Dr. Jacobi's works. Collected essays, addresses, scientific papers and miscellaneous writings of A. Jacobi ..

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COLLECTANEA JACOBI

IN EIGHT VOLUMES

Vols. 1, II and III, Pediatrics
Vols. IV and V, General Thera-
peutics AND Pathology
Vols. VI and VII, Important Ad-
dresses, Biographical, and His-
torical Papers, Etc.
Vol. VIII, Miscellaneous Arti-
cles, Authors' and Complete Top-
JCAL Index

DR. JACOBI'S 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, Soci§t6 de Pediatric de Paris,
Soci6t6 d'Obstgtrique, de Gyn6cologie et de Pediatric de Paris,
American Academy of Arts and Sciences; Foreign Member
of the GeSellschaft flir Geburtshiilfe 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 Laryngologlcal Association, Pediatric Society of St.
Petersburg, Pediatric Society of Kiev, Royal Academy of
Medicine, Rome, Deutsche Gesellschaft fiir Kinderheilkunde,
Verein ftir 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. II

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

w

7

AT' %
CONTENTS

VOLUME II

PAGE

GENERAL THERAPEUTICS 9

From " Therapeutics of Infancy and Childhood."
Third Edition, 1903.

DISEASES OF THE ORGANS OF CIRCULATION . t7

From " Therapeutics of Infancy and Childhood."
Third Edition, 1903.

TUBERCULOSIS 73

From Keating's " Cyclopedia of the Diseases of Chil-
dren." Vol. II, 1889.

PHTHISIS 105

From Keating's " Cyclopedia of the Diseases of Chil-
dren." Vol. II, 1889.

PULMONARY TUBERCULOSIS 131

From Keating's " Cyclopedia of the Diseases of Chil-
dren." Vol. V. Supplement by W. A. Edwards,
1899.

DENTITION AND ITS DERANGEMENTS .... 159
Lectures I and XIII on " Dentition and Its Derange-
ments," published in 1862, by BaUi^re Brothers, New
York.

FUNCTIONAL AND ORGANIC HEART MURMURS

IN INFANCY AND IN CHILDHOOD .... 175

President's Address, American Climatological Asso-
ciation, 1900. The Medical News, May 12, 1900.

5

809755

CONTENTS

PAGE

TREATMENT OF INFANT DIARRHEA AND DYS-
ENTERY 185

The American Journal of Obstetrics and Diseases of
Women and Children, July, 1879.

SOME IMPORTANT CAUSES OF CONSTIPATION IN

INFANTS 219

The American Journal of Obstetrics and Diseases of
Women and Children, May, 1868.

ACUTE RHEUMATISM IN INFANCY AND CHILD-
HOOD 233

Delivered in the amphitheatre of Bellevue Hospital,
February, 1875.

THE MEDICINAL, MAINLY MERCURIAL, TREAT-
MENT OF PSEUDO-MEMBRANOUS CROUP . . 269
Medical Record, May 24, 1889.

"SUMMARIES" ON DIPHTHERIA 299

From " A Treatise on Diphtheria." W. Wood & Co.,
New York, 1880.

LOCAL TREATMENT IN DIPHTHERIA .... 325
Therapeutic Gazette, March, 1894.

LARYNGISMUS STRIDULUS 333

Lecture delivered at the College of Physicians and
Surgeons of the University of the State of Nevtf York,
1869. New York Journal of Medicine.

CATARRH OF THE INFANTILE LARYNX ... 345
First lecture in a course delivered at the College of
Physicians and Surgeons, 1859. New York Journal
of Medicine.

ACUTE CATARRHAL LARYNGITIS (FALSE OR

' SPASMODIC CROUP) 357

From " System of Medicine," Peffer, Vol. Ill, 1885.

6

CONTENTS

PAGfi

tSEUDO-MEMBRANOUS LARYNIGITIS .... 371
From "System of Medicine," Peffer, Vol. Ill, 1885.

CHANGES OF BREAST-MILK 387

From " Intestinal Diseases, Infancy and Childhood."
Davis, Detroit, 1887,

THE SALIVA 397

From " Intestinal Diseases, Infancy and Childhood."
Davis, Detroit, 1887.

DENTITION 403

From *' Intestinal Diseases, Infancy and Childhood."
Davis, Detroit, 1887.

INTESTINAL MALFORMATIONS 413

From " Intestinal Diseases, Infancy and Childhood."
Davis, Detroit, 1887.

TABES MESENTERICA 421

From Keating's " Cyclopedia of the Diseases of Chil-
, dren," Vol. III.

CASE OF SEPSIS IN A NEWBORN INFANT ... 435
Read before the Seventeenth Annual Meeting of the
American Pediatric Society, Lake George, N. Y., June
18, 1905. Archives of Pediatrics, November, 1905.

CATELEPSY IN A CHILD THREE YEARS OLD . . 439

American Journal of the Medical Sciences, April, 1885.

NEGLECTED CAUSES OF INFANT MORTALITY . 445
The Medical Record.

GENERAL THERAPEUTICS OF INFANCY
AND CHILDHOOD

Therapeutics of infants and children has gone through
its various stages between the era of dull and ignorant pre-
scribing and that of impotent and conceited nihilism and
of churlish pessimism. But neither a deluge nor an ab-
sence of drugs makes a physician, nor do they contribute,
per se, to the welfare of a single individual or of the
community.

The first indication in therapeutics is a correct diagnosis.
The most efiicient treatment is local, and the cause, seat and
essence of a morbid process should be known, or at least
sought for. Many a diagnosis at the present time is still
simply symptomatic, though less so than in bygone times.
Half a century ago, or less, symptoms like paralysis, con-
vulsions, dropsy, or jaundice were considered full-fledged
and sufficiently scientific diagnoses; to-day even chlorosis,
pernicious anaemia, diabetes, epilepsy, and many others re-
quire etiological differentiation to be understood and ap-
propriately treated. The most promising therapy of the
future — serotherapy — owes its origin and importance to
nothing but an accurate bacteriological diagnosis.

Much has been said of the difficulty of a diagnosis in
the diseases of infancy and childhood, and the conse-
quent difficulty experienced in treating them. I do not
believe that the diagnosis in the case of an adult is much
easier; in many instances it is more difficult. The latter
will often mislead you intentionally, or because he is car-
ried away by prejudices and preconceived notions; the
infant may conceal by not being able to talk, but will
certainly not tell an untruth. Besides, the ailments of
children are rarely complicated, and usually a single diag-
nosis tells the whole story. If it be not made, it is per-
haps best for the practitioner not to attempt much doctor-

9

Dft. JACOBI'S WORKS

ing, beyond the relief of the most urgent symptoms, and
for the patient to be let alone. For, happily, most dis-
eases have a tendency to get well, either completely or par-
tially, and many will run a more favorable course when
not meddled with.

This does not mean, however, that I discourage treat-
ment even in such ailments as run a typical course extend-
ing over a number of days or weeks. On the contrary, I am
opposed to the practice — much too common — of those who
do not, for instance, wish to interfere with a whooping-
cough because it finds its natural termination after several
months. This is true, but many of the children also find
their natural termination during these months. Every
day of whooping-cough is a positive danger. A lobular
pneumonia which occurs in the second or third month of
the disease, and proves fatal or terminates in tuberculosis,
would have been prevented if the original affection had
been removed or relieved by treatment. A physician ad-
vising no treatment in such cases as terminate unfavorably
in this manner ought to be held responsible for his neg-
lect. Nor do I approve of the practice of " meeting
symptoms when they turn up." My responsibility is not
lessened by my busying myself with subcutaneous injec-
tions of brandy, when a collapse has set in which I ought
to have foreseen and prevented, or with giving digitalis
when on the fifth or sixth day of a pneumonia the pulse
is flying up to l60 or 200. Anybody can perform that
sort of perfunctory expectant treatment extending from
the first call to the writing of a death certificate. What I
expect of a physician is to know beforehand whether or
not that individual heart will carry its owner through an
inflammatory or infectious disease without requiring stim-
ulation. Many a case might be saved by a few grains of
digitalis or another cardiac tonic or a few efficient doses
of camphor or musk, if administered in time.^

i"Our platform should be: In order to obtain indications
for treatment make a diagnosis. That art is becoming both
more accessible and, through honest and hard work, more easy
with the aid of modern methods. Remember that most diseases
have, indeed, a tendency to spontaneous recovery, but also that

10

GENERAL THERAPEUTICS

Altogether^ it has always appeared to me most satisfac-
tory to treat children, and particularly infants. They are
truthful, unsophisticated; they are what they appear, and
they appear what they are. In their patliology and thera-
peutics there is no mysticism, no faith-cure, no spiritism,
nor any other diabolism. Their diseases are seldom in-
fluenced by mental impressions and emotions, and for that
reason " suggestion," hypnotism, or any other confidence
game has no power over them, certainly not to the same
degree as over adults. But older children may be influenced
to a certain extent. Neurasthenia, neuralgias, and hysteria
are not unknown among them ; like strong irritations of the
senses, the incautious causation of emotions and the awak-
ening of autosuggestions may become dangers to psychical
life and lead to somnambulism, hysteria, and intellectual
and moral perversities of all kinds. Imitation, or emotional
contagion, in a schoolroom leads to chorea, in a dormitory
to enuresis. Children's nature and that of their ailments
are simple enough, but j^ou must know how to understand
them. Unfortunately, however, for incompetent practi-
tioners, children are no mere miniature editions of adults,
and their ills and whims and peculiarities must be known,
patiently studied, and, together with the ignorance and
the prejudice and caprices of the parents, endured.

Though pediatrics is no specialty like, for instance, oph-
thalmology, and the practice prevailing in Europe, mainly
in Germany, on the part of tliose who are in the market for
business and reputation, of advertising themselves as chil-
dren's specialists (" Kinderarzt "), is both ludicrous and
reprehensible, there is enougli in the physiology and pathol-
ogy of infancy and early childhood to justifj'^ the most
careful attention to their peculiarities, mainly on the part
of those who have laid a solid foundation of general medi-
cal study. This is essential. That is why pediatrics should
form the most important branch of the very last year — the
fourth with us — of a medical curriculum. In the con-
templation of the healthy and of the morbid condition of

recovery is not always complete and that invalidism should not
be invited through neglect of treatment." (Trans, of the Med.
Soc. of the State of N. Y., 1901.)

11

DR. JACOBI'S WORKS

the young the first consideration is the imperfection of
the tissues. Cell-growth is still or is apt to remain em-
bryonal. That is why hemorrhages are so frequent soon
after birth and why most tumors encountered in later life
have a foetal origin. Voluntary and involuntary muscular
action at that age is insufficient. Circulation is different
from what it is to be, the heart is comparatively large and
strong, the arteries in part larger (carotids, renal) com-
pared with the size of the organs they supply, and com-
parted with their own size as attained in later years. Di-
gestion is not competent compared with that in adults.
Muscular action is defective, and the gastro-intestinal
secretions not equal to those of advancing growth; still,
it should be known that the differences are not so great as
prejudice or the obstinacy of often refuted impressions
will have it. For to this very day there are innumerable
men who will simply not submit to what has often been
and may easily be proven to be a fact, that the new-
born has a diastatic amylum-digesting ferment in his sali-
vary glands. The nervous system of the newborn is but
little receptive, is still less apt to exhibit reflex action than
later on; in the young infant the inhibitory function is
scantily developed. The most characteristic feature of the
young is their growth ; developmental diseases are very fre-
quent. To this class belong those of the locomotor system,
osteitis and epiphysitis of every kind, including spondylitis,
rhachitis, and scoliosis; of the nervous system, such as
meningitis and encephalitis; of the lymphatic system, such
as adenoids, hypertrophies of the tonsils, adenitis, peri-
adenitis, and polypi of the rectum. In close connection
with his disorders is the congenital condition of mucous
membranes. On the combination of the imperfect or mor-
bid condition of those two rests the condition we call
scrofula. The respiratory organs have their own peculiar-
ities; their inflammations have a peculiar type in early
years, and the narrowness of the larynx explains many of
the imminent dangers connected with even a thin diph-
theritic exudation. Infectious fevers generally can be best
studied in infancy and childhood. These are only a few
instances proving that a large part of general and special

12

GENERAL THERAPEUTICS

nosology can be studied in infants and children only, and
that both hygienic and drug therapeutics cannot be com-
plete by far without the information drawn from the mor-
bid conditions of infancy and early childhood.

The period of puberty requires particular attention on
the part of the therapeutist. There are sudden changes.
The heart grows suddenly, the blood-vessels, formerly wide,
are relatively narrower; the body grows, with it the head;
metabolism is very active, the muscles gain strength, the
sexual organs develop and send to, and derive from, the
central nervous system new sensations and impulses. He-
reditary taints show themselves at that period, epilepsy and
insanity reveal the neurotic taints of parents or grand-
parents ; so marked are such outbreaks of developmental
origin that, when intermitting, they may return during the
climacteric period. Growth may stop, however, at that time;
small stature, deformity of the genitals (with or without
hernia), absence of beard may explain and detect the previ-
ous criminal. In milder cases there are general feebleness,
neurosis, headaches, chlorosis, menstrual irregularities,
changes of character, with or without onanism, or the onset
of constitutional diseases. No new diseases need appear
about this period, but the impressibility and vulnerability
of the nervous system, the tendency to anaemia occasioned
by the sudden growth, and the frequent lack of harmony
in the development of the different organs are able to start
hidden diseases and tendencies, and require the most pains-
taking care of the judicious practitioner in regard to diet,
hygiene, and medicinal therapeutics.

There is one all-important principle in treating infants
and children which cannot be repeated too often. They
are very liable to become anaemic, to submit to general in-
anition, and to suffer from failure of the heart in spite
of its anatomical and physiological vigor. These facts ren-
der it urgent that the physician never lose sight of the gen-
eral condition of the patient while attending to a local
disorder.

Good treatment is always preventive; it should save
strength, if any be left, and provide at once for such com-
fort as will facilitate physiological functions. Do not in-

13

DR. JACOBI'S WORKS

sist, at the cost of a patient's life, upon having a very ac-
curate local diagnosis when a pleuritic baby with a pulse
of 180 and agony imprinted on its pinched, flushed face,
appeals for mercy. It may die while and because you are
satisfying your " scientific " interest. Or when a patient,
old or young, gets into a hospital ward after a tedious
ambulance trip that exhausted whatever vitality was left,
let there be no routine bathing and no close examination un-
til the patient has been rested and a stimulant and prob-
ably food have been administered. To act differently may
kill him.

Then, attention must be paid to the way the sick are
placed or kept in bed. As long as they are conscious they
will aid the doctor in determining their posture; but grave
infectious fevers, such as meningitis, influenza, typhoid,
etc., impair consciousness and the self-protection it affords.
A patient must not be allowed to rest on the same side
always. Hypostatic congestion of a lung may be prevented
or even cured by proper alternation. Gangrene may thus
be prevented. Other suggestions which should force them-
selves on the attentive physician, and might be multiplied,
are as follows:

Congestion of the cranial cavity and meningitis require
a rather erect or at least semi-recumbent posture. Con-
vulsions thus originating may be relieved by changing the
horizontal position into one more vertical. Care should be
taken, however, not to raise the head alone and thus inter-
fere with the circulation of the neck. The trunk must be
raised with the head at the same time. Be also sure that
no feather pillow or mattress add to the internal heat.
Anaemia of the brain requires a horizontal or nearly hor-
izontal position; temporary syncope, a temporary lowering
of the head and upper part of the trunk even below the
horizontal level.

Spondylitis, no matter whether tuberculous or traumatic,
requires absolute rest on a mattress ; the former is more
frequent, and in its incipient stage may heal with rest and
general proper treatment. The latter will, however, never
snjffice without the former. Marked rhachitis requires rest.
Bending limbs should be discouraged from walking, soft-

14

GENERAL THERAPEUTICS

ened cranial spots protected by a hollow air or hair
pillow, and bending ribs and spine demand carrying in a
well-lined brace (pasteboard, leather, wood, felt, wire) until
after months the bones are sufficiently hardened. A
rhachitic child should never be carried on the arm before
the bones are hardened, and surely not persistently on the
same (right) arm. Scoliosis is the invariable result.

Children suffering from retropharyngeal abscess, pharyn-
geal phlegmon, or laryngeal obstruction bend their heads
back to facilitate respiration. Until fully relieved, their
heads should be supported in the position voluntarily as-
sumed. In incipient pleurisy they will try to lie on the
healthy side; when eifusion has taken place, however, on
that of the effusion, to give fairer play to the healthy side.
In local pneumonia, mainly of the upper lobe, a rather erect
position is preferred; in a total pneumonia of a whole side
or an extensive lower lobe affection most patients prefer
a nearly horizontal position, with slightly raised head only,
to permit extensive excursion of the diaphragm and the co-
operation of abdominal respiration. Heart diseases with
dilatation and hypertrophy and pericardial effusion re-
quire semi-recumbent position in bed or erect posture out
of bed. Dilatation of a bronchus and abscess or gangrene
of a lung demand posture on the healthy side ; thus ex-
pectoration of the putrefying or putrid mass is facilitated.
Moreover, in that position the inhalation of disinfectants
is rendered easier. During pulmonary hemorrhage the pa-
tient should, if possible, lie on the affected side to prevent
to some extent the blood from running into the healthy
lung.

Proper feeding and nursing of the infant prevent the
numerous gastric and intestinal diseases of the earliest
period, which either destroy life at once or lay the foimda-
tion of continued ill health. For that reason a rather large
part of my literary labors has been dedicated to the ques-
tions of diet and hygiene. These and medication belong
together. That is why the first chapter of this work neces-
sarily contained some remarks on medication, and this
one, dedicated to therapeutics, cannot abstain from refer-
ring to diet. Those who still object to drug medication on

15

DR. JACOBI'S WORKS

the " principle " of ignorance, or worse, are requested to
kindly determine the boundary line between medicinal and
hygienic agents or products. Attention to respiration and
circulation and to the functions of the skin are of similar
moment. Their requirements will be discussed in special
chapters. The subjects of climate, massage, electricity,
orthopaedics, and gymnastics will find their places with the
diseases of the lungs, muscles, nerves, joints, etc. Bath-
ing, cold washing, exercise, and sufficiently long interrup-
tions of school hours to avoid exhaustion are subjects of
vital importance. Physicians and humanitarians have de-
claimed against premature schooling, too long hours, too
short recesses, and objected to the overcrowding of the
curriculum and to the vanity of incompetent school-masters
and mistresses who utilize the poor victims in behalf of ex-
hibitions; mostly in vain thus far. A child of seven or
nine years should not have more than two or three hours
daily, one of which should be spared for intermediate re-
cesses; 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. If the mentally slow
were taught separately, bodies and minds of all classes of
children would be benefited beyond the possibilities of a
hot-house instruction. The best exercise of the child is
play in open air. Compulsory gymnastics in badly venti-
lated localities cannot take its place successfully, and may
add to exhaustion and ill health. It is an unfortunate fact
that when the claims of physical development were urged
upon school authorities, gymnastics were added to the over-
crowded curriculum as a matter of business necessity, or
of conviction, not always willingly or intelligently. The
summer vacations of public 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 appre-
ciated, and the necessity for such a change was acknowj-.

16

?

GENERAL THERAPEUTICS

edged by the authorities, and therefore ( ! ) the second
Monday of September was selected for the beginning of
the school season, so as to afford the children an extra
week's broiling in the city sun and an opportunity to lose,
as they did formerly, the benefit derived from the summer
vacation. The sanitary reason for this loss of a beneficent
opportunity was said to be the virtuous anachronism of an
eighteenth-century school superintendent, still in office in
this twentieth century until a few months ago, who said
he preferred the influence of the school-room to that of
the New York streets for the New York boy. The good
effects of the excursions of the St. John's Guild and the
air funds and of the Sanitaria of the Guild and the
Children's Aid Society, and many other sensible charities,
are steps in the right direction.

The beneficent influence of fresh air is enhanced by that
of light. Rooms situated toward the north exhibit a musty
odor compared with those directed toward the south. Sun-
light oxidizes organic substances and destroys bacteria.
Light without warmth has been recommended against ba-
cilli, syphilis, furunculosis, and lupus. Others recommend
against the latter light and warmth, as also against rheu-
matism where it is said to cause perspiration without urea,
and against neuralgias ; the same is recommended for the
increase of erythrocytes and haemoglobin. Old clinicians
and pln'siologists appreciated the influence of light. Win-
slow charged insufficient light in the houses with being
the cause of retarded mental and physical development and
of rhachitis. Moleschott knew the slowness of metabolism
in children when not exposed to light. In light the elimi-
nation of carbonic acid and the assimilation of oxygen are
increased. In open air the temperature of the body is
higher bj^ 0.5° C. than in dwellings. It is true, however,
there is the additional influence of air (and exercise?).

The subject of bathing, or rather of hydrotherapeutics
in general, deserves some preliminary remarks in connec-
tion with a future discussion on " bathing." There is
hardly a topic which deservedly has attracted the attention
of the profession (and of the public) in the last decade
or two to a greater degree than that of water and of its

17

DR. JACOBI'S WORKS

uses as a remedy. As I am writing no history, I mention
but two (modern) names that merit most credit in out-
lining both the indications and the methods of its uses,
Winternitz, in Europe, and S. Baruch, in America. Cold
water was long believed to have an antipyretic action only.
Now the indication to reduce the temperature of the body
arises when an excessive frequency of the pulse, degenera-
tion of the tissues of the heart and other muscles, of the
kidneys and of the brain, dryness of the mucous membranes,
and impairment of absorption appear to result from it, but
from it alone. Cerebral symptoms, such as delirium and
convulsions, are then not uncommon. Particularly is that
so in the onset of a disease, while the same temperature may
be readily endured at a later stage. That is why the ele-
vation of temperature alone, without the above dangers
either present or feared, should yield no indication for
antipyretic treatment; indeed, many a child bears easily
4 temperature which carries danger to another; and there
are high temperatures in some diseases, such as many
forms of typhoid fever or of intestinal auto-infection, which
do not seem to interfere much, for a while at least, with
the ease and comfort of the patient. Unfortunately, how-
ever, the thermometer, ranging 103° F. or more, is often
permitted to establish indications, and the reduction of
temperatures appears to become a fad and the only ac-
knowledged duty of many practitioners.

To reduce temperatures we have drugs and water. Of
the former, quinine should not be relied on except in ma-
laria, also in some septic fevers, when it may be used by
itself or in combinations during remissions. The coal-tar
preparations, antipyrin, salipyrin, lactophenin, phenacetin,
etc., will all reduce temperatures, and have their occa-
sional indications, but are known to depress, one more, the
other less, the action of the nervous system and the func-
tions of the heart, and even to destroy blood-corpuscles.
Acetanilid has the latter effect more than any of the rest
and should be discarded altogether. Their administration
requires the utmost care, and frequently demands the com-
bination with stimulants to guard against detrimental
effects.

18

GENERAL THERAPEUTICS

The temperature of the young body is easily influenced
by apparently slight causes; it may rise and fall almost
suddenly. A sudden rise and a continuous heat may prove
dangerous; remissions and intermissions are loopholes for
escape from dangers. These dangers are not so much the
direct result of a high temperature as of the toxic eff"ect
of circulating microbes or their products. A moderate
degree of temperature is well tolerated and should not be
interfered with. In many cases it should be looked upon
as a reaction of the organism only and in others should be
considered welcome by its eifect on the destruction of mi-
crobes and toxins and its favoring the formation of anti-
toxins in the infected blood and cells. Not infrequently
the very worst and most unmanageable cases of sepsis,
diphtheritic, scarlatinous, or puerperal, run their bad or
fatal course with low temperatures, while those with high
temperatures will recover.

Water, when properly employed, lowers the tempera-
ture, but has none of the depressing effects of the coal-tar
antipyretics. On the contrary, it stimulates the nerves of
the skin and by reflex those of the whole system, par-
ticularly of the heart ; it increases heart and arterial pres-
sure, thereby aids oxidation of tissues and diuresis, and
appears even to increase the amount of haemoglobin and of
red cells. In this respect there can be no longer a dif-
ference of opinion ; but in regard to the use of cold wash-
ing, with or without friction or affusion, of packing, of
ice applications, of hot, warm, or cold baths, of the dura-
tion of an application or of a bath, and of the degree of
temperature requiring or permitting their employment
in an individual case, no iron-clad rule will ever hold
good.

A cold bath (from 60° to 75° F.) is seldom, if ever,
appropriate for a baby of less than eight months or a
year, and never in congenital heart disease. If given at
all, it ought to be interrupted when the child begins to
shiver or the lips become bluish ; it cannot be expected
to have a good effect unless the feet share immediately in
the reaction which should take place after the bath. A
cold bath should, according to circumstances, sometimes

19

DR. JACOBI'S WORKS

be preceded or followed by the administration of a stimu-
lant, and usually not be extended beyond four or five min-
utes and be accompanied by friction of the surface, mainly
of the extremities. A warm bath (from 85° to 98° F.)
differs so much from the temperature of a feverish child
(from 101° to 107° F.) that a reduction will also be read-
ily accomplished by it. Besides, the patient submits to
it more readily. The temperature of the bath decreases
from minute to minute, or, if necessary, may be lowered
by adding cold water. A warm bath, when given for the
purpose of reducing temperatures, should last longer, —
from five to fifteen minutes, — and may be given a number
of times daily. After a cold bath the child should be
covered warmly, particularly the feet, at least until the
cutaneous circulation is fully restored; after a warm bath
the covers should not be too heavy, in order not to lose the
benefit of copious radiation from the surface. Packs of
cold water, iced or not, need not, in most cases ought not,
to cover the whole body of the child ; arms, feet, and legs
should be left out. A single thickness of a common towel
or napkin is wrapped around the body, exclusive of the
arms, either the chest alone, or the abdomen alone, or both,
and the thighs, according to the more local or more general
effect which is to be attained; and a layer of oil-silk or
rubber cloth, and over it a flannel sheet or blanket should
cover the pack. To reduce local congestion or inflam-
mation (conjunctivitis, peritonitis, arthritis, meningitis)
cold water, ice-water, or ice-bags may be used. Small
children do not tolerate ice applications to the head for
any length of time, collapse resulting the more readily
the thinner the skull. Applications should not be too wet;
small pieces of cloth cooled on a lump of ice should be fre-
quently changed in cases of conjunctivitis. Extensive
meningitis requires at least two ice-bags, the effect of which
should be carefully watched.

Cold compresses, well wrung out and covered with flan-
nel and oil-silk, to small or large surfaces, and allowed to
remain from twenty to fifty minutes until the skin is hot,
are efficient stimulants. Hot baths (from 96° to 105° F.)
act as stimulants, but should be given sparingly and be of

20

GENERAL THERAPEUTICS

short duration, as too exciting or exhausting, when last-
ing long, for most patients. The head must be cooled while
the body is immersed. Short hot baths, with or without
mustard and with or without cold applications to the head,
dilate the superficial blood-vessels, and will be found use-
ful in an occasional case of pneumonia, in collapse, or to
favor the cutaneous eruptions of scarlatina and of measles.
After removal from the bath, the patient should be covered
with hot blankets, and a hot drink, such as water, an
aromatic tea, or milk, should be given freely to promote
perspiration.

When bathing is resorted to as a means to lower or to
increase blood-pressure, the effect of medicines given at
the same time should be taken into consideration. Mor-
phine lowers it, digitalis increases it; a bath to counteract
the effect of morphine should have a lower temperature; to
relieve that of a dose of digitalis, a higher temperature. -
That is why the dose of a bath — that means its tempera-
ture and its duration — should be adapted to the normal
and the morbid conditions of the individual patient.

Because of its grave importance, I repeat here that milk
and drinking-water are safest when boiled. It is to be
hoped that, whenever fresh and fairly sterile milk cannot
be obtained, the method of sterilizing milk devised by
Soxhlet, of Munich, and introduced in New York by Caille,
and systematically employed by Rotch, of Boston, and his
followers, will prove successful. Mental and physical
labor ought to be easy and pleasant. Factory work for
children is an abomination, and not only a cruelty com-
mitted against the individual helpless child, but a danger to
the future of the republic, which cannot be expected to
thrive while the physical and intellectual development of
the future citizen is crippled by the greed of the manu-
facturer and the recklessness or the partiality of legis-
latures.

It is evident, therefore, that preventive medicine is com-
ing to the front as the main reliance of the future, in which

2 Karl Lewin, Phys. Diat. Therapie, Wiener Klinik, No. 8,
1901.

21

DR. JACOBI'S WORKS

the public-spirited and well-informed general practitioner
will again be recognized as superior in breadth of horizon
and good citizenship to the merely dexterous specialist.
Besides preventive medicine, drug therapeutics has not
been left behind in the evolution of practical medicine.
Since the times of Magendie, who supplied us with the
first alkaloids, the laboratories of the pharmacologists, both
in professional chairs and in factories, have added to our
exact knowledge of drugs and their effects. At the same
time physical therapeutics has developed simultaneously
with drug therapeutics. The claim of some of the most
modern writers, however, that physical therapeutics, such
as hydrotherapy, electricity and galvanism, and the study
of climate, is an accomplishment of the last few years, is
not justified by the history of therapeutics. Only the
books get bigger and sometimes out of proportion to our
increased knowledge. Physical therapeutics has been ex-
tolled as " merely aids to natural processes," and " not med-
icines in the usual meaning " of the word. On that score
superiority has been claimed for it. What that expression
means I am at a loss to explain. I do not take a medi-
cine to be a bullet that kills a disease from afar, nor a
rope that strangles it. The enthusiasm of " physical thera-
peutists has sometimes grown into fanaticism. Does physi-
cal therapeutics militate against drugs ? make them un-
necessary, useless, or injurious? If water and massage
and electricity are " natural " aids, are iron, digitalis, mer-
cury, arsenic, alcoholics, or acids " unnatural "? The nar-
rowness of some minds cannot be better demonstrated than
by the angry shopkeeper rivalry of doctrines or teachings
or therapeutical aids meant to work for the same legitimate
and humane ends.

In the administration of medicines excitement on the
part of the patient must be avoided ; the nervous system of
infants and children loses its equilibrium very easily. Fear,
pain, screaming, and struggling lead to disturbances of the
circulation and to waste of strength. Preparations for
local treatment or for the administration of a drug must
be made out of sight, and the latter ought not to have an
unnecessarily offensive taste, Naphtalin, iodoform, beta-

22

GENERAL THERAPEUTICS

napthol, rhubarb, and such like should be shunned. The
absence of proper attention to this requirement has been
one of the principal commendations of " homoeopathy,"
whatever that ma}^ have been the last twenty or thirty
years. Still, the final termination of the case and the
welfare of the patient are the main objects in view, and
the choice between a badly tasting medicine and a fine-
looking funeral ought not to be difficult. In every case
the digestive organs must be treated with proper respect;
inanition is easily produced, and vomiting and diarrhoea'
must be avoided, unless there be a strict and urgent indi-
cation for either an emetic or a purgative. The most cor-
rect indications and most appropriate medicines fail when
they disturb digestion; it is useless to lose the patient while
his disease is being cured.

The administration of a medicament is not always easily
accomplished. Indeed, it is a difficult task sometimes, but
one in which the tact or clumsiness of the attendants has
ample opportunity to become manifest. For " when two do
the same thing, it is by no means the same thing." Al-
ways teach a nurse that a child cannot swallow as long as
the spoon is between the teeth ; that it is advisable to de-
press the tongue for a moment and withdraw the spoon
at once, and that now and then a momentary compression
of the nose is a good adjuvant. That it is necessary to
improve the taste as much as possible need not be repeated.
Syrups turn sour in warm weather, glycerin and saccharin
keep; the taste of quinine is corrected by coffee (infusion
or syrup), chocolate, and " elixir adjuvans," a teaspoonful
of which, when mixed each time before use, suffices to dis-
guise one decigramme == one and a half grains of quinine
sulphate. Powders must be thoroughly moistened; unless
they be so, their adherence to the fauces is apt to produce
vomiting. On the other hand, their prescription and prep-
aration require care; for instance, many powders absorb
moisture, such as potassium citrate, sodium bromide, cal-
cium chloride, piperazin, lysidin, chloral hydrate, dry
vegetable extracts, extracts of animal organs, citrate of
iron and ammonium ; others form a fluid when in combina-
tion, for instance, antipyrin and sodium salicylate; others,

23

DR. JACOBI'S WORKS

like resorcin, change their color. Air-tight bottles or the
addition of licorice powder correct some of these changes.
Capsules and wafers are out of the question because of
their size; pills, when gelatin-coated or otherwise pleasant
and small, are taken by many. The rectum and the nose
may be utilized for the purpose of administering medicines
in cases of trismus, cicatricial contraction, or obstreperous-
ness. Both of these ways it may become necessary to re-
sort to for weeks in succession.

The rule not to prescribe incompatible medicines is valid
at every period of life. For the treatment of children
the following facts should be remembered. Corrosive
sublimate should be dissolved in alcohol or in distilled
water with the addition of sodium chloride. Calomel and
iodides should not be given together or in close succession;
calomel cannot be mixed with calcined magnesia ; potas-
sium permanganate not with syrup, or with tannin, sul-
phur, glycerin, alcohol, or sweet spirit of nitre; potas-
sium chlorate not with carbon or with sulphur; alkalies
not with alkaloids ; tannic acid should not be prescribed
with alkaloids or albumin.

The effect of a medicine depends on its dose and the
readiness with which absorption and elimination take place.
Medication, when its effect is wanted speedily, should be
continued during the night; mainly in such patients as
have healthy kidneys. In infants and children sodium
salicylate, for instance, is readily eliminated, much more
rapidly than in advanced age. Both absorption and elim-
ination are very active in infancy and childhood ; but
they vary. Curare, for instance, is eliminated speedily,
and must be repeated quite frequently ; potassium iodide
soon after its administration, but there are traces in the
urine after some days ; phosphate of lime appears in the
urine and faeces directly; potassium chlorate is excreted
through the kidneys within a few hours ; silver and mercury
may take a long time in exceptional cases. Absorption
takes place the more readily the more the solution in
which the medicinal substance is held is diluted; but it
depends greatly on the condition of the surface or tissue
which is selected for the introduction of the drug. A horny

24

GENERAL THERAPEUTICS

skin absorbs but little; inunctions require a clean surface,
and are best made where the epidermis is thin and the net
of lymph-ducts very extensive, on the inner aspect of the
forearm and the thigh. A congested stomach, a catarrhal
or ulcerated rectum, are more or less indolent and disap-
point our expectations quite frequently. High tempera-
tures of the body exert their influence on mucous mem-
branes and their secretions and absorbing powers, so that
absorption and efficacy are diminished or annihilated. That
the doses must be adapted to the ages of the patients is
self-understood; but to establish fixed rules is more than
merely difficult. To give as many twentieths of the dose
of an adult as the child has years is a fair average; but
this rule suffers from very numerous exceptions, like all
the other rules that have been decided upon not at the
bedside but at the writing-table. Like foods which are
tolerated by the adult, but are not tolerated by the young,
though the amounts be diminished in proportion to their
years, so there are medicines which are not borne by the
infant. Nor are the doses the same for every adult. As
healthy persons thrive on different quantities of food, so
there is a variableness in the amount of medicines re-
quired for full effect. Besides, there are idiosyncrasies
which in some forbid the use of a medicine apparently in-
dicated and borne with success by others. There are
those who respond quickly, and sometimes too quickly, to
very small doses of opium; others in whom a minute trifle
of mercury produces salivation. It is this class of cases
which gives rise to much disappointment and requires all
the tact and foresight of a good physician. In some the
system gets used to a drug after a short time. Babies,
after having taken opiates for some time, demand larger,
and sometimes quite large, doses to 3'ield a sufficient effect.
Excessive doses continued a long time have produced mor-
phinism in children as in adults. Some drugs are required
in proportionately large doses. Febrifuges and cardiac
tonics, such as quinine, antipyrin, digitalis, strophanthus,
sparteine, and convallaria, are tolerated and demanded by
infants and children in larger doses than the ages of the
patients would appear to justify. Potassium iodide may

25

DR. JACOBI'S WORKS

be given in doses of one or two drachms (four or eight
grammes) daily in meningeal affections, while in the same
one of the heart tonics, caffeine, must be shunned because
of its — under these circumstances — exciting and irritating
effects. The same may be said of alcohol, which must not
be administered in cerebral congestions unless they be of
septic origin. Mercurials affect the gums very much less
in the young than in advanced age. Corrosive sublimate,
in watery solutions of one to eight or twelve thousand, may
be given to a baby of two years with membranous croup
in doses of a fiftieth of a grain every hour or two hours
for five or six days in succession, with rarely as much as
jthe most trifling irritation of the gums or of the stomach
and intestines. In urgent cases of hereditary syphilis it
can and should be administered on a similar plan for
weeks, and, somewhat modified, for many months, to be
resumed after an interruption of weeks, and later on of
months.

If it be the object of medication to accomplish an end
and to fulfil an indication with the least expense to the
organic economy, and within the briefest possible time, we
do not score a success in very many instances. Indeed, not
every aim is reached directly and not all indications can
be fulfilled at a moment's notice. As the object of eat-
ing and drinking is the reproduction and the growth of
the body, as many a meal is required to produce a lasting
and visible effect, and as every one of the meals is neces-
sary for the sum total of the final results, so the adminis-
tration of numerous small doses of medicines extending
over weeks, months, and even years may be demanded for
a certain purpose. Particularly is this so when chronic
ailments of the blood, the nervous system, or tissue anom-
alies are concerned. To affect rhachitis, phosphorus re-
quires weeks. The faulty sanguification of chlorosis is
mended by iron, if at all, after weeks or months. Pernici-
ous ansemia, sarcomatosis, even chorea require the persistent
and protracted use of gradually increasing doses of arsenic.
Syphilis and chronic conditions of hyperplasia require mer-
cury or the iodides, or both, to accomplish the desired end,
through months and even years. The organotherapy of

26

GENERAL THERAPEUTICS

myxoedema or of cretinism has to be continued for months
and years and resumed after interruptions. Even the
effect of digitalis, as a heart stimulant and, by its effect
on the smallest blood-vessels of the heart muscle, a nutrient
of the heart itself, is obtained solely through the per-
severing administration of small doses in many chronic
cases.

The dose of a medicine depends no less on the mode and
locality of its administration. Modern therapeutics favors
as much as possible local medication, like modern pathology,
which requires local diagnoses. Subcutaneous administra-
tion demands smaller doses, the rectum sometimes a slight
increase. There are some medicines which are absorbed
and act as well in the rectum as through the mouth; this
is a subject, however, to which we shall return. The man-
ner of application results also in different effects. The
inunction of the official ointment of potassium iodide is
well-nigh inert; its effect is almost exclusively that of mas-
sage, for iodine makes its appearance in the urine after
days only. Potassium iodide in glycerin, rubbed into the
skin a number of times, may eliminate iodine after a day,
in lanolin after a very few hours.

At this place it is well to remember the great additions
to our therapeutical possibilities, though in a few words
only. Our materia medica has been enriched with alkaloids
and enabled us to give invariable and exact doses and to
render medicines palatable, — advantages much greater than
those derived from electrotherapy, Rontgentherapy, or even
hydrotherapy. The gigantic strides of chemistry have fur-
nished a large number of synthetic drugs, many of them
of great efficacy for good and evil, and some very
creditable to both the learning and enterprise of manu-
facturers. Serotherapy and the medication supplied by the
thorough study of the ductless glands are in part due to
them. But, after all, the weapons our ancestors had in
the shape of mercury, iodine, opium, digitalis, and others
have not become dull; indeed, modernized medicine has
nothing like them, just as not one of the later or latest
modern means of diagnosis excels or equals percussion
and auscultation as taught eighty years ago.

27

DR. JACOBI'S WORKS

Of serotherapy I shall speak again; organotherapy may
be mentioned. here. It was introduced to meet the dangers
of the absence of " internal secretion." This is a term
extensively employed, at first in regard to the adrenals
{Brit. Med. Jour., August 10, 1895), by Schaefer and
Oliver, and generally admitted to be descriptive and tell-
ing. It is applied to some of the processes, partly physio-
logical and partly chemical, of the formation and dis-
integration of material in different parts of the organism.
Saliva, gastric and pancreatic juice, and bile are external
secretions, and carried off by efferent ducts. Internal
secretion, however, requires no efferent ducts, indeed, no
.glandular stricture, for it occurs also in muscle and in
brain substance. Internal secretion is carried off into the
lymph and blood directly. Liver and pancreas appear to
have both external and internal secretions; but the thy-
roid, thymus, spleen, and adrenals appear to have inter-
nal secretion only. Their absence or removal or destruc-
tion by disease causes death with the symptoms of a chronic
infection. This may result from one of two sources, or
from both. Either those organs have the function of form-
ing certain materials required in the organic economy, or
that of destroying poisonous effete results of metamorpho-
sis. Thus the absence or destruction or extirpation of the
thyroid causes cachexia, that of the pancreas diabetes, that
of the adrenals often Addison's disease. In regard to the
thyroid, we are now certain that myxoedema and some
forms of cretinism are favorably influenced, or even cured,
by the administration of the thyroid glands of animals.

At best, organotherapy requires patience and time. Some
of its effects cannot be obtained except by administering
the substitute for the absent or defective organ persist-
ently. Myxoedema and semicretinism are liable to relapse
when medication ceases or is unduly interrupted. This
will not be corrected, it is to be feared, until a normal
organ is implanted into the suffering organism and made
to perform its physiological functions. Thus far surgery
has not succeeded in yielding the coveted results.

The rectum of the infant and child has been rising in

28

GENERAL THERAPEUTICS

the estimation of the practitioner since the times of ther-
mometry ; for it is certainly the safest and . easiest place
to take the temperature. For therapeutic measures it is
also invaluable.

The rectum of the young is straight, the sacrum but
little concave, the sphincter ani feeble, and self-control is
attained only gradually. Thus a rectal injection is easily
either allowed to flow out or vehemently expelled. There-
fore one which is expected to be retained must not irri-
tate. The blandest and mildest is a solution of six or
seven parts of sodium chloride in a thousand parts of
water ("saline solution"). This may be made to serve
as a vehicle of medicine, unless incompatible with the
latter, which it will be but rarely. A medicated enema
which is to be retained should be tepid and small in
quantity, half an ounce or little more or less, and carried
up well into the rectum, for the immediate contact with
the sphincter may cause its expulsion. Care must be taken
to exclude air from the syringe, which, for small quan-
tities, must be a well-fitting piston syringe of hard rub-
ber, with a long nozzle. This must be well oiled, and in-
troduced, not straight, but with a gentle turn, so as to
avoid folds in the anal mucous membrane (in the same
way a thermometer ought to be introduced). The nozzle
must not be too thin, as it is liable to be caught; the small-
est nozzles of fountain syringes are therefore in most
cases improper; the larger size is more appropriate for
any age. The injection must be made while the patient
is lying on his side, not on his belly over the lap of the
nurse, for in this position the space inside the narrow in-
fantile pelvis is reduced to almost nothing.

When medicines are to be injected, the rectum ought
to be empty, as in infants it mostly is. When it is not,
an evacuating injection ought to precede the medicinal one
by half an hour. It ought to be of the mildest possible
nature, for any irritation of the rectum, from the local
effect of an enema to a catarrhal or dysenteric process,
reduces its faculty of absorption. The medicinal solu-
tion must not be saturated; indeed, very soluble medica-

29

DR. JACOBI'S WORKS

ments only are to be selected for medicinal enemata. Nor
must they be acid or contain anything irritating. Alco-
holic tinctures require relatively large quantities of water;
quinine salts must not be selected unless very soluble, such
as the muriate, the bromide, the carbamide (bimuriate with
urea), or the bisulphate. The addition of a small amount
of antipyrin renders quinine very soluble. No acids must
be used for the purpose of keeping it in solution. Sodium
salicylate, also antipyrin, exhibit their full power through
the rectum, and permit of full doses. Frequently, how-
ever, the rectal doses are a little larger than those given
by the mouth.

Larger enemata are not retained, and are therefore
utilized for the purpose of emptying the bowels. This
effect is easily obtained in infants and children, for their
faeces are soft and movable, with the exception of those
cases in which improper medicines (large and continued
doses of calcium salts and bismuth or astringents), or badly
selected food (casein and starch in undue quantities), or
an excess of the normal great length of the colon descend-
ens and sigmoid flexure have given rise to large accumula-
tions of hardened faeces. Small quantities are seldom suffi-
cient for the purpose of relieving the bowels, unless they
act as irritants ; in this manner glycerin, pure or with
equal parts of water, may produce an evacuation readily.
Irritants, however, should not often be used, for obvious
reasons. An evacuant injection may weigh from a fluid-
ounce to a quart, in some. It ought to be given while the
child is lying down; the liquid must not enter the bowels
quickly or vehemently, the fountain syringe not hang more
than ten or twelve inches above the anus. If that pre-
caution be observed, occasional pain or faintness or vomit-
ing can be avoided. If water, or water with two-thirds
of one per cent, of salt, be insufficient now and then, more
salt or soap may be added for the purpose of enforcing
the evacuation. Half a tablespoonful of oil of turpentine,
with a pint of soap and water, often acts charmingly;
so does the addition of a few drachms of tincture of assa-
foetida, in conditions of constipation, flatulency, and nerv-
ous excitability, also in convulsions; or glycerin in ob-

30

GENERAL THERAPEUTICS

stinate constipation. A few ounces of olive oil is often
preferable, as an evacuant, to anything else.

Large injections will have other indications besides that
of evacuation of the bowels. In many cases of intense
intestinal catarrh large and hot (from 104° to 108° F.)
enemata will relieve the irritabilitj- of the bowels and con-
tribute to recovery. They should be repeated several times
daily. When such evacuations contain a great deal of
sticky, viscid mucus, the addition of one per cent, of
sodium carbonate will liquefy the tough secretion. When
there are many stools, and these complicated with tenes-
mus, an injection, tepid or hot, must or may be made after
every defecation, and will speedilj' relieve the tenesmus.
In such cases flaxseed tea or thin mucilage may be sub-
stituted for water.

When the bowels are in a state of chronic catarrh or
ulceration, the injections ought to be particularly large
and contain astringent or alterant medicines. Though they
be expelled immediately, enough of the dissolved or sus-
pended remedy will remain upon the mucous membrane.
Zinc sulphate, alum, lead acetate, tannic acid, silver ni-
trate, salicylic acid, carbolic acid, and creosote have been
used in such medicated injections. One-per-cent. solu-
tions will suffice. Salicylic and carbolic acids may prove
uncomfortable or dangerous because of their effect on the
kidneys, and ought to be dispensed with. Silver nitrate
requires some precaution. From half a grain to five grains
or more in an ounce of distilled water may safely be in-
jected; but this enema must be preceded by an evacuant
consisting of water only, and followed by one containing
some sodium chloride for the purpose of neutralizing the
nitrate and protecting the anus and external parts from
local irritation. It will also be found advantageous to
wash the anus and perineum with salt water before in-
jecting the silver solution. In many cases where one of
the above-mentioned agents appeared to be tolerated badly
or proved inefficient, bismuth subnitrate (or subcarbonate),
mixed with water or with gum-acacia water in different
proportions, proved very acceptable and successful.

Suppositories are useful both for evacuating and medic-
Si

DR. JACOBI'S WORKS

inal purposes. Soap is utilized for the former purpose
by the public at large, and the same material differently
mixed, with or without medicinal additions, such as atropine,
by the irregular trade. Local medicinal applications to
the rectum are best made by means of injections, but a
general effect is also obtained through a suppository.
Opiates, and narcotics generally, exhibit their full power
when the suppository is retained. Extract of hyoscj^amus,
from half a grain to a grain in a suppositorj^, to be re-
peated from, two to five times daily, shows its effect in
relieving vesical spasm nearly as well as when taken in-
ternally. Quinine is gradually dissolved and absorbed.
Extract of nux, both in ointments and in suppositories,
acts well in prolapse of the rectum and debility of the
sphincter.

Subcutaneous injections of remedial agents ought to be
made more frequently than appears to be customary. The
extremities, particularly their lower halves, should be
avoided, for their constant motion and the relative absence
of fat in their subcutaneous tissues are liable to give rise to
local irritation, swelling, or suppuration. The abdominal
wall or the lumbar region is preferable. The recommenda-
tion to use the interscapular space was made by famous
men who worked in the laboratory and did not know what
inconvenience there may be in a back, punctured and often
sensitive, on which a patient is to seek his rest. A sharp
and aseptic needle and gentle friction of the injected part
is all that is required. The solutions used must be clear
and without any solid ingredients. When they have been
preserved for some time they ought to be filtered before
being used, particularly when fungous growths have begun
to make their appearance in the liquid. The latter may
be preserved best by adding a small quantity of alcohol,
salicylic acid, or boric acid. The doses must be as small
as possible, and the medicine diluted more than in the
case of adults. This is mainly required when a caustic
effect is to be feared. While, for instance, Lewin advised
for adults a solution of four grains of hydrargyri bichlor-
idum in an ounce of water, one or one and a half grains
give a more appropriate solution for infants. One or two

32

GENERAL THERAPEUTICS

daily doses of eight or ten drops continued for weeks will
prove very useful in those urgent cases of hereditary
syphilis which are characterized by pemphigus on the soles
of the feet and the palms of the hands in the first days
after birth. Brandy and ether may be used undiluted as
in adults, but the latter is particularly painful and the
greatest care must be taken as to the locality injected.
The subcutaneous tissue must be reached and the cutis
penetrated by inserting the needle at a nearly right an^le
from the surface. Chloral hydrate dissolves readily
in two parts of water, but a solution of one in four or
six is better tolerated. For the ready symptomatic treat-
ment of convulsions it renders good service. Antipyrin is
well borne in solutions of one in six or eight parts of water,
camphor in from four to six parts of sweet almond oil.
The fluid extracts of digitalis and ergot are very apt to
give rise to indurations and, perhaps, abscesses. As a rule,
the most convenient medicaments for hypodermic adminis-
tration are the very soluble alkaloids. One or three drops
of Magendie's solution of morphine or the corresponding
solution of morphine muriate is vastly preferable to the
internal use of narcotics for bad pain in pleuritis or pleuro-
pneumonia, or in peritonitis of advanced childhood. It
may be mixed with atropine sulphate for the reasons regu-
lating its use in the adult. The latter by itself has been
found quite effective in the case of an epileptic boy, who
had taken the same drug internally without any success.
If possible, it ought to be injected during the aura; if not,
twice a day. Apomorphine muriate is a ready emetic in
doses of a thirtieth or a fifteenth of a grain. Pilocarpine
muriate can be injected in doses of from one-twentieth
to one-eighth of a grain. Its reckless use, both hypoder-
mically and internally, has led to occasional mishaps, but
the drug is a powerful agent for good when carefully
applied, and has saved for me several cases of meningeal
hyperaemia and cerebral oedema, mostly of nephritic origin.
Strychnine sulphate, while in the same affections it has
mostly proved inefficient when taken internally, has ren-
dered efficient services in enuresis depending on paralysis
or weakness of the sphincter of the bladder and in pro-

33

DR. JACOBI'S WORKS

lapse of the rectum and fecal incontinence resulting from
paralysis of the anus which depended either on disease or
congenital incompetency. In these cases a daily dose of
a fortieth or a twenty-fifth of a grain — according to the
age of the patient or the severity of the case— is sufficient.
More frequent doses, however, are required in the diph-
theritic paralysis of the respiratory muscles, which is dan-
gerous and apt to become fatal unless speedily relieved.
A daily dose hypod. will yield fair results, when long con-
tinued, in the later stages of spinal or cerebral paralysis,
where its internal administration is entirely or well-nigh
useless. Quinine salts must be neutral when injected; I
prefer the bromide, the muriate or the carbamide. They,
particularly the last, are among the most soluble. The
carbamide dissolves readily in from four to six parts' of
warm water; the latter temperature ought to be preferred
in every case of subcutaneous injections. Quite saturated
solutions ought to be avoided, because it has happened to
me that the water of the solution was speedily absorbed,
and the quinine remained as a foreign body in the sub-
cutaneous tissue. Caffeine, in combination with sodium and
salicylic or benzoic acid, is an excellent heart stimulant,
and has rendered splendid service in urgent cases of heart-
failure or pulmonary oedema depending on cardiac disease.
Sodio-caffeine salicylate and benzoate are soluble in two
parts of water, and are readily absorbed. Both should be
avoided in those cases which are complicated with cerebral
irritation or sleeplessness. Fowler's solution, carefully fil-
tered and diluted with at least twice its quantity of dis-
tilled water, may be injected into healthy or morbid tissues
without often risking irritation and abscess. Still, I have
seen a splenic abscess after such an injection in a case of
sarcoma of the spleen. Undoubtedly, the continued use of
arsenic renders very efficient services in sarcoma ; but as
it has to be used quite a long time, it is almost impossible,
except in hospital practice, to resort to h3'podermic medica-
tion. There is no harm in this, however; for a slow, grad-
ual increase of the drug is tolerated by the stomach to
such an extent that very large doses (amounting to half
a drachm = two cubic centimeters) of Fowler's solution

34

GENERAL THERAPEUTICS

daily, well diluted, may finally be administered after meals
to children of six or eight years.

Subcutaneous injections have reached an extensive field
of usefulness in serotherapy. After it was proved that
animals could be immunized against certain virulent bac-
teria, it was found that the blood-serums of previously im-
munized animals ^ could be utilized as powerful remedies
in infectious diseases of man. In the article on diphtheria
more has been said of the effect of its antitoxin, the prep-
aration and knowledge of which is due to Aronson, Roux,
and Behring. Tetanus and diphtheria are certainly influ-
enced by their proper antitoxins to a remarkable degree.
Asiatic cholera is likely to be the next great scourge of
mankind to be stripped by its antitoxin (Haffkin) of
part of its fury. Neither Marmorek nor others, how-
ever, have thus far succeeded in producing an antitoxin
which is as effective as those of (tetanus and of)
diphtheria in such infectious diseases as appear to be con-
nected with, or dependent on, streptococci (puerperal dis-
eases, erysipelas, scarlatina, and some forms of abscesses,
of angina, and of mixed diphtheria). Nor are the claims
of Coley, who, with antitoxin procured from the coccus of
erysipelas and from bacillus prodigiosus, exhibits inter-
esting results in sarcomatosis (not in carcinosis), generally
accepted by all. In many more diseases antitoxins have
been recommended; prematurely it appears, for neither
croupous pneumonia nor typhoid fever nor syphilis has
been benefited thus far. Nor have the attempts at obtain-
ing an antitoxin to take the place of calf vaccinia in the
immunization against variola been successful. Not infre-
quently the lymph usually employed is mixed with bac-

3 Xot to be mistaken for the congenital protection afforded by
the presence of " alexins " in the blood-serum of the newborn.

Certain infectious diseases leave in the circulation an immuniz-
ing substance which protects its bearer against relapses. This,
at least, is the only possible explanation of their protection. This
fact suggested the possibility of a successful treatment of
measles, pneumonia, and scarlatina with the blood-serum of such
persons as had just passed through one of those maladies. Good
results are reported. Personal experience I have none.

35

DR. JACOBI'S WORKS

teria and other impurities. The cases of tetanus appearing
after vaccination should not shake the faith in vaccination
nor relax the efforts to make vaccination compulsory, but
should be a vrarning against careless preparation of
vaccine. Thus far, however, a sterile blood-serum of the
vaccinated calf cannot be obtained in sufficient condensa-
tion and efficacy.

In organotherapeutics the hypodermic method is no longer
employed extensively, since the internal administration of
the different tissues, or their extracts, or other modes of
preparations is both efficient and (mostly) palatable. Many
of the secretions and tissues of the body of man and beast
were used in olden times under the reign of crude empiri-
cism or bestiality, — blood, bile, urine, faeces, hair, bones,
etc. Of the modern organ extracts, cerebrin, hepatin,
lienin, renin, pulmonin, oophorin, spermin, didymin, the re-
ports on which are not all dictated by an unpolluted scien-
tific spirit, not much can be said as yet. Those which
have been proven to be valuable, particularly to children,
will be discussed later.

The subcutaneous injections of cocaine, according to
Schleich's method of " anaesthesia by infiltration," will
prove a great gain to the practitioner, inasmuch as, with or
without the previous use of ethyl chloride, it will facilitate
many operations. Maybe its principal advantage will lie
in this, that many abscesses and furuncles will be dealt
with before they are permitted to get larger. Their anti-
neuralgic action will not be required frequently, because
of the relative scarcity of neuralgias in childhood. In al-
most every case the solution is to consist of cocaine muriate
0.1, morphine sulphate 0.02, sodium chloride 0.2, distilled
water 100.0.

Inhalation is resorted to in two different ways. Either
the air of the room or of a tent is impregnated with the
substances to be introduced into the air-passages, or these
substances are introduced through sprays or atomizers of
different shapes and patterns. Some of the latter have
always appeared to me very faulty and not to the purpose
at all. Tubes introduced into the mouth, through which

36

GENERAL THERAPEUTICS

substances are to be carried down, will land them in the
mouth; it takes all the self-control and intelligence of an
adult patient to allow the object in view to be accomplished.
The oral cavity of the infant or child is small, the tongue
is coiled up, and the faucial muscles will not relax. Nose
and mouth must cooperate to allow inhalations to enter
the larynx, or the former alone must be relied on. A spray
calculated to reach the larynx of infants or children is
always best introduced into and through the nose. In this
way, at all events, the posterior part of the pharynx and
the respiratory tract are reached to best advantage. The
manner in which the spray is employed in diseases of the
nose and pharynx is quite often too perfunctory, with no
other result but to make the patients wakeful and restive;
and it should not be forgotten that no access to the trachea
and bronchi is possible except during a deep inspiration.
The difficulty of accomplishing that in children is obvious.
Real inhalation, however, means filling the lungs with a
gas or vapor. Warm steam will do good service in bron-
chitis and pneumonia, when the bronchial secretion is
viscid and expectoration difficult, and in diphtheria, for
the purpose of softening membranes and increasing the
secretion of a thin and normal mucus. Cases of fibrinous
bronchitis I have seen getting well in bath-rooms, the hot
water being turned on for days in succession and the air
thick with steam. An excellent inhalation in the inflam-
matory conditions of the respiratory organs is that of am-
monium muriate. Every hour, or at longer intervals, a
gramme or more of the salt — the quantity depending in
part on the size of the room — is burned on the stove or
over a live coal or an alcohol-lamp. The heavy white cloud
fills the room, is easily borne by both sick and well, and im-
proves expectoration. Oil of turpentine can be utilized in
a similar way. Its action is both expectorant and disin-
fectant. In the latter stages of pneumonia, when the bron-
chial secretion is thick, viscid, or deficient, and expectora-
tion and cougli are wanting, the room may be filled with
turpentine vapor. This can be accomplished in different
ways. A large soft sponge may be soaked with turpen-
tine, with or without the addition of some oil of sassafras,

37

DR. JACOBI'S WORKS

and suspended at the bedside. Or a kettle of water may be
kept boiling day and night on the fireplace or over an alco-
hol-lamp (this is preferable to a gas-stove, which consumes
too much oxygen), and a tablespoonful of turpentine, more
or less, poured on the boiling water every hour or two
hours. The same may be done to advantage in diphtheria,
with or without a teaspoonful of carbolic acid in addition
to the turpentine, and in gangrene of the lungs. The in-
halation of benzine, cresolin, and similar substances, and
of the coal-gas of gas-works, has often been recommended
in whooping-cough. In its worst forms, particularly when
it is complicated with convulsions, the frequent inhalation
of chloroform is sometimes life-saving. A baby of six
months, with hourly attacks of convulsions, I kept alive
by putting him under the influence of chloroform at the
beginning of every attack, and continuing that treatment
for several days. Asthmatic attacks will do well some-
times with inhalations of chloroform, ether, and spirits
of turpentine in different proportions, mostly 1 to 2 to 4.
Chloroform is well tolerated by the young, but should be
avoided in the cases of lymphatic patients. Sudden deaths
may be (and appear to have been) encountered in them,
and may occur after weeks as a result of the parenchyma-
tous changes in the heart caused or increased by the drugs.
Amyl nitrite also will influence them favorably; as a pre-
ventive of epileptic attacks I have experienced occasional
success with its administration. But in collapse, with
paralysis of peripheral blood-vessels, it certainly renders
good service. With the inhalation of oxygen for the pur-
pose of bridging over the most dangerous period of a
suffocating pneumonia and of improving tissue-change in
general anaemia and ill-nutrition, the profession is well
acquainted. It is no use to deny that effect on theoretical
grounds afforded by the alleged law of the diffusion of
gases. If those who write books for practitioners would
but study disease at the bedside ! With tlie inlialation of
ether as an antidote to poisoning with santonin I have no
personal experience. Ozone inhalations have been highly
recommended in anaemia, whooping-cough, and septic fevers.
We shall have to learn more of its effects, and particu-

38

GENERAL THERAPEUTICS

larly in regard to a ready and reliable method of its
preparation. A. Caille, while regretting the clumsiness and
expensiveness of apparatuses, uses it in chlorosis, secondary
anaemia, and whooping-cough. A personal communication
of his speaks also of a case of tuberculosis in an adult
successfully treated with ozone inhalations extending over
several years.

In pulmonary tuberculosis the inhalation of disinfectant
vapors is employed less than the necessity of the cases would
appear to indicate. Carbolic acid, turpentine, eucalyptol
have been utilized for that purpose. The object is to sup-
ply the lungs with those substances in thin dilutions con-
stantly. Prudden has proved that carbolic acid in twelve
hundred parts of water stops the emigration of leucocytes
in inflammatory disorders. Thus high dilutions, though
they be hardly perceptible to the senses, and certainly not
to a disagreeable extent, may be amply sufficient. It is
for this reason that Feldbausch invented small apparatuses
filled with a disinfectant substance to be persistently worn
in a nostril.

The inhalation of chloroform, which is, on account of
the average vigor and healthiness of their hearts, preferable
to ether for the purpose of producing anaesthesia in the
cases of infants and children, is rather unsatisfactory at
the earliest age because of the superficial character of
respiration. So is that of ether, which, moreover, may
become contraindicated in every period of life because of
its detrimental effect on the kidneys and on the respiratory
organs. It frequently begets nephritis, which anyway is
frequent in infancy and childhood, bronchitis, and pneu-
monia. The effect of the anaesthetic is very temporary, and
the administration must be repeated and closely watched
during a convulsion or an operation. The difficulty in
obtaining a complete narcosis is particularly great in the
new-born. The stage of excitement is brief, the pulse
becomes frequent, and the pupils contract. After a short
time, however, tlie pulse becomes slow and the pupils
dilate. The after-effects are not so inconvenient as they
often prove in the adult; infants and young children vomit
less frequently and less profusely, and certainly with

39

DR. JACOBrs WORKS

greater facility and ease than adults. They are liable to
remain under the influence of the anaesthetic a long time
after an operation has been completed. After tracheotomies,
which I never performed without chloroform unless the
children were asphyxiated by carbonic acid poisoning, the
patients are apt to sleep long and undisturbed. Thus they
require ceaseless watching until the effect has surely passed
away. Through the opened trachea the children will get
under the influence of chloroform very easily. Five or six
drops on a sponge or on some absorbent cotton, held in the
mouth of the tube by means of a pair of pincers, have an
almost instantaneous eff"ect, and came near destroying — -
when I undertook to change the tracheal tube on the third
day — a successful case of mine forty years ago, before
I had the experience detailed in the previous remark.
Further care is also required in regard to patients in ill
health. Chronic pulmonary and heart diseases do not tol-
erate chloroform very well, but the diagnosis of these con-
ditions is more readily and quickly made in children than
in adults. Adipose children are liable to faint. The
usual operations in the mouth, such as resection of tonsils,
incisions of abscesses, and evulsion of adenoids, it is best
to perform without an anaesthetic, for the amount required
to overcome the resistance of the masseter and buccinator
is so large, generally, as to possibly endanger the life
of the patients, besides the impossibility of obviating suc-
cessfully the entrance of blood into the digestive organs,
where it is inconvenient, or into the respiratory organs,
where it is a positive danger.

Of the two anaesthetics, ether and chloroform, the latter
should, as a rule, be preferred in infancy and childhood,
except in a case complicated with heart disease. It is
the heart that runs its risk during the use of chloroform.
The average vigorous young heart is less exposed to its
dangers, but still its power of resistance should not be
relied on too long. For several reasons operations should
be performed quickly, though children are anaesthetized
more readily than adults. For, after all, chloroform and
ether are not indifferent agents, and may prove destructive;

40

GENERAL THERAPEUTICS

the loss of a few ounces of blood is a serious matter, so
long as a baby of thirty pounds has not over one and a
half pounds at best; and blood-pressure is diminished so
long as the operation requires the uncovering of a large
part of the surface. For every operation requiring an
anaesthetic a saline solution should be kept ready for sub-
cutaneous injection. Among the disinfectants carbolic acid
should not be used at all; even iodoform has occasionally
proved dangerous.

Gargles of any description require a certain degree of
training and self-control, and are therefore rarely avail-
able for children of less than seven or eight years. The
liquids thus employed do not reach any farther than to the
uvula, the pillars of the soft palate, and the anterior part of
the tonsils. Whatever succeeds in passing them is swallowed.
Thus the alleged efficacy of gargles is greatly overesti-
mated. Astringents, however, have a certain influence in
reaching beyond the area of contact, but through their
secondary effect on contiguous tissue only. When a thor-
ough effect is aimed at, it is better to rely on sprays,
which may affect the whole pharyngeal cavity, or on in-
sufflations of powders; this latter plan is rather unpleasant,
and should be followed in children in exceptional cases
only. As, however, in most cases where a local effect on
the pharynx is desirable the local affection spreads over
the posterior nares as well, spraying or (much better) ir-
rigating the nose is preferable. The liquids thus emplo3'ed
reach the pharynx, and are either swallowed — which is
often an indifferent matter — or expelled through the mouth.
When these methods are undesirable, — for instance, when
the liquids injected enter the Eustachian tube, — ^they may
be poured into the nasal cavities from a teaspoon or a pi-
pette. A common medicine-dropper will seldom suffice;
one of the nasal cups for sale everywhere will do better.
There is many a case of diphtheria in which the very gen-
tlest method of cleansing and disinfecting the surface of
the naso-pharyngeal cavity ought to be selected.

When no liquids are tolerated, medicated ointments may
be introduced into the nostrils by means of a camel's-hair

41

DR. JACOBrS WORKS

brush, or poured in. Ointments prepared with vaseline,
glycerin, or cold cream are good vehicles for that pur-
pose. Sponges and bruslies ought to be avoided whenever
the young patient objects to them strenuously. No vio-
lence must be used for several reasons. The child's
strength must not be exhausted by his attempts at self-
defence, and most local affections of the throat get worse
by any injury done to the epithelia. Even galvano-cauter-
ization can and must be applied witliout much violence.
Persuasion, patience, and cocaine will render its employ-
ment possible in many instances.

The skin in infancy and childhood participates in the
anatomical structure of all the tissues at that early period,
inasmuch as it contains more water than in advanced age.
Besides, it is thinner, and its lymphatics are more nu-
merous, larger, and more superficial. This explains some
peculiarities in regard to the effects of many medicaments.
Hot air in apparatuses, as used by Tallerman and others,
of 140° C. and more, should be watched, and lower tem-
peratures tried first. It is employed more in chronic than
in acute ailments, arthritis of all forms, deformans and
gonorrhoeal included, muscular and other chronic rheuma-
tisms, and the intense chronic muscular spasms of talipes
valgus (very rare in children), also the progressive ossify-
ing myositis, and chronic osteitis and periostitis. Electricity
in all its forms is sometimes efficient, and a relatively
mild current may suffice. This fact is of particular impor-
tance, as, moreover, the bones also are thinner and more
succulent. To act upon the brain, very mild currents only
must be used. The spinal cord is less accessible, and ap-
pears to require rather large doses from large electrodes.
The galvano-caustic effect resembles very much that ob-
tained in the adult. In most cases it should be closely
watched while being employed; thus, for instance, in the
operation on angiomata, or diseases of the tonsils or nose,
it readily destroys more than was intended.

Sinapisms, when not mixed with flour, must not be per-
mitted to remain more than a few minutes. As soon as
the skin begins to be discolored they should be removed.

42

GENERAL THERAPEUTICS

When that is done, they may be repeated every few hours,
and they are active derivants in many cases of deep-seated
congestive processes. The same remark is due in refer-
ence to the use of mustard-baths. A hot mustard-bath ren-
ders good services in suppressed or insufficient cutaneous
eruptions of an acute character, internal hemorrhages,
meningitis, and pneumonia; but it must not be continued
beyond reddening the skin; if so managed it may be re-
peated.

Vesicatories have lost much of the esteem in which they
were held in former times. I remember the time when
many a case of pleurisy, articular inflammation, herpes
zoster, was not permitted to get well without a Spanish-
fly blister. Nor am I of the opinion to-day that it will
do no good in some such cases, provided it be not used dur-
ing the feverish stages. But their drawbacks are many. A
plaster will not stick to an emaciated and uneven surface,
and is even apt to give rise to gangrene when the surface
circulation is very defective. In these cases the wound will
heal badly. The skin of the infant being very vulnerable,
eczema and impetigo will easily arise on ever so slight
a provocation. The local pain of the application produces
irritation, nervousness, and sleeplessness. This is particu-
larly so if the application be made on the extremities or
on the posterior surface of the body. The kidneys are
frequently affected by cantharides, dysuria being the re-
sult in many cases, which then require energetic camphor
treatment for the relief of the torturing symptoms.

There are some absolute contraindications to the ex-
ternal use of cantharides : the presence of diphtheria in any
shape or manner, and such diseases as are liable, during
the prevalence of an epidemic, to become complicated with
diphtheria. Therefore, no vesicatory must be used during
nasal, pharyngeal, or laryngeal diphtheria (croup), or
in the different forms of pharyngitis, or in laryngeal ca-
tarrli, or in erysipelas, or in diabetes.

When a plaster cannot be expected to remain on tlie
surface and to have its full effect, cantharidal collodion
may take its place. The application will prove more ef-
fective when the surface is first washed with vinegar or

43 ' •

DR. JACOBI'S WORKS

irritated by a sinapism^ which, liowever, is allowed to re-
main a few minutes only. Then a flaxseed poultice or
warm-water applications may be applied over the vesica-
tory to diminish the pain and accelerate the effect. Very
young infants ought not to carry a vesicatory more than
an hour, at least not on the same spot. That is why to
them the cantharidal collodion is less adapted. The plas-
ter may be shifted from place to place.

After the epidermis has been raised, the serum must
be allowed to escape through small punctures, but not so
as to moisten the adjoining parts, for the cantharidin con-
tained in the serum may exert a disagreeable local ef-
fect. The epidermis ought not to be removed, and no ir-
ritating ointment used to keep up a secretion. To cover
the sore surface, vaseline or cold cream is preferable to
common fats, which may be, or become, rancid. The best
final dressing is borated cotton and a bandage. Vaseline
ointments with opium, lead, or zinc, and powders of zinc,
bismuth subgallate, iodoform and amylum in equal parts,
or salicylic acid one part, with from thirty-five to fifty
of starch, will find their occasional indications.

In many affections of the skin, powders, solutions, lini-
ments, ointments, and baths are employed. The skin is
thin and irritable. Erythema will follow the contact with
water quite often; thus many forms of dermatitis contra-
indicate its frequent use. Acute and chronic eczema get
on better without than with it. Therefore astringent
solutions are less advisable than astringent ointments. For
superficial effect these must be prepared with vaseline or
cold cream, either of which may readily be combined with
lead, tannin, zinc, bismuth, salicylic acid, or iodoform. In
not a few cases, on a very sore surface, denuded of its
epithelium and oozing, the powders alone, or combined
with starch or talcum in different proportions, will prove
very effective. Oleates ought to be avoided ; the}^ irritate
the skin and produce eruptions.

As the skin is thin and succulent, and the lymph-ducts
of the young quite superficial, large and numerous, sub-
stances will penetrate the skin quite readily. Ointments
with that object in view must be prepared with animal fats,
particularly ^ith adeps lanae hydrosus of the United States

44

GENERAL THERAPEUTICS

Pharmacopoeia (lanolin), to which, when rather tenacious
and dry, ten per cent, of water may be added. Still,
much friction may by itself irritate the surface and give
rise to suffering.

In the very young, ice and ice-water applications are
not tolerated a long time. Ice to the cranium, the bones
of which are but thin, is liable to produce collapse; about
the neck and occiput it is better borne and often beneficial.
Warm fomentations and hot poultices are very beneficial
in many morbid conditions of the trunk and extremities,
but dangerous when applied to the head and not carefully
watched. General baths are frequently required, local
baths but seldom ; foot-baths may be given while the patient
is lying down, but hot fomentations are more readily made,
and do not require the same amount of watching, nor are
they equally objectionable to the young patient.

Depletions were frequently resorted to scores of years
ago. Modern practice has learned how to do without
them, though we should be willing to assume that they were
more frequently indicated than many of us believe at
present. At all events, it ought to be taken into considera-
tion that there is but a single pound of blood in a baby
of twenty pounds, and that a patient rapidly reduced by
sickness is least able to stand a loss of blood ever so small.
Thus a venesection will hardly ever be thought of in the
case of a baby; at all events, I hope never to repeat the
opening of a jugular vein, practised by me on an infant
taken with convulsions depending on, and adding to, cere-
bral congestion, forty years ago. But there are cases of
older children that bear, or rather demand, a venesection.
Its indications are over-extension and insufficiency of the
(mostly the right) heart with impeded pulmonary circu-
lation, with intense dyspnoea and cyanosis, in which the
largest doses of digitalis have been given in vain. In one
of his cases Baginsky opened the radial artery Avhen he
did not succeed in getting blood from a vein. Such cases
are occasionalh' pulmonary oedema during the incipiency of
the crisis in a croupous pneumonia, or, principally, old
mitral incompetencies with immense dilatation and failing
compensation. The objects to be accomplished are the

45

DR. JACOBI'S WORKS

relief of the feeble heart muscle and the restoration of its
contractility. A further indication for a venesection maj^
be afforded in occasional cases of uraemia or eclampsia,
similarly to its employment in the adult. Local depletions
were once more frequent, though the liability of the skin
to inflammation and furuncle was well understood, and
the excitement of the little patient was such, now and
then, as to lead to an increase of the symptoms and even
to convulsions. Among the occasional drawbacks was also
the possible loss of blood after the leeches had fallen off.
In such a case the local use of tannic acid, alum, perchloride
or subsulphate of iron, digital pressure, or in bad cases
the ligature underneath a harelip needle, which was in-
serted through the wound, were resorted to. A solution of
from twenty to fifty per cent, of antipyrin in water,
which may be immediately followed by a solution of tannic
acid (mostly not required), is a powerful styptic. The
indications for depletion were bad and painful cases of
pleurisy and peritonitis, and cerebral inflammatory diseases.
In the two former, the indication to relieve pain is more
readily fulfilled by ice or the subcutaneous use of mor-
phine or cocaine. In the latter, the mastoid process and
the septum narium are the points on which the leech or
leeches ought to be applied. It is the latter spot which I
prefer, when I have the choice, in those rare cases of brain
diseases of infants and children in which I still feel
justified in recommending a depletion. Altogether, how-
ever, many of the olden-times indications for blood-letting
have proved deceptive. It does not serve as an anti-
phlogistic in all sorts of fevers and inflammations, or as
an evacuant of an alleged plethora, or as a sedative and
anaesthetic, but it certainly may be employed to divert a
local stasis, even in cases in which apoplexy is feared. In
toxic conditions, particuarly in intense sepsis, it should be
carefully avoided, though acute poisoning may be relieved
by it. Uraemia, or carbon oxide poisoning may, as I said,
be benefited by a venesection, and the diminished circula-
ting medium replaced by a saline solution administered
either subcutaneously or injected in the rectum or directly
into a vein.

46

DISEASES OF THE ORGANS OF
CIRCULATION

I. THE HEART

Both in acute and in chronic diseases of the heart the
amount as well as the quality of food requires some modifi-
cation. In many cases the loss or diminution of appetite
will regulate the former. As a rule, however, the amount
taken ought to be much less than the same person would
take when in health. Not only ought the total quantity
to be less, but also that consumed at each meal should be
comparatively small. It is best, therefore, to divide the
meals into halves and even thirds, so as to cause the patient
to eat every two or three hours. Digestibility must be
improved by slow eating. The diaphragm should not be
annoyed by large quantities of food or by the evolution
of gases. Therefore but few carbohydrates (very little
fat) are to be given at one time, and the digestion of nitro-
genous foods, such as meats (eggs) and milk, with or
without cereals, ought to be aided by pepsin and dilute
hydrochloric acid. The latter is an excellent adjuvant
to the digestion of milk prepared according to J. Ru-
disch's formula (25 min. of dil. HCl., one pint of water,
1 quart of milk; boil for a few moments; keeps well; quite
palatable; digestible). At all events, milk is the main food
to be given in cardiac ailments. Its digestion has a further
advantage in this, that it does not result in the physiological
congestion of the stomach, liver, and spleen, which be-
comes irksome after large and heavy meals by disturbing
circulation and thereby adding to the labor of the heart,
and that it does not contain the large mass of fat-forming
elements present in the mixed food of healthy advanced
childhood or adult age. Altogether, it is best to slightly
underfeed the patient; thereby the action of the heart is

47

DR. JACOBI'S WORKS

facilitated, — an object which must never be lost sight of.
For the same reason fast drinking, even of water, must
be avoided, for its sudden absorption fills the blood-vessels
too suddenly for comfort, and its speedy elimination does
not diminish the momentary overwork. This warning is
of particular importance as regards iced liquids, which
act both by their bulk and by reflex. This advice is by no
means superfluous, either to medical men or to the sick.
It was urged by Williams more than fifty years ago. Stokes
prohibited the use of large quantities of soups or milk.
And it has been again introduced by Oertel with such
impressive emphasis that thirsting has become almost fash-
ionable and a craze among the fanatics.

That stimulants, such as coff'ee, tea, and alcoholic bever-
ages, must not form part of the regular diet in cardiac
disease is self-understood. They may be required as me-
dicinal agents, however, upon positive indications.

In every form of cardiac disease absolute rest both of
body and mind is among the very first indications. The
latter is just as important — perhaps more so — here as in
diseases of the nerves and nerve-centres. Fretting, worry-
ing, crying are detrimental, and must be avoided. Thus,
it may become necessary to take a child out of bed tem-
porarily, to gratify and quiet him ; or to change his position,
for the recumbent position of an hypertrophied heart
may cause dragging of the phrenic nerve or of the sym-
pathetic plexus ; or to raise the trunk and head to relieve
intracranial hyperaemia and the consecutive irritation of the
pneumogastric nerve; or to give a mild opiate or a dose of
potassium bromide to insure quietude or sleep. The child
must be permitted to select his own position; he knows
best where he is most comfortable; but rest he must. The
diseased heart is in its most favorable condition when
working least; the number of heart-beats is reduced by
ten or twenty-five in the recumbent position. Rest is not
only a curative, but a preventive agent. Many a life-long
cardiac aff"ection could be warded off" if care were taken
in time. We are becoming more and more aware of the
frequency of aff'ections of the heart muscle. Myocarditis
in a chronic, subacute, and acute form is of very frequent

48

DISEASES OF ORGANS OF CIRCULATION

occurrence. In or after every case of typhoid fever, scar-
latina, diphtheria, or smaU-pox we should be prepared to
be overtaken by some cardiac disease, either interstitial
myocarditis or parenchymatous degeneration. Rest in bed
or on the lounge (the former is better) will act as a pre-
ventive. It ought to be continued for weeks in almost
every case. Like the paralysis consequent upon infectious
diseases, which develops after weeks, heart disease may
occur from the same cause, partly as a consequence of
actual primary alterations, partly of nerve exhaustion.
So long as the pulse becomes more rapid on exertion, or
on getting out of bed, absolute rest is the best remedy
and safeguard. In these cases it is not always possible
to distinguish between functional debility and actual dis-
ease. Autopsies too frequently tell us of our mistakes.
Trifling changes in size cannot be measured by percussion,
feeble murmurs cannot always be estimated according to
their exact value. Functional murmurs are not so frequent
in the child as in the adolescent or the adult, and exceptional
only in the infant. On the other hand, organic cardiac
diseases have a better chance to be cured — really cured —
in the young than later. So much the greater is the re-
sponsibility of the medical man in cases of preventable
or remediable cardiac disorder. Even patients suffering
from the very worst forms are apt to feel better within a
very few (hours or) days after being confined to bed, with
strict diet and loose and comfortable clothing. These cases
teach us the lesson of what can be accomplished through
the same regime in milder or incipient forms, by reducing
the labor of the heart and at the same time of the volun-
tary muscles, with their influence on circulation and blood-
pressure, and by diminishing the over-activity as well of
the general innervation as of the cardiac nerves, both ex-
citing and inhibiting.

It is difficult to decide to what extent exercise should
take the place of rest in individual chronic cases. The
hearts of patients are as little alike as are their noses
and finger-tips, and their treatment ought to be as in-
dividual as the size and shape of their gloves. Neither
fit everybody. Nor is the rule adopted to-day that which

49

DR. JACOBI'S WORKS

will accomplish the best end in a month or a year for the
same patient. The heart is neither in health nor in dis-
ease a uniform body. Its innervation may change from
minute to minute^ its nutrition is dependent on sudden or
gradual alterations. A heart muscle is influenced in its
arterial supply, venous discharge, and lymph circulation
not only by its own health or disease, but by the ever-
changing conditions of the other organs. Thus, many of
the rules given one day may not remain valid another.
Still, after a fair time has elapsed since the occurrence
of an acute myocarditis or endocarditis, exercise should be
recommended. The child may get up and have his quiet
pla}'' sitting at the table, may begin to walk on the level
floor, and may indulge in mild gymnastic exercise. More
must not be permitted until the mucous membranes become
a little more tinged, the arteries fuller, the heart quite
regular. The systematic rules recommended by Stokes and
by Oertel refer more to adults, with their incipient fatty
degeneration and chronic myocarditis, than to children. In
these, while they bear the imprint of cardiac changes, no
iron-clad rules hold good. Gentle exercise and long rest
should alternate.

Gentle exercise may be replaced or complemented by
massage of the skin and the muscles, both of which are
so essential for circulation and metabolism. The blood
circulating in a resting muscle during one minute amounts
to 17.5 per cent, of its weight; in a contracting muscle
to five times as much. It is easily seen to what extent mas-
sage, hydrotherapeutic irritation of the whole surface, and
excitation of the muscles by the interrupted current must
do good without an exertion of the heart muscle. The
avoidance of the latter, while the muscles are gently ex-
ercised by " resistance movements," is the peculiarity of
the Schott treatment at Nauheim. It is indicated in a
great many cases; in others it is Oertel's climbing ex-
ercises. In all it is the judicious mind and common sense
of the physician in charge of the individual case.

The skin requires judicious attention. Exposure to
cold, with its consecutive contraction of the cutaneous
blood-vessels, overloads the viscera, retards circulation, and

50

DISEASES OF ORGANS OF CIRCULATION

increases the labor of the heart muscle. A cold general
bath, therefore, is dangerous (as also in the atheromatous
degeneration of the old) in acute carditis (where local
application of cold to the heart region acts quite favor-
ably) or in extreme muscular weakness of the heart. On
the other hand, a brief cold sponge-bath or wash, with
thorough friction, is an intense stimulant and may be used
to advantage for a weak heart, unless the extremities be
cold and the mucous membrane cyanotic. In these latter
conditions, hot washes and frictions, with or without alco-
hol, should take its place. In the average condition of
the diseased heart general hot bathing must be avoided.
It overstimulates and paralyzes, and proves an actual
danger in both acute and chronic cases. Newspaper read-
ers will remember the reports of people who go to the hot
or " Turkish " bath with their heads erect and full of their
own therapeutical wisdom, and leave it with their feet
forward. A warm bath, the temperature of which ought not
to be over 90° or 92° F., is often relished. In fact,
both the talking child and the infant will soon tell you
the exact temperature best adapted to their wants. In
these cases actual want and comfort are identical. The
baths, particularly the first, must be limited to a few
minutes ; at all events, they should never be continued
after the slightest weakness of the pulse is noted. The
debilitating or fatiguing effect of the bath must be avoided.

The mineral springs which have obtained a reputation in
the treatment of chronic heart disease, like the German
Nauheim and Oeynhausen, owe their effect to the stimu-
lating action of the salts and of the carbonic acid contained
in them. It should be remembered, however, that not in-
frequently carbonic acid, both internally and externally,
may cause tachycardia and arrhythmia.

Like hot water, hot air is contraindicated in heart disease.
The wilted forms of the little ones soon show the effects
of summer heat. A temperature of from 65° to 70° F.
and fairly dry air are best for them. High altitudes do
not agree with cardiac disease, particularly when no com-
pensation has facilitated the heart's action. Compensation
is not complete until the hypertrophied left ventricle,

51

DR. JACOBFS WORKS

having become so by mitral incompetency, transmits as
much blood into the aorta as the pulmonary artery does
into the lungs. Until that stage has been reached, the
lungs are comparatively hyperaemic and subject to catarrh,
oedema, or bleeding. In this condition, therefore, the in-
fluence of the rarefied air of high altitudes should be
avoided; as a rule, I recommend an altitude of not more
than from one thousand to fifteen hundred feet to children
affected with chronic endocarditis.

In the therapeutics of the heart it is most important not
to mistake a functional disturbance of the heart's action
for the immediate result of heart disease. The contractions
of the heart (the pulse), as to number and rhythm, are
more frequently influenced by disorders of other organs
or of the organic economy in general. The pulse may be-
come arrhythmic from cardiac (mainly myocardial) disease,
but also from meningitis, from neuroses (chorea, hysteria,
epilepsy), from anaemia in convalescence after grave dis-
eases, in chlorosis, in universal obesity, even in the appar-
ently healthy; from the autoinfection caused by constipa-
tion or by jaundice; or from the eff'ects of medicines.
It is self-evident that all these diff'erent causes, and not
their common symptom, should be treated.

The functions of the heart and blood-vessels are best
considered together, from a clinical point of view. To-
gether they control the normal blood-pressure and circu-
lation; when these are disturbed, it is mostly (not always)
the same remedies or drugs that influence at the same time
the heart and the arteries. Such disturbances are either an
increase or a lowering of blood-pressure, and alterations
in the circulation which are characterized by slowness or
frequency of the pulse. In the diseases of the yoimg it
is mostly cardiac stimulation that is required with a view
of contracting both heart and arteries. Its indication is
furnished by primary feebleness of the heart muscle, or by
that which is secondary to acute or chronic inflammatory
or infectious diseases, or meningitis ; sometimes by con-
genital undersize; by impaired brain function after hemor-
rhages, in syncope, or in chronic cerebral anaemia ; in tedious
convalescence; by insufficient diuresis; by pulmonary

52

DISEASES OF ORGANS OF CIRCULATION

oedema; by reflexly lowered blood-pressure in shock, in
colic, or after extensive burns ; by hemorrhages ; or by toxic
dilatation of blood-vessels caused by chloral hydrate, ni-
trites, pilocarpine, or muscarine. Angina is, fortunately,
very rare, for acute or chronic aortitis is very uncommon.
Whenever it occurs it may cause a neuritis of the cardiac
plexus near the coronary artery and under the influence
of peri- or (and) myocarditis.

Blood-pressure and circulation are improved by physical
means, such as transfusion, salt-water infusion, lowering
the head and raising the feet, ligature of the extremities,
manual compression of the abdominal aorta, and hydro-
therapy in different forms. The centres of the medulla
and of the spinal cord are influenced by strychnine and
ergot; the vasomotor centres and the heart by caffeine,
camphor, ammonium, and musk; the vasomotor centres and
the peripheric vasomotor nerves by hydrastis; the heart
by alcohol, atropine, and sparteine; the heart and arteries
by digitalis, strophanthus, adonis, convallaria, hellebore,
and apocynum.

Among the principal remedies employed for the purpose
of reducing blood-pressure and dilating peripheric vessels
are warm baths, or foot-baths with or without mustard,
warm clothing, rest in bed, narcotics, such as morphine and
chloral hydrate, acids and alkalies, and the nitrites.

At the head of the list of heart and blood-vessel stimu-
lants stands digitalis. It increases the action of the heart
muscle and thereby increases cardiac pressure. It is indi-
cated in all conditions of weakness of the heart muscle
so long as the latter is not decomposed and the arteries
are in their usual structural condition. Primary changes of
the heart muscle hardly ever occur in childhood, for uncom-
plicated fatty degeneration, in which digitalis is contra-
indicated, is almost unknown at an early age. Secondary
parenchymatous degeneration is, however, a frequent oc-
currence in and after infectious diseases, such as typhoid
fever, dysentery, rheumatism, scarlatina, diphtheria, and
others. Digitalis is useless and sometimes worse than use-
less in nervous affections, such as the palpitations of
Graves's disease, or neurasthenia, or of hysteria. In all

58

DR. JACOBI'S WORKS

probability the effect of digitalis is mostly felt at first in
the left ventricle, which is more muscular, but in the right
ventricle almost as soon. By acting on the left ventricle
is regulates the general circulation and facilitates aspira-
tion of the venous blood and the circulation in the lungs
and in the right heart. It strengthens the systole and
lengthens the diastole. During its administration the con-
tractions of the heart become more vigorous and less fre-
quent, the arterial pulse slower and fuller, the urine in-
creases in quantity, cyanosis and dyspnoea diminish, and
dropsical symptoms gradually disappear. When large
doses have been given for some time, accumulation of the
effect takes place. The pulse becomes quite slow and
irregular, and vomiting sets in. If possible, this effect
should be avoided.

For how long a time may digitalis be administered when
given in moderate doses? This question has often been
asked and as often answered. Unfortunately, the prepara-
tions sold in the markets are of different strengths and
vary too often; so it is best to rely on preparations which
are not liable to spoil on one's hands. With that proviso,
I can say, from an experience of several dozens of years,
that I cannot agree with those who stop the administra-
tion of digitalis after a few days, to begin again after
an intermission. Moderate doses may be given day after
day for months without any ill effect and with great bene-
fit. Nor is it necessary to alternate between cardiac stimu-
lants so long as no uncomfortable effect of digitalis makes
its appearance. Only when the patient cannot be seen
for many weeks in succession, the practitioner may feel
like alternating digitalis and strophanthus weekly.

In practice we. are often disappointed. The preparations
are as various as are the firms of wholesale, or sometimes
retail, manufacturers or tradesmen. The United States
Pharmacopseia is, after all, the best stand-by of the prac-
titioner, and its list of drugs and that of the National
Formulary of the Pharmaceutical Association are suffi-
ciently large to suit any taste. The infusion of digitalis.
when reliable, may be given to a six-year-old child in doses
of a teaspoonful two or four or five times a day, the

51

DISEASES OF ORGANS OF CIRCULATION

fluid extract (I have often expressed my predilection for
" Squibb's ") two or three minims daily, the solid extract
from one-half to one grain daily (0.03 to 0.06). They
are not equivalent, the infusion being weaker by contain-
ing the digitonin, which is highly soluble in water and
acts rather as an antidote to digitalin and digitoxin. The
tincture of digitalis, when reliable (not fixed up by mixing
a poor " fluid extract " with alcohol), ought to be a com-
petent equivalent of the fluid extract, if both be made
of the English leaf gathered in July. It has been found
that when digitalis, though English and gathered in mid-
summer, is kept, the preparations made of it later lose in
strength, so that those made nine months afterwards dis-
play only one-third or one-fourth of their original power.
The main constituent is digitoxin; of it there is less in
sunless summers, to such an extent that it varies from 0.1
to 0.62 per cent, of the herb. Gorges (JBerl. klin. Woch.,
August 13, 1902), for that reason, recommends a dialysate
(made by Golaz in Saxon Switzerland) of digitalis pur-
purea and grandi flora, of which children of two or three
years are given from two to six drops three times a day.
Indeed, children bear digitalis and cardiac stimulants
generally better than adults, and in comparatively larger
doses. Digitalin I have used a great deal. Unfortunately,
the wares sold by that name are very unequal: they are
resinoids, not alkaloids. I have used ten or twenty times
the doses recommended in books and price-lists without
any eff'ect whatsoever that could be relied on. For many
years I have given it up. In urgent cases a six-year-old
child must take from one to five minims of the fluid ex-
tract at once. That dose may be repeated after a few
hours, and perhaps again, until the effect is perceptible.
Then it is time to slacken off" or stop altogether. It is
particularly in those cases in which the pulmonary circu-
lation is obstructed, either by local pulmonary inflamma-
tory processes or by cardiac incompetency, that this mode
of proceeding is advisable.

The eff'ect of digitalis is not limited to the heart ; the
arteries are also aff'ected by it. On this account digitalis
is often contraindicated in senile aff"ections of the whole

65

DR. JACOBI'S WORKS

vascular system. As they (atheromatous conditions) are
not found (except in a few cases of the literature) in
infancy and childhood, this contraindication is rare in
early age. There is a single exception, however, to this
rule, — viz., in abnormal congenital smallness of the ar-
teries, which is not so excessively rare as may be presumed,
and is a frequent cause of life-long migraine, neurasthenia,
hysteria, and chlorosis. In these conditions, thus caused,
digitalis is not so well tolerated when given by itself.
It acts better when combined with a nitrite.

