859, E. Noeggerath and I published a big volume, " Contribu- tions to the Diseases of Women and Children," at an expense to ourselves of $800; a few years afterward we sold the edition as waste paper for sixty-eight dollars, a clear profit compared with nothing. Thirteen years passed, and I suffered from fire ; some rare books and specimens that I could never replace burned down with the University Medical College build- ing on Fourteenth Street. Over the ashes of my prop- erty Tammany Hall was erected, which refuses to burn, at least in this world. About the same time I cashed my first big hospital check in the shape of a petechial typhus, of which I got well after public prayers had been offered by some good old ladies. After seventeen years, I scored quite a success when I refusing to resign got myself expelled from a pub- 9 AUTHOR'S PREFACE lie institution for proving a hundred per cent, mortality amongst our babies, and for insisting upon a farming- out system. Thus things have been going on for years and decades, with and without any merit of mine. Once, only a few years ago, I had even my style criticized, if not corrected. There was a gentleman who had been working for a hospital thirty years. Then the matron found fault with him, and vice versa, and he was told that he would be permitted to resign, if he could not adapt himself to the lady. He resigned, for it is not everybody that prefers to be expelled. Thereupon, and on account of this maltreatment of a meritorious officer, I offered my resignation, which was accepted because the tone of my letter was declared to be unpleasant. Such specimens of the practical wisdom of other people I have enjoyed many times. Once in a while I had (like Jonathan Swift) to write or talk for their betterment, if not for their approval. Thus for in- stance : In another hospital the trustees interfered with the mode of electing medical officers, contrary to their own by-laws, which they might have altered if they had waited only two weeks. But they were in such a hurry to override themselves and overturn their doctors ! So I had to send them my message that they were no longer a parliamentary body, and also my resignation. In the course of a long life I have scored a choice lot of successes of that and other kinds, but after all, the definition of success as understood by different people varies very greatly. Still I must not forestall my future memoirs, which must be expected to contain many experiences not al- ways of a pleasurable order. But, at least, they have been instructive. I learned from them, and the lessons 10 AUTHOR'S PREFACE derived from them have benefited me, and as I intended they should, perhaps others. That my methods were always correct or politic, I do not say. Indeed I am certain that if I had displayed more patience in my at- tempts at improving such conditions as I found faulty or defective, I might have been more successful in carry- ing my points. I trust my mistakes, some of which may be traced in a number of papers, may interest my friends of the growing generation. They may remem- ber Cicero, who found that " the ears of the masses are dull," that a truth, when unpleasant, requires more than a single promulgation. Perhaps the revolutionary spirit of my youth and a warm temperament which boiled at a low temperature, made me overlook the slow pace at which reforms are established. Reforms re- quire alterations of opinions and tendencies, and or- ganic changes are of slow evolution. Looking back- wards forty years, I can imagine that the very ladies of the Nursery and Child's Hospital, like the trustees of other establishments, impressed with their good in- tentions and the originality of their positions, elated by the financial support furnished by the city and the State, but not accustomed to attend to the actual work connected with financial and mortuary records, and ad- verse to be taught by a mere doctor who proved a mor- tality in their institution of one hundred per cent., could have been with a certain amount of diplomacy, made glad and proud of improving both their methods and results. My old papers, rehearsed in one of these volumes, will tell a story which has not been the only one since. As our system of controlling public institu- tions has not met with radical changes, errors of ad- ministrations are always possible. If I have any ad- 11 AUTHOR'S PREFACE vice to give to my colleagues to whom much is given and from whom much is demanded in their connection with public affairs, it is to exhibit more patience but no less firmness. But I forget that this is no pulpit or platform. My following remarks may be briefer. The friends who urged me to republish old papers complained of their being hidden in transactions and forgotten magazines, and regretted that half of them were never reprinted, and that such reprints as existed at all were not acces- sible, except in a few large libraries. Some were more considerate than others. They wanted me to publish merely a volume or two of my therapeutic papers. So I began a process of examining and sifting, and here is the result. There are a number of historical studies. They contain facts and references which may prove useful to those who are in need of them. Indeed, there are persons whose historical interests are not limited to what has happened since the beginning of the twen- tieth century. Some are even so learned as to quote others besides themselves and their friends. An objec- tive report of historical facts should always be welcome. The history of medicine is neglected amongst us. Only of late we hear of an occasional course of lectures on this most important subject, and I know of no profes- sorship, not even lectureship, on the history of medicine in our schools. With the exception of a single quarterly journal devoted to the history of medicine, we have only John Watson's " The Medical Profession in An- cient Times," 1856; " The Nose and Throat in Medical History," by Jonathan Wright; Alvin A. HubbelPs " The Development of Ophthalmology in America," 12 AUTHOR'S PREFACE 1800-1870, 1908; Samuel D. Gross "Lives of Eminent American Physicians and Surgeons," 1861 ; " A Century of American Medicine," by Clarke, Bigelow, Gross, Thomas and Billings, 1876 ; the valuable works of Pack- ard and Mumford, and a very few others (Roswell Park, N. S. Davis). We have no systematic attempts at writing up ancient, modern, or our own medical history. The history of diphtheria is illuminated in a number of my papers. I have seen the scourge since 1858, and written about it many times since I860, thus embodying our advancing knowledge on the subject until to-day. The clinical description has not made much progress these many decades. Therapy, however, has changed wonderfully. O'Dwyer's intubation rendered tracheo- tomy almost obsolete indeed, after seven hundred tracheotomies of my own I have had no opportunity to operate since O'Dwyer ; and Behring's antitoxin has reduced the mortality to one-third. That the anti- toxin is useless in the very worst of septic cases, is pitiful ; still more pitiful is the fanaticism of all pos- sible sexes which objects to the bold use of alcohol, the best of antiseptics in these desperate and otherwise hopeless cases. In many of my addresses, those, who will look for them, may find many facts connected with the establish- ment of pedriatics as a special study and a subject of special teaching. It is a delight to know that beside J. Lewis Smith, Rotch, Holt, Huber, Griffith, Koplik, Northrup and Forchheimer there are scores of younger men who are forming what may be termed an American school of Pedriatics. The development of institutions, such as the New 13 AUTHOR'S PREFACE York Academy of Medicine, the Societies of the City and County, and State of New York, of libraries, and of national and international congresses will also be found alluded to, or discussed. At all events I believe that an attentive reader will be rewarded by much useful material. A number of cases reported dozens of years ago, have never lost for me the interest I took in them when they were first observed. I hope that my many talks on the principles of medical ethics will coincide with the opinions of most of my readers. The moral groundwork of a gentleman's feelings and be- havior was always the same, through centuries man's heart has always been human, only tastes differ and usually in trifles. Whether the profession of America will always object to a physician taking out a patent I do not know. They permit it in Europe. Whether we shall always object to a man printing his actual or pretended specialty on his shingle or his card, I cannot know. They do it in Europe ; but I trust, we shall always deem it objectionable, as soliciting pre- sumptuousness or lack of taste. But these things show perhaps only absence of judgment, but no lack of heart and conscience. But that there are men in the pro- fession who give or demand bribes, take " commissions " from apothecaries, instrument and bandage makers, nurses, men and women manufacturers, in the shape of cash or stock, consultants both medical and surgi- cal that is no longer professional, no longer even the competition of an honest tradesman : it is robbery, which pollutes the moral atmosphere of professional life, and fleeces the consumer of your services, i. e. the patient. My views regarding the principles of therapy, both 14 AUTHOR'S PREFACE hygienic and medicinal, I trust are agreeable to those who live a modern life, without superstitious belief in things because they are old, and without faith in the new stuffs merely because they are new. Many papers and addresses contain my views con- cerning the most important and momentous question at all times and before all nations, viz : the feeding of in- fants. If the problem were settled to everybody's sat- isfaction, it would not be necessary to speak again at this place. It is a satisfaction however to know, that modern physiology and biochemistry have not changed the practical teaching furnished me by domestic and clinical observations these more than fifty years. That a number of men high in our ranks are joining me quietly and unostentatiously in giving the babies a fighting chance against overdone theories and detri- mental practices of notoriety-seeking persons, is a source of congratulation. Long may they live, I mean the babies. Those friends of mine and of all the babies are not the ones you so often meet- in connec- tion with interviews, haphazard telephone conversations and reports of cases in the daily papers. They are clever enough to avoid being called in the public col- umns " expert in the diseases of children," " famous professor of pediatrics," and what not. Indeed these short-sighted people prefer to make an honest reputa- tion of their own and they succeed. In regard to the discussion of medical and sanitary problems in the daily press, our views may not always agree. It is customary to extol it, like the stage, and the pulpit, as the indispensable, omniscient and moral and most influential power. I mean to join in that praise^-of its possibilities, but I think we could add 15 AUTHOR'S PREFACE to its indispcnsability, omniscience, moral power and influence, without the necessary commission of many mistakes on the part of an uninformed, though ever so bright news-hunting, reportorial staff. What I have occasionally proposed was this, that a great paper should have on its editorial staff a thorough medical man whose whole or most of whose work should be dedicated to the study and discussion of popular medicine and sanitation in all its branches. Give him a large salary and be sure you will strike a cheap bar- gain by paying him well. At that rate your paper will secure, for ten thousand dollars a year, a reliable report and sound criticism of what you and your pub- lic is anxious and entitled to learn. A still better plan is this. In matters of political and social importance hundreds of newspapers have their central bureau, the Associated Press. The newspapers of the country should have their cen- tral bureau of sanitation and preventive medicine. Let them spend as much money on this center, say thirty or fifty thousand dollars, or more, as much as a single large life insurance company spends for a medical staff, for its commercial purposes. At that rate the papers can procure whatever knowledge there is, both old and new, and may at once become what they wish to be, and wish to be credited with, and deserve to be, foun- tains of popular science, teachers of the people, found- ers of a more intelligent, better informed, and healthier nation. The central bureau should be for all, furnish equal information for all, both for the people and its governments, without the dangers of grave mistakes, misleading sensationalism and corrupting competition. I should add a few words in regard to myself and 16 AUTHOR'S PREFACE the editor of these volumes. Dr. William J. Robinson has been my critic and guide. If I have fault to find with him it is that as a critic he was too lenient. It gave him evident pleasure to republish whatever appeared to contribute to the demonstration of the life-evolution of a man whose public utterances seemed to him to furnish some, though ever so slight, addi- tions to the scientific, mental and ethical acquisitions of the medical profession and its standing in the commonwealth. Being a good citizen himself, a de- termined adversary of doubtful or wrong practices amongst us, a strenuous fighter against past and pres- ent evils and in favor of a right-minded, strictly scien- tific and ethical future, he thought he met in my writ- ings a congenial spirit and sympathetic though modest ally. That is why he, though occupied with the duties of a medical practice and the editing and prac- tical creation of three scientific journals including his epoch-making " CRITIC AND GUIDE " has burdened himself with the arranging, editing, printing, proof- reading, translating, indexing, binding, indeed every- thing connected with the production of these volumes. If there be any merit in them it is his ; if the books lead to any praiseworthy results, the credit belongs to him. 19 East 47th Street. A. JACOBI. 