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
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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<<Q. He also examined 35 infants that had lived longer
than two hours; 24 had pus (70^). Evidently the latter
class had been exposed to a microbic invasion. The diag-
nosis in the living infant is very difficult, mostly impossible,
on account of the large size of the Eustachian tube,
which after having admitted the infection, allows the pus
to escape into the pharynx and the rest of the alimentary
canal. Many of the newly-born that die with unexplained
fevers perish from the septic material, or its toxins,
absorbed in the middle ear or the intestines. Nor are
older children exempt. Geppert (Jahrb. f. Kind., xlv,
1897) found a latent otitis media in 75^ of all the in-
mates of the Children's Hospitals. Both latent and known
otitis is often connected with pneumonia, or with pneu-
monia and enteritis. In individual cases it may be difficult
3 Aschoff, Z. f. Ohrenh. Vol. xxxi.
68
to decide which of the two or three is the primary, which
the secondary affection.
The great vascularity of the middle ear, but still more
the accessibility of the funnel-like Eustachian tube in
the infant, renders otitis media very frequent. Schwartze's
assertion that otitis media furnishes 22^ of all ear cases
in general or special practice is surely correct. Besides,
difficult hearing is very frequent in the young, a fact of
the greatest import to pedagogy. As early as 1886 Bezold
found that of 1,900 school children 25^ had only one-
third, and 11^ of the others only one-fifth of normal hear-
ing. The frequent affections of the nose and pharynx in
the young explain these facts and exhibit the possibilities
of preservation. Finally, the immature condition of the
mastoid process and "of the floor of the external canal is
best appreciated by the practitioner, general or special,
who deals with their abscesses.
Whether deafmutism is the result of consanguineous
marriage cannot be definitely asserted. It is rrot often
hereditary, quite often it appears to be the result of fam-
ily alcoholism, it sometimes depends on arrest of develop-
ment and foetal inflammation, but is more frequently an ac-
quired condition. Not rarely children are affected after
they have been able to speak. The majority of cases are
caused by cerebral or cerebro-spinal inflammation. Ac-
cording to Biedert, 55$ are of that class, 28$ are caused
by infectious diseases (cerebro-spinal meningitis, scarla-
tina, typhoid fever, diphtheria, also variola and measles),
3.3$ by injuries, and only 2.5$ are original ear affections.
Thus many of the congenital cases, and most of the ac-
quired, are preventable. More and more will our deaf-
mute institutions avail themselves of this knowledge, and
will learn how to teach their children not only how to
read and write, but also how to hear.
Not to the same, but to a great extent, pediatrics and
ophthalmology join hands. Infectious diseases, such as
diphtheria, affect the conjunctiva and sometimes the
cornea. Syphilis of the cornea, with or without chronic
iritis, is the form of parenchymatous or diffuse keratitis.
A frequent tumor in the eye of the young is glioma, and
69
DR. JACOBI'S WORKS
frequent symptomatic anomalies are strabismus and
nystagmus both of them the results of a great many
and various external or internal causes, with sometimes
difficult diagnoses.
The connection of pedology with dermatology is more
than skin deep; some of the most interesting problems
of the latter must be studied on antenatal and postnatal
lines. The congenital absence of small or large parts of
the surface is probably due to amniotic adhesions; sebor-
rhea and the mild form of lichen, also the furunculosis
of infant cachexia and atheroma, to the rapid develop-
ment, in the second half of intra-uterine life, of the
sebaceous follicles ; ichthyosis, to the same and to a
hypertrophy of the epidermis and the papillae of the
corium, sometimes with dilatation of their blood-vessels
and with sclerosis of the connective tissue. Congenital
anomalies, such as lipoma, sarcoma, naevus pigmentosus,
open all the question's of the embryonal origin of
neoplasms; and the eruptions on the infant surface
unclose to the specialist the subject of infectious diseases.
We recognize in the pemphigus of the palms arrd soles
syphilis; in herpes, gangrene, in what I have described
as chronic neurotic pemphigus, the irritable nervous
system; in eczema, constitutional disturbances of the
nutrition; in erythema, local irritation or intestinal auto-
infection; in isolated or multiple forms ranging between
hyperaemia and exudation, the effect of local irritation
or the acute or chronic influence of drugs. A dermatol-
ogist who knows no embryology or pedology, a pediat-
rist who knows no dermatology, is anything but a com-
petent and trustworthy medical practitioner.
The diseases of the muscles interest the pediatrist, the
surgical specialist, the orthopaedist, the neurologist, to
an equal extent. Many forms of myositis are of infec-
tious origin. Amongst the special forms of muscular
atrophy it is the hereditary variety which concerns the
first. The spinal neuritic atrophy, the myogenous,
progressive dystrophy, including the so-called pseudo-
hypertrophy, Thomson's congenital myotonia, and atro-
phic defects of muscles mainly the pectoral, but also
70
HISTORY OF PEDIATRICS
the trapezius, quadriceps, and others no matter whether
they are primary or myogenous (this probably always
when there is a complication with progressive dystrophy),
are of special interest to the neurologist. I need not do
more than mention torticollis in order to prove that
neither the pediatrist nor the orthopaedist, nor the general
surgeon can raise the claim of sole ownership.
The relations of pediatrics to forensic medicine are
very close. Nothing is more apt to demonstrate this
than the immense literature in every language on
infanticide and all the questions of physiology, physics,
and chemistry connected with that subject. The mono-
graphs and magazine essays of the last two centuries
written on the value or the fallacy of the lung test in the
dead newborn would fill a small library. Much atten-
tion has been paid by physicians and by forensic authors
to lesions and fractures of the newly-born head, and to
anomalies of the female pelvis causing them. Apparent
death of the newly-born and the causes of sudden death
in all periods of life have been studied to such an extent
as to render negative results of police investigation and
of autopsy reports less numerous from year to year.
Most sudden deaths receiving the attention of the-
authorities occur in the young. There were (Wm.
Wynn Westcott in Brit. M. J., Nov. 7, 1903) in
England and Wales during ten years 15,009 overlain
infants; in 1900, 1,774. In Liverpool, out of 960 inquests
there were 143 on babies that had died of such suffoca-
tion by accident or malice aforethought; in London, in
1900, 615; in 1901, 511; in 1902, 588. In London they
had annually 8,000 official inquests, one of 14 of which
were on overlain infants. The etiology of sudden deaths
would be far from complete, indeed the most difficult
questions could not be solved except by the facilities fur-
nished by the observations on the young. Foreign
bodies in the larynx, beans, shoe-buttons, and playthings
generally, even ascarides (Bouchut), bones and pieces of
meat aspirated during vomiting, acute oedema of the
glottis, aspiration of a long uvula, or of the retracted
tongue, the rupture of a pharyngeal abscess or of a suppu-
71
DR. JACOBI'S WORKS
rating lymphoid body into the trachea, a suddeir swell-
ing of the thymus in the narrow space between the
manubrium and vertebral column, which at best measures
only 2.2 cm., even a coryza in the narrow nose of a small
infant filled or not with adenoids are causes of sudden
death
The nervous system furnishes many such cases. It
is true there is no longer a diffuse interstitial encepha-
litis, such as Jastrowitz would have it, nor is the hyper-
trophy of the brain by far so frequent as Hiittenbrermer
taught, but there are sudden collapses and deaths by falls
on the abdomen, by sudden strangulation of large
herniae and other shocks of the splanchnic nerve. There
are sudden and unexplained deaths in unnoticed attacks
of convulsions, in the first paralytic stage of laryngismus
stridulus, in glottic spasms from whatever cause, in the
paralysis or, according to Escherich, laryngo-spasm of
what since Paltauf has been denominated status lymphat-
icus, in cerebral anemia, no matter whether it is the
result of exhaustion or, as Charles West taught us 60
years ago, from the mere change of position of a pneu-
monic or otherwise sick baby, when suddenly raised
from its bed. Or death may occur suddenly (a very fre-
quent occurrence) in the heart failure of pareirchymatous
degeneration of the heart muscle as it occurs in and after
diphtheria, influenza, and other infectious diseases, or in
the acute sepsis of appendicitis and other intraperitoneal
affections, whether recognized or not. For the absorb-
ing power, even of the normal peritoneum, is enormous.
Of a very acute infection (" infectio acutissima "), Wer-
nich spoke as early as 1883.
In gastroenteritis, the terminating broncho-pneu-
monia may destroy life quite suddenly; there is a capil-
lary bronchitis of the very young with no cry, no moan,
and no cough, but with sudden death; there are in
extreme atrophy, fatal emboli into the pulmonary, some-
times renal, more often cerebral arteries. There are the
cases of uremic convulsions, sudden, with sudden death,
which are often taken to be merely ^reflected or " prov-
idential," because the frequency of acute nephritis in the
72
HISTORY OF PEDIATRICS
newly-born and the infant, with its fever and its uremia,
in spite of the publications of Martin and Ruge, Vir-
chow, Orth, Epstein, and my own, is not yet fully
appreciated. That is so much the more deplorable as
the diagnosis of nephritis at any age is readily made
by the examination of the urine, which is so easy to
obtain in the young. Other suddenly fatal conditions,
such as the acute or chrome sepsis I mentioned before,
often quite unsuspected, entering through the umbil-
icus, the intestine, or the middle ear, are quite frequent.
I have been careful not to mention any cause of death
that may just as well be and has been studied in the
adult: hemorrhages, the many forms of sepsis of later
periods of life, poisons, such as carbolic acid and iodo-
form, interrse cold or heat, insolation, etc., for it is my
duty to exhibit the relation to forensic medicine of
pediatrics only. Forensic medicine has to guard the
interests of all. Nothing in all medicine is more diffi-
cult than the discovery of the cause of death. The best
knowledge of the advanced practitioner, of the path-
ologist, of the chemist, of the bacteriologist, of the
obstetrician, should be at the service of the people.
Every European country understands that and acts on
that knowledge. Our own Massachusetts has broken
away from the coroner's institution, which was a fit
authority for a backwoods municipality, but is so no
longer for a cultured people of eighty millions. Now and
then, even an expert, or a body of experts, does not suc-
ceed in discovering the cause of death. What shall we
say of a system which now and then does discover the
hidden cause of a sudden death? When the New York
State Legislature six months ago passed a bill abolishing
the no longer competent office of coroner, our good cul-
tured mayor, a gentleman and author, vetoed it for the
reason that the irew law was not perfect. It was not
pronounced perfect by anybody, no law is nor ever was.
That is why it appears he prefers something that always
was and is, and always will be perfect, namely, the
absurd incompetency and anachronism of the coroner's
office. That is perfect. I have not hesitated to express
73
DR. JACOBI'S WORKS
myself strongly and positively, for I have been called
upon to speak to you about the relation of pediatrics to
other sciences and arts politics included, than which
there is no more profound practical and indispensable
science and art. The greatest historical legislators
understood that perfectly well, when they knew how to
blend hygiene and religion with their social and political
organization 1 .
One of the greatest questions which concerns at the
same time the practical statesman, the humanitarian
and the pediatrist, is that of the excessive mortality of
the young. The Paris Academy of Medicine enumer-
ated in its discussions of 1870 the following amongst its
causes: Poverty and illness of the parents, the large
number of illegitimate births, inability or unwillingness
on the part of mothers to nurse their offspring, artificial
feeding with improper material, the ignorance of the
parents in regard to the proper food and hygiene, expo-
sure, absence of medical aid, careless selection of nurses,
lack of supervision of baby farms, general neglect and
infanticide. If there be anybody who is not quite certain
about the relationship of sciences and arts, he will still
be convinced of the correlation and co-operation of igno-
rance, indolence, viciousness and death, and shocked by
the shortcomings of. the human society to which we
belong. Most of them should be avoided. Forty per
cent, of the mortality of infants that die before the end
of the first year takes place in the first month. That is
mostly preventable. A few years ago the mortality of
the infants in the Mott Street barracks of New York
City was 325 per mille. Much of it is attributable to
faulty diet.*
Amongst those who believe in the omnipotence of
4 Measures taken for the purpose of obtaining wholesome milk
are not quite new. Regulations were given in Venice, 1599, for
the sale of milk. Milk and its products of diseased animals were
forbidden. The Paris municipality of 1792 enjoined the farmers
to give their cows healthy food. Coloring and dilution of milk
were strictly forbidden, and in 1792 they knew in France how to
punish transgressors.
74
HISTORY OF PEDIATRICS
chemical formulae, there prevails the opinion that a baby
deprived of mother's milk may just as readily be
brought up on cow's milk; that is easily disproved. In
Berlin they found that amongst the cow's-milk-fed babies
under a year the mortality was six times as great as
amongst breast-fed infants. Our own great cities gave
us similar, or slightly smaller, proportions, until the
excessive mortality of the very young was somewhat
reduced by the care bestowed on the milk, introduced
both into our palaces and tenements. Milk was exam-
ined for bacteria, cleanliness, and chemical reaction. It
was sterilized, pasteurized, modified, cooled, but no
cow's milk was ever under the laws of nature changed
into human* milk, and with better milk than the city of
New York ever had, its infant mortality was greater
this summer than it has been in many years.
That hundreds of thousands of the newly-born and
small infants perish every year on account of the
absence of their natural food is a fact which is known
and which should not exist. Why do we kill those
babies or allow them to be killed? Why is it that they
have no breast milk? A large number of women work
in fields, still more in factories. That is why their
infants cannot be nursed, are farmed out, fed artificially,
with care or without it, and die. It is the mis-rule pre-
vailing in our social conditions which compels them to
withhold milk from the infant while they are working
for what is called bread for themselves and their fam-
ilies. Many of these women, it is true, would not have
been- able to nurse their newly-born, for their own
physical condition was always incompetent. The same
may be said of women in all walks of life. Insufficient
food, hard work, care, hereditary debility and disease,
tuberculosis, alcoholism of the woman's own father,
modified syphilis or nervous diseases in the family
aye, the inability of her own mother to nurse her
babies, are ever so many causes why the mother's foun-
tain should run dry. Statistics from large obstetrical
institutions (Hegar) prove that only about 50^ of women
are capable of nursing their offspring for merely a few
75
DR. JACOBI'S WORKS
weeks. In the presence of such facts what are we to say
of the refusal of well-situated and physically competent
women to nurse their infants ? I do not speak of the
" 400," I mean the 400,000 who prefer their ease to their
duty, their social functions to their maternal obligations,
who hire strangers to nurse their babies, or worse yet,
who make-believe they believe the claims of the infant
food manufacturers, or are tempted by their own physi-
cians to believe that cow's milk casein and cow's milk
fat may be changed into woman's casein and fat, that
chemistry is physiology, that the live stomach is like a
dead laboratory bottle, that the warmth of the human
bosom and that of a nursing flask are identical, and that
cow's milk is like human milk when it carries the
tradesmark " Certified," or " Modified." Physiological
chemistry itself teaches that the phosphorus combina-
tions in woman's milk in the shape of nuclein and
lecithin are not contained in* cow's milk, and that the
large amounts of potassium and sodium salts contained
in cow's milk are dead weights rather than nutrients,
and particularly the large amount of calcium phosphate
occurs in a chemical, not in a physiological, combina-
tion. But lately, by no means the first time, Schloss-
mawn and Muro (Munch, med. Woch., 1903, No. 14),
have again proved that the albuminoids of woman's
and cow's milk are essentially different, both in their
lactalbumin and the globulin, and Escherich and Marfan,
that every milk has its own enzymes.
The quantitative and many of the qualitative differ-
ences of cows' and human* milk have been known a long
time. No addition or abstraction of salts, no addition
of cow's fat will ever change one into the other. But it
appears that every new doctor and every new author
begins his own era. There is for most of modern writers
no such thing as the history of medicine or of a specialty^
or respect of fathers or brothers. In modern books and
essays you meet with footnotes and quotations of the
productions of yesterday that look so erudite, but also
with the new discoveries of old knowledge which you
would recognize if the quotation marks had not been
76
HISTORY OF PEDIATRICS
forgotten by accident. So it has happened that many
learn for the twentieth time that the knowledge of the
minimum amount of required food is a wholesome
thing, that the amount of animal fat in infant food is
easily overstepped, that we have discovered that the
Dutch had a clever notion when they fed babies on
buttermilk with reduced fat; we are even beginning to
learn what our old forefathers practiced a hundred years
ago, and physiologists taught a third of a century ago
namely, that the newly-born and the very young infant
not only tolerate small quantities of cereals but that they
improve on it. Indeed, the names of Schiller, Korowirr,
and Zweifel have been rediscovered. We have also
learned just lately, it appears what was always
known, that morning and night, idleness and work,
health and illness, while altering the chemical compo-
sition of woman's milk do not necessarily affect its
wholesome character. We are beginning to learn that
it is impossible to feed a baby on fanatical chemical
formulae, for they are not prescribed by Nature, which
allows latitude within certain limits. We are even
beginning to learn that if that were not so there would
be no artificially fed babies alive, and possibly very
few participants in the St. Louis Congress of Arts and
Sciences.
The inability or reluctance of women to nurse their
own infants is a grave matter. From a physical, moral,
and socio-political point of view there is only one calam-
ity still graver, that is to refuse to have children at all.
It undermines the health of women*, makes family life a
commercial institute or a desert, depopulates the child
world, reduces original Americans to a small minority,
and leaves the creation of the future America in the
hands of twentieth century foreigners. The human
society of the future will have to see to it that no pov-
erty, no cruel labor law, no accident, no luxurious indo-
lence, must interfere with the nursing of infants. I
believe in the perfectibility of the physical and moral
condition's of the human race. That is why I trust that
society will find means to compel able-bodied women to
77
DR. JACOBI'S WORKS
mirse their own infants. Infants are the future citizens
of the republic. Let the republic see that no harm
accrues from the incompetence or unwillingness to nurse.
Antiquity did not know of artificial infant feeding. The
first information of its introduction is dated about 1500.
Turks, Arabs, Armenians, and Kurds know of no arti-
ficial feeding to-day. It takes modern civilization to
expose babies to disease and extinction. I know of no
political or social question of greater urgency than that
of the prevention of the wholesale murder of our infants
caused by the withholding of proper nutriment. May
nobody, however, feel that all is accomplished when an
infant has finally completed his 12 months. Society
and family owe more than life they owe good health,
vital resistance, and security against life-long invalidism.
But even willing mothers may have no milk. We
require a stronger, healthier race, and one that physic-
ally is not on the down grade. The nursing question is
a social and economic problem like so many others, like
the childbearing question*, that confront modern civiliza-
tion.
We are building hospitals for the sick of all classes,
and insist upon their being superior to the best private
residences; asylums for the insane, neuropathies, and
drunkards; nurseries and schools for epileptics, cretins,
and idiots ; refuges for the dying consumptives ; and
sanatoria for incipient tuberculosis. We are bent upon
curing and upon preventing. Do we not begin at the
wrong end? We allow consumptives and epileptics to
marry and to propagate their own curse. We have no
punishment for the syphilitic and the gonorrhoeic who
ruins a woman's life and impairs the human race.
Man, however, must see that his kind shall not suffer.
One-half of us should not be destined to watch, and
nurse, and support the other half. Human society and
the State have to protect themselves by looking out for
a healthy, uncontaminated progeny. Laws are required
to accomplish this ; such laws as will be hated by the
epileptic, consumptive, the syphilitic, and the vicious.
No laws ever suited the degenerates against whom they
78
HISTORY OF PEDIATRICS
were passed, and it is unfortunate that while health and
virtue are as a rule not contagious, disease and vice are
so to a high degree.
Modern Therapeutics, both hygienic and medicinal,
has gained much by the close observation of what is
permitted or indicated or required in early age. Since
it has become more humane (remember it is hardly a
century since Pinel took the chains off the insane in
their dungeons, and not more than half a century since
I was taught to carry my venesection lancet in my vest
pocket for ready use) and more scientific, so that what-
ever is outside of strict biologic methods is no longer
" a system," but downright quackery the terrible
increase of the latter as a world-plague is deemed by
rational practitioners and the sensible public an* appal-
ling anachronism. It appears that the States of the
Union are most anxious (and have been partially suc-
cessful) to rid themselves of it, while some at least of the
nations of Europe are greater sufferers than we. Accord-
ing to the latest statistics, there is one quack to every
physician in Bavaria and Saxony ; ten quacks in Berlin,
with its emperor and other accomplishments, to every
forty-six physicians. Its general population has increased
since 1879 by 6l%; the number of physicians, 1702%;
that of the quacks, 1600^
One of the main indications in infant therapeutics is
to fight anemia, which is a constant danger in the dis-
eases of the young, for the amount of blood at that age
is only one-nineteenth of the whole body weight, while
in the adult it is orre-thirteenth. The newly-born is
particularly exposed to an acute anemia. His blood
weighs from 200 to 250 grammes. It is overloaded
with haemoglobin which is rapidly eliminated, together
with the original excess of iron. This lively metabolism
renders the infant very amenable to the influence of
bacteria, and the large number of acute, sub-acute, or
chronic cases of sepsis is the result. Besides, the prin-
cipal normal food is milk, which contains but little iron.
That is why pediatrics is most apt to inculcate the les-
sons of appropriate posture, so as not to render the brain
79
DR. JACOBI'S WORKS
suddenly anemic, and of proper feeding and of timely
stimulation before collapse tells us we are too late, and
the dangers of inconsiderate depletion. The experience
accumulated in pediatric practice has taught general
medicine to use small doses only of potassic chlorate;
large doses of strychnine and alcohol in sepsis, of
mercuric bichloride in croupous inflammations, of heart
stimulants, such as digitalis, when a speedy effect is
wanted, of arsenic in nervous diseases, of potassic iodide
in meningitis ; it has warned practical men of the
dangers of chloroform in status lymphaticus ; 5 it has
modified hydrotherapeutic and balneological practice,
and the theories of hardening and strengthening accord-
ing to periods of life, and to the conditions of previous
general health.
The appreciation of electricity as a remedy has been
enhanced by obstetricians, pediatrists and general prac-
titioners. It is but lately that we have been told (P.
Strassmann, Samml. Klin. Vortr., 1Q03, No. 353) that a
newly-born and an infant up to the third week are per-
fectly insensible to very strong electrical currents. The
incompetency of mere experimental work, not corrected
or guided by practice, cannot find a better illustration,
for there is no more powerful remedy for asphyxia and
atelectasis than the cautious use of the interrupted or of
the broken galvanic current.
The domain of preventive therapeutics expands with
the increased knowledge of the causes of disease. That
is why immunizing, like curative serums, will play a
more beneficent part from year to year, and why the
healthy condition of the mucous membrane of the nose,
mouth, and pharynx, which I have been advising these
forty years as a prevention of diphtheria, has assumed
5 In the meeting of the Society for the Study of Disease in
Children, May 27, 1904, Mr. Thompson Walker alluded to the
collection of ten cases with status lymphaticus in which death
had occurred at the commencement of chloroform administration,
or during it, or immediately after the operation. In addition to
the usual changes, a hyperplasia of the arteries had been noted,
leading to narrowing of the lumen.
80
HISTORY OF PEDIATRICS
importance in the armamentarium of protection against
all sorts of infectious diseases.
Amongst the probabilities of our therapeutical future
I also count the prevention of congenital malformations,
which, as has been shown, are more numerous than is
generally known or presumed, and often the result of
intrauterine inflammation. In a recent publication F.
von Winckel (Samml. Klin. Vortr., 1904, No. 3?3)
emphasizes the fact that the general practitioner or the
pathologic anatomist sees only a small number, that
indeed the majority are buried out of sight, or are pre-
served in the specimen jars of the obstetrician. The
known number of malformations compared with that of
the normal newly-born varies from one to thirty-six, to
one to one hundred and two or more. They are met
with in* relatively large numbers on the head, face and
neck altogether in 53.2$ of all the 190 cases of mal-
formation observed in Munich during twenty years. A
number of them is the result of heredity, of syphilis
or other influences. How many are or may be the
result of consanguineous marriages will have to be learned.
In all such cases the treatment of the parents or the
prohibition of injurious marriages will have to be insisted
upon. The number of those recognized as due to amniotic
adhesions or bands is growing from year to year. Kiim-
mel could prove that of 178 cases, 29 were certainly of
that nature. External malformations have long been
ascribed to them; proximal malformations, such as
auricular appendices, harelip, anencephalia, cyclopia,
flattening of the face, anophthalmia, hereditary poly-
dactylia (Ahlfeldt and Zander, Virchow's Archiv, 1891),
and lymphangioma of the neck, have been found to be
caused by amniotic attachments or filaments. Is it too
much to believe that the uterus, whose internal changes,
syphilitic or others, are known to be very accessible to
local and general medication, should be so influenced by
previous treatment that malformations and foetal deaths
will become less and less frequent?
The problem of the health and hygiene mainly of the
older child refers to more than its food. The school
81
DR. JACOBI'S WORKS
question is in the foreground of the study of sanitarians,
health departments, physician's, and pedagogues. Its
importance is best illustrated by the large convention
which was organized in Stuttgart, April, 1Q04, as an
International Congress for School Hygiene. Pediatrists,
pedagogues, and statesmen formulated their demands
and mapped out future discussions. Rational pediatrics
would consider the following questions : Is it reason-
able to have the same rule and the same daily sessions
for children of eight and perhaps of fifteen years, and for
adolescents? Certainly not. The younger the child the
shorter should be the session, the longer and more fre-
quent the recesses. There should be no lessons in the
afternoon, or only mechanical occupations, such as copy-
ing, or light gymnastics. There should be no home
lessons.
The problem of overburdening was carefully con-
sidered by Lorinser in 1836, and by many since. It deals
with the number of subjects taught, the strictness and
frequency of official examinations, and should consider
the overcrowding of school rooms. We should try to
answer the question whether neuroses are more the
result of faulty schooling or of original debility, heredity,
underfeeding, lack of sleep, bad domestic conditions, or
all these combined. In Berlin schools they have begun
to feed the hungry ones regularly with milk and bread.
No compulsory education* will educate the starving. The
child that showed his first symptom of nervousness
when a nursling, the child with pavor nocturnus, or
that gets up tired in the morning, or suffers from motor
hyperaesthesia, pointing or amounting to chorea, unless
relieved instead of being punished by an uninformed or
misanthropic or hysterical teacher, gets old or breaks
down before the termination of the school term or of
school age. There should be separate classes for the
feeble, for those who are mentally strong, or weak, or of
medium capacity. All of such questions belong to the
domain of the child's physician, the physician in gen-
eral. The office of school physician is relatively new.
Whatever we have done in establishing it in America
82
HISTORY OF PEDIATRICS
has been preceded by countries to which we are not in
the habit of looking for our models. Bulgaria and
Hungary have no schools without physicians. On the
other hand, Vienna has none for its 200,000 school
children. It is reported that the aldermen refused to
appoint one. One of them objected for the reason that
the doctor might be tempted to examine the Vienna
lassies too closely. His business would be, and is, to
look out for the healthfulness of the school building, its
lighting, warming, cleanliness, the cleanliness of the
children and their health, and that of the teachers. A
tubercular teacher is a greater danger to the children
than these, who rarely expectorate, to each other. He
would take cognizance of the first symptoms of infec-
tious diseases, examine eyes, ears, and teeth, and inquire
into chronic constitutional diseases, such as rachitis and
scrofula in the youngest pupils. He might undertake
anthropometrical measurements and benefit science
while aiding his wards. He would be helped in all these
endeavors by the teachers who must learn to pride
themselves on the robust health of their pupils, as they
now look for the accumulation of knowledge which may
be exhibited in public examinations.
They would soon learn what Christopher demon-
strated, that physical development, greater weight, and
larger breathing capacity, correspond with increased
mental power, joining to this the advice that a physical
factor as well as the intellectual one, now entirely relied
upon, should be introduced in the grading of pupils.
(Charles F. Gardiner and H. W. Hoagland, Growth and
Development of Children in Colorado. Trans. Am.
Climatological Ass'n, 1903.)
Our knowledge of the physiology and pathology of
the nervous system of all ages would be defective with-
out lessons derived from the foetus and infant. Amongst
the newly-born we have often to deal with arrests of
development, such as microcephalus, or with that
form of foetal meningitis or of syphilitic alterations of
blood-vessels which may terminate in chronic hydro-
cephalus. When the insufficient development of reflex
83
DR. JACOBI'S WORKS
action irr the newly-born up to the fifth or sixth week
has passed, the very slow development of inhibition
during the first half year or more, together with the
rapid increase of motor and sensitive irritability, explains
the frequency of eclampsia and other forms of convul-
sions. Many of them require, however, an additional
disposition, which is afforded either by the normal rapid
development of the brain, or the abnormal hypermia
of rachitis. The last 25 years have increased our
knowledge considerably in many directions. Congenital
or premature, complete or partial, ossification of the
cranial sutures lead mechanically to idiocy, or paralysis,
or epilepsy; it is a consolation, however, to know that
the victims of surgical zeal are getting less irr number
since operators have consented to fear death on the
operating table, and thoughtful surgeons have come to
the conclusion to leave bad enough alone. In the very
young the fragility of the blood-vessels, the lack of coagu-
lability of the blood, the large size of the carotid and
vertebral arteries, the frequency of trauma during
labor and after birth, the vulnerability of the ear and
scalp, contribute to the frequency of nervous diseases,
which before the fifth year amounts to 87^ of all
the cases of sickness. Rapid exhaustion leads to
intracranial emaciation and thrombosis, the so-called
hydroencephaloid of gastro-enteritis. The large size and
number of the lymph vessels of the nasal and pharyngeal
cavities facilitate the invasion into the nerve centers of
infections which show themselves as tubercular menin-
gitis, cerebro-spinal meningitis, and polio-encephalitis,
or more so, poliomyelitis, and as chorea of so-called
rheumatic -- mostly streptococci origin. Xose and
throat specialists, as well as anatomists, have con-
tributed to our knowledge on these points another proof
of the intimate dependency of all parts of medicine upon
one another. Now all these conditions nre not
limited to early life, but their numerical preponder-
ance at that time is so great that it is easy to understand
that general nosology could not advance without the
overwhelming number of well-marked cases amongst
84
HISTORY OF PEDIATRICS
children. Amongst them are the very numerous cases
of epilepsy. They escape statistical accuracy, for many
an epileptic infant or child dies before his condition is
observed, or diagnosticated ; a great many cases of
petit mal, vertigo, dreamlike states and somnambulism,
fainting, habit-chorea, truancy, imbecility, incompetency,
or occasionally wild attacks of mania, or the per-
versity of incendiarism, or in older children religious
delirium, even hysteric spells, are overlooked or perhaps
noticed or suspected by nobody but the family physi-
cian ; or, in the cases of the million poor, by nobody.
They are cared for or neglected at home, and the seizure
is taken to be an eclamptic attack due to bowels, worms,
colds, and teeth, exactly like three hundred years ago.
Of equal importance in this disease to the pediatrist,
the pedagogue, the psychiatrist, the judge, the states-
man, no matter whether in office or a thoughtful citizen,
is the influence of heredity. The old figures of Eche-
verria, which have been substantiated by a great many
observers, tell the whole story. One hundred and thirty-
six epileptics had 553 children. Of these, 309 remained
alive; 78 (25^) were epileptic; how many of the 231
that died had some form of epilepsy or would have
exhibited it nobody can tell. He observed a dozen cases
in one family. While in his opinion 29-72% showed a
direct inheritance from epileptic parents, Gowers has a
percentage of 35, and Spratling, who has lived among
epileptics nearly a dozen years, 66.
Epilepsy is acknowledged to be one of the causes of
imbecility, or genuine idiocy. In very many instances
it should be considered as the co-ordinate result of con-
genital or acquired changes in the skull, the brain, and
its meninges, and particularly the cortex. In a single
idiot institution, that of Langenhagen, 15< to 18^ of
the 395 668 inmates were epileptic ; in another, Dalldorf .
18.5^ to 24.3^ of 167344; in a third, Idstein, 36<? of
101 (Binswanger, in Xothnagel, Syst. Path. u. Ther., Vol.
xii, 1,310).
Its main causes are central. External irritations,
worms, calculi, genital or nasal reflexes, may be occa-
85
DR. JACOBI'S WORKS
sional proximate causes. But cauterization of the nares,
and still more, circumcision, and clitoridectomy prove
more the helplessness or recklessness of the attendant
than the possibility of a cure. The individual cases of
recovery by the removal of clots, bones, or tumors, are
great and comforting results, but if epilepsy and its rela-
tions are ever to disappear, it is not the knife of the
surgeon but the apparatus of human foresight and justice
that will accomplish it. Most of the causes of epilepsy
are preventable. To that class belongs syphilis and
alcoholism in various generations, rachitis, tuberculosis
and scrofula, many cases of encephalo-meningitis, and
most cases of otitis. A question is attributed to a royal
layman, "If preventable, why are they not prevented?"
If there is a proof of what Socrates and Kant said,
namely, that statesmanship cannot thrive without the
physician, it is contained in the necessities of epilepsy.
Prevention, preventives and hygienic, medicinal, and
surgical aids have to be invoked, unfortunately with
slim results so far.
The influence of hereditary syphilis on the diseases
of the nervous system has been studied these 20 years,
both by neurologists and pediatrists. Its results are either
direct that means characteristically syphilitic or meta-
syphilitic that means merely degenerative. Hoffmann
cured a case of syphilitic epilepsy in a girl of nine years
in 1712. Plenk describes convulsions and other nervous
symptoms depending on hereditary syphilis, and Nil
Rosen de Rosenstein describes the same in 1781. The
literature of the later part of the eighteenth, and of the
first half of the nineteenth century is silent on that sub-
ject, though the cases of affections of the nervous system
depending on hereditary syphilis are very frequent
(thirteen per cent, of all the cases, according to Rumpf
die Syph. Erk. d. Nervensystems, 1889). Jullien (Arch.
Gen., 1901) reports 260 pregnancies in 43 syphilitic
matrimonies. Of the children, 162. remained alive.
Half of them had convulsions or symptoms of meningitis.
According to Nonne (Die Syph. d. Nervens., 1902)
hereditary syphilis differs from the acquired form in
86
HISTORY OF PEDIATRICS
this that several parts of the nervous system are affected
simultaneously; and that arteritis, meningitis, gum-
mata, and simple sclerosis occur in combination. Simple
cerebral meningitis and apoplexies are very rare.
Encephalitis is more frequent. Probably spinal dis-
eases are more frequent, according to Gilles de la Tou-
rette, Gasne, Sachs, and others. Tabes dorsalis is not
frequent, but may rather depend on an atavistic syphilitic
basis; for altogether the nerve syphilis of the second
previous generation as a cause of disease in the young is
not very rare. (E. Finger, W. klin. Woch., 13, 1QOO.)
What we call neuroses are not infrequent in infants and
children. Neuralgias are not so common as in the adult,
but would be more frequently found if sought for. Even
adipositas dolorosa has been observed in childhood.
Hysteria is by no means rare, and its mono-symptomatic
character, so peculiar to early age, adds to its nosological
importance. Its early appearance is of grave import. Its
often hereditary origin makes it a serious problem,
under-alimerrtation or ill-nutrition, rachitis and scrofula,
frequently connected with and underlying it, may make
it dangerous and a fit subject for the study of educators,
psychologists, judges, and all those whose direct office it
is to study social and socialistic problems. Hysteria is
not quite unknown amongst males, though the large
majority are females.
Some of the vaso-motor and trophic disturbances are
less, others more frequent, in the young than in the
adult. Amongst 129 cases of akroparaesthesia there is
only one of Frankl Hochwart in a girl of 12 years, and
one of Cassirer in a girl of 16. Sclerodermia is met with
mostly in mature life, but the cases of Neumann at 13
days, and those of Cruse, Herxheimer, and of Haushalter
and Spielmarm, who observed two cases in one family,
all of them when the infants were only a few weeks old,
prove that the same influences which are at work in
advanced age, namely, hereditary disposition, neu-
ropathic family influence, low general nutrition, colds,
trauma, and so on, may play their role in infant life.
Nor are infant erythromelalgias numerous. Henoch
87
DR. JACOBI'S WORKS
saw one in a teething infant, Baginsky in a boy of 10,
Heimann one in a girl of 13, Graves one in a girl of 16;
that mean's three or four cases below 13 or l(j years of
age, out of a number of 65 collected by Cassirer in
his monograph. (Die Vasomotorisch-trophischen Neu-
rosen, Berlin, 1901.) In half a century I have seen but
one that occurred in early age, namely, in a boy of 12,
who got well with the loss of two toes. On the other
hand, the symmetrical gangrene of Raynaud and acute
circumscribed cedema of Milton and Quincke, 1882,
treated of by Collins in 1892, are by no means relatively
rare in infancy and childhood. There are a few cases of
the former that occurred in the newly-born. Two I
have seen myself. There are those which have been
observed at 6 months (Friedel), 9 months (De France),
at 15 months (Bjering), at 18 months (Dick). In the
year 1889 Morgan collected 93 cases, 13 of which occurred
from the second to the fifth, 1 1 between the fifth and
tenth, and 15 between the tenth and twentieth years.
Amongst the 168 cases collected by Cassirer, 20 occurred
under the fifth, 8 between the fifth and tenth, and 25
between the tenth and twentieth years of life. Like
most nervous diseases, these cases had either congenital
or acquired causes, amongst which a general neuropathic
constitution, and the hereditary influence of alcohol,
chlorosis, and anemia are considered prominent. Of
acute circumscribed oedema, 28 cases are found below
nine years of age in Cassirer's collection of 160 cases, one
of which at the age of one -and a half months is reported
by Crozer Griffith, one at three months by Dinckelacker.
Again hereditary influence is found powerful. Osier
could trace the disease through five generations.
The connection of pediatrics with psychiatry is very
intimate. Insane children are much more numerous
than the statistics of lunatic asylums would appear to
prove, for there are, for obvious reasons, but few insane
children in general institutions. It is only those cases
which become absolutely unmanageable at home that
are entrusted to or forced upon an asylum. The example
of the French, who more than 50 years ago had a
88
HISTORY OF PEDIATRICS
division in the Bicetre for mentally disturbed children,
has seldom or not at all been imitated. Thus it happens
that though not even a minority of the cases of idiocy
become known, its statistics is more readily obtained than
that of dementia of early life. Some of its physical
causes or accompaniments have been mentioned
asphyxia with its consequences, ossification and asymmet-
rical shape of the cranium, accidents during infancy
and childhood, neuroses that may be the beginning or
proximate causes of graver trouble. Infectious diseases
play an important part in the etiology of intellectual
disorders. Althaus collected 400 such cases. They
were mainly, influenza 113, rheumatism 96, typhoid
fever 87, pneumonia 43, variola 41, cholera 19, scarlatina
16, erysipelas 11. In most of the cases there were
predisposing elements, such as heredity and previous
diseases, or over-exertion of long duration. The over-
worked brain's of school children were complained of as
adjuvant causes of lunacy by Peter Frank as early as
1804. We are as badly off or worse, a hundred years
later.
There is one ailment, however, that appears to hurt
children less than it does adolescents or adults, that is
masturbation. There are those cases, fortunately few,
which depend on cerebral disease, and original degen-
eracy, but in the large majority of instances mastur-
bation, frequent though it be, has not in the very young
the same perils that are attended with it later on when
the differentiation of sex has been completed and is
recognized. Babies under a year, and children under 8
or ten will outlive their unfortunate habit, and do not
appear to suffer much from its influence. Whatever
is said to the contrary is the exaggeration of such as like
to revel in horrors. The same exorbitant imagination
is exhibited in other statements. What Lombroso and
his followers have said of the faulty arrangement of the
teeth, prognathic skulls, retracted nose, short and
attached lobes of the auricle, as distinct symptoms of
mental degeneracy, belongs to that class, and need not
always be taken as the positive signs of insane crimi-
8.9
DR. JACOBI'S WORKS
nality. There is so much poetical exaggeration and word
painting in them that Lombroso and also Krafft-Ebing
are the pets of the prurient lay public. In its midst
there must be many who are anxious to believe with
Lombroso that brown hair and eyes, brachycephalic
heads, and medium size of the body characterize the
insane criminal, if only for the purpose of scanning the
hair and eyes and heads of their near friends and their
mother-in-law's relatives.
It is certainly not true that, as Lombroso will have
it, children are cruel, lazy, lying, thievish, just as little
as according to him all savages are like carnivorous
animals, and essentially criminal, while others are con-
vinced that by nature they are amiable, like Uncas, and
virtuous like Chingacook, and have been rendered sav-
age only by the strenuousness of conquering immigrants.
Nor is it true that the idiot brain is merely arrested at a
stage similar to anthropoid, or even saurian develop-
ment, for it is less arrest of development than the influ-
ence of embryonal or foetal disease, beside amniotic
anomalies that cause the irregularities of the encephalon.
Amongst the worst causes of idiocy is cretinism, both
the endemic, and the sporadic. Every cretin is an idiot,
not vice versa. The first could be prevented by State
interference which would empty the stricken valleys ;
the latter depends on thyroidism, with or without a
shortening of the base of the skull, and is partially
curable. The idiotism of cretinism causes a fairly
uniform set of symptoms; that which depends on other
causes exhibits varieties, though not so many as imbe-
cility, which, too, should not be taken to be the result of
a single cause. Osseous and cartilaginous anomalies
about the nose are pointed out by William Hill, chronic
pharyngitis and nasal polypi by Heller, enlarged tonsils
by Kafemann in one-third of the cases, some pharyngeal
or nasal anomaly in four-fifths by Schmid-Monnard.
Adenoids are frequently found as complications. Oper-
ations to meet all these anomalies have been performed
with improvement of the mental condition in some, of
the physical in many more, mainly when the anomalies
90
HISTORY OF PEDIATRICS
were complications only. But after all we should be-
ware of the belief in miracles and in infallible cures.
Mainly the tonsils have been puffed up to be the main
causes of many human troubles and their removal a
panacea. According to a modern writer it prevents tu-
berculosis, but the prophet is a little too bold, for he
adds that with the exception of himself there are very
few able to accomplish it. Defective or diseased brains
are frequent in most conditions. The former class allows
even imbeciles to excel in some ways. In that class may
be found calculating experts, chess-players, or mechanical
draughtsmen.
Imbecile persons may be taught sufficiently to prepare
for the simple duties of life. There are, however, many
transitions between the complete imbecile, the mild im-
becile, and the merely slow and dull. That is why the
condition is frequently rrot appreciated. In his school the
imbecile child is slightly or considerably behind his class,
and the laughing-stock of the rest. As he is intellectually
slow, so he is morally perverse or is made to become so.
He knows enough to lie and libel, to run away from school,
and from truant to become a vagrant. It is true it will
not do to declare the imbecile per se identical with the
typical criminal, but as many of them are illegitimate, or
of defective or alcoholic parents, or maltreated at home,
or diseased and deformed, they get, by necessity, into con-
flict with order and the law. Thompson found 218 con-
genital imbeciles among 943 penitentiary inmates. Knecht,
41 amongst 1,214. When the imbecile is once a prisoner
his condition is not liable to be noticed on account of the
stupefying monotony of his existence.
What is more to be pitied, the fate of the immature
or imbecile half-grown child that naturally acts differ-
ently from the normal, or the low condition of the State
which instead of procuring separate .schools for the half-
witted, or asylums, has nothing to offer but contumely
and prison walls, and increasing moral deterioration?
There is the stone instead of the bread of the gospel.
Modern society has commenced, however, to mend old
injustices. Every civilized country admits irresponsibility
91
DR. JACOBI'S WORKS
before 4he law below a certain age, and gradually the
mental condition of the criminal is taken into considera-
tion and made the subject of study. But still thousands
of children and adolescents are declared criminals before
being matured. The establishment of children's courts is
one of the things, imperfect though they be, that make
us see the promised land from afar. When* crime will be
considered an anomaly, either congenital or acquired in
childhood, a disease; when society will cease to insist upon
committing a brutality to avenge a brutality; when self-
protection will take the place of revenge, and asylums
that of State prisons then we shall be a human, because
humane, society.
CONCLUSIONS
Pedology is the science of the young. The young are
the future makers and owners of the world. Their phys-
ical, intellectual and moral condition will decide whether
the globe will be more Cossack or more Republican, more
criminal or more righteous. For their education and train-
ing and capabilities, the physican, mainly the pediatrist,
as the representative of medical science and art, should
become responsible. Medicine is concerned with the new
individual before he is born, while he is being born, and
after. Heredity and the health of the pregnant mother
are the physician's concern. The regulation of labor laws,
factory legislation, and the prohibition of marriages of
epileptics, syphilitics, and criminals are some of his pre-
ventive measures to secure a promising progeny. To him
belongs the watchful care of the production and distribu-
tion of foods. He has to guard the school period from
sanitary and educational points of view, for heart and
muscle and brain are of equal value. It is in infancy
and childhood, before the dangerous period of puberty
sets in, that the character is formed, altruism inculcated,
or criminality fostered. If there be in the commonwealth
any man or any class of men with great possibilities and
responsibilities it is the physician. It is not enough, how-
ever, to work at the individual bedside and in a hospital.
In the near or dim future, the pediatrist, the physician,
92
HISTORY OF PEDIATRICS
is to set in and control school boards, health departments,
and legislatures. He is the legitimate adviser to the judge
and the jury, and a seat for the physician in the councils
of the republic is what the people have a right to demand.
Before all that can be accomplished, however, let the
individual physician not forget what he owes to the com-
munity now. Mainly to the young men amongst us I
should say, do not forget your obligations as citizens.
When we are told by Lombroso that there is no room in
politics for an honest man, I tell you it is time for the
physician: to participate in politics, never to miss any of
his public duties, and thereby make it what sometimes it
is reputed not to be in modern life- honorable. A life
spent in the service of mankind, be our sphere large or
narrow, is well spent. And never stop working. Great
results demand great exertions, possibly sacrifices. After
all, whether everything in science and politics that now is
our ideal will be accomplished while we live or after we
shall be gone, we shall still leave to our progeny new
problems.
THE HISTORY OF CEREBRO-SPINAL MENIN-
GITIS IN AMERICA
NOTHING is more difficult to ascertain than the age of
certain diseases, which by reason of their distribution
and mortality have attained historical significance. The
most notable in the category is syphilis. The number of
people who believe it to have sprung from nihility at the
close of the fifteenth century, or who consider it an article
of importation by the immoral Indians from Indianola
into blissful, innocent Spain, has not diminished. Most
likely cerebro-spinal meningitis will fare the same fate.
What we call cerebro-spinal meningitis to-day was first
described, with certainty, in 1805. Lersch cites, in a
short note, also the year 1803 (Volksseuchen, 1896), but
gives no data of the literature. In all probability this
disease existed, either sporadically or endemically, at an
earlier period. Meredith Clymer (Epidemic Cerebro-
Spinal Disease, Phil. 1872) gave expression to his pre-
sumption that occasional cases with a similar symptom-
complex had been observed in the United States toward
the end of the eighteenth century.
The malignant fever which Daniel Sennert describes in
1611 is most likely one and the same disease, and later
was characterized as spotted fever, cerebro-spinal typhus,
cerebro-spinal fever and cerebro-spinal meningitis. Ac-
cording to Webber (Boylston Prize Essay in Boston Med.
and Surg. Jour. 1866), from the thirteenth century on-
ward, symptoms descriptive of cerebro-spiiral meningitis
have been enumerated. The accounts have not always been
accurate, ' the principal symptoms have been variously
depicted; it is quite likely that our disease and exanthe-
matous typhus were often mistaken for one another, like
syphilis, which before the end of the fifteenth century was
often, if not always, confounded with measles and variola
95
DR. JACOBI'S WORKS
(J. K. Proksch, Beitrage zur Geschichte der Syphilis,
1904). Sir John Pringle, in 1752, wrote, in his observa-
tions on diseases of the army, about a prison and hospital
fever in which pus was found on the brain, and Bascome
in his history of epidemic pestilences, London, 1851, re-
fers to a local epidemic, in Roettingen, Bavaria, in 1802,
in which young, strong males, with painful stiffness of
the muscles of the neck, died within twenty-four hours.
The best history of cerebro-spinal meningitis of all
countries is to be found in the third volume of Historisch-
Geographische Pathologic by August Hirsch, 1886. The
" Epidemic Cerebro-Spinal Meningitis and its relation to
other forms of meningitis a report of the State Board
of Health of Massachusetts, Boston, 1898," by W. T.
Councilman, F. B. Mallory and J. H. Wright, offers
valuable contributions. That part of the second volume
of Puschmann's Geschichte der Medicin, edited by Victor
Fossel, is quite superficial. The Subject Catalogue and
Index Medicus contain naturally everything desirable, and
much that is not so.
The great knowledge revealed in our periodical litera-
ture is collected with the aid of a secretary from the above
named sources, from Virchow-Gurlt's Jahresbericht and
other encyclopaedia. Without quoting these works too
much I will give you a short survey of the occurrence of
cerebro-spinal meningitis in the United States, which more
often than any other country has been invaded by this
plague. Hirsch divides its history into four periods 1805-
1837; 1837-1850; 1854-1875; 1876 up to the time that his
book was published we may say, with interruptions, until
to-day. In the first, third and fourth periods the United
States was severely affected, whereas during the second
period France bore the brunt of the disease. It is to be
hoped that the period we have been going through since
last year is not the precursor of a fifth period. In 1806
the disease was epidemic in New Hampshire, Massachu-
setts, Connecticut, New Jersey and Vermont; in 1807 in
Canada; in 1808 in Virginia, Kentucky and Ohio; 1809 in
New York and Pennsylvania; 1814 in Maine; 1814-1816
in New England in general. The epidemic then gradu-
96
HISTORY OF CEREBRO-SPINAL MENINGITIS
ally died out. However, in 1823 we hear again of an
epidemic in Middletown, Conn., and in 1828 in Trum-
bull, Ohio. From then until 1842 we have no data.
The most important contributions to the literature are
by L. Danielson* and E. Mann (1806), "A singular and
very fatal disease which lately made its appearance in
Medford, Mass.," which appeared in the Medical and
Agricultural Register, Boston ; further, a contribution by
a committee of the Massachusetts Medical Society (James
Jackson, Thomas Welch and J. C. Warren) of the year
1809, printed in 1813 in the second volume of the Trans-
actions; and above all, the book of Elisha North of 1811,
which is worthy of the name of a classic. The title of this
book which contains 249 pages is: "A Treatise on a
Malignant Epidemic Commonly Called Spotted Fever,
etc."
Dr. North's book contains among other things the
history of the epidemic of Litchfield county, Connecticut,
by Dr. Samuel Woodward of Hartford, besides a good
description of the clinical picture of the disease by Dr.
Bertort. Under the influence of Brownianism, which did
not prevail in England, although it was prevalent in Ger-
many and America, he sought the immediate cause of the
disease " in the increase in the serfsorial power of sensa-
tion with the decrease of the sensorial power of irrita-
tion." Whoever cannot understand this, must console him-
self with the fact that during the following 30 or 40
years, medicine in Germany, for instance, was an absolute
blnnk, with indescribable buncombe, and we may indeed
congratulate ourselves that we have outlived the era of
the Svstems. During the second period (according to
Hirsch) the disease was very widesprend with us, from
1842-1850; in 1842 in Rutherford county. Tennessee, and
in Montgomery, Alabama; in 1845 in Mt. Vernon, Illinois;
in 1846 and 184? in Arkansas; in 1847 in Vicksburg, Mis-
sissippi, in 1 Tennessee and in Missouri. The disease was
especially virulent among the recruits of a regiment that
bad been sent from Mississippi into swampy quarters near
New Orleans. In 1848 Montgomery, Alabama, was af-
fected for the second time ; also Pennsylvania along the
97
DR. JACOBI'S WORKS
Ohio river and Worcester, Massachusetts. In 1850 there
was a severe epidemic in the negro quarters of New Or-
leans, as we find it among populations who live in wretched
hovels with insufficient nourishment.
From 1850-1856 the United States were free from the
disease. In 1856 and 1857 we find it in Salisbury, North
Carolina (Dickson in Trans. A. M. A.}; in the same year
it prevailed in the western part of New York, especially
in Onondaga, Chemung and Madison (Thomas in Trans.
Med. So. St. of N. F.). During the war, 1861-1864, the
disease was far reaching. In the winter of 1861-1862 it
existed in the Army of the Potomac near Washington;
likewise in a negro colony quartered by the Confederates
in Memphis. In 1862 and 1863 it appeared in the camp
around New Bern, N. C., with the same clinical and ana-
tomical manifestations which had been observed in 1810;
and also in Massachusetts in 1864 and 1865. Massa-
chusetts then remained free from the disease until it ap-
peared in Boston in 1872 and 1873 (J. B. Upham in Re-
port of the State Board of Massachusetts, 1874). It had
appeared in Philadelphia in 1863. This epidemic was de-
scribed in 1867 by Alfred Stille in a monograph which has
retained its value, entitled " Epidemic Meningitis." The
same author published an article in 1885 in Pepper's Sys-
tem of Medicine, which is still very instructive.
During the epidemic which prevailed at Philadelphia
in 1863-1866, the whole city was severely affected; also
Indiana and Iowa; and likewise the Confederate troops
in Norfolk, Va., whose camps were pitched in swampy
regions, and those who were in hospitals. At this time the
disease appeared for the first time at the military school
in Newport, R. I. Mobile, Ala., Illinois, New Jersey,
Vermont along the Connecticut river, Connecticut and
Ohio were severely affected. There were bad epidemics
in two hospitals and in the orphan asylum at Washington.
From 1860-1874 we find epidemics over the entire length
of the land, especially during the winter and spring.
After 1876 the disease showed itself sporadically at far
separated points. In 1893 the disease once more became
epidemic in New York (H. Berg in Archiv. Fed. May,
98
HISTORY OF CEREBRO-SPINAL MENINGITIS
1894). This author emphasizes the non-contagious nature
of the disease. It also appeared in the Layaconing Val-
ley in Maryland in 1893. Simon Flexner and Lewellys
J. Barker in the Amer, Jour, of the Med. Sc. (February
and March, 1891) describe this epidemic from a prac-
tical and strictly scientific standpoint. Appended to this
article there is a two-page bibliography of the most valu-
able essays on this subject. In some of their cases the
pneumococcus was found.
During these decades the disease did not die out. Occa-
sionally for long periods the mortality was low; then
suddenly it would rise. For instance, during many years
only isolated cases developed in Montreal; so also in the
Boston City Hospital, from 1880 to 1896, only 39 cases
died. But during the first month of the epidemic of 1897
there were 42 fatal cases. Stille reports but few cases
in Philadelphia from 1864-1865, and from 1872-1873.
Pepper carries the report along until 1892 and Abbott
brings it up to date. How rapidly the mortality changes
will be seen from the following figures: Philadelphia had
in 1884, 124 deaths; in 1893, 23 deaths; in- the succeeding
years seriatim, 22, 35, 18, 17, 7, 10; 24 in 1898, and in
the first 4 months of 1899, 89 deaths.
In New York the disease was endemic in 1867-1868
(Brown, Med Record, April, 1868). Somewhat later,
Ohio and Indiana were affected; between 1869 and 1870
we find the disease reappearing in* Alabama, Pennsylvania,
and Virginia, in 1871 in Minnesota and Pennsylvania, in
1872 in New Jersey, the cities of New York and Brooklyn,
Onorrdaga county, also Illinois, South Carolina and part
of Georgia. Concerning Augusta, Ga., I was kept in-
formed at that time by Dr. Ford. The cases were not
numerous but fulminating, and occurred almost exclusively
among the most miserable class of negroes. In 1873
Massachusetts suffered severely, Indiana and Michigan to
a less extent.
Children were chiefly affected during 1806 in Massa-
chusetts, 1847 in Tennessee, 1857 in Elmira, 1863 in
Philadelphia, 1864 in Illinois, 1870 in Virginia. Adults
between 20 and 30 years were chiefly affected in 1811 in
99
DR. JACOBI'S WORKS
Milford, Court., in 1848 in Montgomery, Ala., and in
1857 in Brookfield, N. Y. Out of 2909 cases reported
from Massachusetts 405 occurred in the first nine months
of 1897. Of these there were 316 under one year, 146
between one and two years, 26 per cent.
I herewith present a list compiled by the New York
Board of Health. In considering it, the increase of popu-
lation from 1866 to 1901 must be taken into account.
Q.-4- S-i -M ft-* 1 ^ '
fto 3TS "El ?'5i 5 "So
o c 3 c c 3 o c D c c
e 2c 5-3 3 If Sc -2c
a5 <u * o> ft* 3 <;; > o> aa>
t. C P g Cg ft C .0 g fig
,jj!3 3 C C C o <Dp>- 5
U H 03 (In U H 02
1866 .............. 18 588 486 767,979 .23 7.66 6.33
1867 .............. 33 654 674 808,489 .40 8.09 8.34
1868 .............. 34 627 820 851,137 .39 7.39 9.63
1869 .............. 42 688 725 896,034 .47 7.68 8.09
1870 .............. 32 812 750 943,300 .34 8.61 7.95
1871 .............. 48 755 623 955,931 .50 7.90 6.52
1872 .............. 782 770 848 968,710 8.07 7.95 8.75
1873 .............. 290 682 666 981,671 2.95 6.95 6.78
1874 .............. 158 627 563 1,031,607 1.53 6.08 5.46
1875 .............. 146 599 643 1,044,396 1.40 5.74 6.16
1876 .............. 127 613 697 1,075,532 1.18 5.70 6.48
1877 .............. 116 514 556 1,107,597 1.05 4.64 5.02
1878 .............. 97 604 569 1,140,617 .85 5.29 4.99
1879 .............. 108 609 536 1,174,621 .92 5.18 4.57
1880 .............. 170 617 582 1,209,196 1.41 5.10 4.82
1881 .............. 461 675 764 1,244,511 3.70 5.42 6.14
1882 .............. 238 659 714 1,280,857 1.86 5.15 5.57
1883 .............. 223 541 719 1,318,264 1.69 4.10 5.45
1884 .............. 210 683 797 1,356,764 1.55 5.03 5.87
1885 .............. 202 639 844 1,396,388 1.45 4.58 6.04
1886 .............. 223 721 872 1,437,170 1.55 5.02 6.07
1887 .............. 203 621 952 1,479,143 1.37 4.20 6.44
1888 .............. 173 493 914 1,522,341 1.14 3.24 6.00
1889 .............. 145 543 839 1,566,801 .93 3.47 5.36
1890 .............. 136 556 856 1,612,559 .84 3.45 5.31
1891 .............. 189 583 932 1,659,654 1.14 3.51 5.69
1892 .............. 230 605 1,020 1,708,124 1.35 3.54 5.97
1893 .............. 469 607 1,160 1,758,010 2.67 3.45 6.60
100
HISTORY OF CEREBRO-SPINAL MENINGITIS
^ bo *- bo bo ^ bo '-' bo bo
P.S 3.S B B . -S
gS ^S Jj E g 1 &E pS J3 S
O H 02 PL| O EH 02
1894 213 598 926 1,809,338 1.18 3.31 5.12
1895 204 585 871 1,873,201 1.09 3.12 4.65
1896 178 511 784 1,906,139 .93 2.68 4.11
1897 232 517 755 1,940,553 1.20 2.66 3.89
1898 258 593 782 1,976,572 1.31 3.00 3.96
1899 287 609 742 2,014,330 1.42 3.02 3.68
1900 201 585 544 2,053,979 .98 2.85 2.65
1901 201 501 596 2,095,686 .96 2.39 2.84
1902 190 571 633 2,139,632 .88 2.67 2.96
1903 195 566 448 2,186,017 .89 2.59 2.05
1904 1,083 470 588 2,235,060 4.85 2.10 2.63
Absolute figures, however, prove nothing, relative ones
much more; e. g. in 1866 the population of New York was
767,979; in 1904 it was 2,235,060. You will notice that,
besides, the errors of another kind are not excluded. The
cerebral diagnosis of many doctors who fill out death cer-
tificates are often inaccurate. This list contains as causes
of death, cerebro-spinal, tuberculous and " simple " menin-
gitis. In the first six years 1866-1871 the percentage of
deaths from cerebro-spinal meningitis was very low, in
the first year 23-100 of the total number of deaths. Then
we find a sudden increase in 1872 to 8.07 per cent.; 1873,
2.95 per cent.; 1874, 1.53 per cent.; 1875, 1.40 per cent.
Then 1 there followed a gradual decrease. In 1880 we find
it rising again to 1.41; 1881, 3.70; from 1882 to 1888
the mortality varied from 1.86 to 1.14. In 1891 it rose
again to 1.14; 1892, 1.35; 1893, 2.67; 1894, 1.18; 1895,
1.09; 1896, 0.93; 1897, 1.20; 1898, 1.31; 1899, 1.42; 1900
and 1901, under one per cent.; 1902 and 1903 under 0.90;
1904 it again rose to 4.85. Please notice that the mortal-
ity percentage during 1904 did not reach double that of
1893, and that it is only a little more than" half as large
as during the epidemic of 1871. However, the 782 deaths
of the year 1872 are much more terrible (in a population
101
DR. JACOBI'S WORKS
of less than one million) than the 1083 deaths of the yeaf
1904 with a population of 2^ million.
For comparison I present to you the list of deaths of
the past three months of 1905, again from the official
figures. In 1905 there died in Manhattan, not in Greater
New York:
Cer. Sp. Men. Mening. Tub. Men.
In January 94 144 40
In February 139 179 36
In March. . 295 259 37
528
582
113
You will notice that the alleged increase of deaths due
to simple meningitis has been doubled in two months. One
cannot but surmise that many of these cases may have
been those of cerebro-spinal meningitis. On 1 the other
hand we must not forget that during an epidemic many
deaths are wrongly attributed to the disease then prevalent.
The above figures are increased from 10 to 12 per cent,
by including all the cases occurring in Greater New York.
The following list proves this clearly:
Greater New York.
Manhattan.
Bronx.
M.
F. Total. M. F. Total. M. F. To.
1898
201 156 357 131 114 245
1899
. . . 223
171
394
150
111
261
13
13
->fi
1900
. . . 174
132
306
103
75
178
15
8
3
1901
. . . 152
115
267
92
81
173
18
10
"8
1902
. . . 145
120
265
96
78
174
7
9
16
1903..
151
120
271
100
73
173
9
13
22
1904.
759 642 1,401 532 471 1,003 51 29 80
Brooklyn.
Queens.
Richmond.
M. F. Total. M. F. Total. M. F. Total.
1898
52
30
82
9
5
14
3
3
1899
52
30
94
5
4
9
3
1
4
1900
50
43
93
4
4
8
2
2
4
1901
37
20
57
5
3
8
1
1
1902
33
24
57
4
7
11
5
2
7
1903
31
26
57
8
10
16
3
1
4
1904
147
128
275
20
9
29
9
5
14
102
HISTORY OF CEREBRO-SPINAL MENINGITIS
We find the largest mortality from cerebro-spinal menin-
gitis in Manhattan in the 4th, 5th, 6th, 7th, 8th and 14th
wards. These are the wards in which we meet, besides
other social atrocities, the largest number of dark rooms,
of which there were two years ago in Manhattan 212,615,
in Brooklyn 139,928, in Queens 8,666 aird in Richmond
452.
Of the cases under 15 years of age there died of cerebro-
spinal meningitis in New York:
1895 16T
1896 157
1897 201 In Greater New York. All ages.
1898 210 301 357
1899 232 326 394
1900 153 251 306
1901 165 221 267
1902 156 221 265
1903 158 225 271
1904 805 1056 1401
The proportion of children that died compared with the
number of deaths in Manhattan is accordingly as 805:-
1003; and for Greater New York as 1056:1401. That is
to say that in the boroughs outside of Manhattan the mor-
tality among adults was higher than among children.
Everywhere, however, the large majority of cases are
children.
Distribution. The disease occurs in the temperate
and sub-tropical zones and is therefore adapted to the
United States. It is found most frequently in the winter
and spring. .Of 85 epidemics occurring in North America,
there were 37 in the winter, 18 in the winter and spring,
and 23 in the spring. Low temperatures and the presence
of catarrhal disease are mentioned. However, we find the
disease even in mild winters, e. g., 1862 in Connecticut and
1 866 in Kentucky. Many similar ones are referred to by
Hirsch (pages 398 and 399). On the other hand, dur-
ing some very cold winters we find only one city or region,
One class of people, or one regiment of soldiers, affected.
According to Frothingham in 1861-1862 one regiment that
103
DR. JACOBI'S WORKS
was particularly well quartered was afflicted with menin-
gitis, while other regiments suffered from malaria.
The epidemic character of the disease has been too fre-
quently observed to be questioned. Occasionally it ap-
pears sporadically. About 30 years ago there were two
parts of New York where the disease was very prevalent,
the neighborhood of Chatham Square, James and Oliver
streets, and the neighborhood south of West Houston
street and west of McDougall street. At that time I saw
two fatal cases within one week in* a room in Charlton
street. The one case was a baby of 6 months that died in 8
hours, the other a child of 2 years that died in 20 hours.
The autopsy in one case showed the usually prevalent fibri-
nous exudate. Different authors have different views con-
cerning the spread of the disease, especially direct conta-
gion. Vieusseux, who described the Geneva epidemic of
1805, dclared the disease to be non-contagious. He gave as
his reason for this belief the fact that when two cases
occurred in one family, they developed at the same time.
North states in* his book of 1811 that travelers who came
from an immune place to an infected one contracted the
disease. He attributed it either to contagion or to local
influences. According to Hirsch, in the first large epidemic
in Franken the disease spread in a regular course from
northeast to southwest. Love reports that in 1847 only
one regiment in New Orleans was affected. One French
regiment, in which meningitis was prevalent in 1840, was
transferred to Algiers. After a short time natives also
were afflicted, the only time that the disease was ever ob-
served in North Africa. During our war meningitis de-
veloped in public institutions after an infected regiment
h.-'d been quartered in the city. Nowlin in the Jour, of
the Am. Med. Assoc., 1891, reports five cases in Shelby-
ville, Tenn., of which two developed in one house. Such
occurrences are not isolated. Hence it is not of much mo-
ment when occasionally an observer, as for instance H.
Berg. (Arch. Pediatrics, 18Q4), reports that he never ob-
served two cases in one house. I have had no personal
experience of contagion in any of my hospital services.
However, last week a rrurse at the Harlem Hospital, who
104
HISTORY OF CEREBRO-SPINAL MENINGITIS
had taken care of meningitis cases, died of the disease.
In like manner, Dr. Craig of Philadelphia died a martyr
to his duty. In 1904 most of my hospital cases suffered
from nasal catarrh; in many cases the coccus was found
in the secretion, in one case also in the conjunctival secre-
tion. No infection of other patients in the ward was ob-
served. Whether, as in malaria and yellow fever, an in-
termediary agent of infection such as the mosquito is re-
quired, or as in recurrent fever the bedbug, remains to
be proven.
Dr. E. G. Janeway had the following experience: The
coffin containing the body of a woman who had died of
cerebro-spinal meningitis was opened, and a strand of
her hair cut off. This strand was taken home by a wo-
man, and frequently handled by her as well as by a child
living in the same house. Both this woman and the child
developed meningitis, and nobody else in the house was
affected.
In the United States a disproportionately large number
of negroes was afflicted. In New Orleans in 1850 only
negroes contracted the disease; likewise in Memphis, 1862-
1863, those that were huddled together there by the Con-
federates were the only ones affected. In like manner
only negroes were stricken* in Mississippi in 1862, in Mary-
land and in Mobile, Ala., in 1864, and in Philadelphia in
1867. However, A. Hirsch, who did not know of the con-
ditions from personal observation, correctly surmises that
not the race but the lodging, food, and general social
conditions are responsible for the development of the dis-
ease. Whoever has observed the conditions in the south
can verify this statement. I have recently visited one of
the most civilized southern communities, Augusta, Ga.
There are two negro quarters. In orre of them an intelli-
gent negress has for a dozen or more years been conduct-
ing a school for children of from 6 to 16 years. I saw
hundreds of cleanly washed children both at work and at
play, in clean, almost holiday attire. I was so struck
that I inquired if it was a holiday. These four or five
hundred children were all from the neighborhood. The
houses, as well as the inhabitants, were clean, and there
105
Dfc. JACOBFS WOfcKS
was a little garden in front of each house. Evidently the
teacher and the children infected the entire suburb with
their culture. There, in all likelihood, meningitis, if at
all, will develop equally among the white aird colored peo-
ple. In another suburb I saw no gardens, no paint on the
miserable reeking dwellings, and no clean linen on the
line. Here we shall find meningitis in the future.
106
CEREBRO-SPINAL MENINGITIS SYMPTOMA-
TOLOGY AND TREATMENT
SYMPTOMATOLOGY
IT is not worth the while this evening to go deeply into
the symptomatology of the disease in general. I am not
diligent enough to go through all the modern journal
literature and from six books compile a new one nor to
compile a new paper from manuals. You know from ex-
perience how one learns to disdain this kind of fame. But
I will, in a few remarks, relate what during the last year
and a half appeared surprising to me and was at variance
with earlier observations.
The usual symptoms were headache, torticollis, vomiting
in most cases one or more times, occasionally convulsions
and coma, sometimes early but most often towards the end.
Kernig's sign was present in all but two cases in a pa-
tient of 25 years and one of 4 years.
Spots were not always present early, but at some time
or another during the course of the disease; in a small
number of cases strictly ischemic but becoming hyperemic
after many minutes and remaining for several minutes
longer.
In some cases the phenomena were unilateral at first
and only gradually showed themselves on both sides of
the body. A child of 3 years had a right total hemiplegia
that was distinct for weeks, besides general symptoms.
The pupils were almost always alike: in the beginning
of the diseases they were contracted as a rule, and later
on, as coma increased, dilated; in every case they re-
sponded but slowly to light and in rare instances not at all.
What I have just said is in direct contradiction to
my observations during the epidemic thirty years ago.
There I almost without exception found the pupils strongly
107
DR. JACOBI'S WORKS
dilated from the very beginning of the disease, with no
response or very little to the influence of light; and this
symptom was considered as pathognonomic for the disease,
and was ascribed by me to irritation of the cervical gan-
glion controlling the dilator pupillae. It is worth the
while to experience several epidemics of the same infectious
disease.
I had a similar experience with the spots. In every
earlier epidemic they appeared on the first day with such
regularity that I believed also this symptom could be used
for differentiation from other forms of meningitis. And
this I taught up to a few years ago, but have since
learned better. There are very many ways in which to
err.
Among 58 cases there were petechiae in 8, erythema
with petechiae in 1, papulous eruption in 1, general hy-
peremia with pustules in 1, uniform hyperemia in 1, and
mottled hyperemia in 1 case, herpes in a small proportion
of the cases, and not at a definite period of the disease;
if it indicates an attack, it must be inferred that its ap-
pearance was belated for any length of time up to the end
of the third week.
Apparently during the present epidemic the skin is not
implicated as it was in former epidemics. Such differ-
ences are noted in the literature of various years and
different localities. Vieusseux in his report on the Geneva
epidemic in 1805 does not mention skin lesions at all,
while North refers to their frequent occurrence in the
epidemic of 1811. The name "spotted fever" dates
from that time, and Upham speaks of the possibility of
confounding the disease with typhus.
General hyperesthesia was very rare, which is decidedly
at variance with the general behavior of former epidemics.
Opisthotonos in a high degree was rarely pronounced,
torticollis always ; moderate rotation of the head was pos-
sible in many cases, and in a few was even easy and pain-
less.
Nasal catarrh was common last year (1904) but rare
this year (1905).
108
CEREBRO-SPINAL MENINGITIS
In a few instances taking a slow and fatal course ir-
regular breathing of a Cheyne-Stokes' character set in
early.
The deafness remaining after epidemic cerebro-spinal
meningitis is probably not to be viewed in the sense in
which it was described' by Voltolini, who (Mon. f. Ohr.,
1867) looked upon it as an independent inflammation
of the labyrinth. According to him it announced itself
by intense headache, vomiting, high temperature and con-
vulsions, which continued for several days and generally
ended in recovery, but with deafness and trembling gait.
It is probable that he had before him as a rule cases of
cerebro-spinal meningitis of short duration. I observed
deafness as an incurable sequel of the disease more fre-
quently last year than this.
Blindness I have never seen in patients recovering. Os-
ier (Johns Hopkins Hospital Bull., 1892) reports a case
of chronic cerebro-spinal meningitis the secondary blind-
ness in which disappeared after a long period.
Other complications I have seen only very seldom this
year. Among the many cases treated at the Roosevelt
Hospital there was only one case of arthritis, one case of
purulent pericarditis found at the autopsy. Pneumonia
seems to have been very rare this year; consecutive neuritis
I have not seen, most patients do not live long enough to
get it. Renal irritation in the beginning does not seen:
to lead to nephritis.
The spleen is not so swollen as it is in the majority of
other infectious diseases.
Councilman, as well as Jaeger (Zeit. f. Hyg., xix., 1895),
believed that animals in general are inaccessible to inocu-
lation with the meningococcus ; but Heubner produced the
disease (Jahrb. f. Kinderk., 1896; Deut. Med. Woch.,
1897) by introducing cultures into the spinal canal of
goats. The entrance to the central nervous system thus
appears to be easy enough anatomically. The extensive-
ness of the lymphatic network in the nose, -the conjunctiva
and the ear, the frequency of wounds of the surface in
these organs, the thinness of the plate of the ethmoidal
109
DR. JACOBI'S WORKS
bone, make it appear really wonderful that Weichselbaum's
diplococcus, which was found also in the conjunctiva by
Schwabach in 1891, and in otitis by Scherer (the same
diplococcus that was found by Heubner in 1896 in the
subarachnoid fluid), does not more often reach the interior
of the central nervous system.
In those cases where the disease is confined to the nerve
centres, direct infection from person to person must be
very difficult.
From an anatomical point of view all cases of menin-
gitis are cerebro-spinal, that is, the brain and spinal cord
are affected simultaneously. The arachnoid and pia
should not be considered separately. The former con-
stitutes the serous surface connected with the dura and
one side of the subdural space. The pia represents a
loose connective tissue containing lymph spaces and blood-
vessels. As the choroid plexus this total membrane ex-
tends into the ventricles. In the spinal cord the serous
arachnoid and the pia are separated somewhat and form a
real subdural space, but are connected by numerous fibrous
trabeculse.
If in meningitis the spinal cord is affected more pro-
foundly than the brain, and especially if the presence of
the meningococcus intracellularis is considered of etiologi-
cal importance, we are in the habit of referring to it as
cerebro-spinal inflammation. In its epidemic appearance
the membranes of the spinal cord are affected more de-
cidedly than at other times, but the inflammation progresses
along the course of the nerves and into the substance of
the central organs. Changes in the tunica intima do not
occur, however, in cerebro-spinal meningitis. In contra-
distinction to this, in tuberculous meningitis tuberculous
deposits occur along the course of the vessels and in the
fibrino-purulent exudate. True, the staphylococcus aureus,
the streptococcus and the diplococcus lanceolatus produce
epidemic cerebro-spinal meningitis, but they can be differ-
entiated by their behavior in other tissues. Finally, the
greater or lesser extent, depth and copiousness of the ex-
udate, and the suddenness or slowness of the intoxication,
J10
CEREBRO-SPINAL MENINGITIS
afford the best explanation of the variability of the symp-
tomatology.
TREATMENT
Preventive measures cannot positively prove to be ef-
fective, with the exception possibly as immunizing doses
of an antitoxin. Inasmuch as in cerebro-spinal meningitis
the invasion probably occurs only through the mucous
membranes, the old rule holds which I have recommended
since forty years in connection with diphtheria, namely:
to keep the nose and throat healthy. I cannot understand
why a modern author recommends the particularly mildly
antiseptic boric acid as a general prophylactic.
There can scarcely be anything less consoling than a
resume of the various treatments that have been proposed.
They seem to have had no influence, positively less than
the character of the epidemics, the mortality having ranged
from 30 per cent, to 90 per cent. In my own experience,
which extends over several epidemics, the death-rate has
been from 30 per cent, to 70 per cent. A summary of
various methods of treatment is given in a paper read
by Stockton two months ago before the State Medical
Society and since published in the March number of the
Albany Medical Annals. What I have advised during
four dozen years can be found in my " Therapeutics."
Let me briefly relate what I did myself and what I ob-
served. The main thing in every case, whether severe or
mild, is isolation, rest and moderate darkness. I deem it
well to keep the head raised, rather by raising the head end
of the bed than by the use of pillows only. It is essen-
tial to give sufficient food, as the disease may last for
weeks and months and death not seldom sets in from in-
anition or under symptoms of starvation. Therefore every
remission of temperature should be utilized for feeding.
If vomiting be frequent, small, oft-repeated meals must be
given. Such a meal is occasionally retained if 1 or 2
drops of Magendie's solution or a 2-mg. (%2 grain) tablet
of morphine have been put into the mouth a few minutes
before, as far backward as possible. Once in a while
feeding through the stomach tube becomes necessary, and
111
DR. JACOBFS WORKS
I have it done three or four times daily. Rectal alimen-
tation is seldom successful.
Rest at night, and even also by day as far as prac-
ticable, should be insisted upon. Bromides have proved
of little avail, hyoscine useless ; chloral by enema one or
more times a day in doses of 0.03 to 0.05 gm. (^ to %
grain) has sometimes had the desired effect; the best re-
sults were obtained with the opiates morphine and most
often codeine in not too small doses.
A very up-to-date city colleague claims to have obtained
marvelous results with the continued administration of large
doses of morphine. We will probably at an early date
read an " interview " in some papers ! The matter is of
no further value.
The head should be covered with an ice-cap, and if
possible a small bag should also be put at the back of
the neck, but the latter application is difficult and at times
impossible.
Occasionally I applied leeches to the nape of the neck
and the mastoid processes. Cupping I did not do, nor
have I resorted to bleeding since twenty years. A purga-
tive should be given in the beginning of the treatment,
preferably calomel. What is ordinarily a large dose may
prove insufficient; it is not rare to meet with a child 3 or
4 years old who has taken as much as 0.5 gm. (7^ grains)
of calomel in half a day, without the desired purgative ef-
fect or any other particular result. Vinegar and water
enemas may assist the action. Saline purgatives are indi-
cated, but it is rarely easy to give them. Baths are useful,
but difficult to employ, because the patients are obdurate
and suffer considerably during the manipulation. Hot
baths I scarcely ever gave. Sponging with alcohol and
water should be practiced for well-known reasons and has
some effect. Should it not have sufficient influence upon
high temperature, small doses of phenacetine may be ad-
ministered, preferably combined with a small quantity of
caffeine. Antipyrine I have used in this disease but little ;
during the many years that I have known this remedy it
has seemed to me to fail to exert its usual action in brain
trouble.
112
CEREBRO-SPINAL MENINGITIS
Symptoms of weakness I have combated with camphor,
musk or caffeine, seldom with alcohol.
I have been partial to the iodides, particularly sodium
iodide, and in larger doses, that is, the smallest receive
as much as 5 to 8 gms. (1% to 2 drachms) daily. They
are well borne as in all forms of meningitis, and they show
themselves promptly in the urine. For about ten years I
was as obstinate as the disease; but the disease I regret
to say has exhausted my patience. Since four or five
weeks I have completely abandoned the iodide treatment,
and my results have not been any poorer than formerly.
In olden times I employed sublimate hypodermically, but
without visible benefit. Six weeks ago a 5-months old child
was brought to me at the hospital with cerebral symptoms
striped look, slow reaction of the moderately dilated
pupils, slight Kernig, sallow skin with mild yellow dis-
coloration around the eyebrows and very slight torticollis.
To me the diagnosis of syphilitic hydrocephalus appeared
more probable than any other, and I even dispensed with
lumbar puncture. The child took thrice daily 0.003 gm.
(^20 grain) of sublimate and 0.05 gm. (f grain) of sodium
iodide, and seemed to improve a little after a week or two.
But after three weeks the torticollis increased and the men-
ingococcus was present in the turbid spinal fluid. The
case ended fatally.
During the period in which I employed the iodides as
the routine treatment I did not perform lumbar puncture
in every case ; since that it has been the rule with me, partly
as a diagnostic measure and in part as a remedy. A single
puncture does not always suffice to establish the diagnosis;
sometimes, when made early, the coccus is not found, but
will be after one or several days. More frequently it hap-
pens, however, that the coccus appears two or three times
and then, after a few days more disappears again, as the
cases may vary also in other ways. Occasionally, but rarely,
only a small quantity of a thick fluid exudes ; and some-
times there is no flow at all. Here probably the foramen of
Magendie is occluded. In many cases, however, the fluid
is under pressure and the first 20 cc. or 30 cc. flow out in
a stream; gradually the pressure diminishes. I have rarely
113
DR. JACOBI'S WQRKS
drawn off or been able to get more than 30 cc. In these
cases I have occasionally seen a lessening of the coma,
but no effect upon the moderate dilation of the pupils. 1
am of the opinion that lumbar puncture is indicated in
many cases, while I have never seen it have a harmful
effect in any. I performed it in many cases three or
four times or even oftener, for our cases as a rule gave us
only too much time for its performance. A child of 4
years, in whom constant drainage was kept up, died.
Crede's ointment I used in two cases ; collargol I em-
ployed per rectum in doses of 0.1 to 0.2 gm. (1^ to
3 grains) dissolved in 1 to 2 tablespoonfuls of boiled water,
in two other cases for weeks, once or twice daily, but
without demonstrable benefit.
In view of the hopelessness of the treatment, I made a
trial during the last five or six weeks also of diphtheria
antitoxin. Dr. Weitzfelder had favored me with informa-
tion on the subject before he published his experiences or
his views. I take it for granted that the method and its
theory as propounded by Dr. Wolf of Hartford are known
to you. Dr. Wolf discovered in his laboratory that there
was an antagonism between the antitoxin and cultures of
the meningococcus. The doses I employed subcutaneously
or by intramuscular injection were those recommended to
me by Dr. Weitzfelder, namely: 6000 units for children.
I gave from three to six such doses in the course of as
many or more days. My results were negative, as were
also those obtained by my colleagues in other divisions
of Roosevelt Hospital. Quite a number of cases were
treated, without appreciable effect. I then proceeded in
a manner outlined by Dr. Francis Huber, a colleague of
Dr. Weitzfelder at the Gouverneur Hospital and Physi-
cian to the Beth Israel Hospital, who had an abundance
of material at his disposal. I injected 1500 units of
diphtheria antitoxin into the spinal canal, after withdraw-
ing the usual quantity of fluid.
I made about 40 such injections, and the results con-
firmed the old story that not all laboratory observations
can be utilized clinically. My best case, which will shortly
be discharged as cured, did not receive any injection or
114
CEREBRO-SPINAL MENINGITIS
any kind of treatment whatever. Several of the injected
cases are doing very badly, some are in a fairly good
state just like the other cases, receiving different treat-
ment or going without treatment. Unfortunately, in in-
ternal medicine many, very many, cases are necessary to
try out any particular remedy or method of treatment
and arrive at a positive conclusion. Nothing is more
deceiving than premature reports in our journal liter-
ature, written with an enthusiastic desire to teach
something new and useful, but really playing into the
hands of whimsical doubt and even unjustified nihilism.
My hospital colleagues did just as I did. The Depart-
ment of Health placed at our disposal countless thousands
of units.
A few of our cases are briefly described in the follow-
ing:
Man of 28, sudden attack, petechiae, coma, high tem-
perature. 12,000 units injected subcutaneously on second
day, 10,000 more 12 hours later and 8400 on third day,
making 30,400 units in all. Died on fourth day. Several
lumbar punctures had been made.
Man of 18, case similar to preceding. 12,000 units hy-
podermically on second and third days. Died on third
day.
Child of 8 years, severe case. 6000 units subcutane-
ously on second, sixth and seventh days, 1500 intraspinally
on eleventh and eighteenth days. Not quite dead as yet.
Child 3^/2 years old, mild case. Vomiting, delirium, tor-
ticollis. 6000 units on third, fifth, seventh and tenth days,
subcutaneously, 1500 intraspinally on twelfth day. On
twenty-eighth day temperature still intermittent but grad-
ually falling, spinal fluid clear.
Man of 41, severe attack, only occasionally conscious.
2000 units intraspinally on fifth and seventh days. Died
on eighth day.
Child of 6 years, severe attack, unconsciousness, convul-
sions. 1500 units intraspinally on third day. On eighth
day still high temperature, but conscious.
Child of 8 years, severe case, with chills, headache, de-
lirium, opisthotonos. 1500 units intraspinally on fourth
115
DR. JACOBI'S WORKS
day, on seventh 1500, on tenth 2000, on eighteenth 1500
and on twenty-third 600 units subcutaneously. On twenty-
fourth day brain and spinal fluid clear. Temperature
intermittent. Deaf.