In those cases in which the effect of digitalis appears
to be retarded, or the practitioner has " reason to doubt
the qualities of his drug," another one may be substituted
for it or combined with it. I plead for occasional combina-
tions of drugs. The " simple prescription " flag of the
" one drug only " fanatics waves over a childish affectation.
They forget that they are prescribing half a dozen different
constituents in their " one drug " digitalis. Moreover, when
the heart requires stimulation, we should remember that
it is a composite organ ; the muscle, the ganglia, the pneumo-
gastric, sympathetic, and vasomotor nerves are suffering
simultaneously. The tincture of strophanthus may be
taken by the same child to the daily amount of from six
to twenty-five minims; the fluid extract of convallaria
majalis in the same or somewhat larger doses. Again I
suggest that in most cases it is best to ascertain the
moderate dose to be administered a long time in succession
by giving a good dose from the very beginning and watch-
ing its effect. Of sparteine sulphate (better than other
preparations of scoparius) eight or ten doses are required
daily, altogether amounting to from one;-half to two and a
half grains (0.03 to 0.15). Caffeine from two to ten
grains, or sodio-caffeine salicylate (or benzoate) from four
to fifteen grains a day, are fair doses, the effect of which
will be pleasant in most cases. The sodio-caffeine sali-
cylate (or benzoate) is well adapted for subcutaneous
use; it dissolves readily in twice its weight of water and
is not a local irritant; it is therefore easily employed. The
eflFect of these injections is often marked. Nearly twenty
years ago I published a case of cardiac pulmonary oedema,

56

DISEASES OF ORGANS OF CIRCULATION

among others, in which recovery was the undoubted result
of their use. There is, however, a positive contraindica-
tion to the use of caffeine (and coifee), — viz., cerebral
hyperaemia, either active or passive, or a tendency to con-
vulsions. The same contraindication holds good for strych-
nine sulphate, which has conquered a trusted place as a
cardiac stimulant. If there be time, it may be given in-
ternally, daily, to the amount of from one-sixtieth to one-
twentieth of a grain (0.001 to 0.003) for many days or
weeks in succession. Urgent cases require its subcutane-
ous administration. Large doses, up to one-fourth or one-
third grain (fifteen or twenty milligrammes), may be given
to a child of ten years, in emergencies of collapse and
sepsis, in a day, but such doses must not be continued,
except in thorough sepsis. Sodio-theobromine salicylate
has been introduced (as " diuretin ") by G. See. It is a
diuretic rather than a cardiac stimulant, and, unlike the
former, is often found wanting. It appears to act prin-
cipally on the epithelia of the uriniferous tubes. Calomel
in small doses is certainly a cardiac sedative, and, as it
is surely a diuretic, it is entitled to the many praises
bestowed on it by the older rather than by modern physi-
cians. Salines owe their effect upon the heart mainly to
their action on the digestive and the urinary organs, with
the exception of the bromides and iodides, the former of
which act as sedatives, and thus save labor and soothe
irritation. Potassium iodide has a more direct effect. It
dilates arteries, diminishes arterial tension, and aids elim-
ination through the bronchial mucous membranes and the
kidneys. Obstructions of the pulmonary circulation de-
pending on the heart are its appropriate indication. Scle-
rosis of the coronary arteries is not, or hardly ever, found
in the young; therefore this is an indication exclusively
belonging to advanced age. A child of six years may read-
ily take from five to twenty grains (0.3 to 1.25) a day, in
three or four doses, in plenty of water, after meals. It
need not often be interrupted because of the gastric
symptoms produced. The nitrites and their preparations
play an important part in lowering blood-pressure. They
dilate blood-vessels by paralyzing the vasomotor centres

57

DR. JACOBI'S WORKS

(not the central nervous system), mainly the peripheric
vessels. Large doses transform haemoglobin into methaemo-
globin and thereby cause cyanosis, dyspnoea, and sometimes
methaemoglobinuria. Amyl nitrite may be inhaled in drop
doses; nitroglycerin (trinitrin, glonoin) is given in doses of
from one-five-Jiundredth to one-two-hundred-and-fiftieth
grain (one-eighth to one-fourth milligramme) in solution.
The spiritus glonoini of the United States Pharmacopoeia
contains one-one-hundredth grain in one drop. The eifect
of sodium nitrite, from one to four grains (0.06 to 0.25)
a day, in solution or in powder, is milder but more per-
manent. Sweet spirit of nitre is of an unequal compo-
sition; its action on the kidneys is more pronounced than
that one the circulation in general.

There are occasional cases in which the secondary com-
pensation required by mitral incompetency is not fully
established, and serious disturbances of the circulation arise
therefrom. The dangerous symptoms may be cyanosis and
pulmonary (or) and cerebral oedema. There are, besides,
stupor or convulsions, dyspnoea, dilated veins, cold ex-
tremities, and a small and intermitting pulse. It is in
these cases that a few of the above-mentioned large doses
of digitalis may do good ; here it is that wavering and
indecision become criminal. Whenever digitalis does not
have any effect, a venesection may. Our ancestors were
less pusillanimous. Maybe they overdid bleeding, but in
an urgent case they did not fail to open a vein. I know
that I have several times saved the lives of children (and
adults) by opening a vein quickly.

Chronic (and sometimes the final termination of acute)
cardiac diseases may lead to heart-failure. In such cases
stimulants are indicated. Alcohol must not be given by it-
self and in large doses in cerebral hyperaemia of any
kind. A child of six years may take from three to
twenty grains ((0.2 to 1.25) of camphor internally; sub-
cutaneously, a solution of one part in five of sweet almond
oil should be used, and from five to fifteen drops injected
repeatedly. Ether may be given, in doses of from three
to ten drops, in alcohol and water, and ammonium car-
bonate, in frequently repeated doses of from one-half to

58

DISEASES OF ORGANS OF CIRCULATION

two grains (0.03 to 0.125), in anise-seed water or in milk.
Musk internally, strychnine subcutaneously, may be re-
quired. The more urgent the case appears to be the
greater is the indication for combining several of these
remedies.

Myocarditis. — Though myocarditis, both acute and
chronic, is far from being so common in the child as in
the adult, it is nevertheless not infrequent; it is, indeed,
remarkable how often it is not diagnosticated, or how little
its occurrence is appreciated. Its symptoms are, it is true,
sometimes very few. The disease is met with either in
connection with endocarditis, pericarditis, very often with
rheumatism, etc., or is quite frequently uncomplicated.
Then it is parenchymatous, and the result of the toxic in-
fluence of infectious fevers (diphtheria, influenza, dysen-
tery, etc.).

In its treatment muscle stimulants must not be given.
Digitalis is contraindicated. The recommendation of Hef-
fen, to administer ergot, I cannot approve of, for by its
action on the muscular fibres it increases vascular pressure,
and thereby secondarily the labor of the inflamed heart
muscle. Whatever relieves this temporarily is welcome.
Therefore, potassium or sodium iodide combined with a
bromide will act favorably. Here is also the place for
morphine, either in large doses at long intervals or in small
doses more frequently administered, together with ice to
the chest. During attacks of collapse, or during weakness
or prostration, ether, camphor, and alcohol should l)e
given, either internally or in an urgent case subcutane-
ously. A dose of calomel will relieve the bowels. Enemata
for the same purpose daily, for regular evacuations are the
best regulators of intra-abdominal circulation. In chronic
cases iron may safely be given with the iodide; not in acute
ones, which are injured by it through the increase of vas-
cular irritation. Absolute rest, both physical and mental,
is essential. That is why Oertel's and Schott's teaching
of systematic exercise should be followed with great care
only, even in chronic cases. The extremities should be
kept warm (stockings) and ice-bags or wet cloths applied
to the heart. Derivation by extensive mustard-plasters and

59

DR. JACOBI'S WORKS

by hot foot-baths taken in a semi-recumbent position should
be tried. A very small pulse demands nitrites. The usual
cardiac stimulants, such as digitalis, strychnine, etc., are
contraindicated, particularly in cases of arrhythmia or gal-
.lop rhythm when referable to myocardial weakness.

Acute dilatation of the heart is now and then encountered
after the parenchymatous changes of the heart muscle fol-
lowing infectious diseases. Forchheimer (Festschrift)*
studied it in connection with influenza and its etiology as
myocardial and nervous, both the muscle and the nerve de-
generating under the influence of a toxin. In children
the myocardial insufficiency is the cause of the dilatation,
rarely vice versa, and the latter should be met with
absolute rest extending over weeks or months, warm
bathing, iodides, and nitrites, and opiates.'- Recovery is
much impeded by concomitant pericardial adhesion.

Endocarditis. — That it is " never primary " is a mistake
shown by Henry Hun in Festschrift. " Our forefathers
knew that rheumatism might begin in the heart." On
the other hand, heart diseases are rarely uncomplicated;
endo-myo-pericarditis, this complex of varieties, is often
found in combination, and the " carditis " of our predeces-
sors was a good diagnosis based on truth. The treatment
of this disease is more promising in the child than in the
adult, for entire recovery is more frequent in early life
than later; but it is important that the diagnosis should
be made early. In order not to be taken unawares, we
ought to remember that many a systolic murmur that is
mistaken for endocardial is myocardial, and that endo-

* " Festschrift " refers to the volume of scientific papers pre-
sented to Dr. Jacobi by his admirers in America and Europe on
the occasion of his seventieth birthday. — Ed.

1 F. Forchheimer quotes Charles West, who observed, forty
years ago, in influenza a combination of symptoms, of which
dyspnoea was the principal one, disappearing in two or three
days, followed by " extreme depression, cool, moist skin, a very
feeble pulse, and labored respiration. ... In this condition
the children, though quite conscious when roused, lay generally
dozing, while, though the somewhat livid hue of the lips and sur-
face seemed to imply the existence of some serious mischief
in the lungs, there was nothing to be heard but a large moist
rale."

60

DISEASES OF ORGANS OF CIRCULATION

carditis may be present without, at least for some time,
exhibiting a murmur; there are, indeed, cases which run
their full course without a murmur. This is eminently so
in ulcerous endocarditis: (fever irregular, murmur chang-
ing, sometimes quite absent, symptoms [sometimes fulmi-
nant]— Henry L. Eisner in Festschrift — of malaria, tend-
ency to emboli not infrequent after gonorrhoea, and then
not quite so bad prognostically as is suggested by S. S.
Adams in Festschrift). On the other hand, it is also nec-
essary to remember that functional murmurs are not so
common in the child, particularly in the infant, as they are
in the adult. Thus, every murmur — though there be no hy-
pertrophy developed as yet — should be suspected of being
dependent on organic disease. This may also be surmised
in most cases of acute chorea, which sometimes precedes
and ushers in, instead of following, endocarditis; and in
every case of articular rheumatism, the symptoms of which
may be sometimes so slight as easily to be overlooked.
Acute endocarditis is also common as a sequela of the
chronic form and as part of septico-pyaemia. It is not
uncommon as the result of acute and chronic nephritis,
and of infectious diseases, such as scarlatina, measles,
typhoid fever, variola, tuberculosis, and carcinosis, and is
frequently complicated — mostly through the intercession
of pericarditis — with pneumonia and pleurisy, also with
perihepatitis, perisplenitis, and generalized erythema. Fre-
quent and careful examination, therefore, during the exist-
ence of such ailments, while it facilitates an exact and
complete diagnosis, suggests the best method of prophylaxis.
Most of the cases of endocarditis we meet with in children
being due to acute rheumatism, every case of the latter,
though ever so slight, must be watched, put to bed, and
treated with sodium salicylate, which may be given a long
time after apparent recovery, or resumed with every new
attack. Almost every form of " growing pain " ought to
be so treated, and in no case of infectious disease must
the patient be permitted to leave the bed before much
of his previous strength has been restored.

The special treatment of acute endocarditis requires
absolute rest in bed, a dose of calomel sufficient to open the
bowels, and regular discharges through the course of the

61

DR. JACOBI'S WORKS

disease by means of enemata rather than of purgatives.
Frequent but small meals, and articles of food as sug-
gested above. If thirst be great, drinking should be per-
mitted often rather than much at a time. No alcohol in
the beginning. Depletion by leeches is rarely indicated,
and then only when there is a serious complication with
painful pleurisy. In rheumatic endocarditis depletion is
not tolerated. For severe pain which depends on pleural
complication the subcutaneous injection of a few drops of
Magendie's solution of morjDhine is preferable. Dry or
wet cupping will sometimes relieve in such cases ; other
derivants, such as sinapisms, will often suffice. Vesicatories
I do not advise in an acute case, the patient having enough
to suffer from nature's infliction. Ice applied in a bag,
which must not be too heavy, or ice-water cloths, well wrung
out, are beneficial in most cases, rheumatic or other. The
head and trunk must be raised so as to make the patient
as comfortable as possible. Blue ointment has been recom-
mended over the heart and other places, but I cannot say
that I have reason to advise it. Strong diuretics, such as
act by increasing blood-pressure, must not be given ; mild
salines will answer best; a small dose of calomel may be
given from time to time. According to the indications
noted above, potassium iodide, with or without an opiate,
will answer best, in doses of from fifteen to twenty-five
grains (1.0 to 1.75) daily, for a child of six years. An
opiate at night secures rest; potassium bromide may be
given through the day. If the case be rheumatic, as it
mostly is, sodium salicylate, from fifteen to thirty grains
(1.0 to 2.0) daily, will be tolerated and found serviceable.
Phenacetin may take its place sometimes, in daily doses,
all told, of from five to ten grains (0.3 to 0.6). It acts
as a febrifuge, an antirheumatic, and a sedative at the
same time, better than quinine, a dose of which may, how-
ever, answer well now and then, particularly during re-
mission. Antipyrin rarely, acetanilid never. Aspirin (sol-
uble in alkalies, therefore not affected by the stomach) may
be given in endocarditis when it is, as usual, rheumatic, in
three daily doses of from eight to fifteen grains (0.5 to
1.0) each. Serious attacks of dyspnoea are best relieved

62

DISEASES OF ORGANS OF CIRCULATION

by morphine, either internally or subcutaneoiisly, or by
lead and opium. Drastics will seldom be required and
seldom answer the purpose. The nitrites may be tried,
though they have not served me so well, or so often, as I
formerly thought I had reason to expect; they act best
when the pulse is dangerously small. When cachexia and
debility are prominent symptoms, tonics and stimulants are
indicated early. In bad septic cases chloride of iron may
be given at an earlier period. When streptococci are
found in the blood, the antistreptococcus serum (Marmorek)
may be injected in repeated doses of from five to ten cubic
centimetres daily, Crede's ointment should be used at the
same time, fifteen grains once or twice a day; subcutaneous
injections of yeast and of nuclein have been recommended.
Among the stimulants, I think highly of camphor and
ammonia. Among the direct cardiac stimulants enumerated
above, digitalis ought to be given only after the acute
changes in the muscular tissue of the heart have been re-
paired. (There is hardly a case of endocarditis unaccom-
panied by myocarditis.)

It is here that the experience and tact of the practitioner
must decide an important point. In the further evolution
of the case, digitalis with quinine, digitalis with bella-
donna, digitalis with strychnine, or with bromide, or with
iodide, together with stimulation of the peripheric circula-
tion by friction, either dry or with alcohol or hot or cold
water, find their own indications.

The hygienic treatment of chronic endocarditis has been
disposed of in former remarks. The medicinal agents of
most importance are digitalis and iron. Constipation and
over-exertion must be avoided. In connection with the
latter, the education and training of the child should be
so guided as to prepare him for his future trade, business,
or vocation. As endocarditis terminates so often in valvu-
lar disorders with consecutive hypertrophy, his future life
ought not to be exposed, if avoidable, to great excitements
or hard physical labor. A child so affected must not take
coffee, tea, or alcohol in any shape as an article of diet.
He must not be trained to become a military man, a pugilist,
or a medical practitioner.

6S

DR. JACOBI'S WORKS

The management of valvular changes resulting from
endocarditis is more successful in childhood than in the
adult. Compensation is brought about by consecutive hy-
pertrophy; thus it is facilitated, about puberty, by the
rapid growth of the heart at that period of life, and particu-
larly by the increase in size of the aorta and also of the
arteries in general, thereby easing the circulation. Besides,
purely vascular disease, which is so common in the adult,
is a rare exception in the child. Moderate exercise con-
tributes its share in increasing the growth of muscular
tissue of all kinds, and should be recommended, according
to Beneke,^ as also in undersize of the heart.

Pericarditis. — The pericardium is more accessible to the
influence of cold applications than the heart. They gen-
erally act well; but we must be prepared to meet with
doubtful or no success in many cases, for pericarditis is
but rarely a primary or uncomplicated disease; indeed, it
is more frequently fatal on account of its complications
than of effusion. Myocardial changes (fatty degeneration
mostly in the adult), acute oedema or acute inflammation
of the myocardium in acute articular rheumatism, chronic
interstitial myocarditis, or tubercle, or syphilitic gumma,
or complications with purulent mediastinitis or pleuritis,
are not uncommon. In pneumonia, pleuritis, and scarla-
tina, pericarditis is not unusual ; in rheumatism frequent.
The internal treatment of pericarditis is, therefore, in part
directed by the complications. Digitalis is indicated mainly

2 From birth to the seventh year the volume of the heart in-
creases from twenty-three to one hundred cubic centimeters,
by no means in proportion to the weight of the body. Still, this
increase is ^^ry much greater than that of the lumen of the
arteries when compared with the length of the body. The pul-
monary artery is wider than the aorta until puberty; afterwards
they are equal or the aorta becomes larger. The subclavian ar-
teries and the common carotids are very wide compared with the
length of the body (thereby causing physiological and pathological
congestions of the cranium and its contents). Between seven
and fifteen years the volume of the heart is from one hundred
and thirty to one hundred and forty cubic centimetres; at that
time the large arteries increase in absolute width.

64

DISEASES OF ORGANS OF CIRCULATION

in cases which are rather complicated; strophanthus, con-
vallaria, and potassium iodide may take its place or be
combined with it, according to the suggestions made above.
Morphine is demanded in most cases, if only to give rest
for the night. The fever may require phenacetin, aspirin,
sodium salicylate, or (during a remission) quinine. After
the fever has disappeared, or while it is waning, absorption
of the effusion may be promoted by caffeine, sparteine,
diuretin, iodides, and ^ vesicatory over the heart. Effu-
sion into the pericardium is not often so copious as to pro-
duce suffocation, but I am afraid that puncture of the
pericardium to relieve the fatal pressure is not made so
often as it ought to be. Fortunately, errors in the diagno-
sis are not very easily made; still, they do occur, for I
have been called to perform paracentesis of the pericardium
where there was some pericarditis, more hypertrophy of the
heart, and much pleuritis. The operation is not difficult,
the liquid being so copious as to give the heart ample
space to recede in a semi-recumbent position. The aspira-
tion should be made in the left mammillary line, in the
sixth intercostal space. In the same neighborhood, at
the upper margin of the fifth or sixth rib, the incision is
made to remove pus, and irrigations may be made after-
wards. Drainage has also been established in such cases.
If at the same time there be pus in the pleural cavity, it
may become necessary to select another spot for the peri-
cardial operation. A. Fraenkel recommended it on the
right side of the sternum. The heart has been punctured
during the aspiration without evil result; but I am not
prepared to say, even with Biedert, that " the puncturing
of the heart is not connected with any danger."

Hydropericardium, no matter from what cause, must
be treated on the same principles as those which are valid
in hydrothorax.

Syphilis of the pericardium and of the heart, if diag-
nosticated or suspected, require their own specific treat-
ment.

Neuroses of the heart are not so frequent in the child as
in the adult. The diaphragm, on account of its higher
location, may annoy the heart in tympanites ; undue motility

65

DR. JACOBI'S WORKS

(ptosis) of the heart may be congenital; solidification of a
lung may render posture on the opposite side difficult and
cause tachycardia or arrhythmia; early chlorosis or Graves's
disease, alcoholism, the use of coffee or tea, masturbation,
and early neurasthenia, often on an hereditary basis, may
cause — mostly about the time of puberty — all the symptoms
of slow, fast, or irregular heart's action. The treatment
should meet the causes: cold water washing and bathing,
cold applications to the heart, moderate gymnastics, no se-
dentary life, little schooling in the usual meaning of the
word, codeine one dose for the night, sodium bromide or
monobromated camphor in a few doses daily, enema daily,
a purgative occasionally, physical and mental hygiene.

Congenital anomalies of the heart claim attention from
the moment of birth. The newly-born candidate for
cyanosis is liable to suffer from asphyxia, the rules for the
treatment of which need no repetition here. When the
troubles, being the result either of embryonic arrests of
development or of foetal inflammations, prove incurable,
almost the only thing to be done for the little sufferers
is to protect them as much as possible. If they be so
unfortunate as to grow up, exercise should be avoided, —
indeed, is avoided. Alcohol is indicated in conditions of
collapse only ; no blood must ever be taken ; laxatives should
be sparingly given, if at all. The temperature in which
the little waifs are to live ought to be equable, moderately
warm, their wearing apparel warm and comfortable. Con-
gestive disorders which would require the use of cold in
otherwise healthy children must mostly do without it, as
the patients seldom bear it. Mild vegetable acids are
coveted by many. Only those who appear to develop hyper-
trophy of the heart should take digitalis or strophanthus,
provided their effect on the arteries need not be feared.
Small doses of an opiate will often relieve their discomfort
and dyspnoea. The combination of digitalis with iodides,
administered for months in succession, gave relief in a
number of cases in which the patients lived four years or
more.

There are anomalies of the infant heart which are
congenital, or nearly so, and still not comparable in dig-

66

DISEASES OF ORGANS OF CIRCULATION

nity to arrests of development. Rheumatism, scarlatina
(rarely), or inflammations of some intrathoracic viscus,
when contracted in early life, may result in cardiac com-
plications. They are on the left side of the heart (while
foetal endocarditis affects the right half pre-eminently).
Hcematoma at the free margin of the mitral valve is formed
immediately, or soon after birth, below the endocardium.
It is liable to disappear, and with it, by recovery, or by
compensation, or by increased frequency of the cardiac
movements (by which the blood-wave becomes smaller and
the valve excursion shorter), the systolic mitral murmur
caused by it (like that which is caused by rheumatic endo-
carditis) ; but excrescences, hard noduli (Cruveilhier), cica-
trization, and insufficiency of the mitral valve may per-
sist (Luschka, Virch. Arch., vol. xi.). The latter is easily
diagnosticated and requires the usual treatment of acquired
chronic endocarditis. As blood-nodules on the cardiac
valves, Berti (last in Arch. f. Kinderheilk., vol. xxxi., 1901)
describes what he takes to be, not hemorrhages, but ectasias
and cysts and evolution processes of the valvular tissue
with disappearance of the vascular net. Treatment as
above, if anj?^.

The ductus arteriosus Botalli becomes nearly obliterated
within two weeks, entirely within three months, by the
aspiration of its blood into the newly opened lungs, by its
being bent by the traction of the lungs, by the proliferation
of the spindle-shaped cells of the tunica media, and finally
by thrombosis. Theo. Escherich (Festschrift) describes, in
cases of patency of the duct, sudden attacks of shallow
or absent respiration, cyanosis, bulging eyes, swelled lips,
slow heart action, and tonic contractions of the extremities.
His treatment consists in B. Schultze's method of treating
asphyxia. It is to be repeated many times daily,
without much exertion, just enough to keep the lungs
acting.

Ptosis of the heart (dislocation downward) has been
observed with epigastric pulsation as the result of weakness
of the connective tissue of the great vessels which sustain
the heart. Varicosities and sclerosis were noticed as conse-
quences. Possibly a proper epigastric support may have

67

DR. JACOBI'S WORKS

a good effect. Four cases of Feranini (Cenlralhl. f. inn.
Med., January 6, 1899) were complicated with mitral
stenosis, small size and asymmetry of the cranium, feeble
bones, stunted growth, and deformed chest and extremities;
once with mental weakness.

Congenital undersize of the heart does not appear to be
so frequent as that of the arteries. Indeed, in many cases
of undersized arteries it was found of normal size, or some-
what larger. In the latter case the heart was not always
hypertrophic; on the contrary, in most instances there was
some fatty degeneration of the flabby muscle. Like every
small organ, the small heart may be built up by moderate
and persistent gymnastic exercise, a small dose of strych-
nine given three times a day for weeks or months in suc-
cession, cold washing and friction, and an altitude of
from one thousand to fifteen hundred feet. A cer-
tain amount of muscular growth will probably result from
it; it is quite welcome, for the labor of the heart requires
either an organ of sufficient size or one of unusual strength.

Neoplasms of the heart (carcinoma, sarcoma, fibroma,
myoma, lipoma, myxoma, tubercle, echinococcus, cysticercus,
and syphiloma) are rare in early life, the last named more
frequent than the rest, and the only one that so far can be
reached by (antisyphilitic) treatment.

II. THE BLOOD-VESSELS

The structure of the blood-vessels is sometimes very
defective, the walls being thin, fragile, and pervious. In
such cases hemorrhage, small or copious, is a frequent
symptom. The frequency of hemorrhages in the newly-
born, leading, when in the cranial cavity, to asphyxia,
convulsions, idiocy, or early death, is, among other
reasons, caused by the thinness of the vessel-walls, whose
tissue has not yet quite evolved from its embryonal
condition. This, or a similar condition, may continue for
life. This hypoplastic state, however, is not, of necessity,
general: it may be local. The early nose-bleedings of
some, though they have no heart disease, and the congenital
tendency to aneurism, mostly in places where the elastic

68

DISEASES OF ORGANS OF CIRCULATION

tissue, either from arrest of local development or by mi-
crobic destruction, is either scanty or absent (usually at
the origin of branches, Eppinger), prove the occasional
occurrence of these circumscribed and local defects.^ A
uniform thinness of many or all of the arteries, however,
is most likely to be complicated with narrowness, which
has been studied by Virchow, See, and others in its rela-
tion to incurable chlorosis, palpitation, and cardiac asthma.
That thinness which predisposes to fatty degeneration of
the intima and media, to sclerosis of the adventitia, to
atheromatous endarteritis, and to the formation of aneurism
at an early age has not been made the subject of active
treatment, so far as I know, except by myself. I feel
convinced that the administration of phosphorus, — not phos-
phates of any kind, — with its stimulant effect on the growth
of connective tissue in general, has rendered me good serv-
ice in habitual tendency to cutaneous, mucous, and inter-
nal hemorrhages. H cemophilia of moderate degrees ap-
peared to improve under its use, and the children to be
safer and better developed. The dose for a child of three
years should be from one-fiftieth to one-thirtieth of a grain
(0.001 to 0.002) daily; that means from two to three
minims of the oleum phosphoratum, or from one to one
and a half teaspoonfuls daily of the elixir phosphori
(United States Pharmacopoeia of 1890).*

Atheromatous degeneration of arteries, large and small,

3 A. Jacobi, Extracranial Aneurism in Early Life. See
Index.

4 The unreliability of the percentage of phosphorus when dis-
solved in oil, and particularly in cod-liver oil, is the cause of the
ill success in the hands of observers and of the clouds of Euro-
pean magazine articles that rain down on the profession If
they would only use, now and then, the preparations of the U. S.
Pharmacopoeia ! Binz, who favors phosphorus therapeutics
(mainly in rhachitis), recommends a method to determine the
percentage of phosphorus in oil solutions (Centralbl. f. inn. Med.,
November 14, 1902). A phosphorus solution which is invisible in
the dark becomes visible when warmed. Such solutions as con-
tain little phosphorus require a relatively high temperature for
that end.

69

DR. JACOBrS WORKS

in babies, children, and adolescents is rare, but cases are
from time to time reported. In another part of these vol-
umes I have spoken of the recommendation of lactic acid in
these conditions. Syphilitic vascular changes require their
specific treatment. Tuberculosis of blood-vessels, mainly-
small arteries, has been known a long time. Bacilli enter
through the lymph and the blood circulation, are frequently
perivascular first, and find their way into the intima.

Thrombosis of veins in general, and of the sinuses of
the dura mater in particular, is the result of retardation
of the (general or) local circulation and of coagulation
of blood by marasmus from whatever cause: rapid elimina-
tion of water (cholera infantum), debility of the heart,
pressure on veins, or inflammation in the neighborhood
(for instance, caries of the petrous bone). In the same
way thrombosis of the femoral vein may be caused by
peritonitis or by a pelvic tumor (or by fractures not set).
In the cranium the right transverse sinus is most fre-
quently affected, but quite often also the inferior petrous,
cavernous, and longitudinal sinuses. Such thromboses cause
hyperaemia, oedema, or extravasations ; it is by their symp-
toms that the diagnosis is made. The treatment must be
preventive in order to be successful. Early attention to
the ear and mastoid process, treatment of diarrhoea be-
fore inspissation of the blood and heart-failure take place,
timely stimulating and roborant treatment, and not pro
re nata, — that is, when it is just a little too late, — are
the best preventives. The subcutaneous injection of large
quantities of warm sterilized water, with sodium chloride
(7 to 1000), is capable of preventing the inspissation of
the blood resulting from acute and copious diarrhoea, and
often proves life-saving.

Welch refers a number of venous thromboses to cardiac
diseases (Festschrift), mainly to advanced mitral affec-
tion with failing compensation, tricuspid insufficiency, and
pulmonary infarctions. Flexner asserts the frequency of
terminal bacterial infections in heart diseases. All this
preaches the sermon of preventive treatment (arid cura-
tive so far as possible) of cardiac and of infectious dis-
orders.

70

DISEASES OF ORGANS OF CIRCULATION

Congenital local dilatations of blood-vessels, capillaries,
smallest veins, and smallest arteries, together with an in-
crease of their number, and mostly with incompetent struc-
ture, are known by the names ncevus, telangiectasia, angi-
oma. Their color depends on the nature of the blood-
vessels composing the anomaly, also on their distance from
the surface, their size on the extension of the morbid
process, and their size and consistency on the admixture
of connective tissue. They are found in all sorts of tissues
and organs, mostly on or below the surface of the body.
In the subcutaneous tissue, when mixed with much connec-
tive tissue, they are liable, after having remained unchanged
for many years, to undergo sarcomatous degeneration.
Therefore, and because of their tendency to rapid growth
in every direction, with increasing deformity and possible
danger from hemorrhage, the early removal of all those
which do not exhibit from the beginning a tendency to
fade and finally disappear is indicated. The methods
followed to obtain that end are very numerous. Vaccina-
tion over a naevus will generally destroy it, but may do
so but partially, and will leave a bad scar. Plasters of
tartar emetic and of Vienna paste cannot be controlled to
such an extent as to destroy the growth only. Injections
of perchloride or subsulphate of iron are known to have
given rise to extensive thrombosis, gangrene, and death;
injections of alcohol have been tried, but have not, I think,
reached farther than the ear of the medical public. Cor-
rosive sublimate in collodion (1 to 8) is an excellent
caustic where the naevus is not extensive, particularly on
the head; it rarely requires more than a single application.
Fuming nitric acid is perhaps the best of all local ap-
plications; the pain is but temporary, and the effect cir-
cumscribed and fairly thorough. But it ought to be
used for superficial naevi only, and even then requires repe-
tition in a number of instances. Excision is a good method
if the operation can be performed in a short time and all
the morbid parts can safely be removed without loss of
too much blood. The ligation of angiomatous tumors is
indicated where they can be entirely grasped either with-
out or with the aid of needles run through their base;

71

DR. JACOBI'S WORKS

but time is required for them to fall off finally, and the
wound demands careful and persistent antiseptic treatment
until the danger from local infection has passed and a
smooth scar has been perfected. Electrolysis has been
praised very highly, particularly in the treatment of the
extensive wine-marks. Still, personally, I never saw a
satisfactory result in these cases. There remained always
speckled, whitish scars of small size alternating with the
original discoloration, — a result which I should not claim
as an improvement upon the original condition. The actual
cautery is the most satisfactory of all our remedies ; very
few will at present use it in any other shape than that
of the galvano- or the thermo-cautery. The heat should
not be excessive: white heat destroys blood-vessels too
rapidly to permit of simultaneous coagulation of the blood,
and produces hemorrhages. Dull-red heat will accomplish
a cure. A momentary application suffices for a superficial
naevus; its action can always be controlled and strictly
localized, and the formation of the scurf secures against
surface infection. Nor are large angiomata inaccessible
to it. When these are to be destroyed, it is best not to
attempt too much at first. It is unnecessary to destroy
everything; long after the direct effect has passed away,
coagulation in the blood-vessels and slowly progressing
cicatrization result in the gradual lessening of the swell-
ing. When the tumor ceases to diminish in size, the opera-
tion is repeated, sometimes after many weeks or even
months. The cautery is then introduced into the very spot
at which the previous application was made. In this way
the cicatrix remains localized. As a general rule, a cica-
trix following the application of the actual cautery is
smooth and becomes more so and less perceptible from year
to year.

72

TUBERCULOSIS

The definition of the term " tubercle " has experienced
a great many changes. Originally it means a prominence
or protuberance. In the Latin translations of Hippocrates
it stands for cold (caseous) abscesses. Francis de le Boe
(Sylvius^ 1614-1672, in " Praxeos Medicae Idea Nova,"
1 667-1 674) applies the name to small bodies met with in
diiferent tissues and developed from presumed invisible
glands, Baillie (1761-1823) to an abnormal product of
scrofulous origin, Bayle (1774-1816) to an independent
specific neoplasm endowed with great tendency to caseous
degeneration. With him, indeed, the latter was character-
istic of, and solely found in, tubercle. He and Laennec
(1781-1826) looked upon the tubercle as the cause of con-
sumption (phthisis), the latter author adding to pathology
and nomenclature the term " tubercular infiltration." Lebert
(1813-1878) described the microscopical "tubercle cor-
puscle " as consisting of disintegrated cells, or free nuclei,
thus enabling everybody to discover tubercle wherever it
did and did not exist. Schonlein (1796-1848) was the first
to use the term " tuberculosis."

According to Virchow, the tubercle is an organized,
though not vascularized, neoplasm composed of round cells
with very vulnerable and deciduous membranes and very
numerous nuclei. These may be so copious, indeed, that
the membranes are sometimes not discovered. The tubercle
is small; even the smallest, however, is often a conglom-
erate; it is of gray color, turning yellow through caseous
(fatty) degeneration, which begins in the centre. It leads
to tubercular " infiltration " by the aggregation of many
tubercles and secondary inflammation in the neighborhood;
or to ulceration; or to the hardening of the small body
(" fibrous tubercle ") by disintegration and absorption of
the cells and the increase of the, originally, scarce and
thin connective tissue.

73

DR. JACOBI'S WORKS

The small epithelioid cells with their nuclei were soon
found not to be the only microscopical constituents of the
tubercle. Virchow, Rokitansky, and many others, found
" giant cells/' and Th. Langhans claimed them as almost
constant constituents. They are of spherical shape, con-
tain from twenty to a hundred nuclei, with leucocytes in
their periphery, and a very fine reticulated tissue between
these constituents.

The reticulated tissue, and giant cells, are mostly found
in chronic tuberculosis. In this process a considerable
amount of fibrillar connective tissue is met with in the
periphery of the deposits. In the acute process small
spherical cells are more frequently found; they are also
copious in the periphery of tubercles when they undergo
caseous metamorphosis. This latter process is apt to
spread into the surrounding congested or inflamed tissue;
quite often the very caseous masses contain tubercles still
intact.

To identify, however, caseous degeneration with tuber-
culosis would be a mistake. The former is no neoplasm,
nor intimately connected with a specific neoplasm, but a
retrograde metamorphosis. It is not characteristic of any
single pathological tissue or condition, for, besides being
found in tubercle and inflammatory deposits, it may be the
final stage of development in pus, cancer, and typhoid in-
filtrations.

Nor are giant cells pathognomonic of tuberculosis. They
are found in the disintegrating osseous substance, in the
cavity of the uterine sinuses near the insertion of the
placenta, near foreign substances experimentally introduced
into the peritoneal cavity, in pneumonia, syphilitic en-
darteritis and gummata, in healthy granulations, sarcoma,
and actinomyces, and in the subcutaneous tissue of animals
into which silk, hair, and other foreign bodies had been
introduced for the purposes of experimental research
(Birch-Hirschfeld).

Thus, neither the histological structure of the tubercle
nor its tendency to caseous degeneration suffices to char-
acterize tuberculosis as a specific disease of an infectious
nature. The latter has long been assumed to exist by com-

74

TUBERCULOSIS

mon consent, and appears to be finally demonstrated by
R. Koch's discovery of a specific bacillus which gives rise
to a local irritation and the formation of the specific
noduli. Modern pathologists have agreed in this, that
only such products, though histologically the same or simi-
lar, as contain, and result from, the specific bacilli, de-
serve the name of tuberculosis. Thus, tuberculosis is de-
fined as an infectious disease which shows, as the result
of immigration and proliferation of a specific bacillus,
conglomerates, small or large, consisting of cells with few
or many nuclei and nucleoli, and (as they are without
blood-vessels) disposed to undergo speedy caseous degen-
eration. In the latter condition, when recent, the tubercle
is called yellow. The accumulation of a great many
yellow tubercles forms what is called an infiltration. Cal-
cification is the result of copious hyperplasia of cellular
tissue round a tubercular infiltration. Softening is a more
frequent occurrence, and leads to the disintegration of
viscera, cold abscesses in the subcutaneous tissue, and al-
terations of mucous membranes. '^

Etiology. — Congenital predisposition need not be iden-
tical with hereditary transmission. The former may result
where numerous children are born of non-tuberculous par-
ents in too rapid succession; from puny development of
the infant; from under-size of the heart, from anaemia

1 Thus, according to the present state of the pathological doc-
trine, tuberculosis demands the presence of the bacillus. Still,
there are processes which are tuberculous in everything but the
bacillus. Thus, Malassez and Vignal found zoogloea only, mostly
without bacilli, in " tubercles " produced in experimental pro-
ceedings. Similar results were obtained by Cartro and Soffia:
their zoogloea could be inoculated successfully. Biedert reports
the case of an acute pulmonary tuberculosis without bacilli.
Rlbbert met with small bodies consisting of lymphoid and other
cells, giant cells included, without bacilli, which he prefers to
call multiple lymphomata solely because of the absence of the
micro-organisms. Eberth describes the same condition under the
head of " pseudo-tuberculosis." Biedert (Lehrb. d. Kinderkr.,
1887, p. 533) suggests that there must be either an affection
which cannot he distinguished from tuberculosis, or a condition
of the bacillus which renders its recognition impossible.

75

DR. JACOBI'S WORKS

based upon stenosis of the pulmonary artery, or from
congenital shortness or premature ossification of the costal
cartilages in the upper part of the chest, by which the
apices are prevented from expanding and the circulation
of the blood is impeded.

Hereditary transmission of tuberculosis has been claimed
as a fact by common consent, because of the frequent
occurrence of the disease at an early age, and the great
number of cases observed in a family. Vogel looks upon
heredity as the principal etiological factor. For he ob-
served that a child of a healthy family when living with
a predisposed family under the worst possible hygienic
surroundings would not suffer, while all the rest would
succumb. Thus he concludes that external influences are
injurious to those only who are predisposed, no matter
whether heredity is visible in the propagation of either
a predisposition or a virus. It is the latter in which
Baumgarten believes. Brehmer, however thinks but little
of either mode of transmission, because " not more than
one-third or one-half of all the cases " occur in families
in which there is a multiplicity of cases.

Hereditary transmission ought not to be presumed to
exist at all except in cases which occur at a very early
period of life. Infants of tuberculous parents, though
they fall sick with tuberculosis, or atrophy, or marasmus,
when but a few months old, may suffer from the conse-
quences of a germinative process, but their disease majf
also be due to direct contagion, or tuberculous food. Still
less conclusive are those cases which make their appear-
ance in bones, or glands after a number of years only.
It is mainly this class of cases that has given rise to
the theories based on predisposition, or on the gradual
transmutation of scrofulosis into tuberculosis.

Hereditary transmission of tuberculosis is not accepted
by a number of the most critical pathologists. Bcnda
denies the possibility of the transmission of bacilli through
sperma which has its origin in nuclei not infected by
parasites. He did not find them in sperma secreted by
tuberculous testicles, nor in that of phthisical patients
whose testicles were healthy. Virchow takes it for granted

76

TUBERCULOSIS

that tuberculosis resulting from infected sperma ought to
develop at a very early period of life, in which it is rare,
or at birth, when he knows of no such case. He even
found the foetus without tubercles when the mother had
tubercular endometritis, and does not admit the possibility
of a direct transmission unless the circulation of the pla-
centa be abnormal. Still, under certain circumstances
the blood-vessels of the placenta are known to be pervious.
Coloring substances have been found to penetrate into the
body of the foetus by Reitz and Mars, while other ex-
perimenters have but negative results. The bacilli of an-
thrax have been found in the foetus by a single observer,
those of septicaemia by a very few. That, however, some
medicinal substances will traverse the placental circula-
tion and be found in the foetus, we know; also that syphilis,
variola, relapsing fever, malaria, may be transmitted from
the mother to the foetus. Such facts exist, though they
may be explainable only by the assumption of a morbid
alteration in the walls of the blood-vessels of the placenta
or its insertion.

There are, however, some facts which render the theory
of a direct transmission of tuberculosis somewhat probable.
Thus, in the spermatic canals of non-tuberculous testicles,
in eight men dying of phthisis, C. Jani found bacilli five
times, and four times in the prostate glands, out of six
autopsies. Besides, there are a few cases of congenital
tuberculosis of animals on record. I willingly exclude
Czokor's calf of three weeks, and the two calves of Hert-
wig's of two and four months; for all of them may have
contracted acute tuberculosis after birth by direct com-
munication or the milk sucked from a diseased udder.
But Johne has the report of an eight months' foetus of a
calf, with universal tuberculosis.

In the human race no case of a similar nature has been
known, but in I86I I attended a phthisical woman in her
first confinement. She belonged to a consumptive family,
had suffered herself before she got married, and died in
the third week after confinement. The foetus was born
at the end of the seventh month of utero-gestation, and
lived a few minutes only. There were numerous gray

77

DR. JACOBFS WORKS

miliary tubercles in the tissue of the liver near the sur-
face, a few in its peritoneal covering and the spleen, and
on the pulmonary pleura. The father was healthy and
remained so for years. Thus this isolated case, the only
one of the kind ever observed by me, appears to prove
the possibility of a direct hereditary transmission from
the mother to the offspring. Epstein's two hundred babies
of tubercular mothers yielded a negative result. There is
but one of them who had tuberculosis at the age of ten
weeks.

There are other observations which appear to prove that
hereditary transmission is more frequent than is allowed by
those who insist upon inhalation as the only cause of tu-
berculosis. Indeed, such observations are numerous. In
the earliest period of life, tuberculosis is mostly found in
the lymph-bodies and the bones. Why not first in the
lungs, if inhalation brought it on? It has been noticed
that healthy babies, raised in tubercular families, are not
liable to be infected, while the children of parents who
died of tuberculosis while the former were quite young,
would still die of tuberculosis, though removed to healthier
quarters.

Though the cases of tuberculosis in the very first weeks
of life be ever so scarce, we cannot say that any age is
entirely exempt. Baumgarten met with cases of tuberculo-
sis at the age of one month, which were so advanced
as to make its starting during foetal life probable. Steiner
and Neureutter report cases of tuberculosis occurring at
the age of eight weeks, F. Weber cavities at less than three
months, Demme on the twelfth day, Steffen at three weeks.
Demme has another case of a baby three weeks old with
tuberculosis of the intestine, and bacilli; and another one
of four weeks with pulmonary cavities. Between the fourth
and sixth months of life I have met with it in a number
of instances. Lorey gives the ages of one hundred and
sixty-two tubercular cases among children as follows: from
the first to the third month, one; from the third to the
ninth, eleven; from the ninth to the twelfth, thirty-one;
between the first and the second year, fifty-five; from the
second to the fourth, forty-one; and from the fourth to

78

TUBERCULOSIS

the twelfth, twenty-three. In Biedert's tables containing
the ages of the young affected with pulmonary tuberculosis
six and eight-tenths per cent, were observed under one
year of age, forty-eight from the first to the fifth, twenty-
seven from the fifth to the tenth, and eighteen per cent,
from the tenth to the fourteenth year. Thus tuberculosis is
comparatively rare under one year, undoubtedly because
of the comparatively few opportunities for infection: as
a rule, these early cases are due to, or connected with,
the existence of catarrhal pneumonia, or intestinal difficul-
ties, or marked scrofulous disposition. Between the ages
of two and four years it is quite frequent, the lungs, pia
mater, and intestine being the very organs through which
it is apt to become fatal. In the former two, in early
childhood it is not readily of a primary character; at that
age the intestines, bones, and lymph-bodies are more liable
to be the seats of the original inlet than the lungs. These
are more easily affected, primarily, in advanced childhood,
and about the period of puberty.

The former belief that acute tuberculosis was more fre-
quent in the young, and the chronic variety in the old,
holds good no longer, since a larger number of diseases of
the bones and lymphatic glands have been recognized to
be of a strictly tubercular character. It is particularly
the latter organs that are exposed to infection, because of
their superficial location, and, in infancy and childhood,
the comparatively large size of the lymph-ducts, the greater
vulnerability of the surface which facilitates the access of
a virus, and the physiological activity of the whole lymph-
circulation.

This is but one of the many instances of the peculiarities
of disposition depending on the nature of the tissues.
Others are found in the different degrees of the energy
of respiratory movements, the various conditions of the
epithelium, the secretion of the muciparous glands, and
the circulation in the lungs. In the latter, tuberculosis is
not so frequent in the apices of the young as in those of
the adult, because of the larger amount of air entering them
in the former. In them, indeed, it is the lower parts of
the lungs which are often the preferred seat of the malady.

79

DR. JACOBFS WORKS

And those lungs which are anaemic, either on the basis of
general anaemia or as the result of the stenosis of the pul-
monary artery, are much more liable than those affected
with chronic venous stasis depending on emphysema, ky-
phosis, or congenital or acquired disease of the heart.

Animals have been made tubercular by the inhalation
of tubercular sputum. The viability of the bacilli and
their spores is such as to render them dangerous though,
or because, they have been in a dry state on the floor of
the room, in carpets, linen, or clothing, for a long period.
They will not easily locate in the external parts of the
respiratory organs where the air is cool and its current
capable of carrying them out as well as in. That " bad "
air is a cause of general tuberculosis has always been
accepted as undeniable. The latter would increase with
crowding. In the foundling asylum of Stockholm, Abelin
noticed that the proportion of cases of tuberculosis would
increase with the number of inmates. In the light of mod-
ern pathology the " bad " condition of the air may signify
as well the prevalence of bacilli as the presence of in-
jurious gases and the diminution of individual air-space.

Inhalation has always been considered as one of the
principal sources, or the principal source, of acquired tu-
berculosis. Many of the reports, however, which were
meant to prove the frequent occurrence of such cases,
leave ample room for doubt: thus, for instance, those of the
ten new-born babies said by H. Reich- to have been in-
fected by a consumptive midwife, who had the unfortunate
habit of insufflating the respiratory organs of the young
with her own breath.

In order that virus, or a bacillus, may find a resting-
place, the surface must be in a morbid condition. A mucous
membrane of normal consistency and function is not very
liable to admit infectious diseases. Neither diphtheria nor
tuberculosis finds a safe nest on a healthy membrane. As
long as a mucous membrane is covered with normal mucus
and protected by vibrating epithelium, foreign bodies,
from particles of carbon and metal to bacilli, are liable to

2 Berl. Klin. Woch., 1878, No. 37.
80

TUBERCULOSIS

be expectorated. Only the air-cells which have no fim-
briated epithelia allow bacilli to rest and to develop. All
the other surfaces of the respiratory organs are endowed
with means of self-defence. The latter, however, is greatly
interfered with either by an abnormal structure of the
integuments or by actual lesions. The former may be
inherited from parents suffering from chronic infectious
diseases, such as tuberculosis or carcinosis, or acquired by
previous exhausting ailments, anaemia, or chlorosis; the lat-
ter may result from measles, whooping-cough, typhoid fever,
or scarlatina, or inflammation or gangrene of the lungs,
which thus give rise to a predisposition to tuberculosis by
having prepared the surface for the admission of the virus.

The bacillus, however, is not found floating in the air
and ready for inhalation unless under exceptional circum-
stances. To be inhaled it must be dry. As long as sputum
is moist, or after having been dry, is again exposed to
moisture, it cannot be mixed with the air and thus enter
the lungs of another person. Besides, the bacillus has a
greater specific gravity than air, and falls to the ground.
But it may adhere to bedclothing, or the bedstead, or the
walls of the room, or the floor which has been soiled.
Thus, children of a phthisical mother may all be infected
by their close contact with her and her surroundings, while
a nurse, or the husband who goes about his business, is
not suffering. Thus, also, the phthisical patients in the
wards of a hospital are uninjurious as long as no expec-
toration is permitted anywhere but in a spittoon containing
some water.

Still, the frequency of tuberculosis makes its transmis-
sion easier than the explanation of the latter in every case.
Thus, for instance, Spillmann and Haushalter,^ having made
the observation that flies would concentrate round the sputa
of tubercular patients, kept a number of them under a
bell-glass, where they died the following day. Their ex-
crements deposited on the glass and the contents of their
abdomens exhibited an abundance of bacilli tuberculosis.
As these bacilli are very hardy, their transportation by

sLa France Med., 1887, t. ii. No. 101.
81

DR. JACOBI'S WORKS

the fly to the food of human beings, and those contained
in the dried remains of the fly, appear to open a possibility
to the transmission of tuberculosis to an almost incredible
degree.

Besides, the bacillus of tuberculosis is of slow growth,
and thus facilitates self-protection on the part of the en-
dangered organ and organism; though, on the other hand,
it is very tenacious of life. For a five-per-cent. solution
of carbolic acid destroys it after twenty-fqur hours only,
and a still longer time is required by a one-per-mille solu-
tion of bichloride of mercury. It does not even perish
when exposed to a high degree of heat: G. Cornet exposed
mattresses to the eff'ect of public steam-heating apparatuses
six times, and still found bacilli uninjured and active.

The entrance of tuberculosis through the skin or wounds
is among the possibilities. As long, however, as the skin
remains in a normal condition, it aff'ords protection against
the entrance of tuberculosis. But abrasions and wounds
create a disposition. Still, the development of bacilli ap-
pears to require a higher temperature than that of the
very surface, and a sufficient time for their sure installation.
Thus is explained why the number of authenticated cases
of the invasion of tuberculosis through the skin is still
limited. Willy Meyer collected* twenty-eight such cases ;
M. B. Schmidt and others have since published a few
more. Eighteen of the twenty-eight were those of Jewish
infants subjected to ritual circumcision, which permits,
or requires, the sucking out of the wounds by the lips of
the operator. The incubation-period lasted from ten to
fourteen days; after that time the first symptoms showed
themselves as inguinal adenitis. Of the eighteen, nine
died, five exhibited symptoms of scrofula, and four were
not under observation afterwards. In a few (adult) cases
of wound-infection the disease remained local ; still, it is
probable that, as the development of tuberculosis is a grad-
ual one, many isolated cases due to local infection may
become generalized after a while. Chronic inflammations
of the skin may frequently give access to the virus. Demme

*N. Y. Med. Presse, June, 1887.
82

TUBERCULOSIS

found chronic impetigo in four hundred and thirty-seven
out of eight hundred and seventy-three cases of diseases
of the bones and joints.

In the Congress^ assembled at Paris in July, 1888, for
the study of tuberculosis. Dr. Degive, of Brussels, alluded
to the possibility of transmitting the disease by vaccination.
In his city the calf from which the virus has been taken
is killed; when it is found to have been healthy, the virus
is used for both human vaccination and the artificial in-
fection of other animals. But even the danger from virus
taken from a diseased animal is but very slight. For the
bacillus does not easily penetrate through merely super-
ficial wounds, and certainly not into the serum of the vesicle
any more readily than is done by the syphilitic poison.
Thus no danger appears possible unless blood be mixed
with the serum of the vesicle used for the vaccination
of the human being.

One of the inlets of tuberculosis is undoubtedly the ali-
mentary canal; indeed, there are some who attribute every
case — or almost every case — of tuberculosis in the young
infant to the influence of food containing the bacillus.
Koch has established the fact that the latter may pass
through the stomach and remain intact; in the intestinal
canal it may be found mixed with food and nasal and
pharyngeal mucus. In the healthy digestive organs it will
do no harm ; indeed, the normal stomach will not permit
it to live. But the absence of acids in the feverish stomach,
and the changes produced in the mucous membrane by
abnormal digestion, sedentary life, emotions, serious ill-
ness, or constitutional ill-nutrition of the digesting surfaces,
may yield conditions favorable to the invasion.

This may take place when the bacillus is an accidental
admixture to the ingesta, or is swallowed with the expec-
toration, all or most of which is carried downward by in-
fants and children. Thus a constant auto-infection is added
to the original disease when this is located in the lungs.
But the main opportunity for the invasion is furnished
by the meat and milk of tuberculous animals. In the

5 Congres pour I'fitude de la Tuberculose, Paris, 1889, p. 157.

83

DR. JACOBI'S WORKS

slaughtering houses of Rouen there were 1.43 per mille
tubercular heads of beef, O.OQ of calves, and 0.38 of hogs:
these figures are the average of the four years between
1884 and July of 1888. There were furnished in Mon-
tauban, in the course of seven years, 4.07 per mille of
tubercular beef among all that were slaughtered. Fiirn
found twenty-two tuberculous geese in three hundred and
sixty-five autopsies, Reimann sixty-two hens among six
hundred, and eleven pigeons affected with the same disease
among one hundred and thirty-eight autopsies. Walter K.
Sibley found bacillus mostly in the peripherous parts of
caseous masses removed from fowls,*' and in undoubted
lymphomata, undergoing central necrosis,^ taken from a ser-
pent, also from a peacock and an owl. Among sheep and
goats, which move in fresh air, there were but few affected
with tuberculosis. The influence of air and exercise is quite
marked, so much, indeed, that T. Spillmann found from
thirty to forty per cent, of all the stall cows of Nancy to be
sick with tuberculosis. Even more than this percentage of
tubercular animals is obtained by Brush for those which
are " improved " by persistent breeding in. The opinions
in regard to the danger attending the eating of meat taken
from tuberculous animals are by no means uniform. In
the muscular tissue the bacillus develops but incompletely:
indeed, it has been observed to die within six days. E.
Nocard found invariably that the inoculation of meat juice
taken from tubercular animals had but little success ; and
Arloing, another of the great veterinarians of France, had
the same results in his experiments. Both, however, found
an abundance of bacilli in the glands, kidneys, spleen, and
liver of the diseased animals. All of these organs are de-
clared to be very dangerous under these circumstances,
but the meat is deemed to be innocuous or but little danger-
ous in all but a very few cases. G. Butel, however, con-
siders the meat of tubercular animals to be injurious under
all circumstances. Baillet fears it only when the malady
has rendered the animal thin and languid ; but, again,

6 Trails. Path. Soc, London, 1888.

7 Virch. Arch., vol. cxvi. p. 104, 1889.

a4

TUBERCULOSIS

Veyssiere advises the exclusion of the meat of every ani-
mal suspected of tuberculosis, and emphasizes the fact
that hogs are very subject to the disease.

The same difference of opinion prevails in reference to
the milk of tuberculous animals. B. Bang found that
milk of phthisical women could be inoculated with no dan-
ger at all. The inoculation of milk taken from twenty-
one diseased cows yielded a trifling success in but two
instances. But the majority of authors see more harm in
such milks, and there are those who, like V. Galtier, find
bacilli and danger not only in the milk of infected cows,
but also in its products, such as cheese, buttermilk, and
whey. Koubassoff attributes great danger to every milk
of tubercular cows, Bollinger and Nocard only to that
which is taken from tubercular udders. Still, authors of
equally high reputation, such as Bouley and Bang, do not
deem the presence of a tubercular mastitis necessary;
the latter is declared to be a rare disease by Nocard, a
frequent one by Degive and Van Hertsen. Upon this,
however, all appear to be agreed, that heat destroys the
dangerousness of milk obtained from infected animals.
From 60° to 75° C. diminish it considerably. Milk heated
to 85° C. is deemed safe.^ For thirty years I have insisted
upon the necessity of avoiding raw milk among the foods
of children.

Localization. — There is hardly an organ in the infant
or child which may not be affected by the tubercular
process.

Cutaneous tuberculosis may appear in a primary and
secondary form.

The primary form, or lupasy-is-iiot very frequent dur-
ing childhood, but still many of the cases met with in
adolescence and advanced age date from early life. It
has a very slow development. It is found on the face
and extremities, and sometimes extends to the mucous
membrane of the mouth, nose, pharynx, and larynx. On
all of the latter it yields a diffuse infiltration, not
nodulated, of gray color and irregular surface, inter-

8 Congres pour T Etude de la Tuberculose, Paris, 1889.
85

DR. JACOBI'S WORKS

rupted by rhagades and ulcerations; while in the former
it consists of red or brownish noduli, which are deeply
embedded in the corium, with an occasional tendency
to disintegrate and either form ulcerations or result in
a desquamative process or a cicatricial atrophy. Ana-
tomically, it is composed of small nests of round cells em-
bedded in the interior of the corium, giant cells (mainly
in the large noduli), and hyperplastic proliferations re-
sembling those of epithelial carcinoma. It contains the
tubercle-bacillus, and tuberculosis can be produced by its
inoculation. It is not uncommon to find general tuberculosis
in other members of the same family. Still, the tuber-
cular nature of lupus has been doubted by Kaposi, because
of the paucity of the bacilli in the morbid changes, the
non-appearance of general tuberculosis in the same in-
dividual after a long duration of the lupus, the impossi-
bility of multiplying lupus by inoculation, and the almost
universal immunity from lupus of the other members of
the same family.

The secondary form of cutaneous tuberculosis starts from
tubercular joints, mucous membranes, and caseous and sup-
purating lymph-bodies. Fistula in ano may give rise to it,
as, indeed, tuberculosis is apt to appear near the mouth,
the anus, and the genital organs. In one of my cases,
that of a girl of seven years, the process commenced from
a neglected abscess in the right axilla. The fistulous and
undermined ulcerations spread in every direction, extended
over the chest, resulted in tuberculous abscesses extending
towards the abdomen, and finally in pyothorax, with gen-
eral miliary tuberculosis. This form is not nodulated, not
hard, and not of that slow growth extending over years
so characteristic of lupus, but is more ulcerous, of irreg-
ular outlines, and with but little infiltration. From syphilis
of the cutis it is best diagnosticated by its very slow
growth and the absence of the indurated boundary peculiar
to the syphilitic ulceration.

In the joints and bones tuberculosis is frequent. Many
of the cases of caries are of that nature ; a large percen-
tage of the cases of ostitis of the foot and ankle and of
spondylitis belong to this class; also a number of cases

86

TUBERCULOSIS

of caries of the mastoid process^ with or without facial
paralysis, and of otitis media, extending to the bone. The
fungous arthritis is pre-eminently tubercular, for bacilli
may be found in many a case. This class of cases is quite
dangerous when left alone to such an extent as to lose
its local character. If removed by an operative procedure,
the localized tuberculosis loses its dangerous nature, and
general infection may be avoided.

On the pleura, also, tuberculosis may be either primary
or secondary. In infancy and childhood the former occur-
rence is but rare; as a rule, tubercular pleurisy, or tubercles
on the pleura, are met with in generalized tuberculosis.
In that case the tubercles are small or large, gray, yellow,
or caseous; large caseous tubercles are mostly found on
the point of contact of the adhering pleura. The assump-
tion that every pleurisy is tubercular is based on theory
only; for the cases of chronic pleurisy, of thickened pleura
carried many years without a trace of tuberculosis, are by
no means rare. The fluid of the pleural cavity found in
tubercular pleurisy is either serous or purulent; in very
rare cases there is blood mixed with the serum, or clear
blood. Tuberculosis of the pericardium I never found, ex-
cept complicated with that of the pleura, or as a part of
general acute miliary tuberculosis.

The low temperature of a part of the nose, the constant
motion of the air-current, and the presence of secretion
on the mucous membrane render primary tuberculosis of
that organ a rare occurrence. Still, the so-called scrofu-
lous ozaena is very often tuberculous; even that, however,
is quite often not primary, but the result or accompaniment
of neighboring or general tuberculosis. In and about it,
giant cells and bacilli are met with. The majority of cases
of nasal tuberculosis are of a secondary nature. It is
either miliary, the nodules are gray or yellow and disinte-
grate very readily, or it exhibits large ulcerations of ir-
regular shape, or, thirdly, large tumors, mostly on septum
or conchae; they rarely extend to the bone, and consist of
connective and granulation tissue and miliary tubercles.

Both primary and secondary tuberculosis of the pharynx
is relatively scarce in infancy and childhood, though its

87

DR. JACOBI'S WORKS

surface be constantly exposed to the contact with infected
expectoration. Still, I have seen quite a number of cases,
mainly between the ages of seven and fourteen, in which
both miliary tubercles and painful tubercular ulcerations
were found on the soft palate, tonsils, posterior wall of
the pharynx, and nares. In a few cases the ulcerations
were so deep, and the accompanying oedema so extensive,
that fluids would escape through the nose. In one case
the diagnosis from syphilis could not be made except after
a certain time; as a rule, however, syphilitic ulcerations
are less numerous, but deeper and steeper, and apt to heal
under specific treatment.

Tuberculosis of the larynx is not so frequent in children
as in adults. Of primary cases, or such as I could take
for primary, I have seen but very few. At all events, when
the diagnosis of tuberculosis of the larynx had been made,
the appearance of pulmonary symptoms was but a ques-
tion of a short time. Still, there is no reason why bacilli
should not locate in the mucous membrane predisposed by
the presence of catarrhal erosions, mainly on the vocal
cords and in the interarytenoid space, also on the edges
and the inferior aspect of the epiglottis. It is on these
localities that both miliary tubercles and ulcerations are
sometimes found. Mild symptoms of catarrh, hoarseness,
cough, are observed at an early period, speaking and
pressure are painful, the expectoration contains pus, blood,
bacilli, and sometimes elastic fibres, and the laryngoscope
reveals an incomplete closure of the glottis, the presence
of tubercles or ulcerations, and, occasionally, localized
oedema (perichondritis).

In the thymus gland tuberculosis is not rare at all. It
was met with by Dr. Koplik and myself three times in
sixty autopsies of infants under a year, twelve of whom
had generalized tuberculosis. Sometimes it is found in
the thymus, while no other organ, and no other member
of the same family, is affected."

Tuberculosis of the peritoneum is rarely a primary dis-

9 Con^^s pour rf-.tude de la Tuberculose, Paris, 1889. See
Index.

88

TUBERCULOSIS

ease, and then acute or with high fever and urgent symp-
toms. It is mostly secondary, a part of general tuber-
culosis, or connected with protracted suppurations, or
depending on embolism. It may originate in more advanced
age in uterine tuberculosis, the tubes being the connecting
link, or result, in the child, from intestinal ulcerations or
disintegrated mesenteric glands. Sometimes it is quite
local, in an intestinal adhesion opposite an open or cica-
trized ulceration; in other cases it extends over large sur-
faces and may result in wide-spread adhesions, contrac-
tions, perforations, and hemorrhages. The tubercles found
may be small or large, gray, yellow, or caseous. The ac-
comjjanying inflammation may result in the effusion of
large quantities of serum containing much albumen, or in
fibrinous thickening of the peritoneum of the abdominal
wall, liver, spleen, and omentum, with considerable glan-
dular swelling, or the formation of large masses of exuda-
tion, between which and malignant tumors, mainly sar-
comata, the diagnosis may be quite difficult. Still, not all
of these exudation-tumors are of tubercular nature. I have
seen them, from the size of a hazel-nut to that of a goose-
egg, sometimes in large numbers, as the result of a chronic
exudative peritonitis of non-infectious character, and dimin-
ishing in size and disappearing altogether until a perma-
nent recovery. The temperature may not be very high
(" peritoneal tuberculosis "), or may be quite elevated
(" tubercular peritonitis ") ; other symptoms, such as fluc-
tuation, pain, dulness on percussion, meteorism, diarrhoea
or constipation, jaundice by compression of the ductus
choledochus, obstruction by pressure on, or contraction of,
intestines, depend on the extent of the affection and its
more or less acute character. In the case of a boy of
seven 3'ears who died with general tuberculosis, I found,
beside large quantities of serum, which filled the abdominal
cavity, complete adhesion and thickening of all the intes-
tines, so as to yield the consistency and hardness of paste-
board. In the very young children isolated peritoneal
tuberculosis is but rare; it is, however, a frequent occur-
rence in generalized miliary tuberculosis; in older children
I have seen many cases in which — mostly on the founda-

89

DR. JACOBI'S WORKS

tion of glandular degeneration — the disease, usually of a
chronic character, appeared to have been the starting-point
of the general affection.

The tuberculosis of the liver, spleen, and supra-renal
bodies is, with very rare exceptions, secondary to, or a
part of, general tuberculosis. Those organs are generally
affected only towards the fatal termination, the tubercles
being gray or yellow, seldom large and caseous.

The kidneys, both capsule and substance, participate in
generalized tuberculosis. A large tubercle, of the size of
a hazel-nut, I have seen in the left kidney of a girl of
eight, who exhibited caseous degeneration of many of the
bronchial and mesenteric glands, and cavities in both apices.
Such a condition may be presumed to exist wlien a tuber-
culous child exhibits haematuria or dysuria. Tubercular
ulcerations of the ureters or bladder I have not met
with.

Tuberculosis of the vulva, in a girl of seven years, I have
seen but once. It appeared in the shape of lupus com-
plicated with angry-looking ulcerations, the edges of which
were lined with miliary tubercles. The uterus and its ap-
pendages, except in cases of general miliary tuberculosis,
I have not seen affected.

Tuberculosis of the testicles is not quite rare. Henoch
has seen a few cases at the age of from one and a half
to seven years, the epididymis being hard and nodulated,
occasionally; and Koplik has but lately described the
case of an infant. Sometimes it is primary, but almost in
every case there was tuberculosis in other organs, mainly
in the bones (caries) and peritoneum. My youngest case
was seven months old; at that time the right testis was of
the size of an egg, hard, and irregular. It had been
known to swell but six weeks before it was presented.
It grew rapidly to double its size, and had not lost its
hardness when the infant died of general miliary tuber-
culosis (meningeal, pulmonary, and mesenteric, mainly)
within a few months. In the case of a boy of three years,
who also died of (chronic) general tuberculosis, the right
testicle was of the size of a walnut when first seen, and
did not increase much in size when caseous degeneration

90

TUBERCULOSIS

took place, and botli testis and the adliering scrotum were
pierced by a number of suppurating fistulit. Cicatrization
of such fistulae has been observed, but none of my few
cases lived long enough for such a termination of the
local process.

The interior of the intestinal tract may become the seat
of tuberculosis through the medium of the circulation, or
by the ingestion of bacilli contained in sputum, meat, or
milk. I know of no instance where intestinal tuberculosis,
well develojied, was proved to be tlic ])rimary or sole af-
fection, nor is it probable that tuberculosis processes
should develop to any extent without implicating the neigh-
boring glands at least ; but it nuist be admitted that there
ma}^ be sucli a possibility. The solitary follicles and Peyer's
patches are the main localities for tubercular deposits ;
their forms are those of miliary nodules or infiltrations,
their changes the same as those which take place in other
organs. They disintegrate in the centre, ulcerate until
they perforate, unless peritonitic adhesions prevent this
ominous termination, and give rise to secondary miliary
deposits in and round their very edges. These ulcerations
are found mostly from the lower part of the small intes-
tines to the ascending colon, but also to the rectum. Ac-
cording to their seats, they produce pain, diarrlura con-
taining mucus and blood (in one ease Biedert made the
diagnosis by the jDresence of tubercle-bacilli in the evacu-
ations), and tenesmus.

The lymphatic glands are involved in almost every tu-
berculous process. That swelled " scrofulous " glands pre-
ceded, or were complicated with, tuberculosis, was acknowl-
edged to be a fact long before the bacillus was recognized.
The lymph-bodies of the neck and omentum, and the bron-
chial and retroperitoneal glands, are among those most
frequently affected. Their morbid condition remains some-
times latent for a long period. When they undergo caseous
degeneration and suppuration, they may give rise, through
embolism, to pyaemia or general tuberculosis, or, when near
the surface, to tuberculous ulceration and fistulous destruc-
tion of the skin.

Their relation to tuberculosis has been described in the

91

DR. JACOBI'S WORKS

article on scrofulosis, in the " Cyclopaedia of Diseases of
Children."

As far as the subject of the abdominal glands is con-
cerned, we shall have to return to it in the discussion of
tabes mesenterica. There the consideration of intestinal
tuberculosis will again occupy our attention. The bronchial
and tracheal glands in their connection with the tuber-
culosis of the lungs will also be treated of under the head
of tubercular consumption; and the tuberculosis of the
nerve-centres will form a part of the article on tubercular
meningitis.

Blood-vessels are the seat of tuberculosis very frequently,
inasmuch as their walls are the main receptacles for
the deposit of the bacilli and tubercles in acute miliary
tuberculosis. It originates along the finest ramifications.
In very rare chronic cases, larger blood-vessels are af-
fected, and may give rise, by weakening the elasticity of
the walls, to aneurisms.

Symptomatology. — If we are again to characterize in
a few words the nature of the tubercular infection, the
process will be described thus : Through inhaling the
dried and pulverized sputum of the consumptive, or through
a local tubercular deposit undergoing disintegration and
absorption, the bacilli are admitted into the circulation.
That admission takes place through the lymph-dticts or
the blood-vessels, mostly of the smallest size. But the
largest vessels also have been known to be the direct car-
riers of the poison,- — for instance, the thoracic duct, in
a case of Ponfick, and large arteries and veins (Weigert)
which become adherent to and perforated by neighboring
caseous tubercles. If but little morbid material be ad-
mitted, or but little in repeated doses, the result is chronic
tuberculosis or isolated tubercles in a gland, bone, joint,
or nerve-centre; if there be much at a time, the result is
acute miliary tuberculosis. A predisposition may be created
under the influence of serious diseases, extensive suppura-
tions, debilitating causes of every description, overcrowding
and impaired health in cellars, factories, scliools, nurseries,
orphan asylums, prisons, and barracks, and by a number
of infectious diseases which are eminently dangerous to

92

TUBERCULOSIS

the structure of the respiratory mucous membranes, such
as measles and whooping-cough.

General tuberculosis has no such distinct symptomatology
of its own as many of the other infectious or contagious
diseases. Its localizations are so numerous that the in-
dividual cases exhibit a great variety of symptoms. Under
the heads of the different organs, in the future essays and
volumes of this work, the tuberculosis of the glands, the
lungs, the meninges, the peritoneum, etc., will be dis-
cussed. Thus a few remarks must suffice here; they will
refer mainly to the symptoms of the chronic and the acute
form.

In both, the symptoms belonging to the general disease
may be obscured by those of the organ solely or mainly
affected. Still, there are a number of changes, mostly in
the chronic condition, which, if they do not suffice to es-
tablish the diagnosis, render it highly probable. The ma-
jority refer to the state of the general nutrition.

In most cases this is defective. The children are thin
and puny, or emaciate visibly, in spite of good and suffi-
cient nourishment and fair digestion, and the absence
of fever. Others, particularly infants fed on breast-milk,
are, moreover, troubled with cough and elevated tempera-
tures, but may lose no weight for many months; still, they
arouse our suspicion by the above-mentioned symptoms and
some unaccountable anaemia. The complexion in most cases
is either pale or sallow; occasionally this result of anaemia
and ill-nutrition alternates with a general or circumscribed
flush on the cheeks, or is replaced by a cyanotic hue in those
in whom the venous circulation is embarrassed by large
glands or pulmonary disease. The sclerotic is bluish,
the eyes moist or dry, and their expression languid or
sad.

The skin is flaccid, wrinkled, and devoid of elasticity,
dry, and liable to peel in very small scales. Perspiration
and sudamina are found in such only as develop incidental
attacks of fever or have a somewhat elevated tempera-
ture constantly. When anaemia has reached a rather high
degree, there is oedema about the ankles or lumbar region
(the locality depending on the position of the child, whether

93

DR. JACOBI'S WORKS

mostly erect or recumbent), and about the face when there
is glandular swelling near the jugular veins.

The bronchi are mostly affected with catarrh, but fre-
quently to a very slight degree only. Contrary to what
might be expected in the presence of but few local pul-
monary symptoms, there may be much dyspncea, due to
the multitude of miliary tubercles, or to the intensity of
the hydraemic condition^ or to the debility of the heart-
muscle, or to all of these causes combined.

A frequent occurrence is the enlarged size of many of
the accessible glands. Palpation reveals them round the
neck, also in the inguinal regions, seldom in the axilla or
abdomen. The tracheal and bronchial glands are often
very numerous, and the dulness on percussion over their
site is quite marked. It is particularly perceptible over the
manubrium sterni, where, however, the persistence of the
thymus gland may give rise to mistakes, and in the sub-
clavicular regions. Here, too, the diagnosis may be diffi-
cult. For not only may the glands be swollen mainly on
one side only, or more markedly than on the other, but the
lungs, or one of them, may yield the same percussion-note
in the presence of a chronic infiltration.

It is the acute form of tuberculosis which participates
eminently in the characteristics of infectious diseases. It
is always attended with fever and the appearance in many
organs of numerous isolated miliary tubercles, which but
rarely have the time to become confluent and form infil-
trations. The latter, when found at autopsies, are mostly
of older date than the miliary deposits. In these cases
the infecting material spreads through the circulating lymph
and blood from a single centre, which can be recognized
in many instances. Caseous degeneration has long been
suspected, and finally recognized, as the fountain-head of
the generalized disease. The lymphatic glands, bronchial,
tracheal, mesenteric, and retro-peritoneal, in their intimate
relations with the lymph-ducts and the circulation of the
blood, furnish the morbid material an easy road to the
rest of the body. If that material consist of disintegrated
cells and nuclei only, the result will be some process or
processes of embolism, with local anaemia, inflammation,

94i

TUBERCULOSIS

disintegration of tissue, or pyaemia; if it contain specific
bacilli, miliary tuberculosis will follow. The most rapid
course of the malady must be expected when the growing
gland proliferates into the lumen of a vein. In this way,
besides the glands, caries of the bones, tubercular arthritis,
and purulent pleuritis or ulceration of mucous membranes
will lead to the same end. Defective conditions of the
latter, such as are the results of whooping-cough, measles,
or typhoid fever, furnish, besides, ample opportunities for
the admission of the bacillus from outside. After this has
been accomplished, the formation of a tubercle is explained
by M. V. CorniP'' in this way: that bacilli penetrating
Into the tissue-cells give rise to a nutritive and formative
irritation, exhibiting as its first result a subdivison of the
cells. This process takes place in the cells of the con-
nective tissue, the endothelia of the blood-vessels, and the
epithelia. Besides, the presence of bacilli produces embolic
processes in the capillaries, and gives rise to alterations
in the walls of the blood-vessels and emigration of leuco-
cytes. These again emigrate, and penetrate into the tuber-
cles while in the process of formation.

The tubercles are either gray — in the very recent state —
or yellow. Both varieties are mostly found together. They
are met with in and on the liver, lungs, kidneys, intestines,
pia mater, peritoneum, pleura, bones, dura mater, brains,
pericardium, stomach, thyroid, but rarely about the genital
organs and the muscles.

The order in which they have been here enumerated in-
dicates their susceptibility and numerical importance. The
thymus gland has proved to be also affected more fre-
quently than was known before. Indeed, I have found
an instance in which that body was the primary seat of
the disease. It is probable that it will be found to be
a more frequent abode of tubercular deposits than the
choroid, retina, and iris.

The very multitude and variety of organs in which the
tubercular deposits gain a footing and undergo further de-

10 fitudes exp. et clin. sur la Tuberculose, publ. sous la dir. de
M. le Prof. Verneuil, Paris. 1887, fasc. i.

95

DR. JACOBI'S WORKS

velopment, explain the difference in, and the multiplicity of,
the symptoms. The fever and some tumefaction of the
spleen are common to all acute infectious diseases. Indeed,
the latter is enlarged though there be no local tuberculosis
of the organ either on the surface or in its tissue, and may,
under these circumstances, be mistaken for that of typhoid
fever.

When the respiratory organs are the principal seat of
the tubercular infection, the sj'mptoms do not always cor-
respond with the extent of the lesions. As, however, this
subject will be treated of more extensively in a subsequent
paper, an outline only of the changes and symptoms con-
nected with the pulmonary localization of general tuber-
culosis will be given on this occasion. There is bronchitis,
sometimes quite extensive, with all the physical signs of
hyperaemia and thickening of the mucous membrane, and
expectoration which, when brought up at all, contains fewer
bacilli than are found in tubercular consumption proper.
Blood appears but rarely, except in the latter form. Cough
is not so frequent as the pulmonary and bronchial changes
would lead us to expect, because of the frequent prevalence
of the brain-symptoms. There is sometimes a high degree
of dyspnoea, particularly in those cases which exhibit car-
diac debility at a very early period of the malady. Respira-
tion is often quite rapid (without much apparent dyspnoea),
though there may be but little solid infiltration. Indeed,
percussion yields often but a negative result even in ad-
vanced cases. Not infrequently the soft friction-sound of
accompanying tubercular pleurisy is more evident than
are physical symptoms belonging to the lungs, with the
exception of those instances in which an acute and exten-
sive pneumonia takes the place of the multiple, but small,
alterations.

Encephalic tuberculosis and tubercular meningitis will
form the subject of a special article. Here it may be
mentioned only that the principal symptom of an infec-
tious disease, viz., fever, is often absent in these forms.
Indeed, though the disease is of the most serious nature, —
the localization in the brain giving rise to retarded and
irregular pulse, vomiting, peripheral contraction, and par-

96

TUBERCULOSIS

alysis of a multitude of muscles in different organs, to
the suppression of secretions, and even to convulsions and
coma, — the temperature of the body is not liable to be
raised before the very end of life.

Diagnosis. — The diagnosis of miliary tuberculosis is by
no means easy. Both in the adult and in the child it has
often been mistaken for typhoid fever, and vice versa. It
is true that in miliary tuberculosis there is " often " pallor
and cyanosis, slow and intermittent pulse, and dyspnoea
without objective symptoms; but these are the cases which
offer no difficulty, as a rule. The most serious cases are
exactly those in which the diagnosis is apt to go astray.
Typhoid fever in the young is by no means the regular
strait-jacket disease, as some text-books still insist upon
describing the same disease when in the adult; its tem-
perature does not follow the exact curve claimed in print,
the daily curves are sometimes double, the temperatures
are either high or low through the whole course of a case,
there are, or may be, bronchitis, splenic tumor, diarrhoea,
roseola, or chills. Now, all these symptoms are found in
acute miliary tuberculosis as well. Even Ehrlich's diazo-
test of the urine is not conclusive; indeed, it has long been
acknowledged that, in the differential diagnosis between
the two, it is unreliable. Now, it is true that in miliary
tuberculosis the bacillus may be found in the blood, in the
expectoration if there be any, or in the stools, or miliary
deposits may be discovered in the choroid or retina. But
there will be many cases in which even the most expert
diagnostician will fail. Indeed, even as well-marked an
affection as tubercular meningitis may be difficult of diag-
nosis from typhoid fever, particularly on account of the
fact that genuine meningitis (not to speak of meningeal
symptoms) may be an actual complication of typhoid fever.

The diagnosis of tuberculosis from a malarial process is
not always made quite readily. The latter may linger
longer; there may be no fever observed or existing; or an
occasional rise of temperature, lasting from a day to a
week or more, is noted, and occasional apyrexia extending
over days or weeks. There is now and then thirst, dry and
hot skin, perhaps no chill, but increasing emaciation, anae-

97

DR. JACOBI'S WORKS

mia, and listlessness. The same symptoms will be found
in chronic tuberculosis, in which the local symptoms may
be very indefinite or obscure. Even feverish cases of tu-
berculosis may not be quite conclusive, in the absence of
positive local symptoms. In tuberculosis exacerbations of
temperature take place mostly towards the evening, those
of malaria frequently in the forenoon. But " frequently "
and " mostly " yield no diagnosis in an obscure individual
case; it must not be decided by a presumable average any
more than by the result of questionable treatment. For
the assertion that quinine will relieve the fever of malaria,
while it is ineffective in that of tuberculosis, must be re-
ceived with many grains of salt.

Prognosis. — The prognosis of tuberculosis is always
grave. The termination of the acute miliary form is al-
most always fatal. The large number of recoveries some-
times reported does not agree with the experience of those
who see their cases from beginning to end. A single visit
does not always suffice to make the diagnosis; on the con-
trary, localized miliary tuberculosis may often be presumed
to exist without a sufficient cause. Thus only can I ex-
plain the fact that one of the foremost and most con-
scientious consulting physicians in the American profession
gave it as his honest conviction that one-sixth part of all
cases of tubercular meningitis got well.

The chronic form may recover. Even in autopsies made
on persons who died of miliary tuberculosis we are apt to
find localized tubercles so hardened and encysted that they
at least cannot be accused of having given rise to the acute
infection. Besides, the finding of solitary tubercles in the
lungs (or occasionally other organs) in the post-mortem
examinations of people dying of miscellaneous diseases is
more than an occasional occurrence. It is quite frequent
in the adult, and not unusual in the bodies of children of
ten or twelve years. Thus, indeed, chronic tuberculosis
may heal, temporarily or permanently; but still the prog-
nosis in every case which has been diagnosticated ought to
be rather worse than merely guarded. That rule is more
imperative in the young than in the adult; for it is in the
former that, in consequence of the greater activity of lymph

98

TUBERCULOSIS

and blood circulation and absorption^ a universal infection
originating from a local cause is more easily accomplished.
Many organs are affected at the same time. In one hun-
dred and sixty-two cases of tuberculosis, Lorey found
twenty-two of acute miliary infection, sixty-two of tuber-
culosis in the bronchial glands, eighty-three in the lungs,
twenty-nine in the brain, twenty-one in the bones, and
twenty in the spleen.

Treatment.— Tuberculosis cannot be prevented, or lim-
ited, under our political and social circumstances, by the
prohibition of marriages of tuberculous people, or the
separation of children from their parents, or the removal
of phthisical workmen from their shops or factories. Nor
would such measures be successful to such an extent as
has been presumed by hasty reformers. For, indeed, the
danger of the propagation of tuberculosis from person to
person by respiration is but slight; no current of air is
capable of removing bacilli or spores from a moist surface
such as the mucous membrane of the bronchial tubes or
the surface of a cavity. For the same reason, neither the
faeces expelled from a tuberculous intestine nor the urine
eliminated from diseased urinary organs can often trans-
mit the malady.

The bacilli conveying the disease are far from being
ubiquitous. They have a higher specific gravity than air,
water, or even pus ; their growth is slow, and easily inter-
rupted by .the presence of putrefaction and other schizomy-
cetae endowed with rapid proliferation ; they require a tem-
perature of at least 30° C. (86° F.), which they cannot
find permanently except in the animal body; and it is in
the latter only that they find their nourishment. Here
they develop and multiply, and become dangerous when,
after leaving it, they are preserved in a dry state. Even
thus, a certain length of time — perhaps six months — de-
stroys their efficacy; and, though one-seventh part of man-
kind die of tuberculosis, mostly of the lungs, it is evident
that the expectoration of months and years becomes dan-
gerous in relatively but rare instances. In order to be so,
the sputum must be dry, finely distributed, and inhaled;
for, though tuberculosis may be found in most tissues and

99

DR. JACOBI'S WORKS

organs, the lungs are the principal inlet and outlet. Even
here, however, the invasion into the system is not easy. For
its principal localitj'^ must be the very finest ends of the
bronchial ramifications and the air-cells; if deposited in
the larger bronchi, the bacilli would be readily expelled
by the secretion of the muciparous glands and the uninter-
rupted activity of the ciliated epithelium. Still, it is the
sputum, dry, finely pulverized, and entering the lungs or
coming in contact with sore surfaces, which yields the
principal danger, and the main preventive measure is its
disinfection or destruction before it can do any harm.

Though the bacillus is long-lived and not easilj^ de-
stroyed, there are a great many waj's of preventing the
disease from spreading. The best preventive is a healthy
mucous membrane. A simple catarrh may afford an inlet,
and ought, therefore, not to be made light of in a family
or surroundings in which tuberculosis has foimd a home.
The bronchitis of measles and whooping-cough, rendering
the surface amenable to infection, requires care; nothing
• can be more dangerous, therefore, than the supercilious in-
difference too often exhibited by practitioners dealing with
these diseases, as unworthy of their attention, because they
are self-limited in their course of weeks or months. As the
communicability of the bacillus is very great when it is in
a sufficiently dry state to be inhaled, the expectorated sub-
stances must not be permitted to be preserved on towels
or handkerchiefs, or to remain on bedding and floor, or
spoons, or vessels, or whiskers from which the innocent
kiss of the child will be poisoned. The sputum must be
deposited in a moist vessel, and soon removed; in the sink
and sewer, or on the field with the rest of the sewage,
which will render the bacillus of tuberculosis innocuous by
moisture or destroy it by putrefaction, it will do no harm.
The patient will protect himself from auto-infection by
remembering that his own sputum, when dry, is a weapon
turned against himself. Besides, a thorough disinfection
must be applied to clothing and furniture by excessive
heat, great care exercised in the selection of the school,
companions, and nurses, and the room thoroughly disin-
fected in which a consumptive patient has lived or died.

100

TUBERCULOSIS

Von Esmarch recommends to rub down the walls, and the
wood of the furniture, with bread.

Much may be done by the enforcement of public hygiene.
Among the working-men or -women of a factory ten per
cent., more or less, are consumptive. Their sputum is
expectorated on floors and furniture, will get dry and pul-
verized, and inhaled. Thus the germ is carried over the
community, old and young. From the tailoring establish-
ments large and small, ready-made clothing-shops, etc., the
material to be worked up is given to the tens of thousands
of men and women in whose dingy tenements tuberculosis,
diphtheria, and other contagious diseases are indigenous.
From these they infect the community. This frightful
fact is sufficient to discourage the most hopeful philan-
thropist; it proves again the embarrassments and dangers
of our social conditions, and the great difficulties an enlight-
ened public hygiene will have to overcome.

That no child ought to drink milk without its being
thoroughly boiled, goes without saying, when it is under-
stood that tuberculosis is a frequent disease of the cow,
and both its milk and its meat may become the cause of
infection; the former, however, only (though there are
those who do not agree with this statement) when the udder
participates in the disease, which is of common occurrence,
though difficult to diagnosticate; the latter but rarely, be-
cause the muscular tissue is almost exempt from tubercu-
losis. Thus, indeed, the danger is reduced to a minimum
when the meat is thoroughly heated, and the organs of the
animal most subject to the invasion of the disease (such
as liver, thymus, lungs, and viscera in general) are ex-
cluded from the bill of fare.

The preventive extirpation of tubercular glands has been
recommended and practised extensively. It is mainly the
glands of the neck which are accessible. They are in-
fected by every irritation of the head, face, mouth, and
nares. In all of these parts primary tuberculosis is not
frequent at all, but the invasion of bacilli and their trans-
mission from the superficial sores to the glands is at least
a possibility. At all events, however, the larger number
of the tumefactions owe their origin, not to the specific

101

DR. JACOBI'S WORKS

bacilli, but to an irritation of a less dangerous kind.
Now, when caseous degeneration takes jolace in a gland
swelled by any cause whatever, though not of a siDccific
order, the absorption of the detritus may lead to embolic
processes; if, however, the caseous gland contains the
bacillus, tuberculosis will follow absorption. In every case,
then, the extirpation is advisable. But the final result of
every such operation is jeopardized by the fact that,
generally, we have not to deal with a single isolated gland,
but with a great many. For this reason the oj^eration is
liable to fall short of its aim, because of the impossibility
of removing everything morbid. It is particularly in young
children that this ill success has been experienced.

Cold abscesses, of tubercular nature, must be treated ac-
cording to their seat and origin. Those of the subcutane-
ous tissue may be incised, their walls scooped out, disin-
fected, and either drained or filled with iodoform gauze.
Now and then the advice has been given to wait for a
spontaneous rupture of the surface, but incision and anti-
septic treatment are preferable. Those connected with
bones, and sometimes so by long and sinuous fistulae, re-
quire operations of greater magnitude, extending to and
including the bones.

The treatment of tubercular disease of the bone must
be local, though in many cases it be as unpromising as
general medication. In tubercular spondylitis neither the
operative nor the expectant nor the medicinal plan is very
successful. Coxitis is more amenable to the former, and
its results are more favorable. The same can be said of
the tubercular affection of the knee-joint, the ankle-joint,
and the bones of the tarsus. The methods of the opera-
tion cannot be identical ; whether resection, the scoop, or
ignipuncture is selected must depend on the extent and
location of the lesion. After the operation, and sometimes
without it, iodoform treatment has been found beneficial.
At all events, the diseased capsular ligaments must be
effectually removed.

Whatever aids in fortifying the tissues against the in-
vasion of bacilli must be looked upon as welcome, inasmuch
as the treatment of the established disease is among the

102

TUBERCULOSIS

most unpromising. For the effect of antifermentative or
antibacteric remedies when introduced into the animal or-
ganism unfortunately does not correspond with that pro-
duced in the test-tubes. G. Cornet publishes a series of
experiments^^ made on one hundred guinea pigs and ten
rabbits previously infected with tubercle-bacilli, either sub-
cutaneously, or through inhalation of the finely-distributed
material. The remedies employed were tannin, acetate of
lead, garlic, pinguin, sulpliide of hydrogen, menthol, corro-
sive sublimate, creolin, and creasote. The latter dimin-
ished the secretions, but none of them, though introduced in
large doses and for long periods, exhibited any antibacillary
effect. Nor did altitude have any effect, for some of the
animals infected in Berlin were sent to Davos in Switzer-
land, unsuccessfully.

The antibacteric medicines which thus far have been of
most service to operative surgery cannot be expected, with
our present knowledge, to be made useful in the treatment
of chronic or acute general tuberculosis. The subject,
however, will be discussed more extensively in the article
on pulmonary tuberculosis. The very necessity of empha-
sizing the strengthening of the system against the inroads
of the disease, indicates the comparative powerlessness of
the body against its devastations when once begun.

My experience with arsenic in pulmonary phthisis, as
a tissue-builder and nutrient, leads me to recommend it in
the other forms of localized and universal tuberculosis.
Of phosphorus I have not seen so much in this direction,
but its effect is the same, and its superior efficacy in the
chronic and subacute diseases of the bones ought to justify
its administration in behalf of the system threatened with
tuberculosis. As the feeble connective tissue requires ar-
senic and phosphorus, so the incompetent heart-muscle needs
its own tonics; for digitalis, spartein, and caffein, while
stimulating the heart into supplying the provinces of the
body with more blood, render the same service to the heart,
and thus improve the general nutrition. When acute tuber-
culosis has made its appearance, the medical treatment can

11 Zeitsch. f. Hygiene, 1888, v., 98-133.
103

DR. JACOBI'S WORKS

be symptomatic only. The general principles of thera-
peutics must be applied here as elsewhere: antipyretics,
narcotics, and stimulants will find their places according
to the most prominent symptoms. Unfortunately, the dis-
ease, when fully established, leaves the practitioner no
better opportunities than to fulfil the indications suggested
in the interest of euthanasia.

104

PHTHISIS

It was but a few years ago that the question could be
raised in earnest whether tuberculosis and phthisis were
identical. As great an authority as Ruehle denied that
identity, though he admitted that phthisis was more than
a mere inflammation, and questioned, though phthisis caused
tuberculosis, whether the latter gave rise to the former in
every instance.

Of late, not only are tuberculosis of the lungs and
phthisis considered identical, but both are assumed to be
the exclusive result of the invasion of a specific bacillus,
whose effect consists in local irritation, with formation of
small neoplasms and a morbid process with either an acute
or a chronic course, the latter of which terminates in either
extensive destruction or induration of tissue.

Its symptoms either are those of a general morbid con-
dition, such as emaciation, pallor, fever, anorexia, perspira-
tion; or there are some direct symptoms, such as cough',
expectoration, dyspnoea, pain, and palpitation. Besides
these symptoms, there is not infrequently the same in-
vasion of a specific bacillus into glands, bones, and joints.

In the adult the tubercular deposits in the lungs prefer
the apices. The reasons for this predilection are various.
The lungs are firmly fixed at the hilus ; thus the dia-
phragm cannot change the consistency of the pulmonary
tissue and the lumen of the bronchial tubes to the same
extent in the apices as in the lower lobes. Besides, the
weight of the arms presses mostly upon the upper lobes.
Furthermore, the current of air brought up from the lower
part of the lungs is liable to repel the secretion trying to
find its way out, into the upper lobes. This very secre-
tion, the apices being less supplied with blood than the
rest of the lungs, is thicker and more viscid, and pre-
vents the air from getting in to the same degree as in

105

DR. JACOBI'S WORKS

the other parts of the lungs; and^ finally, what has been
called the phthisical habitus is mostly developeti in the
upper part of the chest, thus compressing the upper lobes
of the lungs more than the rest. Thus the circulation
in that part of the lungs is more sluggish, and bacilli
which have once entered are not apt to be easily expelled.

Contrary to what we see in adults, in whom tubercular
deposits mostly take place in the apices, the principal
changes in the tuberculosis of children are often seen in
the lower lobes. The reason may be found in the fact
that the influence of the phthisical habitus develops in
advanced years only. For the disproportion between the
costal cartilages and the ribs, particularly in those cases
in which premature ossification takes place, increases from
year to year, thus adding to the difficulty of aeration in
the upper part of the chest in the course of advancing
years. Besides, the frequent attacks of broncho-pneumonia,
which are apt to be the starting-points of tuberculosis,
are more frequently observed in the lower lobes, and near
the mediastinum.