17 EDITOR'S PREFACE I KNOW of no other man, either among the living or among those who have passed on, who in our country has had such an important influence on the develop- ment of medicine in all its phases, as has Dr. Abraham Jacobi of New York. The adjective important is, however, not adequate nor quite satisfactory. An influence may be important, and yet not beneficial; or it may be only partially beneficial, and it is sometimes a vexed problem to determine whether a man's influ- ence has been more beneficial than harmful or vice versa. No such problem confronts us in estimating the activity of Dr. Jacobi. For his influence has been wholly for the good, for the highest good both of the profession and of humanity. Bear this last word in mind. For great as Dr. Jacobi is as a physician, great as a teacher, great as an investigator, he is equally great as a humanitarian. Not here is the place, nor is mine the ability to speak of Dr. Jacobi's ser- vices to medicine proper ; of his services to pediatrics ; of the debt the little children the world over owe and forever will owe him ; of the thousands of lives that he has saved personally ; nor will I dilate here upon the indebtedness the profession owes him for holding aloft " and lighting its path with the torch of therapeutic op- timism in the midst of the stark-darkness of thera- peutic pessimism and despair ; nor will I speak here of his services in having brought American and Euro- 19 EDITOR'S PREFACE pean medicine closer together, his services in making us those of us who deserve to be respected respected abroad. I hope that all this will be adequately and properly done in another place by an abler pen than mine. What I want to allude to here is Jacobi, the physician-man. Jacobi belongs to the noble few who have perceived that the dispensing of pills, powders and decoctions is not the physician's only function, nor even his highest function. He belongs to the noble few who many years ago perceived that many diseases had a social-economic basis, and that if we wanted to do any good we had to improve the economic and sani- tary conditions of the people. And this he preached at every opportunity even when his preaching was not welcome. He belongs to the noble few who regard the physician's role as something more than that of a reliever of aches and pains he perceived the role of the physician's role as something more than that of a sanitarian, a preventer, a critic, a guide. And while he has sometimes been a severe critic, he has always been willing and ready to act as a guide. And his guidance has always been a safe and reliable one. What attracted me to Dr. Jacobi long before I had the pleasure of his personal acquaintance was his sturdy honesty, his rugged fearlessness, which one could read- ily feel in his public speeches and addresses. He never missed an occasion to inculcate a wholesome lesson. And he was never afraid of his audience. Where an- other person would pour out fulsome, cloying praise, he would offer healthy criticism; where another per- son would dispense nothing but taffy, Dr. Jacobi would present a good dose of Epsom salt ; to dispense undeserved flattery has always been as distasteful to 20 EDITOR'S PREFACE him as to receive it. And if his audience did not like some of the wholesome but bitter truths that he gave them, why, he just let them dislike them. His ad- dresses, at the various annual, decennial, semi-centen- nial and centennial celebrations, his presentation and banquet speeches, are very, very many in number. I have read them all, and I cannot think of one which could be characterized merely as a conglomeration of nice, soft words, of adulatory, obsequious, flattering phrases ; there is not one, as far as I remember, that does not contain some gentle satire (or one perhaps not quite so gentle) on our foibles and failings, on our egotism, on our desire to seem what we are not, on our sins of omission and commission. By his frank speeches he has made some enemies well, we love him for the enemies he has made. The entire history of American medicine during the past half century is reflected in Dr. Jacobi and in his writings. Not only has he been a faithful chron- icler, but, what is more important, he has been to a great extent the maker of this history. He has kept tab on the progress of medicine in every one of its branches, and he has always kept step with the pro- cession. Often, very often, we find him in the van- guard, but never, never in the rear, never among the laggards. And he who wants to know the history of medicine in America during the past half century, must read the writings of A. Jacobi. Therein he will find expressed its hopes and disappointments, its progress and backward movement ; every step leading to the elevation of the profession he will find therein praised and encouraged, while every step tending to degrade our great profession, every step leading to falsehood, 21 EDITOR'S PREFACE hypocrisy, mediocrity and commercialism has been scorched by him in no uncertain terms. Excellent as is the quality of Dr. Jacobi's writings, their quantity no less excites our admiration. Especially so, when we recollect that he has not rehashed any text-books and then published them as his own, and that he has never written because of an unquenchable cacoethes scribendi. No, Dr. Jacobi writes only when he has something to write and he speaks only when he has something to say. Unfortunately many of his essays and papers have been hidden away in periodicals which are not readily accessible, or in society transac- tions which are altogether inaccessible ; some of his addresses have never been published, and others have been delivered or written in German. Some of the ad- mirers of Dr. Jacobi, among whom I most emphatically count myself, have thought it a great pity to have so many of his excellent, important and even epoch-mak- ing writings become practically lost. They thought it an injustice to Dr. Jacobi and a sin against posterity. Dr. Jacobi was approached on the subject. With the modesty of true greatness he could not see it our way. He did not think that his writings were really of such importance, etc. Finally he was prevailed upon. And I have been honored with the task of selecting, editing, arranging, translating and preparing for the printer the enormous mass of the material of which Dr. Jacobi is the author. The task seemed an enor- mous one, but no task is difficult into which you put some love. How I have acquitted myself of this labor of love, I leave others to judge. The arrangement of the matter is, as far as feasible, both by subjects and chronological, but no pedantic 22 EDITOR'S PREFACE rule has been followed. A more or less logical arrange- ment seemed to us the best. In writings extending over a period of over a half a century, some repetition is unavoidable. To minimize this, the articles have in some cases been condensed. Others have, on account of their historical value, been considered too important to admit of their abbrevia- tion or condensation in any way. And it was consid- ered much better to incur the risk of occasional repe- tition than to run the danger of eliminating and losing a single historically or scientifically valuable sentence. For the sake of historical fidelity, it has seemed best, as a rule, to leave the spelling and the nomen- clature as they appeared originally. We will therefore meet in these volumes : anaemia and anemia, haemor- rhage and hemorrhage, peritonaeum and peritoneum, hypermanganate of potassa and potassium perman- ganate, hydrochlorate of ammonia and ammonium chloride, therapeutical and therapeutic, etc., etc. The author has kept pace both with the simplified spelling and the constantly changing pharmacopeial nomen- clature. May these volumes which we trust will remain a monument of Dr. Jacobi's varied activity aere peren- nius more permanent than bronze also serve as an inexhaustible source of inspiration to the profession of our country, the profession which Dr. Jacobi has loved so well, the profession which in spite of its im- perfections remains the noblest of all professions ! WILLIAM J. ROBINSON. 12 MT. MOBRTS PARK W. 23 CONTENTS VOLUME I AUTHOR'S PORTRAIT (Steel plate) . . . Frontispiece AUTHOR'S PREFACE 7 EDITOR'S PREFACE 19 TABLE OF CONTENTS 25 INTRODUCTORY CHAPTER 27 From Keating's " Cyclopaedia of the Diseases of Children," Vol. I. THE RELATIONS OF PEDIATRICS TO GENERAL MEDICINE 41 Address delivered before the American Pediatric Society at Washington, D. C., September 20, 1889. Archives of Pediatrics, November, 1889. THE HISTORY OF PEDIATRICS AND ITS RELA- TION TO OTHER SCIENCES AND ARTS ... 55 Address delivered before the Congress of Arts and Sciences, St. Louis, Mo., September 21, 1904. Ameri- can Medicine, November, 1904. THE HISTORY OF CEREBRO-SPINAL MENINGITIS IN AMERICA 95 Transactions of the Medical Society of the State of New York, 1905. CEREBRO-SPINAL MENINGITIS: SYMPTOMA- TOLOGY AND TREATMENT 107 Part of a paper read before the Deutsche Medicinische Gesellschaft der Stadt New York. New Yorker Medi- cinische Monatsschrift, April, 1.905. Translated from the German. The history of Cerebro-Spinal Menin- gitis and the mortality statistics of the disease have been omitted from this article, as they are dealt with adequately in the preceding paper. DIPHTHERIA: ITS SYMPTOMATOLOGY AND TREATMENT 121 From " The Twentieth Century Practice of Medi- cine." THE PATHOLOGY AND TREATMENT OF THE DIF- FERENT FORMS OF CROUP 213 Read before the Medical Society of the County of New York. American Journal of Obstetrics, Diseases of Women and Children, May, 1868. 25 CONTENTS CHOLERA INFANTUM 253 From " The Twentieth Century Practice of Medi- cine." TYPHOID FEVER IN THE YOUNG 293 Read before New York State Medical Society, October 25, 1899. Pediatrics, Vol. VIII., No. 12. ANAEMIA IN INFANCY AND EARLY CHILDHOOD 323 Read before Medical Society of the County of New York, December 27, 1880. Archives of Medicine, Vol. V., No. 1, 1881. TREATMENT OF INFLUENZA IN CHILDREN . . 347 Part of a paper read before the Medical Society of the County of New York, November 26, 1900. Medical News, December 15, 1900. OTITIS MEDIA IN CHILDREN 357 Read before the New York Academy of Medicine under auspices of the Section on Otology, Decem- ber, 1904. Archives of Otology, No. 2, 1905. NEPHRITIS OF THE NEWBORN 369 Read before the Medical Society of the District of Columbia, November 28, 1895. New York Medical Journal, January 18, 1896. THE PREVENTION OF TUBERCULOSIS IN SCHOOL CHILDREN 393 Lecture delivered' before Teacher's College, New York. Teacher's College Record, March, 1905. CAUSES OF EPILEPSY IN THE YOUNG . . . .411 Read before the National Association for the Study of Epilepsy, November 5, 1902. American Medicine. December 13, 1902. TREATMENT OF ENURESIS 431 From Keating's " Cyclopaedia of the Diseases of Children," Vol. III. ' RACHITIC DEFORMITIES: ETIOLOGY, CLINICAL HISTORY AND LESIONS 439 A discussion at the meeting of the American Ortho- pedic Association at Washington, D. C., May 30, 1894. Stenographic report. Archives of Pediatrics, Sep- tember, 1895. 26 INTRODUCTORY CHAPTER * UPON me has been conferred the honor of introducing to the medical public the essays of all the distinguished men contributing to this great work. Though with some hesitation, it is with still more satisfaction that I comply with this demand. For the very enterprise marks an im- mense progress in the history of both general medical and pediatric literature. Indeed, when I began my profes- sional life, such a collection of monographs as will here be offered could not have been written. Now, that during a single generation there should have been such a thorough change in the methods of both medical thought and work, is a source of the most intense gratification, as well to me as to every other man who has absolute faith in the per- sistent evolution of science and the improvement of the race. That there should be any doubt as to the propriety of a large special work on the diseases of children, I can hardly believe in the present stage of development of American medical literature. As far as I am concerned, I never objected to being found among the adversaries of the wildfire of specialism which has been spreading among the groups of medical men. On the contrary, I am still of the opinion I expressed eight years ago when I opened the first session of the Section on Diseases of Children, of the American Medical Association, at its meeting at New York. With more pertinacity than logic, pediatrics (compre- hending the anatomy, physiology, pathology, and thera- peutics of infancy and childhood) has also been claimed as a specialty. This is a mistake, however, which has been made more frequently on the continent of Europe than with us. It is there that practitioners and authors [ * This formed the Introductory chapter to Keating's " Cyclo- paedia of the Diseases of Children." It has seemed appropriate to use it as the introductory chapter to the volumes on Pedi- atrics. Editor.] 