Child of 7 years, sudden attack, chills, headache, vom-
iting, torticollis. On third and fifth days 1500 units intra-
spinally. On fifteenth day temperature between 98 and
101 F., consciousness returned, neck less stiff, some
appetite.
Child of 6 years, mild attack, convulsions. On fourth
and three following days 6000 units each time subcutane-
ously. On forty-eighth day temperature still 101 to 102
F., patient irritable and emaciated. Will probably die.
Child 4% years old, severe attack. On twelfth and
following five days 6000 units each time. Very emaciated,
hydrocephalus. Will doubtless die.
Child of 12 years. On sixth day 1500 units intra-
spinally, on seventh day 12,000 subcutaneously. On fif-
teenth day patient conscious. Will recover.
Child of 10 years, mild attack. On fifth day 1500 units
intraspinally, on seventh day same. On fourteenth day
patient pretty well, with acute inflammation of right knee.
Of th 21 cases 9 have already died.
During the year 1904 we had 25 cases in adults,
15 = 57.6 per cent, proving fatal; 23 in children,
10 = 43.5 per cent, ending in death. From January 1 to
April 1, 1905, we admitted 36 cases. Of these 20 are no
longer in the hospital, 1 1 children and 5 adults being still
here. Two of the 1 1 children received no antitoxin, 6 re-
ceived intraspinal injections of it (on the average 1500
units, one or more times), in 3 it was injected subcutane-
ously. One case has recovered, another is nearly well but
deaf, a third nearly well but with acute inflammation of
one knee; 1 case quickly recovered without any treatment,
1 seems to be improving but is doubtful, 1 has improved but
still has intermittent pyrexia, 1 has had a relapse, 2 are
exceedingly emaciated, 1 has high temperatures which in-
termit, however, 1 has a low temperature with all the
signs of chronic inflammation. Of the 5 adults remaining
alive, 1 is perfectly well, 1 very doubtful, 2 on the way
116
CEREBRO-SPINAL MENINGITIS
to recovery, 1 is much better but occasionally irrational
and may recover.
Of 5 children leaving the hospital -during these three
months, 1 was discharged January 14th with deafness, no
antitoxin had been administered; 1 discharged cured Jan-
uary 20th, no antitoxin; 1 died March 1st, no antitoxin;
1 died March 29th, had antitoxin; 1 died April 2d, had
antitoxin.
Only 1 of the 15 adults in the hospital since Jan-
uary 1st has been cured, without antitoxin; 4 died with-
out antitoxin; 10 died in spite of antitoxin treatment. In
all probability our cases this year (1905) will show a
mortality of 60 per cent.
Since January 1st, 1904, 85 cases have been admitted;
16 are still at the hospital, 69 have passed from obser-
vation. Of these 25 died during 1904, 3 were taken away
uncured and their termination is unknown, 17 (out of 20)
can be proved dead thus 42 deaths out of 66 cases,
equivalent to 64 per cent., up to date. Of those who have
remained living 3 are deaf and 1 is blind.
Once death set in within 30 hours, in a child 12 years
old; once within 38 hours from the onset of the disease,
in a child of 3 1 /, years. In the latter case the pupils
were unequal, and there were convulsions, coma and a
temperature of 103 to 109 F. Death survened in
another case after 2 days, while in still another after
55 days. Still longer periods of sickness have not yet
terminated in death, the patients are still struggling. A
child 3 years old was dismissed after 55 days with
deafness; one of 10 years was discharged cured after 90
days ; two of 5 years were discharged perfectly cured on
the 69th and 76th day, respectively, one of 8 years on
the 100th day. Thus", of 100 patients two-thirds died
and several were crippled. Whether the affected nervous
centre of those who have recovered will ever be perfectly
normal is uncertain. Those of us who have become fa-
miliar from personal observation with the obstinacy of
the disease process, will probably not be able to dispel
their doubts as to the completeness of the recovery. ^For
me there is nothing more sad and more disheartening than
117
DR. JACOBI'S WORKS
a hall filled with cases of epidemic cerebro-spinal menin-
gitis.
POSTCRIPTUM,
Nulla dies sine linea. That is almost literally true in
regard to medicine, whose practical benefits are appreciated
by everybody except the hypocrites or fanatics of the
" antivivisection " creed. The hopelessness of the victims
of the meningococcus is no longer absolute or even nearly
absolute. Simon Flexner's name has suddenly, and de-
servedly, become a household word in both hemispheres.
I listened to him recently when he lectured at Baltimore
before the Medical and Chirurgical Faculty of Maryland,
(May 14th 1909)- He was as modest and withal hopeful
as always. He is rather doubtful and cautious when others
are joyful and enthusiastic; but he cannot disclaim the
beneficial results of his antimeningitis serum. Even to-day
cerebro-spinal meningitis is amenable to treatment, thanks
to Flexner, and many who formerly would have died of
the infection, are now saved.
When Flexner was in a position to supply patients with
his serum, the New York epidemic was relenting. That is
why he does not consider our local experience as momentous
or conclusive, but prefers to reckon with the bad cases of
a beginning epidemic only. The epidemics of the middle
West have been grave, but were decidedly influenced by
the use of the serum. Of seven cases in the Jefferson, Mo.,
barracks only two died; of five in which the diagnosis was
made early, all recovered with the serum. In McKinney,
Texas, after four cases had died in a single family,
five other cases, who could be supplied with the Flexner
serum, recovered. The speaker mentioned three recov-
eries in five cases occurring in the practice of Dr. Koplik.
The most conclusive results have been obtained in the
recent epidemics of Europe, where the diagnoses were
made earlier and the serum treatment resorted to in due
time. England, Scotland and Ireland have active epi-
demics, and the disease is decidedly modified by the serum.
The. former mortality of 75 per cent, has been reduced to
40 per cent, in Edinburgh, to from 25 to 30 per cent, in
118
CEREBRO-SPINAL MENINGITIS
Belfast. The character of the cases has changed; the
protracted chronic course which extended over several
months, ceased abruptly in the hospital wards. France had
a severe epidemic of two or three months. Netter had
fifty cases. Of ten children under two years of age that
were treated with Flexner's serum, he lost one. Calmette
treated fourteen soldiers in the barracks of Lille. One
died. Three were sick outside the barracks with no serum.
They all died. Roux expresses himself as being greatly
struck with the results of serum treatment. And as we
go to press we glean from the Lancet (May 15, 1909)
that the epidemic in France, which is now on the decline,
has made two things perfectly plain: the one is that the
disease is extremely contagious and the other that the
use of anti-meningococcic serum is of great value. The
epidemic in the garrison at Evreux, which M. Vaillaire
studied with particular care, showed that the contagion
spread from one soldier to another when they occupied con-
tiguous beds in the same room. Some reservists who had
been in barracks at Evreux and who had been sent home
when the epidemic broke out carried the infection with
them even if they showed no signs of the disease them-
selves. One of them, who was quite well, infected his
wife who died; another infected four other persons, of
whom two died. Examination of the troops in barracks
showed that in 19 per cent, of them the meningococcus
was present in the naso-pharyngeal mucous membrane.
Of 24 cases treated otherwise than by serotherapy 16
died, and of the same number of cases treated with the
serum only four died, the mortality in the one case being
66.6 per cent, and in the other 16.6 per cent. The earlier
that the serum is administered the better are the results
and therefore an early diagnosis is of much importance.
The world does move.
119
DIPHTHERIA: ITS SYMPTOMATOLOGY AND
TREATMENT
INTRODUCTION
Definition. Diphtheria is a specific, infectious and con-
tagious disease characterized principally by epithelial
changes and by the exudation of fibrin on or in mucous
membranes, or on the surface of wounds, or in the de-
nuded rete Malpighi, constituting the so-called pseudomem-
branes. These are mostly found on the accessible mucous
membranes of the digestive and respiratory organs. Their
morphological structure in the throat, nares, larynx, and
other places is identical, but they have been studied chiefly
in the throat, where they are most frequently found. They
consist of finely reticulated fibrin holding exudate cells,
leucocytes, some few erythrocytes, and characteristic
microbes. When they are superficial, it is the epithelial
protoplasm which is thus transformed; when they are deep-
seated with a tendency to necrosis, ulceration, and finally
(if recovery take place) cicatrization, it is the fibrillar
basic substance of the connective tissue, chiefly of the.
mucous membrane, sometimes also of the submucous and
deeper structures. This view, which underlies the discus-
sions of all my contributions to the subject of diphtheria
since I860, has lately been again most forcibly demon-
strated by Baumgarten (Berliner klinische Wochenschrift,
Nos. 31 and 32, 1897).
History Diphtheria has been epidemic on the Atlantic
coast of North America since 1857. The disease was al-
most unknown at that time my paper on diphtheria and
diphtheritic affections in the American Medical Times of
August llth and 18th, I860, was the first (or among the
first?) of those which were written on the subject in
our part of the country during the last half century but
121
DR. JACOBI'S WORKS
the literature has since grown immensely. It was very
extensive when I collected it in my essay on " Diphtheria "
in the second volume of Gerhardt's " Handbuch der Kin-
derkrankheiten " (1877). It soon took such dimensions
that neither in my " Treatise on Diphtheria " (New York,
1880) nor in Pepper's "American System of Medicine"
(Vol. I., 1885), nor in other publications did I do more
than refer to authorities for the elucidation of particular
points. For many years past it has been the etiology of
the disease which has created a literature of its own ;
so has that part of the subject which treats of antitoxin
and of intubation. Symptomatology in all its bearings
and morphology have not received many valuable addi-
tions ; for clinical observations, when correct and correctly
reported, are not " subject to change and at the mercy of
unknown factors," as a great experimenter has lately said.
On the contrary A the vast amount of labor, as exhibited in
endless journal articles and books on special topics, which
has to be spent on the establishment, verification, or refu-
tation of a single fact in bacteriology, does not prove
that " the results obtained by experimentation in the labora-
tory are unambiguous " to the exclusion of clinical em-
piricism. Thus it happens that on the following pages I
shall frequently repeat statements (many now out of
print) which have been found correct in the course of time,
and give advice that will still be found serviceable though
it was offered decades ago.
Virchow distinguished between croupous and diphtheritic
membranes. In his opinion the former was fibrinous with
cell proliferations, epithelia, and pus, and was superficial
on top of the mucous membrane; the latter was an ex-
udation into the tissue of an amorphous, dense, and coagu-
lated fibrin which did not always injure or implicate the
surface epithelium, but would necrose the deeper tissue
and give rise to ulceration before healing. But he ad-
mitted that complications between the two were very com-
mon indeed. Weigert and Cohnheim were of the same
opinion as far as the morphological condition and localiza-
tion of the membranes were concerned ; the essential process
according to them was a combination of necrosis and in-
122
DIPHTHERIA: SYMPTOMS AND TREATMENT
flammation, and their causes, after Recklinghausen and
Nassiloff had assumed the primary change to be a microbic
invasion, were bacteria and toxins.
According to Wagner the only difference between croup
and diphtheria membranes was the fine structure of and
the admixture of pus cells to the former. Both of them
had their origin in the epithelium, while Buhl looked for
it in the mucous membrane itself, in the cells of which nu-
clear or cystoid proliferations took place.
I cannot detect much difference in the theories which
have since been brought forward, for instance, in those
of Oertel or of Heubner. The question is always one of
degeneration of epithelia, of the presence of leucocytes,
an exudation of fibrin, more or less admixture of blood,
of hyaline masses, and of new formation of more or
fewer round cells in different localities. Oertel comes to
the conclusion that, after all. the localization of the process
is the final cause of the form and appearance of the
pseudomembrane. Why he should make the effort of sug-
gesting the differentiation between a primary and a sec-
ondary membrane, the former consisting of direct surface
deposits, and the latter of membranous deposits in the tis-
sue which are produced by the presence of other surface
deposits in the neighborhood, is not quite intelligible ex-
cept on the score of " completeness."
For some years it has become customary to distinguish
between those pseudomembranes which are caused, or ac-
companied, by the Klebs-Loeffler bacillus, and those which
contain the " pseudobacillus " or staphylococci and princi-
pally streptococci. That these microbes do not establish
any disease by their mere presence, that on the contrary
they are met with to an indefinite degree in the mouths
and throats of the healthy, is well understood. That they
may be considered pathological, or pathogenic, the presence
of pseudomembranes and the presence of the microbes
in the pseudomembranes in some stage of development is
required. The Klebs-Lreffler bacillus is, however, not al-
ways found in every stage of the illness; it appears to
perish quite often towards the maceration period. When
found it is located in the superficial layers of the pseudo-
123
DR. JACOBI'S WORKS
membrane only, and not throughout its whole thickness;
the coccus, however, pervades its whole substance, usually
in greater numbers in the deeper layers. To explain the
absence of Klebs-Lceffler bacilli from these, it is assumed
that they are destroyed by other microbes. Still they are
credited in the same way in which they can be proven
to do so in the laboratory with evolving the toxin which
gives rise to all the symptoms and dangers of certain
forms of constitutional diphtheria.
Pseudomembranes containing Klebs-Loeffler bacilli are
called by almost universal agreement diphtheritic, those
with pseudobacilli and cocci pseudodiphtheritic. Local
diphtheria (" diphtheritis "), constitutional diphtheritic
infection, and diphtheritic sepsis are different degrees of
the same disease. The first may run a fairly mild course,
or be the initial stage of the second and (or) third. Those
cases which present both bacilli and streptococci in their
membrane are called cases of mixed infection. It has been
claimed that cases of the second class, that of streptococcus
infection, are of little virulence and attended with but
little danger. This opinion leads to cruel mistakes in
management, both by boards of health and by such medical
men as are influenced by them. For not only are many
uncomplicated cases very grave, but the mixed infections
are the very worst forms met with in practice. More-
over, the streptococcus cases are contagious, contrary
opinions notwithstanding. Still, it is important to mention
at once that accurate differentiation has its great practical
value, for the reason that it is solely the bacillary variety
that can be influenced by the diphtheria antitoxin (see
below).
The part played by microbes in diphtheria is not yet
absolutely clear. The Klebs-Lreffler diphtheria bacillus
and a similar bacillus that is not virulent are found in dia-
betic and in common tuberculous lungs, in noma, in em-
pyema, on chancres, in ozaena, and in vaccinia pustules.
It is claimed that there are differences between the two;
the pseudodiphtheria bacillus is described as plumper,
shorter, and more uniform than the genuine Klebs-Loeffler,
but this difference is not so striking as not to be denied
DIPHTHERIA: SYMPTOMS AND TREATMENT
by many; nor is there unanimity among different examiners
in regard to other differences. Many go so far as to
deny the possibility of a differentiation. Loeffler himself
has finally come to the conclusion, lately expressed in the
Congress of Hygiene at Madrid, that the genuine diph-
theria bacillus cannot be diagnosticated in any other way
than by its power to generate the diphtheria toxin and
by the influence the diphtheria antitoxin has on the bacil-
lus, or rather on the disease. Thus it is acknowledged
that there are saprophytes which can be distinguished from
genuine diphtheria bacilli by nothing but the absence of
virulence.
Another authority, C. Fraenkel, admits that the degree
of virulence is so variable that it cannot be employed for
differentiation. A very virulent bacillus loses its virulence
by a change of the culture medium, and feebly virulent
bacilli are rendered highly so by adding streptococci
(Roux and Yersin). Moreover Trumpp mixed " pseudo-
bacilli " found in the pus of empyema with diphtheria
toxin (not bacilli), made new cultures, and obtained very
virulent bacilli; and he found that repeated injections of
pseudobacilli would finally kill like genuine bacilli.
F. Schanz (Deutsche medicinische Wochenschrift, No.
37, 18Q8), who lately elaborated these considerations and
facts, adds the pertinent remark that a bacillus which is
so frequently found on the mucous membranes of the
healthy or of the convalescent without the presence of
diphtheria, appears to play only an inferior and secondary
part in the development of disease. He thinks that the
bacillus increases on inflamed surfaces and attains the
power of producing a toxin in the membranous exudation
only; that it is this toxin which adds to the danger of
the disease, and that the presence of streptococci increases
its peril; and that it is not impossible at all to assume
that diphtheria originates from an unknown cause of its
own, but becomes more virulent by the action of the
toxin of the Klebs-Lceffler bacillus (with or without the
aid of streptococci), whose effect may be destroyed by
the diphtheria antitoxin.
Evidently the question of the origin (single or multiple)
125
DR. JACOBI'S WORKS
of diphtheria does not seem to be settled to the satisfac-
tion of all. According to Theobald Smith (Boston Medi-
cal and Surgical Journal, August 25th, 1898) "it is only
clinicians whose voices are sometimes raised against the
Klebs-Lreffler bacillus as the chief cause of diphtheria " ;
but Loeffler himself, and C. Fraenkel, and others, equally
conscientious, are more careful than formerly in express-
ing positive views and are less averse to retracing their
steps.
There are other questions in connection with diphtheria
which seem to be positively settled, for instance, that of
the morphology of the pseudomembranes. In Gerhardt's
" Handbuch " and in my " Treatise " I studied the sub-
ject with a view to elucidate the differences in the con-
dition of morphologically identical pseudomembranes when
found in different locations. 1
Marphology of Pseudomembranes. Twenty-five years
ago Trendelenburg infected the trachea of a rabbit with
diphtheritic deposits which he had removed from the
pharynx and tonsils, in the tissues of which they were
deeply and firmly imbedded. The new deposits, however,
did not take so deep and firm a hold on the tissues as
the original ones, but adhered lightly to the mucous
membrane of the trachea to which they had been trans-
planted. This and many other similar facts cannot be
explained by the nature of the pseudomembrane., but by
the histological character of the mucous membrane only,
which varies with the locality. Its different elements,
viz., the epithelium, basement membrane, connective tissue
interwoven with elastic fibres, with blood vessels, with
nerves from the cerebrospinal and sympathetic systems,
and frequently with spindle cells, and the papillae ducts
of numberless glands, all influence the pathological process
going on upon the surface.
The mucous membrane of the mouth contains a large
i These bacteriological statements and the following referring
to the morphology of pseudomembranes are considered by the
author necessary for the explanation of much that he has to say
on symptomatology and treatment.
126
DIPHTHERIA: SYMPTOMS AND TREATMENT
number of elastic fibres mixed with cellular tissue and
covered by a thick coat of pavement epithelium; its up-
permost layer contains flat cells, the second a larger quan-
tity of polygonal cells, and the lowest oval ones which
assume a perpendicular relation to the mucous membrane.
From the mucous membrane a number of papillae extend
into the epithelium, and in this respect they resemble
the papillae of the skin. Acinous muciparous glands are
frequent, and most numerous in the anterior aspect of the
soft palate. Lymph vessels are very numerous in the lips,
tongue, uvula, soft palate, anterior and posterior pillars
of the soft palate, and cheeks. The uvula contains so
many that, if they be injected its circumference is in-
creased two or three fold. They empty into the deep
facial lymph bodies to which they communicate diph-
theria as well as other infections. The lymphatics of the
tongue are in intimate connection with the upper layer of
the deep cervical, those of the floor of the mouth and many
from the tongue connect with the submaxillary lymph
bodies. The efferent vessels empty their contents into the
superior jugular lymph nodes, situated in the trigonum
cervicale superius, and finally into the fifteen or twenty
inferior jugular (or supraclavicular) nodes which with
numerous anastomoses form the jugular lymphatic plexus.
The tonsils are conglomerations of an indefinite number of
follicular bodies, each of which has a thick capsule which
is of irregular shape, and consists of connective tissue
lined by mucous membrane and pavement epithelium. The
connective tissue contains a number of closed follicles,
each inclosing numerous lymph corpuscles. The follicles
have been considered identical with, or analogous to, the
lymph bodies ; this assumption is purely problematical, since
it has not been possible thus far to verify the existence
of afferent or efferent ducts. The practical deduction
from this is that the tonsils have little connection with the
lymphatic system, and that a disease limited to a tonsil is
not liable to infect the organism immediately and intensely.
The mucous membrane of the nasal cavities is of vary-
ing degrees of thickness; it consists of connective-tissue
127
DR. JACOBI'S WORKS
fibres with numerous nuclei, is free from elastic fibres,
but is supplied with a large number of nerves and an
abundance of blood-vessels; the Schneiderian membrane
possesses in fact a larger number of blood-vessels than
do most of the other mucous membranes. That is why,
with its submucous tissue, it frequently is the seat of
swellings and hemorrhages, as well in diseases of distant
organs which give rise to venous stagnation, as from the
slightest local provocation. The inner surface of the car-
tilaginous portion is lined with pavement epithelium; the
lower region of the real nasal cavities, the so-called respir-
atory portion, through its whole length supplied with
branches of the trifacial nerve, is lined with cylindrical
epithelium and contains a large number of mucous glands.
The upper or so-called olfactory portion is lined with cili-
ated epithelium, and is supplied, according to Todd and
Bowman, with long, straight, tubular glands. Here the
lymphatics are but poorly developed, while in the inferior
portion they are very numerous : all their openings com-
municate directly with the deep facial and posterior sub-
maxillary lymph bodies. Thus it can be readily under-
stood why the slightest irritation, by a nasal catarrh for
instance, in a child produces a temporary or permanent
swelling of the lymph nodes and why the nares should
necessarily, by their multitude of toxin absorbing lymph
follicles and ducts, be among the most dangerous localiza-
tions of diphtheria.
The epiglottis carries a layer of pavement epithelium of
0.2 mm. in thickness on its anterior superior surface, that
on its posterior surface being from 0.06 to 0.1 mm. in
thickness. The superficial layer consists of spheroidal or
polygonal cells, the deeper is of cylindrical cells arranged
perpendicularly to the surface. Near the insertion of the
epiglottis, the polygonal cells disappear, the cylindrical
occupy the surface, and are furnished with cilia 0.005 mm.
in thickness. Beneath these there are round and oval
cells in considerable number, so that the whole epithelial
coating has a thickness of 0.5 mm. Ciliated epithelium is
also found on the false vocal cords and in the ventricles
of the larynx. Polygonal pavement epithelium forms the
128
DIPHTHERIA: SYMPTOMS AND TREATMENT
covering of the posterior surface of the pharynx, of the
aryepiglottic folds, where the mucous membrane possesses,
in addition, a heavy and lax submucous tissue, and of the.
true vocal cords. As one approaches the laryngeal ven-
tricles and trachea, the previous coating is replaced by
delicate ciliated epithelium. The mucous membrane in
the neighborhood of the laryngeal ventricles is itself very
loosely attached, exceedingly thin, and frequently thrown
into folds on the vocal cords. Acinous glands are here
abundant, being fifteen to twenty to the square centimetre,
and arranged lengthwise. Around the ventricles they are
very numerous, and their outlets are lined with cylindrical,
rarely with ciliated epithelium. The true vocal cords are
not supplied with glands of any kind.
The acinous glands have no lymphatics leading into
them, but the latter may be seen in other parts of the
mucous membrane of the larynx and in the submucous
tissue. In fact, they are both large and numerous, and
have the general character of lymphatics, as regards the
endothelium in particular. In the epiglottis of the new-
born they form but a single layer, in the larynx and trachea
two layers, and in certain parts which are covered by a
considerable amount of submucous tissue, there are even
three layers. Innermost the lymphatics are arranged per-
pendicularly to the surface ; outermost, horizontally.
The comparative absence or scantiness of lymphatics
over the larger part of the surface accounts for the ab-
sence of constitutional symptoms in localized laryngeal
diphtheria (" pseudomembranous croup "), and the exten-
sive layer of pavement epithelium accounts for the per-
sistence of membranes both on the epiglottis and in some
parts of the larynx.
The mucous membrane of the trachea and bronchi con-
tains more elastic than fibrous tissue, a moderate amount
of lymph vessels, no lymph bodies, but an abundance of
mucous glands, and is freely supplied with ciliated epithe-
lium. .
Among all the tissues and organs thus far spoken of,
the elastic tissue, which is an important element in the
formation of connective tissue, is least affected by chemical
129
DR. JACOBI'S WORKS
or organic influences. It is not present in the mucous
membrane of the nose, but to a considerable amount in
the buccal cavity, is very abundant in the walls of the
lymph follicles of the tonsils, and predominates in the
trachea. The influence of these anatomical conditions on
the diphtheritic process must be very marked. It can
easily be demonstrated that where the elastic tissue is pre-
vailing, a resistance to diphtheritic impregnation is main-,
tained for a long time, but when it has been forced to
yield, there is a corresponding resistance to recovery.
It is the pavement epithelium that gives the easiest foot-
hold to diphtheritic membrane. Where it is most abun-
dant, the diphtheritic process can best settle and develop.
That is why the tonsils, not from their prominent situa-
tion alone, but from the character of their surface also,
are favorable to the reception and further development
of an infection, and their elastic and connective fibres,
when at last affected, are apt to harbor the process a long
time. Ciliated epithelium, on the other hand, is not liable
to be invaded. It occupies a higher rank in the scale of
animal formation, and has a more complex function and a
greater power of resistance ; besides, it expels by its con-
stant movements microscopic foreign bodies.
The presence of a large number of mucous glands im-
pedes, as a rule, by the presence of the normal secretion,
an extensive destructive action upon the tissues. The se-
creted mucus assists in removing epithelial masses, and even
fibrinous exudations, from the surface. The underlying
tissues themselves do not always take an active or prom-
inent part in the process ; the serum of the mucus pene-
trates the parts which are the seat of morbid deposits,
and tends to predispose the latter toward maceration, and
the mucous secretion raises mechanically the superjacent
deposits from their bed. Thus it is that the deposits in
the respiratory portion of the nasal cavities are frequently
cast off through the nostrils, probably because they have
been produced in excess; and in a similar manner, the
membranes that have formed in the trachea are ejected in
a semisolid condition through a newly made tracheotomic,
or even the natural, outlet. The large number of mucous
130
DIPHTHERIA: SYMPTOMS AND TREATMENT
glands in a part of the larynx and in the whole trachea
is unquestionably the reason why the lymphatic vessels
of the mucous membrane, even where they are present in
large numbers, are not influenced by the overlying loosened
masses, and will not absorb; hence laryngeal anl tracheal
forms of diphtheria hftve a decidedly local character, and
are mostly devoid of constitutional symptoms.
The vocal cords form the borders of the narrowest aper-
ture of the air passages ; they detain or retain foreign
bodies, whether malignant or otherwise; they are covered
with pavement epithelium which, as has been remarked,
is the principal resting and breeding place of the diph-
theritic affection. They have no defence furnished by
muciparous follicles, and therefore if there is any part
which is predisposed to a local diphtheritic infection it is
certainly the vocal cords. That is why in the beginning
of an epidemic of diphtheria, or when it is dying out,
a local diphtheritic infection can still take place, and indi-
vidual cases occur now and then with an almost insignifi-
cant power of infection. Such occurrences took place
previous to the ubiquity of diphtheria forty years ago,
and are still met with under the same conditions, giving
rise to the so-called sporadic membranous croup.
On the other hand, the absence of acinous glands on the
vocal cords must serve to a certain degree as a guard
against the disease. Dry, atrophic, but at the same time
uninjured and smooth conditions of the mucous membrane
of the fauces tend to ward off an attack of diphtheria.
A more or less moist or viscid condition of the surface is
necessary in order that the infecting material may cling
thereto. The comparative dryness of the vocal cords,
however, considered by the side of the perpetually moist
and uneven surface of the pharynx, would not appear so
favorable to the deposition of foreign infectious elements.
Thus there are certain conditions predisposing to, others
antagonizing infection. They demonstrate, however, why
laryngeal croup is more frequent in winter than in sum-
mer, in direct proportion to the greater frequency of laryn-
geal catarrh in winter than in summer. Diphtheritic mem-
branes on the vocal cords are not easily cast off, for there
131
DR. JACOBI'S WORKS
are no subjacent muciparous glands whose secretion could
wash them away. No general infection can arise from
them, for they have no lymphatic vessels which could
serve as carriers cf the poison; furthermore, suffocation
from a local cause occurs too early to enable the few
neighboring lymphatics to absorb and transport the toxin
elsewhere, in case the deposits should finally become mac-
erated.
The comparative absence of the lymphatics and the
paucity of blood-vessels explain why diphtheria of the
tonsils has so mild a character. The large number and
size of, as well as the direct communication of the lym-
phatic ducts of the Schneiderian mucous membrane with
the lymphatic glands of the neck account for the dangerous
character of diphtheria of the nose. However, direct in-
fection, i.e., the absorption of the poison into the body, is
not always dependent on the lymphatics, for they have
occasionally neither enough time nor the opportunity to
use their power. For instance, in those cases of diphtheria
of the nose in which early and slight epistaxis occurred,
the poison appears to have been absorbed directly into the
blood-vessels. Then we fail to observe the ordinary swell-
ing of the neighboring glands of the neck, but the general
symptoms are very rapidly developed. Usually, however,
infection results through the lymphatics. The fluid con-
tents of the tissues, or such particles or elements as are
suspended therein, be they of a gaseous, chemical, or para-
sitic nature, are conducted to the lymph nodes and into
the circulation. There may be, however, two impediments
in the current. In the first place, the foreign material
may be present in too large an amount to circulate with
ease; the result will be stagnation and consequent irrita-
tion, either in the fascia propria or in the substance of
the lymph nodes. By pressure, the capillary circulation
becomes interfered with, proliferation ensues, the circu-
lating lymph mingles with the white corpuscles from the
lymph spaces, and the result is an abscess in the intra-
or periglandular tissue. Or the foreign material is re-
tained in the interior of the fascias, in the connective
tissue, or in the dilated lymph vessels of the cortical sub-
132
DIPHTHERIA: SYMPTOMS AND TREATMENT
stance. Thus fluids injected into the cortical substance
have been found collected in the external portions of the
lymph nodes, where it was impossible for them to be
carried into the circulation. Hence the lymph nodes may
serve as the receptacle of noxious elements which have cir-
culated in the lymph current, with or without danger to the
integrity of its tissues. In this manner a second attack of
diphtheria may often find its explanation in the absorption
of stowed-away poison ; as we see in the case of syphilitic or
other infections, which may either be stored in the lymph
body unchanged and inactive, or if their presence prove ir-
ritating, give rise to speedy suppuration, and even elimina-
tion, provided the abscess be opened sufficiently and early.
Dissemination of Diphtheria. Diphtheria is a conta-
gious disease. It is usually transmitted from the sick to
the well by the moist or dry discharges from the nose and
throat of the sick person. This transmission may take
place directly or indirectly in so many ways that is is not
always possible to trace an individual case to its source. It
is the multiplicity of mostly unknown modes of transmis-
sion which confuses and bewilders. The vulnerability of
the young mucous membrane, the frequency of nasal and
pharyngeal catarrh, the narrowness of the nose, the large
size and softness of the tonsils, the frequent fermentation
of food in the mouth, the sucking of the soiled little fin-
gers, together with the influence of family disposition,
which is more powerful in the young, the constant inter-
course of children with each other in large families and
in densely populated houses and districts, in schools and
on playgrounds, the possibly long period of incubation
during which the disease is contagious though giving rise
to no symptoms, act as just so many predisposing causes
of contagion ; and the large number and size of the lym-
phatics in the young render every attack so much the more
dangerous.
The very facts that diphtheria need not always be of the
same type; that many cases of lacunar or follicular amyg-
dalitis (" tonsillitis ") are diphtheritic that there are as
many cases out of bed and out of doors as in bed and in-
doors; that, particularly in adults, diphtheria may last
133
DR. JACOBI'S WORKS
long and give rise to but few embarrassing symptoms, and
that a mild case of diphtheria may, by contagion, produce
very serious ones, render contagion by nursery maids and
other domestics, by teachers, seamstresses, sick-nurses,
workmen, factory girls, shopkeepers, barbers, and all other
persons mingling with the many extremely easy. The vi-
tality of the diphtheria germs is persistent, as is well
known, and may extend over years. They cling to solid
and semisolid bodies, are imported in milk, cling to walls
and floors, to toys, to curtains, towels, clothing, and bed-
ding which is so often kindly donated to the poor by the
benevolent well-to-do when they wish to get rid of their
own dangers. They stick to omnibus and carriage cushions,
to car seats, to the either ready or custom made coat on
one's shoulders near which one's baby will nestle the
very coat that is sold in Broadway palaces after it has
been made in the pest-stricken tenement sweating shop.
The very restlessness of our people, the frequency of
moving into unknown and often infected quarters, is an-
other cause of doubling the number of cases. There can
be no doubt, besides, that many animals horses, chickens,
cows have and spread diphtheria. Thus it appears that
we ought to think twice, and indeed many times, before
admitting among the causes of diphtheria new factors
which cannot be proved.
" No contagion could be traced." That is the introduc-
tion to every wild and unproven theory of indigenous
spontaneous generation. When a case of cholera breaks
out in a village a thousand miles away from the coast, is
there anybody in our time who looks after chemical poison
in a well or filth on the roofs? We look for direct or in-
direct contagion from a tangible source. Why not so in
diphtheria ? In the New York Medical Journal of Sep-
tember 27th, 1886, I quoted from Isambert the case of
a medical assistant who had nasal diphtheria many months,
and then travelled half a year to get rid of the last
remnants. He fully recovered; but how many deaths did
he cause going from railroad car to railroad car, from
stagecoach to stagecoach, from hotel to hotel? How many
may have been the physicians who searched in vain for
134
DIPHTHERIA: SYMPTOMS AND TREATMENT
the cause of the sporadic cases suddenly springing up in
their towns, and the epidemics generated by them along
the roads on which the luckless wanderer after his own
health had strewn out his curses ? Nobody suspected the
traveller who left days ago, just as nobody may be able
to trace every outbreak of cholera to the unknown person
who carried it upon his person or in his bowels. Nor is
this an isolated case of a long duration of diphtheria.
Cadet de Gassicourt operated for laryngeal diphtheria
after eighteen, twenty-three, and forty-three days. Sanne
had croup patients who recovered after twenty-seven,
thirty-two, and sixty days. I know of many cases of
diphtheria protracted into the second or even the third
month.
Golay reported the case of a boy of five years who had
the diphtheria bacillus three hundred and sixty-two days.
During this time he had three acute attacks of diph-
theria and four injections of antitoxin. Golay draws the
conclusions from his report (Revue medicate de la Suisse
Romande, 1897) that a fortnight's isolation after the dis-
appearance of the false membrane, as advised, is inade-
quate; he does not believe in recovery until three or four
examinations for bacilli made in intervals of a week each
have proved unsuccessful. He also finds that the presence
of the bacillus in the throat does not interfere per se
with the general health; also that the bacillus is apt to
remain a very long time unless there is a complicating
streptococcus infection. In this case he tried many local
applications (Loeffler's included) in vain.
Such facts, pointing as they do to the ready communi-
cability of diphtheria, have influenced my opinion from
early times. I cannot see anything miraculous in the sud-
den appearance of a bacillus diphtheria or a streptococcus
in a person apparently not exposed to it. During an
epidemic there is nobody not exposed to it, and everybody is
subject to it under favorable circumstances. The latter
mean a fit condition of the human integument, either cutis
or mucous membrane, which makes it liable to become a
resting-place for the germ. That fit condition is a slight
or severe wound, abrasion, denudation of the surface. As
135
DR. JACOBI'S WORKS
no healthy surface becomes erysipelatous in spite of ery-
sipelas being epidemic (" erysipela non est sine vulnere,"
Galen), as Fehleisen's bacillus requires a sore, so diph-
theria^ being ubiquitous and waiting for a chance, will
stick to a cutaneous wound, a stomatitis, a pharyngeal or
nasal catarrh, and will rapidly multiply. A resected ton-
sil will thus be covered with a pseudomembrane within a
day.
I have been quoted as favoring the sewer-gas origin of
diphtheria, though (with the exception of a careless ex-
pression on page 50 of my " Treatise on Diphtheria ")
I always, since I860, strenuously expressed my con-
viction of the communicability of diphtheria solely by con-
tagion (direct or indirect). Jenner in 1861, Wilks in
1873, Thorne Thome in 1893, expressed the same opinion.
I believe it is the latter careful and most painstaking ob-
server whose statements, together with the discussion on
the subject contained in the British Medical Journal of
1893 and 1894, in which Wilks, Davis, Priestley, C. M.
Jessop, and J. Bunting in opposition to George Johnson,
Parker, C. N. Allfrey, N. G. Warrey, and P. G. Mar-
riott favored the exclusive contagion theory, have done
most to establish the latter forever in the minds of our
British brethren.
The vitality of bacilli is remarkable. It is true that
direct light kills them after a while; even diffuse light
has a similar though slower effect. It is also true that
they do not live outside the body so long as on the hu-
man mucous membrane, and that one observer (Spengler)
did not find them after one hundred and twenty days, and
others (Wright and Emerson) found few only on brushes,
and none on clothing or on the finger nails. But Abel
found them on children's building blocks after five months.
They resist desiccation a long time, in membranes (Roux
and Yersin, Park, Lceffler, Germano), in tissues (Lceffler,
d'Epine et de Marignac), and in dust (Reyes, Germano).
Rapid desiccation, even by means of sulphuric acid, does
not injure their virulence, which is preserved the better
(being protected against oxidation) the thicker the sur-
rounding dust. The latter may be the vehicle of conta-
136
DIPHTHERIA: SYMPTOMS AND TREATMENT
gion. Moreover, weeks and months after an attack of
diphtheria, bacilli have been and are constantly met with
in the throat, nose, antruin, and middle ear. We should
not forget that no number of negative observations can
outweigh a single positive result. And we do know, those
of us who have not forgotten the value of clinical ob-
servation, that the infection of diphtheria in bedding and
in rooms, which harbored diphtheria a year previously,
has started it again in newcomers after they had dwelt
there long enough for incubation.
There is no origin for diphtheria except in contagion.
Sewerage has nothing to do with it. In a paper published
in the Transactions of the Third Congress of American
Physicians and Surgeons (189-i) I presented the follow-
ing conclusions :
The atmosphere contains more or less specific disease
germs, both living and dead.
They are frequently found in places which were in-
fected with specific disease.
In sewer air fewer such germs have been found than
in the air of houses and schoolrooms.
Moist surfaces that is. the contents of cesspools and
sewers and the walls of sewers while emitting odors do
not give off specific germs, even in a moderate current
of wind.
Splashing of the sewer contents may separate 'some
germs and then the air of the sewer may become tem-
porarily infected, but the germ will sink to the ground
again.
Choking of the sewer, introduction of hot factory refuse,
leaky house drains, and absence of traps may be the
causes of sewer air ascending or being forced back into
the houses. But the occurrence of this complication of
circumstances is certain to be rare:
Whatever rises from the sewer under these circumstances
is offensive and irritating. A number of ailments, in-
clusive perhaps of sore throats, may originate from these
causes. But no specific diseases will be generated by them
except in the rarest of conditions. For specific germs are
destroyed by the process of putrefaction in the sewers,
137
DR. JACOBI'S WORKS
and the worse the odor the less is the danger, particularly
from diphtheria.
The contributing causes of the latter disease are very
numerous, and the search for the origin of an individual
case is often unsuccessful.
Irritation of the throat and nasopharynx is a frequent
source of local catarrh; this creates a resting-place for
diphtheria germs, which are ubiquitous during an epidemic,
and thus an opportunity for diphtheria is furnished.
Of the specific germs, those of typhoid fever and
dysentery appear to be the least subject to destruction
in cesspools and sewers. These diseases appear to be
sometimes referable to direct exhalation from privies and
cesspools, but very few cases, if any, are attributable
to the action of sewer air.
The impossibility or great improbability of the infection
of specific diseases, except dysentery and typhoid fever,
rising from sewers into our houses, protected as they are,
or ought to be, by good drains and efficient traps, should,
however, not lull our citizens and authorities into indolence
and carelessness. For the general health suffers from
chemical exhalations, and the vitality of cell life and the
power of resistance are undermined by them.
SYMPTOMATOLOGY
Prodromes. After an incubation period lasting from
a few hours to fourteen days, prodromes may precede the
characteristic symptoms of diphtheria from a few hours
to several days; some of them are identical with those of
general malaise, and nausea; occasionally vomiting, seldom
other infectious diseases. They are lassitude, headache,
diarrhoea, more commonly constipation ; universal muscu-
lar sensitiveness, and some stiffness of the neck. The
throat is complained of by older children as being dry;
the mouth is easily opened, there may be no discoloration
of the fauces, or a hyperaemia only which, as if it were
traumatic, may be quite local. The tonsils and phar} T nx
are seldom sensitive to the touch, but the swallowing of
fluids is rather difficult. In those cases in which a swelling
138
DIPHTHERIA: SYMPTOMS AND TREATMENT
of lymph bodies is noticed near the angle of the lower
jaw at this early period, there is pain on pressure. The
temperature is seldom raised except in these cases ; in
them nervous symptoms are observed, such as chills and
convulsions. There is rarely a short pharyngeal cough,
still less frequently a hoarse voice, or dyspnoea, or laryn-
geal stridor.
SYMPTOMS
The Throat. Most cases of diphtheria begin in the
throat. The tonsils being large in the young, and ex-
posed to superficial lesions occasioned by catarrhal proc-
esses, and to injuries of the epithelium (during degluti-
tion), are most readily invaded by bacilli and other mi-
crobes. There may be no, or a slight, or a high elevation
of temperature. This difference, like all other symptoms,
depends on the various degrees of virulence of the in-
vading micro-organisms, on the previous immunity, and
on the different powers of resistance on the part of the
patients. When the temperature is high (104-107) there
may be a convulsion, or vomiting, or sometimes diarrhoea.
But these symptoms of the initial stage are rare.
The throat is red, all over in most cases, or locally;
mostly on the tonsil, or near it. there is a grayish or
whitish spot, the size of the head of a pin, or larger.
Sometimes the first inspection reveals the presence of a
membrane of the same color or brownish. The small
grayish spot will increase within a few hours or a day
until it grows into a membrane, or there are more than
one, four or six or more, which soon coalesce. The mem-
brane may be thin like a film, or thick; lying rather loose
on the mucous membrane, or tightly adhering so that its
removal is difficult and attended with a little bleeding;
when it is removed it is reproduced in a few hours or
half a day. The grayish discoloration is not always mem-
branous; quite frequently it is caused by an exudation
into the tissue and cannot be removed at all. Then it
does not come away at any time but undergoes a process
of necrosis, and if it heals at all does so only by healthy
granulations springing up on the ulcerating surface. The
139
DR. JACOBI'S WORKS
neighboring tissues, mainly the uvula when it is covered
with membrane, become oedematous and may swell con-
siderably. Then deglutition, respiration, and articulation
may suffer accordingly. At first the membrane has no
odor. In bad cases, and after some days, when maceration
begins, there is some odor, which may be very offensive
and fetid in septic cases. In the neighborhood of the
membranes the lymph bodies will swell, the region of the
tonsils becomes painful on pressure, and there is some, or
much, swelling, which depends in part on the tumefaction
of the lymph bodies alone, and in part on that of the
surrounding loose tissue. The face is pale and sallow,
may be bloated even in mild cases, and its expression is
liable to be that of indolence and apathy; in bad cases of
sepsis and when the veins of the neck are compressed by
exudation the color may become livid. There are but few
mild cases of uncomplicated diphtheria that do not exhibit
some constitutional symptoms; the pulse becomes a little
frequent and small; in bad cases it is very small, very
frequent, or very slow. Those cases in which the pharyn-
geal diphtheria spreads into nasopharynx, nares, or larynx
have their own additional symptoms ; they will be consid-
ered below, so will be those which terminate in destruction
of tissue in the throat in consequence of deep ulceration
and gangrene, which may even result (though that oc-
currence be rare) in perforation of the soft palate, or
its adhesion to the posterior wall of the fauces.
The local symptoms of diphtheria may be very indis-
tinct, even absent. As early as I860 I described cases
of diphtheria without membrane, this being absent either
in the first stage only or altogether. At the present time
the bacteriological proof corroborates what I then had
ample reasons to conclude from clinical facts. The term
catarrhal diphtheria has been accepted by many since,
though it has been combated by others. That such cases may
occur in families in other members of which well-authenti-
cated instances of diphtheritic membranes are met with has
been substantiated by many, among whom I am glad to
count Baginsky. To call such cases " masked diphtheria "
appears unjustifiable, so long as the diagnosis is made,
140
DIPHTHERIA: SYMPTOMS AND TREATMENT
as now, by the presence of the bacillus and of acute sur-
face changes in the mucous membrane.
Diphtheria may, and frequently does, present itself, with
its solitary dots on the tonsils, in the form of follicular or
lacunar angina. Long before the advent of a bacteriologi-
cal diagnosis that fact became clear to me. Still the nu-
merical percentages of such cases will change even accord-
ing to seasons and epidemics. 2
This follicular form of diphtheria is often noticed in
adults, and is a frequent cause of communication of the
disease, the more easily as adults are less liable to suffer
from constitutional symptoms. But I never said what I
have been charged with, that diphtheria is spread by
adults suffering from follicular amygdalitis (tonsillitis).
On the contrary, what I did and do say is that what was
called in an individual case by that name and then gave
rise to diphtheria, was diphtheria, and therefore caused
diphtheria. Nor do I say that every case of follicular
affection of the tonsils is diphtheria, and that diphtheria
in general is spread by follicular amygdalitis in general,
but I claim that this name is too often only a cloak for
the lack of a correct or complete diagnosis. " Follicular "
and " lacunar " are adjectives describing a locality, noth-
ing else. There are cases of a follicular or lacunar amyg-
dalitis of a catarrhal, a purulent, a fibrinous, and a diph-
theritic character, and the name ought to be dropped from
our nomenclature, because it gives rise to mistakes unless
it be complemented with a descriptive adjective (Medical
Record, November 27, 1886). This variegated condition
2 If Edmund Meyer's 55 cases of " typical " angina lacunaris
gave him staphylococcus aureus in 15, a mixture of staphylococcus
and streptococcus in 24, streptococcus pyogenes in 14, and Klebs-
Loeffler bacillus in only 2 instances, he had an experience dif-
ferent from those of Lennox Browne, Koplik, and Feer (" Aetio-
logische und klinische Beitrage zu Diphtheric,' 1894, p. 43). The
latter should hold himself responsible for the following words
literally translated: "It is an established fact that many cases
of lacunar anginae are of diphtheria origina, though Jacobi's opin-
ion, according to which that is so, has become untenable through
bacteriological research."
141
DR. JACOBI'S WORKS
of the tonsils and pharynx was also described by me in
an article " On Diphtheria and Diphtheritic Affections,"
in the American Medical Times, August llth and 18th,
I860, and in C. Gerhardt's " Handbuch der Kinderkrank-
heiten," II., 1877.
The follicular form of amygdalitis (diphtheritic or
other), causing local and small circumscribed alterations
only, may easily be mistaken for a similar circumscribed
deposit which is not in a tonsillar lacuna, but on some
other part of the tonsil. This punctuated diphtheria is
mostly seen in larger children, in adolescents, and in adults,
for the reason that renewed attacks of pharyngeal inflam-
mation so harden and cicatrize the tonsillar surface that
extensive exudations can no longer take place. The broad
statement is justified that pharyngitis creates a disposition
to diphtheria and to the formation of large membranes in
the very young, and rather destroys it or causes only small
exudations in advanced age. But whether membrane or
dot, they are equally contagious. A mild variety begets
that which is mild or severe, as the severe form may
produce its like, or a mild variety. This mild variety is
that from which adults are apt to suffer. It made me
proclaim the warning that there is as much diphtheria
out of doors as indoors, as much out of bed as in bed.
With this variety the adult is on the street, engaged in
business, in the schoolroom, in the railroad car, in the
kitchen, and in the nursery. With this variety parents,
while complaining of slight throat trouble, which is not
heeded, kiss their children and infect them (Medical
Record, November 27th, 1886).
The confusion in regard to the accurate diagnosis of
an individual case is caused by the difficulty of always es-
tablishing the temporary presence or absence of the Klebs-
Loeffler bacillus. Having noticed the frequent identity of
lacunar " tonsillitis " with diphtheria, C. Fraenkel, E.
Czaplewski, and others " believe " that bacilli are actually
more common than is generally assumed, and that numer-
ous alleged cases of streptococcus pseudodiphtheria are,
after all, caused by the bacillus, and that, on the other
hand, uncomplicated bacillary diphtheria is quite rare.
142
DIPHTHERIA: SYMPTOMS AND TREATMENT
Another cause of confusion was the assumption that gen-
uine bacillary diphtheria was the most dangerous form
of the disease. There was a time when the diagnosis of
diphtheria was made by the omniscients from the ter-
mination of the case: if the patient died, it was diphtheria;
if not, not. The advent of the bacillus has changed that;
the bacillus case is at once made out to be the most dan-
gerous and fatal case. Nothing is more erroneous. As
a rule the uncomplicated bacillus case is not among the
fatal cases ; as a rule the uncomplicated streptococcus case
is not fatal; but the mixed case is ominous. The elimina-
tion or non-appearance of one of these components is a
favorable occurrence. The latest illustration of this fact
is the report of Strassburger, who states that the large
majority of diphtheria sufferers in Bonn carried Klebs-
Loeffler bacilli which were comparatively harmless. These
mild cases were not complicated with streptococci, which
were present in every grave case.
Skin. An erythematous eruption, more or less general,
appears sometimes on the skin immediately with the in-
vasion of diphtheria, or after a few days only. It is either
evanescent, scarcely visible for more than a few hours, or
covers a large surface and remains some days. It has been
mistaken for scarlet fever, but is not generally attended
with a high temperature and with the intense stomatitis
and glossitis of scarlatina; by the lower temperature it
is also distinguished from the erythema which is liable in
predisposed infants or children to accompany many fever-
ish diseases.
This eruption of diphtheria does not appear to be pro-
portionate to the seriousness of the illness. At all events
it has nothing in common with erysipelas, which, however,
is apt to accompany such cutaneous diphtheria as follows
abrasions of the skin, and is found on tracheotomy or
other wounds. Such local deposits of diphtheritic mem-
branes are often found on the local denudations of scratch
wounds, eczema sores, or vesicatories. They are apt to
remain local ; but, on the other hand, in many cases in
which the first localization of diphtheria is in the skin,
it will affect the neighboring lymph bodies and infect
143
DR. JACOBI'S WORKS
the whole body. As a rule, however, it is amenable to early
and effective treatment, and that is why Trousseau de-
clared most cases of cutaneous diphtheria to be devoid of
danger.
In connection with these cutaneous alterations may be
mentioned the more or less local or general emphysema
which occurs sometimes during or after tracheotomy. I
had that disagreeable experience a number of times, on ac-
count of my preferring to operate mostly below the thy-
roid gland. There the mediastinal tissue is sometimes in-
jured, and during the intense dyspnoea a local emphysema
of the subcutaneous tissue is the instantaneous result. Even
from a slight rupture of pulmonary alveoli much air will
escape and the whole body may become transformed, as it
were, into a bulging, crepitating balloon.
Extensive oadema is sometimes noticed, even without al-
buminuria.
In connection with the alterations of the skin petechiae,
purpura, and ecchymoses may be mentioned, though, in-
deed, they might find their proper place also under the
head of the organs of circulation. Like scarlatina and,
still more, measles, and, indeed, all infectious diseases,
diphtheria (principally the mixed bacillus and streptococ-
cus infection), mainly when the myocardium is altered and
when blood-vessels are obstructed, will result in effusion
and either small or large extravasations. Beside the lat-
ter in its different forms urticaria, erysipelas, and variola-
like eruptions will be observed. There is, however, no
eruption that is pathognomonic of genuine diphtheria.
The local lesion of the mucous membranes gives rise
to bloody discharges from the nares or the pharynx.
When sepsis is very intense and gangrene deeper, actual
hemorrhage will occur. The large majority of dangerous
or fatal hemorrhages come from tracheotomy wounds, now
and then, perhaps, from mere pulmonary hyperaemia and
apoplexy, sometimes after the loosening of membranes, or
from erosion of larger blood-vessels. Now and then the
pressure of an improper tracheotomy tube would cause it,
as in Ganghofner's and in Maas's cases of hemorrhage
from the innominata, sometimes the septic destruction of
144
DIPHTHERIA: SYMPTOMS AND TREATMENT
a carotid artery, as in a case described by me (Transac-
tions of the Association of American Physicians, 1898),
or that of other large blood-vessels would lead to a fatal
termination from profuse bleeding.
Nose. The diphtheritic membranes spread quite often
from the throat to the nasal cavities, mainly when the
posterior aspect of the uvula is affected. The latter's fre-
quent contact with the posterior wall of the pharynx dur-
ing deglutition exposes the posterior wall of the pharynx
as well. In many such cases the membrane is very thick
and dense, and apt to obstruct the nasal passages some-
times to such an extent as to close them entirely. Usually
there is no or very little nasal discharge ; but articulation
becomes " nasal " and the voice " thick " very soon, and
respiration is hampered. The deep facial lymph bodies
near the angle of the lower jaw are more or less swollen.
Whenever they are so, the nasopharynx should be examined.
Primary diphtheria of the nose (diphtheric or diph-
theritic rhinitis) is of frequent occurrence. Either with-
out any prodromi, or during or after an acute or a chronic
nasal catarrh, with much or with little discharge, there is
a thin, serous, or slightly flocculent secretion which is more
or less profuse, sometimes not, sometimes slightly, other
times intensely fetid. Hence, during the prevalence of a
diphtheria epidemic, every nasal (or pharyngeal) catarrh
requires immediate attention. This primary form may also
lead to the exudation of thick membranes, as described
above; the general consecutive symptoms so much to be
dreaded do not depend, however, on the thickness of the
membranes. On the contrary, in many cases with only
thin membranous deposits the lymph bodies are more af-
fected, and the effect of the toxin becomes painfully vis-
ible in the either very slow or rapid and feeble pulse with
all the other symptoms of a generalized sepsis. The cervical
adenitis has but little tendency to suppuration ; but a gan-
grenous degeneration takes place mainly in the mixed in-
fections, or chronic hyperplastic infiltrations tell their
tales for years to come. There is no more dangerous
form of diphtheria than that of the nares. Still more,
however, than the foul-smelling cases are to be feared
145
DR. JACOBI'S WORKS
those which exhibit few membranes, but at an early period
a sanguinolent discharge. In these not even the lymph
bodies may swell, but absorption will take place directly
through the blood-vessels, which are open, as is proved
by the very presence of blood in the discharges.
So long as the final clinical diagnosis of diphtheria de-
pends on the presence of the bacillus, if found, in the
membrane or in the discharge, the numberless papers
strutting about the magazines to prove either the innocu-
ousness or the dangerousness of fibrinous rhinitis, or again
the presence or absence of bacilli in fibrinous rhinitis, or
its ability or inability to cause faucial or laryngeal diph-
theria, are superfluous vaporings of single observations.
Whenever nasal diphtheria is diagnosed in any of its
forms, or even strongly suspected, danger should be as-
sumed to exist. In most cases the infection is mixed, very
mixed. Edmund Meyer (Archiv fur Laryngologie und
Rhinologie, IV., 1896) found in twenty-two cases of " fi-
brinous rhinitis," nine times streptococci and staphylococci
albi and aurei, and thirteen times Klebs-Lceffler bacilli;
Guarnaccia, in his cases of " caseous rhinitis," found Klebs-
Lceffler bacilli, streptococci, staphylococci aurei and albi,
sarcina lutea, bacillus subtilis, bacillus proteus, leucocytes
containing microbes in their nuclear protoplasm, and
streptothrix alba.
The conjunctiva of the upper (more frequently) or the
lower eyelid becomes diphtheritic either primarily or sec-
ondarily (when the nose and lacrymal ducts are primarily
affected). Diphtheritic conjunctivitis is not a frequent
disease sometimes I do not see a case in a year; thirty-
five years ago it was frequent and destructive. Evidently
the epidemics differ in regard to virulence. Usually the
membrane spreads rapidly from one eyelid to the other;
when the palpebral conjunctiva is smooth, dry, and pale,
while that of the bulbus is chemosed, the whole lid becomes
red, swells and stiffens, and a membrane is first deposited
in floccules, which soon coalesce into solid masses. These
are so thick as to press upon the cornea, which speedily
becomes hazy and ulcerates. Perforation takes place, the
iris prolapses, and sometimes the eye is destroyed within
146
DIPHTHERIA: SYMPTOMS AND TREATMENT
a single day. It takes the membrane a few days to begin
maceration.
The accurate diagnosis of the character of the mem-
brane should be made in the usual way; in many cases
simple film preparations, to the exclusion of cultivation,
are sufficient. It is claimed by Moray (Annales d'oculis-
tique, April, 1895) and Sydney Stevenson (British Medi-
cal Journal, June 18th, 1898) that quite often the dis-
charge from the eye contains only that microbe which is
the cause of the inflammation. There is only one source
of confusion likely to arise, viz.. that between Klebs-
Lceffler and xerosis bacilli. 3
According to Ammann 4 the cornea may be affected by
the Klebs-Loeffler bacillus, alone, but is mostly invaded
only when strepto- and staphylococci are present. Once
he found non-virulent bacilli together with the virulent.
The ear is liable to take part in the diphtheria of the
nasopharynx. Membranes may continue into the funnel-
like aperture of the Eustachian tube, which in the young
is relatively larger than in the adult, or the specific ca-
tarrh (a mere surface diphtheria) may extend into the
3 The main points of distinction are (according to Stevenson) :
1. Both stain by Gram's method, but the diphtheria organism
loses its gentian violet, when in alcohol, much more quickly than
the xerosis bacillus. 2. Klebs-Loeffler bacilli give rise to an acid
reaction when grown in neutral bouillon or milk, while xerosis
bacilli never do. 3. The latter, when inoculated into guinea-pigs,
cause nothing more than a swelling at the site of the puncture.
4 The xerosis bacillus is believed by Schanz to be identical with
the Klebs-Loeffler. Its microscopical features vary, but not more
so than those of the latter and of the " pseudobacillus." It dif-
fers in this also that, though it is always combined with strep-
tococci, it is not believed to be virulent, inasmuch as it does not
cause diphtheria. Still, there is a case of von Hippel examined
by C. Fraenkel also which proved the virulence of the xerosis
bacillus. It was met with in the conjunctival sac of a man who
had been operated upon for cataract. It was found to be very
virulent in animal experimentation, though on the eye of the
patient there was no kind of inflammation, least of all diphtheria.
The absence of diphtheria, however, in the presence of Klebs-
Loeffler bacillus on mucous membranes is a frequent occurrence.
147
DR. JACOBI'S WORKS
middle ear. Since I collected what little literature there
was in 1880 (" Treatise," p. 75), instances of that kind
have multiplied. The drum membrane, the external meatus,
and the lobes are subject to diphtheria when the surface
epithelium has been injured. A complication with erysipe-
las I saw thirty years ago on the external ear of a newly-
born child ; in older children I have seen that same un-
fortunate complication during bad epidemics ; also, with-
out erysipelas, a gangrenous disintegration of the cheek,
of the external ear, sometimes down into the bones, with
all the possibilities arising in the various forms of otitis
media and osteitis. While some died of sepsis, others would
succumb to thrombotic obstructions of a sinus.
The kidneys are liable to participate in most infectious
diseases, even in the common forms of pharyngitis; in
none more so than in diphtheria, no matter whether mild
or grave. Evidently the irritation caused by the elimina-
tion of the toxin damages either merely the functions or
the substance of the kidneys. Albuminuria is seen early,
about the third or fourth day, even on the second, in per-
haps one-third of all the cases, while the quantity of the
urine is rarely diminished, sometimes increased. Blood
there is very rarely, even in septic cases less frequently
than in scarlatina. Urea is present in normal or fair
quantities, and the salts are nearly normal. Cylindroids
(mucin) and sometimes hyaline casts are found in these
simple cases in which the albumin may be present a few
days or a week, without exerting an influence on either
the temperature or the other symptoms. Sometimes,
after having been quite copious, it disappears very sud-
denly.
Actual nephritis is not so frequent as in scarlatina, but
it occurs. Hyaline casts in larger numbers, turbid cells,
small granular casts are the first microscopical symptoms,
which may be followed by large granular casts and oc-
casionally only a few red blood cells. The urine becomes
scanty, the skin more pallid, the collapse more intense.
In this nephritis of diphtheria there is less oedema, less
dropsy, less uraemia than in that of scarlatina or other
complications. Convulsions are not even so frequent in
148
DIPHTHERIA: SYMPTOMS AND TREATMENT
this stage as they may be in the incipient stages of such
cases as begin suddenly and with a high temperature. The
patients die, now and then, without losing consciousness
to their last hour. A fatal termination is not so common
as in other complications. When albumose is found, to-
gether with considerable albumin, Berlin (Miinchner medi-
cinsche Wochenschrift, No. 42, 1897) believes the prog-
nosis to be rather favorable. Still in most of the cases
at the clinic of Strassburg in which he made his obser-
vations, the renal complications were only trifling.
The bronchi and the lungs participate in various ways
and at various times. The pseudomembrane, whether
streptococcic or bacillary, descends into the ramifications of
the air tubes, or it is first formed in these, where it may
become localized or whence it may ascend. This " fibrin-
ous bronchitis " may run a rapid or a slow course. After
the pseudomembranes have been thrown off, a mucopuru-
lent inflammation may remain and prove danger&us to the
exhausted patient. Pulmonary oedema, with intense bron-
chial hyperaemia and extensive dilatation of the blood-ves-
sels, results from the rarefaction of air in the lungs during
laryngeal obstruction. This form can be best observed
during a tracheotomy when it is made after a long dura-
tion of stenosis; an incredible amount of cedematous fluid
will ascend from the trachea under such circumstances.
The intense bronchitis accompanying it is frequently the
forerunner of elevations of temperature and of broncho-
pneumonia within one or two days. Broncho- or fibrinous
pneumonia may also follow the aspiration of membrane
(as well as of food) during dyspnoea. The microbic na-
ture of the membrane determines frequently the microscopic
character of the consecutive pneumonia, which may be
simply pyococcic but appears to be mostly attended with
or caused by the Klebs-Loeffler bacillus (Wright, Kanthack,
Stephens, Flexner). In the septic form, or under ordi-
nary circumstances also, a gangrenous pneumonia has been
observed. Most pneumonias observed in diphtheria accom-
pany, or are dependent on, the laryngeal form (croup).
That is why percussion and auscultation do not yield so
conclusive results in such cases ; for dulness may be found
149
DR. JACOBI'S WORKS
over a merely atelectatic area, and the respiratory murmurs
are obscured by the transmitted sawing, loud, laryngeal
sounds. Still when the hitherto low temperature is re-
placed by a high one, and the normal long-drawn inspira-
tion of uncomplicated laryngeal diphtheria (croup) gives
way to great frequency of respiration, the suspicion point-
ing to pneumonia becomes almost a certainty.
Like strepto and staphylococci the Klebs-Lceffler bacillus
is found in tuberculous lungs. It is easily seen that, as
it is frequent on the mucous membranes of the upper part
of the respiratory organs, it may readily appear in its
lower distributions. Whether it modifies the tuberculous
disintegration remains an open question. The influence
of the streptococcus on the tuberculous process is assumed
by all to be powerful for evil. While it is possible and
appears to be proven that the presence of streptococci
interferes with the growth of Klebs-Loeffler bacilli, other
observations have shown that under certain circumstances
the non-virulent bacilli may become virulent under the
influence or in the presence of streptococci (Schiitz in
the Berliner klinische Wochenschrift, April 18th, 18Q8).
The oesophagus rarely participates in the diphtheritic
affection of the pharynx beyond a distance of from 2
to 3 cm. where its tissue is healthy. If it is not healthy,
for instance near cicatricial contractions, membranes may
be found at any place. They may be deposited loosely
on the mucous membrane and easily floated, or may be em-
bedded in the tissue, and then lead to necrosis.
The stomach participates in the symptoms of incipient
diphtheria by vomiting, which, however, is not frequent.
Gastric pain and vomiting may precede cardiac paralysis.
Membranes, however, are found in exceptional cases only.
In one I concluded they were swallowed before death.
The intestinal tract has diphtheritic (dysenteric) mem-
branes in the rectum and colon, sometimes in connection
with pharyngeal (and nasal) diphtheria. Mixed (bacillus
and streptococcus) infections are sometimes complicated by
a septic diarrhoea with gangrenous fcetor, and at the same
time with purpura, nephritis, and intestinal hemorrhages.
Schwabe has reported the case of a physician who died
150
DIPHTHERIA: SYMPTOMS AND TREATMENT
of a septic diarrhoea contracted by swallowing membranes
aspirated from a tracheotomy wound.
The cases of diphtheria of the bladder, vagina, and
penis recorded by me in my " Treatise " of 1880, pp. 86-
90, do not bear perhaps the present test of bacteriological
diagnosis. But several cases, so verified, or diphtheria of
the vagina, and of circumcision wounds have been seen
by me since. One of the former was met with in a case
of nasopharyngeal diphtheria, two of them were followed
by a faucial affection, one of these was puerperal. The
inguinal lymph bodies were not much affected, but a slight
swelling I never missed. One patient with diphtheria of
a circumcision wound, neglected and gangrenous, died
with large inguinal adenitis. Nisot, Bumm, and J. Whit-
ridge Williams (American Journal of Obstetrics, August,
1898) report cases of diphtheria of the vagina (and
uterus). In the case of the latter the woman was (pos-
sibly) infected by the physician. Her new-born baby and
several other children caught the disease from her, and the
baby died.
There is rarely a case of diphtheria in which the lymph
bodies in the neighborhood of the diseased locality are
not affected. The latter determines the swelling which
is to take place. Previous remarks explain why a diph-
theria limited to the tonsils does not cause much swelling
of the lymph bodies, or why that of the vocal cords when
uncomplicated exhibits no secondary adenitis at all, and
why a nasal diphtheria with sanguinolent discharge from
open blood-vessels, though constituting a formidable va-
riety of the disease (the toxin being introduced directly
into the blood circulation), should show no tumefied lymph
bodies. These are irritated by the absorption from the
diseased surface, the swelling corresponding both to its
locality and the gravity of the case. Bacillary diphtheria,
not or but little complicated with streptococci, shows less
adenitis than when the affection is thoroughly mixed. Sim-
ple streptococcic membranes yield more adenitis than a
mild bacillary diphtheria. That is why so many cases of
scarlatina in which the complication with streptococci is
more frequent than that with bacilli, have more faucial
151
DR. JACOBI'S WORKS
and cervical tumefaction than diphtheria. Suppuration is
less common in the Klebs-Loeffler affection Lennox
Browne's opinion notwithstanding than in the streptococ-
cic or in the mixed infection. Large abscesses are not
frequent. Though the swellings be ever so immense in
mixed infections, they do not abound. There may be
many of them, but they are mostly small. The degenera-
tion which takes place is rather a necrosis and gangrene
than suppuration.
The seat of the adenitis corresponds with that of the
diphtheria. The posterior nares correspond with the deep-
seated lymph bodies below and near the angle of the lower
jaw to such an extent that this diphtheria, though no mem-
branes be visible, may thus be diagnosticated. In very
grave cases the swelling will even extend to the parotid.
The heart is probably affected in every case of diph-
theria. In Gerhard's " Handbuch der Kinderkrankheiten,"
Vol. II., 1877, I mentioned the symptoms with their ana-
tomical foundation which I characterized as extravasations,
cellular and nuclear alterations (myocardial), and endo-
carditis, first mentioned by Bridges. Among 17 autopsies
recorded by Reimer there was fatty degeneration of the
heart in 6, and ecchymosis of the myocardium in 3 cases.
In addition to frequent hyperaemia of the abdominal vis-
cera there were emboli of the liver in 3, with capillary
hemorrhages in its peritoneal covering in 1, and emboli
in the spleen in 5 cases.
The symptoms do not always correspond with the tangi-
ble anatomical changes. The results of the thousands of
anatomical and microscopical examinations which have been
made these forty years, though they be insufficient to
explain the physical foundations of the morbid symptoms,
do not justify the establishment of a " diphtheritic fever,"
which I resorted to in I860 for the purpose of classify-
ing just such cases in which the symptoms did not appear
to be based on palpable changes There is no case ever
so mild apparently that will not affect the heart's function
at once to a certain extent. From mild cases to the
gravest there are gradual transitions The skin is pale,
yellowish, livid, cyanotic, sometimes the lividity and cya-
152
DIPHTHERIA: SYMPTOMS AND TREATMENT
nosis are quite localized, the pulse is feeble, mostly fre-
quent ; in bad cases sometimes slow, often irregular and
intermittent; in the worst cases filiform when near or over
200, apparently of normal volume (still compressible) when
quite slow (30 to 50), sometimes dicrotic, or galloping.
The heart is sometimes still more irregular than the ar-
terial pulse. Its transverse diameter is enlarged, mainly
over the right ventricle; the sounds are muffled and drawn
out, and in this way audible over a large surface. Real
bellows murmurs, when localized, are met with in endo-
carditis only. The complex of symptoms belonging to
actual parenchymatous myocarditis will generally not set
in before the end of the first week. Turbidity of cell
structure, fatty or waxy degeneration, and loss of cross
striation are the anatomical changes which have been veri-
fied hundreds of times ; they correspond to a certain degree
of cardiac incompetency and are probably due to the in-
fluence of the diphtheria toxin only.
Mollard and Regaud (Annales de I'Institut Pasteur,
1897) found affection of the myocardium, together with
changes in other viscera, in every one of their eighteen
cases of experimental diphtheritic intoxication. Occasion-
ally it was confined to the muscular tissue, which became
abnormally striated and sometimes, through disintegration
of nuclei and protoplasm, was destroyed. Others report
the presence of numerous nuclear alterations in the car-
diac muscle (Kretz), another (Hibbard, Boston City Hos-
pital, 18Q8) "in the vagus some evidence of degenerative
changes."
The liver is enlarged and easier to feel than the spleen.
Its size and resistance may increase tremendously when
the circulation becomes sluggish under the influence of
general exhaustion and sepsis, and of myocardial changes.
Jaundice is met with in very grave and septic cases.
The spleen in enlarged in most cases, but difficult to
palpate because of its softness, and to percuss because of
the tympanites which frequently attends the disease. Even
under normal circumstances the percussion of the spleen
in the very young is not a successful procedure.
In Reiner's cases the blood was frequently normal, very
153
DR. JACOBI'S WORKS
often watery and dark, at times leucocytotic ; the latter
condition was also noticed by Bouchut and Labadie-La-
grave. Wunderlich reported two cases of Hodgkin's dis-
ease which developed during diphtheria; Bouchut and Du-
brisay found leucocytosis with considerable disproportion
in the number of red and white cells, which, however, was
not great enough to justify the diagnosis of leucocythaemia.
Many examinations of the blood have been made since,
all with similar results. Thus Gabritchevsky found hy-
perleucocytosis in every case of diphtheria. It is greatest
in fatal cases; during convalescence and after the injec-
tion of antitoxin it diminishes. A progressive hyperleu-
cocytosis in diphtheria justifies a bad prognosis, and the
analysis of the blood gives useful information regarding
the value of treatment. Ordinarily the white cells vary be-
tween 11,450 and 25,000, and in fatal cases between 29r
500 and 51,000. J. L. Morse, who quotes Gabritchevsky,
comes to similar conclusions (Boston City Hospital Re-
ports, 1895).
The nervous system is profoundly affected by diphtheria.
During the first days of a pharyngeal diphtheria the soft
palate may so swell as to interfere with respiration and
deglutition. In most cases an improvement will take place
with the restitution of the tissues to a fairly normal size,
and the local paralysis will be only apparent. In other
cases this apparent paralysis may change into an actual
one in the second or third week or later. Usually, however,
the difficulties of respiration and deglutition are moderate
indeed, paralysis is liable to follow apparently mild cases
in preference to those which exhibit a vast amount of
pharyngeal exudation and after convalescence has actually
set in or progressed for some time a peculiar array of
symptoms will make its appearance. Usually the paralysis
begins in the throat, the uvula appears elongated, the soft
palate becomes gradually immovable, articulation is nasal,
deglutition becomes difficult, fluids instead of being swal-
lowed may be discharged through the nose, or, when the
muscles of deglutition are becoming paralyzed, run down
the larynx and cause cough and pneumonia. This paraly-
sis of the soft palate is mostly bilateral, sometimes uni-
154
DIPHTHERIA: SYMPTOMS AND TREATMENT
lateral. A week or two after the beginning of the pharvn-
geal paralysis, often while it is getting better, the accom-
modation of ocular movements becomes faulty in conse-
quence of the symmetrical paralysis of the ciliary nerves
(Eulenburg). Paralyses of the internal and external rec-
tus are less symmetrical. The pupils are not affected,
other branches of the motor oculi and the abducens but
rarely. Total ophthalmoplegia has been observed in a few
cases only. After thousands of similar observations have
been made, the observations of Scheby-Buch are still class-
ical. Of 38 clinical cases of paralysis of accommodation
24 resulted from diphtheria ; of these 20 were located in
the throat, 3 started from wounds, 1 from the vagina, 1
from the skin. There was no mydriasis, with one excep-
tion. Refraction, which was invariably diminished, and
vision, which was slightly impaired, became normal again
with the restoration of health. This paralysis of accom-
modation was complicated with paralysis of the palate in
10 cases, in 9 cases it was uncomplicated, as in many
other instances noticed before and after Scheby-Buch.
Sometimes it would occur several or many weeks after the
appearance of the pharyngeal paralysis.
Next in the usual order is paralysis of the muscles of
the trunk and of the upper and lower extremities, fre-
quently preceded by paraesthesia or anaesthesia of some or
all the fingers and the palm (and other parts of the hands)
and feet, also of other parts of the surface. These af-
fections of the sensitive nerves may be quite local. I have
met with anaesthesia of the trunk. Even the sensory
nerves may become paralytic, the organ of taste in a case
of Magne's ; more instances may be found in my " Treat-
ise," p. 101, in some of which the sensitive changes were
such as to cause ataxia. The temperature sense has been
found diminished sometimes. The motor paralysis of the
extremities may increase until the limbs are entirely use-
less for weeks; as a peculiar mitigation may be mentioned
the comparative immunity of the fingers in many cases.
The sphincters of the bladder and of the anus are rarely
affected, likewise the muscles of the larynx and the respi-
ratory muscles. When both the external respiratory mus-
155
DR. JACOBI'S WORKS
cles and the diaphragm are mildly taken there is cough,
flapping thoracic respiration, and some dyspnoea. In
severe cases the patient dies of apnoea, sometimes sud-
denly. Peristalsis is rarely paralyzed; but a single case
of extreme constipation has come to my notice, and Bagin-
sky, with his ample opportunities for observation, has seen
a few only. Hemiplegia is found but rarely, and scarcely
at all in the very young. One such case has been pub-
lished by J. W. Branan. This writer says: " There are
thirty-five cases in all recorded in medical literature of
postdiphtheritic paralysis of cerebral origin. Six cases
have come to autopsy ; in one of these a hemorrhage was
found in the internal portion of the lenticular nucleus, with
destruction of the neighboring part of the internal cap-
sule. In the other five cases there was embolism of the
Sylvian artery. ... In the total thirty-six cases
there was complete recovery in four, death in seven ; in
all the others there was permanent paralysis of greater or
less extent."
A case of acute disseminated sclerosis of the spinal cord,
with neuritis, in diphtheria has been recorded by S. G.
Henschen (Berlin, 1896).
The peripheral nerves act according to no rule. Some-
times the knee reflexes are diminished or absent early, at
other times late. Reaction of degeneration is quite common
in advanced cases, but will disappear in the course of the
general recovery.
In the beginning of a diphtheria the prediction that
paralysis will follow or not cannot be made. The very
worst cases may be spared, mild ones will often be fol-
lowed by paralysis; the latter fact has been substantiated
in certain experiments made by Heubner. The location
of the diphtheritic process is indifferent in regard to par-
alysis; it was found twenty-five years ago by Gaytton,
Scheby-Buch, and myself, also by Maingault (1854, 1859),
who deserves the credit of having added most (after
Bretonneau) to our acquaintance with diphtheritic paraly-
sis, to be connected with diphtheria of the genital organs.
The cause of paralysis is not local, but general and toxic.
In some seasons and epidemics the percentage of diph-
156
DIPHTHERIA: SYMPTOMS AND TREATMENT
theritic paralyses is quite high (ten to thirty), in others
low; that is why the figures belonging to a long series
of consecutive cases only should be considered. Now and
then the order in which the symptoms of paralysis follow
each other is not disturbed; but sometimes precisely the
contrary holds good. Indeed, in many seasons it is char-
acteristic of diphtheritic paralyses to follow no certain
course, passing by some parts of the body and attacking
others.
The unexpected occurrence of sudden death in diph-
theria has sometimes been discussed in connection with
the nervous system, at other times with the heart. At all
events it is the result of a cardiac paralysis, due to a
change either in the ganglia or in the pneumogastric or
in the sympathetic fibres. My first case of the kind was
observed in 1857 and described in Gerhardt's " Handbuch,"
II., also in my " Treatise," p. Q4-. No explanation was
found at the autopsy. It occurred before Zenker, Hiller,
and Mosler described parenchymatous inflammation and
granular degeneration of the heart muscle, and before
the anatomical causes of defective or interrupted inner-
vation were the subject of much study. Afterwards those
changes described by Zenker in connection with all sorts
of infections and feverish diseases, also amyloid degenera-
tion, or heart clots formed by incompetent muscular action
of the heart, or thrombi resulting from sluggish circulation
in distant small veins, or such as form in the small veins
of the neck during the labored respiration of croup, were
accused together with defective or paralyzed innervation.
Buhl found also apoplexies in the spinal ganglia and in the
gray substance of the spinal cord. As but few patients
die of or during diphtheritic paralysis, the opportunities
for making autopsies are comparatively rare. Still, before
1880, a number of observations were made which compare
favorably with the results of modern researches. Buhl
found considerable thickening of the spinal nerves at the
junction of the posterior and anterior roots, with hemor-
rhages and diphtheritic exudation in the superficial connec-
tive tissue in these places. Oertel described in the sheath
of the nerves in the cerebral and spinal meninges and in
157
DR. JACOBI'S WORKS
the gray substance of the cord voluminous nuclear infiltra-
tion, in one case extensive hemorrhages in the spinal men-
inges, with nuclear proliferation in the gray substance of
the cord; Pierret found disseminated meningitis with peri-
neuritis of the neighboring roots, characterized by infil-
tration of nuclei between the nerve fibrillae; Charcot and
Vulpian, degeneration of the palatine nerves and fatty
disintegration of the palatine muscles; Dejerine, atrophy
of the anterior-roots secondary to a myelitic degeneration
of the ganglia of the anterior horns ; also in two cases
liquefaction of myelin and loss of axis cylinders in in-
tramuscular nerves.
The changes caused by diphtheria- in the nervous sys-
tem as described by one of the very latest writers on thia
much discussed subject (John Jenks Thomas, Boston City
Hospital, 1898) are: 1. Marked parenchymatous degen-
eration of the peripheral nerves, sometimes accompanied
by an interstitial process and by hyperaemia and hemor-
rhages ; 2. Acute parenchymatous degeneration of the
nerve fibres of the cord and brain; 3. No changes or but
slight ones in the nerve cells ; 4. Acute parenchymatous
and interstitial changes in the muscles, especially in the
heart muscle; 5. Occasional hyperaemia or inflammation
or hemorrhages in the brain cord, or in rare cases severe
enough to produce permanent troubles such as multiple
sclerosis or hemiplegia. The writer adds that cardiac death
probably takes place through the action of the toxin on the
cardiac nerves. It is evident that the last twenty years
have not added much, if anything, to the findings of the
authors of decades ago.
To this may be added the results of some late experi-
mentation. When B. MouraviefF injected diphtheria toxin
into the subcutaneous tissue or into the peritoneum of
guinea-pigs, acute or chronic symptoms made their appear-
ance. Among the former were, in the ganglion cell of
the anterior columns of the spinal cord, peripheral chro-
matolysis and extensive vacuolization, but no anaesthesia
nor paralysis; among the latter were paralysis and more
neuritis than ganglion-cell changes. Extensive peripheral
neuritis was found only after five or six weeks.
158
DIPHTHERIA: SYMPTOMS AND TREATMENT
PROGNOSIS
Epidemics differ. In some, mostly on account of the
prevalence of mixed infections, the mortality is high, in
others it is low. The last few years, not through the in-
fluence of antitoxin only, have been decidedly favorable,
compared with many epidemics since 1858. The prognosis
should always be considered uncertain, if only for the
multiplicity and variety of possible complications.
Previous good health and vigor do not insure a good
prognosis. Not infrequently a system accustomed to suf-
fering, or perhaps immunized against known and unknown
infections, though the general condition may seem unfavor-
able, will escape destruction, while a robust child will
soon succumb. That is why the rich suffer at least as much
as the poor. But when the infection is at an end, con-
valescence is speedier and more uninterrupted in the vigor-
ous and well-to-do. Probably the external circumstances,
better air, change of room, more thorough disinfection of
rooms if there was a previous case, have a good deal to
do with that result.
Very young age is unfavorable. The mortality is great-
est below the first year of life, very large between the
third and fourth, low after the eleventh or twelfth.
Children are more liable to suffer than adults. Very
old people are almost immune; still I have seen a man of
eighty-six years who had diphtheria and recovered. Very
young infants are less subject, though, when they are
taken, more endangered than children of from one to five
years; still in 1880 I reported and quoted cases of diph-
theria which occurred in the newly-born. In regard to
morbidity there appears to be no difference as to sex; mor-
tality, however, has always been greater in boys. Among
infants less than seven or eight months old the majority
of cases occur under the third month.
In the child the mucous membrane of the mouth, throat,
and nose is very soft and succulent; catarrhal and inflam-
matory changes with their epithelial alterations are fre-
quent; the nasal cavities are narrow; the tonsils are com-
paratively large, indeed they are but rarely covered by
159
DR. JACOBI'S WORKS
the anterior pillars. Thus invasion and retention of bacilli
are facilitated. The large size and number of the lymph
vessels predispose to the absorption of toxins when formed.
Children who are able to creep and to walk do not excel
in cleanliness. Their fingers are equally well acquainted
with their nares and their mouths as with the dust, dirt,
and parasitic deposits on the floor of the room. Their
lips are tentacles which examine and lick the crumbs on
the floor, the toys in the dust, many of which are of wood
or of felt and harborers of dust and microbes. Their faces
and hands are seldom clean, and their handkerchiefs and
towels are common property.
Such babies as cannot creep or walk are safer because
they are mostly kept away from the floor and in their
beds; they are not in intimate contact with their equals
and possible sources of infection, but are nursed by adults.
Their food is breast milk, or when artificial it is boiled.
It was noticed a long time ago by Home and Canstatt that
babies at the breast had but little disposition to " croup."
Indeed such infants are not so subject to any of the con-
tagious and infectious diseases as older children. Perhaps
Schmid and Pflanz (Wiener medizinische JVochenschrift,
No. 42, 1896) are correct in their opinion that woman's
milk contains antitoxic materials; perhaps the immuniz-
ing alexins of the blood serum in the newly-born are suf-
ficiently powerful to guard against infections to a certain
extent.
After the third month of life there is a copious secre-
tion, slightly acid, from the mouths of infants. Both its
quantity and its reaction militate against microbic invasion;
that is why at that period diphtheria is less common than
even in the first period of life : even a common angina is
not frequent unless in cold seasons or after sudden changes
of temperature, or when originating from a nasal catarrh
which is of frequent occurrence.
The prognosis is favorable when the affected surface
is not extensive and not in very intimate connection with
the lymph circulation. That is why uncomplicated diph-
theria of the tonsils and local cutaneous diphtheria, which
latter is very amenable to treatment, are apt to be mild.
160
DIPHTHERIA: SYMPTOMS AND TREATMENT
Diphtheria of the lips and cheeks is of fair prognosis,
partly because of the accessibility of these parts and partly
because of the facility with which the natural secretions
macerate and expel the membranes.
The thickness and solidity of the pseudomembrane are
not bad in themselves. Even in the nose a massive mem-
brane is not so dangerous as the thin, flocculent, putrid
or sanguinolent discharge. Recoveries will occur though
solid deposits fill both nares and have to be removed with
probes and pincers. Fetid discharges need not be fatal,
and bloody oozing which facilitates the direct absorption
of toxins into the circulation may be successfully treated
with irrigation, as taught by me these nearly forty years,
when conscientiously made. Nor does the foul and sweet-
ish odor of the breath justify a fatal prognosis, such as
Roger, Oertel, and Kohts would pronounce. Everything
depends on the accuracy and efficacy of the local disin-
fection. Still, nasal diphtheria when not interfered with
is more fatal than even the laryngeal form.