Age. — According to Portal, tuberculosis of the lungs
may be congenital. James Clark found it frequently after
the second year; Meessen rarely in the first j^ear, some-
what more frequently in the second ; Koranyi very seldom
before the third or fourth year. Ruehle met with acute
miliary tuberculosis in some instances during the first
period of life, with pulmonary phthisis, not, however, be-
fore the first dentition; Trousseau very often in the first
years of life; Papavoine only between the fourth and fifth
years; and of Guersant's hospital patients one-eighth of
all those in the second year were tubercular.

The large institutions of New York City aff'ord few
facilities for adding statistical material of this kind, be-
cause of the very small amount of hospital accommoda-
tions for such children and the incompleteness of the
information to be derived tlierefrom. But every practi-
tioner with ample means of observation meets with a great
many cases of general miliary and likewise pulmonary
tuberculosis. Demme had imder hospital observation in
the course of twenty years, 36,148 cases, 1932 of which

106

PHTHISIS

were of tuberculosis; 1580 of the latter were pulmonary.
Biedert collected 8332 cases of tuberculosis, 6.4 per cent,
of which were those of children. Within three years
Fiirst observed 4000 cases of children's diseases up to the
fourteenth year of life. Of the 330 tubercular cases among
them, 247 were pulmonary; one was two weeks old, one
six, one seven, fifteen from two to three months, seventeen
from three to six months, forty from six to twelve months,
sixty-six from one to two years, eighty-two from two to
four years, thirty-nine from four to six years, forty-six
from six to ten years, and twenty-two from ten to four-
teen years. Thus, according to Fiirst and Demme, the
largest number of cases was met with between the second
and fourth years. According to Baginsky, eight per cent,
of all cases of pulmonary tuberculosis are met with under
the tenth year.'^

Some more points connected with the question as to the
age at which tuberculosis may be met with, the reader will
find discussed in the essay on tuberculosis contained in
this volume.

Causes. — The etiology of tuberculosis in general has
been treated of so extensively in the paper on tuberculosis
just alluded to that I may be permitted to refer to it for
all particulars. It is worth while, however, to insist upon
a few points.

In children the pulmonary artery is relatively larger;
thus the lungs are more succulent and liable to furnish
a very fair rcsting-ground for the bacillus. Besides, in
the early years of life the right heart is still predom-
inating, with the same result.

The invasion of the bacillus which is not only the cause
of phthisis, but also the principal source of broncho-pneu-
monia and caseous pneumonia, may take place by direct
inspiration. In every instance it is the smallest bronchi
that furnish the best resting-place. In these cases tlie
bronchial tubes are found thickened at a very early period.
The upper air-passages, nares, pharynx, and larynx, being

1 Maximilian Herz, Ueber Liingentuberkulose im Kindesalter,
Wien, 1888.

107

DR. JACOBI'S WORKS

cooler and more exposed to strong currents of air, have
therefore fewer cases of local tuberculosis. Even before
the discovery of the bacillus, the inhalation of sputum was
proved to be the cause of tubercular infection by Tap-
peiner, who, at that early time, accused beds and clothing
of transmitting the disease. Contagion is not only not
prevented by the drying up of sputum, but, on the con-
trary, it appears that as long as it is moist it is not at-
tended with any particular danger. When tuberculosis
develops from cheesy degeneration, the first changes are
found in the blood-vessels or in the lymph-ducts and
glands. The former are thickened, the latter enlarged.

Hereditary disposition has formerly been characterized
from two points of view. A direct transmission can be
proved in but few instances, but the propagation of a
peculiar debility or inefficiency of either the whole or-
ganism or special organs deprives the individual of its
power to resist injurious influences or deleterious invasions.
Altogether, the number of cases in which hereditary in-
fluences can be traced is very great; in Demme's cases of
tuberculosis of bones and joints in 69-6 per cent., in that
of the lymphatic glands in 65.4, in visceral tuberculosis in
71.8, and in lupus in 37.8 per cent.

The relation of scrofula to tuberculosis has been dis-
cussed by Dr. Ashby in the Cyclopaedia. He proves that
the assumption of a disposition on the part of scrofulous
persons to become tubercular has to give way to the knowl-
edge that what was called scrofulous was tubercular in
many instances. In " scrofulous " deposits the bacillus tu-
berculosis has been found, and scrofulous material has been
inoculated so successfully as to produce tuberculosis.
Schiiller inoculated caseous masses taken from a gland,
with the result of producing tuberculosis of the osseous
tissue; the same experiments of many observers resulted
in general tuberculosis. Cohnheim proved the tubercular
nature of fungous arthritis, caseous adenitis, and pneu-
monia; Cornil, of many hypertrophied glands and fungous
synovitis; Demme, of ostitis, multiple periostitis, and the
granulating ostitis of the phalanges. Many cases of chronic
" scrofulous " eczema and nasal and aural catarrh ex-

108

PHTHISIS

hibit the bacillus. Still, there are cases in which the lat-
ter is absent, but the necrobiosis (Virchow) of the glands
is such as to facilitate the invasion of the bacillus and to
impair the resisting power of the cells.

The introduction of the tubercular virus through the
digestive tract, by means of the milk and meat of tuber-
cular cows, particularly in cases of tubercular mastitis, is
of at least occasional occurrence. It cannot be denied,
though many feeding-experiments proved failures. Skin,
mucous membranes, and glands are also ready gates for the
entrance of the bacillus. It has been stated before that
eczema and impetigo, scrofulous inflammations and ab-
scesses, and nasal and aural catarrhs are liable to be in-
fected with the bacillus.

The phthisical habitus may not give rise to pulmonary
phthisis at all; a disposition is but one of the factors.
Its definition comprehends a great many changes, not one
of wliich, by itself, would appear dangerous. But the sum
total of the symptoms exhibited even in early childhood has
something very characteristic. There are the relatively
great height of the body compared with its weight, the
thin bones and muscles, transparent and delicate skin, scanty
subcutaneous tissue, the extensive nets of superficial veins,
the flushed or pale cheeks, pale mucous membranes, flat
chest with short sterno-vertebral diameter, large intercostal
spaces, shortness of costal cartilages either congenital or
resulting from premature ossification, the marked depth
of the supra- and intra-clavicular fossae, the promi-
nent scapulae, the clubbed finger-ends, and the feeble
heart.

Varieties of Pulmonary Tuberculosis. — Pulmonary tuber-
culosis is met with in three forms, viz., 1st, acute miliary
tuberculosis of the lungs ; 2d, acute or subacute caseous
pneumonia; 3d, chronic phthisis.

x\cute miliary tuberculosis has formerly been shown to
result from the local tuberculosis of joints, bones, and
glands. It is but the termination of the tuberculous
process which, after having been local, becomes general
through an extensive embolic distribution. Acute tubercu-
culosis may also be mostly local, and death may set in

109

DR. JACOBI'S WORKS

before the disease becomes generalized. It is liable to re-
main confined to the lungs when the starting-point was
from the bronchial or mediastinal glands.

Acute and subacute caseous pneumonia takes its origin
from catarrhal (broncho-) pneumonia^ as a rule; in some
instances, from the fibrinous variety. It is attended with
cough and fever (somewhat remitting in the morning), fre-
quent and superficial respiration, all sorts of auscultatory
signs, from the finest sibilant and subcrepitant to the large,
moist, and dry rales, and occasional cyanosis, from a slight
hue of the lips to the ashy discoloration of intense suf-
fering. Bronchophony is more frequent than bronchial
respiration. The results of percussion are not always con-
clusive ; there are but slight changes sometimes ; it is here
that the gentlest tapping only will yield differences of
sound. Recovery is apt to take place in from ten to fifteen
days. Relapses — or, rather, new attacks — may occur, and
still recovery take place. Particularly is this so in cases
resulting from or complicated with pertussis or measles;
they may last months. In many the respiration never
becomes normal, either through induration of the pulmonary
tissue, or through fatty degeneration or enlargement of the
heart. Many such cases undergo extensive caseous degen-
eration,— mainly those which originated in whooping-cough,
measles, scarlet fever, and diphtheria, particularly in such
children as suffer from the results of rhachitic contraction
and curvature, and incompetency of the thoracic muscles.

Chronic phthisis is the most frequent variety. Still, it
is not common before the end of the first year. Fiirst's
cases' run from the fourteenth month to the twelfth year.
But there is not a year which does not furnish me with a
case or two at that early period. Children of a few years
are frequently affected, and cases occurring at eight years
and upward are by no means rare.

Their symptoms do not vary particularly from those of
adults. In younger children some symptoms are difficult to
discover. Cough is often overlooked for some time; it is

2 Maximilian Herz, Ueber Lungentuberkulose im Kindesalter,
vVien, 1888.

110

PHTHISIS

short and apparently easy, or, on the other hand, hard,
or loose, and mucous. Expectoration is either scanty, or is
inaccessible to inspection and examination because it is
swallowed. Hemorrhage, mild or severe, is of rare occur-
rence.

Temperature is high in the afternoon and in the night;
remission takes place in the morning. But rarely the
high temperature is met with in the morning. Sometimes
the remission is so intense that the temperature becomes
quite normal or even subnormal. Remission of too short
a duration means danger. After midnight perspiration is
as frequent and- intense as it is in adults; it is liable
to increase the tendency to emaciation, which is always
very great. A girl of four years, weighing forty-five
pounds, I have seen losing sixteen pounds in ten weeks.
When, in addition, the digestion becomes disturbed and
diarrhoea sets in, the fatal termination is reached sooner.

Respiration is superficial and frequent; this symptom
sometimes precedes every other, before auscultation and
percussion reveal anything. But in most cases there are
one or more limited areas of dulness. Gentle percussion re-
veals it more readily than strong tapping. By itself, how-
ever, the dulness is no conclusive evidence of tubercular
infiltration, for, as a result of simple interstitial inflamma-
tory hyperplasia and cicatrization, retraction of pulmonary
tissue, particularly below the clavicle, diminished respira-
tion, prolonged expiration, even slight cavernous breathing
resulting from dilatation of a bronchus, may remain be-
hind. But in these old and permanent indurations the
symptoms are not changeable, and there are no acute or
recent ones to accompany them. In phthisis, however, there
are auscultatory signs of an acute or a subacute character,
and mostly quite extensive. Large and small rhonchi —
viscid and loose, loud and fine, dry and moist, crepitant,
subcrepitant, sibilant (particularly on deep inspiration) —
are heard together or in alternation. . Now and then there
is bronchial respiration; still, bronchophony is much more
frequent than bronchial respiration, because of the relative
smallness of the infiltrations which permit of air-space be-
tween them; cavities yield cavernous breathing in propor-

111

DR. JACOBI'S WORKS

tion to the size of the abscess. When it is small, as it is
apt to be, cavernous breathing is very apt to disappear
temporarily, when the cavity fills up Avith secretion or pus.

Pathological Anatomy. — In dead bodies the results of the
tubercular process are various; slight they are but rarely.
Indeed, I remember but a single case, that of a girl of six
years, who died suddenly at a very early period of the dis-
ease, of hemorrhage. The post-mortem appearances differ
in acute and chronic cases. In the former the tubercular
deposits are gray, after some time yellow, small, and very
numerous. A great number are found on the bronchioles,
many of which are thickened. When the process lasts
longer, infiltrations take the place of nodules, through con-
fluence; the bronchial glands are swollen, sometimes cheesy
in the centres, and the pleurae are adherent.

The invasion of the bacillus results in local irritation
and hyperaemia, emigration of leucocytes, formation of giant
cells, and increase of the epithelial cells. Thus miliary
nodules are formed and the connective tissue is increased;
thus tubercular infiltration is brought on, and the lumen
of the bronchus may become narrow, and atelectasis result
therefrom. The tubercle, being without vessels, is apt to
undergo caseous degeneration; thus the alveoles are filled
with the caseous mass, and form small cavities, many of
which coalesce by the disappearance of the perishable
septa and develop into cavities of larger or even immense
size. The transmission of the process into other parts of
the lungs takes place either in the proximity, by contiguity
of tissue, or through blood-vessels or lymph-ducts. Some-
times the formation of cavities takes place late, if at all;
in such cases a whole lobe may be solidified, partly through
large masses of tubercular infiltration and partly through
the new formation of interstitial tissue. Its hyperplasia
takes place through the proliferation of connective-tissue
cells and their transformation. Its existence prolongs the
course of the disease and affords a certain degree of safety ;
for not infrequently it forms hard and thick capsules for
small or large abscesses, which thus are deprived of a
great deal of their danger. They may even be retained so
long that exsiccation and calcification occur.

112

PHTHISIS

Other anatomical changes are the following: bronchiecta-
sis,— the bronchial tubes become dilated b}' the shrinking
of the adjacent newly-formed connective tissue; emphysema
in the i^ulmonary tissue not yet filled with tubercle; sup-
purative pleurisy, in consequence of tlie presence of tuber-
cles in or near the surface of tlie jileura, and through the
direct communication of blood- and h'mpli-vessels between
lung and pleura, in wliich case adhesion and thickening
of the pleurae become additional causes of disturbances of
circulation and blood-supply ; pneumothorax, when the
pleura was perforated before adhesion became established.
Finally, dilatation of the right ventricle, often with fatty
degeneration of the heart-muscle, is the frequent result of
the difficulty encountered by the cavities of the heart in
trying to discharge its contents.

Symptoms. — One of tlie earliest symptoms of pulmonary
phthisis is atrophy in many of tlie patients. It is more
common in the very young than in those of more advanced
years. I knew a tubercular baby of seven months that
weighed exactly seven pounds. This atrophy is probably
so intense for the reason that the disease is not confined to
a single organ. The skin is flabby, waxy, yellowish or
white, wrinkled, inelastic, and often covered with pityriasis ;
the bones, clieeks, and scapulae are prominent ; the eyes
half closed, or open and staring, without expression, list-
less. The subcutaneous tissue is very scant}', the voice
thin, and the cry low or inaudible. These symptoms of
complete atrophy, however, are not characteristic of tuber-
culosis; but in every case of atrophy the lungs ought to
be examined with the utmost care, no matter whetlier there
is much cough or not. Pulmonary changes may be very
much advanced and still the physical symptoms not very
evident, and, again, tubercular infiltration not very ex •
tensive but the physical signs very perceptible. Now and
then those of catarrh or of pleurisy only can be found,
both of which may improve either spontaneously or under
treatment.

It is the totality of tlie symptoms that is important for
diagnosis, — the simultaneous existence, for instance, of he-
reditary influence, chronic eczema or impetigo, disease of

113

DR. JACOBI'S WORKS

bones and joints, glandular swellings, some dyspnoea, cough
more persistent than, perhaps, violent, and the permanence
and relative invariability of the physical signs.

Fever is more distinctly noticed in children of somewhat
advanced age. The temperature must be taken frequently,
inasmuch as remission may be expected daily and the
temperature is sometimes subnormal. The fever is either
continuous or hectic, or its type is inverse. Brunniche
found that the morning temperatures are apt to be higher
than those of the evening in all cases in which pulmonary
tubercular infiltration is complicated with miliary general
tuberculosis.

Cough is not a prominent symptom in the incipient stage
of chronic tubercular infiltration of the lungs. It is some-
times not noticed at all by the attendants, is frequently
merely short and hacking like that arising from a slight
pharyngeal irritation, and becomes more frequent and ve-
hement later on. It may then often be found paroxysmal,
resembling that of whooping-cough, with cyanosis, dyspnoea,
and vomiting. It may be dry and very painful, the pain
being attributed to the epigastrium, the muscles of which
are under a perpetual strain ; or moist. Still, sputa are
scanty, for the expectoration is swallowed as soon as it
reaches the pharynx. When some of it is obtained, the
microscopical appearance is that found in more advanced
age. Of pidmonary elements there are disintegrated al-
veolar epithelia and elastic fibres of lung-tissue. Bacilli
are foimd, but not always so readily as in the adult.

Blood is not a frequent admixture in the expectoration
of phthisical children. Now and then it is met with, but
profuse hemorrhages are rare in children. They may be
idiopathic, for in one case of I. HofFnung's no disease of
a lung could be found. One case of his occurred from
thrombosis of the pulmonary artery, one from pulmonary
apoplexy in a new-born child, two from gangrene, one
from a suppurating gland wliich perforated into a brancli
of the pulmonary artery and a bronchus, and five in pul-
monary phthisis. In four of the latter the bleeding came
from a ruptured aneurism of the pulmonary artery. I
do not remember more than half a dozen cases of pulmo-

114

PHTHISIS

nary hemorrhage in children except those which took place
in violent attacks of whooping-cough. Only one of my
cases — phthisis — was three years old; one, a girl of eleven,
had repeated attacks extending over a year, which appeared
to depend on or were accompanied by a mitral insufficiency,
and exhibited infiltrations of the upper lobe afterwards;
the others occurred in children affected with phthisis, early
or late stage of from seven to eleven years. From a diag-
nostic point of view the absence or presence of larger
amounts of pus may be noticed. I remember cases of
pulmonary abscess, a few of them resulting from perfo-
rating empyema, which bled quite freely. In pertussis
copious hemorrhages are frequent. They may become dan-
gerous in this, that blood coagulating in the finest bron-
chioles may give rise to local collapse of the lung — atelec-
tasis— and lobular pneumonia in consequence, in this way
increasing the disposition or liability to tubercular in-
vasion.

The part played by the lymphatic glands is a very im-
portant one. Their primary swelling may be due to gen-
eral " scrofulosis," or result from the bronchial catarrhs so
often met with in small children, particularly those affected
with rhachitis and pertussis. The disintegration and lique-
faction of their centers may give rise to embolic processes
and result in pyaemia. The mucous membrane of the res-
piratory surface being hyperaemic and eroded, the bacillus
finds its way into the gland, where it irritates and produces
the changes mentioned above. Two possibilities then arise.
The bacillus may not stop long in the gland, but may be
carried through the vasa efferentia into the circulation,
and thus light up a miliary tuberculosis. Particularly is
this the case where the gland is in close communication
with large lymphchannels ; thus peritoneal tubercles are
very apt to be carried into the thoracic duct. Or the irri-
tation produced by the presence of the bacillus can give
rise to excessive formation of connective tissue; the capsule
of the gland and its interstitial tissue will be thickened,
and thus the bacillus locked up. Thus the gland may reach
a considerable size, and feel fairly hard to the touch, even
when its center is already much advanced in its softening

115

DR. JACOBI'S WORKS

process. The very size of the glands may give rise to seri-
ous symptoms: the circulation of the pulmonary artery and
vein, the superior cava, and the jugular may be compressed,
resulting in oedema, haemoptysis, infarctus, and considerable
swelling of external veins, very probably, also, in passive
accumulation of blood in the cavities and the muscle of
the heart. Their softening and suppurative perforation
aflpect, and infect, the neighboring parts of the lungs. Thus
it is that the tuberculous process is so very apt to begin,
and to be most extensive, about the hilus, where the glands
are present in large numbers. The pneumogastric nerve,
too, and its branches, are annoyed by numerous and swelled
bronchial glands. Persistent hoarseness, before any laryn-
geal symptoms can be made out, and indeed before those
of phthisis have been developed at all, can be explained
in this way. Fleischmann observed a case of intense laryn-
go-spasm which was thus caused. Early pleuritis, and dull
pain posteriorly, here find their explanation. Intense dysp-
noea may be the result of large glandular swellings and
their mechanical effect upon a large bronchus or the tra-
chea, and haemoptysis that of a glandular abscess perforat-
ing into a blood-vessel. All such occurrences may take
place unexpectedly. For the presence of large masses
of glandular swellings is not easily diagnosticated, some-
times is not even suspected. The closed cavity of the chest
does not permit palpation, auscultation is sometimes not
successful because the respiratory murmurs are easily trans-
mitted through the solid bodies, and even percussion does
not always give a satisfactory result. But quite often the
local absence, or diminution, of respiration, or the coarse
character of the latter in a limited locality, besides dullness
over the manubrium sterni, and occasionally near its left
or right margin, together with the presence of glands about
the neck, in the axilla, and in the inguinal regions, bids
fair to facilitate a cprrect diagnosis.

Complications. — The complications of pulmonary tuber-
culosis with tuberculosis of other organs are very frequent.
I hardly remember a case of the former without an affec-
tion of the pleura, either simple adherent, or suppurative, or
tubercular pleuritis, or pneumothorax. Tubercular menin-

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PHTHISIS

gitis is not frequent in cases of chronic phthisis, but in
those complicated, either from the beginning or toward the
fatal termination, with miliary tuberculosis of the lungs, it
is often found as the result of the distribution of the process
over the whole system. The liver participates with a peri-
hepatitis which sometimes glues the organ to the diaphragm,
or with fatty degeneration, which is quite common in
chronic phthisis, or with small or large tubercular deposits
upon or in the liver. Their size varies : some are large, the
majority small. They undergo softening but rarely. The
tubercular degeneration of the system is of a similar nature,
perisplenitis and tubercles being met with, but not so com-
monly as in the liver. The kidneys exhibit the same class
of changes, only in smaller numbers. Pyelitis has been ob-
served as the result of the disintegration of a tubercle, and
abscesses in the parenchyma I have seen myself, from the
same cause. The stomach suffers less than most other or-
gans. Externally tubercles are found as a part of tuber-
cular peritonitis, internally an ulceration has been found
occasionally; its functions are often not disturbed. Gastric
catarrh may result from the impediment to circulation con-
nected with every pulmonary or cardiac disease, but, as
a rule, the function and particularly the secretions remain
normal, and facilitate the ingestion and assimilation of
large quantities of food. The bowels participate much
more freely. In a chronic consumption they are rarely
normal; hyperaemia is frequent, and ulcerations are not
uncommon. They are mostly found in the lower parts
of the small intestine, as future papers will show, but not
uncommonly also in the duodenum, csecum, colon, and in
protracted cases even in the rectum.

Prognosis. — The prognosis depends on a great many
factors. Intense scrofulous diathesis and hereditary dis-
position, and protracted morbid processes in glands, bones,
and joints, yield a bad prognosis, though the duration of
the tubercular process be ever so long. Measles and
whooping-cough contracted under such circumstances are
bad, because they are liable to lead to extensive lesions
of the lungs. They occur frequently between the second
and the fourth year, and therefore tuberculosis is readily

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DR. JACOBI'S WORKS

developed at that age. Those cases which occur in the
first year, as also those before puberty, about and after
the tenth year, are quite unfavorable. Rapid increase of
atrophy, with loss of appetite, is bad. So are rapid respi-
ration and persistent high temperature, cyanotic hue and
night-sweats, and the presence of a cavity. The perma-
nence of mixed auscultatory symptoms, such as fine sibilant
and moist rales, large moist rhonchi, and bronchial res-
piration (or only bronchophony), is a very ominous sign.

Treatment.^ — Hereditary predisposition to tuberculosis
being quite frequent, and transmitted even by parents who
still appear to be in fair health, every catarrh in the chil-
dren of such parents must be carefully watched. The
premature ossification of the costal cartilages, most fre-
quently found about the superior part of the chest, and the
consecutive shortening of the sternovertebral diameter,
give rise to contraction of the thorax and insufficient ex-
pansibility of the (upper lobes of the) lungs. In such
cases the aeration of the blood suffers at a very early date,
catarrh and inflammatory thoracic diseases are liable to
become dangerous, and gymnastic exercises are required
in early childhood.

Direct transmission from the parents to the childl*en is
probably not frequent, but it is possible, and therefore the
child must not share the room and bed of the consumptive.
Kissing must be refrained from; it may often be the cause
of contagion, though tuberculosis is not so frequently trans-
mitted in that manner as some other diseases, — for ex-
ample, diphtheria.

A consumptive mother must not nurse her infant. She
is a greater danger than one afflicted with syphilis. Her
milk is a positive injury, as is the milk of tubercular cows,
though the udder may not be diseased. Two cows out of
a hundred are tubercular. Hence the least that can be done
is to boil the milk intended for the nourishment of the
infant. By thus observing the rule which I have enjoined
these twenty-five or thirty years, the milk can be made

3 Some of the following pages are from the Archives of
Pediatrics, October, 1888.

118

PHTHISIS

more innocuous than is possible for the butter or cheese
obtained from such cows. These rules ought to be strictly
obeyed, though there be exceptions to the universal experi-
ence. An instance of such exceptions is mentioned bj'
Biedert, than whom there is no more reliable observer. He
reports the cases of children who were fed a long time
on the milk of tubercular cows without being attacked
themselves.

Great care must be taken in the selection of a wet-nurse,
and of the help about the house with whom the children
are to be in contact. The air about the house and about
the school must be pure, the school hours interrupted by
physical exercise, and chronic ailments, such as rhachitis,
carefully watched and treated, to avoid the debility of the
tissue which facilitates the invasion of the tubercular gviest.
It is particularly measles and whooping-cough that must
be carefully watched.

But all these and other measures which are the results
of the different adjuvant causes in the development of tu-
berculosis have been elaborately discussed in my paper on
tuberculosis, to which I here refer.

Among the causes of consumption monotony of food has
been enumerated by many. It is evident that it cannot
account for much in the cases of infants or children, whose
habits are ])lainer and whose digestive functions are more
adapted to simpler and more uniform articles of diet. Most
of these, while in health, are satisfied with milk, cereals,
and but little meat. Sweet cream may be added to the
milk, but more than a few ounces are not digested through
the course of a day. Cod-liver oil acts mostly through
its fat. During the afebrile condition and chronic emaci-
tion of phthisis, overalimentation, introduced by Debove,
may be tried to advantage, while insufficiency of gastric
digestion, if it exists at all, may be stimulated by the ad-
ministration of artificial gastric juice (pepsin with muriatic
acid) and mild stomachics (gentian, nux, diluted alcoholic
beverages). Where exercise cannot be procured to a suffi-
cient extent, or is contraindicated by the necessity of en-
forcing temporary, but absolute rest, massage, according to
S. Weir Mitchell's plan, will take its place. During fever,

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DR. JACOBl'S WORKS

overalimentation has to be stopped; it deranges digestion
and slowly increases the fever. Alcoholic stimulants will at
that time often take its place to advantage. While they
do not act well in certain over-irritable natures, with over-
sensitive hearts, and in haemoptysis, they are good stimuli
for the general system, diminish perspiration, and act fa-
vorably in diarrhoea.

In the treatment of tuberculosis no single factor is bene-
ficial by itself. The quality of the air alone will not cure
the sick, any more than will a certain mixture of salts and
water in a mineral spring, or some known chemical relation
of albuminoids and carbohydrates in an article of food.
Insufficient clothing and bedding, unheated rooms, draughty
halls, indigestible food, strong coffee and tea, hot cakes and
cold drinks, late hours, lively hops, brass instruments and
pianos disturbing midnight rest, kill as many, in proportion,
in Colorado, Florida, Southern France, and Italy, as in
New York. It must never be forgotten that the change of
climate is mostly a negative remedy, and cannot be ex-
pected to offer more than the possibility of favorable ex-
ternal circumstances.

Moist air is a better conductor of warmth than dry air.
Hence loss of temperature is more rapid in moist air than
in dry air. Dry air, therefore, may be very much cooler,
and is still better tolerated in spite of its lower tempera-
ture, and affords more protection. In adults haemoptysis
appears to be a frequent occurrence during the season of
increasing atmospheric moisture (spring). According to
Rohden's researches, a rapid increase of the percentage of
water in the blood is frequently sufficient to produce a
hemorrhage. The drinking of large quantities of water,
therefore, ought to be avoided, and no residence should be
selected for a patient subject to haemoptysis where the at-
mosphere is very moist. Dry altitudes, such as those of
New Mexico, have given me good results in pulmonary
hemorrhage. At all events, no place must be selected where
the percentages of moisture in the air are liable to change
rapidly. The imiformity of an insular climate, while
benefiting the average case of phthisis, is, therefore, not
so dangerous to those who have bled from their lungs.

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PHTHISIS

Nevertheless^ dry air and a higher scale of the barometer
are preferable.

The diversity of opinions in reference to the climato-
therapeutics of phthisis resulted from the circumstance that
the indications were not distinctly understood. Neither
cold nor warm, neither dry nor moist, air by itself is a
remedy. Warm air does not cure, but it enables the pa-
tient to remain out of doors. The temperature must be
uniform, sudden currents of air avoided, and the atmos-
phere free of microphytes. At an altitude of sixteen hun-
dred feet their number is greatly reduced (Miquel), there
are but few at a height of two thousand six hundred feet
(Freudenreich), a very few at six thousand, and absolutely
none at twelve thousand feet, provided the parts are not,
or but little, inhabited. Over-population of elevated vil-
lages and cities diminishes or destroys their immunity. In
the factories of the Jura Mountains, with a large working
population, at an altitude of three thousand five hundred
feet, tuberculosis is frequent.

Protection against sudden- gusts of wind and rapid
changes of temperature is an absolute necessity. The
elevated valleys (or rather recesses of mountains) of Colo-
rado deserve their reputation in pulmonary diseases. Davos
is dusty, windy, and exposed to frequent changes of tem-
perature during the summer, and must not be advised for
that season. Woods are warmer in winter, cooler in sum-
mer; so is the ocean. Both, therefore, well deserve their
reputation in the chronic ailments of the respiratory organs.

Not the thinness of the atmosphere, but its purity, is
the requisite, together with a high percentage of ozone.
The latter is developed under the influence of intense light,
the presence of luxuriant vegetable growth, particularly of
evergreen trees (Terebinthinaceae), and the evaporation of
large sheets of water. Thus, ozone is found on moderate
or high altitudes, in needle-wood forests, and near or on
the ocean.

In the general hygienic treatment of tuberculosis the
skin requires particular attention. Sudden changes of tem-
perature, which strike the surface suddenly and work their
effects on internal organs by reflex, — " colds," — in spite

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DR. JACOBI'S WORKS

of the modern superciliousness of some who deny any
pathological change unless the exclusive work of bacteria,
will always hold their places in nosology. The skin must
be both protected and hardened. Wool, or wool and cotton,
must be worn near the skin, the feet particularly kept
warm, no wet or moist feet permitted, undergarments
changed according to season and the alternating tempera-
tures of days or weeks, and every night and morning. It
is of the greatest importance to impress upon the minds
of the very poorest that thej'^ must not wear during the
day what they have slept in. Still, while protection is .to
be sedulously sought after, vigor is to be obtained by ac-
customing the surface to cold water. The daily morning
wash may be warm at first, and become gradually cooler,
— alcohol being added to the water in the beginning (al-
cohol alone is unpleasant through its withdrawing water
from the tissues), and salt always. The temperature of
the water being gradually diminished, the same treatment
can be continued during the winter, with a pleasant sensa-
tion of vigor. The subsequent friction with coarse bathing-
towels sends a glow over the surface and through the
whole body. The easiest way to start the habit is by wash-
ing; a short sponge- or shower-bath will take its place
soon, and a cold plunge will be borne even by the weak
afterwards.

It has become fashionable with many to feign a con-
tempt for internal medicines in the treatment of tuber-
culosis, pulmonary and otherwise. I am glad I cannot
share their opinions. Thus, for instance, I look upon
arsenic as a powerful remedy in phthisis. It was eulogized
as early as 1867 by Isnard, in a monograph, for its effect
in both malaria and consumption, in both of which he ex-
plained its usefulness through its operation u])on the nerv-
ous sj'stem. He claimed that suppuration, debility, emaci-
ation, vomiting, diarrhoea, and constipation would improve
or disappear under its administration. The doses of arsen-
ious acid used by him in the cases of adults amounted to
from one to five centigrammes (one-sixth to five-sixths of
a grain) daily.

Arsenic is certainly a powerful remedy. It is known to

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PHTHISIS

act as a poison and a strong caustic. It prevents putre-
faction, though as an antiseptic it ranks even below sali-
cylic acid. It acts favorably in malaria, chronic skin
diseases, and maladies of the nervous system, and has con-
siderable, and sometimes unexpected, eifects in the treat-
ment of lymph-sarcoma And sarcoma. It is also said to
improve, in the adult, sexual desire and power, and in
animals physical courage. Thus there is a variety of
effects the intrinsic nature of which may be found, uni-
formly, in the action of the drug on the function and
structure of the cell, which, though varying in different
organs, has the same nutritive processes. Arsenic has a
stimulating effect on cell-growth. In small and frequent
doses it stimulates the development of connective tissue
in the stomach, in the bone and periosteum, everywhere;
in large doses, by over-irritation, it leads to granular de-
generation. Like phosphorus, arsenic builds in small doses,
destroys in large ones. By fortifying the cellular and all
other tissues, both fibres and cells, it enables them to
resist the attack of invasion, both chemical and parasitic,
or to encyst or eliminate such enemies as have penetrated
them already. Thus it finds its principal indication in the
blood-vessel walls resulting in pulmonary hemorrhage.

The doses must be small. A child a few years old may
take two drops of Fowler's solution daily, or a fiftieth or
fortieth of a grain of arsenious acid, for weeks or months
in succession. This amount may be divided in three doses,
administered after meals, the solution largely diluted. There
is no objection to combining it, according to necessity,
with stimulants, roborants, or narcotics, and to giving it
for an indefinite period, unless the well-known symptoms
of an overdose — gastric and intestinal irritation and local
oedema — make their appearance. But they seldom will,
particularly when small doses of opiates are judiciously
added to it. In almost every case, perhaps in every one,
it is desirable to administer it in conjunction with digi-
talis.

In the vertebrate animals digitalis increases the energy
of the heart-muscle and its contractiton ; thereby it increases
arterial pressure and diminishes the frequency of the

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DR. JACOBI'S WORKS

pulse. By increasing arterial pressure it favors the se-
cretion of the kidneys, improves the pulmonary circula-
tion, empties the veins, thereby accelerates the flow of
lymph and the tissue-fluids, and exerts a powerful in-
fluence on the metamorphosis of organic material, — that
is, general nutrition. In addition, what it does for the
general circulation and nutrition it also accomplishes for
the heart-muscle itself. The blood-vessels and lymph-cir-
culation of the latter are benefited equally with the rest.
Thus digitalis, while called a cardiac stimulant, contrib-
utes largely to the permanent nutrition and development
of the organ. This eifect is not only of vital importance
for the economy of the system on general principles, but
an urgent necessity in view of the fact that there appears
to be a relative undersize of the heart, either congenital
or acquired, in cases of phthisis; and there is certainly
such a predominance of the size of the pulmonary artery
in the young, particularly over the aorta, that the normal
succulence of the lung becomes pathological quite readily
when the insufficiency of the heart-muscle tends to increase
low arterial pressure within the distributions of the pul-
monary. The selection of the preparation to be adminis-
tered is not an indifferent matter. The infusion and the
tincture are sometimes not well tolerated by the stomach ;
digitalin, not being a soluble alkaloid, but a glucoside, is
not always reliable in its eff'ects, nor of equal consistency
and strength; a good fluid extract, or the extract, is borne
well and may be taken a long" time. A child a few years
old may take about two minims of the former daily, more
or less, for weeks and months, or its equivalent in the
shape of the extract (two-thirds of a grain daily) ; the
latter can easily be given in pills, to be taken in bread, or
jelly, and combined with any medicines indicated for spe-
cial purposes, such as narcotics, or nux, or arsenic, or iron,
— ^the latter to be excluded in all feverish cases, or in all
cases while fever is present. So long as there is no urgent
necessity for a speedy effect, digitalis will suffice by itself;
as a rule, it does not operate immediately in the small
doses above mentioned. The addition of strophanthus, or
spartein, or caffein, all of which are speedily absorbed

124.

PHTHISIS

and eliminated and exhibit their effect rapidly and without
danger or inconvenience of cumulation, will prove ad-
vantageous in many cases.

Other medicines have been used in great numbers. Spe-
cifics have been recommended, and symptomatic treatment
has been resorted to. The success of the latter depends on
the judgment of the individual practitioner. No text-
book or essay can teach more than general principles and
their adaptation to the average case, and the measures to
be taken in a number of exceptional occurrences. The
indications for the use of narcotics, stimulants, expecto-
rants, and febrifuges will change according to the cases
and their various phases and changes. In every case the
necessity may arise for antipyrin, antifebrin, phenacetin,
salic54ate of sodium, or quinine. It may be necessary to
decide the question whether the administration is to be
made through the mouth, rectum, or subcutaneous tissue,
or how their effects are to be corrected or combined. I
have often found that a hectic fever would not be in-
fluenced by quinine, or by antipyrin, or by salicylate of
sodium, but the combination of the first with one of the
latter would frequently have a happy effect. However,
in a great many cases where the fever persists, the use of
quinine in sufficient doses, from five to ten grains daily,
proves more satisfactory than the modern antipyretics with
their prompt but temporary action.

The change in our pathological views, or rather the
addition of a new factor in our etiological knowledge, has
directed our attention to the antisepsis of the respiratory
organs. It is not necessary to destroy bacteria in order
to make them relatively harmless. It is impossible to kill
the bacillus without killing the normal cell, but very mild
antiseptics suffice to stop the efficiency and proliferation of
the parasite. Thus we can hope that the future will teach
us to reach the destructive process in the lungs. It is
quite possible that the inhalation of hydrofluoric acid will
not prove more beneficial than the rectal injection of sul-
phide of hydrogen, but the internal use of creasote (one
to three minims to a child daily) and terebene (two to
four minims every two or three hours) and the inhalations

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DR. JACOBI'S WORKS

of turpentine, eucalyptol, menthol, and many others, ap-
pear to rouse our hopes for a future effective treatment.
Much more than hopes we cannot have at this moment.
But it is useless to despair, either passively or actively.
For the present, it is certainly a desperate activity which
tempts an enterprising hero of the reckless knife to cut
away a part of a lung which is the seat of a general and
disseminated process, and a misdirected enthusiasm tem-
pered by mercenary tendencies that pretends to bake bacilli
out of existence by means of a clumsy and inefficient ap-
paratus.

Ulcerations of the tongue and pharynx are painful some-
times to such an extent as to require frequent attention.
A well-directed spray of one part of nitrate of silver in
two hundred parts of distilled water (glass to be of neu-
tral, blue, or black color), administered once a day, will
be found serviceable in average cases. Some are so bad as
to interfere seriously with deglutition. I have been obliged
to use a cocaine spray before every meal.

Gastric catarrh must be relieved, for a healthy stomach
is indispensable for the economy of the organism. It is
liable to suffer from the disordered pulmonary circulation,
but just as often suffers by mistakes made in the diet
of the patient. Large quantities of alcoholic beverages or
the same not sufficiently diluted are often the causes of
disturbances. So is iron which has been given injudiciously
for the alleged purpose of meeting the prevailing anaemia.
Milk is sometimes not tolerated; it may be substituted by
butter-milk, koumys, kefir, matzoon, or peptonized milk;
or it may be prepared with dilute hydrochloric acid, in
such a manner that one part of the latter is mixed with
two hundred and fifty parts of water and five hundred
parts of raw milk; the mixture is then scalded: it keeps
better than plain milk, and proves very digestible. Or
milk may be mixed with barley, oatmeal, rice, etc., or re-
placed altogether, temporarily, by farinaceous food. Fer-
mentation in the stomach requires resorcin, bismuth, or
creasote; the anorexia of intense chlorosis is sometimes
benefited by small doses of sulphur; and a protracted ca-
tarrhal condition may be speedily improved by the washing

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PHTHISIS

out of the stomach with warm water in which bicarbonate
of sodium, resorcin, or th3'mol in small doses has been
dissolved.

As tubercular patients are liable to be affected with
pleural irritation and inflammation, they must not undergo
great exertions, as climbing, or give way to boisterous
laughter. An attack of pleurisy requires a recumbent
posture, mostly in bed, and warm poultices. A subcu-
taneous injection of a small dose of morpliine will relieve
the pain, and table-salt, half a teaspoonful to a teaspoon-
ful in water, several times a day, proves the best of diu-
retics and absorbents.

Among the localizations of tuberculosis in children, that
of the larynx is not frequent, but it is met with. Accord-
ing to Heinze, laryngeal tuberculosis is not produced by
contact, but through the medium of the blood. But the
expectorated masses are undoubtedly a frequent cause of
the local infection, and, as a rule, the larynx is invaded
rather than the lungs. Besides nodulated inflammatory
swellings in the mucous membrane, submucous tissue, and
glands, sometimes even between the muscles, there are
small granulations and ulcerations on the cords, with uni-
versal catarrh, oedema, and phlegmonous destruction. The
symptoms are those of catarrh and ulceration, and depend
on the locality and severity of the lesion. In some cases
the diagnosis of pulmonary tuberculosis could not be made
in the beginning, and that of the local aff'ection was based
on the duration of the ailment, the persistence of the
fever, and the steady emaciation. ^ At first the laryngo-
scopic examination revealed catarrh only, and later ulcera-
tion and infiltration. The local treatment is that of the
catarrh, — inhalation of warm vapors, steam, turpentine,
carbolic acid, muriate of ammonium; poultices round the
neck; opiates at bedtime. The lactic-acid spray and the
application of iodoform have not served me so well as a
daily spray of a solution of one part of nitrate of silver
in from two to five hundred parts of distilled water.
Stronger solutions are rather harmful. The pain produced
by ulcerations located on the epiglottis and arytenoid car-
tilages is somewhat relieved by the application (by brush

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DR. JACOBI'S WORKS

or spray) of bromide of potassium, morphine, or cocaine,
or an appropriate mixture of two or three of them.

The air around patients suffering from laryngeal phthi-
sis may be moist; but it is a mistake to believe that it must
be warm. Cold air is warmed before it enters the larynx
and lungs, provided it enters the respiratory tract through
the nares. Only when it is admitted through the mouth
does it remain somewhat cool when reaching the larynx.
Thus the nares must be kept as normal as possible, and
competent no matter with what difficulties. Nor will open
windows interfere with the comfort of the patient, provided
draught is avoided; this can be easily accomplished by
screens or otherwise.

Tubercular ulcerations of the intestines may descend to
the rectum; in that case the local symptoms, and mainly the
tenesmus, may be alleviated by warm injections containing
gum acacia or bismuth, with or without opiates. Food and
drink must be warm. Bismuth may be given in doses of
from two to ten grains every hour or two, so as to form
a protection to the sore intestine. Tannin I have not seen
do very much good. Naphthalin sweeps the whole length
of the tract and acts favorably as a disinfectant. I have
seen almost immediate improvement after its use. From
four to ten grains may be given daily. Now and then
the stomach rebels against it; in that case, resorcin, in
doses of from one-fourth to one grain, in powder or in
solution, may be given for the purpose of disinfection
from three to eight times. Though it is very soluble, it
is effective to a certain extent. All of the above may be
combined with bismuth, or lead, or opium. Such prepara-
tions of salicylate of bismuth as were accessible have not
rendered the services I had expected to obtain, judging
from the reports of some European writers. Hydragyrum
bichloride cannot be relied upon for any effect in the low-
est parts of the intestinal tract, because of its great solu-
bility, the necessity of great dilution, and its ready ab-
sorbability.

Fistula in ano is a rare occurrence in children under all
circumstances. I remember but two cases, in tuberculous
girls of about ten years. No matter whether they be

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PHTHISIS

accidental complications, or the tubercular poison (bacilli)
be conveyed to the parts through the circulation, or the
fistula be the result of the presence, in the faeces, of
bacilli, and their action on defective epithelium, practice
has changed entirely during the last decade. The axiom
that fistulae in a consumptive patient must not be inter-
fered with has given way to a more rational theory and
sounder practice. The sooner they are operated upon and
treated, the better.

In pulmonary hemorrhages the application of a lump of
ice or an ice-bladder over the locality of the hemorrhage
acts favorably, either through the direct influence of the
cold temperature or through the reflex contraction of the
bleeding vessels. Subcutaneous injections of fluid extract
of ergot, or of ergotin in glycerin and water, are apt to
give rise to induration or abscesses: hence it will be left
to the practitioner to decide in an individual case whether
that risk may be taken. Sclerotinic acid has been recom-
mended for the same purpose. A syringeful has been in-
jected hourly of a solution of one part in five of water.
It is claimed that no local injury is done by it; but it is
painful, and has been corrected by the addition of mor-
phine. The latter may be given internally also for the
purpose of relieving the patient's symptoms, both objec-
tive and subjective. If it cannot be swallowed well, the
proper quantity of Magendie's solution, not diluted in
water, is readily absorbed through the mucous membrane
of the mouth or throat. The internal administration of
ergot may be supported by that of mineral acids and digi-
talis. Of the latter, a single dose of from two to five
grains, or its equivalent, acts well. The dilute sulphuric
acid is both efficient and palatable; ten or fifteen drops
in a tumbler of (sweetened) water will be readily taken
to advantage. Acetate of lead, in doses of one-sixth to
one-half of a grain, every hour or two, according to age
and the severity of the case, is preferable to tannin; it
can be given with morphine or digitalis, or both. The
patient requires absolute rest and encouragement, and must
be induced to make long forcible inhalations, and told to
suppress the cough as much as possible. To relieve it

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DR. JACOBI'S WORKS

opiates may be required. For the purpose of stopping
hemorrhages the inhalation of the sesquichloride of iron
(one to one hundred) has been recommended. As it was
not expected to enter the bronchial tubes, its effect was
presumed to be by reflex action. I have tried it, but can-
not sufficiently recommend it.

As a general rule, among adults as well, a subcutaneous
injection of morphine in the very beginning has a good
effect. The pulse becomes fuller and softer, the patient
quiet. The application of a ligature round an extremity I
have not had occasion to try on a child. So long as there
is any bloody expectoration the patient must remain in
bed, and be kept on plain and fluid food.

Night-sweats are not uncommon in the tubercular phthi-
sis of children from five to twelve years of age. They are
favorably influenced by the same remedies which are apt
to relieve the adult; such are sponging with vinegar and
water, or alum, vinegar, and water. A powder of sali-
cylic acid three parts, oxide of zinc ten, and amylum ninety,
or salicylic acid three, amylum ten to twenty, and talcum
eighty or ninety, dusted over the suffering surface, is quite
beneficial and soothing. For internal administration the
dilute sulphuric acid, ten or fifteen drops in a tumbler-
ful of water, is found enjoyable by a great many. A single
dose of atropinae sulphas (one-three-hundredth to one-hun-
dredth of a grain) at bedtime, or agaricin (one-fiftieth to
one-twentieth of a grain), or duboisin (one-hundredth to
one-fiftieth of a grain) will succeed in bringing relief.
When there is an indication for opium, it may be combined
with any of them. When the digestion is good, a sufficient
dose of quinine (three to six grains), with or without ext.
ergot, (the same dose), or ext. ergot, fluid, (one scruple
to half a drachm), deserves a trial when for any reason
the above remedies are discarded.

130

PULMONARY TUBERCULOSIS

The following pages are meant to supplement, not to
repeat, the article on " Phthisis," and, as far as it con-
cerns pulmonary tuberculosis, that on " Tuberculosis."
Hence the remarks on the varieties and the pathological
anatomy as well as on the symptomatology of pulmonary
tuberculosis will be found brief. The attention of the
reader is mainly asked for the chapters on etiology and
on the preventive and curative treatment, which may be
found interesting when read in connection with the previ-
ous two papers.

I. NATURE AND DEFINITION

The question raised on page 105 of this volume, in the
article " Phthisis," concerning the identity of " phthisis "
and pulmonary tuberculosis, was answered affirmatively.
Still, Malassez and Vignal succeeded in the experi-
mental creation with or without co-operation of bacilli,
by zoogloea, of tuberculous masses and small " tubercles "
in which nothing but zoogloea were found. Similar
microbes were met with in bone-abscesses by Castro
and Soffia two years later (in 1885). Ribbert examined
in 1884 miliary tubercles and found no bacilli, but big
and giant cells, and preferred the name of multiple lym-
phoma for that reason. Biedert, however, when having the
same experience, suggested that the occasional presence
in the blood or in pus or serum of some additional alkali,
which might interfere with perfect staining, explained the
absence of bacilli. Eberth produced in guinea pigs tuber-
culosis which contained no bacilli and was therefore called
pseudo-tuberculosis. Eppinger found in such tubercular
infiltrations not bacilli, but cladothrix, and called his prod-

J3l

DR. JACOBFS WORKS

uct pseudo-tuberculosis cladothrichica. But all these ex-
ceptional facts or products should not militate against the
acceptance of the essential unity of the tubercular process,
which cannot exist without the bacillus tuberculosis (Koch),
no matter whether it is found in the lungs, bones, glands,
or other tissues.

Tubercle bacilli retain their infecting power a long
time. But they proliferate as parasites only, and even
become less virulent by passing, in the course of experi-
mentation, through a series of living bodies. They also
suffer from putrefaction and persistent dessication to such
an extent as to cause merely local affections with a ten-
dency to heal, but no general infection; and those origin-
ating in the animal body seem to be less dangerous than
those raised in the human body. Thus a certain compara-
tive safety is afforded, after all. When an invasion of
bacilli has taken place, their first effect is a copious pro-
liferation of the tissue cells, particularly of those of the
connective tissue. Epithelial and giant cells are formed
in large numbers ; their nests show a sharp delineation ;
leucocytes increase in their neighborhood by emigration.
These processes, together with the formation of a sur-
rounding capsule, take from ten to fourteen days after
invasion (inoculation) ; then the " tubercle " is perfected.
When there are many round cells in the composite mass
the product is called a lymphoid tubercle; when there are
but few of them (particularly in the periphery), the mass
is accordingly called a large cell (or epithelial) tubercle.
The enclosed bacilli are sometimes destroyed by pressure
and become harmless ; if not, a new infection may take
place in the neighborhood, or bacilli are spread by the
blood, and still more by the lymph-currents. The tuber-
cle is devoid of blood-vessels, and therefore a disintegra-
tion of the central mass is of frequent occurrence. This
disintegration spreads in the direction of the periphery
and causes the tubercle to look yellowish white. This
" caseous " degeneration is mainly observed in larger tu-
bercular masses, but also in the smaller " miliary " de-
posits. Caseation is very liable to terminate in softening,
rarely in calcification. The latter is equivalent to com-

132

PULMONARY TUBERCULOSIS

plete recovery; tlie former is a constant source of local
irritation, of new bacillary invasion, of repeated bronchial
and peribronchial congestion and diffuse infiltration of
the pulmonary tissue (caseous pneumonia). It should not
be forgotten, however, that caseation does not necessarily
mean tuberculosis, for it is also met with as the final trans-
formation of sup})uration, or of cancerous or of typhoid
infiltration. Nor are giant cells characteristic of tuber-
culosis. Witliout the ])resence of the bacillus tuberculosis
the diagnosis of tuberculosis should not be considered
complete.

11. DISPOSITION

The disposition to tuberculosis of the lungs is jiartly
local, partly general. Tlie relatively smallness of tlie
heart (Brehmer, Fels) and the contraction or narrowness
of the pulmonary artery render tlie tissue of the lungs
anaemic. Sliortness of the cartilage of the rib, found to
be congenital by Frcund forty years ago, and rhachitical
alterations of the chest interfere with respiration and cir-
culation. The rliachitical depression, mainly acting upon
the lower part of the cliest, cripples particularly the lower
lobes of the lungs and ])rep;ires them for inflammation and
tubercular dejjosits. Infants puny at birth, twins, babies
born in rapid succession or of anannic and poverty-stricken
parents, over-crowding in ill-ventilated, smoky dwellings
and school-houses. ])re\ious catarrlial pneumonia, whoop-
ing-cough, measles, or influenza, trauma by blow or fall,
glandular enlargements, bone-disease, or cold abscesses
anywhere in the body, persistent eczema or furunculosis,
chronic nasal catarrh or ulceration, pliaryngitis, amygdalitis
(" tonsillitis ") of various kinds, sometimes even clironic
gastritis or enteritis, offer under favorable circumstances
just as many inlets to ])ulmonary tuberculosis. Otlier in-
fectious diseases, sucli as scarlatina, crouj^ous j^neumonia,
or typhoid fever, do not so frequently create a predispo-
sition. Like rhacliitis, which does not act by its mechanical
results only, but by the general anaemia caused by it,
scrofulosis, not identical with tuberculosis, prepares tlie

DR. JACOBI'S WORKS

soil for it by its constitutional anomalies; for scrofula is
characterized by vulnerability of all the tissues, the long
duration of and slow recovery from superficial or deep-
seated lesions, the frequency of relapses, the rapid dis-
integration of newly-formed tissues, and the enlargement
of glands and their tendency to caseous degeneration. It
is particularly the latter organs which are often connected
with the first symptoms of pulmonary tuberculosis. In
two ways the bronchial (and other) glands may become
responsible for them: either the bacilli enter the vulnerable
glandular tissue with greater facility (for even healthy
epithelia and mucous membranes allow bacilli to penetrate),
or the capsulated and dormant bacilli, unless destroyed by
pressure, are waked up and disseminated by the chronic
congestion of the parts.

It has been intimated above that every disturbance of
general or local metamorphosis creates a dispositon to tu-
berculosis by impairing blood and tissues. That is why
bad innervation from loss of blood, slow convalescence,
care and trouble (in the older child and the adolescent),
and also why colds, have their bad influence and predis-
pose to pulmonary tuberculosis. Indeed, the dangers of
sudden exposure and of abrupt changes of temperature,
which alter the circulation both of the surface and of the
deep tissues, either directly or by reflex action, are too
evident to be reasoned or smiled away by the fad of
recognizing nothing but microbes as the sole and omni-
present sources of every ailment or malady.

In close connection with this subject is that of the
danger arising from bad or insufficient air. Density of
population, crowded rooms, uncleanliness and closed win-
dows work in two directions. By the exhaustion of oxy-
gen and increase of carbonic acid and noxious gases they
impair the blood and tissues. By the accumulation of
bacilli on floors and walls and in the air they dissemi-
nate the almost ubiquitous malady, and the other detri-
mental influences — dirt, improper food, and so on — are
liable to go hand in hand with those enumerated above.
This is equally the case in animals and in man. The
report of Dr. E. W. Hope, medical officer of health of

134

PULMONARY TUBERCULOSIS

Liverpool/ is particularly interesting. According to him,
the cow shipments in Liverpool are under the immediate
supervision of two well-qualified inspectors, who attend
to the legal requirements as to light, ventilation, and
cleanliness, while no such supervision is required in the
country. The result is that of one hundred and fortj^-
four samples of milk taken from sources within the city,
in three, or 2.8 per cent., was found the bacillus tuber-
culosis, while of twenty-four taken at the railway stations
29-1 per cent, infected the guinea-pig.^

A disposition is also created by a defective condition
of the respiratory tract. Though bacilli may be swept
through a normal tissue, it ought to be taken as a fact
that as long as a bronchial mucous membrane is cov-
ered with normal mucus and protected by vibrating epi-
thelium, foreign bodies, from particles of metal and car-
bon to bacilli, are liable to be expectorated. Only the
air-cells which have no fimbriated epithelia allow bacilli
to rest and develop with greater facility. All the other
surfaces of the respiratory organs are endowed with means
of self-defence. This is, however, greatly interfered
with either by the abnormal structure of the integuments
or by actual lesions. The latter need not be direct, as
in whooping-cough or measles; they may be indirect. For
but lately Kohler * published a case which makes it prob-

2 British Medical Journal, July 17, 1897.

3 Some of the facts reported to prove the absolutely favorable
influence of fresh air are rather startling. When Hutinel makes
the statement that among eighteen thousand children in charge of
the Paris " assistance publique " there were but twenty cases of
tuberculosis, we are — considering the immense mortality of these
children^tempted to ask whether they lived long enough to de-
velop the disease. S. Bernheim reports the cases of three pairs
of twins born of three women: one of each pair was supplied
with a wet-nurse and kept at home, and died of tuberculosis;
the others were fed artificially, but in the country, and remained
healthy. Such results, if not too surprising to be believed, are
too exceptional to establish a rule. It looks as if they proved
too much.

*Viertelj. f. gerichtl. Med., July, 1897.

135

DR. JACOBI'S WORKS

able that the disposition to tuberculosis may be increased
or a previous affection may relapse as the result of a
trauma, but also that when an injury or a concussion of
the thorax is not very conspicuous, their effects may be
long delaj^ed.

Abnormal structure of the integuments may either be
inherited from parents suffering from chronic infectious
diseases, such as tuberculosis or carcinosis, or acquired by
previous exhausting ailments, anaemia, or chlorosis. (P.

The question whether vaccination may cause tubercu-
losis or scrofulosis has been in Germany the subject of an
official inquiry, and replied to lately by Gerhardt and
Leyden. They refer to the fact that the discovery of
the bacillus excludes the possibility of such a causal con-
nection except in those rare cases in which the fever at-
tending vaccination may be assumed to favor the prolif-
eration and dissemination of bacilli previously lodged in
tubercular lymph-bodies, or in which erysipelas, sepsis, or
syphilis is caused by a gross mistake in vaccination. They
also point to the frequency of tuberculosis at all times,
and emphasize that it has certainly not increased since
vaccination was made compulsory; that, on the contrary,
in the armies of the German Empire, since vaccination
was made obligatory, the mortality from tuberculosis has
decreased. These experiences and the conclusions there-
from tally with mine as stated on page 82.

The small vaccination wounds do not count. They can-
not be compared in any way with those of circumcision
or other operations whose occasional influence in admit-
ting tuberculosis was discussed on page 82, nor with
the long-lived erosions and sores of eczema and impetigo.
Whenever bacilli are admitted in this way, the result is
more apt to be a generalized miliary than a pulmonary
tuberculosis.

III. ETIOLOGY

The origin of pulmonary consumption is in almost all
instances attributed to the inhalation of bacilli. As they
are certainly deposited on bedding, clothing, and on the

136

PULMONARY TUBERCULOSIS

floors and walls of rooms, nothing appears to be easier
than that the long-lived microbes should be admitted to
the air of the room and thus be inhaled. In this way
the contagion of acute exanthems is certainly disseminated.
Tubercle bacilli, like everything solid, when floating in
motionless air, are certain to sink gradually, and the in-
ference is that children are more liable to inhale them, a
mode of infection which 1 have claimed to be probable in
cases of diphtheria.^ This mode of propagation has been
taken to be the principal one in pulmonary tuberculosis.
On page 81 I said that the bacillus, " to be inhaled,
must be dry. As long as sputum is moist, or, after hav-
ing been dry, is again exposed to moisture, it cannot be
mixed with the air and thus enter the lungs of another
person. . . . The phthisical patients in the wards of
a hospital are uninjurious as long as no expectoration is
permitted anywhere but in a spittoon containing some
water." To such an extent has this belief controlled the
teachings of medical men that the rules and regulations
of health departments have concerned themselves with this
mode of transmission only. Experiments, however, appear
to prove that the air-currents usually found in a room are
not suflScient to detach dry bacilli fastened with their sur-
rounding sputum to the walls or floors. It is only strong
currents, such as are caused by sweeping, beating, brush-
ing— perhaps even by violent slamming of doors — that will
float them. Under these latter circumstances it is cer-
tainly possible that dry bacilli may be detached in this
way and infect those present. But experiments on ani-
mals have not yet proved that they could be infected by
inhalations thus conducted; and it is quite possible that
boards of health will have to alter or rescind both their
opinions and the practical rules built on the foundation
of former knowledge.

But lately Fliigge *' published a long series of experi-
ments and observations which appear to be able to stand
accurate tests. Crying, sneezing, coughing, even talking,

5 Treatise on Diphtheria, 1880.

6 Zeitsch. f. Hyg. u. Inf. Krankh., Bd. xxv., 1897.

137

DR. JACOB rS WORKS

detach sputum in more or less invisible quantities. Every-
body's experience yields such instances — palpable ones —
in the sick and the well. Such moist particles, mostly
infinitely small, were proved to remain in the air of a room
five hours. Indeed, an air-current of from one to four
millimetres in a second (equal to from twelve to fifty feet
an hour) sufficed to float them for that length of time.
In this manner the contagiousness of pulmonary tuber-
culosis is even more pronounced than by assuming the dry
sputum to be the only means of conveying the disease,
and the direct transmission from husband to wife or chil-
dren, or between patients in a hospital ward or sanitarium,
becomes almost a matter of course, so that the medical and
humanitarian devices planned on hitherto imperfect knowl-
edge require a far-reaching revision.

However, the occurrence of direct contagion is difficult
to demonstrate as long as one-seventh of the population
of the temperate zone dies of pulmonary tuberculosis, and
as long as the inroads into the circulation on the part of
bacilli are so numerous, indeed, and often so mysterious,
that Bollinger speaks of " cryptogenetic origin." It will
be stated in another place that the initial lesion need not
correspond with the locality of invasion; subcutaneous in-
fections cause pulmonary lesions ; lymph-nodes are dis-
eased without an affection of the corresponding mucous
membranes, and represent the " latent " form of tuber-
culosis. It has been the tendency to underestimate the
amount of direct contagion. A committee of the French
Academy examined the cases of two hundred and thirty-
three consumptive couples; in about twenty direct conta-
gion could be found. Still, if the experience of the thou-
sands of general practitioners be consulted, the results
will be different.

It has also been stated that nurses and emploj^ees in
hospitals and State prisons, as long as they are not over-
worked and underfed, do not become tubercular; but other
reports prove the danger to which nurses in consumptive
wards are exposed. Cases of tuberculosis occurring in a
hitherto healthy family after the return of a consumptive
member are quite frequent. The increase of tuberculosis

138

PULMONARY TUBERCULOSIS

in proportion to the density of the population points in
the same direction; and cases like that of Demme, who
boarded a healthy baby with the family of a consumptive
man, and acquired for it at the age of eight months
ozaena, bacilli in the nasal mucus, and tubercular menin-
gitis, are not at all exceptional.

Direct contagion is perhaps at no time more readily
accomplished than immediately after birth, when the baby
is kept in bed with the mother and exposed to the dan-
gers of contact. What I stated as the result of Fliig'ge's
recent experiments and the facility of inhaling the finely
distributed particles of contaminated sputum explains best
the unfortunate situation of the newly born. Frobelius,
whose babies were transferred from the obstetrical wards
to the foundling hospital after a number of weeks, had a
mortality from tuberculosis of 0.4 per cent, of all his
deaths in the first year (21.7 per cent, general mor-
tality in 91,370 infants from 1874 to 1883). Epstein,
who transferred immediately after birth, had none at
all.

Direct hereditary transmission was discussed by me on
pages 76-78. There are still those who are convinced
that there is no congenital tuberculosis in man;" those
who believe in its direct transmission;* those who sus-
pect its existence, though the malady exist in relatives
only;® and those who think it but rare. That it occurs
in some instances, at least, there can be no doubt. If
there were but isolated cases like those reported by me
(see page 77) and by Birch-Hirschfeld, who found
bacilli in the liver of a calf extracted by Csesarean sec-
tion, the question would be decided affirmatively. Mean-
while the list of undoubted cases is longer.

Hereditariness of tuberculosis and hereditary disposi-
tion should not be considered equivalent, as has been shown
elsewhere. It is true it is difficult to discriminate be-
tween the two in the case of a tubercular infant of a
few weeks or months. For the younger the tissue, and the

7 Biedert, Handbook, p. 93. » Liebermeister.

» Lorey.

139

DR. JACOBI'S WORKS

more copious its proliferation, the less is its resisting
power. It is a well-established fact that pathological
changes are most liable to take place during the period of
most active physiological growth. Moreover, the forma-
tion of a tubercle need not take more than ten or four-
teen days after the invasion of a bacillus. On the other
hand, there is no reason why tuberculosis, like syphilis,
could not be stowed away in a single organ, and remain
latent, or dormant, for an indefinite period.

Hereditary transmission may be either placentar or ger-
minative. The placenta, when healthy, is a perfect filter,
but, in spite of this perfection, anthrax, malaria, variola,
and so on, are known to pass it, and tubercle bacilli have
been found in the blood of the umbilical vein, the liver,
spleen, and kidneys of the fcetus. In connection with this
subject I do not care to emphasize the finding by F. I.eh-
mann of giant cells in the villi of the chorion, for giant
cells are not exclusively found in tuberculosis, but also
in sarcoma, syphilitic endarteritis and other conditions.
The possibility of germinative transmission is proved by
lahni and Weigert, who found bacilli in the juices of
testes and prostates without tubercular alterations of those
organs; by Spano, who found them in sperma; by Maf-
fucci, Baumgarten, Pander, and Gartner, who injected ba-
cilli into the external layer of the egg-albumin and caused
the chick to be tubercular. It appears, however, that a
certain number of bacilli are required to cause an infec-
tion. To have that effect, a bacillus culture diluted in a
proportion of one to four hundred thousand was required
in subcutaneous injections, one to one hundred thousand
was demanded for inhalation, and one to eight in feeding.
When but eight (up to forty) bacilli were injected, no
infection took place. If, therefore, a certain condensa-
tion or number be required, it becomes doubtful whether
one ovule or spermatozoon may be sufficiently saturated
with them to cause during cohabitation an hereditary trans-
mission. Besides, not all the bacilli are of equal efficacy.
Still, as from forty-five to seventy-five millions have been
calculated to dwell in a single cubic millimetre of sputum,
the number of the microbes is so incalculable as to sug-

140

PULMONARY TUBERCULOSIS

gest their power to do harm wherever their presence,
though in small number, is discovered.

Age. — There are not many additional facts concerning
the occurrence of tuberculosis in early age since the data
given on page 107. It becomes, however, more and
more evident that it is very frequent. J. Mackenzie
states that of 1591 consumptives who died in London
hospitals, only 65 were under fifteen years; but we do
not learn to what extent children were admitted, as
compared with adults. Among 3575 deaths from tuber-
culosis in one year, there were in Berlin 95 under one
year, 89 from one to two, 91 from two to five, 38 from
five to ten. Of Demme's 59,000 sick children, 2410 (4
per cent.) were tuberculous; 87 of them died of acute
tuberculosis. Of all the deaths occurring in Tiibingen
under one year, there were, according to Dennig, of tuber-
culosis 25 per cent.; from one to two, 20; from two to
three, 8.3; from three to four, 6.7; from four to five,
11.7; from five to six, 3.3; from six to seven, 6.7; from
seven to eight, 3.3; from eight to nine, 6.7; from nine
to twelve, none; from twelve to thirteen, 3.3; from thir-
teen to fourteen, none; from fourteen to fifteen, 5 per
cent. Calculated in periods of five years each, the first
yields, among all the causes of death, 71.7 per cent, due
to tuberculosis, the second 20, the third 8.3 per cent.
For the same periods, O. Miiller furnishes 50, 26, and 23.3
per cent. Altogether, in 500 autopsies made at Munich,
he found tuberculosis • in 40 per cent. L. Emmet Holt
has added valuable material, thus refuting for these last
years my statement made about ten years ago that
New York institutions had failed to contribute to our
statistical knowledge by publishing the results of 1045
autopsies made in the New York Foundling (Northrup)
and the Babies' Hospitals. In the 1045 autopsies, tuber-
culosis was found in 14 per cent, in those of the Babies'
Hospital (sick infants only admitted) ; in the Foundling
Hospital (admission indiscriminate, sick or Avell), 10 per
cent. Total number of Holt's cases, 119-

In these 119 cases the lungs were aff'ected 117 times,
the pleura 69, the branchial lymph-nodes 108, the brain

141

DR. JACOBI'S WORKS

40, the liver 77, the spleen 88, the kidneys 46, the stom-
ach 5, the intestines 40, the mesentery 38, the peritoneum
10, the pericardium 7, the endocardium 1, the thymus 3,
the adrenals 2, the pancreas 3.

Among the organs accused of being the direct cause of
pulmonary tuberculosis is the nose. It contains cocci and
bacilli of all sorts, for no organ is more accessible; in-
deed, no cavity is free of microbes, not even (according
to Zaufal) the middle ear. On the Schneiderian mem-
brane and all over the naso-pharynx they are met with in
large numbers; adenoid growths are covered with them;
some writers go so far as to claim them as positively
tubercular. Dieulafoy inoculated sixty-one guinea-pigs with
the secretion of healthy persons; eight of the animals be-
came tubercular. That does not prove anything, how-
ever, but that the surfaces of our integuments may be
and are" covered with all sorts of noxious elements which
become pathogenous only when causing ulcerations, or
when carried, by accident or intentionally, into the circu-
lation. In the same way several infectious diseases result
from inoculations made from the scrapings of a healthy
mouth.

Primary tubercular ulcerations of the nose are acknowl-
edged to be quite rare. It should not be overlooked that
while bacilli are frequently found and catarrhal erosions
are numerous, the latter should not be taken for tuber-
cular. On the other hand, it is claimed that normal nasal
mucus is bactericide. If that be. true, as microbes are
ubiquitous, most nasal discharges would no longer be " nor-
mal " if the microbes remained active enough to cause an
infection. Still, a modern author utters the startling news
that " retro-nasal catarrh is the main foundation of pul-
monary tuberculosis."

According to others, this exclusive claim of the naso-
pharynx seemed ill founded. Their attention was mostly
fixed on the tonsils. Like the larynx, the tonsils were
found to become infected by expectoration. When pul-
monary tuberculosis was not very extensive, or the dis-
ease was confined to the bones, or the mucous membrane
of the pharynx was either not much inflamed or was cica-

142

PULMONARY TUBERCULOSIS

trizedj and the tonsils were small, hard, and pale, the
latter were mostlj' found not to be much affected, and even
when bacilli were found in or on the tonsils, in which no
caseous degeneration was shown, the cervical lymph bodies
would mostly be exempt. But, on the other hand, it has
been claimed that in nearly all cases of pulmonary tuber-
culosis the disease is also in the tonsils ;^° that it begins
in the superficial lacunae, the morbid contents of which
are forced into the tissue by the act of deglutition; and,
finally, that while pulmonary tuberculosis is almost al-
ways accompanied by that of the tonsils, the latter is not
only attended by but causes the former.

^\liat I mean to insist upon is this : that undoubtedly
bacilli are found frequently in the nose and in the
pharynx. But their presence does not mean tuberculosis.
Nor does it appear that tuberculosis of the lungs is
(often) occasioned by their presence. Among the four
hundred and sixteen autopsies of Frobelius on tubercular
infants the lungs were affected in everj^ case, the pharynx
in none. When the pharynx and naso-pharynx are tuber-
culous they are liable to infect the neighboring Ij^mph-
nodes first. Moreover, it appears that if intestinal and
mesenteric tuberculosis is apt to be present with that of
the pharynx, that may be so in consequence of a uniform
morbid disposition on the part of the whole intestinal
tract. The uniformity of morbid disposition is a well-
established fact on other — -for instance, the respiratory —
tracts also.

IV. SYMTOMATOLOGY

The symptomatology of chronic pulmonary tuberculosis
is amply discussed elsewhere, pp. 113-115. The difficulty
of diagnosis in many cases has not been lessened. Fre-
quently it is still the totality of, in part, insufficient symp-
toms that is to be consulted. Percussion never yields a
reliable result except when quite gentle; auscultation may
be valuable, but in some cases it reveals nothing whatso-

10 E. Schlesinger, Berliner klinische Wochenschrift, September,
1896.

143

DR. JACOBFS WORKS

ever. The normal puerile respiration may be a little
coarser, generally or locally. The usual symptoms of
bronchitis are sometimes all that can be found. Sud-
denly, now and then, a localized bronchial respiration can
be heard corresponding with a local dullness, for infil-
trations take place quite frequently. They may disappear
again, or they may migrate; some or all of the deposits
may either disappear or remain. Respiratory murmurs
may change. A bronchial respiration which was of long
standing may temporarily disappear because of the ob-
struction of a normal or the filling up of a dilated
bronchus. The most characteristic auscultatory symptom
is the persistence, in a given locality, not always near
the hilus or in an apex, of a subcrepitant rale. Cavities
are rare, and generally small. They are difficult to find,
and often their diagnosis is deceptive — more so than in
the adult. Percussion that yielded dullness near a clav-
icle may not do so after a while; an infiltration may
contract; the neighboring pulmonary tissue may in part
cover the hardened spot, or may become emphysematous
and yield a semi-tj^mpanitic sound in place of the former
dullness. This emphysematous change does not so readily
take place in cases of extensive interstitial pneumonia
(peribronchitis), which finally results in retraction of an
extensive part of the pulmonary tissue, preferabh^ in the
upper lobes.

A heart-murmur may accompany chronic tuberculosis.
When it is not cardiac, it may, in rare cases, result from
compression, by cicatrizing tissue, or by an infiltration, of
the pulmonary vein.

In connection with what was said on page 114, on
the fever accompanying chronic tuberculosis of the lungs,
it will be remembered that the temperature has no partic-
ular type. It is sometimes higher in the morning and at
noon than in the evening; frequently it is only the ex-
pression of the collateral bronchitis and pneumonia, there-
fore in the course of time it may be high or low alter-
nately. When suppuration sets in it may be hectic. In
acute miliary tuberculosis of the lungs, which may occur
without for some time being complicated with general tu-

144

PULMONARY TUBERCULOSIS

berculosis, the temperature is generally higher — 104° F.
and more, sometimes less. Miliary tuberculosis may be
confined to a part of the lungs ; then the temperature
may be moderate. It may become normal after a while,
to rise again when a new miliary infiltration takes place
in the same or another portion of the lungs.

The condition of the blood is not materially changed.
What alterations there are result from accompanying sep-
ticaemia or fever (red cells diminished), or from haemop-
tysis, extensive infiltration, the presence of cavities, and
from pyogenic fever (leucocytosis).^^ Some changes of
the blood which have been noticed in (tuberculosis of)
the nursling, such as the presence of eosinophile cells and
of occasional nucleated red cells (normoblasts), are physi-
ological and not pathological. ^-

Nor is the condition of the urine conclusive of tuber-
culosis. It was believed to exhibit an undue amount of
indican. The latter is found in proportion to the atrophy
or the increased intestinal putrefaction which accompanies
chronic tuberculosis, and to its complication with broncho-
pneumonia and the inflammation of serous membranes.

V. COMPLICATIONS

Complications with tuberculosis of the stomach, the in-
testines, and the mesenteric glands are not so frequent in
children as they are in adults. Indeed, the stomach is
rarely affected. Primary tuberculosis of the intestine is
very rare indeed, and but few trustworthy examples are
found in the literature besides those furnished by Demme.
The mesenteric glands are the seat of tuberculosis far less
frequently than the bronchial glands (one to ten). There-
fore the number of cases of tuberculosis acquired by in-
halation exceeds immensely those depending on intestinal
infection. In those children whose gastric juice is not
sufficient, or is entirely absent, bacilli may pass the stom-

11 R. C. Cabot, A Guide to the Clinical Examination of the
Blood, 1897.

12 Hock and Schlesinger, Beitr. z. Kinderheilk., ii., 1892.

145

DR. JACOBI'S WORKS

ach and prove injurious. Tubercular mothers who (not
an uncommon practice) chew their children's food before
giving it to them may thus transmit their disease. In
the milk of tuberculous cows bacilli are, as a rule, found
only in the presence of general miliary tuberculosis and
of tubercular mastitis. Thus direct transmission through
milk is an exceptional occurrence. Still it does occur, and
therefore pasteurization or sterilization is demanded as a
matter of safety. It should not be forgotten, however,
that the successful inoculation of milk bacilli into guinea-
pigs does not prove that the same danger attends the
same milk when it is introduced into the human alimen-
tary tract.

The kidneys of tuberculous young children suffer like
those of tuberculous adults. Amyloid degeneration and
chronic diffuse nephritis, toxic nephritis of variable se-
verity, and congestive conditions in different stages de-
pending on venous obstruction are not uncommon. Be-
sides, transitory albuminuria, with or without an excess of
phosphates or of urates, or of both, is frequently ob-
served, mostly in very anaemic children and those in whom
hereditary disposition to tuberculosis is well marked. That
it is common in tuberculosis of the kidneys, which appears
to complicate that of the lungs quite often, even before
marked symptoms of nephritis are in evidence, is readily
understood.

VI. DIAGNOSIS

The surface alterations of scrofulous children are
closely connected with the lymph-bodies and lymph-cir-
culation, which is more active, as the vessels are larger,
at an early age. To distinguish between Ihe scrofulous
and the tubercular nature of the swelling of the lymph-
bodies we have no means besides their bacteriological ex-
amination. The main question is whether in the first pe-
riod of scrofulous affections the tubercle bacillus can be
found. Litten ^^ reports the results of nineteen autopsies
of scrofulous children. In one only a few bacilli were

13 Berliner klinische Wochenschrift, 1897, N. 28.

146

PULMONARY TUBERCULOSIS

found in the lymph-bodies; in that case, there were also
the symptoms and pathological changes of pulmonary tu-
berculosis. Nor were other scrofulous symptoms identical
with tuberculosis; no bacillus was found in one hundred
and twenty-nine cases of dry or vesicular eczema. Of
forty-two softened lymph-bodies of the neck and thirteen
extirpated glandular conglomerates, three only had scanty
bacilli; these three were complicated with extensive lesions
in the glands and bones, one of them with such in the
knee-joint. Twenty-three children with acute multiple
suppurations of the subcutaneous tissue had no bacilli ;
the result was also negative in five cold abscesses with
thin pus, but positive in seven with thick, caseous pus and
proliferating membrane. There was no bacillus in the
catarrhal secretions of the noses, the ears and the eyes
of one hundred and thirty-eight scrofulous children. Thus
in the initial stages of scrofula there are no tubercle ba-
cilli, therefore these cannot be the causes of scrofula, nor
are they the sources of the peculiar vulnerability and the
singular form of chronic inflammation characteristic of
scrofula.

VII. PROGNOSIS

The remarks on prognosis made on page 117 are
correct as far as our present and past knowledge goes.
To them I beg to refer the reader. Prognosis is mostly
grave, in many instances doubtful. Pulmonary tubercu-
losis may practically heal, however; that is proved by the
autopsies, which reveal the presence of caseous, indurated,
even calcified tubercular infiltrations which either were or
never were diagnosticated during life; but even in such
bacilli retain their vitality a long time, and may be en-
abled any time to renew their virulence and proliferation
by the occasional influence of bronchitis, pneumonia,
Koch's tuberculin, or other irritants. Therefore, not to
speak of the unfavorable prognosis furnished by exten-
sive infiltration or cavities, a dormant or an apparently
recovered case, in spite of ample nutrition, fresh air, ex-
ercise, and cold water, ought not to be pronounced cured
without mental reservation.

147

DR. JACOBI'S WORKS

PREVENTION AND TREATMENT

The peculiar scrofulous condition of the tissues, mainly
of the skin and mucous membranes, witli their passive
congestion, facile disintegration of the epithelia, and slug-
gish recovery after injury or disease, is the very soil for
the invasion of tuberculosis. Identity of the two condi-
tions does not exist except in an erroneous diagnosis.^*
The very efficacy in scrofula of remedies which are not
borne at all in tuberculosis would prove the differences in
the nature of the two. The treatment of scrofulous in-
fants and children has the purpose of rendering the tissues
more capable of resisting the invasion of infectious proc-
esses. Sea-bathing and the use of mineral springs con-
taining iodine, such as St. Catherine's or Kreuznach, the
systematic use of cold water, with friction of the surface,
the occasional administration of diaphoretics, and the per-
sistent use of iodides (of potassium, sodium, or iron) and
of cod-liver oil, will be required in scrofula. Of all this
medication the use of cold water to harden the skin and
to stimulate and strengthen both the cutaneous and the
general circulation, and of cod-liver oil, is the only treat-
ment applicable both to scrofula and to established tuber-
culosis.

Among the preventives of pulmonary tuberculosis the
destruction of the tubercle bacillus — easily accomplished
outside the organism — before its entrance into the lung-
tissue takes a high rank. No internal remedy, however,
will prove effective, for no living tissue bears disinfec-
tants strong enough to annihilate the microbe. Whenever
lymph-bodies, cavities, sinuses, ulcerations, joints or bones
are affected with tuberculosis and the disease is almost
certain to spread, timely surgical interference will pre-
vent the extension of the morbid process. A tubercular
gland must not be permitted to suppurate and burst, but
should be enucleated in time. Tubercular abscesses and

14 See article by Ashby, Keating's " Cycle, of Dis. of Children,"
Vol. II.

148

PULMONARY TUBERCULOSIS

■fistulas should be scraped out, the pyogenous membranes
removed, and the surface kept disinfected until recovery
is completed. Tuberculous joints and bones may require
exsection, but in most cases repeated injections of iodoform
emulsions (better than solutions), with the occasional re-
moval of loose particles, will prove effective. Another
method of conservative treatment has been introduced by
A. Bier. Encouraged by the fact that lungs in a condi-
tion of passive hyperaemia resulting from cardiac disease
or from kypliosis have a rather pronounced immunity from
tuberculosis, he advised the production of a passive venous
congestion of the tubercular joints by bandaging the limb
below the affected joint and compressing it above with an
india-rubber band. To secure a moderate amount of hy-
peremia and local cyanosis only, the bandage should be
loosened once or twice daily. Such a degree of passive
hyperaemia is known to give rise to the new formation of
connective tissue and to induration, which is expected to
afford a certain degree of protection ^^ against the pro-
liferation and action of bacilli. That is what Landerer
expected to accomplish by the local injection near the
joint of cinnamylic acid, and Lannelongue by that of a
10 per cent, solution of chloride of zinc. That is also
the effect Koch meant to attain when he advised tuberculin.
The remedy was expected to light up a sufficient amount
of interstitial irritation and consecutive hyperplasia to
encapsulate the bacilli and render them innocuous.

The bacilli should be destroyed in milk and meat. Pas-
teurization of the former and thorough heating of the
latter are all that is required. Muscles are seldom tuber-
culous, more frequently the kidneys, spleen, and liver are;
it is principally the latter which require attention. After
all, tubercular infection from these two sources is not
frequent, but ought to be, and may be, avoided altogether.
(Pages 83-84 this vol.) When cow's milk is suspected,
the buttermilk, butter, or cheese made of it should not be
eaten. The milk of a tubercular mother or wet-nurse may
be dangerous; what is more so is the direct contact of

15 See my Therapeutics of Infancy and Childhood.

149

DR. JACOBI'S WORKS

the baby with the tuberculous patient and the inhalation
of bacilli.

As preventives and curatives, proper feeding, clothing,
and the hygienic treatment of the skin (pages 121-122)
are of the first importance. Nothing of any account could
be added to former rules. As to the climatic treatment of
pulmonary tuberculosis, I refer to on page 120. I think
I have given these matters much attention then and since.
The remarks I then made I could but repeat now; the
briefness of this reference to what I consider most im-
portant should not be a temptation to think of bacilli first
and last and of hygiene least. The most urgent indication
is always to protect the organism against an invasion,
and to fortify it and enhance its powers of resistance.

Among the preventives, as a means of diagnosticating
tuberculosis in cattle I should mention tuberculin. After
it failed as a healing agent, the attempts at reducing its
danger and rendering it a positive remedy have not been
given up. Tuberculoidin and tuherculocidin (Klebs) were
obtained by clearing the tuberculin of its bacilli by treat-
ing it with alcohol, but the confidence these modifications
commanded was not greater than that placed in a serum
recommended by Maragliano, which seems to contain no
antitoxin, or the cantharidin introduced by Liebreich. But
lately Koch recommended a new tuberculin, obtained by
disintegrating dry bacilli by a mechanical process (the
latter is claimed by Buchner, a priority question we have
nothing to do with). The new tuberculin, which contains
the insoluble parts of the bacilli (while the old was said
to contain those soluble in glycerine), is claimed to pos-
sess a positive immunizing power. It is sold in vials
holding one cubic centimetre (=15 minims=15 grains).
One per cent, of it is the dry material of tubercle bacilli
in a condition of mechanical disintegration. The first dose
to be injected into the subcutaneous tissue of an adult
should be one-five-hundredth of a milligramme of the dry
substance (one-fifth milligramme of the fluid). To obtain
this dose, one part (one minim) of the fluid tuberculin
may be mixed with five thousand parts of a preserving
fluid. One minim of this mixture contains the required

l.'JO

PULMONARY TUBERCULOSIS

dose of one-five-hundredth of a milligramme. The sol-
vent is a six per mille salt-water solution containing twenty
per cent, of pure glycerin. Salt water alone will not
preserve. Injections should be made every other day,
and the temperature should be watched. An elevation of
more than ^° C. should be avoided, and no new injection
be made until the temperature is again normal. Slowly
the doses should or may be increased to twenty milli-
grammes of the dry substance (two cubic centimetres, two
original bottles of the fluid). If there be no reaction, it
is best to desist, or to inject at long intervals only. Be-
fore this amount is reached, the injections ought to be
made once or twice in a week.

There are cases, however, without any reaction. A pa-
tient of mine, who died in Bellevue Hospital lately of
pulmonary tuberculosis, received from me a daily injec-
tion of the new tuberculin. The first dose was one-tenth
of a minim, which was carefully but persistently increased.
Within a fortnight the dose reached three minims, with no
effect on the temperature whatsoever.

The exaggerated claims of the old tuberculin are not
repeated for the new. This is said by Koch to exert its
influence in the very beginning of the morbid process,
when there is no complication with streptococci or septi-
caemia, and when the temperature of the body does not
exceed 38° C. (100.4° F.). It is readily seen that under
these circumstances there will be but few cases of pul-
monary tuberculosis in children in which, because of the
difficulty of the diagnosis at that age and in that stage,
the remedy could be administered with any show of justi-
fication.

Behring,^® while claiming that Koch's new tuberculin is
weaker than the old, announces that he has prepared a
stronger one from very virulent dry cultures of tubercle
bacilli. He claims to have a tuberculin twenty-five thou-
sand times stronger than a dose fatal for one gramme of
guinea-pig weight, or eighty times stronger than a dose

16 Twelfth International Medical Congress, Berlin, Session
of June 10, 1897.

151

DR. JACOBI'S WORKS

fatal to a guinea-pig of ten ounces in weight. His mode
of preparing his tuberculin is evidently similar to that of
Koch, but his statements are made with his old intrep-
idity.

Immunization, either indirect, by employing the blood-
serum of immune animals, or direct, by injecting small
quantities of bacteric poison, virulent or attenuated, as
the case may be, has less favorable results in tuberculosis
than in some other bacteric maladies. Koch's tuberculin
was a glycerin extract of pure cultures of tubercle bacilli
containing a great many of the latter. Its remedial effect
was, when the first universal enthusiasm had cooled down,
either soon found to be nil, or, on the contrary, many
chronic cases were rendered by it acute and speedily fatal.
But it has retained a great power for good as a preven-
tive, through its application for diagnosis. When in-
jected into cattle, those affected with tuberculosis re-act
speedily by some elevation of the temperature. If all
the cattle of the land were subjected to that test, and
those responding affirmatively were killed, the country
would be cleared almost entirely of the tuberculous ani-
mals which supply milk and meat. It "is true that the
percentage of cases of tuberculosis contracted from either
milk or meat, according to what has been stated before, is
small; but, though small, it is too large if it is avoidable.

Medicinal treatment (page 126) of pulmonary tuber-
culosis takes no low rank.

Creosote was introduced into practice, both for inhala-
tion and for internal administration, in 1877. No direct
influence on bacilli should be looked for from it. What
it can do is to better the condition of the patient. It
will often improve appetite, combat putrefaction, thereby
facilitate assimilation, and (sometimes) relieve diarrhoea.
The doses vary. Almost incredible doses have been given
— from ten to fifteen cubic centimetres==from two to four
drachms daily, and more, to adults. Probably from one
to ten drops daily is a dose for children which, accord-
ing to their ages, may be administered for a long time.
The carbonate of creosote, almost tasteless, and easily
borne, is a proper substitute in similar doses. Neither
ought to be persisted in when the appetite does not im-

152

PULMONARY TUBERCULOSIS

prove within a reasonable time, or during a pulmonary
hemorrhage, or when the urine, which requires frequent
examination, contains, or is beginning to contain, albumin.

These last seven years I have replaced creosote by
guaiacol, which forms nearly sixty per cent, of the very
best creosote in the market, recommended by Schiiller,
Sahli, and others. A child will readily take from six to
fifteen drops daily (according to age) in from three to
four doses. It is best taken after meals, in sugar-water,
in milk, or in cod-liver oil. There are but few who ob-
ject to it. Those who do may take one of its salts — the
benzoate (benzosol), salicylate, cinnamate, or carbonate.
Of these I have employed mostly the last, occasionally
the first. They are (almost) tasteless, and are readil)'^
taken in doses of as many (or more) grains as the fluid
guaiacol contains drops. With guaiacol I have been less
disappointed than with any other internal remedy admin-
istered in pulmonary tuberculosis, cod-liver oil not ex-
cepted. It is a good stomachic, appetite and digestion
improve under its use, the cough gradually becomes looser,
less purulent, and the rales more mucous, and the body-
weight is apt to increase. While creosote is not well tol-
erated in the stage of cavities and hectic fever, guaiacol
is not only borne, but appears to exert its beneficial in-
fluence even in that condition. There are few patients
who do not derive some benefit from its internal use. Ex-
ternally, it has been recommended to subdue hectic fevers.
For that purpose the chest and abdomen are painted with
the pure guaiacol several times daily. It has the advan-
tage over creosote of not being contraindicated either in
hemorrhage or in renal complication.^^

I do not fear that it will be replaced by ichthyol (sul-
pho-ichthyolate of ammonium), which has been eulogized
by Cohn, Scarpa, Le Tanneur, H. Fraenkel, and others.
Adults (children in proportion) are expected to take from
one-fourth of a grain to four grains in a capsule before
every meal, or from twenty to forty drops four times a
day of a solution in equal parts of distilled water. In

IT See my paper in the International Medical Magazine, Novem-
ber, 1892, and Transactions of the Climatol. Association, 1893.

153

DR. JACOBI'S WORKS

8pite of the admixture of aromatic oil, it has a bad taste,
and will be administered with difficulty.

The favorable influence of cod-liver oil in the chronic
pulmonary tuberculosis of children is an established fact.
Its effect is probably not due to its minute percentage of
potassium, sulphur, iodine, bromine, phosphorus, and iron.
Perhaps the large number of peculiar organic bases (as-
elline, morrhuine, etc.) contained in it, particularly in the
dark varieties, has more to do with its effects on meta-
morphosis and nutrition. At all events, the free fat acids,
of which there is one-half of one per cent, in the light,
five per cent, in some dark specimens, appear to control
digestion. Its wholesome effect cannot be due to its fat,
for cream or some other fat, in daily doses of from two
to eight teaspoonfuls, could not replace cod-liver oil. It
is quite possible that we have not yet found out the exact
nature of the remedy. Perhaps its action is due to some
glandular substance which works similarly to the thyroid
extracts.

Arsenic in small doses (page 123) still justifies in
my experience its reputation as a cell-growth stimulant
and general nutritive when administered either by itself
or with digitalis. Fowler's solution should be given,
well diluted, after meals, in three daily doses, for weeks
and months, or until (which is rare) gastric or intestinal
irritation or local palpebral oedema makes its appearance.
The daily dose depends on the age of the child, and
should vary between one and five drops. If Fowler's
solution be not well tolerated, its equivalent in arsenous
acid will act equally; indeed, the latter is often tolerated
for a much longer time than the former.

The preparations of digitalis are the same that were
formerly recommended. What we now know of digitoxin
and digitalinum verum, which have similar effects, does
not commend them for general practice. A good tincture
of the English leaves, the fluid extract, and the solid ex-
tract are best fitted for children's use. When complaints
are heard of their inefficiency the fault lies generally with
the insufficiency of the dose. As soon as digitalis begins
to cause arrhythmia of the pulse it is advisable to reduce

154

PULMONARY TUBERCULOSIS

the dose and combine it with strophanthus, or adonis, or
cafFeine, for its most favorable effect is obtained before
the pulse becomes irregular. In the first stages of its
effect it lowers the pulse and increases the blood-pressure,
mainly of the left ventricle; and thus, while it stimulates
the whole circulation, it relieves the lungs, they being
supplied by the right ventricle, which is not so stimulated
by the drug.

Inhalations of different kinds were discussed on page
126. In addition (and partly in repetition) it ought to
be remembered that they are (or were) intended to destroy
bacilli, to act on the products of inflammation or of dis-
integration, or to influence cough or expectoration. No
bacillus can be reached except, if at all, in the tissue
which harbors it, and inhalations take effect on the sur-
face only. Neither medicines nor hot air have any other
effect. Oxygen, nitrogen, sulphide of hydrogen, hydro-
fluoric acid, iodoform, carbolic acid, creosote, have been
employed in vain. Turpentine inhalations are frequently
beneficial by loosening, in some cases diminishing, expec-
toration from suppurating surfaces, and, mixed or not
with eucalyptol or other disinfectants, by relieving the
fetor of pulmonary gangrene. The inhalations of com-
pressed air will prove advantageous in chronic processes
where the object is to expand the contracted lung-tissue.

Operative procedures are less indicated in pulmonary
tuberculosis of children than in that of advanced age.
The opening of a superficial large and copiously secret-
ing abscess is a rare indication, for the latter seldom
occurs except in the semi-adolescent, and, if it does, the
prognosis is at any rate absolutely fatal. Besides, the
dissemination of the tubercular process is so general in
the lungs of the young that not more than a slight tem-
porary improvement can be expected of an operation.