27 DR. JACOBI'S WORKS advertise themselves, for reasons of their own which would not be approved of here, as " children's physicians " and " specialists." Pediatrics, however, is no specialty in the common acceptation of the term. It does not deal with an organ, but with the entire organism at the very period which presents the most interesting features to the student of biology and medicine. Infancy and childhood are the links between conception and death, between the fcetus and the adult. The latter has attained a certain degree of invariability. His physiological labor is reproduction, that of the young is both reproduction and growth. As the history of a people is not complete with the narration of its condition when established on a solid constitutional and material basis, so is that of man, either healthy or diseased, not limited to one period. Indeed, the most interesting time and that most difficult to understand is that in which a persistent development, increase, and im- provement are taking place. This appears to have been felt, instinctively, from the very beginning. The history of pediatrics, therefore, is as old as that of medicine. Their literatures have developed uniformly, from superstitious beliefs to empirical state- ments and the methodical researches of the present time. The last centuries, particularly the last decades, are re- plete with text-books on the diseases of children, mono- graphs on their pathology, physiology, and hygiene, and journals, quite a number of which are now published in the four principal languages of the civilized world. These monographs and journals have contributed a great deal to the amount of medical knowledge. Special re- searches of the normal condition of embryonic, foetal, and infant growth, the study of the functions of the organs in their constant development and changes, and anatomical and clinical investigations, have contributed to prove that pediatrics does not deal with miniature men and women, with reduced doses and the same class of diseases in smaller bodies, but that it has its own independent range and hori- zon, and gives as much to general medicine as it has re- ceived from it. There is scarcely a tissue, or an organ, which behaves 28 INTRODUCTORY CHAPTER exactly alike in the different periods of life. The bones contain less phosphates in the young and exhibit other chemical differences, their anatomical structure is differ- ent, their increase less periosteal, than in advanced years. The cartilaginous condition of the epiphyses gives rise to a number of disorders ; the cartilages between the epiphy- ses and diaphyses are subject to all forms of disease, from a simple irritation resulting in abnormal growth (for in- stance, after eruptive fevers) to a separation, by suppura- tion, of the epiphyses. There is hardly a chapter more interesting than that of the relation of the bones of the cranium to its contents. A solid skull serves as a sup- port to the brain and its blood-vessels, or it may prove an obstacle to their development; an insufficient degree of ossification, and an undue amount of sutural substance, will enhance the possibility of enlargement of the blood-vessels and the liability to effusion. Premature ossification, how- ever, either partial or general, is a cause of asymmetry, epilepsy, or idiotism, and influences the course of inter- current diseases. The large size of the head, which is equalled by that of the thorax about the middle or the end of the third year only, is in close relation to the physio- logical growth of the brain and its pathological changes. The veterbral column is quite flexible, but straight, and mainly so in its upper portion. Its very flexibility is a ready cause of the frequent occurrence of scoliosis. Its distance from the manubrium sterni is so small that oc- casionally a thymus, and frequently enlarged lymph-bodies, are a cause of irritation or compression. The base of the thorax is, however, relatively wide, while its height is less. This becomes particularly striking by the almost rec- tangular insertion of the ribs at the transverse processes of the vertebrae and the sternum, and by their almost hori- zontal and circular position by which the respiration be- comes less costal, and the viscera of the abdominal cavity, mainly the liver, appear more prominent. Changes of a pathological character are quite frequent about this time, and a frequent cause of disease in later life. Hueter's researches on the congenital contraction of the chest, and Freund's investigations on the premature ossification of the 29 DR. JACOBI'S WORKS costo-cartilaginous junctures, are exceedingly important, in- asmuch as they explain many of the isolated cases of thoracic insufficiency, phthisical habitus, and pulmonary in- competency. The nervous system of the young is but in a preparatory condition. The brain is large, but contains a large per- centage of water, is soft, and its gray and white sub- stances differ but little in color and composition. The spinal cord has not yet the consistency of a later period ; the anterior horns are predominant, and therefore more frequently the seat of pathological changes. The periph- eral nerves are relatively large, but little excitable, in the first days. Their excitability grows very fast, however, towards the end of the first year, and quite out of pro- portion with the slow development of the inhibitory centers. Thus it is that about that time convulsive symptoms are so very frequent. For a short time after birth the con- ducting fibres between the undeveloped brain (it takes the psycho-motor centers of Ferrier and Hitzig a month to exhibit the first signs of existence) and the pyramidal fibres of the cord perform no functions ; thus the first movements of the newly-born are not controlled by will- power at all, but subject to reflex exclusively. After that time the brain develops very fast indeed, but far from uniformly in all its parts. It is a most interesting study thus to follow the evolution of the cerebral functions in their dependency upon the anatomical development. The digestive organs of the infant exhibit a great many peculiarities in their anatomy, physiology, and pathology. The epithelial " pearls " along the median line of the palate, and the thinness of the mucous membranes over the roof of the oral cavity and along the gums, give rise to early trouble, the small size and vertical position of the stomach to a number of abnormal symptoms, the con- genital malformations of the intestine to serious dangers, the abnormal length of the lower part of the colon to an unusual form of protracted constipation, the prevalence of polypi in the rectum to hemorrhages of a kind seldom found in advanced age. The glands required for the di- gestive processes are but gradually prepared for their 30 INTRODUCTORY CHAPTER functions. The salivary glands are but partially active at birth, the pancreas requires time for its full develop- ment, the secretion of lactic predominates over that of muriatic acid in the stomach, the intestinal lymph-bodies are in part, particularly the patches of Peyer, so behind their future size and formation as to change their func- tions considerably. The time of dentition adds to the in- terest of the period, more, it is true, from a physiological and anatomical standpoint than on account of patho- logical reasons; for its alleged causal connection with the large number of diseases attributed to its mere occur- rence has been greatly exaggerated. In connection with these brief remarks on some of the peculiarities of the alimentary tract of infancy, I may be permitted to merely allude to the question of nutrition and feeding. Several meetings of the Children's Section of the German Association of Physicians and Naturalists, the last one of that in the American Medical Association, and the deliberations of every medical society in every land, prove its importance. These questions belong, as special stud- ies, eminently to pediatrics ; physiology and chemistry can teach the general principles only, and to clinical observa- tion is left the final settlement of the hygiene of infancy. The relation of nurse's to mother's milk, the utilization of cow's milk in all its different forms as one of the con- stituents of artificial foods, the value of farinaceous ad- mixtures, the addition of animal foods, the proportions of salts and water, the quantity to be administered, the length of intervals between meals, the alterations required in sickness, are just so many questions which demand persistent study and special industry. The blood and the organs of circulation exhibit the most interesting differences in the young as compared with the adult. The young infant (and child) has less blood in propor- tion to its entire weight; this blood has less fibrin, fewer salts, less haemoglobulin (except in the newly-born), less soluble albumin, less specific gravity, and more white blood- corpuscles than the blood of advanced age. There are some other differences, depending on age, in 31 DR. JACOBI'S WORKS the composition of the blood, more or less essential. The foetal blood and that of the newborn contain but little fibrin, but vigorous respiration works great changes in that respect. Nasse found the blood of young animals to co- agulate but slowly. In accordance with that observation, it strikes us, in regard to cerebral apoplexy of the new- born, that the time for coagulation of the blood must be longer than in the adult; for hemorrhages are apt to be most extensive in the infant. In the sanguineous tumor (kephalhaematoma) of the newly-born, the blood remains liquid in the sac for many days. In apoplexy it is apt to spread all over the hemispheres, and has plenty of time to perforate and penetrate the pia in all directions, destroy much of the cerebral tissue, and flow down the spinal cavity. These occurrences are so frequent in the infant, and so rare in the apoplectic adult, that they can hardly be explained except through the insufficient co- agulability of fostal and infant blood. The size and vigor of the newly-born heart offer a ready explanation of the rapid growth of the infant body, and mainly those organs which are in the most direct com- munication with the heart by straight and fairly large blood-vessels. In this condition are the head and brain. Thus the latter has an opportunity to grow from 400 grammes to 800 in one year; after that period its growth becomes less marked. At seven, boys have brains of 1,100 grammes; girls, of 1,000. In more advanced life its weight is relatively less, 1,424 in the male and 1,272 in the female. At the same early period the whole body grows in both length and weight. The original length of 50 centimeters of the newly-born increases to 110 with the seventh year; the greatest increase after that time amounts to 60 (in the female 50) centimeters only. In the same time the weight increases from 3.2 kilogrammes to 20.16 in the boy, from 2.9 to 18.45 in the girl. This gives a proportion of 1 to 6 or 7, while after that time the increase is but three- or fourfold. The normal relation of the weight of the heart to that of the lungs, between the second and twentieth year, is 1:5-7; in scrofula it is 1:8-10. That means, the heart 32 INTRODUCTORY CHAPTER is smaller than normal, in the latter condition. Other parts of the system of circulation exhibit traits of their own. It is particularly in the " torpid " form of scrofula that, by virtue of insufficient circulation, the lymphatic system participates pre-eminently. This fact is the more impor- tant, as the size, patency, and number of lymphatics are quite unusual in infancy. Sappey found that they could be more easily injected in the child than in the adult, and the intercommunication between them and the general system is more marked at that than at any other period of life. These facts have been confirmed by S. L. Schenk, who, moreover, found the net-work of the lymphatics even in the skin of the newly-born endowed with open stomata, through which the lymph-ducts can communicate with the neighboring tissue and cells. In rhachitis, the heart is of average size, but the arteries are abnormally large. Great width of the arteries lowers blood-pressure. This allows of the best explanation of the murmur first discovered by Fisher, of Boston, over the open fontanelles of rhachitical babies, a very much better one than that proposed by Jurasz, who looks for their cause in irregularities of the canalis caroticus. Still, it is a mistake to believe that these murmurs, audible over the brain, belong to rhachitis only. They are found in every condition in which the blood-pressure in the large arteries of the cranial cavity is lessened. E. Hoffmann discovered the peculiar fact that the ar- terial pressure is very small in the newly-born animal. Even as large arteries as the carotid, when cut, do not spurt as in the adult. This low arterial pressure is one of the reasons why cords not ligated will often not bleed, with the exception of those cases in which the arterial pressure is increased by a moderate degree of asphyxia, or when the lungs are not inflated in consequence of in- complete development of the muscular strength in the pre- maturely-born foetus. According to a number of actual observations made by R. Thoma, the post-foetal growth is relatively smallest in the common carotid, and largest in the renal and fem- oral arteries. Between these two extremes there are DR. JACOBI'S WORKS found the subclavian, aortic, and pulmonary arteries. These are differences which correspond with the differences in the growth of the several parts of the body supplied by those blood-vessels. In regard to the renal artery and the kidney, it has been found that the size of the former in- creases more rapidly than the volume and weight of the latter. Thus it ought to be expected that the frequency of congestive and inflammatory processes in the renal tissue will be almost predestined by the disproportion between the size of the artery and the condition of the tissue. More- over, the resistance of the arterial current offered by the kidney-substance depends also upon the readiness with which the current is permitted to pass the capillaries. Now, it has been found experimentally that their per- meability is greater, and that within a given time more water proportionately can be squeezed through them, in the adult, than in the child. This anatomical difference may therefore be the reason why renal diseases are so much more frequent in infancy and childhood from all causes, with the exception of that one which is reserved for the last decades of natural life, viz., atheromatous de- generation. In the arteries of medium and small calibre the elastic membrane is a thin and simple membrane; it is only in larger arteries that elastic fibres will also extend into, and mix with, the adjoining layers. The elastic membrane is particularly thin, may even be entirely absent, where the branches are given off from the arteries. It is here that spontaneous hemorrhages are most apt to take place. It is here also that, in later life, aneurisms are met with, such as find no ready