Large swellings of the lymph bodies near the affected
surface are ominous. They are not so frequent in uncom-
plicated bacillary diphtheria, as when the process is com-
plicated with staphylococcic infection. Streptococci are
still more dangerous Variot's latest opinions as expressed
in his " Diphtheric et Serumtherapie," 1898, notwith-
standing on account of the early septicopyaemia which is
apt to complicate the case. This mixed infection is mostly
observed in diphtheria of the nares and nasopharynx. The
frequently immense swelling of the lymph bodies near the
angles of the lower jaw, together with periadenitis, is
dangerous and will very seldom get well unless through
the most careful disinfection of the original seat of the
toxic infection. The outlook improves with the diminution
in size of the lymph nodes and the accompanying peri-
adenitis.
The degree of danger does not rise or fall with the
temperature of a case. High fever attends sometimes a
moderate catarrh of the pharynx, always a deep-seated
inflammation of a tonsil that is how an acute merely fol-
licular " tonsillitis " may be distinguished from genuine
161
DR. JACOBI'S WORKS
diphtheria and a general catarrhal laryngitis. A " pseudo-
croup " is therefore liable to set in with a high tempera-
ture; a laryngeal diphtheria is not attended with fever
so long as it is local and uncomplicated. Still, an attack
of diphtheria may set in with a high temperature even
convulsions are observed, partly occasioned by high tem-
perature, partly by toxin which will fall with the speedy
elimination of the toxin. Low temperatures do not mean
a mild character of the infection ; on the contrary, a low
temperature may attend cases of great gravity. Subnormal
temperatures are very ominous ; they accompany asthenia
or collapse. If a moderate temperature be followed by
a sudden rise, this may signify a sudden extension of the
disease, but means usually the advent of a complication in
a distant organ. A cold, clammy surface is a sign of bad
prognostic import.
The pulse is very variable. It is seldom proportionate
to the respiration, being usually more rapid. So long as
it is of fair volume, and not too much out of proportion
to the temperature of the body, the heart is strong enough;
as soon as it becomes rapid and feeble, and moreover ir-
regular, the prognosis becomes more grave. Under these
circumstances the most active stimulation is demanded.
In some instances the weak heart is not even able to mul-
tiply its beats, and the pulse becomes slow a most dan-
gerous symptom. If a frequent, compressible, and inter-
mittent, or a slow and intermittent pulse be met with, to-
gether with a puffy, leaden, apathetic, and cachectic face,
the prognosis is quite bad.
All of these symptoms mean a deterioration of the heart's
action either by the direct effect of toxin on the nerves
a genuine cardio-pulmonary paralysis or by the pres-
ence of clots in the heart, of myocardial disintegration,
or of a real ulcerous endocarditis. The latter is, however,
more commonly the result of a streptococcal than of an
uncomplicated bacillary invasion.
Affections of the blood-vessel walls leading to petechiae
or ecchymoses imply a bad, but not a fatal, prognosis.
The otitis media accompanying or depending upon diph-
theria is prognostically not so bad as that which is ob-
162
DIPHTHERIA: SYMPTOMS AND TREATMENT
served in measles or scarlatina. Though deafness is not
an infrequent outcome, operations are not so often de-
manded. Meningitis may occur in the contiguity of the
tissue or by lymph communication; in either case it orig-
inates from the pharynx or from the nares, and often
passes through the cribriform plate.
Pulmonary complications impair the prognosis. Broncho-
or croupous pneumonias, many of which are caused by
aspiration of more or less septic material, pulmonary hem-
orrhages, atelectasis caused by local impediments, and nerv-
ous incompetency are dangerous. The descent of mem-
brane from the larynx or the spontaneous formation of
membrane in fibrinous (not always diphtheritic) bronchitis
is dangerous.
Paralysis of the laryngeal muscles and the presence
of pseudomembranes in the larynx (" croup ") are grave
complications. There was a time when almost every pa-
tient was doomed, viz., before tracheotomy was introduced
by von Roth, Krackowizer, and Voss into American prac-
tice. Even then the prejudice against the operation was
great. When I performed it frequently after I860 a
famous surgeon was known to ask in all seriousness
whether Dr. J. did not cut too many throats. Its results
were impaired by improper procrastination and by the sep-
tic character of many of the epidemics. Improved anti-
sepsis in tracheotomy, and O'Dwyer's intubation, which
has almost entirely replaced the former operation, and its
combination with the use of antitoxin have so much re-
duced the mortality of laryngeal diphtheria that old sta-
tistics have lost all except their historical value.
Albuminuria, which is often observed on the third or
fourth day of the disease, is not by itself a grave symptom.
Large quantities of albumin will sometimes disappear in
a single day or in a few days as they will occasionally
do in other affections of the throat. So long as the amount
of urine and the percentage of urea are normal or nearly
so, the danger is trifling. But the presence of many epi-
thelial cells, large casts, or blood, diminished or absent
micturition, and perhaps even green or fecal vomiting, are
grave symptoms. The intactness of the cerebral faculties
163
DR. JACOBI'S WORKS
during these attacks of nephritis should not be taken as
a mitigating sign. In many cases and in many different
epidemics I have seen consciousness preserved until within
a few minutes before death. It is fortunate that actual
nephritis is not so common in diphtheria as it is in scar-
latina; altogether diphtheritic nephritis is not fatal to the
same extent as the same disease when occurring in scar-
latina.
The average case of diphtheritic paralysis permits of a
fair prognosis. The patient generally gets well in from
six to eight weeks under proper treatment. Extensive
neuritis with fatty degeneration of the myocardium may
paralyze the heart; paralysis of the pharynx and of the
vestibule of the pharynx may lead to aspiration pneumonia ;
ciliary paralysis may remain permanent; that of the respi-
ratory muscles may cause apncea and death, and that of
the sphincters of the anus and of the bladder, in the rare
cases in which they have been observed, or of the spinal
cord (tabes, hemiplegia) may last forever. That is why
the prognosis in every case of diphtheria should be a
guarded one until recovery is found to be complete.
TREATMENT
Preventive Treatment, Prevention is partly the busi-
ness of the physician, but should be mostly that of the in-
dividual, or of the complex of individuals, viz., the town,
state, or nation. A child sick with diphtheria must be iso-
lated, though the case appear ever so mild, and if possible
the well children should be sent out of the house. If that
be impossible, let them remain outside, in the open air, as
long as feasible; let them sleep in the most distant part of
the dwelling with open bedroom windows during the night,
and let their throats be examined every day. The watchful
eye of an intelligent father or mother may discover devi-
ations from the norm, so that the physician can be noti-
fied. Let the temperature of the well children be taken
once a day, in the rectum. The expenditures of a few min-
utes of a mother's time will be repaid by the discovery of a
slight anomaly, which may require the presence of the phy-
161
DIPHTHERIA: SYMPTOMS AND TREATMENT
sician. Happily, there are many mothers who keep and
value a self-registering thermometer as an important addi-
tion to their household articles. The attendant upon a case
of diphtheria should not come in contact with the rest of
the family, particularly the children, for the poison may be
carried, although the carrier remains well or apparently
well. The physician should see the well or suspected child
before he visits the patient. Though not in protracted con-
tact with their patients, medical men should use reasonable
caution. Those visiting a diphtheria ward or a diphtheria
patient should wear a clean linen cap or coat, or a rubber
garment. E. M. Buckingham (Boston Medical and Sur-
gical Journal, February 14-th. 18Q5) disinfects the soles
of his boots after leaving his ward, and soaks his hands
and wrists in a solution (1:1000) of corrosive sublimate
which is allowed to dry. Unnecessary petting of the pa-
tient on the part of the well ought to be avoided, kissing
must be forbidden, the bedclothing and linen are to be
changed often and disinfected, and the air must be kept
cool and often changed.
During the epidemic of diphtheria, and in families
stricken with diphtheria, the boiling of water and milk
should be enforced.
The well or apparently well children of a family in
which there is diphtheria must not go to school or to
church. The former necessity is beginning to be recog-
nized by the authorities and teachers and also, in con-
sequence of compulsion, by parents; but I have seen chil-
dren after being excluded from the schools taken to church.
Schools ought to be closed entirely when many cases have
occurred. Even when the school children have not been
extensively affected, but a diphtheria epidemic has com-
menced in earnest, it will be better to close the schools
for a time. If that be not advisable, the teacher ought
to be instructed to inspect throats, and directed to ex-
amine every child in the morning, and send home every
one barely suspected. This is not superfluous even where
a regular medical inspection has been introduced, as in
New York City.
The Board of Health of the State of New Jersey has
165
DR. JACOBI'S WORKS
issued the following school regulations, which, if obeyed,
cannot fail to have a good influence and should be adopted
by similar authorities.
" I. Each day during the prevalence of infectious dis-
ease, after the school is dismissed, the janitor is to scrub
with warm water, soap, and a stiff scrubbing-brush all
parts of doors, casings, and other woodwork which can be
touched by the hands of children. II. The floor should
be in good repair and without open cracks or crevices.
It should be sprinkled with clean water daily before being
swept. III. Lead pencils (there should be no slates)
should every day be immersed in a five-per-cent. solution
(1: 20) of carbolic acid and wiped dry. IV. Books which
have been used by a pupil who is suffering from any one
of the communicable diseases should be destroyed by fire
or they may be treated by exposure to formaldehyde gas.
V. During each vacation the walls and woodwork should
be wetted with a solution of bichloride of mercury
(1: 1000) and the windows should be kept open to admit
great floods of sunlight and pure air. VI. Water coolers
are unclean and unnecessary. They should not be al-
lowed in school buildings. When practicable drinking
fountains, consisting of a jet of water rising from the
center of a piece of marble, requiring no cups, should be
supplied. VII. Individual seats and desks should be pro-
vided in every school. VIII. Light and airy cloakrooms
should always be provided, and hooks should be so sepa-
rated that the garments of different pupils will not come
into contact."
In times of an epidemic, every public place, theatre,
ballroom, dining-hall, tavern, should be treated like a hos-
pital. Where there is a large conflux of people, there
are certainly many who carry the disease with them. The
spitting nuisance should be persistently suppressed. Dis-
infection at regular intervals should be enforced by the
authorities. Public vehicles must be so treated. That
they should be disinfected after a case of smallpox has
been carried in them is deemed quite natural. Hardly a
livery stable-keeper would be found who would not be
anxious to destroy the possibility of infection in any of
166
DIPHTHERIA: SYMPTOMS AND TREATMENT
his coaches. He must learn that diphtheria is, or may be,
as dangerous a passenger as variola. And what is valid
in the case of a hack is more so in that of railroad cars,
whether emigrant or Pullman. They ought to be thor-
oughly disinfected in times of an epidemic, at regular in-
tervals, for the highroads of travel have always been those
of epidemic disease, and railroad officers and their families
have often been the first victims, of the imported scourge.
Can this be accomplished? Will not railroad companies
resist a plan of regular disinfection because of its ex-
pensiveness ? Will there not be an outcry against this
despotic violation of the rights of the citizen, and the
independence of the moneybag? Certainly. But that also
happened when municipal authorities began to compel par-
ents to keep their children at home when there were con-
tagious diseases in the family, and when a smallpox pa-
tient was arrested because of endangering the passengers
in a public vehicle. In such cases, it is not society that
tyrannizes the individual; it is the individual that endangers
society. And society begins at last, even in America, to
believe in the rights of the commonwealth, as compared
with the exclusive rights of the democratic enemy of all
the rest. The establishment of state and national boards
of health proves that the narrow-minded theories of the
strict constructionists have not only disappeared from our
politics, but also from the conscience and intellect of
society.
As stated above, every case of diphtheria demands iso-
lation, during the winter on the upper floor of the dwell-
ing; the windows should be open as much as possible, the
furniture of the sick-room reduced to the least possible
quantity, the room changed if possible every few days,
and the bedding renewed frequently.
To what extent the infecting substance may cling to
surroundings is best shown by the cases of diphtheria
springing up in premises which had not seen diphtheria
for a long time, but had not been interfered with ; and best,
perhaps, by a series of observations of autoinfection. When
a diphtheritic patient has been in a room for some time,
the room, bedding, curtains, and carpets are infected; the
167
DR. JACOBI'S WORKS
child is getting better, has a new attack, may again im-
prove, and is again stricken down. I have seen some of
these children die; but also others who improved immedi-
ately after having been removed -from that room or that
house. If in any way possible, a child with diphtheria
ought to change its room and bed every few days.
The sick in crowded houses and quarters ought to be
transferred to a special hospital, which ought not to be
too large. The Willard Parker Hospital of New York,
with its seventy beds for scarlatina and diphtheria, estab-
lished through the combined efforts of the medical profes-
sion, 5 is in that respect a praiseworthy example. The large
amount of good it is doing would grow in geometrical pro-
gression if there were, as there ought to be in a large and
ambitious metropolis, half a dozen institutions of the same
class, not only for the poor, but for the well-to-do also,
both towns-people and strangers. I have advocated, for
dozens of years, the erection of a hospital for the accom-
modation of infectious diseases breaking out among the
thousands of strangers staying in New York City at all
times. As long as there is no place for them to go to,
the cases of scarlatina, diphtheria, etc., are hidden in the
boarding-houses and hotels, and are infecting the popula-
tion at large. It is but a few years since a movement for
the establishment of such an institution was begun; the
hospital for scarlatina and diphtheria was finally estab-
lished a year ago.
When diphtheria breaks out in a house, either private
or tenement with no facility for isolation, and where there
is no hospital in which to seek refuge, the well should be
removed to a healthy place; in large cities, temporary
homes ought to be provided for that purpose, to benefit
the children of the poor. If the rich would but remember
that their children will be affected through the many links
between them and the poor (servants, messengers, schools,
dresses brought home from the tailor or seamstress, or pur-
chased in the stylish and expensive establishments which
5 See my presidential address before the Medical Society of
the State of New York in the Transactions of 1882. [Vol. vii of
the present edition of Dr. Jacobi's Works.]
168
DIPHTHERIA: SYMPTOMS AND TREATMENT
give out the work to tenement working-people, and toil-
ers in sweat shops), their very egotism would compel them
to do in their own interest what the humanitarian instinct
may not suggest to them.
Prevention can accomplish a great deal for the individ-
ual. Diphtheria will not, as a rule, attack a healthy in-
tegument, either cutis or mucous membrane. The best
preventive is, therefore, to keep the mucous membrane in
a healthy condition, as I have tried to practise and teach
these forty years. Catarrh of the mouth, pharynx, and
nose must be treated in time. Many a chronic nasal
catarrh, with big lymph bodies round the neck, requires
sometimes for its cure but two or three daily warm salt-
water irrigations (1: 130) of the nose, and besides, if
the children be large enough to do so, gargling. The
addition of one per cent, of alum or less will often
be found useful. This treatment, however, must be con-
tinued for many months, and may require years. Still,
there is no hardship in it, and no excuse for its omission.
A. Cattle's many eloquent appeals have done much to popu-
larize it. The nasal spray of a solution of nitrate of sil-
ver, 1 : 500-1,000, when there are erosions, will accelerate
the cure. Its application should be repeated every day or
every few days for some time.
Krieger regarded the inhalation of dry (particularly fur-
nace) air as the main predisposing cause of diphtheria on
account of its deteriorating influence on epithelia. For a
similar reason C. Briihl and E. Jahr demand that both
heating apparatuses and ventilators should be so arranged
and so ample as to equalize the humidity in winter and
summer, especially in bedrooms and in schools. The chil-
dren should be hardened and strengthened by the use of
cold water. Not only houses but whole districts may be
treated on the same principles. Favorable climatological
changes have often been produced by irrigation, the estab-
lishment of new channels, of water-courses, and intelli-
gent forestry. But it would cost millions to save lives
wholesale; and all these millions are required to destroy
lives wholesale in haphazard wars. In accordance with
the above-mentioned principles authors emphasize the neces-
169
DR. JACOBI'S WORKS
sity of keeping the mucous membranes moist, and of pre-
venting fissures and disintegration of the epithelia. In
the last two or three decades the latter advice has been
insisted upon by all those who had waked up to the neces-
sity of prevention. Among others C. G. Rothe (1884) ad-
vised besides hygienic measures the frequent use by all the
inmates of a stricken house of a gargle consisting of car-
bolic acid, alcohol, tincture of iodine, glycerin, and water;
also the use by all children of a school of a solution of
thymol (1:1,000) and cyanide of mercury for the very
mildest affections. In connection with such advice one
remark will always be in order, viz., that medicinal gargles
and irrigations should not be as unpalatable and malodor-
ous as they can possibly be made; children should not be
made to look upon preventive measures as a punishment.
It was not always good-will and intelligence or knowl-
edge that dictated either reasoning or recommendations.
There is J. Renan for instance, who in his " Diphtheric,"
Paris, 1889, recommended the free use, among preventives,
of sulphurous acid and turpentine. Altogether the litera-
ture of diphtheria is not free even from religious and
political bias. According to Renan's monarchistic prej-
udices the inferiority of preventive practice in (republican)
France is due to the changeability of its government.
According to that theory Turkey and Russia would excel
in preventive medicine, for barring occasional assassina-
tions their governments are stable enough.
For its salutary effect on the mucous membrane of the
mouth, chlorate of potassium or of sodium, which is still
claimed by some to be a specific in diphtheria, or almost
so, is counted by me among the preventive remedies. If
it be anything more, it is an adjuvant only. It exhibits
its best effects in the catarrhal and ulcerous condition of
the oral cavity. In diphtheria it preserves the mucous
membrane in a healthy condition or restores it to health.
Thus it prevents the diphtheritic process from spreading.
Diphtheria is seldom observed on healthy or apparently
healthy tissues. The pseudomembrane is mostly surrounded
by a sore, hyperaemic, oedematous mucous membrane, to
which it will then extend. Indeed, this hyperaemia pre-
170
DIPHTHERIA: SYMPTOMS AND TREATMENT
cedes the appearance of the diphtheritic exudation in al-
most every case. The exceptions to this rule are formed
by those cases in which the virus may take root in the in-
terstices, pointed out by Stoehr, between the normal
tonsillar epithelia. Indeed, many cases of throat disease
occurring during the prevalence of an epidemic of diph-
theria are but cases of pharyngitis which develop only
under favorable circumstances into diphtheria. These
throat diseases are so very frequent during the reign of
an epidemic that in my first paper on diphtheria, while
reporting two hundred cases of genuine diphtheria, I
mentioned besides one hundred and eighty-five of pharyn-
gitis without a visible membrane.
These cases of pharyngitis, and those of stomatitis and
pharyngitis which accompany the presence of membranes,
are benefited by the local and general effect of potassic
chlorate. When the surrounding parts are healthy or re-
turn to health, the pseudomembrane remains circumscribed.
The generally benign character of purely tonsillar diph-
theria, which is apt to run its full course in from four to
six days, has in this manner contributed to secure to
chlorate of potassium the undeserved reputation of being
a remedy, the remedy, in diphtheria. The dose of the salt
must not be larger, in twenty-four hours, than gr. xv.
(1 gm.) for an infant a year old, not over gr. xx. or xxx.
(1.5-2 gm.) for a child from three to five years. An adult
should not take more than 3 iss. (6 gm.) daily. These
amounts must not be given in a few large doses, but in
frequent doses and at short intervals. A solution of 1
part in 60 may be given in doses of a teaspoonful every
hour or half a teaspoonful every half-hour in the case of
a baby one or two years old.
It is not too late yet to raise a warning voice against
the use of larger doses. Simple truths in practical medi-
cine do more than merely bear repetition they require
it. For though the cases of actual chlorate of potassium
poisoning are no longer isolated, and ought to be gen-
erally known, fatal accidents are still ocurring even in
the practice of physicians. When I experimented on my-
self with half-ounce doses, forty years ago, the results
171
DR. JACOBI'S WORKS
were some gastric and intense renal irritation. The same
were experienced by Fountain, of Davenport, Iowa, whose
death from an ounce (30 gm.) of the salt has been imr
pressively described in Alfred Stille's " Materia Medica,"
from which I have quoted in my " Treatise on Diphtheria."
His death from chlorate of potassium induced me to warn
against large doses in my lectures as early as I860. In
my contribution to Gerhardt's " Handbuch der Kinder-
krankheiten," Vol. II., 1877, I spoke of a series of cases
known to me personally. In a paper read before the
Medical Society of the State of New York (Medical Rec-
ord, March 15th, 1879) I treated of the subject mono-
graphically, and alluded to the dangers attending the pro-
miscuous use of the drug, which had even then descended
into the ranks of domestic remedies; and finally, in my
" Treatise on Diphtheria," I collected all my cases and the
few then recorded by others. Since that time numerous
instances have been reported. Death probably occurs from
methaemoglobinuria (as shown by Marchand, of Halle, in
1879), produced by the presence of the poison in the blood,
and by consecutive nephritis.
The conscientious use of salt water as a preventive meas-
ure will prove more successful when combined with the
daily cold-water bath or ablution than all the offensive
smells and tastes which have been recommended.
Large tonsils should be resected and adenoid growths
removed while there is no diphtheria; for during an epi-
demic every wound in the mouth is liable to become diph-
theritic, and such operations ought to be postponed, if
feasible. The scooping out of the tonsils, for whatever
cause, I have given up since I became better acquainted
with the use, under cocaine, of the galvanocautery. From
one to four applications to each side are usually sufficient
for every case of enlarged tonsils or chronic lacunar or
deep-seated follicular amygdalitis (" tonsillitis "). It is
advisable to cauterize but one side at a time, in order to
avoid inconvenience in swallowing afterwards, and to burn
the surface inward. Cauterization of the center of the
tonsils may result in swelling, pain, and suppuration, un-
less the cautery is carried entirely to the surface; that
172
DIPHTHERIA: SYMPTOMS AND TREATMENT
means, the scurf must be on, or extend to, the surface, and
not remain inside the tissue. Another precaution is to
apply the burner cold, press it on, and then heat. The
actual cautery is, however, not always required; a strong
hook, without or with Gleitsmann's cutting edge, bent to
a convenient angle, introduced into a follicular fistula, and
torn through the super jacent tissue, will also cause cicatri-
zation and a cure.
Nasal catarrh and proliferation of the mucous and sub-
mucous tissues may require appropriate treatment with the
electrocautery in many chronic cases, but the cases which
demand it are less frequent than those in which the tonsils
need correction.
The presence of lymph-node swellings round the neck
should not be tolerated. They and the oral and nasal
mucous membranes affect each other mutually. Most of
them could be prevented if every eczema of the head and
face, every stomatitis and rhinitis resulting from unclean-
liness, injury, or infection, were relieved at once. Pains-
taking care of that kind would prevent many a case of
diphtheria, glandular suppuration, deformity, or pulmon-
ary consumption.
Prevention of diphtheria by immunizing doses of anti-
toxin appears to be possible, but the effect does not last
beyond a few weeks.
Slawyk's report, published in the Deutsche Medicinisclie
Wochenschrift, No. 6, 1898, is very interesting. In Hueb-
ner's division of the Charite Hospital of Berlin relapses
or endemic infections were quite common in spite of care-
ful preventive measures until immunization by antitoxin
was resorted to. The doses, of two hundred units con-
tained in 8 c.c. each, were repeated every three weeks.
In this way the place remained free of diphtheria. As a
matter of experiment immunization was discontinued on
October 1st, 1897. Three cases of diphtheria, one of
which terminated fatally, occurred in the first -part of
November. The preventive injections were then made
again, and during the following two and a half months,
up to the time the report was published, no new case had
been observed. Neither early age nor any complicating
173
DR. JACOBI'S WORKS
disease appeared to furnish a contraindication to the in-
jections.
Similar results have been obtained in New York arid
elsewhere. The duration of the immunity so obtained is,
however, limited. It has frequently been observed that a
dose of from two to four hundred units of antitoxin, when
given for immunizing purposes, appeared to be successful,
until the child was taken with diphtheria thirty or forty
days after the injection.
In connection with the preventive measures detailed
above, I now add, though they be in part a repetition of
what has been said, the regulations of the New York
Health Department which have been in force for some
time. They are clear, concise, and to the point.
" If possible, one attendant should take the entire care
of the sick person, and no one else besides the physician
should be allowed to enter the sick-room. The attendant
should have no communication with the rest of the family.
The members of the family should not receive or make
visits during the illness.
" The discharges from the nose and mouth must be
received on handkerchiefs or cloths, which should be at
once immersed in a carbolic solution (made by dissolv-
ing six ounces of pure carbolic acid in one gallon of hot
water, which may be diluted with an equal quantity of
water). All handkerchiefs, cloths, towels, napkins, bed
linen, personal clothing, night clothes, etc., that have come
in contact in any way with the sick person, after
use should be immediately immersed without removal from
the room in the above solution. These should be soaked
for two or three hours, and then boiled in water or soap-
suds for one hour.
" In diphtheria and scarlet fever, great care should be
taken in making applications to the throat or nose, that
the discharges from them in the act of coughing are not
thrown into the face or on the clothing of the person mak-
ing the applications, as in this way the disease is likely
to be caught.
" The hands of the attendant should always be thor-
174
DIPHTHERIA: SYMPTOMS AND TREATMENT
oughly disinfected by washing in the carbolic solution,
and then in soapsuds, after making applications to the
throat or nose, and before eating.
" Surfaces of any kind soiled by the discharges should
be immediately flooded with the carbolic solution.
" Plates, cups, glasses, knives, forks, spoons, etc., used
by the sick person for eating and drinking must be kept
for his especial use, and under no circumstances removed
from the room or mixed with similar utensils used by
others, but must be washed in the room in the carbolic
solution and then in hot soapsuds. After use the soap-
suds should be thrown into the water-closet and the vessel
which contained it should be washed in the carbolic so-
lution.
" The room occupied by the sick person should be thor-
oughly aired several times daily, and swept frequently,
after scattering wet newspapers, sawdust, or tea leaves on
the floor to prevent the dust from rising. After sweeping,
the dust upon the woodwork and furniture should be re-
moved with damp cloths. The sweepings should be burned,
and the cloths soaked in the carbolic solution. In cold
weather, the sick person should be protected from draughts
of air by a sheet or blanket thrown over his head while
the room is being aired.
" When the contagious nature of the disease is rec-
ognized within a short time after the beginning of the
illness, after the approval of the Health Department in-
spector, it is advised that all articles of furniture not neces-
sary for immediate use in the care of the sick person,
especially upholstered furniture, carpets, and curtains,
should be removed from the sick-room.
" When the patient has recovered from any one of these
diseases the entire body should be bathed and the hair
washed with hot soapsuds and the patient should be dressed
in clean clothes (which have not been in the room during
the sickness) and removed from the room. Then the
Health Department should be immediately notified, and
disinfectors will be sent to disinfect the room, bedding,
clothing, etc v and under no conditions should it be again
175
DR. JACOBI'S WORKS
entered or occupied until it has been thoroughly disin-
fected. Nothing used in the room during the sickness
should be removed until this has been done.
" The attendant, and any one who has assisted in car-
ing for the sick person, should also take a bath, wash
the hair, and put on clean clothes, before mingling with
the family or other people after the recovery of the pa-
tient. The clothes worn in the sick-room should be left
there, to be disinfected with the room and its contents
by the Health Department."
Among the disinfectants employed to advantage in dwell-
ings formalin has of late taken a high rank. A spray of
a two-per-cent. solution has been found available. From
60 to 70 c.c. of dissolved concentrated formalin is believed
to be sufficient for the space of one cubic meter (thirty
cubic feet). One gram of formaldehyde evaporated from
Schering's lamp or other apparatus renders the same ser-
vice; or the substance may be allowed to evaporate grad-
ually. Meanwhile the eyes should be protected by glasses,
the nose by a mask, the hands by vaseline. Still, if
Symansky be correct (Zeitschrift fiir Hygiene, etc., xxviii.,
1898, p. 237), even formalin leaves much to be desired.
He claims, while mentioning in its favor that it does not
injure clothing and furniture, with the exception of chang-
ing red aniline dyes into purple, that its best effect is ob-
tained at high temperatures and in dry atmospheres, and
that it has but little penetration and destroys no spores,
and for that reason yields no absolutely safe results.
LOCAL TREATMENT
The local remedies employed have been used for the
purpose of either directly destroying the pseudomembrane,
such as nitrate of silver, carbolic acid, the actual cautery;
or to dissolve them, such as the alkaline carbonates, the
chlorides, steam, papayotin; or to act as astringents, such
as limewater and the chloride and subsulphate of iron;
or to disinfect, such as the potassic chlorate, chloral hy-
drate, turpentine, carbolic acid, mercury^ sulphur, bromine,
iodine, iodoform, chlorine water, and peroxide of hydro-
176
DIPHTHERIA: SYMPTOMS AND TREATMENT
gen. The methods of application have been either local
administration by the attendant, or washes and gargles,
sprays, injections, or inhalations.
The local treatment of the mouth and throat has two
indications; first, to maintain or restore a healthy condi-
tion of the mucous membrane of the cavities; second, to
influence the diseased surface. Gargles in any shape will
reach the oral cavity only. They never touch anything
beyond the anterior pillars of the soft palate, and seldom
more than a small part of the tonsil. The gargles with
potassic chlorate, or with the sodic benzoate or biborate
have only a preventive, not a curative, effect; still, they
ought not to be neglected when the children are old enough
to use them. Mild solutions of the above salts may also
be introduced into the mouth of babies from time to time
by means of a brush or a pipette. Local applications to
the throat, even where they are possible, ought not to be
made with powders. They are apt to nauseate and pro-
duce vomiting by their mere contact. Even powders for
internal administration require careful mixing with water,
for they are liable to irritate the throat; thus, the direct
application of calomel, of the oxide of mercury, or of sul-
phur ought to be avoided. Applications of substances with
bad taste or those that give pain must not be made, be-
cause the struggling and consecutive exhaustion of the pa-
tient will do more harm than the remedy will do good.
That is so with a number of substances, particularly with
the chloral hydrate, and even with the chloride of sodium
which has been recommended, like a hundred other things,
as a local application to the pseudomembrane of the
tonsil.
In diphtheria the danger arises first from suffocation.
That can be easily recognized, and the indications for
the treatment by mechanical means that is, intubation or
tracheotomy are readily found. These are the cases in
which repeated fumigations with gr. vii.-xv. (0.5-1 gm.)
of calomel, under a tent or in a small room, are used to ad-
vantage. Steam will also answer well under the same
circumstances.
When the diphtheritic pseudomembrane is within reach,
177
DR. JACOBI'S WORKS
it should be either destroyed or disinfected. For that pur-
pose one or two drops of a fifty-per-cent. solution of car-
bolic acid in glycerin may be applied once (not more than
twice) a day, or of the tincture of iodine, or of a solution
of 1 part of the bichloride of mercury in 100 or 500
parts of water, several times a day. It is in these cases
that chlorine water has been injected through the surface
into the upper layers of the tonsils. But we should never
forget that only a small part of the pharynx is accessible
to such treatment, and that it is only one class of patients
that can be subjected to it. In order to be effective, the
application must be thorough. None but adults or older
children, and of them only a small number, will submit
to opening their mouths and to the applications. It is
that very class of patients who can be induced to gargle
with some little, though very little, success. Smaller chil-
dren will object, will defend themselves, will struggle.
It takes many an anxious moment to force open the mouth ;
meanwhile, the patient is struggling, perspiring, scream-
ing, and exhausting his strength. One may succeed in
forcing open the jaws, then there begins the practice of
making applications, of swabbing, of scratching off the
pseudomembrane, of cauterizing, of burning. The strug-
gling child will prevent the limitation of the application
to the diseased surface. One cannot help injuring the
neighboring epithelium, and thus the morbid process will
spread. Instead of doing good, we have done harm; for,
indeed, no local application can do so much good as the
struggles of the frightened children do mischief. I have
seen them die while defending themselves against the at-
tempted violence, leaving doctor and nurse victorious and
alive on the battlefield. It is incredible, but it is true,
that more than one have recommended using the electro-
cautery or the thermocautery on the throat of the baby,
after forcing the mouth open! It is almost incredible,
for the offenders cannot have been ignorant of the fact
that what they can reach with their instruments is but very
little besides the tonsil, and they might have known that
it is just the tonsils that are least apt to favor the ad-
mission of sepsis into the circulation.
178
DIPHTHERIA: SYMPTOMS AND TREATMENT
There is an easy way of using disinfectants on the
throat and mouth, viz., to give medicines which are at the
same time disinfectants, digestible, and easy to take; to
give them in small doses but frequently ; to see that when
they have been given, no water or milk is taken imme-
diately afterwards, so as not to wash them off from the
mouth and throat. Such medicines are mild dilutions of
the tincture of chloride of iron, or lime water, or solutions
of boric acid, or of bichloride of mercury, or of benzoate
of sodium, most of which will act both by their consti-
tutional and their local effect.
Diphtheria is most dangerous when located in the nose
and nasopharynx. The changes taking place in the nares
may be an extensive catarrh, besides the diphtheritic de-
posits. The diphtheritic membranes are sometimes very
thick, and contain a great deal of fibrin. Sometimes they
are so thick as to clog the nares and prevent respiration.
Underneath them copious absorption of toxins may take
place. In most cases, however, the diphtheritic membranes
are not so thick. Some of them macerate very readily,
and the toxin is very speedily absorbed through the ex-
ceedingly copious lymph ducts, and sepsis is the result.
In some cases of diphtheria, however, the membranes can
hardly be seen. The discharge from the nose is liquid
and acrid, contains small flakes and some blood. These
are the cases in which the toxin is absorbed directly into
the circulation. All of these forms may lead to necrosis
and gangrene of the tissue, and produce a very peculiar,
sweetish, nasty odor. Thus, the inhaled air is poisoned,
and, being carried down into the lungs, acts as an addi-
tional peril. The most dangerous locality is the posterior
nares, with their direct communications with the lymph
bodies below the angle of the lower jaw. The pseudo-
membranes, the lymph ducts, and lymph bodies, swarm with
bacilli and toxin, with streptococci, with staphylococci, and
lead to immense tumefaction between the ears and clav-
icles, to the formation of multiple small abscesses, to hem-
orrhages, to sepsis. All of these forms of nasal diph-
theria require immediate, persistent, and efficient local
treatment, for it is safe to say that every case of genuine
179
DR. JACOBI'S WORKS
or mixed nasal diphtheria has a tendency to terminate
fatally.
The local treatment consists in cleansing and disinfect-
ing. In most cases these two are identical, for if we
simply succeed in washing out the macerating material,
that proves sufficient. In order, however, to have that
effect the washing and disinfecting must be done often
every half-hour, every hour, every two hours, day and
night. In the bad cases, in which the nares are clogged
with pseudomembrane, the cleansing and disinfecting are to
be preceded by forcing a passage through the nares with a
probe covered with wadding and dipped in carbolic acid.
Particularly is this indication urgent when there is sopor,
which owes its origin partly to the difficulty of respiration
and carbonic-acid poisoning and partly to the septic con-
dition. The methods of local treatment, besides the one
just described, are the (not always successful) applica-
tions of ointments within the nose by means of the brush
or wadded probe, or the use of the spray or syringe or
irrigator, or the use of a spoon or a nasal cup or a feed-
ing-cup, through which liquids are poured into the nares.
The indispensability of these nasal administrations cannot
be urged too positively. Park thinks that " when the
strength is good and the nostrils and throat are full of
discharge and membrane, it is well to insist on cleansing
by irrigation; when, however, the child is much prostrated,
and struggles against it, irrigation may have to be omitted "
(" An American System of the Practice of Medicine," i.,
p. 684). I believe, however, that in nasal diphtheria local
treatment is the vital indication.
In making local applications it is important that the
whole surface should be touched; therefore neither oint-
ments nor instillations from a medicine-dropper are avail-
able in the average cases in which the whole nasopharynx
is the seat of the affection; nor as a rule will the atomizer
convey a sufficient amount of liquid into the cavities to
be of much use. A spoon or a small feeding-cup, or better
one of the nasal cups made for the purpose, the nozzle of
which is narrow enough to enter the nose, will do fairly
well, and will allow the introduction of liquids into the
180
DIPHTHERIA: SYMPTOMS AND TREATMENT
nares in small or large amounts, all of which will enter
the throat, be either swallowed or flow out of the other
nostril or out of the mouth. The irrigator (fountain syr-
inge) is liable, by undue pressure, which cannot always be
well measured, to injure the ear. It is true that this cannot
take place very readily so long as the whole naso-
pharynx is covered with pseudomembrane, but this will
not always remain, and then there is a possibility of
the injection, when forced in, entering the middle ear.
This will take place the more readily the younger the in-
fant, because the pharyngeal orifice of the Eustachian tube
is relatively larger and more funnel-like in the very young
than in those of more advanced age. On the other hand,
this configuration of the Eustachian tubes favors the es-
cape of fluids from the middle ear; that is why otitis media
in the very young is often painless. I generally prefer
a small glass syringe with a conical nozzle of soft rubber.
It will close up the nostril, the pressure can always be
measured and modified (it should be very gentle), and it
is effective. The injections must be made with the patient
in the recumbent or semirecumbent position. On no con-
dition, however, must a child with diphtheria be taken out
of bed for the purpose of having the nares washed and
disinfected. I know of many cases in which the patient
died simply from being repeatedly taken up. The in-
jection or irrigation is best made by a person who sits
on the edge of the bed behind the patient, and raising his
head gently supports it with his chest. A towel should
quickly be thrown over the chest of the patient, and an-
other attendant should secure the patient's hands. All
preparations should be made out of sight. Slow irrigation
should always be preferred to injection when there is some
bleeding after every application.
The fluids to be used may be quite simple, but should
always be warm. In many cases a solution of table salt
in water (7: 1,000), or boracic acid (2 or 4: 100), or lime
water will answer all purposes. The latter is particularly
indicated when there is a thin, acrid, slightly fetid dis-
charge. A more efficacious disinfectant than all of those
mentioned is the bichloride of mercury, 1 part mixed with
181
DR. JACOBI'S WORKS
10 parts of chloride of sodium or chloride of ammonium
in from 2,000 to 10,000 parts of water. It may be used
freely.
If moderate quantities of a mild solution of bichloride
of mercury be swallowed while being injected, no harm is
done. Where there is a fetid odor, the nares ought to
be deodorized frequently by carbolic acid or creolin or
permanganate of potassium.
Carbolic acid may be used in solutions of from 1 to
10: 1000 parts of water, but it should not be forgotten
that there is some danger in swallowing it, because of the
nephritis to which it may give rise. For the same pur-
pose of deodorizing, creolin may be used in one-per-cent.
solution. Loeffler's solution of alcohol 60, toluol 36, and
tincture of iron sesquichloride 4 parts, does not act better
than others, has a bad taste, is objected to very strongly,
and gives rise to exhausting struggles. Permanganate of
potassium in solution (1:250) may be applied once or
twice a day to the fetid nares with a probe wrapped in
absorbent cotton, or may be used for spraying, for injection,
or for irrigation in a solution of 1 : 2,000-4,000 many
times a day. Peroxide of hydrogen is a powerful disin-
fectant; some of its eulogizers condemn such preparations
as are acid, others those which are not acid. Solutions
which are not very dilute will coagulate the soluble albumin
of the surface tissue with which they come in contact;
form membranous deposits which are frequently mistaken
for diphtheritic pseudomembranes ; giye rise, when the
membranous artefacts will have been thrown off, to local
sores, which may, and very often do, furnish a resting-
place to new microbic invasions. This should be taken into
consideration, and is true, though one of the manufacturers
of this substance once tried to increase the vigor of the
advertisement of his wares by coupling with it his convic-
tion of my ignorance on the subject.
For the purpose of dissolving membranes, papayotin
(not the proprietary medicine sold under a similar name)
has been used in five-per-cent. solutions, as a spray, by
injection, or as a direct application by means of a sponge
or brush. Many years ago I employed it in greater con-
182
DIPHTHERIA: SYMPTOMS AND TREATMENT
centration to dissolve the diphtheritic membranes of the
trachea below the tracheotomy tube. Its application in
powder does not answer well. For the same purpose tryp-
sin has been employed in five-per-cent. solutions, mixed
with bicarbonate of sodium.
The cervical lymphadenitis, of which I have spoken as
the result of nasal diphtheria, must be treated persist-
ently and effectively. This treatment may be preventive
and curative. The preventive treatment consists in the
nasal injections described. The rapidity with which large
swellings diminish when irrigations are made frequently
and conscientiously is often surprising. When large tume-
faction has taken place, tincture of iodine has been ap-
plied externally; in that way it is useless. Mercurial oint-
ments and oleates have been applied; they also are useless,
either as actual remedies or as a means of massage. An
ointment of potassic iodide and adeps lanae hydrosus
(1:6-8) is more readily absorbed and less irritating. Ice
externally is rational, but it is useless so long as the
infection is not stopped. I have in a number of instances
injected iodoform, in ether, into the swelled mass, but it
is too painful and too efficacious, and does not pay for the
agitation, anguish, and exhaustion of the unfortunate child.
So, indeed, there is no remedy, besides the preventive
measures, except in occasional long and deep incisions into
the immense mass. We hould not wait for fluctuation
or even semi-fluctuation to become apparent. A great deal
of the swelling is inside the fascia. Abscesses, when they
form, are seldom large. The contents consist more of
necrotic tissue, which ought to be laid open as soon as
possible and disinfected. The incision must be a long
one in many cases from ear to clavicle. The disinfection
of the wound may be obtained by applications of subnitrate
of bismuth or tincture of iodine, and by iodoform or
other antiseptic gauze. No carbolic acid should be used
for disinfection, because of its tendency to give rise to
hemorrhages. When a hemorrhage takes place, it will
usually stop under pressure with antiseptic gauze; but
sometimes, when a large blood-vessel has been eroded, it
is very copious. In such cases the actual cautery, acu-
183
DR. JACOBI'S WORKS
pressure, or sometimes the ligature of blood-vessels has to
be resorted to. Chloride of iron and subsulphate of iron
must never be used on such necrotic surfaces. They give
rise to a thick coagulated scab under which septic absorp-
tion is apt to take place.
Sanguinolent discharges from the nostrils may usually
be arrested by the conscientious application of cleansing
and disinfecting solutions (in most cases gentle irrigation
works best). But the subsulphate or perchloride of iron
should generally not be employed for the reason above
given. The application of a solution of antipyrin (1: 10,
sometimes 1:3) by means of a swab or a spray will gen-
erally prove satisfactory in hemorrhages. In urgent cases
a tampon saturated in a solution of antipyrin is required;
its; styptic property is enhanced by the addition of a small
amount of tannic acid.
Moderate hemorrhages from the throat should be treated
in a similar way, and by ice-bags properly applied. Un-
less they be parenchymatous their locality should be in-
quired into for the purpose of the localization of a styptic
antipyrin, or the actual cautery. If there be an erosion
of a large vessel, such as the carotid artery in a case
reported by me in the Transactions of the Association of
American Physicians (18Q8), nothing short of the ligation
of the vessel is appropriate. If it be the jugular vein
which is ruptured, either ligation or compression should
be resorted to.
Local treatment has lost its credit with some who be-
lieve that antitoxin alone should be relied on in all cases,
and for all indications. That is a grave mistake, which
will again be referred to below.
For the purpose of softening and macerating pseudo-
membranes steam has been extensively utilized. Its in-
halation is useful in cases of catarrh of the mucous mem-
branes, and in many inflammatory and diphtheritic affec-
tions. On mucous membranes it will increase the secretion
and liquefy it, and thus aid in the throwing off of the
pseudomembranes. Its action is the more pronounced the
greater the amount of muciparous follicles under or along-
side a cylindrical or fimbriated epithelium. Thus it is
184.
DIPHTHERIA: SYMPTOMS AND TREATMENT
that tracheobronchial diphtheria and the non-bacillary
forms of fibrinous bronchitis are greatly benefited by it.
Children affected with them I have kept in small bath-
rooms for days, turning on the hot water, and obliging
the patient constantly to breathe the hot vapor. In several
such cases I have seen recovery with that treatment.
Atomized cold water will never yield the same result;
nor have I seen the patented inhalers do much good.
Still, where the surface epithelium is pavement rather than
cylindrical, and where but few muciparous follicles are
present, and when the pseudomembrane is rather immerged
in, and firmly coherent with, the surface for instance,
on the tonsils the steam treatment is less appropriate.
On the contrary, moist heat is liable in such cases to favor
the extension of the process by softening the hitherto
healthy mucous membrane. Thus it takes all the tact of
the practitioner to select the proper cases for the admin-
istration of steam, not to speak of the judgment which is
required to determine to what extent the exclusion of air
(oxygen) from the steam-moistened room or tent is per-
missible.
Steam may be properly mixed with medicinal vapors.
In the room of the patient water is kept constantly boiling
over the fireplace, provided the steam is prevented from
escaping directly into the chimney, on a stove (the modern
" self-feeders " are insufficient for that purpose and are
abominations for every reason), over an alcohol lamp, if
we cannot do better, but not on gas, if possible to avoid
it, because of the large amount of oxygen which it con-
sumes. Every hour a tablespoonful of oil of turpentine,
or of eucalyptus, and perhaps also a teaspoonful of carbolic
acid, is poured on the water and evaporated with it. The
air of the room is filled with steam and vapors, and thus the
contact with the sore surfaces and the respiratory tract
is obtained with absolute certainty.
The secretion of the mucous membranes is sometimes
quite abundant under the influence of steam, but is still
more, like that of the external integuments, increased by
the introduction of water into the circulation. Therefore,
drinking of large quantities of water or of water mixed
185
DR. JACOBI'S WORKS
with alcoholic stimulants should be encouraged. Over a
thoroughly moistened mucous membrane the pseudomem-
brane is more easily made to float and to macerate.
To evolve large volumes of steam the slaking of lime
has been resorted to. It is both an old and an effective
procedure. Not only is the object in view accomplished
by it, but it is the best means of bringing lime into con-
tact with the morbid surface. In a room in which lime
has been slaked, everything is covered with it. Thus this
method of profiting by the local effect of lime is decidedly
preferable to the almost nugatory effect of lime water
sprayed into the throat.
In connection with these measures, taken for influencing
the mucous secretions and exudations of the mucous mem-
branes, I may here refer to some internal medication re-
sorted to with the same object in view. It was to fulfil
the same indication of softening the pseudomembrane, by
increasing the secretion of the mucous membranes, that
pilocarpine or jaborandi was highly recommended (Gutt-
mann) as a panacea in all forms of diphtheria. There
is no doubt that the secretion of the mucous membranes
is vastly increased by the internal administration, or by
repeated subcutaneous injections of the muriate or nitrate
of pilocarpine, but the heart is enfeebled by its use. I
have seen but few cases in which I could continue the
treatment for a sufficient time. In many I had to stop it
because after some days of persistent administration I
feared for the safety of the patients. Therefore, as early
as 1880, at the meeting in that year of the American Med-
ical Association at Richmond, I felt obliged to warn
against its indiscriminate use in diphtheria. Thus it has
shared the fate of all the hundreds of remedies and meth-
ods which have been declared to be infallible and have
been found wanting.
The diphtheritic conjunctiva should be irrigated fre-
quently, every half-hour or every hour, with a mild anti-
septic solution (boracic acid 1-4: 100). These irrigations
are quite often difficult to make because of the massive
infiltration of the tissues. To counteract this and its pres-
sure on the eyeball, I saw, thirty years ago, a deep hori-
186
DIPHTHERIA: SYMPTOMS AND TREATMENT
zontal incision made through the external angle. In some
cases the pressure was relieved in spite of the extension
of the diphtheria along the wound. Ice applications to
the eye are always indicated, particularly at first. If bags
will not be tolerated, cloths large enough to cover the
eye should be placed on a lump of ice and applied fresh,
without previous wringing, every two minutes. These ice
applications should, however, be watched. They are liable
to increase the anaemia caused by the infiltration of the
tissues and give rise to necrosis. Such occurrences should
be met by warm applications, which may increase the
tendency to maceration. Abscesses in the lower part of
the cornea should not be opened. Accompanying eczema
or erythema of the cheeks should be treated with an
iodo form-vaseline ointment (1:6-10), and cellulitis of the
surrounding tissue of the cheek according to the common
principles of antiseptic surgery.
Ammann treated six serious cases of diphtheria of the
eye with repeated injections of antitoxin, which were not
successful. It appears its effect is doubtful when the
cornea is affected, and mainly, as it happened in his cases,
when diphtheritic conjunctivitis and keratitis were com-
plicated with the presence of cocci.
GENERAL TREATMENT
The dietetic treatment of a case of diphtheria, either
simple and uncomplicated, or mixed, or septic, should be
guided by circumstances and general principles. Solid
food is rarely relished and generally refused, though there
be but little pain in swallowing. A child may be per-
mitted to go without food for the first day or longer. But
the tendency to leucocytosis, hydraemia, and toxic exhaus-
tion demands measures for the preservation and restora-
tion of strength. Milk in different forms, with and without
farinaceous admixtures, broths and beef juice, eggs in
acceptable form, and alcoholic stimulants at an early time
should be insisted upon. It should be superfluous to urge
the necessity, while trying to remove the disease, of pre-
serving the patient.
187
DR. JACOBI'S WORKS
The medical treatment of an average case of pharyngeal
diphtheria can be made to combine the indications of both
internal and local administration. For forty years I have
employed the tincture of the chloride of iron. It is an
astringent and antiseptic. Its contact with the diseased
surface is as important as is its general effect; therefore
it should be given frequently, in hourly or half-hourly
doses, even every twenty or fifteen minutes. An infant
of a year may take 3 or 4 c.c. (3 i.) a day, a child of three
or five years 8 or 12 c.c. (o ij. or iij.). It is mixed with
water so as to make the dose half a teaspoonful or a tea-
spoonful; a drachm or two drachms (4 or 8 c.c.) with a
small quantity of chlorate of potassium (see above), in
four ounces (120 c.c.) allows half a teaspoonful every
twenty minutes. No water must be drunk after the medi-
cine. As a rule, it is well tolerated. There are some,
however, who will not bear it well. Vomiting or diarrhoea
is a contraindication to perseverance in its use, for noth-
ing must be allowed to occur which reduces strength. A
good adjuvant is glycerin, and better than syrups. From
ten to fifteen per cent, of the mixture may consist of it.
Now and then, but rarely, it is not at all tolerated. When
diarrhoea sets in glycerin should be discontinued. Still,
these cases are rare; indeed, the stomach bears glycerin
very much better than the rectum.
I have seen so many bad cases recover under the ad-
ministration of chloride of iron, when treated after the
method detailed above, that I cannot rescind former ex-
pressions of my belief in its value. Still, I have often
been so situated that I had to give it up in peculiar
cases. They were those in which the main symptoms were
of so intense a sepsis that the iron and other rational
methods of treatment were not powerful enough to pre-
vent the rapid progress of the disease. Children with
nasopharyngeal diphtheria, large glandular swelling, feeble
heart, and frequent pulse, thorough sepsis, and irritable
stomach besides, those in whom large doses only of stimu-
lants, general and cardiac, may possibly bring any relief,
are better off without the iron. When the circumstances
are such as to leave the choice between iron and alcohol,
188
DIPHTHERIA: SYMPTOMS AND TREATMENT
it is best to omit the iron and rely on alcoholic stimulants
mostty. The quantities required are so large that the
absorbent powers of the digestive tract are no longer suf-
ficient for both.
Nor is iron sufficient or safe in those cases which arc
pre-eminently laryngeal. To rely on iron in membranous
croup means both waste and danger.
When pharyngeal diphtheria has reached the larynx in
its descent, or when bronchial diphtheria in its ascent
has resulted in sudden laryngeal stenosis, the above anti-
diphtheritic treatment avails but little. That neither gen-
eral nor local depletion has any effect, except that of
hopelessly reducing the patient's strength, has long been
recognized; also that vesicatories add new diphtheritic
exudations on the denuded surfaces to those already on
the mucous membranes. Emetics are of no use unless a
peculiar napping sound betrays the presence of half-de-
tached membrane in the air passage. In such a case
they are apt to save life. Massage of the larynx has
been recommended by Bela Weiss. I cannot say that
the few cases in which I advised the procedure were
successful ; it may be that the constant repetition of the
advice to use mercurial or other ointments over the larynx
is based on the observation of an occasional good effect
of the friction (" massage ") attending their employment.
Locally, lactic acid, in more or less saturated solution,
has been eulogized as a solvent of the membranes in the
larynx, when often applied either by brush or spray. Most
of the cases in which I have seen it used were not suc-
cessful; but an untoward result in these cases is, unfor-
tunately, not exceptional. I have seen, or believe I have
seen, papayotin dissolve membrane when applied in a mix-
ture of one part in two parts each of glycerin and water.
Particularly would that occur in pharyngeal diphtheria
slowly descending. Lime water is still used as a spray
and has its admirers. Lime slaked in a small room, or
under a tent, is decidedly more effective, for during that
process a large quantity of lime is carried up and inhaled;
at the same time the softening and solvent effect of the
steam is obtained, but the latter is not always so benefi-
189
JACOBI'S WORKS
cent as it appears;. In many the application externally
of cold water or ice-bags to the neck is vastly preferable.
But in most cases of anaemic and highly nervous children
the latter are not tolerated. Constant inhalations of tur-
pentine or carbolic acid from a kettle of boiling water
have impressed me as beneficial in a large number of cases.
Inhalations, in a small room or under a tent, of calomel,
which is sublimated in doses of gr. viij. or x. (0.5 gm.),
every hour or at longer intervals, are certainly effective.
The patient remains in bed as much as possible, and
may continue such expectorants as he perhaps took for
previous catarrhal symptoms; he may also take diaphoretics
and warm beverages ; an occasional opiate to excite dia-
phoresis and to procure some rest. The continued use of
chlorate of potassium, when the invasion of the larynx
is complete, is rather superfluous. Antipyretics are out of
the question unless there is a very high temperature de-
pending on a complication (general diphtheria, pulmonary
inflammations). Pilocarpine injures by debilitating the
patient; the cases which are really benefited by it are
exceedingly rare. Mercurials have resulted in more actual
recoveries than has any other internal treatment. The
cyanide and iodide have been recommended. For nearly
twenty years I have employed the bichloride in doses of
I mgm. (gr. %o) or more once every hour. The smallest
babies take one-fourth or one-third of a grain daily for
days in succession. Almost never will a stomatitis follow,
and no gastric or intestinal irritation, provided the di-
lution be in the proportion of at least 1 : 8000. An oc-
casional slight diarrhoea may require the addition of a
few drops of camphorated tincture of opium. I can
repeat a former statement, that never before the antitoxin
period (see below) have I seen cases of croup getting well
in such numbers, either without or with tracheotomy or
intubation, as when under mercurial treatment. I would
not be understood, however, to limit the use of mercury
to laryngeal diphtheria; it has equal effects in that of
the pharynx, and mostly in the streptococcic and in the
mixed forms of diphtheria. In connection with this state-
ment I wish to emphasize again the necessity of not relying
190
DIPHTHERIA: SYMPTOMS AND TREATMENT
on a single method of treatment in a disease so dangerous
and whimsical as diphtheria. The self-complacent nihilism
which relies exclusively on pathological research and
laboratory methods has more than once impeded the medi-
cal and social and humanitarian position of clinical medi-
cine. It is a pleasure, therefore, to quote an author who
has won laurels in bacteriology: " The giving internally
of the tincture of the chloride of iron or of the bichloride
of mercury in small frequent doses has considerable local
effect upon the mucous membranes of the throat and
pharynx" (W. H. Park).
When, in laryngeal diphtheria, internal treatment proves
unsuccessful, intubation or tracheotomy should be resorted
to. A small, frequent, and intermittent pulse, aphonia,
cyanosis, and marked retraction, with every inspiration, of
the supraclavicular fossae and the epigastrium, are most
urgent indications for the operative procedure. They
should not be allowed to last. I shall not here be tempted
to discuss the criminality of allowing a child to suffocate
without resorting to mechanical relief, or to compare the
two operations with each other. I can only say that for
years I have not seen a case in which intubation would
not take the place of tracheotomy, and have, therefore,
not performed the latter. Intubation takes the place of
tracheotomy in most cases; in none does it make it im-
possible when required in the opinion of the operator.
The latter operation may be preferred or become neces-
sary for the purpose of getting at the trachea and bronchi
for the mechanical removal of membrane and other local
treatment, rare though the cases be in which such pro-
cedures are attended with success. It is probable that the
many secondary tracheotomies which are still performed in
Europe when intubation is alleged to be insufficient will
not be considered requisite in the future. Nor is it prob-
able that Bokai's method of using intubation as an ad-
juvant to tracheotomy will be followed long even by that
distinguished clinician himself. Since 1891 his practice
has been first to perform intubation and then tracheotomy,
removing the tube just before he makes his incision into
the trachea.
191
DR. JACOBI'S WORKS
In the vast majority of cases of pseudomembranous
laryngitis the Klebs-Lceffler bacillus is found ; and all of
them are, therefore, fit subjects for the use of the diph-
theria antitoxin. Since its introduction both general and
local (laryngeal) diphtheria have been greatly benefited.
At its Washington meeting in May, 1897, the American
Pediatric Society received the " Report of its committee
on the collective investigation of the antitoxin treatment
of laryngeal diphtheria in private practice." Its salient
points are as follows: The number of cases reported dur-
ing the eleven months ending April 1st, 1897, was 1704
mortality, 21.12 per cent. The cases occurred in the
practice of 422 physicians in the United States and Can-
ada. Operations employed: Intubation in 637 cases, mor-
tality 26 per cent. ; tracheotomy in 20 cases, mortality 45
per cent. ; intubation and tracheotomy in 1 1 cases, mor-
tality 63.63 per cent. Number of States represented, 22,
besides the District of Columbia and Canada. Non-op-
erative cases, 1036, mortality 17-18 per cent.; operated
cases, 668, mortality 27-24 per cent.
Two facts may be recalled in connection with these
statements: First, that before the use of antitoxin 90
per cent, of cases of laryngeal diphtheria required opera-
tion; under the antitoxin, however. 39-21 per cent. Second,
that the percentage figures have been reversed: formerly
27 per cent, represented the recoveries ; now, under anti-
toxin, this figure represents the mortality. The committee
expects still better results when antitoxin will be admin-
istered earlier and in larger doses, and recommends that
all patients with laryngeal diphtheria, being two years or
over, should receive as follows: Two thousand units at
the earliest possible moment, two thousand units after
twelve or eighteen hours, unless there be an improvement,
and the same dose twenty-four hours after the second
dose, if there be still no improvement. Patients under two
years should receive one thousand or fifteen hundred units.
Dr. Dillon Brown's personal experience being unusually
large and carefully recorded. I add without comment the
following figures reported by him. He divided his intu-
bation cases into three clases: Previous to November,
192
DIPHTHERIA: SYMPTOMS AND TREATMENT
1890; from November, 1890, to September, 1894 (calo-
mel sublimation period); from September, 1894, to April
1st, 1897 (antitoxin period). Of 442 cases of intubation
without calomel sublimations and without antitoxin, 27-3 per
cent, recovered. Of 295 cases of intubation with calomel
sublimations, 41.6 per cent.; of 69 cases of intubation
with antitoxin, 67-8 per cent, recovered. Without subli-
mations, 10.1 per cent.; with sublimations, 13.2 per cent.:
with antitoxin, 23.3 per cent, recovered. During the first
year with antitoxin, there were recoveries after operation
in 38.4; during the second year in 62.9; during the third
in 94.7 per cent. The apparently bad results during the
first year were probably due to two causes: inferior an-
titoxic serums and insufficient doses.
Caille sums up his personal experience as follows:
" Tracheotomy and intubation cases, before antitoxin, 280
cases, 30 per cent, recovered; 17 intubation cases, with
antitoxin, 3 deaths. Over one-half of all laryngeal cases
treated with antitoxin recovered without operation. In
every case of acute progressive stenosis 1500 to 2000
units of diphtheria antitoxin should be administered at
once, and the dose may be repeated in twelve to twenty-
four hours, and so on until relief is manifest."
In Baginsky's hospital service there were 1258 cases
of diphtheria in the years 1890-94; 418 tracheotomies and
135 intubations were performed, with a total mortality in
these 533 operations of 62 per cent. In the 418 trache-
otomies the mortality was 64.4 per cent. ; among these
were 77 which were performed after intubation ; these 77
had a mortality of 69 per cent.; 58 intubations without
secondary tracheotomy had a mortality of 41.8 per cent.
This condition of things changed with the inauguration of
antitoxin treatment. No case of laryngeal stenosis de-
veloped in those in whom the remedy was injected before
the larynx became affected. Thus it was that in 525 cases
there were but 53 tracheotomies and 54 intubations, the
former with 34 deaths, the latter with 2. It became neces-
sary to perform tracheotomy after a previous intubation
in 12 cases, of which 9 ended in death. The speedier
disintegration of the membranes and the almost general
193
DR. JACOBI'S WORKS
discontinuance of their growth after the injection of an-
titoxin are the reasons why Baginsky has since preferred
intubation to tracheotomy.
At that early time in which his results were published,
Heubner performed 33 operations in 181 cases viz.. 23
tracheotomies with 52 per cent., 10 intubations with 80
per cent, recoveries a remarkable improvement over the
figures of the ante-antitoxin period.
At the International Congress of Moscow Monti made
the statement that in his service cases of laryngeal stenosis
were apt to get well under the sole influence of antitoxin,
that an operation was resorted to only when that treat-
ment proved unsuccessful (after some days), and even
then was likely to be successful. Without antitoxin, in
former times, his intubations would yield a mortality of
from 25 to 40 per cent., now while antitoxin was employed,
12 per cent. Only in the "mixed" infections the mor-
tality rose to 33 per cent.
It is useless to quote any more experiences in regard
to the efficacy of antitoxin in diphtheritic stenosis of the
larynx. In many cases it renders operations unnecessary;
in those operated upon the prognosis is improved. Still
many die; of those following "mixed" infections many
die. If there be those who shoulder the responsibility of
relying on a sole remedy, which frequently heals and
frequently fails, to the exclusion of every other helpful
medication or contrivance, they are as short-sighted as
those who still refuse altogether to acknowledge the great
efficacy of antitoxin in diphtheria. The fanaticism of
the one should not be permitted to justify that of the
other. The satisfaction at having a powerful remedy like
antitoxin should not engender the nihilism which begins
after the subcutaneous injection of serum. This cannot
be said too often, particularly in reference to " mixed "
infections. It is only the bacillus part of the malady which
can be counteracted by antitoxin. The mixed infections at
least, with their virulence and danger, should not be left
to die without medication beyond injection and " expect-
ant " neglect.
Heart failure is usually developed gradually. It is
194
DIPHTHERIA: SYMPTOMS AND TREATMENT
foreshadowed by an increasing frequency and weakness of
both heart beats and pulse, by an occasional intermission,
by unequal frequency of the beats in a given period (say
of ten seconds), or by the equalization of the interval be-
tween systole and diastole, and diastole and systole. This
latter condition, which is normal in the embryo and foatus,
is always an ominous symptom; so is the too close proximity
of the second sound (so as to become almost inaudible)
to the first.
Heart failure is due. besides the influences common to
every disease and every fever, to tissue changes in the
myocardium, in its nerves, in the endocardium, and to the
gradual formation of blood clots. These changes may be
due to the malnutrition of the tissues resulting from
every septic condition of the blood, or to specific altera-
tions due to the diphtheritic process. Failure may come
on after having given warning, or it may be on us without
any. Thus every case of diphtheria ought to make us
anxious and afraid. Indeed, there is no safety and no
positively favorable prognosis until the patient is quite
recovered, and even advanced beyond the period in which
paralysis may develop.
Whatever enfeebles must be avoided ; absolute rest must
be enjoined. The patients must be in bed, without ex-
citement of any kind; they must take their medicines
which ought to be as palatable as possible and their
liquid food, and evacuate their bowels in a recumbent or
semirecumbent position; crying and worrying must be pre-
vented; the room must be kept airy and rather dark, so
as to encourage sleep if the patients be restless; and rest-
less they are, unless they be under the influence of sepsis,
and thereby subject to fatal drowsiness and sopor. In no
disease, except perhaps in pneumonia, have I seen more
fatal results from exertion on the part of the sick, or from
anything more fatiguing than a sudden change of posture.
Unless absolute rest be enforced, neither physicians nor
nurses have done their duty. The latter must avoid all
the dangers attending the administration of medicines, in-
jections, sprays, and washes. Preparations for the same
must be made out of sight, every application should be
195
DR. JACOBI'S WORKS
made quickly and gently. On no account must a patient
be taken out of bed for any of these purposes. I know
of children dying between the knees of nurses who called
themselves trained and had a diploma.
The use of pharmaceutical preparations, such as digitalis,
strophanthus, sparteine, caffeine., besides camphor, alcohol,
and musk, should not be postponed until feebleness and
collapse have set in. These are at least possible, even
probable, and it is certain that a cardiac stimulant will do
no harm. It is advisable to use it at an early date, par-
ticularly in those cases in which perhaps antipyrin or
antifebrin (the indications for which are certainly rare,
as excessive temperatures are very exceptional) is given.
Besides, it is not enough that the patients should merely
escape death; they ought to get up, cito, tuto, et jucunde,
with little loss and speedy recuperation ; a few grains of
digitalis or their equivalent preferably a good fluid ex-
tract may or should be given, in a pleasant and digestible
form, daily. When a speedy effect is required, one or two
doses of two to four minims each are not too large, and
must be followed up by smaller ones. When it is justly
feared lest the effect of digitalis be too slow, I give, with
or without it, strophanthus. in doses of from one to six
drops of the tincture, or sulphate of sparteine. Of the
latter an infant a year old should take gr. %o or 4 (6-15
mgm.) four times a day as a matter of precaution, and
every hour or two hours in an emergency.
Of the same importance are alcoholic stimulants. The
advice to wait for positive symptoms of heart failure and
collapse before employing the life-saving apparatus is
bad. There are cases which will get well without treat-
ment, but we do not know beforehand which they will
be. No alleged mild case is safe until recovery has taken
place. When heart failure has once set in and it fre-
quently occurs in apparently mild cases our efforts are
too often in vain. Thus alcoholic stimulants ought to be
given early and often, and in large quantities, thoroughly
diluted. There is no such thing as danger from them
or intoxication in septic diseases 100 c.c. (3 iii.) daily
may suffice, but I have often seen 300 c.c. (3 ix.) or more
196
DIPHTHERIA: SYMPTOMS AND TREATMENT
daily of brandy or whiskey save children who had been
doing badly witli 100 c.c. (3 iii.).
Caffeine, or, in its stead, coffee, is an excellent cardiac
tonic, except in those cases in which the brain is suffering
from active congestion. For subcutaneous injections the
salicylate (or benzoate) of caffeine and sodium, which
readily dissolves in two parts of water, is invaluable for
emergencies, in occasional doses of from gr. i-v. (6 to 30
cgm.) in from m ij.-x. of water. From gr. v.-xx (0.3-1.25)
of camphor may be given daily, as camphor water, or in
a mucilaginous emulsion, which is easily taken. It does not
so disturb the stomach as carbonate of ammonium is apt
to do. For rapid effect it may be administered hypoder-
mically, in four to five parts of sweet almond oil, which
is milder and more convenient than ether. Strychnine
may be added regularly from the beginning of danger,
and mainly in cases with little increase of temperature.
Its effect is more than momentarily stimulating. A child
of three years will take gr. %20 (0-5 mgm.) three times
a day, and much more in an urgent case, and then subcu-
taneously. But the very best internal stimulant in urgent
cases is Siberian musk. I prefer to give it from a bottle,
in which it is simply shaken up with a thin mucilage.
In urgent cases it ought to be administered in sufficient
doses and at short intervals. When ten or fifteen grains
given to a child one or two years old within three or
four hours will not restore the heart's action to a more
satisfactory standard, the prognosis is very bad.
Nephritis, parenchymatous, interstitial, and glomerular,
and the varieties of pneumonia are frequent complications
or consequences of diphtheria. The treatment of either
of them requires no particular discussion in this place.
Nor does oedema of the glottis yield indications differing
from those of the same affection occurring from other
causes.
Diphtheria of the skin and of the sexual organs requires
disinfectant ointments. I have mostly relied on iodoform
one part, in from eight to twelve parts of fat.
Diphtheritic paralysis, though of manifold anatomical
and histological origin, yields in all cases a certain num-
197
DR. JACOBI'S WORKS
ber of identical therapeutical indications. These are the
sustaining of the strength of the heart by digitalis and
other cardiac tonics. This is an indication on which I
cannot dwell too much. Many of the acute, and most of
the chronic, diseases of all ages do very much better by
adding to other medication a regular dose of a cardiac
tonic. While it is a good practice to follow the golden
rule to prescribe simply, and if possible a single remedy
only, it is a better one to prescribe efficiently.
Besides, there are some more indications: mild prepara-
tions of iron, provided the digestive organs are not inter-
fered with; strychnine, or other preparations of nux
vomica, at all events ; in ordinary cases a child of three
years will take gr. % three or four times a day ("to-
gether 0.002 gm.). Local friction, massage of the throat,
of the extremities, and trunk, dry or with hot water, or
oil, or water and alcohol; and the use of both the inter-
rupted and continuous currents, according to the known
rules and the locality of the suffering parts, find their
ready indications. The paralysis of the respiratory mus-
cles is quite dangerous ; the apnoaa resulting from it may
prove fatal in a short time. In such cases the electric
current used for short periods, but very frequently, and
hypodermic injections of sulphate of strychnine in more
than text-book doses, and frequently repeated, will render
good service. I remember a case in which these, with the
occasional use of an interrupted current, and occasional
artificial respiration by Sylvester's method, persevered in
for the better part of three days, proved effective. In a
few cases of diphtheritic paralysis the use of antitoxin
appeared to score a success. Other forms of paralysis
(hemiplegia, ataxia) demand a treatment like the above,
modified by their peculiar circumstances or symptoms.
Orrhotherapy. The use of diphtheria antitoxin has
been discussed several times on previous pages, mainly as
regards its effect as an immunizing agent and its action
in laryngeal diphtheria. It has passed its experimental
stage as safely as if it had been employed these fifty years,
and has created a literature of its own on which bacteriolo-
gists, chemists, medical and surgical clinicians, practical
198
DIPHTHERIA: SYMPTOMS AND TREATMENT
men and theorists, friends and enemies have been at work.
No matter what the nature of its action may be, whether
when injected under the skin of a diphtheria patient it
supplements the antidote created by the toxin of diph-
theria in the blood or the cells of the patient, or whether
it aids the antitoxin into which the toxin is believed by
some to be changed (Buchner, Smirnow, Metchnikoff) or
which is the product of reaction (Behring, Ehrlich ),
this action can no longer be doubted. Discussions on that
point are fruitless. When the injection is to be made, the
syringe should be sterilized each time, for no poison is en-
tirely safe. A carbolic-acid solution of five per cent., and
absolute alcohol will suffice for that purpose. The injection
should be made into a loose and copious subcutaneous tis-
sue, not into the skin, and not into muscles. The abdomen
is more sensitive than the lumbar region and the thigh,
and the subscapular or intrascapular region. The latter
should not be selected unless the subcutaneous tissue is
quite abundant. According to the severity of the case six
hundred, one thousand, fifteen hundred or two thousand
" units " should be injected. The dose should be repeated
unless the symptoms both constitutional and local be
improved within twelve or twenty-four hours. Sixty-five
hundred units were successfully used in a bad case of noma
of the vulva, in which diphtheria and putrefactive bacteria
were found by Petrushky (Deutsche medicinische Wochen-
schrift, 1898). The puncture should be covered with an
antiseptic gauze, or with iodoform collodion.
A " unit " is equivalent to 1 c.c. of what is called " nor-
mal serum." Normal serum is the blood serum of an
immunized animal which was made so efficacious that 0.1
c.c. antagonizes ten times the minimum of diphtheria poison
fatal to a guinea-pig weighing 300 gm. (about 10 ounces).
The universal demand is for early injection. There is
unanimity in the experience that the prognosis is impaired
by procrastination. The latest report from Vienna is only
6 Ehrlich thinks the antitoxin is the result of functional over-
exertion of the cell protoplasm which has been irritated by the
circulating toxin, and compares this process with the hypertrophy
of overexerted organs.
199
DR. JACOBI'S WORKS
a repetition of what has been known these four years.
When antitoxin was injected on the first and second day,
only 6.7 per cent, of all the cases died, on the third 19,
on the fourth 23, on the fifth 31, on the sixth 33.3 per
cent.
This fact has become so fixed in the minds of many
practitioners who believe themselves responsible for the
welfare of their patients, that in doubtful cases in which
the diagnosis of " diphtheria " or " pseudodiphtheria "
has not been made on account of time, and in view of the
innocuousness of antitoxin when injected unnecessarily,
and believing that whatever discomforts there may arise
after the injection do not compare with the danger of the
disease when not combated in time, they " inject the an-
.titoxin and settle the question of diagnosis afterwards "
(Charles G. Jennings in Medical Age, February 25th,
1898). In general that practice is to be recommended in
bad cases and bad seasons, for the bacteriological diag-
nosis can be completed before another injection is required,
if at all.
All forms of diphtheria are liable to be benefited by
antitoxin, from the simplest to the septic, from the un-
complicated to the mixed, the latter less than the former.
It is this mixed form in which I look upon the neglect
of other treatment, both local and general, as simply
criminal. The statistics both of hospitals and of private
practice have grown immensely, and are daily growing;
they are the staple article of our journal literature. I
would therefore refer the reader to what I quoted in
my " Therapeutics of Infancy and Childhood," and will
conclude with a few of those data which are quite
recent.
Of the report of the diphtheria committee of the Clini-
cal Society of London The Lancet (June 4th, 1898) pub-
lishes what follows:
" For the purpose of the inquiry 832 reports of cases
were collected, but upon examination 199 of them had to
be rejected, either because the committee were not satisfied
as to the evidence of diphtheria or because the amount of
antitoxin administered was not stated in normal units,
200
DIPHTHERIA: SYMPTOMS AND TREATMENT
leaving 633 available for further analysis. Of the cases
which presented symptoms more or less severe of laryngeal
affection nearly one-half escaped the operation of tracheot-
omy, a very much larger proportion than is usually the
case in laryngeal diphtheria treated in other ways. The
tracheotomies performed may be divided into two groups :
(a) Tracheotomy within twenty-four hours of the first
injection, and (6) tracheotomy at a later period. Only
2 out of the 75 belong to group (6). The committee
drew especial attention to these facts, and also to the re-
sults of the operation of tracheotomy, in which the mor-
tality amounted to 36 per cent., as opposed to 71.6 per
cent, in the control series compiled from the records of the
general hospitals before the introduction of antitoxin. The
mortality fell as age increased, but it was in the first five
years of life that the lessened mortality in the antitoxin
series was most marked. It was to the lesser frequency
with which membrane extended to the larynx and trachea
in cases treated by antitoxin and to the effect of the anti-
toxin on them when membrane was present that the less-
ened mortality in the antitoxin series was mainly due.
The total mortality in the 633 cases amounted to 124, or
19-5 per cent., as opposed to 29-6 per cent, in the non-
antitoxin control series. Not only was the mortality in the
antitoxin series much less than in the other, but the dura-
tion of life in the fatal cases was longer, a fact which
has considerable bearing on the frequency with which
paralytic symptoms occurred. The closest investigation
failed to discover any connection between the occurrence
of paralysis and the amount of antitoxin injected, nor
did the period of the disease at which it was first used
appear to exert any influence on the occurrence of paralytic
symptoms. Some form or other of rash followed the in-
jection of antitoxin serum in very nearly a third of the
cases. The rashes could be divided into two main types:
those which were of an erythematous and those of an
urticarial character; the former largely predominated. In
no instance did the presence of a rash appear to have any
bearing on the ultimate result of the case. Joint pains
which were not met with in the non-antitoxin series and
201
DR. JACOBI'S WORKS
were apparently due to the antitoxic serum were observed
in a small number of cases. The percentage of deaths
with suppression of urine was found to be practically
the same in the antitoxin and the non-antitoxin series.
The general result of the inquiry showed that in the cases
treated with antitoxin not only was the mortality notably
lessened, but the duration of life in fatal cases was also
prolonged. The injection of antitoxin may produce rashes,
joint pains, and fever; with these exceptions no prejudicial
action has been observed in the series of cases investigated
to follow even in cases in which a very large amount
of antitoxin serum has been used."
According to Buchwald (Miinchner medicinische Wochen-
schrift, 1898, No. 14) of 563 patients treated without
antitoxin, 57.72 per cent, died; of 311 treated with it,
28.93 per cent. died. Tracheotomies were required in 57
per cent, in the ante-serum period, in 30.86 per cent, dur-
ing the serum time. Albuminuria was observed in 36.65
per cent, of all the injected cases, paralysis in 93 cases,
exanthems in 74, pain in joints, without swelling, however,
in 2, otorrhoea in 10, bronchopneumonia in 36 cases. Most
of the latter were fatal. Besides antitoxin, good nutrition,
stimulants, and irrigation of the nose and mouth were em-
ployed.
Axel Johannessen communicated to the Moscow Con-
gress a report covering 1131 cases of diphtheria observed
during 1890 by 71 Norway physicians. Those cases were
treated with antitoxin; there were 73 deaths (6.5 per
cent.) ; this percentage is reducible to 5.3 per cent, by
deducting the cases that came under treatment while mori-
bund. From 1867 to 1893, before the antitoxin period,
the mortality was 23.5 per cent.
Escherich had in Prague a mortality of 9 per cent.,
compared with 36 per cent, of former times.
John E. Walsh (New York Medical Journal, June 18th,
1898) publishes the following figures. In 1895-96 there
were treated in the District of Columbia:
Cases with antitoxin, 174; died, 23=13.2 per cent.
Cases without antitoxin, 152; " 53=34.9 "
202
DIPHTHERIA: SYMPTOMS AND TREATMENT
In 1896-97 there were:
Cases with antitoxin, 285; died, 21=z 7.3 per cent.
Cases without antitoxin, 335; " 89=26.6 "
Of the 285 antitoxin cases there were 238 below twelve
years, with a mortality of 8.9 per cent.; of the 335 non-
antitoxin cases there were 256 below twelve years, with
a mortality of 33 per cent. Of 86 over twelve years
treated with antitoxin none died; of 113 of the same age
treated without antitoxin, 8 died. In the last seven months
preceding the publication 422 cases were treated: 211
with antitoxin and a mortality of 8, or 3.8 per cent. ;
190 without antitoxin and a mortality of 65, or 34.2 per
cent., as in the pre-antitoxin period. The treatment em-
ployed in 21 cases was unknown to the writer.
Among the very latest statistics are those of Kronlein
(Zurich), who reported to the Twenty-seventh Congress of
German Surgeons (April, 1898) on 1773 cases of diph-
theria observed in the clinical hospitals of the university
during the years 1881-97. A recapitulation of the results
is presented in the following table:
PRE-ANTITOXIN PERIOD
ANTITOXIN PERIOD
a
6 2
J^
00
5^2
New diphthe-
ria house
1889-1804
a *
22
H oo
00
i <
||t
a
3*4
* -g 2
u ~
z
Total
485
230
47. 4#
354
211
59.6$
131
19
14.5#
851
304
35.7$
308
227
73.7$
543
77
14.15?
1,336
534
39.9
662
438
66.1$
674
96
14.2*
437
55
19.5*
17
36
35. 6#
336
19
5.6#
Deaths
Mortality
Operations
Deaths
Mortality
Cases not operated
Deaths
Mortality
In all the 437 cases in the antitoxin period the Klebs-
Loeffler bacillus was demonstrated. Kronlein's statistics
203
DR. JACOBI'S WORKS
prove the following facts: While the morbidity of the
whole district (city and country) remained unaltered in
the antitoxin period, the mortality decreased considerably
mainly in the surgical clinic, in operated (tracheotomy
or intubation) or non-operated cases, and principally in
the first years of life. While previous to the institution
of antitoxin treatment one-half of all the cases had to
be operated upon, this percentage has fallen to 23.1 per
cent, since that time.
After the injection of antitoxin improvement set in
speedily; the temperature diminished; the deposits on, and
the membranes in, the throat and air passages soon
loosened, and the diphtheritic secretion of the nose be-
came speedily less ; the lymphadenitis of the neck dimin-
ished; the diphtheria process did not descend into the air
passages; mild laryngostenosis did not increase; there was
no diphtheric infection of the tracheotomy wound, which
was observed in one-third of all the cases of former times;
and the tube could be removed as early as the third,
fourth, or fifth day after tracheotomy.
During the same period albuminuria was observed in
36.6 per cent, of all cases of diphtheria, pronounced ne-
phritis in 4.6 per cent., and postdiphtheritic paralysis in
12.5 per cent. Exanthems of the most various forms,
with mild general symptoms only, were met with in 8
per cent. ; they were attributed to the serum. None was
found after small injections made for the purpose of im-
munizing healthy persons.
To gainsay, with such statistics at hand, the superiority
of antitoxin to any other single remedy known to us for
diphtheria is a foolhardy undertaking. But there are some
drawbacks met in its employment which are acknowledged
by all, and exaggerated by some. I refer to disagreeable
symptoms with which the administration of antitoxin is
charged, and which are said to take place in the blood,
on the skin, in the joints, in the respiratory, circulatory,
urinary, digestive, and nervous systems. Even sudden
death has been claimed as one of the results of antitoxin
injections.
Dr. James Ewing studied the effects of antitoxin on the
204
DIPHTHERIA: SYMPTOMS AND TREATMENT
number and nature of leucocytes (New York Medical Jour-
nal, August l?th, 1895). While leucocytosis begins a few
hours after the invasion of diphtheria, and increases mainly
as regards myelocytes (uninuclear and neutrophilic gran-
ules which are never found in the lymph nodes) up to the
climax of the disease, and steadily declines during con-
valescence remaining high only in most of the bad and
fatal cases antitoxin causes, according to Ewing, a re-
duction of the number of leucocytes within thirty minutes
after the injection. This reduction affects mainly the
uninuclear leucocytes, while the proportion of well-stained
multinuclear cells is increased. In favorable cases tht
leucocytosis never again reaches its original height
after the injection; in severe and very bad cases it is
followed in a few hours by more leucocytosis and fever.
In very bad cases the immediate result may be either
rapid increase or decrease of leucocytes, and death. The
multinuclear leucocytes found in the blood in favorable
cases after treatment with antitoxin show an increased af-
finity for gentian violet. This change may be observed
within twelve hours after the injection, and its non-oc-
currence is a very unfavorable prognostic sign.
John S. Billings, Jr., found after the employment of
antitoxin some little diminution in the number of blood
cells. In six cases so treated he met with a steady rise,
and the decrease of haemoglobin was less marked than in
cases of uninfluenced diphtheria.
Urticaria, 'sometimes with increased temperature, simple
or complicated with erythema (simple, or multiform, or
exudative with or without extravasation) is observed at
different times, very soon or a few days after the injection
round the puncture, or after one or more weeks in different
parts of the body. Now and then the efflorescence requires
some predisposition, for it has been noticed in one child
of a family while the rest remained free. Horse serum
containing no antitoxin is known to have caused the same
eruption ; this effect appears to be more marked in the
serum of one horse than in that of another. It is similar
to what hag been observed after transfusion of the blood
of heterogenoug animals. The small amount of carbolic
205
DR. JACOBI'S WORKS
acid contained in the antitoxin should not be held re-
sponsible for the eruption; nor can the local irritation be
charged with causing eruptions which take a week or weeks
to develop. Altogether this urticaria behaves like the
vasomotor or neuropathic cutaneous irritations observed in
predisposed persons after the use of oysters, crabs, or
strawberries.
Herpes (nasal, labial, aural) has been noticed in a few
instances, notably by Baginsky, and by Mya, who observed
at the same time a " critical " fall of the temperature of
the body.
Other forms of eruptions, macular, papular, and erythe-
matous, also petechiae with or without larger extravasations,
have been recorded. Desquamation is observed in pro-
portion to the degree of dermatitis. Some observers speak
of many cases, others of few, others (Rumpf) never saw
any eruption.
W. T. Coues reports fifty cases of antitoxin injections
for the purpose of immunization. A child of five years
received five hundred units, a baby of one day fifty, those
under six months three hundred, under a year four hun-
dred. The older children were not affected in the least;
the infants were restless and cried long after the injec-
tion. The' temperature of three infants reached 101
F. five hours after the injection; the next morning it was
normal. On the morning following the injections the
younger children had slight coughs, which passed away in
two or three days. Urticaria occurred in 14 cases out of
the 50 injected; a punctated erythema in 2 ; in 1 there
were soreness and pain in the right knee-joint, which
passed off in two days (Boston Medical and Surgical
Journal, July 14th, 18Q8).