The symptomatic treatment of cough is one of the
urgent indications of pulmonary consumption. When it is
mild it requires no attention. Severe spells of coughing,
however, may injure the pulmonary tissue by the rapid
alternation of expiratory pressure and spasmodic inspira-
tion; indeed, they may lead to emphysema of the hitherto

155

DR. JACOBFS WORKS

healthy parts. They may force muco-pus with bacilli into
alveoli not yet affected, and thus spread tlie morbid proc-
ess. Docile children should be taught to suppress cough,
no matter from what source, for cough begets cough.
When the irritation is pharyngeal, the frequent drinking
of water, or of an alkaline water, or of milk, or the
sucking of a liquorice lozenge, or of a part of the
officinal trochiscus of ipecac and morphine (one-fortieth
grain in each), from time to time, is indicated. The
latter, or a part of it, will render good service in this
also, that it may prevent vomiting when taken from
five to fifteen minutes before meals. A drop of Mn-
gendie's solution on the tongue, not diluted, will have
the same effect. Sprays with alkalies or turpentine, the
inhalation of steam, whether pure or medicated with
aromatics or disinfectants, and, finally, the long list of
expectorants, the indications of which every one is fa-
miliar with, may or ought to be used according to indica-
tions, and a dose of Dover's powder, or codeine, or some
other opiate, administered at bedtime if required. Sul-
phonal is credited with diminishing exuberant expectora-
tion, while acting as an hypnotic. Docile children should
be taught how to expectorate. When the acid secretion of
the stomach which destroys bacilli is deficient, the appe-
tite poor, and the mucous membrane of the intestine ca-
tarrhal or ulcerated, the ingested bacilli are capable of
lighting up intestinal, mesenteric, or peritoneal tubercu-
losis.

In the management of the fever which attends pulmo-
nary tuberculosis (page 125) we should remember
that it is the effect of various agents. The invasion of
bacilli into new territories, the proliferation of the mi-
crobes of suppuration and putrefaction, and the progress
of inflammatory changes are equally concerned. The ques-
tion whether it is proper to interfere with every rise of
temperature is a very nice one. It is true that it increases
the disintegration of albuminoids, and ought not to go on
for an indefinite time, but many patients feel better with
a moderate rise than with a normal (or perhaps subnor-
mal) temperature. High hectic fevers are better influ-

156

PULMONARY TUBERCULOSIS

enced by a combination of quinine with a coal-tar prepa-
ration than witli either of the two. The latter has a quiet-
ing and soporific effect not possessed by the former; stilly
in every individual case the indications may vary. When-
ever acetanilid, or phenacetine, or antipyrin, acts unfa-
vorably on the heart, it ought to be combined with caf-
feine, or strychnine, or camphor in appropriate doses.
When they cause an undue amount of perspiration the
remedies recommended (page 130) for night-sweats
will be aptly combined with them. Atropine, agaric acid,
camplioric acid (0.25-0.5 gramme, four to eight grs.
daily), may then be given in fractional doses, while full
doses would be administered for night-sweats at bedtime.
Former remarks on pulmonary hemorrhage (pages
129-130) are still valid. The most powerful remedy
is absolute rest, which should continue for days after its
cessation. The applications of ice and morphine suffi-
cient to enforce rest, both physical and mental, are indi-
cated. The popular and frequently effective dose of a
teaspoonful or more of table-salt in a little water, with
or without the addition of vinegar, may cut short an
incipient bleeding. Drinking should be reduced to a mini-
mum, to avoid unnecessary blood-pressure. The doses of
acetate of lead, in order to be effective, should be " large."
From four to twelve grains a day may be given a child
of ten years to advantage. It shoidd be remembered
that they are demanded a few days only, and no poison-
ous effect need be feared. Some opiate, the extract of
opium or codeia, should be continued, so as to keep up
the quieting effect of the first doses of morphine. Cough-
ing, sneezing, — indeed, efforts of any kind, — are danger-
ous. That is why inhalations advised for the (very ques-
tionable) local effect of astringents should be omitted.
Tying the extremities to stop bleeding should not be con-
tinued long; the ligatures ought to be loosened after
twenty or thirty minutes, and should never be so tight as
to constrict arteries as well as veins. Our knowledge of
the action of ergot in hemorrhages of the lungs (or other
organs) has neither increased nor been refuted during
the last decade. Some attribute its effects t« the diminu-

157

DR. JACOBI'S WORKS

tion of blood-pressure owing to the presence of ergotinic
acid, others to the artery-contracting action of the cornu-
tine. At all events, as long as the chemical and physio-
logical researches concerning the drug are not finished,
clinical experience ought to be valued most highly. It
is favorable, but the subcutaneous effect is marred by the
local irritation apt to be produced by the fluid extract.
Sclerotinic acid, besides being painful, is liable to be de-
composed by microbes, which are rarely absent from ergot
preparations, and will hardly fulfill the expectations in
regard to it.

The complication with iniestinal tuberculosis is not fre-
quent; less so in children than in adults, perhaps because
the former do not suffer as long as the latter. It is in-
frequent (in comparison with the large number of cases
of pulmonary tuberculosis) because of the facility with
which bacilli are either destroyed in the acid secretion
of the stomach or swept through the whole length of the
intestinal tract. That is why the presence of tubercle ba-
cilli in the faeces is not a conclusive evidence of intes-
tinal tuberculosis. Nor is it permissible to claim diarrhoea
as the conclusive proof of tuberculous enteritis. A sim-
ple catarrh, or the presence of hardened faeces which re-
quire castor oil or enemata, may be expected during the
course of tuberculosis as under ordinary circumstances.
When the suspicion of tubercular colitis is justified, large
enemata (the hips being raised), containing from one to
five per cent, of subnitrate of bismuth, and possibly some
disinfectant like thymol (1 : 2000 of warm water or of
starch decoction) are indicated. They should be given
daily, or several times a day. Internally, the remedies
recommended formerly - (page 129) will act well.
What I said of bismuth, opium, lead, naphthalin and re-
sorcin still holds good. Corrosive sublimate I do not value
any more highly at present than formerly. Salol may
be added to bismuth, from eight to thirty grains (0.5-2.0)
daily. Warm fomentations (water or poultices) over the
abdomen have a gratifying effect when there is colic or
persistent sensitiveness pointing to the presence of a tu-
bercular peritonitis.

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DENTITION AND ITS DERANGEMENTS

FIRST LECTURE

To a truly scientific physician nothing is more evident
than that the physiology and pathology of the human or-
ganism have not been sufficiently elucidated. The medical
sciences are by no means completely developed; they never
will be, for they combine a knowledge of all the varied
and intimate physiological functions and obscure patho-
logical changes of the physical and mental organs of the
human frame; they never can be, for their basis, the human
organism, will and must undergo changes and further de-
velopment. Those powerful minds who have done most,
and are still in our times working most successfully, for
the advancement of medical knowledge, have been and are
still the first to admit the truth of this proposition, and
are the first also to acknowledge that more remains to be
done than has been done hitherto. Fortunately, however,
there are a large number of subjects so well known and so
clearly understood, that even in this ever-changing science
we are enabled to point out the way to further investiga-
tions, to arrange in mathematical order our conclusions, and
win thereby for medical science not only a place amongst
the so-called exact sciences, but the acknowledgment of
educated men, that it is the noblest and most comprehensive
amongst them.

Having the honor, as I believe, of being the first in this
country to teach infantile pathology as a distinct and fully
independent branch of medical education, I did not deem it
proper to begin with a subject liable to be misunderstood,
mistaken, or misconstrued. A subject of this description I
have therefore determined, in this preliminary course, to
consider at length, viz., the Physiology and Pathology of
Dentition — a subject which is but imperfectly understood.
But there should be nothing mysterious about it; the pro-

l.'')9

DR. JACOBI'S WORKS

cess of the early formation and the final development of
teeth is well understood, and on this safe basis we are able
to rest our conclusions relating to pathology and thera-
peutics. So little, however, can we rely on the correct in-
terpretation of facts by observers, that even here we shall
have to contend with prejudice and ignorance.

You know that among the public at large, even among
the educated part of the community, teething is regarded
as one of the two scapegoats of all the diseases of infan-
tile age. Teething and worms are among mothers acknowl-
edged as the universal and all-powerful sources of disease.
Whenever an innocent ascaris or a puny oxyuris is observed
in the faeces of a child, worms are, for years to come, con-
sidered as the undoubted cause of any disease that may
occur. Teething, a normal, physiological development, tak-
ing place at an age which for many reasons is subjected to
a large number of diseases, has a strong hold on the imagi-
nation of frightened maternal minds. The first dentition
generally occupies the first years of early infantile life;
a period in which the child is peculiarly liable to diseases
both numerous and frequently of a dangerous character. As
the protrusion of a tooth (and in the average a tooth will
cut every month) is a remarkable phenomenon, and is
something new and visible to the eyes of even the most
shortsighted, it is believed to be the cause of every unfavor-
able occurrence in early life. A mother will bring to you
her child, thin, emaciated, and anaemic, with sunken ej'^es
and the wrinkled physiognomy of old age, and tell you that
she is well aware the poor thing is suffering from teething,
and that therefore nothing can be done to alleviate its suf-
ferings. She will never be convinced that her child is dy-
ing from her own neglect; that she has allowed a slight
catarrh of the intestines, perhaps, to degenerate into incur-
able ulceration of their follicles. Thus you will learn that
ignorance and prejudice will attribute all, or nearly all,
the diseases of the infantile age to a normal process. To
the same cause are attributed inflammations of all the ex-
ternal and internal organs, the brain and its membranes,
air passages and lungs, mouth, throat, stomach, and intesti-
nal canal ; as also cough, vomiting, diarrhoea, and dysentery,

160

DENTITION AND ITS DERANGEMENTS

derangements of the secretion and emission of urine, chronic
eruptions of the skin, convulsions and paralysis, exudations
of serum, and extravasations of blood, in any of the numer-
ous organs of the infantile body. Teething is thus con-
sidered the sufficient cause of most of the terrible diseases
which prove fatal to thousands of the rising generation.
I can assure you that the readiness to attribute all the dis-
eases of infantile life to teething has destroyed more human
beings than many of the wars described in history. For
though parents are so much impressed with the belief of
the dangers of teething, still they never think of attempting
to save the lives of their children by counteracting the sup-
posed life-endangering power of a normal process.

The common supposition that teething is a predisposing
cause of disease, nay, even a disease in itself, prevails
over all civilized and half-civilized countries. What is
now, however, the belief of the public, has been the convic-
tion of the medical world through centuries, almost down
to the present time. General experience shows that the
persuasion of the scientific world, after having been given
up to make room for more correct opinions, has remained
in the public at large; and it is to be feared that it will
not soon be removed. And it would be fortunate if this
prejudice were confined to the public. But unfortunately
it still lingers in the medical profession, and it is for this
reason that I have dwelt upon it so lengthily. Nothing
is more common than to hear doctors of medicine, young
and old, in cases of infantile disease, diagnosticate teething,
after mother and nurse have done so before; and nothing
is more frequent than to be told that the death of a child
was the consequence of dentition. I have seen, in this city,
a certificate of death, in which the direct cause of the
death of a child five years of age, with his jaws full of
teeth, was attributed to teething. Consider for one moment
the absurdity of the conclusion that a normal, physio-
logical process is fatal to the existence of a living being.
Who has ever ventured to assert that menstruation, or preg-
nancy, or the climacteric years, are the direct causes of
death? It is equally absurd to assert it of dentition; yet
such statements are daily made by physicians. According

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DR. JACOBI'S WORKS

to the census of England, in the year 1857, there were
in the United Kingdom 3,992 deaths from teething, 3,791
of which occurred in children of less than two years; 201
in children of from two to five years. Between the years
1845 and 1850, there died in London, according to the
report of the registrar-general, no less than 3,466 infants
from teething, and the disorders caused by the gen-
eral irritation attending dentition ; the total number of
deaths from all causes being 258,271, giving the proportion
of one death from teething to seventy-four from all
causes. And the census of the state of New York offers
the following numbers: In the whole state there died, in
the year 1855, from teething, 626 children; of these cer-
tificates of causes of death, 254 were made in New York
County, 132 in Kings, 35 in Erie, 24 in Rensselaer, 41
in Albany, 30 in Monroe. It is not stated whether a part
of those unfortunate children who died from teething had
not the full contingent set of teeth of first dentition.

Let me first state that teething, in the common accepta-
tion of the term, is not the gradual development or forma-
tion of teeth, but the time and act of their penetrating the
gums. This takes place, in the average, beginning from
the sixth, seventh, or eighth months to the twenty-fourth
or thirtieth month of life. I may also in this place enu-
merate the symptoms which are often observed during, or
(shall I say) in consequence of teething. In a large num-
ber there are no symptoms at all. The first, and the second,
and perhaps all the other teeth, will cut, and without any
disease or trouble of any kind. In others the mouth is
hot and red, with the exception of those thin parts of the
gums below which the teeth are visible; even the lips have
a higher color and temperature; the child puts its fingers,
or anything in its reach, into the mouth; is pleased with
having its gums rubbed; bites the nipple when sucking;
or if the mouth is inflamed and aphthae are present, and
the tonsils swollen, it is disinclined to take the breast, try-
ing it often, but just as often loosing its hold. At the same
time there is a copious salivation, the saliva being usually
tough, viscid, and more like mucus than saliva. The child
has all the usual symptoms of slight or moderate fever;

162

DENTITION AND ITS DERANGEMENTS

warm hands, a rapid pulse, flushed or pale face, intense
thirst, vomiting, constipation, or diarrhoea with green mu-
cous passages. The most common of these is diarrhcEa.
Pain in the bowels is very common, as digestion appears
disturbed; tears are secreted abundantly; the blood-vessels
of the conjunctivae are injected. A slight cough, hoarseness,
pain in passing the scanty urine, secretion from the nose,
are not unfrequent occurrences. Such symptoms are apt
to disappear entirely in three or four days or a week, with
or without treatment. But sometimes the symptoms are
graver from the beginning or they are aggravated by en-
demic or epidemic influences, or the peculiarities of indi-
vidual dispositions to disease.

In some cases the fever will not disappear so readily
without leaving grave consequences; the pulsations of the
heart and arteries will not decrease in number; the action
of the heart will not be of less power and impetuosity than
before; the tongue, mouth, and lips remain dry; thirst so
extreme that you cannot take the tumbler from your little
patient's hands before he has completely emptied it. Res-
piration is accelerated, numerous, short, and superficial.
The eye is sensitive to the light; headache becomes mani-
fest from the corrugation of the muscles of the eyebrows,
and the peculiar aspect of suff'ering. Excretions and secre-
tions are scanty, faeces dry and hard, urine red. Vomiting
and diarrhoea, if they had been present before, now cease.
The child will appear more depressed, but easily excited;
slight local convulsions will prove the introduction to severe
attacks, which generally terminate fatally. In other cases
the tongue is hard, dry, black; teeth and lips of the same
color, corresponding with the symptoms characteristic of
typhoid fever. Such cases are very likely to terminate
fatally. The last symptoms in such cases are paralysis of
some abdominal organ, especially of some part of the intes-
tine. Another train of symptoms attributed to teething, is
the following: A child is feverish; pulse frequent and
small; temperature of the extremities considerable; but the
face is pale from the beginning; lips and mucous membrane
of the mouth, hot, red, and dry; tongue covered with a
greyish white fur; restlessness; anxiety; respiration hurried

16.3

DR. JACOBFS WORKS

and short; vomiting and diarrhoea. Frequently such a de-
pression of the general strength is combined with these
symptoms — the more so as the most intense and often re-
peated vomiting and diarrhoea are very apt to exhaust the
little patients — that the child dies in a day or two in con-
vulsions consequent upon inanition, and local or general
paralysis. In a certain number of cases the principal symp-
toms cease, and the child recovers. In a certain other num-
ber vomiting will stop, but the diarrhoea continues. The
deluded mother who felt a little uneasy at the severe
character which teething seemed to have assumed, is grati-
fied, after the main symptoms have passed by, to find that
her child is suffering from diarrhoea only, and that in this
manner teething will be made easy and comfortable. But
alas ! this deception on the part of the mother is too often
fatal to the child. The diarrhoea is allowed to go on for
days and weary weeks ; the digestion becomes hopelessly
destroyed ; the abdomen immensely distended with gas ; the
mesenteric glands swollen and impermeable to chj'^me; the
catarrh and over-secretion of the glandular follicles of the
intestine lead to deep ulcerations of the intestinal canal ;
the diarrhoea becomes also more frequent, serous, mucous,
or bloody; the arms and legs of the little sufferer dwindle
away; and the countenance becomes emaciated and senile.
The scene closes with a consoling certificate from some
doctor or druggist, affirming that teething was the cause of
death. Thus millions of infants are destroyed by ignorant,
prejudiced, and incorrigible advisers. I say incorrigible.
I know that mothers will always consult their prejudices
first, the prejudices of their neighbors next, perhaps at
some late time common sense, and finally they may seek
the advice of an educated medical man. I know that a
mother who has just consigned a beloved child to the
grave will go home with throbbing heart, and repeat the
follies which cost her the child she has lost. If you remon-
strate with her for neglecting the second, as she did the
first, she will reply, Was not the child teething? Would
you prevent the child from teething naturally? Is not
teething necessary? Was it her fault that the child got
teeth with difficulty? The true inference would be that

164-

DENTITION AND ITS DERANGEMENTS

nature neglected much, and that it was greatly at fault in
the matter of dentition. I once read the newspaper an-
nouncement of the death of a child, in which the parents,
while inviting all their friends and acquaintances to attend
the funeral, affirmed that " the Lord hauled the dear child
up to heaven by the teeth." Now, in this case, neither the
father nor mother was at fault.

I shall not, in this place, proceed to point out the other
symptoms of diseases attributed, whether rightly or
wrongly, to teething, as the symptoms of cerebral inflam-
mation, of convulsions, of general and local paralysis. At
a later period in this course of lectures I shall return to
these subjects for practical purposes. It will better an-
swer my design to give you a sketch of what dentition is,
anatomically and physiologically, in order to show clearly
the normal and abnormal course it may take. I shall thus
be able to explain and limit the numberless complaints
generally attributed to teething. If I can relieve your
minds of the impression that dentition destroys the thou-
sands and even tens of thousands of innocent beings who
are yearly sacrificed in reality to the prejudices of other
times, I shall be abundantly satisfied.

THIRTEENTH LECTURE

It has been the object of my lectures to prove that den-
tition is neither a disease nor a direct cause of diseases,
except in very rare cases. I believe I have shown that all
those diseases of the cutaneous, circulatory, respiratory,
and nervous organs, generally attributed to dentition, are
in no, or very loose, connexion with the physiological proc-
ess of teething; that further, pathological occiirrences can-
not, in themselves, be accounted for by a simple and undis-
turbed physiological process; and finally, that disturbances
are very rare indeed. It is, therefore, at least superfluous
to more than mention these facts, as they are too fresh in
your memory to require more than a mere reference to m_v
former lectures. Now, if dentition is no disease, what
right have I to speak of the therapeutics of dentition.'' I
answer myself, that I have none. The diseases we have
reviewed with each other, which were said to depend on

165

DR. JACOBFS WORKS

dentition, require a treatment of some kind. But you have
learned that their presumed dependency on dentition had
not the least influence on their treatment. Thus we cannot
even say that dentition, as it has not the slightest effect
on the nature of those diseases, the etiology of which
may be very complicated, has certainly none on their treat-
ment.

Thus there is no treatment of dentition as such. What-
ever treatment has been resorted to, has even in former
times been very rarely of a general character. We should
have to except from this general remark the common prac-
tice of purging by remedial agents such children as would
not suffer from diarrhoea during the protusion of a tooth
or a group of teeth. But there are a number of loc;3l
contrivances that have been resorted to, partially for the
purpose of curing such diseases as were considered the
consequences of dentition ; partially, however, for their pre-
vention. Among the latter I comprehend the articles pre-
pared from leather, wood, bone, India-rubber, which are
destined to help the little ones in the work or the gradual
absorption of the gums, or to relieve whatever annoying
sensation they have or are supposed to have. I do not
think that they can hurt, at all events I am not afraid of
the inflammation which several authors suppose to follow
the frequent use of these things. As to other means of
alleviating or escaping the sufferings of dentition, every
country, both civilized and barbarous, has invented its
own ; and what the instinct of the people did not furnish,
has very frequently been sinned by those who ought to
have known, and taught, better. Thus, according to Dr.
Magaziner, the inhabitants of the regions around the Cas-
pian Sea fill a quill with metallic mercury, and envelop it in
a piece of leather or a woolen rag, in order to influence the
secretion of milk in the female breast. Suspended over
the chest, it is believed to increase the amount of milk,
which it is believed to decrease when the metal is sus-
pended on the back. This popular belief Dr. Smirnoff has
attempted to transfer into practice and science on quite a
different territory. He applied the same contrivance in
cases of " difficult dentition," and succeeded so well that he

166

DENTITION AND ITS DERANGEMENTS

instantaneously made his discovery public. Up to this time
the world has proved ungrateful. The modern Greeks, as
we learn from the communications of Pr. Landerer, of
Athens, to the Archives of Pharmacy (Oct. 1851), alleviate
difficult dentition, and accelerate the protrusion of teeth,
by daily frictions of the gums with the fresh brain of
hares. A number of curious facts of a similar nature could
be collected, if it was worth while in times where the brains
of medical persons are still overtaxed to excel by some un-
expectedly clever invention of their own. I have availed
myself of some former opportunity to speak to you of Dr.
Delabarre's Dentition Syrup, by which not only the tick-
ling sensation of the gums of teething children is removed,
but at the same time the immense number of diseases fol-
lowing this tickling sensation are prevented. It ranks
with the numerous nostrums of the newspaper advertise-
ments, and will, I hope, be forgotten with them.

Of the treatment of such diseases as have been believed
to depend on dentition, I have spoken at different occa-
sions, at the same time when I took some pains to eluci-
date their etiology; the measures for the purpose of pre-
venting disease, by protecting the infantile organs, and by
a proper diet, further, the measures for securing easy
dentition, by securing general health, have repeatedly been
the subject of our conversation. There is, however, one
of the numerous means used for the purpose of alleviating
dentition and curing dental diseases, on which I feel both
bound and inclined to make a few remarks, viz., scarifica-
tions of the gums for the purpose of allowing a more rapid
protrusion of a tooth, and thus affording protection or
recovery from dangerous dental maladies.

Scarification of the gums has been practised for hundreds
of years. Ambrose Pare lanced the gums of his own
children. Harris, Van Swieten, and others practised the
same operation, but never before the gum would be stretched
and prominent over the tooth, leaving its alveolus. They
were of the opinion that the premature performance of the
operation would be followed by a cicatrix of so solid a
character that at a later time the tooth would find serious
difficulties in piercing the gums. Benjamin Bell, how-

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DR. JACOBrS WORKS

ever, and Richter, assert that deferring the operation until
the period mentioned renders it entirely unnecessary; for
the derangements following difficult dentition are percept-
ible before the piercing of the gums; therefore the gums
must be lanced early in order to encounter the dangers
of difficult dentition; if the incision were' made prematurely,
it might be repeated. Richter, moreover, believes the use-
fulness of lancing the gums to consist in the haemorrhage
produced by this operation. Others advise to delay its
performance until other means to check or remove morbid
symptoms have failed. Girtanner praises it as the safe-
guard of many children who would have been lost without
it; Camus, however, declares it to be both useless and in-
jurious; he also doubts if the convulsions so generally at-
tributed to the influence of difficult dentition really de-
pend on the presumed cause.

The methods of the operation that have been recom-
mended are just as various as the opinions concerning its
value. One makes a single transverse incision, the other, a
cross incision; others act in the former manner over the
incisors, in the latter, before the appearance of the molars.
Boyer removes the whole portion of the gum as far as it
covers the tooth, attempting in this manner to avoid the
rapid reparative process generally following the operation,
which is of such power and rapidity that Hunter was
compelled to scarify ten times for the very same tooth.
Again, others report that a single transverse incision is
sufficient to remove very severe symptoms. This observa-
tion has particularly been made in cases of convulsions,
which sometimes would not return after a sufficient incision.
Mombert urges this fact, but at the same time advises not
to lance the gum before the tooth is really ready to pierce
it. His reason for this advice is the solidity of the cica-
trization. He often repeats the operation, but is averse to
cutting to any depth. In his opinion it becomes but rarely
necessary for the incisors, more frequently for the molars,
most often for the canine teeth ; because in these the gums,
from their pointed and conical form, are still irritated after
the sharp crown has commenced penetrating. The incision
is to be made without hesitation where, with the presence

168

DENTITION AND ITS DERANGEMENTS

of dangerous symptoms, the teeth show their white color
through the gums, when these are extended, hot, and
swelled, when the infants cry constantly, where soothing
applications to the gums have been unsuccessful (such a
soothing application is said to be: mel. rosar. 5 ij ; succ.
citr. 3j; aq. amygdal. amar. 9 ij), and where the general
symptoms have not given way to the generally known
remedies. If the symptoms are no less after the incision,
or return after hours or days, the operation must be re-
peated ; suppuration is very seldom observed. Unless, how-
ever, a third incision removes the morbid symptoms, there
must be other causes for them. Thus, the author makes
incisions where the symptoms were not removed by the
generally known remedies ; and where incisions will not
help, he concludes that dentition is not the cause of the
symptoms, and probably returns to his " generally known
remedies." What they are is not known to us. A curious
manner both of diagnosticating the nature of an ailment,
and of curing it.

The most emphatic eulogizer of the scarification of the
gums is Marshall Hall. I cannot do him more justice, nor
prove more impartial, than by quoting his very words.
He says:

" There is no practical fact, of the truth and value of
which I am more satisfied, than that of the effect and effi-
cacy of scarification of the gums in infants, and not in
infants only, but in children. But the prev^ailing, I may
say the universal, idea on this subject is, that we should
lance the gums only when the teeth are ready to pierce
through them, and only at the most prominent part of the
gums, and as the occasion to which I have referred may
require ; and no idea of this important measure can be
more inadequate to its real value. The process of teething
is one of augmented arterial action and of vascular action
generally, but it is also one of augmented nervous action;
for formation, like nutrition, secretion, etc., generally, is
always a nervo-vascular action ; and of this the case in
question is, from its peculiar rapidity, one of the most
energetic. Like other physiological processes, it is apt to
become, from that very character of energy, pathological,

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DR. JACOBI'S WORKS

or of morbid activity. It is obviously, then, attended with
extreme suffering to the little patient; the brain is irritable,
and the child is restless and cross ; the gums are tumid and
heated; there is fever, an affection of the general vascular
system, and there are, too, frequently convulsions of various
degrees and kinds, manifested in tlie muscles which move
the eyeball, the thumb and finger, the toe, the larynx, the
parietes of the respiratory cavities ; and the limbs and frame
in general, affections of the excito-motor part of the nerv-
ous system, and of the secretion of the liver, kidneys,
and intestines, affections of the ganglionic division of that
system.

" It is to the base of the gums, not to their apex merely,
that the scarification should be applied. The most marked
case in which I have observed the instant good effect of
scarification, was one in which all the teeth had pierced the
gums. Better scarify the gums one hundred times unneces-
sarily, than allow the accession of one fit of convulsions
from the neglect of this operation, which is equally impor-
tant in its results, and trifling in its character. And it is
not merely the prominent and tense gums over the edges
of the teeth which should be divided; the gums, or rather
the blood-vessels, immediately over the very nerves of the
teeth, should be scarified and divided. Now, while there
is fever or restlessness, or tendency to spasm, or convulsion,
this local bloodletting should be repeated daily, and in
urgent cases even twice a day. A skillful person does it in
a minute, and in a minute often prevents a serious attack;
an attack which may cripple the mind, or the limbs, or even
take the life of the little patient, if frequently repeated.
There is, in fact, no comparison between the means and
the end; the one is trifling, and the other so momentous.

" There is a phrase among nurses, viz., the breeding of
teeth, which may be taken as evidence that before the teetli
actually reach the borders of the gums, they may prove
the source of much irritation."

Where " a phrase among nurses " is taken as " evidence,"
or where every case of convulsions is attributed to the proc-
ess of dentition, because now and then a fit will occur in
consequence of some irregularity in the protrusion of a

170

DENTITION AND ITS DERANGEMENTS

tooth, we may have to expect such practice as recommended
in the quotations you have just been listening to. It is
true that a simple incision into the gums is generally not
at all a dangerous thing, but to repeat the same operation
to such an extent, to again and again divide the gums,
appears both cruel and absurd. Moreover, Marshall Hall's
own countrymen report cases of scarification of the gums
made after his fashion, after which copious haemorrhages,
suppurations, and ulcerations "would take place. Not to
speak of the fact, that all authors recommending frequent
scarification were at the same time opposed to repeating it
too frequently in rhachitic and scrofiilous infants; but 3'^ou
know, that just these are the very ones who are most sub-
ject to the symptoms of what they call difficult dentition.
Not to speak of the further fact, that both the practice of
lancing the gums where you wish to avoid the trouble of
making a diagnosis, and stopping to lance when you see no
success, and therefore suspect some other cause of the mor-
bid symptom, is unscientific and unworthy. Marshall Hall
affirms never to have lost a child from difficult dentition —
the greatest recommendation for his surgical cure of both
difficult and easy dentition. I may state the same result of
my own practice among teething infants, viz., that although
I hardly make more than ten or twelve scarifications of
gums in the course of a year, I have also never lost a case
from " difficult dentition."

I see very few indications for the lancet during the
period of dentition. You may cut where the gums are an
impediment to the protrusion of a tooth or where the
gums themselves are the seat of a disease giving rise
to general symptoms, especially of the nervous system.
Thus, inflammation of the gums justifies an incision, for
the sake of relieving the tension of the tissue; the same
practice is followed in inflammations of the tongue, of
the fingers, etc. Even mild cases in very irritable children
may be treated in the same manner. But the incision it-
self, especially when repeated, may be a cause of irrita-
tion, sometimes visible in the fact that during the preva-
lence of follicular or other stomatitis the gums will be
found covered with superficial ulcerations. I need not

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DR. JACOBI'S WORKS

add, that while exudative processes, such as diphtheria,
are active in the system, every wound of this description
will give rise to new diphtheritic deposits. I, then, scarify
the gum in cases of intense local hyperaemia and in in-
flammation: these are the cases in which the loss of a few
drops of blood, which have no effect on either the healthy
or the diseased system in general, is decidedly advanta-
geous. I should scarify, and have done so, several times
during my practice, in caseS of convulsions in tender, deli-
cate, irritable patients, in whom I found the gums swollen,
and where a correct diagnosis could not be made instan-
taneously; especially in such as had been once relieved by
the same operation; for I must confess that once or twice
in my life, not oftener, I have observed the instant ter-
mination of an attack of convulsions after I lanced the
gums. But always be sure that the tooth is near the sur-
face. I know that new cicatrices will easily tear, but
old ones will not; and I have seen real trouble arising from
teeth that had been cut weeks before they were ready to
pierce the gums ; if 3'ou mean to call it a piercing, for under
normal circumstances the process is one of slow absorption
of the gum. I have known cases in which practitioners
had lanced the gums two or three months before the final
appearance of the tooth, a practice which is annoying, or
useless, or dangerous to the child, and certainly not in-
dicative of much diagnostical power and therapeutical
knowledge in the doctor. It is not even uncommon to
find a retardation of the protrusion of a tooth where you
expected its daily appearance. A child becomes sick, with
the symptoms of fever, and some local symptoms which
you will or will not diagnosticate, according to your ac-
complishments as a diagnostician. You lance the gums,
and expect not only the appearance of the tooth, but also
a termination of the untoward symptoms. Nothing of
the kind occurs. To the contrary, the child gets thinner
and sicker, and no tooth. Where the system is intensely
suffering, where emaciation takes place and nutrition is
interfered with, it is but natural that the growth of a
tooth should also stop. In such cases you may safely
predict that no tooth will appear before the child will

172

DENTITION AND ITS DERANGEMENTS

get well, or at least better. During convalescence the tooth
cuts. You say that it made its appearance after the
organism had been sufficiently restored to allow of phos-
phate of lime being spared for the building of teeth; the
mother says, that because the child was well when the
tooth came and was through, the child suffered from its
tooth. You say, the child cut a tooth, after it was well
enough. She says, it got well after it cut a tooth. Cer-
tainly there are difficulties in teething, but often during,
not from.

In one of my first lectures I have spoken of the direct
injury done to the tooth by incisions. The consistency
of the tooth is the less the younger the child ; and that
harm is done to a tooth by the effect of a hard and sharp
instrument cannot be denied. If you expect to effect any-
thing by an incision, you must be sure of dividing it
down to the tooth. But you can scarcely avoid injuring
the tooth in cutting down upon it. If this danger exists,
and it does exist, it is the more to be feared from those
often-repeated scarifications recommended by Marshall Hall
and others. Thus while your incisions are of no use in
the present, they are positively injurious to the future.
There is something absurd and unworthy of the high
standing of our profession in performing any, though slight,
operation, which is useless; but it is a revolting thought to
perform one that is worse than useless, viz., injurious. It
is unworthy of the high vocation of our profession to re-
sort to an action which gives the impression to the rela-
tions of the little sufferer, that not only something has been
done, but that the right thing has been done, and which,
nevertheless, is destined, in most cases, to cover the want
of a diagnosis, and the ignorance regarding the causes of
the disease. The language of disease in infantile life is
intelligible enough. It is your province to listen to it, and
to understand it.

173

FUNCTIONAL AND ORGANIC HEART

MURMURS IN INFANCY AND

IN CHILDHOOD

I ASK your permission to utilize the time afforded me
for a presidential address by discussing a few points con-
nected with cardiac murmurs, both functional and organic,
mainly in infancy and in childhood. In the last volume
of the Transactions of our Association, I published a pa-
per on functional cardiac murmurs. I avail myself of
this opportunity to again return to the same subject with
a single contribution which I think of some importance.
On that occasion I quoted a remark of mine of the year
1888 (Brooklyn Medical Journal, March) which reads:
" The heart (of the infant) exhibits functional murmurs
but rarely. Wlienever there are murmurs present in the
infant, it is safe to attribute them to organic disease rather
than to mere functional disorder." The last few years
have produced many contributions to the same subject,
particularly in Germany. Two authors of eminence, Hoch-
singer and Soltmann, deny absolutely the occurrence in the
first three years of life of functional murmurs. The per-
sistent discussion of these statements, both in societies
and in the journals, have, however, brought out a few in-
stances of a murmur in the very young that may well be
taken as functional. One of them I quoted last year.
After all, it appears undeniable that even a single case
contradicting the categoric dicta of the two eminent
works is capable of shedding light on a difficult topic.

Helen D. (colored), thirteen months of age, rachitic,
was admitted to the " Jacobi Ward " of Roosevelt Hospi-
tal March 19th, with pneumonia and some pus cells in the
urine. The last physical signs of pneumonia disappeared
about April 6th; on the 10th there was some vaginal dis-
charge but DO gonococci were found. It disappeared after

175

DR. JACOBI'S WORKS

a few days. All this time there were marked remissioirs
in her high temperature, the thermometer showing 105°
F. and more in the evening, and less than 101° F., down
to 99° F., in the morning. Plasmodia were not found in
spite of renewed examinations which were made before
quinine was administered. Large doses of the latter were
then given daily up to 10 grains a day, also subcutaneous
injections during the remission. Careful search for pus
everywhere was negative. On April 10th a systolic mur-
mur was heard which gradually increased and fortified
the diagnosis of septico-pyeluria. Then, while quinine
was continued, Crede's ointment, 1 gram daily, was used;
within a day the temperature fell to 102° F. in place of
105° F., and the child appeared comfortable for some
days, smiled and took food. At no time could pus be dis-
covered. There was no dullness, and respiration had be-
come normal with absence of any physical changes or
symptoms. The murmurs grew less and could not be found
on April 17th, nor afterward at any time. About the
same time the temperature rose again and exhibited the
same steep curves of previous weeks. The infant was
evidently sinking and could not be examined closely dur-
ing the last six days of her life. She died on the 23d.
The autopsy revealed a recent suppurative pleurisy of the
right side, surely a few days old only, and absolutely no
other abscess or ulceration. The cause of the pyemic fever
is unknown to me. But the subject of greatest interest
to me was the heart. Here was an infant with sepsis,
with a marked systolic murmur that took a few days to
become quite loud; then it gradually diminished and was
absolutely lost during the last six days of life. A close
examination of the heart by the pathologist of Roosevelt
Hospital, one of the gentlemen connected with the Path-
ological Department of Columbia University, revealed
positively nothing abnormal in the heart. So here was a
functional mitral murmur in a baby of thirteen months
of age.

Neither it nor an organic nnirmur should, however, be
mistaken for extracardial murmurs. I have seen that error
committed. Extracardial murmurs in children, mostly

176

FUNCTIONAL AND ORGANIC HEART MURMURS

systolic, are very infrequent in infants below two years,
because at that early time the heart is larger in proportion
arrd less covered by the lungs. When these grow, how-
ever, and in the presence of a tumor or of adhesions be-
tween the pleura and the pericardium, the murmur ap-
pears, soft or grating; is mostly heard anteriorly only; is
arhythmic, not synchronous with the contraction of the
heart ; is strong in deep inspiration ; disappears when
there is no breathing, and is less audible in a recumbent
thait in an erect posture.

Hochsinger terms extracardial those murmurs which
are now and then observed in grave anemia, mainly leu-
cocythemia, and not infrequently with rachitic deformi-
ties of the heart. It will not do, however, to be overcon-
sistent. In grave anemia we might well think of the myo-
cardial structure-changes which result in irregular con-
traction ; and in rachitis the more extensive contact of the
heart with the ill-shaped chest annoys the heart-muscle
sufficiently to impede symmetrical contraction.

If murmurs mean organic valvular disease in most
cases, the latter does not necessitate the presence of a
murmur. Mitral stenosis need have no murmurs at all.
Osier long ago emphasized the fact that ulcerous endo-
carditis may not exhibit any murmur, and that the diag-
nosis of the condition is thereby rendered difficult. I have
seen proofs of that statement in autopsies. When the de-
posits take place at the insertion and not at the edge of
the valves, there is, or need be, no murmur. Two months
ago I lost a child two years of age who was under close
observation six weeks for pneumonia, endocarditis, and,
finally, meningitis, of which he died. This endocarditis
was diagnosticated by the usual symptoms and was marked
by a loud systolic mitral murmur. The patient was in a
fair way to recover from his endocarditis (pneumonia
having disappeared before the heart was affected), when
meningitis developed. During that recovery the murmur
became gradually less from day to day until it disappeared
entirely. There was certainly an apparently complete re-
covery from endocarditis. The specimen which I shall ex-
hibit to you before the end of the session shows still a

177

DR. JACOBI'S WORKS

slight thickening of the edge of the mitral valve and iso-
lated small thickenings at a little distance. But for these
findings the murmur might have been classed as functional ;
as it is, there is merely a proof that a partial, probably
also a complete, recovery from endocarditis may take
place. That happens, perhaps, more frequently in the
very young than in advanced years. For although endo-
carditis is very frequent at an early age, valvular lesions
are mostly — but mostly only — milder than in the adult,
and compensation is easier. Moreover, murmurs are not
so apt to be loud because the vessels are relatively wide
compared with the heart. At about puberty the relation
of the width of the blood-vessels to the volume of the
heart is 61:290, while in the newly-born it is 20:25, viz.,
almost identical.

What I said of the possibility of a bona fide recovery
from endocarditis is mainly due to the changes I alluded
to last year. I spoke of Bouchut's proliferating endocar-
ditis (endocardite vegetante), called valvular nodes by
Albini, blood-cysts by Luschka and Parrot and lately
(1898) blood-nodules by Berti. They are small eleva-
tions, principally on the lower side of the valves, and give
rise to a systolic mitral murmur in the newly-born, which
may either last a lifetime or disappear in time with the
growth of the organ, or with increasing absorption, or
with progressing compensation.

Endocarditis is not always easily diagnosticated. That
there may be valvular lesions without a murmur, I think
I have shown. However, endocarditis does not necessarily
mean valvular lesion, nor does it necessarily imply dilata-
tion and accentuated pulmonary sound ; nor is it followed,
at least for years, by obstructions and disturbance of com-
pensation, for in the very young the right ventricle is more
muscular, expels its contents more readily into the blood-
vessels, which are still disproportionately wide, and thus
protects the auricles against dilatation. But what endo-
carditis does accomplish in many innocent-looking cases
is through its complication with myocarditis.

Most murmurs mean organic lesions either in the valves
or in the myocardium. In that respect all ages are alike,

178

FUNCTIONAL AND ORGANIC HEART MURMURS

But there are possibilities in the infant which modify the
explanation of the usual observations; and there are con-
ditions in which the diagnosis may be very difficult. For
instance, besides the frequent mitral systolic murmurs
that result from infectious diseases, most commonly from
rheumatic invasion, there are those that originate in con-
traction, or more or less obliteration of the mitral orifice,
or adhesion of the valve. These conditions are not always
complicated. There is, for instance, the case of Gerhardt,
that of a baby who died at the age of four months. Still,
they are very rare, very much more so than in the pulmo-
nary artery, or even in the aorta where some have been
noticed and ascribed to syphilis.

In persistence of the ductus arteriosus Botalli there is a
loud systolic murmur over the sternal end of the second
left intercostal space. It extends upward into the vessels
of the neck mainly of the left side and is audible posteri-
orly in the left interscapular space. It is connected with
a characteristic dulness nearly oblong, extending along
the left margin of the sternum to the clavicle. Within a
few months lately I have seen two cases in which the diag-
nosis was obvious. But uncertainty may arise when there
are complications with valvular anomalies (either rudi-
mentary development or excrescences) or with interau-
ricular communications, or with stenosis or atresia of the
aorta or of the pulmonary artery, or with a narrow bicus-
pid orifice. These complications are more dangerous
than the patency of the channel itself, because the num-
ber and degree of accompanying conditions, such as ex-
tensive murmurs, cyanosis, and hypertrophy of the right
ventricle, depend on them. When not so complicated,
patency of the duct is compatible with a fairly long life.

In congenital stenosis of the pulmonary artery there is
in the sternal part of the second left intercostal space a
systolic miirmur which is not transmitted into the carotid,
except when there is a complication with defects of the
ventricular septum. It may be mentioned that the second
pulmonary sound is feeble, that there is cyanosis with
clubbed fingers and hypertrophy and dilatation of the
right ventricle. These are not present when, instead of

179

DR. JACOBI'S WORKS

stenosis, there is a complete atresia of the artery. In
that case the riglit heart is small or rudimentary.

Absence of the ventricle I have never seen or diagnos-
ticated unless complicated with stenosis of the pulmonary
artery. In these latter cases there is a loud murmur over
the sternum which extends far down and upward into the
vessels of the neck. The secondary pulmonary sound is
accentuated only when there is a hypertrophy of the right
ventricle; when both ventricles are hypertrophied the sec-
ond aortic and pulmonary sounds are of equal strength.
The frequent statements in the books that pulmonary ste-
nosis with defect of the septum is characterized by hyper-
trophy of the heart, I cannot verify. On the contrary,
the absence of much hypertrophy I find to be character-
istic of that condition; it has led me to a correct diagnosis
which I could verify by the autopsy. The record of one
such case may be found in the Archives of Pediatrics of
a number of years ago.

Another class of cyanotic cases owes its origin to an
arrest of development of the common arterial trunk which
did not separate into the aorta arrd pulmonary artery. In
these cases, contrary to many statements, I found but little
hypertrophy or dilatation, sometimes none at all. The
loud murmur is heard over the sternum a little to the right
and to the left, about the insertion of the second and third
ribs ; it is very audible posteriorly, but much less than
anteriorly.

Very loud murmurs, audible at a distance, without the
ear touching the chest, I have heard more in adults than
in children, without having an opportunity to make an
autopsy. They are always systolic and are mostly attrib-
uted to hypertrophy and believed to be muscular only. In
a few cases, however, I am certain that no increase of per-
cussion dulness or of cardiac impulse corresponded with
the loudness of the tone; so I was inclined to believe that
the peculiar phenomenon was due to torn and swinging
papillary muscles. Not infrequently the general condi-
tion of the patient is vastly better than the formidable
noise would appear to suggest.

Organic murmurs, when present, are not always audible.

180

FUNCTIONAL AND ORGANIC HEART MURMURS

They may not be heard at all when the heart-beats in-
crease in number. Then the blood-wave is small and the
excursion of the valve short. Diminution of temperature,
or a few doses of digitalis, therefore, restore a murmur
which was temporarily absent; but under ordinary cir-
cumstances also, as I said before, an organic murmur may
disappear for two reasons, one of which is recovery, the
other compensation. I think I proved that the disappear-
ance of a murmur, as, for instance, in Case III. and Case
IV., described by Starck in Arch. f. Kind., IQOO, p. 200,
does not prove it to be functional. Nor is there any rea-
son why an endocarditic thickening should not be ab-
sorbed as well as those on other tissues.

A few words only on myocardial changes. About mid-
dle-age myocardial changes are mainly caused by every-
thing that gives rise to hypertrophy and dilatation. We
find mostly a diffuse increase of the intermuscular con-
nective tissue with atrophy of the muscular tissue which
first was hypertrophic. The senile heart is very apt to
exhibit hypertrophy and dilatation of a peculiar type.
There is atheromatous degeneration of the coronary and
the minute nutrient arteries. There is consequently an
annoyance or destruction of the lymph interstices and
channels in and on the myocardium, and of the two large
trunks that carry the myocardial lymph to the mediastinal
lobes, and, finally, degeneration of the myocardium re-
sulting in either macroscopic, more or less local, thicken-
ing or in atrophy. That is why the contraction of the or-
gan is liable to be irregular, and partial, in instalments,
as it were, although there be no accompanying sclerotic
alteration of the pericardium, or thickening of the valves
and of the endocardium.

What we call debility of the heart is a symptom of a
great many different conditions. There is a congenital
atrophy which is liable to lead to lipomatosis, there are
intoxications by infectious diseases, alcohol, syphilis, ma-
laria, and tuberculosis ; nutritive disorders, such as rach-
itis and scrofula, overexertion and premature schooling
with constipation, and subacute and chronic nephritis, one
of the most frequent and most frequently overlooked dis-

181

DR. JACOBI'S WORKS

eases of early infaircy. I mention only those causes of
myocardial acute, subacute or chronic changes that are
most common in the young, but should emphasize that
what is called debility or failure at any age is in all the
cases so occasioned not functional, but the result of or-
ganic lesions. Two most interesting cases of heart de-
bility I found connected with purpura. Only in one could
I obtain an autopsy. There were numerous blood-points
in the walls of both ventricles and a livid appearance of
the muscle.

In infants and children myocarditis is mostly parenchy-
matous.

Most intense and persistent myocardial changes are
found after influenza and after diphtheria; they are most
injurious at about puberty — fortunately, however, diph-
theria is not so frequent at that age — when the heart is
no longer disproportionately strong and large, than in ear-
lier years. Schmalz reports 81 cases of chronic cardiac
disorder originating in 500 cases of diphtheria. In some
seasons — ^for instance, in the severe New York epidemics
of 1870 and 1874 — the proportion was much larger. In
many arhythmia and murmurs last for life; they may be
modified by a protracted recumbent position during con-
valescence, and by resorting to absolute rest extending
over weeks whenever increased cardiac disturbance is ob-
served. The systolic murmur is extensive, but mostly heard
in the mitral and pulmonary regions, at the same time
that now and then there is an increase of transverse dul-
ness. But more characteristic than the extensive murmur,
which often by the absence of localization facilitates the
differential diagnosis, is the irregularity of the contrac-
tion of the heart. The condition of the heart-muscle
changed by myocarditis (parenchymatous or hyperplastic,
it makes no difference) is not uniform. Neither a kidney
nor the myocardium is equally affected and changed in all
its parts. That is why arhythmia is so frequent. No
matter how many causes, either in the heart or nerves or
distant organs, are charged with causing it, the most fre-
quent cause is chronic myocarditis.

A peculiar form of arhythmia mostly complicated with
a murmur is the duplication of one of the heart-sounds.

182

FUNCTIONAL AND ORGANIC HEART MURMURS

It is not always easy to distinguish which of the sounds it
is that is so affected. Now and then we hear a dactylus—
uUj in other cases or at other times an anapestus uu — .
The cause of this gallop-rhythm must be either in the
myocardium or in the valves. From careful and long ob-
servation of individual cases, and from the improvement
that rest alone is able to work on the case in regard to
the annoying symptoms, there is no doubt in my mind that
it is the former. The first sound appears to slit up when
the two atrioventricular valves are not working simulta-
neously, the second, when the aortic and the pulmonary
valves do not act together. This lack of synchronicity,
however, depends on the lack of muscular myocardial co-
aptation. A similar symptom may be had in mitral ste-
nosis, particularly after a slight exertion, and in hyper-
trophy and dilatation of the right ventricle when the valves
close in different times.

The gallop-rhythm is a suspicious symptom inasmuch
as it proves the exhaustibility of the heart-muscle. I kept
the children in bed for months, and a single exertion suf-
ficed to renew or to increase the duplication. Thus, a long
rest is required and attention to general hygiene, food in
small and digestible quantities, and regulation of the bow-
els. In most cases iodide of potassium is indicated and
strychnine or some other cardiac stimulant. Strychnine
should not be feared, because it should not be forgotten
that parts of the heart are probably in an intact or nearly
intact condition, and permit of stimulation. If that be
done carefully, the galloping rhythm ceases to be such a
bad omen as some declare it to be.

Clara R. was discharged June 8, 1899, after having
been in the hospital for chorea. This returned about
the end of January, 1900, she then had pneumonia, from
which she recovered. She was readmitted March 3, 1900,
with chorea mostly of the right upper extremity, very ir-
regular heart-action, dulness reaching more than one cen-
timeter beyond the right margin of the sternum, while in
an erect position, and marked duplication of the second
sound at the apex and to the right of it. The impulse was
feeble. Radial pulse small. Muscular power generally
feeble, with costiveness and at one time incontinence of

183

DR. JACOBI'S WORKS

urine resulting therefrom. The latter was almost sud-
denly relieved by increasing the doses of Vioo ^f ^ grain
of strychnine to ^/.r,o of a grain, three times a day. When
her general strength improved and her color brightened,
the duplication disappeared gradually; but whenever her
conditiorr appeared worse, under the influence of a low
barometer, for instance, it would reappear. She was kept
in bed and was discharged April l6th without her dupli-
cation, and with her heart not reaching beyond the me-
dian line of the sternum when in a sitting posture.

This Association fills a place peculiarly its own. Its
aims and objects appear sympathetic to every physician
who is more than merely an anatomist or pathologist, and
better than a mere prescription-writer. The class of phi-
losophic doctors whom Hippocrates calls " godlike " be-
cause he says they strive to learn the connection of things,
belongs here. The climatic and atmospheric influences
of Nature on man, mainly as they aff"ect the human crea-
ture through the respiratory and circulatory organs, is the
object of your study. That is why there is, and should be,
a peculiar incentive to become a member and why the
applications for admission were always very numerous,
and the roll of the membership has become large. We
have been very forturrate in not losing by death any of
our members, except Dr. J. C. Mulhall of St. Louis, whose
loss we have to deplore.

The danger of swelling the ranks too rapidly is very
great indeed. This year, however, we are singularly for-
tunate in the character and standing of our candidates.
In connection with this matter, it is hardly necessary to
point to and to emphasize the established policy of the
Association to admit only men whose position is established
or who through at least a few publications connected with
our study have proved their right to apply.

Feeling as I do that the contributions should be sponta-
neous unless there be a preparation for a set discussion,
I felt a few months ago that there might not be a suflS-
ciency of material for your meetings. I was happily mis-
taken, for there is ample work for you. The American
democratic spirit has prevailed again.

184.

TREATMENT OF INFANT DIARRHEA
AND DYSENTERY

Of all the deaths in the first year of life forty per cent.,
in round number, are due to disease of the digestive organs,
and half as many to such of the respiratory organs. In the
second year, the main cause of death changes completely,
for of all the forty-five deaths taking place in that year, but
nine are due to digestive, and thirtj^-six per cent, to res-
piratory disorders. Thus in the first year, stomach and
intestines, in the second, bronchi and lungs, are the sources
of high death-rates. The respiratory organs are better
protected, usually, in the first year, and the digestive organs
treated more improperly. Such infants as survive the first
are exposed to the same parental ignorance and careless-
ness concerning the requirements of the respiratory organs
during the second.

Mortality diminishes with every day of advancing life.
Every additional hour improves the baby's chances for pres-
ervation. Almost one-half of the infants dead before the
end of the first year, die before they are one month old.
Thus the causes of disease are the more active the earlier
they are brought to bear upon the young with their defect-
ive vitality.

Two grave conclusions are to be drawn from this fact.
The first is, that the diminution of early mortality depends
on avoiding diseases of the digestive organs by insisting
upon normal alimentation. This is principally important in
the first few months. While breast-milk has been shown to
lower infant mortality through the whole first year, it
does so more in the first few months. Thus, though an
infant may not be fed on breast-milk through the whole
normal period of nursing, a great gain, indeed, is accom-
plished by insisting on nursing, though for a limited time,
perhaps two months only. There are but few mothers
but will be capable of nursing during that brief time, and

185

DR. JACOBI'S WORKS

none who ought to be spared the accusation of causing
ill-health or death to her baby if she refuses to nurse it
at least through the first dangerous months. The second
conclusion, resulting from many figures, is this, that the
dietetic problems and rules for the infant concern the
digestive organs mainly, so much so, indeed, that infant
dietetics and the dietetics of the infant digestive organs
appear nearly identical.

It is true that in this city we meet with a high mor-
tality, even in children of more than a year. The second
summer is regarded with awe and fear amounting to su-
perstition. In fact, public opinion looks for a higher mor-
tality in the second than in the first summer. The fallacy
of this assumption can be easily corrected by tlie statistical
reports ; and the high mortality rate itself could be easily
reduced by such parents as would feel convinced that it
is external causes which kill their children, and not the
natural course of development. The second summer is
the period of danger in part only because of the heat of
the season, but mainly of the errors in feeding. Conscien-
tious and intelligent families in good circumstances are not
apt to lose their infants in their second summer.

Nor is it necessary that here, and on this occasion, I
should insist upon the danger incurred by the belief that
diarrhea — a pathological condition — is a normal attendant
on and a relief of a physiological process such as dentition.
This much is certain, that very few, if any, popular be-
liefs have been more destructive than this, that an intes-
tinal catarrh must be left alone, no matter from what source
it originated.

Healthy infants have a normal tendency to loose, liquid,
or semi-fluid evacuations from the bowels. The causes lie
partly in the condition of the intestinal tract, and partly
in the nature of the normal food, viz., breast-milk. The
peristaltic movements are very active; the young blood-
vessels are very permeable; the transformations of sur-
face cells very rapid; the peripheric nerves are superficial,
more so than in the adult, whose mucous membrane and
submucous tissue have undergone thickening by both nor-

186

INFANT DIARRHEA AND DYSENTERY

mal development and morbid processes. In the young in-
fant, the peripheric ends of the nerves are larger in pro-
portion than in the adult, the anterior horns of the nerve
centres are more developed than the posterior ones. Thus
the greater reflex irritability of the young, particularly in
regard to intestinal influences, is easily explained. Besides,
the action of the sphincter ani is not quite powerful, the
feces are not retained in the colon and rectum, and no time
is afforded for the reabsorption of the liquid or dissolved
constituents of the feces. Moreover, the frequency of acids,
sometimes normal, in the small intestines gives rise to the
formation of alkaline salts with purgative properties.
Hoppe-Seyler found free acids in the feces of dogs and
adults. Wegscheider met them in nurslings who received
nothing but mother's milk. An explanation of this occur-
rence may be this, that the quantity of food is often too
large, but it is just as probable that the amount of digestive
fluid is too small. For the diastatic eff'ect of the pancreas
is limited at that as at any other age.

The nature of breast-milk, even when absolutely normal,
is such as to facilitate frequent, large, and fluid evacua-
tions.

First, as to its fat. Careful investigations led Weg-
scheider to the following important results: fats are not
completely absorbed; one part leaves the intestine in a
saponified condition; a second part, as free, fatty acid; a
third, as fat in an unchanged condition.

Where no food is given but mother's milk, which con-
tains fat in proportionately smaller quantities than cow's
milk, and finely suspended and easily absorbed, a good
deal of fat is eliminated without any change.

What has been called detritus in the feces is not all
undigested casein, but, on the contrary, it is mostly fat, and
very probably remnants of intestinal epithelium. This milk
detritus, so-called casein, and mainly consisting of olein,
margarin, and stearin, is not soluble in water, acids, or
alkalies, but very soluble in alcohol and ether.

Practically this fact is of the very greatest importance.
Fat is not completely absorbed under the most normal cir-

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DR. JACOBI'S WORKS

cumstances. Fat-acids are easily formed, and accumulate
to such an extent that they are found in moderate quan-
tities in even the healthiest nurslings. Superabundance
of fat-acid is a common derangement of digestion and
assimilation, and it impedes the previously normal secre-
tion of other digestive fluids. Thus there is a plus of
fat, even in the normal food of the nursling, the breast-
milk.

The conclusion, then, which I will record here at once,
is that we have to be very careful in the preparation of
artificial food. It is almost certain that we give too much
fat; it is scarcely ever probable that there is too little.
Therefore the addition of cream is reprehensible, no matter
in what shape. Whenever cream and cream mixtures have
been recommended, inventors and backers have always made
the statement that such mixtures are, " as a rule," well
tolerated. It is a doubtful praise, however, that food should
be simply well tolerated, " as a rule." The fact alluded to
has probably been the cause why Liebig has, in his arti-
ficial food, only forty per cent, of the fat contained in
mother's milk.

Thus in the most normal milk there is more fat than
required. Whenever changes set in, the disproportion can
be greater yet. For milk is no stable article, its chemical
composition permits of a great latitude indeed. Normally
it is the result of transformed glandular substance.^

The mammary gland is no filter, through which the se-
rum of the blood, or the solutions of salts, or the trans-
formed foods are rendered accessible to the hungry young.
The quality and quantity of milk depend upon the develop-
ment of the gland. Milk is not the product of the action
of the cells; it is the transformed cells, the very organ.
Thus, the nursling is the veriest carnivorous animal. As
long as the epithelium has not undergone a total change,
the secretion is not milk, but colostrum, with its large
globules. The character of the gland influences the milk,
much more than food. The latter influences milk only by

1 Compare " The Influence of Menstruation, Pregnancy, and
Medicines on Lactation," in Vol. IV, page 297.

188

INFANT DIARRHEA AND DYSENTERY

building up the gland, the cells of which receive materials
of different kinds, the principal of which is albumen.

In accordance with this, the nature of milk is beautifully
illustrated by its chemical composition. Its ashes are tis-
sue ashes, not those of plasma, for they contain much
potassa and phosphate of lime, but little chloride of
sodium.

In the first period of lactation the glandular transfor-
mation is not yet accomplished. The secretion is of a dif-
ferent nature. It requires days to exhibit casein. Until
then the protein shows the nature of albumen. At the
same time the percentage of butter and salts is very high
indeed, both of which explain the laxative character of
colostrum. No less do macroscopic and microscopic obser-
vation convey the impression of its being incomplete. It
is yellowish, thickish, the fat globules are large, unequal,
sticky, and mixed with epithelium almost unchanged. There
is less potassa and more soda than in normal milk, approxi-
mating it to the chemical character of plasma. Besides,
colostrum of the cow has not unfrequently been found to
contain blood and to coagulate when being boiled. Thus
colostrum is more like a transudation than a glandular
secretion. Such colostrum is not only met with in the first
week after confinement, but in disturbances of the general
health, in anaemia, fevers, pregnancy, or advanced age of
mother or nurse. Also when the gland itself is insufficient,
or the woman too young, or slowly convalescent, or neurotic
and liable to vasomotor disturbances. The administration
of such milk disturbs the health of the infant through the
bringing on of gastric or intestinal catarrh.

Thus there is no stability in the nature of breast-milk,
and very much less in the human than in the animal fe-
male, for obvious reasons. Its constituents and effects may
even change from hour to hour, from day to day, sometimes
it will be milk, sometimes milk with transuded serum.

That a mere transudation should contain all sorts of ma-
terial circulating in the blood-plasma is evident. Therefore
colostrum is apt to transfer to the nursling the liquid con-
stituents of the mother's blood, no matter whether normal
or abnormal, beneficial, or injurious, organic or inorganic.

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DR. JACOBI'S WORKS

The reports of infants harmed by the mother's opiate, in-
fluenced by her taking mercury, belong, therefore, mostly
to the earliest period of lactation, or to a period of sickness
or debility on the part of the woman. The more normal
the mammary secretion the less the danger in this respect.
Very few persons, however, are always in undisturbed
health.

Thirdly as to sugar. It is abnormally plentiful in colos-
trum, and in some milks, at times, its percentage is lower
than normal. In the former it is purgative, in the latter
its absence one of the causes of constipation. Thus the
addition of a piece of sugar — which need not be milk-
sugar — to breast-milk is apt to heal constipation in the
infant. I dissolve it in the smallest possible quantity
of water, say a teaspoonful, and let the baby take it be-
fore each nursing.

Fourthly as to casein. When present in an abnormally
high percentage, it may act in two ways. It will either
constipate, particularly as the high percentage of casein
and a low one of sugar go hand in hand, mostly — or by
remaining undigested, and acting as a local irritant, thereby
producing diarrhea. In these cases of diarrhea the stools
are mixed with white flocculi, small or large, sometimes
in astonishing quantities and for a long period. The treat-
ment of such diarrhea is by no means very simple, unless
the breast-milk is changed. When such a change cannot
take place, I add oat-meal gruel or barlej'-water in such
a manner, that a few teaspoonfuls of it are administered
to the baby before each nursing. I shall return to the
consideration of this proceeding.

The natural food of the infant being sometimes a cause
of tendency to diarrhea, and of actual diarrhea, the admin-
istration of artificial foods must necessarily be inferred to
threaten a real danger. Let us examine some of the ar-
ticles of food mostly used for the young.

Goat's milk ought to be rejected because of its large
percentage of fat, not to speak of its odor, which at times
is very disagreeable.

Cow's milk contains more butter than human milk. If
the latter, as stated above, is not entirely digested, cow's

190

INFANT DIARRHEA AND DYSENTERY

milk butter will certainly leave even more remnants to
encumber the intestinal canal.

The reaction of human milk is alkaline, that of cow's
milk rarely to the same degree. It is apt to become acid
soon after milking, and has been found to exhibit acid
reaction while still in the udder.

But the main difficulty lies in the large percentage and
in the nature of the casein of cow's milk.

The casein of cow's milk and the casein of woman's milk
are two different substances. When isolated by alcohol, by
which both are thrown out of their combinations to a cer-
tain extent, the chemical properties are found to differ
widely. Thus obtained, cow's casein, when moist, is white;
when dry, yellowish. It reddens litmus-paper, and acidu-
lates water, in which it is soluble in the proportion of
1-20. Woman's casein, however, in its moist condition, is
yellowish, alkaline, or neutral, and dissolves almost entirely
in water, the solution being of neutral reaction. Vie-
rordt and Biedert found the quantity in the two milks
to differ, there being less in woman s milk than in
cow's milk.

When exposed to artificial gastric juice they also act
differently. In a surplus of it woman's casein is dissolved
in a short time; cow's casein in twenty-four hours. Mineral
acids, lactic acid, acetic acid, tartaric acid, Epsom salts,
phosphate of lime in solution, coagulate cow's milk in
hard and dense masses ; not so human milk. Solutions of
both kinds of casein in alkalies show many similar prop-
erties; but the sediment produced by the addition of lactic
acid can yield essential differences. Thus there is a chem-
ical as well as a physical difference between the two species
of casein. Although their relation to artificial gastric juice
has not been found to differ to that extent by Dr. C. P.
Putnam, of Boston, it is upheld by a number of other ob-
servers, and the fact is beyond a doubt that pure cow's
milk is very much less digestible than human casein. At
all events, it should be so considered, and infants should
have only as much casein as proves digestible. One of the
alleged means of combating the improper effect of casein
is to increase the relative amount of fat by adding it

191

DR. JACOBI'S WORKS

to the food. It is true that in this way a more proper re-
lation of the two can be obtained, but certainly no more
proper relation of the two to the insufficient condition
of the infant digestive organs.

Besides, the addition of^cream to either casein or fresh
milk has something very doubtful about it, as at the time
when cream has formed upon milk, by simply allowing it
to stand, the formation of lactic acid is going on all the
time. At all events, no addition we know of can render
cow's casein more digestible than Nature made it, and the
only thing which can be obtained by any sort of manipu-
lation of the milk is to make it less injurious. Perhaps,
however, the plan upon which Dr. J. Rudisch has acted
may recommend itself to the attention of the practitioner.
In order to make cow's milk more digestible, he has intro-
duced into my practice a mixture which promises to be of
great value in all those cases in which coagulability of the
milk is the prominent obstacle to its usefulness. The mix-
ture suggested by him, and used by us up to this time
mainly in diseases of adults, such as anaemia, gastric ca-
tarrh, ulcer of the stomach, slow convalescence, etc., is the
following: to one pint of water, one-half teaspoonful of
officinal dilute muriatic acid is to be added. To this mix-
ture add one quart of raw cold milk; mix the two liquids
thoroughly and then boil for ten or fifteen minutes. I
have found this preparation to be very digestible, and well
tolerated by very feeble digestive organs. Not only clini-
cal experience favors this preparation, but direct experi-
ments also. When " liquid pepsine " is added to common
milk, coagulation takes place very rapidl}', and in thick
coherent masses. The same liquid pepsine, when added to
the above mixture, produces so slight a coagulation that it
can scarcely be observed. The coagula also are small, and
do not adhere firmly to each other. Essence of rennet
coagulates common milk speedily and completely ; the above
mixture more slowly and not so completely. The coagu-
lation of common milk exhibits, after a certain time, thick,
dense, and firmly coherent masses. The coagula produced
by the above mixture are fine, loose, and are easily separated
when the liquid is shaken.

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INFANT DIARRHEA AND DYSENTERY

Valuable as this preparation of cow's milk may prove
in future, there is one method for making cow's milk more
available, which is at once simple and effective. No cow's
milk ought to be administered without the addition of
chloride of sodium. Not only cow's milk, but also — and
even much more so— farinaceous admixtures to cow's milk
require its presence in the food.

The method of preparing condensed milk with the ad-
mixture of such great quantities of sugar as to yield from
thirty-nine to forty-eight per cent, of sugar in its solid
ingredients is a well-known process. With regard to this
preparation, Kehrer says that when sufficiently diluted it
readily induces the formation of lactic acid, and that deli-
cate children will not thrive on it. In such cases he deems
it necessary to add barley-water or oat-meal gruel as well
as antacids. Fleischmann also accuses it of causing a pre-
disposition to thrush and diarrhea. He lays stress upon
the fact that, even when it has been properly diluted, the
proportion of the protein compounds to the carbohydrates
is diminished, and thereby its nutritive value impaired. My
oM'n experience with condensed milk, which has been rather
extensive, even though to the proper degree, it is apt to
be followed by disagreeable results ; although the influence
of the large amount of sugar does not operate in the man-
ner as above alleged. For the sugar which is added to
condensed milk is not the easily decomposed milk-sugar.
Yet catarrh of the stomach and bowels is a frequent re-
sult of its use. I have seen few children enjoy undisturbed
health who were fed exclusively upon condensed milk.
Those, however, who take it mixed with a certain propor-
tion of barley-water, either regularly, as I recommend, or
in cases of temporary necessity, as advised by Kehrer,
thrive quite well. I cannot say that I have been able to
discover anj' material difference, whether condensed milk, or
good ordinary city milk, was given in this way. But it
should not be forgotten that barley-water is a more de-
sirable addition to the mixture than oat-meal gruel, because
of the laxative effect which the latter may have. If the
condensed milk be given in this way, we need not fear a
repetition of Daly's experiences. He found that children

193

DR. JACOBI'S WORKS

took condensed milk readily, and grew fat; but in case
they fell sick, they showed but slight endurance; they
began to walk late; their fontanelles were slow in closing,
and other signs of rhachitis showed themselves.

The preventive treatment of diarrhea, depending on
defective alimentation, consists in so changing and arrang-
ing the milk used for babies that the casein will not coagu-
late in large lumps, and thus become more digestible. That
object can be obtained by adding such farinaceous food
as does not contain much starch. Some little starch is di-
gested from the first days of life, the parotid having dia-
static effect; in a few months after birth such vegetables
as contain starch in moderate, but not overwhelming per-
centage, may be used as additional infant food. Still, it is
not absolutely necessary that every particle of ingesta
should, in all instances, be digested and assimilated. That
is impossible; the very breast-milk contains such amoimts
of fat that it cannot all be digested and absorbed. The
requirement is only that not enough should remain undi-
gested to encumber and irritate the intestinal tract.

The principle on which I base the theory of this treat-
ment is simple enough. It has appeared in previous
papers of mine, and also been published by a former
clinical assistant of mine, in the Journal of Obstetrics, a
number of years ago. It consists in diluting the boiled
and skimmed milk with barley-water or oat-meal gruel.
It must be boiled to check its tendency to become sour,
to remove a portion, though small, of its casein and fat,
and to expel the gas contained in the raw milk to the
amount of three per cent.

Of the two, as may be known, I prefer barley for
general use.

The prepared commercial barley is characterized by its
fineness and whiteness. But these qualities are suspicious
characteristics ; the less the quantity of the yellowish outer
layers of the barley, the less is it to be recommended. The
prices of the grain, though low, vary in such a manner
that adulteration by refining pays very well. I would,
therefore, recommend that the barley-corn which is em-
ployed for infant diet should be ground as thoroughly

194

INFANT DIARRHEA AND DYSENTERY

as possible in a cofFee-mill, both in order to diminish the
period necessary for cooking it, and also in order to retain
the gluten. It is even preferable, for very young infants,
to cook the barley whole for hours, thereby to burst the
outer laj'^ers of cells, empty their contents, and then, by
straining, to get rid of the larger part of the starch which
is found toward the centre. The next best method consists
in crusliing the whole grains of barley, and not to employ
the so-called pearl barley, which is barley minus husk. At
a more advanced period of life the latter preparation, with
its greater amount of starch, will suffice, however, because
oat-meal, on account of its larger percentage of fat and
mucin, is more liable to relax the bowels. In other respects
the chemical composition of the two is so nearly alike that
it would be immaterial whether we choose one or the
other.

But there is no danger to which little children are so
liable as that which arises from their tendency to diarrhea.
My advice, therefore, is to administer barley to children
who manifest a tendency to diarrhea, and oat-meal to those
having a tendency to constipation, and, whenever a change
occurs in the intestinal functions, to give one or the other,
according as constipation or diarrhea predominates.

I hold this mixture to be the conditio sine qua non of the
thorough digestion of the milk. It, only, will insure the
proper nourishment of the infant. With this food alone I
have seen children endure the heat of summer without any
attack of illness whatever. It is because I am so deeply
convinced of its importance that I return to the subject
here. In this climate, so perilous to infant health, where
severe derangements of digestion belong to the most com-
mon of the daily experiences of the practitioner, I have
had occasion again and again to be convinced of the re-
liability of my mixture. It has this advantage, too, that
it necessitates no dependence upon the honesty or com-
petence of the apothecary or manufacturer, but this mix-
ture can be prepared by any one, however poorly situated.
I conceived it to be necessary to discover a kind of food,
suitable to the infantile age, which could not be- spoiled
through ignorance and fraud, nor be liable to have its price

195

DR. JACOBI'S WORKS

enhanced hy trade dealers. All of these indications have
been fully met in the preparation which I have described.

The object I desire to attain is to insure a slow action of
the gastric juice, or of the excess of acid in the stomach
upon the casein of the milk, and this object I attain under
all circumstances. Should a slight diarrhea occur, or a little
casein be vomited (a rare accident, to be sure), or casein
occur in the stools, then all that is necessary is to diminish
the proportion of milk. It may sometimes be necessary,
though very seldom, to withdraw the milk entirely for a
time, but only in cases of real illness. If the physician or
attendants have properly apportioned the ingredients of
the mixture, we may be rather sure that the child's digestion
and assimilation will be regular and normal. Infants that
are partly nourished at the breast almost invariably thrive
well with the addition of my mixture. Children, from their
fourth or fifth month and upward, may often be fed with
it exclusively, and not unfrequently nothing else is given
from the day of the birth. I can positively affirm that
in all these cases assimilation and increase in weight have
proceeded quite normally. Altogether, the brief form in
which I laid down the above principles, years ago, and in
which they have been published several summers by the
New York Health Board (See Infant Diet, 2d ' Ed.,
1876, p. 118) for the benefit of the general public, rich
and poor, has always been foimd satisfactory.

The addition of barley or oat-meal for the purpose of
rendering milk digestible is not, however, absolutely in-
dispensable, though I have learned to prefer them. For
gum-arabic and gelatine are also very valuable ingredients,
indeed, of infant foods.

As far as the former is concerned, Frerichs, Lehmann,
and Husemann did not admit its imdergoing any change in
the human body. Gorup-Besanez believes in its solubility,
but not in its digestibility; hence if, in his opinion, gum-
arabic is an important aid in digestion, it is so for one
reason only, namely, that it acts mechanically, and ren-
ders the coagulation of milk less dense. Of late, however,
Uffelmann has made some experiments with a solution of
gum-arabic of the strength of eighteen parts of the gum to

196

INFANT DIARRHEA AND DYSENTERY

two hundred of water. His experiments were made upon
a boy upon whom gastrotomy had been performed, thus
affording opportunity for making direct observations. When
he introduced this solution into the boy's stomach, he found
grape-sugar after some time, no saliva being present. The
same transformation has been observed in the Munich
laboratory.

Fifteen grammes of the above solution yielded five cen-
tigrammes of grape-sugar after forty-five mixmXes;' thirty
grammes gave tmenty-eight centigrammes after sixty min-
utes. The liquid taken from the stomach in the latter case
was very acid indeed. It matters not whether this acid
was inside the stomach previously, or was developed dur-
ing the presence of the gum-arabic solution; in both in-
stances it appears that the development of muriatic acid
and the transformation into grape-sugar go hand in hand.
It is possible, then, that it will be found practical, in those
cases in which the object is not simply to mix milk with
gum-arabic, but also to derive benefit from the digestion
of the gum, to add a small quantity of muriatic acid.

Gelatine, in the opinion of many, when combined with
milk, fulfills two indications. The .one is the same as that
obtained by the mechanical effect of gum-arabic and fari-
naceous articles; the other is found in its usefulness as a
tissue-building material. Guerard quotes Jean de Lery,
who speaks as follows: " Ay ant experimente que cela
(skins, parchemin) vaut au besoin, tant que j'aurais des
collets de buffles, habits de chamois, et telles choses ou il y a
sue et humidite, si j'estois enferme dans une place pour una
bonne cause, je ne me voudrois pas rendre pour crainte de
la famine." Papin is reported to have made the offer to
Charles II. of England to furnish for the use of poor-
houses and hospitals " un quintal et demi de gelee " with
" onze livres de charbon." This offer was refused because
a dog was paraded before Charles wearing a sign-board
containing said dog's request not to be deprived of his
mess of bones.

The French Academy of Medicine has taken great pains
to discover the properties of gelatine. After Magendie in
1848, Vrolik in 181i, Berard in 1850, and Edwards and

197

DR. JACOBI'S WORKS

Balzac, had published their reports upon the subject,
Guerard comes to the following conclusions: 1. That gela-
tine is very nutritious; 2. That very probably it is of great
importance in the process of building up cellular tissue,
therefore absolutely necessary for the preservation of life.
Frerichs, Metzger and De Barry, Schroeder, Kuehne,
and Etzinger, found that gastric juice changes gelatine in
such a manner that it loses the property of gelatinizing.
This effect was not produced when it was treated with
muriatic acid only. On the other hand, Imthurn also at-
tributes the effect to the influence of muriatic acid. It
is true that Meissner and Kirchner have entirely denied
the changeability of gelatine by means of gastric juice.
But Gorup-Besanez is of the opinion that gelatine is pep-
tonized in a manner similar to the albuminates. It seems
that UfFelmann has also settled this question. He found,
in the gastrotomized boy, first, that while he was feverish,
and again without fever, the gelatine was speedily dis-
solved in the gastric juice. It was so modified at the end
of one hour that it would no longer coagulate, and was
easily diffused. To produce this change by means of
artificial gastric juice, he found, however, that from eighteen
to twenty-four hours were necessary, and in both instances
there was no offensive odor. When the experiment was
performed within the stomach, he occasionally observed
the presence of grape-sugar. When that occurred, the
temperature of the body was elevated. No grape-sugar was
ever found when the gelatine was exposed to the action of
artificial gastric juice. Gelatine digested in gastric juice
retains its essential chemical properties. It resembles pep-
tone, inasmuch as it is not precipitated by acids. It differs
from peptone, inasmuch as its diffusibility is less, and,
when dissolved in acetic acid, it can be precipitated by
ferrocyanide of potassium. It is so much like peptone
that its digestibility can hardly be doubted, not to speak
of the direct observations made by Uffelmann. There is
one point, however, not to be lost sight of, viz., that it is
apt to putrefy, and therefore requires the addition of a
small quantity of muriatic acid. The latter point is of
great practical importance; for, in acute diseases, in slow

198

INFANT DIARRHEA AND DYSENTERY

convalescence, in anaemia, the secretion of pepsine and
muriatic acid is very much limited. For that reason muriatic
acid should be added whenever gelatine is administered.

When it is to be mixed with milk, in such cases, the
plan as recommended by Dr. Rudisch, and specified above,
will perhaps be found most useful.

Curative Treatment. — So far as nutriment is concerned,
the amount of food should not be larger than we have
reason to expect can be easily digested. At all events,
either lengthen the intervals between the meals or reduce
the quantity of food given at one time, or both. When
diarrhea makes its appearance in infants who have been
weaned, it is desirable to return them to the breast. Those
who never had breast-milk may be given the breast if they
can be induced to take it, but only rarely will this be found
possible. Whenever a child at the breast is taken with
diarrhea, the passages from the bowels should be studied
as to their contents. If a certain amount of curd is found
in them^ the least that is to be done is to mix the breast-
milk with barley-water. This may be done in such a man-
ner that, each time before nursing, one or two teaspoon-
fuls of barley-water is given the child, so that the fari-
naceous food and the breast-milk will mix in the stomach.
Or, it may be found advisable to alternate breast-milk
and barley-water. In bad cases, particularly when the
milk is found to be white and heavy and contains a great
deal of casein, it will be found necessary to deprive the
child altogether of its usual food. In such cases, the child
will do better on barley-water alone (this to be continued
for one or two days), than to expose it to the injury which
will certainly follow the continuation of the casein food.

When diarrhea occurs in children who have been fed
alone upon cow's milk, unmixed or mixed, it is necessary
to reduce the quantity of cow's milk in the mixture. As
a rule, we have to remember that cow's milk alone is apt
to produce diarrhea, and it should be considered as a maxim
that, whenever diarrhea makes its appearance, the amount
of cow's milk given to the child should be reduced. When
a mere reduction of the quantity does not suffice, it is very
much better to deprive the child of milk food altogether.

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DR. JACOBFS WORKS

Not infrequently the removal of milk from the bill of fare
is the only thing which will restore the child to health.
It is possible that a mixture, such as recommended by Dr.
Rudisch, of which I have spoken before, will be found
digestible, even in such cases. My experience, however, is
not sufficient to decide that point. In many cases, as a
dietetic measure, it will be found advisable to add one or
two tablespoonfuls of lime-water to each bottle of food
with which the child is supplied.

In those cases in which barley-water does not seem to
suffice as a nutriment, or where it would be dangerous to
allow children to lose strength, a mixture which I have used
to great advantage is the following: Mix the white of one
egg with four or six ounces of barley-water, and add a
small quantity of table-salt and sugar, just sufficient to
make the mixture palatable. The child can take this either
in large or small quantities, according to the cases.

In such cases in which the stomach is irritable and vom-
iting has occurred, it is now and then better to give a small
quantity, even one or two teaspoonfuls, and repeat the dose
every ten, fifteen, or twenty minutes, than to give larger
quantities at longer intervals.

In those in which the strength of the child has suffered
greatly, it is necessary to add brandy to the mixture in
such quantity that the child will take from one drachm
to one ounce (grammes 4.0 to 30.0), more or less, in the
course of twenty-four hours.

In those extreme cases in which the intestinal catarrh is
complicated with gastric catarrh, where the passages are
numerous and copious, and vomiting constant, where both
medicines and food are rejected, there is frequently but one
way to save the patients, and that is to deprive them ab-
solutely of everything in the form of either drink or food
or medicine. It is true that such babies will suffer greatly
from thirst for an hour or two, but it is a fact that, after
two or three hours, these children will look better than
before the abstemious treatment was commenced. Not in-
frequently four or five hours of total abstinence will suffice
to quiet the stomach and diminish both the secretion and
the peristaltic movement of the intestinal tract. In some

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INFANT DlARkHEA AND DYSiEN'TEllY

cases six or eight hours of complete abstinence will be
required; or such children maj' be starved for even twelve
or sixteen hours, with final good results. The first meals
afterwards must be quite small, and they will be re-
tained, and, as a rule, such children will subsequently
do well.

I need not say here that, in addition to the dietetics for
the digestive organs, it is necessary to supply the patient
with as much cool, fresh air as possible. The worst out-
door air, when cooler, is better than close in-door air. The
undeveloped condition of the nerve-centre in the normal
infant, the relaxation of the inhibitory nerves by heat, the
absence of radiation from the surface, the lacking stimulus
• — during hot weather — of the cutaneous sensitive nerves,
the diminished metamorphosis of tissue, the diminution
of the powers of digestion, not only by shortening nutri-
tion, but by directly lowering the secreting powers of di-
gestive glands in the stomach and intestines, are just as
many factors in the production of the very worst forms of
infant diarrhea.- I have kept very bad, desperate cases
out all night upon the bluffs over the East River. The
windows must not be closed. If possible, the children
should be sent immediately to the country and into the
mountain air.

The second indication consists in the removal of undi-
gested masses retained in the intestinal tract. Not only in
cases in which the diarrhea has resulted from previous
errors in diet of the child, but also in those cases de-
pendent upon sudden changes of temperature and exposure,
it is desirable to empty the intestinal tract of its ballast.
For that purpose castor oil, calcined magnesia, or calomel
may be used. So far as the latter is concerned, the dis-
crepancy of opinion with regard to its efficiency will prob-
ably be found to depend upon the variation in the
size of the doses recommended by different authors. When
a purgative effect is desired it should not be given in small
doses, and, according to age, from two to six (0.1-0.4)
grains should be administered.

2 Compare: "Infant Diet," second ed., 1876, pp. 101-116.

201

DR. JACOBI'S WORKS

Third. Nothing should be given that contains salts in
any sort of concentration. Thus, beef-tea should be
avoided. It has come very largely into use in practice
among children both in this country and in Great Britain.
In Germany, too, it has found very many advocates, and
among some who have abandoned the obsolete notion that
when prepared in the customary way it contains a large
proportion of protein in its composition. It must be re-
membered that this form of meat-extract contains a very
large amount of salts, and that the direct effect of these
upon the intestinal canal may be productive of very un-
pleasant consequences. It is a mistake to give it when the
intestines are irritated or very susceptible of irritation,
for the reason that diarrhea is apt to directly follow its
use. Nevertheless, I have often seen beef-tea given under
these very circumstances for no other object than the vain
one of furnishing the child with a great amount of nourish-
ing food. This is very commonly done during the obstinate
and exhausting diarrhea of summer. If people insist upon
giving it, and there is no special contraindication to its
use, in a given case, it should be administered only in
connection with some well-cooked farinaceous vehicle, and
the best of all for this purpose is barley-water; or it may
be mixed with beaten white of egg, but no more chlo-
ride of sodium should be added. For the main danger in
beef-tea is the concentrated form in which its salts are
given.

Fourth. Everything should be avoided that increases
peristaltic motion. Thus, carbonic acid and ice internally.

Fifth. Avoid whatever threatens to increase the amount
of acid in the stomach and intestinal tract. There is so
much acid in the normal, and still more in the abnormal
stomach and intestinal tract, that it is absolutely necessary
to neutralize it. For that purpose any alkali, perhaps, will
suffice, but it is safer to resort to preparations of calcium
than of sodium or magnesium. Soda and magnesia, when
introduced into the stomach and duodenum, will find a
number of acids and form laxative salts. Frequently I
use carbonate of lime; not infrequently phosphate of lime.
Both of these will act as antacids, but the latter prepara-

202

INFANT DIARRHEA AND DYSENTERY

tion is to be preferred in those cases in which free phos-
phoric acid is deemed of importance for the purpose of
facilitating pancreatic digestion.

So far as lime-water is concerned, its administration, cer-
tainly, is correct chemically. But we should not place too
much reliance upon this popular remedy. We should not
forget that it contains about one part of lime to eight
hundred of water, and that it is necessary to swallow at
least two ounces of the fluid in order to obtain a single
grain of lime.

A further indication is, the necessity of destroying fer-
ments. For that purpose most metallic preparations will
do fair service. One of these, that has been extensively
used, is calomel, and now in small doses frequently re-
peated: YxQ, Yi, or y2 a. grain (0.1-0.15-0.03), every two
or three hours. As to its effect as an antifermentative,
there can be no doubt. It is very uncertain, however, as
to how it produces this effect. It is possible that it acts
by a portion of the drug being changed very slowly to the
bichloride of mercury, which is known to be a very
powerful agent in the prevention of fermentation. It
is certain that one portion, at least, of the mercury is
used to bind sulphide of hj'drogen, which often acts in a
poisonous manner. Infants will bear calomel very well,
perhaps for the reason that elimination is so much more
rapid in them than in adults.

Nitrate of Silver, when given for the same purpose,
should be largely diluted. From 34o to Yiq of a grain
(0.0015-0.004), dissolved in a teaspoonful or tablespoon-
ful of water, may be given every two or three hours, and
not infrequently with fair result. At all events, it does not
answer to use a concentrated solution. Whenever it is con-
centrated, it acts more as a caustic than as an astringent.
This remark is especially important with regard to injec-
tions of nitrate of silver into the rectum, where it is apt
to do as much harm as good. Even a mild solution — one or
two grains to the ounce of water ((1:500 or 250) — when
injected into the rectum is apt to give rise to tenesmus and
soreness about the anus ; whenever it is to be given in that
way, the solution should be mild and largely diluted, or

203

DH. JACOBI'S WORKS

the anus and its neighborhood sliould be washed with salt
water before the injection is administered.

Bismuth acts very favorably. Moderate cases of diar-
rhea will usually show its effect very soon. Doses of from
^ to 2 or 3 grains (0.03-0.20), given every two or three
hours will act very favorably indeed. In those cases in
which the diarrhea has lasted for a long time, and a large
surface of the intestinal tract is certainly implicated, the
doses of bismuth should be large in order to be certain of
immediate contact of the drug with the sore surface.

A final indication is the depression of the hyperesthesia
of the general system and of the intestinal tract in par-
ticular. The effect of opium is very probably an anatomi-
cal one, and brought about in such a manner that a com-
bination takes place with the nerve plasma. As this is so
much softer and succulent in the child than in the adult,
the effect is so much stronger. There have been authors
who condemned the use of opium altogether, which, cer-
tainly, is incorrect. The doses should be small, and they
may be repeated frequently. Administered in this manner,
opium can be used with perfect safety both internally and
in an anaemia. For, when the doses are small, it is possible
to stop before an overdose has been given. One of the rules
for giving opium is this — the child should not be waked
up for the purpose of taking the medicine. Opium does
not always act as a depressant, but sometimes as an ex-
citant. This difference in the effects produced by the drug
is well known. Very small doses will act as an excitant,
while relatively large ones will act as a depressant. The
exciting doses will, when accumulated, also show their
constipating effect, and whenever there is fear of collapse,
it is safer to give ^oo of a grain (0.0003) every half-hour
or hour, than to administer Y^q of a grain (0.0012) every
two hours.

Alcohol. — Small and frequent doses will certainly stim-
ulate the nervous system, digestion, and circulation, and
they also stimulate the skin and increase perspiration.
Alcohol, given in this manner, certainly arrests fermenta-
tion. Moreover, it takes the place of food, and will act
favorably as food when no solid carbohydrates are toler-

204.

INFANT DIARRHEA AND DYSENTERY

ated by the intestinal tract. As it is absorbed in the
stomach, so does it protect the intestinal tract. It has been
found that, when only small quantities of milk and pure
alcoliol and water are given as food, the body increases
in weight. But it is absolutely necessary that the alcohol
or the alcoholic preparation should be pure. Fusel oil
will dilate blood-vessels, produce and increase congestion,
and prove dangerous. Where no good brandy or whiskey
can be procured, it is better to use alcohol in substance di-
luted with water.

Finally, it is necessary to reduce the amount of secre-
tion taking place from the surface of the intestinal tract.
For that purpose astringents may be used, such as alum,
lead, tannic acid, pernitrate of iron, and, what has already
been spoken of, nitrate of silver. In all those cases in
which the stomach participates in the process to any con-
siderable extent, almost any astringent will prove ineffect-
ive. Neither alum nor lead nor tannic acid may do other-
wise than irritate the stomach, and it will be necessary
to depend altogether upon nitrate of silver, or, better, upon
bismuth, for the purpose of meeting two indications. To
fulfill several indications at the same time, it is often good
practice to combine remedies.

The main indications are to neutralize acids, to reduce
nervous irritability, to arrest secretion, and to change the
condition of the surface of the catarrhal mucous mem-
brane.

For that purpose, in the generality of cases, I combine
bismuth, opium, and chalk according to the following
formula :

5^ Bismuth subnit gr. i. (0.05)

Prepared chalk ._^^..^,,„.^^_-,^ .grs. ij. (0.10-0.20)

Dover's powder gr. J (0.02)

This combination is suitable for a baby ten or twelve
months of age, and the dose can be repeated every two
hours. In all those cases in which acid is very abundant,
it is necessary to increase the doses of antacids without
necessajily giying large doses of opium.

205

DR. JACOBI'S WORKS

Whenever it is necessary to stimulate, and alcohol alone
does not meet the requirements, resort may be had to hot
bathing. This is especially serviceable in those cases in
which the surface is cool and the temperature of the body,
measured in the rectum, is pretty high. A hot bath in
which the child may be kept for two or three minutes will
restore some warmth to the surface, dilate blood-vessels,
reduce temperature, and act as a nervous stimulant. To
relieve intestinal pain, plain warm fomentations ; to relieve
heat, cold applications are sufficient.

Camphor stimulates the heart, and reduces temperature,
and may be used internally or subcutaneously according
to the necessities in the case. For subcutaneous injections
camphor may be dissolved in either oil or alcohol. The
effect derived from camphor as a stimulant is not perma-
nent, but still very much more permanent and steady than
that produced by carbonate of ammonia.

The dose may be from |^ to ^ a grain (0.015-0.03)
every hour or two, when only a moderate stimulation is
required. In urgent cases it may be given in doses of from
five to ten grains (0.3-0.6) in the course of an hour, and
usually the effect will be favorable.

It is, however, only in cases in which real collapse is
present that doses of five or ten grains will be required,
and it may then be administered dissolved in alcohol, and
with or without musk.

There is no remedy that will act more favorably in con-
ditions of great debility and collapse — collapse with or
without spasmodic symptoms — than musk. It is true it is
scarce, very frequently spurious, is expensive, and must
be given in larger doses than usually recommended. But
in cases of collapse, doses of five or ten grains (0.3-0.6)
should be given at once, and should be repeated every half-
hour or hour. More than two or three such doses will not
be required to yield a result.

The dysenteric miasma^ being unknown, the rules com-
monly obeyed in the hygienic management of all miasmatic

8 Compare the author's essay on Dj'sentery in Gerhardt, Handb.
d. Kinder-Krankheiten, Vol. II, 1878.

206

INFANT DIARRHEA AND DYSENTERY

and infectious diseases are valid in an epidemic of dysen-
tery as well. Streets, water-closets, and sewers must be
disinfected effectively, dwellings and hospital wards vacated
from time to time, and individuals protected by frequent
and careful ablution and the disinfection of clothing. Spe-
cial care ought to be taken lest many dj'senteric patients
be admitted to children's or, in fact, all hospitals. Their
number ought to be limited when they are admitted to
special wards, and smaller than that of typhoid fever
patients when received in general hospitals. Dysenteric
evacuations are to be disinfected and removed, soiled bed-
linen disinfected and washed.

Those in relative health are to give the greatest possible
care to their digestive organs. Indigestible food must be
avoided rigorously during an epidemic. Vegetables con-
taining a large percentage of cellulose, salads, cabbages
must be refused to children of even advanced age, and
even ripe fruit ought to be refused as a rule. Even
healthy children of three or five years will, now and then,
without apparent cause, under normal circumstances pass
soft peas or whortleberries, though well prepared, while
there is no apparent change along the whole length of
their alimentary canals. Animal milk, too, requires great
care when given to younger children, nay, common cases
of diarrhea require that the amount of milk given them
should be rescinded. Cow's milk, when unmixed or mixed
with water only, acts in part as an irritant during an epi-
demic or individual disposition to diarrhea. In regard to
that, I have heretofore laid down the rules according to
which cow's milk, unless there are positive indications for
total abstinence, can be rendered digestible. More: great
care ought to be taken lest the physiological constipation
resulting from the unusual length of the colon descendens
and the doubling and even trebling of the sigmoid flexure
should act as a cause of disease. At all events, one or two
enemata must be given daily. They are also, and even more
so, required where habitual constipation depends upon
rhachitical debility of the muscular layers of the intestinal
tract. When there is an actual indigestion from either
alimentary or atmospheric causes, a purgative is required.

207

DR. JACOBI'S WORKS

I prefer a single effective dose to small refracted admin-
istrations, but no drastic to a child of one or two j^ears.
Five or ten grains (0.3-0.6) of calcined magnesia, three or
six grains (0.2-0.4) of calomel, with an alkaline addition,
one or two teaspoons of castor oil, half a teaspoonful or
less of the fluid extract of rhamnus frangula, act both
effectively and agreeably. Pain and tenesmus may be pre-
vented by the addition of codein, or extract of opium, both
of which have less of the constipating effect of the gum,
or by extract of hyoscyamus. I need not add that in times
like these the usual care is to be taken of the general
health. Woolen or canton flannel undergarments ought to
be changed every morning or night, so that they have am-
ple time to get rid of the accumulated moisture. The
stockings also ought to be of wool or thick cotton, must
cover the entire leg and part of the thigh, and be changed
frequently.