explanation by an injury. The anatomical structure of the three umbilical vessels differs from that of all the rest of either arteries or veins in many points, principally in this, that there is no elastic membrane and no intima in the arteries. Some elastic tissue is found near the umbilicus, and it gradually in- creases in the abdominal cavity; but the intima is not de- veloped in the arteries until they are in close proximity to the iliac. Thus by the massive and powerful develop- ment of the muscular layer it is explained why there are 34 INTRODUCTORY CHAPTER so few hemorrhages though no ligature has been applied to the cord. The umbilical vein differs from the arteries very much less than is usual with veins and arteries in any other parts of the body. The muscular layer is very large and strong in the vein. There is no intima. None of the three vessels emits branches; there are no vasa vasorum and no nerves in their walls. Altogether, the growth of the internal organs and the whole body does not proceed uniformly. In this respect the blood-vessels do not stand alone. What Beneke called the morbid disposition of the several ages, is best ex- plained by these variations in growth and power. That author spent much time and labor on the measuring of blood-vessels in particular. It was he that found the ar- teries proportionately wide until the period of puberty. From that time the heart increases rapidly, and the ar- teries less. In infancy the relation of the volume of the heart to the width of the ascending aorta is 25 : 20, before puberty 140:56, and after puberty 290:61. Thus it is that the general arterial blood-pressure of infants is less and the heart-beats are more frequent. After birth the pulmonary artery is much larger than the aorta; after the first year the width of the former compared with that of the latter is 46 : 40, in the adult 35.9:36.2, in advanced age 38.2:40.4. It is easily under- stood to what extent both the normal development and the diseases of the lungs may be influenced by these relative sizes of the vessels. That the size and strength of the right heart should have a favorable influence on the course of a pneumonia is an inference deserving of credit. The reverse of the normal oversize of blood-vessels in the infant and child is found in abnormal smallness, par- ticularly of the arteries. The worst, and mostly incurable, forms of chlorosis are the results of this anomaly. They have been studied by Trousseau, Virchow, See, and others, in connection with a small, or normal, or fatty heart, and in their complications with occasional hemorrhagic dia- thesis. All forms of persistent anaemia may depend on this insufficient development of the arteries: the specimens 35 DR. JACOBI'S WORKS taken from a woman of thirty-two years, who died with all the symptoms of " essential " anaemia, are in my pos- session. To the consideration of the organs of circulation I have given so much prominence because of their pre-eminent influence in etiology. The changes of periods of life and advancing age are mainly occasioned by the altera- tions in the structure of the walls of the blood-vessels. Their original thinness and fragility occasion hemorrhages in the newly-born, as does their anomalous condition in senility. Nor is there any organ which is not constantly under the control of the blood-current. This chapter would, however, grow to undue length, and encroach too much upon the legitimate province of the special essays devoted to the consideration of the subjects to which I should only allude, were I to continue to enlarge upon them. A few more remarks, therefore, may suffice. There are anomalies and diseases which are met with in the infant and child only. Among this class we meet con- genital diseases and malformations, the affections of the umbilical cord, of the ductus arteriosus, and of the tunica vaginalis of the spermatic cord, atelectasis and cyanosis, the diseases of the thymus, the anomalies of the intestinal tract, congenital constipation, as I have called it, result- ing from the exaggeration of the normal length of the long sigmoid flexure, and, finally, rhachitis. Other diseases are mostly found in children, or with a characteristic symptomatology and course. Both acute and chronic hydrocephalus, acute eruptive diseases, whooping- cough, and diphtheria are mostly found at an early age. Diphtheria is very liable to assume different characters in different ages ; even the simple inflammations of the tonsils vary in severity and nature according to the amount of tissue destroyed or new hyperplastic connective tissue formed in the course of repeated attacks. Almost all the diseases of the intestinal tract in children have their pe- culiarities, and require the special study of foods and hy- giene. The majority of cases of intussusception take place in infants, in localities with symptoms of their own. There are diseases which affect both the young and the 36 INTRODUCTORY CHAPTER old; in them the size or nature of the organ, or the difference in the degree of irritatibility, affect the sympto- matology of the case considerably. In the narrow larynx of the child, diphtheria gives rise to the complex symp- toms of pseudo-membranous croup. Tracheotomy and in- tubation are subjects eminently belonging to pediatrics. In the vulnerable infant only, intestinal worms will give rise to convulsions; and the large majority of cases of polio- myelitis and polioencephalitis also are reserved for infancy; indeed, so great is the difference between the ages, that the infant is the proprietor of the medio-canellata, while the adult glories in the taenia solium as a tenant. Let me add that there are differences of many degrees in many other diseases, accordingly as they occur in the young or in the old. The pneumonia, tuberculosis, typhoid fever, rheumatism, epilepsy, and diabetes of the young differ considerably from the same affections of the adult, in their clinical and, sometimes, anatomical aspects. Therapeutics of infancy and childhood are by no means so similar to those of the adult that the rules of the latter can simply be adopted to the former by reducing doses. The differences are many. Among the antifebriles cold is tolerated less, quinine more, in proportion, than in the adult. So are antipyrin and antifebrin, also phenacetin. Heart-stimulants are also borne in relatively large doses: thus, digitalis, strophanthus, and sparteine. Caffeine is less advisable except where there is positively no cerebral complication of a congestive or inflammatory nature. Of the narcotics, opium must be watched; its doses must be relatively small. Belladonna is borne in rather large doses, and hyoscyamus can be given in much larger doses pro- portionately in spasmodic conditions of the bladder than in advanced age. Some of the powerful medicines are required in smaller, some in larger doses. Chlorate of potassium demands great care; carbolic acid becomes poi- sonous in small doses given to the very young, even ex- ternally; preparations of arsenic are borne in rather larger doses for many weeks and months ; corrosive sublimate mercurials generally in rather large doses, because of the extraordinary immunity in regard to stomatitis and to 37 DR. JACOBI'S WORKS the gastric and intestinal irritation so often observed in the adult. Now, what has been done to facilitate the acquisition of knowledge on all these points by the student and prac- titioner of medicine? Very little indeed. There never was any systematic instruction in the diseases of children, by a teacher appointed for that branch of medicine ex- clusively, until (in I860) I established a weekly children's clinic in the New York Medical College, at that time in East Thirteenth Street. That was the first of its kind in the United States. When the college ceased to exist (in 1865) I established a children's clinic in the Uni- versity Medical College and in 1870 in the College of Phy- sicians and Surgeons. In both these institutions, as also in the Bellevue Hospital Medical College, such clinics have existed since, and a number of the medical schools of the country have imitated the example. In them, a single hour weekly, during the regular courses of the winter, is given to the student of medicine for the special study of the diseases of children, who will, in his future practice, form the majority of his patients. In the course of four so-called years, which the legislatures of our States pronounce sufficient for the attainment of all medical knowledge required for the welfare of the coun- try, the student is pressed very hard for time. There are a number of branches which he is taught to deem worth his while and attention, by being told that he will be examined in them before obtaining his diploma ; but the diseases of children are not now among these. To my knowledge, there is no school in the country which lays the least stress on that branch of instruction; for I hope there is nobody nowadays, even among the teachers of medi- cine, who believes that a few didactic lectures of the pro- fessor of " theory and practice " are a sufficient prepara- tion for the preservation of the children of the people. No examination being required by those to whom the stu- dent looks for direction and enlightenment, he neglects the study, to find out too late the mistake he has made in so doing. It is no consolation that in Great Britain the same com- 38 INTRODUCTORY CHAPTER plaints are made. But a few months ago the chairman of the Section of Diseases of Children, Dr. Cheadle, spoke in feeling terms of the neglect in the schools and clinical institutions of Great Britain of this most important part of practical medicine, before the British Medical Asso- ciation. The continent of Europe has made more rapid progress. Most of both the large and the small univer- sities have their chair of the Diseases of Children, not a " clinical " one, which means the authority given an en- thusiastic worker to teach as much or as little as he can in an hour weekly, without recognition, thanks, or reward, of a doctrine not officially recognized; they have hospitals in which to teach practically every day what has been taught in didactic lectures and learned from books, and their students know beforehand that they will have to prove, before being permitted to practise, their acquaint- ance with what they are compelled to learn of the diseases of children. Thus it is in France and Italy, in Germany, Austria, and Sweden ; thus it is now in Russia, but not so in England and in our country. What can be done to improve this state of things? Every future improvement in general medical education will favor the study of pediatrics. There will be a time in the near future when the student in medicine will be aware that he will have to pass an examination in the sub- jects connected with the physiology and pathology of the young. There will be another time when the medical courses will be both long and numerous enough to permit of clinical instruction in the diseases of children being given three or six times a week, and another in which there will be bedside teaching. For that purpose it is that either special hospitals or large wards in general hos- pitals are an absolute necessity. It is in them only that the student, and the professional man also, may learn under supervision, and without the danger of each having to fill with victims a burying-ground of his own, both how to diagnosticate a disease in a child and how to nurse and treat a sick one. In hospitals alone can good ob- servations be made in reference to the course of diseases, and the effects of remedies and methods of treatment. 39 DR. JACOBI'S WORKS Moreover, special societies must be founded for the pur- pose of studying questions connected with pediatrics, or special . sections formed in larger and established asso- ciations. The new Children's Section in the New York Academy of Medicine, that of the American Medical As- sociation, and the successful organization of the American Pediatric Society prove the intensity of the interest the American profession has commenced to take in the sub- jects legitimately belonging to that part of medical science and practice. Finally, all of the latter, as well as those to which I could but incompletely allude, as all others suggesting them- selves to the careful observer and thorough student, must be the themes of persistent individual study. Besides, as there must be time to learn other men's observations, so time must be found to contribute what is new and val- uable in every professional man's life. The basis on which to proceed is to be furnished by this Cyclopaedia, the introductory remarks to which I am kindly permitted to offer. This book bids fair to contain all that is known at present on the anatomy, physiology, pathology, and therapeutics of infancy and childhood. May the American profession see to it that this same book, while being a digest both of the labors of the past and the attainments of the present, shall become the solid foundation of suc- cessful scientific work in both the near and distant future. 