Abscesses, occasionally with lymphangitis, have been ob-
served by Monti, Variot, and others. When they occurred,
fault was found with the serum which was not considered
germ-free, or with the skin which was charged with not
having been aseptic, or with the undue thickness of the
needle and subsequent infection of the wound, or with
the perforation of too many layers of tissue down into the
muscles, or with the condition of the syringe, which it is
206
DIPHTHERIA: SYMPTOMS AND TREATMENT
difficult, no matter whether the piston is leather or asbestos,
to render absolutely safe. In a few instances symptoms
were observed which were attributed to the entrance of
air into a small vein.
Arthropaihies were noticed with or without exanthems.
Swelling and pain of a knee or an ankle-joint were noticed
a few times, together with urticaria in the second week
after an injection. These lasted a day or a week or
more. They are not frequent, for there are observers who
have never seen them in any of a large number of cases.
It should not be forgotten that they are symptoms which
occasionally occur in diphtheria not treated with anti-
toxin.
Lymph bodies now and then swell after an antitoxin in-
jection, but only in connection with an eruption or an
arthropathy.
Antitoxin has been charged with causing pneumonia.
The latter is so frequent a complication of diphtheria in
all its stages that the attempt to substantiate the charge
seems hazardous. If antitoxin affects the mucous mem-
branes favorably it is not likely to produce bronchitis or
pneumonia. Possibly Lennox Browne feared this alleged
effect when he considered the use of antitoxin contra-
indicated during the existence of a bronchopneumonia.
It has also been accused of developing a latent tuber-
culosis into one of more rapid progress. That is barely
possible, inasmuch as every fever, for instance after vac-
cination, is held to have a similar effect. But it is very
much more probable that the invasion of the Klebs-Loeffler
bacilli and of the streptococci of the diphtheritic attack,
according to previous statements referring to their com-
plications with tubercle bacilli, leads to the outbreak.
A secondary fever, lasting a day or longer, has been
observed after ten or fourteen days; it often coincides
with an eruption of urticaria, and seems to be a legiti-
mate symptom of the latter. In most cases, however, an-
other etiology is more probable. It is more often con-
nected with the diphtheria than with the antitoxin treat-
ment. In many cases there may be a new invasion, mostly
cocci; there may be an abscess, a rhinitis, a tuberculosis.
207
DR. JACOBI'S WORKS
With an abscess, or still more commonly with rhinitis,
lymph bodies will swell and the temperature will rise.
After an injection of antitoxin vomiting and diarrhoea
have been noticed and have been explained as the result
of intoxication with a fibrin ferment. On the other hand,
Baginsky is positive that he has geen those symptoms less
often after antitoxin than in cases of diphtheria not so
treated. It appears not improbable that the blind confi-
dence in antitoxin has something to do with an occasional
case of gastrointestinal irritation. For with some every
other treatment is neglected, while antitoxin is being ad-
ministered, and it is quite possible that abundant mem-
branes not removed by irrigation, while being rapidly
loosened and thrown off, are swallowed.
Albuminuria and nephritis are not at all met with after
the injection of antitoxin by some observers (Riether in
none of 1450 cases) ; frequently by others (Soltmann in
72 per cent.). They occur within a week. Sorensen re-
ports no albuminuria when he operated with Danish serum,
but many cases after the use of French serum. That ex-
perience would go to show that either the normal horse
serums were different, or that the preparation of the an-
titoxin was not identical. The small amount of phenol
contained in it should not be accused, for it is too minute
even to be discovered in the urine. What should not be
overlooked is the fact that both albuminuria and nephritis
are common occurrences, beginning in the very first week
of a diphtheria, sometimes within a few days, before an-
titoxin is administered or has had time to take effect.
Among 181 cases of Heubner's of those injected on the
first day of the disease five-sixths remained free; on the
second, two-thirds; on the third, one-half; on the fourth,
one-third. In 525 cases of Baginsky's treated with anti-
toxin there was albuminuria in 40.95 per cent., clinical
nephritis in 12.57 per cent., and post-mortem nephritis in
15.80 per cent. However, among Q33 treated without an-
titoxin there was albuminuria in 42 per cent., clinical
nephritis in 25.78 per cent., and post-mortem nephritis in
16.31 per cent. rather a favorable showing for antitoxin.
In Strassburg (Sieger, in Virchow's Archiv, 1897) renal
208
DIPHTHERIA: SYMPTOMS AND TREATMENT
affections were frequent after the injection of antitoxin;
but though some of them lasted weeks or months, they
were benign and without morphological elements in the
urine.
In some cases albuminuria will change, either totally
or partially, into albumosuria, under what appears to be
bacterial or antitoxin influence.
The existence of the after-effects is not denied by any
of the most enthusiastic admirers of antitoxin, but it is
claimed by all that no serious or lasting bad results fol-
low, and that if every life threatened by diphtheria were
known to be protected by the alleged untoward or uncom-
fortable effects of the remedy, we should willingly submit
to them in every case. The balance of what we know of
antitoxin is thus far favorable, and this addition to our
therapeutical powers will forever be remembered as cred-
itable to Emil Behring. The lack of recognition which
was some time ago withheld from him by many was, most
unfortunately, his own fault. The morbid vanity and some
personal motives displayed in almost every one of his
writings tallied so badly with the tendencies and the spirit
of a scientific benefactor as to render suspicious both his
veracity and his motives. 7 Still, the grateful medical pro-
fession and the public will not forget his work. That his
preoccupation and his limited horizon should dwarf his
judgment is a matter of regret. It is a pity he is not a
clinician, but only a scientific famulus. If he were a
clinician he would not have been tempted into asserting
that organotherapy has accomplished nothing, that cellular
pathology has proved sterile, that remedies combat main
symptoms only, that medicine has had hitherto therapeuti-
cal principles only but no therapeutical experimentation,
7 This was written in the first edition of my " Therapeutics of
Infancy and Childhood " some years ago. Those who thought I
was too severe in criticising the motives of the man have since
learned that he has obtained in this country, where no physician
deigns or would dare to descend into the arena of bargaining and
shop-keeping, a patent right on his wares, which I am credibly
informed secured him more than a million marks in a single vear
in his countrv-
209
DR. JACOBI'S WORKS
and that his experimental therapeutics is in conscious op-
position to medication (German Congress for Internal
Medicine, June, 1897).
Behring himself explains the occurrence of undesirable
effects of his serum only by the accidental and indifferent
albuminoids and salts contained in the serum. They are
according to him greatly reduced by increasing concentra-
tion, even to the dry state which he succeeded in obtain-
ing. In the concentration the antitoxin is " absolutely
uninjurious, without poisonous effects in man or animal,
healthy or sick." According to H. C. Ernst, J. N.
Cooledge, and H. A. Cooke (Journal of the Boston Society
of Medical Science, May, 1898), the antitoxic property
of antidiphtheritic serum can be removed from one part
of the serum and added to another by a method of frac-
tional freezing, the bottom layers showing greater strength.
By this method serum of high potency, more or less per-
manent, can be obtained.
Like Behring, Henry W. Berg (Medical Record, June
18th, 1898) attributes undesirable effects, eruptions follow-
ing the administration of antitoxin, to some original
impurity. " It is probable, almost certain, that many
of the eruptions are due to a toxalbumin contained in the
serum of the horse which should be strained through a
fine Chamberland filter. Neither the pure serum of
the horse nor the diphtheria antitoxin loses any of its power
by filtration."
The adversaries of antitoxin have tried to make it re-
sponsible for diphtheritic paralysis, without any reason.
It is true that there are many cases of paralysis occurring
in children previously treated with antitoxin, but it has
always appeared to me that the number was swelled by
some of those who would have succumbed without anti-
toxin long before the period of paralysis was due. Ap-
parently mild cases of diphtheria are followed by paraly-
sis ; it is certainly true that many a case is changed into
a mild one by antitoxin. . It is after all better to have
a paralytic child with the great probability of a final re-
covery than a corpse without even a chance of paralysis.
Moreover, I cannot imagine a more difficult task than to
210
DIPHTHERIA: SYMPTOMS AND TREATMENT
calculate statistics on totally absent bases. The average
number of paralyses varies according to the cases, the se-
verity of the epidemics, and probably to the treatment
also. And finally, large numbers of cases, like those of
Baginsky, appear to prove the contrary of what has
been alleged. Among 993 patients before serum therapy
was introduced there were 68 cases of paralysis, or 6.8
per cent.; among 525 in the antitoxin period there were
27, or 5.14 per cent. Schmidt Rimpler feels certain that
his patients with accommodation paralysis recovered more
speedily under the use of antitoxin than without it.
Sudden deaths have occurred after the injection of anti-
toxin, the doses being in some instances quite small. The
case of the Langerhans child in Berlin, who died after
having received an injection of antitoxin, is not explained
in spite or because of loud vituperations and vilifications.
Most reporters of cases have been satisfied with the admit-
ting they know of no explanation. Belin publishes one
of the latest cases, and admits that death cannot positively
be attributed to the influence of the serum. Nifong (Med-
ical Review, May 7th, 1898) gave a boy of fifteen years,
of slight build and with feeble circulation, fifteen hundred
units. After ten minutes there were pallor, numbness of
the extremities, cyanosis, swelling of the face, and vom-
iting. Death occurred in thirty-five minutes. Two girls
received the same dose of the same serum obtained from
the city chemist of St. Louis without a bad result.
Rauschenbusch observed on his four-year-old daughter,
who had taken three times the dose while sick with diph-
theria two years previously, pruritus, urticaria, vomiting,
sopor, and heart failure after two hundred units injected
for the purpose of immunization. It does not appear that
a connection between heart failure and sudden death on
the one hand and antitoxin on the other has been estab-
lished in any case, and venturesome and generalizing
speculations are not able to shed light on obscure subjects.
At all events, a single finding, a suggestion, or a suspicion
of vomiting and aspiration of a solid body into the air
passages, or of the inpection of air into a vein, or excite-
ment and fright, or a lymphatic state, or a large thymus,
211
DR. JACOBI'S WORKS
if at all applicable to an individual case, does not permit
of a universal interpretation.
After all, we can well agree with the conclusions of
Dieudonne when he says that the treatment of diphtheria
with serum is an essential advance in therapeutics, that
its effect is more frequently favorable than that of former
methods, and that accessory consequences do not outweigh
the useful effects.
H. Biggs recapitulates many of his previous writings in
a paper read before the Society of the Alumni of Belle-
vue Hospital, as follows: " Since the introduction of an-
titoxin treatment the mortality of diphtheria is reduced
to one-half, its course is shorter and milder; an injection
made within the first two days reduces the mortality to
five per cent. ; the earlier it is made the better the result.
Small quantities of concentrated serum are tolerated by the
very youngest babies. If antitoxin is not a specific it is
certainly the best remedy in our possession against diph-
theria. The genuine (that is, uncomplicated bacillary)
cases are more amenable to its favorable influence than
mixed infections. It has no secondary effects on heart,
kidneys, or nerves. Heart failure and paralysis whenever
observed are caused by diphtheria, not by antitoxin."
THE PATHOLOGY AND TREATMENT OF THE
DIFFERENT FORMS OF CROUP
THE term of " Croup " has been applied to many widely
different conditions. All of these conditions, however,
have one symptom in common, viz., dyspnoaa, or attacks
of dyspnoea, bordering on suffocation, and depending on
local obstruction of the, or in the, larynx. As I do not
pretend to give an essay on croup complete in all its bear-
ings, I simply refer to the immense number of text-books,
articles, essays, and monographs written on the subject.
The subject of this paper is wholly practical, mostly clin-
ical. It is based almost exclusively on my own observa-
tions, examinations, and experience. Thus, if I have to
spend some time in speaking of things known to all, I
beg your pardon and indulgence ; and for what I have to
state that is unexpected or uncalled for, your approbation
or refutation.
The mildest form of what is frequently called croup,
and in severe cases may actually prove deserving of the
name, is acute catarrh of the larynx. Its causes are very
numerous. Inhalation of cold air, of dust, or other irri-
tants ; contact of a hot liquid with the lining membrane of
the larynx; over-exertion of the voice; the influence of
cold temperature diminishing that of the body, particu-
larly neck, throat, and feet, and mostly in individuals with
thin epidermis and a great tendency to copious perspira-
tion; spreading of the catarrhal process from the nose or
bronchi, or the pharynx, for instance after the inordinate
use of snuff or alcohol, to the larynx, in the contiguity of
the tissue. Besides, there are a number of general diseases,
which are complicated with, or exhibit amongst their symp-
toms, a catarrh of the larynx; thus measles, scarlatina,
213
DR. JACOBI'S WORKS
variola, erysipelas, typhus and typhoid fever, and influ-
enza.
The anatomical lesions found in persons who have died
while affected with catarrh of the larynx do not always
correspond with the symptoms encountered during life.
The mucous membrane of the larynx is so replete with
elastic fibres that after death even, the blood is squeezed
out of the dilated capillaries. In very severe forms of
catarrh, small apoplexies, ecchymoses occur now and then,
and will be found after death, occasionally. The mucous
membrane is denuded of the normal vibratile cylindrical epi-
thelium which forms the uppermost epithelial layer of the
larynx. The mucous membrane is reddened, moist, succu-
lent, loose in its tissue; the sub-mucous tissue is now and
then oedematous, and sometimes, even in an acute catarrh of
quite a recent date, small superficial ulcerations have been
found. Thus the anatomical changes left in the mucous
membrane of the larynx, after death, fully correspond
with those found in the mucous membranes of other organs.
Sometimes the traces of catarrh are clear and distinct,
sometimes nothing is found in post-mortem examinations.
An example of this fact is the occasional absence of all
and any post-mortem results in children who have died
in a severe attack of gastro-intestinal catarrh, so-called
cholera infantum. While in some there are all the traces
of catarrh, and its sequelae, from simple hyperaemia to
follicular ulceration, there is no alteration in others.
The acute catarrh of the larynx, as mentioned, with its
capillary injection, its throwing off and rapid disintegra-
tion of the epithelium, and its oedematous infiltration, is
by no means universal in all cases. In some, the epiglottis,
or the mucous membrane of the inferior vocal cords, or
the Wrisbergian, Santorinian, and arytenoid cartilages ;
the aryepiglottic folds, the true vocal cords, or the in-
ferior part of the larynx, may be affected either separately
or contemporaneously, with or without a similar affection
of the contiguous regions between nose, pharynx, and
lungs. The symptoms of the affection will frequently vary
in correspondence with these anatomical differences.
The acute catarrh of the larynx is seldom, from the be-
214
TREATMENT OF CROUP
ginning, a feverish disease. The patients feel comfortable,
and the functions of the diseased organ alone are abnor-
mal. There is a certain degree of sensibility in the region
of the larynx, a burning or itching sensation. The voice
is altered, becoming indistinct and hoarse, in consequence
of the thickening of the margins of the vocal cords, which
the muscles are no longer able to force into as many vi-
brations as before. Besides the itching and burning sen-
sation, and hoarseness, there is another symptom present,
namely, severe cough, occurring in paroxysms, as if pro-
duced by some foreign body touching the mucous membrane
of the larynx. Expectoration is not copious; in the com-
mencement of the disease there is none, or it is clear and
serous, containing some few cylindrical epithelia, and a
few from the lower layers. In the other stages of the
disease, particularly in the course of recovery, the expec-
toration becomes more consistent, more purulent, and yel-
lowish. In a somewhat advanced age only will children
remove their expectoration voluntarily; they will swallow
whatever touches their fauces, and therefore it is very
difficult sometimes to obtain any information as to the
nature of the expectorated substances. Physical explora-
tion by means of the laryngoscope yields, at this age,
and with the uncontrollability of most children, but few
results.
The sub-mucous tissue is much swollen in some excep-
tional cases only, as far as adult persons are concerned.
For the glottis, and particularly its posterior third, forms
a pretty large opening in adults, and the entrance of air
into the respiratory organs is not prevented by the tume-
faction of the mucous membrane. Even children do not
suffer very often from constant dyspnoea, in consequence
of a simple laryngeal catarrh. Although in them the glot-
tis is short and narrow, the swollen chordae vocales, by
means of the constant and uninterrupted action of the pos-
terior crico-arytenoid muscles, are sufficiently distant from
each other not to prevent the entrance of air. But some-
times children, who have been coughing and hoarse during
the day, without feeling sick, will be observed to awake
suddenly in the night, with an attack of suffocation. In-
215
DR. JACOBI'S WORKS
spiration is extremely difficult and exhausting; in the ut-
most height of their anxiety and trouble, the children will
roll about, stretch their necks and grasp their throats ;
their cough is hoarse, rough, barking. These attacks have
been and are very often mistaken for croup, have been
and are described as pseudo-croup, false croup, and usually
disappear without leaving a trace, after a duration of one
or a few hours. These are the attacks which readily dis-
appear after the administration of hot milk, or hot sponges
over neck and throat, and by emetics, and which have won
for these remedies the reputation of being infallible in
croup, when given in time. You may be certain that all
the children who are reported to have suffered from croup
four, six, and twelve times, and have always been saved
were simply suffering from attacks similar to those of which
I have just been speaking. Perhaps the sudden attacks of
suffocation are produced by a momentary swelling of the
mucous membrane and narrowing of the glottis, which the
muscular action could not counteract, as sometimes a nos-
tril is thoroughly impermeable in consequence of a severe
cold. But it is better explained in the following manner:
The suffocative attacks almost always occur in the course
of the night; they diminish and disappear, after the child
has been awake for a time, with screaming, coughing, and
vomiting ; and will appear anew after the patient has
again fallen asleep. From this fact it is probable that
the cause of the sudden suffocative attacks is due to the
exsiccation of a collection of tough secretion in the larynx
and glottis. At all events, the quick operation of the above-
mentioned remedies is best explained in this manner. Thus
I always give the advice, during the first two nights of
an acute laryngeal catarrh, not to let the children sleep
beyond a certain time. Awake them from time to time
and let them drink. I prefer them to cough more fre-
quently and mildly to exposing them to violent spells of
both coughing and dyspnoea.
Some have attributed a large part of the symptoms to
spasm ; the affection has even been called spasmodic laryn-
gitis. Now, actually every cough, no matter of what sort,
is a convulsive action, but this is not the meaning of those
216
TREATMENT OF CROUP
who emphasize the spasmodic element in this affection.
They lay stress on the presence of a constant spasmodic
condition of the glottis. But the intermission of the
symptoms refutes that assumption, and the only real af-
fection of the glottis in this disease, namely, thickening
of the vocal cords, resulting in obstruction, excludes in-
termission in toto. Moreover, the sound of the cough is
hoarse, or barking. Those, however, who are acquainted
with the inspiratory spasm of the glottis, or the inspiratory
muscles, that is, diaphragm, intercostales, scaleni, serrati,
as in whooping cough and in laryngismus stridulus, or
so-called crowing inspiration of children, know that the
convulsive sound is sibilant, higher in the scale, in conse-
quence of the narrowing of the glottis. The same sound
is produced even in expiratory spasm, which, however, is
very rare. It is known that, under common circumstances,
expiration is simply the passive result of the elasticity
of the lung tissue. Thus expiration is always incomplete,
part of the gas remaining in the lungs. It may become
more complete by the aid of the abdominal muscles, espe-
cially the transversus abdominis. Thus we can speak of
expiratory spasm or paralysis in some, though rare, cases,
but even in these the sound of the cough, and the inter-
mission of the symptoms, refute the presence of a spas-
modic element in acute catarrh of the larynx. We are but
too prone to fall back, for the explanation of pathological
symptoms, on the nervous system, of which we know still
less than of the rest. Facts frequently disagree with our
comfort and convenience.
Thus far I have mentioned but such symptoms of acute
laryngeal catarrh which, as slight swelling of the mucous
membrane, oedematous infiltrations of the sub-mucous tis-
sue, and occasional dyspnoea, will readily get well either
spontaneously or on expectative or simple treatment. It is
easily understood, however, that the symptoms may be
grave in consequence of real and complete obstruction or
closure of the glottis.
This may be the result of two different conditions:
1. Direct contraction of the lumen of the glottis by con-
siderable tumefaction of the true vocal cords ; by tume-
217
DR. JACOBI'S WORKS
faction of the inferior vocal cords covering the inner mar-
gin of the superior ones ; by swelling of the posterior wall
of the larynx; and by an accumulation of secretion brought
about by the impeded function of the congested and oedema-
tous larynx.
2. Deficient dilatability of the glottis, that is, impeded
motion of the arytenoid cartilages, and the true vocal cords ;
by swelling of the integuments of the Santorinian and
arytenoid cartilages, and subsequent immobility of these
cartilages and the true vocal cords inserting on the vocal
processes ; and, finally, by paralysis of dilating muscles.
When such complete obstruction takes place, the same
symptoms as those of membranous croup, or foreign bodies,
or polypous growths, or acute oedema, obstructing the wind-
pipe, will appear, with the same indications and the same
results, unless these indications are fulfilled.
As to the course, duration, and termination of the milder
form of acute catarrh of the larynx, it may be added that
usually after a few days the larynx ceases to be as sensi-
tive, the cough subsides, the hoarseness vanishes, and the
disease terminates in recovery, after a week or two. But
a duration of several weeks is not uncommon, and do not
forget that the infantile organism has a great tendency
to inflammatory affections, and to the exudative processes,
and that the infantile vocal cords will not bear so well
as those of adults, a thickening of their substance and a
considerable narrowing of the rima glottidis. The patient
may be apparently well during the day but troubled by
attacks of coughing every morning and night, and this
state of things may last for a long time, until the catarrh
and its consequences have become chronic, and removable
with difficulty only. But more serious consequences may
follow the slightest dyspnrea, continuing for a long time;
a smaller amount of oxygen enters the blood than is neces-
sary for normal combustion, and for a complete and regular
physiological metamorphosis of the organism. This is
undoubtedly proved by the assertions even of adult patients,
suffering from slight laryngeal catarrh, who will experience
sufFocative attacks, and surprise you by showing a mass
of mucus brought up after long coughing, dry, hard, some-
218
TREATMENT OF CROUP
times slightly tinged with blood, and exactly bearing the
outlines of Morgagni's fossae between the superior and in-
ferior vocal cords, or some other part of the larynx.
It is a remarkable incident that just the reverse of what
has been presumed to be correct, is so. The fact that
children die of croup, who on the post-mortem table do not
exhibit much anatomical obstruction in the larynx, proves
a paralysis rather than a spasm of the larynx. Animals
whose pneumogastric nerves have been cut, and whose glot-
tis is paralyzed in consequence, die with the exact dyspnoea
of croup. Moreover, let us consider for a moment in which
condition the mucous membrane, the sub-mucous tissue,
and the muscles of the larynx may be found. There is
succulence, swelling, oedema. There is in consequence of
this condition of the mucous membrane, O3dematous infiltra-
tion and paleness of the submucous tissue and the muscles.
Thus, to prove by analogy, in pleuritis the intercostal
muscles are paralyzed and bulging out; in peritonitis and
enteritis there is succulence, oedema, and paralysis of the
muscular layer of the intestine, by which the absence of
peristaltic motion and the prevalence of flatulency and
constipation must be explained. The same pathological
fact holds good for the several constituent tissues of the
larynx.
Further: the base of the two arytenoid cartilages form-
ing (by stretching forward and inward) the vocal processes,
are very large in adults, so large, indeed, as to form a
triangular surface, the " pars respiratoria " of Longet.
This part does not exist in children, as the base of the
cartilages is brt narrow, and thus the glottis from anterior
to posterior is but a uniformly narrow slit bordered by
the vocal cords. Now when the air in the trachea is rare-
fied and a full current of air falls on the vocal cords,
and the dilators of the vocal cords, namely, the posterior
crico-arytenoid muscles, are paralyzed, the vocal cords,
oblique in their relation to each other, are approximated,
or entirely closed. By sucking the air out of the trachea
of a child from below, this fact can easily be verified in
the fresh anatomical specimen. Thus when the symptoms
of croup are the result of membranous obstruction of the
219
DR. JACOBI'S WORKS
larynx, both inspiration and expiration are impeded; when
of paralysis, the inspiration suffers more seriously than
expiration. This latter is especially the case, when the
pharynx is implicated in the croupous process, as in so-
called descending croup. For it is the mucous membrane
of the pharynx which forms the integument of the mm.
crico-arytenoidei portici, which in normal inspiration, when
healthy, enlarge the glottis.
As far as the treatment of acute laryngeal catarrh, or
spasmodic laryngitis, or pseudo-croup, is concerned, it is
better to accustom healthy children to the usual causes of
the affection than to guard them too cautiously. Such
as have been affected before, will be most liable to be taken
sick again. They ought to be dressed carefully according
to the temperature of the atmosphere. If there is any-
thing as injurious as it is unaesthetical, it is the naked
shoulder and leg of a shivering child. But they ought to
be accustomed to inhale fresh air, and to the free use of
cold water, river and sea-bathing. Such will be the most
efficient preventives. Common cases of acute laryngeal
catarrh, produced by atmospheric influences, require warm
foot-baths and mild diaphoretics, hot tea or milk, subace-
tate of ammonia, tartar emetic in small doses ; the irrita-
tion of the skin by hot sponges, sinapisms, and the appli-
cation of cold water to the throat; a severe attack of suffo-
cation or dyspnoea will now and then require an emetic:
ipecac in infants, ipecac with tartar emetic in more ad-
vanced age. I state, however, that I take exception to
the too general use of emetics in these so-called cases of
croup, when no other symptoms but hoarseness or a bark-
ing cough show themselves. In cases of serious dyspnoea
alone they ought to be administered. This much I can
assure, that not one out of a dozen of the children en-
trusted to my charge are punished to such an extent in this
affection. Wherever a complication is found of pharyngeal
with laryngeal catarrh, astringent gargles or applications,
or inhalations of tannic acid, or alum, or nitrate of silver,
in strong solutions, or in substance, are useful. Even
when not applied to the larynx directly, they will frequently
prove beneficial by contracting the dilated blood-vessels
220
TREATMENT OF CROUP
of the contiguous membrane, and thereby influencing the
catarrhal condition of the larynx. Permit me, however, to
exclude from this remark the effect of the gargles. If
they are expected to have the same influence on the dis-
tant portions of the pharynx and the larynx, as the direct
applications by the probang, no matter of what form, or
the pulverizer, their effect is overestimated. In the act of
gargling, the liquid does not reach further than the velum
pendulum, and the anterior aspect of the tonsils at the
best, and for the reason of this plain physiological fact,
that whatever is thrown beyond will certainly be swallowed
and not ejected again, we ought not to expect too much
from their use.
No blood-letting, local or general, is beneficial. Fatty
food is injurious; vegetable acids are beneficial; so are
alkalies. Whether the chemical composition of the mucus,
which contains more chloride of sodium than the blood,
thereby depriving the blood of this salt, or the physiologi-
cal effect of bicarbonate of soda, restoring the vibratile
action of the cylinder, epithelium, has anything to do
with this beneficent effect, I hesitate .to assert. The tem-
perature of the sickroom is to be mild and uniform, the
air moist, and every exertion of the larynx, speaking,
crying, coughing, must be avoided, prevented, or prohibited.
Many an attack of coughing may be frowned or scolded
down in older children; for frequently it is the giving in
to the first slight irritation to cough which gives rise to
a severe attack. The best means, however, to suppress
the irritation of the laryngeal mucous membrane is the
internal administration of narcotics. It is hardly worth
while to try hyoscyamus, belladonna, hydrocyanic acid.
You will always find a moderate dose of Dover's powder,
or morphia, or codeia, administered several times a day, or
a larger dose at bed-time, to yield a favorable effect
in soothing the irritated mucous membrane of the larynx,
and in suppressing, or at least diminishing, the trouble
and the danger from continued coughing.
The number of so-called expectorants administered in
laryngeal catarrh, as in that of the rest of the mucous
membrane of the respiratory organs, is very large indeed:
SSI
DR. JACOBI'S WORKS
ipecac, squill, senega, tartar emetic, sanguinaria, and id
genus omne. My own opinion of their value is not very
great. I hardly ever prescribe them. As this is so, I
have to beg your pardon for swelling their number by two
others. One is the oxysulphuret of antimony, similar in
its chemical composition to kermes mineral, on the expec-
torant qualities of which I published an essay in the New
York Journal of Medicine, ten years ago. After the fever
of catarrhal affections has subsided, and where no diar-
rhoea is present, and the powers of the patient not ab-
solutely low, it may be given, in doses of from one-fourth
to two grains, from four to eight times a day. It does
not exhibit the depressing nor the purgative effect of
other antimonials, although after a while it will be dis-
covered in the passages, unchanged; and may be given
as a powder, or in mixtures, with or without adjuvants,
or sedatives. The other is the hydrochlorate of ammonia,
or chloride of ammonia. The so-called resolvent, anti-
neuralgic, anti-rheumatic effects of this salt have been
mentioned, and sometimes extolled, in Great Britain and in
our country. It was sometimes spoken of as a powerful
remedy, undoubtedly because of its being an ammoniacal
preparation ; and I have sometimes read, and heard of late,
of its wonderful effect, and the possibility of its being a
dangerous drug. The truth is, that its powers of both
injuring and benefiting have been greatly exaggerated.
For decennia, while it was comparatively unknown, and
sometimes feared, in England and America, it was the
common accommodation drug of German practitioners.
In doubtful and plain cases, danger or not, indication
or not, if no other innocent or convenient thing would
strike the non-inventive genius of the practitioner, chloride
of ammonia was resorted to. It was the squills or the
calomel of the Englishman. You would find as many
recipes with chloride of ammonia on the counters of a
German, as calomel on those of an English drug store.
Thus it may be considered probable that its strong or in-
jurious effects cannot be very marked. What I can say
of it is this: I have no high opinion of its effects ex-
cept those referable to the mucous membrane, particu-
222
TREATMENT OF CROUP
larly of the respiratory organs. Its effects on the mucous
membrane of the stomach and intestines are far inferior
to those which may be obtained by a judicious use of
emetics, alkalies, and acids, especially the bicarbonate of
soda, and the muriatic, or the nitromuriatic acids, or the
usual salts of silver or bismuth. But its effects on the
mucous membrane of the trachea, larynx, and bronchi are
marked, in all such cases, but in those cases only, in which
the liquefaction of a tough, hard, viscid secretion is re-
quired. In a catarrhal affection, when the fever has
subsided, and expectoration appears insufficient, it will be
administered with marked benefit. Here, and here only,
lies its sphere. It may be given in doses of gr. xx. or gr.
xl. a day, with or without a sedative to diminsh local nerv-
ous irritation, hyoscyamus or belladonna; and will be ad-
vantageously combined with the same amount of chlorate
of potassa or a somewhat larger dose of chlorate of soda,
in complications with catarrh of the pharynx. It may be
given through the day, while towards bed-time, or at
nine or ten o'clock, a sufficient single dose of opium, or
an opiate, may be administered. Such are the outlines of
the rules according to which the usual form of laryngeal
catarrh ought to be treated. Those forms, however, in
which a complete obstruction, or an almost complete closure
of the larynx takes place, from such causes as enumerated
before, and in which the above treatment proves ineffi-
cient, require other means to ward off the fatal termina-
tion by suffocation. These are the forms which deserve
the name of catarrhal croup, and require as sound and
quick a judgment as a steady hand. They are not fre-
quent, but they will occur, in every land and practice.
Just as surely as a case of polypus, or foreign body in the
larynx requiring interference, may be met with any day,
although sometimes not in a dozen years, a case of catar-
rhal croup threatening speedy death from suffocation may
be met with. Every physician is acquainted with the
occurrence of acute oedema of the glottis, and the necessity
for establishing an artificial entrance of air into the lungs,
and every one may meet with a case of catarrhal croup in
which the omission of tracheotomy is homicide.
223
DR. JACOBFS WORKS
Dr. Kiihn has collected 149 cases of foreign bodies in
the larynx, treated with tracheotomy, and 109 recoveries;
73 cases of oedema of the glottis, and 54 recoveries; 52
cases of syphilitic laryngitis, and 39 recoveries ; 28 cases
of perichondritis and necrosis, and 5 recoveries ; 4 cases
of angina tonsillaris, and 1 recovery; 22 cases of epilepsy,
and 20 recoveries ; 1 1 cases of wounds of the larynx, and
10 recoveries; 12 cases of combustion, and 6 recoveries;
35 cases of diseases of surrounding organs, and 5 recov-
eries; 5 cases of polypi, and 4 recoveries.
Such figures are reason enough why the name of those
should be remembered and blessed who learned and taught
to temporarily supply the lungs and blood with their es-
sential nutriment. We shall soon see that their example is
not only valid in cases of walnut shells, bones, copper
pennies, pieces of china, coffee beans, pebbles, and sugared
corn imbedded in and obstructing the air-passages, but
in every sort of air-passage obstruction, both accidental
and pathological.
From our considerations of the treatment of croup, how-
ever, non-obstructing catarrh on one side, foreign bodies,
polypi, ulcerations, with oedematous swelling, as in typhoid
fever, typhus, syphilis, tuberculosis, and spasm of the glot-
tis, must be excluded. The diagnosis of true croup has
for a long period been thought to be dependent on the
presence of membranes, and consecutively the distinction
between croup and pseudo-croup, according to their pres-
ence or absence, was considered unimpeachable. But there
are a number of cases on record in which tracheotomy was
performed for croup, and no membranes found. Or after
pseudo-croup had lasted and been diagnosticated for days,
all at once membranes were found in the larynx, with
the exclusion of the pharynx. Or in other cases the symp-
toms were so urgent that tracheotomy was performed
for what was shown to be simple catarrh with consider-
able oedema, and with or without pharyngeal membranes.
And sometimes the membranous deposit was found in the
pharynx alone, and nothing beside it, after death. For
these reasons a diphtheritic, a membranous, a catarrhal
and spasmodic croup were distinguished. But this much
224
may be stated here, and practitioners will admit the fact,
that the affection will frequently, especially when there
is no epidemic diphtheria, commence by " pseudo-croup,"
and afterward assume a more formidable character. As
this is so, the possibility of cutting the process short
by proper dietetic measures, provided always that there
is no constitutional diphtheria, cannot altogether be denied.
The unbiased examination of all these cases of croup
met with yields but one common and essential symptom,
namely, obstruction of the larynx, from a nutritive dis-
order. Its form will differ. Of the anatomy of simple
obstructing catarrh I have spoken. Another form is the
follicular process of the tonsils with its subsequent changes,
the formerly so-called herpetic angina of the trachea,
which I have characterized already in a paper on diph-
theria, published in August, I860, in the New York Medi-
cal Times. It is exudative, membranous in character, fever-
less, but will not unfrequently be followed by larger
croupous or diphtheritic deposits. Another form is the
membranous deposit proper, a fibrinous exudation, amor-
phous in character, mixed with mucus and blood corpus-
cles and normal epithelium. It is either deposited upon
the mucous membrane, and then can be easily lifted up
from it, or into it and into its subjacent tissue. The first
form has frequently been called croupous, the latter diph-
theritic. But whatever clinical difference there may be
between a simple membranous inflammation and consti-
tutional diphtheria, there is no anatomical difference be-
tween the membranes wherever they make their appearance.
Another form, and not a very unfrequent one, is originally
confined to the epithelium, which rapidly undergoes fatty
degeneration which may or may not be complicated with
fibrinous exudation. The soft, pultaceous, easily macerating
diphtheritic masses are of this character; and the fearful
cases of diphtheria with rapid necrosis of the tissue are
usually of the same nature. The neighborhood may be in
different conditions, oedematous or dry, hyperaemic or
anaemic. CEdematous and hyperaemic condition is more
commonly found ; a dry condition is a frequent occurrence
in the necrobiotic process of that fatty degeneration; an-
225
DR. JACOBI'S WORKS
semia of the surrounding parts, or interspersed portions^
depends on compression of capillaries by infiltration, which
means new-formed cells and connective tissue ; moreover, let
us not forget that we have fortunately passed by the time
when the nutritive disorder called inflammation was al-
ways thought to depend on previous congestion of the
parts.
All those forms of change of tissue are not found un-
complicated in every given case. When large surfaces
are taken at once, you may see in the mouth a catarrhal
proliferation or croupous condensation of the epithelium,
on the tonsils a diphtheritic deposit imbedded in the tis-
sue, on the larynx and trachea a plain croupous deposit,
and in the bronchi a muco-purulent secretion. And again,
under the same endemic and epidemic influences you will
find a case of catarrh, a case of croup, a case of diph-
theria, a case of follicular exudative amygdalitis, in the
same family in the same week. Thus it appears that in
the long list of morbid conditions met with, catarrh on
one side, diphtheria on the other, are but the starting
and terminating points between which all the different
shapes and forms may be registered according to their
dignity, their modification depending on individual, local,
endemic and epidemic influences; the only form which is
perhaps, but perhaps only, to be excluded, being the necro-
tizing diphtheria. And when we compare the clinical nature
of the affection we find similar differences. The affection
may be local without fever, or simply febril, or local and
obstructing, or obstructing and poisonous. In some cases
the process will not even be confined to the respiratory
organs, but, similar to the rinderpest of animals, the di-
gestive organs will participate in the process, and skin,
kidneys, spleen, may follow.
Thus great may be found the difference of the anatomi-
cal lesion in croup, but the stenosis, obstruction of the
larynx, is the common symptom of all forms.
After the symptoms of tumefaction, succulence, and in-
creased secretion, with their paralyzing influence on the
mobility of the vocal cords, and with its barking or sound-
less voice or cough, have passed by, or without these pre-
226
TREATMENT OF CROUP
monitory symptoms, inspiration becomes impeded, its dura-
tion prolonged, and its sound sibilant. The respiratory
efforts are increased in consequence; the levatores alarum
nasi active, the muscles of the thorax overstrained. Ex-
piration short, no interval between expiration and inspira-
tion, mouth and nostrils open. The superior portion of the
thorax flattened, the supra-clavicle regions sunk, sternum
and scrobiculus cord is drawn in; the inferior part of the
abdomen bulging out; larynx and trachea ascend and de-
send considerably with every expiration and inspiration to
compensate for the diminished amount of air admitted
to the lungs. The flushed face becomes pale, now and
then the child is soporous, vomiting will occur spontane-
ously while emetics are losing their effect, respiration is
superficial, attacks of suffocation will alternate with sopor.
Sometimes for a change, entire remissions, mostly in the
morning, will take place, and the child breathe more
quietly and appear more comfortable, until with an attempt
at deep inspiration, exactly like animals in whom the pneu-
mogastric nerves have been cut, a fearful attack of suffo-
cation sets in.
Part of these symptoms result from the abnormal amount
of carbonic acid retained in the blood; not from reten-
tion of the blood in the brain; for as long as inspiration
alone is impeded, blood is not repelled into the brain,
nor into the integuments, and therefore we notice no
cyanotic hue, except in a severe attack of coughing, or
except toward the fatal termination when the heart is
becoming paralyzed and the arteries insufficiently filled.
Then the veins are dilated by the circulation being im-
peded. To the contrary, when the elastic lung tissue, not
sufficiently filled with air of normal density, affords more
room for the capillaries to dilate, when there is less pres-
sure on the walls of these lung capillaries, the result is
congestion, catarrh, bronchitis, and broncho-pneumonia in-
side, while the external surface is the paler. Thus bron-
chial catarrh and bronchitis with its sequelae not, however,
croupous pneumonia, which requires other causes is the
direct effect of impeded circulation, and therefore the
frequent cause of death even after tracheotomy has re-
227
DR. JACOBI'S WORKS
lieved the dyspnoea. Cyanosis, and impletion of the veins
generally, is the result both of impeded expiration and
inspiration, when the larynx is almost fully obstructed
by membranes. As expiration can be attended with greater
muscular force than inspiration, the blood will effectually
be repelled into the venous system. Thus will occur direct
brain symptoms not depending on carbonic acid poison-
ing; from this source the immense and dangerous dilata-
tion of the veins of the neck and thyroid gland as met with
in many cases of tracheotomy; from this source also, local
or general cyanosis. With the exception of a very few
cases in which the obstructing membrane is fortunately
expelled, nothing else but death can be expected. It will
ensue from gradual paralysis, or sometimes from sudden
suffocation by loose or nearly loose membranes obstructing
the glottis.
Among the most dangerous symptoms in the final de-
velopment of the process, I mention the following as con-
siderably impairing the prognosis:
1. Emetics administered, and no relief.
2. Emetics administered, and no effect.
3. Constant increase of dyspnoea.
4. No more remissions between the attacks of suffoca-
tion.
5. Feeble, frequent, and intermittent radial pulse, the
intermission coinciding with inspiration.
The indications for the treatment of croup must neces-
sarily be dependent on its anatomical and physiological
character.
The character of croup is: suffocation by insufficient
or absent entrance of air into the lungs in consequence
of a nutritive disorder of the larynx.
The obstructing causes are either oedematous swelling,
or paralysis of vocal cords, or presence of membranes, or
two or all of these factors. The indication is to remove
the one or all of them by the proper means, and to pre-
vent the morbid process from increasing. To give a list
of the remedies which have been given in croup for the
purpose of drenching the blood and system with a " sol-
vent," " antiplastic," etc., remedy, would be to write a
228
TREATMENT OF CROUP
list of almost every remedial agent of the pharmacopoeia,
and would be only a further proof of the well-known fact
that the number of " valuable/' " inestimable/' " infallible,"
remedies grows with the danger and incurability of the
disease.
Those who have seen in croup nothing but a common
and always uniform affection of inflammatory character,
have administered mercury in almost any form, calomel
in small and large doses, the bichloride, the sulphide, or
the alkaline carbonates or bicarbonates, or the sulphide of
potassium. Those who saw in croup nothing but just a
more or less innocent continuation of the follicular process
of the mouth in a downward direction, relied on the chlorate
of potassa or soda. Others would rely on the sulphate of
copper in small doses, until the two ends of the intestinal
tube were overflowing with it; others again, who laid more
stress on the nervous, and especially spasmodic, symp-
toms, would lead into battle the salts of quinia and mor-
phia, the narcotic extracts, belladonna, hyoscyamus, asa-
foetida, also nux; such as had seen symptoms of infection
with croup would rely on the muriate of iron, nux, bromine,
carbolic acid. All of them have been considered infallible
by their godfathers, and all of them are known to fail.
I do not mean to make the slightest attempt at re-
futing them, first, because it requires more time than I,
and more patience than you, have. If a case getting well
under a treatment, or in spite of a treatment, is to give
credit to this treatment in the eyes of the short-sighted,
we cannot help it; we can simply deplore the still pre-
vailing omnipotence of the " post hoc ergo propter hoc."
One of the indications was, treatment of the paralysis
of the vocal cords. Can we expect to remove this paralysis,
say by electricity, which is the most powerful antiparalytic
remedy? It appears not, for the simple reason that this
paralysis is secondary. It depends on the oedematous
soaking of the posterior crico-arytenoid muscles following
the oedema of the mucous membrane of the crico-arytenoid
folds. Thus this paralysis cannot be influenced except by
removing this oedema from mucous membrane and muscle.
This appears impossible, for instance by an incision, scari-
229
DR. JACOBI'S WORKS
fication, because it is not local. You would possibly by a
well-directed scarification diminish it, but not remove it
Even local oedema glottidis has been known to require
tracheotomy after scarifications had been freely made.
Moreover, the case is more unfavorable still for a direct
interference. The very oedema of the mucous membrane
(and sub-mucous tissue), of the crico-arytenoid folds giv-
ing rise to the paralysis of the glottis is itself but second-
ary, the original cause being almost in every case the
diphtheritic and oedematous condition of the pharynx. After
all I have said, it appears doubtless that we have to give
up the idea of interfering with, or removing, the paralysis
of the glottis as met with in croup, the nature of the
paralysis itself being as much the cause of this impossibility
as the rapid course of the morbid process. A mild case
may find time to get well, a serious one will suffocate.
The next indication, in case membranes are deposited,
no matter whether of the hard or pultaceo'us character,
is to remove these membranous deposits.
For this purpose there have been recommended:
1. Internal treatment.
2. Mechanical treatment.
The internal treatment has been mentioned above ; it
was meant to have its effect according to the laws either
of physiological chemistry, or the pathology of neuroses.
The latter has failed. And so is the first sure to fail,
in your minds, if I shall succeed in proving that the same
remedies which were thought powerful enough to dissolve
membranes by their presence in the blood, are entirely
powerless to dissolve the same membrane under your eye,
in your basin, in constant contact with a stronger solution
or dose of the remedy than you would dare to administer
internally.
The mechanical or local treatment recommended is the
mechanical removal of the membranes within reach, with
forceps, brushes, etc.
Application of remedies expected to dissolve or soften
the membranes, for instance glycerine.
Application of caustics, and astringents, alum, tannin,
chloride of iron, mineral acids, nitrate of silver, by means
230
TREATMENT OF CROUP
of gargles, direct local application with the probang, the
forceps, the brush, or the pulverizing apparatus.
Removal of membranes by emesis.
The gentlemen are sufficiently acquainted with the local
application of nitrate of silver to the interior of the
larynx, inasmuch as part of the most important literature
on the subject is ours. The name of Horace Green is more
deserving of the respect of Americans for his local treat-
ment of the air passages his treatment of croup I should
not, however, include in his great improvements in science
and art than that of Loiseau of that of the French. Now,
it has been presumed that nitrate of silver would prove
very destructive to the laryngeal false membrane, and
therefore has been widely recommended. But I wish to
remind you of the results of your local application to
the pharynx in cases of simple diphtheritic deposits. Un-
less you take, and are allowed, a rather long time, to me-
chanically tear up and destroy the membranes, with some
effort and even violence, you will not succeed. The mem-
brane is even apt to shrink and harden, is not destroyed, its
base is intact, and a new crop may follow. It is charac-
teristic in nitrate of silver that its effect is so very much
confined to the exact point it comes in contact with. In
a few minutes I shall have to relate a frightful proof
of this fact.
Thus the very virtue of the agent is a drawback where
you want extensive destruction and a quick effect. A long-
continued application is out of the question. I have lost
a child, in whose larynx I operated with a saturated solution
of nitrate of silver, by instantaneous death. And those
few cases which I have read of, and one or two cases that
friends have reported in medical societies, cases in which
the probang with a solution of nitrate of silver proved
effective, prove, in my opinion, nothing for the nitrate of
silver, but everything as far as it goes for the moist pro-
bang with its direct mechanical effect, and its indirect
effect in producing coughing, etc.
We ought not to forget that the local treatment of
croupous or diphtheritic membranes in the pharynx when
desirable, is a great deal easier than in the larynx. The
231
DR. JACOBFS WORKS
facility is greater, and the organ neither so vital nor so
vulnerable. And what applications to membranes may be
expected to do, will be seen by the following results of
direct experiments, part of which I have had frequent
chances to repeat:
Lime water requires thirty to fifty hours to disintegrate
false membranes, and three days or more to entirely dis-
solve them. It requires from four to ten hours to thor-
oughly liquefy the soft pultaceous diphtheritic deposits.
Hydrates of potassa and of soda, 1 : 500, act more slowly
than lime water.
Permanganate of potassium, 1:120, disintegrates false
membranes in its outer parts, while the interior remains
hard and solid, in ten hours.
Carbonate of lithia and carbonate of soda, 1: 100-150,
had the same effect in the same time. About the same
time is required by the constant effect of chlorinated
water.
Nitrate of soda, 1 : 200-300, has no effect on membranes.
Iodine, the officinal tincture, or a solution of 1 : 200,
shrinks and hardens them.
Nitric acid, 1 : 50, has the same effect. So has acetic
acid, except on the soft diphtheritic masses, which get dis-
integrated.
The only agent which dissolves membranes soon, but
one which is hardly fit for use for obvious reasons, is
ammonia.
Carbolic acid, applied to a membrane or a pultaceous
diphtheritic deposit, shrinks it in a short time, making
it removable to a high degree. The difficulty, however,
of applying it to the larynx and bringing it into contact
with a sufficiently large surface is very great indeed.
To normal tissue it is not without danger. Thus I am
not prepared to say what it may be made to do in croup
of the larynx, while I am pleased with its local effects
in the same affection of the fauces. To act quickly it
must be applied very little, if at all diluted, and requires
an experienced hand.
Subsulphate of iron and sesquichloride of iron ait, al-
though, perhaps, not so vigorously, similarly to carbolic
232
TREATMENT OF CROUP
acid. They have, however, the disagreeable property of
shrinking and coagulating, and as it were accumulating
in a bulk, whatever of albuminous substances is in reach.
Thus mucus and blood are coagulated and form with the
iron a firm, hardly removable mass, which may interfere
with both deglutition and respiration, and give rise to great
annoyance. And another one which it will be worth while
to experiment with is bromine. One grain of bromine,
one grain of bromide of potassium, in three hundred and
sixty grains of water, will liquefy a membrane in a few
hours.
Thus it appears that unless bromine will prove effective,
it is not worth while to try the effect of anything but
lime or carbolic acid. This much is sure, that it will prove
effective, to a certain extent, where it can be retained in
contact with diphtheritic masses. Thus I am pleased with
their effect in nasal diphtherite, where the deposits are
frequently softer, thinner, half solid only. Frequent, say
hourly, injections of lime water into the nose have evi-
dently rendered me good service; how far, however, this
effect will show itself in the larynx, where the application
cannot be made so thoroughly nor so frequently, or
how far the few reports of a cure by the inhalation of
pulverized lime water can be trusted, remains to be seen.
At all events, the scarcity of the reported successes and
we may be sure that real or apparent successes in the
treatment of croup will not be concealed is in exact pro-
portion to the insolubility of false membranes, and to the
rapid course and usual fatal termination of the disease.
Concerning the removal of membranes by emesis, we
know that emetics stand almost foremost in the list of
the remedies recommended in every form of croup, for
their revulsive and diaphoretic, and their mechanical ef-
fect. Of the first I have no idea unless it means the sec-
ond. My opinion of this, the diaphoretic effect, and the
necessity or advisability of diaphoresis, I have briefly
stated. Thus, no efffect but the mechanical one appears
reliable; and it is reliable in some cases. When the
dyspnoea depends on the collection and accumulation of
mucus in the larynx, or when mucus is one of the factors
233
Dfc. JACOBI'S WORKS
only, it will alleviate the symptoms, and may be resorted
to and repeated. When the obstruction is membranous, it
will be of less importance, inasmuch as the membranes are
mostly closely attached in the beginning, that is, for days,
to the larynx, especially in those places which, like the fos-
sae Morgagni, are less exposed to the current of air from
the lungs. But the effect of the emetics is greater than
that of the most severe spell of coughing, because of the
dilatation of the glottis which takes place during vomiting.
In this dilatation a larger portion of the larynx is exposed
to the current of air emanating from the lungs than in
coughing. Thus there is hardly an objection to trying the
effect of an emetic in a case of membranous obstruction
of the larynx, which will best be diagnosticated by the
expiration being impeded like inspiration, with a view of
detaching it from the walls of the larynx; especially is it
indicated when membranes are partially loosened. This
condition is sometimes diagnosticated amidst the most ur-
gent dyspnoea by a peculiar loud, clashing, flapping sound,
particularly in expiration. Whenever relief is obtained, it
ought to be repeated from time to time, not otherwise.
When the symptoms of general paralysis from deficient
decarbonization of the blood are on the increase, reac-
tion will cease, and emetics will withhold their effect,
even at a period where spontaneous vomiting may still
take place. When such is the case the most powerful of
all irritants, cold effusions to the head, or neck, or the pit
of the stomach, may still rouse the reaction of the ob-
longated spine and the pneumogastric nerves.
Of the remedies which ought to be resorted to I have
spoken already. I prefer the sulph. cupri to any of the
rest. The mode of their producing emesis is the same,
and as emesis only is required, the most reliable medica-
ment ought to be selected.
The indication of cutting short the process of obstruc-
tion, to interrupt the course of the disease, has appeared
to many to require the use of diaphoretics, depletion, vesica-
tories, warm applications, or cold applications.
Diaphoretics. Their effect is perceptible in cases of
simple catarrhal hyperaemia only. The dilatation of the
234
TREATMENT OF CROUP
capillaries of the surface is apt to empty internal blood-
vessels. Thus it is rational to try diaphoretics in cases
of catarrh, or wherever for a little while the diagnosis
between catarrh and croup is doubtful. While, however,
it would be worse than unwise to expose the body of the
patient to cold air, we ought not to forget that it is un-
physiological and worse than wasting time to expect the
reduction of a nutritive disorder of such an extent from
the administration of internal diaphoretics, or diaphoretic
external treatment.
Local depletion has frequently been recommended.
Leeches were to be applied to the throat, to the manu-
brium sterni. The same can be said of them as of dia-
phoretics. They may not be very injurious in catarrh;
theoretically they may even be justified, although the
same end is better obtained by more innocent remedies;
they may not hurt robust and vigorous children whose
strength is not so easily consumed. But again, inflamma-
tion and hyperaemia do not always coincide, and exuda-
tion is not prevented by leeching. To the contrary, the
well-known fact that the proportion of fibrin in the blood
increases with every depletion, ought to make us very
cautious indeed. Moreover, the danger of local or general
depletion in diphtheria ought to be too well understood to
be underestimated. For nearly ten years, in this city and
over the world, diphtheria has been prevalent, with all its
local destructiveness and its constitutional poison ; the large
majority of cases of croup have been of a diphtheritic
character. The result of depletion in such cases is but
too often the rapid increase of exhaustion, and the forma-
tion of diphtheritic deposits on the sore surface. Thus
I consider the use of depletion in croup as excusable in
but few cases, although hardly ever indicated; in the ma-
jority of cases it is dangerous.
What I have said of depletion is also valid for vesica-
tories. It is characteristic for diphtheria that not only
mucous membranes, but the cutis too, wherever it is de-
nuded of its epidermis, will be readily covered with mem-
branes or pultaceous deposits. Thus eczematous or im-
petiginous sores will undergo this change; and those who
235
DR. JACOBI'S WORKS
have performed tracheotomy or any other operation in a
diphtheritic individual, or during the prevalence of an
epidemic, have had sufficient reason to be shocked at diph-
theria exhibiting its eruption within twelve or twenty-four
hours. I have seen dozens of tonsils removed from ap-
parently healthy individuals in such seasons, covered with
diphtheritic deposits within a day, and remember to have
lost a case of resection of the head of the femur from the
same cause. Thus, beware of vesicatories. Their usual
result is not a relief, but diphtheritic covering or disin-
tegration of the affected part, and frequently collateral
swelling. I do not assert too much when I say that the
only effect I have ever seen from their use has been very
unfavorable.
Both warm and cold applications have been made to
the larynx, externally, for the purpose of alleviating the
symptoms, or interrupting the progress of the disease.
Can we expect an effect, by either of the two, on the
formed and deposited membrane? No. Thus we cannot,
in fact, expect to influence the fully developed disease
by either. Or on the collateral oedema and consecutive
paralysis of the vocal cords? Exactly the same must be
true. Now, in inflammatory and exudative processes in
other organs and regions we use both warm and cold
applications, but it appears to me for different indications,
and for different purposes. There is no doubt that warm
poultices in a certain advanced stage of peritonitis or
pneumonia will do a great deal to promote the absorption
of exudation, and the comfort of the patient; but absorp-
tion we do not expect in croup of the larynx, and com-
fort there is none. But wherever we do have a conges-
tive disease, an inflammation based upon hyperaemia, a
dilated condition of the blood-vessels, cold applications,
when the parts are within easy reach, are the only reason-
able means to fall back upon. If this is true of enteritis,
peritonitis, or pneumonia, it is so much the more so in
affections of the larynx with its easy access and its close
proximity to the skin. The only thing I should not like
to dispense with in the treatment of croup, is, therefore,
ice, which, if anything, is the most simple, unexhausting,
236
TREATMENT OF CROUP
and direct remedy possible. There is, in fact, no period
of croup in which it has any contraindication, although its
effect is only to be considered as preventive of exudation.
Of all the remedies as used in croup, we cannot say
anything better than that most of them are useless, some
injurious. From what I have stated as my experience,
and that of hundreds of better men, and from what I
know to be the experience of the large majority of the
gentlemen present, the great mortality statistics of croup
are but too well confirmed. Statements of such epidemics
in which seventy or seventy-five per cent, of all the cases
of true croup have died, are highly favorable, such with
ninety or ninety-five per cent, not at all uncommon.
Thus, very little reliance can be placed on the judg-
ment and the diagnostic powers of such as save a large
majority of their cases, or who rely on infallible pet
remedies.
As a general rule, I like the bowels of the patient moved
by an injection to give his abdominal muscles and dia-
phragm as fair play as possible. I apply ice in com-
fortable bags to his larynx. I now and then, according to
the condition of the fauces, try sesquichloride of iron, or
carbolic acid, to the visible membranes. I have not seen
yet that I have succeeded in directly influencing the laryn-
geal deposits. When the diagnosis is any way doubtful.
I allow a mixture of chlorate of soda or potassa with
chloride of ammonia, frequently repeated, say one to three
drachms of the former to one-half to one drachm of the
latter per day. When attacks of dyspnoea or suffocation
come, an occasional emetic. When with all this the symp-
toms become graver, pulse more frequent, or even irreg-
ular, and all the other symptoms enumerated before show
themselves, I cannot but confess that I have no more
power over the process, and that it will, as far as human
experience and foresight go, destroy the patient, unless
you find the means of supplying the lungs with oxygen.
For this purpose the development of oxygen in the pa-
tient's room has been resorted to. How much oxygen
they do obtain by such process, is uncertain; it is still
more improbable that the patients, in the condition in
237
DR. JACOBI'S WORKS
which they are, can be made to inhale voluntarily. More-
over, pure oxygen is not fit for respiration, on the con-
trary, it causes dyspnoea in the healthy; the mixture in
which oxygen is in the atmosphere appears to be the only
proper food for the blood, and alone capable of keeping
up the diffusion of gases through the walls of the pul-
monary capillaries.
For the same purpose Bouchut invented and described
his " tubage." He introduced, so he said, tubes between
the vocal cords, through which the croupous children would
immediately breathe quietly and sufficiently. Now, in a
larynx filled with membranous or other diphtheritic de-
posits, this is a plain impossibility. Only in cases of par-
alysis of the vocal cords such a proceeding could be
thought of. Whether it can be done or endured, I do
not know. But I do know that Bouchut has not succeeded
himself, inasmuch as he asserts that the children into
whose glottides he introduced his tubes, expressed to him
their gratitude, by words, immediately after. When re-
porting on this " tubage " of Bouchut's, Trousseau al-
ready stated that the hitherto known laws of physiology
would forbid a child to speak with the vocal cords held
aside, and steadied by a solid tube in the rima glot-
tidis.
For this purpose, finally, we perform tracheotomy; that
is, we afford the air access to the lungs below the ob-
structed point. Thus tracheotomy is not a cure for croup,
it is simply a means to keep the patient from suffocating
until the process above has completed its course. As soon
as the larynx will be pervious again, you expect to close
your artificial opening. Thus tracheotomy appears on a
level, but more favorable than these, with paracentesis
of the bladder, operation for artificial anus, or thoraco-
centesis for acute copious effusion. Thus there ought to
be no contraindication when the prominent symptom is
dyspnoea, and suffocation. I cannot imagine any compli-
cation of croup that would prevent me from opening the
trachea when the child is dying of suffocation. This is
so plain to my understanding that I should consider it
even a cruelty to refuse tracheotomy when I knew before-
238
TREATMENT OF CROUP
hand that the child was surely going to die. Whoever
has seen children die of croup, fully conscious, gasping,
raving for air until they are slowly strangled in your
arms, under your eyes, will at least bless a proceeding,
the consequence of which will in most cases be an easier
death; with the exception of those in which solid mem-
branes will, after the operation, migrate down into the
smallest ramifications of the bronchial tubes.
Nor do I acknowledge that tender age, the age under
two years, ought to be held as contraindication to the
performance of the operation.
Now, it is a fact that the results of the operation at
this age are much less favorable than at a more advanced
period. All and every statistical record yields the same
evidence. But lately, Giiterbock has published one hun-
dred cases of tracheotomy for croup, one of which was
under a year, one under two years, both terminating
fatally. As far as the rest is concerned of those operated
upon, between the second and third year the percentage of
recovery was 33 1-3; between the third and fourth year,
40 per cent.; between the fourth and fifth years, 38 8-13
per cent. ; between the fifth and sixth year, 44 4-9 per
cent. ; between the sixth and seventh year, 44 4-9 per cent. ;
between the seventh and eighth year, 14 2-7 per cent.;
between the eighth and ninth year, 25 per cent.
Theoretically, there is no reason for tender age being
an excuse why suffocating infants should be left to a
sure death. If, however, clinical experience would sus-
tain the contraindication as such, we might be satisfied with
leaving them to their fate. But fortunately the case is
not so bad after all. For there are a number of cases
on record in which tracheotomy performed on very young
children proved successful. I will not urge the case of
Scoutetten, erroneously attributed to Sedillot lately, who
operated on an infant of six weeks, as it has been de^
clared to have been a case of so-called pseudo-croup; al^-
though, even if this was so, the advisability and possibility
of the operation was clearly proved by this very case.
But the cases of Baizeau, in an infant of ten months, and
in another pf fifteen months; the case of Isambert, six-
239
DR. JACOBI'S WORKS
teen months; Archambault, thirteen and eighteen months;
Royer, nineteen months; Vigla, seventeen months; Potain,
eighteen months ; Moutard-Martin, eighteen months ; Trous-
seau, thirteen months; Barthez, thirteen and seven months,
prove the very fact that the general indication for trache-
otomy, namely, obstructive disease of the larynx, remains
valid.
Dr. Krackowizer's earliest case of recovery, in this
city, was not two years old. He removed the tube on the
child's third birthday, but was compelled to introduce it
again for a few days.
The result of my own cases of tracheotomy is as fol-
lows : I have operated on sixty-eight children, sixty-seven
times for croup, once for a foreign body contained in the
larynx. The case was that of an infant of eleven months,
who had a flat bone seven lines long and one to four lines
wide lodged in the larynx while being fed. The danger
appearing imminent, dyspnoea growing from minute to min-
ute and resulting in a general cyanotic hue of the face,
and emetics proving useless, help was immediately sought
for and the operation of tracheotomy performed about two
hours after the accident. The foreign body was dislodged
from below upward through the tracheal opening with
great difficulty; after it had been removed the dyspnoea
was not entirely relieved, and the child did not breathe
normally except through the tube only. It appeared that,
although there was no longer a foreign body inside the
larynx, it had during its stay there worked changes re-
sulting in obstruction. It was, therefore, impossible to
remove the tube, symptoms of laryngitis showed them-
selves after a few days, high fever set in, and the infant
died on the eleventh day after the operation, of traumatic
laryngitis. The post-mortem appearances were: intense
catarrhal injection, intermingled with an occasional ec-
chymosis of the epiglottis, considerable swelling of the
entire mucous membrane of the larynx, and sloughing of
the fossae Morgagni and part of the vocal cords.
Of the sixty-seven cases of tracheotomy for croup,
thirty-eight were made on boys, twenty-nine on girls. Of
the sixty-seven, thirteen recovered; of the thirty-eight,
240
TREATMENT OF CROUP
eight recovered, of the twenty-nine, five recovered. Thus,
the total percentage of recoveries is about nineteen and a
half.
The percentage looks a little more unfavorable than it
really is. For there are five cases, boys of two, two, two,
and five years, and a girl of nineteen months, who swell
the lists of my mortality unnecessarily. One boy died in
my presence while I was preparing the table and instru-
ments. A single incision opened the trachea of the child
hastily thrown upon the table and pulled over its edge,
but too late. In another case I was induced to operate,
although I found the little girl dying, by the attending
physician, who had been patiently extorting the permis-
sion of the parents and waiting for the surgeon for many
hours. The other three cases were of a similar description;
for hours no emetic had resulted in emptying the stomach,
no external irritation yielded a reaction, and if I had had
the control of the case I should not have performed the
operation. At all events, these five operations were made
on individuals who either were dead or dying, and in
whom the indication for an operation had long passed
by. Thus I am justified, I believe, in saying that there
are thirteen recoveries, namely, twenty-one per cent., out
of sixty-two operations. You will, besides, please not for-
get the fact that I have frequently had to wait for the
permission to operate for hours beyond the normal indica-
tion, and that this very delay has in many cases impaired
the chances of the patients. This complaint of mine is
as easily understood as it is expressed by all of those
surgeons who have operated in a large number of cases,
and in other than hospital practice. But the blame is not
confined to the attendants and relatives only, it has some-
times been myself who is to be blamed for delay, as I
am positive to have lost good opportunities by procrastina-
tion. Especially in those cases which take a very rapid
course, such procrastination has occurred; it is but too
natural, now and then, to hesitate in spite of your exact
knowledge of the indication, before you operate on a child
who a few hours before was perhaps the picture of
health. And still, nobody would think of hesitating when
241
DR. JACOBI'S WORKS
a foreign body was located in the larynx, though I re-
luctantly confess that I believe I have lost lives by losing
time. A case of this description occurred but lately. A
boy of a little more than two years was taken with hoarse-
ness and moderate fever, and a croupy cough. The mes-
sage did not reach me before the following morning, when
I paid my first visit at 10 a. m. Hardly any deposit on
a (the left) tonsil, great dyspnrea, but voice not gone,
the muscles of the thorax in thorough exertion, perspira-
tion, pulse of 140. The mother had during the night ad-
ministered chlorate of soda, and applied ice water to the
throat. Treatment continued, with an occasional emetic,
until I should call in the afternoon. Visit at 5 p. m.
More dyspnoea and perspiration, dyspnoea constant, cya-
notic hue of lips and nose, pulse 150 to 160, irregular. Still.
I try the effect of an emetic; it takes effect, but gives no
relief. Then I call on Dr. Chamberlain for assistance in
the operation, which is performed at 7 p. m. The relief
afforded by it is striking, but below my expectation ; three-
quarters of an hour after the operation the respiration is
rougher, harsher than normal, 36 to 40, pulse 124 to
128, the patient tolerably quiet, but spells of restlessness,
which, however, do not last very long. At 10 p. m. an
occasional crepitant rale, 44 to 48 respirations, 150 pul-
sations, heat of skin increased, no dull percussion sound.
I fear a beginning broncho-pneumonia, and state my un-
easiness concerning the termination of the case to Dr.
Chamberlain, who kindly accompanied me. At 3^ a. m.
I was sent for, only to learn that the child had died soon
after the messenger went for me. The post-mortem exami-
nation revealed, besides the complete membranous obstruc-
tion of the larynx, a few thin and small membranes cor-
responding with the first five or six cartilages of the tra~
chea, intense injection and ecchymotic discoloration of the
lining membrane of the trachea and bronchi with their
ramifications, a general and intense oedema of the lungs;
no pneumonia, no hemorrhage, no collapse of the lung.
Those who are conversant with the mechanical influence
of the rarefaction of the air inside the lungs, and the
disproportion between the tension of blood in the ves-
TREATMENT OF CROUP
sels and the diminished atmospheric pressure on their
walls from outside, will be apt to explain the post-mortern
appearance and the mode of dying. It has been the only
case of uncomplicated, fatal pulmonary oedema after croup
and tracheotomy which I have seen, and there are but few
such cases on record. The tendency is much more to the
development of an exudative than an effusive process, and
while broncho-pneumonia is a frequent occurrence, uncom-
plicated pulmonary oedema is as rare as it is instructive.
Of my patients one was at the age of 1 year 1 month;
one, 1 year 2 months ; one, 1 year 7 months ; one, 1 year
10 months; five, 2 to 2| years; nine, 2^ to 3 years; six-
teen, 3 to 4 years, twenty-three, 4 to 5 years ; seven, 5 to
6 years; two, 7 to 8 years; and one 10 years.
Recoveries took place :
1 at the age of 2J to 3 years, 1 out of 5 operations,=20 per cent.
3 " 3 "4 " 1 " 16 " =19
7 " 4 " 5 " 1 " 23 " =30 "
2 " 5 " 6 " 1 " 7 " =284-7"
The after-treatment in some of these cases was pro-
tracted, and therefore the tube had to remain in some a
pretty long time. It was removed in two cases on the 17th
day, one on the 18th, one on the 20th, one on the 27th,
one on the 29th, one on the 30th, two on the 35th, one
on the 42d, one on the 44th, one on the 46th, and one on
the 54th day.
The cause of the long duration of the after-treatment
was in four cases of a peculiar nature. It was found that
in the second week after the operation, the larynx hav-
ing expelled the macerated membranes, would resume its
functions, and the patient breathe normally through the tube
and its upper fenestra, and the larynx, the anterior open-
ing of the tube having been closed by a cork. But the
removal of the tube from the trachea gave rise to instan-
taneous attacks of dyspnoea and suffocation, which were
instantly removed again by the replacing of the tube.
This occurrence would take place so regularly that the
patients would not admit the removal of* the tube after-
243
DR. JACOBI'S WORKS
ward. The cause of this strange and unsatisfactory oc-
currence was found to be the presence of polypoid ex-
crescences, sometimes numerous, of the size of a pin's head
to that of a pea and more, originating on the margin of
the tracheal wound, in one case on the lower portion of
the sore larynx itself. It required a great many appli-
cations of nitrate of silver, or subsulphate of iron, to de-
stroy them; their disappearance would instantly relieve
the symptoms and allow of the final removal of the tube
from the trachea. Such is the case of the boy D'Echauf-
four, a patient of Dr. Hoeber's, for whom I performed the
operation, at No. 67 Sixth Street, whose final recovery
was long deferred by such new-formed granulations, and
who is still said to suffer now and then from sudden at-
tacks of dyspnoea, which (although I have not seen the
child for some time) may still depend on the presence
of small polypous excrescences, giving rise to obstruction
or spasmodic contractions, when forced inspirations are
taking place.
Not all of my operations were made on uncomplicated
cases of laryngeal obstruction. In two, bronchitis had been
diagnosticated in the incipient stages of croup, and almost
all the cases, from 1859 to 1867, were complicated with
local and general symptoms of diphtheria. Seldom have
I operated on a case, without fever attending it from the
beginning; seldom without the presence of swelling of the
adjoining lymphatic glands. Those who have watched the
prevalence of local diphtheria and general diphtheria in
this city from 1858 up to this day, will feel satisfied that
my statement is not exaggerated.
Now, while I admit that with symptoms of general diph-
theria complicating a case of laryngeal diphtherite called
membranous croup, the prognosis of the operation becomes
more doubtful, I lay stress on the very same fact for the
reason, that even in such cases, the only indication for the
operation rests in the local obstruction. For it is easily
understood, that while general diphtheritic poisoning with
insufficient obstruction does not indicate tracheotomy; it
is just as plain common sense that suffocation from ob-
struction of the larynx complicated with a constitutional
244
TREATMENT OF CROUP
affection, requires the only possible relief just as urgently
as suffocation from obstruction of the larynx without such
a complication. Seeing a person suspended by the neck
and being strangled, we should hardly investigate into the
propriety of cutting the rope from the point of view that
the sufferer might be or is affected at the same time, with
tuberculosis, carcinosis, or diabetes.
Still, there are other complications of croup which in
the opinion of many authors have contraindicated the op-
eration. Among these is bronchitis, and broncho-pneu-
monia, or other serious diseases. But among the number
of my recoveries is the boy Rinaldo, of 94 Catherine
Street, who had been suffering from bronchitis before the
membranous obstruction of the larynx, resulting in im-
minent danger of life, with the usual symptoms, required
tracheotomy, who developed bilateral pneumonia after the
operation, and still got well; and the boy D'Echauffour,
of 67 Sixth Street, who was taken with scarlatina, three
days after the operation, and also recovered. I mention
these facts to show that no regard and no prejudice ought
to detain us from opening a new base of supply, when the
original, normal one is cut off.
Death followed the operation, out of the 54 fatal cases,
within 62 hours, in four cases; within 1 day in seven; on
the 2d day in three; the 3d in eleven; the 4th in ten; the
5th in seven; the 6th in four; the 7th in one; the 9th in
one; and the 13th in one.
The causes of death were the following:
Suffocation before the operation was finished, 1. It was
the case of a girl of five years, hearty and robust; no
difficulty in the performance of the operation until the in-
cision into the trachea was made. Five cartilages being
incised, I was astonished not to find the peculiar strong
gushing sound of sudden respiration; so much the more I
hurried to insert the tube, which after repeated attempts
I found impossible. Thinking the trachea might be ab-
normally narrow, I tried to introduce the inner tube only;
impossible. I then inserted an elastic catheter, but could
not succeed in introducing it. Meanwhile, the child died.
Fearing I had not opened the trachea at all, and pushed
245
DR. JACOBI'S WORKS
my instrument downward in front of the trachea in the
loose cellular tissue, I removed the dilator and found the
incision correct. I then forced a silver probe into the
trachea, and felt some hard mass giving way after some
pressure. The problem was then easily solved. The
trachea and bronchi were densely filled with membrane, my
incision had penetrated the trachea but not the membrane,
thus my tube doubled the membrane inside the trachea, de-
taching it from its anterior wall; and thus, the child was
strangled in the attempt to save her life.
Carbonic acid poisoning, asphyxia, 6. Operation per-
formed too late.
Anaemia and exhaustion, 3.
General diphtheria, 8.
Bronchitis, 6.
Broncho-pneumonia, 15. Two of these died soon after
the operation; one, a case of Dr. Blumenthal's, in which
the diagnosis of the complication could not be made before
the operation, in consequence of the laryngeal sounds cover-
ing the auscultatory symptoms belonging to the lungs ;
half an hour after the opening of the windpipe.
Bilateral croupous pneumonia, 1.
Broncho-pneumonia and gangrene of the lungs, 1. A
girl of ten years, in 157 Eldridge Street, in whose neigh-
borhood a large number of cases of diphtheria and croup
occurred at that very time, 1864, showed the symptoms of
general diphtheria on the first day after the operation.
Every accidental sore on her skin became covered with
diphtheritic membranes, and the wound assumed a fearful
character. The diphtheritic necrosis of the tissue crept
along the margin of the wound, along the intermuscular
tissue, dissected as it were the single muscles, destroyed
part of them and the whole of the surrounding cellular
tissue, destroyed part of the cartilages until the tracheal
wound was more than an inch in length, and one-third of
an inch in width, so that the tube moved freely in the large
aperture. On the fifth day extensive broncho-pneumonia,
and on the eighth gangrene of the lungs commenced to
show its fearful symptoms. The girl died on the thir-
teenth day.
246
TREATMENT OF CROUP
Uncomplicated pulmonary oedema (the case spoken of
above). 1.
Suffocation from the membranous deposits extending
into the smallest ramifications of the bronchi, 5. Four
of them died on the third day; two exactly after sixty
hours. One, a patient of Dr. Ranney's, on the fifth day.
All of these cases did apparently well for some time, until
the exudative process showed its presence far below. In
some the process did not stop at all after the operation,
but went gradually on. In some there was a complete
rest, or intermission, and the chances very good indeed,
thus in Dr. Ranney's case for three days. Then at once,
the process would commence anew and not terminate until
death.
Miliary tubeculosis, 1. A little girl had suffered from
broncho-pneumonia some time previous; was reported to
have recovered, but to have remained feeble. On the
third day after the operation a violent fever set in, with
general bronchitis. She died within thirty-six hours after.
The post-mortem examination revealed an abscess half an
inch in diameter in the upper lobe of the left lung, and
cirrhosis of part of the same lobe, and miliary tuberculo-
sis of recent date.
Exhaustion and pneumonia, 1. This was a very unfor-
tunate case of the following description: A little girl
of four years, a patient of Dr. Levings', appeared to do
well after the operation, for some days. I commenced
local cauterization of the larynx for the purpose of re-
moving the membranes on the second day, and continued
the same every day until the fifth. I held the solid stick
of nitrate of silver by means of a forceps which I in-
troduced into the trachea, end upward. With an unex-
pected movement of the child, I lost hold of the caustic,
which fell downward and was not recovered. Incessant
and violent coughing, day and night, with rare intermis-
sions, was the next, pneumonia the final result. The child
died on the ninth day. The post-mortem examination re-
vealed no tracheitis, no bronchitis in the ramification of the
first order, little injection in those of the second. A piece
of nitrate of silver sticking to the inner side of the right
247
DR. JACOBI'S WORKS
large bronchus immediately imbedded in a thick albumin-
ate, and not entirely obstructing the lumen. No injection
in the neighborhood of the lining membrane. Old caseous
infiltration by the hundred in the two upper, and the mid-
dle lobe of the right lung. A recent hepatization in the
middle lobe of the right lung, and in the two lower lobes.
Dr. Lothar Voss has placed at my disposal the statistics
of his operations of tracheotomy performed for croup be-
tween 1853 and 1867. He has operated forty-three times,
on twenty-three boys and twenty girls. Of the twenty-
three boys, four recovered; of the twenty girls, six.
How much the prevalence of general diphtheria ap-
pears to have interfered with the results a fact which
has also been proved by my own experience, as I have no
case of recovery for instance in 1865- is shown by the
fact that of his six cases operated before the end of 1858,
five recovered; while of the remaining thirty-seven oper-
ated upon between 1859 and 1867, but five recovered. Three
of his cases were under two years, namely, 1 year 1 month,
1 year 8 months, 1 year 11 months, all of them girls, none
of whom recovered. The only fatal case in 1858, the sixth
of the number, was successful enough as far as tracheotomy
itself is concerned, although it is counted among the unfa-
vorable cases, the tube being removed on the ninth day.
The child appeared quite well, but feeble. General and lo-
cal diphtheria set in, of which and of the consecutive
anaemia, the child died on the thirty-first day after the
operation.
The ages of the children on whom Dr. Voss has op-
erated are the following: 1 to 2 years, three cases; 2
to 3 years, fifteen; 3 to 4 years, ten; 4 to 5 years, eleven;
5 to 6 years, two; 6 to 7 years, one; and 7 to 8 years,
one.
Of those who recovered, the age was 4 years 2 months ;
4 years ; 4 years 3 months ; 3 years ; 4 years ; 2 years
4 months ; 2 years 6 months ; 2 years 6 months ; 2 years
6 months; and 6 years 5 months.
In these ten cases the tube remained 8, 6, 8, 19, 14,
14, 8, 8, 5, 6 days. Some delay took place, usually,
before the wound, which I, in my cases, have found to
248
TREATMENT OF CROUP
heal very fast, would close and remain so. Thus, a
complete closure required in nine cases 18, 21, 19, 26, 25,
25, 30, 22, 17 days. On the tenth there is no record.
There are, besides, three cases which virtually belong to
the recoveries, as far as the operation and its influence on
the laryngeal obstruction is concerned. A child of 2 years
10 months was operated upon, the tube could be removed
on the ninth day, but before perfect union of the wound
had taken place, general diphtheria set in, and destroyed
the patient on the thirty-first day; a child of 2 years 2
months had the tube removed on the seventh day, and died
of bronchitis on the eighth ; and a third one, of 5 years
2 months, after the tube had been removed on the eighth
day, died on the sixteenth of pneumonia and consecutive
pulmonary abscesses.
Death occurred, after the operation, in thirty cases,
which have been accounted for: within twelve hours in
five cases; within 1 day in three; 1 to 2 days in four;
2 to three days in five; 3 to 4 days in five; 5 days in two;
6 to 7 days in two; 10 days in one; 16 days in one; and
31 days in one.
And the causes of death are, according to the Doctor's
account of thirty cases, the following: anaemia in one;
convulsions in two; asphyxia in two; croup descending into
the bronchial tubes, eighteen, (three of these were com-
plicated with general diphtheria, two with convulsions;)
emphysema in two; pneumonia in three, (two of which
resulted in pulmonary abscesses;) bronchitis in one; and
suffocation by accidental removel of tube in one.
Mr. Chairman, I hold in my hands, besides the statis-
tics of my own sixty-seven and Dr. Voss's forty-five cases,
a list of fifty-six cases of tracheotomy performed for croup
by Dr. E. Krackowizer, our townsman. Of his fifty-six
cases, fifty-five belong to this city, one to Europe (fatal).
He operated on
23 in 1852-60, with 5 recoveries, and 18 deaths.
6 " 1861, " 3 " 3 "
4 " 1862, " 1 3
6 " 1863, " 3 " 3
5 " 1864, " 3 2
249
DR. JACOBI'S WORKS
6 in 1865, with 1 recovery, and 5 deaths.
2 " 1866, " - 2
3 " 1867, " - 3
55 16 39
The causes of death were croup and bronchitis, thirty;
infectious diphtheria, three; scarlatina, one; tracheal gran-
ulations and attacks of dyspnoea, and exhaustion, 54 days
after the operation, and 4 weeks after the wound healed,
one; exhaustion and pulmonary oedema, four; suffocation
during the operation, one. Total, forty.
I further, Mr. Chairman, in presenting this fourth list
of statistics to you and the Society, desire to pay due hom-
age to the memory of a deceased physician who is re-
membered by a number of those present, although over
his accomplishments and expectations the grave has been
closed these last ten years. Dr. Waldemar von Roth was
the first among us who operated extensively for croup;
and if he had no other merit to fall back upon, that would
be sufficient that his memory should never die out from
among both his professional brethren, and the public. Be-
tween August, 1852, and January, 1856, he operated on
forty-eight cases, eleven of which recovered. Of the thirty
boys 9, and of the eighteen girls 2, recovered. He re-
cords in 1852, six operations, and two recoveries; in 1853,
eleven operations, and three recoveries; in 1854 sixteen
operations, and two recoveries; in 1855, nine operations,
and two recoveries; and in 1856, six operations, and two
recoveries.
My last statements have been rather cursory, Mr. Chair-
man, as I have been afraid of taxing your patience too
largely. I shall consider it my duty, as this subject has
come up for consideration, to present all the statistics
from which I have drawn to-night, to the medical public.
What, however, my object has been, in speaking of a
subject on which every one has obtained more or less
knowledge, is clear. I meant to sift vague or misunder-
stood doctrines, to show that no harm is done by acknowl-
edging the limits of our science and art, to prove that it
is of more importance to know what cannot be accomplished
250
TREATMENT OF CROUP
by the internal administration of medicines than to fight
an overpowering enemy with remedies, the number of which
is surpassed only by their powerlessness, and finally, to
state the results of tracheotomy in more than two hundred
cases of croup, every one of which would, surely, have
perished without it. Let those fifty doomed children saved
by the operation, and let those whose sufferings were at
least alleviated, plead before you the cause of tracheotomy.
251
CHOLERA INFANTUM
HEALTHY infants have a normal tendency to loose, liquid,
or semi-liquid evacuations from the bowels. The cause of
this looseness lies partly in the condition of the intestinal
tract, and partly in the nature of the normal food, which
is breast milk. Peristaltic movements in the healthy child
are very active. The young blood-vessels and lymph ducts
are very permeable, and the transformation of the surface
cells is very rapid. In this way transudation from blood-
vessels and the lymph bodies of the intestine is facilitated.
The peripheral nerves are very superficial, more so than
in the adult, whose mucous membrane and submucous tis-
sue have undergone thickening both by normal develop-
ment and morbid processes. In the young infant the pe-
ripheral ends of the nerves are longer in proportion than
in the adult. The anterior horns in the nerve centres are
more developed than the posterior ones. Moreover, through
the defective development of the inhibitory centres, the
reflex irritability of the young, particularly with regard to
intestinal influences, is greater. Besides, the retentive
action of the sphincter ani is not very powerful; the faeces
are not retained in the colon and rectum, which is straight
and adjacent to the steep infantile sacrum, and but little
time is generally afforded for the reabsorption of the liquid
part of the intestinal contents. All this illustrates the
facility with which a moderate or even a copious elimina-
tion of liquid stools may take place.
Moreover, the frequency of acids, sometimes normal, in
the small intestine, gives rise to the formation of alkaline
salts with purgative properties. Hoppe-Seyler found free
acids in the faeces in dogs and the human adult. Weg-
schneider met them in nurslings who received nothing but
mother's milk. An explanation of this occurrence may be
found in the fact that the quantity of food is often too
253
DR. JACOBI'S WORKS
large; but in many instances the amount of digestive fluid
is too small, and thus fermentation is caused in place of
normal digestion. Moreover, the diastatic effect of the pan-
creatic juice is limited at a very early age, and undigested
material is carried off. In this way, the movements may
become quite loose, without the occurrence of extensive or
deep anatomical alterations. Superficial changes, however,
may take place; they consist in the hyperaemia of the
surface in rapid transmutation of epithelium, and the for-
mation of mucus.
Most cases, however, of actual diarrhoea originate in ex-
cessive peristalsis, which may be either local or general.
If it be limited to the small intestine exclusively, the
contents retained in the colon may become dry, and the
presence of hyperperistalsis in the former may then be
doubtful. It may be caused firstly by irritation of local
(intestinal) origin, or secondly by irritants furnished either
by the nervous system or by the blood.