When the disease has made its actual appearance, the
diet requires great attention. Altogether it would be wrong
to force nourishment into a patient whose appetite is im-
paired and fever high in the very beginning of the disease.
But there is hardly another disease in which consumption
and emaciation are so rapid by both actual expulsion of
substance and nervous exhaustion as in dysentery. There-
fore, the little patients ought to be supplied soon with a
certain amount of food. Barley-water with milk, or barley-
water with milk and the whites of eggs, will suffice for a
long time, and will prove digestible; if not, small doses
of pepsin with muriatic acid, or lactopeptin, or bismuth,
or pancreatin, or milk prepared according to the plan
of Dr. Rudisch, will enhance their digestibility. In some
cases, broiled or raw beef, in small quantities, but fre-
quent doses, is well tolerated, provided that the stomach
and small intestines have not participated in the actual
morbid process from the commencement. This happens
very often indeed. In every feverish disease, and mainly
such of the abdominal organs, saliva is reduced in quan-
tity, and the stomach less liable to digest. Besides, a
large tract of mucous membrane is sore or inflamed, and
liable to be irritated by passing solids, meat fibre, casein,

208

INFANT DIARRHEA AND DYSENTERY

cellulose. Whenever the tongue is coated, the region of
the stomach irritable, it is best to refuse even raw beef
and milk, until the tongue begins to be more normal. Nay,
even Leube's beef solution, one of the sheet-anchors during
recovery, ought to be dispensed with, except in conditions
of great urgency. Beef-tea is contraindicated. I emphasize
that fact, as one of the first general advices in the practice
of many of us is the administration of beef-tea, in regard
to which, I refer to such remarks as I made before. All
nourishment ought to be tepid. Ice increases peristaltic
motion and gives rise to pain and tenesmus. So do effer-
vescent beverages, Selters, Apollinaris. In mild cases, par-
ticularly in the beginning, stimulants, either alcoholic or
other, are not required. But I do not share the opinion
of such as forbid them absolutely; on the contrary, they
will prove both pleasant and effective during the periods of
increasing debility and convalescence. In these conditions,
from half an ounce to two ounces (15.0-60.0) of brandy or
whiskey daily, in small and frequent doses, and largely
diluted with mucilaginous or farinaceous fluid, are very
salutary, not to speak of the cases of great debility and
actual collapse. In such conditions, there is hardly a dose
of alcoholic or other stimulants which, where temporarily
required, ought to be considered too large. Ten grains of
camphor and four ounces of brandy administered to a
child of two years in such a condition, during a single
hour, I know to have saved its life. It is better for
children to take in the course of one day three or six
ounces of brandy, ten or twelve grains of camphor, or
twenty or thirty grains of musk, than it is for parents to
bury them on the next.

The regulation of the surrounding temperature is of
great importance, even in the mildest cases. What appears
a mild case to-day may be a serious one to-morrow. The
temperature of the room need not be above 70° F., but the
little patient ought to be in bed and well covered. His
linen must be warmed before being put on, changed fre-
quently, the body often washed, particularly the anus;
bed-pan and evacuations disinfected, windows opened. The
feet have a constant tendency to get cool and ought to be

209

DR. JACOBI'S WORKS

warmed constantly. One tepid bath at. least ought to be
taken daily; for no other purpose the patient must leave
his bed. Tepid fomentations will alleviate colic, warm
injections tenesmus. Of these latter I shall have to say
more.

In many mild or moderate cases, this dietetic treatment
of an attack of dysentery may suffice, but its effect is not
to be relied upon solely, for at any moment medicinal treat-
ment may become urgently indicated. Personally, I al-
most feel like counting the administration of a mild pur-
gative in the first commencement of a dysenteric attack
among the dietetic indications. A copious evacuation from
the bowels appears to be an essential aid in procuring a
mild course for the incipient morbid process. When, after
all, a rapid recovery can no longer be expected, after these
dietetic measures, the indications for treatment are plain.
The local morbid process is to be inhibited, the peristalsis
to be moderated, the irritability of the intestines to be
reduced to a minimum, and the morbid products removed
both as quickly and gently as possible.

As I said before, I like to begin the treatment with a
purgative. Calcined magnesia (with or without some sali-
cylate of soda, according to the condition of the stomach),
castor oil with opium, the fluid extract of senna or rham-
nus frangula, or from three to eight grains of calomel, to
be followed by a dose of Dover's powder. I am well
aware of the objections to mercury, and know of but
few indications for its administration except in syphilis.
Its protracted use, although it is not so apt to give rise to
stomatitis as it is in adults, may still prove so deleterious
in its effect upon the general system that this application
has been greatly rescinded in the last twenty years of
my practice. The objection alluded to is, however, more
valid in regard to small and frequent doses than to single
larger ones, and cannot contradict, therefore, the warm
recommendations of calomel on the part of, particularly,
English physicians. Still, purgatives are indicated in the
commencement only of dysentery, not through its whole
course, as has been advised in the dysentery of adults. In
the latter, accumulations of feces of old date are not at

210

INFANT DIARRHEA AND DYSENTERY

all rare, in fact, there are very few adults where they
may not be met with. In children the intestines are
smaller, the contents more liquid, relaxations and diver-
ticles rare, and accumulations less frequent and less copious.
Thus, though adults may require purgatives in the course
of a dysenteric attack, children, as a rule, do not require
such a repetition. But lately a young friend was, by the
advice of a consulting physician, awed into giving a pur-
gative in the third week of a dysentery doing well on
bismuth and opium ; to some disadvantage. Where, however,
an indication appears to arise, the purgative ought to be
castor oil or magnesia, no longer calomel or a drastic.

We know of many recommendations of emetics. Their
effect was described as revulsive; their general and prin-
cipally their diaphoretic powers were praised. Still I
think that a warm bath and warm beverages, while they
are just as effective, are less violent. Ipecacuanha has
been recommended more than any other remedy of that
class, but not for its emetic effect. On the contrary, Mc-
Lean, Woodhull, and others insist upon avoiding the nau-
seating effect. McLean administers a hot bath, and a dose
of opium or chloroform.' This is followed by a dose of
twenty-five or forty grains of ipecac; he allows his patient
to suck ice, but no drink for two or three hours, and uses
sinapism or oil of turpentine as derivants. A smaller dose
of ipecac is given after eight or ten hours. Sometimes
another dose of eight or twelve grains is required on the
following day. Recovery is said to set in soon. This
ipecac treatment is reported to have resulted amongst the
military in England, where it was first introduced, as " ra-
dix antidysenterica," in better statistics than the former
routine treatment with mercury and depletion. The latter
I cannot recommend. Except the anus, no tangible locality
has blood-vessels connected with those of the diseased mu-
cous membrane. There is no indication for leeching the
abdominal surface as long as there is no complication with
peritonitis. Generally the consumption of blood is so large
in dysentery that saving blood is more advisable than
taking.

Great sensibility of the left hypogastric region and heat

211

DR. JACOBI'S WORKS

will be alleviated^ however, by the application of ice.
But it must not be forgotten that very young infants bear
ice but a short time, whether applied to head or abdomen.
I advise to watch the effect of the application either of the
ice bladder or the ice-cold cloth. Now and then, even in
adults, we meet with an idiosyncratic incompatibility with
cold. It has to be taken into account. Sometimes warm
applications of either water or poultices prove more efficient
in regard to the two indications, which consist in allevi-
ating irritation and reducing temperature. Sometimes a
simple warm application, which may be changed every
few hours, or a cold application which is permitted to get
warm on the skin, will result in reducing both pain and
temperature, as both physiological laws and therapeutical
experience may lead us to expect.

Opium (and its alkaloids, morphia and codeia) is invalu-
able in dysentery, notwithstanding the contrary opinion
of a number of authors. The objection to its use is de-
cidedly exaggerated. Such accidents as have been reported
in the journals to result from its administration must be
attributed to the fact that either the dose was absolutely or
relatively too large compared with the idiosyncrasy of the
little patient. Dysentery both requires and tolerates larger
doses of opium than an average diarrhea. In this respect
this disease stands abreast with peritonitis. The main in-
dications are to relieve pain, reduce peristalsis, and dimin-
ish the copious serous secretion ; no other remedy fulfills all
of them so well. For this purpose it ought to be given
internally; for enemata containing opium may act favor-
ably, but the more intense the tenesmus the less reliance
can be placed on its effect, and the amount of the opiate
thus brought into real action cannot be estimated. From
amongst the opiates I prefer a tincture, or the wine, or
opium in substance, or Dover's powder; but rarely have
I injected morphia under the skin. The effect of the
drug is easily watched and controlled, by commencing with
moderate doses, not repeating them too often, and being
guided by the effect obtained. If opium is to be replaced,
opium with hyoscyamus, or with belladonna, or hyoscyamus
or belladonna alone, may take its place temporarily.

INFANT DIARRHEA AND DYSENTERY

After the purgative administered in the first stage of the
disease has proved efficient, astringents ought to be re-
sorted to at once. They may either be given in combina-
tion with opium separately. They are expected to pass
wholly or partly through the entire length of the intestinal
canal, thus coming in contact with the inflamed and ulcerous
mucous membrane. Amongst those eligible are tannin,
gallic acid, and vegetables containing the same (ratanhia,
cinchona, catechu), besides subacetate of lead, nitrate of
silver, and pernitrate of iron.

The daily doses of tannin range from eight to fifteen
grains, (0.5 to 1.0) with opium or Dover's powder, lead in
doses somewhat smaller, nitrate of silver one-sixth of a
grain to one grain (0.01 to 0.06) in plenty of water, liquor
ferri pernitratis fifteen to fifty minims, in a mucilaginous
or farinaceous vehicle. The single doses ought to be but
small, but their administration frequent. There is an-
other remedy which, in my estimation, stands very high,
\iz., the subnitrate or subcarbonate of bismuth. Not only
does it cover and protect the mucous membrane, but it also
has a decided antifermentative effect. Thus it is surely
indicated in irritated conditions of the mucous membrane;
it seldom fails when given in sufficient doses. There is no
harm in sometimes giving it in such doses that part of
the introduced material will pass through the entire length
of the intestinal tract without undergoing decomposition.
As its taste is not disagreeable, it may be given together
with tannin and opium; the daily dose ought not to be
less than one drachm or a drachm and a half (4.0 to 6.0).
At the same time the passages ought to be examined as to
their reaction. Abundant acid, so frequently found in the
slightest intestinal anomalies, requires the additional ad-
ministration of alkalies. In most cases carbonate of lime
is preferable to either magnesia or the carbonate or bi-
carbonate of soda, the salts of both of which are apt to in-
crease diarrhoea. Sometimes, particularly when the stomach
can be relied upon, the salicylate of soda may be added to
the internal treatment. Besides the favorable effect of
the soda in the intestinal tract, the salicylic acid may
prove beneficial both by its anti-febrile and disinfectant

213

DR. JACOBI'S WORKS

action. In regard to the use of lime-water, I refer to
some previous statements.

At the same time accidental complications may yield
their own indications. McLean reports many cases of com-
plications with malaria, necessitating the use of quinine;
others cite scurvy requiring antiscorbutic treatment.

When the catarrhal or inflammatory form of dysentery
is complicated with diphtheritic deposits or degenerations,
either superficial or deep-seated, or when large portions of
mucous membrane are expelled and ulcerations are devel-
oped, the indications for energetic treatment become more
and more urgent. Local treatment is required to astringe,
to disinfect, to produce new granulations. For that pur-
pose astringents, carbolic and salicylic acid may be re-
sorted to. To what extent local treatment can be useful^
G. Thomas has proved but lately in a very tedious and
protracted case. A lady suffering from chronic dysentery
through many years, and reduced to the lowest possible
degree, recovered within a short time under the repeated
applications of a small amount of concentrated nitric acid
made to the surface of the ulcerated rectum through a
speculum.

The local treatment requires the use of enemata. Their
indications vary. They are to evacuate the bowels, or to
reduce the irritability of the diseased intestine, or to
accomplish an actual cure. These indications cannot al-
ways be fulfilled separately; sometimes two, sometimes all
three can be fulfilled at the same time. The nature and
quantity and the temperature of the liquid to be injected
depend in part on the end aimed at, in part on the irri-
tability of the individual intestine. Sometimes the bowel
objects to the introduction of small amounts; sometimes,
however, large quantities are tolerated very easily indeed.
To introduce small amounts, the selection of the syringe
is a matter of indifference. To inject large quantities,
however, undue pressure and local irritation must be
avoided. Thus the fountain syringe alone will answer;
it ought to hang but a trifle above the level of the anus,
say from six to twenty inches. The temperature of the
liquid is not always a matter of great importance. Some

214

INFANT DIARRHEA AND DYSENTERY

recommend the injections to be ice-cold^ some, however,
tepid; both care frequently recommended as panaceas. But
the practitioner will soon ascertain that some bear and re-
quire the one, some the other, some indeed very hot ones.

In my experience, for the large majority of patients
tepid injections answered best. Not seldom is the intes-
tine in such a condition of irritation that even small quan-
tities of a very cold fluid are expelled at once. And
again, there are cases in which enormous amounts of
either cold or warm water are readily received. To ac-
complish the purpose of evacuating the bowel, plain water
will often suffice, but one-per-cent. solutions of salt in
water will usually prove more acceptable. Additions of
bitartrate of potassa, or castor oil, have proved so un-
comfortable in my hands that I have discarded them long
ago. However, when the secretion of mucus on the rectal
mucous membrane was very large, one or two-per-cent.
solutions of bicarbonate of soda answered very well in-
deed. For the purpose of clearing the intestines, either
of feces or the morbid products, a single enema is in-
sufficient. It ought to be repeated several times daily.
When much mucus is secreted and tenesmus intense, it
may be applied after every evacuation. In many cases
the substitution of flaxseed tea or mucilage of gum acacia
will prove advantageous. I had to continue them for
weeks for both their evacuating and alleviating eff'ect.
When, however, the latter eff'ect alone is aimed at, small
quantities will usually suffice. An ounce or two of thin
mucilage, or starch-water, or flaxseed tea, with tincture
of opium, or better, extract of opium, prove very comfort-
ing. Glycerine in water has been recommended for the
same purpose. The former alone, or but slightly diluted,
irritates, nay, cauterizes. It will require close judgment
and individual experience to ascertain the degree of di-
lution.

When a local curative eff'ect is aimed at, injections of
small quantities will be found deficient. As the local
lesions are often extensive, the amount to be injected
must be pretty large. Almost always astringents are re-
quired. Sulphate of zinc, of alumina, subacetate of lead,

215

DR. JACOBI'S WORKS

nitrate of silver, tannin, chlorate of potassa, ergotin,
salicylic and carbolic acids, and creasote have been recom-
mended. Of the more common astringents I prefer alumina
or tannin in one-per-cent. solutions. Creasote answered
well in solutions of one-half of a per cent. Salicylic
acid resulted more frequently in pain than in benefit.
Carbolic acid in solutions of one-half of a per cent, has
proved very beneficial, but I have learned long ago to
be very careful in regard to its administration when I
observed a case of poisoning with that substance. A
young man suffering from chronic dysentery was to be
treated with injections of carbolic acid in a one-per-cent.
solution. As it was expected that but a limited quantity
would be tolerated before expulsion, no amount was speci-
fied. The intestine, however, being in a paralytic condi-
tion, received enormous quantities, until finally ten drachms
(40.0) of crystallized carbolic acid disappeared in his
bowels. That want of caution came near destroying the
patient.

Injections of nitrate of silver may prove very useful
in cases not quite acute. Before the solutions of a quarter
of a per cent., or one, or two per cent, are injected, the
intestine ought to be washed out with warm water with-
out salt. After the injection has been made, it ought
to be neutralized with a solution of chloride of sodium;
it is still better to wash the anus and the portion of the
rectum within easy reach with that solution before the
medicinal injection be made. For even the mildest solu-
tions are liable to give rise to intense tenesmus, when no
such care has been taken.

In chronic cases, where the ulcerations are but few,
or in the lower portion of the bowels only, small quantities
suffice. But more acute cases and extensive lesions re-
quire large injections, the patient being on his side, or
in the knee-elbow position. In a number of cases, both
mild and severe, where neither the usual astringents nor
nitrate of silver appeared to answer, I have been very
successful when resorting to injections of subnitrate of
bismuth. The drug is mixed with six or ten times its
amount of water; of this mixture from one to three ounces

216

INFANT DIARRHEA AND DYSENTERY

(SO.0-100.0) are injected into the bowel which has been
washed out previously, twice or three times daily. The
success was satisfactory, though a large portion of the
injected mixture was soon expelled.

Suppositories containing the above substances may prove
beneficial. But in order not to irritate they must be so
soft as to melt readily. They may always contain some
opium. But its admixture is not always sufficient to re-
lieve the irritability of the rectum. For to accomplish
this end, opium must at least begin to liquefy and to be
absorbed, and absorption cannot be relied upon except
where a part, at least, of the mucous surface is in a tol-
erable state of integrity.

217

SOME IMPORTANT CAUSES OF CON-
STIPATION IN INFANTS

Constipation is by no means a rare affection in very
young infants. However, as in old age also, it has so
frequently been taken as an almost physiological occur-
rence of but little importance, that its prognostical mean-
ing and its pathological nature have often been under-
estimated. It is true that many cases are attended with
but little danger, but no less true, also, that the simple state-
ment of an infant's bowels being costive ought not to be
considered as a valid diagnosis of the causes which give
rise to such a condition.

The causes of costiveness in early infantile age do not
differ, in many cases, from those prevalent in adults.
They may be classed under a few heads, according to
whether they are referable to the contents of the intes-
tines, or their motory power and secretions, or local ob-
structions, or deficient innervation. Many of the serious
diseases of adult age complicated with constipation are not
often met with in infants, nor are the most dangerous
forms of ailments of the nervous system — for instance,
acute hydrocephalus — frequent occurrences in the very
tender age to which our attention is here directed. Still,
there are a great many hygienic, pathological, and ana-
tomical influences which will have the result of rendering
the alvine evacuations dry, scanty, or rare. It is the more
important of these we mean to discuss, leaving out the
symptomatology and therapeutics of the generality of
cases as described in almost every text-book on theory and
practice, or diseases of children.

Before turning to this task we may, however, state at
once, that there are cases of temporary constipation which
do not belong to any one of the classes alluded to. For
instance, almost every feverish disease has a greater tend-

219

DR. JACOBI'S WORKS

ency to result in costiveness in infants than in adults, no
matter whether the intestinal tract is the seat of the af-
fection or not. We need only allude to this fact, known
to every pathologist and practitioner, in order to distin-
guish these cases of temporary constipation from the
chronic disorder.

A common cause of constipation in infants is improper
food. The more bulky such food, the more tendency to
constipation, with the exception of those cases in which
the irritation of the alimentary canal, by the unusual vol-
ume and nature of the contents, results in catarrhal dis-
charges from the mucous membrane. Thus, infants fed,
on amylaceous food principally, especially potatoes, rice,
or arrowroot, instead of breast-milk or a proper substitute,
are liable to suffer from constipation. The appropriate
change in the baby's diet will in all probability be all
that is required to mend this abnormal condition.

But breast-milk, or its apparently proper substitute, is
also apt to yield the same results. We meet with a
number of babies of two or four months who empty their
bowels once a day only, or once in two or three days.
The consecutive disorders of general nutrition may not
be very great in the beginning, but even the occasional
attacks of colic, the straining (sometimes inefficient) in
passing faeces, the congestion to the head and brain, and
perspiration, in their efforts to procure an evacuation, are
always noticeable facts which are but the precursors of
more urgent symptoms. The faeces are hard, pass in small
lumps, and are of a white color and cheesy appearance;
now and then they are covered or mixed with a viscid
mucus, the result of intestinal irritation, or even with
streaks of blood, the result of straining and local lesion.
The above condition and appearance are due to a large
quantity of firmly coagulated casein admixed with the
faeces in a certain proportion, sometimes, however, to such
an extent that the evacuation appears to consist of casein
only.

The presence of casein in the passages in this hard
and firmly coagulated condition depends on one of two
causes. There is either, in the gastric secretion, too

220

CAUSES OF CONSTIPATION IN INFANTS

much acid for a normal digestion, or there is too much
casein in the milk.

When milk is introduced into a normally digesting
stomach, it undergoes a speedy but loose and soft coag-
ulation, which is very easily overcome by the action of
the rapidly secreted pepsine. When, however, the gastric
secretion is abnormally acid,^ — a very frequent occurrence
in young infants, — the coagulation of the milk will take
place more rapidh^ than normal, and at tlie same time the
coagulated mass will be hard and solid. The differences
of these two conditions can be easily appreciated on
noticing the masses thrown up a few minutes after nurs-
ing or feeding; loose, and with no apparent effort, or
solid, in large lumps, and often with a great struggle.
Whenever these masses will not be thrown up from the
stomach they will pass down the intestinal tract, not at
all or but little changed by the digestive process. Their
size will obstruct the canal, and their dryness will keep
them from being readily expelled.

We are not unfrequently in a position to recognize the
cause of this condition in the color and taste of the
mother's, or the mixture of the cow's milk. It is deficient
in sugar, but more defective by its too large amount of
casein The mere change of a wet-nurse or a different
dilution of the cow's milk is often sufficient to change the
infant's digestion and evacuations at once; but the former
is not always possible or expedient, and the latter must
be understood. We have frequently found that a simple
addition of sugar to the breast-milk would suffice to pro-
cure the necessary change, or the mere addition of sugar
and water to the former dilution of cow's milk would have
a similar result. Our plan is, in the former case, simply
this: to give the infant, every time, and just before being
laid to the breast, from half a drachm to a drachm of
loaf sugar, dissolved in a teaspoonful of tepid water;
very often, a few days will exhibit a marked improvement.
But in many instances this plan does not work to entire
satisfaction, inasmuch as the proportion of the gastric
acid to the coagulable casein is not sufficiently influenced.
What we want further is a more gradual or slower effect

221

DR. JACOBI'S WORKS

of the may be otherwise normal acid on the casein. For
the purpose of obtaining this end, we mix the cow's milk,
if the infant be fed on such, with some thin mucilage in-
stead of water, with the expectation that the effect of the
acid will be rendered less rapid, and the coagulation less
hard. Gum-arabic water will often do good service, gum
being a completely indifferent substance; as a general rule,
however, we prefer a decoction of barley or oatmeal, well
strained, with the addition of salt and sugar, as the proper
vehicle of milk. This plan holds good for breast-milk
as well as for prepared cow's milk. Where the breast-
milk contains too large a proportion of casein, we replace
sometimes the solution of sugar by a tablespoonful of
sweetened barley-water, or strained oatmeal gruel, which
is to be administered just before nursing; the latter being
the preferable substance, on account of its more laxative
effect.

In all such cases, however, in which the fault is more
on the side of the gastric secretion than of the super-
abundance of casein, it is necessary to neutralize the
surplus of acid. In many we have to continue the treat-
ment for a long period. The antacids mostly in use are
magnesia (calcined of the carbonate), bicarbonate of soda,
and carbonate of lime. If the antacid effect of the three
agents be considered equal, we find the bicarbonate of soda
the most convenient addition, particularly to artificial food,
because of its gentle laxative effect, and of its solubility.
A few grains may be admixed to every meal, with happy
results. We add here, that wherever antacids are indi-
cated, the selection of the remedy will depend on the pres-
ence of either diarrhoea or constipation; the former re-
quiring the carbonate of lime, the latter magnesia or
soda.

Besides, the condition of the gastric juice and the milk,
or rather the disproportion between them, resulting in
solid and insoluble coagulation of the casein, we have
to recognize as a frequent and important cause of con-
stipation in infants, a certain condition of the intestinal
tract. We do not mean the deficient action of the muci-
parous follicles of the intestines, but an insufficient degree

£22

CAUSES OF CONSTIPATION IN INFANTS

of muscular power and action, depending on general
rachitis. We understand by rachitis, by no means the
well-known affection of the bones resulting in their lack
of phosphates and surplus of water and fat, but con-
sider this character of the osseous tissue as but a partial
illustration of the whole morbid process. Rachitis is
the condition of general malnutrition which results in the
above peculiar softening of the bones during their physio-
logical development, in the deficient formation of muscular
tissue, in the abundant deposits or non-absorption of fat,
together with all the symptoms attending on these and
other anomalies. In fact, there is hardly an organ, scarcely
any part of the body, which is not affected to a certain
degree,. before the series of changes which will take place
in the long bones, viz., swelled epiphyses and curved
shafts, have exhibited themselves to such a degree as to
be recognizable to even an untrained eye. Amongst the
first symptoms which will become perceptible we count
muscular debility.

The principal organs on which rachitis shows itself are:
the thymus gland, which remains large beyond its normal
. time ; the bronchial glands, which become enlarged ; the
thorax, with its two longitudinal grooves along the costo-
cartilaginous junctures and its horizontal groove above
the insertion of the diaphragm, its consecutive raising of
the sternum and ensiform process, its flat dorsal and angular
lateral portions, its triangular shape and general short-
ness, with all its consequences on the position and char-
acter of the thoracic and abdominal viscera ^ the cranium,
with its baldness (especially posteriorly), perspiration,
square shape, and local softening on the parietal and
occipital bones, and with its general hyperaemia; the brain,
with its congestion and tendency to effusion; the copious
subcutaneous tissue, the pale surface, the muscular debility,
the swelling of the epiphyses, and the curvature of the
long bones. Of all the symptoms which have been enu-
merated, the latter is most alluded to as important, and
still it is the least important, inasmuch as when it is
noticed the injurious effects of the whole process have
already had too much chance to exhibit themselves.

223

DR. JACOBI'S WORKS

It would be out of place here to prove to what extent
general and local diseases, hereditary and acquired ten-
dencies, are apt to generate rachitis, or in which manner
rachitis is liable to give rise to consecutive diseases.
But this much is evident to every pathologist, that the
early recognition of rachitis amounts to a great saving
of health or life. Now, there is no symptom which will
show itself in its full development sooner than muscular
debility in general, and muscular incompetency of the in-
testinal tract in particular. It is true that a trained eye
will appreciate the first sign of the longitudinal thoracic
groove, and the contemporaneous pain on taking hold of
an infant's trunk; or that an educated finger will recognize
the first beginning of local rachitic softening on the cranial
bones as early as in the second or third month, sometimes ;
but fully as early as these symptoms, the rachitical con-
stipation of the baby will be perceptible. An infant may
be born in good condition, meconium will pass off normally,
all the functions will appear normal for some time. It
will look healthy, round, fat, but pale; hair is but scanty,
and constipation will set in despite of there being no ap-
parent surplus of casein in the milk, or of acid in the
gastric juice. There must be a physical cause for every
abnormal function; where there is no local obstruction,
no faulty secretion, apparently no improper food, the loco-
motive power of the intestinal tract must be looked after.
It is more frequently at fault than the rest of the parts
concerned in digesting. When such a constipation is found
in an infant at that early period, it may be that some other
cause can be found; but when at the same time or a little
later the scalp, covered with scanty hair, begins to per-
spire freely, and the thorax begins to look short, or respi-
ration appears to become more abdominal than can be ex-
plained by any known morbid condition of the thoracic
viscera, the diagnosis of rachitical incompetency of the
intestine is tolerably safe. There can be no doubt that
there are other symptoms of rachitis which, when fully
developed, render the diagnosis of the disease more posi-
tive; but there is no symptom in the whole series which
directs our attention so much and at such an early period

224

CAUSES OF CONSTIPATION IN INFANTS

to the imminent danger as this constipation. We seldom
fail in being correct, when we attribute protracted con-
stipation in an apparently healthy but fat and pale baby
of two or three months, whose bowels have been in toler-
able order during the first month of life, to rachitis. Thus,
while we recognize the disease thus early, we shall not
only be enabled to treat the annoying symptom rationally,
but also to ward off the further development of the other
threatening symptoms.

Nothing would be more incorrect than to try the ef-
fect of laxatives, on constipation depending on rachitical
incompetency of the intestinal muscle. They would act
momentarily, and leave the muscle more powerless than
before; their place is to be taken by injections of cold
water. The indications are: such a change in the food
as will contribute to keeping the bowels moist and slippery,
but principally such modification of food, and such medical
treatment, as are known to benefit where all the symptoms
of rachitis are fully . developed. The mother will, accord-
ing to circumstances, have to be replaced by a good nurse,
where the cause of rachitis in the baby can be traced back
to the mother, or to an insufficient condition of her milk;
or the nurse must be changed, for similar reasons. Very
often artificial feeding is still better than either mother
or wet nurse, when these cannot be found of first order.
Iron and phosphates are important ingredients of any
food the baby is to have; extracts or infusions of beef,
boiled barley or oatmeal mixed with milk, are the prin-
cipal requirements as far as food is concerned. Oatmeal,
carefully strained, is to be preferred as long as the gentle
laxative effect of the additional mucilage is still desirable.
Iron may be given in addition, either as syr. phosphat.
compos., 10 to 15 drops, or as syr. iodid. ferri, 4 to 10
drops, three times a day; and no dietetic rule known to
favor a healthy general development ought to be lost
sight of. As in general rachitis, cod-liver oil will prove
very satisfactory, both through its general qualities and
its local effect on the mucous membrane of the intestine.
The principal part of the laxative effect of colostrum is
not due to its large proportion of salts, but to its amount

225

DR. JACOBI'S WORKS

of fat, which favors speedy locomotion of the contents
of the bowels. Thus a teaspoonful or less of cod-liver oil
mixed with the iron will favor the same purpose in
rachitically constipated infants, while it at the same time
improves their general condition. Now and then a ver}'
obstinate case may require for a week or two the one-
hundredth part of a grain of strychnia, twice a day, in
addition, or such other improvements on the above detailed
plan as the individual judgment of the attending physi-
cian may direct. At all events, the diagnosis of a case
is, to a well-educated and balanced mind, of infinitely
greater value than any number of detailed rules and pre-
scriptions.

Besides the abnormal condition of the milk, and the
insufficient development and function of the muscular
layers of the intestines, there exists a cause for consti-
pation in infants which has not, to my knowledge, been
touched at all in medical literature. And still it is frequent
and constant, dates from the first hour of life, and for
this very reason will often be recognizable in its difference
from rachitical constipation, which in the large majority
of cases takes its commencement in the second or third
month only. This frequent and important cause I allude
to, depends on the normal anatomy of the intestine, par-
ticularly the colon, of the foetus and newborn.

The length of the intestinal tract is much greater (in
proportion) in the later periods of foetal life than in the
adult, while it is but inconsiderable in the early months
of utero-gentation. The small intestines of a foetus of
eight months are twelve times as long as its body, while
the proportion in the adult is but eight to one. The
colon has a length two and two-third times as great as
the body in a foetus at full term, while the same propor-
tion in the adult is that of two to one. Now the ascending
and transverse cola are very short in the foetus and new-
born; thus the descending colon, having to make up for
the difference, is the longer in proportion. While, then,
the whole intestinal tract grows but slowly in the j^oung
foetus, it increases rapidly in the maturing foetus, and
diminishes in proportion some time after birth. Mean-

226

CAUSES OF CONSTIPATION IN INFANTS

wliile the pelvis grows very slowly in the latter period of
utero-gestation, and the long colon descendens, with the
sigmoid flexure and rectum, finds no space for comfort-
able accommodation, as in later life. This disproportion
remains intact, as we have had scores of opportunities to
convince ourselves at the dissecting table, for several, some-
times for six or ten, years.

The consequence of the long colon being crowded down-
wards, by a narrow abdomen, large liver, etc., into a narrow
pelvis, is a number of curvatures instead of the one sig-
moid flexure. Tims it happens, that in its place there is
a curvature of the gut, permitting it to escape to the right;
thus it happens, further, that the real sigmoid flexure is
found either in the median line, or still more frequently
on the right side. Thus, since this anatomical condition
of the foetal and infantile colon has been appreciated, par-
ticularly since the memorable discussion of the subject in
the French Academy of Medicine, in January and Feb-
ruary, 1859, the proposition has been made to establish
artificial anus in infants in the right instead of the left
side, and a number of operations have been made at
this place accordingly. From this point the colon turns
down into the pelvis, forming the rectum, which, in accord-
ance with the above facts, is very rarely found in infants
on the left side exclusively, but almost always steps be-
yond the median line, and very frequently is met with
mostly in the right side of the pelvis. The exact measure-
ments and facts may be easily reached in the literary rec-
ords; suffice it here to allude to these, and to state the
anatomical fact in our researches on its clinical bearing
to be this: that the colon descendens in the newborn and
young infant is very long in proportion ; that the space
to which it is confined is too narrow; that, therefore, — •
not to speak of other reasons leading to the same result^
— it will bend ; that folds and curvatures will form, and
that the locomotion of the contents of such multifariously
bent and curved intestines must necessarily be impeded
to a greater or less extent.

Two cases, in which the flexures of the descending colon
were unusually numerous, and developed in the highest

227

DR. JACOBI'S WORKS

degree possible, are, while they elicit a painful interest,
uncommonly fitting to illustrate the physiological obstruc-
tion which may take place in the intestines at an early
age. A finely developed boy was born in a family of
healthy and robust parents, some five years ago. No con-
stitutional or acquired diseases of any importance could
be traced in either of them, or in the two older children;
no malformation of any kind had ever occurred in either
of their two families. The newborn baby did well for
some twelve or fourteen hours, but no passage of meconium
made its appearance, and vomiting set in about the end
of eighteen or twenty hours. The finger detected no ob-
struction of the rectum, sphincters acted normally, and
above them the finger entered what appeared to be a
pouch, beyond which neither the finger nor bougie could
be introduced. Frequent attempts at pushing up bougies
failed, nor did injections of water forcibly made into the
bowels prove any more successful. Injection of air or gas
was not resorted to. The diagnosis of mechanical obstruc-
tion at a part of the rectum or colon beyond reach was
made, and confirmed by all the symptoms of such a con-
dition— violent vomiting, etc., the prognosis of the case
expressly stated to the relatives, and Littre's operation for
artificial anus held out as the only means of saving the
infant's life, and accepted. On the third day the left
iliac region, in front and a little above the spina anterior
superior, appeared to fill up, and yielded a somewhat
duller percussion sound. The operation was therefore
performed at this spot, in the presence of Drs. James R.
Wood, L. Voss, and some other professional gentlemen; it
resulted in our finding a pouch of the descending colon
filled with a large amount of meconium, which was readily
discharged through the artificial opening. The patient
did well for a short period, but died of peritonitis on the
fifth day after the operation. The post-mortem examina-
tion yielded the following results: The part of the colon
fastened to the abdominal wall was no longer dilated. Be-
sides the consequences of peritoneal inflammation nothing
was abnormal in the immediate neighborhood. All the
parts above the incision, and all the other viscera were not

228

CAUSES OF CONSTIPATION IN INFANTS

diseased. Below the point of incision lay the colon, turned
three times upon itself, three flexures covering each other
in such a manner that the subjacent one was always
about half an inch longer than the one above it. The
lowest of the three, crowded down into the pelvis, was
entirely compressed, contracted, and contained nothing
but a little hardened mucus; the middle flexure contained
the same mucus, and a small amount of meconium; the
upper one was filled with meconium as far as the con-
tracted lumen of the bowel would allow, and its outer left
portion was the one which had appeared dilated by the
meconium crowding down from above. The inferior flex-
ure reached beyond the median line, stretched upwards to
nearly the spina anterior superior of the right side, and
from there the intestine turned back in an acute angle
into the pelvic cavity, doubled upon itself, reached the
median line on the right of the empty bladder, and ter-
minated as rectum in its normal place. When the bowel
was removed, it measured from the point of incision in
the left hypogastrium to the anus nearly fourteen inches.
The ascending colon was of normal length; the transverse
colon was not in its normal position, but stretched from the
right hypogastrium to the left spina anterior superior,
diagonally, in an almost straight line, forming an acute
angle with the uppermost curvature we have described,
and giving rise to the pouch we found dilated before and
during the operation.

We have, then, a case of mechanical obstruction, brought
about by the abnormally long descending colon, which may
be taken as an arrest of development only, inasmuch as
its relation to the length of the colon ascendens and
transversum agrees with their foetal condition about the
fourth or fifth month of utcro-gestation ; by the diagonal
position of the transverse colon forming an acute angle
with what ought to have been the descending colon; by
the compression of the bowel by its own flexures, which
were much more numerous than normally; by the narrow-
ness of the newborn pelvis, the space of which was still
getting more narrow by the bladder filling up more than
before; by the infant's crying, and crowding the thoracic

229

DR. JACOBI'S WORKS

and abdominal viscera downwards upon the intestine, and
by the tract filling up with food, faeces, air, and gas. Thus
the very acts of crying and nursing, which will bring on
evacuations of the bowels of the newborn, were the cause
of increasing the obstruction by compressing the guts,
more than three times doubled upon themselves.

We hardly know what the result would have been if,
instead of the injections of water, those of air should have
been made, with sufficient force and in sufficient numbers.

Not long after this case. Dr. L. called us to see a case
of mechanical obstruction of the intestine, also beyond
reach, with exactly the same results of examination, and
the same symptoms. Our local examination by means of
finger and bougies failed, as in the above-mentioned case,
with the exception of our seeing a little blood oozing
from the rectum after repeated attempts at pushing our
examination upwards. This blood was in our opinion the
proof of our tearing a thin membrane or soft mass, which
we thought was but the lower portion of inflammatory con-
glutination. Despairing of the case, we still forced our
bougie up, without having much reason to congratulate
ourselves on any favorable result, and forced as large quan-
tities of water upwards as the gut would hold this side
the obstruction. We did not succeed, however; proposed
the formation of an artificial anus ; were refused, and left.
Meanwhile the injections were now and then repeated by
the attendants, and towards the end of the third day,
twelve hours after our visit, a large quantity of meconium
was evacuated, vomiting ceased, and the baby was saved.

We have no reasonable doubt but that this latter case
of intestinal obstruction was of the same nature as in the
first described instance. We consider the two cases, and
have therefore described them with some minuteness, as
valuable contributions to the doctrine of congenital obstruc-
tions, and have no hesitation in expressing our belief that
many a case of supposed imperforate colon may have been
of the character we have tried to describe. Thus, the
indications for inflating, and by inflating turning, and
thereby opening the guts, and for all such means as the
ingenuity and knowledge of the practitioner will command,

230

CAUSES OF CONSTIPATION IN INFANTS

ought not to be set aside until the case is really hopeless.
Besides, not many parents will consent to the operation
for artificial anus; and to what extent, and at what late
period a desperate-looking case may be relieved, our second
case is amply competent to show.

But let us not forget that it was no point of the chapter
on imperforate rectum or colon we meant to elucidate,
but that we spoke of infantile constipation. The object,
however, of our reports is obvious enough. The cases we
have narrated suffice to show to what extent the normal
anatomy of the foetal guts when arrested in their develop-
ment to but a slight degree, can prove injurious in the
born infant; and the few facts set forth by us concerning
this anatomical condition are of such a nature that every
medical man will be able to verify them in post-mortem
examinations.

If we have succeeded in showing that such cases of
constipation in very young infants, which date from birth
(not, as in rachitis, from the second or third month),
occur in otherwise healthy individuals, and in which the
evacuations of the bowels are normal enough, with the ex-
ception of the faeces being somewhat dry, in consequence
of the absorption of water being facilitated by the ex-
tensive surface of the mucous membrane of the long and
curved colon descendens — will result from the simple fact
of the length and curvatures of the colon, we have at the
same time succeeded in pointing out the treatment. For
it is of just as much importance to learn which cases
ought to be left alone, as it is to find the indications for
the medicinal treatment of those requiring it. The cases
we have alluded to require no treatment except the proper
diet, and cold-water injections, until the growth of the
pelvis and the increase in size of the abdominal and pelvic
cavities give a natural and favorable termination to a con-
dition which must be understood, to avoid mistakes in its
appreciation and treatment.

231

ACUTE RHEUMATISM IN INFANCY AND
CHILDHOOD

Gentlemen: — This little girl, three years old, was
presented to you last Saturday, the day after her admis-
sion. She came with a history of a pharyngitis, for
which she had been treated with so much success, that
the mucous membrane of the fauces exhibited but few
remnants of that disorder. Still, you remember, the child
appeared to suffer. There was dyspnoea, respiration about
forty in a minute, temperature 104°, pulse 160 and more,
respiration over the upper lobe of left lung diminished,
in some places harsh, approaching the bronchial, some
little bronchophony, and corresponding dullness on per-
cussion. At the same time, we were told that there was
slight oedema of the feet. From these symptoms pneu-
monia in the left upper lobe was diagnosed. One pe-
culiarity, however, required further study, viz., that al-
though the number of respirations and of pulsations were
both increased, the proportion between the two was nor-
mal; whereas, with pneumonia, there should be an ex-
cessive number of respirations. We looked farther for an
explanation of the undue frequency of the pulse. It
was found, as we thought, in the previous history of the
child. When nine months old, she had whooping-cough,
which lasted a long time, was complicated with fever, and
succeeded by frequent and protracted attacks of cough-
ing. Thus we explained the frequency of the pulse by
the presence of a chronic pulmonary infiltration, in con-
sequence of which the heart had to overcome the obstacles
in the pulmonary circulation by accelerated contractions.
Besides, the long-continued venous obstruction, and the
general hydraemia of the patient appeared to explain the
oedematous swelling of the feet. The treatment was to
consist of a daily dose, or two, according to circumstances,
of five grains of quinia, with a sufficient number of doses

233

DH. JACOBI'S WORKS

of digitalis to reduce the pulse; for we feared that the
heart might be exhausted by its over-exertion. There was
still another reason for this medication. In the hasty ex-
amination we were jDcrmitted to make, the child being
very sick and the amphitheatre cold, I noticed that the
mitral systolic sound was rather prolonged and muffled.
Still, no diagnosis was based upon that fact at the time,
although that of endocarditis suggested itself. I ordered
the digitalis to enable us to make a diagnosis of the
cardiac disorder, if .any there were; for a murmur will
frequently be heard when the heart's action is rendered
slower. The blood-wave being smaller, when the heart
moves fast, irregularities of the valves may not be de-
tected, while as soon as a larger amount of blood passes
over the diseased surface, the morbid sounds become dis-
tinct. On the next day, the general condition of the
child was much improved; temperature 101-102^, dyspnoea
not so marked, but a distinct murmur was heard over the
mitral valve, taking the place of the first sound. En-
docarditis, with incompetency of the mitral valve, sus-
pected on the previous day, was then diagnosticated in ad-
dition to the pneumonia. Greater attention was then paid
to the CEdema of the feet. We learned, as part of the
child's history, that not only had the oedema existed be-
fore the dyspnoea set in, but also that the patient had
been unable to walk for a number of days, and passive
motion had been painful, both in the ankle and knee-
joints. This important fact finally completed our diag-
nosis. We had to ;leal with acute articular rheumatism, rheu-
matic endocarditis and pneumonia occurring contempora-
neously or in quick succession. To-day the child appears
much more comfortable than last week. Temperature aver-
ages 101-102, reached 104 but once all the week. The symp-
toms of acute pneumonia have nearly disappeared, and no
new attack has taken place, d^'spnoea is moderate, but
the bellows murmur is very loud, both anteriorly and
posteriorly, both right and left. As there is no unusual
amount of venous obstruction, the external veins not being
much dilated, and no general oedema exists, we have rea-
son to believe that this loud murmur results from friction

234

ACUTE RHEUMATISM IN INFANCY

of bloody not only over the mitral valve, but over the
roughened surface of the entire endocardium, also in-
volved in the morbid process.

Look at this other patient. She is a girl of ten years,
well built and robust. She denies ever having had pul-
monary disease, but reports that for six weeks past she
has suffered from severe pains in her limbs, particularly
in the knee and ankle joints; has been confined to her bed
for a fortnight, and now cannot walk without pain;
has had a slight, short cough for weeks, which has been
harder and more protracted during the last week; finally,
during the last five or six days, has raised blood: yes-
terday as much as a cupful. Altogether, she feels very
ill. Upon examination, we find considerable dullness over
the upper lobe of the right lung, both anteriorly and
posteriorly, with some bronchial respiration above, greatly
diminished vesicular murmur, and some fine rales ; large,
moist rales are disseminated over the left lung. Finally,
and most noticeably, we discover at the heart rough-
ness of the first sound at the pulmonary orifice, and
prolonged to the left, in the course of the pulmonary
artery. The diagnosis is clear; acute articular rheu-
matism, endocarditis at the orifice of the pulmonary ar-
tery, solidification of the right lung, and pulmonary hem-
orrhage. Now an affection of the pulmonary artery is'
extremely rare in rheumatic endocarditis, particularly when
no other locality of the heart is affected. We ought,
therefore, to inquire whether, in our case, this stenosis
be not perhaps congenital. The age of the patient ren-
ders this question more pertinent than would be the case
were she more advanced in years. For in congenital dis-
ease of the heart, it is precisely the pulmonary artery
which is most often affected, and the lesion may persist
later in life, — causing symptoms of heart disease with
or without cyanosis. In order to decide the question,
whether the existing lesion be congenital or acquired, I
offer the following considerations:

In congenital stenosis of the pulmonary artery, either
the foramen ovale or the ventricular septum must be found
patent. In neither case is considerable hypertrophy of

235

DR. JACOBFS WORKS

the heart a necessary consequence. If, however; a con-
siderable hypertrophy of the right heart is found, with
the usual change of the position of the heart in such cases,
you may conclude that the anomaly is acquired, and thus
it is here. The heart, as measured by percussion, is
twice its normal size, and this hypertrophy is confined
to the right ventricle; — the percussion sound is dull to
about a half inch beyond the right margin of the ster-
num, but not beyond the line of the nipple towards the
left; and from the pencil-marks made while I am per-
cussing, you will perceive that the heart is in an oblique
position. Our case then is one of the exceedingly rare
ones of endocarditis, wholly or mostly confined to the
right side, and to the pulmonary orifice exclusively.

But its interesting features are not yet exhausted. Is
pulmonary hemorrhage such as our patient describes a
frequent occurrence in a recent case of pneumonia? Is
it frequent in childhood? Neither the one nor the other.
What then does it mean here? It means that some of
the deposits in the pulmonary orifice have been torn off,
once or repeatedly, that the mass was carried into the
lungs, and that both the pneumonia and the hemorrhage are
the results of an embolic process and infarctus. Thus,
the second exceptional circumstance is in close dependence
upon the first, and both render the case one of rare
interest.

Third case: This little girl is four years old. She
has been well until four weeks ago. At that time she
refused to walk or stand. The ankle-joints were swollen
and painful to the touch, and the knee-joints and wrists
were in the same condition. The history is not very
clear, as we have no other report but that of the mother,
and that only contains the fact that the ankle-joints were
first affected, the wrists next in order. Both are still
swelled and painful. A rather loud bellows murmur re-
places the first sound of the heart over the mitral region.
These details suffice already for the diagnosis. Rheumatic
Polyarthritis ^ and Endocarditis. The patient has a short
hacking cough, and is said to suff"er from frequent at-
1 noXui numerous, apOpov joint.
236

ACUTE RHEUMATISM IN INFANCY

tacks of nose-bleeding. In the lungs no abnormal re-
spiratory sound Is heard except some mucous rales. You
know that slight pulmonary oedema and bronchial catarrh
accompanied by this peculiar short cough, are frequent,
indeed, almost inevitable consequences of mitral incom-
petency. To the same lesion is due the epistaxis, which
never occurred before this sickness. It is the result of
the retardation of venous circulation in the copious and
loose connective tissues of the nares, than which there is
none more richly supplied with blood-vessels. In this
connection, take it for granted, as a general experience,
that large numbers of cases of epistaxis in infancy and
childhood are the results of mitral insufficiency, mostly
attended by general hydraemia.

What are the elements common to all these cases? In
all exist synovitis of a number of joints, and endocardi-
tis, while other symptoms or complications vary. The
membranous connective tissue is inflamed and secreting
over many and large surfaces. The peculiarity common
to both the synovial and the serous membranes is the
large number of blood-vessels, and the absence of glands.
Their difference consists in the absence, on the interior
of the synovial membrane, of the dense layer of epithelium
which covers both the serous and mucous membranes.
Therefore, the capillaries of the interior of the synovial
membrane flow not below, but between the cells, a large
number of which are mixed with the connective tissue.
The intima secretes synovia, not from glands, not from
transformed epithelium, not from blood-serum, but from
the nutritive lymph pervading the connective tissue cells
and interstitial spaces. Its secretion is easily induced;
motion of the joint is sufficient to increase it. Local ir-
ritation is a ready cause for hyperaemia, hyperplasia, loss
of superficial cells, and increased liquid secretion similar
to that on the serous membrane. Such local irritation
may be simply confined to one joint, as in traumatism,
or multiple, and extending over a number of joints at
the same time. In the first case we speak of a mon-
arthritis,^ in the last polyarthritis. Polyarthritis — in-
2 /zovo? single

237

DR. JACOBFS WORKS

flammation of many joints — cannot result from an in-
jury, it must be attributed to some general and diseased
condition, which, from its very generality, must be sought
either in the vascular or nervous systems.

In regard to the first, it is remarkable how various
are the specific blood diseases that may be accompanied
by multiple joint-disease. Scarlatina, variola, pyaemia,
and puerperal fever are the best known. In the first,
an erythematous inflammation seems to be determined by
an elimination of the poison upon the surface of the
synovial, analogous to that taking place upon the skin
and digestive mucous membrane. In variola, where en-
docarditis has been recently described, articular swell-
ings are either due to hemorrhage (analogous to those
in haemophilia), or to an effusion of pus, and these are
identical with the arthritis of traumatic or puerperal
pyaemia. Arthritis is well known to be one of the most
dangerous symptoms of pyaemia, and in the purulent
effusion which it determines, is in striking contrast with
the serous or serofibrinous effusion of a rheumatic poly-
arthritis. This effusion, which sometimes precedes pain,
need not be inflammatory in the beginning; that is,
there need not be in the beginning the characteristic
process in the cell elements. Thus far it may be com-
pared with the rapid effusion of pus in generalized purulent
peritonitis, where the blood is overcharged with white
blood-corpuscles, and the process is accompanied with paral-
ysis of blood-vessels. It appears, therefore, that the
presence of foreign matter in the blood constitutes a
powerful predisposition to polyarthritis. This fact, de-
rived from observation of diseases other than rehumatism,
has been taken as a strong support to the theory that
in rheumatism some foreign material does circulate in
the blood, be that lithic acid, lactic acid, or something else.

Still, the matter is not so easily settled. There is a
great difference between pyaemia, scarlatina, and rheu-
matism, in their nature, and in their results on secret-
ing surfaces. In pyaemia we know pus to be present,
and pus is passed through the blood-vessels. In scar-
latina we presume, almost know, that there is a foreign

238

ACUTE RHEUMATISM IN INFANCY

body in the bloody although Recklinghausen's bacteria
theory is neither proven by him nor confirmed by others.
This foreign material is not visible as yet; at all events
it cannot be compared to that in pyaemia in size or char-
acter. What do we see as the result of this material
irritation in its synovial and serous eliminations? The
rheumatic effusions of scarlatina are not always puru-
lent; on the contrary, they are mostly serous; somewhat
thicker and darker in many instances, it is true, but
purulent in but few instances. Still, pus is found some-
times in the synovitis and periostitis of scarlatina. But
where is pus not found? Is it not the legitimate result
of any obstruction of the circulation, as soon as leucocytes
have a chance to escape? and are they not found in al-
most all and any effusions ? Besides them, and pretty
normal effusion of the surfaces, nothing is known as yet
to exist in scarlatinous eliminations. Where then is its
peculiar foreign material? If we assume it to be present
in the effusion, let us not forget that such assumption
cannot yet rank as a fact in the building up of a
theory.

And now, of what nature is the effusion in rheumatism?
Purulent? By no means. Additional leucocytes may be
found in the serum of any effusion, as stated before; but
the consistent character of the synovial and serous effu-
sion in rheumatism is markedly watery and deprived of
solid admixtures. It compares somewhat with copious
effusions from large surfaces of mucous membranes. The
mucous membrane of the intestinal tract will secrete a
similar liquid by the gallon ; that of the vagina even by
the ounce or pound.

Thus, while the act of pouring out depends on the
condition of the surface, which acts as a sieve, the nature
of the morbid process underlying it cannot be explained
by its result, particularly as long as the constituents of
the discharge, though changed in proportion, are given
off by the normal organism. The fact of purulent dis-
charges taking place in pyaemia never solved the prob-
lem of its nature, and what we know of the nature of
scarjatinpu§ effusion never taught us the essence and origin

239

DR. JACOBI'S WORKS

of scarlatina; and it is equally certain that the nature
of rheumatic effusions never exhibited its causes. And as
to changes in the blood in rheumatism.'' Neither the
lactic acid nor the lithic acid has ever been shown to
exist; not even in the liquids effused by the effect of
vesicatories have they ever been found.

It is much more rational to assume that some changes
in the blood-vessels must coexist with the multiple fluxions
which constitute the fundamental phenomena of the dis-
ease. I have already alluded to that form of arthritis
■ — if it can be claimed as an arthritis — which occurs in
haemophilia, a disease in which the coats of the blood-
vessels are congenitally altered or imperfect. It has been
suggested that an alteration in the lining membrane of
the vascular system was itself the original cause of the
changes which almost certainly take place in the course
of the disease. Thus, in rheumatism also, the cause of
the various effusions would lie, no matter what its origi-
nal source will be found to be, on the whole surface
of the intima of the blood-vessels, from the endocardium to
the smallest artery or vein, even the vasa vasorum. Endo-
carditis, then, would not be the complication of rheumatism,
but its highest and most developed expression. I shall re-
turn to that question, and then you will see why it is that
principally' the left side of the heart, and principally the
left vertricle, and principally again the atrio-ventricular
orifice and mitral valve are affected.

The influence of the nervous system upon the con-
dition of joint effusions is seen both in acute and chronic
diseases. Hysterical arthralgia, however, described by
Brodie, Stromeyer, Esmarch and others, does not fairly
belong here. But recently Charcot discovered profound
organic lesions of the articulations as a consequence of
various diseases of the spinal cord. Besides, fatigue and
exhaustion, prolonged lactation and an irritable nervous
system, are just as many sources of predisposition to
rheumatism. And the fact that warm bathing, tonics
and nervines exert frequently a wholesome influence in
rheumatism, appears to point in the same direction.

There is no proof, however, for the assumption that

240

ACUTE RHEUMATISM IN INFANCY "

rheumatism is nothing but a neurosis. Dr. F. Lente
(The Neurotic Origin of Disease^ New York, 1875) says
of J. K. Mitchell's tendency in that regard : " All of his
cases are such of organic disease of the spine, or injury
to the medulla, except one " (p. 9)- This one case,
however, claims only that it got well after bleeding, cup-
ping over the spine repeated twice, and the administra-
tion of salts and magnesia; nor does Dr. Lente's own case
appear more conclusive, for the lady of eighty-three whose
case he reports (p. 14), appears to have suffered from
general thrombosis. She had senile gangrene, inflamma-
tion of both wrists, and cerebral symptoms.

If, then, the general nervous system be not called upon
for a direct explanation of facts, what would you ex-
pect to take place when a sudden change of temperature
affects the surface of the body? The irritated cutaneous
nerves exert their reflex action upon the vaso-motor nerves,
the superficial blood-vessels become contracted, their con-
tents are suddenly driven below the surface into the
vascular system of the large viscera, or of the serous
and mucous membranes. Voluntary muscles and lungs
are in constant expansion and contraction, and are, there-
fore, not very apt to be inundated. But the surfaces of
mucous and serous membranes, offering less resistance,
are the receptacles into which the blood chased from the
surface of the skin is suddenly crowded together. The
lymph contents are disturbed, epithelial cells softened and
darkened, and secretion of lymph and serum, and, in
some cases, migration of white blood-corpuscles may take
place. It depends on circumstances, previous disease,
or vulnerability, whether the result will be a " catarrh "
of a mucous membrane or a " rheumatic " secretion of
synovial membranes, just as it depends on individual
disposition whether the mucous membrane of pharynx or
intestine, or bronchi, suffer most after wetting of the feet,
or similar occurrences.

This is not the only mode by which sudden contrac-
tion of the blood-vessels proves dangerous. The sur-
face of the body, fourteen square feet in the adult, less
aibsolutely, but more in proportion to height and weight,

241

DR. JACOBI'S WORKS

in the child, is the principal road through which the
system gets rid of its heat. The cooling process is de-
pendent upon a normal and sufficient cutaneous circula-
tion. Sudden contraction of the blood-vessels means ac-
cumulation of heat in the body; that is, " fever," with its
consequences on the structure of tissue. As early as 1852,
Virchow described, as the result of fever, parenchymatous
inflammation with increase of nuclei, and indistinctness of
cell contents. In 1864, Zenker described in the muscles
of persons suffering from typhoid fever, a waxy degen-
eration, beginning in the connective tissue of the muscles,
of simply degenerative, non-inflammatory character. His
observations are correct, his explanation of the process
is insufficient. For the term " degenerative " process
does not necessarily involve a result from, or complication
with, inflammation. Thus, traumatisms and trichinosis
determine waxy degeneration and cell proliferation at the
same time. In accordance with this, Waldeyer looked upon
fever as a constant cause of both passive changes and cell
proliferation, and Popoff" has but lately (1874) described,
as the results of increased temperatures, all the above
changes. They are principally found in the diaphragm,
recti abdominis, and arteries, in all feverish diseases,
such as scarlatina, variola, measles, typhoid fever — and
principally in those which exhibit the highest tempera-
tures, such as scarlatina. They are probably a principal
cause of chronic endocarditis, and may be also of chronic
inflammation of almost any organ. At all events, we have
good reason to believe that organs like the synovial and
serous intimae, immensely stocked with cells, and swim-
ming in blood and lymph, are very apt to be aff"ected by
heat alone so produced, or rather accumulated, by the
sudden contracting of the surface circulation.

A third cause of polyarthritis may not be general, but
is frequent, viz., previously contracted endocarditis, with
soft fibrinous masses deposited on any part of the endo-
cardium. These, detached and swimming along in the
circulation, may form emboli. In the muscles, they may
remain undiscovered; in the brain, they may produce paral-
ysis or chorea; in the joints, attacks of arthritis; in

843

ACUTE RHEUMATISM IN INFANCY

the lungs, infarctus and hemorrhage; and in the skin,
ecchymoses in the shape of either purpura, or peliosis.

Thus you have a clue to many of the points of inter-
est in acute rheumatism, both of adults and children.
Children ! Is rheumatism a frequent affection in child-
hood? Most books say No, the age of five or seven
years is considered by many the earliest period of its
occurrence, and a large number of them admit these only
as rare exceptions in infancy. Two cases at a very early
age, nine weeks and seven months, both by Staeger, have
been reported in the journals. As a rule, however, you
will find that the frequent occurrence of rheumatism in
infancy and childhood is resolutely denied, although every
practitioner will have plenty of opportunity to come
across non-congenital heart diseases at an early age. You
have to-day seen three cases of the disease, two of which
came here with a diff'erent diagnosis, and several have
recently passed under your notice, while numerous old cases
of endocarditis have presented themselves in the course
of a short time. Thus, you are prepared to disbelieve
the axiom that rheumatism is rare in infancy and child-
hood, and, on the contrary, suspect its rather frequent
occurrence.^

While, however, it is frequent, it is rather diff'erent in
many respects from the symptomatology of the same af-
fection in the adult. I shall not occupy our time with a
recapitulation of what you know from your lectures and
otlier clinics. For this clinic has been established for the
purpose of exhibiting the diff'erences in the symptomatology,
eitology, pathology, and therapeutics of the diseases of

3 In this connection I may, however, add that uncomplicated,
muscular rheumatism is rare in young children. In most cases,
where it appears to be present, the muscular pain can be easily
explained. In torticollis, there is often an aflfection of the spinal
column, or a hemorrhage in the sterno-cleido mastoid muscle.
Roger compares the torticollis of infants with the lumbago of
adults, which is often traumatic, or the result of rupture of
muscular fibres. Gubler found articular rheumatism, endocarditis,
and chorea some time after muscular rheumatism. "Growing
pains " are probably of rheumatic origin, in not a few instances.

243

DR. JACOBI'S WORKS

infancy and childhood from the same class of disorders
at an advanced age, and so of forming a sort of com-
parative pathology and therapeutics. There are several
peculiarities, which I shall enumerate briefly: In the
rheumatism of children, the swelling of the joints is often
but trifling, and sometimes disappears after a short time.
The pain corresponds with the rapidity and quantity of
effusion, and is, therefore, not always excessive; it is
even trifling, and easily overlooked in rachitical indi-
viduals in whom flabbiness of synovial membranes and
ligamentous apparatus are two permanent characteristics.
Redness is but slight, or does not exist. Temperature is
but rarely very high, as long as polyarthritis is the only
symptom, and sometimes even low, after the first attack
of an acute endocarditis has set in. Increase of tem-
perature may often appear suddenly, and can sometimes
be traced to an embolic process.* Unless there is endo-
carditis, respiration is in proportion to the fever; per-
spiration is not copious, urine not scanty, not often loaded
with uric acid. On the contrary, it is frequently copious
(particularly in early complication with mitral incompetency
and venous obstruction), and pale. The course of the
disease is perhaps still less regular than in the adult. It
may last a few days, or many weeks or months. It may
depend on hereditary pecularities in the structure of the
synovial intima or it may be induced by neglect of skin,
diet, etc. The relation of the sexes to each other as met
with in adult rheumatism does not hold good in the infant
or child. Exposure being a frequent cause, men will
suffer more frequently than women. Of children, how-
ever, I have, I believe, met with more female than male
patients. Our patients to-day are all of that sex, and the
larger number of our heart diseases are also in girls.

4 The child presented at the head of the list, had, on the 14th,
p. M., a sudden increase of temperature to 104f. At my visit
the 15th, we found the systolic murmurs less, the first sound
setting in in a normal manner, but terminating in a murmur.
Evidently a segment was torn oflF, and deposited somewhere as
an embolus, as yet we do not know where.

244

ACUTE RHEUMATISM IN INFANCY

Visceral so-called " complications " are as frequent in
young as in the old, indeed much more so. Pneumonia
and Bright's disease are rare; the tendency is rather in
the direction of the mucous and serous membranes. Pharyn-
gitis, laryngitis, bronchitis, peritonitis, are met with, peri-
carditis and pleuritis are not at all rare. But you will
find, that as well in these " complications " as in the origi-
nal synovitis the secretion is more serous than fibrinous.
Therefore, friction sound is exceedingly rare in both rheu-
matic pleuritis and pericarditis of infancy and childhood.

After this rapid review, let us look into some special
facts. I said the urine is not so red, not so scanty, as in
adults. This corresponds somewhat with the physiological
conditions of the renal secretion in the young. In a
child of three years the proportion of the weight of the
kidneys to that of the whole body is 1: 146; in the adult,
1 : 230. Lecanu found the whole amount of urine, in
a child of three or four years, in twenty-four hours,
225-325 grammes (gr. = 16 grains). Scherer, in one of
three and a half, 755; Rummel, in a boy of three, 885-
904; in a girl of five, 698-722.

A kilogramme (two pounds) of the adult's body dis-
charges 29-5 grammes of urine, 0.420 urea, 1.101 solids,
28.4 water; of the child's body, 47.4 grammes of urine,
0.810 urea, 1.515 solids, 45.9 water, in twenty-
four hours. Salts are also increased in the child;
mucus, extractive materials and uric acid are less
by about one-half. The younger the child, the larger the
proportion of urine and water, the smaller that of uric
acid. According to Uhle the secretion of urine, urea and
chloride of sodium, is treble that of the adult, uric acid
being less in proportion. The urine of the newly born
has a specific gravity of but 1,005 or 1,007. The amount
of uric acid is in an inverse ratio to that of urea. Fever
increases urea, according to Bartels, but not uric acid,
as long as respiration is unimpeded. Therefore, copious
deposits in the straight lobules of the newly-born, so com-
monly met with up to an age of three weeks, are the re-
sult of insufficient supply of oxygen, and diminish rapidly

245

DR. JACOBI'S WORKS

where respiration is speedily and thoroughly established.
They are found more in babies who have died of, or
with asphyxia (Gerhardt, Dis. of Children, p. 4). The
urine is particularly pale and light where mitral insuffi-
ciency is an early symptom of rheumatism, or where
hydraemia is an early complication. This is to be feared
because, as I have stated before, salts and nitrogen are
rapidly eliminated through the kidneys, and besides, even
in normal conditions, the amount of carbon eliminated
through lungs and skin is almost twice as large in the
child as in the adult (Scharling). Moreover, the fever,
which would increase the amount of eliminated solids, is
generally not excessive, and if high, seldom of long dura-
tion. The lesions required for effusion, and correspond-
ing diminution of temperature, are generally not so thor-
ough in the child as in the adult.

One more remark on the inflammation of joints in the
child. Both traumatic and idiopathic inflammations are
frequent. In infancy and early childhood there is less
exposure, and therefore one great cause of rheumatism is
eliminated. At that period of life the mucous membranes
are more apt to suff'er. The smaller joints are not so
easily or so frequently afl^'ected as the larger ones; thus,
those of the maxilla, sternum and vertebrae are seldom
the seat of inflammations. At any age the joints of the
lower extremities are more liable to disease than any other,
because their synovial membranes are larger, and because
morbid materials circulating in the blood are more easily
deposited in the extensive network of blood-vessels cover-
ing the intima. Thus it is that the pyaemia of the newly-
born is so very apt to cause suppurative arthritis of the
knee-joint. Finally, the rapid growth of the synovial
membranes, and of osseous tissue at the epiphyseal line
of the bones, inside the joint, constitutes an important pre-
disposition to pathological changes.

The cardiac manifestations of acute rheumatism ex-
hibit in children a number of peculiarities. Their anatomi-
cal condition must necessarily be similar to that in adults.
In both adults and children the mitral valve is most
commonly afi"ected; pericarditis comes next in frequency,

246

ACUTE RHEUMATISM IN INFANCY

lesions of the aorta next, and myocarditis last. That
endocarditis of the right heart is very rare indeed, I have
stated before. In all ages the origin of the valvular
affection is the same. The valves are simply duplicatures
of the endocardium covered with one or two layers of
pavement epithelium, and joined to each other by elastic
and connective tissue. The incipient stage of valvular
inflammation consists in the production of a nucleated
blastema with elongation and new formation of blood-
vessels and hyperplasia of the connective tissue. Later,
the epithelium exfoliates, and fibrine is deposited on the
abraded surface. The valve may thus harden and re-
tract, or else in certain cases soften, yield to blood pres-
sure, and permit the formation of aneurysms, or even
perforation. Similar changes may occur over the whole,
or part, of the endocardium.

What is the relative frequency of heart disease in rheu-
matism in infancy and children? Most authors agree
upon one fact, viz.: that in early age the large majority
of cases, rare though they be reputed to be, exhibit local-
izations in the heart. For instance, Picot finds these in
37 cases out of 47, Claisse in 14 out of 18. As far as
my own experience goes, I can say that I look upon
the absence of heart complication in rheumatism, at that
age, as very exceptional. Further, I know cases in which
endocarditis was for some time the only manifestation of
the disease, this preceding all articular aff'ections, and
many writers on diseases of children have made the same
observation. At the present time I am in attendance
on an intelligent and delicate little boy of four years,
who, with the exception of slight pain in the knee-joint
through one or two days, which, but for the unusual care
and attention of the family, might easily have been over-
looked, has had no symptoms of rheumatism, except well-
marked endocarditis, resulting in mitral incompetency.
The large number of cases in which the final results of
endocarditis — venous stagnation, bronchial catarrh, epi-
staxis, chorea, dropsy — are the first subjects of complaint,
bear out this observation to its full extent. In many of
these the history of the first rheumatic affection will

247

DR. JACOBI'S WORKS

be remembered, in others it has never been noticed, or
has been forgotten. This may happen so much the more
frequently, as endocarditis itself may set in without much
fever, or other symptoms; a fact which ought to be care-
fully kept in mind, and induce us to examine day after
day, even the slightest case of joint affection, for its
heart complication. Murmurs, in the beginning, when in-
dicating serious lesions, will be accompanied with more
or less rise of temperature. But when they are the re-
sult of mere congestion of the surface, and functional in-
competency of the valves, no variation of the thermometer
may be observed. Such a condition exists as well on the
endocardium as on the intima of the synovial membranes.
Or a murmur may be a temporary symptom of irregular
contraction of the heart, the consequence of a true mus-
cular rheumatism of its walls. For this, although rare,
may coincide with acute articular rheumatism. In both
of these instances the murmur is likely to disappear, after
some time, in the same manner as it will cease with the
cessation of functional anaemia in advanced age, or even
after certain slight inflammation occurring in febrile dis-
eases, as variola. In children, however, anaemic murmurs
are very rare indeed. Yet the diagnosis of endocarditis
is by no means beyond the reach of a doubt, for, although
a genuine inflammatory murmur may disappear, the ma-
jority of temporary murmurs are of a non-inflammatory
character.

As the frequency of endocarditis in the rheumatism of
infants and children is indubitable, is there an explanation
of the fact? I look for it first, in the anatomical and
physiological peculiarities of the young heart. In the new-
born child the heart weighs from eight to thirteen drachms,
while that of the adult weighs eight ounces. Thus the
adult heart has but six times the weight of that of the
newborn. But the weight of the whole adult body is
twenty-five times that of the newborn. Thus, the
newly-born heart is four times as heavy, in proportion,
as that of the adult. With this relative increase in mus-
cular substance, increased activity of its function goes
hand in hand. Again, the manner of circulation of the

248

ACUTE RHEUMATISM IN INFANCY

blood-current must be emphasized. The circulation of blood,
even in the large arteries, does not depend solely upon
the action of the heart-muscle and the elasticity of the
artery walls, but also upon the activity of the voluntary
muscles. When these contract, the small blood-vessels are
emptied; when they rfelax, these are filled by aspiration.
This important factor contributing to rapid circulation
is not so active in the infant, where the muscular system
is but inadequately developed. Thus, the heart-muscle
has to perform part of the labor which in advanced years
is borne by the voluntary muscles. Nor is this all. From
its ventricular orifice to the insertion of the ductus arteri-
osis Botalli the aorta is narrow in early age; the young
heart has to overcome this narrowness, in fact, has to dilate
the aorta to its later norm. With its labor corresponds
its size, as the size of a voluntary muscle with its exer-
tion. Thus, the heart of a baby of fifteen months is about
as large as that of a child of five years. But not only
will its size grow with its labor, but also its danger.
Any organ with a rapid physiological action — ^be this
action nutritive, that of growth, or dynamic exertion —
is liable to become the seat of pathological changes. A
fine illustration of this point is yielded by the statistics
of heart diseases in the foetal and post-natal periods.
Before birth, the function of the heart is principally per-
formed by its right half, after birth by the left. In con-
sequence, the diseases of the foetal heart are met with on
the right side in ninety or ninety-five per cent, of all the
cases, while the large majority of heart diseases after
birth, in any period of life, are found on the left side.

While I laid these facts before you merely for the sake
of proving that the danger of an organ grows with its
work, and that the frequency of heart complications in gen-
eral rheumatism of the young is the result of its physio-
logical dignity and labor, they prove something besides.
You have heard that the large number of heart diseases
in the newly-born and very young infant are confined to
the right side; they are congenital. The large majority
of heart diseases in the child of five years and upwards
are found in the left side; they are acquired. What

249

DR. JACOBFS WORKS

does that mean? It means the statistical fact that the con-
genital heart disease seldom lasts into childhood ; it de-
stroys life. It means, further, that almost all the numer-
ous heart diseases of childhood up to puberty do not date
from birth, but are the result of the most common cause
of cardiac disease — rheumatism. And with this consid-
eration in view, I know you will never forget that the
doctrine of the rare occurrence of rheumatism in the young
is an illusion, and be prepared to look for and meet with
this grave disorder in many instances.

The long list of manifestations of rheumatism in child-
hood is not yet closed, however. The anatomical equality
of serous membranes, and the nature of the meninges
of the cerebro-spinal cavities, render the effusion into
these parts an a priori probability. But theoretical con-
clusions are not required where facts are frequent. For
no complex of organs is so liable to rheumatic disorders
as those constituting the nervous system. Not even peri-
pheric nerves appear to be exempt, since Rigal observed
the occurrence of a severe neuralgia of both face and
abdomen, in a boy of fourteen, before the joints became
the seat of tlie manifestation of the disease.

The attention of authors has been principally directed
to the brain and its meninges. Symptoms of both irri-
tation and depression have been noted. Hyperaesthesia,
contraction of the pupils, hallucinations, oppression, melan-
cholia and physical diseases in general, and coma, have
been met with in many instances. Where and as long
as the symptoms of irritation prevailed, the prognosis was
generally favorable, symptoms of depression, such as coma,
were invariably considered fatal. For it is a peculiarity
of rheumatism, that its cerebral manifestations are more
steady, less changeable, than are the symptoms of a com-
mon non-rheumatic meningitis or encephalitis. In post-
mortem examinations a number of anatomical lesions were
found in both brain and meninges. Anaemia, hyperaemia,
meningitis, with oedema into the arachnoid, with effusion
into the space between dura mater and pia, fibrinous de-
posits, thickening and adhesions of the pia, dilatations of
the sinuses, fatty degeneration of blood-vessels, encephali-

250

ACUTE RHEUMATISM IN INFANCY

tis in its different stages, softening of the gray substance
of the large ganglia, emboli, and apoplectic deposits have
been found. Over this array of conditions I pass so
cursorily because I mean to add, at once, an important
statement, viz., that they are principally based upon ob-
servations made on the adult. As a general rule, the symp-
toms resulting from affections of the nervous centers differ
greatly in the young and old. Where you have delirium
in the adult, you have convulsions in the child. The
symptoms enumerated before belong principally to the
sensitive sphere; the same effusions in the child affect the
motory powers principally. Besides, there is a peculiarity
in the rheumatism of the young already alluded to, which
I think is mostly explained by the rapidity with which
effusions take place in that period of life, viz., that fever
is generally less in the rheumatism of the young, and con-
sequently its anatomical results, of which I have spoken
before, and which are very marked in the nervous sys-
tem, are less pronounced. A further difference is this,
that a fatal termination is less frequent in the young
than in the adult. Thus, very few post-mortem examina-
tions are on record. Such as are mentioned, however, and
the nature of the disease, and its essential equality with
the same affection in the adult, facilitate our conclusion
that the local lesions must be of a similar character,
though not of the same gravity.

I have said that the nervous disorder manifested in
rheumatism is of the motory order. All of you have seen,
in the course of your studies, a number of cases of St.
Vitus' dance, or chorea minor. You remember that the
23rincipal symptom was the inability of the will to control
the voluntary muscles, to adapt and coordinate them to a
certain purpose. The children twist and twitch while
sitting, contort their limbs, stumble in walking, stutter in
speaking, and drop knife and fork, or use them inap-
propriately. This symptom is not developed at once. Now
and then you learn a preliminary history — pain, restless-
ness, nervousness and disturbed sleep. The first appear-
ance of the motor disorder is mostly observed in the right
upper extremity; after a while the lower extremity of the

251

DR. JACOBFS WORKS

same side participates, and the rest of the voluntary mus-
cles follow suit. In a large number of cases the affec-
tion follows this course; it is apt to be unilateral in the
beginning. The sphincters remain unaffected. Not al-
ways, however, is the affection so general; frequently but
a few muscles of the face, or face and neck, are dis-
turbed. During sleep the contortions will stop. In some
severe cases they may, however, continue. In these the
contact with the bed, and involuntary contractions of
the muscles suffice to result in choreic movements. Mus-
cular efforts during dreams will have the same effect. Most
patients are between five and fourteen years old. While,
however, adults, such as pregnant women, are liable oc-
casionally to chorea, the very young are by no means
exempt. E. H. Richter reports a case of chorea in the
newly-born ; at the age of a few months it has been
observed a number of times, and I remember a few cases
at two and three years. The majority of patients belong
to the female sex ; they are mostly anaemic and thin, sel-
dom in previous good health. Complications with nervous
disorders of different kinds are not unusual; some of them
are of a hyperaesthetic, some of a paretic, or paralytic,
character. Both physical and intellectual efforts result in
speedy fatigue. The intellect is sometimes impaired. Neu-
ralgias, especially of the intercostal nerves, with distinct
points of Valleix, are not infrequent. In a few cases
I have noticed herpes zoster. In others there is uni-
lateral paresis or paralysis, either contemporaneous with,
or subsequent to, chorea; in/ others, epilepsy. Grisolle
relates a case of chorea complicated with paraplegia,
which terminated favorably in a few days; Trousseau,
a similar one of chorea, paraplegia and rhachialgia;
Picot, one of rheumatism, chorea, endocarditis and para-
plegia.

Some of the patients have a hereditary tendency to
nervous disorders. In their families runs insanity, epi-
lepsy, hysteria or diabetes. Other etiological facts are,
injuries, mental emotions, irritation, or exposure to sudden
changes of temperature. Some cases are of reflex origin.
Pharyngeal, intestinal and sexual irritations play a prom-

252

ACUTE RHEUMATISM IN INFANCY

inent part in the etiology of chorea. Chronic pharyngeal
catarrh, through its irritation of the trigeminus nerve,
is a frequent cause of local chorea confined to face and
neck. But the presence of worms in the intestinal tract
is not so frequent a cause of disturbance in the young,
with us, as in Europe. The prevailing belief in their
influence is communicated to us from transatlantic coun-
tries, where the food of the working classes is very coarse,
and worms are more frequent. This influence is exag-
gerated, no doubt; but sexual irritation is probably not
estimated at its full importance. Masturbation is too com-
mon a habit amongst little ones to be overlooked; and still
I know that the fact of its frequent existence is not
sufficiently appreciated by my professional brethren. Bad
habits and wickedness on the part of nurses, vesical ca-
tarrh and gravel, narrow prepuce and accumulation of
smegma around the glans penis, vaginal catarrh and
oxyurides in the rectum are just as many determining
causes. But the main cause of chorea is rheumatism.
The connection between the two was known, amongst older
writers, to Stoll and Bouteille, later to Copeland and
Bright, until in 1850 Lee and Botrel, and in 1866-68, in
the Archives Generates, Roger made chorea and rheu-
matism the subject of elaborate and successful treatises.
For a long time it was assumed that chorea depended on
rheumatism through the intermediate link of endocarditis.
Now, it is true that endocarditis is found in chorea; thus,
Olge reports its existence ten times in sixteen fatal cases.
But you have heard that endocarditis is but seldom ab-
sent in acute rheumatism of the young. Thus it appears,
that chorea, endocarditis and polyarthritis are but the co-
ordinate symptoms of one and the same aflfection. If
acute rheumatism was the cause of endocarditis, and en-
docarditis or rheumatism the cause of chorea, we should
always find those symptoms in the same order. The ef-
fusion of the joint would lead, endocarditis would follow,
and chorea finish the series. It is, however, not so. You
have heard that endocardical rheumatism may precede the
inflammation of the joint; and in the same manner chorea
may precede either endocarditis or polyarthritis. In a

253

DR. JACOBFS WORKS

boy of three years^ I have observed general chorea four
or five days before the slightest symptom of rheumatism
was perceptible in the joints. When the joints became
aifected the choreic movements grew less. After a week
the articular swelling receding, chorea became more prom-
inent again. In this manner nerve and joint rheumatism
alternated three times in the course of two months^ until
finally the case wound up with a mild endocarditis, ter-
minating in insufficiency of the mitral valve.

There must be some lesion either in the organ of the
will (Klebs), or the center of coordination (Cyon), or
some other part of the nervous center which causes the
peculiar symptoms of chorea. The readiness with which
the majority of cases get well, either temporarily or per-
manently, appears to prove that in this majority of cases
the anatomical change can certainly not be very great.
But an alteration in the nutrition of the parts we shall
have to assume, leaving out of sight the few reported cases
of cerebral tubercle, hypertrophy of the odontoid process,
cerebral hypertrophy, and softening, which, resulted
amongst others, in choreic symptoms. The alterations
effected by fever alone vary with the height of tempera-
ture. Any long-continued change in the blood-vessels
must result in serious changes of nerve tissue, probably
of an anaemic character. Whatever changes take place,
are probably most perceptible on the left side of brain.
For the left carotid is the more direct route to the brain ;
its size is greater, the nutrition of the left brain more
active; consequently the right side of the body more
thoroughly innervated. In the same manner, and accord-
ing to the principle that pathological action is liable to
be in proportion to the degree of physiological func-
tion, the left brain is the seat of pathological lesions. A
lesion in the left side of the brain is the principal cause
of aphasia (complicated with right hemiplegia). So chorea
begins on the right side, and there also are found some
of its complications, such as paralysis. Of all the lesions,
from simple hyperaemia to inflammatory changes and em-
bolic infarctuses, each can lead to chorea, and such cases
as are observed with long duration and great severity,

254i

ACUTE RHEUMATISM IN INFANCY

fatal termination, or complication with paralysis, belong
to the latter class. As the majority of cases are, how-
ever, temporary and mild, it is to be assumed that slight
nutritive changes in the nerve centers are frequently the
only causes. Restitution of these to their normal con-
dition, would, in a month or two, relieve chorea. Thus
the ready action of arsenic in most cases would be ex-
plained by its effect on nutrition and assimilation in
general.

Hitherto, I have spoken of chorea as principally con-
nected with lesions, or nutritive disorders, within the
cranial cavity. There is one form, however, which is
by no means very rare, and still has not been described,
as far as I know, as fully as it deserves, viz., that class
which depends on hyperasmia or inflammation of the spinal
meninges. Brown-Sequard observed that dogs suffering
from chorea would still remain choreic after the spinal
cord had been separated by a cross-section in its upper part.
Onimus and Legros have rendered dogs choreic by in-
juries to the posterior roots of cervical spinal nerves and
posterior gray column of this part of the cord. They place
the seat of chorea here. In my own experience, spinal
meningitis of the upper part is a frequent cause of chorea.
Fifteen years ago, I reported the case of a girl of nine
years who was presented with a violent form of chorea,
the contortions of which exceeded anything I had ever
seen before. The attack had come on very suddenly; the
child had been perfectly well before. It struck me that
the face was less affected than the rest of the bod}^, and
thus my attention was at once directed to the upper part
of the spinal cord. Pressure on the cervical portion,
especially the spinal processes was exceedingly painful,
and increased the spasmodic actions^ Was the pain simply
neuralgic.'' or was it inflammatory? The thermometer
answered the question very readily: The temperature was
104, and remained in that vicinity for another day. Ice,
ergot, with purgatives, relieved both the meningitis and
chorea M'ithin a week, confirming the theory of the etiology
by the result of the treatment. This case is by no means
a solitary one. I have seen a number which were just

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DR. JACOBI'S WORKS

as marked as this one^ and a great many besides in which
fever and the extent of the inflammation were not so well
marked. One of this kind was presented to you a fort-
night ago; you remember a choreic girl of nine years,
in whom pain, on slight pressure upon the cervical portion
of the vertebral column, was very perceptible. In this
case also the thermometer had to decide the character of
the pain, whether neuralgic or inflammatory, and the
etiology of the disease. The temperature ranged from
101 to 102, on several days, without any other symptoms
to explain this rise of the temperature but the spinal af-
fection. Mark the slightness of the increase, in that case,
and remember that in the large majority of cases of sub-
acute spinal meningitis the thermometer does not rise
so high. For that reason it is important to avoid every
possible source of mistake in your measurement. We have,
therefore, preferred to measure in the rectum, rather than
the axilla.

The difl^'erential diagnosis of acute rheumatism is but
rarely difficult, though many of the symptoms belonging
to the joints are not well pronounced in the young. Still,
mistakes are possible. Inflammation of the tendons, or
the subcutaneous tissue in the neighborhood of a joint, may
mislead the careless practitioner. Foreign bodies in the
joint, contractions of tendons, ought not to deceive a care-
ful observer. " Growing pains " are not infrequently in-
flammatory rheumatism, and many an endocarditis of later
years may be traced back to the " growing pains " which
are but dimly remembered. In many instances, however,
they are but the expression and result of muscular fatigue.
Thus, sensitiveness and pain are the result of a chemical
change taking place in the muscular tissue, in which phos-
phate of potassa and lactic acid are accumulated through
over-exertion. When those products and their elimination
are proportionate, no pain is felt; when the former is in-
creased while the latter is retarded, the result is evident.
Therefore, not only physical over-exertion, but insufficient
circulation also results in the sensation of painful ex-
haustion. The latter acts through its tardiness in reliev-
ing the tissue of its cast-off material, and thus you under-

256

ACUTE RHEUMATISM IN INFANCY

stand why " growing pains " (not rheumatic) are so often
noticed in pale, anaemic children.

An occasional source of error may arise from swelling
of a joint resulting from hemorrhage into its cavity, lesion
characteristic of that singular congenital disease, haemo-
philia. Some of you recollect a boy of five or six years
presented a few days ago in my clinic at the College of
Physicians and Surgeons. His history j'ielded nothing
but this, that after he was six months old, a tendency to
bleeding became apparent. A slight cut would not close,
nose-bleeding was frequent, subcutaneous and cutaneous
hemorrhages took place on the slightest provocation, and
when we saw him there were blue, black, yellow, green
discolorations on several parts of the body, viz., both fore-
arms, glutaeal regions, left scapula, left knee, etc. The
left knee, besides being discolored, was considerably dis-
tended. The swelling had begun, two days previously, quite
suddenly, without any fever, and at the commencement
without pain. There was no fever when presented, but
considerable pain both spontaneous and on pressure, the
result of the sudden lesion of the synovial membranes.
Look out, then, for enlargement and inflammation of the
joint, in cases of purpura, scurvy, and haemophilia. When
you take the accompanying symptoms into due considera-
tion, you ought not to be mistaken, however, in your diag-
nosis.

Not quite so easy, sometimes, will you find, at your first
visit, the diagnosis from some affections of the bones. In
infants and children, the bones, before their final ossifi-
cation, which is not entirely completed before the twentieth
year, are more succulent, softer, and endowed with a more
extensive circulation than in advanced years. Osteomye-
litis, however, can hardly be mistaken for joint disease,
as it is confined to the diaphysis and reaches the epiphysis
only through participation in the morbid process of the
periosteum. In these cases a serious suppuration extend-
ing up to the joint may complicate the diagnosis. But
such affections are, happily, rare, except, perhaps, in syphi-
litic tuberculous, or scorbutic individuals. But the very
neighborhood of the joint, or rather the epiphysis of the

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DR. JACOBI'S WORKS

bones, and the intermediate cartilages between the epiphysis
and diaphysis, are occasionally the seats of perplexing proc-
esses. You know there is always a lively physiological
action going on at the boundary line between the two,
which is restricted by increasing ossification only. This
latter takes place in different bones at different periods
of life. The direction of the nutritive arteries determine
its period. Where they converge, as at the elbow joints,
ossification takes place early; where they diverge, later.
Therefore the knee-joint is exposed to osteochondritis
more than any other, as well for pathological reasons as
for mechanical ones. The intermediate cartilage is very
apt to be destroyed by an inflammatory process. Suppur-
ation may take place, the epiphysis secede from the dia-
physis, and the joint get filled with pus. Thus, many
an acute case of arthritis may puzzle you as to its original
source. In the hip-joint especially, the determination of
an only or principal cause of coxitis, and its original seat,
may be rather difficult. For at birth, the upper epiphysis
of the OS femoris comprehends head, neck, and both tro-
chanters. A few years afterwards, by progressive ossifi-
cation, the neck forms part of the diaphysis, while head
and trochanter major constitute each a separate epiphysis.
Finally, however, the trochanter also undergoes the process
of ossification, and the head alone remains, for many years,
in its epiphyseal condition.

In" conclusion, I have to speak, from a diagnostic point
of view, of disorders of a nervous character which are the
more perplexing to many medical men, the more they have
been accustomed to look upon nervous (hysterical) symp-
toms as the privilege of the adult female. But the male
sex may become hysterical, and the child certainly will
in many instances. Now, I cannot here go into the ques-
tion to what extent hysteria is found in childhood. Re-
member but this, until we shall find an opportunity to re-
turn to the subject, that nervous symptoms of the most
serious types are not excessively rare in children, and
are more than simply indicative of what will occur in fu-
ture. Well-developed neuroses of the motory, sensitive and
vasomotory nerves are by no means exceptional in child-

258

ACUTE RHEUMATISM IN INFANCY

hood. A girl of about eight years was under my treat-
ment for some time, for a neuralgia of the right ulnar
nerve, without fever or spinal complication. After some
time a moderate swelling of the subcutaneous tissue of the
carpus, and in the neighborhood of the shoulder- joint,
was added to her difficulties. They disappeared, to be re-
placed only by a very severe neuralgic pain of the toes
of her right foot. Her sufferings were intense for a long
time; they appeared to be mitigated when an (Edematous
swelling of her right foot made its appearance. A pro-
tracted tonic and galvanic treatment was required to restore
her. Another girl of five years was presented for acute
rheumatism of the right shoulder joint, wliich was said to
have lasted several weeks, and to be very painful. There
was excessive sensitiveness to the slightest touch, and some
swelling. But it struck me that since the commencement
of the attack neither the heart nor another joint were
attacked, that there was no fever, that deep pressure pro-
duced no more pain than superficial, that the pain extended
over the n. thoracicus longus as well as the shoulder and
upper arm ; and finally, that the swelling was not exactly
in the shoulder-joint, but above, nearer to, and to the rear
of the acromial end of the scapula. Thus my diagnosis
was secured. I had to deal with a neuralgia of the cervical
plexus, and not with rheumatism. Just at present I have
under observation a boy of eight years, who has a slight
mitral incompetency, contracted while suffering from chorea
some years ago. Two months ago he was attacked with
rheumatism of both wrists, knees, and ankle-joints. A num-
ber of the joints of the feet took part in the process.
There was moderate fever and distinct swelling of wrists,
knees, and ankles. After some weeks his fever was gone,
and swelling very moderate indeed. Still his complaints
grew no less; he was taken with sudden attacks of exces-
sive pains, gave rise to screams and yells, commencing
about dark, and lasting all night; was very sensitive even
in daytime to the gentlest touch, and exhibited such a dis-
proportion between his objective and subjective symptoms
that my suspicion was directed to other quarters than
before. Then I recollected that in periods of great men-

259

DR. JACOBI'S WORKS

tal anxiety, his father, many years ago, suffered from very
severe and well-pronounced attacks of hysterical convul-
sions, and that his mother, a refined, intellectual and
neurotic woman, while the subject of ooj^horitis, had been
disturbed by neuroses both peripheric (mostly neuralgic)
and cerebral. My little patient had no more fever for
some time; there was hardly any swelling left; he was
quite comfortable at certain times, screamed fearfully —
without tears — on the slightest touch on certain points, and
got frequently quiet under protracted and deep pressure,
particularly when his attention was diverted to other quar-
ters. The pain was, and is, not confined to those points
mostly sensitive in sciatica; in fact there is no pain about
the hip-joints or the sciatic notches. A number of cutaneous
branches of the crurals are affected, as also the ramifica-
tions of the synovial membranes. At the same time, neither
heart nor spinal cord participates in the process. The in-
flammation of the joint has been the cause of irritation
in the sensitive nerves of both synovial membranes and
skin. In accordance with the diagnosis of neurosis (neural-
gic only, no vasomotor complication being present), the
treatment has been changed long ago. Iron and galvanism,
with roborant diet and warm bathing, are the remedies on
which I am at present relying, with a satisfactory, though
slow, result. In all these cases I have, while I related
them to you, pointed out the pathognomonic symptoms of
importance, and, therefore, do not repeat them. Nor can
I, at this occasion, relate cases of the same nature, though
with different symptoms. However, I desire to impress
upon your minds again the variety of forms and seats of a
neurosis of this kind. It may be mixed in character — motor,
sensitive, and vasomotor. Paralysis or paresis, neuralgia,
local eruptions and redness in certain territories of blood-
vessels, local chills, perspiration, oedema, are thus ex-
plained. If not so mixed, neuralgic only for instance, this
neurosis is very puzzling in the selection of its locality.
The styloid process, the internal condyle of the femur are
pet places. But any cutaneous branch, no matter whether
near a joint, or on the general surface, of the sciatic, cru-
ral, obturator, saphenus, tibial nerves may prove the source

260

ACUTE RHEUMATISM IN INFANCY

of annoyance and suffering. In the adult, the " spinal irri-
tation " of the public (formerly of the profession also)
is mostly but a cutaneous or meningeal neuralgia.

The indications for treatment of acute rheumatism vary
according to the character of the affection and the affected
locality. Inflamed joints must be rested, local and general
heat reduced, hyperaemia removed, exudation and internal
pressure diminished, and pain relieved. A few remarks
will probably suffice to point out the means of obtaining
the required results as far as possible.

The inflamed joint, or joints, can be rested on wire, wood
or plaster splints, lined with cotton. In what position?
An experimental injection into the knee-joint of the dead
body determines moderate flexion. (Bonnet.) Thus it ap-
pears that this slight curvature is the easiest position for
the diseased joint; it is that in which the cavity is the
largest. But when the disease appears to last long, an-
other consideration comes up. For some time after recov-
ery the joint will not be available when flexed, although
the result may not at all be an anchylosis. Thus it de-
pends on individual cases whether the joint is to be fastened
in eitlier extension or flexion.