40 THE RELATIONS OF PEDIATRICS TO GENERAL MEDICINE GENTLEMEN: Progress and success, in order to be com- plete and unmistakable, require centralization of means and co-operation of men. The pioneer in his seclusion, the hard-working settlement, the thin population of a county, the joining of the disseminated parts to form a state, and the amalgamation resulting in the establishment of a powerful and world-moving nationality, exhibit an example of the geometrical increase of strength resulting from the combination of forces. The isolated labors of the greatest men in the history of science never accomplished anything beyond a spasmodic and stationary advance. Twenty cen- turies in succession lived on the unchanged teachings of Hippocrates, Aristotle, and Galen. The establishment of institutions of learning in modern times, mainly since the fifteenth and sixteenth centuries, multiplied the names of men, though none reached those three ancients, who, in contact with others equally dis- posed, labored successfully in the interests of science. Paracelsus, Descartes, Sydenham, Boerhaave, Van- Swieten, Haller, Pete Frank, and Bichat promoted science,, partly through contest, partly through co-operation with fellow-laborers. The multiplication of institutions, the similarity of aims and ambitions, the establishment of faculties and learned societies, accomplished, through the co-operation and friction thus created, a progress more pronounced in decades than formerly in centuries. The best results, however, were obtained by the volun- tary association of scientific men all over the world. In this century, the German Association of Naturalists and Physicians, the British and the American Medical Asso- ciation, the numerous local and provincial societies, and last, though by far not least, the American Congress of Physi- 41 DR. JACOBI'S WORKS cians and Surgeons, with its many special associations and societies, have not only encouraged scientific originality, but raised the average standard of the profession at large. That is what the isolated labors of individual men never attained. From this point of view I hailed the proposal to form an American Pediatric Society with satisfaction and delight. Thirty years ago I contemplated the formation of a section for the purpose of studying the diseases of children in the New York Academy of Medicine, and failed. These nine years the American Medical Association had its sec- tion on diseases of children, the first meeting of which took place under the presidency of S. C. Busey, and the New York Academy of Medicine has a flourishing pediatric section under J. L. Smith. To-day this national association has convened without difficulties and with all the promises of speedy success. The spontaneity of its origin is a guarantee of vitality and prosperity. My failure at that early time did not signify that no attention had been paid in the United States to the physiology and pathology of infancy and childhood. It simply meant that the relations of pediatrics to practice and to the other departments of medicine were not yet duly appreciated. In most countries in Europe it was the same. In America the names of Dewees, Stewart, Eberle, Condie, Charles D. Meigs, John Forsyth Meigs, and W. V. Keating are still holding an honorable place in the history of pediatrics. But their labors were individual and isolated. Though their teach- ings were appreciated, the profession at large was not sufficiently advanced to look upon the close and special study of the diseases of children as a necessity from the twofold point of view under which I began early to con- sider it. I was ever of opinion that not only had special occupation with infant pathology and therapeutics its re- ward in itself, but its connection with every other special doctrine aided and fostered the intimate and profound knowledge of other branches of medical science and art. Thus the future connection of this society with the Trien- nial Congress of American Physicians and Surgeons will prove a mutual benefit to all parties concerned. In an introductory to the " Cyclopaedia of the Diseases 42 PEDIATRICS AND GENERAL MEDICINE of Children," edited by John M. Keating, I have tried to establish the claim of pediatrics to be considered a spe- cialty. Not that it is one in the common acceptation of the term. It does not deal with a special organ, but with the entire organism at the very period which presents the most interesting features to the student of biology and medicine. Infancy and childhood are the links between conception and death, between the foetus and the adult. The latter has attained a certain degree of invariability. His physiological labor is reproduction; that of the young is both reproduction and growth. As the history of a people is not complete with the narration of its condition when established on a solid constitutional and economic basis, so is that of man, whether healthy or diseased, not limited to one period. Indeed, the most interesting time, and the one most difficult to understand, is that in which persistent development, increase, solidification, and improvement are taking place. I have tried to prove that " pediatrics does not deal with miniature men and women, with reduced doses and the same class of diseases in smaller bodies, but that it has its own independent range and horizon, and gives as much to general medicine as it has received from it." My rea- soning was that there is scarcely a tissue or an organ which behaves exactly alike in the different periods of life. I tried to prove that assertion by a cursory consideration of the osseous tissue, the nervous system, the digestive organs, the blood and the system of circulation, and the require- ments of general therapeutics in the young. To these ex- positions I added a few remarks on the peculiar character of the diseases of infancy and childhood. There are anom- alies and diseases which are encountered in the infant and child only. There are those. which are mostly found in children, or with a symptomatojogy and course peculiar to them; and those, finally, which affect both the young and old, with such varieties, however, both in symptoms and course, as depend on the size or nature of the afflicted organ or organism, or the difference in the degree of its irritability. The relations of pediatrics to the several special parts t)R. JACOBI'S WORKS of the extensive field of scientific medicine are very various. Internal medicine owes many of its best results to the ob- servations made on infants and children. It is in them that constitutional and developmental diseases are either best or exclusively studied. In this connection I remind you only of scrofula, rhachitis, anaemia, and chlorosis. Infectious diseases, such as diphtheria, scarlatina, measles, varicella, parotitis, pertussis, and tuberculosis, mainly of the bones and joints, of the glands and peritoneum, are mostly en- countered in infancy and childhood. Neoplasms are not only frequent in young children, more than forty cases of sarcoma of the foetal or infant kidney alone were col- lected by me for the International Congress of Copen- hagen five years ago, but rouse the most intense interest, from the fact that Cohnheim tried to trace every neoplasm of later life to its embryonic or foetal origin. All the actual or alleged disorders belonging to dentition, most forms of stomatitis, amygdalitis, and pharyngitis, includ- ing latero- and retro-pharyngeal abscess, many of the most frequent and important diseases of the nose with their con- sequences, and of the larynx, are met with in the young. It is in them that catarrhal pneumonia has been studied prin- cipally, atelectasis almost exclusively. Some of the forms of diarrhoea, and still more of constipation, are exclusively the property of young children. It is in them, also, that inter- nal medicine has learned the pathology of muscular pseudo- hypertrophy; from them, finally, that it has improved and increased diagnostic resources, for nobody can study Fin- layson's contribution to the first volume of the Cyclopaedia without finding many of them greatly depending on certain peculiarities of the several infant organs. The surgery of infancy and childhood is so peculiar, its indications so varying, the number of cases so large, and some of the operative procedures so exclusively or almost exclusively adapted to, or necessitated by, surgical diseases of the young, that the transactions of surgical societies and journals are largely filled with discussions on subjects be- longing to the sphere of pediatrics. I remind you of the frequent occurrence of congenital malformations requiring interference; those of the anus and rectum, hare-lip and 44 PEDIATRICS AND GENERAL MEDICINE fissured palate, spina bifida and hydrocephalus. The sev- eral forms of bone-disease, in the vertebrae, the hip- and ankle-joints which require resection or scooping, demand special knowledge and skill, because of the dignity of the intermediate cartilage. Osteotomy is more frequently per- formed in the rickety young than" at any other age or in any other disease. Tubercular swelling of the lymph-bodies occurs more frequently in the young than in advanced years. The majority of tenotomies are performed on children. Tracheotomy and intubation belong pre-eminently to early age. The largest number of tracheotomies performed by an individual operator is furnished by an author who does not claim any merit as a professional surgeon. The operation for pyothorax is mostly required in the young, and taxes the experience and prognostic judgment of the medical man to an unusual degree, because of the variety of indications depending upon the amount of flexibility of the ribs and the extent of complications. Invagination is mainly seen in the very young. Twenty-five per cent, of all the cases occur under one year ; fifty-three under ten. Two-thirds of those under a year are between the fourth and sixth months. Perityphlitis, though rare in infants, is not at all infre- quent in children of seven or eight years and upward; and both it and intussusception require often surgical inter- ference. Indeed, so common are the claims on surgical skill in the practice among infants and children, that among the most instructive and interesting surgical treatises are those which discuss the surgery of childhood alone. I will only recall the special works of Guersant, Forster, Bryant, Giraldes, Holmes, St. Germain, and the fifteen hundred pages written by a dozen different authors in C. Gerhardt's " Manual of the Diseases of Children." It is a good move on the part of the editors of the new treatise of Henry Ashby and G. A. Wright that one of the authors is an ex- perienced operating surgeon. The connection of pediatrics with neurology is very in- timate indeed. Many of the most interesting neuro-phy- siological data have been secured by our special colleagues. Thus, Soltmann's researches prove that in the new-born the inhibitory centres of the cerebral cortex are almost not 45 DR. JACOBFS WORKS formed at all, and that the motor and sensitive irritability increases rapidly about the fifth and sixth months. This is the time at which reflex excitability is very great. It has also been 1 found that the inhibitory function of the cardiac nerves is but feeble in the very young. The contraction un- der the influence of the electric current resembles very much that which is observed in the fatigued animal, and the peripheral nerves exhibit a slight excitability only. Many other observations can be made on the infant only, thus, for instance, those concerning the first awakening of per- ception. On the first or second day of life hearing is active ; sight sufficiently developed to be affected by light and dark- ness; taste and smell exist, but are feeble, and the sense of touch is mainly demonstrable on the lips. The percep- tion of pain is but slightly developed. Many such special contributions to the physiology of the nervous system gathered in the young could be introduced here. I can omit that in the presence of those who know; but refer to the special works of Kussmaul, G. Darwin, and Preyer, which treat of the psychology of the infant, and to the general treatises on the physiology of the young by Alleix, Vierordt, and Vittorio Massini. Neuropathology also owes a great many results to the ob- servations made on infants and children. Disorders of the nervous system are very common in the young. Of all the deaths resulting from diseases of the nervous system, eighty- seven per cent, take place during the first five years of life. Their frequency is best understood by the consideration of their many causes. Many are inherited or acquired during foetal life. Others are due to the insufficiency of the protec- tion afforded to the brain. Thus it is that any trauma, the pressure of a narrow pelvis or the forceps, a fall which in the very young produces rather a general disorder than a local lesion, leads to serious consequences. The neighboring organs, such as the ear, or the scalp, are liable to affect the brain; for that reason otitis and impetigo are dangerous processes. The very anatomical development, the increas- ing separation of the two cerebral substances, and the in- competency of the centres of inhibition and those of co- ordination, lead to morbid processes. Anomalies of the 46 PEDIATRICS AND GENERAL MEDICINE bones, such as rhachitic softening and, still more, premature ossification, interfere with the cerebral development or lead directly to serious or incurable alterations. The incom- plete structure of the blood-vessels is another frequent cause of disease from mere temporary congestion to serous effusions or to extravasations. Thus we have an expla- nation of many of the facts unaccountable to the super- ficial observer only. The number of neuropathies not di- rectly fatal is excessive in the young. Convulsions of every description, eclampsia, chorea, tetany, epilepsy (poliomy- elitis), Friedreich's ataxia, gather their most copious har- vest among infants and children. And again it is these on whom most of our knowledge of cerebro-spinal menin- gitis and cerebral meningitis has been obtained. Neurology's sister, psychology, is indebted for much of its wealth to the study of the intellectual life of infancy and childhood. It is sufficient to refer again to the valu- able and influential researches of Kussmaul, the younger Darwin, and W. Preyer. Psychiatry also has learned from the mental aberrations occurring at an early age, the more so as many of the causes of mental disease in later life must be traced back to embryological data and the morbid changes of infancy. Asphyxia of the newly-born, with its resulting effusion, extravasations, or thromboses, is a fre- quent cause of life-long epilepsy, stupidity, or idiocy. Diseases affecting the brain at an early period preclude the formation of ideas. The absence of inhibitory and psychomotor centres in the newly-born animal precludes the equilibrium required for a normal mental organization. The disposition to psychical disturbance resulting from in- dividual constitution, the influences of heredity, and