The first class embraces improper and indigestible foods,
or excessive quantities. The abnormal composition of
mother's milk is an occasional cause. Mothers who are
sick, or convalescing, or subject to strong emotions, those
who nurse too often, or suffer from tuberculosis or
syphilis or anaemia, or are pregnant or menstruating, do
or may secrete an anomalous milk. The colostrum secreted
immediately after childbirth may cause diarrhoea; so may
milk which contains too much either of fat, or casein, or
sugar, or salts. It is mainly the casein, whose coagulation
causes more intense disorders in the young than the
causes leading to stercoraceous diarrhoea in the adult. An
excess of fat is very irritating by the formation of acid.
It is true that it is not the only element of perturbation
in the usual food of the young, viz., milk. The milk sugar
and albumin, as well as the fat, may give rise to the de-
velopment of acids. In that respect the albuminoids (casein
principally) are not very injurious, even milk sugar is but
moderately so; but as the oxidizing power is greatly re-
duced in gastrointestinal disorders, the products of the
decomposition of fat are very active. Together with fat
acids, carbonic acid and sulphide of hydrogen are formed.
25*
CHOLERA INFANTUM
Their irritating effect may give rise to hypersecretion,
only, but frequently leads to catarrh. A similar effect is
caused by purgatives, mainly by salts either medicinal or
contained in fruit or certain abnormal milks. Parasites
act similarly, from lumbricoids to trichomonads or amoebae.
It is true that when present they have not always caused
the liquid stools in which they are found indeed, in a
case lately observed of intestinal ulceration of long duration
trichomonads were not found for months, until at last they
appeared in incredible numbers, thus suggesting that it was
the abnormal condition of the intestine and of its con-
tents which facilitated their existence, and not vice versa.
But the occasional improvement of diarrhoeal diseases after
the removal of such parasites allows of but little doubt
that they may be the actual cause of the liquid and of-
fensive stools in which they are found.
The intestines may be irritated by changes of innerva-
tion, less, it is true, in infants and children than in adults.
Experiments on the pneumogastric, sympathetic, and
splanchnic nerves have furnished ample proofs of their
influence on intestinal secretion and peristalsis, but it is
mainly clinical observation which has established its ex-
istence. Trousseau discoursed extensively on nervous diar-
rhoea. The gastric and intestinal crises of tabes dorsalis
are frequent occurrences. Beard quoted both constipa-
tion and diarrhoea among the symptoms of neurasthenia;
Mobius claims the same for migraine; the action of tobacco
is of daily experience. Nor is it out of place to remember
the influence of rapid changes of temperature among the
most frequent causes of diarrhoea, in all seasons, and for
all ages. Thus the prevalence of bacteria and toxins in
our etiological reasonings should not be able to dislodge
reflex hyperaemia and secretion from their correct places
as causes of disease. Like the nasal mucous membranes,
the intestinal surface is profoundly and suddenly influenced
by colds. Wet feet and exposure of the perspiring skin
to a cold or draught will convince the most obstinate and
exclusive claimant of bacterial rights of his dependence on
other external factors.
Intestinal irritation, with peristalsis and hypersecretion,
255
DR. JACOBI'S WORKS
is often caused by changes in the blood. Pilocarpine, or
salines and other purgatives injected under the skin cause
diarrhoea. So does uraemia, sometimes without any ana-
tomical alterations of the pale mucous membrane, other
times with catarrhal, ulcerous, or croupous changes de-
pending on the action of ammonium carbonate. Extensive
burns of the surface of the body exhibit similar results.
They are also observed in malarial poisoning. Infections,
such as those in lobar pneumonia, influenza, erysipelas, and
septicaemia, may cause intense diarrhoea, with or without
visible alterations. Even typhoid fever may give rise to
extensive transudations without either catarrh or ulcera-
tions of the mucous membranes. That is mainly so in a
certain number of young patients, in whom Peyer's plaques
are but slightly developed and but slightly changed. Ho-
denpyl's latest researches prove that even without glandular
changes typhoid fever may exhibit all sorts of typhoid
symptoms. Asiatic cholera, finally, by its toxin, which is
absorbed and reaches the intestinal glands, results by hy-
persecretion and failing absorption, in very copious dis-
charges. We shall see that cholera infantum exhibits the
same symptoms.
SYMPTOMS
Cholera infantum may be preceded by symptoms of
gastric or intestinal, or gastrointestinal catarrh, but is fre-
quently ushered in without any prodromi. Vomiting and
diarrhoea, often diarrhoea without vomiting, with either a
moderate or a high elevation of temperature, are the first
symptoms. Vomiting follows the ingestion of food or drink
immediately, and may be continued without this cause. In
the latter case nothing but mucus and a serous fluid, later
bile, are brought up ; the latter in small quantity, until its
secretion and elimination stop altogether. The alvine dis-
charges are copious and numerous, from half a dozen to
two dozen a day. They are acrid at first, alkaline after-
wards, and watery. They contain no bile but large masses
of intestinal epithelia and bacteria. The abdomen is soft.
The thirst is intense, the pulse small and frequent, the
voice hoarse or gone, the fontanelle depressed, the skin
256
CHOLERA INFANTUM
cool and inelastic to such an extent that it can be raised
in folds. At this time the temperature of the cavities, if
it was high at all, sinks to or below its normal level.
The cornea becomes turbid, respiration difficult, and general
collapse sets in. The rapid loss of water from the circu-
lation results in anuria and in thickening of the blood, by
which are caused cerebral symptoms depending on the
slowness of intracranial circulation, or on actual thrombo-
sis. Listlessness with exhaustion, and convulsions when oc-
curring from these sources are called hydroencephaloid.
They are complicated with those caused by uraemia, which
originates in the absence of renal secretion. The latter does
not depend, however, on the copious loss of liquid through
intestinal oversecretion alone, but also on actual nephritis,
which is recognized by the presence of red blood cells
and leucocytes, and of hyaline, epithelial, and granular
casts in the small amount of urine either spontaneously
evacuated or secured by catheterization. If the patients
live long enough, they develop in the lower extremities
sclerema which has the tendency to ascend slowly. Chronic
cases, or those which turn to a slow recovery, are also
apt to cause furunculosis of long duration, with frequent
relapses, great suffering, and possibly change into actual
septicopyaemia. Pneumonia, pleurisy, peritonitis, and men-
ingitis may follow. They may be the results of thrombo-
sis, or of the original microbic infection which need not,
and seldom does, limit itself to the intestinal tract. Alto-
gether the symptoms of the different stages of cholera in-
fantum are explained in two ways, either by the direct
intoxication, or by the abstraction of fluids from the or-
ganism.
COMPLICATIONS
One of the most interesting complications or sequelae
of cholera infantum, indeed of all such intestinal disorders
as present or furnish toxins', is that with renal derangement
or disease. Like the liver, the kidneys while their tissues
are normal eliminate microbes from the blood (Biedl and
Kraus). 1 This process is increased by diuresis, an obser-
vation which is of considerable value for therapeutics.
257
DR. JACOBI'S WORKS
The first functional change is albuminuria. It may be of
no account even when it is cyclical, and when it makes
its appearance only when the patients are out of bed,
and differs greatly in its import from the formation of casts
which depend on morbid processes either in the secreting
epithelium or in the intercellular substance. Genuine
nephritis, either parenchymatous or intercellular, occasion-
ally with shrinking, with hemorrhage, rarely amyloid, and
seldom exhibiting dropsy, retinitis, vascular tension or
cardiac hypertrophy, is a very frequent result of intestinal
toxicity. In a small hospital containing little more than
forty beds, I noticed lately at the same time four cases
of nephritis evolving out of and accompanying protracted
colitis.
PATHOLOGICAL ANATOMY
When the disease has lasted only twenty-four hours
there may be few or no changes in the gastrointestinal mu-
cous membrane. When it has lasted longer, the mucous
surface is deprived of its epithelium (under the influence
of excessive fermentation and secretion brought about by
toxins, nerve influence, or ingesta). Between the gastric
glands round cells are deposited in large numbers in the
mucous membrane of the stomach. The gland cells are
swollen, and according to Fischl and Heubner 2 their nuclei
are stainable only with great difficulty. The same round-
cell proliferation takes place in the lower parts of the in-
testinal tract; here also the epithelium of the villi is thrown
off. The blood-vessels are dilated and filled with blood.
Lieberkiihn's glands are rarely intact; they exhibit funnel-
like dilatations and an increase of cells, which is also
manifest in other glands. Peyer's plaques, too, are large
and rich in newly formed cells, which are also found be-
tween the muscles. Microbes are met with in large num-
bers and in many varieties. Bacterium lactis aerogenes
mostly in the upper part of the bowels, and B. coli com-
mune mostly in the colon, are common. Among them there
are streptococci and liquefj'ing bacilli which are inconstant
though frequent in all sorts of diarrhoea. So far as bac-
terium coli commune is concerned, it was discovered by
258
CHOLERA INFANTUM
Escherich in 1885. At that time it was considered to be
harmless. But in 1889 it was found by Larnette in two
cases of perforation peritonitis; its cultures caused experi-
mental peritonitis in animals. Since that time it has
been met with in many tissues of the human body, into
which it has emigrated during the moribund state or after
death; but it appears also to be settled that it may cause
inflammation, suppuration, and sepsis in many diseases, such
as enteritis, colitis, typhlitis, peritonitis, cystitis, pyelone-
phritis, cholecystitis, meningitis angina, pneumonia, endo-
carditis, arthritis, salpingitis, endometritis, lymphangitis,
panaritium, gas phlegmon, and puerperal fever. Lately a
case of peri- and endometritis was published by Uhlen-
huth, 3 who claims that in his patient the bacterium coli
exhibited three different degrees of virulence.
Like Escherich, Booker found no specific bacteria in
diarrhoeas, but mixtures of many; proteus vulgaris was
mostly found in the colon, also in the stomach, least in the
small intestines. When streptococci are extensively met
with, they give rise to symptoms resembling an irregular
typhoid fever, and depending either on streptococcal infec-
tion or on the absorption of a toxin. All of them are
or may be the causes of the palpable changes in the in-
testinal surface; when they are severe and lead to ulcera-
tion, microbes may be swept into the circulation. In this
way the lungs are known to be infected. Still it should
here be emphasized that intestinal ulceration does not al-
ways require the presence and action of bacteria to any
or to such a degree as in diphtheritic or gangrenous colitis,
where they are mostly in evidence.
The contents of the bowels are copious and thin, exactly
like those which are observed in children who have died of
convulsions during the hot season. In sunstroke both the
stomach and the intestines are apt to be found in the same
condition. This similarity is very suggestive. It appears
to show that cholera infantum, when fatal on the first
day, proves so by paralysis exactly as in insolation. At
that early time surely cholera infantum is not yet enteritis.
This is primary in the other forms of intestinal overse-
cretions; in cholera infantum it is secondary. The kid-
259
DR. JACOBI'S WORKS
neys are large and pale, with fatty degeneration of the
parenchyma, and sometimes pus in papillae and calyces.
Bacterial emboli are rare, certainly much rarer than in the
lungs. The liver shows the same cloudy swelling of the
parenchyma which is met with in the kidneys. Other patho-
logical changes are the intense rigor mortis, and the dark
color and defective coagulability of the blood. The me-
ninges and the lower part of the lungs are hyperaemic.
These results were partly found, and partly confirmed by
one of the most industrious and careful of modern bac-
teriologists who at the same time is a clinician, Booker,
who spent years of labor on his researches on the bacterial
nature or complications of the different forms of intes-
tinal disorders, both light and grave. He published ninety-
two bacteriological examinations, in all of which he found
the bacterium lactis aerogenes and coli commune; in most
of them also streptococci and proteus vulgaris. The num-
ber of his autopsies was thirty-three; the cases were classed
by him as acute and chronic gastroenteritis. In the former
the local alterations of the intestine were but few; but the
general infection, including that of the lungs in which bac-
teria were found, and that of the spleen and kidneys which
were mostly affected by toxins, was very intense. The
later exhibited many alterations both of an inflammatory
and a degenerative nature, which differed with the local-
ization and the destructive influence of the bacteria. When
he met with these same results in the living, the prognosis
depended on the clinical symptoms, which differed widely
in individual cases. This observation of a pathologist who
is at the same time a clinician proves again the insufficiency
of pathological anatomy when confined to the dead-house,
or of bedside observation when not guided by histological
and bacteriological research.
The ubiquitous appearance of a great many varieties
of microbes which were present in all sorts and grades of
intestinal disorders, induced Booker to venture upon a class-
ification which is partly clinical, and partly bacteriological.
He distinguishes three forms of diarrhoeal diseases : (First )
The dyspeptic diarrhoea, with no inflammation, with no leu-
cocytes or epithelia in the lumpy acid stools, with plenty
260
CHOLERA INFANTUM
of bacteria coli communia, and few specimens of bacterium
lactis aerogenes. This is sometimes an independent form,
but other times the first stage of (second) the streptococcic
gastroenteritis. This has the character of a general in-
fection, the intestines are ulcerated or suppurating, the
stools contain mucus, leucocytes, and streptococci. These
are sometimes very numerous, in some instances mixed with
bacteria coli communia. When cocci are prevalent, the
cases are very obstinate and fatal. Booker's third form
is a bacillary gastroenteritis. It exhibits less local inflam-
mation than intense toxaemia. A great many varieties of
bacilli are found, with or without streptococci. Not one
of these three classes, however, is claimed as a clinical
or pathological entity; on the contrary, transitions between
them are pronounced to be very frequent. 4
After all, observers agree in the absence of a constant
and pathognomonic microbe. Among others, Baginsky and
Stadthagen found a body (probably basic) in the cultures
of a bacillus from cholera infantum which is probably
identical with one obtained by Brieger in decomposing
horseflesh, that is very poisonous, acts on frogs like curare,
dilates the pupils, and stops the heart in diastole.
ETIOLOGY
The theories established for the explanation of cholera
infantum changed with those governing etiology in general.
Fifty years ago almost all the diseases of the infant, and
some of the mother, were traced back by Thomas Ballard
to " fruitless sucking." Infant cholera was by some con-
sidered identical with Asiatic cholera. Some unknown at-
mospheric influence, sewer emanations of undescribed na-
ture, evaporations of the upper strata of the earth, ma-
laria, moisture, the oscillations of the barometer, or of the
subsoil water were charged with being the causes of cholera
infantum, with equal and positive fervor.
When etiology became more bacteriological, microbes
were accused, for instance, those of the genus ascophora, by
Bouchut; others looked for poisons, as Sonnenberger, for
the presence in the food of plant alkaloids.
261
DR. JACOBI'S WORKS
The temptation to attribute cholera infantum to the di-
rect influence of microbes was combated by the fact that
too many of the latter were found, and that it became diffi-
cult to identify a single one as the cause of cholera infan-
tum. Neither Escherich nor Baginsky nor Booker con-
vinced himself that there was a direct connection between
the presence of special bacteria with the symptoms of
cholera infantum. Baginsky found twenty species or va-
rieties of bacteria, mostly saprogenous, none of which could
be claimed as pathogenous. Thus chemistry, after having
long been neglected, had to be called in. Uffelmann and
Seibert accused the decomposed milk sold in large cities,
Lesage a poison produced by some microbe not specific,
Vaughan his tyrotoxican. The poisonous substance would,
in the opinion of many of these authors, be evolved out of
milk, even out of breast milk. Difference of opinion, how-
ever, became apparent in regard to the question whether
the poison entered ready made with the milk, or was de-
veloped out of it in the alimentary tract of the infant.
Both of these opinions are founded on facts ; in many cases
both roads were found accessible to the poison.
The first stages of cholera infantum do not look alike.
Some cases begin very abruptly, others have a slight gas-
trointestinal disturbance or prodrome. The patients are
less than two years old. In the vast majority the feeding
is artificial, and with but few exceptions the attacks occur
during the hot months of the summer, on such days as
furnish only a slight difference between the tempera-
tures of day and night, and during the weeks following
them.
Constant heat is undoubtedly a prominent etiological
factor. It appears, however, that when and where the
babies are habituated to a warm climate, they do not suffer
like those who are suddenly exposed to excessive tempera-
tures. The differences of temperature, as collated by
Meinert, between January and July, are in Africa 3.4
C. (6.1 F.), in South America 4.2 (7-5 F.), in Aus-
tralia 13 (23.4 F.), in central Asia and Europe 26.1
(47 F.), and in North America 28.4 C. (51.1 F.). The
sudden heats of the temperate zones are among the prin-
262
CHOLERA INFANTUM
cipal causes of cholera infantum; in them it is most fre-
quent, though it be found in warm climates.
How does heat affect the babies, indirectly or directly?
Its indirect effect is best appreciated when it is remembered
that breast-fed babies do not suffer like those artificially
fed. Meinert's observations in Dresden 5 yielded eighteen
deaths among the former, four hundred and sixty among
the latter in eleven hot summer weeks. This agrees with
what every practitioner learns from his own experience.
That coarse and fermentable food leads to catarrhal irri-
tation of the intestine which may precede cholera infan-
tum, or to the formation of a toxin or toxins which cause
it without a previous anatomical lesion, is easily under-
stood.
Is there anything like a direct influence of heat on the
baby with the result of causing cholera infantum? It has
always appeared so to me. In a brief paper r^ad before
the Verein Deutscher Aerzte in 1858 it is contained in
the minutes of the society I took that stand; and again
in 1868 in a paper 6 entitled " Concerning the Neglected
Causes of Infant Mortality in the City of New York."
Twenty years ago Clark Miller 7 pointed out the striking
resemblance between cholera infantum and sunstroke. He
claimed the symptoms belonging to the former as due to
paralysis. Meinert shares his opinion to its full extent.
Both are disease of the hot season, and caused by un-
interrupted heat. Hot days relieved by cool nights are
well tolerated; it is the constant heat which proves detri-
mental. Constancy is still more dangerous than temporary
excess. A relatively lower temperature, but relentless
and moist, demands most victims. High temperatures with
wind and drought are comparatively safe; absence of ven-
tilation is destructive. No wall ventilation takes place
during summer; and in the first weeks of the autumn the
houses remain warmer than the surrounding air, for the soil
retains the temperatures soaked in during the summer.
All this is worse in large cities, in crowded streets, where
the buildings are high and exclude wind and draught, in
narrow flats or tenement houses, in residences with scanty
windows looking in one direction only. In them the
263
DR. JACOBI'S WORKS
babies are housed, there they are stifled in their beds. If
they be breast fed, they are now and then taken up and
changed about. If not, they are given their bottles in their
cribs without perhaps changing their positions. Lehmann
experimented on such babies buried in their beds, and found
that they inhale four times the amount of carbonic acid
received by those not so buried. They are the ones that
are liable to suffer, though or rather because they are not
exposed to the sun, from isolation ; they are the very vic-
tims of cholera infantum. For in addition they lack what
is most essential to keeping up circulation and tissue meta-
morphosis, viz., water. Sweltering in their unclean and
hot bed prisons they are given the exact food they receive
on cool days. The very adults who will satisfy their
thirst by copious draughts of water, will never think of giv-
ing an extra allowance of it to their starving young ones.
The breast-fed infant is better off in that respect also.
The mother or nurse, drinking ad libitum, dilutes her milk,
for breast-milk is no unchangeable article like the Gordon-
Walker or Gaertner; it may change in certain limits its
percentage of constituents every hour of the day, every
day of the week.
The question whether heat causes cholera infantum by
its direct or indirect effects is therefore easily answered.
It acts in both ways. By fermenting and spoiling the
baby's food, mainly cow's milk, it produces deleterious
ptomains. By paralyzing its nervous system it causes the
characteristic gastric and intestinal disturbances, overse-
cretion and non-absorption. Both of these need not coin-
cide with, or depend on, catarrhal or other changes of the
alimentary tract. But these latter will become apparent
when the former have lasted more than a day.
No single cause will always have a uniform effect. In-
dividual power of resistance and vitality increase or lessen
the action of external circumstances. A certain predis-
position is always required to make a living being submit
to a morbific influence. Not everybody suffers from inso-
lation when exposed to protracted heat. Nor is the same
food equally dangerous to all. In the foundling hospital
of Prague, under Epstein's control, the mortality of the
264
CHOLERA INFANTUM
infants is excessive; that of the same class of infants when
sent to the country and fed on the same material, is com-
paratively trifling. In a small ward of a hospital or in a
private room of a poorly equipped residence the mortality
of infants is not so great as in large wards or big in-
stitutions. When thirty years ago I proved that in such a
one every infant that was kept a few short months died,
I was expelled for my pains. Still the fact remains
exactly so. One of the most assiduous and learned pedia-
trists of modern times, Heubner, had the same experience.
He expects the little waifs in his hospital to live only when
he is able to transfer them to the country, or to their own
poverty-striken homes. Thus not even better hereditary
influence, or constitution, or previous good condition are
safeguards ; and bad food alone is not the only detriment.
It should not be forgotten that in many cases the fatal
intestinal disorder is of microbic origin, or is readily be-
coming complicated with microbes and their toxins. They
are contagious. There is no hospital or nursery ward with-
out them. The clothing and bedding are soiled, the nurses
stain their fingers with it, and going from one baby to
the other, feeding, washing, changing clothes, infect one
after the other from a single source. Infection of the intes-
tinal tract takes place not only through the mouth but also
through the anus. This source of infection is almost
unavoidable. Heubner succeeded in reducing his mortality
by more than twenty per cent, by simply employing a set
of nurses for the exclusive duty of attending to the
diapers, and another set for feeding and other attendance.
As long as a single nurse has the whole attendance on a
number of infants, absolute cleanliness of her fingers is
practically an impossibility. If in every such institution
the mother could be kept with her infant, the danger of
contagion would be relatively small.
DIAGNOSIS
The diagnosis of " cholera infantum " becomes difficult
only in those cases which have developed out of catarrhal
conditions of the alimentary tract under the same in-
265
DR. JACOBI'S WORKS
fluences which give rise to all sorts of disturbances, viz.,
constant solar heat and inappropriate feeding. For the
purposes of practice an exact diagnosis in difficult cases
is perhaps not always very important. For no matter
what the case may be called, the indications presented by
the local changes in the alimentary tract and by the con-
stitutional symptoms exhibited by the patients are more or
less identical. Still the diagnosis of " cholera infantum "
from other forms of gastrointestinal disturbances should
be made; in many of the latter the successful treatment
depends on the exact knowledge of the condition of the
bowels. There are several forms of diarrhaea which should
be known in this connection, viz., fat diarrhoea, catarrhal
enteritis, and follicular enteritis.
The name of " fat diarrhoea " was given by Biedert to
a condition in which the normal proportion of fat in the
infant faeces, which amounts to from four to twenty-five,
mostly from nine to eleven per cent., is increased to from
forty-one to sixty-seven per cent. In this form of di-
arrhoea the discharges are shining and glossy with fat of
yellowish or gray color, sometimes greenish, mixed with
mucus, and mostly very malodorous. The fat molecules
are large, in the normal faeces small. It should be re-
membered, however, that the percentage of faecal fat is
liable to be increased in every attack of dyspepsia (Tscher-
now, Uffelmann).
This fat diarrhoea may be primary or secondary. The
first is the direct result of the ingestion of an excess of
fat, and is relieved by correcting the composition of the
food. Fat should be diminished, and sometimes withheld
altogether. For some days the substitution of egg water
(albumen beaten up in water or in barley or toast water),
or of a thin chicken broth is advisable. There are some
babies who from the moment of birth bear milk, even
breast milk, in great dilution only an illustration of the
justice of my demand of ample dilution of the food given
to the newly-born and very young.
The secondary form of fat diarrhoea, not depending
solely on an excess of fat, is due to catarrhal conditions
of the intestine, or to disease of the pancreas. In autop-
266
CHOLERA INFANTUM
sies duodenal catarrh, a large size and dry condition of the
pancreas, a contraction of the orifice of the choledochus
and pancreatic ducts, parenchymatous pancreatitis and
fatty degeneration of the liver have been found. A mod-
erate amount of the latter, however, is met with under
normal conditions of the baby.
In intestinal catarrh (catarrhal enteritis) there are fever,
diarrhoea, and pain, and when the affection begins in the
stomach, vomiting also. The babes are pale, and draw up
their legs, and when the catarrh descends to, or begins in,
the rectum, there is tenesmus. The evacuations in the
beginning contain remnants of food, and have a stronger
odor than normal faeces, still they are not very offensive;
afterwards they are liquid, light yellowish or brownish in
color, strongly acid, but later of an alkaline reaction, with
many specimens of bacteria (none of which is character-
istic of the affection), epithelium, mucus, sometimes pus,
and remnants of food of all kinds ; the percentage of
water is very large, amounting to ninety to ninety-five per
cent., while in normal faeces of the nursling it is but
eighty-five per cent., and in older children eighty to seventy-
five per cent. ; particularly is the percentage of water
large in all those cases of diarrhoea which depend upon,
or are complicated with, disturbances of the circulation
brought on by diseases of the heart, the lungs, or the
liver. If the evacuations were first odorless, they become
faecal, afterwards acid, and in protracted cases and so-
called follicular enteritis, cadaveric.
In the beginning of the disease there is sometimes herpes
labialis, and the urine is diminished in quantity, but is
entirely arrested only in the very worst cases which have
a tendency to become choleraic. In a few cases recovery
is quite rapid; in others the disease terminates in so-called
follicular enteritis, or in chronic intestinal catarrh.
When there is diarrhoea we have to conclude that the
upper part at least of the colon is affected. Food remnants
will require two or three hours to pass from the pylorus
to the caecum; until then the contents are fluid. Below that
point they become rather dry; not so when part of the
colon is also in a catarrhal condition. Thus, when they
267
DR. JACOBFS WORKS
are quite fluid, an affection of the upper part of the colon
necessarily exists and results in undue peristalsis.
Duodenal catarrh can be diagnosed only when it is com-
plicated with jaundice, as, when uncomplicated, it never
gives rise to diarrhoea. Catarrh of the jejunum and
ileum is seldom isolated without the upper part of the
colon participating in the process, and it must be sup-
posed that they are disordered when the stomach is affected
in a case of diarrhoea. When the faeces are fairly solid
and contain conglomerate masses of mucus thoroughly
mixed with the faecal masses, we make the diagnosis of
isolated catarrh of the small intestine. Further, when the
faeces contain a great deal of undigested material we may
also conclude that we have to deal with a complicated
catarrh, involving both the small intestine and stomach;
this is the condition in which undigested food is seen in
the faeces (" lientery "). But it must be remembered that
gastric catarrh alone, with anaemia and abnormal peristalsis
of the stomach and upper part of the small intestine, is
of itself able to propel undigested food with abnormal
rapidity.
When there is bile in passages of green color, yielding
a distinct reaction with nitric acid, and attached to the
mucus and cylindrical epithelium and round cells, we have
also to conclude that the catarrh has its seat in the small
intestine, as under normal conditions there is but very
little or no bile in the large intestine.
It has been stated that when there is considerable per-
istalsis and rumbling (audible or perceptible on palpation)
in the middle of the abdomen and its lower part, the af-
fection is in the small intestine; that they are lateral and
in the upper part, when the large intestine is involved.
Still, neither pain nor locality is absolutely pathoffnomonic.
There is one condition, however, that is so. When the
mucus is not thoroughly mixed with the faeces, when the
faeces are wrapped up in or covered by it after evacuation,
then the mucus comes from the colon, and we have to deal
with catarrh of this part of the intestine; and when the
faeces are still solid, the catarrh has its location in the
lower part of the colon.
268
CHOLERA INFANTUM
As a general rule, acute catarrh of the lower part of
the colon generally furnishes pure mucus mixed with blood,
particularly in the catarrhal form of dysentery. When the
secretion from the colon is very considerable, the bowels
are evacuated more or less frequently, in large quantities
or smaller ones, suddenly and with a gush, and usually
without tenesmus, which is observed only when the lower
portion of the rectum is involved in the morbid process.
In follicular enteritis the pathological changes are those
of catarrh, but the most severe alterations take place in
the solitary follicles and in Peyer's patches. Both of these
are enlarged and prominent, and grayish or grayish-red,
the latter surrounded by a red zone; now and then ulcera-
tions are found. The microscope also reveals a large num-
ber of newly formed round cells, disintegrated or not. In
the ulcerations there are large masses of detritus and bac-
teria. The lymph vessels and lymph bodies participate
in every severe form of intestinal catarrh, and there is
a large amount of acute and chronic tumefaction of the
mesenteric glands.
The symptoms vary according to whether this particular
form is connected with acute or chronic intestinal catarrh.
In the first variety there are fever and diarrhoea, frequent
and copious discharges, all accompanied by pain ; the in-
clination to evacuate the bowels is constant, and there is
some tenesmus. When the latter is present, the passages
are small, greenish, foamy, have an insipid, musty, and
after a while cadaveric odor, are covered with mucus, some
blood and pus ; actual hemorrhage is rare. Under the
microscope are seen mucus, blood, pus, and round cells,
unchanged or undergoing disintegration, and bacilli and
zooglcea.
The symptoms are liable to increase very rapidly, and
complications with pulmonary diseases and peritonitis are
not infrequent. Although the disease is a very serious
one, slow recovery may take place.
269
DR. JACOBFS WORKS
PROPHYLAXIS
There are many measures of a public character that
would, and could, be taken in the interest of prevention
of cholera infantum and all other intestinal diseases in a
more advanced condition of public hygiene. The demand
for more air space to the individual, for the separation of,
and less stories in tenement houses, for protection against
the sun in our streets, for extensive street sprinkling, for
street cleaning, for an abundance of large and small parks
and covered piers, for public baths reserved for infants
and children, for a close and strict supervision of our
markets by the health departments, will be complied with
in some distant future when human society and the state
recognizes their responsibilities to the individual in con-
tradistinction to the egotism and individualism of the pres-
ent. Indeed many questions of the public hygiene and
welfare are of a social and politico-economic nature only;
and the safety of the individual depends on the sense of
responsibility demonstrated by the state through its laws
and institutions established and managed in the interest
of all.
Private houses and rooms should be kept cool in summer
and well ventilated. Our windows, which can never be
opened more than half, are badly arranged. If a prize
had been set on faulty construction it would have been
awarded to the man who devised our present arrangements
for light and air. The dwellings in the tenements of the
poor, with windows on one side only, with an impossibility
of procuring a draught, are the main sufferers from these
windows of which the upper half only can be lowered or
the lower half raised.
No weaning should ever take place in summer, except
for very urgent reasons, and with the possibility of pro-
curing good substitutes, inclusive of fresh or aseptic milk.
To this the most careful attention should be given. No
family should be without red and blue litmus paper, to
make sure of the absence of acidity. Altogether the rules
which have been published by the Health Department
of this city these thirty years, with but slight modifications
270
CHOLERA INFANTUM
of and additions to my original draft of 1866, have proved
useful and successful.* Diarrhoeas must not be neglected.
Diarrhoea from " teething," if it existed at all, should not
be overlooked any more than that depending on its usual
causes.
NORMAL FEEDING
The most important preventive of cholera infantum (as
of other intestinal diseases or disorders) is appropriate
and digestible food; in the vast majority of cases this is,
for the poor infant, human milk. Whenever that cannot
be had, propeo* substitutes should be provided. Among
them the milk of the goat and that of the cow take the
highest rank. The former, however, contains too much
* The original draft of those rules, which was but slightly al-
tered afterwards, was as follows:
If you nurse your baby:
Do not nurse your baby oftener than once every two or three
hours.
Do not nurse a baby of more than six months oftener than five
times in twenty-four hours. When it is thirsty in the mean time,
give it cold water. In very hot weather only, mix a teaspoonful
of whiskey with a tumblerful of water.
If you cannot nurse your baby:
You cannot bring it up without milk. But the milk (cow's
milk) must not be given pure, nor with water.
Boil a teaspoonful of barley, ground in the coffee-mill, with a
gill of water and a little salt for fifteen minutes, then add half
as much boiled milk and a lump of loaf sugar, and give it luke-
warm from a nursing-bottle.
Bottle and mouthpiece are always to be kept in water when not
in use.
Babies of five or six months, half barley water and half boiled
milk, with salt and loaf sugar.
When the bowels are costive, take farina instead of barley
flour.
When they are very costive, take oatmeal gruel; strain it be-
fore mixing with milk.
When you have but half enough breast-milk use the same food.
Give the food and breast-milk alternately so that your milk has
time to get fit for your baby to take.
You may give beef tea or. beef soup mixed with your barley or
271
DR. JACOBI'S WORKS
casein and fat, besides being otherwise incongruous. From
many of my writings, and mainly from the second edition
of my " Therapeutics of Infancy and Childhood " 8 I here
condense the following points:
The mixed milk of a dairy is preferable to that of one
cow. Cow's milk should be boiled before being used. Con-
densed milk is not a uniform article, and its use is pre-
carious for that and other reasons. Skimmed milk obtained
in the usual way, by allowing the cream to rise in the
course of time, is mostly objectionable, because such milk
is often acidulated. The caseins of cow's and woman's
milk differ both chemically and physiologically. The for-
mer is less digestible. There ought to be no more than one
per cent, of casein in every infant food. Dilution with
water alone may appear to be harmless in many instances,
for some children thrive on it. More, however, appear only
to do so, for increasing weight and obesity are not synony-
mous with health and strength. A better way to dilute
cow's milk, and at the same time to render its casein less
liable to coagulate in large lumps, is the addition of
decoctions of cereals. Their mechanical effect, however,
is not the only one which is obtained. They add to the
nutritiousness of the food by their albuminoids, and are
certainly not injurious because of their relatively small
percentage of starch, for from the very first month of
life a distinct diastatic effect is produced by the oral se-
cretion; it increases with every month. Even infusions
of the parotids, prepared at different times after death,
farina or gruel to babies of five months and older. When ten
or twelve months old, a piece of rare beefsteak every day to
suck on.
No child under two years ought to eat from your table.
Rummer complaint :
When babies throw oif and purge, give nothing to eat and noth-
ing to drink for at least four or six hours. After that you give
a few drops of whiskey in a teaspoonful of ice water now and
then, but no more until you have seen the doctor.
Stop -giving milk at once.
Give no laudanum, no paregoric, no soothing syrups, no teas.
When you see the doctor, trust in him and not in the women.
They do not know better than you do yourself.
272
CHOLERA INFANTUM
produce the same effect. Infusions, however, of the pan-
creas taken from the bodies of infants who have lived three
weeks produce no such changes. The diastatic power of
the pancreas begins with the fourth week only, and re-
mains feeble up to the end of the first year. Kriiger
(1891) found in the foatus of seven months a sugar-form-
ing ferment which increases towards the normal end of
intrauterine life, is still small in quantity at birth, but then
grows so rapidly that it is as active about the eleventh
month of life as it is in the adult.
Zweifel experimented with infusions of different glands.
That of the submaxillary glands of an infant did not
transform starch into sugar, even after the lapse of a whole
hour. The effect of an infusion of the parotid of a baby
seven days old was distinct after four minutes; however,
that of the parotid of a baby who had died at the age of
eighteen days, of gastroenteritis, did not act until the
lapse of three-quarters of an hour. Nor was a diastatic
result obtained by a similar infusion made of the parotids
of a baby prematurely born, and of one who died of diar-
rhrea and debility.
In the healthy baby, however, that diastatic effect is not
absent. In connection with this fact it is also important
to know that the effect produced by saliva persists in the
stomach for a period of from one-half to two hours.
But this ceases, and starch will no longer be changed into
grape-sugar inside the stomach, as soon as the secretion
of hydrochloric acid has begun in the digestive process.
This is a very important fact, because it shows that the
farinaceous food of the infant or child, though it be not
masticated and pass the mouth very rapidly, is in the
stomach still under the influence of the saliva. For hydro-
chloric acid is not secreted at once. The first acids in the
stomach while digestion is going on are organic, mostly
lactic. This is found to be contained in that organ when
gastric juice is removed from it in the first period of
digestion. Thus in a gastrostomized boy Uffelmann found
under normal circumstances, during the first half-hour,
lactic acid only; afterwards hydrochloric acid. The latter
is not met with during fevers of any kind, provided the
273
DR. JACOBI'S WORKS
temperature is high, nor during a severe gastric catarrh
(nor in dilatation of the stomach resulting from congenital
or other constriction of the pylorus). In these conditions
farinacea (amylacea) are taken to advantage, principally
because the diastatic effect of saliva is not disturbed.
In anaemia and in convalescence, particularly from fevers,
the functions of the stomach are impaired. In them both
pepsin and hydrochloric acid are wanting. To increase
their secretion large quantities of water are required.
Infants' food ought to be mixed with large quantities
of water, not for the sick only, but under ordinary cir-
cumstances. In diseased conditions of the stomach the free
dilution of children's nourishment with water is demanded
upon the following additional facts. Only to a certain
limit, if at all, will pepsin be furnished for digestive
purposes. Probably a portion of this is not entirely util-
ized, because a great quantity of water is necessary to
assist in pepsin digestion. In artificial digestion albumin
often remains unchanged until large quantities of acidu-
lated water are supplied. Without doubt many disturb-
ances of digestion are to be explained by a deficiency of
water, certainly many more than are due to an excess of
it, for the latter is speedily relieved by rapid absorption.
When metamorphosis is generally slow, water in abund-
ance increases the elimination of urea and carbonic acid.
When the urine is scanty and of too high specific gravity,
water protects the kidneys from undue irritation. It acts
on the mucous membranes as it does on the external in-
teguments. In laryngitis and bronchitis it liquefies viscid
expectoration; in many forms of constipation it acts bene-
fically by increasing the secretion of the muciparous glands
of the intestines. Ice and ice-water, or iced carbonated
water, in small quantities, but frequent doses, relieve hyper-
aesthesia of the stomach and stop vomiting. Another regu-
lar addition to the milk food of infants and children should
be that of sugar. Its percentage in the milk of the woman
is larger than in that of the cow. Immediately after the
milking of the cow the milk-sugar begins to be changed
into lactic acid. This process, after the rennet of the
stomach has exerted its coagulating effect, together with
274
CHOLERA INFANTUM
the gradual conversion of fat into acid, is the final cause
of curdling. The large amount of sugar in woman's milk,
together with its smaller percentage of casein (about
one per cent.) and butter, gives it the peculiar bluish
color and gives to the colostrum of the first days after
birth (it contains plenty of salts besides), its tendency to
loosen the bowels. This property becomes manifest, some-
times under abnormal circumstances. Thus in the milk of
anaemic women sugar is occasionally found to an unusual
degree. In their cases the other solid matters may also
be diminished, still this is not uniformly so. The infants,
however, suffer often from obstinate diarrhoea.
The conversion of milk-sugar into lactic acid takes
place very rapidly Under its influence cow's milk turns
sour at once. Not infrequently is it acid from the first;
it has been found to be so in the udder; in most cases it
is " amphoteric," neutral. Thus the question arises what
kind of sugar is to be used as the addition to the food of
children both well and sick.
Cane-sugar is not so easily transformed. Indeed, it is
utilized for the purpose of counteracting the rapid con-
version of milk-sugar, and for the preservation of articles
of food in general. Trade is not so slow in availing itself
of the results of organic chemistry as the medical profes-
sion. Condensed milk remains unchanged a long time,
on account of the plentiful addition of cane-sugar, in spite
of the original presence of milk-sugar in it. Therefore it
is not at all an indifferent matter whether milk-sugar or
cane-sugar be added to the food of infants and children.
I have always insisted upon the selection of the latter for
that purpose. Biedert employs cane-sugar in his cream
mixture.
In the sick the absorption of sugar is slower than in
the healthy. Besides, during most diseases, particularly
those of the alimentary canal, there is more abnormal fer-
ment in the mouth and stomach. Thus but little sugar
ought to be given, and never in a concentrated form.
Grape-sugar and dextrin are absorbed equally. Cane-sugar,
according to Pavy, is partly inverted into grape-sugar and
partly absorbed. All appear to be changed, when given
275
DR. JACOBI'S WORKS
in moderate quantities, into carbonic acid and water, even
during slight fever.
In that form of constipation of small infants which de-
pends on a relative absence of sugar and superabundance
of casein in the breast-milk, the addition of sugar acts
very favorably. A piece of loaf sugar (a teaspoonful or
less) dissolved in tepid water (or oatmeal water) should
be given before each nursing, and will often prove the
only remedy required for the regulation of the bowels.
The physiological effect of chloride of sodium is very
important, no matter whether it is directly introduced
through the mother's milk, or added as a condiment to
cow's milk, or to vegetable food. Both of the latter con-
tain more potassium than sodium, and neither ought ever
to be given, to the well or sick, without the addition of
table salt. A portion of that which is introduced may be
absorbed in solution; another part is, however, broken up
into another sodium salt and hydrochloric acid. Thus it
serves directly as an excitant to the secretion of the glands
and facilitates digestion. Therefore during diseases in
which the secretion of gastric juice is interfered with, or
in the beginning of convalescence, when both the secreting
faculties and the muscular power of the stomach are want-
ing, and the necessity of resorting to nitrogenous food is
apparent, an ample supply of salt ought to be furnished.
The excess of acid which may get into the intestinal canal
unites with the sodium of the bile in the duodenum, and
assists in producing a second combination of chloride of
sodium, which again is dissolved in the intestines and ab-
sorbed. Its action in the circulation is well understood;
it enhances the vital processes, mainly by accelerating tis-
sue changes through the elimination of more urea and car-
bonic acid.
A very important fact is also this: that the addition of
chloride of sodium prevents the too solid coagulation of
milk by either rennet or gastric juice. Thus cow's milk
ought never to be given without table salt, and the latter
ought to be added to woman's milk when it behaves like
cow's milk in regard to solid curdling and consequent
indigestibility.
276
CHOLERA INFANTUM
Habitual constipation of children is also influenced bene-
ficially, for two reasons: not only is the food made more
digestible, but the secretions of the alimentary canal, both
serous and glandular, are made more effective by the pres-
ence of sodium chloride.
A certain amount of fat is digested even in fevers of
moderate severity, thus also in typhoid fever. But it is
a good rule rather to reduce its quantity, because when in-
fants were fed on cow's milk during capillary bronchitis,
the fat in the faeces was known to amount to forty per
cent, of the solid constituents. A few additional remarks
will render the subject clearer, and show that it is very
easy to give too much fat.
Infant faeces are comparatively copious, although the
baby receives absolutely nothing but mother's milk. What
has been called detritus in the fasces is not exclusively un-
digested casein, but principally fat and large masses of
intestinal epithelium. This so-called detritus is not soluble
in water, acids, or alkalies, but quite soluble in alcohol
and ether. Casein is also present when it has been taken
in too large quantity, or when there is too much free acid
in the stomach. In those cases there are large quantities
of it in the faeces.
An important practical application of this fact is the
following: As it is true that fat is not completely ab-
sorbed, even under the most normal circumstances; as free
fat acids are so easily formed and accumulated; as they are
found in moderate quantities, even in healthy babies; as
a surplus is very apt to derange digestion and assimilation,
and to prevent the normal secretion of either of the diges-
tive fluids; as there is a superabundance of fat in the nor-
mal food of the nursling, the conclusion is justified that we
should be very careful in preparing foods for the healthy
or sick. It is very easy to give too much fat. It is hardly
probable that there is too little. The subject of "fat
diarrhoea/' which depends on the excess of fat in infant
food, has been discussed on page 266. It is also well
illustrated by the observations of V. and I. S. Adriance. 9
They have succeeded in proving, by exact chemical and
clinical researches, some facts which were known, but per-
277
JACOBFS WORKS
haps not sufficiently appreciated. Both excessive fats and
proteids in the milk of the mother may cause gastrointes-
tinal symptoms in the nursing infant; the former may be
reduced by diminishing the nitrogenous elements in the
mother's diet; the latter by the proper amount of exercise.
Excessive proteids are especially apt to cause gastrointes-
tinal symptoms during the colostrum period, and particu-
larly during that of premature confinement, when their per-
centage is higher. Premature infants are, therefore, in
particularly great danger, and their food ought to be
greatly modified and watered.
In connection with this question I may also be permitted
to 'allude to the indiscriminate administration of cream and
the routine treatment with cod-liver oil in case of sick-
ness; even normal digestion disposes only of a limited
quantity of fat (cream, butter, cod-liver oil) ; twenty-five
per cent, of it in the food, as lately recommended, 10 is
excessive. One of the preparatory stages of its assimila-
tion is the formation of oleic acid; lipanin, which has
been recommended in place of cod-liver oil, contains six
per cent, of that acid, the physiological preparation of
which the body is spared by its administration. There may
be very few conditions in which the digestion is so slow
as not to insure some of the required transformation, but
in chronic dyspepsia of different sorts fat is badly di-
gested and absorbed, and lipanin may take its place. A
small amount of starch is digested at the very earliest age.
But cereals containing a small percentage of it only are
to be preferred. Barley and oatmeal have an almost
equal chemical composition; but the latter has a greater
tendency to loosen the bowels. Thus, where there is a
tendency to diarrhoea, barley ought to be preferred; in
cases of constipation, oatmeal. The whole barley corn,
ground for the purpose, should be used for small children,
not only the center (which is preferred because of its
white color), because of the protein being mostly con-
tained just inside and near the husk. The newborn
ought to have its boiled milk (sugared and salted) mixed
with four or five times its quantity of barley water, the
baby of six months may take them in equal parts. Gum
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CHOLERA INFANTUM
arable and gelatin may also be utilized in a similar manner.
They are not only diluents, but also, under the influence
of hydrochloric acid, nutrients. Thus, in acute and de-
bilitating diseases which furnish no or little hydrochloric
acid in the gastric secretion, a small quantity of the latter,
well diluted, should be provided for.
This, my method of infant feeding, which is suited for
the stomachs and purses of the rich and poor alike, is,
however, not the only one proposed and found satisfactpry.
No single method, indeed, is the only one, nor does it suit
every case. It is only an occasional chemist who expects
the organic stomach to behave like a chemical reagent;
clinicians, however, admit exceptions to the working of
their rules and regulations, though their conception were
ever so correct and physiological. Still the endeavors to
improve the diet of the young, and thereby to remove
the dangers of intestinal disorders and the sources of ex-
cessive mortality and invalidism, are going on. Nothing
has been more successful in that direction than the wide-
spread practice of sterilization and pasteurization of cow's
milk. Both are the logical development of the plan of
treating milk by boiling which I have persistently advised
these forty years at least, and detailed in my " Infant
Diet " la in Gerhardt's " Handbuch," 12 in Buck's " Hy-
giene," 13 in " Intestinal Diseases of Infancy and Child-
hood," 14 and in my clinical lectures delivered during more
than one-third of a century. There can hardly be a doubt
that if raw milk could always be had unadulterated, fresh,
and untainted, and as often as it were wanted, it would
require no boiling. It would even contraindicate it, for
high temperatures destroy not only some of the dangerous
bacteria, but also those whose action is desirable for nor-
mal digestion. Besides, there are those who strongly be-
lieve that boiling causes chemical changes. But such ideal
milk cannot be had so long as cows are tuberculous, as
scarlet fever and diphtheria are met with in the houses
and about the clothing and on the hands of dairy men and
women, and as typhoid stools are mixed with the water
which is used for washing utensils.
Now, what is it that boiling can and will do? Besides
279
DR. JACOBI'S WORKS
expelling air, it destroys the germs of typhoid fever,
Asiatic cholera, diphtheria, and tuberculosis, also the oidium
lactis, which is the cause of the change of milk-sugar into
lactic acid and of the rapid acidulation of milk with its
bad effects on the secretion of the intestinal tract. Some
varieties of proteus and most of bacterium coli are also
rendered innocuous by boiling. Thus it prevents many
cases of infant diarrhoea and vomiting, but not all of them,
for the most dangerous bacteria are influenced neither by
plain boiling nor by the common methods of sterilization.
Boiling, or sterilization, is not, however, a safe protection
under all circumstances. Aerobic bacteria, the so-called
hay or potato bacilli, have very resistant spores, which
develop in time. They are found in cow-dung and in the
dust of stables, of the soil and streets, and of hay; they
render the milk alkaline and bitter; they peptonize casein
and liquefy it and make the milk still more bitter. They
are very poisonous; their pure culture gives young dogs
a fatal diarrhoea. It takes hours of sterilization to kill
them; in some instances it required five or six hours.
Even the bacillus butyricus takes an hour and a half.
But such a protracted sterilization, besides being far from
certain in its effect, is a clumsy procedure and one not cal-
culated to benefit the milk. That is why hay-feeding is an
absolute necessity, for the bacilli are destroyed by a six
weeks' drying. Besides, it is important to keep the stables
scrupulously clean, to avoid dirt and dust, to employ peat
instead of straw for bedding, to wash the udder and tie
the tails before milking, to throw away the first milk, and
to remove foreign material from the milk by the centrif-
ugal machine. But no absolute security can be guaranteed.
Therefore Fliigge adds to his expositions a warning against
some wholesale manufacturers who, always anxious about
somebody's their own welfare, were (are?) known to
conceal the changed condition of the milk and the separa-
tion of butter particles by coloring the glass of their
bottles.
Whatever I have here brought forward is certainly not
to disparage the boiling of the milk; it is meant to prove
the danger of relying on a single preventive when the
280
CHOLERA INFANTUM
causes of intestinal disorders are so many It is true, how-
ever, that the large majority of the latter depend on causes
which may be met by sterilization, but not by sterilization
only; also by pasteurization, that is, heating the milk to
70 C. (165 F.), and keeping it at that temperature for
thirty minutes a procedure which destroys the same germs
that are killed by a more elevated temperature without
much change in the flavor and taste of the milk. Pasteur-
ization, however, is rejected by H. Koplik.
One of the questions connected with the employment of
sterilized or pasteurized milk is whether the milk to be
used for a child ought to be prepared at home, or whether
the supply may be procured from an establishment where
large quantities of milk believed to become immutable for
an indefinite period by sterilization are kept for sale. In
regard to this problem, Fliigge plaintively expresses his
regrets that " we have allowed ourselves to be guided by
people who are neither hygienists nor physicians, but chem-
ists, farmers, or apothecaries, and whose actions have been
based on three false beliefs. Of these the first is that boil-
ing for three-quarters of an hour destroys germs; the sec-
ond, that whatever bacteria remain undestroyed are innocu-
ous ; and the third, that proliferating bacteria can always be
recognized by symptoms of decomposition." Nothing is
more erroneous. Soxhlet himself, the German originator
of sterilization, knew at an early period that the fer-
menting process is now and then but partially interrupted
by boiling, that butyric acid may be found in place of
lactic acid, that a strong evolution of gas may be caused
after such boiling, and that such milk may give rise to
flatulency. Indeed, milk which happens to contain the
resistant spores of bacteria becomes a better breeding-
ground for them by the very elimination of lactic acid,
and the longer such sterilized milk is preserved and offered
for sale the worse is its condition. It may be true that
these conditions are not met with very frequently, but
an occasional single death caused by poisonous milk will
be more than enough. Therefore, the daily home steriliza-
tion is by far preferable to the risky purchase from whole-
sale manufacturers who cannot guarantee because in the
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DR. JACOBI'S WORKS
nature of things they cannot know the condition of their
wares.
Another alteration of a less dangerous character, but far
from being desirable, is the spontaneous separation of
cream from sterilized milk which is preserved for sale.
Renk 15 found that it took place to a slight extent during
the first weeks, but later to such a degree that 43.5 per
cent, of all the cream contained in the milk was eliminated.
Sterilization has been claimed to be no unmixed boon
because of its changing the chemical constitution of milk.
Still, opinions on that subject vary to a great extent, the
occurrence of changes being both asserted and denied by
apparently competent judges. But what I have said a
hundred times is still true and borne out by facts viz.,
that no matter how beneficial boiling, or sterilization, or
pasteurization may be, it cannot transform cow's milk into
woman's milk, and that it is a mistake to believe that the
former, by mere sterilization, is a full substitute for the
latter. It is true that when we cannot have woman's
milk we cannot do without cow's milk. There is no al-
leged substitute that can be had with equal facility or in
sufficient quantity. But, after all, it is not woman's milk.
Babies may not succumb by using it, and may but seldom
appear to suffer from it ; indeed, they will mostly appear to
thrive on it; but it is a makeshift after all and requires
modifications. Hammarsten was the first to prove the
chemical difference between the casein of cow's and wo-
man's milk. Whatever was known on this subject at that
time I collated in Gerhardt's " Handbuch." 12 The casein
of woman's milk is not so easily thrown out by acids or
salts as that of cow's milk, and is more readily dissolved
in an excess of acid. But lately Wroblewski demonstrated
the difference in solubility of the two milks. Woman's
casein retains, during pepsin digestion, its nuclein (pro-
teid rich in phosphorus) in solution, it is fully digested;
in cow's casein the nuclein is not fully digested, a " para-
nuclein " is deposited undissolved and undigested. Be-
sides, woman's casein contains an additional albuminoid
which is not identical with either the known casein or
albumin (H. Hoplik 16 ). Of the albuminoids in woman's
282
CHOLERA INFANTUM
milk sixty-three per cent, is casein, thirty-seven per cent,
lacto-albumin (Schlossmann), which being directly absorb-
able constitutes an essential difference from cow's milk;
all of the latter has to be transformed during the digestive
process before it can be assimilated. Besides, there is
(Wroblewski) in the human milk another proteid rich in
sulphur, poor in hydrocarbon, and, according to several
authors, in albumoses and peptones.
K. Wittmaack and M. Siegfried 1T published lately their
essays on nucleon (the phosphoric acid of muscle) in the
milks of cow, woman, and goat, and on phosphorus in the
milks of the cow and the woman. Their conclusions are
accepted by E. Salkowski as correct, which, I should say,
proves them to be so. Cow's milk contains 0.057, goat's
milk 0.110 and woman's milk 0.124 per cent, nucleon. In
cow's milk the phosphorus of the nucleon amounts to six
per cent, of the total amount of phophorus contained in
the milk; in woman's milk 41.5 per cent. That means that
in cow's milk not one-half of its phosphorus is in the or-
ganic combinations of casein and nucleon; in woman's
milk almost all of it is. In cow's milk the phosphorus not
utilized for organic combinations is contained in the inferior
phosphates. E. Salkowski adds the following remarks:
" These conditions are evidently of the greatest moment
in the nutrition of the nursling. As the development of
bones is more readily accomplished in nurslings fed on
woman's milk than in those fed on cow's milk, the probable
conclusion is that nucleon has an important part in the
absorption and assimilation of phosphorus." The same
should be said of calcium, which also combines with nu-
cleon. Though woman's milk contains less calcium than
cow's milk, more calcium is utilized out of the former, and
the nucleon is evidently an important factor in its ab-
sorption also.
Ergo, cow's milk is not woman's milk. It is not iden-
tical with it. Sterilization does not change its character;
it merely obviates such dangers as result from the pres-
ence of most pathogenic germs and from premature acid-
ulation. The substitution of cow's milk or of sterilized
cow's milk for woman's milk as the exclusive infant food
283
DR. JACOBI'S WORKS
is a mistake. Experience teaches that digestive disorders,
such as constipation or diarrhoea, and constitutional derange-
ments, such as rachitis, may be produced by its persistent
use, and it appears to be more than an occasional (at
least co-operative) cause of scurvy.
Since the advisability of finely dividing and suspending
the casein of cow's milk and of adding to the nutritiousness
of the latter caused me always to advise the admixture of
cereals with it, even in the very first days of infancy,
the subject of infant feeding has never been lost sight
of by medical men, scientists, and tradesmen. No subject
has been treated more extensively, more eagerly, sometimes
even more spitefully, than that of infant feeding. The
philosopher's stone has not been so anxiously sought for
nor so often found as the correct infant food and the
appropriate treatment of cow's milk in medical journals,
books, and societies.
The debilitating influence of persistent summer heat may
be counterbalanced by improving the vitality and resisting
power of the young. It is true no newborn baby should
be bathed in cold water, but the gradual diminution of the
temperature of the water used for ablutions may go on
until after a few weeks or months the healthy infant
bears washing and friction with cold water perfectly well.
In the heat of summer it should be so treated several
times a day. The clothing should be quite thin; those
who perspire freely should have no linen next to their
bodies; altogether, cotton or thin flannel, both of which
gradually absorb and give off perspiration, are preferable.
In very warm weather a single loose gown should be suf-
ficient. No feather beds or pillows should be permitted.
Surely the baby would be better off in a hammock, the
head being supported by a hair or air pillow. Babies in
bed should have their positions changed from time to
time.
The mouth of the newborn infant requires the utmost
care. It is a frequent inlet of microbes and toxins, and
when its mucous membrane is injured, it adds a new ele-
ment of danger to the different forms of intestinal and
septic disturbances which are not at all uncommon at the
284
CHOLERA INFANTUM
earliest age. The attempts at cleansing the mouth may
prove dangerous. All the integuments of the newly-born
are in a condition of desquamation. Clumsy rubbing with
coarse or stained cloths by the fingers of a nurse or doctor
that are not absolutely aseptic, is a direct cause of infec-
tion. Even the water in which the baby is bathed may add
to that danger. What is called Bednar's aphthae is nothing
but the ulcerations of the very thin mucous membranes
mainly on and near the alveolar processes; these heal
but slowly and complicate every disorder of an infectious
nature. If such a mouth is filled with sugar, teas, or syrups
of questionable composition, the consequences are often
bad.
Cow's milk will always be one of the foods administered
at any age. In the country, when the cattle are not tubercu-
lous, and when no diphtheria, scarlatina, and typhoid
fever can vitiate the milk, it should be given fresh, modi-
fied by the addition of barley or oatmeal water. City
milk is no longer fresh. In many medium-sized European
cities milk is delivered within four hours after milking
(in Frankfort, for instance, since 1877); in New York it
takes from ten to sixteen hours or more. No such milk,
unchanged, is fit for the use of young infants. Boiling,
sterilization, or pasteurization is therefore indispensable,
partly to destroy the bacterium aerogenes, partly to render
innocuous such pathogenous germs as may have been ad-
mitted during the long' time which elapsed between milking
and consuming.
Even if it were possible to compound an accurate sub-
stitute for breast milk, this has the advantage of its free-
dom from pathogenous germs, and of its changeability
under divers circumstances. Alterations of breast milk
depending upon moderate changes of food taken by the
mother or wet-nurse are as a rule not hurtful; its dilution
by the ample quantities of water taken by them in hot
weather is a direct advantage to the nursling. The same
quantity and quality of food is not equally digestible in
summer and in winter; what is well borne and demanded
in the winter, by the adult or by the young, proves an
excess in summer. " Modified milk," " Gaertner's milk,"
285
DR. JACOBI'S WORKS
and their like are always the same, day in and day out;
breast milk, however, may change. The main danger at-
tending the uniformity of food is, in hot weather, the in-
sufficient amount of water, of which our babies do not re-
ceive enough. Casein, sugar, fat, and salts should not
only have their due average admixture of water, but the
latter should be given in extra doses during hot weather.
Perspiration thickens the blood, hinders the circulation,
and may even lead to thromboses ; it is good practice,
therefore, to give breast-fed children a drink of water
which should be boiled and thereby sterilized before each
nursing; and to dilute the artificial food given to those
who are brought up on the bottle, and to let them all
have water between meals to their heart's content.
TREATMENT
The most perceptible symptoms of cholera infantum are
vomiting and diarrhoea, both of which are in the large
majority of cases to say the least the effects of irrita-
tion or paralysis caused by bacteria and toxalbumins.
Whatever is still within reach and active, should be re-
moved by irrigation. If there is reason to suppose that
the stomach still contains foreign materials, it should
be washed out, no matter whether the attack is attended
with fever or not. Both bacteria and toxalbumins may
prove fatal without much increase of temperature; indeed,
many attacks of cholera infantum behave in this respect
like diphtheria, puerperal fever, or other septic processes,
the worst forms of which are often accompanied with low
temperatures. A mouth gag is not always required for
the purpose of irrigating the stomach, but in most cases
it facilitates the procedure; a cork firmly planted between
the alveolar processes will generally suffice to enable the
fingers to perform their work. No solid stomach tubes
should be employed. Soft elastic catheters, Nos. 16 to
30 French, according to age, will suffice. The baby,
wrapped up in a blanket and sitting on the lap and be-
tween the arms of an attendant, is satisfactorily immo-
bilized, and its head is sufficiently fixed and bent forwards
286
CHOLERA INFANTUM
so as not to narrow the space between trachea and verte-
bral column. There are but few cases in which the oesoph-
agus is missed at the first attempt; when the tube has
once entered, the slight contraction behind the larynx is
easily overcome, and the catheter slides down. By means
of a glass tube and an india-rubber tube attached to it,
the connection with a funnel, through which tepid water
is slowly poured in, is easily established. The flow is
graduated by the elevation of the funnel. When a few
ounces have been allowed to fill the stomach, the funnel
is lowered and the liquid runs out. The same procedure
is repeated, while the amount of liquid is increased, until
the water returns clear. Vomiting alongside the tube is not
harmful. The " fountain syringe " in common use among
us will answer every purpose. In individual cases, when
the indication of direct disinfection appears urgent, the
tepid water (or 0.6 per cent, salt solution) may contain
resorcin (one per cent.) or thymol (.02 per cent.) or
permanganate of potassium (.02 per cent.). As a rule
these additions will not be required; nor is the irrigation
of the stomach indispensable when the patient is seen some
time after the vomiting has ceased. In bad cases, however,
any doubt in that respect should be dismissed in favor of
irrigation. It will not often be required a second time.
The next step in the treatment of cholera infantum is
the washing out of the intestinal tract as far as it is ac-
cessible. The fluid to be introduced is the same as above.
In a number of instances when there seemed to be intense
pain or tenesmus, I have mixed subcarbonate or subgallate
of bismuth with the water. The baby should be placed on
one side, the nozzle of the fountain syringe introduced a
few inches, and the instrument suspended a foot or two
over the anus. To facilitate the flow, the hips should be
somewhat raised; in some instances the gentle manipulation
of the abdomen answers the same purpose. To introduce
a long tube in order to reach the colon is either unneces-
sary or contraindicated. For in the infant the sigmoid
flexure is so long that no tube passes the convolutions
which are apt to cover one another, and sometimes reach
to the opposite side of the upper pelvis. When the tem-
287
DR. JACOBI'S WORKS
perature of the body is high, the injection should be cool;
when there is collapse, it should be hot. In the latter
case, a small amount of alcohol (one per cent.) or good
brandy or whiskey (two or three per cent.), or coffee
should be added to the injection. These irrigations should
be continued until the fluid returns clear; they should be
repeated when the diarrhoea returns, and particularly when
the stools are offensive. That all the injected fluid should
be expelled is not necessary; on the contrary, as the loss
of organic water has been great, and some of the dangers
of cholera infantum depend on that very loss, it is de-
sirable that the intestine should retain and absorb some
fluid. That loss is so serious indeed that the introduction
of water becomes an urgent necessity. To fulfil this in-
dication in emergency cases, subcutaneous infusions of salt
water (6: 1000), with or without the addition of sodium
carbonate (10: 1000) are required. The water, however,
should be sterilized, and the whole procedure must be
aseptic. It is true that many of the cases which indicate
it will die; but it is not the infusion, but the disease
that kills. I feel certain that a few of the patients I
have seen the last half-dozen years were thus saved.
In connection with the question to what extent disin-
fectants added to the irrigations destroy bacteria or other
toxins, I should state here that this effect need not be ac-
complished and still salutary action may be obtained. Many
years ago Prudden proved that a one-twentieth of one
per cent, solution of carbolic acid annihilates the action of
bacteria, not indeed by killing but by paralyzing them.
To prevent them from evolving toxins is as beneficial as
to destroy them.
The same remark should be made in regard to those
internal remedies which appear to be indicated, mainly in
those cases which owe their origin to, or are evolved out
of any of the forms of prodromal enteritis or entercoli-
tis, for the purposes of disinfection. Vaughan believes
that much harm and no good can be obtained from them,
but every clinician knows that the eminent bacteriologist
is mistaken. It is true that calomel, naphthol, naphthalin,
salol, and camphor in medicinal doses do not diminish the
288
CHOLERA INFANTUM
number of bacteria nor even of saprophytes, but the effect
of the microbes becomes less virulent.
Constant vomiting forbids the introduction of food or
drink. Whether there be thirst or not, the patient must
be starved. While he is so deprived his thirst will de-
crease rather than increase. This period of total abstinence
may last from four to twelve hours. After this some bear
small pieces of ice quite well; but to begin with it too
early excites vomiting and peristalsis. A teaspoonful of
boiled water, cooled, may be given every five or ten minutes.
That may be alternated with, or replaced by thin and
thoroughly cooked and strained barley water. It is un-
irritating and well borne. What a critic 18 of Pepper's
text-book says, viz., that " thousands of children are killed
by the injudicious" (?) "use of barley water" that
this is " a popular fallacy " and " merits oblivion," is a
mistake and reads like a huge joke. Later on egg water
may be given, that is the white of a fresh egg beaten up,
and finally shaken in a bottle containing 150 or 200 c.c.
of barley or rice water, in small amounts.
No milk must be given at this stage; no sterilized or
pasteurized milk, no breast milk. It is true that under
ordinary circumstances milk feeds babies, but in these ex-
traordinary circumstances it feeds bacteria. No milk must
be given, if it take a week or more, until the alvine dis-
charges begin to change, and are no longer malodorous.
Now and then a teaspoonful of a mild tea, or a few drops
of a good whiskey in barley water may be given once every
five or ten minutes, or at longer intervals. A mixture which
has served me well in many cases, after the starvation
period had passed and the stomach began to exhibit some
little tolerance, is the following: One hundred and fifty
cubic centimetres of barley water, the white of one egg,
one or two teaspoonfuls of whiskey, some salt and cane
sugar to improve the taste. Of this a teaspoonful is ad-
ministered every five or ten minutes.
When milk is to be fed again it should not exceed ten
per cent, of the barley water with which it is to be mixed.
To prepare it with hydrochloric acid, according to the
prescription of Dr. Rudisch which I have frequently used
289
DR. JACOBI'S WORKS
these more than twenty-five years, will often be found
profitable. The method is to mix 2 c.c. of dilute hydro-
chloric acid with a pint of water and to add thereto a
quart of milk. This is to be boiled. If ever there be
coagulation, it merely proves that the acid was mistakenly
used in excess.
Internal medicinal treatment is mainly indicated in
those cases which developed on the basis of a dyspeptic,
catarrhal, or follicular enteritis. As irrigations of the
rectum act on the lower part of the bowels only, the small
intestines may be cleared by a purgative. If castor oil
be retained, it will have a good effect. To mix it with
tincture of opium is unwise at that stage in which the
emptying of the tract of injurious masses is the main indi-
cation. Calomel may take its place, and will be well
tolerated in frequent (hourly) doses of 4 to 5 mgm. (gr.
Yi5 to ^2)- It should be continued until the stools show
its effect, which they will do though the remedy remain
in the mouth and be there absorbed after having been
transformed into a mercurial albuminate. If there be an
excess of acid (lactic, acetic, or butyric) in the stomach,
calomel should be combined with an alkali, mainly chalk,
the carbonate and phosphate of which have the additional
advantage of forming with the fat an insoluble combina-
tion which acts as a protective cover to the sore mucous
membrane. Doses of from 5 to 10 cgm. (gr. i.-iss.) may
be given every two hours. The subnitrate, the subcar-
bonate, or the subgallate of bismuth in doses every two
hours of from 15 to 100 mgm. (gr. ^-iss.) acts as a dis-
infectant, partly by binding sulphide of hydrogen, and
protects the sore surfaces. Salol should not be given in
larger doses than from 3 to 15 cgm. (gr. ss.-iiss.), re-
sorcin from 15 to 30 mgm. (gr. -.) These are prefer-
able to many others because of their indifferent taste.
When the time has arrived for astringents, nitrate of
silver in solution, 2 to 4 mgm. (gr. %o~%r>) * n a * ea "
spoonful of water, or gallic acid in doses of from 5 to 15
cgm. (gr. i.-iiss.), or tannalbin or tannigen, in doses of
from 3 to 12 cgm. (gr. ss.-ii.) all of them in intervals of
two hours may be administered.
290
CHOLERA INFANTUM
Are there any indications for opium, or is it totally
contraindicated ? It certainly limits secretion and hyper-
acidity better than morphine Its effect is slower than
the latter, and therefore safer and local. It also di-
minishes hyperperistalsis ; it is, through its effect on the
sensitive nerves or on the ganglia, a sedative, and an in-
hibitory agent through strengthening the splanchnic. Fi-
nally it relieves pain. Thus it is readily seen that in the
incipient stages of dyspeptic and stercoraceous diarrhoeas it
finds no place, but when the bowels are emptied, it ful-
fils its indication of relieving pain and hypersecretion and
of stimulating in small doses the heart. Under these
conditions a baby of six months may take from four to
ten drops of the camphorated tincture of opium, or an
equivalent, every two, three, or four hours.
Great sensitiveness of the abdomen may also be relieved
by warm fomentations, with water, or with poultices.
They should be covered with oiled silk, or an india-rubber
cloth and flannel. Care should be taken lest the clothing
and bedding get moist. Warm bathing may occasionally
take their place. In cases of collapse the temperature of
fomentations or baths may be raised a little beyond the
normal temperature of the blood. When there is great
pain combined with high temperature of the body, cool
applications to the abdomen are indicated. The cloth
wrung out of cool water, secured and protected as above,
should be changed when it becomes hot.
Great care should be given to the relief of the ex-
hausted and paralytic condition of the patient. There are
those cases which require stimulation at once. It is in-
dicated when the fontanelle is depressed at an early time,
the pulse very small and frequent (150-220) and hardly
perceptible at the wrist, and the complexion ashy. To
rely on internal stimulants is out of the question; there
are, however, many opportunities for subcutaneous appli-
cations of the salicylate (or benzoate) of sodiocaffeine,
of the sulphate of strychnine, of camphor, or of whiskey.
The first may be employed in doses of from three to
eight drops of the saturated solution (1:2), the second in
doses of from 0.5 to 1 mgm. (gr. %2<r%o)j *^ e third in
291
DR. JACOBI'S WORKS
doses of from four to ten drops of a solution of four
times its weight of sweet almond oil; of the last from
fifteen to twenty-five drops may be injected. All of
these administrations may be repeated according to indi-
cations. The same remedies may be used internally if
the condition of the stomach permit. The very best stimu-
lant is Siberian musk, of which from 3 to 10 cgm. (gr.
ss.-iss.) may be given every half -hour, until from three
to six doses will have been taken.
BIBLIOGRAPHICAL REFERENCES
1. Biedl und Kraus: Zeitschrift fur Hygiene und Infektion-
skrankheiten, xxvi., p. 376, 1897.
2. Fischl und Heubner: Zeitschrift fur klinische Medicin,
xxix., 1896.
3. Uhlenhuth: Zeitschrift filr Hygiene und Infektionskrank-
heiten, xxv., p. 476, 1897.
4. Booker: Johns Hopkins Hospital Reports, vi., 1896.
5. Meinert: Medical Annual, 1893.
6. Jacobi: Medical Record, December 18, 1868.
7. Clarke Miller: American Journal of Obstetrics, 1879.
8. Jacobi: Therapeutics of Infancy and Childhood, 3d ed.,
Philadelphia, 1898.
9. V. and I. S. Adriande'- Archives of Pediatrics, 1897.
10. Berliner klinische Wochenschrift, June 14, 1897.
11. Jacobi: Infant Diet, New York, 1874.
12. Jacobi: Die Pflege und Ernahrung des Kindes in Ger-
hardt's Handbuch der Kinderheilkunde, vol. i., 1877 (2d ed.,
1882).
13. Jacobi: Infant Hygiene in Buck's Hygiene, New York,
1883.
14. Jacobi: Intestinal Diseases of Infancy and Childhood,
Detroit, 1887.
15. Renk: Archiv fur Hygiene, xvii., 1893.
16. H. Hoplik: New York Medical Journal, April 13, 1895.
17. Wittmaack und Siegfried: Zeitschrift fur physiologische
Chemie, xxii., 1896-97.
18. Book Review in The American Therapist, June, 1894.
292
TYPHOID FEVER IN THE YOUNG
THE literature of the typhoid fever in infancy and child-
hood is very copious ; that of the last twenty years is not
exactly worthless; indeed, a number of magazine articles
are quite valuable. But they do not compare with the
very first publications on the subject which appeared at a
time when typhoid fever had not long been recognized as
an independent morbid entity. Amongst those which should
be read to-day, in order to gather almost everything con-
nected with the subject, with the exception of the Diazo
and Widal tests, are Tapin, in the Jour, des Conn. med.
et Chirurg. of 1839, who explains the apparent infre-
quency of typhoid fever in the young by the mildness of
most cases; F. Rilliet, De la fievre typhoide chez les en-
fants, Paris, 1840; the article on the subject in Rilliet
and Barthez's great Handbook in 1853; Louis and Andral
in 1841; a paper of A. Baginsky in Virchow's Arch. Vol.
49; of Henoch in the Charite Ann. Vol. II, 1877; the
thesis of Georges Montmoullin, 1885 (Observations sur la
fievre typhoide de 1'enfance), and the article of C. Ger-
hardt in the second volume of his great " Handbuch," in
1877- The most meritorious of all the contributions to the
knowledge of our subject, however, is the little book of
Edmund Friedrich, Der Abdominal Typhus der Kinder,
Dresden, 1856. My advice to all modern and future writers
on any topic connected with the question of typhoid in
children is to first consult the 102 pages of that mono-
graph, which is apt to teach the often forgotten lesson
that medicine is not of to-day nor of yesterday; that there
have been great and good men worth knowing, before we
were born, and that the history of our science and art is
sadly neglected amongst us.
Infection and Contagion. The opportunities for infec-
tion or for contagion are the same for the young and for
the old. The bacillus has been found active though it had
293
DR. JACOBI'S WORKS
been dry for months ; in the soil and in clothing after
one or two months. Into water and into the soil it is
introduced with typhoid discharges which carry contagion
though they have been in contact with putrid material.
This experience explains isolated cases and those attribu-
table to the influence of sewers and privies, and the trans-
mission through the atmosphere. Flies have been charged
with carrying the poison. Infected water that is used for
drinking or for washing the bottles and cases in which
milk is kept, is responsible for hundreds of epidemics.
Contagion from patient to patient in a hospital or in a
tenement, by bedding, by the hands of the attendant, by
the use of the same unwashed thermometer for the typhoid
and non-typhoid are surely either possibilities or facts.
The fetus and newly born may obtain their typhoids
through the blood of the mothers ; contagion through the
milk of the mother is not improbable, though in most of
such instances the suspicion may be directed to other
sources of the malady. Small infants have a great ad-
vantage in this that their typhoids are not frequently
attended with characteristic stools, and that for this reason
a hospital case is not so dangerous to its neighbors-; that
they are not roaming about the floors where older children
pick up infection, and that the water they drink or eat
is almost always boiled. The latter fact alone explains
the relative absence of typhoid fever from the first year of
life.
SYMPTOMATOLOGY.
Temperature. The severity of the illness need not cor-
respond with the body temperature. A girl of 9 years,
whose case is reported by Gerloczy, in D. Med. Woch.,
No. 15, 18Q2, had unconsciousness, diarrhea, very frequent
pulse, universal hyperesthesia, roseola, abscesses, and bron-
chial catarrh, and got well after thirty-nine days. During
all this time there was no increase of her body temperature.
It appears that very severe cases of typhoid fever when
exhibiting bad cerebral symptoms are liable to have low
temperatures on account of the thorough sepsis prevailing.
If so, the prognosis is very bad.
291
TYPHOID FEVER IN THE YOUNG
Belei Medvei (Intern. Klin. Rundschau, 1891, No. 35
and 36) observed a girl of 12 years that was taken sick
with severe headache, restlessness, chill, pain in neck, un-
consciousness, miosis, unequal pupils, rapid respiration, and
a temperature for four days from 36.8 to 37-5 C. Then
the temperature rose and the typhoid symptoms of spleen
and cecum, and diarrhea made their appearance.
This absence of high temperature does not astonish those
who see a good deal of sepsis and of sickness complicated
with weak heart. Temperature and danger need not cor-
respond. The very feeble are not as a rule subject to high
temperatures any more than the very old; and quite often
the worst cases of sepsis are those which exhibit low tem-
peratures. That is a fact best known to those who see
much diphtheria or much puerperal fever.
Observations of high temperatures previous to the ap-
pearance and recognition of the symptoms are not fre-
quent. While an adult would be about his work, the infant
or child is seldom considered sick enough to claim atten-
tion and attendance. That is why chilliness and chills are
readily overlooked; indeed, the latter are not marked as
a rule in any illness of the young. The rise of the tempera-
ture in the typhoid of the young is mostly gradual; it is
high in the second stage with slight remissions and gradually
falls toward the end of the disease. This rule, if it can be
called so, is, however, subject to many exceptions. The
temperature of small infants may be very irregular, is in
man} 7 cases rather low and uniform, in others high with
few and short remissions. Irregularities, moreover, often
depend on complications. After all, neither those are al-
ways right who consider the typhoid of the nursling and
infant as a uniform severe disease, like Baginsky and
Roemheld, nor those who make light of it. The degree of
individual infection, and the nature of the epidemic are
factors that have to be considered.
Complications which disturb the regularity of the tem-
perature curves are, for instance, otitis, which is quite
frequent. In connection with it we should not forget that
the otitis media of the infant need not terminate in per-
foration of the drum membrane; for the pharyngeal end'
295
DR. JACOBI'S WORKS
of the Eustachian tube is so large a funnel at that early
age as to permit the discharge of pus from the middle
ear. An occasional complication is scarlatina; in the last
two years malaria was a more frequent complication of
typhoid than I have ever known it to be. Suppurating
arthritis, diphtheria of the throat or of the vulva, both
bacillary and streptococcic, are detrimental in the same
way. Constipation is also an occasional cause of the rise
of temperature; the regular visiting hours of hospitals,
even without clandestine feeding, are apt to increase tem-
peratures. Now and then there are two regular daily
curves. That is another reason why the rectal temperature
should be taken at least four times in twenty-four hours.
Digestive Organs. The condition of the lips, the tongue
and the mouth may depend on previous catarrh, angina, or
the presence of adenoids ; otherwise on the severity of the
typhoid, and exhibits the same surface changes of the
epithelium and mucous membranes that are observed in
the adult. The lips are frequently dry, the tongue mostly
moist, its epithelium accumulated in the centre, the edges
red, or the whole tongue red and dry, covered with dry
epithelial scabs, torn or ulcerated. Large ulcerations are
mainly noticed during unconsciousness, smaller ones may
be quite numerous on the hard and soft palate in every
severe case. There is no herpes. The throat shows angina,
the tonsils are swollen, in exceptional cases covered with a
pseudomembrane which once, in a boy of 9 years, continued
through the whole length of the esophagus to below the
cardia. In bad cases of older children, or in the few that
occur in the nursling when the mouth is kept open because
of the narrowness in the naso-pharynx, of indolence or
unconsciousness, thrush is met with as it is in the worst
cases of adult typhoid, or in moribund phthisis. Stomacace
is less frequent, noma still less so; the latter is observed
only toward the end of the illness, or during apparent
convalescence. Fortunately, during nearly fifty years I
met with half a dozen cases only, one in a baby of 8
months, one in a girl of 1 1 years, all fatal. Baginsky,
however, reports a case of noma that recovered. It may
be added that noma is not quite so frequent after typhoid
296
TYPHOID FEVER IN THE YOUNG
fever as after some other infectious diseases, prominent
amongst which is measles, where I have seen at least a
dozen instances. Parotitis may terminate in perforation,
either outward or through the external ear. An abscess
of the submaxillary gland I have seen in few cases only.
Otitis media is an occasional complication originating in
pharyngeal changes. The appetite is proportionate to the
fever, the dry mouth and the degree of unconsciousness ;
during convalescence the hunger is great and conducive to
dangerous mistakes in diet. Vomiting is noticed in bad
cases, and is caused by the condition of the digestive mu-
cous membrane, occasionally by meningitis, and sometimes
by accompanying or consecutive nephritis.
Diarrhea is a frequent symptom in typhoid fever, either
before its apparent outbreak, or in the first week, or at a
later period. It appears to be of a catarrhal nature, in-
duced probably by the presence of bacilli and their toxins.
In the later periods of the disease it certainly depends on
the presence of ulcerations. But to expect diarrhea as a
common symptom is a mistake occasioned by the statements
of many European books. In the other hemisphere diarrhea
appears to be more general than with us. I think we miss
it in one-half of our cases.
Even the assumption that where there are ulcerations
there must be diarrhea is not founded on uniform facts.
In ward 28 of Bellevue, in 1877, I had a girl of 11 years
that was under close observation during her typhoid fever
for several weeks. The case was one of unusual severity
spleen, lungs, skin and nervous system yielding the usual
symptoms ; there was no diarrhea at any time. She died
with the symptoms of perforation. Perforation caused by
one of the typhoid ulcerations was found at the autopsy.
Nor is this the only case of the same description in my
experience. In the Proceedings of the Pathological So-
ciety, twenty-five years ago, there is mentioned the case
of a man who died in my service in Mount Sinai, also
with perforation of an ulcerating intestine, with no previous
looseness of the bowels.
Constipation is not an uncommon symptom in the begin-
ning of typhoid fever of the young, though diarrhea may
297
DR. JACOBI'S WORKS
develop toward the end of the first or during the second
week, while, on the other hand, diarrhea may be observed
among the prodromi or in the first week, and be replaced
by constipation.
Almost in all cases of typhoid, in the young and in the
old, intestinal ulcepations are common. But exceptions to
this rule are met with.
S. Flexner and N. M. Harris (Bull. Johns Hopkins
Hospital, December, 1897) detail the case of a man of 68
years who had typhoid fever with bacilli in many organs,
but no intestinal lesions; A. G. Nichols and C. B. Keenan
(Montreal M. Jour., January, 1898) one with positive Wi-
dal test, and tumefied spleen and mesenteric lymph nodes,
and no intestinal lesions; E. Hodenpyl, one that died on the
seventeenth day of illness with ulcerations in the large in-
testine, but none in the small. This absence of intestinal
lesions is rare indeed in the adult; in the young, mainly
in the very young, it seems to be less rare. As a rule,
it may be stated that the intestinal tract suffers more in
advanced age, the blood more in the early.
According to Bryant (Brit. Med Journal, 1899, L, p-
766) fifteen cases of typhoid fever are known to have
exhibited no intestinal lesions. His case was that of a
boy of 1 year and 9 months ; it occurred in a family in
which there were other cases of typhoid fever. There was
a characteristic fever curve, diarrhea, tympanites, tumefac-
tion of the spleen, and a positive Widal reaction. At the
autopsy there were pure cultures of bacilli in the en-
larged mesenteric glands, but no intestinal ulceration.
In one of his autopsies Henoch found but one Peyer's
plaque that was slightly swelled.
In N. Y. Med. Journal of July 29th, A. J. Hartigan,
assistant in the Bender Laboratory of Albany, N. Y.,
reports two cases of typhoid infection without any intestinal
lesions. Of the older literature of such instances he quotes
Louis, more than half a century ago, and Litten, Moore,
and Church between 1880 and 1882. He then continues:
" The bacteriological era in the investigation of these forms
begins with Banti, in 1887. In his case death took place
on the twenty-eighth day of the disease. No intestinal
298
TYPHOID FEVER IN THE YOUNG
lesions were found, but the spleen and mesenteric glands
were swollen ; in them bacilli morphologically similar to
the bacillus typhosus were found." He quotes seventeen
authors, and adds his own cases, without, however, men-
tioning Hodenpyl.
It should, however, be stated that the statistics of intes-
tinal ulcerations with perforation are not conclusive ; many
are observed in private practice, not counted, not reported,
and forgotten. Now and then, again, a case is reported
as a curiosity without reference to the number of cases
observed and other important points. Barrier met with
two perforations in 24- cases, a very unusual proportion.
Montmoullin reports seven cases in which perforation was
diagnosticated, three of which recovered a proportion of
spontaneous recoveries able to arouse the jealousy of any
operator.
Barrier and Bouchut made long ago similar observations
on the adult, so that they concluded that the anatomical
alterations of the intestine may be absent. Chiari (Z. f.
Heilk., 1897) while finding lesions in the stomach, and
bacilli in different organs, and septic symptoms, found no
intestinal lesions. In nineteen collected cases, while the
Widal test was positive, the same absence of intestinal
lesions was marked. So the latter is not conclusive. The
last case of the same nature was published by A. Me.
Phedran in the October issue of the Phil. Monthly Med.
Journal (1899).