Local and general depletion have been recommended.
Tlie latter diminishes the temperature, but does not prevent
it from speedily rising again. • Besides, it increases hy-
draemia and the amount of fibrine in the blood; both of
these conditions facilitate effusion. Thus, you will hardly
meet with a case in which general depletion will appear
required. Local depletion has no such lasting ill-effect.
But still its indications are limited; for there is but a
limited vascular connection between the skin and joint. Be-
sides, the intima which is hyperaemic is separated from
the surface by the mass of the synovial membrane, which
has but a scanty supply of blood-vessels. Moreover, the
vessels of the surface and the synovial intima belong some-
times to different vascular territories. On the knee-joint
only matters are a little more favorable, and, therefore,
now and then a small number of leeches will prove bene-
ficial, at least temporarily.

A better effect on the dilated blood-vessels is observed

261

DR. JACOBI'S WORKS

by the application of ice. It contracts blood-vessels, re-
duces the temperature, and prevents effusion and suppura-
tion. For all of these purposes it is more reliable than any
other application. Thus we are, as for other beneficent
innovations, under great obligation to Esmarch, who has
introduced ice into the treatment of arthritis. It is indi-
cated in the acute stage, where swelling is considerable,
and temperature high. While, however, it renders the in-
flamed parts anaemic and prevents effusion from taking
place, it also prevents absorption of the effusion. Thus,
after the swelling and temperature have been reduced, the
indication for ice has passed. Then it becomes necessary
to increase vascular pressure and stimulate the lymphatics
by warm applications. Poultices, warm water, cold appli-
cations which remain long enough to become warm, and
warm baths take the place of ice.

Thus the internal pressure is relieved. Now and then,
where this pressure is felt to a disagreeable degree, and
the neighboring muscles are affected with reflex spasms,
distraction of the joint, by extension, is recommended on
the plan which is followed in chronic coxitis. In most
cases, however, this method is inappropriate, because too
painful. A frequent method consists in local derivation.
For that purpose both vesicatories and tincture of iodine
are recommended. The former may either be kept on until
vesication has taken place, or removed when the skin has
become hyperaemic, and their application repeated. The
latter acts favorably by causing dilatation of external blood-
vessels, over a number of joints, and by thus relieving the
internal congestion. Theoretical reasoning, more than ac-
tual proof, relies on the presumed stimulation of the vaso-
motor nerves of the interior by the external irritant. From
these several points of view, the use of stimulating embro-
cations may be considered. In chronic cases they may do
good (friction only will oftentimes) — in acute cases they
will prove injurious.

When, after the reduction of fever, a sufficient time
has elapsed for us to believe that no further absorption of
effusion will take place, or where a fibrinous exudation in
the joint remains stationary, with or without the compli-

262

ACUTE RHEUMATISM IN INFANCY

cation of subcutaneous cedema, gentle compression is re-
quired. Collodium, flannel bandages, cotton with linen
bandages, elastic bandages, plaster of Paris will be found
serviceable. Puncture of the joint cannot be objected to
when the contents are purulent. Extravasations of blood
contraindicate puncture; and serous effusions will require
it in those rare cases only in which the effusion is very
copious, of very old date, and the synovial membranes
greatly expanded and in an abnormal condition. In a few
such cases I have opened the joint with a fine trocar, al-
ways taking care that neither the- cartilage was hurt nor
air admitted. Dieulafay's aspirator has been successfully
used for this purpose.

In this connection I ought to speak also of the galvanic
current as a means of producing absorption. Mild cur-
rents passing through the joints from one to three times
daily, and from five to ten minutes, each time, have a
beneficial effect. When obtained, this may perhaps be
attributed to a tonic influence exerted upon the walls of
the blood-vessels and lymphatics ; in virtue of which the
rate of circulation is increased.

Finally, the indication for directly relieving pain may
require the application of chloroform, belladonna, opium,
or veratria, according to circumstances, in lotions or oint-
ments. Severe pain may necessitate a subcutaneous injec-
tion of morphia. Atrophine has been used in the same
way.

Hitherto, gentlemen, I have spoken of external applica-
tions only. Internal medication is resorted to upon the
same indications which have been set forth. To relieve
vascular pressure, aconite, digitalis, veratrum, colchicum,
or quinia, are administered. Whichever you may select,
do not forget that all of them require larger doses than
the usual proportion-tables in your text-books on materia
medica appear to justify, and further, that whatever ef-
fect is to be obtained, must be secured speedily. The
inflammatory process is a very rapid one, and the pre-
vention of its spreading and resulting in copious effusion
is worth while accomplishing. On veratrum I rely where
the reduction of the pulse is a principal object; aconite and

263

DR. JACOBI'S WORKS

digitalis are slower in their action, but may be continued
for a longer period. The beneficial effect of these different
cardiac sedatives is more perceptible in the quality of the
pulse — which becomes softer— than upon its rapidity. The
general rule is to push the dose until the pulse has fallen
considerably, but not to the norm, then to maintain the
dose for two or three days; then cautiously diminish. At
any rise in the pulse, the dose must be increased, for a
recrudescence of the articular affection is threatened. This
rule holds especially for quinia. Veratrum is, in careless
hands, the most dangerous of the cardiac sedatives, and
cannot be handled so freely. The dose must often be di-
minished more rapidly, lest tlie vascular sedation become
excessive.

The effects of quinia have been studied extensively in
the last seven or eight years, and a vast amount of litera-
ture has been accumulated through the combined efforts
of investigators of all countries. Although their results
have been meagre, they are still positive enough to justify
its intelligent administration. Several facts appear to be
estabished: First, that in spite of Briquet's apparently
conclusive results, quinia has no direct effect upon the
nervous system, either cerebral or peripheric. No effect on
the sympathetic and pneumogastric nerves has been pro-
duced, and the effects upon circulation are not brought
about by any direct action of its own on the vasomotor
nerves or the cerebrum. For when the medulla is cut, quinia
will reduce fever, although the connection between blood-
vessels and brain is destroyed. Secondly, it reduces the
amount of uric acid in the renal secretion, also the number
of white corpuscles in the blood, and, when given in suffi-
cient doses, depresses pulse and arterial pressure, and re-
duces the temperature. In frogs, it reduces reflex irri-
tability also. Besides, it acts as an anti fermentative by in-
terfering with the chemical decomposition of animal ma-
terial. Now the qualities enumerated above render quinia
the principal antiphlogistic. Amongst the prominent symp-
toms of inflammation we count the increase of white blood-
cells, the dilatation of blood-vessels, the slowness of local
circulation, and the accumulation, stoppage, amoeboid

264,

ACUTE RHEUMATISM IN INFANCY

changes^ and finally emigration of white blood-cells. (Se-
rous effusion is a co-ordinate effect of the mechanical ob-
struction.) I can imagine that the increase of white
blood-cells alone suffices to bring about all the other
changes. Remember that in the capillaries circulation is
two-fold: in the centre the rapid motion of the red blood-
cells; along the wall the slow, easily retarded, pushing
along of the leucocytes. The simple fact of their con-
siderable increase obstructs circulation both of themselves
and their comrades more advanced in the scale of animal
perfection. They rest, crowd each other, become unwieldy,
assume different amoeboid shapes and motions, press on the
thin walls of the capillaries, and force their way through
the dilated interstices. The mechanical obstruction in and
dilatation of the smallest vessels acts on those of larger
size behind them, which, although of normal consistency
and function, will also become dilated. Quinia, by reduc-
ing leucocytes permits the capillaries, which have no elas-
ticity of their own, to resume their original size under the
pressure of the outside tissue, and the larger blood-V^essels,
endowed with an elastic adventitia and muscular layer,
to contract over the reduced sizles of their contents.

At all events, no matter whether this attempt at sim-
plifying an apparently intricate subject covers the whole
ground or not — (I believe it does)- — this fact is sure, that
quinia has conquered its place at the head of the anti-
phlogistic remedies. Do not forget, however, that small
doses have no such effect. When indicated at all it ought
to be given in a dose of five grains, once, twice, or three
times daily, to a child of one or two years. What I taught
more than fifteen years ago — that quinia and vascular sed-
atives in general are tolerated and required by the young
in apparently disproportionate doses — is acknowledged as
correct by the theory and practice of a large portion of
the profession at the present time. I will only add, that
you ought to be certain of the solubility of your prepara-
tion. The sulphate ought to be avoided. Select the bi-
sulphate, or better, the muriate, and never forget that the
stomach absorbs less under the influence of a feverish
condition. The question of subcutaneous administration of

265

DR. JACOBI'S WORKS

quinia in rheumatism, has, I believe, not yet been mooted.
But it is as plausible as for intermittent fever. When
the stomach rebels against the remedy, the rectum may
take its place. But it will absorb nothing unless in
solution.

The majority of the remedies which are recommended in
apyretic rheumatism are either absorbents or derivants.
Iodide of potassium (or sodium) acts as a diuretic, and,
furthermore, appears to restrain the transformation of cells
into connective tissue. Thus, it is effectually used, as
soon as the acute stage of rheumatism is stayed, in pleuritis,
pneumonia, glandular affection, and inflammations of the
connective tissue in general. As soon as " organization " of
exudations has taken place — that is, as soon as hyper-
plastic connective tissue has resulted from the nutritive dis-
order, the remedy proves unavailing. You know, for in-
stance, from what I formerly said about the difficulty of
reducing the size of tonsils or lymphatic glands in a chronic
condition of enlargement, that in such cases the knife has
to take the place of internal remedies. Thus, what ef-
fect you hope to obtain from the administration of iodide
of potassium, ought to be looked for soon. No matter
whether the rheumatic manifestation takes place in the
joint, heart, or nervous centre, the iodide ought to be
given early, immediately after the fever has been sub-
dued, in doses of from fifteen grains to a drachm or
more, according to age. Whether colchicum has any effect
besides being an arterial sedative, and acting upon the
mucous membrane of the intestine, is doubtful. The same
may be said of colchicine. In three or four daily doses of
%50 of a grain each, which may be gently increased from
day to day, to a child of four or five years, it is apt to
produce vomiting and diarrhoea, with occasional relief to
the general symptoms. Alkaline salts have been praised
for their effect upon neutralizing supposed acids contained
in the blood. You have heard that this acid condition is
doubtful, and know that the amount of uric acid in the
urine of children, no matter whether rheumatic or not, is
not large. If it is an object, however, to neutralize uric
acid, you will perceive at once, that potassa salts are better

266

ACUTE RHEUMATISM IN INFANCY

suited than those of soda. The former combining more
readily with uric acid than the latter, bitartrate of potassa,
or citrate of potassa, would be preferable to Rochelle
salts or Vichy water. Their principal effect is, probably,
besides the increase of intestinal secretion, to be sought for
in the larger amount of urine, the secretion of which in-
creases with its alkaline condition.

The indications for therapeutical interference in the
manifestations of rheumatism in heart, brain, and spinal
cord, differ hardly from those in the joints. The applica-
tion of ice, the use of digitalis, aconite, quinine, iodide
of potassium, follows the general rules. Endocarditis, and
particularly pericarditis, require the immediate and con-
stant use of ice, which will prove the more beneficial, the
nearer to the surface the affected locality. Hence its
beautiful results in pleuritis and laryngitis. When the
acute stage has passed by, you need not fear the use of
warm bathing of about 90° in heart diseases any more
than in other subacute or chronic inflammations. The
atheromatous degeneration of advanced age may contra in-
dicate them, but no excitement of the heart's action is to
be feared in children, in whom atheromatous degeneration
scarcely ever exists.

I shall conclude with a few remarks on the choreic man-
ifestation of rheumatism. Of the large number of reme-
dies which have been resorted to, I rely principally on
arsenic. I have alluded to that before. Next in order
I consider bromide of potassium; last, nitrate of silver,
or atropia. Rest is secured by chloral-hydrate, or large
doses of bromide of potassium; the muscular irritability
soothed by subcutaneous injections of woorara. Very
efficient in protracted and feverless cases, as also in chronic
cases of rheumatism in general, is a daily bath containing
from three to five ounces of the sulphide of potassium, and
the galvanic current. In several instances a moderate cur-
rent conducted through the whole length of the spine has
moderated severe forms of chorea, after therapeutical
agents have proved unsuccessful. Most of this may have
been known to you. What is not so commonly known, is
my treatment of those cases of acute chorea depending

267

DR. JACOBI'S WORKS

upon meningeal or medullary congestion or inflammation,
of the pathology and diagnosis of which I have spoken be-
fore. Antifebriles, mild purgatives, ice, sometimes tinc-
ture of iodine, and principally ergot, have been relied upon
in my own practice. I conclude with a single remark
upon the dose of the latter. I am positive that its failures
are mostly due to insufficiency of doses. For some ob-
servers in this city have acknowledged that, after experi-
encing many failures with small doses, they know of no
remedy the effects of which are more reliable than ergot
since they have increased the quantity of the drug. Less
than half a drachm of Squibb's Fluid Extract I rarely
give. I repeat this dose three or four times daily. A
child of four or five years may take from two to four
drachms daily, for many weeks in succession. Bad re-
sults I have never seen. With the exception of a few
cases recorded in the journals, the stories of poisoning,
epidemic or otherwise, acute or chronic, concern individuals
or communities whose constitutions were previously broken
down by long-continued misery and starvation.

268

THE MEDICINAL, MAINLY MERCURIAL,
TREATMENT OF PSEUDO-MEM-
BRANOUS CROUP

In 1868 I formulated the indication for the perform-
ance of tracheotomy in pseudo-membranous croup as fol-
lows : " There ought to be no contraindication when the
prominent symptoms are dyspnoea and suffocation. I can-
not imagine any complication of croup that would pre-
vent 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, in many cases, to
refuse tracheotomy, when I knew beforehand that the
child was surely going to die from other causes. 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 bless a proceeding the conse-
quence of which will at least be an easier death in most
cases. Nor do I acknowledge that tender age, that under
two years, ought to be held up as contraindication to the
performance- of the operation " {Journal of Obstetrics,
vol. i.. May, 1868, p. 49). And on page 57: "While I
admit that with symptoms of general diphtheria complicat-
ing a case of laryngeal diphtheritis, called membranous
croup, the prognosis of the operation becomes more doubt-
ful, I lay stress on the fact that even in such cases the
only indication for the operation rests in the local ob-
struction. 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 obstruction of the larynx complicated
with a constitutional 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

269

DR. JACOBFS WORKS

hardly investigate into the propriety of cutting the rope
from the point of view that the sufferer might be, or is,
effected at the same time with tuberculosis, carcinosis, or
diabetes." Such are the principles which have guided
most of those who have operated. The result has been
that Monti could collect 12,736 cases of croup with general
diphtheria, 3109 of which (26.7 per cent.) were saved by
tracheotom^^ Those indications for tracheotomy in croup
are still valid. I did not discover them, but I understood
them and acted in accordance with them almost ten years
previous to my writing. At that time I was not at all in
the fashion, just as little as those who frequently operated
before me, viz., Drs. von Roth, Krackowizer, and Voss.
On the contrary, the question was seriously asked if Dr.
Jacobi did not cut altogether too many throats. I refer
to that fact because it is alwaj's instructive to turn to the
history of theories and facts in our science and art. Now,
since that time the drift of public opinion has entirely
changed. What I insisted upon as a necessity, viz., that
amongst the few operations every general practitioner ought
to know, and be prepared to perform any time, tracheotomy
was the foremost, has been appreciated since to its full
extent. I feel certain that hundreds of practitioners in
this city have performed tracheotomy, or are capable, will-
ing, and anxious to perform it. The extent of this change
is very great indeed. One of the proofs is certainly the
fact that renowned gentlemen, who are identified in the
respectful opinion of the professional public with what
has been called internal medicine, commenced and carried
on an instructive and valuable discussion on the surgical
treatment of croup, in this very hall. The unity of
medicine cannot be better proven than by that fact, and
in order to prove my appreciation of the same, and of the
necessity of keeping together the disjointed members of
the body medical, which threatens to be dissolved into
soulless and spiritless specialties, I may be permitted, after
having performed four hundred or more tracheotomies my-
self, and witnessed several hundred besides, to claim a
little attention for the consideration of some points concern-
ing the medicinal treatment of pseudo-membranous proc-

270

PSEUDO-MEMBRANOUS CROUP— TREATMENT

esses in the resi^iratory organs, which has been given up
by very many as well-nigh hopeless.

Two cases of pseudo-membranous croup were treated in
my service in Mount Sinai Hospital in the following man-
ner: The patients, one less, the other more than two years
old, were kept in a temperature of somewhat more than
70° F., under a tent which was filled with steam and the
vapor of turpentine, as I shall detail afterward. They were
given besides /^o grain of pilocarpium muriate, according
to the method of Guttman. Neither of the cases was or
became severe, neither of them was septic. I make that
statement because I believe it to be important in regard
to the value to be placed upon the recommendations of
Guttman in general. Altogether I have not modified mj''
opinion on the efficiency of the drug expressed during
the sessions of the American Medical Association of 1881,
about eight months after the first article of Guttman,
on the efficacy of pilocarpium in croup and diphtheria
made its appearance. Its statements appeared exagger-
ated, the drug was recommended as a specific, no case ever
so severe or septic was said to be inaccessible to its heal-
ing influence. My first experiments were, therefore, made
with septic cases, both pharyngeal and laryngeal. In
every one of them I fully believe I accelerated the fatal
termination by hastening cardiac failure. But in a num-
ber of cases I do not hesitate to state that the softening,
macerating, disintegrating effect of the copious secretion
brought about by the jaborandi preparation was quite
marked. One of the cases in the Mount Sinai Hospital
got well. The other got better, but the pulse became fre-
quent and small, the general strength failed, and the treat-
ment had to be given up after three days. The same re-
sults I have obtained in private practice. A child of but
a little over a year did not tolerate the debilitating effect
of the pilocarpium more than two days, in spite of careful
alcoholic stimulation. The final recovery I was always in-
clined to attribute to two factors, viz., 1, the macerating
effect of the drug; 2, the timely withdrawal of the treat-
ment with pilocarpium, while the rest of the treatment was
continued. One case, three years old, I have seen recover

271

DR. JACOBFS WORKS

with a fair amount of strength after having been im-
prisoned in a tent four days. A few more had to be dis-
charged from it for fear of fatal exhaustion. My final
opinion is, therefore, that the effect of pilocarpium is cer-
tainly a powerful one, inasmuch as it increases the secre-
tion of the mucous membranes of the respiratory tract and
thereby facilitates the maceration of the pseudo-mem-
branes, but that its debilitating effect must be watched
and counteracted constantly and necessitates the interrup-
tion of its use in a great many cases.

In many, steam inhalations have been a powerful ad-
juvant in the treatment of croup. My opinions, as ex-
pressed in my " Treatise on Diphtheria," have not
changed these four years. I then said, in regard to their
administration :

" Quite remarkable effects have been expected of, and
claimed for them. It is true that pseudo-membranes, like
everything else, become softened by the warm vapors. It
is also probable that steam increases the secretion of the
mucous glands, and thereby possibly loosens the overlying
membranes and favors their removal, but it must not be
forgotten that it also softens the healthy tissues, and that
this change in character enables the poison, whatever be
its nature, to penetrate more deeply into them. These
two hypotheses must be kept in mind when, in any case,
the question of the employment of steam arises.

" Steam for the purpose of softening the tissues and of
provoking the secretion of mucus and suppuration has been
used to a considerable extent; in fact, in England and
America it constitutes an important part of the treatment
of diphtheria of the larynx. The patient must inhale it
directly from a vessel, or in a tent which is more or less
closed, or breathe the atmosphere of the room after it
has been saturated therewith. For the latter purpose,
water is kept constantly boiling, or lime slaked, or red-hot
stones put in water from time to time. The results from
this procedure in diphtheria of the larynx have not always
been pleasant. I have rq^eatedly had the joy of seeing
children with croup become less cyanotic after their removal
from an atmosphere of vapor, and I can readily see that

272

PSEUDO-MEMBRANOUS CROUP— TREATMENT

pure atmospheric air would be more agreeable and whole-
some to a child with stenosis of the larynx than an atmos-
phere laden with steam.

" I have seen cases of fibrinous bronchitis getting well,
when I had every reason to attribute the recovery to the
persistent use of steam. I have known a baby locked
up in a small bath-room, with one window, the hot water
running persistently for days, filling the room so as to
produce a constant fog, and make every person in the
room drip. The result was highly gratifying; the baby
got well, and so did another, whom I had the good for-
tune to benefit by my experience in that case. Again I
insist, steam will improve, steam will impair. Individualiz-
ing is a great art. In regard to the steam therapeutics, it
is, however, not too difficult. Its object is to soften, but
principally to increase the secretion from the mucous mem-
brane, and thereby throw off the superjacent membrane.
This can be done to advantage only where there is a natural
tendency to it, that is, where there are a great many muci-
parous follicles under a cylindrical or fimbriated epithelium.
This is the condition on part of the pharynx, but not on the
tonsils ; in a small portion of the larynx, in the trachea and
bronchi, not on the vocal cords. Wherever there is pave-
ment epithelium on the normal surface, and where the
membrane is imbedded into the tissue, steam can hardly
be expected to do good. In the other cases it will. Thus
the' locality of the diphtheric process determines to a
great extent whether steam is indicated or not. If it be
used, the necessity of a full supply of atmospheric air
must not be disregarded. Steam, with an overheated room
and without pure air, is liable to be as injurious as steam
in pure air is beneficial in a number of cases." I may
say in most cases; for though the number of muciparous
glands may be small in some places, the macerating effect
of vapor is always observed to a certain extent.

I may be also permitted here to refer, in regard to
the inhalations of turpentine, to what I published on page
186 of the work alluded to.

" For years I was in the habit of using turpentine,
either the oil or the rectified spirits, as an inhalation in

273

DR. JACOBI'S WORKS

bad cases of pneumonia, where hepatization was very ex-
tensive, and expectoration and resolution did not com-
mence^ with very good results in children and adxilts.
The vapors of turpentine are so volatile and penetrating
(and certainly the procedure of Taube so disagreeable to
the patient, if it be permitted at all by children) that the
usual method of inhaling from an apjiaratus appeared to
me to be very superfluous. I allow the patient to re-
main in his bed, and keep water boiling constantly on an
alcohol lamp, on the stove, or over the gas. A table-
spoonful of spir. rect. or ol. terebinth., more or less, is
poured on the water, care being taken that nothing is
spilled in the fire. Thus the room is constantly filled
with a penetrating odor of turpentine, which is not at all
disagreeable, even when in great concentration. The effects
are very satisfactory indeed. Where circumstances al-
lowed or required it, I raised a tent over the bed, large
enough not to give inconvenience to the patient, and to
admit either the whole apparatus or the tube containing
the mixed vapor of water and turpentine. This plan I
followed in many cases, also in the case of laryngeal
diphtheria of a girl of two years, in the children's service
of the Mount Sinai Hospital. The baby was in a room
of her own with a nurse. A tent was raised over the
bed. Four days and nights was she exposed to the water
and turpentine treatment, awake or asleep; not only she,
but also the nurse, whose presence under the tent was
insisted upon by the patient whenever she was awake.
It ought to be stated that the case was not (or was not
allowed to become.'') a very serious one. It was serious
enough to be diagnosticable, to produce hoarseness, aphonia,
dyspnoea, and to render the perception of pulmonary
murmurs impossible; but there never was cyanosis, with the
exception of a slight hue on the upper lip. She got well
with no other treatment but by iron and pot. chlor. solu-
tion. As a practical addition, I may say that the nurse
did not suffer much more than she would have done after
the same time passed in a close room, and in constant at-
tendance upon an exacting and whimsical patient."

Now, Mr. Chairman, I take it for granted that when

PSEUDO-MEMBRANOUS CROUP— TREATMENT

a number of practitioners give up part of an evening to
listen to a fellow-member, they expect that he will not
tell them what he copied from text-books for his Ijenefit.
I therefore abstain from enumerating the remedies in and
out of the Pharmacopoeia which have been recommended
in the treatment of croup. With your permission I
select one now for discussion, which is not new, it is true;
but the historical view I deem necessary will prove that
the consideration of mercury in its application to cases of
pseudo-membranous croup is still advisable.

Samuel Bard administered calomel in doses of three or
five grains daily. Rush also recommended calomel in his
" Medical Inquiries." Bretonneau employed the same, and
also inunctions of blue ointment. After their use he ob-
served the cough get moist, the pseudo-membranes become
looser, the sputa more copious and mucous. In his opinion
the result of tracheotomy after mercurial treatment is
rather more favorable. But Trousseau opposed it, and
his authority was sufficient to suppress its use almost en-
tirely. Autenrieth, in Germany (1807), gave from one
to four grains of calomel every hour, never less than fif-
teen grains altogether. Joseph Frank, Stieglitz, Billard,
Fahrner, Ruppius (1838), Benson, G. B. Wood (1847),
in his " Treatise on the Practice of Medicine," Hein
(1849), Bourgeois (1850), Brown (1850), Lowenhardt
(1848), Burow (1864, Journal f. Kinderk.), Steppuhn
(1864, Journal f. Klinderk.), Bartels (1867, D. Arch. f.
Klin. Med.), are in favor of mercurial treatment. Burow
used corrosive sublimate, gr. j.; white of one egg; distilled
water, S iv. ; a teaspoonf ul every hour, until three or four
grains were taken altogether. Eighteen undoubted cases
of croup are reported by him, eleven of which recovered;
of these eleven three only were tracheotomized.

Miquel (1848) administered one-sixth of a grain of
calomel, and two and one-half grains of alum, either alter-
natively or together. By the administration of alum he
hoped to prevent salivation. His method has been ex-
amined and partially adopted by Guersant, Blache, and
Trousseau, also by Millet, who had five successes in seven-
teen cases of croup.

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DR. JACOBFS WORKS

Oppolzer (1868) gave calomel and iodide of potassium,
gr. j. of each every hour^ after an emetic had been ad-
ministered before.

Bohn and Monti have opposed the use of mercury in
croup. The latter, however, modifies his opposition to a
great extent in his latest book. Bohn gave calomel, twenty
to forty grains in twenty-four or forty-eight hours,
and up to an ounce and a half of blue ointment besides.
He never saw any injury done by it except once, a mild
exfoliation from the upper jaw, and of twenty cases thus
treated eight recovered. Though he says that but two of
these were very severe, the result is so favorable that
Rauchfuss is correct in asking why, after all, Bohn should
object to the use of a remedy which has rendered him
such good services (Gerhardt's Handbuch, vol. iii., 2, 1878,
p. 210,).

Guesant (art. " Croup " in " Dictionnaire de Medecine,"
in thirty volumes, 1832-1845) expresses himself as fol-
lows : " A class of remedies which ought not to be neg-
lected in confirmed croup, when one is called in the be-
ginning, and the symptoms are not too pressing and the
patient too feeble already, are mercurials. Certainly they
fail sometimes, but a great many successes are due to
them. I have seen three cases of croup getting well
under this treatment, and in one of them the symptoms
ceased as by magic when salivation commenced. Seven
recoveries are mentioned by Bretonneau. Inunctions into
the neck, the gums, the inner sides of the arm and the
axillae must be made simultaneously, together with calo-
mel internally. The latter must be given as an alterant,
and not with purgative effect. To avoid this, it must be
given in refracted doses, one-fourth or one-half grain
every half hour or every hour, with gum powder, or sugar,
or candy, and not swallowed. When no laxative effect at
all is produced, the doses must be larger, but always given
in the same manner. But we must not overlook the fact
that mercurials, particularly when they produce saliva-
tion, throw the patient sometimes into such a state of
debility as to prove fatal. Bretonneau quotes such in-
stances. Thus it is prudent never to try this mode of

276

PSEUDO-MEMBRANOUS CROUP— TREATMENT

medication on subjects with a feeble constitution, or such
as are debilitated by previous sickness, and to suspend the
use of mercurials where injurious effects become visible,
and give tonics instead. For this reason it is best to
resort to that kind of medication in the summer only,
and perhaps not to employ it at all in the cold or moist
seasons."

Barrier (" Traite pratique des Mai. de I'Enfance," 3
ed., tome i., p. 394, I86I): "Mercurials have enjoyed,
and are still enjoying, a great reputation in the treat-
ment of croup. The preparations most in use are calomel
and the blue ointment. Small doses would not obtain an
effect in due time, and in croup a rapid result must be
looked after. Thus, according to the age of the child,
.02 or .05 grammes of calomel (gr. % to %) must be given
every half hour, with the addition of a small dose of
opium to avoid the purgative effect, and three or four
times daily one or two grammes of the blue ointment
(in older children to be doubled) are used on different
parts of the surface in inunction. This method is praised
by Guersant."

Of forty-one cases of croup, observed by Bartels, and
not treated with tracheotomy, five recovered with mer-
curial inunctions. They were all serious cases, laryngeal
stenosis and constitutional diphtheria were fully developed
in all. Within three days the main symptoms improved,
the croup membranes disintegrating. According to Frerichs,
who advises to introduce large amounts of mercury into
the system within a short time, he rubbed into the sur-
face, in different places, 1.25 grammes (9j.) of the blue
ointment every hour. Several times he used as much as
75 grammes (5 ijss.). Anaemia and hemorrhages were
observed in two cases, but still the patients recovered.
The same treatment was used by him for the fibrinous
tracheo-bronchitis succeeding tracheotomy.

Dr. C. Rauchfuss, in his elaborate paper on " Fibrin-
ous Laryngotracheitis," printed in the third volume of
C. Gerhardt's Handb. der Kinderk., expresses himself in
the following manner : " When Burrow published his re-
markable cases, his accurate descriptions and his results

277

DR. JACOBI'S WORKS

induced me to try the croup treatment with corrosive sub-
limate. Its results were so satisfactory, compared with
other methods of treatment, that I have remained true to
it since and joined to it the inunctions with blue oint-
ment; or, if the condition of the gastro-intestinal mucous
membrane forbade the internal administration, I limited
the treatment to inunctions extensively. The remarkably
satisfactory results of a very energetic mercurial treat-
ment has been appreciated as well by many colleagues,
both in and out of the hospital, as by myself. When
tracheotomies were performed, or autopsies made, it was
almost always noticed that the pseudo-membranes were
in a condition of muco-purulent disintegration at an un-
usually early period. Also in bad cases of catarrhal laryn-
gitis, with considerable subchordal tumefaction and stenosis
without pseudo-membranes, have I noticed that tumefaction
disappeared soon and a copious muco-purulent secretion
followed. Thus I look upon the diminution of the phleg-
monous process in the mucous membrane and the copious
secretion from the muciparous glands as the main results
of the mercurial treatment. I have a large experience,
but am not aware of a single case in which an energetic
but brief mercurial treatment was attended with evil con-
sequences, with one exception. This is a very intense
and diffuse erythema, of the surface, resembling scarlatina,
which may give rise to increased temperature. It is met
with after inunctions, when the skin is perspiring. When
it occurs the external treatment must be stopped, the child
bathed, and the medication restricted to the use of the
bichloride. Some of my mercurialized patients are at the
present time ten or twelve years old, and in good health.
Constitutional diphtheria, in its intense form, I do not
consider a contraindication; fibrinous tracheo-bronchitis is
a direct and urgent indication. Thus the treatment is
to be continued after tracheotomy has been performed.
But it is self-evident that no astonishing results can be
obtained in either form, and when I eulogize the mercurial
treatment, if compared with other modes of treatment,
I do so hoping that it may soon be replaced by a more
successful one."

£78

PSEUDO-MEMBRANOUS CROUP— TREATMENT

And in regard to inunctions in particular, he adds : " I
never saw bad results of the inunctions with forty or fifty
grammes (ojss.). Sometimes I have, not without fear,
however, used seventy-five or one hundred grammes. In
but one of the latter cases the medicinal results were bad;
never since have I employed more than fifty grammes,
but never less than forty."

My own experience in regard to mercury, up to the
summer of 1880, when I finished my "Treatise on Diph-
theria," is condensed on pages 188-190 in the following
sentences :

" In regard to the action of mercurial remedies, I am
no longer so sceptical as I was a quarter of a century ago.
For a dozen years I hardly ever prescribed mercury, sup-
posing that the harm it might do could be avoided by
substituting other medicines, and that its effect, except in
syphilis, could be obtained by other means. I admit that
the experience of many subsequent years has changed my
views to a certain extent. I known that in chronic in-
flammatory troubles, which I considered incurable in former
times, a good many favorable results have been due, at
my hands, to the protracted influence of mercurials; thus,
for instance, in chronic inflammations of the nervous
centers, particularly the spinal cord. I also know that
when the constitutional effect of mercury could be ob-
tained speedily, cases of fibrinous tracheo-bronchitis got
well in an unexpected manner. To accomplish that it
is necessary to give small doses very frequently. Calomel,
.5 to .75 (grs. viij. to xij.), divided into thirty or forty
doses, of which one is taken every half-hour, is apt to
yield a constitutional eflf'ect very soon. Such doses, with
minute ones, a milligramme or more (gr. Yqq)) of tartar
emetic, or ten or twenty times that auiount of oxysulphuret
of antimony, have served me well in fibrinous tracheo-
bronchitis. But the mucous membrane of the trachea and
bronchi is more apt to submit to such liquefying and
macerating treatment than the vocal cords. The latter
have no muciparous glands like the former, in which they
are very copious. And while the tracheal membrane is
apt to be thrown out of a tracheal incision at once, though

279

DR. JACOBI'S WORKS

of more recent date, the pseudo-membrane of the vocal
cords, if not interfered with, takes from six to sixteen or
more for complete removal. Still, a certain effect may
even here be accomplished, for maceration does not depend
only on the normal mucus of the muciparous glands, but
on the total secretion of the surface, which will be in
constant contact with the whole respiratory tract. Thus,
either on theoretical principles, or on the ground of actual
experience, men of learning and judgment have used mer-
cury in such cases as I detailed above, with a certain
confidence. The actual benefit derived therefrom cannot
have been great, for the mortality from croup has no-
where been encouraging. Nor is it an enjoyable proof of
its efficacy that Bartels is known to have lost confidence
in it in his ripest old age, either for its general un-
satisfactoriness, or for the reason that the general char-
acter of all the cases in the epidemics of his later years
changed the nature of his cases from the inflammatory to
the septic type.

"If ever mercury is expected to do any good in these
cases of suffocation by membrane, it must be made to
act promptly. That is what the blue ointment does not.
In its place I recommend the oleate, of which ten or
twelve minims may be rubbed into the skin, along the
inside of the forearms or thighs (or anywhere, when their
surface becomes irritated), every hour or two hours. Or
refracted doses will be useful, such as given above; or
hypodermic injections of corrosive bichloride in one-half
(or one) per cent, solution in distilled water, four or
five drops from four to six times a day, or more, either
by itself or in combination with the extensive use of the
oleate, or calomel internally. The hypodermic injections
act very promptly and favorably, as I repeatedly con-
vinced myself; for instance, in those cases of hereditary
syphilis, which, from the presence of volar or palmar
pemphigus and general cutaneous eruptions at birth yield;
as a rule, an almost fatal prognosis under ordinary cir-
cumstances, and with the ordinary treatment."

Henoch (Varies, iih. I^inderk., 1881, page 306) is op-
posed to mercurial treatment: " It cannot be denied

280

PSEUDO-MEMBRANOUS CROUP— TREATMENT

that the vigorous antiphlogistic treatment employed against
this dangerous malady, particularly formerly (such as
leeches, frequent emetics, and mercurials), together with
the lack of appetite and repugnance to food, produced
debility and anaemia." And (page 642), " A few times
I believe to have seen a favorable eifect of blue oint-
ment applied every two hours in doses of 1 gramme each;
and thus felt induced to try it in a large number of
cases. These trials, however, terminated so unfortunately
as to make me despair of a favorable result. A boy, aged
eighteen months, was undergoing inunctions for syphilis'
when he was taken with pharyngeal diphtheria. Of one
hundred cases treated in this manner but one terminated
favorably; of the rest thirty-three died without an opera-
tion, and sixty-six were tracheotomized."

E. Charon (" Contrib. a la Pathologic de I'Enfance,"
1881, 2 ed., page 49) takes the same stand: " Is there
a medicinal treatment of croup.'' None in my opinion
which is deserving of any confidence. The best proof is
the long list of methods of treatment recommended in
all of the books in different periods. As soon as a valu-
able remedy will be discovered able to remove the pseudo-
membrane or prevent it fxom descending into the re-
spiratory organs, we shall all know it. Until then it is
better to abstain from all sorts of medication, and more
than any other, from emetics and local cauterizations."

On the other hand, H. C. Wood, in his " Treatise on
Therapeutics," 1876, 2d ed., page 369, expresses himself
as follows : " Calomel is useful in severe laryngitis, and
especially in the pseudo-membranous variety where the
"type is sthenic; and no time should be lost in bringing
the system under its influence."

In Reynolds' " System of Medicine," vol. i., however,
mercurials are hardly mentioned amongst the remedies
to be employed, and J. Lewis Smith is of the opinion
that mercurial treatment in croup " has been properly
discarded."

Bartholow ("A Practical Treatise on Materia Medica
and Therapeutics," 1882, 4th ed., page 235): "Large
doses of calomel — five grains every four hours — are said

281

DR. JACOBI'S WORKS

to be very efficacious in true croup or membranous laryn-
gitis. It is claimed that it allays spasm and checks the
formation of the false membrane. The author is scepti-
cal in regard to the utility of calomel in this affection.
There is, however, no doubt as to the value of the sub-
sulphate as an emetic in this disease. If given early,
so high an authority as Dr. Fordyce Barker, of New
York, claims that a fatal result will most certainly be
averted."

The first to recommend cyanide of mercury in diph-
theria was A. Erichsen (St. Petersburg Woch., 1877, vol.
ii., p. 14). He objects to the employment of the blue
ointment, because of the uncertainty of the dose ab-
sorbed, and of other preparations, because of their actual
or alleged disturbance of the digestion. His diphtheritic
patients were from seven months to thirty years of age.
The pseudo-membranes became thinner and loosened within
a short time, not only in pharyngeal, but also in laryngeal
affections. Three cases, seven months, two and a half,
and three years of age, were treated exclusively with the
drug, and a hot sponge externally. No lotions or gargles
were used, only two daily applications of tincture of
iodine were made for the purpose of circumscribing the
morbid process. The dose was .0006 gramme up to the
age of three years (Koo g^*-) every hour, and twice that
amount for older children. Of twenty-five patients Erich-
sen lost one of cardiac paralysis, another of suppurative
parotitis, and a third one of a complication with meningitis ;
in all, however, even in those last mentioned, the diph-
theritic process became extinct.

Annusschat also recommends (Berliner Klin. Woch.,
1880, No. 43) the cyanide of mercury in diphtheria. Of
one hundred and twenty patients fourteen died. They
were from one to fifteen years of age. The dose was a
teaspoonful of a mixture of cyanidfe of mercury 0.1 to 0.2
in 100 water every hour. Benzoate of sodium was blown
into nose and pharynx. Stimulants were given besides.
Some cases recovered after three or four days, some after
six or eight. The more unfavorable or septic the cases,
or the more the larynx was affected, the less favorable was
the result of the medication.

282

PSEUDO-MEMBRANOUS CROUP— TREATMENT

H. Schulz (Centr. f. Klin. Med.) recommends the sub-
cutaneous administration of mercury, mainly the cyanide,
as recommended by C. G. Rothe. The latter (" Die
Diphtheric," etc., Leipzig, 1884) reports the following:
" A girl of three years, whose brother, four years old, had
just died of diphtheria, appeared nearly moribund after
an illness of a fortnight. Complete aphonia, stenotic respi-
ration, and a high temperature rendered the prognosis
very bad indeed. I then gave every hour a drachm of
the following mixture: Hydrarg. bicyan., 0.01; aq. dest.,
60; tr. aconiti, 1. When five or six doses had been taken
respiration became moister, the cough looser, viscid mucus
was expelled, and the night was less restless. The child
finally recovered with several perforations of the soft
palate, otitis media, and perforation of the drum mem-
brane.

"Since that time (September, 1880), I have employed
the same drug in ninety-eight cases, six of which were
complicated with scarlatina, and the result was favor-
able, inasmuch as the duration of the cases appeared to be
shorter, and the local process exhibited unmistakable mod-
ifications (Allg. Central., 1880, No. 89; Deutsche Med.
Woch., 1881, No. 34). Of these ninety-eight cases, the
first seventy-one terminated in recovery. In the seventy-
second, a girl, three years old, the pharynx being nearly
clear of membranes, the larynx was suddenly affected after
an inhalation of lime-water, and the patient died within
a short time, even before the completion of laryngeal
stenosis. This was the first case in which the larynx be-
came affected during the treatment. Two more cases in
children of from two to three years terminated fatallj'.
The treatment was not commenced before the fourlh
day; at that time croup had already commenced. These
three cases, as also that of a boy of five years with
' genuine croup,' whom I was called to see a few hours
before his death for the purpose of performing trache-
otomy, have convinced me that no effect must be expected
from the remedy when the larynx is already affected;
that, however, when it is employed in time, it will obviate
the affection of the larynx and the fatal termination. By
an affection of the larynx, however, I do not mean mere

283

DR. JACOBI'S WORKS

hoarseness and barking cough, or aphonia, all of which
may last for days and still terminate favorably, but real
stenosis.

" In place of the cyanide I sometimes give the bichloride :
hydrarg. chlor. corros., 0.01-0.015; sodii chloridi, pepsin,
aa 0.5; aq. destill. 60; tr. aeon., 1-2 — a drachm every
hour, with the same result. The tincture of aconite was
added for its effect on the temperature, the pulse, and the
pharyngeal irritation."

With these quotations and reports the historical review
of our subject is almost exhausted, if I mean to confine
myself to the most important literary productions only.
Still, a very few must still find places to prove the dis-
crepancy of opinions. I copy the following from J.
Forsyth Meigs and William Pepper ("A Practical Treatise
on the Diseases of Children," 7th ed., 1882, p. 906):

" Recently Dr. G. A. Lynn (' Trans. Pennsylvania State
Medical Society, p. 886, 1879) reported remarkable re-
sults from the use of large doses of bichloride of mercury
in grave eases of diphtheria. He found that even so large
a dose as gr. Y^o every three hours was well borne by
children one year old, and asserts that from his experi-
ence it prevents the spread of the membrane or the de-
velopment of blood-poisoning, and acts as much as a spe-
cific in diphtheria as quinia does in intermittent fever.
These bold assertions have been corroborated by several
good observers. We have not used this remedy sufficiently
to authorize an expression of opinion, but a truly re-
markable case, occurring in the practice of Dr. T. I.
Yarrow, in Philadelphia, and seen by us in consultation
(' Address on Medicine,' by William Pepper, M.D., ' Trans.
Am. Med. Assoc.,' 1881), where this remedy was used in
the above manner with excellent results, convinces us
that further cautious trials should be made in this direc-
tion. The same may be said for the treatment by enor-
mous doses of calomel, which has been advocated by some
good observers as producing specific curative effects. It
is difficult to define the cases in which it might be justi-
fiable to try either of these modes of treatment, but
it seems to us that it would chiefly be in cases where a

281

PSEUDO-MEMBRANOUS CROUP— TREATMENT

continued tendency to pseudo-membrane showed itself,
while as yet no extreme degree of blood-poisoning had
occurred."

In the latest French text-book, however (A. Deschroi-
zilles, "Manuel de Path, et de Clinique Infantiles," 1884,
p. 326) the following sentences are found:

" Mercurials have been eulogized in America, and are
still fashionable in England. In France they are not
believed in at all. Mercury has been used in the form of
calomel in repeated doses, or the blue ointment has been
employed round the neck. In spite of what has been
said in England to the contrary, they debilitate, purge,
and salivate, impoverish the blood, and facilitate hemor-
rhages. Therefore they have been almost given up."

Finally, in E. Bouchut's " Clinique de I'Hopital des En-
fants Malades " (1884) mercury is not mentioned at all
amongst the remedies employed in Europe. Thus it is
evident that the difference of opinions in regard to the
availability of mercury, in croup, is very great indeed.
But there is a peculiar feature in the controversy which
cannot escape your attention. It is this, that those who
speak of the subject in a text-book, and in brief text-book
fashion, are apt to trifle with it because of their tendency
to teach accepted facts only, while some of those who
have personal observations to relate in full, appear as the
friends of the mercurial treatment.

My own experience is not a very extensive one, but by
what I have since seen my opinions of 1880 are some-
what modified in favor of accepting the beneficial results
of mercury in croup. Particularly was I struck with,
and encouraged by the force of the statements made by
Pepper, cautious though they were, before the American
Medical Association at Richmond, in 1881, and alluded
to before. Since that time I have employed, or recom-
mended, mercury in many cases, and I believe with fair
result. I am not, however, of those who never lose a
case. But what I have seen is at your service. Allow me,
therefore, to detail a few cases as instances only, and
finally to draw some conclusions.

Case of Dr. G. Mourraille. — F. M , female, aged

285

DR. JACOBI'S WORKS

three years and eight months. The doctor was called
March 28th, 4 p. m. The little girl had slept well the
previous night and took her breakfast as usual; com-
plained of headache and refused to go out at 2 p. m.
Took tinct. ferr. mur., gtt. iij. every hour, and was or-
dered for the evening a dose of pulv. dover. and hydrarg.
c. cret., aa gr. j. At that time, temperature 101^°. gray
extensive, but thin deposits on tonsils; no cough. Was
called again at 8 p. m. Powder had been taken. Cough
frequent and croupy, voice hoarse, great dyspnoea, face
congested, but not cyanotic. 11 p. M. : Same condition ;
child has not slept. Another dose of pulv. dover. and
hyd. c. cret., aa gr. j. Child falls asleep about midnight.
Respiration less disturbed, cough less frequent, but of
the same character; sleep restless. Consultation on the
29th, 9 a. m. : Temperature, 101°; voice feeble and hoarse;
cough hoarse; pharyngeal membranes less extensive; respi-
ration croupy; moderate praecordial and supraclavicular
recession. Bichloride of mercury, gr. %4 every hour in
water. Night restless; voice and cough not changed, but
respiration rather easier.

March 30th. — No change in the general symptoms, but
more diphtheritic deposits in the throat. Twenty-four
doses of the bichloride of mercury had been taken by
3 p. M. It was ordered to be renewed. About 8 p. m.
several loose passages, with griping pain. The remedy
was discontinued and pulv. Dov. and hyd. c. cret., aa gr.
j., given instead. Night fair; voice hoarse; cough rather
looser; respiration rather easier.

March 31st. — The bichloride resumed in the morning,
followed by loose passages. About noon one drop of
the wine of opium was ordered with each hourly dose.
In this way the remedy was well tolerated. The night
was rather satisfactory; three doses only of the medicine
were given.

April 1st. — Cough, loose; respiration, pretty easy; no
membranes in the pharynx; the medicine is continued
until 2 p. M. In the evening pulv. dov. and hyd. c. cret.

April 2d. — Voice hoarse, but cough more catarrhal.
Treatment discontinued. Child very nervous. Pulse in-

286

PSEUDO-MEMBRANOUS CROUP— TREATMENT

termittent. Doses of bromide potass., gr. vj., in the even-
ing. Night good. Temperature from March 28th to
April 6th, 99° to 101° (rectum), the latter in the after-
noon's mostly. Cough lasted until April 12th, hoarseness
to Aj^ril l6th. The total amount of bichlor. hydrarg.
was grs. ij.

Case of Dr. T. N. Burchard. — Fibrinous bronchitis in
a child five months old, treated with corrosive sublimate ;
recovery. — Called March 30th, 6 a. m., to see Lelia

H , aged five months. Found her suffering with

dyspnoea, croupy respiration, and painful cough. The
child had been perfectly well the day previous, and had
been out for a ride. Two months before had had a severe
capillary bronchitis which lasted eight days. Examination
revealed hyperaemia of fauces, no swelling or membrane
visible. Physical examination of lungs negative. Ordered
mustard cloth to throat, to be followed with hot fomenta-
tions, two grains of quinine and a diaphoretic mixture of
ipecac, nitre, and spirits of Mindererus. The room to be
kept filled with steam. 9 a. m.: Had passed a comfort-
able day, and vomited considerable phlegm at 7 p m. Pulse,
120; temperature, 94%°; respiration, 38. Fauces red, no
membrane; physical examination of lungs negative; respira-
tion croupy; cough painful; voice absent. Ordered whis-
key, gtt. viij . q. 2 h. ; paregoric, gtt. iij . q. 2 h. ; diaphoretic
mixture to be continued. 12p.m.: Child very weak. Pulse,
152; respiration, 34. Ordered carb. ammon., gr. ij., and
tinct. digital., gtt. ij. Whiskey, gtt. xv., to be repeated at
end of half an hour.

March 31st — 3 a. m. : Child sleeping, breathing more
easily. Pulse, 148; temperature, 103^°; respiration, 32.
11 A. M.: Pulse, 132; temperature, 103°; respiration, 35.
Respirations easier; cough not so jiainful; voice still ab-
sent. Diaphoretic mixture discontinued. Whiskey, gtt.
X. q. 3 h. ; quinine, gr. ij. 1 p. M. : Seen by Dr Jacobi
in consultation. Pulse, 132; temperature, 101%°; respira-
tion, 68. Physical examination of throat and lungs nega-
tive. Percussion over lungs posteriorly and apices anteri-
orly, extra-sonorous; a few faint sonorous rales heard pos-
teriorly. Diagnosis of acute laryngitis confirmed. Since

287

DR. JACOBI'S WORKS

last visit, however, respirations have doubled in frequency,
with falling temperature. Dr. Jacobi suspects the exuda-
tive process is invading the bronchi. Pneumonia, pleurisy,
and capillary bronchitis can be positively excluded. Or-
dered hydrarg. bichloridi, gr, ^,o q. 1 h. ; stimulants, poul-
tices, and steam to be continued as before. 6 p. m. : Pulse,
132; temperature, 101f°; respiration, 70. Condition about
the same; voice absent. 7.50 p. m.: Vomited after taking
corrosive sublimate. 12 p. M. : Again seen by Dr. Jacobi.
Pulse, 132; temperature, 10lf°; respiration, 62. Has
taken Yqq gr. bichloride of mercury each hour since
2 p. M.

April 1st. — 8 A. M.: Passed comfortable night; vomited
corrosive sublimate at 4.45 a. m. Pulse, 128; temperature,
102°; respiration, 64. Ordered whiskey, gtt. xv. q. 2
h. ; bichloride to be continued. 1 p. m. : Seen by Dr.
Jacobi. Pulse, 132; temperature, 10lf°; respiration,
66. Fauces slightly red; no swelling or membrane; ex-
amination of lungs negative, save few sonorous rales heard
posteriorly. Has taken and retained twenty-two ^-50 gr.
doses of corrosive sublimate. Ordered treatment con-
tinued. 6 p. M. : Pulse, 132; temperature, 101^°; respi-
ration, 64. Noticed slight puffiness on left side of neck;
lymphatic glands not enlarged; no swelling of tonsils. 10
p. M. : Pulse, 120; temperature, 100^°; respiration, 48.
Had natural movement at 8 o'clock, followed by a loose
one at 8.45. Ordered paregoric, gtt. iij. and to omit one
dose hydrarg. bichloridi. 11.30 p. m.: Seen by Dr. Jacobi.
Pulse, 132; temperature, 100|^°; respiration, 53. Mother's
milk having failed, ordered barley-water and milk. Whis-
key, gtt. XV. q. 2 h. The hydrarg. bichloride to be continued,
unless diarrhcea or vomiting supervene. Physical examina-
tion of throat and lungs as before.

April 2d. — 2.45 a. m.: Vomited considerable phlegm;
swallows with difficulty; child's appearance worse. Or-
dered brandy to be substituted for whiskey, gtt. xv. q.
2 h.; tinct. digital., gtt. ij. q. 2 h. Poultices and steam to
be kept up. 9 a. m. : Child supposed to be dying ; marked
dyspncea with cyanosis. Pulse indistinguishable; respira-
tion, 72. Found above conditions to be dependent upon

288

PSEUDO-MEMBRANOUS CROUP— TREATMENT

accumulation of mucus in the throat. Inverted the child,
wiped out mucus from throat with finger; stimulated the
child with friction, brandy, carb. ammon. and tinct. digital.
9.30 A. M. : Color and breathing greatly improved; con-
siderable mucus in bronchi ; caused vomiting by finger in
throat. After vomiting, pulse about 160; respiration, 48;
temperature 101°. Neck more swollen; hyperaemia of
throat increased. 1 p. M.: Dr. Jacobi in consultation.
Child has taken twenty-two doses of hydrarg. bichloride
during past twenty-four hours, all except one dose having
been retained. Dr. Jacobi detected a swelling on left side
pharyngeal wall, low down, of phlegmonous character.
Child's general appearance improved. Ordered brandy,
gtt. xij. q. 2 h.; milk and barley-water to be continued;
other treatment as before. 11 p. m. : Seen by Dr. Jacobi
in consultation. Pulse, 144; temperature, 100^°; respira-
tion, 60. Treatment continued.

April 3d. — 9 a. m.: Child passed comfortable night,
coughing less, and sleeping more. Two small, green
movements during the night. Pulse, 140; temperature
10lf°; respiration 66. Swallows better; cough less painful;
hyperaemia of throat less; swelling about the same. Ex-
amination of the lungs gave numerous moist rales over
both lungs, posteriorly. Percussion extra-resonant. Treat-
ment continued. 1 p. M. ; Seen by Dr. Jacobi in consulta-
tion. Has taken and retained twenty-one doses hydrarg.
bichloride. Pulse 150; temperature, 100f°; respiration 60.
Ordered brandy, gtt. xv. q. 2 h. ; tinct. digital., gtt. ij. q.
4 h. ; hydrarg. bichloridi, gr. %o <1- 1 h- 3.35 p. m. : Had
large constipated movement. 4.35 p. M. : Vomited consid-
erable phlegm. Pulse, 150; temperature, 101 J°; respira-
tion, 68. 11 p. M. : Breathing much better. Takes and
retains nourishment and medicine. Nostrils considerably
occluded with mucus. Pulse, 144; temperature, 100^°;
respiration, 52 Has vomited some curdled milk during
the evening. Swelling in throat about the same. Con-
dition of lungs unchanged.

April 4th. — 4 a. m.: Sleeping quietly. Respiration, 38;
pulse, 132. Feet and legs very cold; hot-water bag applied
to them. Brandy and carb. ammon. given freely. 5.30

289

DR. JACOBI'S WORKS

A. M.: Small constipated movement followed by loose move-
ment at seven o'clock. Vomited sour milk several times
during the night. Child very restless, but general condi-
tion improved. 1 p. M. : Seen by Dr. Jacobi. Pulse, 160;
temperature, 101^°; respiration, 54. Has taken nineteen
%o gr. doses of bichloride since yesterday. 6 p. m.:
Nursed ten minutes freely this afternoon. Treatment
continued.

April 5th — 9 a. m. : Has passed a comfortable night.
Has vomited phlegm a number of times. Stomach quite
irritable; substitiited inunctions of the oleate of mercury in
place of the bichlorides. 1 p. M. : Seen by Dr. Jacobi in
consultation. Pulse, 132; temperature, 100°; respiration,
28. Asleep. Has nursed twice during the morning; swell-
ing in throat less ; poultice discontinued. Ordered brandy,
gtt. XV. q. 3 h. ; tinct. digital., gtt. ij. q. 4 h. ; hydrarg.
bichloridi, gr. %o <!• 8 h. Steam to be continued as be-
fore.

April 6th. — 9 A. M. : Passed comfortable night. Vomited
phlegm twice or' three times during night. Pulse, 128;
temperature, 100°; respiration, 32 Voice returning; cough
stronger and less frequent. Ordered whiskey, gtt. x. q.
4 h. ; tr. digital., gtt. ij. q. 8 h. Child nursing.

April 10th. — Steam discontinued. Thoroughly convales-
cent.

April 15th. — Child was taken to Lakewood, N. J., to-
day.

Case of Dr. E. J. Hogan. — Croup; tracheotomy ; bron-
chial croup; recovery. — I was called to see Milton R ,

aged two years, on March 9th. Two persons living in
the house had suffered from pharyngeal diphtheria about
a month previously. The child seemed to have a mild
laryngeal catarrh with moderate dyspnoea. A careful ex-
amination failed to reveal more than congestion of the
pharyngeal and tonsillar mucous membrane. His temper-
ature was normal. General condition excellent.

On the evening of March 10th he was breathing easily,
pulse good, temperature normal; so much better, indeed,
that I did not think it would be necessary for me to call
again.

290

PSEUDO-MEMBRANOUS CROUP— TREATMENT

An alarming dyspnoea developed at about 3 a. m., March
11th. A physician, called in the emergency, administered
turpeth mineral, which was followed by emesis and partial
relief of the dyspnoea. A profuse diarrhoea, lasting over
twenty-four hours, also resulted from it.

During the morning of the 11th, the symptoms became
steadily more threatening. (There were occasional re-
missions of short duration.) Pulse, 140 to 150; respira-
tion, 50 to 60; cyanosis, at times very marked; semi-coma;
considerable epigastric and suprasternal recession. On
percussion, pulmonary resonance good. Auscultatory signs
masked by the noisy laryngeal breathing. Neither Dr.
McMahon (who had been called to see the case) nor my-
self could detect any membrane in the throat or nose. We
both agreed as to the necessity of an early tracheotomy.
Meanwhile the child was taking carbonate of ammonia
internally and lime vapor inhalations.

Laryngo-tracheotomy was done by Dr. F. Lange at
2.30 p. M. No anaesthetic used, patient being insensible.
Two bleeding veins were ligated. A portion of the first
tracheal ring was removed after the windpipe had been
opened. A thin, soft, easily detached membrane was re-
moved from the trachea. A tube was inserted, covered
with a sponge wrung out of hot water. The wound was
treated with corrosive sublimate solution (1/2000) and iodo-
form; no spray used; no internal treatment except small
doses of Dover's powder (p. r. n.) for cough.

On the evening after the operation the child was breath-
ing easily through the tube and took nourishment (milk)
freely. The pulse had fallen to 120. Temperature (rec-
tal), 102.2°.

March 12th. — In the afternoon the patient began to suf-
fer from increasing obstruction below the tracheal wound.
Loud tracheal rales. Respirations very rapid. Both tubes
removed in the evening by Dr. Lange, who, by the aid
of a catheter and aspiration, freed some pieces of thick,
very dense, adherent membrane. Later seen also by Dr.
Jacobi (10 p. M.). Breathing still much obstructed. Ex-
amination of chest negative. On the suggestion of Dr.
Jacobi the bichloride of mercury was administered in doses

291

DR. JACOBI'S WORKS

of %2 of a grain hourly, with the expectation of its favor-
ing the disintegration and separation of the membranes.

From this time on it never became necessary to re-
move the outer tube for the sake of cleaning the trachea.
The use of the feather with occasional instillations of a
solution of common salt sufficed to remove any material
causing obstruction. The bichloride was suspended on the
third day, on account of intestinal irritation. The gums
were not affected. On March 14th, the temperature reached
102.2°; on March 21st, 104.8°. On these two occasions,
quinine was given, eight grains morning and evening in
divided doses. On about the ninth day the patient was put
on the elixir of gentian and iron (Wyeth's). The tube
was removed on March 22d ; after its removal the wound did
nicely. During the course of the disease albumen in small
amounts and some hyaline casts were found in the urine.

In connection with the report of his case, Dr. Hogan
says: " My experience with the bichloride in this case,
it is fair to state, has been such that I would feel it an
injustice to withhold it from a patient in the future, under
similar circumstances. Previous to its administration, as
the history shows, there was a rapid formation of very
dense, thick membrane, with every prospect of death from
tracheal occlusion. Afterward, the case went on steadily
to a favorable termination. Even granting the possibility
of a coincidence, it would seem that a resort to this means
is both rational and expedient."

These three cases are but specimens of what I have
frequently seen in my own practice, and in that of col-
leagues, some of whom may be present. Not only have
I seen a certain number of cases of pseudo-membranous
croup, mostly complicated with pharyngeal diphtheria,
getting well without tracheotomy with mercurial treatment,
but the percentage of recoveries after tracheotomy in the
last three years, in my experience, has been greater than
through ten years previously when no mercury was em-
ployed.

Now, I am not so enthusiastic as to generalize on the
strength of my cases — even dozens of cases count but
little when we recall the fact that statistics without great

292

PSEUDO-MEMBRANOUS CROUP— TREATMENT

numbers are deceptive — but I know that for years past,
with mercurial treatment, my established axiom, that in
authenticated cases of membranous croup, not tracheot-
omized, the mortality amounted to ninety or ninety-five
per cent., has been happily shaken in its foundations.

In regard to the preparations of mercury to be used I
agree with Voit and Hartnack in this, that it is best to
agree upon a very few of the preparations of mercury in
medical practice. The bichloride may be given in a dilu-
tion of more or less than 1 to 15,000, that is, a grain
in a quart, or Baerensprung's albuminate, or Bamberger's
peptonate, may be employed. The latter's patients who
used either, subcutaneously, were not salivated, though
nothing was done to prevent salivation, and increased in
weight during the treatment. Albuminate taken inter-
nally disturbed the stomach in no way; its favorable ef-
fect on the appetite has been observed occasionally. Soluble
preparations in large dilutions are easily absorbed by the
mucous membranes (or by ulcerated surfaces), thus they
act in baths. In somewhat concentrated form it may give
rise to inflammation, in stronger concentration to cauteriza-
tion; gastric and intestinal disturbances may reach the
degree obtained by arsenic or cholera, and prove fatal.
Pills with larger doses of mercury lose their dangerousness
by meeting with plenty of albumen to form albuminates,
particularly when given after meals.

The corrosive sublimate is a strong anti fermentative.
Bacteria are killed by it in dilutions of one to twenty
thousand (Buchholtz), or according to others, one to three
hundred thousand. At all events it is ten times as powerful
as thymol and benzoate of sodium; twenty times more than
cresot or benzoic acid, or oil of thyme; thirty times than
salicylic acid, or eucalyptol; one hundred times than car-
bolic acid, salicylic acid or quinia. The deductions of
Dr. Wm. H. Thallon, of Brooklyn, as published in the
New York Medical Journal of April 12th and 19th, prove
not only that the bichloride of mercury is a proper anti-
fermentative to be given, but also that the doses must be
large when compared with those prescribed or permitted
by the books.

29S

DR. JACOBI'S WORKS

Hydrargytum bichloride combines in the stomach with
chloride of sodium^ is absorbed as such, and changes into
an albuminate with the albumen of the blood. Dissolved
albumen, it is true, is coagulated by hydrargyrum bichlor-
ide, and antagonized and rendered not absorbable; but both
a surplus of albumen and the addition of chloride of sodium
restore its solubility. These conditions are mostly found
in the stomach, and always in the blood. In an alkaline
solution of albumen, hydrargyrum bichloride produces no
coagulation when sodium chloride was added. Thus, sub-
cutaneous injections meeting with the alkaline tissue fluid
are best tolerated when sodium chloride is added to the
mercurial solution. The contents of the stomach and its
fluids are mostly acid, however. Marie found that acid
solutions of albumen are not coagulated at all by hydrargy-
rum bichloride; a slight obscurity of the solution is pro-
duced, however, by the addition of sodium chloride, so that
the latter may better be dispensed with in internal medica-
tion, unless the dose of the hydrargyrum chloride be large.
Marie expresses even the opinion that large quantities of
the sodium chloride may disturb digestion by its shrinking
influence upon the hydrargyrum albuminate. He found
that in artificial digestive fluid hydrargyrum chloride does
not coagulate peptone in a solution of one to three thou-
sand, nor does it throw out the pepsine in a solution of
one to one hundred, or less (Arch. f. Exper. Pathol, u.
Pharm., vol. iii.).

In regard to the treatment of croup after the perform-
ance of tracheotomy, I finally make the following frag-
mentary suggestions :

The temperature of the room must not be too high,
not much over 70° F. The air must be kept moist. A
kettle with boiling water on an open fireplace works
quite well, provided the steam enters the room, and not
the chimney. To obviate the latter, a tin cylinder, of
the shape of a fish-horn, may be thrown over the spout of
the kettle, which is generally too short. The old-fashioned
cooking oven in the room, or a stove of former patterns
will do as well. The self-acting stoves are bad; they give
out a great deal of coal-gas, and have no place where to

294

PSEUDO-MEMBEANOUS CROUP— TREATMENT

put a kettle. Gas-stoves of any shape or pattern are in-
jurious; gas consumes so much more oxygen than alcohol
that a large alcohol lamp^ to boil water on constantly,
serves the purpose better. When the room is large, or
cold, part of it may be easily changed into a closet by means
of a few nails driven into opposite walls near the ceiling,
ropes, and bed-sheets. Into such a closet, or tent, the steam
may be introduced by a tin tube, the alcohol lamp remain-
ing outside the sheets. A tablespoonful of spirits of tur-
pentine may be poured on the boiling water every half
hour, or hour. The steam or vapor, however, must not
be too thick. Oxygen must not be excluded. Many years
ago I demonstrated the necessity of allowing a full supply
of oxygen by the case of a baby who suffered from de-
scending croup, after tracheotomy was performed. He
was in convulsions from carbolic acid gas poisoning. When-
ever I introduced oxygen from a bystanding cylinder into
the tube, the convulsions would cease, and the cyanosis
decrease; when I stopped the supply, cyanosis and con-
vulsions would return. Thus it may frequently be neces-
sary to open a window, more or less. Here, as in every-
thing else, the judgment of the physician will decide upon
the indications of the individual case.

The nutrition of the patient has generally suffered much.
Before the operation but little food was taken, still less
was digested, and the operation itself and the anaesthetic
have added to the previous weakness or exhaustion. Mod-
erate feeding and stimulation are therefore to be com-
menced soon. Vomiting after chloroform I have seldom
seen to last long or to be embarrassing under these cir-
cumstances. Feeding and stimulation is the more neces-
sary the more the hungry lymph-vessels are liable to ab-
sorb injurious material when not supplied with healthy
food.

Is internal treatment required? The general treat-
ment must be continued. If it consisted in the adminis-
tration of hydrargyrum, either internally or externally, it
must be continued. If its effect was not sufficient to
clear the larynx and to render the operation unnecessary,
it will or may be sufficient to complete its effect in the

DR. JACOBI'S WORKS

next day or twd, to prevent the process from descending
or the membranes becoming too many or too thick. No
changes ought to be made in the treatment unless there
be changes in the symptoms. Not infrequently the first
symptoms of broncho-pneumonia come on within a few
hours after the operation, recognizable by frequent pulse,
respiration frequent beyond proportion, and physical symp-
toms. The stomach is not very reliable. Quinine answers
best hypodermically. From six to ten grains may be in-
jected at once. The preparation which has served me best
in the last few years is a solution of the carbamid in five
parts of water. If an additional remedy is required, from
twenty to thirty grains of sodium salicylate may be given
in the course of three or four hours, in hourly doses, to
reduce the temperature. Tincture of digitalis will prove
advisable at the same time when the heart appears to
require it. Strychnise sulphas will act as a powerful nerv-
ine; a twenty-fifth of a grain may be given to a child,
two years of age, every two hours, until four doses, or
five, will have been taken. The rest of the treatment
of the complications depends on their nature and character.
It is not the name of the disease which has to be treated,
here as in every case, but the individual patient.

In regard to stimulants I have but little to say. I use
alcohol in the most pleasant shape, preferring brandy or
whiskey. I use a great deal of camphor, ten to forty
grains daily, or in cases of urgency, Siberian musk, from
two to five grains, every half hour or hour, until from
fifteen to twenty grains have been taken, in cases of col-
lapse or great prostration.

In this connection I have nothing to say about local
applications to the trachea, or the handling or removal of
the tube. My subject was a limited one. Besides, I
meant to suggest rather than to teach. My object was to
impress upon the minds of my colleagues, and particu-
larly those younger than myself, the necessity of not
despairing, even before one of the most serious problems
of medical practice. This one fact I will urge upon you,
trite though it may be, and ridiculous though its expression
may appear, viz., that the name of a disease is not the ob-

2P6

PSEUDO-MEMBRANOUS CROUP— TREATMENT

ject of treatment, that the name of a drug is not the re-
quirement in a morbid process, but its intelligent and
appropriate use. Scores of times have I been told, for
instance, that my method 'of treating diphtheria • with
tincture of iron was carried out in an individual case, when
I found that three or four drops of tinct. ferr. mur. had
been administered three or four times a day. This may
serve as an instance, but also as a warning. It is not
enough to administer hydrargyrum bichloride; to be effect-
ive, enough must be given, and quickly enough. The doses
must be large, and largely diluted. Both local and con-
stitutional effects must not be feared. They will seldom
be met with. If they are they amount to little in com-
parison with the mortal enemy you are going to fight.
Mercurial stomatitis in infants is very rare indeed, and
will readily heal. In larger children, of from two to five
years, it appears but late, if at all; as a rule, the admin-
istration of mercury is the less objectionable the younger the
patient. My doses have varied from Yqo to ^4 of a grain
(1 to 2^ milligrammes) every hour, and the treatment has
been continued from one to six days.

To conclude, however, I shall here suggest again, what
has been the gist of the remarks of the evening, in brief
words :

First. — The mercurial treatment of pseudo-membran-
ous affections of the respiratory organs is promising of
great results.

Second. — The corrosive sublimate is the preparation
best adapted for internal medication. *

Third. — The system must be brought under its influ-
ence speedily, by frequent doses.

Fourth. — It must be given in dilutions of 1 to at least
3000 to 5000.

Fifth. — Babies of tender age bear one-half grain and
more a day, and many days in succession.

Sixth. — Salivation and stomatitis are rarely observed,
and appear to heal kindly. Gastro-intestinal disturbances
are not frequent; they are moderate, can be avoided by
the administration of mucilaginous and farinaceous food,
or of mild doses of opium.

297

T)k. JACOBI'S WORKS

Seventh. — If not well tolerated, the inunction of suffi-
cient and frequent doses of hydrargyrum oleate takes the
place of the corrosive chloride, either together or alter-
nately with the internal administration.

Eighth. — The treatment of croup may be preventive to
a great extent. Most of the cases are complicated with,
or descend from, diphtheria of the fauces. Here the pre-
ventive treatment of croup must begin. Without desiring
to encourage mere local treatment, which in unwilling pa-
tients has to resort to force or violence, and thereby does
great harm, I point to the peculiar local effect of mercury
on the pharynx, both in the healthy and sick, as a means
to influence the threatened invasion of the larynx.

298

"SUMMARIES" ON DIPHTHERIA

The following are the summaries appended to the chap-
ters of Dr. Jacobi's " A Treatise on Diphtheria/' pub-
lished in 1880 (William Wood & Co., New York):

SUMMARY OF HISTORY

Aretaeus is the first whose description of diphtheria has
reached us.

Asclepiades practised scarification of the tonsils and
laryngotomy.

Cffilius Aurelianus recognized diphtheria of the pharynx
and larynx and the diphtheritic paralysis of the soft
palate.

Frequent epidemics are known to have taken place in
the second half of the sixteenth century over the larger
part of Europe.

Diphtheria of the skin and of wounds was described
by Herrera in 1515.

Communication of diphtheria through a wound in the
finger is reported by Mercado in I6O8.

An autopsy was made in l64£, and membrane found in
the larynx.

The suffocative, asthenic, and paralytic forms of diph-
theria were described by Heredia in 1690.

The first cases known in America occurred in Roxbury,
Mass., in December, 1659- About that time, and mainly
about 1671, the disease was very prevalent. It recurred,
1735, in New England, and never disappeared for any
length of time until the beginning of this century. The
main writers during this period are Douglas I. Dickinson,
Calwalader Colden, Samuel Bard, Jacob Ogden, John
Archer, Peter Middleton, Richard Bailey.

299

DR. JACOBI'S WORKS

Samuel Bard proved the identity of all forms of diph-
theria, cutaneous, pharyngeal, nasal, laryngeal, tracheal.
So did Bretonneau fifty years later, and Trousseau, Louis,
Rilliet and Barthez, and all the great clinicians.

Contagiousness was never doubted, but mainly sustained
by Bourgeoise in 1823.

Virchow discriminates the catarrhal, croupous, and nec-
robiotic forms, 1847.

Graefe describes diphtheria on conjunctiva and cornea
in 1854.

The main objects of the scientific literature of the sub-
ject in the last twenty years have been the microscopical
histology and etiology, besides the reports of cases, epi-
demics, and therapeutics.

SUMMARY OF ETIOLOGY

Diphtheria is pre-eminently a disease of childhood. It
is not frequent amongst adults, very rare in old age.

It is not frequent in the first year. Still there are, for
physiological reasons, more cases before the third month
than between the third and seventh or eighth.

The sexes are liable to be taken in about equal propor-
tion. Laryngeal diphtheria is more frequent in boys.
Recoveries from it in girls.

Diphtheria is apt to recur in those who once had it.
Even membranous croup has been observed twice in the
same patients.

Some individuals, and even families, have a certain de-
gree either of immunity or predisposition.

Exposure and " colds " may act, but as proximate causes
only. Most cases take place in the winter months in our
climate, but there is no " invariable season law."

Filth " contributes to the generation of diphtheria, as
it does to dysentery and typhoid fever.

The question of a live origin of contagious disease in
general was raised by Henle in 1840, also by Sir H. Hol-
land, and Eisenmann.

Some pathologists find the morbific source of diphtheria
in bacteria. " No bacteria, no diphtheria." This is not

SOO

" SUMMARIES " ON DIPHTHERIA

truer than that fermentation or putrefaction depend on
bacteria only.

The presence of bacteria in the diphtheritic blood has
not been proven. There is no theoretical ground for as-
suming that preventing the bacteria of a diphtheritic patch
from making their way through the underlying mucous
membrane will, per se, prevent general diphtheritic in-
fection of the system. On the contrary, the septic and
putrid poison is claimed by A. Hiller as distinctly chemi-
cal. Of the same nature, viz., chemical, is very probably
the poison of those of the infectious and contagious dis-
eases in which the presence of a characteristic parasite is
a recognized fact, as anthrax and relapsing fever.

SUMMARY OF MANNER OF INFECTION AND CONTAGION

The entrance of the diphtheritic poison into the system
is not the same in all cases.

There are cases in which the origin of the disease is
decidedly local.

There are others in which the poisoning of the blood
through inhalation is the first step in the development of
the disease.

In many cases, both a sore integument and the lungs
are the inlets of the poison simultaneously.

It is probable that the configuration of the vestibules
of the respiratory apparatus, and the amount of active'
poison, and the duration of the exposure to it, modify the
intensity of the symptoms and the course of the disease.

Diphtheria is very contagious. Both the patient and
his surroundings, dwelling, furniture, towels, etc., convey
the disease. In dwellings it rises to the upper stories with
the current of warm air. The poison clings mostly to
mucous membranes. Mild cases may communicate seri-
ous ones and vice versa. The period of incubation lasts
two days or more. It may last a fortnight. Fresh wounds
do not require so long to be affected. In these cases the
supposition is, that the patient was already influenced by
the epidemic. Visible symptoms of diphtheria are often
noticed after the constitutional ones.

801

DR. JACOBI'S WORKS

SUMMARY OF SYMPTOMATOLOGY

The first invasion of pharyngeal diphtheria resembles
sometimes very much that of a catarrhal pharyngitis. The
latter is general. Local hyperaemia points to either trauma
or diphtheria.

Three forms of diphtheria are found in the fauces: the
" croupous/' the " diphtheritic," and the " necrotic."

Glandular swelling about the neck is not always very
marked. The above three species of diphtheria may each
be found in mild or severe attacks. The last is apt to be-
come septic and fatal. Nasal diphtheria is either the con-
tinuation of the process from the soft palate, or primary.
It is complicated with and characterized by rapid swelling
of the deep-seated facial glands in most cases.

A chronic catarrh of pharynx, nares, and larynx is some-
times observed after the acute attack.

Diphtheria of the conjunctiva terminates often in de-
struction of the sclerotic and prolapse of the iris. It is
frequently the only symptom of diphtheria, and purely
local.

The ear is affected either through the Eustachian tube,
or in and from the external auditory canal.

Diphtheria of the epiglottis is rarely found extensively
on the upper surface, more on the lower, and sometimes
in more or less isolated spots on the free margin. When
complicated with but slight laryngeal affection, tlie croupy
symptoms are but mild. They are apt to be of long dura-
tion.

Local (Edematous infiltration of the upper posterior por-
tion of the larynx interferes with inspiration more than
with expiration; membranous deposits in the larynx with
both, and result in the worst forms of " membranous
croup." Tracheal diphtheria is mostly the result of de-
scending laryngeal membrane. But there are cases of
primary tracheal diphtheria which, when ascending, re-
sult in speedy suffocation.

The lungs may be the seat of either broncho-pneumonia
from several causes, or fibrinous pneumonia. The diag-

302

"SUMMARIES" ON DIPHTHERIA

nosis is very difficult, both auscultation and percussion
yielding but doubtful results, unless there is a sudden in-
crease of fever and of respiratory movements. Blood
entering the lungs during tracheotomy may result in
broncho-pneumonia.

Diphtheria of the mouth is not frequently primary,
mostly secondary, and the deposits are first seen on sore
surfaces. The same is true in regard to the oesophagus.
Its upper portion is often affected in cases of pharyngo-
laryngeal diphtheria. Solid fibrinous deposits are met
with in typhoid fever, variola, and other infectious dis-
eases.

The intestine is affected with diphtheria (beside the
dysenteric process) in its upper and lower portions. In
animals very extensive intestinal diphtheria has been ob-
served.

Recent wounds are liable to be affected with every one
of the three forms of diphtheria within a day, or later,
after an operation. Local or general cutaneous erythema
is sometimes found. Complications of diphtheria with
erysipelas are not uncommon, and dangerous. The blad-
der, in cystitis, or after operative procedures, vagina when
eroded, prepuce when operated upon, and placenta are
the seats of diphtheritic deposits.

Albuminuria is frequent, is mostly not dangerous, ac-
companies sometimes a rapid process of elimination of the
poison, occurs often at an early period of the disease, does
not depend on, nor does it increase, the fever, seldom lasts
over a week, but is sometimes one of the symptoms of
diffuse acute nephritis of a very grave character.

The heart may suffer from defective innervation, granu-
lar degeneration, thrombosis, or endocarditis. The blood
may be of a dark color, but is not leukocythaemic.
Pseudo-leukaemia, however, has been observed during diph-
theria.

Thus the course of diphtheria is very various, progno-
sis doubtful, relapses are frequent, the temperature of
the blood is not pathognomonic, the amount and rapidity
of absorption and elimination changing.

The nerypug ^s^stem suffers often; sometimes in the very

303

DR. JACOBI'S WORKS

beginning of the disease collapse is developing, and may
lead speedily to a fatal termination.

Diphtheritic paralysis is considered peripheral by some,
central by others. It does not always commence in the
soft palate; the latter has been known not to participate
in the paralysis at all. The muscles of accommodation
are frequently affected, also the extremities, in some in-
stances sensory nerves, sometimes the respiratory apparatus
with dangerous results. Paralysis occurs mostly during
convalescence from diphtheria, exhibits no regularity in
the succession of the parts affected, does not injure the
sphincters, and is in most cases amenable to treatment.
While, in the majority of cases, the disease appears to
strike the trophic fibres of the motory nerves, the action
of the electric and galvanic currents is very variable. In
but a few cases ataxy has been observed.

SUMMARY OF PATHOLOGY

The membrane, or the granular infiltration, are charac-
teristic of diphtheria. Its contents are, more or less, fibrin,
changed epithelium, blood, mucus, and pus. The main
changes take place in the pavement epithelium, accord-
ing to E. Wagner. The epithelium is as rapidly re-
newed as changed. The views of histologists do not,
however, agree about the nature or the importance of the
epithelial transformations. The doctrine that the diph-
theritic process is caused, excited, or aided by bacteria is
either sustained or denied by many. The membranes pro-
duced by artificial irritation are considered by some iden-
tical with, by others to differ from, the genuine diphtheritic
product. The former view is held by the foremost clini-
cians.

Most organs are liable to participate in the diphtheritic
process, the blood (thin, black), the heart (granular,
fatty, hemorrhagic, thrombotic, endocarditic), the lungs
(several forms of inflammation, infarctus, oedema, emphy-
sema), the spleen and sometimes the liver (large, hy-
peraemic, soft), the kidneys (congested, nephritic), the
muscles (ecchymotic, degenerated, atrophic), the glands

304

" SUMMARIES " ON DIPHTHERIA

(swelled, ecchymotic, gangrenous, suppurating), the in-
testine and other viscera.

The several forms of diphtheria have a peculiar predi-
lection for certain organs or part of organs. This predi-
lection depends on the character of the surface and its
epithelium. The greater or less amount of elastic tissue,
the number or absence of muciparous glands and of lymph
vessels, the nature of the epithelium (pavement, ciliated,
or fimbriated), determine the character of the membrane
in the different locations. Copious secretion of mucus in-
duces early maceration.

The vocal cords are apt to serve as resting-places for
the diphtheritic poison, but constitutional infection is pre-
vented by the absence of lymphatics, and rapid macera-
tion by that of muciparous glands.

Nasal diphtheria is apt to be very fatal by the immense
net of lymphatics in the Schneiderian membrane, or by
direct absorption into the superficial blood-vessels.

Lymphatic glands swell very considerably, but suppurate
but rarely. They may serve as depots from which re-
absorption and relapses may take place.

SUMMARY OF DIAGNOSIS

Diphtheria is characterized by its membrane. The diag-
nosis from muguet is easy. Complications with follicular
stomatitis lare of occasional occurrence. Follicular in-
flammation of the tonsils is recognized by its local char-
acter, by the ready removal of the deposits, and the easy
introduction of a probe into the follicle. The congestion
in the diphtheritic pharynx is sometimes less pronounced
than in catarrhal pharyngitis. In the latter the hyperaemia
is general, in the former it may be local.

Fever is not always high. Sometimes the temperature
is even low in very bad septic cases. High temperatures
in the beginning are less frequent than, for instance, in
scarlatina. Glandular swelling may be absent for many
reasons.

Nasal diphtheria has much glandular swelling; may, in
some distinct cases, have none at all.

305

DR. JACOBI'S WORKS

Diphtheritic laryngitis has less fever than catarrhal
laryngitis, and when uncomplicated shows no glandular
swelling. The character of the laryngeal membranes does
not depend on the condition of the pharynx. Complete
aphonia and uniform difficulty of inspiration and expira-
tion indicates membranous obstruction; difficult inspiration
with easier expiration and but partial hoarseness or al-
most clear voice indicates the presence of local oedema
and consecutive paralysis of the vocal cords.

Primary diphtheria of the trachea is difficult to diag-
nosticate; it is likely to exist when after apparently ca-
tarrhal symptoms those of laryngeal stenosis occur very
suddenly and fatally. The progress of the diphtheritic
process downwards can be watched through the tracheot-
omy tube and estimated by the absence of irritability of
the mucous membrane of the trachea.

The diagnosis of pneumonia accompanying laryngeal
diphtheria is not impossible. In the other forms of diph-
theria it is recognized by its usual symptoms.

The cutaneous eruption of diphtheria is usually distinct
from scarlatinous eruptions, and the diagnosis easy in most
cases. Albuminuria is mostly an early symptom, and dis-
appears more readily than in scarlatina.

Diphtheritic paralysis is recognized by the previous his-
tory of the disease, by the frequency of its starting from
the pharynx, its irregular course, its mostly peripheric
character, and the absence of symptoms belonging to
bladder or rectum. It is mostly motory, sometimes sen-
sory or sensitive,

TREATMENT GENERAL REMARKS

Every case should be treated on general principles; thus
it is not possible to lay down a routine treatment for every
individual case. High fever should be reduced by spong-
ing and baths, quinine, and sodium salicylate; collapse
speedily treated, and severe reflex symptoms, as vomiting,
etc., checked at once. Whether to employ for this pur-
pose ether, wine, cognac, champagne, or coffee, must be
decided by the physician in individual cases. The ad-

306

" SUMMARIES " ON DIPHTHERIA

ministration of the remedy, whether by mouth, by injec-
tion into the bowels, or subcutaneously, as I have em-
ploj'^ed cognac, ether, alcohol, and camphor dissolved in
ether or alcohol, in some cases with decided and rapid
success, must depend on the condition of the organs and
on the urgency of the case. At all events, it may be stated
that all the above remedies are frequently of no service
because they have been administered too late, and in too
small doses, and hence we may infer that to obtain the
proper results both from external and internal treatment,
the remedy must be employed early and often, and in suf-
ficient quantity. If I have ever had cause to feel con-
tented with the results of treatment in diphtheria, it is
owing to the fact that I did not lose time. Moreover,
the nourishment of the patient is a matter of very great
importance, and should not be neglected, and no medicines
resorted to which are apt to derange the digestion of the
patient. It is true that caution must be exercised in the
food administered to febrile patients, but we must bear in
mind that, when the lymphatic vessels are kept empty, and
no new and proper material is introduced into them, the
absorption of locally existing poisonous substances is pro-
portionately increased.

I dwell particularly on the foregoing remarks for the
reason that, in diphtheria, unlike certain diseases having
a typical course and those of a simple inflammatory
character, expectant treatment should not be indulged in.
Oertel's advice, that when neither high fever nor compli-
cations are present we should quietly wait, and " act only
when new and most alarming symptoms present them-
selves," is decidedly perilous. A mild invasion does not
assure a mild course. Never has a " perhaps superflu-
ous " tonic or stimulant done harm in diphtheria, but
many a case had a sad termination because of a sudden
change in the character of the disease, putting the bright
hopes of the physician to shame. Only the philosopher
may be a passive spectator; the physician must be a
guardian. When I again read, in the work of the same
meritorious author, " that when in exceptional cases, in
children and young people, death is imminent, not from

307

DR. JACOBI'S WORKS

suffocative symptoms in the larynx and trachea, but from
septic disease and blood-poisoning, it is necessary to
resort to powerful stimulants," it strikes me that he is
frequently too dilatory with his remedies, and furthermore,
that his experience concerning the terrible septic form of
diphtheria, which is so frequently met with in some epi-
demics, must have been very limited at that time. In New
York, during the past twenty years, for every death from
diphtheritic laryngeal stenosis, there have been three from
diphtheritic sepsis or exhaustion. To generalize from a
few cases or years would be unsatisfactory. But few
authors have displayed the modesty of Krieger, who had
repeated opportunity for observation (" Etiological
Studies," Strassbourg, 1877), yet in his careful essay on
the " Predisposition to Catarrh, Croup, and Diphtheritis,"
refers to the insufficiency of his own observations.

When a modern writer (Ripley, Med. Rec, July 31st,
1880) teaches that " diphtheria is a self-limited disease,"
" which runs its course from a few hours to weeks," and
may " end in recovery, according to the character of the
epidemic and idiosyncrasy of the patient, even without
medicine," he certainly stretches the definition of a self-
limited disease to undue proportions, while in regard to
spontaneous recovery he states what may be said of any
and every disease. His teaching that the only rational
plan of treatment of diphtheria is a symptomatic one, is
dangerous, because it is apt to seduce into the neglect of
preventives, and of the timely resort to medication, to
say the least. It is true that the results of no treatment
cannot be uniformly successful, but at all events the indi-
cations for causal treatment are commencing to be known
at last. In that respect we have progressed somewhat be-
yond the most thoughtful therapeutics of the disease, as
developed in the course of the last century, and so well
illustrated by the " Tentamen medicum inaugurale de
cynanche maligna," by Thomas Wilson, Edinb., 17P0. He
says, p. 24 : " Cum hactenus nullum inventum est remedium
quod contagionem in corpus receptam suffocare possit;
cum medicamenta pleraque quae putredinem corrigere di-
cuntur, corpus ej usque functiones manifesto roborant; et

308

"SUMMARIES" ON DIPHTHERIA

denique, cum hunc morbum comitantur virium prostratio,
et, etiam ab initio^ summa functionum debilitas, qualis
evacuantia omnigena prohibet^ indicationem curandi unl-
earn, scil. debilitatis efFectibus obviam ire, proponam. Hinc
corporis conditioni obviam itur praecipue tonica et stimu-
lantia administrando." (As no remedy has yet been found
which can extinguish the contagion after it has been re-
ceived into the body, as most medicines which have the
reputation of correcting putrefaction, are roborants for
the body and its functions, and lastly, as this disease is
attended with great prostration and such debility of func-
tions as to preclude the use of all sorts of evacuants, I
propose but this one indication for treatment, viz., to meet
the effects of debility. This is fulfilled by the adminis-
tration of " mainly tonics and stimulants.)

While speaking of stimulants, I will say a few words
in regard to the dose to be given. There is more danger
in diphtheria from giving too little than too much. When
the pulse begins to be small and frequent, they must be
administered at once. A three-year-old child can com-
fortably take thirty to one hundred and fifty grammes of
cognac, or one to five grammes of carbonate of ammonia,
or a gramme of musk or camphor in twenty-four hours.
In the septic form especially, the intoxicating action of
alcohol is not observed, the pulse becomes stronger and
slower, and the patient becomes restful. In those cases in
which the pulse is slow, together with a weak heart's
action, the dose can hardly be too large. The fear of a
bold administration of stimulants will vanish, as does that
of the use of large doses of opium in peritonitis, of quinine
in pneumonia, or of iodide of potassium in meningitis or
syphilis. I know that cases of young children with gen-
eral sepsis commenced immediately to improve when their
one Imndred grammes of brandy was increased to four
hundred in a day.

The remarks I have made in reference to the general
treatment of diphtheria naturally render superfluous a
discussion of the value of abstraction of blood. For no-
body would dare to resort to jugular venesection, as our
predecessors did in the last century. It may be safely

309

DR. JACOBFS WORKS

asserted of the latter that it has no influence on the proc-
ess^ but frequently increases the local swelling and makes
the patient more anaemic. There is no case in which a
resort to it would not be criminal. I can distinctly recall
the time when bleeding and calomel formed the ground-
work of the treatment. Until the year 1862, the death
rate in Rupert, Vermont, from diphtheria was ninety per
cent., according to the reports of the local physicians, and
particularly of my pupil. Dr. Guild, who at that time
finished his studies in New York and commenced prac-
tising. When, in the same epidemic, bleeding and calomel
were replaced by stimulants and iron, with chlorate of
potassium, ninety per cent, recovered.

That attention must be paid to the general condition,
mainly during a retarded convalescence from previous sick-
ness, is self-evident. Any complications, too, must be sub-
jected to early treatment. Diarrhcea must be mentioned
among these; it reduces the patient's strength very quickly;
likewise, the early appearing nephritis which may sud-
denly end life.

One important axiom must be borne in mind, namely,
that prevention is more easy than cure. I do not refer
simply to the removal of the healthy members of the
family beyond the danger of infection, or to the isolation
of the patient. If the latter becomes necessary, the first
indication is his removal to the top floor of the house.
There are, in addition, however, certain prophylactic meas-
ures which will prove valuable in the hands of every good
physician. It is necessary under all circumstances that
the mouth and pharynx of every child be constantly kept
in a healthy condition. Eruptions of the scalp must be
treated at once, and glandular swellings of the neck caused
to disappear. But lately some cases of laryngeal diph-
theria have been traced directly to the presence of sup-
purating bronchial glands, with or without perforation
(Weigert, in Virch. Arch., Vol. 77, p. 294, 1879). The
same rule applies to nasal and pharyngeal catarrhs, the
treatment of which should be begun in warm seasons,
when general or local remedies yield better results. En-
larged tonsils should be resected, or, where that cannot

310

" SUMMARIES " ON DIPHTHERIA

be done, scraped out with Simon's spoon, at a time when
no diphtheritic epidemic is raging. It is important that
this take place at a time when, even though sporadic cases
of diphtheria occur, the danger of infection is not great;
for, during the height of an epidemic, every wound will
give rise to general or local infection. This holds true
for wounds of any part of the body, as well as of the
mouth. I therefore avoid an operation at such a time,
provided it can be postponed.

Prevention, after all, is but in part the business of the
physician. It is mostly that of the individual, or the com-
plex of individuals, viz., town, state, nation. Those sick
with diphtheria must be isolated, though the case appear
ever so mild, and if possible, the other children sent out
of the house altogether. If that be impossible, let them
remain outside the house, in open air, as long as feasible,
with open bedroom windows during the night, in the most
distant part of the house, and let their throats be exam-
ined every day. The watching eye of a father or mother
will discover deviations from the norm, so that the physi-
cian can be notified. Let the temperatures of the well
children be taken once a day, in the rectum. Ten minutes
of a mother's time are well repaid by the discovery of
a slight anomaly, which may require the presence of the
physician. Happily, there are many mothers who keep
and value a self-registering thermometer as an important
addition to their household articles. The attendant upon
a case of diphtheria must not get in contact with the
rest of the family, particularly the children, for the poison
may be carried, though the carrier remain well, or appar-
ently well. Unnecessary petting of the patient on the
part of the well ought to be avoided, kissing forbidden,
the bed-clothing and linen to be changed often, and dis-
infected, the air cool and often changed.