con- genital neurasthenia can be studied at the very earliest age. The symptoms of fully-developed or imminent or future mental disease are more readily studied in the young than at more advanced age, for in the young the slightest deviations will tell. Such symptoms, which are easily rec- ognized, are waywardness and restlessness, grimacing, con- vulsive twitching and convulsibility, abnormal sleep, re- tardation of growth, and excessive masturbation. Wher- ever they are found to be not the direct results of easily 47 DR. JACOBI'S WORKS appreciated causes, as, for instance, what I have perhaps wrongly called local chorea depending on chronic naso- pharyngeal catarrh, psychical disturbances may well be feared. They are more frequent than the reports of lunatic asylums would appear to prove. For there are but few insane children in the institutions, for obvious reasons. It is only those cases which become absolutely unmanageable at home which are intrusted to an asylum. Thus it is that we can obtain more accurate statistics of idiocy than of de- mentia of early years. The anatomical symptoms of degen- eration, leading sooner or later to mental disorders, are stud- ied to best advantage mostly in infants and children. Of epilepsy, which mostly starts early, it is not necessary to speak here. I shall only allude to the deformities of the cranium due to general or local premature ossification of the cranial bones and fontanelles, to the peculiarities of the position of the teeth and ears, the retraced root of the nose, the asymmetry of the head and face, due either to unilat- eral atrophy or hypertrophy, and the shortened base of the skull. Besides, there is the excessive number of cerebral diseases manifest at a time when the increasing growth of the organs continues to add to the acquired lesions ; also trauma and insolation. Finally, the impressibility of the young is such that the causes of mental disturbance in every age chorea, hysteria, epilepsy, anomalies of the ears, nose, and heart, the presence of helminthes, the parox- ysms of malaria, the anatomical results of typhoid fever, rheumatism, erysipelas, and pertussis, and the nutritive dis- orders resulting from anaemia, chlorosis, and alcohol -have very much more serious results when occurring at an early age. There are some causes leading to mental disturbances which are certainly more common in the young, viz., imi- tation, fear, fright, masturbation, and the protracted mis- takes constantly made in regard to training and education. The over-worked brains of our school-children have been complained of in this connection as early as 1 801 by Peter Frank, and will yet form the subject of a few more re- marks. The history of the embryo and foetus finds its legitimate termination in that of the infant and child. Thus embry- 48 PEDIATRICS AND GENERAL MEDICINE ology, teratology, and pedology, with pediatrics, are but chapters of the same book. The scientific consideration of any one of them is impossible without that of the others. The theories of heredity and consanguinity refer equally to all. The most important changes and diseases met with in the young human being cannot be studied without the knowledge of its previous history, and the intelligent ap- preciation of embryology cannot be attained without the exact knowledge of its final outcome. Excessive or de- fective growth, arrest of development, and foetal inflam- mation are the heads under which a large number of anomalies of the infant can be classified. The frequent occurrence of carcinoma, sarcoma, and lipoma in the young favors Cohnheim's theory, according to which those neo- plasms owe their origin to the persistence of embryonic tissue. Abnormally inverted circulation explains the acar- diac monstrosity; deficiency of building material accounts for the absence in many cases of limbs or parts of limbs. The laws of duplication, including intrafoetation, are now well understood, and the gigantic growth of limbs or parts of limbs, akromegaly and macroglossia, are as important in the life of the born as they are interesting from the point of view of embryological development. Many symptoms of rhachitis, syphilis, and haemophilia cannot be understood except in their embryological connec- tion. The same is valid in regard to congenitally dislocated and horseshoe kidney, and transposition of the viscera. Insufficient closure of embryonic fissures explains encepha- locele, porencephaly, spina bifida, bifid uvula and epiglottis, cleft palate, lips, and cheeks, pharyngeal fistulae, hernia, and the communications between the intestinal tract and the uro-genital organs, and the persistency and patency of the urachus. Inflammatory processes give rise to spontaneous amputa- tion, the adhesions of the placenta to the head, to the most severe forms of obstructions and defects in the intestine, to the stenosis of the pulmonary artery, the aorta, and the atrioventricular orifice. I must not, however, multiply examples of the intimate correlation between embryology and the malformations and 49 DR. JACOBI'S WORKS diseases of the child. These few instances, I believe, will suffice to show to what extent the most exact and special study of the anatomy, physiology, and pathology of the child is a connecting link between, and the safest foundation of, a number of the most important branches of medical re- search. Indeed, if all the teaching obtained from pedology and pediatrics could be disjoined from those branches, these latter would be stripped of their best material. Though the history of pediatrics is but a brief one, it can safely be stated that those specialties have been to a great part feeding on and been built up by the observations and investigations of men specially interested in the dis- eases of children. You will find, when you look over the programmes of the nine associations which now form the American Congress year after year, that topics which in future will be the legitimate province of the American Pediatric Society, have attracted much of their attention. From the first hour of life the infant requires special study. Its diet has been a source of ever-watchful re- search on the part of many of the best minds. In modern times, Zweifel, Korowin, Biedert, Bouchard, not to men- tion A. V. Meigs and Rotch among us, have deserved well of the subject. Not only diet, however, and indi- vidual hygiene have been studied on the child; the most vital questions of public hygiene are also connected with pediatrics most intimately. Besides such as every think- ing man is deeply concerned in, it is mainly two topics that attract attention of those who take an interest in children. I allude to the school and to constitutional dis- eases. My remarks to-day can be but fragmentary; still, I must not, both in the interest of our science and of hu- man society, omit to emphasize the fact that it still appears as if our schools were establishments organized to produce near-sightedness, scoliosis, anaemia, and both physical and intellectual exhaustion. Contrary to the treatment a colt receives at the hands of its owner, human society, or the state, permits or directs that the powers of a child should be rendered unfit for its future functions, physical, mental, and moral, for these three are indelibly interwoven. It requires physical and mental education to fertilize the soil 50 PEDIATRICS AND GENERAL MEDICINE for the evolution of morals. Thus the physician, and par- ticularly he who makes pediatrics his special study, is a pedagogue by profession. The question of school-house building and school-room furniture, the structure of bench and table, the paper and type in the books, the number of school hours for the average child and the individual pupil, the number and length of recesses, the hours and duration of intervening meals, the alternation of mental and physical training, the age at which the average and the individual child should be first sent, have been too long decided by school-boards consisting of coal-merchants, carpenters, cheap printers, and undertaught or overaged school-mistresses, not, however, of physicians. The health and vigor of the American child in early years seems, ac- cording to Bowditch, superior to those of the European. Why is the youth and maiden, particularly the latter, so inferior? Why is it that anaemia and neuroses eat the mar- row of the *land, and undermine the future of the country by degenerating both the workers and thinkers of the com- munity, and the future mothers? If there is a country in the world with a great destiny and a grave responsibility, it is ours. Its self-assumed destiny is to raise humanitarian and social development to a higher plane by amalgamating, humanizing, and civilizing the scum of all the inferior races and nationalities which are congregating under the folds of our flag. Unless the education and training of the young is carried on according to the principles of a sound and sci- entific physical and mental hygiene, neither the aim of our political institutions will ever be reached nor the United States fulfil its true manifest destiny. That manifest des- tiny is not so much the political one of excluding Euro- peans from our continent, North or South, for indeed the participation of European civilization in the gradual work of removing barbarism ought to be very welcome, but of raising the standard of physical and mental health to possible perfection, and thereby contributing to the wel- fare and happiness of the people. Another subject in which, for the same reason, pedology and pediatrics are profoundly interested is that referring to constitutional and infectious diseases. Most of them belong 51 DR. JACOBI'S WORKS to early life, and therefore interest you in this society. The vast majority of them can be avoided, mortality greatly diminished, and ill-health resulting therefrom prevented. Ninety-nine cases out of every hundred of rhachitis need not exist. Before we were overrun with the poverty-stricken population of Europe, rhachitis was hardly known among us. Unless the social position of the many be improved and the laws of hygiene understood and obeyed, it will in- crease until we shall be on a level with Ireland, Switzer- land, and Northern Italy. Where the prevention of syphi- lis lies, or ought to lie, we fully know. How we could avoid dysentery and typhoid, the number of which increases with the size of tenements, the insufficiency of sewers, with the number of large summer hotels, and defective drain- age, we thoroughly appreciate. Scarlatina, morbilli, diph- theria, whooping-cough, need not destroy or maim hun- dreds of thousands if contagion were avoided; and, un- less that be done, mankind, state, town, have not per- formed the most rudimentary function of their existence. After all, we need not boast of our civilization, which in- deed requires healing and mending both from a social and medical aspect. If we would but concentrate our means for fighting pre- ventable disease and death as they concentrate them in Eu- rope for the purpose of preparing for, and carrying on, wars! If we did, we should save as many hundred thou- sands as they seek to destroy. If, besides, but every phy- sician knew and appreciated his duty and his honorable vocation, which consists in preventing and curing disease, and spending his best efforts in ameliorating human exist- ence ! What, then, shall we say of those of our brethren who do not feel it below their dignity to study electricity, or to make believe they do, for the avowed purpose of sup- planting the hangman? Questions of public hygiene and medicine are both profes- sional and social. Thus, every physician is by destiny a " political being " in the sense in which the ancients de- fined the term, viz., a citizen of a commonwealth, with many rights and great responsibilities. The latter grow with increased power, both physical and intellectual. The 52 PEDIATRICS AND GENERAL MEDICINE scientific attainment of the physician and his appreciation of the source of evil enable him to strike at its root by ad- vising aid and remedies. Such increase of knowledge as the combined efforts of the members of the American Pedi- atric Society can result in from year to year, such interest as it can raise in its own labor, such impetus as it can give to the profession at large in the direction of special re- search, such power as it can exert on the instruction in pediatrics of students in the medical schools, such influ- ence as it may have among the wealthy public with a view to establish and endow special hospitals for infants and children in proving beneficial to all branches of medi- cine, will be an everlasting blessing to mankind. 