Gurgling in the ileo-cecal region, both with and without
pressure, is common in intestinal catarrh, both infectious
and non-infectious; that is why, under ordinary circum-
stances, it should not be held to be characteristic of typhoid
fever. It would be more so, if complicated with constipa-
tion, and with some of the more frequent symptoms of
typhoid fever.
Incontinence of the sphincter ani when met with is not
so much the local result of the infection as of unconscious-
ness ; when it occurs during convalescence, it depends on
hyperperistalsis, mostly combined with colic.
Tympanites is usually very moderate, for extensive peri-
tonitis is very uncommon, except with perforation. Sensi-
299
DR. JACOBI'S WORKS
tiveness of the abdomen is frequent, without the diagnosis
of local peritonitis being always within easy reach. This
latter form is, however, quite frequent, for in the autopsies
of children, or of adults who died of other diseases, local
discolorations and thickenings, of a grayish white, or yel-
low color, are often found on the peritoneal layer of the
intestine, above, near or below the cecum. They are the
results of previous local peritonitis corresponding with the
locality of ulcerations during typhoid fever, or any of the
forms of enteritis in former years. Unexpected perfora-
tions of the intestine, occurring in advanced years, during
apparently perfect health, are the final results of such local
peritonitis.
Hemorrhages in the very young are exceptional, and
mostly mild in children of more than four years. I have
seen it more than a dozen times. In a girl of 10 years,
the loss of blood was such, there being several hemorrhages
in the course of the third week, that I attributed the super-
vening heart failure to exhaustion only. Both the number
and severity of the hemorrhages appear to depend on the
character of the epidemic or on the season. In the very
young, I sometimes saw no tinge of blood in five years,
and in a single season eight years ago I met with two,
not fatal, cases of hemorrhage, in girls of 5 and 7 years.
This very autumn I have seen four cases of typhoid fever
in children of from 5 to 9 years, in which mild hemor-
rhages occurred. Of Henoch's nine intestinal hemorrhages,
five were quite mild.
Circulatory Organs. The organs of circulation are not
affected to the same extent as in adults. The average
heart of the young is stronger, and less diseased. Endo-
and pericarditis, embolisms and thrombroses are rarer than
in advanced age, except in very bad and protracted cases,
in which the myocardium was deteriorated by the bacillary
toxin. For the same reason complete adynamia, is not so
frequent at least in the first week or weeks. During in-
creasing inanition, however, the circulation is impaired, as
best shown by the coldness of the feet. The gums bleed
but rarely, the nose not so often in infants, and the very
young, as in older children. The pulse, mainly during the
300
TYPHOID FEVER IN THE YOUNG
first two weeks, except in the small infant, where it is
liable to be feeble and frequent, is either in correspondence
with respiration and temperature, or frequently slower and
quite strong. When it becomes feeble and frequent, with
or without intermissions, it impairs the prognosis, and
demands persistent stimulation. It is rarely dicrotic.
When it is in this weak condition, the heart sounds are
no longer distinct; they are muffled, one or the other splits
in two, and an apex murmur becomes audible. This
should not be taken as merely functional; the myocardial
weakness which occasions it is toxic and organic, and may
remain a permanent lesion.
Spleen. The irregular respiration of nervous, or fright-
ened infants and children, their tympanitic colon, and
high diaphragm, possible exudation in left pleura or lung,
and the struggle against examination, whether painful or
not, render the diagnosis of the condition of the spleen
difficult. In perhaps one-half of the cases it is, however,
successful. Percussion succeeds less than palpation, which
may reveal the lower edge of the spleen. It is rarely felt
before the end of the first week, about the time when
roseola appears ; earlier, however, when the fever is un-
usually high. When it diminishes rapidly in the middle
of the third week, the prognosis is good ; if not, there will
be a relapse. When a relapse takes place, the spleen,
which was greatly reduced in size, is liable to swell very
rapidly. Permanence of this swelling of the spleen, how-
ever, is much rarer after typhoid than after severe ma-
larial fevers, and abscesses are quite exceptional.
The Respiratory Organs. The nasal mucous membrane
is dry, covered with thin crusts, and irritated like the lips,
which are in a similar condition. Epistaxis is not infre-
quent in older children. Together with pharyngitis there
may be a catarrhal laryngitis. This, and the dryness of
the mucous membrane cause hoarseness and cough. Edema
of the glottis, which is fortunately rare, causes dyspnea
and strangulation. Superficial and deep ulceration of the
trachea or larynx, and perichondritis are exceptional, but
I have met the necessity of performing tracheotomy in
such cases twice. One was the case of a girl of seven, in
301
DR. JACOBFS WORKS
which scarification of the interior of the larynx was un-
successful the child was saved by the operation. The
other tracheotomy was made during convalescence on a boy
of ten years, because of an abscess developing over and
behind the manubrium sterni. He died after many weeks
of pyemia, the main source of which was found about the
lowest rings of the trachea, and the mediastinal lymph-
nodes. Bronchial catarrh is frequent, without much cough,
as long as the respiration is shallow; with cough on deep
respiration ; catarrhal pneumonia is not rare, and mostly
bilateral; croupous pneumonia is also apt to be bilateral.
The more frequent form of pneumonia, however, in the
protracted cases of feeble patients, is hypostatic, with a
tendency to become bilateral at once, and to extend.
Pulmonary gangrene is exceptional, but should be feared
in every case of infectious broncho-pneumonia, compli-
cated with a weak heart.
Pleuritis is comparatively rare, purulent in exceptional
cases only, sometimes sanguinolent, though there be no
complication with tuberculosis.
Complications with diphtheria of the bacillary variety
(nasal, pharyngeal, or laryngeal), are not common. When
they occur during the prevalence of a diphtheria epidemic,
they are grave accidents.
Urinary Organs. The urine is mostly of a high color,
contains in the beginning much urea and uric acid, less
chlorides than normal, indican sometimes, albumin fre-
quently at an early period and more so during the height
of the disease, renal epithelia, blood, thin granular casts,
and occasional bacilli. The renal irritation exhibited by
the microscopic appearance is that which is usual in most
infectious diseases, and is due to the effect of the toxin
while being eliminated through the kidneys. Symptoms con-
nected with this elimination need not be very marked and
need not lead to nephritis. Still, the latter may follow.
Even pyuria has been found, for instance, by G. Blumer,
in children, one of 13 and one of 10 years (Johns Hop-
kins Rep., Vol. V).
Retention of urine is rare in children, but occurs when
there is coma or much peritonitis. In that case, and when-
302
TYPHOID FEVER IN THE YOUNG
ever it is important to secure urine for examination, cathe-
terizations should be resorted to. It is more easily per-
formed in the young than in the adult and more readily
in boys than in girls. Under ordinary circumstances, when
the catheter is not employed for some reason or other a
big ball of absorbent cotton will collect urine enough for
the usual examination of the urine. Polyuria is seen dur-
ing convalescence when much water is drunk. In that
period dropsical effusions may be observed with or without
albumin; it should also not be forgotten that salicylic acid
or antipyrin when employed may cause edema; and, fur-
ther, that there may be nephritis without albuminuria. The
Diazo test is mostly positive towards the end of the first
week, and remains so until the middle of the third, some-
times very much longer. At all events, however, its absence
is no proof against the presence of typhoid fever. Roem-
held missed it altogether in many cases.
The observations made by Lafleur and others, that the
urine voided after cold bathing exhibits a high degree of
toxicity, would rather speak in favor of that treatment;
for the more toxic the urine and dangerous to the labora-
tory animal, the less toxin there is left in the patient.
Elimination, as speedily as possible, is what should be
aimed at. And whatever diuretic effect there is in cold bath-
ing, as in other remedies, is welcome as long as the con-
dition of the patient permits it. How rarely that is so,
will be seen in the remarks I have to make on therapeutics.
Skin. The tendency of the skin is to be dry; that is
why chronic eruptions are liable to disappear during the
illness and to return when recovery is complete. This dry-
ness is also the cause of the transverse fissures under the
knee which Koebner explains by the co-operation of the
lifeless epidermis, the vigorous growth of the extremities
and the flexed posture of the knee; it also causes the ex-
tensive desquamation before and during convalescence.
The characteristic roseola exhibits the same peculiarities
that are noticed in the adult; it is absent in perhaps 20 per
cent. Morse collected 671 cases, in 406 of which it was
present; Henoch found it 362 times in 381 cases. It is not
uncommon in the very young. I found a few spots on the
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DR. JACOBFS WORKS
epigastrium of a newly born that died on the sixteenth day
of its life; Gerhardt (Handb. Vol. II, p. 373) met with
roseola (and a tumefied spleen) in a baby of three weeks.
It may appear as late as the eleventh, even the fifteenth,
or seventeenth day, is mostly not so copious as it is in
the adult, and occurs preferably on the chest and abdomen,
but also on the back and on the extremities. When the
temperature is high at an early date, roseola may appear
early, on the third or on the fourth day, and new crops may
occur afterwards. In relapses it is more frequently missed
than in the primary attack, but a new crop in the fourth
week means a relapse. Petechiae are not frequent, but do
occur in children of more than seven or eight years, also in
the very young; when complicated with extensive purpuric
extravasation they are ominous.
Miliaria is sometimes observed when there is exceptional
perspiration; and erythema during the height of the dis-
ease when there is much intestinal disorder and coma as the
result of direct toxic, or of auto-infection. Eczema is the
result of uncleanliness only; gangrene, abscesses, furuncles,
and pustules are frequent occurrences, but in the later
periods of the disease only.
In bad cases, and mainly when the hygiene of the skin
was neglected, abscesses will appear in it and in the sub-
cutaneous tissue, preferably on the head, face and chest.
Slight irritations are sufficient to act as proximate causes.
A child of two years developed the first abscess on the
epigastrium in consequence of a subcutaneous injection of
quinin. More followed, mainly on the hands, fingers, and
feet, more than sixty were incised in the course of a few
weeks, until, finally, recovery set in.
In a child of two years I saw copious hemorrhages about
the ear, groins, and neck with consecutive gangrene; in a
boy of nine, extensive destruction of the skin over more
than one-half of the abdomen; in both cases with final re-
covery.
The desquamation of typhoid fever may be quite copious
and resemble that of measles or even of scarlatina. On
the other hand, some of the eruption of the two latter may
resemble the roseola of typhoid fever. That is why the
TYPHOID FEVER IN THE YOUNG
diagnosis may become difficult, particularly as there are
cases of which I have seen some, in which the latter and
one of the former may be contemporaneous. Thus Cos-
grave (Brit. Med. Jour., Jan. 16, 1897), reports five cases
in which scarlet and typhoid fever were coincident without
seeming to increase the degree of danger. Both started
at the same time.
From George M. Gould's American Year Book, 1898, p.
625, I quote Amitrano, who reports a case of typhoid fever
developing in convalescence a scarlatiniform eruption with
fever which was followed by desquamation. After this
fever had subsided marked meningeal symptoms appeared
for a few days. These disappeared, and after desquamation
was complete a second intense erythema appeared, which
was also followed by desquamation, after which recovery
ensued.
Bones. The bones suffer in different ways. The charac-
teristic increase of growth after infectious fevers is mostly
observed in scarlet, and in typhoid fevers. Epiphyseal and
general pain about the extremities is frequent in typhoid
fever, and some degree of epiphysitis is common, in conse-
quence of this irritation. Periostitis and osteomyelitis have
been observed, and bacilli have been found in the latter.
Before the advent of the bacillus, I lost a child of four
years with osteomyelitis of the right femur, in spite of
early operation. Such cases are fortunately not frequent,
but it appears they occur in from one to two per cent,
of all typhoid fevers. Chondritis is still more infrequent,
with less serious results.
Nervous System. The nervous system of the young is
believed not to be affected by typhoid fever, as it is in the
adult. There are cases in which the general condition of
the patient appears to be unusually good, compared with
the toxic nature of the whole process, and with the height
of the temperature. In many instances I concluded, from
nothing but the apparent comfort and ease of the patient,
when the high temperature would have suggested the pres-
ence of severe subjective symptoms, that everything but
typhoid fever could be excluded. The same holds good of
that in adults. In them ambulant cases are by no means
305
DR. JACOBI'S WORKS
rare, and those in bed often demand permission to get up,
expressing the most complete satisfaction with their con-
dition, while their temperature ranges at or above 104.
Other children are apathetic, or somnolent, or peevish, and
restless. The " typhoid state " should not by itself be
taken as a symptom of typhoid fever. It may be absent
altogether, and is found now and then when there is no
typhoid. Headache is frequently complained of, or is be-
trayed by vertical wrinkling. Hearing may be bad, the
conjunctiva injected and the cornea cloudy under the in-
fluence of the toxic disturbance of the trifacial nerve.
Grinding of the teeth, sopor, or delirium, and vehement
screams resembling those of meningitis, are occasionally
met with. Such symptoms, though ever so severe, need
not correspond with the elevation of the temperature at
all; the latter may be rather low, while the intoxication
is quite pronounced. Not every case of seeming cerebral or
meningeal symptoms should be attributed to cerebral af-
fection only; still, contractures, or convulsive movements
may occur when there is an effusion from the pia mater.
Such complications of genuine meningitis with typhoid
fever certainly occur, and not only after the eighth or
tenth year when gradually the typhoid fever in the young
resembles more and more that of advanced age. Kernig's
symptoms may be employed to clear up the diagnosis of
genuine meningitis.
Some of the symptoms common to both may be explained
differently. Vomiting may be due to the toxic degeneration
of the cerebral substance, or to meningitis, or to the ab-
normal condition of the stomach, or even of the pharynx, or
to nephritis. Coma or delirium I have seen in typhoid, in
meningitis, also in cinchonism, and under the influence of
salicylic acid.
As a consecutive symptom aphasia was found twenty
times by Henoch; half a dozen times I have seen it in the
course of many years ; with the exception of one that sud-
denly died, probably of myocardial degeneration, all of
them got well. Polyneuritis is not rare. In severe epi-
demics it is frequently seen, usually with a favorable ter-
mination, It is due to tissue alterations, occasioned by
300
TYPHOID FEVER IN THE YOUNG
the influence of the bacillary toxin. Hemiplegia is rarely
observed; a case of " cerebellar ataxia " in a boy of seven,
which terminated in recovery, was reported by Luigi Con-
cetti, in La Pediatria, No. 8, 1898.
Paraplegia is more frequent, and still more so is local
paralysis, under the influence either of the toxin, or of a
hemorrhage, or of an embolus. Amongst them are paraly-
sis of the glottis, which necessitated a tracheotomy in a case
of Rehn's, and of the abducens (which I have seen in
quite a number of cases, most of which were obstinate,
some permanent) and of the accommodation muscles of the
eye. Paralysis of the sphincter of the bladder is not in-
frequent.
Psychical disturbances are seen as the sequelae of every
infectious fever, mainly scarlatina and typhoid. Four such
cases were reported by S. S. Adams to the American Pedi-
atric Society in 1896. They may result from inanition,
or from the parenchymatous tissue changes caused by the
toxin, or from meningitis. Mania and melancholia are
the two forms mostly met with. Not all of them termin-
ate favorably. Two of my early cases died in lunatic
asylums in rather advanced years. The motor disturbances
not paralytic, which follow typhoid, particularly chorea,
have all got well in my recollection, a few only with re-
lapses. It struck me that post-typhoid chorea was less
subject to recurrences than other forms.
I now give the particulars of two sets of observations,
which will prove that the symptoms, course and complica-
tions of the typhoid fever of the young may greatly differ
from one another, or from any average description of its
nosology. One I published in the Arch Ped., March, 1885.
The number of typhoid fever cases treated in the Chil-
dren's Pavilion of Bellevue Hospital, from October, 1882,
to September, 1884, was 25. Of these 11 were males, 14
females; 17 ran a single course, 5 had relapses, 3 were
sick over a period of from four to six weeks, without per-
mitting the second attack to be distinguished from the
first by an alleviation of the symptoms. In seven cases
a distinct chill was mentioned as ushering in the illness;
in half a dozen more several attacks of chilliness were
307
. JACOBFS WORKS
noticed. The ages of the patients ranged from 2 to 14
years, the average 9- Pain in the ileo-cecal region was
complained of in fourteen cases, diarrhea was noticed in
fifteen, bloody stools not amounting to hemorrhages in
three; in three constipation was mentioned as a notable
fact ; in the first week of six epistaxis was observed. Tume-
faction of the spleen was noted in sixteen; roseola was
observed in fourteen cases. Its first appearance was no-
ticed between the fifth and seventh day ; it lasted from
five to ten days. Premonitory symptoms were reported in
nine cases ; in four they lasted two weeks. They consisted
in lassitude, loss of appetite, change of temper, and in
some few cases, diarrhea set in a week before the initiating
chill or chilliness. Five of my cases died ; one remained
stupid and hard of hearing for sometime, but recovered.
Contrary to my experience, as expressed in a lecture on
typhoid fever (Medical Record, Nos. 17 and 18, 1879),
in which I claimed a mild type and a low mortality for
the typhoid fever of infancy and early childhood, this
Bellevue service of mine had a mortality of 20 per cent.
similar to that of (Esterlen, who estimated it at 22 per
cent., and Friedrich, who reported 23 per cent., in chil-
dren under five years of age.
In 1882 and 1883 we had a bad epidemic of typhoid
amongst all classes and ages. The guests of summer hotels
and boarding houses imported hundreds of cases, and the
whole population suffered in consequence, infants and half-
grown children as much as the rest, and the mortality all
over the city was high. The hospitals have always more
than their share, however, and their statistics must neces-
sarily be erroneous. Errors are occasioned by the fact
that with us at least hospitals do not contain the average
cases, but as a rule those only who fare badly and promise
badly. A poor family will nurse their children, while they
require but little care; only that one which is seriously
ill, and gives a great deal of trouble and a bad prognosis,
is sent to the hospital. Of that class, many will die.
That is why the mortality of a hospital does not indicate
the general character of the epidemic. That is also why
the general practitioner, singly or collectively, is the better
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TYPHOID FEVER IN THE YOUNG
judge and statistician. He sees all the cases in a family,
those remaining at home, and those sent to a hospital;
sees the mild and the severe cases, and counts those who
survive. Six cases in a family, one of which is sent to
and dies in the hospital, may give the family practitioner
a mortality of 16, the hospital attendant one of 100 per
cent.
Another series of observations was published by F.
Sbrana (Arch, de Med des Enf., Jan, 1899). He reports
on seventy-two cases of typhoid children, from 16 months
to 8 years old, whom he observed in Tunis; 75 per cent,
of all cases occurring in that sub-tropical city were in
children; in one family there were four, in another three
cases. Why there should be a prevalence of cases in
children, is perhaps best explained by Jeannel's report
made to the Fourth French Congress of International Medi-
cine, in 1898. He observed an epidemic of typhoid fever,
in which the communication may have occurred through
the dust of the street into which the typhoid dejections
were thrown. The principal and first sufferers were chil-
dren who were playing in the street, and not very particu-
lar as to what they carried to their mouths. Both their
size and their habits I counted many years ago and re-
peatedly since, amongst the causes of the frequency with
which follicular angina, and also diphtheria are observed
amongst the young.
The premonitory symptoms of the majority of cases con-
sisted in anorexia, with headache, vomiting and constipa-
tion; the run of temperatures was quite irregular. In 50
per cent, there was epistaxis in the beginning; diarrhea
began at a later period of the disease. Gurgling in the
ileo-cecal region was not observed in patients less than
three years old, and was altogether not common. Roseola
was noticed in one-third of the cases, the spleen was en-
larged in every one after the fifth or sixth day. There
was no intestinal hemorrhage, and the fever disappeared
by lysis. There was a furfuraceous desquamation in four
cases ; the mortality was 1 1 per cent.
There were many complications ; suppurating parotitis in
two; peritonitis from perforation, one; purulent pleuritis,
309
DR. JACOBI'S WORKS
one, with considerable dilatation of the stomach during
convalescence; aphasia in five; orchitis of the left side
without suppuration, one; and meningitis, three; two of
the last terminated fatally. All these cases looked very
much like cerebro-spinal meningitis ; still there was the
tumefied spleen, and no herpes. In other cases there were
milder cerebral symptoms, such as dysphagia, partial con-
vulsions, aphasia, and inequality of the pupils, without
strabismus, or vomiting.
AGE, MORTALITY
Friedleben placed the greatest frequency of typhoid in
childhood between the 5th and 8th year, Griesinger be-
tween the 5th and llth, Lceschner and Friedrich between
the 5th and 9th, Rilliet and Barthez between the 9th and
14th, Barrier between the 5th and 15th year, and Faucon-
net between the 10th and 20th year. A few other figures
contained with the above in Gerhardt's Handbuch, Vol. II..
are as follows: Murchison noticed that 20 per cent, of all
the inmates of the fever hospital were less than 15 years,
Von Franque collected all the typhoid cases of the province
of Nassau, and found 2021 of 11,028 to be less than 10
years, Gaultier gathered many French statistics, and re-
ported 31 per cent, below 15 years. In a small town
Baginsky counted sixteen cases under 10 years out of a
total of 50, Rosenthal 28 in 115, Schaedler 11 in 144.
Holt (Textbook, p. 1008) quotes 970 cases from eight
authors ; 8 per cent, were under 5, 42 per cent, from 5
to 10, 50 from 10 to 15 years old. Montmoullin (These de
Paris, 1885) reported fifteen cases under two out of a total
of 295 under 15 years. Schavoir, in Stamford, Conn.,
collected 406 cases of all periods of life; of these 68
were under 5 years, 72 between 5 and 10 years. Morse
reports 284 cases in the Boston City Hospital; 3 were
under 5 years, 77 from the fifth to tenth, and 204 from
the tenth to the fifteenth year. He also concluded that
typhoid is unusual in infancy, because the Widal reaction
was negative in two cases of simple diarrhea, forty-five
cases of fermental diarrhea, and three of ileo-colitis, with
the exception of one whose mother had typhoid fever years
before. It will be seen, however, that in none of these
310
TYPHOID FEVER IN THE YOUNG
cases the diagnosis of typhoid fever was made or suggested.
As there was no typhoid there was no Widal.
All these figures and results are in confirmation of the
earliest observations. Griesinger, for instance, wrote in
1857 (Virch. Handb., II., 2, 124): "Typhoid fever is
very rare in the earliest infancy; it is only from the sec-
ond to the third year that the disposition becomes greater;
after that time it grows rapidly, so that typhoid fever is
quite frequent amongst us." (Germany.) Bouchut denies
the occurrence of typhoid in the newborn. According
to him it occurs first between the first and second year.
There are, however, well observed cases of typhoid fever
in the newborn. Gerhardt quotes Charcellay who saw
it in a child of eight days; Bednar, five days; Necker,
thirteen days, and reports a case of his own at three
weeks. I had a case, the mother having typhoid fever when
the child was born. In the latter I diagnosticated the
disease on the ninth day. There were a few spots on the
epigastrium on the sixteenth day, a large and soft spleen,
and Peyer's plaques swollen and rather soft, not yet ul-
cerated. The infant died on the sixteenth day of her
life. C. P. McNabe (New York Medical Journal, Feb.
19th, 18Q8), observed typhoid fever, complicated with
whooping cough and pneumonia in a baby a few weeks
old.
The possibility of the transmission of typhoid fever to
the fetus is beyond any doubt. Clinical experience proves
such a transmission for typhoid fever, malaria, measles,
scarlatina, variola and syphilis; also in erysipelas, relaps-
ing fever, tuberculosis and sepsis. In young sheep anthrax
was found as early as 1882; chicken cholera and glanders
are transmitted in the same way. But it is possible that
the epithelium of the placenta is a frequent barrier, and
the suggestion of Malvoz's that the transmission of an
infectious disease from the mother to the fetus takes place
only when the villous epithelium is injured, I have always
considered to be correct. He emphasizes the fact that of
twins one may be affected while the other goes free. All
these points are discussed by W. Fordyce in the Brit. M.
Jour., of Feb. 19th, 1898. The typhoid fever of the
mother may destroy the fetus, may allow it to be born
311
DR. JACOBI'S WORKS
alive but weak, or alive and vigorous. Which of these
results occurs depends on the amount of bacillary toxin
transmitted or on circumstances unknown to us in an in-
dividual case. But the facts are firmly established. The
fetal intestine was found diseased by Manzoni in 1811,
Charcellay in the same year, Weiss in 1862. Bacilli were
found in the fetus by Reher and Neuhaus in 1886; in
the blood by Eberth in 1 893 ; and the same results were
obtained by Freund, Levy, Ernst, and Durck. Other good
observations were made on the living child. The W r idal
test was found positive in a healthy infant 7 weeks old,
that was born when the mother was in the third week of
typhoid fever, by Crozier Griffith (Med. News, May 15th,
1897); and by Mosse (Progres Med., March 13, 1897) in
a newly born, whose mother had typhoid fever when in
the sixth month of her pregnancy, and whose milk and
placental blood gave the same positive reaction. Perhaps
the case of Landouzy's will also prove the possibility of
transmission though not through the placenta (Soc. de
Biol. Nov. 6, 1897). A healthy baby showed a positive
Widal test, while the woman had typhoid three months
after confinement. As the baby had no other symptoms of
typhoid fever, it is fair to suggest or to believe that trans-
mission to a sufficient degree took place through her milk.
The transmission of typhoid bacilli into the fetus is dem-
onstrated by a case reported by Etienne (Gaz. hebdom.,
1896, No. 16). A woman of 18 years expelled on the
twenty-ninth day of her typhoid fever a fetus in the
fifth month of uterogestation. In its blood taken from the
right heart, the spleen, the liver and the placenta were
typhoid bacilli, but no changes in the other organs. It ap-
pears that the death of the fetus resulted from the toxin
which acted so rapidly that the organs had no time to
participate in the process.
If, however, typhoid fever has been found by some in the
fetus, in the newborn, in the nursling, there are those
who never saw it at that age, and therefore are inclined
to deny its occurrence.
In the Arch. Fed., 1895, p. 916, Dr. W T . P Northrup
speaks of the results of 2,000 autopsies in children under
312
TYPHOID FEVER IX THE YOUNG
5 years. Not one presented the lesions of typhoid fever.
He also quotes Dr. N. Page of the Children's Hospital in
Philadelphia, who says : " I have had from six to ten ty-
phoid cases in children in the house constantly since I came
on duty here, but not one of them was under 6 years."
Dr. Ch. G. Kerley observed not a single case of typhoid
fever among 1,326 children, 85 per cent, of whom were
under 2 years, and 95 per cent, under 5 years of age ; nor
was a single typhoid lesion found in HO autopsies. He
adds that there was no case in the three years following
his observations, under his successor in office.
Again, however, Steffen reports on 148 cases of typhoid
in the young; 2 were less than 1 year, 26 from the third
to the sixth, 34 between 6 and 9 years. Of Wolberg's
277 cases, however, the majority were as usual from 6 to
12 years old. Henoch reports on 9 cases below 2 years,
59 from 3 to 5, and 187 from 5 to 10 years, with a mor-
tality of 12 per cent. He also reports of the finding of
typhoid ulcerations 14 times in 26 autopsies. Ashby and
Wright declare typhoid fever to be " not common under 3
years," while Rilliet and Taupin as early as 1810 pro-
nounced it to be " not at all rare." About the same time
Billard published his experience. According to him ty-
phoid fever was rare in the first year, increased slowly
toward the fifth, and was quite frequent between the fifth
and fifteenth.
Maria Rivoire described an epidemic which reigned in
Marseilles in 1896 and 1897 (These de Montpellier, 1898).
In and after May of 1897 there were 105 cases among
children, of whom 21 died 20 per cent.; in 1896 4*3 cases
with 15 deaths 31 per cent. Of 1270 cases collected
during those two years there were:
Below 5 years 26, 6 deaths 23 per cent.
Between 5 and 10 years 59, 13 deaths 22 per cent.
15 20 289, 42 l-i.5
20 : 25 347, 63 18.5
25 30 262, 54 20.5
30 " 40 " 154, 25 17
40 ' 50 30, 7 23
Above 5 years 10, no deaths.
313
DR. JACOBI'S WORKS
According to these figures the largest mortality occurred
between the tenth and fifteenth year; the mortality of
children below 5 or below 10 years equalled that of adults
between the fortieth and fiftieth year.
H. Curschmann (Nothnagel, Spec, Pathol. u. Therap.
III.) reports on 451 children (250 male and 201 female)
observed with typhoid fever in the Hamburg Hospital be-
tween 1886 and 1887- Of these, seven were 2; nine were
3; sixteen, 4; eighteen, 5; thirteen, 6; twenty-two, 7;
twenty-seven, 8; forty-four, 9; fifty, 10; fifty, 11; sixty,
12; seventy-one, 13; and sixty-four 14 years old.
Of Brouardel's 16,036 cases observed between 1880 and
1889, 36 were 1 year and under, 1,041 under 5, 1,265
from 6 to 10, and 1,386 from 11 to 15 years old.
According to an excellent report published by Dr. I.
Rudisch, in the Mount Sinai Hospital reports (1899), on
974 cases of typhoid fever, which occurred from 1883 to
1898, 124 occurred in children below ten years, and 90
between the eleventh and fifteenth; a total of 214 cases.
Of these one was six, another ten months of age. There
were altogether below five years 37 cases, six of which
died 16.21 per cent., and 87 between the sixth and tenth,
7 of which died ^8. 75 per cent. The exact figures for
the first year were 5 cases with 3 deaths, for the second
6 with no death, the third 5 with no death, the fourth 10
with 1 death, the fifth 1 1 with 2 deaths, the sixth 1 6 with
2, the seventh 20 with 1, the eighth 11 with no death, the
ninth 24 with 3, the tenth 16 with 1, and from the eleventh
to the fifteenth 90 cases with 9 deaths.
One of the principal points made by Dr. Northrup is
that the ulcerations claimed for typhoid fever are not
characteristic at all; that, indeed, they are found in com-
mon intestinal diseases of non-infectious nature. That is
what Hervieux contended thirty years ago, when he said
that follicular swellings and superficial ulcerations in the
intestines, and swelling of the mesenteric lymph nodes
were found without any specificity in the morbid process.
This observation, and the assumption of uniformity in
the nature of these ulcerations, was indeed the reason why
in France for a long time the terms typhoid fever and
314
TYPHOID FEVER IN THE YOUNG
dothienenterite were synonymous. But as early as 1877
C. Gerhardt emphasized the fact that the peculiar typhoid
(" markige ") infiltration and the formation of scurfs,
which are mentioned now and then are distinctively different
from the ulcerations of follicular or other enteritis. It is
true, however, that in many cases there is a difference be-
tween the young and the adult. The changes in the plaques
of the former are more hyperplastic (they are not so in
enteritis), of the adult more necrobiotic. Nowadays the
presence of the bacillus typhosus in and about doubtful
ulcerations would furnish another positive diagnostic sign.
DIAGNOSIS
It is determined by the symptoms enumerated above,
and while it is mostly easy in the adult, becomes more
difficult in the very young. I choose to take it for granted
that in doubtful cases the diagnosis of dentition and worms
is nowadays confined to a certain class of illiterate women
and obsequious practitioners only; but the differential diag-
nosis of the typhoid in the very young from a catarrhal
fever, or influenza, or glandular fever, even from an in-
testinal auto-infection may remain difficult through many
days even for the skilled and thinking. The fever curve
is very apt to be irregular, mainly in enfeebled children
and in the presence of one of the many complications.
There are even some cases in which the disease sets in
suddenly with a high temperature; there are those, how-
ever, in which a high temperature is apt to be deceptive,
for I believe with A. Fairbarn (Jour. Am. Med. Ass., April
12, 1897) that the first symptoms may be overlooked for
many a day. A cerebral pneumonia may exist half a week
or more without being recognized, until the development of
the disease and careful examination clears up the diagnosis.
Influenza may assume the characteristics of typhoid to a
certain extent. Meningitis may be recognized, if by no
other symptoms, by means of a lumbar puncture and ex-
amination of the cerebro-spinal fluid. Altogether a rather
slow pulse when not in proportion to the height of the
temperature, the condition of the tongue, the swelling of
S15
DR. JACOBI'S WORKS
the spleen, and the presence of roseola render the diagnosis
secure even without the Diazo and Widal tests. In other
instances, however, we arrive at a result by exclusion only.
There is hardly a single clinical symptom which alone
proves the presence of typhoid fever; the simultaneous
presence of many is a more perfect guide. The diazo test
is nearly conclusive when tuberculosis and pneumonia may
be excluded; it may be expected to be positive in 90 per
cent, of all the cases between the end of the first and the
middle of the third week. The greatest difficulty is met
with in those infants that yield few or no local symptoms
except those of a septic infection only. Lymph nodes are
sometimes found tumefied; their swelling in the inguinal
region, however, from other causes is so frequent that,
when found alone it should not count. The presence of
herpes should generally be taken as proof of the absence
of typhoid fever. The presence of the bacillus in the
discharges would be the best symptom if we commanded a
readier practical method for its discovery, provided there
be other symptoms which make the case suspicious of be-
ing typhoid fever. ,
Much is naturally made of the presence of bacilli in the
discharges of doubtful cases, and quite often the diagnosis
had to depend on it. To what extent is that justified?
There may be cases in which I should utterly refuse to ac-
cept the diagnosis of typhoid fever unless there be some
one or more adjuvant symptoms, for the same reason that
makes me refuse the diagnosis of diphtheria when there
is n6thing but the presence of Klebs-Loeffler bacilli, or
that of tuberculosis when bacilli are deposited on some
mucous membrane.
PROGNOSIS
The character and the mortality of typhoid fever are
apt to vary according to seasons and epidemics. Bagin-
sky places the mortality at 9 per cent., Montmoullin at
8.8, Steffen at 6.7, Henoch at 1.5, Wollberg at 4.7. In hos-
pitals it is liable to be greater than in general practice
for the reason that as a rule bad cases only are sent to
public institutions. Still, in the Children's Hospital of
816
TYPHOID FEVER IN THE YOUNG
Philadelphia there were 137 cases, three of whom died
(2.66 per cent.) ; in the Boston City Hospital, the mor-
tality in 284 children, under 15 years, was 6 per cent.,
while amongst 3,396 adults it was 13.5 per cent., and Holt
collects 2,623 children with a mortality of 5.4 per cent.
On the other hand, of Schavoir's (New York Medical
Record, 1895) 192 patients (mostly in private practice),
under 15 years, 2 died = 1 per cent.
Nurslings and the very young, also those approaching
adolescence, are more endangered than those in the inter-
mediate years, according to Roca (Ann. de Policlin. de
Bordeaux, 1897), and Roemheld (Jahrb. f. Kinderh., Vol.
48). High continuous temperatures are not always fatal,
though they be complicated with a frequent pulse, nor are
petechiae absolutely ominous. A moderately slow pulse,
and the occurence of marked remissions are favorable, par-
ticularly when the fever is not terminated within three
weeks. This continuation beyond the usual time is quite
common in the very young, and when the case is ap-
parently mild. A speedy recovery may be expected when
the spleen gets smaller about the sixteenth or seventeenth
day; if it remains large, the case will go on. Compli-
cations of any kind, pneumonia, meningitis, previous heart
diseases, with feeble peripheral circulation (cold feet),
laryngeal edema, hepatic or splenic abscesses add to the
danger; that with malaria is not very dangerous provided
it be recognized at an early time. Some of these compli-
cations are frequently called sequelae; but as they share
in the microbic etiology of the disease, they should be con-
sidered here. To this class belong erysipelas (mostly
facial), otitis media, hematomata, which are sometimes very
large and destructive to the implicated or super jacent cutis,
arthritis, furunculosis, abscesses of all kinds, and occasion-
ally an anemic dropsy, not attended with an affection of
the kidney, the occurrence of which was noted by Grie-
singer nearly half a century ago.
Relapses are by no means rare, either after complete
apyrexia, or with a moderate amount of remission about
the end of the third week, or without any or much change
in the temperature. They come after apparently mild, or
317
DR. JACOBI'S WORKS
after severe cases, without or with errors in hygiene or
diet; when there was apyrexia, they were mostly of a
shorter duration than when the fever remain continuous, or
exhibited a slight remission only.
TREATMENT
The food should be liquid. My invariable rule is, with
adults also, to insist upon that demand until apyrexia has
lasted ten days. The patient should be encouraged to drink
water frequently; the admixture of from eight to twelve
drops of dilute hydrochloric acid to a tumbler full of water,
or sweetened water, is a pleasant and disinfectant drink.
Of albuminoids, peptones, and " peptonoids," and of beef-
juice, only a certain quantity is digested or absorbed; the
good that is to come from them is not from swallowing,
but from digesting. The lips and tongue should be kept
clean. Older children will wash and gargle. When the
tongue is red and dry, and fissured, one or two daily ap-
plications may be made with a clean camel-hair brush, of
a one or two per cent, solution of nitrate of silver. The
nose should be kept clean, washed out with normal salt
solution in urgent cases. To guard against hypostasis of
the lungs and the cord, the posture in bed should be
changed from time to time.
A purgative dose of calomel in the very beginning will
act beneficially not so after the second half of the first
week when diarrhea and hemorrhages may be caused by it.
Constipation requires warm water enemata daily; diarrhea,
frequent irrigations with water' of from 95 to 100 F.
When the discharges are offensive, thymol, or perman-
ganate of potassium may be added in a proportion of 1 :3,-
000-4,000. Internally, bismuth, sulpho-carbolate of zinc,
salol, naphthalin are indicated. Bronchial catarrh demands
no special treatment in most cases ; if the secretion is
viscid, and dyspnea present from that cause, camphor is
serviceable. Collapse requires strong stimulants, by mouth
and sub-cutaneously ; diluted alcohol, camphor in sweet al-
mond oil 1 : 4, and the salicylate or benzoate of sodium
and caffein, soluable in two parts of water, answer best
318
TYPHOID FEVER IN THE YOUNG
for that purpose. Insomnia, great excitement, and con-
secutive psychoses may require chloral hydrate. When the
heart is feeble, croton chloral should be selected instead.
When these symptoms are accompanied with heat of the
head, cold applications to the head, ice water, ice bags
are soothing. The head should, under such circumstances,
be kept as high as comfort permits. Sopor or coma should
be treated with cold affusions, while the body is submerged
in water of 90 or 95 degrees.
Is it desirable to resort to antipyretic treatment? If
so, in what class of cases, mild, medium or grave? This
latter classification, however, should not exist, for the ap-
parently mild case may turn out to be a grave one. Or is
it desirable to allow high temperatures to persist?
The vis medicatrix naturae has been eulogized in infec-
tious fevers. However, the wholesome influence of intense
body heat on bacteria and toxins has become very doubt-
ful, and good observers like Fliigge deny the new gospel
of the increase of phagocytosis by high temperatures ab-
solutely. Nor is the disintegration of tissues by heat alone
successfully contradicted. Thus, after all, we need not en-
joy the presence of high temperatures as a blessing, dis-
guised or undisguised, and should reduce them. This
much is certain, that the comfort of the patient is enhanced,
and grave nervous symptoms alleviated, when the hot, dry
skin becomes cooler and moist in proportion to the reduc-
tion of the general temperature.
Which are the means by which we can effectually obtain
it? The number of antiferbrile medicaments has grown
immeasurably; the cautious practitioner will do well, how-
ever, not to embark in the dark sea of unknown territories,
guided by nothing but the flashlight advertisements of the
drug manufacturer. Some of the new remedies are actual
dangers. Acetanilid is a poison like all anilins; it changes
hematin into methemoglobin, and thus cause the cyanosis
that is so frequently noticed. Antipyrin is perhaps the
safest; sodium salicylate annoys the stomach and the kid-
neys, which are very liable to suffer from the typhoid toxin
alone. Quinine acts well during intermissions and re-
missions,, not however when high temperatures are continu-
319
DR. JACOBI'S WORKS
ous. The cardiac stimulants digitalis, strophanthus, spar-
tein, camphor, alcohol which improve the general and cu-
taneous circulation, and thereby the radiation of heat from
the skin, are mighty weapons in the hands of the intelli-
gent medical adviser, who moreover need not limit himself
to the few remedies I mentioned.
All of these remedies, however, do not exhaust our re-
sources ; indeed they are only of minor importance. With-
out knowing all of it the old poet exclaimed " hudor arts-
ton/' the water is the best. Cold water and warm water
are our most reliable and at the same time the safest anti-
pyretics. Stress should be laid on the latter title, because
many of the very apostles of hydrotherapy, perhaps in-
fluenced by shaky phagocytosis and toxin theories, belittle
it in comparison with the nerve stimulating powers of
water. Now, cold bathing is frequently contraindicated; it
is not borne when the heart is feeble from whatsoever cause ;
for instance, long duration of the disease, complications
with pneumonia, peritonitis, or hemorrhages, previous bad
health or, in the adult, excesses. No stimulant given before
or during the procedure is certain to counteract the par-
alyzing effect on the peripheral circulation. When after
a cold bath the feet remain cold and the pulse small,
the bath was contraindicated, and did harm. The patients
in public hospitals are quite often of a low vitality, and
feel the cold bath as a shock; at all events, most of those
who arrive in the hospital after a week or two have passed
the time when the cold bath might have done good. Of
this nature is the latest experience of I. Rudisch in the
Mount Sinai Hospital (Mt. S. Rep., Vol., 1899). He says:
" The Brand treatment reduced the mortality a little over
2 per cent. This reduction occurred in the cases which
had been sick two weeks or longer, outside the hospital.
Since the introduction of the Brand treatment there has
been an increase in the number of cases of pneumonia and
phlebitis, and a decrease of those of furunculosis and
nephritis. Relapses have increased 2.5 per cent. The
death rate in the relapse cases before and since the in-
troduction of the Brand treatment is practically the same.
It haS not reduced the number of complicated cases as a
320
TYPHOID FEVER IN THE YOUNG
whole, but has decreased the number of deaths from toxe-
mia in the causation of the mortality of typhoid fever."
This does not speak well for the indiscriminate use of
cold water for hospital patients.
The dangers of cold bathing are not encountered in warm
bathing. This is not the place to prove for the thou-
sandth time that a bath of 95 or 90 F. when of suffi-
cient, even when of short duration, will reduce a tempera-
ture of 104 or 106. It is simply a fact. Such a bath
may easily be given every three or five hours; even ap-
parently mild cases should have two or three daily, from
the beginning to the end of the illness. They reduce the
temperature, the accompanying frictions stimulate the cu-
taneous and general circulation, the general condition is
improved, the so-called typhoid state relieved, and re-
lapses become less frequent. Warm bathing should be the
principal treatment of all typhoid fevers, not to the ex-
clusion, however, of occasional medication calculated to
have similar effects. The combination of frequent and
protracted bathing with proper medication will always re-
main appropriate, though our resources should, as we ex-
pect, be increased by serotherapy. The searching for it,
and the frequent insufficiency of medication in skilful or
unskilled hands, both by thoughtful or routine practi-
tioners, have caused us too often to neglect our most ac-
tive helps. Even where serotherapy has scored its most
deserved laurels, for instance, in diphtheria, the almost
boastful limitation to the use of antitoxin, to the exclusion
of other internal and external treatment, is a mistake.
What is to be treated is not the bacillus, but the organism
invaded by the bacillus; and the clinician should know that
bacteriology is an indispensable aid to clinical medicine,
but not clinical medicine itself. Thus, when we shall find
an antitoxin for the typhoid bacillus, we shall still require
adjuvant treatment for the typhoid man, woman and child.
321
PATHOLOGICAL processes are but the utterances of physi-
ological functions performed under abnormal circumstances.
Those functions depend on the anatomical condition of
the tissues or organs. While this relation has long been
established in the minds of medical men, the former,
though acknowledged theoretically, is frequently not
heeded. As a rule, the pathological anatomy of a dis-
eased organ is stated, in connection with the history of
a case, or the description of a class of cases, but the
reference of an anatomical predisposition of tissues or
organs to special morbid processes is mostly neglected.
It is mainly Beneke who has studied disease from this
point of view, and it is from his various essays and works
on kindred subjects that some of the exact data to be
laid before you are taken.
By rights, every treatise, essay or paper on a pathologi-
cal subject ought to commence with the normal anatomical
condition of the organ or tissue to be dealt with. Thus,
only, an intelligent appreciation of the facts becomes pos-
sible, and thus, only, when every case is viewed in this
light, the practice of a medical man is raised above the
level of routine and drudgery.
When, some time ago, Mr. President, I had the honor
of reading before our Society a paper on infant diarrhoea
and dysentery, I emphasized the fact that healthy infants
have a normal tendency to loose liquid or semi-fluid evacu-
tions from the bowels. The causes I stated to lie partly
in the conditions of the intestinal tract, and partly in the
nature of the normal food, viz., breast milk. The latter
do not concern us now, but the former I repeat merely for
the purpose of establishing, in a few examples, the close
connection between anatomical structure and physiological
323
DR. JACOBI'S WORKS
and pathological conditions. The peristaltic movements
in the infantile intestine are very active; the young blood-
vessels very permeable; the transformation of surface cells
is very rapid. The peripheric nerves lie very superficially,
more so than in the adult, whose mucous membranes and
submucous tissues have undergone thickening by both nor-
mal development and morbid processes. In the infant,
the peripheric ends of the nerves are larger in proportion
than in the adult, the anterior horns of the nerve cen-
tres more developed than the posterior ones. Thus, the
great reflex irritability of the young, under intestinal and
other influences, is easily explained. Besides, the action
of the sphincter ani is not quite powerful, the faeces
are not retarded in the colon and rectum, and no time is
afforded for the re-absorption of the liquid or dissolved
constituents of the faeces. Moreover, the frequent occur-
rence of acids, sometimes in normal conditions, in the
small intestines, gives rise "to the formation of alkaline
salts with purgative properties.
On the other hand, constipation in the very young is
sometimes the result of grossly anatomical conditions of
the intestinal tract. I should not have to allude to the
fact at the present time if it were not for the following
reasons: Firstly, this form of constipation illustrates ex-
ceedingly well the connection between anatomy and func-
tion ; secondly, the routine treatment of constipation by
the administration of purgatives would be very dangerous
in just such a case; and lastly, what I have published about
the subject more than ten years ago, and repeated in
the treatise on hygiene, edited by Dr. A. Buck, appears
not to have been noticed to such an extent that the suf-
fering infants can be sufficiently benefited. At least, in an
essay on constipation, published but lately and presumably
considered complete in its etiology, this important cause
of the most obstinate form of constipation in the very
young is not mentioned at all.
It therefore bears repetition ; it is, in a few words, as
follows: Until the fourth or fifth months of foetal life,
there is no colon ascendens, and it is still short at birth.
Notwithstanding that fact, the large intestine at birth
324
ANEMIA IN CHILDHOOD
is comparatively longer than that of the adult. While
in the infant it is nearly three times the length of the
entire body, it is but twice that length in the adult. Now,
the colon ascendens is very short in the newborn, the
transverse colon is not much longer; thus, the main part of
the excessive length belongs to the colon descendens, and
mainly to the sigmoid flexure, which Brandt found from
fourteen to twenty centimetres, and myself in one case
thirty cm. in length. This exorbitant length of the sig-
moid flexure at the entrance of the narrow pelvis, gives
rise to more than the simple curve found in the adult.
Not infrequently the main curve is found on the right
side instead of the left, and sometimes the repeated
bending upon itself of the elongated gut is such as to
seriously retard, and in a few instances prevent, the pas-
sage of faeces.
The two instances hitherto spoken of illustrate the close
connection of two conditions noticed in very early life
depending upon the anatomical structure of the affected
organ. In brief, I shall allude to two others which be-
come manifest at a little later period of infant life. Thus,
in rhachitis, while the heart is of average size, the arteries
are abnormally large, the liver is of extraordinary volume,
and the lungs are small. Great width of arteries lowers
the pressure of the blood. One of the results of this
physiological fact is the murmur audible in the brain of
rhachiticial babies, which, by no means, as Jurasz ex-
plained it, results from the anomalies of the carotic canal.
Another result of the low blood pressure is the retarda-
tion of the circulation in the muscles, and more yet about
the epiphyses, which swell and soften. It is not the growth
of the epiphyses alone which, by itself, results in general
rhachitis, for the epiphyses are still in their cartilaginous
condition up to adolescence, and some do not ossify until
the twentieth year of life; but no rhachitis is met with at
this advanced stage. Thus it is by no means the anatomi-
cal condition of the cartilaginous tissue which is one of
the causes of rhachitis, but the condition of the arteries
supplying the epiphyses. Besides, the large size and active
condition of the liver give rise to a copious formation of
325
DR. JACOBI'S WORKS
cholestearin, the importance of which, in the establishment
of a hyperplastic condition of cartilage cells and tissue
elements in general, has long been recognized. Thus, os-
sification becomes irregular and defective, and the rhachiti-
cial bone contains an abnormally large quantity of fat, in
contrast with the deficient percentage of lime, which either
is not introduced or not assimilated in consequence of the
faulty nature of the preliminary stages of osseous de-
velopment.
Some other peculiarities are found in the condition which
has been called scrofula. The normal relation of the heart
to the lungs, between the second and twentieth years, is
1 : 5-7; in scrofula it is 1 : 8-10. This circumstance, coupled
with an acquired debility of the nervous system, results in
an insufficient supply of blood to both lungs and organism,
and defective oxygenation, particularly in those cases which
by common consent have been called torpid scrofula. It
is mainly in these that the lymphatic system pre-emi-
nently participates in the symptoms. The size and number
of the lymphatics are very great in infancy. Sappey
found that they could be more easily inj ected in the child
than in the adult, and the intercommunication between
them and the . general system is more marked at that
than any other period of life. These facts are but lately
verified by S. L. Schenck, who, moreover, found the net-
work of the lymphatics in the skin of the newly-born en-
dowed with open stomata, through which the lymph-ducts
can communicate with the neighboring tissues and cells,
and vice versa (Jacobi, " Treat, on Diphth.," p. 31).
The blood of the newborn differs greatly from that
of the infant at a period but little advanced. The haemo-
globulin in the umbilical artery amounts to 22.2 per cent,
of the whole solid constituents, while in the venous blood
of the mother it is but 13.99 per cent. The first to prove
this high percentage was Denis, in 1830, who found the
correct proportions by determining the quantity of iron
contained therein. Poggiale found a similar proportion of
the hsemoglobulin in the newborn and the fully-grown
dog, viz., 16.5: 12.6 per cent., and Wiskeman's results
are similar. The total amount of the blood contained in
326
ANAEMIA IN CHILDHOOD
the newborn is, however, smaller than in the adult, the
relation of its weight to the total weight of the body being
in the former, 1 : 19-5; in the latter, 1:13.
These conditions, however, are being changed soon. The
high percentage of haemoglobulin commences to decrease
instantly. Young animals have less than old ones; in the
calf and oxen the proportion is 11.13: 13.21.
Denis found it to diminish until the age of six months,
and a very slow increase up to the thirtieth year. Leich-
tenstern found the following proportions: if the blood of
the newborn contains haemoglobulin 100, that of a child
of from six months to five years contains 55 ; of from five
to fifteen years 58. At the age of from fifteen to twenty-
five it is 64, 25-45=72, and 45-60 it is 63. Subotin also
found less in young animals than in old ones; also less
when the amount of nitrogenous food was reduced. Leich-
tenstern found the percentage of haemoglobulin to decrease
in the very first two weeks. It was lowest at the age
of from six months to six years ; after that time a slow in-
crease takes place. But even in the very vigor of life, in
the third and fourth decennia, the percentage of haemo-
globulin is smaller than in the newborn.
There are some more differences in the composition of
the blood of the young, more or less essential in character.
The foetal blood and that of the newborn contains but
little fibrine, but vigorous respiration works great changes
in that respect. Nasse found the blood of young animals
to coagulate but slowly. How this is in the infant cannot
be determined until more and better observations will have
been made. There are less salts in the blood of the young,
and according to Moleschott, more leucocytes. Its specific
gravity in the young is 1 045-1049; in the adult, 1055.
Thus, letting alone the newborn, the result from the
above figures is this: The infant and child has and re-
quires more blood in proportion to its entire weight, but
this blood has less fibrine, less salts, less haemoglobulin,
less soluble albumen, more white blood corpuscles, and
less specific gravity.
The large arteries in the newborn and the infant are
wide, and consequently the blood pressure is but low. This
327
t)ft. JACOBI'S WORKS
is mainly so in the first five years, in the subclavian and
common carotid. Thus the brain has a chance to grow
from 400 grammes to 800 in one year; after that period
its growth becomes less. At seven, boys have brains of
1100, girls of 1000 grammes. In more advanced life its
weight is relatively less; 1424 in the male, and 1272 in
the female. At the same early period the whole body
grows in both length and weight. The original 50 cm.
of the newly-born increase up to 110 with the seventh
year; the greatest increase after that time amounting to
60 (in the female, 50) centimetres only. In the same
time the weight increases from 3.2 kilo, to 20.16 in the
boy; from 2.9 to 18.45 in the girl; a proportion of 1 to
6 or f, while after that time the increase is but three-
or four-fold.
As the organs grow, so do the peripherous blood-vessels.
Their size is in proportion to the large blood-vessels.
Only the heart grows toward the seventh year, perhaps,
only because it requires an over-exertion to overcome the
sluggishness in the circulation of the large and small
blood-vessels. It is smallest, with large arteries, in the
first year (particularly in the second half) at the same
time that the growth is most intense. Thus it appears that
the growth and physiologically low blood pressure go
hand in hand.
The sizes of the large blood-vessels do not grow equally,
nor do they exhibit the relative proportions to each other
of the normal development of the adult. The pulmonary
artery is from two to four centimetres larger than the
descending aorta. That means for the lungs more active
work, but also more tendency to disease, particularly as,
since the closure of the ductus Botalli, the aorta, from
which the bronchial arteries are sent off, assumes con-
siderable proportions within a short space of time.
At this time the lungs begin to rival the liver, which in
the first days of life was twice as large as both lungs
combined. At this time, the amount of carbonic acid
eliminated by the lungs is increasing steadily to relative
proportions not known in the adult, in the same manner as
the amount of urea eliminated is relatively larger than in
328
ANEMIA IN CHILDHOOD
the adult, in consequence of the size of the kidneys, which
are proportionately larger than in the adult.
Water prevails in the organs, even to a greater extent
than the smaller specific gravity of the blood appears to
justify. The brain in all its parts, but not equally in all,
contains a high percentage of water, the exact figures of
which can be found in " Buck's Hygiene," 1st vol., p. 139.
The muscular tissue has a percentage of 81.8 (E. Bischof)
in the newborn; of 78.7 in the adult. Schlossberger
found the following figures: in a calf of four weeks 79.7;
the grown-up animal, 77; the young duck, 85.4; the old 72.
The labor required of both heart and lungs is greater
than in the adult; thus fatigue is more easily experienced,
and the necessity of sleep, the interruption or absence of
which adds to the exhaustion and waste, is readily ex-
plained. More physiological work is done by these two
organs, and, moreover, in a manner somewhat different
from what we notice in the fully developed individual. In
him, nothing is required but the sustenance, or rather,
constant reproduction of the bulk of the body; in the child,
not only reproduction, but a new development of tissues,
a constant growth, must go on.
Within one year after birth, the young creature attains
three times its original weight. Thus we have to deal
with a being whose organs are in constant exertion, or al-
most over-exertion. Now, metamorphosis of matter is not
controlled by the inhaled oxygen alone, for the living
organism is not only what Liebig took it to be, an oven;
its intensity depends certainly in part on nerve influences.
As the nerve cells contain so much more water than in later
periods of life, it is very probable that their electro-motor
action differs from that exhibited later on. Besides, the
predominating development of the medulla oblongata, the
anterior horns and trophic nerves, points to the same con-
clusions. All this action and activity is at the expense of
the system. But that is not all. Not only exertion and
almost over-exertion, when compared with the efforts of
the merely self-sustaining adult system, but constant pro-
duction of new material, and all this at the expense of a
blood which contains less solid constituents than the blood
329
DR. JACOBI'S WORKS
of the old. Thus the normal oligaemia of the child is in
constant danger of increasing from normal physiological
processes. The work before a baby has to be performed,
under the most favorable circumstances, with, so to speak,
a scarcely sufficient capital. The slightest mishap reduces
the equilibrium between that capital and the labor to be
performed, and the chances for the diminution of the
amount of blood in possession of the child are very fre-
quent indeed.
Thus, the vulnerability of the young being great, and
diseases in early infancy and childhood so very frequent,
cases of anaemia are met with in every day's practice, and
in every form, complicated and uncomplicated, with great
emaciation or without it, and either curable or not. A
condition so frequent, so variable, so dangerous, deserved
to be treated in monographs by the best men amongst
practitioners and writers, and still there is scarcely any
text-book, any journal, in which a competent and compre-
hensive view of the subject can be found. There is but
one noteworthy exception to this fact. Dr. Forster, of
Dresden, contributed two years ago a valuable essay on
the subject in one of the most praiseworthy literary under-
takings of modern medical authorship. There are two
great works in paediatric literature recognizable as land-
marks. The first were the three volumes of monographs
published by Rilliet and Barthez. The second is the great
manual on diseases of children, edited by C. Gerhardt. In
its third volume Dr. Forster's article has been published.
Like others before him, he makes a distinction between
idiopathic and symptomatic anaemia.
The former diagnosis is made when there is no tangible
cause at all, or none which still persists; the latter when
the change in the blood, with all its consequences, is at-
tributable to a previous or present sickness. Perhaps it is
idle to consider the question at all, whether there can be
a genuine, primary idiopathic anaemia. When we sift the
matter, we shall come to the simple conclusion that every-
thing has its cause, is but a result, and secondary to some-
thing else. From this point of view, and strictly speaking,
objection could be raised to the term idiopathic pneu-
330
monia, peritonitis, or meningitis. When we make use of
it, we mean to state only that the local affection is no
longer complicated with any other that could be diagnos-
ticated, and, possibly, removed.
In this sense there are cases of idiopathic anaemia, in
which the original infant disposition to it, of physiological
character, has been raised to a pathological dignity. But
the large majority of cases are of markedly secondary char-
acter, and cannot be appreciated or treated rationally with-
out the recognition of the original causes. They are of
the most various character. In fact every disease occur-
ring in infancy and childhood may give rise to anaemia.
Very few diseases when they have run their full course
and terminated in what we are pleased to call recovery,
leave the organism or the affected organ in as perfectly
a normal condition as previously. The frequent recur-
rence of simple diseases such as pneumonia points to the
fact that changes have been worked which create a con-
stant predisposition to pathological processes in the same
organ. Thus, in most cases of anaemia the diagnosis
of the whole case must extend to the organ first affected,
and the treatment, while it may be directed against the
result, is incomplete unless the causal indications be ful-
filled.
Hemorrhages result in anaemia in a number of instances.
They are of different character and importance. There is
true melaena; umbilical hemorrhage; hemophilia; primary
or secondary purpura; internal hemorrhages of the new-
born; cephalhsematoma ; hemorrhages from rectal polypi;
epistaxis depending on coryza ; epistaxis at a more ad-
vanced age from heart disease and abdominal stagnation;
hemorrhages in diphtheritic angina; and such as take place
during or in consequence of operations for hare-lip or
ritual circumcision. Death may result from many of them,
such as melaena, hemophilia, pharyngeal hemorrhages, or
circumcision; others are of but little gravity, such as the
sanguineous tumor of the newborn; others are apt to
result in permanent ailing. As a rule, however, an acute
anaemia is more easily overcome than one that is of a
more chronic nature, and thereby undermines the vitality
331
Dft. JACOBI'S WORKS
and strength of the organs while it slowly robs them of
their nutriment. Infants who are thus stricken recover
but slowly or not at all. Young animals resist starvation
to a less degree than old ones. A dog of two days bore
starvation in Magendie's laboratory but two days ; a dog
of six years, thirty. Similar results were obtained by
Chossat in his experiments on pigeons. Thoroughly anaemic
and delicate babies seldom recover entirely, like starving
young animals which never attained their normal condi-
tion though they were carefully fed afterward. The
recruits of the Prussian army born in the starvation years
of 1816 and 1817 were of a very inferior character physi-
cally. To this class also belong the children born prema-
turely and of delicate parentage, though there were no
recognizable constitutional disease, and of mothers afflicted
with a disease of the uterus or placenta, inflammatory,
syphilitic, or otherwise; or of such as suffered much
during pregnancy or lactation; also those born with con-
genital diseases, cyanosis, or neoplasms, which are by no
means so rare as has often been believed and said, or the
peculiar smallness of the heart, and principally the ar-
teries, to which Virchow attributes many cases of chlorosis.
I have met with half a dozen of such cases, in which
the supply of blood to the body was diminished by this
anomaly, and Dr. Skene reported a case of probably the
same nature which was published in the Journal of Ob-
stetrics and Diseases of Women and Children, Oct., 1876.
Besides the diseases and affection of the newborn
there are others which develop in later life and lead to the
same results. It is often acquired in endocarditis, for
instance; acute inflammatory rheumatism, which is very
frequent, yields in most cases but little swelling of the
joints, comprises most cases of so-called growing pain,
and has a much more marked tendency to the production
of an endocarditis than the same affection in the adult.
Protracted diarrhoea injures to a greater extent than con-
stipation. It acts not only by direct and immediate loss
of serum, through which it can prove fatal in a short
time, but more frequently by its consequences. The
mucous membrane of the intestinal tract becomes thick-
332
ANAEMIA IN CHILDHOOD
ened, the submucous tissue oedematous, the muscular layer
cedematous or hyperplastic ; the adventitia sometimes un-
dergoes fatty degeneration. Erosions and ulcerations are
apt to become chronic, and frequently the n^esenteric
glands are the seats of congestive and hyperplastic proc-
esses. An intestinal catarrh cannot last any length of time
without irritating, congesting, enlarging, and finally in-
durating, or provoking caseous degeneration of the neigh-
boring lymphatic glands. The cause of the diarrhoea is
indifferent in this respect. None can last without con-
secutive injury to the lymphatic glands which is apt to
become permanent and deteriorate sanguification for the
future. The unmistakable practical conclusion from this
fact is that every diarrhoea must be stopped as soon as
possible. Neither summer heat, nor that great scapegoat
dentition must be permitted to yield a pretext for the
continuation of a diarrhoea, no matter how innocent it may
appear.
Malaria, which is too often diagnosticated when the real
nature of the disease is not recognized, and frequently
overlooked because of the irregularity and the little pro-
nounced character of the attacks. The first stage of the
attack is often not recognizable. The attacks are apt to
come at irregular times ; are more quotidian than tertian,
often concealed by accompanying symptoms such as con-
vulsions, and, therefore, sometimes not accessible to a
ready diagnosis. On the other hand, the influence of ma-
laria is apt to undermine the general health, render the
child intensely anaemic, and swell the spleen considerably
before ever giving rise to a real attack.
Nephritis, with albuminuria, not the acute cases, but
those chronic ones which slowly undermine the nervous
system and exhaust by direct loss ; pernicious anaemia, with,
it is true, as far as I know, but two cases occurring in
children, recorded in the literature of this recent sub-
ject; leucocythaemia ; sleeplessness from any cause such as
malaria, whooping-cough, or indigestion; mercurial ca-
chexia, rare though it be ; congenital or hereditary syphilis ;
rhachitis, with its influence on blood glands and bones, its
shortening ; flattening and even retraction of the thorax,
333
DR. JACOBI'S WORKS
its curvature of the spine, and compression of the lungs
and heart; fatty liver; enlargement of the lymphatic
glands, mesenteric, bronchial or otherwise; the complex
of symptoms comprehended under the general head of
scrofula; diseases of the bones of the most various kinds,
from congenital or premature ossification of the costal
cartilages, with its consecutive contraction of the chest and
compression of its contents, to the chronic or subacute
osteitis of the vertebral column or any of the other parts
of the skeleton, with its final termination in amyloid de-
generation of the viscera; and finally, to conclude with,
diseases of the lungs and pleurae, caseous deposits, cirrhotic
induration, emphysema and empyematic deformity.
In anaemia both the skin and the mucous membranes are
pale, of a yellowish hue, thin and flabby. A certain
degree of apparent elasticity of the skin and subcutaneous
tissue is noticed only in cases of oedematous effusion.
Those organs or tissues which are least in use emaciate
first; that is, in very young children, fat and muscle.
But there are cases in which fat is persistently retained,
and in which it is often increased in quantity. For, when
the red blood globules are destroyed, there is scarcity of
oxygen, and for that reason the combustion of the al-
buminous substances becomes incomplete, and fat, the
physiological result of this incomplete combustion, is de-
posited in large masses. Particularly is this the case
when anaemia is either complicated with or is the result of
general rhachitis when at the same time the glands and
the chest are suffering from the results of the rhachitic
processes. An illustration of this peculiar occurrence,
which is by no means rare, is also seen in the peculiar
appearance of acardiac or acephalic monsters, which con-
tain a large amount of oedematous fat, in consequence of
the exclusively venous character of their circulation.
In consequence of the ill nutrition and the emaciation of
the muscular tissue these infants and children are easily
fatigued. In general, the functions of all the organs suffer
considerably. And with such debility, irritability goes
hand in hand. The nervous system is less affected than
any other, because of the rapid growth and development
334
which it undergoes at that period of life. Not infre-
quently, babies who are anaemic and emaciated are in the
very best of spirits, because their brains are comparatively
in good condition. A certain amount of emaciation can
be easily recognized by the depression of the fontanelles
of babies under one year old or even later; but the emaci-
ation of the brain does not increase at a rate which cor-
responds with the loss in weight of the other organs and
tissues of the body. In addition, the very sinking in of
the fontanelles, which allows us to estimate the amount
of emaciation that has taken place inside of the cranial
cavity, leads us to the fair conclusion that the emaciation
of the rest of the body has taken place to an unusual ex-
tent; and any baby with considerable depression of the
fontanelles must be considered in danger from the degree
of inanition present.
Murmurs in the jugular veins are not very frequent in
infancy and early childhood. Murmurs in the carotids
and over the large fontanelles, however, are not at all
rare. It is not true that these murmurs, audible over the
brain, belong to rhachitis alone. They are found in every
condition in which blood pressure in the large arteries of
the cranial cavity is lessened.
The heart itself seldom exhibits functional murmurs.
Whenever they are present, it is safer to attribute them
to organic disease than to merely functional disorder. Be-
sides, it is now well known that acquired endocarditis is
by no means rare, and, moreover, that it occurs even more
frequently in the articular rheumatism of the young, be
it ever so slight, than of the adult. Although the brain
be not so liable to suffer from emaciation, dependent upon
anaemia, as other organs, still there are a number of cases
in which headaches, attacks of syncope, sleepiness, etc., or,
on the contrary, sleeplessness and hysterical attacks, are
the result of anaemia alone, and disappear when this con-
dition is relieved. Not a few of the babies and children
who cry the greater part of the night have no other ail-
ment besides general anaemia, and such children are fre-
quently relieved by a meal or some stimulant before they
are put to bed, or given during the interruption of their
335
DR. JACOBFS WORKS
sleep. The pulse of such children is sometimes very much
accelerated; sometimes, however, it is slow, and sometimes
irregular. I have known such children, in whom for
months, and occasionally for years, I have feared the de-
velopment of cerebral affections from the very fact that
their pulse was both slow and weak; and yet, when their
general condition was improved both the regularity and fre-
quency of the pulse were increased.
The pulse, however, is, perhaps, amongst the symptoms
which are most unreliable at this age. In the baby it is
best counted during sleep, and better over the fontanelle
than upon the radial artery. It will change very fre-
quently, not only with alternate sleeping and waking,
with rest and restlessness, but sometimes without apparent
provocation. A slight amount of muscular action will
change its character more or less, and frequently consid-
erably. Physiologically, the pulse is very apt to be more
frequent at the age of two and a half or three months
than earlier or later, because it is at about that age that
muscular movements are actually developed.
Very few anaemic children have a good appetite except
at the beginning. The influence of anaemia is general in
regard to all organs of the body. Circulation is deficient,
and the normal secretions are defective or deficient in con-
sequence. That is, both appetite and digestion are im-
paired, and sometimes destroyed, and cannot be restored
until the general condition of the child is improved.
The slowness of the circulation and its insufficiency, and
the watery condition of the blood, are apt to give rise to
catarrh of the pharynx and larynx and the respiratory
organs in general. Besides, the walls of the blood-vessels
are known to suffer in anaemia. They become thin, and
undergo fatty degeneration, which Ponfick has found in
the heart, and in the intima of the larger blood-vessels
and in the capillaries. In consequence of the thinness of
the blood and the changed condition of the blood-vessels,
serous transudation, and, now and then, extravasations will
take place. The same occurrence is noticed in the adult in
conditions of anaemia. It not infrequently occurs that
those who have least blood lose it most easily. Anaemic
336
ANEMIA IN CHILDHOOD
women are very apt to have copious menstruation, and
when their general condition has been improved, both
blood and blood-vessels resist this tendency to hemorrhage.
There is one consequence of the anaemic condition which
is of the utmost importance, and requires urgently that it
should be removed in the shortest possible time.
Whenever a disease sets in it is more liable to result
fatally in consequence of impaired powers of resistance,
and where there is the slightest tendency to effusion or to
exudation these processes will become more extensive and
dangerous in less time than in the normal organism. A
pneumonia, a peritonitis, a pleurisy, occurring in an
anaemic child, is attended with a great deal more danger
than when either of these affections occurs in a child
enjoying good general health.
That epistaxis in a child 5, 6, or 8 years old should last
as long as the patient is in a generally impaired condi-
tion, is just as frequent an occurrence as it is a common
experience to meet with almost constant improvement after
a change of diet, change of air, and a few doses of
iron.
The predisposition to anaemia in the child is very great,
as proved before, and the causes of its deveolpment very
numerous. These causes must be, according to circum-
stances, either prevented or remedied. For genuine cases
of idiopathic anaemia are certainly very rare, and an ac-
curate diagnosis will find it to be symptomatic in almost
every case, and to depend on the lesion of some organ, or
system of organs. The danger of anaemia is greatest at
the time of the most rapid growth, still it is a cause of
slow destruction in every age. The nursling is more ex-
posed than the child, for the growth of all the organs,
with very few exceptions, is most intense at the earliest
period of life. At that time, besides actual disease, insuf-
ficient food, or improper food, are frequent causes, the
latter a more frequent one than the former, and often the
more dangerous one of the two. Infants whose mothers
or nurses have not enough milk, simply starve; they lose
weight, strength and color. As long as their lungs and
muscles will hold out, they will scream. Some of the yell-
337
DR. JACOBI'S WORKS
ing heard in the night amongst the tenement-house popula-
tion, and sometimes in the better-situated classes, too,
comes from starving babies. After a while the yelling
turns into a whining, and any slight disease terminates the
baby's suffering. This condition is recognized by the ab-
sence of local disease anywhere, by the gradual emacia-
tion, and is characterized by the paucity of otherwise nor-
mal faeces. Many a case of alleged constipation is one of
starvation. Where there was no food, there are no evacua-
tions, and when a baby is reported as having but one nor-
mal passage a day, or even less, the suspicion is that it has
not enough to eat. The remedy is easily recommended,
for it consists in nothing but a sufficient quantity of
proper food.
Improper food is a much more frequent cause. A few
remarks must suffice here, for it is impossible to go over
the whole ground of infant hygiene in a short paper which
is more meant to suggest than to teach. A few points,
however, I must not omit, because of the frequency of the
sins committed. The contraindications to a woman's nurs-
ing a baby must be obeyed. Nursing during pregnancy,
or extended over too protracted a period, must be forbid-
den. The latter is, if possible, more serious than the
former. Many a case of rhachitis or anaemia owes it origin
to the baby being nursed into the second year. A baby
whose development is not normal, for instance, whose first
tooth does not appear at the regular age of seven or
eight months, is either suffering from a previous disease
of it has insufficient or improper food. If nursed, there-
fore, it ought to be weaned, or partially so. Many a
flabby child at the breast will thrive when weaned at last,
and good barley and cow's milk will make better muscle
and teeth than poor mother's milk. An inherited or in-
heritable or communicable disease on the part of the
mother or wet-nurse, such as consumption, rickets, syphilis,
serious nervous diseases, intense anaemia forbid nursing.
In not a few cases the individual milk of mother or wet-
nurse does not agree with the baby. When such is the
case, unless the fault can be detected and remedied, wean-
ing is required. In most cases it is possible to trace the
338
ANJEMIA IN CHILDHOOD
indigestibility and insufficiency of a mother's milk to the
absence or prevalence of a special constituent, mostly
either sugar or and mainly so casein. A ^beautiful
illustration of this fact was but lately exhibited by a baby
patient of Dr. A. N. Smith. The mother's milk was un-
doubtedly too white and too caseinous. The baby's diges-
tion was faulty, his assimilation quite defective. The ad-
dition of some farinaceous decoction to each meal from
his mother's breast a few teaspoonfuls given before each
meal remedied the evil somewhat, but the patient's life
was finally saved by nothing but weaning and exclusive
artificial feeding. It is impossible, however, to consider
now the question of infant food to any extent. Such
principles as I have laid down in Buck's Hygiene, and
very briefly in my paper on infant diarrhoea and dysentery,
have guided me through the better part of my life. I shall
not, therefore, tire your patience by repeating them.
There are, however, a few simple words which I cannot
repeat too often. Avoid solid food .in the care of an in-
fant. Avoid cow's milk either undiluted or diluted with
water only. Avoid condensed milk diluted with water
only. Use no milk without the addition of some
gelatinous or farinaceous decoction, barley, oatmeal, gum
arabic, gelatine. In anaemia, add beef soup to the uniform
infant food daily. Give solid food, that is a small piece
of meat, a crust of bread, half an egg, about the end of
the first year. Keep up this simple diet for another year,
and add slowly such articles of food as physiology and
experience permit. Prohibit bad habits, such as irregular
and fast eating, cold feet and highland-fashion legs, and
enforce out-door exercise; children before and after an
out-door play are different beings. Avoid crowded school-
rooms and the excess of private lessons. A child sleeping
after a healthy exercise of his muscles and lungs will
finally, besides being stronger and healthier, learn more
than one who hangs his pale cheeks, sleeping over his
books. We have laws to protect children from being sent
to work in factories, or to be employed on the stage, but
we have none to protect them from the equally destructive,
incessant schooling in close rooms, without air or exercise.
339
DR. JACOBI'S WORKS
There are too many books bought for Christmas and too
few skates.
Amongst the medicinal agents iron has long been the
main resort in anaemia and chlorosis. This was so even
before the time when hemoglobin was isolated and found
to contain all the iron of the blood. As it was found to
benefit the cases of anaemia and chlorosis, in which the
red blood corpuscles were undoubtedly diminished, it was
believed that iron had the ability to directly increase the
number and the quality of the red blood globules. But
the question whether it is really the iron which produces
this effect has not been answered to the satisfaction of all,
for a great many of the cases get well while no iron what-
ever is given, and in consequence of change of diet and
the securing of rest and a better general condition. Be-
sides, there are a number of cases in which the administra-
tion of iron is absolutely unavailing. Moreover, there is
plenty of iron in almost every article of food. Boussain
gault found that thus eight or nine centigrammes (gr.
iss.) of iron are daily taken into the body. The same
quantity has been found by Fleitmann to be eliminated
by the kidneys and the intestinal canal. Thus, there cer-
tainly are cases of chlorosis which have not been caused
by the absence of iron ; and it cannot, therefore, be said
that the iron, by supplying this lack or by removing this
absence, cures chlorosis.
But it is still a question whether the iron thus given,
under circumstances which are entirely abnormal, does not
improve the chances of recovery in just these conditions.
The doses given would certainly be too large, when com-
pared with the iron contained in the food and with the
amount of iron present in the whole quantity of circulating
blood, three grammes and no more.
Compared with this small quantity, the doses we are ac-
customed to administer are certainly large. Speedy elimi-
nation, too, takes place, through which the whole or nearly
the total amount of the ingested iron is removed. But it
has not been found whether the iron does not act in some
other way besides increasing the amount of the metal con-
tained in the hemoglobin.
340
ANAEMIA IN CHILDHOOD
After iron has reached the stomach it is decomposed into
an oxide, and is absorbed, probably in the form of an al-
buminate. There can be no doubt, according to Dietl and
Heidler, that it is absorbed in the stomach, and very prob-
ably the upper part of the small intestine also. It reap-
pears in the bile and the pancreatic juice. Not only is that
the case after it has been introduced into the stomach, but
it will also reappear in the bile secretions of the intestine
and pancreatic juice, according to A. Mayer, after it has
been injected into the veins. It is true that Quincke was
sometimes unable to find iron in the intestinal secretions
after it had been injected into the blood, but it seems to
be well established, according to the experiments of Pro-
kowski, that the temperature of the blood is elevated, the
pulse accelerated, and the blood pressure increased after
the use of iron. For this reason it ought not to be given
during the height, or even during the course of inflam-
matory fevers. A number of its preparations are cer-
tainly vascular excitants. But for this very reason,
while it is contraindicated in inflammatory fevers, it cer-
tainly is indicated and required in most cases of septic
fevers.
The preparations most beneficial in anaemia of children
are, in my opinion, the following: the lactate, the tincture
of the pomate, the iodide, the pyrophosphate, the subcar-
bonate, and the tincture of the chloride.
The lactate and the pomate are very digestible, and may
be given whenever the indication for the use of some mild
preparation of iron is established.
The syrup of the iodide has an advantage over the other
preparations of iron, because by its use two indications
may be met that is, where the additional aid of an ab-
sorbent is desired. Therefore, it is the proper remedy in
cases of slow convalescence after inflammations resulting
in exudation, particularly in disease of the glands and
the lungs. It has, moreover, one peculiarity which makes
it much more desirable than many other preparations, and
that is, it is easily decomposed in the stomach; the iodine
is set free, and acts as an anti fermentative in the many
cases of disturbed gastric digestion, occurring even in nor-
841
DR. JACOBI'S WORKS
mal children, and almost certain to take place in children
whose circulation has been disturbed or whose gastric se-
cretions are certainly below their normal amount in conse-
quence of a deficient supply of blood.
The subcarbonate of iron is a very mild preparation,
easily digested, and properly combined with a number of
drugs, such as bismuth or bicarbonate of soda, is of con-
siderable value when, in slow convalescence or progressive
anaemia, this gastric catarrh threatens to interfere with the
improvement in the general condition. The doses may be
larger than those of any of the other preparations. A
child two years will easily bear from 25 to 50 centi-
grammes daily. This quantity, combined with twice or
three times as much subcarbonate of bismuth, and, if neces-
sary, three or four times that amount of bicarbonate of
soda, is a very proper remedy to be used in the conditions
alluded to.
The tincture of the chloride of iron, when neutral, is a
preparation which is also easily digested. Doses of a
gramme daily, or more, are very readily digested, and
prove beneficial. This can be easily combined with the
bitter tinctures, stomachics, etc. The tincture of the muri-
ate of iron is the one, amongst the ferruginous prepara-
tions, with the exception of those partly composed of ether,
the acetate, for instance, which must be regarded as a vas-
cular irritant, and wherever the action of the heart is
lowered and blood pressure is diminished, it is the prepara-
tion which will be found most beneficial.
In a number of cases, the choice among the several
preparations of iron is an indifferent matter, at least, so it
appears to be. Still it has seemed to me that, in those
cases in which I have had to deal with anaemia attended
by gastric catarrh and digestive incompetency in the up-
per portion of the small intestine, the pyrophosphate
proved very satisfactory. I have employed the compound
hypophosphates and phosphates a great deal, which com-
bine iron, potassa, lime, and soda, and, although it is
well known that the elimination of these metals and
metalloids is almost as rapid as their ingestion, still it ap-
pears that the effect produced by such combinations is a
342
ANAEMIA IN CHILDHOOD
very happy one in just such conditions as those of which
we have just spoken.
All these preparations are of special value in chronic
anaemia, which is by far the most common affection. Acute
impoverishment of the blood, such as that caused by severe
puerperal hemorrhage or hemorrhage from the bowels, is
fortunately very rare in infancy and childhood. Therefore,
the opportunity for transfusion of human blood is seldom
offered, even to those who are most fond of that particular
operation.
The doubtful results of transfusion upon a large scale
have induced a modern writer to make a number of small
transfusions by means of the hypodermic syringe. He
would withdraw blood from the vein of a healthy person
and introduce it directly and immediately into the veins of
the sick child, and he states that he has done so with
favorable results. It seems to me that the plan is rational
enough, but the future must decide whether the results
will be as favorable as they have been reported, and
whether there will not be grave objections to what is de-
scribed as a very trifling operation. If it be successful,
it would certainly, under equal circumstances, have the
preference over the slow process of gastric, or of rectal
alimentation, no matter whether injections of defibrinated
blood or other nutrients are used.
In cases of chronic anaemia I have frequently used ar-
senic; one or two minute doses daily, after meals and well
diluted with water, and with benefit. Of one thing there
is no doubt, and that is that arsenic does good in a pe-
culiar torpid condition of the stomach which will not digest
and assimilate in consequence of the absence of both nerve
power and gastric juice. Both in adults and in children,
I have given it for the purpose of improving general nu-
trition, and I have not seen in children what very fre-
quently occurs in adults when arsenic is given for nervous
disorders, namely, gastric derangement. With iron, with
or without stomachics, I have seen the appetite improving,
the mucous membrane filling with blood, and vigor return-
ing under its restorative influence. Doses: from two to
five drops daily, of Fowler's solution.
343
DR. JACOBI'S WORKS
In this connection, I will state that strychnia, in my
hands, has proved very beneficial as an adjuvant to either
arsenic or iron. To a child two years old a dose of %
of a grain may be safely given daily, and this dose may
be continued for a long time. Its action is well known in
cases in which the digestion and the entire nervous power
of the patient are simply lowered, and a few weeks' ad-
ministration, together with proper food and either iron or
arsenic, has changed the condition of the anaemic child
considerably.
Phosphorus, in about the same doses as strychnia, has
also produced very happy effects. They may be brought
about by the influence of phosphorus upon the nervous
system, or they may be explained by the effect which the
remedy produces when given in diseases of the bones.
Some ten years ago, Georg Wegner found that the frac-
tured bones of rabbits fed upon minute doses of phos-
phorus, would unite much more rapidly than the frac-
tured bones of those animals which were left to themselves.
Since that time I have been in the habit of giving phos-
phorus in cases of acute and chronic disease of the bones
of an inflammatory character, and in caries particularly,
and my impression is that the large majority of cases do
very much better when small doses of phosphorus, say %5o
to %oo f a grain daily, are given, than when the dis-
ease is left to pursue its course without the use of this
remedy. It is true that the time required by such a
process as caries is long under any circumstances, but it
has seemed to me that even caries of the ankle joint and
the metatarsus was apt to progress very favorably in the
course of a number of months when phosphorus was used,
whereas years were required in other cases which had not
received the same treatment.
I do not know that it has been used extensively in
rhachitis, but it is not improbable that the good effect
which phosphorus produces in anaemia, mostly of rhachi-
ticial children, is partly due to the fact that the bones
especially show an increased tendency to normal develop-
ment.
In many cases cod-liver oil is very serviceable; I need
344
ANEMIA IN CHILDHOOD
not speak of its effect, and shall only say that frequently
the contraindications to its use are overlooked. Most
children do not bear it well in the summer, when it is
apt to produce either gastric catarrh or diarrhoea. Some
do not bear it at all at any season of the year. It is with
cod-liver oil as with any other remedy, particularly iron,
of which I have already spoken. There are children who
do not bear either, and, therefore, they must be treated
without these remedies. At all events, it should not be
forgotten, whenever digestion is impaired, whenever there
is gastric catarrh, that these cases require preliminary treat-
ment before the administration of either cod-liver oil or
iron is resorted to.
345
TREATMENT OF INFLUENZA IN CHILDREN
Prophylaxis. Is there anything like a preventive of in-
fluenza? There is, contrary to Berger (Die Infections-
Krankheiten, 1896), and others, no infectious disease of
equal communicability, either direct or indirect. Under
extraordinary circumstances only is there a possibility of
avoiding contact. Influenza may be prevented from en-
tering a ship coming from distant ports, or a ship carry-
ing it may be quarantined with rather more theoretical
than practical effect. Influenza may be kept out of a
monastery or a prison or out of an insane asylum or bar-
racks if there is no intercourse with the rest of the world.