The well, or apparently well, children of a family that
has diphtheria at home, must not go to school nor to
church. The former necessity is beginning to be recog-
nized by the authorities and teachers, and also in conse-
quence of partially enforced habit by parents, the latter
will be resisted longer. Schools ought to be closed en-

DR. JACOBI'S WORKS

tirely when a number of cases have occurred. Even when
the school children have not been affected to a great ex-
tent, but a diphtheria epidemic has commenced in earnest,
it will be better to close the schools for a time. If that
be not advisable, the teacher ought to be taught to examine
throats, and directed to examine every child's throat in
the morning, and return home every one barely suspicious;.
In times of an epidemic, every public place, theatre,
ballroom, dining-hall, tavern, ought to be treated like a
hospital. Where there is a large conflux of people, there
are certainly many who carry the disease with them. Dis-
infection must be enforced by the authorities in regular
intervals. Public vehicles must be treated in the same
manner. That it should be so when a case of small-pox
has happened to be carried in such, appears quite natural.
Hardly a livery-stable keeper would be found who would
not be- anxious to destroy the possibility of infection in
any of 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 poor hack, is more so in that of
railroad cars, whether emigrant or Pullman. They ought
to be thoroughly disinfected in times of an epidemic, in
regular intervals, for the high roads of travel have always
been those of epidemic diseases, and railroad officers and
their families have often been the first victims of the
imported scourge. Can that be accomplished.'' Will not
railroad companies resist a plan of regular disinfections
because of its expensiveness ? Will there not be an out-
cry against this despotic violation of the rights of the
citizen, the independence of the money bag.'' Certainly
there will be. But there was also, when municipal author-
ities commenced to compel parents to keep their children
at home when they had contagious diseases in the family,
and when a small-pox patient was arrested because of en-
dangering 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 be-
gins at last, even in America, to believe in the rights
of the commonwealth, and not in the rights of the demo-
cratic person only. The establishment of State and Na-

312

"SUMMARIES" ON DIPHTHERIA

tional Boards of Health proves that the narrow-hearted
theories of the strict constructionists have not only dis-
appeared from our politics, but also from the conscience
and intellect of society.

The sick-room must be kept cool, the windows kept
open — more or less — in the night, the floor frequently
washed, the linen soaked at once, the excrements removed.
Dead bodies ought to be kept moist, for infectious ma-
terial, chemical or otherwise, will spread more easily when
dry. Attendants must not talk unnecessarily over the
mouth or diphtheritic wounds of the patient, and will do
well to carry a little dry loose cotton — to be changed often
— in each of the nostrils, for it prevents the transport of
infection from septic material to such as would be con-
sidered exposed undei" ordinary circumstances (Wernich
in F. Cohn's Beitr., III., 1859). A very urgent and im-
portant mode of prevention consists in disinfection.

THE TONSILS

In mild cases of diphtheria of the tonsils I at times en-
deavor to destroy the membrane, but only when it can be
reached with ease. In my opinion, the indiscriminate use
of mineral acids and lunar caustic has done more harm
than good. Where I can easily reach the membranes, I
usually apply concentrated carbolic acid; where the mem-
branes are not entirely within reach, I desist from this
procedure. A scratching of the mucous membrane and a
wounding of the epithelium would assist in spreading the
membranous process in a very short time to the surround-
ing parts. I have already discussed the tendency of the
disease to extend rapidly, and the danger of creating fresh
wounds. In most cases of simple tonsillar diphtheria, I
administer small doses of chlorate of potassium or sodium
in water, or the tincture of the chloride of iron, so that
from two to eight grammes (5 ss.-ij.) are taken in a day.
I add a little glycerine, partly for the sake of keeping the
remedial agent longer in contact with the diseased sur-
face, partly for its own antifermentative effects, and give
it in short intervals. The accompanying fever is usually

313

DR. JACOBI'S WORKS

not high, and the neighboring glands are as a rule but little
swollen or not at all. When there is a slight swelling of
the lymphatic glands, cold water or ice applications are
usually all that is needed. The latter should be made
according to general indications. The glandular (and
peri-glandular) swellings are less the result of an actual
filling-up with foreign matter than of secondary irritation.
Ice has a happy effect in such cases, both on internal ad-
ministration, in the form of frequent small quantities of
ice-water, ice-pills, ice-cream, and iced medicaments, as
also externally by ice-cold cloths, or india-rubber bags filled
with ice.

In general, the treatment of the swelled glands must be
both based on its causes, and adapted to the present con-
dition. The adenitis and periadenitis is of secondary na-
ture, the irritation being in the mouth, pharynx, and nares.
In these localities it is where the main treatment is re-
quired. The sooner the primary affection is removed, or
relieved, or rendered innocuous, the better it is for the
secondary complaint. Frequent doses of chlorate of po-
tassium, or sodium, or biborate of sodium (or benzoate?)
in mild doses frequently repeated, according to the prin-
ciples laid down in another part of my Treatise, mouth
washes, gargles, nasal injections with water, salt water, or
solutions of disinfecting substances are not only indicated,
but highly successful. When the case is recent, cold ap-
plications are required, but no washes. When it is of
older date, stimulant embrocations are in order. Iodine
ointments are absorbed but slowly; mercurial plasters do
good in some cases ; iodide of potassium dissolved in
glycerin (1:3-4), frequently applied, iodine in oleic acid
(1:8-12), iodoform in collodion or flexible collodion
(1:12-15) applied twice daily, the latter frequently with
very good result, are beneficial.

DIPHTHERIA OF THE NOSE

results either from an extension of the morbid process from
the pharynx, or occurs primarily. It occasionally mani-
fests itself by a peculiar, thin, flocculent discharge, not

314

"SUMMARIES" ON DIPHTHERIA

necessarily copious, and at times even trifling, and very
often by a very early swelling of the glands of the neck,
especially those behind and beneath the angle of the jaw.
Nasal diphtheria often occurs where the nasal mucous
membrane has for a long time been the seat of catarrh.
Especially during the prevalence of an epidemic of diph-
theria must we be careful not to allow a nasal catarrh to
have its own way; we must likewise guard against con-
sidering the thin and flocculent discharge in infected cases
as a mucous secretion. Whatever be the origin of nasal
diphtheria, whether primary or the result of a similar
affection in the throat, local treatment should at once be
instituted, and if this be done, the great majority of cases
will terminate favorably. The danger in this form of
disease consists in an excessive absorption of putrid sub-
stances, and in the breathing of contaminated air. The
indications for treatment are clear and decisive. The in-
terior of the nasal cavities must be thoroughly cleaned
and disinfected. If this be commenced early, the original
seat of the affection may be reached, and the disin-
fectant process will, as a rule, have good results. It is
not necessary to select very energetic disinfectants ; a so-
lution of twelve to twenty-five centigrammes (two to four
grains) of carbolic acid in thirty grammes (an ounce) of
water is at once mild and effective, and hardly gives rise
to more discomfort than luke-warm water. Nasal injec-
tions must be made very frequently, until each time the
stream of fluid has a free exit through the other nostril
or through the mouth. They must be made at least ever}'
hour, and even oftener if necessary; at the same time it
is advisable to be careful that the fluid does not enter
the Eustachian tube. This can be prevented, to a certain
extent, by compelling the patient to keep the mouth open
during the procedure. I have seldom seen evil, or only
disagreeable results from the administration of nasal in-
jections in diphtheria. Still, a medical friend assures me
that he has seen convulsions to follow an injection, an
occurrence I never met with. It is likely that the mucous
membrane of the pharynx is swollen as far as the openings
of the Eustachian tubes, to such a degree as to render

815

DR. JACOBI'S WORKS

the entrance of fluids into the latter improbable. The
hardness of hearing, which is of so frequent occurrence
in the course of a severe catarrh or diphtheritic attack,
seems to indicate that the mucous membrane of that part
is in a state of swelling. An ordinary syringe will suf-
fice. However, when administered by parents or nurses,
the blunt nozzle of an ear syringe or nasal douche is
preferable; furthermore, by using the latter, the distribu-
tion of fluid is more equal. Occasionally here, as in local
applications to the mouth and pharynx, the atomizer may
be used to advantage; but the tube must be properly
introduced into the nostrils. There are cases of nasal diph-
theria, however, which are far more troublesome to manage
than the foregoing would seem to indicate. I have seen
cases in which the nasal cavities, from the anterior to the
posterior nares, were filled and completely occluded by a
dense solid membranous mass. I was then compelled to
bore a passage with a silver probe, to gradually introduce
a larger-sized one, and then to apply the pure carbolic
acid, in order to remove the densest and thickest masses,
and finally was able to make injections; even in such cases
I have often had the gratification of being able to give
a favorable prognosis. The dangerous secondary swell-
ings of the glands will often subside after a steady em-
ployment of disinfectant injections for from twelve to
twenty-four hours, but it must not be forgotten that these
injections require to be made very frequently, either every
hour or half-hour. We must not be drawn from our line
of duty by the patient's desire for rest and sleep, but
must continue the treatment uninterruptedly. It will be
found that the children frequently do not object to this
method of treatment; I have even met with some who,
after convincing themselves of the relief afforded thereby,
asked for an injection. When we are about to bring each
injection to a close, it is well to press together the nasal
cavities for an instant with the fingers. By this procedure
the fluid (unless doing so spontaneously) is forced back-
wards to the pharynx, and is swallowed or ejected through
the mouth and thus washes the pharynx and mouth at the
same time. Frequently, however, this latter object is

316

" SUMMARIES " ON DIPHTHERIA

obtained with every inj ection ; for, the palate being swelled,
(Edematous, and paretic, the fluid is not prevented from
reaching the pharynx, even in the average case. In regard
to the choice of a disinfecting agent, I have but a few
words to say. I believe that no one of them has important
qualifications above the others. I avoid those which stain,
and produce firm coagula. For the latter reason I do
not use the subsulphate and perchloride of iron; for the
former, the permanganate of potassium. I employ, as a
rule, carbolic acid in solution, of the strength above men-
tioned. Where there is but a slightly fetid odor, I have
frequently employed lime-water, or water, with glycerin,
or a solution (1:100, 1:50) of sodium chloride, or sod.
bicarb., also sod. borate. Disinfecting agents and anti-
septics, whether carbolic acid, salicylic acid, or iron, are
of no service when administered internally only, unless
the seat and cause of the septic infection be attended
to previously. I refer to what I have said above in re-
lation to iron and salicylic acid. Under the local em-
ployment of antiseptics, as described, or by simply wash-
ing out with water, or salt water, most cases recover;
without them, death will result. This much my experience
has assured me of, that there is a certain number of cases
which terminate fatally; but it is likewise true that the
mortality need not be excessively great. It is a great sat-
isfaction to me to learn from a recent paper of R. J.
Nunn {The Indep. Pract., Sept., 1880) that my method is
appreciated and valued to its full extent. The author
speaks very highly of the local treatment with iodine and
boric acid. I cannot grant that it is hard to carry out
the exact and apparently barbarous treatment necessary
for a favorable result, for it is certainly more barbarous
to sacrifice than to save life.

It is a positive fact that when children suffering from
nasal diphtheria, with its peculiarly septic character, are
permitted to sleep much — and they are apt to be drowsy
under the influence of the poison — they will certainly die.
To allow them to sleep is to allow them to die.

The first symptom of improvement is often a rapid
diminution of the glandular swelling. But not in all cases

817

DR. JACOBFS WORKS

of nasal diphtheria these glandular swellings will be so
prominent; in fact, it would be expecting too much to
suppose that all at once there should be a rule allowing
of no exception. The exceptions are of twofold nature:
1st. There is very little absorption through the lymphatic
ducts, and very little, if any, glandular swelling in such
cases where the very beginning of the disease is marked
by slight hemorrhages, or by a discharge of bloody serum
from the nostrils. In these cases, the blood-vessels are so
superficial that they rupture and aid in macerating and
sweeping off the membrane before absorption into the
lymph circulation can take place. These cases are not
always, however, mild in character. Open blood-vessels
do not only discharge, they are also apt to absorb; and
thus it is that many of these cases, be the glandular swell-
ing ever so slight, prove very serious, and thus also, that
they can be saved by very frequent disinfection only.
The second exception is formed by those cases in which
nasal diphtheria, or any other, attacks a mucous membrane
which has been the seat of chronic catarrh and intestinal
cellulitis, with consecutive thickening, induration, and
shrinking. In color, thickness, and consistency, a normal
tonsil, pharynx, or Schneiderian membrane differs greatly
from those which have undergone a hyperplastic tissue-
change. In the latter condition, blood-vessels and lymph
ducts are compressed and atrophied, and no longer a high
road into the system. It is, therefore, rather hazardous
on the part of as careful a practitioner as Dr. Ripley
(Med. Rec, July 24th, 1880) to declare it a folly to ex-
pect to cure the disease by any local application; or of
trying to prevent auto-infection in a system already charged
with the poison. For as there are cases in which its fever-
less character and the local changes clearly mark a case
as probably of merely local origin, local treatment, if it
could or can be applied, is indicated in just these cases;
and secondly, the " system being charged with the poison "
does not mean an unalterable condition; for while elimi-
nation is going on constantly, absorption of new poison is
keeping pace with it more or less. Not even death is an
unchangeable condition, much less a morbid process. Be-

318

"SUMMARIES" ON DIPHTHERIA

sides, Dr. Ripley says : " Even on the theory that these
children die of septicaemia, and that the poison is ab-
sorbed from the nasal cavities, is syringing out these cavi-
ties several times an hour indicated? Who thinks of wash-
ing out an infected uterus, or abscess of the pleural cavity,
or other organ, with any such frequency ? " Certainly no-
body, but nobody ever thinks of an equality of condition
in nasal diphtheria on one hand, and a puerperal uterus
or an abscess on the other. Even in the impossible case
that all the membranes were washed away by a nasal in-
jection, it is nothing new that the membranes will form
again and again, and thus there is always, in addition to
the former infection, a new one, and a necessity to meet
it. If the doctor says: " If carried out as recommended,
it must prove a most exhausting plan of treatment," I re-
fer him to what he relies on, viz., clinical observation, and
very much desire he should try and be satisfied.

DIPHTHERITIC PARALYSES

The treatment of diphtheritic paralysis is simple enough
in many cases; for sometimes nothing but patience and
waiting are necessary. The limbs are usually restored to
their normal condition, if the circumstances be in any way
favorable. Anaemia and debility are invariable concom-
itants, and the diet and medical treatment must be regu-
lated accordingly. We must not forget, however, that
overfeeding and a sameness of diet are not permitted, for
not rarely the muscular coat of the stomach suffers with
the rest of the muscular tissue, and the secretion of gas-
tric juice is very deficient in anaemic individuals. While
therefore, from a therapeutic standpoint, iron is indicated,
we must not neglect to pay particular attention to nutri-
tion and digestion, and to aid the latter with pepsin and
moderate amounts of muriatic acid, well diluted. Quinine
and stimulants are appropriate wherever there is no con-
traindication to their employment. The treatment of par-
alysis itself, where it is not deemed judicious to wait, will
naturally depend on the diagnosis of the condition in
question. This alone can explain why various modes of

319

DR. JACOBI'S WORKS

treatment, the electric current among others, after being
recommended by some authors, are branded by others.
Where we have to deal with those rare changes in the
brain and spinal cord, with apoplexy, " the utmost care
is necessary " in order " not to make the condition still
worse," and in such cases there would be a contraindica-
tion to the use of the faradic current, but this would not
hold true with regard to the use of the galvanic current in
short sittings. Besides, central paralyses are by no means
so frequent as peripherous ones. In most cases, there is
not the slightest elevation of temperature during the course
of the paralytic phenomena. I lay great stress upon this
point, for I am aware that many cases of central con-
gestions and inflammatory processes at times exhibit but
very insignificant elevations of temperature. But as the
diagnosis will depend on a positive knowledge of whether
there have been changes of temperature, I rely on the
rectal temperature only, for many a myelitis runs its
course with no greater elevation above the normal than
one-half or one degree. In all cases in which the temper-
ature is normal or subnormal, I do not hesitate for a
moment to employ the faradic or the galvanic current,
according to circumstances. In addition to the internal
administration of iron, I advise by all means the employ-
ment of nux vomica, in the form of strychnia. I cannot
indorse Oertel's warning against the use of strychnia, on
the ground that, as it acts centrally, it will positively give
rise to an increased irritation of the morbid process in the
spinal cord. The observations of a great many authori-
tise, and my own, which are rather extensive, cause me to
look upon strychnia as the most reliable remedy in diph-
theritic paralysis. Where there is no necessity for haste.
we may give moderate doses, gradually increasing, in
combination with iron; where there is danger in delaj^, it
is more judicious to have recourse to subcutaneous injec-
tions, administered at regular intervals. Henoch has seen
diphtheritic paralyses disappear in three weeks, under the
use of hypodermic injections of strychnia. This, which
has also been my experience on many occasions, cor-
responds with what Demme says (tenth report, 1873) in

320

" SUMMARIES " ON DIPHTHERIA

connection with the treatment of infantile paralysis. His
statements I have seen verified in the latter disease, in
cerebral paralyses and in diphtheritic paralysis. It also
agrees with the favorable results from subcutaneous in-
jections of strychnia in the temples in amaurosis, which
Nagel was the first to witness, and which since have been
observed by others, and by mj^self in several cases. I
especially advocate the use of injections where there are
urgent and dangerous jDaralytic manifestations, as in case
of danger depending on the paralysis of the muscles of
deglutition and of respiration. Of course, where the
former are affected, it is necessary to nourish the patient
artificially, partly, perhaps, by nutrient enemata, but prin-
cipally by means of the stomach-tube. In using the latter,
it is unnecessary to introduce it into the stomach, as it
onl}-^ requires to be passed a few inches below the af-
fected parts, when the oesophagus, far from manifesting
the repugnance displayed by the pharynx, undertakes the
further disposal of the food. In these cases, strychnia
should be injected subcutaneously in the neck, once or
twice daily. In a similar manner, it should be injected
in the region of the chest, diaphragm, or neck, in paraly-
sis of the respiratory muscles or of the glottis. In paraly-
sis of the muscles of accommodation (in which Scheby-
Buch claims to have seen the process cut short by the use
of calabar bean, considered as inert by Hassner) they
may be given in the forehead or temples.

Frictions dry and alcoholic, hot bathing, friction with
hot water, kneading of the affected parts, will be found
beneficial and pleasant.

SUMMARY

Every case should be treated on general principles, with
symptomatics, tonics, stimulants, febrifuges, externally,
internally, or hypodermically.

The uncertainty of the termination, and the frequency
of collapse or sepsis, prohibit procrastination. Waiting
long means often waiting too long.

Alcohol is a very important adjuvant and remedy. The
dose must often be apparently large, from two to twelve

321

DR. JACOBI'S WORKS

ounces daily, according to circumstances. Depletion is
absolutely contraindicated. Debilitating complications,
such as diarrhoea, must be stopped instantly.

Mouth and neck must be kept in a healthy condition.
Stomatitis, chronic pharyngitis, hypertrophy of the tonsils,
glandular enlargements must be relieved or removed pre-
ventively. Acute catarrh of mouth and pharynx requires
the use of potassium or sodium chlorate in doses not ex-
ceeding a scruple daily for a child of a year, one and a
half to two drachms for an adult, every hour, half, or
quarter hour. Large doses are dangerous, result often in
nephritis, and have proved fatal.

The main indication in local diphtheria is local disin-
fection. To disinfect the blood effectively we have no
means. Salicylic acid changes into a salicylate which is
no longer a disinfectant. The amount of disinfectants
required to destroy bacteria is so great that the living
body could not endure them; for instance, carbolic acid,
quinine, and sulphur. But the discipline of the house,
school, and social intercourse can be so modified as to pre-
vent the spreading of an epidemic. The instructions for
disinfectants published by the National Board of Health
are as simple as they are effective.

The inhalation of steam is very useful in catarrh of
the respiratory organs, and also in inflammatory and diph-
theritic affections. In fibrinous tracheo-bronchitis it has
proved quite successful. But it may prove dangerous by
excluding oxygen and overheating the room or tent. Drink-
ing of large quantities of water, with or without stimu-
lants, also incites the action of the muciparous glands and
aids in macerating membranes. The internal use of ice,
and its local application to the affected parts, can be very
useful. But the cases must be selected for each and any
of the remedial agents and applications. The use of
baths, and the cold or hot pack is controlled by general
indications. The usefulness of lime-water and lactic acid
has been greatly over-estimated. Glycerin is a valuable
adjuvant both externally and internally, but not more.
Turpentine inhalations are deserving of further trials,
though naturally they are more effective in purely inflam-

" SUMMARIES " ON DIPHTHERIA

matory than in diphtheritic processes. Inhalations of
ammonium chloride act favorably in catarrhal and infam-
matory conditions and deserve a trial for the purpose of
aiding maceration of membranes. Mercurials are contra-
indicated in the septic and gangrenous forms of diphtheria,
but in those which assume more the purely inflammatory
character with less constitutional debility and collapse, as
in " sporadic croup," or in fibrinous tracheo-bronchitis,
some reliable clinicians claim good results.

Astringents, such as tannin and alum, do not act favor-
ably.

Chloride ferric is amongst the most reliable antiseptic
and astringent agents. Small doses in long intervals are
quite useless. Moderate doses frequently repeated have
a satisfactory general and local eff'ect. A child of a year
must take at least four grammes (a drachm) of the tinc-
ture daily; a child of three or four years, from eight to
fifteen grammes. The same or a larger dose for an adult.
The chloride is to be mixed with water and glycerin in
various proportions, so that a dose is taken every hour,
every half-hour, every ten minutes. Thus the local appli-
cations to the throat become mostly superfluous. Potassium
or sodium chlorate from two to four grammes (3 ss.-i.)
daily may be added to advantage.

Carbolic acid is useful both in local and internal ad-
ministration. According to the object to be reached, it
may be used either in concentrated form, or in a one-per-
cent, solution. Internally, in doses of a few grains to half
a drachm daily.

Salicylic acid acts as a caustic when concentrated; in
moderate solutions it destroys fetor; salicylates are anti-
febriles only. The antifebrile effects of quinine are not
so favorable in infectious as in inflammatory fevers; its
antiseptic action is not satisfactory in practice.

Deliquescent caustics are dangerous. Injury of the
healthy mucous membrane must be avoided. Mineral acids,
and carbolic acid, when their application can be limited to
the desired locality, are preferable.

Bromine both internally and externally is warmly rec-
ommended by Wm. H. Thompson. ^

323

DR. JACOBI'S WORKS

Boric acid, in concentrated and milder solutions, has
been recommended as a local application to membranous
deposits generally, and to the diphtheritic conjunctiva in
particular.

Sodium benzoate does not deserve the eulogies bestowed
on it from theoretical reasoning.

Eucalyptus, sulphur, copaiba, and cubeb cannot be rec-
ommended.

Membranes must not be torn off, and not removed un-
less they are nearly detached. Caustics are contraindi-
cated except where their application can be limited to the
diseased surface. No healthy part must be injured.
Swelled lymph-glands require ice, iodine, iodoform, mer-
cury, poultices, incision, carbolic acid, according to cir-
cumstances, and at all events frequent and careful dis-
infection of the mucous membrane from which their irri-
tation originates. Diphtheria of the nose is apt to be fatal
unless careful treatment is commenced at once. It con-
sists of persistent disinfection of the nares and pharynx
by means of injections. The tendency to sepsis forbids a
long intermission of them. They must be continued day
and night for one or several days, no matter whether the
glandular swelling is considerable or not.

Laryngeal diphtheria proves fatal in almost every case,
unless tracheotomy be performed. It is the less success-
ful the more the epidemic or case bears a septic charac-
ter. Emetics, such as zinc and copper sulphate or turpeth
mineral, are useful for the removal of half detached mem-
branes.

Diphtheritic paralysis requires good and careful feed-
ing, iron, strychnine, the faradic or galvanic current,
friction, hot bathing. Urgent cases indicate the hypoder-
mic administration of strychnine.

Diphtheritic conjunctivitis is benefited by ice and boric
acid ; cutaneous diphtheria, by local cauterization and dis-
infectionj besides general treatment.

324,

LOCAL TREATMENT IN DIPHTHERIA

The bacilli and the toxine of diphtheria will invade
the circulation by direct inhalation into the lungs in but
very few instances. These are some of the cases in which
the constitutional symptoms precede the local. Local de-
posits, however, are not always visible, as, for instance,
in those cases in which the constitutional symptoms are
connected with diphtheria of the nose, where but few de-
posits take place, and the virus — the nasal discharge being
slightly bloody — is absorbed directly into the open blood-
vessels. In the vast majority of cases, however, local
deposits are easily found, and mostly on the mucous mem-
branes, rarely on that of the intestines, very exceptionally
the gastric, more frequently the genito-urinary, particu-
larly the vagina, rarely the bladder, in most cases the
pharyngeal or respiratory mucous membranes. Besides,
diphtheritic pseudo-membranes are found on abrasions of
the skin by scratching, eczema, erysipelas, vesicatories,
and in surgical wounds, such as circumcision and ampu-
tation wounds, tracheal incisions, resection of tonsils or
removals of adenoid growths. It is on the external wounds
that the effect of local treatment can be best studied.

The local remedies employed have been used for the
purpose of either directly destroying the pseudo-membrane,
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 lime-water and the chloride and subsulphate of
iron; or to disinfect, such as the potassic chloride, chloral
hydrate, turpentine, carbolic acid, mercury, sulphur, bro-
mine, iodide, iodoform, chlorine-water and peroxide of hy-
drogen. The methods of application have been either di-
rect local administration by the attendant, or washes and
gargles, sprays, injections, inhalations.

325

DR. JACOBI'S WORKS

The local treatment of the mouth and throat has two
indications, — first, to keep the mucous membrane of the
cavities in a healthy condition or restore them; second,
to influence the diseased surface. Gargles in any shape
will reach the oral cavity only. They never touch any-
thing beyond the anterior pillars of the soft palate, and
seldom more than a small part of the tonsil. The gargles
with chlorate of potassium, the benzoate or biborate of
sodium, 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 produce vomiting by their mere contact.
Even powders for internal administration require careful
mixing with water, or they are liable to irritate the
throat; thus, the direct application of calomel, the oxide
of mercury, or sulphur ought to be avoided. Applica-
tions of substances with bad taste or those that give pain
must be avoided, because the struggling and consecutive
exhaustion of the patient will do more harm than the
remedy will do good. That is so with a number of sub-
stances, particularly with the chloral hydrate and even
with the chloride of sodium, which was recommended some
years ago as a local application to the pseudo-membrane
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 10 to 15 grains of calomel,
under a tent or in a small room, are used to advantage.
Steam will also answer well under the same circumstances.
The second great danger is from exhaustion and heart-
failure, which is not merely functional, but organic. It
is always to be feared, for it is known that apparently
mild cases may thus perish. The indication, then, is
to save as much nerve strength as circumstances will

326

LOCAL TREATMENT IN DIPHTHERIA

permit. The third great danger is sepsis, which is not to
be feared to an equal degree in all cases, for those cases
of diphtheria which are confined to the tonsils, with its
large amount of elastic tissues surrounding it, and with
their scanty communication with the lymph system, are
not liable to produce sepsis, and thereby to terminate
fatally. Both sepsis and fatal termination are the re-
sults rather of those cases which are confined to or im-
plicate the nares and the naso-pharynx.

Where the diphtheritic pseudo-membrane is within reach,
it ought to be either destroyed or disinfected. For that
purpose a fifty-per-cent. solution of carbolic acid in glycerin
may be applied several times a day, or the tincture of
iodine, or solution of 1 part of the bichloride of mercury
in 100 or 500 parts of water. It is in these cases that
chlorine-water has been injected through the surface into
the upper layers of the tonsils. But we must never forget,
first, that only a small part of the pharynx is accessible
to such treatment, and that it is only one class of patients
who can be subjected to it. In order to be effective, the
application must be thorough. None but adults or large
children, and of them only a small number, will submit
to opening their mouth and having the applications made.
It is that very class of patients who can be induced to
gargle with anything like success. Smaller children will
object, will defend themselves, will struggle. It takes
many a good minute to force open the mouth; meanwhile,
the patient is in excitement, perspiring and screaming, ex-
hausting its strength. You may succeed in forcing open
the jaws; then there begins the practice of making ap-
plications, of swabbing, of scratching off the pseudo-mem-
brane, of cauterizing, of burning. The struggling child
will prevent you from limiting your application to the
diseased surface. You cannot help injuring the neighbor-
ing epithelium; thus the process will spread. Instead of
doing good, you have done harm; for indeed, no local ap-
plication can do as much good as the struggling of the
frightened child does harm. I have seen them die while
defending themselves against the attempted violence, leav-
ing doctor and nurse victorious on the battle-field. It is

327

DR. JACOBI'S WORKS

incredible, but it is true, that more than one has recom-
mended using the electro-cautery or the thermo-cautery
on the throat of the baby, after forcing the mouth open.
It is almost incredible, for you are aware that the of-
fenders 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 the
tonsils are not apt to favor the inception of sepsis into
the system.

There is an easy way of using disinfectants on the
throat and mouth; give medicines which are, at the same
time, disinfectants, digestible, and easy to take; give them
in small doses; give them frequently; see that when they
have been given, no water nor milk is taken immediately
afterwards, so as not to wash them off from the mouth
and throat. Such medicines are mild dilutions of the tinc-
ture of chloride of iron, or lime-water, or boric acid, or
bichloride of mercury, most of which will act both by their
constitutional and the local affect.

Diphtheria is most dangerous when located in the nose
and naso-pharynx. 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 toxines may take
place. In most cases, though, tlie diphtheritic membranes
are not so thick. Some of them macerate very readily,
and the toxine is very speedily absorbed through the exceed-
ingly copious lymph-ducts, and sepsis is the result. In
some cases of diphtheria 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 toxine is absorbed directly into the blood.
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 car-
ried down into the lungs, acts as an additional danger.
The most dangerous locality is the posterior nares, with
their direct communication with the lymph-bodies below

328

LOCAL TREATMENT IX DIPHTHERL\

the angle of the lower jaw. The pseudo-membranes, the
lymph-ducts, lymph-bodies, swarm with bacilli and toxine,
with streptococci, with staphylococci, and lead to immense
tumefaction between the ears and clavicles, to the forma-
tion of multiple abscesses, to hemorrhages, to sepsis. All
of these forms of nasal diphtheria require immediate, per-
sistent, and efficient local treatment, for it is safe to say
that every case of nasal diphtheria has a tendency to
terminate fatally. The local treatment is to consist in
cleansing and disinfecting. In most cases these two are
identical, for if we simply succeed in washing out the
macerating material, that would prove sufficient. In order,
however, to have that effect, the washing and disinfecting
must be done often, — every half-hour, every hour, every
two hours. In the bad cases, in which the nares are clogged
with pseudo-membrane, the cleansing and disinfecting is
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 partly to the septic condition. The methods
of local treatment, besides the one just described, are
the application of ointments into 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 feeding-cup,
through which liquids are poured into the nares.

In making local applications it is important that the
whole surface should be touched; therefore ointments are
not available in the average cases where the whole naso-
pharynx is the seat of the affection. The atomizer will
seldom convey a sufficient amount of liquid into the cavities
to be of much use. A spoon or small feeding-cup, the
nozzle of which is narrow enough to enter the nose, will
do fairly well, and will allow the introduction of liquids
into the nares in small or large amounts, all of which will
enter the throat, be either swallowed or flow out. The
irrigator 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 pseudo-membrane, but this will

329

DR. JACOBI'S WORKS

not always remain, and then there is a possibility of the
injection entering the middle ear. This will take place
the more readily the younger the infant, because the
pharyngeal orifice of the Eustachian tube is relatively larger
and more funnel-like in the very young than in advanced
age. I prefer a small glass syringe with a conical nozzle
of soft rubber. It will close up the nostril, the pressure
can always be well measured and modified, and it is ef-
fective. The injections must be made in the recumbent or
semi-recumbent position. On no condition must a child
be taken out of bed for the purpose of having the nares
washed and disinfected. I know of many cases in which
the patient has died simply from being taken up re-
peatedly.

The applications to be made may be quite simple. In
many cases a solution of table salt in water (7 to 1,000),
or boracic acid (3 or 4 to 500), or lime-water will answer
all purposes. The latter is particularly indicated when
there is a thin, acrid, slightly fetid discharge. A more
efficacious disinfectant than all of those mentioned is the
bichloride of mercury, 1 part mixed with 100 parts of
chloride of sodium in from 2,000 to 10,000 parts of water.
It can 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 by carbolic acid or creolin.

Carbolic acid may be used in solutions of from 1 to
10 in 1,000 parts of water, but it must not be forgotten
that there is some danger in swallowing the carbolic acid,
because of the nephritis which it may give rise to. For
the same purpose of deodorizing, creolin may be used in
one-per-cent. solutions.

For the purpose of dissolving membranes, papayotin (not
the proprietary medicine sold under a similar name) has
been used in five-per-cent. solutions, either as a spray or
injection, or direct applications by means of a sponge or
brush. I have used it to dissolve the diphtheritic mem-
branes of the trachea below the tracheotomy tube in greater
concentration. Its application in powder does not answer

330

LOCAL TREATMENT IN DIPHTHERIA

well. For the same purpose trypsin in five-per-cent. solu-
tions has been employed, mixed with bicarbonate of sodium.

The cervical lymphadenitis, of which I have spoken as
the result of nasal diphtheria, must be treated persistently
and effectively. This treatment may be preventive and
curative. The preventive treatment consists in the nasal
injections described. When large tumefaction has taken
place, tincture of iodine has been applied externally; it
is useless. Mercurial ointments have been applied; they
are useless, both as a remedy and as a means of massage.
Ice externally is rational, but it is useless as long as the
infection is not stopped. I have in a number of instances
injected iodoform, in ether, into the swelled mass. It is
too painful and too inefficacious, and does not pay for the
agitation, anguish, and exhaustion of the unhappy baby.
So, indeed, there is no remedy, besides the preventive
measures, except in long and deep incisions into the im-
mense mass. Do not wait for fluctuations or even semi-
fluctuations 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 most
cases from ear to clavicle. The disinfection of the wound
may be obtained by subnitrate of bismuth, by tincture of
iodine and iodoform, or other antiseptic gauze. No car-
bolic acid can be used for disinfection, because of its
tendency to give rise to hemorrhages. When hemorrhage
takes place, it is apt to stop, under pressure with anti-
septic gauze; but sometimes, large blood-vessels having
been eroded, the hemorrhages are very copious. In such
cases the actual cautery, iacupressure, sometimes the liga-
ture of blood-vessels, have 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 absorption is apt to take place.

The treatment of diphtheritic paralysis is in part local.
Friction and massage of the paralyzed limbs, either dry
or with oiled hands, or with alcohol and water, will re-
store circulation and nutrition to the muscles. The prin-

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DE. JACOBI'S WORKS

cipal indications for local treatment, however, are found
in those cases in which the respiratory muscles are par-
alyzed and life is in imminent peril. Fortunately, these
cases are rare, but they require immediate treatment. In
the neighborhood of the paralyzed muscles strychnine in-
jections can be made at brief intervals, and the electrical
current must be passed so as to stimulate the paralyzed
muscles. Care must always be taken, however, not to over-
stimulate, thereby paralyzing the muscles, which is the in-
variable result if the current is allowed to pass through
the tissues uninterruptedly.

332

LARYNGISMUS STRIDULUS

Scarcely in any chapter of infantile pathology do we
meet with more confusion than in the expositions on laryn-
gismus stridulus. The very large number of names that
has been applied to the very same symptoms, shows that
authors agree neither as to the nature of the affection, nor
its cause, nor even always as to its symptoms, or its seat.
Thus only is it possible, that the names of laryngismus
stridulus, apncea of infants, thymic asthma, crop-like in-
spiration of infants, crowing inspiration, spasm of the
glottis, paralysis of the glottis, suffocative asthma, stridu-
lous angina, internal convulsion, and many others, could
be applied to the same affection. Thus only was it pos-
sible to mistake laryngismus stridulus (asthma Koppii) for
spasmodic laryngeal catarrh (asthma Millari), and, as
several modern writers have done, to separate spasm from
paralysis of the glottis ; although it ought to be acknowl-
edged, at last, that the symptoms of glottic spasm and glot-
tic paralysis are not only the results of the same irrita-
tions, but also identical. It is, in my opinion, a fact
which I am sorry to state, that with a single exception
the authors on infantile pathology have been mistaken, at
least in the physiological explanation of the symptoms
of laryngismus. The exception is formed by Dr. Friedle-
ben, of Frankfort, a German, whose name I have had the
honor of bringing repeatedly before the profession of our
country, and whose eminent work, on the physiology of the
thymus gland in health and disease, I again recommend
to your attention. His expositions on our subject are, in
my opinion, so satisfactory and convincing, that I willingly
follow him, as far as I dare, in discussing one of the most
puzzling subjects of infantile pathology.

Laryngismus stridulus is emphatically a disease of infan-
tile age. It is observed in children, both healthy and sick,

8sa

DR. JACOBI'S WORKS

in their sleep or while they are awake, playing, eating,
singing. The first stage of an attack of laryngismus is a
sudden and entire apncea. Respiration is stopped suddenly,
entirely, for a few seconds, even for a minute, the face is
pale and bloodless, in attacks of long duration cyanotic,
the skin cool, the heart scarcely perceptible, the entire
muscular system in a state of paralysis. The second stage
is that of a beginning reaction to this thorough inactivity,
viz., the first action of the recurrent nerve stimulating again
the function of the muscles of the glottis, after which the
spinal nerves commence again to enliven the other respira-
tory muscles to such an extent as to produce a violent, deep,
" crowing " inspiration. In the third stage, finally, the
reaction is complete. Short convulsive expirations restore
the functions of the respiratory organs to their former con-
dition. Attacks of great intensity and long duration are
usually attended with contractions of the hands, and even
general tonic convulsions of the trunk (opisthotonus) and
lower extremities. Sometimes general eclampsia has been
observed to accompany the attack of laryngismus, but also
to return without another attack, or an attack to return
without eclampsia. Involuntary evacuations of the bowels
have been observed to occur during the attack. It is sel-
dom fatal, a large number of attacks have been observed
in a single day, and the disease is apt to last for months.
Whenever death ensues in the attack, it will be in the first
stage; but it may be caused also by exhaustion of the nerv-
ous faculties, or by tuberculosis, or other local diseases be-
ing the last cause of the attacks.

The symptoms of the first stage of laryngismus cannot
be explained except by a functional trouble, by paralysis,
perhaps of the oblongated spine alone, perhaps of the nerv-
ous centers together. We are unable to state what are the
alterations going on in the nervous system, but there is
no doubt that the influence of the period of life in which
laryngismus is observed, of insufficient or unappropriate
nutrition, of foul air and morbid taints are strong enough
to change or interrupt its functions, especially in such
cases where, as will be shown later, peripheric influences
will bring new irritations to bear on the suffering nervous

334t

LARYNGISMUS STRIDULUS

centers. Paralysis of the muscles of the glottis alone is un-
able to produce all the symptoms of the first stage of laryn-
gismus ; for by cutting a recurrent nerve such general symp-
toms could never be produced. And the dissection of both
the recurrent nerves gives rise to real suffocation, pretty
rapidly, but not at all suddenly; lungs and brain are
hyperaemic, the cutaneous veins and heart full of blood;
whereas post-mortem examinations in laryngismus show
a positive absence of hyperaemia in the brain, and anaemia
of the cutaneous veins and the heart. Death in laryngis-
mus ensues in the same manner as in animals whose ob-
longated spine has been cut. They die either instantane-
ously, both respiration and circulation ceasing at once, or
sonae few contractions of the extensors of the trunk and
lower extremities are early observed; repulsion or retention
of venous blood is nowhere found, neither in the brain,
nor lungs, nor heart.

The crowing inspiration, and the convulsive expirations
are symptoms of returning reaction, of the recommencement
of nervous functions. Thus the attack is at an end, but
not the disease. Crowing inspiration, after what I have
said about it, is therefore not at all pathognomonic to our
subject, nor is it right to mistake one for the other, but it
is certainly a very valuable symptom. A very similar proc-
ess is going on in asphyctic n,ewborn infants, in which
the first muscular exertions of the glottis, hitherto unsup-
ported by other respiratory muscles, give notice of begin-
ning life.

Uncomplicated laryngismus is never accompanied with
fever. Its duration is very various, some children being
affected but once in all their life, and recovering, some
dying in the first attack, and some suffering for months,
even years, from a series of mild or severe attacks, until
they will either finally recover, or perish in the last attack.
The disease is most frequent about the commencement of
the first dentition; that is to say, from the seventh to the
twelfth month of life. About this period the general growth
of the body is very remarkable; especially the osseous sys-
tem in all its parts undergoes a rapid development. The
tubular bones grow longer, the medullary cavity wider, the

335

DR. JACOBI'S WORKS

epiphyses thicker; the vertebral column, and the cranium
increase in substance and size, the circumference of the
thorax and abdomen becomes larger; and at the same time
the contents of the large osseous cavities, as brain, spine,
lungs, heart, thymus, and the abdominal viscera gain in
size and weight. This period is somewhat similar to that
of puberty, not only in its physical, but also in its psychi-
cal relations. Neuroses are very common in either of
these periods of life, where with the rapid changes in the
substance and volumes of the organs unexpected clianges
in their functions may be observed to take place. It is
no wonder, then, that the slightest causes may prove suffi-
cient to greatly influence the nervous centers, exposed as
they are to any irritations from any organ; a slight indiges-
tion, fright, refrigeration of the skin, morbid dispositions
of any kind will sometimes suffice to bring on an attack
of laryngismus, with its paralytic influence on the whole
number of respiratory muscles. No less astonishing, how-
ever, is the fact that laryngismus is not very seldom ob-
served at a somewhat later age. Such children as are
sufl^ering from a morbid taint, or rhachitis, or have been
retarded in their general development by severe diseases,
or injured in their health by either bad or superabundant
food, will reach dentition and the general rapid develop-
ment of the osseous system, at an unusually late time.
Thus the attacks of laryngismus will appear later, and
become the severer the more the nervous system has been
affected before. In both very early and very advanced
age cases of laryngismus have not often come under ob-
servation; but there are some related of newborn infants,
and up to the age of six or seven years.

The mildness or severity of the attacks of laryngismus
will depend on the constitution of the patients and occa-
sional causes ; if such was not the case every one would
resemble the other. The milder form will be particularly
recognized by a milder appearance of the first stage of the
attack, viz., the sudden paralysis of all the respiratory
muscles, and the unimportance of the accompanying carpo-
pedal or other spasmodic symptoms. Of this kind are
those mild attacks which are described by Rilliet and Bar-

LARYNGISMUS STRIDULUS

thez, Herard, and Ranking, and called " holding-breath
spells " by J. Forsyth Meigs. The first stage of the at-
tack is not very violent, and crowing inspiration is not
always perceived, but in the cases witnessed myself, I
have never missed the convulsive expirations forming the
third and last stage. " The most frequent cause of the
paroxysms is contradiction. They are determined also
by fright, pain, and crying," but I feel sure, after what
I have observed myself, that the first causes will be such
as have been named above. Further, in Dr. Meigs' opinion,
" they never occur spontaneously, and never during sleep,"
but I am sure that in the case of a tuberculous little girl
of five months the patient was very often, sometimes sev-
eral times during a day, awakened with a slight attack of
laryngismus, or " holding-breath spell." I have been un-
able to comprehend any other difference between an attack
of laryngismi's and of holding-breath spell but that of a
different severity of symptoms of the same affection. There
are cases, however, without any paralysis of the respiratory
muscles, but with crowing inspiration, which are to be
distinguished from laryngismus stridulus. They are not
the consequence of some trouble of the nervous centers,
neither original nor produced by peripheric influences, but
are those affections comprehended under the name of spas-
modic laryngitis, or asthma Millari, which is not a general
neurosis, but a local affection, viz., catarrh of the larynx
complicated with spasm of the muscles of the vocal
chords.

Amongst the peripheric influences which we have been
hitherto taught to consider of foremost importance in pro-
ducing laryngismus, is hypertrophy of the thymus gland.
Hypertrophy of the thymus was considered not only to be
a frequent occurrence, but of particular tendency to exer-
cise pressure on the recurrent nerve and thereby give rise
to attacks of laryngismus stridulus. Even some of the
latest medical journals report some cases of laryngismus
in which this anomaly is said to have been found out as
the cause of death. But Dr. Friedleben has satisfactorily
proved that the number of hypertrophied thymus glands:
that have ever been observed is very limited indeed, and

337

DR. JACOBI'S WORKS

that of all the cases in which the thymus was really hyper-
trophied, only seven-twelfths died of laryngismus. The
majority of thymus glands believed to be and described as
hypertrophied had not at all exceeded, nor even reached,
a normal development, and from careful observations and
measurements, the author arrives at the conclusion that the
thymus gland is not able, neither in its normal state nor
in its hypertrophied condition, to prevent respiration, to
disturb circulation, to cause a pressure on respiratory nerves,
to injure cerebral circulation nor the innervation of the
muscles of the glottis, nor to exhibit in its own substance
a periodical turgescence, produced by retention or repul-
sion of blood. The only periodical turgescence that really
takes place in the thymus, is produced, physiologically,
during the assimilation of food, but it has no influence in
bringing on attacks of laryngismus, as such attacks will
appear at any time and hour, before and after meals, and
with any kind of food.

The whole number of cases ever observed of really hy-
pertrophied thymus glands is about eleven or twelve. All
of them are congenital, and not at all pathological; only
one single case of inflammatory exudation into the tissue
of the thymus and its neighborhood, is known in the whole
range of literature, and even this case did not occur in
infantile age. In all of them, as far as it is stated in the
reports, the thorax was developed in accordance with this
anomaly, and in none of them, consequently, was there
any reason to try the eff"ect of therapeutical influences upon
this congenital, as it were physiological, anomaly.

The only nerve, by which spasm or paralysis of the mus-
cles of the glottis could be affected, is the recurrent. The
only nerves that could be reached and influenced by the thy-
mus gland, could be either the phrenicus, or the vagus
below the origin of the recurrent. The latter is situated
immediately on the trachea and protected on both sides in
such a manner as not to be troubled by either enlarged
bronchial glands or swelled thymus. The only pressure
possible may be produced by the enlarged thyroid and the
lymphatic glands into which it is naturally imbedded. They
will sometimes swell, undergo tubercular degeneration, and

S88

LARYNGISMUS STRIDULUS

give rise even to pathological alterations in the neurilema
and primitive fibres of the nerves.

Thus it appears that the name of thymic asthma is
wholly unscientific, as likewise the name of " asthma Kop-
pii " is not justified by the facts. For Kopp, who wrote
in 1830, has neither been the first to exactly describe this
disease, being preceded by Hamilton in 1818, John Clarke
in 1815, and Alexander Hood in 1827, nor the first to at-
tribute its symptoms to a presumed hypertrophy of the
tliymus gland. This has been considered as the cause of
laryngismus as early as in the seventeenth century by
Feiix Plater, 1712 by Budaeus, 1723 by Richa, 1725 by
Scheuchzer, 1726 by Verdries, about the end of the eight-
eenth century by Peter Frank, 1826 by Velsen, and 1827
by Alexander Hood.

It is not my opinion, however, that affections of the
nervous centers will always be the only causes of laryngis-
mus; it must be considered as an undoubted fact that dis-
turbances of the functions of the vagus and sympathetic
nerves give rise to the very same symptoms. Thus any
troubles of the alimentary canal, superabundance of food
although it may be of good quality, presence of a large
number of ascarides in the intestines, and obstinate consti-
pation produced by vicious nutrition and consecutive torpor
of the muscular layer of the intestinal canal will be reflected
on the nervous centers, and thereby produce the symptoms
of laryngismus. In such cases the results of post-mortem
examinations, and the symptoms during life are exactly like
those following genuine affections of the cerebrum; thus,
at all events, the nervous center is foremost, if not alone,
active in giving rise to the dangerous symptoms during life,
not to speak of those cases of laryngismus which directly
depend on craniotabes or hydrocephalus.

Dentition, too, is often reported to have been the cause
of laryngismus ; the symptoms being taken as reflex ac-
tions produced by the peripheric irritation of the n. tri-
geminus. If the degree of this irritation was such as it
is generally supposed to be, its importance and danger
would certainly not be overrated. But I am not of the
opinion of many, particularly English writers, as Marshall

S39

DR. JACOBFS WORKS

Hall, etc., and of the public at large, that dentition itself
is accompanied with the large number of dangers said to
be brought on by it. In our own country, even in our
large cities, we are used to see, almost every week, denti-
tion enumerated amongst the direct causes of death, and
the prejudice of both public and phj'^sicians lays too much
stress on the supposition that a physiological process will
by itself produce death. Therefore I feel justified in
reminding you of the fact that dentition is almost the
only visible sign of the general alteration which takes place
about this period of infantile age, especially in the osse-
ous system, and certainly it is feared by the public for
no other reason but because it lies open to the eyes of
everybody. There may be, in some rare cases, an abnormal
development of the maxillae and their alveoli, or abnormal
osseous deposits or infiltrations in the osseous tissue and
its canals, and some unusual irritation of the last ramifi-
cations of the n. trigeminus, but the influence of normal
dentition in producing diseases, and causing death, is cer-
tainly not such as is often supposed even by well-educated
medical men.

In some cases, described by Dr. Friedleben, a con-
genital hypertrophy of the thyroid gland has probably been
the cause of laryngismus. The patients were newborn in-
fants, of normal development and born by normal labors.
There were no constitutional causes of the disease, but a
remarkable vascular swelling of the thyroid gland. When-
ever the swelling increased, the veins of the face and head
increased in size also, the face grew livid and the extrem-
ities and spinal column exhibited slight tonic convulsions.
The recurrent nerves were entirely surrounded by the gland-
ular tissue, their neurilema looked unusually red, and their
function was probably injured during the occasional swell-
ings taking place during life-time. Moreover, the anatom-
ical position of the thyroid gland gives a great deal of
probability to the supposition, that whenever its volume
is unusually large it is able to exercise a pressure on the
trachea, and to give rise to retention of blood in the cere-
bral veins, to dyspnoea, to atelectasis, and to a slow car-
bonization of the blood. In such cases we are certainly

340

LARYNGISMUS STRIDULUS

justified in supposing the swelling of the thyroid gland to
be the cause that the nervous centers are not able to act
in a normal way, especially as the children were not in the
period of life when laryngismus is a more common occur-
rence, and when bad food, superabundance of food, and
eccentricities in the normal development may give rise to
paralytic symptoms in the respiratory functions. There is
certainly no less reason to believe in the abnormal function
of the recurrent nerve in such cases, where it is evidently
subject to some pressure from either the swelled thyroid,
or, in a later period of life, of the hypertrophied tracheal
glands.

The latest attempt to discover a general and uniform
cause of laryngismus in some local affection, has been made
by an English surgeon, Mr. Hood. He seems convinced
that the cause of laryngismus, which he considers as identi-
cal with crowing inspiration, is always found in enlarge-
ment of the liver. His pathology is as vicious as his
etiology erroneous, therefore I omit criticizing the opinion
of a single writer, os I consider it my duty to state
scientific facts only, with their logical consequences.

The difference of opinions on the treatment of laryngis-
mus stridulus is as great as on its nature and causes. The
majority of modern writers, considering the disease to be
spasm of the glottis, resort, in the attack, to derivants and
antispasmodics. Applications of spir. sinap., and ol. hyosc,
have been made, hand and foot-baths given, even the in-
halation of chloroform has been recommended. From the
remarks I have made on the nature of the disease, the con-
clusion must be drawn that no result at all can be expected
from the action of those agents. The performance of
tracheotomy, as recommended by some, is of no use, for
the same reason ; no artificial entrance for the air is needed,
where the inactivity of the respiratory muscles is the only
cause of the dreadful attack. Antispasmodics, as cherry-
laurel water, valerian, musk, asafoetida (given internally
and administered in injections) will also fail to answer the
indications. Bloodletting will certainly prove useless, ex-
cept in some cases complicated with severe eclampsia. I
feel almost sure that the first case of what is described

341

DR. JACOBI'S WORKS

as laryngismus, in the excellent manual of Prof, Meigs,
of Philadelphia, in the words of Dr. Pepper, who observed
it in a child of four months, has been somewhat endangered
by the application of sixteen leeches; to say nothing of its
really having been a case of spasmodic laryngeal catarrh,
or asthma Millari, instead of laryngismus stridulus, or
asthma Koppii. The only indication, in an attack of laryn-
gismus, is the thorough irritation of the respiratory muscles.
If electricity could be applied at the right moment, it would
be of great value. At all events the patient ought to be
kept in a sitting posture, and the access of air to be made
as easy as possible. Sprinkling of the face with cold water,
and application of ice or cold water to the sternum, will
act as powerful stimulants. If the respiratory muscles
could not be stimulated enough to recover their physiological
power, artificial respiration must be resorted to. There
are some undoubted cases in literature, of children who had
become asphyctic from an attack of laryngismus, but were
saved by artificial respiration being kept up until the tem-
porary paralysis of the central organs was removed.

Of much more importance than the treatment of a single
attack of laryngismus, is that of the general disposition
and of the cause of the affection. Such authors, as take
it to be a spasmodic affection, propose a protracted admin-
istration of antispasmodics, like those mentioned above;
Bouchut recommends the endermic use of morphia. Others,
attributing it to indigestion, or constipation, or diarrhoea,
or worms, prefer either carminatives, or aperients, or
astringents, or anthelminthics. Those who, like Mr. Hood,
consider hypertrophy of the liver to be the only cause
of laryngismus, do not know of anything more specific than
calomel, and naturally, those who take the hypertrophy of
the thymus as the cause of laryngismus, believe in iodine,
and iodide of potassium as their panacea. This appears
to be less indicated, for to what I have stated before I have
to add, that, with one single exception, all the cases of
hypertrophy acknowledged in literature are congenital,
and not the results of inflammation or exudation. Thus,
iodine, in such cases, is undoubtedly deprived of any effect,
and I have no doubt that wherever iodine has proved to be

842

LARYNGISMUS STRIDULUS

of any benefit in laryngismus, it has done so by its effect
on the small tracheal glands which are able, sometimes,
when hypertrophied, to exercise pressure on the recurrent
nerve. And, certainly, we cannot expect to have any in-
fluence in reducing the size of vascular swellings of the
thyroid gland, which is also a congenital anomaly.

Dentition, finally, is the nightmare of medical men
writing on laryngismus, as on almost every other infantile
disease, particularly in England. Marshall Hall directs,
in laryngismus, the gums to be incised, in different places
and directions, once, two, and even three times a day, and
expects a cure from this kind of scientific butchery. I
warn you most emphatically against following his advice
to the extent in which it is given. In some cases cutting
the gums may be indicated, and I practise it myself, but
this readiness to operate on helpless infants, who are so
unfortunate as to " teethe," that is to say, to be from five
to thirty months old, is a mistake that cannot be too much
reprimanded. I shall avail myself of some other occasion
to explain my views on this custom of " lancing the gums "
in a more explicit manner.

From the remarks I have made on the causes of laryn-
gismus, the therapeutical and dietetical treatment is dis-
tinctly indicated. Any cerebral disease that may be dis-
covered must be attended to; laryngismus consequent on
hydrocephalic condition of the brain will not be cured un-
less the other symptoms of hydrocephalus are removed.
Such is the case also with craniotabes, which will require
a continued treatment with phosphate of lime, and iron,
and tonics in general, before the symptoms of laryngismus
will be extinguished. Every anomaly, both material and
functional, that may have the effect of weakening the or-
ganism in general, and the nervous system in particular,
must be removed, and the general health taken care of.
Nutritious and digestible diet, antiscrofulous treatment, cod
liver oil, iron, and iodide of iron will prove powerful means
of restoring health in the hands of a scrutinizing prac-
titioner. Supposed or diagnosticated swellings of the tra-
cheal glands, pressing on the recurrent nerve, require the
constant use, for a long period, of iodide of potassium, or

343

DR. JACOBI'S WORKS

iodide of iron, and I need scarcely add, that all other in-
fluences of greater or less importance, as of fright, cold, in-
digestion, worms, must not be entirely overlooked, and are
deserving of particular attention, although they have so
often been greatly overrated. Thus it appears that much
circumspection is needed in selecting the means of removing
a disease which may have originated in consequence of many
coordinate influences affecting the nervous centers. One
case, as it occurred but recently in my practice, shows that
even mental education may be necessary, and sufficient,
to act beneficially on the cerebral functions. A little girl
of about eleven months was aff'ected with " holding-breath
spells " for a long time, and to such an extent as to be-
come asphyctic. I found out that the attacks always oc-
curred whenever the child was contradicted, or refused
anything she wanted to lay hands on. I then ordered a
pailful of cold water to be kept always in readiness and
poured over the fretful patient, as soon as any mental
irritation would show itself in occasions like those that
had always been sufficient to bring on the attacks. I may
be allowed to add that three or four administrations of the
same dose, in the course of a week, proved sufficient to
soothe the temperament of the patient, and to entirely
remove her attacks of laryngismus stridulus.

344

CATARRH OF THE INFANTILE LARYNX

The causes of laryngeal catarrh are very various. In-
halation of cold air, of dust, over-exertion of the voice,
entrance of a hot liquid into the larynx; cold of the ex-
ternal surface of the body, and particularly of the feet
and neck; progress of the catarrhal process of the nose
or bronchi, and sometimes even of the pharynx, on the
laryngeal mucous membrane; and finally, certain diseases
attended with decomposition of the blood, as measles, and
sometimes scarlatina, are amongst the causes of laryngeal
catarrh in children.

The anatomical lesions found in individuals who have
died while affected 'with catarrh of the larynx, do not al-
ways correspond with the symptoms during life. The
mucous membrane of the larynx is so full of elastic fibres,
that after death the blood is squeezed out of the capil-
laries. In very severe catarrhs, small apoplexies, or sugil-
lations, occur occasionally, and are visible even after death.
On the mucous membrane there is none of the normal
vibratile cylinder epithelium which forms the upper layer
of the epithelium in the larynx. The mucous membrane is
moist, succulent, loose; the sub-mucous tissue is seldom
(Edematous, but sometimes, even in quite an acute laryngeal
catarrh, small catarrhal ulcerations have been found. Thus
the anatomical lesions left in the mucous membrane of the
larynx after death fully correspond with those found in
the mucous membranes of other organs. Sometimes the
vestiges of catarrh are clear and distinct, sometimes noth-
ing is found in post-mortem examinations. An example of
this fact is the occasional absence of any post-mortem
results in children who have died in a severe attack of
cholera infantum. While in some all the signs of catarrh,
from simple hyperaemia to ulcerations of the follicles, are
discovered, in other cases no alteration at all is found.

345

DR. JACOBI'S WORKS

In chronic catarrh the mucous membrane appears darker,
livid, or brownish. The blood-vessels are varicose and full
of blood, and numerous enlarged follicular glands have been
found in the mucous membrane, which is covered with a
yellowish purulent secretion. As consecutive stages of the
catarrhal process we may mention chronic catarrhal ulcers,
polypous granulations, and thickening and induration of the
submucous tissue.

The acute catarrh of the larynx is seldom, from the be-
ginning, a feverish disease. The patients feel comfortable,
and the functions of the diseased organ are alone abnormal.
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 chords, which
the muscles are no longer able to force into as many vibra-
tions as before. Besides the itching and burning sensation,
and hoarseness, there is another symptom present — viz.,
severe cough, occurring in paroxysms, as if produced by
some foreign body touching the mucous membrane of the
larynx. Expectoration is not copious ; in the commencement
of the disease there is none, or it is clear and serous, con-
taining 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 expectoration becomes more
consistent, more purulent, and yellowish. Older children
only will remove at all the expectorated masses; children
generally swallow whatever touches their fauces, and it is
sometimes very difficult indeed to obtain any information
as to the nature of their expectorations. Physical explora-
tion of the larynx gives no result, or very little indeed.
Sight alone is of some use, as a few remarks will il-
lustrate :

Some five years ago (in 1854), after having attended a
young man suffering from secondary syphilitic symptoms,
I was much troubled by my patient's continual complaint
of his larynx. In order to examine his larynx by sight, I
had this instrument made. It is, as you see, a small oval
mirror, in a wooden frame, and with a flexible handle,
which, when applied to the soft palate and uvula, renders,

• 346

CATARRH OF THE INFANTILE LARYNX

after some exercise, the insight into the larynx possible.
The laryngeal mucous membrane was healthy, and has
proved to be so for five years. As I seldom afterward used
my instrument, and as I, indeed, never thought of render-
ing it profitable in other cases, and to the profession gen-
erally, I certainly do not pretend to have any priority re-
garding this invention. Dr. Manuel Garcia has published
a series of observations and experiments on the examination
of the larynx by sight, in the " Philosophical Magazine
and Journal of Science," vol. x. July to December, 1855.
London : " The method which he has adopted consists in
placing a little mirror, fixed on a long handle suitably
bent, in the throat of the person experimented on, against
the soft palate and uvula. The party ought to turn him-
self toward the sun, so that the luminous rays falling on
the little mirror may be reflected on the larynx. If the
observer experiments on himself, he ought, by means of a
second mirror, to receive the rays of the sun, and direct
them on the mirror which is placed against the uvula."
Dr. Garcia was followed by Professor Briicke, in 1856,
Dr. Tiirck, in 1857, and Professor Czermak, in 1858,^ by
whose experiments a great number of questions regarding
the physiology of the larynx have been answered. For it
is not only possible to see clearly the basis of the tongue,
the margin of the epiglottis, the arytenoid cartilages, the
posterior two-thirds of the vocal chords, Morgagni's fossae,
and a portion of the mucous membrane of the trachea, but
a large part of the posterior (or inferior) surface of the
epiglottis, and sometimes even the bifurcation of the tra-
chea. As to the best method of examining the larynx by
means of the mirror (or laryngoscope^ , it is more profitable
to use reflected light, which can always be brought to a
single point you are about to examine. The reflector be-
fore you is nearly plain, has a radius of about 1^ inches,
and is fixed to the forehead by means of a turning nut-joint,

i"Wien. Med. Wochenschr." 1858. Nos. 13-16. " Sitzungs-
berichte der Mathem. Naturw. Classe der Kais. Akad. d. Wis-
sensch. zu Wien." 1858. Vol. xxix., No. 12, page 557. " Phy-
siologische Untersuchungen tnit Garcia's Kehlkopf Spiegel." Wien,
1858. Pp. 30, and 3 plates.

847

DR. JACOBI'S WORKS

and an elastic strap encircling the head. This apparatus,
as modified by Dr. E. Krackowizer, of this city, is prefer-
able to the one used by the savans of Vienna, which is
perforated in its center, and applied directly to the eye.

There is no doubt that the diagnosis of severe laryngeal
affections is greatly facilitated by the apparatus now before
you, no matter whether the laryngoscope is made of glass,
like my old one, and Dr. Garcia's, or of German silver, as
those now generally used in Vienna, and by me also.

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 dyspncea, in consequence of simple
laryngeal catarrh. Although in them the glottis is short
and narrow, the swollen chordae vocales, by means of the
constant and uninterrupted action of the posterior crico-
arytenoid muscles, are sufficiently distant from each other
not to prevent the entrance of air. But sometimes children,
who have been coughing and hoarse during the day, with-
out feeling sick, will be observed to awake suddenly in the
night, with an attack of suffocation. Inspiration is ex-
tremely difficult and exhausting; in the utmost height of
their anxiety and trouble, the children will roll about,
jump upon their knees and feet, and grasp their throat;
their cough is hoarse, rough, and, as it were, barking.
These attacks have been and are very often mistaken for
croup, have been and are described as pseudocroup, false
croup, and usually disappear without leaving a trace, after
a duration of one or a few hours. These are the attacks
which readily disappear after the administration of hot
milk, by putting hot sponges over neck and throat, and by
emetics, and wliich have won for these remedies the repu-
tation of being infallible in croup, when given in time.
Physicians who are better business men than diagnosticians,
and more shrewd than honest, will readily support, by the
weight of their words, the opinion of the parents that the
child has been suffering from croup, and was saved from

348

CATARRH OF THE INFANTILE LARYNX

a speedy death. You may be certain that all tshe 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 suffo-
cation are produced by a momentary swelling of the mucous
membrane and narrowing of the glottis, which the mus-
cular action could not counteract, as sometimes a nostril
is thoroughly impermeable in consequence of a severe cold.
Perhaps eVen a reflected action is produced by the irri-
tation of the mucous membrane and spasm of the glottis
affected. But it is better explained in the following man-
ner: 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, cough-
ing, 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-
Such attacks will not unfrequently return, the children play-
ing around all day, and appearing to be perfectly healthy,
except a slight hoarseness.

As to the course, duration, and termination of the dis-
ease, it may be added that usually after a few days the
larynx ceases to be as sensitive, 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 or-
ganism has a great tendency to inflammatory affections,
and to the exudative processes, and that the infantile vocal
chords will not bear so well, as those of adults, a thick-
ening 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 only with difficulty. But
more serious consequences may follow the slightest dysp-

S49

DR. JACOBI'S WORKS

ncea continuing for a long time, a smaller amount of
oxygen enters the blood than is necessary for the combus-
tion of matter, and for a complete and regular physiolog-
ical metamorphosis of the organism. This is undoubtledly
proved by the assertions even of adult patients suffer-
ing from slight laryngeal catarrh, who will also experi-
ence suffocative attacks, and surprise you by showing a
mass of mucus brought up after long coughing, dry, hard,
sometimes slightly tinged with blood, and exactly bearing
the outlines of Morgagni's fossae between the superior and
inferior vocal chords, or some other part of the larynx.

In chronic laryngeal catarrh, the larynx is seldom sen-
sitive; there is no longer any burning, itching, or sore
feeling. But in consequence of the hypertrophy of the
mucous membrane and the thickening of the vocal chords,
there is constant alteration of the voice, which is rough,
and hoarse. This chronic hoarseness is sometimes the only
sign of chronic laryngeal catarrh, and wherever it is the
only complaint, or symptom, it is pathognomonic and ren-
ders the diagnosis easy. Every intercurrent, acute irrita-
tion of the laryngeal mucous membrane will thicken the
vocal chords to such a degree as to render vibrations totally
or nearly impossible, and deprive the patients, temporarily,
but entirely, of the voice. At the same time, also, a spas-
modic cough is observed, as in acute catarrh. But when-
ever, in cases of laryngeal catarrh, you meet with a sibi-
lant sound in inspiration or expiration, you may be sure
that you will have to deal with a complication of a serious
nature. It may be that there are exudations of the sub-
mucous tissue of such an amount as to render the glottis
exceedingly narrow, and to produce the sibilation in in-
spiration and expiration, and the vocal chords becoming
stiff and immovable in consequence of this degeneration,
even perpetual extinction of the voice. But generally this
symptom of sibilant inspiration and expiration, together
with some others, as night-sweats, general decline, will
necessarily direct your attention to some not suspected pul-
monary affection, and very generally tuberculosis. I may
be allowed to lay this stress on a fact not strictly belong-
ing to our subject, but you will meet with physicians of this

850

CATARRH OF THE INFANTILE LARYNX

and neighboring cities who, either wholly, or for the most
part, deny the occurrence of pulmonary tuberculosis in in-
fants and children. But I can assure you, who enter upon
a large practice in our climate, that you will have frequent
occasions to see cases of tubercles in the lungs of children,
perhaps every week.

Catarrhal ulceration, produced by catarrh of the larynx,
is not very often found in children; but it may be present
where it cannot be detected, because children are very un-
willing to have the throat closely examined. In an intelli-
gent little girl I could readily detect it by means of the
laryngoscope, which I have exhibited to you. Follicular
ulcers may be supposed to exist in the larynx, when there
are a large number of them in the pharynx, and when
difficulty of deglutition begins to accompany the chronic
catarrh of the larynx. The therapeutical results obtained
by our countryman. Dr. Horace Green, in this very disease,
as far as it occurs in adults, are well known to you, as
they have given this physician a well-deserved reputation,
as well in Europe as in our own country. The diagnosis of
both acute and chronic catarrh is not at all difficult in the
majority of cases; the laryngeal affection alters the voice
itself in such a manner as to render it indistinct and hoarse,
while in nasal and pharyngeal catarrh the resonance of the
voice only is affected. Frequently, however, acute catarrh
of the larynx is mistaken for croupous inflammation.
Whenever a child is hoarse and has a barking cough,
mothers are always afraid of the presence of croup, al-
though there be no other symptom of this much-dreaded
disease ; and particularly in cases where the above-mentioned
nightly attacks of suffocation make their appearance. On
this point I feel satisfied with merely adding a single re-
mark, with reference to symptoms : whenever there is diffi-
culty in diagnosticating between acute catarrh of the larynx
and croup, you may be almost sure of the catarrhal nature
of the case when but a slight trace of nasal catarrh is
observed at the same time, provided that a diphtheritic
discharge from the nostrils is not mistaken for the catarrhal
secretion of the mucous membrane.

After all, laryngeal catarrh is seldom a dangerous disease,

351

DR. JACOBFS WORKS

and fatal cases will always be rare occurrences; but con-
secutive troubles, as thickening of the mucous membrane,
and of the vocal chords, and narrowness of the rima glot-
tidis, may lead to serious trouble. Polypi, and papillary
tumors may even destroy patients, instantaneously, by sud-
denly occluding the rima glottidis. It is important, there-
fore, to attend to prophylactic and therapeutic measures.

In general, it is better to accustom healthy children to
the causes of laryngeal catarrh than to guard them too
cautiously. If they have been affected before, they must
be dressed according to the temperature of the atmosphere,
be exposed to fresh air, and accustomed to cold washing,
to river or sea baths. Such will be the most efficient pre-
ventives. Common cases of acute laryngeal catarrh, pro-
duced by atmospheric influences, require warm foot-baths
and slight diaphoretics, such as tea of elder or lime-tree
flowers, or tartar emetic in small doses, or the hydropathic
application of a cold, wet cloth, covered with flannel, round
the neck. Wherever a complication is found of pharyn-
geal with laryngeal catarrh, astringent gargles with, or
applications of, tannic acid, or alum, or even nitrate of
silver, will prove useful. No blood-letting, however, either
local or general, will be of any use. Fatty food is in-
jurious, while sour or acid liquids are useful. The tem-
perature of the sick-room is to be mild and equal and every
exertion of the larynx, speaking, crying, coughing, must
be avoided as much as possible. For the purpose of sup-
pressing the irritation of the laryngeal mucous membrane,
the best remedy will be found in the internal administra-
tion of narcotics. It is true, that narcotics, like opium,
are generally said not to be well tolerated by the infantile
organism, and there are a sufficient number of cases reported
in the journals to show that even a slight dose of narcotic
may be an overdose to an infant. But you will always find
a slight dose of Dover's powder, repeated several times
a day, to exhibit a favorable eff"ect in soothing the irri-
tability of the catarrhal mucous membrane of the lar3'nx,
and in suppressing or at least diminishing the trouble of,
and the danger from, continued coughing.

And now, gentlemen, allow me to avail myself of this

352

CATARRH OF THE INFANTILE LARYNX

occasion for adding some remarks on the doses of narcotics
that may be administered to patients of infantile age. The
skepticism of our time has a great tendency to do away
with our therapeutical agents, even with the materia medica.
You will often be told that there is no relying on medicines,
that for the most part it will matter little what you do,
that the longer you practise the more indifferent you will
become to the materia medica; in a word, that the effects
of medicines are uncertain. This incredulity in regard to
our therapeutics is wide-spread in our time, and must be
considered as one of the causes of the reign of nostrums
and quackeries of every kind. I dare not take your time to
explain this fact, but shall only express my firm convic-
tion, that the older and more experienced we become, the
more confidence we shall have in the unvarying effects of
medicines, in spite of what has been said to the contrary.

The cause of all this skepticism is found in the absence
of both an exact and a distinct diagnosis, and of strict
indications in the use of medicines. We shall always learn,
that wherever a medicine is really indicated, a good effect
will always follow a good dose, in such a manner that
this one principle. Few medicines , simple prescriptions , and
large doses, will find its full justification. The following
case proves this assertion ; a boy, two years and two months
of age, whom I have been attending for extensive ulcera-
tion of the colon, has taken for three weeks, and digested,
and assimilated, nine grains of opium, in liquid form, every
day. Thus it appears, that, with the exception of indi-
vidual idiosyncrasies, no medicament, especially no nar-
cotic, is to be feared when a real indication is fulfilled by
its administration; the much dreaded opium will lose all
of its supposed danger, and a dose of Dover's powder, as
recommended above, in acute laryngeal catarrh, may be
given with perfect safety.

In chronic laryngeal catarrh, Plummer's composition of
calomel and the oxysulphuret of antimony, joined to a dose
of extr. hyosc, extr. bellad., etc., has been in use for a long
time. The dose of the oxysulphuret of antimony being
very small, and calomel being not at all indicated in catar-
rhal affections of the mucous membrane of the respiratory

353

DR. JACOBI'S WORKS

organs, the good eifect, if any there was, has undoubt-
edly been due to the narcotic. Powerful derivatives, as
application of croton oil, or croton oil mixed with tur-
pentine, rubbed into the skin over the diseased part, will
answer in a large number of cases. So will, in very severe
cases, direct local applications to the diseased parts, either
of solutions of nitrate of silver, alum, etc., by means of
a sponge, or of the same remedies in solid form, or of the
powdered drug, if any intelligent little patient can be found
to inhale it through a quill. Blood-letting is unnecessary,
even in the frightful attacks of suffocation. A sudden ir-
ritation of the skin by means of hot water, or mustard, and
more than anything else, the administration of an emetic
consisting of tartar emetic and ipecac, will remove the at-
tack. After a suffocative attack, do not allow the child to
sleep for a long time, nor soundly; better arouse it from
time to time and offer some water in order to prevent the
mucus from drying up in the pharynx and remaining too
long in the larynx. Even such children as are subject to
periodical attacks, ought to be aroused from time to time
every night, to remove, or at least liquefy the mucus of the
pharyngeal membrane.

There are two other remedies on which I wish to make
some special remarks, because they have been unaccountably
overlooked except in a small portion of Europe ; I mean
the hydrochlorate of ammonia, or better, chloride of am-
monium, and of the oxysulphuret of antimony. The Dis-
pensatory of the United States (Eleventh ed. p. 91) men-
tions the resolvent, anti-neuralgic, anti-rheumatic effects of
the hydrochlorate of ammonia, and scarcely touches the re-
sults obtained by a French savan in chronic bronchitis.
I have no high opinion of other effects of this medicine
but those referable to the mucous membrane, particularly
those 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 diluted muriatic and the nitro-muriatic acid). But its
effects on the mucous membrane of the larynx, trachea, and
bronchia are inferior to none. They are wanted not only

354

CATARRH OF THE INFANTILE LARYNX

in simple catarrhal affections of the respiratory organs^
but wherever there are accidental troubles of the bronchial
or pulmonary functions in typhus, acute exanthems, and
intermittent fever, in short, wherever it is necessary to
facilitate and finally to lessen the mucous secretion and ex-
pectoration. Therefore it is indicated in bronchitis, pneu-
monia, pulmonary tuberculosis, etc.

Similar indications have been set forth by me at a former
occasion, for the use of the oxysulphuret of antimony. But
is cannot be urged too strenuously that certain distinct in-
dications will always limit the use of the two expectorants.
Whoever would contend against the fever of the first onset
of pneumonia, or acute bronchitis, with one of the two,
would soon become aware of his mistake. Their operation
is only to liquefy and facilitate the secretions of the re-
spiratory organs. For this very reason their adaptedness
in catarrhal affections of the larynx is readily understood
and justified.

The dose of the hydrochlorate of ammonia, in infantile
age, is from 9j-3j a day. The simplest manner of pre-
scribing it is to dissolve equal parts of the medicament and
extr. glycyrrh. in water. Narcotic extracts, or whatever
appears to be indicated, may be added to the mixture, or
the medicament may be heated over a slow fire and, evapo-
rating, inhaled by the patient, either directly or by filling
the room with the vapors of the salt. The oxysulphuret
of antimony is given daily, according to the age, in from
4 to 8 doses of gr. ss-j-ij-iij, each, in powder or mixture.
Diarrhoea, wherever it is present, contraindicates its ad-
ministration, as in this case there is a great tendency to
increase the intestinal catarrh.

Now, gentlemen, as I have given like indications for the
use of both the hydrochlorate of ammonia and the oxysul-
phuret of antimony, you will naturally ask whether there is
no difference at all in their effects, and whether those
remedies may be prescribed at random. First, the oxysul-
phuret is an antimonial preparation, and, like the others,
sedative and depressing; the hydrochlorate of ammonia is
a stimulant. To a feeble child suflPering from pneumonia,
or bronchitis, whom you expect very soon will require strong

355

DR. JACOBI'S WORKS

stimulants to keep him alive, you would give no antimonials ;
and in case of a robust, strong boy, whom it will do rather
good than harm to be lowered for a while in order to avoid
a new attack of the inflammatory fever, you will prefer
an antimonial to a stimulant. Again, by the decomposition
of blood accompanying the majority of epidemic diseases,
the constitution of almost every individual is shaken, and
the depressing and enfeebling influence of antimonials is
to be feared; then an expectorant ought to be a stimulant
from the first. During this last epidemic of diphtheria,
there were but very few cases in which the expectorant
eff"ects of the oxysulphuret of antimony could be put to
trial.

S56

ACUTE CATARRHAL LARYNGITIS
(FALSE OR SPASMODIC CROUP)

Pathology. — Catarrhal inflammations of the mucous
membrane and the submucous tissue of the larynx are of
frequent occurrence. They are either general or local;
that is, confined to the epiglottis or the vocal cords, etc.
The affected parts are red (only less so where the elastic
fibres are developed to an unusual degree and capable of
compressing the dilating capillaries) and more or less tume-
fied. Sometimes small hemorrhages occur. The secretion
is either changed in character or in quantity. It is either
mucous or purulent, or (mainly in passive congestions
produced by interrupted venous circulation) serous. The
epithelium is either thrown off or accumulated in some
spots, particularly on the vocal cords, so as to form whitish
conglomerates which may become the abode of schizomy-
cetae. The muciparous follicles are enlarged and dilated;
to this condition is due the granular form of laryngitis,
with the nodulated condition of the epiglottis or the fossae
Morgagni or the inferior vocal cords. ^

When the catarrhal process is of longer duration, the
capillaries and small veins become permanently enlarged;
round cells are deposited between the epithelium and cellu-
lar tissue ; the cellular tissue becomes hypertrophied ; pa-
pillary elevations are formed on the vocal cords. The
disintegration of the epithelium and the bursting of the
tumefied muciparous glands lead to the formation of ero-
sions and ulcerations; the chronic swelling and hypernu-
trition of the muciparous follicles to their destruction by
cicatrization or simple induration; and to atrophy of the
mucous membrane.

Many of the specific causes of inflammation of the
larynx exhibit no peculiar alterations of their own. Scar-
1 Ziegler, Pathol. Anat.
357

DR. JACOBFS WORKS

latina, measles, and exanthematic typhus are complicated
with either a catarrhal (in most cases) or a diphtheritic
laryngitis. Variola, however, has a peculiar form of its
own, with red, pointed, whitish stains or nodules, consisting
of a cellular infiltration or of a deposit upon or into the
upper layers of the mucous membrane, composed of ne-
crotic epithelia and pus-corpuscles or of coherent mem-
brane. Hemorrhages or abscesses are but rare, and chon-
dritis seldom results from it. Even syphilis has not al-
ways changes which are characteristic. The laryngitis
accompanying it is often but catarrhal, without anything
pathognomonic about it. But whitish papules consisting
of granulation-tissue (plaques muqueuses), gummata often
changing into sinuous ulcerations, particularly on the epi-
glottis and posterior wall of the larynx, also perichondritis
with loss of cartilage and deep cicatrization, such as are
not found in either carcinosis or tuberculosis of the larynx,
are frequently met with. Typhoid fever shows different
forms of laryngitis, from the catarrhal to the ulcerous.
Epithelium is thrown off at an early period of the disease;
erosions and ecchymoses follow; rhagades on the margins
of the epiglottis, and a deposit on the anterior wall of
the larynx and the vocal cords, consisting of epithelium
and round cells, are frequent. That they should be mixed
with micrococci and bacteria is self-understood. Not so
that these bacteria are to be considered as the cause of
the disintegration which is taking place, the less so as no
specific typhoid bacterium has been demonstrated, and
several varieties of them are found both in the mouth and
in these ulcerations. These changes are apt to terminate
in ulceration of the epiglottis and false vocal chords; these
will extend in different directions, and to the deeper tissue
down to the cartilage.

In tuberculosis, laryngitis is a frequent occurrence. In
most cases it is secondary to the pulmonary affection, and
due to the direct influence of the contagious sputum —
according to Heinze, however, not to contagion, but to
the influence of the infected blood. In other cases it
appears to develop spontaneously, before any pulmonary
affection is diagnosticated, and may then be due to some

358

ACUTE CATARRHAL LARYNGITIS

poison circulating in either blood or lymph. Tubercular
laryngitis^ according to Rindfleisch, commences in the ex-
cretory ducts of the muciparous glands. That this is so
in a great many cases is undoubted. The first changes
visible are small cellular subepithelial infiltrations or real
subepithelial tubercles, which, while growing undergo gase-
ous degenerations and ulcerate. These ulcerations are
either flat and small or deeper with an infiltrated edge,
and are apt to terminate in secondary nodulated infiltra-
tions and abscesses. Large tumors are not met with, but
oedema and phlegmonous inflammations are by no means
rare.

Etiology. — The predisposition varies according to indi-
viduals, ages, and seasons. Some mucous membranes ap-
pear to be more sensitive than others. The hereditary
transmission of peculiarities of structure of all or some
tissues or organs is apparent, in the case of laryngitis,
in the fact that many children in the same family or the
children of parents who were suff'erers themselves are af-
fected. Children are more liable than adults, infants
more than children: 20 per cent, of all the cases are met
with under a year, 25 from the first to the second, 15
from the second to the third. Not many occur after the
twelfth year. The narrowness of the infant larynx and
the looseness of its mucous membrane aff"ord full play to
injurious influences, such as dust, cold and moist air,
changing temperatures, hot vapors and beverages. Colds,
though their nature and effects can hardly be said to be
understood, are certainly amongst the main causes. Per-
spiring surfaces afford frequent opportunities. One of
the principal causes is insufficient clothing — more amongst
the well-to-do than amongst the poor. The latter have
this blessing in their misfortune, that they are protected
uniformly if at all, and have their skins hardened by ex-
posure. The bare necks and chests, the exposed knees,
the low stockings and thin shoes of the children of the
rich, old and young, are just as many inlets of laryngeal
catarrh, inflammatory disease, and phthisis. Persons suf-
fering from nasal catarrh or pharyngeal catarrh are liable
to have laryngitis. Thus, not only rhachitis, with its in-

359

DR. JACOBI'S WORKS

fluence on lymphatic glands and the neighboring mucous
membranes, but also acute infectious diseases, such as
whooping-cough, measles, influenza, erysipelas, hay fever,
tuberculosis, syphilis, typhoid fever, and variola, are as
many causes of laryngitis. That over-exertion of the voice
should produce laryngitis seems probable, but experience
does not teach that those babies who cry most are most
subject to laryngeal catarrh.

Symptoms. — Acute laryngitis is a frequent disease, and
has always been. Still, in 1769, Millar mistook it for a
sensitive neurosis, considering it as identical with spasm
of the glottis, and recommended antispasmodic treatment.
Guersant understood its nature better. He first (1829)
used the names false croup and stridulous laryngitis. Acute
laryngitis is attended with but little fever in the adult,
but with a high elevation of temperature in the young. In
all, it yields a number of symptoms, part of which are
uncomfortable only; others are liable to become dan-
gerous.

Seldom without any catarrhal premonitory symptoms of
other parts of the respiratory tract, sometimes, however,
without any, there is a burning, tickling, irritating sen-
sation in the larynx — a sense of soreness in it and the
lower portion of the pharynx. Sometimes these sensa-
tions amount to actual pain, to difficulty of deglutition,
and to the sensation of the presence of a foreign body.
Speaking, coughing, cold air, increase the discomfort and
pain. Hoarseness, sometimes increasing into aphonia, fol-
lows soon after, is seldom simultaneous with the first ap-
pearance of cough, but lasts longer than the latter, which
is, according to the severity of the case or the stage of the
disease, changing between loose and dry, hoarse and bark-
ing. Inspiration is apt to become impeded, mainly in in-
fants and children. In these it is often sibilant. It is
followed by a reflex paroxysm of cough, with interrupted
and brief expirations, during which the forcible compres-
sion of the thorax may result in cyanosis. The principal
attacks are met with at night amongst children. Quite
suddenly they wake up with a dry, barking cough, inter-
rupted by considerable dyspnoea, which is great enough

860

ACUTE CATARRHAL LARYNGITIS

sometimes to give rise to much anxiety. They toss about
or cling to a solid body, raise themselves on their knees,
breathe with great difficulty, exhibit cyanosis in its dif-
ferent hues, perspire very freely, and yield all the symp-
toms of the strangulating attacks of membranous croup,
its over-exertion of the sterno-cleido-mastoid muscles and
supraclavicular and diaphragmatic recessions not excepted.
These attacks occur but rarely during the day; on the
contrary, well-marked remissions are quite common in the
morning. Their occurrence during the night is best ex-
plained by the facility with which mucus will enter the
larynx from above during the reclining posture, the in-
creasing dryness of the pharynx during sleep, perhaps also
the nervous influence depending upon the relative diminu-
tion of oxygen and increase of carbonic acid in the respira-
tory centre, leading to spasmodic contractions.

Some of these grave attacks of sudden dyspnoea are
explained by the participation of the submucous tissue in
the morbid process. When that occurs, adults also, who
as a rule do not suff'er from dyspnoea in laryngeal ca-
tarrh, are badly aff'ected. The symptoms are rigor, high
temperature, pain, hoarseness or aphonia, a barking
cough, labored expectoration — which is sometimes bloody
— dyspnoea, orthopnoea, cyanosis. In some cases, to which
the name of laryngitis gravis or acutissima has been
given, the symptoms grow urgent to such a degree that
tracheotomy alone is capable of saving life.

Otherwise, the severity of the symptoms does not gq par-
allel with the local lesions. Particularly in children, hoarse-
ness, cough, and dyspnoea are liable to be grave, while
the local hyperaemia is not intense at all. A pharyngeal
catarrh is very apt to increase the suffering. Complica-
tions with tracheitis or bronchitis are liable to prolong
the course of the disease and to render respiration —
which is not accelerated in laryngeal catarrh — more fre-
quent. Otherwise, the disease runs a favorable course.
Remissions of the severe attacks which may occur in sev-
eral successive nights take place in the morning. Ex-
pectoration, which in the beginning was either absent or
scanty, becomes soon more copious and mucous; the hard,

361

DR. JACOBrS WORKS

barking, loud cough grows looser with increasing secre-
tion. In most cases the violence of the affection is broken
in from three to five days, and the disease runs its full
course in a week or two. But hoarseness may remain
behind for some time; in rare cases aphonia has become
permanent and relapses are frequent. Not infrequently
children are presented who are reported to have had croup
five or ten or more times. In some families all the chil-
dren are subject to laryngeal catarrh, and hereditary in-
fluence cannot be doubted.

The very worst complication of laryngitis is oedema of
the glottis. It affects both the mucous membrane and the
submucous tissue of the larynx. It is met with on the
inferior (posterior) surface of the epiglottis, in the ary-
epiglottic folds, and on the false (inferior) vocal cords,
the submucous tissue of which is of a very loose structure
normally. Amongst its causes — which may be various
(foreign bodies in the larynx, injuries, mechanical and
chemical irritants of any kinds; typhoid, tubercular, vari-
olous, syphilitic ulcerations ; erysipelas of the neighbor-
hood, inflammations of the parotids or tonsils, suppuration
in the pharynx, thyroid body, and cellular tissue of the
neck) — both catarrhal and croupous laryngitis are not at
all uncommon. This is particularly so when they are com-
plicated with cardiac and renal anomalies, pulmonary
emphysema, and compression of the veins of the neck by
glandular swellings; also with changes in the structure of
the walls of the blood-vessels. The last-named pathologi-
cal conditions are alone capable of giving rise to chronic
oedema of the larynx, which is by no means so fatal, but
still dangerous.

In glottic oedema the dyspnoea is both very great and
very sudden. First, it is inspiratory only, but soon be-
comes both inspiratory and expiratory. The swelling is
felt distinctly by the examining finger; the laryngoscope
isf neither required nor advisable.

Diagnosis. — It is by no means easy in all cases. When
laryngeal diphtheria (membranous croup) happens to be
frequent, the most experienced diagnostician will meet with
occasional difficulties. The sound of the barking, explo-

362

ACUTE CATARRHAL LARYNGITIS

sive, tickling cough locates its origin in the larynx, but
the affection may be very mild or very severe. Expec-
toration in small children is not pathognomonic; even
when it is copious it is not brought up, but swallowed.
Fibrinous expectoration would settle the diagnosis of a
croupous process. Depressing the tongue with a spoon or
spatula and producing the movements of vomiturition often
reveals the presence of a tough, viscid mucus rising from
the larynx. It renders the catarrhal nature of the laryn-
gitis positively clear. The frequency or volume of the
pulse is of no -account in diagnosis; it is too variable. Of
more importance is the temperature, at least in children.
Uncomplicated sporadic croup has no increase, or very
little; catarrhal laryngitis is mostly attended with high
fever. In very many cases this symptom has guided me
safely, in spite of the statements of the books. The ste-
nosis of catarrhal laryngitis comes on very suddenly, in
diphtheritic laryngitis mostly slowly. In the former it is
not of long duration; remission sets in soon, and is more
complete than in membranous croup. An attack of ste-
nosis occurs mostly in the night, and is apt to return
with the same vehemence after a fair remission after
twenty-four hours. The frequency of relapses in catarrhal
laryngitis in children who have been affected before must,
however, not prejudice in favor of the catarrhal nature
of an individual case, for not infrequently will those who
have had many attacks be taken with membranous croup
some other time. In the latter the main symptoms — viz.,
stenosis, hoarseness (or aphonia), and cough — will mostly
develop simultaneously and in equal proportion; the unpro-
portionality of these symptoms — for instance, much steno-
sis and cough, but little hoarseness, or barking cough and
hoarseness with little stenosis — would speak for catarrh.
The laryngoscope, when it can be used — viz., in the adult
and very docile children — reveals redness of the mucous
membrane of the pharynx and all or part of the larynx;
also tumefaction of the epiglottis or fossae Morgagni or
aryepiglottic folds. Sometimes the inferior part of the
larynx only is affected; Ziemssen has described a severe
form under the name of hypoglottic laryngitis. The vocal

363

DR. JACOBI'S WORKS

cords can be watched easily. Their proportionate and
parallel contraction is often interfered with.

Tubercular laryngitis, particularly when there is no pul-
monary tuberculosis, is not easily diagnosticated by the
local changes only. The long duration of hoarseness and
fever, increasing emaciation, and the knowledge of the
presence of tuberculosis in the family are more conclusive
than local examinations can be.

Prognosis. — The termination of catarrhal laryngitis in
the adult is almost always favorable. Still, relapses are
frequent, and it may become chronic, with permanent
tickling of the mucous membrane and submucous tissue.
In children it is mostly favorable; still, it is doubtful,
because of the frequency of complication with, or trans-
mutation into, bronchitis, pneumonia, or glottic oedema,
and because of the facility with which in a prevailing
epidemic the catarrhal laryngitis becomes diphtheritic. The
elevation of temperature is not a very significant symp-
tom in regard to prognosis. The danger does not increase
with the temperature at all. On the contrary, those cases
which set in with a high temperature will, as a rule,
terminate soon and favorably. When, however, the tem-
perature rises again after having gone down to the nor-
mal or nearly normal standard, complications or extension
of the catarrhal or inflammatory process must be expected.
Catarrhal secretion from the nasal mucous membrane,
which was dry in the beginning, is a favorable symptom;
so is the looser and moister character of the cough.

Treatment. — Whatever plays an important part in the
etiology of the disease ought to be carefully avoided.
The feet must be kept warm under all circumstances,
nothing being more injurious to health in general, and to
that of the respiratory organs in particular, than cold
and moist feet. Shoes and stockings must be kept dry,
the lattei* changed when wet, and of slowly-conducting
material. No part of the body must be kept uncovered,
and the dresses of .children made the particular object
of care on the part of the family physician. Linen must
not be in immediate contact with the skin, cotton — or,
still better in all seasons, wool — being required for the

364

ACUTE CATARRHAL LARYNGITIS

undergarment. At the same time, the hygiene of the skin
requires attention. Regular washing or bathing need not
be mentioned as a requisite, as it is self-understood. What,
however, cannot be insisted upon too much is this, that the
skin must get accustomed to cold water. The whole body
must be exposed once a day to cold water — washing or
bathing — and well rubbed off afterward with a thick towel.
Young infants and those who are very susceptible to colds
begin with tepid water, the temperature being lower from
day to day. Even children of three or four years enjoy,
finally, a morning bath at sixty or sixty-five degrees F.
in winter. Such as do not get easily warmed up under
the succeeding friction may mix alcohol with the water
they use for washing and sponging purposes, in the pro-
portion of 1 : 5-8. Sea-bathing also makes the skin more
enduring, to such an extent that exposure to cold air has
no longer any damaging influence. In fact, cold air with-
out wind is easily tolerated even by those who have a ten-
dency to respiratory disorders, while wind and draught
must be avoided. From this point of view the change of
climate sometimes required for such as suff'er from ca-
tarrhal laryngitis must be instituted. It is not always
necessary to select a very warm climate; undoubtedly,
many of the winter resorts are badly selected, for the very
reason that they are too warm. On the other hand, great
elevations are not advisable. The sudden atmospheric
changes and fogs of high mountains are injurious.