53 THE HISTORY OF PEDIATRICS AND ITS RE- LATION TO OTHER SCIENCES AND ARTS THE most human of all the gods ever created by the fancy or the religious cravings of mortal man was Phoebus Apollo. It was he that gave its daily light to the awaken- ing world, flattered the senses of the select with music, filled the songs of the bards and the hearts of their hearers with the rhythm and wonders of poetry, that inspired and reveled with the muses of the Parnassus, cheered the world with the artistic creation's of the fertile brains and skil- ful hands of a Zeuxis and Phidias- he, always he, that inflicted and healed warriors' wounds and sent and cured deadly diseases. In the imagination of a warm-hearted and unsophis- ticated people it took a god to embrace and bestow all that is most beneficent and sublime physical, moral, and mental light and warmth; the sun, the arts, poetry, and the most human and humane of all sciences and arts, namely, medicine. Ancient gods no longer direct or control our thoughts, feelings, and enjoyments, either physical or intellectual. The kinship and correlation of hypotheses and studies, experience and knowledge are in the keeping of the phi- losophical mind of man, who is both their creator and beneficiary. To demonstrate this rational affinity of all the sciences and arts, some far-seeing men planned this great Congress. The new departure in the arrangement for it should be an example to future general and special scientific gatherings. Indeed, some of its features were adopted by the organization committee of the International Medical Congress which was to take place at St. Louis, but was given up on account of the limited time at the disposal of the great enterprise. Congresses are held for the purpose of comparing and guarding diversified interests. A free political life re- 55 DR. JACOBI'S WORKS quires them for the consulting of the needs of all classes. Scientific congresses are convened to gather and collate the varied opinions, experiences and results of many men, and to create or renew in the young and old the enthusi- asm of youth. Their number has increased with the modern differentiation of interests and studies. Special- ization in medicine is no longer what it was in old Egypt, iramely, the outgrowth of the all-pervading spirit of castes and sub-classifications, but as well the consequence as the source of modern medical progress. It is difficult, how- ever, to say where specialization ends and over-special- ization begins, or to what extent specialization in medicine is the result of mental and physical limitation or of the spirit of deepening research; or, on the other hand, of in- dolence or of greed; or whether, while specialization ben- efits medical science and art, it lowers the mental horizon of the individual, and either cripples or enhances his use- fulness in the service of mankind. For that is what med- ical science and art are for. Jose de Letamendi is perhaps correct when he says that a man who knows nothing but medicine does wot even know medicine. What shall we expect, then, of one who knows only a small part of med- icine and nothing beyo'nd ? Congresses in general have been of two kinds. They are called by specialists for specialists, or they meet for the purpose of removing or relieving the dangers of lim- itation. This is what explains the great success of inter- national and national gatherings, such as the German, British, American, and others, and what has given the Congress of American Physicians and Surgeons with its triennial Washington meetings its broadening and chasten- ing influence. Nor are medical meetings the only attempts at linking together what has a tendency to get disconnected. Look at our literature. The rising interest in the history of medicine as exhibited in Europe and lately also among us, and individual contributions, such as Gomperz's great book on Greek thinkers; or even lesser productions, such as Eymin's Medecins et Philosophes, 1Q04; or the impor- tant pictorial works of Charcot, Richet, and Hollander, 56 HISTORY OF PEDIATRICS prove the correlation of medicine with history, philoso- phy and art. Our special theme is the history of Pediatrics and its relation's to other specialties, sciences and arts. Now P'riedrich Ludwig Meissner's Grundlage der Literatur der Padiatrik, Leipzig, 1850, contains on 246 pages about 7,000 titles of printed monographs written before 1849 on diseases of children, or some subject connected with pedology. Of these, 2 were published in the fifteenth century, 16 in the sixteenth, 21 in the seventeenth, 75 in the eighteenth. P. Bagellardus de aegritubinibus puerorum, 1487, and Bartholomeus Metlinger, " Ein vast niitzlich Regiment der jungen Kinder," Augsburg, 1473, opened the printed pediatric literature of Europe. In the sixteenth century, Sebastianus Austrius, de puerorum morbis, Basileae, 1549, and Hieronymus Mercurialis, de morbis puerorum tractatus, 1583, are facile principes; in the eighteenth, Th. Harris, de morbis infantum, Amstelo- dami, 1715; Loew, de morbis infantum, 1719; M. Andry, 1'orthopedie ou 1'art de prevenir et corriger dans les en- fants les difformjtes du corps, 1741; Nils Rosen de Rosenstein, 1752; E. Armstrong, An Essay of Diseases most Fatal to Infants, 1768; and M. Underwood, Treat- ise on the Diseases of Children, 1784; also Huf eland, established pediatrics as a clinical entity; while Edward Jenner, 1798, An Inquiry into the Causes and Effects of the Variolae Vaccinse, opened the possibilities of a radical prevention of infectious and contagious diseases, the very subject which, a century later, is engaging the best minds and a host of assiduous workers in the service of plague- stricken mankind. In the United States pediatrics was taught in medical schools, or was expected to be taught, by the professors of obstetrics and the diseases of women and children. The reorganization of the New York Medical College in East Thirteenth street facilitated the creation, in I860, of a special clinic for the diseases of the young. Instead of the united gynaecologic and obstetric clinics held by Bed- ford, Oilman, and G. T. Elliott in their respective medical colleges, there was a single clinic for the diseases of the 57 DR. JACOBI'S WORKS young exclusively. When the Civil War caused the Col- lege to close its doors forever, in 1865, they transferred the clinic to the University Medical College, and in 1870 to the College of Physicians and Surgeons. Meanwhile, other medical schools imitated the example thus presented. The teachers were classed amongst the clinical professors; only in those schools which are forming part of universi- ties and are no longer proprietary establishments, a few now occupy the honored position of full professors; in a very few the professor of pediatrics is a full member of the " faculty." In the English Colonies of America the earliest treatise on a medical, in part pediatric subject was a broadside, 12 inches by 17- It was written by the Rev. Thomas Thatcher, and bears the date January 21, 1677-8. It was printed and sold by John Foster, of Boston. The title is " a brief rule to guide the common people of New Eng- land how to order themselves and theirs in the Small- Pocks, or measles." A second edition* was printed in 1702. Before and about the same time in which American pediatrics received its first recognition at the hands of the New York Medical College, European literature furnished a new and brilliant special literature. France, which al- most exclusively held up the flag of scientific medicine dur- ing the first forty years of the eighteenth century, fur- nished in C. Billard's Traite des maladies des enfants nouveau-nes, 1828, and in Rilliet's and Barthez's Traite clinique et pratique des maladies des enfants, 1838-43, standard works which were examples of painstaking re- search and fertile observation. England, which produced in 1801 I. Cheyne's Essays on the diseases of children, gave birth to Charles West's classical lectures on the dis- eases of infants and children in 1848, and F. Churchill's treatise in 1850. The German language furnished a master-work in Bed- nar's die Krankheiten der Neugebornen and Sauglinge, 1850-53. A. Vogel and C. Gerhardt, both general clinical teachers, gave each a text-book in I860, Henoch irr 1861; and Steffen in 1865-70 published a series of classical essays. 58 HISTORY OF PEDIATRICS The number of men interested in the study and teach- ing of pediatrics grew in proportion to the researches and wants of the profession at large. That is why three large and influential cyclopedias, the works of many authors, found a ready market, namely, C. Gerhardt's Handbuch der Kinder-Krankheiten, 1877-93; John M. Keating's Cyclopedia of the Diseases of Children, Medical and Sur- gical, 188Q-90, and I. Grancher's and I. Comby's Traite des Maladies des Enfants, in five volumes, the second edi- tion of which is being printed this very year. The collective and periodic literature of pediatrics be- gan at a comparatively early time. There was a period towards the end of the eighteenth century when the in- fluence of Albrecht von Haller seemed to start a new life for German medical literature before it lost itself again in the intellectual darkness of Schelling's natural philos- ophy, from which it took all the powers of French en- thusiasm and research, and the epoch-making labors of Skoda, Rokitansky, and finally Virchow, to resuscitate it. About that early time of Haller, there appeared in Lieg- nitz, 1793, a collection of interesting treatises on some important diseases of children (Sammlung interessanter Abhandlungen iiber etliche wichtige Kinderkrankheiten). France followed in 1811 with a collection bearing the title " La Clinique des Hopitaux des enfants, et revue retros- pective medico-chirurgicale et hygienique. Publiees sous les auspices et par les medecins et chirurgiens des hopitaux consacres aux maladies des enfants." Next in order are five volumes of Franz Joseph von Metzler's Sammlung auserlesener Abhandlungen iiber Kinderkrankheiten, 1833- 36. Twelve fascicles under the title Analekteir iiber Kin- derkrankheiten oder Sammlung ausgewahlter Abhandlun- gen iiber die Krankheiten des Kindlichen Alters ; la clinique des Hopitaux des enfants, Redacteur err chef Vanier, Paris, 1841; and I. Behrend and A. Hildebrandt, Journal fiir Kinderkrankheiten, which appeared regularly from 1843 to 1872. It gave way to the Jahrbuch fiir Kinder- heilkunde, which has appeared in quick and regular succes- sion from 1858 to the present time. Three series of Aus- trian Journals between 1855 and 1876 consisted of a dozen volumes only. They contain among other important con- 59 DR. JACOBFS WORKS tributions the very valuable essays of Ritter von Ritter- shayn, who deserved more recognition during his life and more credit after his death, for his honesty, industry and originality, than he attained. Special pediatric journals have multiplied since. The United States has two, France three, Germany five, Italy two, Spain one. As long as they are taken by the pro- fession we should not speak of over-production. I at- tribute their existence to the general conviction that there is no greater need than of the distribution of knowledge of the prevention and cure of the diseases of the young. The literature of pediatrics seems to prove it. Not 7,000 as before 1850, not even 70,000 titles of books, pamphlets, and magazine articles exhaust the number. Pediatric societies have increased at the same rate. The American Medical Association and the British Medical Association founded each a section 25 years ago, the New York Academy of Medicine, 1886. The American Pediatric Society was founded in 1889, the Gesellschaft fiir Kinderheilkunde connected with the German Gesell- schaft der Aerzte and Naturforscher in 1883, the English Society for the Study of Disease in Children, in 1900. There are pediatric societies in Philadelphia, in the State of Ohio, in Paris, Kiew, St. Petersburg, and many places, all of them engaged in earnest work which is exhibited in volumes of their own or in the magazines of the profession. If we add the annual reports of hundreds of public in- stitutions, which are so numerous indeed that a large vol- ume of S. Hiigel, " Beschreibung sammtlicher Kinderheil- anstalten in Europa," was required as early as 184-8 to enumerate them; and an enormous rrumber of text-books of masters, and of such as are anxious to become so, and monographs, and essays, and lectures, and notes prelimi- nary and otherwise, which fill the magazines that most of us take or see, and some of us read we may form an idei to what extent a topic formerly neglected has taken hold of the conscience and the imagination of the medical public. Before 1769 there was no institution specially provided for sick children. They were admitted now and then to 60 HISTORY OF PEDIATRICS foundling institutions and general hospitals. In that year Dr. G. Armstrong established a dispensary in London, which was carried on until he died. A similar institution was founded in Vienna by Dr. Marstalier, in 1784. Goelis took charge of it in 1794, L. Politzer developed it, and it is still in existence. Before the French Republic was strangled, it founded the first and largest child's hospital in Europe, the Hopital des Enfants malades, in 1802. The Nicolai Hospital was established in St. Petersburg, in 1834, by Dr. Friedburg; the St. Anne's Child's Hos- pital, in Vienna, 1837, by Dr. Ludwig Mauthner; and the Poor Children's Hospital, of Buda Pesth, in 1839, by Dr. Schopf Merei, who afterwards founded and directed the Child's Hospital of Manchester, England. Since that time the increasing interest in the diseases of children on the part of humanitarians and of physi- cians and teachers has multiplied children's hospitals. Most of them are small, but they are numerous enough both to exhibit and disseminate the sense of responsibility to the sick and to the necessities of teaching. The United States has been the last country to participate in these endeavors. The mostly proprietary medical schools did not find pediatric teaching to their advantage, and it took the hearts and purses of the public a long time to be opened. The waves of humanitarianism, sometimes directed by a church, and the demands of science have finally over- come previous indolence. There are many general hos- pitals that gradually opened special children's wards. You find pediatric hospitals in some of the larger cities New York, Boston, Philadelphia, Albany, St. Louis, and others. It has so happened, however, that real specialties have appealed more to the general sympathy than pedia- trics. That is why the number of beds in orthopedic and other special hospitals are mostly favored. Practical teaching has not been extensive. Children's hospitals that should be used for that purpose, and that are directly con- nected with a medical school, are but few. It has taken the medical faculties, even of Universities, too much time to appreciate the necessity of special and well-regulated bedside teaching. In some instances lay trustees, guided 61 DR. JACOBI'S WORKS by their medical advisers, have opened their wards before faculties have consented to open their eyes. At the pres- ent time, however, there is hardly a great medical school that does not give amphitheatre or bedside instruction, either in a children's ward of a general hospital or in a special children's or babies' hospital. To a certain extent the teaching of pediatrics in a general hospital has its great advantages. It is not a specialty like that of