It should be kept out of a sanitarium for lung diseases
by strict isolation during an epidemic. Indeed, I know of
no infectious disease that creates a greater disposition to
tuberculosis than influenza. To close a school is unavailing,
for the children will contract the disease outside. Ex-
pectorated mucus and the result of sneezing should, if
possible, be caught and disinfected or destroyed; tools,
toys, towels, handkerchiefs, and linen should be treated,
t. e., washed and disinfected as in other contagious mala-
dies. To protect the children of a household the patient
should be isolated on the upper floor of the house, a de-
mand with which it is impossible to comply in the larger
part of our population. Nurslings, if their mothers be
sick, should meet them for nursing only. Sick and well
children should use disinfectant mouth-washes. I think
water slightly acidulated with hydrochloric acid will do
best. Drinking-water should also be acidulated in the same
manner and may have the same favorable result that is
obtained in Asiatic cholera. The irrigation of the nose
should be a matter of course in the well and in the sick,
for the same reasons that have been urged by myself and
very persistently and forcibly by Dr. C. A. Caille against
347
DR. JACOBI'S WORKS
and during diphtheria. In this way mucus, which accord-
ing to Ruhemann catches bacilli as in a net, is removed and
the mucous membrane is kept in a healthy condition. In
which way the bacillus enters is not entirely clear; if it
invades through the mucous membrane like the pathogenous
bacilli of tuberculosis or diphtheria or cholera, the more
normal the condition of the mucous membrane, the greater
is the protection.
Medicinal preventives have been recommended cod-
liver oil by Ollivier; calcium sulphide by Greene; quinine
by many. Trials with it made on regiments of soldiers
under control in their barracks were equally positive or
negative. My experience with preventives is very small.
Quinine appeared to cause headache and nausea.
Treatment. There is no specific for influenza like qui-
nine for malaria or salicylic acid for rheumatism. Inno-
cent muriate of ammonium, also carbonate of potassium,
sulphocarbolate of sodium, carbolic acid, ichthyol, and other
remedies have been so recommended without the expected
success. Thus, rational, hygienic and symptomatic and sus-
taining medicinal treatment only can be considered. A
purgative dose of calomel should be given in order to clear
the bowels of microbic and toxic ingesta, the bowels ap-
pearing to be the principal point of attack in young chil-
dren. The patient should be kept in bed, the temperature
of the room at 70 F. or more at first, the diet should be
scanty and fluid at first milk, cereals, farinacea, water,
lemonades, and broths. The further development of the
case will gradually indicate eggs, and perhaps in a few
selected instances only alcohol in addition to other medic-
inal stimulants. It is more, however, a slow convalescence
that requires it than the course of the disease itself. In
this respect it appears to differ somewhat from other infec-
tious diseases, particularly typhoid fever and diphtheria.
In the latter the doses of alcohol should be high from the
beginning.
If there be a high temperature, cold water is not indi-
cated either as a bath or as a pack. The irritating cough
which often requires opiates is rather increased than
soothed by it; the characteristic bronchitis of influenza does
348
TREATMENT OF INFLUENZA IN CHILDREN
not bear it; the frequent copious perspiration contraindi-
cates it, and so does a weak heart under all circumstances.
On the contrary, when there is much muscular pain and
restlessness, a warm bath is often beneficial. Hot baths
should be avoided unless a very short one in an occasional
collapse, and Turkish baths require stronger heart-muscles
than we are apt to meet in pronounced cases of influenza.
While many common cases of pneumonia, with fair cir-
culation, are apt to do well with cold packs, influenza pneu-
monias do better with warm ones.
According to Ditmar Finkler of Bonn quinine occupies
a front rank. 1 Out of eighty of his patients treated with
quinine only three made their appearance at the dispensary
a second time, while of those treated with other drugs nearly
one-half reappeared twice or more frequently. The fav-
orable action of this drug has been observed by Dujardin-
Beaumetz, Tessier, Carriere, Pribram and others. Mosse,
to abort the disease, administered 1.0-1.25 grams the first
day, sometimes also the second. Filatow has also observed
its favorable effect especially in children. Others, how-
ever, as Eichhorst, Tranjen and Bowie, had no success in
the use of this remedy, and Leichtenstern believed that the
cases treated with large doses of quinine did worse than
those that were not so treated. In the German collective
investigation reports some praised quinine as giving bril-
liant results, while others were greatly disappointed in its
effects.
Whenever vomiting is severe, stomach feeding is out
of the question. The temporary abstinence and afterward
rectal alimentation find their indication. Alcohol greatly
diluted, peptones, mild salt solutions, and liquid albumins
are readily absorbed in the colon which even in the smallest
infant, though the fetal length of the sigmoid flexure may
be persistent, is made accessible by elevating the hip and
moderating the current by not raising the irrigator more
than a foot above the anus. Peptonized milk, egg and
broths are absorbed in part. Starch in the injection is
dextrinized in the colon and thus adds to the nourishment
1 Finkler. " Twentieth Century Practice of Medicine," Vol. XV.
3-19
DR. JACOBI'S WORKS
of the enema, but though water alonf were injected it would
add to the circulating fluid. That '< why even a large
enema given for the purpose of clearing the bowels may
add to nutrition and strength by such of the injected water
as is almost invariably retained. Thus, severe vomiting
should be treated with refusing to feed through the stom-
ach. The best relief is given by morphine, rarely by ice,
either internally or externally. It is not necessary to send
morphine down to the stomach ; absorption is easy and more
readily accomplished in the mouth or throat. A tablet of
one milligram may be thrown into the mouth of a child
of two or four years, there to be absorbed, or half a drop
or one drop of Magendie's solution may be administered in
the same manner without dilution.
The indications for the treatment of influenza may be
several, the high temperature in many cases, the great dis-
comfort, the restlessness, and the rapidly increasing ex-
haustion. In the treatment of many fevers it is their causes
that require consideration; 2 in others, however, their rela-
tions to, and influence on, the body are the main considera-
tions. When the condition of the latter is fair, and no
danger is incurred on account of the fever, it should be
left alone; when the rise of temperature, however, by itself
is injurious, it should be interfered with. At all events
the treatment of the symptom " fever " gives us no hope
of shortening the disease in which it occurs or of which
it forms a part; on the other hand, it is a satisfaction to
know that, while we increase the comfort and diminish the
immediate dangers, the natural healing process is not dis-
turbed. In this way both the justification and the limita-
tion of the so-called expectant treatment become evident.
To allow a high temperature to deteriorate tissues and ex-
haust the heart or brain, is as injudicious as is the custom
of emphasizing the number of degrees of Fahrenheit as the
only valuable part of a morbid process. To be satisfied
with depressing temperature is a grave mistake, but to
allow pneumonia to run its deleterious course of high tem-
2 Jacobi, A. Fevers and Fever Remedies, Albany Medical
Annals, May, 1900.
350
TREATMENT OF INFLUENZA IN CHILDREN
peratures unchecked with their full influence on the rapid-
ity of respiration and the action of the heart and on the
increase of waste, is equally injudicious.
In their injurious influence on nutrition protracted in-
fectious fevers act, first, like direct losses or like starvation,
and, secondly, as immediate poisons. The younger the pa-
tient, the greater is the danger from that source. That
is why a high temperature without any or with a trifling
remission should not be allowed to last, though its imme-
diate effect may not appear very ominous. When a high
temperature results in a convulsion we never hesitate to
reduce it; here we admit there is a vital indication. Why,
then, not reduce it while there is the danger of a possibility
or probability of its occurrence? Add to these facts the
disposition of the young to inanition which is caused by two
main factors. The first is their rapid metabolism, the sec-
ond and principal one is the relative, almost universal,
insufficiency of the young organism.
Moreover, we should not forget that most of our antipy-
retics are at the same time nervines, analgesics and dia-
phoretics, thus improving comfort and metabolism. They
are surely indicated when bathing is not sufficiently effi-
cient or when baths are contraindicated ; in that case they
may act as adjuvants, as combinations, and procure sleep
and remissions. If I add that there are, however, contra-
indications to the use of medicinal antipyretics because of
possible idiosyncrasies and of the debilitating effects which
many of the antipyretic drugs are apt to exhibit, I merely
say what all have experienced, and what everybody should
remember, viz., that no degree of Fahrenheit and no Greek
name of a morbid process are the subjects of our medi-
cation, but an individual patient. From these points of
view our fever remedies should be judged.
In my paper of 1890 3 I said that acetanilid ought to
be preferred among the poor because of its low price, anti-
pyrin mainly where great solubility was required for the
purpose of its administration in rectal and subcutaneous
injections, and that phenacetin was preferable to either
ajacobi, New York Medical Record, 1890.
351
DR. JACOBI'S WORKS
when it could be given by the mouth, because of its less
uncomfortable effect on the brain, the heart, and the skin.
This opinion I have to modify to a certain extent, not
that I object to what I said of phenacetin, but acetanilid
should never have an opportunity to show what good quali-
ties it may have, in the rich or poor. It should not be used
at all, under any circumstances, not even in the quack
preparations which now and then I know to disfigure the
prescriptions of regular practitioners. Being a derivative
of anilin, acetanilid is poisonous. Not only has it a seda-
tive or rather paralyzing effect on the central nervous sys-
tem, but it destroys the blood and causes anemia by chang-
ing hematin into methemoglobin, though given sometimes
in small doses. That is what gives rise to cyanosis so often
observed, more often than after the administration of any
other of our modern analgesics and antifebriles. ,The poi-
sonous effect is even noticed when the drug is used exter-
nally, mainly on the young. Examples of such cases were
reported at the meeting of the Philadelphia Pediatric So-
ciety, April 11, 1899-
Antipyrin, when employed during normal conditions, in-
creases the tension of the pulse and blood pressure there-
fore it is contraindicated in hemoptysis and produces per-
spiration. It works more on the general central nervous
system than on the center of circulation, that is why it
acts while being antipyretic as a sedative and analgesic.
But it should not be considered as a nervine, for its action
appears to be ushered in through the mediation of the blood
and blood-vessels. The body temperature begins to de-
crease within fifteen or twenty minutes after the first dose;
to render its antipyretic effect more tangible and persistent,
it should be followed by a second within two hours. This
rule, however, does not hold good when the drug is given
for its sedative or analgesic or for its slight anti-rheumatic
effect. Its general effect is mostly good, but its undesir-
able effects are many. Otto Seif ert 4 quotes eighty authors
of note who report disagreeable effects of antipyrin; they
4 Seifert, Otto. Wtirzburger Abhandlungen aus dem Gesammt-
gebiet der prakt. Med., 1900.
352
TREATMENT OF INFLUENZA IN CHILDREN
were observed in the gastro-intestinal, nervous and circu-
latory system, in the skin and in the mucous membranes.
Phenacetin is dismissed with ten. It resembles acetanilid,
but is very much milder in its effect. The transformation
into methemoglobin takes place after large doses of several
grams only. Half-gram doses for antipyretic, gram doses
for analgesic purposes are recommended. The doses to be
given to infants and children should be from fifteen milli-
grams to three centigrams (gr. ^--J).
Salipyrin, the salicylate of antipyrin, is employed by
Finkler. While antipyrin causes perspiration, sometimes
excessively so, he reports a case in which hyperidrosis was
instantly cured by salipyrin. It should be given in twice
the doses of antipyrin, is usually better tolerated than the
latter, particularly by neurotic or neuralgic patients, be-
cause of the relative absence of accidental effects.
Salophen is extolled by Drewes of Hamburg, who pre-
fers it to salicylic acid and to salicylate of sodium, mainly
in the nervous form of influenza. Adults took from one
to six grams, children from three to five decigrams. Fink-
ler, who quotes him, adds: " I believe that most physicians
have arrived at the point where they would not like to be
without these preparations in influenza, but it should cer-
tainly not be forgotten that reports of this kind have quite
frequently been used for advertising purposes."
There is something else that should not be forgotten,
viz., that there is hardly a disease which has as great a
tendency to cause exhaustion and numerous other nervous
symptoms, from languor to heart failure, as influenza. If
there be the slightest indication of such a danger, none of
the above-mentioned drugs should be given without the ad-
dition of a stimulant. That should, according to what I
said before, rarely be alcoholic. Caffein preparations are
vastly preferable; mainly the salicylate (or benzoate) of
sodio-caffein, which being very soluble and readily ab-
sorbed, is almost ideal in its effect. That is why in emer-
gency cases of heart failure its subcutaneous administra-
tion may often become indispensable. The use of strych-
nine is so well understood and so general that I limit my-
self to merely mentioning it.
353
DR. JACOBI'S WORKS
To what extent stimulants should be given in the aver-
age or in the grave cases depends on the general condition
of the patient, and on his medical adviser's knowledge of
his former health and his resisting power. It is probable
that in most cases some daily doses of sulphate of spartein,
five centigrams (gr. 5/6) for a child of two years, will have
a favorable effect. The caffein preparation I mentioned
may be given in doses of from two to six decigrams (grs.
iij-x) daily. When it appears to act as an excitant on the
brain, it should be replaced by camphor in daily doses of
from one to four decigrams. All these doses, however,
should be much increased when strong stimulation is re-
quired, and in an emergency subcutaneous injections of
the same drugs should be used, caffein being soluble in two
parts of water and camphor in four parts of sweet almond
oil.
One of the best stimulants, useful in the gravest of all
cases which are attended with collapse and heart failure,
is sadly overlooked among us, viz., Siberian musk. I know
of nothing better in the most urgent of cases. A child
of two years should take of the 10 per cent, tincture five
to ten minims every half hour until half a dozen or a
dozen doses have been taken. Musk, together with large,
hot enemata, has led me over many a difficult pass, and I
again offer this experience of mine, which now extends
over fifty years, as a contribution to your aid in dire dis-
tress, always, however, reminding you of the fact that all
these measures are not exclusive to influenza, but to all
conditions of nerve exhaustion, no matter from what cause.
At last, let me allude to a singular experience which
was published ten years ago. I do not know that it has
been repeated since. 5 Goldschmidt 6 reports as follows :
" About New Year's, 1890, a lady suffering from influenza
landed in Madeira and disseminated the disease in a short
time. Two months previously there had been an epidemic
6 In the discussion following the reading of this paper Dr.
Holbrook Curtis referred to the internal use of vaccine virus by
himself and others. A. J.
6 Goldschmidt. Immunity Through Vaccination, Berl. klin.
Woch., 1890 and 1891.
35-4
TREATMENT OF INFLUENZA IN CHILDREN
of smallpox and numerous vaccinations and revaccinations
were performed. Now, it so happened that all those who
were successfully vaccinated 112 all told remained free
of influenza. Of 98 who were vaccinated unsuccessfully,
only 15 took sick." The author concludes from this ex-
perience that successful vaccination is a preventive against
influenza. But as yet there is not enough known to justify
any such conclusion with anything like certainty. Still,
it suggests the possibility of a future serotherapy for in-
fluenza and its very serious consequences.
355
OTITIS MEDIA IN CHILDREN
DR. G. HEERMANN published in 1898 a small book on
" Otitis Media in Infancy (Otitis Concomitans)." For a
part of the critical history of that affection I refer you
to him. When I looked over the shelves of our library
which are filled with books and phamphlets written on the
ear, and glanced over the literature contained in the sub-
ject catalogue of the Surgeon-General's Library, I was
glad to remember that I must not take more than fifteen
minutes of your time. This, then, is not an historical
paper.
Otitis media is of frequent occurrence in the very young.
It may combine with the retrograde involution of the em-
bryonal myxomatous tissue, which may disappear soon after
birth but persists often in the airtrum and tympanic cavity
and undergoes purulent softening. Otitis media may ex-
hibit mild and grave symptoms, like every form of inflam-
mation in other organs. For instance, the localized mild
croupous or lobular pneumonia, and one that migrates or
terminates in induration or in atelectasis or abscess, is still
called a pneumonia and nothing else. Otitis may be either
a mere surface affection of the mucous membrane, or one
complicated or not with thrombosis, or suppuration, or
caries, or facial paralysis, or meningeal or other complica-
tions, and is still denominated an otitis. It may be either
primary or secondary to a naso-pharyngeal disease, or
cause or be caused by, or appear contemporaneously with,
pneumonia, meningitis, or enteritis ; it is still an otitis.
That is why I decline to subdivide otitis as Heermann has
done into a bona-fide otitis and a concomitant otitis, the
latter name being given to those forms which are observed
in atrophic or emaciated infants, whose general illness,
however, shows no actual differences in the symptoms or
even in the course of their local disease, or in their bacteri-
357
DR. JACOBI'S WORKS
ology. What we have to remember is the fact that the same
symptoms and extent of local changes do not belong to
all cases equally, and that the same therapy is not adapted
to every case.
Purulent otitis is frequently found in autopsies. Prey-
sing found in those made on 100 infants that died of a
variety of diseases, 81 affected with otitis media. Only
8 were unilateral, so that there were 154 diseased ears among
100 dead infants. Nor are older children exempt. Gep-
pert found a latent otitis media in 75$ of all the inmates
of the children's hospitals he examined. These are the
same results which are obtained by previous and succeeding
observers of the same disease when occurring at different
ages. School-children have been examined in that direc-
tion a great many times, but I give only two instances
which, so far as I know, have not been copied in our
journals. Dillner found among 38 children that had to
be excluded from their schools on account of incompetence
9 still suffering from inflammatory ear diseases; Kalischer,
among 255 children excluded because they made no prog-
ress and hindered their class-mates, 80 with previous or
still persistent middle-ear inflammmations.
Pyogenous microbes enter the middle ear mainly from
the naso-pharynx, which, according to R. O. Neumann, 1
contains even in its normal condition a large number of mi-
crobes, mainly micrococcus pyogenes albus in from 86 to
90$ and the bacillus pseudo-diphtheriae in 98$ of all
cases. In nasal catarrh there is a relative increase of
the bacillus pneumonias of Fraerrkel and Friedlander, of
streptococcus pyogenes, and of the bacillus of diphtheria.
These latter may cause nasal catarrh, while the bacillus
pseudo-diphtheriae is a saprophyte only. Thus my fre-
quent statement that many cases of nasal catarrh during
an epidemic of diphtheria were diphtheritic first based on
clinical observations published in the American Medical
Times, of August, I860, is confirmed by the most recent
bacteriologic research. 2
i"Zeitschr. f. Hyg. und Inf. Krkh.," 1902, vol. 40.
2 " Therapeutics of Infancy and Childhood," 3d edition, p. 407.
358
Microbes get into the middle ear in the contiguity of the
surface of the mucous membrane progressively, not neces-
sarily in every case of diphtheria, scarlatina, or other erup-
tive disease, but still frequently; or they are thrown in
during coughing, vomiting, or sneezing. That is mainly
so when the nares are obstructed by catarrhal swelling, or
by the presence of mucus or of a membrane, or by a high
degree of congenital deviation. Nurslings are in danger
during suckling and deglutition the more so the lower their
vitality and the more fragile their epithelia, the feebler
their circulation and the greater their emaciation. It is in
these conditions that microbes, mainly cocci, which are ubiq-
uitous in the accessible cavities, will enter the tube with
great facility and meet those which are previously in-
habiting it, and which become very effective by the cir-
cumstance that under the influence of ill nutrition, atrophy,
and colds, the vibrating epithelia become paralyzed. This
latter condition is easily produced, on account of the nor-
mally slow air current in the Eustachian tubes and in the
middle ear. A very direct cause of otitis media is found in
the presence of naso-pharyngeal diphtheria or straightfor-
ward " nasal " diphtheria, which in its mild or grave form
is by no mean's so uncommon as a very modern author seems
to believe, who thinks it worth while to publish, in three
long articles, three new cases of primary nasal diphtheria.
It is true that in this paper there is a display of such erudi-
tion as is apt to be exhibited in quotations. The author's
literature goes back to antiquity, and that antiquity to 1900,
aye to 1890. I admit that is uncommon research in our
over-productive journal literature. But there is still more
ancient literature on the subject. 3 In nasal and naso-
pharyngeal diphtheria, otitis media is quite frequent, per-
haps, however, not quite so frequent as we might expect if
3 The contributions to diphtheria, published in the Journal
of Obstetrics, February, 1875; the article on "Diphtheria," in
the second volume of Gerhardt's Handbook, 1877; and the
Treaties on Diphtheria, published by Wm. Wood & Co., 1880;
even the several editions of the Therapeutics of Infancy and
Childhood all of which references are in our own library
contain what would have facilitated modern rediscoveries.
359
DR. JACOBI'S WORKS
we overlooked the cases in which the membrane is solid and
firmly closes the orifice of the Eustachian tube. It is mostly
observed in those cases of nasal diphtheria in which the
membranous deposits are very light and flocculent and
the secretions copious and acrid. It is principally this
class of cases in which the nasal injections or irrigations
introduced by me more than forty years ago prove life-
saving, and, as to ears, preventive.
In diphtheria of the throat, a slight swelling of the mu-
cous membrane or, as I have said, a moderate diphtheritic
deposit may close the Eustachian tubes, and hard-hearing
may be the result. In this class of cases the patient com-
plains not infrequently of intense pain behind the angle
of the jaw and in the ear, and in some cases the diphther-
itic membrane is continued into the tubes, and gives rise to
otitis interna and media, which finally terminates in per-
foration of the drum membrarre, and occasionally in caries
of the bones. Wreder 4 collected 18 cases of diphtheria
of the middle ear in scarlatina, complicated with the same
affection of the fauces and nares. One child with diph-
theria of the mouth and pharyrrx had also diphtheria of
the inner ear. Kuepper saw diphtheria of the middle ear
and Eustachian tube, and Wendt once in the tubes, and,
amongst 84 cases of variola, twice in the middle ear, to-
gether with the same affection in the naso-pharyngeal cav-
ity. 5
A frequent cause of otitis media is scarlet-fever, with
its coccic or bacillary throat affection. In mild or severe
cases there may be perforation of the drum membrane,
necrosis of the drum membrane and of bones, progress of
that process to the antrum and the cells of the mastoid
processes and to the sinuses and meninges, with the results
of pyaemia, brain abscess, or septicaemia. In some of
these cases of scarlatinal otitis media there may be, without
many apparent local symptoms, fever, delirium, diarrhoea,
or bronchitis. Many such cases while yielding no pairt
from pressure on the mastoid process exhibit fever, not
* Monatschr. f. Ohrenh., x., 1868.
5 Quoted from my Treatise on Diphtheria, 1880.
360
OTITIS MEDIA IN CHILDREN
always with a steep pyaemic curve, and merely a swelled
lymph node on the mastoid process. In that condition it
is safer to take these seemingly mild cases seriously, and
to operate. Pus may be, and frequently is, inside the bone.
In measles, influenza, typhoid fever, and variola otitis
media is not quite so frequent as in scarlatina. Otherwise,
all the varieties of nasal, pharyngeal, and naso-pharyngeal
catarrh, also adenoid vegetations and hypertrophied tonsils,
are known to be frequent causes or accompaniments of ear
disease. The influence of hypertrophied tonsils is perhaps
exaggerated in the estimation of many of us in this, that
when uncomplicated they do not easily cause otitis; but it
is true that there are but a few cases in which they stand
alone, by themselves. They are almost always complicated
with catarrh in the neighborhood, and with accumulations of
mucus which cannot be readily dislodged and undergo dis-
integration. To that fact Yeardsley drew attention seventy
years ago. Altogether, to my certain conviction, the role
of the tonsils in other conditions is also over-estimated.
I may be permitted to mention here, as I have done many
times before, that their influence in 1 admitting cocci, bacilli,
and toxins as a cause of scarlatina, diphtheria, tuberculo-
sis, and rheumatism is inferior to the absorbing power of
the numerous surrounding lymph bodies, for these latter
are in a much more intimate connection with the lymph
circulation than the tonsils which are surrounded by a
firm capsule. Some of the causes which carry noxious
material into the tube I have mentioned. I emphasize
again the influence of coughing mainly in whooping-
cough, but also in pneumonia of vomiting, and of sneez-
ing, also possibly of medicinal and other injections into
the nares ; of a transfer by the fingers of enteritic material,
particularly when the Eustachian tube is made more ac-
cessible by a bifid uvula, or when the soft or hard palate
is fissured, or in the presence of impeding adenoids; for
then the levatores palati muscles have no support and the
muscles of the tubes are insufficient and atrophied.
Primary tuberculosis of the middle ear is rare. It may
be the result of bacilli entering from outside through the
perforated drum membrane, or through the Eustachian
361
DR. JACOBI'S WORKS
tube during coughing or sneezing. Secondarily, it de-
pends on invasion through the Eustachian tube in cases of
pharyngeal, laryngeal, or pulmonary tuberculosis, or through
the circulation. This happens mostly during the gland-
ular and bone tuberculosis of the young, and in miliary
tuberculosis. Altogether the reports differ in regard to
the frequency of tuberculosis otitis media. Bezold found
only 127 cases amongst 17,087 ear patients. Amongst the
chronic abscesses of the middle ear 4.4$ are tuberculous.
Few of them occur in infants and children, that is only 5.5$
of the whole number, while the remaining 94.5$ belong
to advanced age (Habermann). Abscesses of the internal
ear though they be in tuberculous children need not re-
sult from or contain tubercle bacilli, though according
to one statistical report 9$ of all the abscesses were said
to have been found in tuberculous children, and a few of
them had miliary tuberculosis. The otitis media depended
in almost every case on pneumococci.
In cerebro-spinal meningitis the ear is often affected,
more, it appears, in some epidemics like that of this year
(1894) than in others. I never saw a case of deafness and
consecutive deafmutism originating in cerebro-spinal
meningitis that recovered. Whether preventive measures
may reduce this untoward experience remains to be seen.
For nasal affections are frequent. In almost every case
of mine, observed this year, there was catarrh; in all that
were examined for it, diplococci mem'ngo-intercellulares
were found in large numbers. This nasal affection may
and does lead to otitis media. The labyrinth deafness
occurring during the height of the disease has thus far
proved very unfavorable.
Inflammations of the inner ear are rare, only two in
Preysing's 197 cases. Perhaps the majority depend on
cerebro-spinal meningitis. In one of these cases the trans-
mission was not even direct, for the first result of the
otitis media was a purulent meningitis, in the course of
which the inner ear of the opposite side became diseased.
Meniere's symptoms, namely, disturbance of the equilibrium,
nausea, and vomiting, are not often observed. They will
always get worse after quinine or salicylic acid.
362
OTITIS MEDIA IN CHILDREN
The contents of the middle ear may be visible through
the drum membrane or not; the latter may bulge or not.
That is why in very many cases otitis media may not be
accessible to a diagnosis, and perforation of the drum mem-
brane is not so common as might be expected. It happened
in only nine of Preysing's 154> diseased ears. This infre-
quency of perforations is believed to be due to several
reasons.
1. The greater resistance of the drum membrane in the
young, the external cutis layer being often thicker than in
the adult, the median connective-tissue membrane very solid,
and the inner mucous membrane with its pavement epithe-
lium at least as normal as in advanced age.
.2. In the young the Eustachian tube is short but wider,
both at the isthmus and at the tympanic orifice, and the
direction of the canal almost horizontal. In the fretus the
opening of the tube is below the level of the hard palate;
at birth it reaches that level; in a child four years old it is
about 3mm above it. 6 That is why Preysing denies the
easy exit of the pus into the pharynx. He claims, what is
true, that the pus is mostly thick, and that pus would
rather, while the baby is on its back, run into the mastoid
antrum than through the tube. But the recumbent posi-
tion is not always kept up, so long as the baby is not yet
on the autopsy table. Bedside and nursery observers will
appreciate this, and pathologists might.
It should be remembered that most of the figures quoted
are taken from poorly developed, emaciated, even atrophic
hospital cases. Now, atrophy affects the mucous membrane
of the Eustachian tube as well as the rest of the body
and adds to the width of the tube, which is thus wider in
this class of patients than in the healthy and well-nourished.
In this latter, perforation of the drum membrane is not so
very rare, though indeed many a case of otitis media in this
very class of patients, after fever, sensitiveness on pressure,
and meninge'al symptoms have been distinctly noticed, will
run a mild course without perforation. Whatever pus does
not find its way into the pharynx no perforation having
e T. Mark Hovell, 3d edition, 1901.
363
DR. JACOBI'S WORKS
occurred is, or may be, absorbed, while the inner mucous
membrane, including that which covers the drum membrane,
will become thickened and give rise to hard-hearing or even
deafmutism. Still there is another possibilty, and indeed
one of frequent occurrence. The copious net of lymph ves-
sels in the young is always very active, in the emaciate and
atrophic very greedy, and the absence (caused by the dis-
ease) of the pavement epithelium of the drum membrane
and of the cylindrical and vibrating of the interior permits
more rapid absorption. This condition is a sufficient ex-
planation of the readiness with which absorption may take
place from the interior of the ear into the lymph and blood
circulation, and lead to deposits in distant organs, to mild
or serious sepsis, to persistent exhibitions of temperature
with no tangible cause, to death, or to slow recovery. More-
over, Preysing found on the inflamed surface, as the re-
sult of copious leucocyte migration, granulation globules
with minute blood-vessels, without epithelia, resembling in
shape small tubercles, and surrounded by slight hemor-
rhages and a narrow ring of beginning organization.
These little granulomata, with their small blood-vessels,
may also favor absorption.
The pneumococcus which is found in otitis is rather
ubiquitous. As we find it in pneumonia, meningitis, peri-
carditis, peritonitis, and so on, we need not be surprised at
meeting it in connection with the otitis of the young, with a
pneumonia, or with an enteritis, and their result. Paeda-
trophy and otitis have been known to combine, more than
half a century. I was taught their clinical cotemporaneous-
ness when a younger student of medicine than I am to-day,
fifty-five years ago. Which of these complications, otitis,
pneumonia, enteritis, or meningitis, is the primary one is
difficult to say in most cases. To my mind, none of them is,
in many a case, the primary cause of the general infection.
Pneumococcus 1 , being present on every healthy mucous
membrane, will enter the circulation from any point, par-
ticularly from the nose, on which, by accident or disease,
the epithelial cover is removed or on which it is disinte-
grated. Thus a meningitis may be the first symptom of a
general pneumococcus invasion. It may be followed by
364
OTITIS MEDIA IN CHILDREN
other localizations or by general sepsis. Persistent diar-
rhrea, often fatal, is frequently observed in such cases.
Homen and Laitinen, quoted by Preysing from Ziegler's
Beitr., vol. xxv., caused hemorrhages orr serous membranes
and diarrhoeas, by injecting only the toxins of strepto-
cocci.
Meningitis connected with otitis media need not be puru-
lent. Dr. Francis Huber published a case of otitic serous
meningitis which recovered permanently. 7 The patient was
a child of two and a half years, suffering from adenoids
and chronic aural discharge. There were general convul-
sions which returned frequently during the ten days pre-
ceding admission. There was semi-consciousness, the pupils
were dilated, mainly the right; there was convergent stra-
bismus and lateral nystagmus, rapid pulse, and taches.
The tendon jerks were exaggerated. On the thirteenth
day the mastoid process was opened, diseased bone removed,
and the dura reached but not opened. Lumbar puncture
was then made twice in two days, SOccm and 16 com of
liquor were removed. It contained no bacteria. Twenty-
two days afterward the child was discharged and remained
well.
In the atrophic infants the bone, with the exception of
some parietal swelling, was not found to be affected. Even
in healthy children* the bony wall of the autrum is very
thin, and small abscesses are apt to perforate before giv-
ing rise to serious injury.
PREVENTION
Nasal, post-nasal, and pharyngeal catarrh should be
treated before they can do harm; adenoids removed, en-
larged tonsils resected, and hypertrophy of the mucous
membrane of the nose attended to. No operation about
these parts is successful unless subsequent cleanliness be
enforced. I have found that some operators neglect to
avoid recurrences by not attending to that rule. One or
two daily warm saline irrigations made from a nasal cup,
during which the mouth should be kept slightly open
T Am. Med., 1903.
365
DR. JACOBI'S WORKS
not injections suffice for that purpose. Adenoids when
small will get well without operation when these irriga-
tions are gently and regularly made. Sprays or the use
of droppers cannot take the place of irrigations. A spray
of a .5 per cent, solution of silver nitrate through the nares
once a week will work well. This application should be
made several weeks in succession.
TREATMENT
A child with an acute otitis media should be in bed,
the head and trunk raised. The raising of the head alone
may lead to annoyance of the circulation of the neck.
No feather pillows under the head. Symptoms will be
ameliorated by a mild antipyretic, a narcotic, a purgative.
Politzer and Valsalva are not adapted to the acute stage.
Severe pain may be relieved by a few drops of cocaine solu-
tion instilled into the ear, occasionally by a leech on the
mastoid process. Warm fomentations with spongiopiline,
or simple warm wet cloths without or with antiseptic solu-
tions should be tried. When pus forms the posterior half
of the membrane bulges first; at its edge the hammer is
distinguished. When an incision is required it should be
made posteriorly and inferiorly. The expulsion of the
pus through the incised wound can be facilitated by Polit-
zeration, but this procedure may drive pus into the cells.
Injections into the external canal should if at all, be made
toward the wall of the canal. Their advisability is fav-
ored and denied in equally strong terms. I do not use
them. More than a dozen years ago I learned from my
specialist friends the use of boric acid. After the ear has
been wiped out with absorbent cotton* it is filled loosely
with boric acid. When this is softened with pus, the ear
is again cleansed and the process repeated. This proced-
ure has proved so successful that I remain true to the ad-
vice of my friends. I have often been told since that the
method is bad and that injections into the external canal
should be preferred, but I have read of deaths that have
occurred after injections in the practice of such men as
Troeltsch, Fraenkel, and Katz, and I cannot help appre-
366
OTITIS MEDIA IN CHILDREN
elating the fact that enough people die without our ag-
gressive co-operation.
To what extent sepsis depending on otitis media, pure
or complicated, can be benefited, is uncertain. Anti-
streptococcus serum is of very doubtful efficacy. Crede
ointment may be used with a certain amount of confidence.
It should be applied once or twice a day. The inunction
should last half an hour, and absorption facilitated by the
addition of a few drops of water to the ointment. Col-
largol acts more rapidly when dissolved in sterile water
and injected into the rectum. Large quantities of water,
drunk, injected into the rectum, or under the skin in the
usual cautious way, are known to cause copious elimination
from the blood, and deserve all the praise which has again
been bestowed upon them by B. Alexander Randall in an
article on " The Treatment of Otitic Septicaemia," which
appeared in the Journal of the American Medical Associa-
tion of November 26, 1904. Nuclein may be tried inter-
nally.
A. Bronner, of Bradford, England, 8 publishes his opin-
ion on the local treatment of some forms of non-suppurative
catarrh of the middle ear by compressed air and a nebulizer,
recommending for the purpose the compressed-air appara-
tuses used in America. He is careful enough to add what
he takes to be a fact that many cases of so-called dry
catarrh of the middle ear are not due to any affection of the
mucous membrane at all, but to a primary disease of the
osseous labyrinth. In these cases the use of the catheter
can do a great deal of harm. If sudden great pressure
be applied, the hearing and tinnitus may become worse.
In dubious cases he uses the catheter with an iodine spray
under very low pressure. It seems probable that in many
of these cases we have after all to deal with the results
of former inflammations that resulted in thickening of the
mucous membrane. It is in these cases, though they be
not syphilitic, that the internal use of an iodid or of " mixed
treatment " may be expected to do good. But as a
rule, and that I emphasize more than anything else, chronic
P British Med. Journal, November 5, 1904.
367
DR. JACOBI'S WORKS
disease of the mucous membrane of the ear will never get
permanently cured unless the chronic catarrh of the naso-
pharynx receive constant attention. After all, the treat-
ment of norr-suppurative disease of the middle ear is rather
ineffective. Nothing is more corroborative of this old ex-
perience than the discussion lately held in the British Med-
ical Association by eighteen gentlemen, well-known in their
specialty and literature, a few of them our own 1 fellow-
countrymen. 9 The latest paper on " The Present Status
of the Treatment for Deafness Due to Chronic Catarrhal
Otitis Media," published by Dr. Philip D. Kerrison in the
Journal of the American Medical Association, November
12, 1904, expresses itself in the same strain.
8 British Med. Journal, November 5, 1904.
368
NEPHRITIS OF THE NEWBORN
NOTHING would have pleased me more than to appear
before you, who have kindly consented to listen to me part
of an evening, with something absolutely new. The his-
tory of medicine, however, exhibits but very few instances
of striking novelty. It is more replete with the proofs of
a slow and steady evolution than with sudden and un-
thought-of revelations. Still, there is one peculiar fea-
ture both in the study of our science and the practice of
our art viz., that wherever we approach it it is intensely
interesting. That is why even the men borne down with
hard work, and altogether too often near the brink of men-
tal and physical exhaustion in the performance of their
arduous daily duties, are always roused to enthusiasm by a
single new experience, an unheard-of fact, a novel hypothe-
sis, or only a new point of view calculated either to enlarge
their horizon or to benefit their fellow men.
To me the connection of the kidneys with the rest of
the organism has been a subject of interest through all my
professional life. These organs are so intimately inter-
woven with the whole physiological existence that either
their anatomy or their function participates in every dis-
ease of every organ. This is particularly perceptible in the
infectious diseases, no matter whether mild or severe. In
many of them one of the forms of nephritis is very com-
mon. In scarlatina, for instance, the desquamative process
is quite active in the uriniferous tubes, and results in a
peculiar form of inflammation; in some cases of scarlatina
and most of the other acute eruptive and infectious mala-
dies it is parenchymatous changes that are more frequently
met with. Thus, indeed, it is worth while to study the
urine in every case of disease. It is true that we are not
always rewarded with the finding of severe lesions; for,
happily, most of the cases of secondary nephritis are neither
369
DR. JACOBI'S WORKS
dangerous nor of long duration. But there is none of
them but may lead to a severe form, with possibly a fatal
termination. Therefore, the frequency of infectious dis-
eases in infancy and childhood ought to fix our attention
constantly in the direction of the kidneys. It is true that
sometimes we are unable to find anything but albuminuria,
which, in the absence of kidney elements under the micro-
scope, we are liable to dismiss as transient and of little
account. But in this we are very apt to be mistaken.
My cases of uncomplicated and transient albuminuria have
become wonderfully scarce since I invariably employ for the
examination of the urine the centrifuge. Among twenty
successive cases where the verdict is_" trace of albumin " I
am certain to find in the centrifuged deposits of nineteen,
within a few minutes, the almost uniform result blood-
cells, hyaline casts, hyaline casts studded with epithelia, or
finely or coarsely granulated casts.
Many of these forms of nephritis are, as I said, short-
lived. Quite often will they disappear within a week or
ten days. But this happy termination is far from being
universal. There is nobody here but has been surprised in
a child of advanced age or in an adolescent by an attack of
uraemic convulsion, the cause of which could be traced to a
scarlet fever which, six or ten years ago, terminated in ap-
parent recovery. The same experience is had with nephritis
from other causes ; for, unfortunately, we know by this time
that besides scarlatina, measles, varioloid, and varicella, even
vaccinia, acute local diseases of the skin, erysipelas, rheu-
matism, typhoid fever, acute and chronic intestinal diseases
may be complicated with or followed by nephritis. For
this reason nephritis is very common in infancy and child-
hood, and ought to be searched for whenever the origin of
prominent or dangerous symptoms is not at once clear.
Fortunately, it is easy to obtain a specimen of urine, for
catheterization is more readily successful in the child than
in many adults. Thus it will frequently happen that a ne-
phritis is found when the prominent cerebral symptoms
suggested the diagnosis of encephalitis or meningitis. Of
the many cases of this nature which I have met with, the
following will furnish an illustration:
370
NEPHRITIS OF THE NEWBORN
A boy of five weeks who had appeared to be in fair
health was taken with high fever and convulsions. The
case occurred in a family living in very moderate circum-
stances, therefore, the medical man had good reason to sup-
pose that the infant had been ailing some days before it
was considered necessary to call him in. The temperature
was 104 to 105 F., the pulse almost uncountable, and the
convulsions had not been frequent when I saw the ..patient.
There was some cyanosis and perspiration over the upper
part of the body; the legs and feet were cold, the head
was very hot. There was no oedema. The pupils were
equal, fairly dilated, contracted a very little, but slug-
gishly, under the influence of a strong ray of light, and
under the same light dilated again and contracted within
certain limits. The equality of the pupils, combined with
that peculiar floating condition of the iris, made me think
of uraemia as the cause of all the cerebral symptoms. The
urine was known to be scanty, but that is what it also is
in meningitis, and in every child that has not been supplied
with a sufficient quantity of water. Fortunately, there was
some in the bladder. Boiling almost solidified it, and the
microscope revealed blood-cells, epithelial and granular
casts, the latter both fine and coarse. The child died; no
autopsy could be had. No clew could be found to the
causation of the fatal disease; and still, the baby was so
young that in all probability the origin of the fatal ne-
phritis might have been found in some occurrence of the
first few days of life.
It is this period of early life to which I mean to direct
your special attention to-night by reporting a few of the
many cases of nephritis met with within a few days or
weeks after birth. Some are primarily renal diseases, some
are secondary. To the latter class belong those nephritides
which are complicated with or dependent upon intestinal
disorders. This connection is quite frequent. In many
instances diarrhoeal disorders are the results of nephritis,
but quite frequently both acute and chronic intestinal dis-
eases appear to be the causes of nephritis, which may be
quite ominous; for indeed it is here as in other diseases,
371
DR. JACOBI'S WORKS
many of which are liable to terminate fatally by their renal
complication. Every practitioner loses many a case of
pneumonia, not through the severity of the pulmonary
lesion, but on account of the accompanying nephritis. In
this way the entero-colitis of the newborn is quite apt to
destroy life through nephritis. In a highly creditable
essay (Arch. f. Kinderk., 1894, xvii, p. 222) Felsenthal and
Bernhard have studied the connection of nephritis with
acute and chronic intestinal disorders of infancy and child-
hood. They have also collected the literature on the sub-
ject. Parrot met with it in the atrophy (" athrepsia ") of
young infants; Kjellberg, Fischl, Stiller, Baginsky, Hirsch-
sprung, Hagenbach, Henoch, Epstein, and others have
recorded cases of nephritis accompanying intestinal dis-
orders. The cases of this description are by no means rare
in the first week of life. When I look over the list of the
numerous cases of the kind I have personally seen, it al-
most seems to me supererogation to record a case; and still
I know that many of my colleagues with whom I saw the
cases appeared to be surprised at recognizing both the
presence of nephritis in such cases and the facility with
which the diagnosis could be made.
The literature on the subject is but scanty. I have,
however, reason to believe that even those who have known
the connection between intestinal diseases and nephritis
quite well have not published their experience. It has hap-
pened to me personally that my chapters on catarrh and
ulceration of the bowels in my Intestinal Diseases of In-
fancy and Childhood, 1887, are silent on that subject by
an oversight of my own. But in the discussion on Two
Cases of Acute Primary Nephritis in Infancy, by L. Em-
mett Holt, one of which was perhaps caused by intestinal
sepsis without that explanation being suspected, I took
occasion to say (Trans, of the Am. Peed. Soc., 1891, vol.
iii, p. 233) : " There are cases of nephritis which compli-
cate intestinal diseases. It is true that many spells of
vomiting and diarrhoea are merely symptoms of nephritis.
A number of cases supposed to be cholera, even Asiatic,
are found to be acute nephritis. On the other hand, where
we have to do with an acute or subacute intestinal catarrh,
372
NEPHRITIS OF THE NEWBORN
a prolonged seizure may give rise to secondary nephritis.
I am positive that it will be found to be much more fre-
quent than it was considered to be." In the Archives of
Paediatrics, June, 1890, p. 420, diarrhea is also briefly
mentioned by me as one of the many causes of nephritis.
It is but two years ago that a colleague presented a boy,
five days old, the child of very poor parents, at my office.
The cord had fallen off and the stump looked normal. The
mouth was slightly covered with sprue. The lips, fingers,
and toes were cyanotic, though the feeble heart appeared
normal; the baby was nearly collapsed. Rectal tempera-
ture, 103 F. For two days there had been loose mucous
discharges in great numbers ; they were slightly offensive,
did not contain meconium any more, but already at that
early time coagulated masses of casein. There was no
tenesmus and no blood. The urine of the second and
third day appeared to the attendants darker than normal;
during the last day but little had been passed. We drew
about ten cubic centimetres of a dark, smoke-colored fluid.
It contained albumin in great quantity, and under the mi-
croscope blood-cells, epithelial and granular casts, and
urates. The baby died the following day. No autopsy.
It was a similar case that I saw with the same gentle-
man a few months afterward. He made the diagnosis be-
fore I met him. It proved one of the most fortunate I
have seen; firstly, because it was not so severe as the for-
mer, and, secondly, because there was ample time to restore
and equalize by warm bathing both the cutaneous and gen-
eral circulation, to cleanse and disinfect the intestine and
fill the blood-vessels, to establish a flow of urine through
the uriniferous tubes by means of copious and frequent irri-
gations of the bowels, and to stimulate the heart by judi-
cious doses of strychnine, of which the infant took nearly a
milligramme during twenty-four hours.
What little I have said of the nature of the discharges,
their offensiveness and frequency, suggests the cause of
the secondary nephritis. It evidently depends on the ab-
sorption of a toxine, no matter whether it originates in the
373
DR. JACOBI'S WORKS
invasion of a streptococcus, or of the bacterium coli, or one
of the other forms of microbes detailed by Booker and by
Jeffries in the Transactions of the American Pcediatric So-
ciety of 1889-
Their absorption is facilitated by some peculiar anatom-
ical conditions.
The muscular apparatus of the intestine of the fretus
and of the newborn is but slightly developed. During
foetal life its function is but trifling, and its contents move
but slowly. Immediately after birth that muscular debility
predisposes to colic, as air which is swallowed; and gases,
both innocuous and putrid, which are developed in the tract,
are expelled with difficulty. Besides, the infantile digest-
ive tract is unexpectedly long. According to Ben eke, the
proportion of the length of the body to that of the small
intestine is in the adult 100 to 450; in the newborn,
however, 100 to 570; in the second year, 100 to 660.
Moreover, the villi are generally numerous and large; some
assert they surpass in size those found in the adult intes-
tine; the capillaries of the villi, it is claimed, have greater
absolute size, so much so that their diameter is larger than
that of the same vessels in the adult. 1 All this tends to
show that both the accumulation of septic material in, and
absorption from, the interior of the intestines is rendered
very easy. The access of microbes to the intestinal tract
of the newborn is by no means difficult. How they en-
ter, through the mouth, the anus, or the blood, I have but
recently discussed in the first number of Paediatrics. Af-
ter all, it seems that the nephritis originating from in-
testinal infection is of a similar nature to what we ob-
serve in typhoid fever or] any of the other infectious
diseases.
Nephritis in typhoid fever of the newborn I have seen
but once, for the simple reason that I have observed but
this one case of typhoid fever in one so young. It was
cursorily mentioned on page 29 of my Treatise on Diphthe-
ria, 1880. The baby died on the sixteenth day of its life,
l A. Jacobi. Intest. Dis. of Infancy and Childhood. George
S. Davis, 1887. Chapter on Intestinal Digestion.
374
NEPHRITIS OF THE NEWBORN
twenty-two years ago. The mother recovered. Its kid-
neys were much congested, the two substances hardly dis-
cernible from each other, and blood oozed from the cut
surfaces. There had been anuria for two days, and no urine
was found in the bladder after death.
In one of the three cases of diphtheria in the new-
born, reported on page 30 of my Treatise, I was favored
with an autopsy. The baby was taken seven days after
birth and died on the ninth. The kidneys were in the
condition described in the previous case. No microscopical
examination of the urine could be had.
In connection with this subject I now present the case
of the youngest patient I have seen destroyed by potassic
chlorate.
B. C., a boy of nine days, was seized, January 15, 1882,
with convulsions, after not having voided urine for several
hours. The last time, when a teaspoonful was passed, it was
of a dark color, stained the napkin, and seemed to give pain
during the discharge. There was constant rectal tenesmus,
with some protrusion of the bowels, some five or six hours
before the convulsion. During all this time the complexion
was sallow, and the lips and finger and toe nails were blue.
I saw the infant after the convulsions, with hardly a pulse,
bluish lips, brownish complexion, the sclerae still yellow and
largely ingested with dilated blood-vessels. Heart beats from
200 to 220 a minute, scarcely perceptible. Within an hour
after my visit he died. The blood in the whole body was of
an intensely dark color, the heart of normal size and struc-
ture, ductus Botalli nearly closed, ductus venosus Arantii
still open. Lungs and spleen were engorged and purplish, so
was the liver. The kidneys were large; a number of blood
points small haemorrhages were visible on the longitud-
inal section; there were, besides, a number of dark streaks
corresponding with the uriniferous tubes, and the difference
between the two renal substances was almost extinct. Their
color was unusually dark, and they offered a strongly
marked elastic resistance to the touch. What little urine
(about two cubic centimetres) was taken from the bladder
contained much pelvic epithelium, and consisted almost ex-
clusively of decomposed blood-cells.
873
DR. JACOBI'S WORKS
The great resemblance of this form of nephritis to what I
had described in the third volume of Gerhardt's Handbuch
der Kinderkrankheiten, article Diphtheria, in 1877, and in a
paper on The Remedial and Poisonous Effects of Chlorate
of Potassium, published in the Medical Record of March
15, 1879, made me inquire rather scrupulously into the his-
tory of the dead baby. The mother had suffered from copi-
ous vaginal discharge during the last few months of her
pregnancy. Neither she nor her surroundings were of the
cleanest. The first few days of the infant's life were nor-
mal. On the third and fourth day sprue developed and
covered lips and cheeks with thick deposits. The midwife
in charge called no physician. She knew the best thing for
sprue and inflicted it. She brushed the mouth with a satu-
rated solution of potassic chlorate, as she proudly asserted,
quite often, and frequently gave a few drops to drink. I
could not learn the strength of her solution. She always
used it and it had a powerful effect, she said. As far as
I was permitted to learn, she dissolved a tablespoonful in
a tumblerful of water; I still found a sediment of the salt
in the bottom of a tumbler.
A case of nephritis after vaccination was reported by
Perl in the Berliner klinische Wochenschrift, 1893, No.
28. It behaved exactly as nephritis in infectious fevers.
The child, two years and nine months old, became very
restless about the usual time of the onset of a vaccinia
fever viz., from the fourth to the fifth day; at the same
time there seemed to be abdominal and lumbar pains.
Within a day after, simultaneously with the appearance of
six vaccination vesicles, there was albumin in the urine to
the amount of one half of a per mille; also haematin,
blood-cells, and some leucocytes. The casts were either
purely hyaline, or hyaline studded with epithelium. The
child was well on the twelfth day. The whole morbid proc-
ess ran its full course in six days, with no serious symp-
toms at all.
The following is a case of a similar description in a
very young infant:
In an immigrant hotel of Greenwich Street, New York, I
saw with Dr. John Bishop, April 4, 1877, two children, one
376
NEPHRITIS OF THE NEWBORN
of four years and one of three weeks, who had been vacci-
nated ten days previously. I was expected to see the older
one, who had an erysipelas of moderate size and severity ; it
got well after twice traveling over the surface of the body.
On the very day of my visit the baby, who had run through
her vaccinia fever with no unusual discomfort, was seized
with an attack of convulsions. When I saw her there was
a rectal temperature of 103, a dazed look, injected con-
junctivse, pupils equal, somewhat dilated, and floating un-
der the influence of light. The latter symptoms induced me
to draw urine and examine it. It was scanty and contained
a trace of albumin, a few blood-cells, and hyaline and
finely granular casts. This nephritis lasted two weeks be-
fore it finally disappeared. During all this time there
was no other convulsion, no oedema, but an occasional vomit-
ing spell and diarrhoea during the first week of the illness;
the pupil symptom persisted ; the temperature varied be-
tween 101 and 103, a moderate remission taking place
in the morning. During the second (and last) week of
the disease all the above symptoms gradually disappeared,
and the temperature went down. In their place a slight
oedema of the lower extremities and of the face was ob-
served. The microscopical changes in the condition of the
urine remained the same about ten days after they were first
discovered. Then they disappeared, and recovery remained
undisturbed.
Renal disorders, more or less dangerous, are direct re-
sults of sudden changes in the circulation, without or with
visible alterations of the blood. To the first class belongs
a case I once saw with a medical friend who had so much
confidence in the vitality and vigor of the newborn that
he commenced to enforce his theories on the necessity of
early hardening immediately after birth. He would plunge
the newcomers into cold water, and feel a grim delight in
taking their incipient breath away and making them shriek
in reflex self-defense. Two of his victims I saw with him;
they died within a fortnight. The second we examined
post mortem. There was a pneumonia, it is true, perhaps
sufficient to destroy life. But the most apparent and prob-
able cause of death, preceded by suppression of urine, was
377
DR. JACOBFS WORKS
evidently bilateral nephritis. Both the kidneys were large,
intensely congested, and blood poured out of the cuts;
the difference between the two substances could not be dis-
tinguished. With him I saw no more such cases, for I sug-
gested the probability that the cold bathing of the new-
born furnished us the specimen. But the more I have seen
of similar cases in the adult, the more do I feel that I was
correct in my charge. For acute nephritis, interstitial,
sometimes haemorrhagic, is an occasionally unavoidable
occurrence in sudden suppression of cutaneous circulation.
Who has not seen death occurring from nephritis, not pre-
ceded by a chronic affection, in persons who have been re-
suscitated from drowning in an ice-cold river, or have been
exposed to a driving rain storm while exerting themselves
to get under shelter, or to cold and sleet in an open sleigh?
What the slow influence of cold can not accomplish in the
healthy and vigorous, what not even a nephrectomy can ac-
complish in the remaining kidney, its sudden effect on the
feeble, or fatigued, or even the vigorous, will easily bring
about. No matter whether the reasons are to be sought
for in an antagonism of the skin and kidneys, or the en-
forced elimination of cutaneous excrements through the
kidneys, the facts are actual. Moreover, direct experiments
made by Lassar unmistakably prove the causation of inter-
stitial inflammation by sudden refrigeration.
Like excessive cold, heat may lead to nephritis and
death. Only once have I seen a newborn sacrificed in
that way through his first bath. The midwife evidently had
anaesthesia or analgesia. Bystanders noticed the steaming of
the water in the bath tub, the suffering of the suffocating
baby, his livid appearance; and the raising of large blis-
ters on the surface told the story. The baby died within
a day, having lost some blood mixed with meconium and
passed no urine. Even the bladder was empty at the
autopsy, and deeply congested. The kidneys were livid
and succulent; blood oozed out of the cut surfaces. Blood
was also extravasated under the capsules. If the case had
run a longer course, in all probability haemoglobinuria,
produced by dissolution of blood-corpuscles, would have
shown itself, as in the experimental researches of Ponfick
378
NEPHRITIS OF THE NEWBORN
and of Wertheim. Changes in the general circulation need
not, however, be of this sudden and violent type, and still
result in some injury.
Indeed, the albuminuria of the newborn is frequently
due to the insufficiency of circulation, and passes off when
the latter is freely established; just as the venous obstruc-
tion caused by heart or lung disease results in temporary
albuminuria in the adult. In a certain number of these
cases of almost congenital albuminuria there is no blood
under the microscope, in others there is, in others there is
more viz., nephritis. It is probable that after most cases
of protracted asphyxia of the newborn albumin will be
found in the urine, with or without blood. Thus the kid-
neys repeat but the process which has been so much bet-
ter studied in the brain by Langdon Down 2 and also by
me. 3
Indeed, in three cases of nephritis, two of which proved
fatal, observed within five weeks after birth, no aetiology
except that of previous long-continued asphyxia could be
elicited. It was in those two that granular and coarse
casts were in the majority; in the one which survived,
there was still after weeks blood and a few epithelial and
finely granular casts.
In congenital heart diseases with cyanosis, albuminuria
is quite common. Again I warn against the facility of
overlooking it. Time and again I am told there is no
albumin in a specimen; time and again there is in such
cases a trace, which is called " only a trace," but yields
fields full of different casts in the centrifugal specimen.
This very trace is sometimes not discovered unless the test
tube be looked at through water, and unless some little
time is given for the coagulation to become visible. Ne-
phritis does not always work with heavy loads of albumin;
that the last stage of chronic nephritis of any period of
life may be without albuminuria for weeks in succession
need not be retold.
I once saw a baby of four months, who had spina bifida
2 Transactions of the Obstetrical Society, London, 1876.
3 American Journal of Obstetrics, xxiv, 1891, No. 6.
379
DR. JACOBFS WORKS
and consecutive paralysis and contractures of both lower
extremities, die with nephritis. We seldom see our patients
with spina bifida when they breathe their last; for, until a
brief time ago, most of them were left to die without an
attempt at relieving them, and a neighboring medical man
was called in at the last minute so that a certificate of death
might be obtained. The same opportunity of observing a
fatal case of nephritis in a little girl of three months I had
about the same time. The patient had a paralysis of both
lower extremities, dating from birth, and occasioned,
probably, by an intraspinal haemorrhage caused during
difficult extraction in breech presentation. Maybe I am
correct when in both cases I attribute the renal changes,
chronic in character, to the fact that the circulation being
impeded by the muscular inactivity of a large part of the
body was more directed toward the internal organs. Maybe,
however, this suggestion does not appear acceptable, 4 for
it is possible to assume that the same violence which caused
a spinal haemorrhage and paraplegia was sufficient to
produce the same effect in the kidneys.
In the newborn we observe not only the adverse re-
sults of the sudden changes from foetal to post-natal circu-
lation, but also lesions depending upon the peculiar struc-
ture of the blood-vessels. The newborn is removed
from the embryo and foetus by a single station only. Its
tissues are in part still embryonic, and endowed with less
solid structure. This is why haemorrhages are so very
frequent in the newborn. Meningeal haemorrhages are
most frequent during the first week, and the slight coagu-
lability of the blood of the newborn adds to its dangers.
In regard to the brain, I have considered this question
years ago, and frequently since, mostly in connection with
asphyxia in the newborn. A large number of cases of
idiocy, epilepsy, paralysis, and insanity in the very young
are due to meningeal haemorrhage of early days often ush-
ered in by asphyxia. Similar occurrences take place in
4 As above stated, not even the removal of a whole kidney
results in a nephritis of the other.
380
NEPHRITIS OF THE NEWBORN
other organs. Disseminated pleural and pericardial haem-
orrhages are quite frequent in the newborn under the
influence of retarded or interrupted circulation. When the
latter improves, the haemorrhagic points may become ab-
sorbed. So it is in the kidneys.
Parenchymatous hcemorrhages are capable of causing in-
flammation in the kidneys as they do in other organs. In
many cases, however, they prove innocuous. In the muscles,
the brain, the lungs, extravasations take place without leav-
ing any trace behind. It is probable that whenever no
healthy tissue is torn, when an extravasation takes place be-
tween fibrillae, absorption takes place. When there is, how-
ever, an actual lesion of tissue, a secondary inflammation is
or may be the consequence. Many years ago I was startled
by an acute nephritis appearing in a delicate but healthy
boy of four years, the son of a well-known practitioner in
New York. None of the usual causes of the disease could
be traced, and I was perfectly at sea until a crop of pete-
chiae appeared over the chest and the extremities. I then
learned that six months previously the child had had another
attack of purpura which gave rise to no symptoms, and
that a few days before the first symptoms of this acute
renal disorder there had been a few petechiae all over the
surface. The urine showed under the miscroscope rather
an unusual amount of blood, together with plenty of blood
casts and granular casts. It struck me, therefore, that the
nephritis was in this case due to disseminated renal haemor-
rhages, and I ventured to give a rather favorable prognosis.
It took but a few weeks before the patient had fully recov-
ered. Two similar cases have been encountered since, one
in a girl of seven, one of eleven years. Both recovered.
Never before did it occur to me to look upon the kidneys
as more than very rare participants in a purpuric process,
except in cases of actual haematuria.
In two newborn infants I have seen similar processes
originating from the same source. A boy of five days
was seen for melcena on his fifth day. There was vomiting
of blood; there were bloody stools. Their color was not
quite black; some of the blood was red, and its origin could
381
DR. JACOBFS WORKS
be assigned to the lower part of the intestinal tract. The
baby appeared to recover a little from the sudden shock of
the loss of blood, when, on the next day, slight traces of
blood appeared in the urine. Part of the blood cells were
tolerably normal. Within another day the quantity of
urine diminished greatly and assumed a smoky hue. The
microscope still revealed blood cells, but also blood casts,
a very few epithelial and many more finely granular casts.
The baby died and the kidneys were removed. Both of
them were markedly congested. On the walls of the pelvis
were superficial haemorrhages ; sections revealed a number
of rather fresh blood points. There was no doubt in the
minds of all those present that the nephritis in this case
was due to the irritation set up by the local haemorrhages.
Another case dates twenty-six years back. After a
protracted labor a boy was born in breech presentation.
Ecchymoses over the abdomen proved the difficulty of
parturition and the summary procedures of the midwife in
charge. Almost the first urine voided by the infant was
bloody, and the diagnosis of traumatic renal haemorrhage
appeared justified. Within a day the blood disappeared
almost entirely, and urine became suppressed. The baby
died on the fourth day, and was subjected to a coroner's
inquest. There was a moderate amount of blood clot under
the peritoneal covering of the liver, the liver was torn to a
distance of about three centimetres, the peritonaeum slightly
torn, and blood had escaped into the abdominal cav-
ity. Both kidneys were large, dark, and blood-stained on
section; the two substances hardly differed from each
other.
These were extreme cases, and their diagnosis was in a
short time followed by death. How many there may occur
in which extravasation is but moderate, and the amount of
local or perhaps unilateral nephritis is not immediately
fatal, perhaps even inclined to get well, is difficult to say.
Large maternities, however, and foundling institutions are
better prepared for observing such occurrences than the
practitioner engaged in private or consulting work.
Frequent causes of nephritis of the newborn are uric-
acid infarctions. They occur from the second to the
382
NEPHRITIS OF THE NEWBORN
twenty-third day, but also before birth. 5 They are of dif-
ferent varieties. In a part or in all of the straight urinif-
erous tubes there are found yellowish-red or brownish,
spherical or angular bodies in such quantities as to form
considerable deposits and, when they are discharged dur-
ing life, to cause large stains of more or less solidity in the
napkins. They are in rare cases accompanied with blood.
They consist of uric acid and of ammonium urate. The
latter is readily soluble in acetic acid, from which uric acid
crystallizes in rhombic shapes. In one case Ebstein met in
the tubuli contorti with yellow globules consisting of uric
acid and an organic stroma which contained no mucus, but
consisted of albuminoids which were soluble in acetic acid,
and exhibited either a concentric structure or irregular
layers. At once the question rises in our minds as to the
nature of this organic stroma. It must strike us that it can
be of either of two origins. It is either depending on a
cause not connected with the presence of the uric-acid in-
farction, or it is the direct consequence of a local irritation
caused by the deposit viz., secondary exudation. In this
manner that form of infarction would, by itself alone, ex-
hibit a mild degree of nephritis.
A second form of renal infarctions is of a hcemor-
rhagic and pigmentous nature. They look very much like
those already described, and are found in the same locali-
ties. They are granular, spherical, or irregular conglomer-
5 Virchow's original opinion, according to which the presence
of uric-acid infarction requires a certain duration of life, has
been to a certain extent rescinded by the proof furnished by a
premature and stillborn foetus which contained uric acid in its
its urine and urate of ammonium as sediment. Moreover,
well-developed uric-acid infarctions were observed by Martin
(Jenaische Ann., 1650) in a foetus born in the unruptured mem-
branes after an unsuccessful attempt at respiration. Hoogeweg
(Casper, Viertelj., 1855) met with them in an infant whose
heart ceased to beat three quarters of an hour before delivery.
Birch-Hirschfeld has a similar case, and Hofmann (Gerichtl.
Med., fifth ed., 1891, p. 748) published the cases of two infants,
one of whom lived but twenty-three hours, the other only fifteen
minutes, who exhibited uric-acid infarctions in full development.
383
DR. JACOBI'S WORKS
ates, which contain crystals of haemotoidin. They are the
results of small extravasations originating in general hy-
peraemia of the canaliculi, and depend on various causes, to
the principal of which I shall return. The usual changes
of haematin alter the color of these deposits, which contain
no crystals of uric acid or ammonium urate, and are not
affected by acetic acid. 6
Calcareous deposits are also found in the newborn.
They occur mainly in the lower end of the straight cana-
liculi, near the papillae, are of a whitish color, and may,
therefore, be mistaken on inspection for interstitial indura-
tions. They are mostly either carbonate or phosphate of
calcium, but rarely triple phosphate, and are soluble in
dilute hydrochloric acid. They are, under favorable cir-
cumstances, deposited into and upon the epithelia.
Which are these favorable circumstances ? Both phos-
phates and carbonates of calcium are known to be deposited
from the blood whenever circulation is retarded or im-
peded; for instance, in the older baby in the latter stages
of epiphyseal rhachitis. In the newborn the circulation
is retarded or impeded by congenital (or rapidly acquired)
heart disease, by general debility, or by asphyxia. As early
as 1883 (Firch. Arch.} Litten counted among such favor-
able conditions a coagulation necrosis occasioned by the
interruption of circulation. Thus these forms of retarded
6 Crystals of haematoidin (=bilirubin) were found by Virchow
as early as 1847 (Verhandl. d. Ges. f. Geburtsh. in Berlin, vol. ii)
in the kidneys, the tissues, and the blood of infants who died while
suffering from icterus neonatorum. Their main location is in
the renal epithelium and in the uriniferous tubes, but rarely
in the urine. They are also found in the fibrinous coagula of
the heat, in the parenchyma of the liver (Orth), and in the
adipose tissue of the omentura (Neumann). Even in macerated
foetuses they were met with by Neumann and Ruge. It appears,
therefore, that at the time of birth, and soon after, bilirubin
exists in the blood and tissues (with or without jaundice) in a
sufficient quantity to permit its getting free in crystalline form
even after death. The presence of genuine uric-acid infarctions
is not influenced by this phenomenon, and they and bilirubin may
occur simultaneously or separately.
384
NEPHRITIS OF THE NEWBORN
circulation, to which I alluded before in a different connec-
tion, exert a baneful influence from a chemical point of
view.
The normal frequency of uric acid and other renal in-
farctions explains the great many cases of gravel and stone
in the very young. They are observed in the earliest age,
contrary to the opinion of Rosenstein. This great author
on the diseases of the kidneys repudiates the connection
between the symptoms of renal colic and vesical calculi,
and between renal infarctions and vesical calculi. He
admits having observed renal colic in the first year of life,
but in a single baby only. Now this is very unfortunate,
and can be explained only, I believe, by some characteris-
tics in the field of his observations. Exceptional cases,
such as those of Woehler and Denis, in which a renal calcu-
lus consisting of uric acid was found in a premature and
stillborn foetus, need not be counted at all. But the ob-
servations of Heusinger relating to the frequent occurrence
of renal calculus in the first year of life are more conclusive.
I met with renal calculus quite frequently when I had more
opportunities to make autopsies of young infants, and have
often alluded to a series of forty post-mortem examinations
made on babies who died of miscellaneous diseases, in six
of whom I found a renal calculus. Nor do I believe I am
mistaken when I express my conviction that many of you
have observed actual gravel in the very young, and many
more the violent spasmodic pains of infants, accompanied
with erections, dysuria, even convulsions, and sudden relief
mostly attended with urination.
It is evident that the presence of crystalline masses in
the tubes and papillae of the kidneys is liable to be danger-
ous. They encroach upon the soft tissue in which they
are imbedded, disintegrate the epithelium, irritate the sur-
face, and produce slight haemorrhage and inflammation. In
many cases of nephritis of the very young there was a dis-
tinct history of dysuria and of copious deposits in the nap-
kins, not infrequently mixed with blood. What gravel and
stone can accomplish in more advanced months and years
is more easily brought about in the half-perfected tissue of
the newborn.
385
DR. JACOBI'S WORKS
In regard to the dangers attending the presence of uric
acid in the kidneys I have more to say on preventives than
curatives. When we deal with gravel and stone in the
kidneys of adults our efforts are directed to the solution of
the deposits. Plenty of water, alkaline mineral waters,
alkalies, mainly potassic salts, lithia, piperazine, arid lysi-
dine are pressed into service. In the newborn, in whom we
must, as infarctions are the rule, except the presence of the
danger, we are in the habit of doing absolutely nothing,
though prevention be within easy reach. Water is, if not
the panacea, at all events the indicated remedy. But in no
period of life is water more withheld from the helpless
creature than in the first few days. Mother's milk is not
forthcoming until a few days have passed by, and then it
appears in small quantities only. Even the experience that
the newborn lose weight by being starved is charged
against Providence, which has willed it so from times ante-
diluvial. If water were given plentiful and as methodically
as syrup of figs or castor oil, much harm could be avoided.
And here permit me a few words pro domo. In regard to
feeding the newborn, I have practised these forty years,
and taught thirty-five, not only that the very young infant
must be fed, but that its artificial food must be greatly
diluted. In those early times I knew only that the baby
would best bear great dilutions, and I mixed a part of boiled
milk with four or five parts of water, or rather of a thin
cereal decoction. The latter have at last been recognized
as correct, even by Heubner, whose main labors for years
have been spent on studying and discussing the question
of artificial infant food. But he still sets his face against
what he calls " Jacobi's exorbitant dilutions." In the light
of what I have had the honor of saying to-night, I profess
to have even in those remote times taught better than I
knew. At those times I considered the question of digestion
only when I recommended large dilutions. It is only a
dozen years ago, perhaps, that I began to consider the ques-
tion of high dilution of the food of the newborn from the
point of view of its beneficence in renal infarction and its
consequences. In 1887 I spoke of its indication for the pur-
386
NEPHRITIS OF THE NEWBORN
pose of dissolving and eliminating uric-acid infarctions in
my Intestinal Diseases of Infancy and Childhood. I can
assure, as I said then, that since my advice of greatly dilut-
ing the food of the newborn, and giving plenty of water
from the beginning, has commenced to be minded, I am
sadly deprived of the many cases of gravel, dysuria, shriek-
ing spells, and consecutive nephritis which were so common
in former times.
The connection of icterus of the newborn with local
changes in the kidneys is of vital interest. In the adult
this intimate dependency upon each other is rare, though
many gross anatomical changes are equally found in all
ages. To that class belong septic infection, syphilis of the
liver, cirrhosis of the liver of whatever origin, obliterations
of the biliary ducts, thrombosis of the portal vein, and
catarrh of the duodenum and choledochus duct.
In the newborn many undoubted cases of icterus are
due to the destruction of red blood-cells in the first few
days, and to the transformation of haematin into haematoidin
(identical with bilirubin). Some of the latter comes from
the many ecchymoses and stagnations, both in the skin and
the subcutaneous tissue, due to the process of parturition.
The destruction of blood-cells in the newborn is a
normal occurrence. According to Hayem and Helot the
blood-cells of the newborn are subject to rapid disinte-
gration. According to Hofmeier the normal congregation
of the blood-cells is absent; they exhibit a greater resist-
ance to salving liquids ; the number of leucocytes is very
changeable, and the size of the blood-corpuscles is very
variable. Silbermann found many blood-cells pale, others,
of normal color in their periphery only; many of various
sizes macro- and microcytes. He also met with nucleated
blood-cells in the liver, the spleen, and the bone marrow;
with cells of the liver, sometimes also of the spleen, and of
the bone marrow containing blood; with red bodies of the
club and biscuit form, evidently changed blood-cells ; and
finally an increase of leucocytes. All of these observations
appear to prove the destructibility of the blood of the new-
born, which is only equaled, or perhaps even surpassed,
387
DR. JACOBI'S WORKS
by the effect of chronic poisoning, in part observed for
experimental purposes. 7
By many the jaundice of the newborn is attributed
to absorption of bile into the blood directly from the bil-
iary ducts into the small vessels of hepatic circulation.
By others a congenital narrowness of the choledochus duct
or an accumulation of mucus in the biliary ducts, or oedema
of the periportal connective tissue, or venous obstruction in
the liver and' consecutive compression of biliary ducts
were claimed as the causes of jaundice. Quincke ex-
plained it by the patency of the ductus venosus Arantii,
and by absorption of bile from the meconium of the intes-
tines.
Meconium is rich in bilirubin. The latter is stored in
it during and after the third month of intra-uterine life.
Biliverdin accompanies it to such a large amount that
Simon (Arch. f. Gynak., 1875) met with four per cent,
of it.
This bilirubin and biliverdin are very liable to be ab-
sorbed through the open ductus venosus Arantii, which re-
mains patent in seventy-seven per cent, of all the new-
born until after the first week of their lives. Its circula-
tion is free, its blood liquid, and there is a direct communi-
cation from the intestinal circulation with that of the vena
7 Toluylendiamine, according to Afanassiew and Stadelman,
exhibits the following results: Dissolution of red blood-corpuscles
and consecutive haemoglobinuria ; increase of the coloring matter
of the bile; anaemia; moderate fatty degeneration of the large
glands; acute parenchymatous nephritis; destruction of renal
epithelia. At the same time the epithelia of the spleen and
liver are seriously damaged either directly by the (experimental)
poison or by the circulation of an altered blood. The urine con-
tains copious conglomerate crystals, which probably are not
organic, but consist of calcium sulphate.
8 Some communication of the same kind, with the same effect,
is brought about between the haemorrhoidal plexus of the rectum
(through the haemorrhoidal vein) and the vena cava, thus cir-
cumventing the liver. Still, it must be remembered that less
absorption takes place in the rectum than in the rest of the
388
NEPHRITIS OF THE NEWBORN
Through the open ductus venosus Arantii the coloring
matter of the bile enters the circulation of the whole body,
circumventing the liver to such an extent that in some
cases of icteric newborn infants it does not participate in
the jaundice at all, and produces different degrees of ic-
terus. When peristalsis is active, circulation and absorption
are so in proportion, and icterus is early; when peristalsis
is but sluggish, and meconium retained unusually long,
icterus may appear at a late period. In premature babies
the ductus venosus is large, and jaundice liable to be early
and very intense. When Elsasser, however, found it closed
in three cases no jaundice was observed. Immediately
after birth the coloring matter of the bile is considerably
increased, and therefrom results another additional cause
of jaundice. Besides, as it has been stated, there is no
period of life in which under normal circumstances so
many blood-cells undergo rapid disintegration. Therein
lies another cause for the formation of bilirubin, and for
a direct thrombotic interruption of circulation in the small-
est blood vessels. Finally, there is no period of life when
elimination is less active than during the first days of life.
At that time the urine is very scanty, the water supply
mostly neglected, and the accumulation of effete material
the rule.
Moreover, bilirubin is but scantily dissolved in the fluids
of the tissues of the newborn; even in strongly alkaline
solutions it is but slightly soluble, according to Hoppe-
Seiler. Thus it is that the coloring matter of bile is met
with in the urine of the newborn in the shape of the
yellow masses (masses jaunes) which have already been
mentioned in connection with urinary infarctions.
When the absorbed and deposited masses are but scanty
they may be eliminated without any symptoms. When
there is enough of them to result in a local irritation,
intestinal tract. Absorption is very much more active in the
upper part of the large intestine. Kiihne knew, 1868 (Physiol.
Chem.), that icterus may originate in absorption from the colon;
and in the small intestines both the amount of meconium and
the absorbability of its bilirubin and biliverdin are much greater.
389
DR. JACOBI'S WORKS
they will cause albuminuria, which is often found in ill-
nourished icteric babies. When there is enough to cause
thromboses, which are quite common in the capillaries of
the portal system, and obstruction of circulation, they
give rise to haemorrhages or to inflammation. As far as
the kidneys are concerned, there is a peculiar anatomical
reason why nephritis is very liable to appear in the very
young.
The post-foetal growth of blood-vessels and tissues
varies considerably. It is least in the common carotid,
largest in the renal and femoral arteries. The renal artery
and the kidneys, however, do not develop proportionately;
the transverse section of the former increases out of pro-
portion to the volume and weight of the latter. Thus it
seems that this disproportion between the size of the
artery and the condition of the renal tissue establishes a
predisposition to congestive and inflammatory conditions of
the organ. Moreover, the resistance in the capillary net of
the young kidney is unusually great. Experiments prove
that the permeability of the capillaries is greater, and that
within a given time a proportionately larger amount of
water can be squeezed through them in the adult than in
the young. This anatomical difference seems, therefore, to
be an additional reason why renal diseases are so much
more frequent in infancy and childhood, from all causes,
with the only exception of that which is reserved for the
very last decades of natural life viz., atheromatous de-
generation. 9
In conclusion, Mr. President, permit me to recapitulate
in a few words the main points of this paper:
Nephritis is a frequent disease of infancy and child-
hood and by no means very rare in the newborn. What
was formerly considered mere albuminuria, or a transient
form of it, we have been taught by improved methods of
investigation, mainly by the use of the centrifuge, to recog-
nize as nephritis. A predisposition to nephritis in the
young is caused by the fragility of the blood-vessels in the
Heart and Blood-vessels in the Young. By A. Jacobi, M. D.,
Brooklyn Med. Jour., March, 1888.
390
NEPHRITIS OF THE NEWBORN
newborn; by the relative imperviousness of the young
renal capillaries compared with the large size of the renal
arteries ; by the feebleness of the young intestinal muscle,
which proves insufficient to expel toxic contents; by the
extensiveness and size of the young intestinal blood-vessels
and lymphatics and the large size of the villi, all of which
favor the absorption of toxines.
From an aetiological point of view, nephritis in the new-
born may be:
1. Congestive (from feeble circulation, congenital heart
disease, asphyxia, or exposure to low temperatures).
2. Obstructive (from the physiological rapid decompo-
sition of the blood of the newborn; the formation of
haematoidin=:bilirubin ; jaundice; the production of methae-
moglobin by chemical poisons, such as potassic chlorate, or
by excessive heat; or the presence of blood in the urinif-
erous tubes).
3. Irritative (from the presence of uric-acid infarctions
or haematoidin infarctions, or purpuric or other interstitial
haemorrhages, or of microbes and toxines in the numerous
eruptive and infectious maladies and in enteritis).
391
LADIES AND GENTLEMEN:
Some weeks ago the Charity Organization published a
Handbook on the Prevention of Tuberculosis. Among the
contributors to it are some of the most eminent physicians
and authors of New York. Thus its statements may well
be accepted as authoritative. Indeed, I know of no volume
which will communicate the same information on the sub-
ject of tuberculosis in as concise, handy, and skilful a
manner. While commending its perusal to all my hearers,
I know I cannot add to its wealth of ideas and its store-
house of truths. What is left for me, therefore, is to apply
many of the facts to a special topic, namely, the problem
of tuberculosis in connection with school teachers and
pupils.
I do not feel certain that there are not many here who
are well acquainted with some or most of what I shall
have to say, for tuberculosis has for years been the sub-
ject of discussion, in lectures, societies, magazines, and
newspapers. Some part of the subject is known to every-
body. What we call consumption, that is, tuberculosis of
the lungs with formation of abscesses and the usual or
frequent termination of the disease in death, is of daily
occurrence and many of you have met it amongst your
friends and relatives. If statistics do not lie, there is no
large company that does not harbor candidates or victims
of the malady in some form or another. Is there anything
that should be studied with greater persistency by those
who, like you, are stationed between science and its ap-
plication, and who have more ample opportunity to dis-
seminate useful knowledge than most other professional
people? Nor should the knowledge of the teacher be
superficial. Only what is thoroughly understood can be
applied or taught in plain words ; and plain language is
393
DR. JACOBI'S WORKS
required when you mean to instruct a child, and through
the child, its family. You have or will have to deal with
the young at a time when his mind is most receptive and
his tongue most communicative. That is why a number of
plain rules are readily grasped and understood by a child,
and the child taught by you may prove a teacher at home
for his father and mother, who have not the time to read,
though some of them may have more literary material than
mere sensational newspaper gossip. In this way the knowl-
edge of the nature and the prevention of tuberculosis may
become disseminated, and the disposition to the dread
scourge may be recognized and gradually extinguished.
Every educated person, certainly every one of you, knows
perfectly well that tuberculosis is the direct result of the
presence in large numbers of a minute microbe, the bacillus
of tuberculosis, or its toxin (or virus) in the body of the
patient. Its influence need not be immediate. It may be
buried away in some part of the organism for a long time
waiting for its chance. That chance will come when some
other disease, particularly one of an inflammatory character,
breaks out, or when such microbes as are the cause of or
connected with suppuration, in small or large abscesses,
combine their forces with those of the bacillus. In such
a case the outbreak is apt to be a very sudden one and
we have an instance of so-called acute tuberculosis or rapid,
or florid, or hasty consumption.
Of the location and the frequency of tuberculosis in the
very young I spoke a year ago at another place. In the
infant and the very young child, where you personally have
few opportunities of close observation, tuberculosis may be
found as a chronic disease, in the end of a bone, or in a
gland; also in the pleura and peritoneum; in its acute state
mostly in the brain and a number of other organs where it
is almost invariably fatal. In your profession you have to
deal with children after the sixth or seventh years and with
adolescents, in whom tuberculosis is very apt to follow the
same course and exhibit the same symptoms which are met
in the adult. Here you find it mostly in the lungs. In not
a few cases tuberculosis may be easily recognized, or at
least suspected. When you have to deal with a child that
394
PREVENTION OF TUBERCULOSIS
is unusually pale, or of low weight, easily exhausted, with
glandular swelling about the neck and narrow chest, tuber-
culosis should be suspected and proper care should be taken,
for it should never be forgotten that tuberculosis may heal
or be made to heal.
As a modification, or as suspicious or incipient symptoms,
you will not infrequently notice the symptoms of what has
been called scrofula. Scrofula is observed in two forms.
There are a number of children, usually brunettes, with dark
hair, florid cheeks, brilliant eyes, low weight, quite fre-
quently with good mental capacity, who display diseases of
the mucous membranes ; their eyes are frequently sore, some
of the glands of the neck, perhaps many, are considerably
swollen. The other form of scrofula is a more sluggish
or torpid one. The children are rather heavy, flabby, mostly
pale, with large and rather hanging cheeks, and big lips,
and there is swelling of the nose and considerable tume-
faction of glands about the neck, with not infrequently
sore eyes, ears, and skin. This is the usual form, and the
one which is apt to lead into tuberculosis during school
age. That is why I wish to direct your special attention
to this form of disease. Of great importance in connection
with it is the presence of those glandular swellings round
the neck, and it is to this that I ask your attention for a
few minutes.
You know that the circulation in the animal body is two-
fold first, that of the blood; second, that of the lymph.
The lymph is disseminated through the body in every organ,
but particularly in and below the mucous membranes. The
absorption of chyle as furnished by digestion takes place
from millions of small glandular bodies, many of them of
microscopic size only. They are disseminated over the intes-
tinal mucous membranes, whose contents they absorb and
carry off into larger vessels, and from them into lymph
bodies or so-called glands of the mesentery, in the im-
mediate neighborhood of the intestines. They are very
numerous all over. From them the current goes on into
still larger vessels until finally they terminate in a large
duct, the thoracic duct, which discharges its contents into
the circulation of the blood. That circulation in the lymph
395
DR. JACOBI'S WORKS
is very extensive and copious. It has been found that an
artificial opening made into the thoracic duct of a young
dog furnished lymph to the amount of between one-sixth
and one-tenth of the weight of that dog within one day,
while an adult dog furnished lymph amounting to only
one-tenth to one-sixteenth of the body weight. In the same
way the lymph apparatus in a young child up to advanced
childhood and adolescence is very much more active than it
is in the adult.
That is why the condition of the lymph glands in the
young is of such importance. Whenever there is any in-
fection of the mucous membrane, the infecting poison is
carried off to the next gland where there is a stopping-
place. That gland will become the seat of irritation or
swelling. That is why to give you an example when-
ever there is only a slight diarrhoea, no- matter from what
cause, over-eating, improper food, medicines, typhoid, colds
never from dentition, for there is no such thing as diar-
rhoea from teething in a healthy child the lymph bodies
in the neighborhood will swell. Unless such a diarrhoea
is soon stopped the irritation will continue, congestion, in-
flammation, and swelling of the glands will ensue, and the
structure of these neighboring glands will be changed.
When such an inflammation of the gland has lasted a long
time and new tissue has been formed in it, it may or will
remain unchanged and unalterable, no matter what you may
do for it.
The same takes place about the lungs. Whenever a baby
or adult has catarrh with some cough and mucous expector-
ation, the neighboring glands in the chest bronchial or
mediastinal will swell, and unless such catarrh is broken
up the swelling may go on until the glands are hardened
or undergo other changes. Sometimes they will form ab-
scesses and break up. Whenever there is in a child or in
an adult, particularly in the young of the age with which
you have to deal, a catarrh of the nasal mucous membrane,
the glands about the neck will immediately swell. This
swelling will pass off when the nasal catarrh passes off.