a spe- cial sense or a tissue. For the purpose of study it had to be segregated, but it will never be torn asunder from general medicine. Vogel and Gerhardt were both general clinicians. The comparative anatomy and physiology, hygiene, etiology, and nosology of pediatrics have been discussed before you by one of the most prominent pediatrists of our era. It will be my privilege to explain, as far as time will permit, its relation to gerreral medicine, to embryology and teratology, obstetrics, hygiene, and private and public sanitation, to therapeutics both pharmacal and operative, and to the specialties of otology, ophthalmology, dermatol- ogy and the motor system, to pedagogy, to neurology and psychiatry, forensic medicine and criminology, and to social politics. Infancy and childhood do not begin with the day of birth. From conception to the termination of foetal life evolution is gradual. The result of the conception de- pends on parents and ancestors. Nowhere are the laws of heredity more perceptible than in the structure and nature of the child. Physical properties, virtues and sins, and tendencies to disease may not stop even with the third or fourth generation. Hamburger and Osier trace an angio-neurosis through six generations, the first case in the series being observed by Benjamin Rush. In many instances still-births, early diseases, atrophy, and undue mortality of the young depend on antenatal happenings. The condition and diet of the mother influences her off- spring. The danger of a contracted pelvis, and the necessity of premature delivery may be obviated by the restriction of the diet, or even by appropriate (thyroid and other) medication of the pregnant woman. Experi- 62 HISTORY OF PEDIATRICS ence and experiment tell the same story. The continued practice of preventing conception causes endometritis. Alcoholism causes chronic placentitis, premature confine- ment, or still-birth. So does chronic phosphorus and lead poisoning. Fortunately, however, the usual medication resorted to during labor is rarely dangerous, for even morphine or ergot doses given to the parturient woman on proper indications affect the newly-born rarely, and chloro- form anesthesia almost never. Scanty amniotic liquor, by the prevention of free intra- uterirre excursions, may cause club-foot; or close contact of the surfaces of the embryo and the membranes give rise to adhesions of the placenta and the head, to filaments and bands whose pressure or traction produces grooving or amputation of limbs, cohesion of toes or fingers, um- bilical meningeal, encephalic, or spinal hernia; not in extra-uterine pregnancy only, where such occurrences are very frequent. Even the majority of harelips and fis- sured palates have that origin. Arrests of development and foetal inflammation are the headings under which most of the anomalies of the newly-born may be subsumed; congenital diseases of the ear and of the heart may result from either cause or from both. Obstructions of the in- testines, the rare closures of the o?sophagus, the ureter, and the urethra, with hydro-nephrosis and cystic degen- eration 1 of the kidneys are probably more due to excessive cell proliferation in the minute original grooves than to inflammation. The insufficient closures of normal embryonic fissures or grooves explain many cases of spina bifida, many of errcephalocele, most of the split lips and palates, all of porencephalus, bifid uvula and epiglottis, pharyngeal and thyroglossal fistulse, the communications between the in- testinal and uro-genital tracts, and the persistency and patency of the urachus. 2 - J. W. Ballantyne, in his Manual of Antenatal Pathology and Hygiene, 190;?, has a separate chapter on the relations of ante- natal pathology to other branches of study, to general pathology, to the biological sciences, such as anatomy, embryology, physiol- ogy, botany, and zoology, and to the medical,, including obstetrics, 63 DR. JACOBI'S WORKS Heredity ireed not show itself in the production of a fully developed disease. It exhibits itself normally either in equality or resemblances, either total or partial, of the body, or some one or more of its external or internal or- gans. In this way it may affect the nervous, the muscular, the osseous, or other tissues. That is why dystrophies in different forms, obesity, achondroplasia, hyperplasia, or atrophy may be directly inherited, while in other cases the disposition* to degeneration only is transmitted. Hereditary degeneracy is often caused by social influ- ences. The immoral conditions created by our financial system make women select not the strong and hearty and the young husband, but the rich and old, with the result of having less, and less vigorous, children. Certain pro- fessions, the vocations of soldiers and mariners, and subor- dinate positions of employees in general, enforce com- plete or approximative celibacy, with the same result. The nations that submit to the alleged necessity of keeping millions of men in standing armies, are threatened with a degenerated offspring, for not only do they keep the strongest men from timely marriages, but they increase prostitution and venereal diseases, with their dire conse- quences for men, women, and progeny. Wars lead to the same result in increased proportion, for tens and hundreds of thousands of the sound men are slain or crippled, or demoralized. Those who are inferior and unfit for phy- sical exertions remain behind and procreate an inferior race; those who believe with Lord Rosebery that an em- pire is of but little use without an imperial race will al- ways, in the interests of a wholesome civilization, object to the untutored enthusiasm which denounces the " weak- ling," and the " craven cowardice " of those who believe in the steady evolution of peace and harmony amongrst men, and, in sympathy with the physical and moral health of the present and future generation, will prefer the cleanly and washed sportsmanship of an educated youth to that of the mud-streaked and blood-stained man-hunter. public health, pediatrics, medicine, psychology, dermatology, sur- gery, orthopedics and medical jurisprudence, finally to gynaecology and neo-natal pathology. 61 HISTORY OF PEDIATRICS A great many diseased conditions cannot be thoroughly understood unless they be studied in the evolving being. Tumors are rarely inherited, but many of them are observed in early life. Lymphoma, sarcoma, also lipoma and carcinoma, and cystic degeneration, are observed at birth, or within a short time after, and seem to favor Cohnheim's theory, according to which many owe their origin to the persistence in an abnormal location of em- bryonic cells. This theory does not exclude the fact that congenital tumors may remain dormant for years or de- cades and not destroy the young. So much on some points connected with embryology and teratology. The connection with obstetrical practice is equally intimate. Three per cent, of all the mature living foetuses are not born into postnatal life this very day. To reduce the mortality even to that figure, it has taken much increase of knowledge and improvement in the art of obstetrics to such an extent that it has become possible by Cesarean section not only to save the foetus of a living, but also of a dead mother, for the foetus in her may survive the dying woman. But after all, many a baby would be better off, and the world also, if it had died during labor. There are those, and not a few, who are born asphyxiated on account of interrupted circulation, compression of the impacted head, or meningeal or encephalic hemorrhage, which destroys many that die in* the first week of life. Those who are not so taken away may live as the result of protracted asphyxia only to be paralytic, idiotic, or epileptic. Many times in a long life have I urged upon the practitioner to remember that every second added to the duration of asphyxia adds to the dangers either to life or to an im- paired human* existence. Besides fractures, facial or brachial paralysis, cephalhaematoma and haematoma of the sterno-cleido mastoid muscle, gonorrheal ophthalmia, with its dangers to sight and even life, may be daily occurrences in an obstetrician's life. All such cases prove the insuf- ficiency of knowledge without art, or of art without knowl- edge, and the grave responsibility of the practical obste- trician*. To lose a newly-born by death causes at least 65 DR. JACOBI'S WORKS dire bereavement; to cripple his future is not rarely crim- inal negligence. Within a few days after birth the obstetrician or the pediatrist has the opportunity of observing all sorts of microbic infections, from tetanus to hemorrhages or gan- grene, and the intense forms of syphilis. Not an uncom- mon disease of the newly-born and the very young is nephritis. It is the consequence, in many cases, of what appears to be a common jaundice, or of uric acid infarc- tion 1 , which is the natural result of the sudden change of metabolism. The diverticula of the colon, as described by Hirschsprung and Osier, and what nearly 40 years ago was characterized as congenital constipation, which de- pends on the exaggeration of the normally excessive length of the sigmoid flexure, belong to the same class. Their dangers may be avoided when they are understood. Of the infectious diseases of the embryo and the foetus, it is principally syphilis that should be considered ; amongst the acute forms variola and typhoid are relatively rare. What I have been permitted to say is enough to prove the intimate interdependence and connection between pediatrics and the diseases of the fretus with embryology and teratology, obstetrics, and some parts at least, of social economics. After birth there are anomalies and diseases which are encountered in the infant and child only. There are also, common to all ages, though mostly found in children, such as exhibit a symptomatology and course peculiar to them. The first class, besides those which are seen in the newly-born, is made up mostly of developmental dis- eases scrofula, rachitis, chlorosis. The actual or alleged ailments connected with dentition, most forms of stomatitis, Bednar's so-called aphthae, the ulceration of epithelial pearls along the raphe, amygdalitis, pharyngitis, adenoid proliferations, latero- and retro-pharyngeal abscesses be- long here. Infectious diseases, such as variola, diphtheria, scarlatina, measles, pertussis, and tuberculosis of the glands, bones, joints, and peritoneum have been most suc- cessfully studied by pediatrists or those clinicians who paid principal attention to pedology. Meissner prints the 66 HISTORY OF PEDIATRICS titles of more than 200 actual monographs on scarlet fever published in* Europe before 1848. Pleurisy and pneumonia of the young have their own symptomatology. Empyema is more frequent and requires much more operative inter- ference. Tracheotomy and intubation are mostly required by the young, both on account of their liability to O3dema of the larynx and to diphtheria, and of the narrowness of the larynx. Of invagination, 25$ occur under one year, 53$ under 10. Appendicitis, sometimes hereditary and a family disease, would long ago have been recognized as a frequent occurrence in the young if it had not been for the difficulty, mainly encountered in the young, and sometimes impossibility of its diagnosis. That is what we have been taught by Hawkins and by Treves, and lately by McCosh. Operations on glandular abscesses, osteoto- mies, and other operations on the bones and joints, par- ticularly in tuberculosis, and on malformations, such as have been mentioned, require the skilful hand of the oper- ating physician in a great many instances. Omphalocele, exstrophy of the bladder, undescended testicle, spermatic hydrocele, multiple exostoses, imperforate rectum, atresia of the vagina, or an occasional case of stenosed pylorus, belong to that class, some requiring immediate operation, some permitting of delay. It is principally infancy that demands removals of angioma, which are almost all suc- cessful, and of hygroma, mostly unsuccessful, mairrly when situated on the neck and resulting from obstruction of the thoracic duct sometimes connected with thrombosis of the jugular vein. Childhood requires correction of kyphosis and scoliosis, and operations for adenoids and hypertrophied tonsils, and furnishes the opportunities for lumbar puncture and laparotomy in tubercular peritonitis ; also supra-pubic cystotomy, and mastoid operations. That gum-lancing is iro operation indicated or permissible in either the young or adult, and not any more so in the former than in the latter, is easily understood by those who acknowledge its necessity only in the presence of a morbid condition of the gums or teeth, and not when the physiological process of dentition exhibit no anomaly. It 67 DR. JACOBI'S WORKS scarcely ever does. Altogether operating specialists would work and know very much less if a large majority of the cases were not entrusted to them by the pediatrist, who recognizes the principle that those who are best fitted to perform it should be trusted with important medical work. So well is the seriousness and difficulty of operative pro- cedures, as connected with diseases of children, recognized by experts, that 1,500 pages of Gerhardt's handbook are dedicated to external pathology and operations, and that special works, besides many monographs by hundreds of authors, have been written by such masters as Guersant, Forster, Bryant, Giraldes, Holmes, St. Germain, Karew- ski, Lanrrelongue, Kirmisson, and Broca. Ear specialists recognize the fact that otology is mostly a specialty of the young. The newly-born exhibit changes in the middle ear which are variously attributed to the presence of epithelial detritus, to the aspiration of foreign material, or to an oedema ex vacua occasioned by the sepa- ration of formerly adjacent mucous surfaces. Pus is found in the middle ear of 75$ of the still-born or of dead nurslings. It contains meconium, lanugo, and vernix. Aschoff 3 examined 50 still-born, or such as had lived less than two hours; 28 of them had pus in the middle ears (55<