When it lasts long, when it becomes a chronic catarrh, the
swelling of the glands remains ; they become hardened, they
396
PREVENTION OF TUBERCULOSIS
are no longer amenable to the effect of medicine or to ex-
ternal treatment; they may finally break down and form
abscesses. While they are in this swelled condition the
lymph current through them will be interrupted, and what-
ever is floating in it will there be caught and infect the
gland. Moreover, the minute capillary blood vessels are
smaller in the glands than elsewhere, and microbes which
are easily passed by capillaries elsewhere and finally
thrown out of the system will be caught in the capillaries
of the glands. In this way the glands around the neck,
that were not primarily infected by disease-producing
germs, may become the receptacles of disease. They may
become tubercular when tubercle bacilli are floating in the
general circulation (although they might have been carried
off if the organs had been healthy), and be caught in the
slow circulation of the gland and there remain. From there
the invasion of the whole body may take place. Thus you
see that, often in a healthy family or in an otherwise
healthy child, a nasal catarrh of some duration may furnish
the first inroad of tubercular bacilli. This is particularly
so in infectious diseases which affect the mucous membrane
to a high degree for instance, in measles or whooping
cough. Measles and whooping cough are often the fore-
runners of tuberculosis.
As long as the mucous membranes are in a healthy con-
dition they may be covered with no end of foreign material,
microbes included, with no danger to the individual whatso-
ever. There are, for instance, very few probably among us
here that do not carry either bacilli of tuberculosis or bacilli
of diphtheria in their noses and throats this very moment.
As long as our mucous membranes are in a healthy condition
the microbes will not be absorbed. As soon, however, as
the membranes are no longer in that healthy condition,
when the microscopical epithelia that cover the membrane
are destroyed or altered or washed off, then those foreign
guests, innocent up to that time, will creep into the sore
tissues and the whole system will become affected. Thus
it may even be that a healthy person, harboring the bacilli
of diphtheria or tuberculosis, may infect other people
though he has not been infected himself.
897
DR. JACOBI'S WORKS
The infection of the glands of the neck does not depend
on a morbid condition of the mucous membrane of the nose
alone; the vast area of the mucous membrane extending
down to the pharynx and upward to the nose may be af-
fected. There is no mucous surface that is covered and
penetrated with small lymph bodies to such an extent as
that of these organs. The lymph bodies in the hind part
of the nose form, when they grow, what has been called
adenoids. They sometimes reach such a size as to obstruct
nasal respiration, compel the patient to have the mouth
open to breathe, and cause him to hear and to sleep with
open mouth, increasing the danger of infection on account
of the wide access given to microbes floating in the air.
In that condition the night is the most dangerous time.
Adenoids and the whole mucous membrane have frequently
been found to be covered with tubercular bacilli, more so
than perhaps the tonsils.
When the bacilli are absorbed, their next lodging-place
is, as I said, the neighboring glands. These glands about
the neck form three tiers all the way down to the clavicle.
From there the lymph current goes downward into the
chest and into the axilla; thus the lymph bodies or so-called
glands swell in the axilla and in the chest. These lymph
bodies in the chest are in direct contact with the mucous
membrane of the large wind-pipes, and in that way with
the smaller wind-pipes and with the lungs. That is quite
frequently the way in which bacilli and other virus enter
the lungs. It is often the process in the adult and in the
adolescent and in the growing child.
When you understand that, you see how important it is
that the mucous membrane of the nose and of the mouth
should be taken care of in the very young and in the grow-
ing child. A great many cases of tuberculosis, diphtheria,
and other contagious and infectious diseases could be pre-
vented if there were no diseased mucous membrane greedy
after infecting material. That is why it should be a rule
in every family where there is the slightest tendency to
nasal and throat catarrh to irrigate the nose and the throat
at least once a day, better twice a day, with warm water in
which a very small dose of common table salt is dissolved.
PREVENTION OF TUBERCULOSIS
This so-called saline solution contains from six to seven
parts of salt to one thousand of water. A good proportion
for practical purposes is half a teaspoonful of table salt
to a good tumblerful of warm water. Part of this should
be filled into a common nasal cup, the head should be
thrown back, and small quantities should be allowed to
run down the nose into the throat. If it be swallowed
there is no harm, but children will learn very rapidly how
to bring up the salt water. In this way the mucous mem-
branes are kept intact, and nobody can tell how many
diseases are kept away by this very simple method. I
can prove that it does have that effect, for you will in-
variably notice that whenever you have a catarrh of the
nose, or even when you see a very severe case of diphtheria
of the nose (one of the most dangerous forms of that
disease), the large swellings of the neck will be reduced
in a very short time by doing nothing whatever except fol-
lowing the rules just laid down. No medicine, no iodine,
no mercury is required, simply the washing out in an
acute disease like diphtheria very often every one or
two hours. In common nasal catarrh, twice a day is suffi-
cient to reduce from day to day, or even from hour to
hour, the size of the glands, unless it have lasted weeks
or months. Sometimes, even when it has lasted weeks, and
not infrequently when it has lasted months, the correct
irrigation of the nose twice or three times a day will grad-
ually, within a few weeks or a month, not only reduce, but
remove, the swelling that had been annoying for many
months or even a year. In this connection I may say that
nothing but irrigations should be used under ordinary cir-
cumstances, and no injections. No syringes should be used
unless ordered by the physician in very bad cases of diph-
theria, where it is important to remove a great many of
the accumulated membranes in as short a time as possible.
I will add, too, as a practical rule, that sprays, which are
so frequently used, are not so effective either in disease or
in comparative health. The washing out of the nose can
be better accomplished by irrigations than by merely spray-
ing.
What I have thus far said would settle in your mind the
399
DR. JACOBI'S WORKS
question whether scrofula and tuberculosis are identical.
They are not identical, but they may become so. Imagine
the original catarrh of the nose and throat, brought on by
exposure, a drenching rain, cold feet, drafts in a trolley
car, exposure of the perspiring skin, met with bacilli which
had been innocent tenants on the mucous membrane; then
these tenants of the surface would enter through the open
door, and a real infection would take place. In that case,
not otherwise, the scrofula or the alleged scrofula of the
glands would turn out to be tuberculosis. Thus wherever
there are swelled glands, wherever there is " scrofula,"
there is not necessarily at the same time tuberculosis, but
there is danger of tubercular invasion. Scrofula, when
fully developed in a child, as observed by you, will show a
number of symptoms that are not found, as a rule, in
tuberculosis. You have sore eyes, sore ears, swollen lips,
and nose; you have the glands, you have the eczema of the
skin ; if all that were always tuberculosis there would be
no possibility of recovery. The scrofulous disposition is
widespread; it extends over the skin, over the mucous mem-
brane, and may show itself even in the bones ; it is char-
acterized by the fact that whenever there is such an in-
fection, whenever there is scrofulous irritation at least, it
is not apt to heal. Scrofulous inflammation and ulceration
are very obstinate. If all that were tuberculosis the patient
would be doomed; but tuberculosis invades the body pri-
marily in a certain limited locality. It may remain in that
locality; it may remain in the end of a bone, in a number
of glands, in a small part of the lung, and there may heal
up. In the beginning, therefore, scrofula is a widespread
general "disorder and in the beginning tuberculosis is a
local disease. That is why on the autopsy table we fre-
quently find tuberculosis in a body where it was not sus-
pected at all. We find deposits, small or large nodules,
particularly in the upper part of the lung, usually the right
lung, that are cases either of dormant or of recovered tuber-
culosis. No such thing is found in scrofula. When scrof-
ula heals, the whole body is changed for the better. When
tuberculosis heals, it is found that it was a local disease.
The invasion of tuberculosis into the human body may
take place by inhalation of the bacilli, or by feeding, with
400
PREVENTION OF TUBERCULOSIS
the exception of the rare cases in which the bacilli get into
the circulation through sores on the skin in chronic eczema,
for instance or through wounds. Thus it is that butchers
may contract tuberculosis of the skin from diseased cattle,
or through an abscess. Milk containing tubercle bacilli
may infect the intestinal tract, or (while being swallowed)
the lymph follicles of the throat, including the tonsils,
and thereby on their downward course, the body. From
either of these places the circulation of the blood or of
the lymph, mainly the latter, may be invaded.
The famous Dr. Emil von Bearing, the discoverer or
rather inventor of the diphtheria antitoxin, proclaims that
almost every tuberculosis case, at any age, originates in
the milk of tubercular cows taken by the infant or child.
In most cases, in his opinion, tuberculosis remains dormant
for many years, and every case of tuberculosis in an adult
is the result of infection by tuberculous milk, during in-
fancy. That is a cruel exaggeration. But surely there are
many undoubted cases of feeding milk of tuberculous cows
that resulted in tuberculosis. My late friend Olivier, of
Paris, has the following report: Thirteen schoolgirls in a
Paris boarding-school were taken with tuberculosis. Six
died. Some of them had the disease first in their bowels.
The milk came from a tuberculous cow with a badly
affected udder. Johne, a great veterinary anatomist, ex-
amined the cow that had the reputation of being the finest
on a farm until she became emaciated and died. Indeed,
on account of her splendid condition, her milk had been
selected by the farmer for his own infant. The child died
of tuberculosis at the age of two years and a half. A case
like this proves, besides other things, the correctness of
my teaching these more than forty years, that it is always
safer to select milk from a herd of cows than from a single
cow, thereby diluting possible dangers. By experiment it
has been proven that the milk of a tubercular cow when
mixed with forty times the amount of healthy milk becomes
devoid of dangers.
But, after all, cases of tuberculosis resulting from the in-
gestion of tuberculous milk are rare. In the stomach bacilli
do not thrive, and tuberculous ulcerations of the intestines
are infrequent. Indeed, the abdominal glands are more
401!
DR. JACOBI'S WORKS
often affected than the mucous membranes of the intestines.
The principal mode of entrance of tuberculosis is that of
inhalation, which may be twofold: either that of the dry
bacilli contained in the dust of the street, or of a room
or public place; or of the moist particles of expectoration
which are thrown about in a coughing spell and float in
the air of a room hours before they are deposited on the
floor. As far as the dry bacilli are concerned, it may take
time and some force to remove them. A moderate air cur-
rent is not sufficient for that purpose. Wherever they are
deposited they are waiting for their chance. Dusting,
sweeping of the dry material, will fill the air with bacilli.
Children's respiratory organs, being nearer the floor than
those of the adults, are most exposed. That is why the
percentage of tubercular school children grows in dispro-
portionate rapidity with every year of their lives.
Now, it may be worth your while to consider the final
location of the inhaled bacilli; do they reach the finest
ramifications of the bronchial tubes and the air cells? It is
not probable, for in the advanced child and the adult the
primary location of tuberculosis is not at all, or very rarely,
in these distant parts. It is much more probable that
during inhalation the dangerous inhalation is deposited in
the posterior part of the nose and in the throat. There
are those, however, who attribute to the tonsils the prin-
cipal, aye, even- the only role in the invasion of tubercle
bacilli. A late author goes so far as to build his plan
of preventing or combating tuberculosis on the total excision
of the tonsils. That is an exaggeration. He claims the
operation must be made according to a certain method,
and, unfortunately, he suggests that there are but few ex-
cept himself who can perform it so as to be effective.
Moreover, it is not true that the tonsil absorbs as readily
as the other thousand of lymph follicles of the nose and
throat. In my studies on diphtheria, before and in 1874
and in 1880, I found that when the tonsil alone was af-
fected, the case was a mild one, and not accompanied by
much swelling of the neighboring glands ; that these latter
swelled principally when the diphtheritic membrane reached
beyond the tonsil; and that when the mucous membrane of
402
PREVENTION OF TUBERCULOSIS
the nose was the seat of the diphtheritic membrane, the
case was so grave that before those times and before the
suggestion of local treatment, every case of nasal diph-
theria was pronounced fatal by a great French authority of
that period, Roger. I showed that the reason for the
relative innocuousness of the tonsil is anatomical. Though
its structure is similar to that of the smaller lymph folli-
cles disseminated in the neighborhood, it is surrounded by
a firm fibrous membrane which, to a certain extent, shields
the system against a rapid absorption of poisonous sub-
stances which have entered the tonsils.
Other modes of entrance of bacilli into the system are
the following: The finger nails of babies, like those of
the adults, are unclean. Though they do not exhibit the
unappetizing spectacle of a mourning ring, they are al-
ways unclean and harbor microbes, both uninjurious and
injurious. A few years ago there was a report of a New
York mother whose cheek was slightly scratched by her
playful baby. The baby had erysipelas microbes under its
nails, and the mother died of erysipelas. Thirty years ago
I lost a warm friend, a great physician, who, 'while in
quiet thought, scratched a small pimple on his cheek. His
erysipelas originated in that very spot. Two German
authors (Preisnitz and Schutz) published in 1902 their
observations on the finger nails of children of from six
months to two years of age. They proved that fourteen
out of sixty-six had tubercle bacilli under their finger nails.
No fixed star is more immovable than the fact that every
one of these young ones had their dangerous pretty fingers
in their noses and mouths. Now, tuberculosis will rarely
make its appearance suddenly. Years may pass before the
invalid lymph glands of the throat and neck give up
their captive microbes and allow them to travel downwards.
That is the time when your pupils develop their tubercu-
losis, no matter whether they imported it from the flying
dust of the street or the dry sweeping of the rooms,
from their own nails, from the crumbs they picked up, or
from their intimate comrades, the toys.
Now, ladies and gentlemen, I have repeatedly spoken of
the fact that microbes, no matter in what numbers, may
403
DR. JACOBFS WORKS
invade the nose and throat and are devoid of danger as
long as the mucous membrane covered by them is healthy,
but that they prove, or may prove, dangerous when a
catarrh destroys the fine film of epithelia which protects
the surface. That is why a cold is always enumerated
amongst the causes of tuberculosis, of diphtheria, of rheu-
matism, even of erysipelas or of scarlatina. As practical
people and bent upon caring for yourselves and others,
you will ask me for the methods of keeping the mucous
membranes in a sound condition, and thus preventing dis-
ease. That can be done by attending to the general health,
and mainly by the hardening process.
Much has been said about hardening. What does it
mean? Nothing but this: -that the resistance of the child
to the effect of external influences should be strengthened.
Is there a uniform method applicable to every child, no
matter of what age or constitution? Certainly not. But
there is one object which should be accomplished in every
infant and child, viz., the invigoration of external circu-
lation. The surface of a child from two to ten years
measures from three to ten square feet. In and under that
surface there is a lake of blood. In vigorous health this
blood is in constant and rapid circulation; within two min-
utes it enters and leaves the surface, comes from and leaves
the center of circulation the heart. Slow circulation in
the surface retards the flow of blood in the whole body,
and impairs the nutrition of the heart and every organ,
causing congestion and insufficient function, and disease.
Rapid circulation in and under the skin, causing rapid
circulation everywhere, propels the totality of the blood
in the child's body (from two to six pounds according
to age from two to twelve years) into and through the
lungs, in which the contact with and the absorption of the
oxygen of the atmosphere take place. Now, the best stim-
ulant of the circulation in general is, besides muscular
exertion (exercise), the stimulation of the skin by cold
water and friction. A child of two or three years should
have a daily cold wash, either after a warm bath, or
standing in warm water which covers the feet, or lying
on the attendant's lap, or on a mattress. A brisk rubbing
404
with a wet towel one or two minutes, and with a dry towel
until the surface is dry and warm, is sufficient. Older
children may have a wet sponge squeezed out over them,
this procedure being followed by the same effective fric-
tion ; or they may plunge into cold water, in the winter a
single moment, in the summer several minutes. While in
any bath, the skin should be thoroughly rubbed.
This rule must not become a routine applicable to every
individual. Cold water and friction require a healthy
heart and a certain degree of strength. A usually healthy
child, when taken sick or when convalescent from a disease,
lacks the necessary vigor, and the routine must be inter-
rupted. A child under size and under weight requires
warmer water and friction. That is why a newly born baby
or an infant of less than one or two years should be
spared a low temperature. This is also why a child whose
feet, after a bath or washing, do not get so warm as the
rest of the body should be rubbed down, not with cold,
but with warm water, or with a mixture of alcohol and
warm water in which table salt or sea salt has been dis-
solved.
It would be wrong, however, to rely on a single method
alone for the purpose of preserving the healthy condition
of the skin, the mucous membrane, or the general circu-
lation. Whatever aids or injures, one part of the body is
apt to aid or injure all. No child can have a normal
circulation in the chest when the abdominal organs are com-
pressed or their circulation interfered with. Children, for
instance, who suffer from constipation, no matter from what
cause I have described one form which results from an
abdominal length and bending upon itself of the lower end
of the large intestines, or others who suffer from pro-
longed sitting, or those who bend over on account of near-
sightedness, all compress their abdominal blood vessels, and
are often afflicted with nose bleeding, congestive headaches,
and general ill-nutrition. That is one of the frequent oc-
currences which necessitate the watchful care of a school
physician and of the teacher.
Physicians and humanitarians have always protested
against premature schooling, too long hours, and too short
405
DR. JACOBI'S WORKS
recesses, and objected to overcrowding of the curriculum,
and to the vanity of incompetent schoolmasters and mis-
tresses, who utilize the poor victims in behalf of exhibitions.
Mostly in vain thus far. In regard to the exhibitions, and
the examinations preceding them, I am sure Dr. Weir
Mitchell has struck a keynote. Only last week in a public
lecture delivered in Philadelphia, he expressed himself
strongly in regard to the influences exerted by the worry
and fear and over-exertion connected with school examina-
tions. It is true enough that without some sort of exami-
nations the standing of the pupils in large schools is hard
to determine, but, on the other hand, whoever has seen
much of children or young people about the time of exami-
nations must be fully satisfied that some modification or
other must be discovered.
Now, as to school hours. A child of seven or nine years
should not have more than two or three hours daily in
school, one of which should be spared for an intermediate
recess. From nine to twelve years the school hours should
be three or four; after that age, not more than five hours,
with frequent and ample recesses. The best exercise during
recesses is play in the open air. Compulsory gymnastics
in badly ventilated localities cannot take its place success-
fully and may add to exhaustion and ill-health. It is an
unforunate fact that, when the claims of physical develop-
ment were urged upon school authorities, gymnastics were
added to the overcrowded curriculum as a matter of busi-
ness interest or of conviction, not always willingly or
intelligently.
The summer vacations of school children ought to be
four weeks longer than they are. The public schools ought
to be closed about the middle of June and reopened in
October. Many years ago the Harlem Medical Associa-
tion and the Medical Society of the County of New York
requested the Board of Education of the city to open the
public schools on the third in place of the first Monday in
September. The soundness of the principle was appreci-
ated and the necessity for such a change was acknowledged
by the authorities, and the second Monday of September
was selected for the beginning of the school season, so as
406
PREVENTION OF TUBERCULOSIS
to afford the children an extra week's broiling in the city's
sun and an opportunity to lose, as they did formerly, the
benefit derived from the summer vacation. The sanitary
reason of this loss of a beneficent opportunity was said to
be the anachronistic conviction of an eighteenth-century
school superintendent, who said he preferred the influence
of the schoolroom to that of the New York streets for the
New York boy.
Teachers are principally concerned with questions con-
nected with the condition of the school buildings. They
should be ample and sunny and not moist; they should be
exposed to fresh air, have ample light and sufficiently
large rooms. All that appears to be understood, but in this
very New York we know that not everything is done
that could or should be done in regard to all these postu-
lates. There should be ample light, not only for the pur-
pose of being enabled to see the dust where it accumulates
and the mud, but light is a remedy in itself. It is true
that only in the last very few years has it been utilized
for the direct cure of general and particularly of local
diseases, but it was known previously that disease-giving
microbes that live a long time in dark places will be
speedily destroyed under the influence of light.
Air space should be ample. It is difficult to say exactly
how many cubic feet are the proper supply. The amount
of cubic feet in a schoolroom, which is occupied a number
of hours only, need not be what it is in a living-room, in a
bedroom or in a hospital. In the latter more than 1000
cubic feet for a person is the least that should be de-
manded. We all know that there are few persons, com-
paratively speaking, in New York, with its immense
tenement-house population, that have as much air supply
as that, but we all know how their health suffers from that
reason. A schoolroom that is occupied only a short time
may perhaps furnish about 200 cubic feet for a child. A
room of 30 by 25 feet and 12 feet high, containing QOOO
cubic feet of air, should not harbor more than 50 children.
At best that would give 180 cubic feet for each child. I
have known of a schoolroom, indeed, of many school-
rooms, that were meant for 60 children and contained for
407
DR. JACOBI'S WORKS
a long time an excess of 130. It is natural that a good
deal of sickness must be the result among teachers and
pupils.
Everybody is theoretically convinced that the blood can-
not be fully aerated, and that the health must suffer, un-
less the air we inhale is pure. The young organism suf-
fers in this respect more than the old, for it requires more
oxygen, comparatively. Unless a sufficient supply of oxygen
is kept up and the percentage of carbonic acid contained
in the air is below seven-tenths of one per cent, good health
is impossible. The deteriorations you have to fight in the
air of your schoolroom are as follows: It is too dry under
the influence of our heating apparatus. Furnaces and most
other heaters furnish a dry air which impairs the surface
of the mucous membranes in the nose, the throat, and the
lungs. There is no more voracious oxygen eater than the
gas stove. Carbonoxid is the result of imperfect combus-
tion, and a very frequent deadly poison. So are the
chlorine gas and the nitric and sulphuric acid contained in
our coal supply. They are liable to change former health
resorts, on account of the increase of factory chimneys,
into questionable or dangerous localities. Add to this
and you cannot exclude them the dust of the houses and
streets with all it contains, particles of stones, metals,
vegetable remnants, and microbes, and, further, the pois-
onous exhalations of the skin and intestines such as sul-
phides, and you will no longer wonder why there are so
many cases of catarrh, bronchitis, penumonia, infectious
fever, and tuberculosis.
The heating should be considered one of the most im-
portant factors of health or disease. The first requirement
of a good heating apparatus is to give no dust and not to
render the air more dry than it naturally is. Our wind in
New York is mostly west wind, that deposits all the mois-
ture before it reaches us. That is why, as a rule, our air
is very dry; that is why our buildings dry out so rapidly
that they may be inhabited as soon as finished, and our linen,
exposed to the air, dries in a few hours; and that is why
our heating apparatus should supply us with a certain
amount of vapor. Our furnaces furnish a dry heat; so
408
PREVENTION OF TUBERCULOSIS
does most of our steam heating. The result is frequent
catarrhs. The temperature of a schoolroom in dry weather
should be about 64 degrees, in wet weather about 68.
I have been in many schoolrooms that are surely over-
heated. In order to modify the heat windows were opened.
The children sitting under or near these windows con-
tract in a great many instances a catarrh, and even pneu-
monia, and I have seen them die from such exposure.
Perhaps it is too much to expect circumspection and ma-
ture judgment from a young teacher. But there should
be no such thing as a really immature teacher. We are
learning from our predecessors, the rules of hygiene are
well understood, and the people have a right to expect
they should be known and obeyed. In that respect, as in
many others, a schoolroom and a school building, like a
hospital, should be models for the whole population, but
not dangers. The halls of a school building should be
slightly cooler, but slightly only, than the schoolrooms, in
order to avoid drafts and a sudden change of the tem-
perature.
If what I have brought before you was partially known
to you all, it is a source of gratification to me. The main
points connected with the origin and prevention of disease
should be known to every educated person. Only in this
way the public at large, which has to rely on superior
judgment and is unfortunately more readily led astray
than guided correctly, can be benefited. We doctors are
never more pleased than when our patients understand the
why and wherefore, in the same way that you are most
enchanted with pupils that ask for and comprehend the
why and wherefore. Unfortunately no walk in life is proof
against ignorance. Moreover, our education is too often
an instruction which runs in ruts. Nothing is more common
than that men and women of good minds and moral in-
stincts should be satisfied or compelled, by lack of time or
opportunities, to neglect widening the horizon of their men-
tal possessions beyond what is nearest to their profession
or inclinations. That is why thousands in our better
classes are so often the victims of quackery and sectarian-
ism, of faith cures, clairvoyance, and un-Christian " sci-
409
DR. JACOBI'S WORKS
ence." Faith belongs to the realm of religion, not of science
of the other, not of this world. Now, the professions of
doctor and teacher are least apt to be caught by glittering
improbabilities or impossibilities. We teach the realities
of both the physical and the intellectual world. That is
why it has given me intense pleasure to speak before
you, though well aware that in a brief time I could pre-
sent to you but 'little that is foreign to you, or too little
of what you had a right to expect. In what I have said
there may be, however, a few practical points of value.
In your professional work, and in your social contact with
the little and the big ones, you will have ample oppor-
tunity, I hope, to put them into effect.
410
CAUSES OF EPILEPSY IN THE YOUNG
THE two series of the Index Catalog of the Surgeon-
General's library contain 125 columns filled in close print
with the titles of books, pamphlets and magazine articles
on epilepsy. In the presence of such a mountain of
erudition, I felt I could do no better than to refer the
anxious litterateur to those wonderful volumes, the pride
and honor of American medicine, and confine the few min-
utes at my disposal to the elaboration, in as few and as
plain words as possible, of some personal experiences, be-
liefs, and criticisms connected with the causes of epilepsy
in the young. I take it that meetings like these should add
to the learning collected in libraries the inspiration of per-
sonal intercourse.
The predisposition to epilepsy may be inherited, or
acquired during intrauterine, or during extrauterine life.
Intoxications of the parents by morphin, lead, or alcohol,
their infection with syphilis or tuberculosis, their constitu-
tional anemia, gout, or diabetes, or a local degeneration
of either testes or ovaries may not cause in the offspring
the identical disease or anomaly, but only a general debil-
ity of the tissues or their innervation. A variety of causes
may have the same result, and a variety of results may fol-
low an identical cause. Quite often the unexpected is
the rule, and a general neuropathy is more frequently ob-
served than a direct inheritance. Still, epilepsy appears
to be more directly inherited than any other cerebral dis-
order. In Echeverria's 533 cases, 29-72$ showed a direct
inheritance from an epileptic parent; Gowers has a per-
centage of 35; according to Spratling, 66% of the epileptic
children have epileptic parents. Whether, and to what
extent, matrimony between relatives contributes to men-
tal disease or degeneration is by no means proved. From
theoretical reasoning, from personal experience, and from
411
DR. JACOBI'S WORKS
the incompetence of statistics, which are amenable to a
contradictory variety of conclusions when handled by dif-
ferent reviewers with different horizons and standpoints, I
cannot admit that two healthy persons, be they ever so
closely related, must, for the reason of consanguinity,
have a diseased child. But to what extent the state of the
future will interfere with the marriages of insane or epilep-
tic people, as also with those of carcinomatous or thor-
oughly tuberculous, remains to be seen. I can imagine
and believe that the offspring of the intellectually and
morally healthy couple will other things being equal and
barring the accidents of pregnancy and birth serve the
improvement of the race, while that of the abnormal must
impair it. From that point of view we should look for-
ward with hopeful expectations to a little more paternal-
ism in our government. There is no country in the world
in which a monarchy is less probable, and the government
of, for and by the people is more certain to come than in
ours; for there is none in which the organization of capital
and the organization of labor are making such rapid strides
towards a peaceful evolution of socialism as in ours. That
is why the younger men among us will live to see the time
in which the sanitation of the country and people, guided
by the legislative influence of the medical profession, will
render impossible the perpetuation of deteriorating or loath-
some diseases.
It is probably impossible ever to ascertain the exact
number of infant or young epileptics. Neither public in-
stitutions nor specialists are in* a position to gather exact
statistics. Very few are as favorably situated as Gowers,
Binswanger, and others. Institutions are filled with
patients in advanced years, specialists see them mostly
in the same way. Many an epileptic infant or child dies
before being observed or treated, or even diagnosticated;
for a great many cases of petit mal, vertigo, dream-like
states and somnambulism, fainting, even hysteric spells,
are overlooked. They are neglected or cared for at home,
and the seizure is taken to be an eclamptic attack. An
example of the kind is now in my hospital ward ; a child
with nephritis after scarlatina which ran its course four
412
CAUSES OF EPILEPSY IN THE YOUNG
months ago. While practically in convalescence he was
taken with an " eclamptic " attack a few days ago. As
there was a daily renal secretion of from 500 cc. to 600 cc.,
a percentage of more than 2 of urea, and no indiscretion
in his diet, the diagnosis of a uraemic intoxication was out
of the question. That obliged us to inquire into his past,
with the result of our learning the history of several un-
provoked convulsions of epileptic character in the course
of the last 18 months. It is the general practitioner who
sees the cases and is able to judge of them according to
their merits. He does not record them, but has more
facilities to see them than even a public dispensary. Many
of these patients are discovered in dispensaries and col-
lege clinics only after a number of attacks have occurred
and succeeded in rousing the suspicions of the parents.
With all these drawbacks, however, I am certain that I
have seen many hundreds of such cases in the course of
marry years. The actual or the proximate cause of general-
ized epilepsy is in the cerebral cortex ; its origin 1 in ana-
tomic lesions of different localities. Thus, epilepsy may be
cerebral, it may be the result of persistently abnormal
circulation, or it may be of a reflex nature. All sorts of
cerebral tumors, solid or cystic; the results of previous
encephalitis and meningitis, from insolation, otitis, nasal
infection, or otherwise; disseminated sclerosis of different
territories; " vasculitis " of the pia mater; the results of
haematomata or of thromboses ; arrests of cerebral develop-
ment of heterotopy of gray substance; premature ossi-
fication of one, some, or all of the cranial sutures and fon-
tanelles ; even the narrowness of the occipital foramen ;
cefebral exhaustion from masturbation or premature venery,
or local anaemia of known* or unknown origin; diseases of
the heart with secondary venous obstruction ; congestion
from other causes (in a case of Gerhardt's, enlargement
of the thyroid) ; the influence of prolonged use of alcohol
or ergot; the sluggish brain circulation attending constipa-
tion and the general toxaemia of intestinal autoinf ection ;
external irritations, such as peripheral tumors, cicatrices,
foreign bodies, and the reflex excitement produced by
carious teeth, Schneideriarr hypertrophy, and nasal and
413
DR. JACOBI'S WORKS
naso-pharyngeal growths ; vesical and renal calculi ; hel-
minthes, from taenia to oxyuris ; in older children delayed
menstruation, are so many different causes of epilepsy.
It is, therefore, only the most painstaking examination* of
all the organs and the whole surface of the body which
gives a promise of finding the cause of the disease as well
as the indications for rational causal treatment.
Jacksonian epilepsy affects a localized group of mus-
cles, and always the same; the spasm is mostly clonic and
painless, and when it becomes generalized the attack be-
gins in the same order. It is frequently, perhaps mostly,
the result of a coarse lesion, a detached bone, a tumor,
an abscess, a localized patch of meningitis, a hematoma,
a cyst, a cicatrix, or a foreign body which by irritation
sets up a series of epileptic convulsions. A (brachial)
Jacksonian epilepsy was cured by the removal of a for-
eign body from the ear by Monflier. But this relation
between" a Jacksonian epilepsy and a local disorder can-
not always be proved. Exceptions are very numerous ;
only lately Z. Bregman and N. Odefeld x came to the con-
clusion that " a tumor occupying a large part of the sur-
face of the frontal lobe may look like a lesion of the cen-
tral convolution. A persistent paralysis of monoplegic
character and suggesting localization in the cortex with
symptoms of Jacksonian epilepsy need not prove a lesion
of the motor zone. Finally, there may be an extensive
lesion 1 of the frontal lobe without corresponding symptoms."
I may add from my own experience that many a case of
Jacksonian epilepsy, when examined postmortem, exhibited
no tangible cause. That is also why many an operation
undertaken for relief was futile.
Intrauterine influences, both inflammations and intoxica-
tions, are certainly powerful as occasional causes of epi-
lepsy. Hereditary syphilis is considered a frequent cause
of epilepsy, both Jacksonian and universal. The former
results from the localization of an organic disease of the
brain, either meningitis, or encephalitis, or softening, or
gummatous infiltration. In accordance with their extent
i Grenzgeb. Med. Chir., 1902, p. 516.
414
CAUSES OF EPILEPSY IN THE YOUNG
or localization there are symptoms of either paralysis or
irritation. When epilepsy is universal or genuine, no such
localization or local symptoms are met with. These cases
show the fate of all those which permit of nothing but the
assumption of an unrecognized cortical alteration. When
children of five or seven years are suddenly attacked with
epilepsy, syphilis should be suspected. These children are
generally undersized and puny, such as Fournier has pic-
tured as parasyphilitic. I have often seen and discussed
them from that point of view, but must confess that though
in the majority no serious nervous disorders seemed to mark
their appearance, in many, however, though no history of
syphilis of the parents could be elicited, visceral lesions
were found in autopsies. Nor are other nervous diseases
of early age exempt from syphilis. In hydrocephalus it
is frequent, in polioencephalitis rare. In 200 cases of this
form of paralysis, Sachs found only 2 that were attribu-
table to hereditary syphilis. From a similar point of view
mostly, the whole subject is thoroughly treated in a classi-
cal book on " Syphilis and the Nervous System," by Max
Nonne, Berlin, 1902.
The conclusion should be that there are not many cases
of epilepsy that can be directly attributed to syphilis.
But a great many epileptics exhibit symptoms that make
them very suspicious. Such are early imbecility or idiocy,
glandular swellings, chronic periostitis, and anomalous
teeth. Not infrequently I found in a family several cases,
one case of epilepsy and others of different cerebral dis-
orders. It appears, therefore, that the syphilitic virus,
more or less modified, acts on the germ from the beginning
of embryonal life with different results.
In this respect it resembles other influences which con-
trol the predisposition to epilepsy, gout, diabetes, hysteria,
or insanity, which are prevalent in a family in one of the
two preceding generations.
Many intrauterine influences exhibit themselves imme-
diately or soon after birth. Among them I may be per-
mitted to speak of hypertrophy of the brain, premature
ossification of the cranium, and spurious meningocele.
Genuine hypertrophy of the brain is not frequent, but
415
DR. JACOBI'S WORKS
I have seen it once with epilepsy that began when the child
was a year old and persisted until the autopsy was made
three years later. The cranium was of normal thickness ;
20 teeth had protruded. The dura mater was tightly ad-
herent to the cranium, pale and tense. When it was in-
cised the solid cerebral substance bulged through the in-
cision. The brain surface was pale and flattened and the
cortex of fair diameter; the white substance pale, hard,
massive; the ventricles small, with no serum. As early as
1806 2 and 1828 3 Laenrrec reported that in several cases
diagnosticated by him as hydrocephalus he found no serum,
but the flattened convolutions of a pale, compressed, elastic
brain. Huf eland (1824) admitted to have made the same
mistake. It was he who first described the bulging of the
elastic brain through the incision of the dura mater. His
cases of this real cerebral hypertrophy that is, a large
brain within a normal skull and those of other older
writers are referred to in E. Noeggerath and A. Jacobi's
" Contributions to Midwifery and Diseases of Women and
Children," New York, 1859, p. 84. Altogether, however,
these cases of abnormal hypertrophy of the white substance
appear to be rare; they should be carefully distinguished
from the large brains of Byron, Cuvier, Turgenieff, and
Cromwell, that were symmetrically large. I think I am
prepared to say that the epilepsy in my case resulted from
the hypertrophy of the white substance and the compres-
sion of the cortex. There was no other tangible hyper-
trophy. Possibly it was the latter alone that caused it, for
hypoplasia of the cortex is reported as the condition of a
young man who died in an epileptic attack, by Ziegler in
the second volume of his " Pathological Anatomy."
Hypertrophy of the brain, that is an abnormal and ab-
normally large brain enclosed in a normal skull, must be
distinguished from premature ossification of the fontanelles
and sutures. In this interesting condition we have to deal
with an originally normal brain tightly enclosed in an ab-
normal cranium. In the book I quoted and in the Journal
2 Journal de Med. Chir. et Pharm., p. 669. 3 Revue Med.
416
CAUSES OF EPILEPSY IN THE YOUNG
of Medicine of 1857, I wrote " on the etiological and prog-
nostic importance of the premature closure of the fon-
tanelles and sutures of the infantile cranium." The ob-
servations of this anomaly were at that time only few.
Extensive studies of the subject had been made by Vir-
chow, Huschke, and Lucae. Hyrtl was the first to show
that pathologic forms of the skull might depend on the
premature closure of single sutures. Cruveilhier, Bail-
larger, and Schiitzenberger reported cases. Gratiolet
studied (1856) the direct relation of cranial ossification in
different races with their intellectual development and
found, for instance, that the coronal suture closes earlier
in the negro than in the white, and that the receding fore-
head and bulging occiput of the former depend on this
precocity of bone ossification. I approached the question
from a nosological point of view. A few of the conclu-
sions at which I arrived, and which are still justified, are
as follows: A brain, in order to arrive at its normal de-
velopment, must have space. The normal closure, not
genuine ossification yet of the sutures and large fontanelle,
takes place about the fifteenth month of life. After that
time the growth of the brain, which, however, does not en-
tirely terminate before the sixtieth year, becomes very
slow. When ossification is premature, the brain when
normal cannot grow, is compressed in its entirety. When
synostosis is uniform the shape of the head is nearly spheri-
cal, when it is local the corresponding part of the skull
and brain is rather flattened, while the opposite is bulging.
In this way the asymmetry of -the skulls of many epileptics
as described by Riecken and by Miiller 4 is easily explained.
When the cranium is sunk in in one or more places, for
instance on and above the two temporo-parietal regions, the
case cannot be one of premature ossification over an origi-
nally normal brain, but is one of genuine microcephalus
depending on an arrest of development. The suggestion of
craniotomy or craniectomy in a case of real premature ossi-
fication may still be justified, the fatality or uselessness
* Virchow's Handbuch, Vol. iv.
417
DR. JACOBI'S WORKS
of such operations notwithstanding. I have not changed
my conviction on that subject expressed in my Roman
address " non nocere " of 18Q4. Their performance by
enterprising operators in cases of undiagnosticated or mis-
taken microcephalia no matter whether the fontanelle is
large or small, or the bone is thin or firm is no longer a
medical question. Where nature made a mistake the doc-
tor must not believe he can correct it by a crime.
The diagnosis is not difficult. When the case is one of
ossification at birth it is only the exaggeration of what may
be observed to develop slowly after birth. In these cases
the cranial bones harden, the fontanelle decreases in size
instead of its normal enlargement up to the eighth month.
They may close at the third, sixth, tenth month. All the
connective tissues of the cranium develop at the same rate.
Many such infants begin to use their limbs early. The
teeth appear early and not, as in occasional cases of rhachi-
tis, in long intervals, but in rapid succession. The first
teeth to appear are not, as in the healthy, the lower incisors,
but the upper. These symptoms, together with the shape of
the head as described before, justify your diagnosis. After
a while the general development is disturbed by the in-
creasing pressure, or irritation, by the interference with
intracranial circulation, and by the additional danger
caused thereby to every occurrence of a slight or serious
ailment. During such a complication the first convulsion
may take place. Often it occurs without any premonitory
symptom, and will return in irregular intervals. Cases
in which epilepsy of later years is due extensively to the
compression of an originally normal brain in an abnormally
compact and uniformly contracted skull I have seen. But
more are due to or connected with a premature partial syn-
ostosis. There are but few normal heads and brains in
the well absolutely symmetrical ; but it is the fate of a great
many epileptics to have a comparatively small cranial cir-
cumference and an absolutely asymmetrical shape.
Savage nations 5 have made observations which show their
5 A. Jacobi: The Intestinal Diseases of Infancy and Child-
hood, Detroit, 1887, p. 103.
418
CAUSES OF EPILEPSY IN THE YOUNG
fear of such ait occurrence. The Makalaka of South
Africa are always anxious to look for the location of the
first teeth, whether in the upper or lower jaw. In Bohe-
mia it is a popular belief that the child whose upper in-
cisors come first will soon die. David Livingstone and
Fritzsch report that some nations in Central Africa kill
the infants whose upper incisors protrude before the lower
ones.
Meningocele spuria means a fissure of the cranium and
of the tightly adherent dura mater under an intact scalp.
It is the result of a forceps operation, of a fall or some
other trauma, of caries, or of syphilis. When the fissure
is superficial it need not interfere with the development
of the brain, for there is not even a permanent loss of
cerebrospinal liquor, but when it is injured down to a
lateral ventricle it results in porencephalia. Rhachtis of
the cranial bones, and the interposition of brain substance
between the fissured bones prevents spontaneous recovery.
A practical recovery without operation may take place by
the interposition of the membranes and of some periosteum.
This spontaneous process may proceed kindly, but irrita-
tion of the compressed parts may cause meningitis and
epilepsy. I made the autopsy, 20 years ago, of a child 5
years old.
I had seen her once when she was a few months old, with spuri-
ous meningocele attributed to a forceps operation. When she
was about a year old she had a violent convulsion preceded by
numerous spells of petit mal. Before she died these were num-
berless; severe epileptic seizures there were no more than half a
dozen all told. She had a moderate amount of liquor in the lat-
eral ventricles and some redema and thickening of the choroid
plexus. Round the fissure of the right parietal bone, which was
closed by interposed cicatricial and hard tissue, there was inside a
pale, hard pachymeningitis, the alteration extending over 3 cm.
in every direction, and a thickened pia, pale near the origin of
the affection, hyperaemic with large veins to a distance of 10 cm.
or 12 cm.
It appears that with the possibility of its resulting in
epilepsy even a spurious meningocele should not be left
alone. A recent case demands the raising of the depressed
419
DR. JACOBI'S WORKS
bone and either bone or periosteum suture. Older cases, if
pronounced inoperable, should be protected by a pad;
iodine injections have proved successful; dropsical lateral
ventricles may be drained.
In the foregoing remarks I have directed your attention
to the unpromising results of intrauterine influences. Let
me turn to another subject, in order to show that there
are other powerful influences for bad, the results of which
may be more frequently prevented than cured.
A frequent cause of epilepsy is asphyxia of the new-
born, frequently the first born no matter from what cause :
moderate or serious compression of the fetal head, com-
pression or prolapse of the cord, intrauterine respiration
and aspiration of liquor amnii or meconium, placentar de-
tachment, morphine or chloral poisoning by the maternal
blood, malformations of intrathoracic or intracranial or-
gans, etc. The anatomical results in the cranium are ex-
cessive hyperaemia, tense veins, sanguineous effusion, ex-
travasation, and thrombosis. When 1 the baby lives at all,
a meningitis or meningoencephalitis may follow, and par-
alysis in many cases; in many more, idiocy or epilepsy or
both are the final results. In one-third part of the cases
of idiocy there is a combination with epilepsy. In a long
life I could trace the cause of the two latter to asphyxia
in hundreds of cases. Without any suggestions, my ques-
tion, Did the baby cry when born, or did the baby live
when' born ? is answered that it did not ; that the
doctor worked over the baby minutes or quarter hours
before it was resuscitated, and that the baby never
was like other infants, never smiled at the usual time,
took little or no notice, and had general convulsions some-
times beginning on one side, quite often. Hundreds of
such cases I had opportunities to present at my clinics ;
never without the warning to my classes that the para-
mount duty of the practitioner is to shorten asphyxia, and
that there is nothing connected with the management of a
case of labor so vital as the prevention or shortening of
asphyxia, the attendance upon the mother, though ever so
urgently demanded, not excepted. A single moment more
or less of the asphyxiated condition may decide the future
420
CAUSES OF EPILEPSY IN THE YOUNG
of the newborn, and the presence or absence of a para-
lytic, idiotic, or epileptic misfit in human society.
The same danger accompanies intracranial hemorrhages
not connected with asphyxia of the newborn. They are
very frequent. The majority of babies who die in their
first week succumb from that cause. The proximate cause
may be found in disturbance of the circulation or in a
trauma, but the disposition results from the incomplete
embryonal structure of the blood-vessel walls. This dis-
position to extravasation is as great in the newborn as
it is, for other reasons, in the senile condition of the arte-
ries, very rarely the veins, of advanced age. The danger
to life is increased in the former by the lack of coagula-
bility of the fetal and infant blood which causes the extrav-
asation to be very copious indeed. When it is not ex-
cessive, it may not destroy life the more is the pity but
the clot and the secondary inflammation and degeneration,
and now and then the final development of a cyst of the
dura mater, will cause hemiplegia, paralysis, idiocy, epi-
lepsy. Many are the instances in which I could find what
pointed unmistakably to the connection of the hemorrhage
with the subsequent life-long disturbance.
The frequency of convulsions in infancy and childhood
is another danger. Those of the first six weeks or two
months of life are of cerebral origin; that is the period
in which clinical experience and Soltmann's experiments
teach us that reflexes are absent or feeble. After that
time convulsions are either reflex or toxic. No matter,
however, how they are produced, every convulsion is a
danger to the brain by the possibility of blood-vessel rup-
ture. Small or large extravasations may occur in every con-
vulsion, no matter from what cause, and endanger life,
or mind, or health. The location or the size of the hemor-
rhage and the dignity of the affected part are of the great-
est import. The danger is not so great when the fontanelles
and sutures are not yet closed, and the expansible blood
vessels may be able to harbor a larger amount of blood
without being torn in their weakest capillary terminations ;
a fully or a prematurely ossified cranium furnishes a greater
disposition to hemorrhage. All this may happen, no matter
421
DR. JACOBI'S WORKS
what caused the convulsion intestinal irritation by un-
digested food or helminthes, acute intoxication by alcohol,
cocci or bacilli or their toxins, in scarlatina, typhoid or in-
fluenza, uraemia, inanition, whooping cough or laryngismus.
Two cases of epilepsy I remember distinctly that were
caused by the convulsions of whooping cough. Another was
due to an apoplexy in an adult. The unfortunate young
man suffered from unmanaged constipation. I was called
40 odd years ago to see him in a fit of what was called a
fainting spell. I found him on the water closet with an
apoplectic attack that soon terminated in hemiplegia of the
right side. A year afterward he had his first attack of
epilepsy, which was followed by a great many more until
he died, long after from what, according to the report of
the case, appeared to be a second attack of cerebral hemor-
rhage. Cases of cerebral hemorrhage occasioned by a con-
vulsion in a child can be treated, but rarely cured ; but many
may be prevented by the speediest possible interference with
the attack. No case of eclamptic convulsion should be left
alone. It requires chloroform, no matter what other in-
dications present themselves. Shortening of a convulsion
from any source, cerebral or reflected, by a single half
minute, may just be in time to prevent a hemorrhage and
subsequent death, or what is worse, paralysis, spastic
encephalitis, idiocy, or epilepsy.
The causes of convulsions in infancy and early child-
hood are so numerous and their dangers so many that it
may be worth our while to spend a few minutes in the
consideration of at least a few of them, with the object of
facilitating an early diagnosis and the possibility of imme-
diate and correct treatment. They are so many, some of
them not generally appreciated, that it will pay us to elim-
inate one at least that is credited with more mischief than
it is guilty of. I mean dentition.
William Philip Spratling 6 expresses himself as follows :
" Next to heredity, it is my firm conviction that dentition,
when severe, and when acting on an organism thai bears the
impress of transmitted weaknesses, plays the most important
6 Medical News, September 15, 1894.
422
CAUSES OF EPILEPSY IX THE YOUNG
role in causing epilepsy in early life. Indeed, I fully be-
lieve that the importance of teething in this respect has
not been accorded the careful attention it deserves." Dr.
Spratling fortifies his position by quotations from Gowers
and from replies received to a circular inquiry. From
among the latter he prints quotations taken from letters
written by me, Dr. G. Elder Blumer, Graeme M. Ham-
mond, Frederick Peterson, and T. S. Clouston, of Edin-
burgh. From Gowers the following words are quoted: " Of
all the cases that commence in infancy, at least three-
quarters date from infantile convulsions ascribed to teeth-
ing." I wish you to note that the words are " ascribed
to teething," not due to teething. I have no doubt he meant
to say " ascribed to teething by the men who sent me the
cases and their histories." Gowers 7 says, literally: "The
influence of the process of the eruption of the teeth is
relegated to its proper place, as merely a possible excitant
in 'a few cases." From my letter Dr. Spratling quotes as
follows : " Every convulsion, ever so slight or short, may
produce cerebral hemorrhage, with all the possible results
epilepsy, idiocy, paralysis, and insanity. Such cases are,
unfortunately, frequent." You will notice that teething
is not mentioned by me. I certainly did not believe, nor
did I mean to infer, that the convulsions spoken of were
due to dentition. Dr. Blumer expresses his belief that
" there is no such thing as a convulsion due to dentition
pure and simple and uncomplicated." Dr. Spratling him-
self emphasizes the requirement of the " impress of trans-
mitted weaknesses " that one must go back of the denti-
tion and regard the disturbance of this process as the
" mere existing cause of the explosion." Dr. Hammond
has " records of several cases in which convulsions, due to
dentition, were followed by true epileptic convulsions." Dr.
Peterson " can recall a number of cases of epilepsy due to
the convulsions of dentition." Dr. Clouston is more posi-
tive than any of the three mentioned correspondents. He
asserts that he has " seen the convulsions of dentition fol-
lowed by prolonged delirium ending in idiocy, or in true
7 Clinical Journal, September 5, 1894.
423
DR. JACOBI'S WORKS
epilepsy, or insanity of adolescents." I again state that the
convulsions giving rise to such cases of epilepsy are called
by the last named three authorities " convulsions due to
dentition." Neither Dr. Blumer nor myself go that far.
I speak of convulsions only, no matter from what cause, and
am, therefore, quite prepared to accept what I think I al-
ways knew and proclaimed to-day, and what Dr. Spratling
expresses in a concluding remark, " that the spasms and
convulsions of infancy are serious manifestations, and if
allowed to go unchecked, may lead to explosions of genuine
epilepsy, and later on to insanity."
Now what is dentition, and what its period?
It begins during uterogestation. The dental sacs of the
20 milk teeth undergo ossification in the fifth month of
pregnancy. Behind them are the sacs for the permanent
teeth. Their separation from the former is not completed
until the fetus is born. Before and after birth there is a
constant growth, the cartilage of the wall of the dental
cavity and of the gums disappears gradually. The two
lower incisors make their appearance between the seventh
and eight months, the upper incisors between* the eighth
and tenth months, six more teeth between the twelfth and
fifteenth months, four bicuspids between the eighteenth and
twenty-fourth months, the four second molars between the
twentieth and thirtieth months. The second visible den-
tition begins about the fifth or sixth year. In the twelfth
year four molars make their appearance, the last of the
whole set, with the exception of the wisdom teeth, which
protrude between the sixteenth and twenty-fourth year.
Thus the period of dentition begins about the middle
of intrauterine life, and ends visibly first with the thir-
tieth month, and secondly with the twelfth year. It is
principally the first which is charged with causing or being
attended by convulsions.
Convulsions occur almost universally between birth and
the thirtieth month; this happens to be the period of denti-
tion. But it is also the period of defective inhibition, of
nephritis, otitis, pneumonia, enteritis, and infectious and
cerebral diseases. All of these are fruitful causes of con-
vulsions; dentition goes on during that period, like the
424
CAUSES OF EPILEPSY IN THE YOUNG
growth of bones and hair and nails, but it is not this phy-
siologic process, but those morbid, mostly acute changes,
that disturb the nvrve equilibrium.
In regard to convulsions, infancy may be divided into
two periods. One comprises the first two months. During
that time reflex action is insufficiently developed. That
is why convulsions at that time are almost always, perhaps
always, of cerebral origin, and caused by hemorrhages, etc.
The other begins with the third or fourth month. About
and long after that time inhibition is insufficiently devel-
oped ; that is why while convulsions of cerebral origin are
not excluded, the large majority are of a reflex nature. The
slightest irritation of the digestive organs, of the integu-
ments, or the organs of circulation gives rise to spasmodic
muscular action which meets with no control on account of
the absence of nerve inhibition. The difficulty of a correct
local diagnosis tempts the attention in the direction of the
known process of dentition. That is why the early periods
of popular and of professional medicine identical in so
many centuries and why the early period of a practition-
er's life, filled as it is with the lack of circumspect experi-
ence are replete with the diagnosis of difficult dentition, or
the legend of the dangers of normal dentition, which, after
all, is a physiologic process.
During the first year or two years of life that means
during that period of physiologic dentition which is most
generally noticed by even the superficial observer, remark-
able changes take place. The heart of the newly born and
the young infant is comparatively muscular and vigorous,
the carotid (and also the vertebral) arteries large, the blood
supply to the head is ampler than at any other part of its
life. The rapid growth of the head and brain connected
therewith, or rather depending thereon, is a well-known
fact. The salivary glands develop rapidly, their and the
mucous membrane's over-secretion begins with the third
month and is not the result of, but co-ordinate with, the
later appearance of the teeth. The rapid growth of the
cortex and of the anterior lobes, greater in proportion than
that of the rest, explains the rapid increase of the infant
intellect and the motor function. Physiologic hyperaemia is
425
DR. JACOBI'S WORKS
very apt to become pathologic on slight provocations, the
more so as the embryonal character of the brain tissue
changes only gradually in the course of a few years. These
are no rrew facts. Even in a book on " Dentition and Its
Derangements," New York, 1862, I could utilize a great
many anatomical data, confirmed and added to since, when
trying to find for dentition its exact place in etiology. My
conclusions of 40 years ago I can still repeat. There is a
certain amount of itching, even pruritus of the gums ; there
is a vasomotor disturbance in the shape of one or two flushed
cheeks; now and then a slight muscular twitching; now
and then a rolling of the eye caused by the incompetence
of the muscles of accommodation met with in every infant
to such an extent that strabismus is common in healthy
babies; but when I said in 1887 8 that I never in 10 years
saw a convulsion due to dentition alone I here repeat the
statement as valid for additional 15 years. Nor is diarrhoea
a symptom of dentition, for infants either at a healthy
breast or on well-selected artificial food have no diarrhoea.
Do you wish another instance of the complete disappearance
of dentition from the etiological horizon? When all of us
were 50 years younger did we not hear of " dental " paral-
ysis? Nowadays we do not even permit the term of
" essential " or " infantile " paralysis. Poliomyelitis does
not fall back upon dentition as a cause. And what is cor-
rect in the case of paralysis is so in convulsion. When
a convulsion, the first appearance of, or rather the cause
of consecutive epilepsy or idiocy, is attributed to dentition,
the history of the case as submitted to us is incomplete,
or our own diagnosis is at fault.
The high estimation in which dentition was held for-
merly has assumed smaller proportions, even among the
maternal public. They do not insist any more as they did
when you and I were 40 or 50 years younger upon having
the baby's gums lanced over conspiring poor little teeth, j ust
as little as they are clamorous any more for worm medicines
for their pets to the former extent. The doctors who know
how to make a diagnosis of a bronchitis, pneumonia, nephri-
8 Intestinal Diseases of Infancy and Childhood, Detroit, 1887.
426
CAUSES OF EPILEPSY IN THE YOUNG
tis, otitis, or a toxic infection are getting too numerous,
and the diagnostic atmosphere is gradually becoming puri-
'fied.
Still, it is claimed that it is difficult to arrive at a diag-
nosis of the occult diseases of infancy. If the difficulty
is, or were, actual, there is a remedy. See to it that the
clinical advantages of our medical schools be so numerous
and so perfected that no young or old doctor is in a position
to accumulate more ignorance than knowledge. Convul-
sions in the young are of frequent occurrence in every
practitioner's rounds. To treat it is something; to prevent
it is better. This very day the number of infectious dis-
eases, with their high temperatures and their toxins; the
many intestinal disorders, with their nerve reflexes, are still
all-powerful. There are still some meningeal affections that
are not always fatal, but highly dangerous in their results.
All this is well understood. But there is a class of dis-
eases which leads as often to convulsions as any other; that
is nephritis. I cannot help emphasizing the fact that it is
common in the newly born and the very young infant;
that infarctions and jaundice are a frequent cause; enteri-
tis, with its indican and its toxins, engenders legions of
cases ; coal-tar medication is a frequent source of evil ; ex-
posure causes some; infectious diseases, from mild varicella
to influenza or diphtheria or scarlatina, a great many. As
the diagnosis is easy to make, requiring the examination of
readily attainable urine only, I admit that the failure to
arrive at a diagnosis is a constant source of surprise to me.
Convulsions from that source are very frequent, and the
vast majority of them, with their possible dreadful conse-
quences, could be avoided. Many a case attributed to
dentition could easily be recognized as nephritic.
Among the important constitutional diseases that have a
great tendency to convulsions is rhachitis, not, as Gowers
says, on account of the late general development caused
by it, but for other reasons. His own words are as follows:
"It is impossible to doubt that the dentition convulsions
are a definite element in the causes of epilepsy. So con-
stant, moreover, is their association with the defective de-
velopment which we call rickets that it is impossible to
427
DR. JACOBI'S WORKS
doubt that the prevention of rickets would have a consider-
able influence in the prevention of epilepsy." In the further
course of his remarks he defines as defective development
mainly its retardation of the growth of the bones, empha-
sizing much less its influence on muscles, lymphatics and
the large viscera.
The retardation of development hurts mostly bone and
tooth formation. But nobody ever claimed that when a
tooth is formed and protrudes late, it is for that reason a
source of irritation and convulsion. The minor or major
attacks of convulsions in rhachitis are always of central
origin. They always mean the hyperaemia or oedema ac-
companying the rhachitical softening of the cranial bones.
When rhachitis is limited to the curvatures of the extremi-
ties, or the development of a rosary or Harrison's groove,
with ever so much deformity, compression of lungs, annoy-
ance of the heart, and dislodgment of the liver and spleen,
there is no convulsion. It occurs in craniotabes which, after
a period of restless, cephalic perspiration and occip-
ital baldness, begins with the third or fifth month of life.
It is attended by hyperaemia and oedema of the galea, skull,
dura and pia mater and brain, not infrequently with effusion
into the ventricles. These central changes cause many
cases of tetany, almost every one of laryngismus stridulus
and a great many of the attacks of convulsions. Once
started they return at uncertain times, and generally disap-
pear with the recovery from rhachitis, produced by proper
food and hygiene,, fresh air and phosphorus. As long as
they last they share the dangers of every attack of eclamp-
sia, viz., oedema, thrombosis, hemorrhage. Not infrequently
they last longer than the rhachitis that caused it. I do
not care to speak of a convulsive habit and to explain the
subsequent epilepsy by this habit; that would be no ex-
planation, but another word only for the fact. The real
explanation is afforded by the objective changes in the
structure of the intracranial contents caused by the con-
vulsive interference with the circulation of large and small
vessels.
The local irritation of phimosis, congenital or acquired,
complicated or not with balanitis, resulting from the changes
428
CAUSES OF EPILEPSY IN THE YOUNG
of smegma or retained urine, may cause erection, sexual
excitement and masturbation in the youngest infants. Head-
aches have often been attributed to it, perhaps only on ac-
count of interrupted sleep; permanent nervous disturbances
have been ascribed to it 30, 20 and 10 years ago more often
than at present. Indeed, a London neurologist has gone so
far as to make the statement that in 25 cases of epilepsy he
found congenital phimosis 1 1 times. In the same way the
nosology of some colleagues of our own country at one
time explained spastic hemiplegia, polioencephalitis and
myelitis, chorea, catalepsy, epilepsy, contractures, also idi-
ocy by the presence of phimosis. Would it could have
been true; for indeed if it had there would have been less
paralyses, less epilepsies, less idiocies. In 29 of 30 cases
of phimosis condemned to be operated upon I find gentle
manipulation sufficient for a reduction of the usually slight
ailment. I can say, however, that I never in my life saw
such a case that I could ascribe to phimosis, and never a
recovery from paralysis, idiocy, or epilepsy due to circum-
cision.
I have mentioned phimosis as one of the causes of mas-
turbation, which has frequently been connected with epi-
lepsy and other derangements of the nervous system. Mas-
turbation was always recognized as a frequent occurrence
in the periods of puberty and adolescence, but very rarely
before 1875 in infants and children. Like its precursor,
the persistent sucking of fingers, it is often semi-conscious
action, more frequent in girls in earliest infancy, in boys
later. Among its causes are manual irritation by nurses,
or misfit trousers, featherbeds, excess of animal foods and
stimulating beverages, rancid smegma under a long or nar-
row prepuce, eruptions on the penis, preputial adhesions,
phimosis, vaginal and vesical catarrh, or vesical qr renal
calculi, oxyuris, constipation, horseback or bicycle riding.
Unless it be continued too long, the unconscious infant and
child does not permanently suffer from masturbation to
the same extent as the adolescent. In the latter I am certain
that epilepsy resulted from the habit in a good many cases.
Such I have seen getting well when it was stopped, and un-
der proper treatment bromides a short time, cold water,
429
DR. JACOBI'S WORKS
lupulin, camphor, and other roborants, continued for years.
Infants and young children are not so punished, except ap-
parently in those cases in which masturbation itself is the
result of a central disease. Goltz places the erection center
in the cord about the fourth lumbar vertebra, others in the
pedunculi cerebri or the medulla oblongata. It is quite
possible that in such cases in which epilepsy follows mas-
turbation, both may be of the same central origin. They
are both probably incurable, and neither a treatment di-
rected to the center, nor irritating vesicatories or brutal
and vulgar clitoridectomy can possibly be expected to have
an effect. Such cases of masturbation are as incurable as
the vast majority of central epilepsy. What I express as
my opinion of clitoridectomy is also valid in regard to
worse methods. Baker Brown is dead, Everett Flood, of
Baldwinville, Mass., appears to be very much alive. 9 He
eulogizes castration and circumcision. The former was per-
formed on 20 males and two females. The cases were re-
ported at the meeting of the American Medical Association
at Atlanta. He admits that castration has " bitter op-
ponents " of the same class that is " howling against
vaccination." I do not howl against vaccination. To me
it is a wonder that the criminal law of Massachusetts has
not yet interfered with these attempts at dealing with
masturbation and epilepsy, both of which render the con-
sent to be mutilated an impossibility on the part of irre-
sponsible, unfortunate sufferers.
Atlantic Med. Weekly, October 24, 1896.
430
TREATMENT OF ENURESIS
THE incomplete development of the sphincters, in the
infant, results in the involuntary emission of urine and dis-
charge of faeces. This condition prevails a year or two,
and is not attended with any subjective sensation, or sen-
sitiveness. The sphincter ani is the first to gain sufficient
strength to retain the contents of the rectum; debilitating
diseases occurring in later years may restore it to its origi-
nal incompetency. The sphincter of the bladder attains
a satisfactory power towards the end of the second year.
When, however, its infantile condition persists beyond that
period, both the urine and the genito-urinary organs being
fairly normal, the involuntary emission of urine continues,
particularly during sleep (enuresis nocturna), not infre-
quently through the day (enuresis diurna), or both in the
night and during the day (enuresis continua). Many of
such cases get well spontaneously about the period of
puberty, when the whole genito-urinary apparatus under-
goes a rapid development. In some the functional weak-
ness, however, persists long beyond that time. Not long
ago I had to relieve the case of a young lady of eighteen
who was getting ready to marry. Most cases are observed
between the third and the tenth year in both boys and
girls, but the majority of the patients between the eleventh
and the thirteenth year, also of those who suffer in more
advanced years, are males.
The muscular debility of the neck of the bladder and the
internal sphincter (in fact, identical organs) is sometimes
but a part of a universal muscular incompetency, which
is found among different classes of children. Some are
slow, dull, and stupid, and lacking in general innervation;
others are simply anaemic, ill developed, and generally
feeble; there are some whose whole vitality appears to be
expended upon their intellectual sphere: they are smart,
quick, spirited, excitable, mentally vigorous though easily
431
DR. JACOBI'S WORKS
exhausted; but their muscles are thin, sensitive, and in-
continence of urine is frequent. In many such cases the
sexual and urinary organs are quite small. There are
others, however, who exhibit no parallelism of debility
in the urinary muscular apparatus and the muscle-supply
of the whole body. In them there may be great muscular
general dovelopment, and the neck of the bladder alone
seems neglected. On the other hand, there may be great
muscular power about the sphincter in an otherwise feeble
and anaemic body. Thus, no certain rule can be established,
and the diagnosis of the exact condition of things may be-
come quite difficult. Still, there is a class of patients in
whom the complication of enuresis with general muscular
insufficiency is very apparent. Indeed, young men who
after moderate venereal excesses suffer much from noctur-
nal or diurnal seminal emissions (with or without in-
continence of urine) are frequently those who have a
positive history of incontinence during their childhood.
In them the whole muscular apparatus was defective; and
the posterior part of the urethra, when narcotized, as it
were, during sleep, gives way before the gentlest pressure
on the part of the expelling muscle of the bladder.
Insufficient innervation has been alluded to as a cause
of incontinence. Children who pass urine while engaged
in eager play may suffer either from debility of the
sphincter or from want of mental control. Particularly
in diseases of the nerve-centers, with sopor and slow men-
tal action, and where the development of the reflex ap-
paratus is slow and defective, the sphincter, which con-
tracts normally while the bladder is filling up, loses its
control. Profound sleep is said to promote incontinence;
still all children have that profound sleep, and but a small
percentage are afflicted with incontinence. Such general
constitutional disorders as scrofulosis and rhachitis have
been charged with producing incontinence, but the vast
majority of scrofulous and rhachitical children do not suf-
fer from it. Slow carbonic-acid poisoning is also credited
with resulting in incontinence; thus it is that G. W.
Major and Ziem explain the incontinence of mouth-breath-
ing children, and E. Bloch the nervous disposition, rest-
432
- :-. .-. . -...;.-.'_ . _- ^ :"; z i .r : .?
::
--.'-
DR. JACOBI'S WORKS
same effect on the bladder, and diabetes mellitus operates
by both the large amount of urine and the alterations in
its chemical composition. Cystitis in all its forms adds
to the irritability of the detrusor: it is a frequent cause of
incontinence when this makes its appearance in children
whose micturition was normal before. Stone in the blad-
der has the same effect. Phimosis and tight adhesion
of the prepuce may produce incontinence, particularly in
those boys who are subject to frequent erections. The
rest of the urinary organs exhibit the same influence. Thus
in every case of enuresis with uncertain diagnosis nephri-
tis, pyelitis, renal calculus, and vaginal catarrh must be
searched for. As a result of incontinence of urine the
bladder is apt to be very much contracted: it holds but
little, and thus what was originally the result of incon-
tinence becomes an additional cause.
Masturbation is not an uncommon cause of incontinence
of urine. I believe that my paper on the subject of mas-
turbation and hysteria in infancy and childhood 1 has di-
rected the attention of the profession to the frequency
of the habit of masturbation, with all its consequences.
Now, in the young the caput gallinaginis is quite large,
and Cowper's gland and the vesiculae prostaticae are suffi-
ciently developed to result in erections. The constant irri-
tation of the part by self-abuse leads to a chronic in-
flammation of the whole prostatic portion and the neck
of the bladder, which is very sensitive. Infants addicted
to the habit are very apt to escape for years its conse-
quences as exhibited in somewhat advanced children; these
suffer from general malaise, dull headaches, alteration of
temper, and somnolence. The genital organs are mostly
changed. The external parts the vulva, the scrotum, and
particularly the glans penis are rather enlarged, and the
urine is sometimes alkaline, and often slightly opaque with
mucus, leucocytes, and spherical and oval epithelia, some-
times even spermatozoa.
The condition of the rectum must be carefully examined
l Amer. Jour, of Obstetrics and Diseases of Women and Chil-
dren, February and June, 1876. See also Vol. Ill of this work.
434
TREATMENT OF ENURESIS
in every case. The plexus pudendus controls both it and
the neighboring organs; the pudendal, perineal, and mid-
dle and inferior hemorrhoidal nerves are disturbed over
the lower portion of the bladder and the vagina. Thus
a rectal irritation produced by the retention of faeces,
the presence of a fissure, which is much more frequent
in infancy and childhood than is generally supposed, and
the effect of worms (mostly oxyuris) in the lower end of
the intestinal tract, are among the more common causes
of incontinence.
Serious disorders of the nervous system, such as epilepsy
or night-terrors, are also among the causes or complica-
tions of incontinence. They, however, and particularly the
latter, need not be taken as causes only; in many cases
the night-terror is but a result, co-ordinate with incon-
tinence, of some distant, frequently digestive, disorder.
TREATMENT. The great variety of the causes of incon-
tinence of urine requires tact and discrimination in the
selection of remedies. General anaemia and muscular de-
bility indicate a diet carefully selected for its nutritious-
ness and digestibility. Gentle massage of the whole body,
sponging with alcohol and water (1:6) or with water, and
efficient friction with thick towels, sea-bathing, and the
use of medicinal roborants, such as iron or arsenious acid,
will always prove beneficial. The elixir peps. bism. et
strychn. of the National Formulary is a good preparation
for use in insufficient gastric digestion, with atony of the
stomach; a child of three years may take a teaspoonful
three times a day.
Attention must be paid to the capacity of the bladder.
In every case, particularly in the evening, the quantity
of fluid must be restricted. The sigmoid flexure and the
rectum must be empty in the night, and patients should
be encouraged to evacuate both bladder and rectum before
retiring. After a few hours' sleep the children ought to
be taken up and roused sufficiently for both purposes.
Muscular debility of the neck of the bladder (sphincter)
requires general and local stimulation. Strychnine or other
preparations of nux vomica prove effective to a certain
extent by improving both the general innervation and the
435
DR. JACOBI'S WORKS
appetite; in desperate cases an occasional subcutaneous in-
jection into the perineum (gr. /4o~%6) nas rendered good
service; an ointment of one part of extract of nux vomica
in from ten to sixteen parts of fat, introduced into the
rectum (size of a coffee or Lima bean) several times daily
will also act well and can be continued for some time.
The same indication is fulfilled by ergot, the fluid or the
solid extract of which may be employed internally. The
interrupted electrical currents is perhaps the most power-
ful local stimulant; one of the eletrodes must be applied
to the perineum, the other to the hypogastrium or the
lumbar region. The advice to apply the negative pole to
the interior of the urethra or bladder and the positive
somewhere externally is bad, because of the danger of
urethritis and cystitis.
Whenever there is oxalic acid or sugar or an excess of
urates and phosphates in the urine, the source of the dis-
turbance must be attended to. The digestive disorders
forming the source of the anomalous condition require
a corresponding change in the diet (diminution of nitro-
genous food) or correction of the functional disorders of
the stomach and liver. Until that object can be accom-
plished the prognosis is very uncertain. Vesical catarrh,
nephritis, and the presence of a calculus in either the
kidney or the bladder have their own indications; the
consideration of which, as they are treated in other parts
of this volume, is here omitted. The hypersesthesia of the
body of the bladder, complicated or not with catarrh,
it is often found without it, requires belladonna or its
alkaloid. Both belladonna and atropine are tolerated in
much larger doses by children, in proportion to their size
or age, than by adults. In many cases a single evening
dose of extract of belladonna (gr. 44!) or sulphate of
atropine (gr. /4oo~/45) answers well, sometimes to an un-
expected degree. Bromide of potassium (gr. vi-xxv), cam-
phor (gr. ii-v), extract, humuli fluidum (min. iv-x), or the
elixir humuli of the National Formulary in teaspoonful
doses, given at bedtime, answer a similar purpose.
Causes of reflex contraction located in the vagina, penis,
or rectum require local correction. Vaginal catarrh is as
obstinate because of its inaccessibility as it is frequent.
436
TREATMENT OF ENURESIS
Polypoid excrescences about the vagina or in the urethra
(of the female) must be removed; if there be phimosis,
circumcision is required. But a great many cases which
are presented for that purpose could easily be remedied
by gentle dilatation of the prepuce. Firm adhesion of the
prepuce requires careful detaching. Intestinal worms must
be removed, and the fact remembered that oxyuris has its
original seat in the upper part of the colon and the lower
part of the ileum, so that rectal injections have but a
temporary effect in most cases. Fissure of the rectum,
mostly of small size and located posteriorly, requires for-
cible dilatation, a procedure which demands no time and
no anaesthetic, but is very efficient.
Irritability of the neck of the bladder and the prostatic
part of the urethra has been treated by Henry Thompson
with cauterization by means of a two-per-cent. solution of
nitrate of silver. A solution of one part in a thousand
of distilled water will be found sufficient, or a solution
of one or two parts of tannin or alum in a hundred. Still,
it is a better plan to introduce either an elastic catheter
or a metal sound into the bladder, every few days, for two
or four minutes. A few drops of a solution of cocaine
instilled into and distributed in the urethra a few minutes
before the insertion of the instrument will in many cases
render anaethesia superfluous.
The latter, however, cannot always be dispensed with.
In the case of a girl of three years, with chronic catarrh
of the bladder and incontinence, anaethesia was required
a dozen times, for two purposes, first, to inject a solution
of nitrate of silver (1:1000) into the bladder, and, sec-
ondly, to dilate forcibly, with increasing amounts of water,
the organ, which had habituated itself not to hold more
than a few drachms of fluid at a time.
Masturbation, which is so frequently the cause of irri-
tation of the prostatic portion, has its own indications. Its
cure is by no means easy. Infants can be watched and
forcible prevention of self-abuse (mostly by the thighs
or hands) exercised; but children of more advanced years
require an unusual amount of firmness and supervision.
Bodily punishment will avail but little; in the treatment
of incontinence from whatsoever cause, nothing.
437
RACHITIC DEFORMITIES: ETIOLOGY, CLINI-
CAL HISTORY AND LESIONS
I RISE with much diffidence, for I am to discuss a sub-
ject with which you are familiarized from day to day.
You see these rachitic deformities so frequently that I am
afraid I shall repeat, from my point of view, things which
are to you matters of daily observation and experience.
Our subject is the etiology and the lesions of rachitic
deformities. By way of introduction, I would say that
rachitic deformities are something new in our country.
You have seen so many of them that undoubtedly the
younger men here do not remember the time when there
were no rachitic deformities in this country. Thirty years
ago there was no rachitis, except very rarely a stray case.
At that time, when I spoke of rachitis and endeavored to
demonstrate a case in my clinic, I had to hunt consider-
ably for material to illustrate this condition. When, twenty-
two years ago, I wrote a paper on the first cases of cranio-
tabes I had seen in New York, it was, with the exception
of one by Parry, of Philadelphia, the first paper on this
subject ever written in our country. The subject of rachi-
tis, therefore, is a comparatively novel one. Since that
time, immigration has been going on, and the poverty-
stricken people from the slums of Europe have been ac-
cumulating here. As with the greater facilities for trans-
portation science has been equalized all over the globe,
so poverty, bad air, and want of every description have
equally spread constitutional diseases here. Since then
we have seen much rachitis here. Thus it is that the
treatment of rachitis in the future, although it will al-
ways remain medical, will also be a social question.
The principal causes of rachitic deformity are numerous
the rapid growth, the thick epiphyses, the soft diaphyses,
the condition of the ossification cartilage, the traction of
439
DR. JACOBI'S WORKS
the muscles, the debility of the muscles, and the pressure
of the atmosphere. The locality where the deformities
are found depends largely upon the intensity of growth.
Growth is most intense in the young child (1) in the
cranium; (2) in the chest; and lastly only in the extrem-
ities. I recapitulate only what you all know when I
speak of the rachitic head, with the thin skin, the dilated
veins, and the open sutures and fontanelles for two, three,
four, or even nine years, as I have seen it. The edges of
the sutures are irregular. Such a head is usually large
actually larger than the normal head relatively it is very
much larger when compared with the frequently small
body. It is so large that it resembles sometimes the
hydrocephalic head. Indeed some of these heads are to a
certain degree hydrocephalic; some are entirely so. Most
of them are brachy-cephalic, quadrangular, with depres-
sion on top. In a peculiar class of cases, first studied by
Virchow, that of the cretins and semi-cretins, rachitis is
combined with a premature ossification of the occipito-
sphenoidal synchondrosis. In this condition the base of
the skull is shortened. At the same time there is a deep
grooving of the root of the nose, the eyes are widely
separated from each other, there is shortening of the
vomer, and the flat palate so characteristic of cretinoid
conditions. Not infrequently the occiput is slightly
flattened, and the oblique diameters are sometimes not
equal, so that one side may appear to be entirely flattened.
This is particularly the case when we deal with rickety
softening of the cranial bones craniotabes. In such
cases there is much perspiration, with loss of hair on the
occiput; the veins are more dilated, the skin thinner and
paler than in the average head. In these cases of cranio-
tabes one side may be flattened and the other side bulg-
ing. The head may even appear to be triangular. Where
one side bulges out, and one side is flattened from pres-
sure, the forehead is very prominent, sometimes even from
three to five times its normal thickness, because of an im-
mense amount of new periosteal soft growth between the
periosteum and the bones, which produces a marked de-
formity of the forehead. This is not always a temporary
440
RACHITIC DEFORMITIES
affair. It is true that craniotabes may leave no trace if it
gets well sufficiently soon, but when there is much de-
posit under the periosteum, it will sometimes remain.
When calcification takes place very suddenly, then the
thickening of the bone will remain unabsorbed for life.
As a rule, however, most of such thickenings are ab-
sorbed.
The condition of the teeth is certainly one which should
be considered in connection with rachitic deformity. The
teeth appear late or irregularly; when early, the intervals
between the first crop and the second, or between the
second and the third are very long sometimes six, eight,
or ten months. The teeth are frequently discolored, and
they decay very easily. Sometimes, however, we find in
the second crop that the teeth are very hard and very
yellow. Not infrequently we see " Hutchinson teeth " in
rachitic children. This is one of the reasons why Parrot
got the idea of explaining every case of rachitis as the re-
sult of syphilis. The lower jaws are short, narrow and
very low, the angles very sharp and prominent. The
alveolar processes turn inward. Thus, the teeth of the
upper jaw do not cover those of the lower jaw. The chin
in some cases is very low. From the foregoing remarks
it will be seen that well-marked rachitic heads present a
very peculiar appearance.
The trunk in rachitic persons is very short. The clavicle
shows much perisoteal thickening; it is very frequently
bent forward by the pulling of the muscles, and there is
not infrequently an infraction between the middle and an-
terior thirds.
The chest is the seat of a great deal of deformity. It is
frequently triangular, sometimes quadrangular; the dor-
sum is flat and the scapula clings to the body. The ribs
being soft, form a groove in which the arms are frequently
buried. There is a predominance anteriorly. On account
of the atmospheric pressure laterally above the diaphragm,
there is a horizontal groove, called " Harrison's groove."
As there is compression above the diaphragm the lower
ribs stand outward. As the chest is compressed laterally
the sternum is made to protrude, particularly about the
441
DR. JACOBFS WORKS
third and fourth ribs, and the antero-posterior diameter
is lengthened. The ribs are prominent at the ossification
point. On the cartilages there are frequently nodulations ;
a complete rosary may be developed quite early. I have
seen it at the age of two months, and a case has been pub-
lished in which there was a complete rosary in a baby of
only three weeks. In these extreme cases the sternum
is flat, and the manubrium stands out; frequently it is
pressed down above so as to stand out at an angle at its
lower end; the lower end of the sternum may be retracted
while the ensiform process protrudes.
Kyphosis is very frequently seen in these cases. It is
often but an exaggeration of the normal curvature. Scb-
liosis has mostly its convexity to the right with compen-
sation above and below. The spinous processes are very
frequently directed to the concavity. The intercostal
spaces are very narrow on the left side, because there is
less curvature of the ribs, and the ribs are bent out.
In the grown-up woman the antero-posterior diameter
of the pelvis is shortened. This is not seen to the same
extent in the babe. In the normal baby the pelvis is small
and the sacrum very steep, not concave as in the adult.
Therefore, when compression has taken place because of
softening, it is still smaller so that often it is quite diffi-
cult to examine the pelvis satisfactorily; the sacrum may
be so changed as to give rise to a convexity inward and
contraction of the two sides. This narrowing may be due
to the mere fact that the softened bones are compressed
on the pillow, or by the arms of the nurse, a pressure
which is slight, it is true, but quite sufficient. In very mild
cases the symphysis is changed but little. In a number
of instances, however, it will be found to be bent forward,
and thus in very early rachitis, the rachitic pelvis is very
similar to the pelvis deformed by osteomalacia. This is
contrary to the usual description in the books on ob-
stetrics.
The extremities suffer in different ways, in all their
parts the epiphyses and diaphyses, the periosteum, and
the epiphyseal cartilages. The epiphysis is frequently
thick and painful, particularly on the forearm and tibia.
442
RACHITIC DEFORMITIES
A number of cases of so-called " growing pains " are
simply instances of rachitic epiphysitis. Sometimes the
thickening is very considerable; in most cases it is uni-
form, but in some it is more developed laterally. This
is particularly the case on the upper part of the thigh.
The diaphysis is usually bent. Semi-fractures take place
in the arm, clavicle and legs from a very trifling applica-
tion of force. The periosteum, however, being soft,
always acts as a shield to the inflamed bone when exposed
to the danger of fracturing. In all those cases in which
there is much curvature, particularly in the lower ex-
tremity, the concavity is inward, and on the forearm and
thighs it is very often anteriorly. The difference in the
direction of the curvatures depends on the influence of the
muscular traction, or of the weight of the body. In the
very young the concavity of the lower extremity is in-
ward because of the effect of the flexor muscles. When
the bones become or remain soft in those who attempt
to walk, the weight of the body results in outward curva-
tures, and lesions of many kinds.
The ligaments are very flabby, and give rise to flat-foot
in children that stand up and attempt walking. The peri-
osteum suffers a great deal, and in different ways. It is
softened and exhibits a thick layer of rachitic deposit. Cal-
cification occurs in time, and then the diaphysis will be
much thicker and harder than in normal conditions. The
bones of rachitic patients, when recovered, are solid and
able to stand a great deal of hardship in later life.
In the rachitic periosteum there may be haemorrhages.
Not infrequently in bad cases of rachitis, and in those
cases which in the course of general illnutrition develop
purpura, there are haemorrhages under the periosteum in
the lower and upper extremities. Many such cases of
decided rachitis, and those which exhibit similar haemor-
rhages without being marked by rachitis, have been thrown
together under the heading of, in this country, " scurvy,"
and abroad, " acute rickets." In all of these cases, the
children are ill-fed; there is a great deal of pain in the
lower extremities and feet, sometimes with and some-
times without periostitis. The haemorrhages will heal and
443
DR. JACOBI'S WORKS
leave a thickening in part of the cases. Haemorrhage of
gums is not a requisite for the diagnosis; it may be absent
in those who have no teeth, or who have ; and present
even where there are no teeth.
Finally, deformities consisting of shortening of the
whole limb are due to the early calcifications of the epiphy-
seal cartilages. It is on this physiological function that
the length of the diaphysis depends. When calcification
is complete, the growth of the bone, and that of the limb
ceases.
I wish to remind you that rachitis is a general constitu-
tional disease. In it we have to deal not only with the
general system, particularly with another part of the loco-
motor system the muscles. The muscles suffer just as
well as the bones in rachitis, and give rise to certain de-
formities. Both voluntary and involuntary muscles are
affected. What has been called rachitic pseudo-paraly-
sis, is not paralysis; it is simply a weakness of the muscles
and nothing else. We should have been spared this new
term. The muscles are simply poorly developed, and in
consequence they are easily fatigued. The involuntary
muscles suffer in the same way.
While the muscular tissue is poorly developed, fat is
liable to be ample. Rachitic children, unless emaciated
by pulmonary or intestinal diseases, are apt to be heavy
and rotund, and their weight and appearance are often
mistaken for healthy development. But they are flabby,
anaemic, and not capable of resisting attacks of ordinary
diseases like well children. They prove, moreover, that
weight alone is. not the measure for healthy and steady
evolution.
The muscles in such subjects are flabby, and conse-
quently the stomach is apt to be dilated, and the muscu-
lar layers of the intestine are apt to yield, thus giving
rise to large, flabby abdomens filled with gas, on the sur-
face of which are dilated veins.
The expansion of the intestines, owing to the weakness
of the muscles, gives rise to constipation. This constipation
is characteristic. Rachitic children become constipated
very early. It is sometimes the first symptom of rachitis,
444
RACHITIC DEFORMITIES
and shows that the muscles participate in the process at
a very early stage. It may begin at the second or third
month of life in a child presenting evidences of fairly good
nutrition ; and it at once leads us to suspect rachitis.
Some deformity of the abdomen may be due to the spleen,
liver and kidneys. In consequence of " Harrison's groove "
the liver and spleen are not infrequently displaced, and
these organs for the same reason may appear larger than
they really are. The kidneys may be found floating.
Most of the cases of floating kidneys occurring in children
that I met with were in rachitic children, showing Harri-
son's groove well developed. But there are cases in which
the spleen and liver are actually enlarged, from slow con-
gestion and interstitial hyperplasia. They cause the same
deformity that is occasionally seen in syphilitic subjects.
This is another reason why Parrot came to the conclusion
that every case of rachitis must be syphilitic.
445
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