Patients suffering from catarrhal laryngitis or a ten-
dency in that direction must avoid all irritation of the
pharynx and larynx. They must not smoke, or talk too
much or too loud. Those few clergymen who suffer from
clergymen's sore throat in consequence of speaking only
will remember that they can speak just as forcibly when
speaking less vehemently. The use of alcoholic beverages,
unless greatly diluted, is prohibited. Catarrh of the nares
and pharynx must get cured. The former will get well in
most cases under the use of salt water. A tepid solution
of one or one-half per cent, of table-salt in water, snuffed
up copiously (a tumblerful) from the hand of an adult
patient, or a similar solution in a small quantity injected

365

DR. JACOBI'S WORKS

through each nostril of a child, twice or three times a
day for weeks and months in succession, will often re-
move a laryngeal as well as a pharyngeal catarrh. Care
must be taken that the fluid passes the whole length of
the nasal canal. It must be applied in the fauces, and
will then be ejected through the mouth, or a small portion
of it swallowed. Many a severe nasal catarrh requires
no other treatment. Some chronic ones require the use of
a spray of nitrate of silver in a solution of one-half to
one per cent, every other day, or of a two per cent, solu-
tion of alum daily. Where both the pharyngeal and nasal
catarrh are complicated with, or kept up by, enlarged or
ulcerated tonsils, these organs must be resected. The
combination of these two measures, exsection of the tonsils
and nasal injections, has proved very beneficial in a great
many cases.

The treatment of an acute case requires great care.
Avoid injurious influences. The patient must be kept si-
lent and quiet in bed. The temperature of the room is to
be about 70° F., the air moistened by vapor, which must
not be allowed to get cold before it reaches the patient.

When swelling and dyspnoea are considerable, particu-
larly in those grave cases attended with swelling of the
submucous tissue, the application of an ice-bladder or
ice-cloths will be found beneficial and agreeable. But
the cases in which these applications are indispensable are
but few. In most of them the necessity of subduing in-
tense inflammation is less urgent than the advisability of
increasing the secretion of the congested larynx. For that
purpose warm poultices, but of light weight, act very
favorably. Inhalation of warm vapors either constantly
or at short intervals, or of muriate of ammonium or spirits
of turpentine, will prove beneficial. The latter is evap-
orated from the surface of boiling water, on which a
small quantity, from a teaspoonful to a tablespoonful, may
be poured every one or two hours. The hydrochlorate of
ammonium is evaporated, 10 or 20 grains (1.0 gramme),
every one or two hours by heating it on a hot stove or
otherwise. The white cloud penetrates the air of the
whole room, and, while not uncomfortable to the well,
serves a good purpose in liquefying the viscid and tough

366

ACUTE CATARRHAL LARYNGITIS

secretion of the mucous membrane. The internal admin-
istration of liquefying and resolvent remedies may prop-
erly accompany the external applications and inhalations.
Amongst them I count the alkalies^ mainly bicarbonate and
chlorate of potassium or sodium and the hydrochlorate of
ammonium. A child of two j'^ears will take daily a scruple
(gramme 1.0-1.5). The iodide of potassium will also
have a good effect and counteract many a predisposition to
chronicity. A child may take from 8 to 15 grains a day
(gramme 0.5-1.0). Hydrochlorate of apomorphine^ grain
VdO-Vso (0.001-0.002), dissolved in water, a dose to be
given every two hours or every hour, is quite sufficient to
act as a fair expectorant without being enough to produce
emesis. Antimonii et potassii tartras has been used more
extensively in former times than at present. An adult
would take gr. /^o'Ms every two hours. Children ought to
be spared the drug, as it is depressing, produces unnecessary
vomiting now and then, even in small doses, and, what is
still worse, diarrhoea. The other antimonial preparations,
such as kermes mineral and the oxj'sulphuret of antimony,
are less depressing and less purging, but also less effective;
and there are but few cases where a good substitute could
not be found. For the purpose of increasing secretion the
hydrochlorate of pilocarpine has been recommended. It
certainly has that effect, but its indications become doubt-
ful in many cases where the saving of strength is of para-
mount importance. I shall return to this subject in my
remarks on the therapeutics of membranous laryngitis.

Derivation is of great service when well directed. Local
depletion must be avoided. A purgative in the beginning
is beneficial — a dose of calomel is as good as, or mostly
better than, anything else. Diaphoretics and diuretics
act quite well ; the best of them all are warm beverages
of any kind. They need not come from the apothecary's
nor be very unpleasant to take — water not too cold,
Apollinaris, Selters, or Vichy, hot milk, tepid lemonade
in large quantities and very often. Sinapisms have a good
effect. When not kept on longer than a few minutes
— long enough to give the surface a pink hue — they may
be applied every hour or two.

Some urgejjt sjymptoms may require symptomatic treat-

367

DR. JACOBI'S WORKS

ment. When secretion is copious, but too tough, and ex-
pectoration insufficient because of both the character of
the mucus and the incompetency of the respiratory mus-
cles, ipecac in small doses or camphor is indicated. A
child's dose of the latter would be gr. ^-^ (gramme 0.015-
0.03) every one or two hours. In these cases the hydro-
chlorate of ammonium may be combined with the carbonate
(ammon.chlorid.5ss. (2.0) ; ammon. carbonat. '•*) j (1.25);
extr. glycyrrh. pur ^ij (2.5); aq. pur. f^iij (grammes
100.0) — teaspoonful every hour. When the difficulty of
expectoration is excessive an emetic may be resorted to.
It is true that infants and children vomit with less strain-
ing and difficulty than adults, but, still, the practice of
flinging emetics around is too common. The unpleasant-
ness of getting up in the night because of a pseudo-croup
in a distant patient's baby is not a correct indication for
encouraging the indiscriminate use of emetics. When they
are required, antimonials ought to be excluded from the
list. Ipecac, sulphate of zinc, sulphate of copper, tur-
peth mineral are preferable.

In urgent cases the hydrochlorate of apomorphia may
be used hypodermically (six or ten drops of a 1 per cent,
solution in water). Cases of such urgency, and so ex-
cessive dyspnoea coupled with cyanosis, as to necessitate
tracheotomy are but very rare. But once in thirty years
and in many more than four hundred tracheotomies have
I been compelled to operate for a case of catarrhal laryn-
gitis. Still, a few such cases are on record. The best-
known amongst them is that of Scoutetten, who operated
successfully on his own daughter six weeks old.

Narcotics prove quite beneficial, particularly in com-
plications with pharyngeal catarrh. A dose of gr. j-jss.
of Dover's powder (gramme 0.05-0.1) at night will se-
cure rest for several or many hours to a child of two or
three years; an adult is welcome to a dose of 10 or 12
grains (0.6-0.75). When the irritation is great during
the day, it is advisable to add a narcotic (acid, hydrocyan.
dil., min. j ; vin opii, min. viij-xij ; codeine gr. ^-^, or
extr. hyoscyam. gr. ij-iij — daily) to whatever medicine was
given. I am partial to the latter, giving it up to gr. viij-x

368

ACUTE CATARRHAL LARYNGITIS

(0.5-0.6) to adults daily in their mixture^ retaining the
single dose of opium or morphine to be taken for the
night. At that time a single larger dose is rather better
than several small ones. Narcotics cannot be dispensed
with in all those cases in which — as, for instance, in tu-
bercular laryngitis — deglutition is very painful, because
of the catarrhal and ulcerous pharyngitis. Bromide of po-
tassium has a fair effect, but frequently fails, and the
administration of morphia before each meal is sometimes
an absolute necessity.

That complications, such as bronchitis, have their own
indications is self-understood. The general rules controll-
ing the treatment of laryngitis are not interfered with by
them. CEdema of the glottis, however, when occurring
during an attack of laryngitis, has its own indications, and
very urgent ones indeed in all acute cases. In chronic
cases a causal treatment is Required according to the
etiology of the affection as specified above. In acute cases
it is not permitted because of want of time. The danger
of immediate strangulation is often averted only by a deep
scarification or the performance of tracheotomy.

Chronic cases require all the preventive measures enu-
merated above and the internal use of iodide of potassium
or sodium ( 9 j-9 iiss = gramme 1.25-3.0 daily, for
adults), and tincture of pimpinella saxifraga three or four
teaspoonfuls daily. When it is given it ought to have an
opportunity to develop its local effect on the pharynx also
by giving it but little diluted, and not washing it down
afterward (tinct. pimpinella saxif., glycerin, ad, teaspoon-
ful every two hours). In these cases, while the local salt-
water treatment recommended above is indispensable, the
nitrate of silver spray mentioned in that connection is here
again referred to as very beneficial indeed. But the so-
lution of 1 per cent, is the highest degree of concentration
allowable. Conducted through the nose, it will reach the
larynx better than through the mouth. When both accesses
are rather difficult the application must be made directly
to the larynx.

369

PSEUDO-MEMBRANOUS LARYNGITIS

Pathology. — Pseudo-membranous laryngitis is charac-
terized by the presence, on and in the mucous membrane,
of a pseudo-membrane of a whitish-gray color, various con-
sistency, and diiFerent degrees of attachment. It has been
called croupous when it was lying on the mucous mem-
brane without changing much or at all the subjacent epi-
thelium and could be removed without any difficulty. It
has been called diphtheritic when it was imbedded into the
mucous membrane and was difficult to remove. This dif-
ference exists, but it does not justify a difference of names
except for the purpose of clinical discrimination; for the
histological elements of the two varieties are the same,
and the difference in their removability is explained by
the anatomical conditions of the territory in which they
make their appearance. The membrane consists of a net
of fibrin studded ^vith and covering conglomerates of
round cells, mixed with mucus-corpuscles, epithelial cells
more or less changed, and a few blood-cells. The fibrinous
deposit is either quite superficial or lies just over the basal
membrane or on layers of round cells originating from the
basal membrane. It is continued into the open ducts of the
muciparous follicles, filling them entirely in the worst
cases, or meeting the normal secretion of mucus in the in-
terior of the duct. The principal seat of the pseudo-
membrane is that mucous membrane which is covered with
pavement epithelium; thus it is that the tonsils are the
first, usually, to exhibit symptoms of diphtheria. But
cylindrical epithelium is by no means excluded. However,
while pavement epithelium is generally destroyed by the
diphtheritic process, the cylindrical epithelium is frequently
found unchanged, or but little changed, on top of the
mucous membrane under the pseudo-membrane.

The nature and consistency of the pseudo-membrane in

S71

DR. JACOBFS WORKS

the larynx is best studied by the light of the study of its
anatomy. There is a great deal of elastic tissue in both
epiglottis and larynx; the mucous membrane of the latter
is thin, and sometimes folded on the vocal cords. The
epithelium of the epiglottis is pavement; only at its in-
sertion it is cylindrical. In the larynx it is also pavement
on the true vocal cords and in the ary-epi glottic folds, and
fimbriated toward the fossae Morgagni and trachea.
Lymph-vessels are but scanty on the epiglottis, still more
so in the larynx. Of acinous muciparous glands there are
none on the epiglottis, none on the true vocal cords; they
are more frequent in and round the fossae Morgagni, with
cylindrical epithelium in the glandular ducts. The trachea
and bronchi contain a good many elastic fibres, less con-
nective tissue, fimbriated epithelium, some lymph-vessels,
but no lymph-glands, and acinous muciparous glands in
large numbers. Wherever the pavement epithelium mem-
brane is abundant the membrane is firmly adherent and
imbedded into the mucous membrane. Where it is cylin-
drical and plenty of acinous glands secrete their mucus,
they are loosely spread over the mucous membrane, from
which they can be easily removed ; while the histological
condition of both the imbedded and the loose membrane
is exactly the same.

Before the membranous deposit takes place the surface
is in a condition of catarrh. Round the membrane the
mucous membrane is red and slightly swollen. Not always,
however, is that so. Particularly, the epiglottis may be
covered on its inferior surface with a solid membrane or
be studded with tufts of membrane, without much or any
hyperaemia. The same can be said of the larynx, which is
supplied with but a scanty distribution of blood-vessels
and a sufficient network of elastic fibres to counteract the
dilatation of blood-vessels peculiar to the catarrhal and
inflammatory processes.

In uncomplicated cases of membranous laryngitis the
membrane is confined to the larynx. Dozens of years ago
— viz., before 1858, when diphtheria began to settle among
us, never, it appears, to give up its conquest again — that
took place in most cases. But since that period we meet

372

PSEUDO-MEMBRANOUS LARYNGITIS

with few such simple cases. As a rule, the membrane
makes its appearance in the pharynx first, from there to
descend into the larynx, and not infrequently into the
trachea and bronchi. In other — fortunately, but few —
cases the membrane is formed in the bronchi and trachea
first, and invades the larynx from below.

Other organs suffer but consecutively and from the re-
sults of impeded circulation only. Thus, in post-mortem
examination hyperaemia of the brain, liver, and kidneys,
and bronchitis, broncho-pneumonia, or pulmonary cedema,
are met with. Only those cases of membranous laryngitis
which are complicated with general diphtheria yield the
additional changes of the latter.

Etiology. — Intense irritants will produce an irritation
on mucous membranes. In the larynx the product is ac-
cording to the severity of the irritation, either a catarrhal
or a phlegmonous or a croupous laryngitis. The irritating
substances may be mechanical, chemical, or thermical.
Heubner produced diphtheria of the bladder by cutting off,
temporarily, the supply of circulation. Traumatic injury
of the throat and larynx will soon show a croupous deposit.
Caustic potassia, sulphuric acid, caustic ammonia, cor-
rosive sublimate, arsenic, chlorine, or oxygen, applied to
the trachea or larynx produce croupous deposits.^ Inha-
lations of heat, smoke, and chlorine have the same effect.
These, however, are not the usual causes of croup. Cold
and moist air is a more common cause, mainly during a
prevailing epidemic of diphtheria. In former times, which
are unknown to the younger generation of physicians, when
no such epidemics existed, the only form of diphtheria oc-
curring now and then was local laryngeal diphtheria called
pseudo-membranous croup. It was then a rare disease,
while at the present time it is of but too frequent occur-
rence. In my Treatise I have explained at some length
the relations of the two.

Age has some influence in its development. The dis-
ease is not frequent in the first year of life; between the
second and seventh years almost all the cases are met with.
1 A. Jacobi, Treatise on Diphtheria, p. 111.
878

DR. JACOBI'S WORKS

There are families with what appears to be a general
tendency to croupous laryngitis. It may return. Even
tracheotomy has been performed twice on the same indi-
vidual.- It is contagious. In the same family, from a
case of croup, either another case of laryngeal croup may
originate or anotlier form of diphtheria will develop in
other members of the household. It is not so contagious,
it is true, as generalized diphtheria must be, for the in-
fecting surface is but small in uncomplicated membranous
croup, and the membrane not so apt to macerate and be
communicated. Boys appear to be affected more fre-
quently than girls. But the previous constitution makes
no difference.

Symptoms. — Membranous laryngitis begins sometimes
with but slight symptoms of catarrh, sometimes without
them. Nasal, pharyngeal, and laryngeal catarrh may pre-
cede it a few hours or a week, with or without fever and
with a certain sensation of pain or uneasiness in the throat
and a moderate amount of cough and hoarseness. This
condition has been called the prodromal stage of mem-
branous laryngitis, though it is just as natural to presume
that the changes in the mucous membrane merely facilitated
the deposit of false membrane. The latter is more apt to
develop on a morbid than on a healthy mucous membrane.
The membranous laryngitis proper dates from the time at
which, with or without an elevation of temperature, a
paroxysmal cough makes its appearance — first in long,
afterward in shorter intervals — which is increased by a re-
clining posture, mental emotions, or deglutition. At an
early period this cough, which is very labored, and gives
rise to dilatation of the veins about the neck and head, is
complicated with hoarseness, which gradually increases into
more or less complete aphonia. Respiration becomes audi-
ble, sibilant, with the character of increasing stenosis. In-
spiration becomes long and drawn ; expiration is loud ;
head thrown back; the scaleni, sterno-cleido-mastoid, and
serrati muscles are over-exerted ; above and below the clavi-
cles and about the ensiform process deep recessions take

2 Treatise, p. 27.

S7't

PSEUDO-MEMBRANOUS LARYNGITIS

place in the direction of the lungs, which are expanded
with air, but incompletely; dyspnoea becomes the prominent
symptom, and occasional attacks of suiFocation render the
situation very dangerous and exciting indeed. These
sudden attacks of suffocation are due — besides the perma-
nent narrowing of the larynx by the membranes, which
gradually increase in thickness — to occasional deposits of
mucus upon the abnormal surface of the larynx and vocal
cords, by partly-loosened false membranes, which now and
then become audible, yielding a flapping sound, by oedema
in the neighborhood, and by secondary spasmodic contrac-
tions. They are mostly met with in the evening and night;
there is often a slight remission in the morning, which
rouses new hopes, which soon, however, prove unfounded.
Meanwhile, the pulse becomes more frequent in proportion
with the increase of dyspnoea, and finally irregular; the
temperature rises but little, and usually only when the
throat or other organs, which are in more intimate con-
nection with the lymph circulation than the larynx, are
particijjating in the exudative process ; and the laryngeal
sounds become so loud as to render the auscultation of the
lungs impossible. The glands of the neck are not swollen
when the process is confined to the larynx. Now and then
small or larger, rarely cylindrical, pieces of false mem-
branes are expectorated, with or without any ameliora-
tion of the condition. In this condition the patient may
remain a few hours or a few days.

Then the dyspnoea will rise into orthopnoea; the anxious
expression and bearing of the little patient — for the vast
majority of the sufferers are children — becomes appalling
to behold ; cyanosis increases ; the head is thrown back ; the
larynx makes violent excursions upward and downward;
the abdominal muscles work in rivalry with those of the
thorax and neck; the surface is bathed in perspiration;
still, consciousness is retained by the unhappy little creature
tossing about and fighting for breath, and in complete
consciousness he is strangled to death. Now and then the
carbonic-acid poisoning renders the pitiful sight a little
less appalling to the powerless looker-on by giving rise
to convulsions or anaesthesia and sopor, which finally ter-

375

DR. JACOBI'S WORKS

minate the most fearful sight, the like of which the most
hardened man, the most experienced medical attendant,
prays never to behold again.

Besides the brain symptoms just mentioned, but few
other organs give rise to abnormal function. In the kid-
neys the stagnant circulation results in albuminuria — in
the bronchi and lungs, in hypereemia, inflammation, and
oedema.

The symptoms described above are the same both in
those cases which are strictly localized and those which
descend from the pharynx. In the latter there is fever
only when the pharyngeal diphtheria was attended with
it. The process descending into the trachea and bronchi
changes the symptoms but little, as far as the laryngeal
stenosis is concerned, for it is the latter which destroys
by suffocation. Only when tracheotomy has been per-
formed, and the immediate danger of suffocation has been
removed, the further progress in a downward direction
gives rise to a new series of symptoms. After the tem-
porary relief procured by the operation dyspnoea will set
in anew, not always, however, of that intense degree of the
laryngeal stenosis; respiration will become dry and loud
again, and a little more frequent than in the uncomplicated
laryngeal cases. Death will finally also result, either from
suffocation or from the symptoms I enumerated above.

Lastly, when membranous laryngitis is but the terniin-
ating development of extensive membranous bronchitis, the
symptoms differ from those described above in this, that
the laryngeal symptoms last but a short time. For days
or weeks no symptoms but those of an ordinary bronchial
and tracheal catarrh were observed: all at once the process
reaches the larynx; in a few hours the very last stage
of croupous stenosis is reached; even tracheotomy does not
relieve the symptoms. Or the fibrinous bronchitis was
extensive enough to give rise to a sufficient number of
symptoms before the larynx was reached. Amongst them
is, foremost, frequency of respiration, because of its in-
sufficiency; diminution of respiratory murmur over the area
supplied with the affected bronchi; sometimes localized
absence of respiratory murmur, while the percussion sound

876

PSEUDO-MEMBRANOUS LARYNGITIS

is sonorous. Another complication is emphysema, either
subpleural or puhnonary. It is not frequent, except in
combination with fibrinous bronchitis. The increase of
respiratory movements is quite sudden, percussion sound
tympanitic, and auscultation negative. Pulmonary oedema
is quite frequent; it is the result of the rarefaction of air
in the bronchi, the consecutive dilatation of the blood-ves-
sels, and the effusion of serum by intravascular pressure.
Every severe case is accompanied with it; in every trache-
otomy it is met with coming up into the incision. CEdema
of the glottis is less common, but it is met with in the
same manner and with the same symptoms which charac-
terize the glottic oedema of catarrhal laryngitis.

Prognosis. — It is not favorable even in the simple and
uncomplicated cases. Infants and children under two
years almost invariably die. The percentage of average
mortality rates very high — from 80 to 90 and more. It
is probable that some recent therapeutical advances have
reduced it, will reduce it, considerably. Tracheotomy is
known to do so certainly, as from 20 to 45 out of 100
operations prove successful. The previous condition of the
patient is of very little account in regard to the course
and termination of the disease; no constitution protects
or saves. The more the disease is local the better the
prognosis. When fever makes its appearance, it means
a complication, such as extending diphtheria or bronchitis
or broncho-pneumonia, and impairs the chances of recovery.
The expectoration of membranous shreds or whole mem-
branes does not improve the prognosis much, as the new
formation of membranes may be very rapid indeed. I
have seen new membranes rising to a formidable extent in
from two to seven hours. The prognosis is improved when
the cough becomes looser, expectoration more purulent,
pulmonary respiration become audible again after having
been covered by the laryngeal noises, rhonchi become moist>
and portions of lungs which before were inaccessible to air
by clogging membranes are reopened. Increasing debility,
frequent and irregular pulse, are ominous symptoms. Even
more so is the failure on the part of emetics to take
effect.

377

DR. JACOBI'S WORKS

Diagnosis. — It may be quite difficult to diagnosticate
croupous from catarrhal laryngitis, particularly in those
cases where the former is not complicated with any visible
exudative process in the fauces. In membranous laryn-
gitis stenosis begins gently (except in those cases which
ascend from the bronchi) and increases gradually; there
are, it is true, remissions in the morning (mostly), but
they are but slight, and the subsequent evenings are worse
than the previous ones. It increases from day to day until
a slight cyanotic hue of the lips is followed with more
general cyanosis. There is no fever or very little, ex-
cept in the cases of generalized diphtheria. The charac-
ter of the cough does not change; perhaps it becomes more
dry and suppressed after a while. Hoarseness does not
improve, but increases steadily into aphonia. Expectora-
tion is but scanty; now and then a small portion of mucus
from the lower portion of the respiratory tract, now and
then shreds of membrane, are expelled.

In catarrhal laryngitis stenosis begins abruptly and
suddenly, and is often at its height a few minutes after
the commencement of the attack. Remission sets jn soon,
is more marked, sometimes complete, and a new attack,
just as sudden as the first, may occur in the next night.
Real cyanosis is but rarely developed; when it is, it
changes soon into a more normal condition. Catarrhal
laryngitis in the child is a febrile disease. In it the
cough changes after a little time, some moisture mixes
with the expectoration and changes both cough and articu-
lation; also, the voice is not equally husky; now and then
a clear note comes in. Close inspection of the throat ex-
hibits sometimes a thick, viscid mucus floating up and
down with the excursions of the larynx in catarrh. It
never has any membranous expectoration.

Local (Edematous swelling of the ary-epiglottic folds,
with or without membranous deposits in some other parts
of the larynx, yield all the symptoms of membranous
croup with its dangers and death-rate. The effect of this
oedema is partial paralysis of the vocal cords. Thus, in-
spiration is impeded, as in membranous obstruction; ex-
piration, however, is free and the voice intact to a cer-

378

PSEUDO-MEMBRANOUS LARYNGITIS

tain extent. This local oedema may be detected by pal-
pation.

General oedema of the larynx (glottis) is fortunately
rare. The attack is very sudden; there is no cold, no
hoarseness, no choking cough, no membrane; there is only
dyspnoea, gasping, asphyxia, sopor, and death, unless re-
lief is given almost instantaneously.

The presence of a foreign body has been mistaken some-
times for membranous laryngitis. The history is a dif-
ferent one; there was no prodromal catarrh; the children
were taken suddenly while playing or eating.

The laryngoscope would be a great aid in diagnosis if
it could be used during the distress of a membranous laryn-
gitis. Still, it has been employed by Ziemssen, Rauch-
fuss, and others. But the opportunities are rare.

Treatment. — The objects of treatment differ with the
various stages of the disease. The inflammatory symptoms
of the commencement, the completed exudation, the macera-
tion and disintegration, and also the expectoration of the
pseudo-membranes, and, finally, the asphyctic stage, have
each their own indications. If there is anything which
must not be recommended, it is depletion. Fortunately,
there are but few practitioners left who still apply leeches
or employ more general depletion, but these few are still
doing too much harm by their practice and teaching. The
application of ice, however, in bags over and near the
larynx, and of iced cloths frequently changed, combined
with the swallowing of small pieces of ice from time to
time, is apt to be beneficial in well-nourished, hearty
children. Such as have been anaemic, with thin mus-
cles and pale mucous membranes, do not bear it so
well.

The most powerful and reliable preventive and solvent,
thus far, is hydrargyrum. It is true that many voices have
been raised against it, but from Bard, Bretonneau, and
Billard to Rauchfuss, Ch. West, Lynn, Pepper, and
others, the remedy has had its admirers. Large single
doses of calomel have been given by some amounting to
15-30 grains (gramme 1.0-2.0), but that treatment has
not found many friends. In small and frequent doses it

879

DR. JACOBFS WORKS

has been of good service to me both in fibrinous laryn-
gitis and bronchitis, particularly in the latter; gr. ^-^ may
be given every half hour or every hour, Tartar emetic
is liable to develop so many unfavorable effects that even
doses — in combination with calomel — of %oo of a grain
require great caution. The most reliable mercurial prep-
aration, in my experience, and the least hurtful, is the
corrosive chloride. In the stomach it combines with the
chloride of sodium, is absorbed without being changed,
and transmuted into an albuminate, during its circulation
in the blood. Babies of tender age bear one-half of a
grain and more, daily, many days in succession. Salivation
and stomatitis are exceedingly rare after its use. Gastro-
intestinal disturbances are not at all frequent; diarrhoea,
if observed at all, is very moderate, and can be avoided
or removed, by the administration of mucilaginous and
farinaceous food or a mild dose of an opiate. But the
administration of the bichloride requires care in regard to
its solution. A fiftieth of a grain may be safely given
to a baby a year old every hour, but it must be dissolved
in one-half of a tablespoonful or a whole tablespoonful of
water. The solution of a grain in a pint of water is
about correct. In those very rare cases in which no prep-
aration of mercury is borne internally the inunction of
sufficient and frequent doses of the oleate of mercury may
take the place of the internal administration or alternate
or be combined with it. The blue ointment is not so
effective as the oleate. The subcutaneous injection of the
corrosive chloride may be added to the modes of admin-
istration if no time must be lost in introducing as much
as possible of the drug into the system. Now and then,
however, the subcutaneous tissue of the child does not
tolerate it well in that form, though the solution may be
not larger than 2 per cent.^ The cyanide of mercury, in
doses of a hundredth of a grain every hour, has been
warmly praised by A. Erichsen and C. G. Rothe.

The large mortality in croup and the inefficiency of
remedial treatment have been the reasons why the recom-

« The Medical Record, May 24, 1884.
380

PSEUDO-MEMBRANOUS LARYNGITIS

mendations of remedies have been very numerous. Alka-
lies were held in great favor during different periods of
our literature, mainly the carbonate and bicarbonate of
potassium (and sodium), in daily doses, to a child, of ^
drachm or 1 drachm or more; also the chlorate of potas-
sium or sodium. As an adjuvant it may be useful; as
an antidiphtheritic or antimembranous remedy it must not
be regarded. What it can do is to 'heal or prevent a
catarrhal stomatitis and pharyngitis. The best and most
reliable is probably the iodide, in larger doses than are
usually given. One or two drachms daily (grammes 4.0-
8.0) are well tolerated when sufficiently diluted. Benzoate
of sodium was recently recommended for its supposed anti-
fermentative and antibacteric effect; its practical utility
is but very limited; not even its antifebrile effect is any-
thing but reliable. Lime-water has not fulfilled in my
hands the promises made by others — neither its internal
use nor spray nor inhalation. The most certain mode of
introducing lime particles into the larynx is, after all,
the inhalation of slaked lime, which allows a quantity
sufficient to be somewhat effective to enter the respiratory
organs. Its comparative inefficiency has been acknowl-
edged by those who add 1 per cent, of the liquor of caus-
tic potassium or sodium to the lime-water.

Quinia, in doses of 15 to 30 grains (grammes 1.0-2.0)
daily, has been recommended by Monti for the same in-
dications, mainly in the commencement of febrile cases.
It has been claimed that cold applications, to be changed
every hour or two according to the Priessnitz or hydro-
pathic plan, had a great power in macerating and disinte-
grating mucous membrane. Many of the successful cases
of these, as of all other specialists, are undoubtedly the
result of the convenient substitution of a grave diagnosis
for a milder one. The effect of such applications in
laryngeal catarrh, like that of warm applications, is un-
doubted. Vesicatories applied to the neck over the larynx
are never useful — frequently injurious by the sore sur-
face becoming the seat of a pseudo-membrane.

Inhalations of warm vapor are decidedly beneficial, but
atomized water is not of equal value. Thus, Richardson's

381

DR. JACOBI'S WORKS

atomizer is not so useful as Siegle's inhaler or other
apparatuses working on the same plan.

Lactic acid, in solutions of 1:10 or 25 (Monti's solu-
tion of 1:200 is certainly too weak), has been applied by
means of a sponge, inhaled, or thrown in from an ato-
mizer for the same purpose. Good results have been
reported, failures also; and still, recoveries are rushed
into print much more readily than failures. The same may
be said of the local applications of glycerin, boric acid,
carbolic acid in solutions of 1 or 2 per cent., salicylic
acid, iodoform, and hypermanganate of potassium; also
of bromine (bromine and potas. bromid. da) 1 : water 500,
or a stronger solution.

Tannin, dry or with glycerin, is rather more injurious
than it can be useful. It is apt to coagulate the mucus
contained in the pharynx and the upper part of the
larynx, and to render the dyspnoea graver than before.
Such an aggravation of symptoms must be carefully
avoided, though it be but temporary. The same must be
said of alum, which has been used solid, in finely-pow-
dered condition, down to a 3 per cent, solution in water.

Spirits of turpentine are inhaled either from an inhaling
apparatus or by saturating the air of the room. Water is
kept boiling constantly on a stove, oven, or alcohol lamp
(not on gas, which consumes a larger quantity of oxygen),
and a tablespoonful of the spirits of turpentine is poured
hourly or in shorter intervals upon the boiling surface.

Hydrochlorate of ammonia can be used in the same
manner as described in the article on Catarrhal Laryn-
gitis.

Hydrochlorate of pilocarpine was introduced into the
treatment of diphtheria and pseudo-membranous croup
some years ago, and recommended as no less than a spe-
cific. It increases, physiologically, the secretion of the
skin, the mucous membranes, the lachrymal and muci-
parous glands, the kidneys. It also depresses the heart's
action. In all cases in which the latter effect is to be
feared the drug is contraindicated ; thus in septic diph-
theria, in pseudo-membranous croup with great asthenia,
in general debility and anaemia. By increasing the secre-

PSEUDO-MEMBRANOUS LARYNGITIS

tion of the mucous membranes it is expected to macerate
the pseudo-membrane and raise it from its bed. This can
be accomplished wherever the membrane is deposited upon
the mucous membrane — that is^ whenever the number of
muciparous follicles is large and the epithelium is cylin-
drical. This is not so on the vocal cords, and thus the
floating effect of pilocarpine cannot be obtained exactly
where it is most needed — that is, on the vocal cords, where
the pseudo-membrane is more intimately imbedded into the
tissue than, for instance, on the posterior wall of the fauces
or the trachea and bronchi. Still, pilocarpine may be tried,
in combination with other modes of treatment, as long as
the heart's action is competent and the general condition
satisfactory. It is dissolved in water; its dose, for a child
a year old, %o grain (2 milligrammes = 0.002) every
hour. A subcutaneous injection every four or six hours of
Yqq grain (three drops of a 2 per cent, solution) will
prove very effective for good and evil. I believe it has
rendered me good service in some well-marked but mild
cases of pseudo-membranous laryngitis, which it either
aided in healing or prevented from getting worse.

Emetics have their distinct indication. It is irrational
to expect any relief from them when the larynx is nar-
rowed by firmly-adhering pseudo-membranes. Their indi-
cation depends on the possibility of removing something
which acts as a foreign body. This something can be
either mucus or loose or partially loose membrane. The
peculiar flapping sound produced by the latter admits of
or requires the administration of an emetic. Above I have
stated which of them ought to be selected. Turpeth
mineral in a dose of from S to 5 grains, repeated in six
or eight minutes, acts quite well. Hypodermic injections
of apomorphine may be required in urgent cases.

The introduction of catheters into the larynx, according
to the methods of Horace Green, is a dangerous proceed-
ing and ought not to be indulged in. It gave the idea to
Loiseau and Bouchut to force a tube into and through the
larynx, full of pseudo-membrane, for permanent use until
the pseudo-membrane would have disappeared. This tu-
bage was rendered ridiculous at once by the assertion of

DR. JACOBI'S WORKS

Bouchut (1858) that children suffering from croup who
were supplied with this laryngeal tube were not only re-
lieved at once, but expressed their gratitude in audible
oratory. Still, there are some cases on record of more
recent date in which tubage is reported to have been at-
tended with success. It is not very probable, however, that
a larynx which admits of no air, because of its being
clogged with firm pseudo-membrane, should be willing to
admit and endure the presence of a tube.

Massage of the larynx has been recommended by Bela
Weiss. It consists in systematical gentle pressing and
kneading of the larynx by the physician while sitting be-
hind the patient. He asserts its satisfactory influence
not only in catarrhal but also in diphtheritic (croupous)
laryngitis.

The inhalation of oxygen has proved rather advanta-
geous in my hands in a few instances. The most memor-
able case of the kind I have mentioned elsewhere. It was
that of a child on whom tracheotomy had been performed.
The pseudo-membranous process, however, invaded the
bronchi, with the result of producing dyspnoea, cyanosis,
and convulsions. Whenever a current of oxygen was in-
troduced into the lungs through the canula both cyanosis
and convulsions would cease, and returned when its sup-
ply was stopped.

But if no medication will have proved successful, the
symptoms of stenosis, dyspnoea, cyanosis, and the supra-
and intraclavicular and epigastric recension increase stead-
ily to an alarming extent. When the pulse becomes fre-
quent and intermitting, even without the presence of
asphyxia and anaesthesia, air ought to be introduced into
the lungs by tracheotomy. No positive rules can be laid
down as to the length of time one ought to wait before
performing it. No subdivision of the disease into several
stages is of any benefit in selecting the exact period in
which the trachea must or may be opened. No alleged
contraindication to the performance of tracheotomy, whether
the tender age of the patient or a complication with either
an inflammatory or an infectious disease, must be con-
sidered valid. The one strict indication for the perform-

384.

PSEUDO-MEMBRANOUS LARYNGITIS

ance of tracheotomy is when the diagnosis of pseudo-
membranous laryngitis is undoubted, the increasing dys-
pnoea, cyanosis, and approaching asphyxia, with the
certainty that a well-directed and sufficient medicinal treat-
ment has been, and in all probability will be, useless. Even
under these circumstances there is no mathematical cer-
tainty. The matured experience of a well-informed and
thoughtful physician will commit but few errors. If there
be the slightest doubt, the operation ought to be preferred
to suffocation.

The nutrition of the patient 'has generally suffered
much. Before the operation but little food was taken, still
less was digested, and the operation itself and the anaes-
thetic have added to the previous weakness or exhaustion.
Moderate feeding and stimulation are therefore to be com-
menced soon. Vomiting after chloroform I have seldom
seen to last long or to be embarrassing under these cir-
cumstances. Feeding and stimulation are the more neces-
sary the more the hungry lymph-vessels are liable to ab-'
sorb injurious material when not supplied with healthy
food.

Is internal treatment required ? The general treatment
must be continued. If it consisted in the administration of
hydrargyrum, either internally or externally, it must be
continued. If its effect was not sufficient to clear the
larynx and to render the operation unnecessary, it will or
may be sufficient to complete its effect in the next day or
two, to prevent the process from descending or the mem-
branes becoming too many or too thick. No changes ought
to be made in the treatment unless there be changes in the
symptoms. Not infrequently the first symptoms of broncho-
pneumonia come on within a few hours after the operation,
recognizable by frequent pulse, respiration frequent be-
yond proportion, and physical symptoms. The stomach is
not very reliable. Quinine answers best hypodermically.
From 6 to 10 grains may be injected at once. The
preparation which has served me best in the last few years
is a solution of the carbamid in five parts of water. If
an additional remedy is required, from 20 to 30 grains of
sodium salicylate may be given in the course of three or

385

DR. JACOBI'S WORKS

four hours, in hourly doses, to reduce the temperature.
Tincture of digitalis will prove advisable at the same
time when the heart appears to require it. Strychniae
sulphas will act as a powerful nervine; ^-, grain may be
given to a child two years of age every two hours, until
four or five doses shall have been taken. The rest of the
treatment of the complications depends on their nature
and character. It is not the name of the disease which
has to be treated, here as in every case, but the in-
dividual patient.

In regard to stimulants I have but little to say. I use
alcohol in the most pleasant shape, preferring brandy or
whiskey. I use a great deal of camphor, 10 to 40 grains
daily, or in cases of urgency Siberian musk, from 2 to 5
grains, every half hour or hour, until from 15 to 20
grains have been taken in cases of collapse or great pros-
tration.

386

CHANGES OF BREAST-MILK

In many of the digestive disorders of the infant the
best preventive, and often curative aid, is the breast-milk
of mother or wet-nurse. That is an axiom, an indisputable
law of nature, as long as the circumstances of the case
are favorable. In view of the great mortality in the first
few months, breast-milk is the one and indispensable
food for those of that age. It is true that a baby may
be taken sick with intestinal disease in spite of being
nursed at the breast, for there are many causes of disease;
it may, indeed, occur that babies are taken sick because
of being at the breast. And it is those cases that both
mothers and physicians ought to be well acquainted with.
Sometimes it is not the breast-milk which is at fault, in
the beginning, but the faulty use it is put to. Many babies
suffer intensely because they are not limited to intervals
of from 2 to 4 or 5 hours, as required by either age or
constitution. In their cases, by too frequent feeding, both
the milk of the mother and the digestion of the infant, are
impaired. Here regularity is the sole indication. Some-
times, though fortunately in few cases only, there appears
to exist an idiosyncrasy not explained, on the part of the
baby who cannot thrive on the milk of the mother, but may
do so after a change of food. In many cases, however,
there are demonstrable dangers in the very breast-milk
of either mother or nurse; there may be an undue per-
centage of fat, or of cheese, or of salts, or of sugar, or
even accidental admixtures. These may occur in the se-
creting organ (thus blood may be found in the milk) or
be traceable to the circulating blood of the whole system;
of the latter they may be the very constituents, or foreign
bodies floating in it. They can be classed as either mor-
bid dispositions or as actual admixtures. Women suf-
fering from constitutional syphilis, chronic consumption,

387

DR. JACOBI'S WORKS

or anaemia, extensive rhachitis, severe nervous derange-
ment, hysterical or other, those suffering from care and
hard work, and those who are compelled to take a great
deal of medicine, will serve their babies best by not
nursing them at all.

In regard to the influence of medicine, the opinions
have been divided. It was claimed that milk, being a
secretion of the gland, and not a transudation from the
blood, could not contain foreign material to any great
extent. That is true as far as an absolutely healthy woman
and normal milk are concerned. But the first period of
lactation yields colostrum, not normal milk, and very often
the latter is changed into a colostral condition, such as
it was soon after birth, containing different-shaped fat
globules, more sugar, soluble albumin, in fact, real blood
serum. This may take place in every case of impaired
health. And the more serum of blood is contained in
any milk, the easier is the admixture of soluble substances
circulating in the blood. As I formulated the subject
some years ago, milk secreted from an insufficient mamma,
by a woman not in full health and vigor, by an old
woman, by a very young woman, by an anaemic woman,
by a convalescent woman, who has consumed a large por-
tion of her albumin, be it circulating or tissue albumin,
by a neurotic woman with frequent disturbances of the
circulation — milk, in fact, which is not the normal trans-
formation of the elements of the mammary glands, but
consists of more or less transuded serum, is apt to be im-
pregnated with elements circulating in the blood. The
indications on the one hand, for the permission to nurse,
on the other, for the administration of medicines to a
nursing woman, require, therefore, a greater strictness than
is usually conceded. At all events, the good results ob-
tained in many cases of ailment on the part of infants,
by artificial feeding, in preference to nursing, are often
better than merely accidental.'^

Changes in animal and woman's milk in consequence
of nursing, diseases, organic and inorganic substances are

1 Inaugural address Trans. Med. So., State of N. Y., 1882.

388

CHANGES Of fiREAST-kiLK

very frequent, and their occurrence was considered to take
place at a time 'when exact analyses were out of the
question.

One of the many pretty stories of the younger Pliny
(xxv. 47) is as follows: Lysippe, Iphinoe and Iphianassa
were the three daughters of Proteus, King of Argos. They
were poisoned by the milk of goats fed on hellebore.
They became insane, roamed about the country, and se-
duced and abducted the other young girls of the com-
munity. The two surviving princesses were cured by Me-
lampus and his brother Bias, who married them, and the
rest by the most vigorous young men who hunted them up.

In Gerhardt's Handb. d. Kinderk. Vol. II, I have col-
lected a large amount of material, partly from reliable
veterinary literature, showing the influence of different
kinds of food, sickness, and drugs upon the milk of ani-
mals. Here I shall refer only to a number of facts be-
longing to our own race.

Zukowski observed that tired and hungry wet-nurses
gave milk that was not nourishing. Among the wet-
nurses at the foundling-hospital in Moscow, the percent-
age of fat in the milk when they were first admitted was
from 1.8 to 3.0 per cent.; among those who had been in
the institution a short time, it was 3.2 to 4.0 per cent.
Seasons of fasting exerted a great influence upon the milk,
especially upon its fatty element, and many nursing chil-
dren were wont to become sick at such times. Upon the
first day of the fast, the fat usually decreased to 0.88
per cent., but rose again to 3.4 per cent, by gradual habit-
uation to the retrenchment in diet, and probably by the
appropriation of an extra quantity of albumin from the
general system, which satisfied the demand of the milk
glands. The instrumentalities most rapid in their action
upon the milk, are those which take eff"ect through the
nervous system, and their action is upon an organ in
which, when functionally active, rapid changes occur.

Firmin (Bull. Therap., 1886; Schmidt's Jahrbucher,
1875, No. 8) reports the case of a child six months of
age, who was attacked with urticaria, fainting, vomiting,
and off"ensive diarrhoea; all of these phenomena were pro-

389

DR. JACOBI'S WORKS

duced by the mother's milk, after she had partaken of
oysters^ crabs, cod-fish, and shad. It may be proper to
mention here an observation which was made by R. Monti
(Schmidt's Jahrb. 173 p. 160). The right arm of a
nursing woman, whose right breast was functionally in-
capacitated by mastitis, was treated locally with ammo-
niacum and camphor; the result was a marked decrease
in the secretion of milk by the breast upon the health}'
side. The passage of coloring matter into the tissues
within a short space of time is a well-known possibility.
According to Mosler, milk will become yellow through the
influence of marsh turnips, caltha palustris, saffron, and
rhubarb. According to Schauenstein and Spath, it becomes
red after the ingestion of rhubarb, garlic, opuntia, rubia
tinctorum; it becomes blue from the ingestion of myosotis
palustris, polyganum, mercurialis, anchusa, and equisetum.
This blue discoloration which pervades the entire volume
of the milk so aff"ected must not be confounded with the
superficial blue layer which occasionally appears upon
milk which has stood for some time. It gradually per-
meates the entire volume when added to milk which is
otherwise pure. The milk thus treated will not lose its;
color by triple filtration. This color is dependent upon
the growth of a fungus, which must not be confounded
with Hessling's sour-milk fungus, and is identical with
penicillium glaucum, and aniline blue, giving rise to severe
attacks of catarrh of the stomach and intestine, and severe
prostration.

Next to the coloring matters, the ethereal oils combine
most readily with milk before it leaves the gland. The
ethereal oil from rape seed, impregnated with sulphur
is quickly passed into the gland. In the same way we
get the peculiar odor from thyme, wormwood and garlic,
when these substances have formed a part of the diet.
The foregoing facts being established, the important ques-
tion, theoretically as well as practically, arises: How far
can disease be propagated through the mediimi of milk?
Not all the chemical and microscopical analyses which have
been made for the purpose of solving this question, can
lay claim to absolute reliability. Percy (" What effect

390

CHANGES OF BREAST-MILK

has the meat or milk from diseased animals upon the
public health." — X. Y. Med. Jour., viii.^, 1866), has con-
tributed reports of forty analyses of milk, which go to
show that there is a chemical difference between the milk
of well and sick cows, and that important ingredients are
entirely wanting in the latter. He admits, however, that
he has not been able to detect the presence of an active
poison in it. During the same decade were published
Hexamer's overdrawn pictures in reference to the swill-
milk scandal in New York, which created a great impres-
sion in Europe and quickly passed out of notice in New
York. Dewees has observed yellow fever among nursing
women and has been unable to see positive harm to their
infants from the use of their milk. D'Outrepont observed
the same thing in patients with petechial typhus. In
typhoid fever I have often made a similar observation.
If the disease be diphtheria, I am chiefly concerned that
the infants should not be exposed to direct contagion and
that they should approach the mothers only for the pur-
pose of nursing. On the other hand well-authenticated
reports are published (Twelfth report of the medical
officer of the privy council 1870 p. 294. — J. C. Gooding in
Med. Times and Gaz. 1126, 1872) to the eff"ect that un-
boiled cows' milk, from animals which were affected with
mouth and hoof disease, produced derangements of di-
gestion, fever, vesicles and swelling upon the lips and
tongue, and marked weakness upon attempting to walk.
There is likewise a published report of a case in which
a number of officers and men belonging to an English
ship, suffered severely after drinking some milk which had
been obtained from goats which had fed upon euphor-
biaceae. This occurred Nov. 27, 1861. In regard to
the infectiousness of animal flesh when taken into the
stomach, authentic reports abound. Gamgee and D. Liv-
ingstone report the flesh of animals which had suffered
from epidemic pleuro-pneumonia, to cause carbuncles and
furuncles. D. Livingstone emphasizes the fact that boil-
ing and roasting did not nullify this poisonous influence.
From this it is sufficiently evident that goats, sheep, cattle,
birds, and fishes may consume many poisonous substances

891

DR. JACOBI'S WORKS

which are harmless enough to them, but are dangerous to
those who afterward eat their flesh. The milk of a syphi-
litic mother was seen to be directly injurious in a case
reported by Cerasi (Gaz. di Roma Jul. 1878).

Gallois, Appay, de Amicis, were unwilling to believe
that this last statement was founded upon fact. The same
is true of Banzon, whose opinion is remarkable, for he is
even willing that tuberculous mothers should suckle their
young. Fr. Unterberger (Rig. Zeitung, 1877, No. 69;
Zeitsch f. Thiermed, 1878, p. 466) gives no absolute opin-
ion upon this subject. He thinks, however, that the milk
from tuberculous cows should be boiled, under all circum-
stances. Bollinger (52nd Vers. d. Naturf. u. Aerzte) be-
lieves, like many others since, that the infection of human
beings is possible by means of the milk of tuberculous
cows. We should, therefore, avoid using the milk of old
cows, which are frequently found to be tuberculous. In
all cases the milk ought to undergo proper treatment be-
fore being used. Virchow (Berl. Klin. Woch. 1879, 17,
18) does not deny the possibility of infection through a
tuberculous cow, and calls to mind the observations of
Kolessnikow (V. Arch. X p. 531) in regard to the patho-
logical changes which take place upon the udder of tu-
berculous cows, and have a possible influence upon their
milk. Uff"elmann relates the case of a child who died from
tuberculosis, where it was impossible to trace the origin
of the disease to anything but the milk of a tuberculous
cow. (Arch. f. Kinderh. II.) Stang had a similar case
in a child five years of age. It is difficult to point to
positive proof in these cases. Many more histories must
be collected before we can be justified in prohibiting the
customary supply of milk in every case of constitutional or
severe local disease. But the interdiction will be war-
rantable in individual cases, upon the ground of prob-
ability.

Of importance in connection with the foregoing is the
question of transmission of inorganic materials into the
milk. While organic chemistry has not yet made sufficient
progress to give a decision as to whether the gramme
of quinine which gives a bitter taste to the milk, exists

392

CHANGES OF BREAST-MiLK

in the milk as quinine or as something else (Chevallier
and Henry), or whether alcohol, opium, or morphine are
again recoverable from the milk, inorganic chemistry, on
the other hand, is capable of better results, although here,
too, there are differences of opinion in abundance. The
direct experiments which were made upon human beings
were only of a clinical character. Experiments upon goats
and cows in this direction have also been made. Harnier
and Simon found no iron (yet the ash residue of human
milk always contains much pheno-phosphoric acid, 0.21
less than that of cow's or swine's milk, according to
Wildenstein), they readily found salts, however, in loose
combination, which quickly disappeared. According to
Bistrow's observation anaemic children improved rapidly,
when those who nursed them took iron. According to
Wildenstein's experiments upon a goat, the quantity of
milk, under the use of iron, was less, but its specific gravity
was greater, and the quantity of iron in the ash increased
two-fold, but not until the iron had been in use for twenty-
four hours. A small quantity of bismuth was found by
Lewald; a large quantity by Chevallier and Henry, and
a trace by Marchand. Fifteen grammes of iodide of po-
tassium were found by Lewald in the accumulations of
four days. In the following three days twenty-one
grammes more were recovered and then all traces disap-
peared. This was in accordance with a previous calcula-
tion. In a further use of iodide of potassium, the milk
gave an iodine reaction at the end of four hours, and con-
tinued to do so for eleven days.

Lazanski made observations upon a syphilitic mother
and her infant five months of age. The mother had been
infected two years previously, had no indications of the
disease upon the genital organs, but had syphilides in
the groins, and swollen glands. The child was affected
upon the skin and the mucous membranes. The mother
received half a gramme of iodide of potassium twice a
day, the result being that the urine gave an iodine reaction
upon the same day that the treatment was begun. In the
child the iodine reaction appeared upon the following
day. Gemmel also relates that a cow which received ten

393

DR. JACOBI'S WORKS

grammes of iodide of potassium daily, began to dispose
of it through the milk glands, upon the tenth day. In a
case where the nurse was treated with iodide of potassium,
a desired effect was soon produced upon the child which
she was suckling. Upon the basis of such facts, Leviseur
recommends in the secondary syphilis of infants, the use
of iodide of potassium through the medium of the breast-
milk, likewise the sulphate of quinine in neuroses of an
intermittent character, and arsenic for the moist erup-
tions upon the skin. Arsenic was found seventeen hours
after it had been given, and it continued to be traceable
for sixty hours thereafter. (Hertwig states that medic-
inal doses for a cow are sufficient to poison the meat.)
Lead may be separated from the milk, likewise oxide of
zinc, and probably all other preparations of zinc. They
were found in from four to eight hours after they had been
given, and disappeared after fifty or sixty hours. Antimony
passes into the milk, therefore special care should be ex-
ercised in prescribing it. Mercury has not been found by
Peligot, Chevallier and Henry, and Harnier, but it has
been found by Lewald and Personne.

O. Kahler has made the cases of three women who were
receiving mercury by inunction, the occasion of accurate
investigations. The milk was examined for mercury by
the chemico-electrolytic method of Schneider, but none
was found. He considers the affirmations of Lewald and
Personne, under this head, as questionable. In my per-
sonal experience, the results of mercurial treatment of
the mothers and nurses of syphilitic infants, where the
disease was hereditary, have not been satisfactory ; but in
cases where the symptoms of the disease first appeared
after the child was some months old, the customary in-
ternal treatment has yielded very beautiful results. Tuda-
kowski was able to detect traces of mercury in three hun-
dred and sixty-six grammes of milk tested according to
Schneider's method. Likewise, Klink treated a syphilitic
mother with twenty-five inunctions of ung. hydrarg., giv-
ing twenty grammes at each treatment. The infant had
large condylomata and adenitis, and quickly improved under
the treatment (during the same period the infant had

S94>

CHANGES OF BREAST-MILK

three baths, each containing 0.3 gramme of corrosive sub-
limate). Carbolic acid, bicarbonate of potassium, chloride
of sodium, Glauber's salts and sulphate of magnesium are
all transmitted to the milk. The vegetable acid salts loose
carbonic acid to the milk, but the alkaline compounds of
sulphur, according to Marchand, do not. Stumpf found
iodine speedily in the milk of woman, but slowly in her-
bivorous animals. It is found in combination with casein,
but in uncertain quantities. Alcohol he did not find in
the milk of herbivores, lead in traces, and salicylic acid
in small quantities. A large number of similar observa-
tions and experiments have since been made, too many to
be here recorded. One of the most interesting is that
of Dr. Koplik, who observed iodine eruptions in a baby,
whose mother took iodide of potassium in but small doses.
(Med. Record, Sept. 24th, 1887.)

395

THE SALIVA

The function of the saliva is two-fold. First, to lubri-
cate, and second, to transform starch into grape sugar.
The latter change is also observed in plants. There is a
large quantity of starch in the potato, with a very small
proportion of the ferment that changes the starch slowly
between spring and winter.

The ferment contained in saliva, which contains 99 per
cent, of water, acts in the same way.

The three pairs of glands which secrete it, begin to
be developed in the second foetal month, are quite notice-
able in the third, and then develop rapidly. The parotids,
for example, weigh two grammes, (half a drachm) at the
age of one month; that is, %5oo part of the weight of
the whole body, that is more in proportion than in the
adult.

At the age of fifteen months they weigh five grammes,
and eight grammes at the age of two years.

Since the time of Bidder and Schmidt, Ritter von Rit-
tershain, and Joerg, during the past twenty-five years, a
great many experiments have been made with reference
to the formation of sugar by the action of saliva.

SchifFer experimented upon babies at the age of two
hours, sixteen days, and two months, and in every in-
stance he found, as the result of the action of saliva on
starch, sugar by Trommer's method.

Korowin made infusions of pancreas and of parotids,
added starch, and the result was that the pancreatic in-
fusion changed starch at a later period than did the
infusion of the parotids. In his experiments the pan-
creas did not change starch in the first month, only slightly
in the second month, but noticeably in the third month.

The infusiofl of the parotids, howeverj was efficient in

S97

DR. JACOBFS WORKS

in the first few days of life, particularly in infants of
large size and well developed. The effect increased visibly
towards the end of the first month, and the quantity of
secretion increased to such an extent that he could collect
a cubic centimeter (fifteen minims), within five or seven
minutes in the fourth month of life.

The saliva of seventeen babies, at the age of from one
to ten days, exhibited the same diastatic power. A num-
ber of these babies remained under observation a long
time, so that no mistake could be made. The number
of his quantitative analyses amounted to one hundred and
twenty. When he compared the diastatic effect of the
saliva of a baby eleven months old with that produced l)y
his own, he found that it was the same from the same
quantity.

Since his first observations Korowin has gone over
the same subject, and has given the results in the Jahr-
buch f. Kinderh., 1875, p. 381; they are as follows: It
is possible to collect the secretion of the oral cavity in
babies a few days old. Still there is some difficulty in
gathering saliva before the age of six weeks. The quan-
tity of this secretion increases towards the end of the
second month, and this augments with every month. The
secretion is almost always acid, unless the oral cavity is
carefully cleansed. After it has been washed out, it is
slightly acid, or slightly alkaline, or simply neutral.

From the very first month of life a distinct diastatic
effect is produced by the oral secretion, and this increases
with every month.

Infusions of the parotids, prepared at different times
after de?th, produce the same effect. Infusions of the
pancreas within the first three weeks of life have not
produced any change; its diastatic effect begins with the
fourth week, and remains feeble up to the end of the
first year.

Zweifel has made a number of observations, and given
the following conclusions: The infusion of the submaxil-
lary glands of the infant do not transform starch into
sugar even when it has been exposed to the influence of
the infusion for one hour. The effect of the infusion

398

THE SALIVA

of the parotid of a baby seven days old was distinct
after four minutes exposure; that of the parotid of a baby
that died of gastro-enteritis at the age of eighteen days,
did not show itself until after the lapse of three-quarters
of an hour.

There was no effect produced by a similar infusion made
from the parotids of a child prematurely born, from
one that died of diarrhoea and debility, from a foetus in
the third month, from a foetus in the fourth month.

An infusion of the submaxillary glands of a foetus in
the ninth month of the utero-gestation produced no effect
upon starch. The parotids of the same foetus produced a
change after three-fourths of an hour.

It is a remarkable fact that different varieties of starch
are not changed into grape-sugar in the same length of
time. Solera found that the transformation of the starch
of the potato was the most rapid; next was the starch
of Indian corn, then that of wheat, and the change of the
starch of rice was the slowest. The same results were
obtained by Malay.

Raw starch changes slowly; boiled starch quickly. Ac-
cording to him the starch of potato required from two to
four hours ; that of peas from one and three- fourths to
two hours ; that of wheat one-half to one hour ; of barley,
ten to fifteen minutes ; of oats, five to seven minutes ; of
rye, three to six minutes ; of potato paste, five minutes.

It is important to know that the effect produced hy the
saliva persists in the stomach, although this effect ceases
within two hours.

It ceases altogether, and the starch will not be changed
in 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 infant food, al-
though it is not masticated and passes the mouth very
rapidly, is still under the influence of the saliva in the
stomach.

Hydrochloric acid is not secreted at once. The first
acids in the stomach while digestion is going on, are of
an organic nature, the lactic (and sometimes the butyric).
Thus it is that when gastric juice is removed from the

S99

DR. JACOBI'S WORKS

normal stomach, it contains organic acids only. So also,
there is no free hydrochloric acid during digestion, for in-
stance, in fever, a considerable amount of catarrh, or in
dilatation of the stomach when the pylorus is constricted.
In that condition amylacea are taken to advantage, prin-
cipally because the diastatic effect of the saliva is not dis-
turbed.

In a gastrostomized boy, Uffelmann found that while
there was no fever, there was lactic acid only in the
stomach and no hydrochloric acid during the first half
hour of digestion; afterwards, hydrochloric acid was
found.

Some starch is digested at the very earliest age. If there
be a moderate surplus, it is expelled like the surplus fat
in normal woman's milk, without annoyance or injury.
Besides being nutritious, to a certain degree, and in its
peculiar way, it serves to dilute cow's milk, to reduce its
percentage in casein, to prevent the latter from coagulating
in large masses, and thus to render it digestible. To ac-
complish all this, no large quantity is required. Thus
those cereals and farinacea are to be preferred which con-
tain a small proportion of starch, and a large one of pro-
tein, or those substances (gum arabic, gelatine) which,
while serving the above indications, are also nutritious.
Of cereals belonging to the former class, I prefer barley,
and oatmeal. Thus the number of available articles is by
no means small. They all come up to the requirements we
look for in such substances. They must be, to be of uni-
versal usefulness to the rich and poor, perfectly simple
and recognizable. They must be accessible, and for sale
everywhere. The mode of their preparation must be per-
fectly simple and easy. They must be cheap.

These requirements are not always fulfilled by the ar-
tificial foods offered for sale. I cannot help referring to
them again, though my doing so before has not increased
the number of my friends, and one of these at least, who
felt offended and injured because he did not think I in-
cluded him with the honest gentlemen amongst the adver-
tising manufacturers, threatened me with a lawsuit.

The community insists, with the utmost pertinacity, upon

400

THE SALIVA

giving their babies, as soon as weaning time arrives, or
before, such articles of food as they know nothing about.
When an adult sits down to a meal and finds placed before
him articles of food with which he is not familiar, he makes
inquiries in regard to such articles before eating them.
The baby, however, is credulously fed upon things with
which the child, father, mother, or doctor has not the
least familiarity; many of which have a composition un-
known to the public, although sold in large quantities.
When some manufacturers deign to say anything about
their merchandise, it is to the effect that the food offered
is the best in the market, that it is the proper thing
and the only thing for children and invalids of all
ages, that the relation of the albuminous substances to
carbo-hydrates is exactly correct, and that a package costs
a certain amount of money. In regard to this subject the
public appear to be smitten with absolute blindness. They
insist upon forgetting that the man who offers for sale,
and advertises at a very heavy expense, does so, as society
is constituted, for his pecuniary advantage. To say that
if the article offered is not good, it will find no mar-
ket, is deceiving ourselves, experimenting on our babies,
relying on the character of a single man or corporation,
on the honesty or intelligence of the manufacturer's chem-
ist, or his superintendent, or his workmen, on the nature
and condition of the elements used in the composition of
the article, and on ever so many influences, which can work
before the manufactured article gets into the hands of the
consumer. Why the sellers and advertisers of unknown
compounds should be more trusted than those who sell a
simple article of food, such as milk, which is constantly
adulterated, can hardly be perceived. Is it necessary to
say that the factory furnace is lighted more in the interest
of the proprietor than for the benefit of the public?

Still, in regard to the growing evil, which has assumed
vast proportions, the profession is at fault, to a certain
extent. There are few but are aware of the inexpe-
diency and sometimes danger attending the exclusive
feeding of cow's milk, and look for substitutes. Examples
of infants thriving on almost any food are numerous; the

401

DR. JACOBI'S WORKS

public taste runs in the direction of the unknown; thus
the responsibility of advice or assent is but a slight one;
many of the foods in the market come in a pleasant form
and convenient for use; thus the food business firm thrives.
Professional men have come to look upon the use of pat-
ented foods as something quite unobjectionable. Those
imbued with the strictest sense of ethics, who would not
patent an invention, nor tolerate the fellowship of a pro-
fessional man who does so, who frown upon patented medi-
cines, because they are unknown and unknowable com-
pounds, or though their components be printed on the
labels, these very men forget their habits and principles
when the question of patent-right and secrecy comes up in
regard to foods. If I add, that many of the scientific
journals of Europe, particularly those of Germany, dedi-
cated to the study of children's diseases, are frequently
used for the purpose of discussing the merits and effects
of some new infants' foods, it is only to show to what
extent the evil has grown.

No profound thinking is required to appreciate the fact
that of a great many of the articles offered for sale a
few only are available compositions. But the very fact
that they are compositions, that everything organic may
spoil, that every compound depends on too many circum-
stances which are apt to interfere with its uniform con-
dition, and that when we rely on a compound, we rely at
the same time on a proprietor, his foreman, his workman,
his chemist, and the wholesale or retail dealer, we feel
that we are easily deceived or disappointed. Besides,
for an article, the constituents of which we can purchase
at a low price, we are taxed to an inordinate extent. I
repeat what I often said before: artificial foods must be
simple, recognizable, accessible, cheap, and easy to pre-
pare. Thus only will they become universally useful to
the rich and poor, to city, country, prairie and backwoods.

403

DENTITION

The formation of the teeth begins in the first third of
embryonic life. According to Goodsir, narrow grooves are
formed, in tlie sixth week of utero-gestation, between what
is afterwards to be the lips and the rudimentary maxillary
processes, at a time when the former are hardly visible.
The first change consists in the formation of wart-like
excrescences upon the bases of the grooves, the grooves,
as it were, forming receptacles for these excrescences.
This is the first indication of the dental sac with a dental
papilla in its cavity. In this cavity the dental substance
is gradually deposited.

This is the way in which dental sacs of the twenty
milk teeth are formed. They undergo ossification in the
fifth month of utero-gestation. Behind them are the sacs
for the permanent teeth, but whether or not there is a
communication between those of the former and the latter,
is not yet known. After they have been separated from
each other, however, there is still some connection between
them and the " gubernaculum dentis." The separation is
complete when the foetus is finally born. About that time
the margin of the dental cavity is cartilaginous, and the
root of the tooth begins to grow, and by its formation
and growth the tooth is pressed forward. During this
jDrocess the cartilage of the wall and the gums is made
to disappear. The lateral wall of the dental sac becomes
the periosteum of the dental root. Sometimes the cartilage
disappears before the tooth has reached it. In those cases
the tooth can be felt before it can be seen. The two
lower incisors will appear, as a rule, between the seventh
and ninth month. Then there is an intermission of from
three to nine weeks, and the upper incisors will appear
between the eighth and tenth month, with an intermission
following of from six to twelve weeks. Six more teeth
make their appearance between the twelfth and fifteenth

403

DR. JACOBI'S WORKS

month ; that is two upper molars, two lateral lower incisors,
and two lower molars. This growth is followed by an in-
termission of from three to six weeks or more. Four bi-
cuspids protrude between the eighteenth and twenty-fourth
month, and the four second molars between the twentieth
and thirtieth month.

These twenty teeth are all the infant has before the
second dentition begins.

The second dentition begins with the protrusion of the
third molars, and this takes place in the fifth or sixth
year. About that time the arteries of the temporary teeth
are obliterated and the nerves disappear. The alveolus
becomes large and the teeth fall out without any caries
taking place. At that time the temporary canine lies in
front of the external incisors and the first molar. Thus
it is that very often in later life the teeth have an oblique
position. The wall between the alveoli of the temporary
and the permanent teeth becomes slowly absorbed and the
milk teeth fall out painlessly, unless the roots of the
teeth have not been absorbed in the order of their first
appearance.

In the twelfth year there protrude four more molars.
Between the sixteenth and the twenty-fourth year four
more molars (or the wisdom teeth) appear, the crowns
of which ossify as late as the tenth year of life.

There may be great anomalies with regard to the ap-
pearance of the teeth. Now and then teeth have been
found at birth. They are generally the incisors. Some
of them hang loose in the gums; some, however, are
solidly imbedded in the gums. Such an occurrence is rare.
Thus it is that in some parts of Germany and Switzer-
land a child born with teeth was regarded as a witch. Ac-
cording to the missionary Endemann, Asiatic nations would
throw a baby with congenital teeth or other malformation
into boiling water.

About some there is a tendency to development of pseudo-
plasms. Majcillary cysts are mostly congenital. They are
either follicular, that is, the results of dilated dental sacs,
or they are periosteal, originating chiefly in the periosteum
of the teeth and not of the maxilla.

404

DENTITION

These cysts may contain bones and teeth. Latterly
they have been explained by proliferation of embryonal
cells. Or they have been regarded as duplicatures of
the external embryonic layer.

Other congenital malformations are cystomata, myxo-
mata, sarcomata, fibromata, which originate during the
embryonic growth of the pulp of the teeth.

Aberrations from the normal time of the appearance
of the teeth as given above are not very rare. Some-
times very late, for instance in rhachitis. At the same
time the fontanels will close later than the normal period
of fifteen months, and the development of the bones of
extremities is also delayed. The lower jaw is small.
Thus it is that after a while, when the permanent teeth
are expected, they crowd each other and become irregu-
lar. Not infrequently lias rhachitis developed during
foetal life, and then, sometimes, several dental sacs are
merged into each other, and instead of two teeth we have
only one. This is a frequent occurrence with regard to
the lower incisors, and corresponds with the insufficient
development of the lower maxilla in rhachitis.

Teeth will also appear at a later period than normal
when the children suffer from chronic disorders, such as
anaemia, slow convalescence, etc.

The protrusion of teeth may be premature. When
this premature protrusion of the teeth occurs with syphilis
or rhachitis, it is the rule that, after the first teeth have
appeared, there will be a long interval before those of
the next growth make their appearance, say from four'
to six months. As a general rule, however, premature
appearance of the teeth is connected with premature ossi-
fication of the bony system in general, and of the fontanels
and sutures of the cranium in particular. When this is
the case, the upper incisors, as a rule, appear first, un-
doubtedly in connection with the fact of the premature
ossification of the upper part of the cranium. This is
a serious occurrence. When premature ossification is con-
genital, it makes parturition difficult and renders the child
idiotic or epileptic. It will have the same influence when
it occurs at the age of three or four months. It will

405

DR. JACOBI'S WORKS

exert a moderate influence of the same kind when it
occurs from the eighth to the tenth month. At all events,
it is impossible on the part of the brain to develop favor-
ably when its bony capsule does not permit of sufficient
expansion of the brain substance.

It is a peculiar fact that even savage nations have
made observations which show their fear of such an oc-
currence. The Makalaka in South Africa are in the habit
of observing whether or not the upper teeth come first.
In Bohemia it is a popular belief that the child whose
upper incisors come first will soon die,

David Livingstone and Fritzsche report that some na-
tions in Central Africa kill the children whose upper
incisors protrude before the lower ones.

In considering the morbid processes which have been
said to originate in normal dentition, it should not be
forgotten that dentition is a physiological process. As a
rule, the gums, even when tumefied, have a pale color
and show no symptom of inflammation. As a rule, also,
there is no fever which can be made out by the ther-
mometer. There is no stomatitis; certainly no thrush,
both of which are pathological conditions. It is true that
there is a certain amount of itching, even pruritus of the
gums, and there is certainly a condition of irritation.
There is very frequently a vaso-motor disturbance in the
shape of reddened cheeks. But even where this is found,
it must not be attributed exclusively to the reflex irrita-
tion of dentition, because there are a great many condi-
tions in which the same symptom is present; for instance,
pulmonary congestion, pleurisy, pneumonia, meningeal ir-
ritation.

It is also true that, now and then, there are slight
muscular twitchings ; and now and then, when the child is
half asleep, the eyes will roll. There may even be slight
twitching of the extremities. There is sleeplessness, but
we must not forget that peripheral irritability increases
from the fifth to the ninth month considerably, and that
the inhibitory centers do not perform all their functions
as in the adult. Thus it is even possible that, now and
then, a convulsion will occur, but so far as I am con-

406

DENTITION

cerned, I have not seen convulsions dependent upon diffi-
cult dentition in the course of the last ten years.

It is also stated that there are eruptions dependent upon
normal dentition. Urticaria, lichen, eczema are attributed
to its influence. It is very questionable whether these
cutaneous affections have anything to do with the momen-
tarily flushed cheeks of which I have spoken. We must not
forget that about the time the teeth make their appearance
congestion of all the parts of the head occurs uniformly.
It is the time at which not only the teeth will protrude,
but the brain and the skull will develop to a greater de-
gree than ever during human life. Thus it is, that, in
most cases, eczema, urticaria, etc., must be explained by
uniform congestion of the parts, and not by nervous or
other influences dependent upon dentition only.

It has also been stated, particularly by Vogel, that
there is, now and then, conjunctivitis on the same side
on which the teeth are protruding, and it is said to be
purulent. Striimpel suggests that this purulent conjunc-
tivitis, which he assumes after Vogel, may be, perhaps,
the result of contiguous irritation, the irritation having
extended from the antrum of Highmore and the nasal
cavities, an explanation which seems to be very much
strained.

It is also stated that pulmonary catarrh, bronchitis,
and broncho-pneumonia are very frequent during, and in
consequence of, dentition. It has been said that the ca-
tarrh may be the result of the large amount of salivation
running out of the mouth upon the chest in such children.
With regard to inflammatory diseases of the chest we must
not forget that there are several causes which, about the
time of dentition, are met with very frequently. It is
the time in which children are more exposed to atmospheric
influences. It must be remembered that within the first
year the mortality among infants is greatest from dis-
eases of the organs of digestion ; in the second year from
diseases of the organs of respiration, undoubtedly in
consequence of the fact that during that period infants
are more exposed to atmospheric changes than earlier in
life. This is one of the reasons why, at the time of
- 407

DR. JACOBI'S WORKS

dentition, not in consequence of dentition, pulmonary
diseases are frequent.

There is another cause, and it is this, that rhachitis
is certainly on the increase in our country. It has always
been more frequent than it has been reputed to be, espe-
cially that form which is unattended by any considerable
amount of glandular swelling. Even the glandular en-
largement need not be visible about the throat, but it is
perceptible in the deep-seated cervical glands, and in the
lymphatic glands of the mediastinum. These swollen glands
give rise to bronchial catarrh, frequently, to acute and
chronic broncho-pneumonia, and not infrequently to phthi-
sis even at that early age.

Another ailment which is frequently attributed to den-
tition is diarrhoea. Is it found in most children who are
teething.'' Certainly not. The large majority of chil-
dren who are either at the breast or whose artificial food
is well selected, do not suffer from diarrhoea, while going
through the process of dentition.

The occurrence of diarrhoea has been attributed to sev-
eral causes. Some have attributed it to swallowing a large
amount of saliva and oral secretion which begins to show
itself in children of three or four months of age, and
continues a number of months. Nobody has ever stated
that the copious salivation of the fourth or fifth month
gives rise to diarrhoea; still, when the infants are six or
seven months old, the diarrhoea is said to be the result
of the same salivation.

Others have said that the reputed dental diarrhoea is
due to nervous influence showing itself in reflex disturb-
ance of the splanchnic nerves. But the explanation has
not been given; still the presumption prevails that this
diarrhoea must be of a neurotic character.

It has appeared to me that the fear lest dentition
should produce diarrhoea has been very much exaggerated.
At all events, the popular belief that there is such a
thing as dental diarrhoea has given rise to the practice
of not caring for such a diarrhoea, and many an incurable
enteritis, and consecutive lymphadenitis and atrophy has
been due to the very fact that such a diarrhoea has been

408

DENTITION

neglected. In all such cases, no matter whether diarrhoea
or bronchitis, or consequent diseases are present, it is
wrong to fall back without looking for the diagnosis of
something more, upon dentition as the cause of these af-
fections. A large number of diseases which have been at-
tributed to dentition owe this erroneous diagnosis to the
fact that the diagnostic powers of the practitioner were
limited like those of the public with which he had to
deal. This much I may add, that the local treatment of
swollen gums, which consists of lancing, has fortunately
become less common and popular than it was in former
times. Although I see a large number of infants in the
course of a year, I can state that in not more than two
cases have I felt called upon or been induced to lance the
gums in the last five years. In a few cases I have done
so under the impression that it might do good, inasmuch
as the diagnosis of my case was not quite clear. In
most cases in which I lanced the gums I found, two or
three days later, pneumonia which was quite easily diag-
nosticated, but which did not develop sufficient symptoms
early enough to prevent me from making my mistake.

Is there anything which has not been attributed to the
injurious influence of the second dentition.'' There are
many amongst the public this very day (perhaps also
amongst the practitioners.'') who would be apt to coincide
with E. Smith (Lancet I, 1869, p- 23), who expresses the
conviction that the copious secretion transmitted from the
oral mucous membrane is a very serious matter. According
to him, the children become pale, thin, restless, appetite
irregular, either diminished or exorbitant, bladder incon-
tinent, constipation alternates with diarrhoea, worms are
more copiously raised in the intestinal mucus. Thus mat-
ters get worse and worse, until the child dies of phthisis.
I should say that " phthisis " might and ought to have
been diagnosticated before, and perhaps prevented, if the
dentition-ridden medical man had known how to look after
chronic glandular swellings, or chronic pleurisy or pneu-
monia, as the possible cause of the fatal termination.

Of 100 deaths occurring in New York City in the
course of one year, 29-63 take place in the first; 10.3 in

409

DR. JACOBI'S WORKS

the second; 4.37 in the third; 2.40 in the fourth; 1.64 in
the fifth; 3.20 in the sixth year. Thus in the first six
years occur 51.28 per cent, of all the deaths. The whole
period from the end of the sixth to the eleventh year
gives only 1.50 per cent, of all the deaths.

Thus there is considerable resistance on the part of
the child's organism, after it has been fully developed to
its seventh and eighth years.

There are some other facts which prove that this time
is rather immune than otherwise.

Growth is most rapid in the first few years of life,
not only in regards the head, but also the rest of the
body. The length of the newborn is 18 inches; that of
the adult 66 inches. The increase in the first year is
10 inches; in the second 4 inches; in the third 4 inches;
in the fourth 3 inches ; in the fifth 3 inches ; in the sixth
2 inches; in the seventh, eighth, ninth and tenth, each 1
inch. Thus there is retardation of growth after the com-
pletion of the seventh year.

The proportion of the upper part of tlie trunk, that is
the chest, to the lower, in the newborn, is as 1 to 2 ; in
the adult as 1 to 1.618. This normal proportion is at-
tained with the eighth year.

The lumbar portion grows principally until the ninth
year; then again between the twelfth and fifteenth, about
the time of puberty.

Between the seventh and ninth years there is retardation
of the growth of the lower extremities, as also the trunk
and the whole body.

In the newborn, the proportion of the upper part
of the head, the skull, to the lower parts is 1 to 1; in
the adult 1 to 1.618. This stationary proportion is at-
tained with the eighth year.

After all, then, this is the time of the second dentition.
Where, now, are the dangers to life.'^

Still, though not a serious danger, a great and perma-
nent inconvenience and injury may originate between the
first and second dentitions. They may result from the
fact that the wall between the cavity of a temporary
tooth grows thinner and disappears very gradually by
premature evulsion of the temporary teethj particularly

410

DENTITION

the bicuspids. The permanent teeth are very easily in-
jured inasmuch as they are imbedded between the roots
of the temporary ones. The damage done by such action
is frequently greater than the result from retardation in
falling out, on the part of the temporary. But in the
latter case, also, the beauty, position, and number of the
permanent teeth can be impaired. Thus at this early time
the advice of a professional dentist is frequently required.

There is but one good cause for premature evulsion of
the milk teeth, namely, general periostitis or ostitis of the
maxilla produced by inflammation of the root of the tooth.

It would be a mistake, however, to believe that we are
more mediaeval than other nations. The measures for re-
lieving the dangers from the cruel attacks by the ambush-
ing teeth, upon the unsophisticated baby, prove better than
anything else how the maternal (and professional?) minds
have been impressed by awe-stricken faith down to the
second half of the enlightened nineteenth century. Ac-
cording to H. H. Ploss,^ in different parts of Germany,
Austria and Switzerland they resort to the following meas-
ures: A trouser button and dried umbilical cord are
kept under the pillow. The tooth of a colt a twelvemonth
old is worn around the neck at the time of the increasing
moon. The paw of a mole — bitten off — is sewed in and
worn around the neck. The baby to be licked by dogs.
The head of a mouse to be used as the above mole head.
Every female visitor gives the baby a hard egg. The baby
is carried to the butcher, who touches the gums with fresh
calf's blood. The gums are touched with the tooth of
a wolf, with the claw of a crab. The baby is supplied
with three morsels from the first meal in the new resi-
dence after the wedding. Bread from the wedding feast
of a newly married couple in good repute. A mass of
lindsprouts cut at twelve o'clock on Good Friday. A bone
found by accident, under the straw mattress. Mother,
wlien first going to church after confinement, kneels on
the right knee first. A man coming to visit, is silently
given a coin, touches the gums of the baby three times
and — goes to the tavern. So he does.

1 Das Kind in Brauch und Sitte der Volker, 1876, II vol.

411

INTESTINAL MALFORMATIONS

The intestine of children is normally longer than that
of adults. Up to the ninth, even to the twelfth year,
the capacity also is greater than that of the intestine in
the adult.

An abnormal length of parts of the intestine may oc-
cur anywhere, but particularly in those parts which are
attached to the mesentery.

There is a malformation that has been called partial
duplication, or reduplication. It is, in fact, not this,
but a diverticulum, so-called by Meckel. This is met with
sometimes in the newly-born, twenty or thirty centimeters
above the ileo-caecal valve; in the adult one meter, some-
times a little higher or a little lower; occasionally even
in the colon, where its aperture is quite large. It extends
from two to ten centimeters, or more, in the direction of
the umbilicus, to which, now and then, it is attached by a
filament. This diverticulum is nothing else but the rem-
nant of the original omphalo-mesenteric duct. Sometimes
the whole diverticulum is attached, inside, to the umbilicus,
making a cul-de-sac or cloaca. Sometimes the cul-de-sac
penetrates the umbilical ring, or it is attached to the
peritoneum below the umbilicus, or it terminates in the
umbilical ring with a fistulous opening, or it adheres
somewhere to the abdominal wall. Sometimes the adhe-
sion to the abdominal wall is only partial, and then
meconium will enter the abdominal cavity. This is found
mostly on the side not covered by mesentery. In rare
cases it is separated from the intestine, and then it is
apt to form a cystic tumor. Now and then there is ne-
crotic destruction of the umbilicus, with pyaemia or sep-
ticaemia, or a fistula resulting therefrom. Now and then
the diverticulum gives rise to twisting of the intestine at
any time during later life. Not every cystic tumor found

413

DR. JACOBI'S WORKS

in the abdominal cavity, however, in or near the intestine,
is of the same character. Some of them belong to the
class of teratoma (foetus in foetu).

Very small cystic tumors have been found in the colon,
soon after birth. Most of them appeared to have been
developed after dysenteric processes, and to be the re-
sults of local extravasations. Some may originate in ex-
udation; some, however, are retention cysts belonging to
the class of those which grow out of swelled glands with
obstructed ducts, and follow a chronic inflammatory process
in the mucous membrane of the large intestine. The local-
ization of the dysenteric process in the lowest part of the
intestines explains why such cysts are absent from the
small intestines. The only case in that neighborhood,
in the newly-born, I know of, has been reported by Dr.
Eugene Frankel, of Hamburg, in Virchow's Arch., Vol.
87, 1882, p. 281. It gave rise to very serious symptoms
of complete obstruction, and terminated fatally. The speci-
men dates from 1851, and was taken from a female child
after she had died, on the eleventh day. When she was
born, and during two days, she ate and defecated nor-
mally. Then vomiting set in. The obstruction was com-
plete, food and feculent matter thrown up. Drastic purga-
tives resulted in evacuations and subsequent diarrhcEa, re-
quiring constipating administrations. Two days after-
wards again constipation, drastics again, and no effect.
At the autopsy the large intestines were found empty,
the small intestines inflated with gas; at the lower end of
the ileum there was a spherical cystic tumor between
mucous and serous membranes of a diameter of 2^ cm. (1
inch), obstructing the lumen of the intestine almost com-
pletely, even in the dead body.

A very important malformation of the intestinal canal
is partial or complete obstruction, stenosis or atresia.
Besides the atresia which can be produced by cystic tu-
mors, as described above, there is now and then a dupli-
cation of the mucous membrane, which is apt to produce
obstruction like the hymen in front of the vagina, and
close the entrance to the cavity either partially or com-
pletely. Sometimes the obstruction is so complete, that

414

INTESTINAL MALFORMATIONS

nothing is left of the intestine except a filament. Then
there is also absence of the corresponding part of the
mesentery. This condition has been observed in a few
cases, particularly in the duodenum, mostly about the en-
trance into the ductus communic choledochus, and also in
the ileum. It has been regarded as the result, either of
foetal peritonitis, or of the twisting of the intestine in
an early embryonic or foetal period, but it is the result,
particularly in the rectum, of actual arrest of development.

I published a rare case of this kind in the American
Medical Monthly, 1861. It was that of a male infant 39
hours old.

The history of the case was given by the attendants in
the following manner: The child had no evacuation of
the bowels for the first twelve hours after birth. A med-
ical man was called in, who removed some obstruction by
means of his fingers from the anus, and gave an in-
jection, whereon a string-like, hard, solid, whitish mass
was removed through the anus. The child then was de-
clared to be all right, and he left. Nevertheless, no regular
passage was had, but the patient evacuated a mass like
that described, but less in quantity, several times. He
commenced vomiting, however, bringing up a black sub-
stance, which was afterwards changed into a brownish or
yellowish-gray mass by the addition of milk, which the
child would readily take from the breast. When the in-
fant was presented he still looked well-developed; no
deformity was perceptible on any part of the body. Ex-
haustion began to show itself, from the somewhat collapsed
face and the sunken fontanelle. Abdomen not much
inflated; only across it, below the liver, and a little down-
ward to the left, an intestine was both seen and felt. It
was inflated with gas, which appeared to be unable to
escape. The rectum was very narrow, but could be ex-
plored to the length of the fifth finger, and no perfect
impermeability found. The faeces removed last were
pretty greenish, solid, about a fifth of an inch in diameter,
and completely formed. Having no other means of diag-
nosis ready, the case was declared to be one of stricture
of the intestine, somewhere between the colon transversum

415

DR. JACOBFS WORKS

and rectum. The last evacuation, however, was subjected
to a microscopical examination, and found to contain a
uniform mass of cells, of average size, with nuclei and
some nucleoli. No fat, nor hair, nor cholesterine, nor large
epithelial scales; thus the evacuation was set down as in-
testinal mucus only, not as meconium. On the next day
the substance thrown up from the stomach was submitted
to a large microscopical examination, and found to con-
tain, besides milk, some crystals of cholesterine and a
large number of large epithelial scales. The case was
then put down as one of complete impermeability of the
intestine, as there were constituents of meconium above,
but not below, a certain point.

Patient died with the symptoms of exhaustion when
seventy-two hours old. Post-mortem examination was made
nine hours after death, but abdominal cavity only opened.
Rectum very narrow, as described above. Above, the
colon appeared only about a fifth of an inch in diameter,
but could be inflated up to the vermiform process; no air
would pass the valve. A tube was then introduced through
a small incision above the ileo-ccEcal valve, and inflation
attempted from above downward; but no air would pass
the valve, thus showing a perfect impermeability. The
whole colon and rectum have a length of about fifteen
inches. Stomach is normal; perhaps a little larger than
usual. Duodenum and upper part of the intestine, to a
length of about fourteen inches, are very much dilated,
and terminate in a very large cul-de-sac; no opening
being found into the remaining part of the intestine,
which all of a sudden become of a decidedly diminutive
size, of perhaps a fifth of an inch in diameter. This is
the size of the intestine all through its length down to
the valve, with the following exceptions. As stated, there
is no connection whatever between the dilated upper por-
tion of the intestinal canal and the suddenly contracted
part, both of them ending in a cul-de-sac. Below this,
about two inches from this first impermeability, the con-
tracted intestine again ends in a cul-de-sac, after which, to
a distance of eight lines, no intestinal cylinder what-
ever is found, the mesentery hanging free in the abdominal

416

INTESTINAL MALFORMATIONS

cavity. Then, again, a small intestinal cylinder, of nine
or ten lines in length is found closed on either end. Again,
the mesentery without its intestinal appendix for about
eight or nine lines. Again, an intestinal cylinder of the
same length. Again, absence of intestine for a similar
distance. A third intestinal cylinder of the same length,
closed on either end, follows this; and again, at last,
free mesentery for about half an inch. Then, finally, the
intestine fairly begins again, uninterrupted in its lumen,
and unchanged as to its diameter of about a fifth of an
inch, and measures, down to the ileo-caecal valve, twenty-
two inches. Thus, the whole length of the intestine,
including, altogether, two inches of mesentery not accom-
panied with intestine, is about four feet and a half, ex-
hibiting in its course, besides the dilatation of the upper
portion, a nearly equal coarctation of the lumen, the colon
being a little larger than the rest, and the rectum not so
narrow as the colon itself, two perfect impermeabilities;
and beyond these four total interruptions of the course
of the intestinal canal, the free intervals being, in the
average, eight or nine lines in length.

Liver, spleen, kidneys, and bladder perfectly normal.
Both of the kidneys contain beautiful specimens of the
so-called uric infarcts.

Cases like the above are more than merely rare. Per-
haps there is, besides an important case in Ammon's Atlas,
and Kiittner's, and Hiittenbrenner's cases, not more than
half a dozen on record. In Kiittner's case the jejunum
ended in a cul-de-sac; then there was a piece of intestine,
of three inches in length, ending in a cul-de-sac on either
side; further, a second of the same description; finally, a
third one, five inches long. Then, at last, the colon, com-
mencing with a cul-de-sac above, and ending in a normal
anus.

A similar case was one I saw with Dr. Henry Schweig,
nearly thirty years ago. With similar anatomical changes,
constant vomiting soon after swallowing food, the baby
lived thirty-five days. Some of these patients exhibit a
remarkable vitality indeed. A case kindly sent by Dr.
Huntington, of New Rochelle, to my college clinic, more

417

DR. JACOBI'S WORKS

than ten years ago, was heard of when thirty-three days
old. How long it survived afterwards, I have not learned.

As already stated, most of the changes occurring in the
rectum are due to arrest of development. The posterior
end of the alimentary canal forms, about the fourth
week of foetal life, a cloaca with the allantois. In its
anterior end are the sexual ducts. The anterior part of
the cloaca is open; the posterior end, corresponding with
a later formation of the intestine, is closed. The two
parts are soon separated, by the canal being bent in at
its posterior end, into the urino-genital sinus and the rec-
tum. The first partial septum is the primary perineum.
It grows gradually, and then separates the opening of
the anus and the sexual organs.

Malformations of the rectum may be of different kinds.

First, the anus is present; atresia of the rectum is far
inside. It may have been the result of twisting, and then
two cul-de-sacs of the intestine may be found in different
positions towards each other.

Second, there is no anus. The rectum opens by a thin
fistula in the perineum ; or in the raphe of the scrotum ;
or in the vulva. Evidently, in embryonic life the septum
was formed too near what was later the sexual opening.

Third, there is no anus. The rectum terminates in a
fistula attached to the mucous membrane of the urino-
genital organs. In these cases everything was normal
except the original perineal septum, and the part of the
intestine which should have developed from the cloaca
missed its development. There are, sometimes, other mal-
formations connected with this anomaly.

Fourth, there is no anus. Sometimes it is indicated by
a dimple. The intestine terminates in the neighborhood
of the promontory. Between the perineum and the intes-
tine there is absolutely no remnant, with the exception of
a few cases in which a residual filament has been found.

In these cases it is possible to assume different causes.

First. — Inflammation and conglutination.

Second. — Arrest of development, perhaps connected with
an excessive absorption of the pars caudalis of the spine.

Third. — The primary perineum may have developed

418

INTESTINAL MALFORMATIONS

posteriorly to an abnormal degree^ thus separating the in-
testine above from the remnant of the posterior part of
the cloaca, which was to become the anus.

Fourth. — There may have been developed a diaphragm,
hymen-like, from the part of the mucous membrane, as
alluded to when the upper part of the intestinal tract was
under consideration.

When the original embryonic abdominal fissure remains
patent, the newly-born may have an ileum or colon which
is also open.

The vermiform appendix may be absent, or nearly so.

The small intestine, also the large, may be too short,
and the difference between the two may be but very small.

There may be anomalies of position. The intestine
may protrude through the abdominal fissure; through a
fissure in the diaphragm in its left half; through the
natural openings, the inguinal and femoral rings, and
others.

Transposition of the intestine may occur independently
or in connection with other transpositions. This anomaly
is the result of the fact that the intestine has to go
through a series of changes of location before it as-
sumes its natural shape.

The colon ascendens or transverse may be entirely ab-
sent.

There are not infrequently small, tumor-like bodies
in the walls of the small intestine. Sometimes they have
been found at the apex of diverticula. They are the
result of a few pancreatic cells separating from the main
body at a very early period of embryonic life.

The symptoms of imperforate rectum and atresia ani
are as follows : No evacuation, no anus, or the exploring
finger gets into a cul-de-sac half an inch or an inch above
the anus. Sometimes, however, the obstacle is very far
above the finger's length. The colon begins to distend,
now and then with dulness on percussion. At first the
swelling may show itself in the hypochondrium first and
extend to the right inguinal region along the lengthened
sigmoid flexure. Vomiting at first yellow, afterwards of
meconium. Inflation, not always uniform, of the whole

419

DR. JACOBI'S WORKS

abdomen, pain, dilatation of the external veins, super-
ficial thoracic respiration, elevation of temperature and
other symptoms of peritonitis.

Treatment: In view of the fact that the imperforate
condition may be apparent, injections ought to be tried
often and copiously. If unsuccessful, they ought to be
followed by the operation, performed for the purpose of
either joining the two unconnected cul-de-sacs or drawing
the rectum downwards, or if that be impossible, of estab-
lishing an artificial anus in the (right or) left side.

420

TABES MESENTERICA

The names by which diseases are known in modern
pathology have come to be derived from their pathological
anatomy in the same degree that local diagnosis has been
brought nearer perfection. Symptomatic diagnoses and
sj'mptomatic terms are becoming rare; though it is true
that there has crept into nomenclature an equally unsci-
entific habit, which consists in applying to a newly-
observed disease or complex of symptoms the name of
their first observer — or inventor. Many formerly accepted
as nosological entities have been given up as such; when
we speak of dropsy, paralysis, convulsion, neuralgia, -epi-
lepsy, or atrophy, we know perfectly well that we have
to deal with a symptom, or a number of symptoms, re-
quiring etiological details for their exact recognition, and
special and varying indications for the treatment of in-
dividual cases. But until a very late period " tabes mesen-
terica," or " tabes mesaraica," has been accepted as a
term applicable to a particular set of symptoms and lim-
ited anatomical changes by which it could be easily recog-
nized. The following pages will be dedicated to showing
that the pathological anatomy of mesenteric tabes is by
no means the same in all cases, and that the term itself
ought either to disappear entirely from our indexes or
be recognized as merely a convenient expression for a
complex of more or less similar sj^mptoms.

Among those, mostly older, celebrities who were of the
opinion that imperviousness of the mesenteric glands was a
satisfactory explanation of tabes mesaraica, that patients
die because the lacteals are no longer able to take up
from the food a sufficient supply of nutriment, and that
they die of starvation, are Thomas Watson, Cullen, and
Bichat. The latter modified the general opinion in this,
that he defined tabes (carreau of the French) as the en-

421

DR. JACOBI'S WORKS

gorgement of the glands of the abdomen, mostly occurring
between the second and eighth years, painful or painless,
complicated with digestive disorders, distention, diarrhoea,
and vomiting, which, however, did not result in the non-ab-
sorption of chyle except in the later periods of the dis-
ease.^ Cruikshank, as early as 1790, thought this block-
ing up of the lymphatic circulation very improbable, and
Guersant formulated his hesitation in accepting the ex-
clusive obstruction theory by declaring that the very diag-
nosis of the condition of the glands was always difficult;
that the examination of all the viscera often resulted in
the discovery of changes which led to the results attrib-
uted to glandular disorders exclusively; that he was not
aware of a single case of disease of the mesenteric glands
not attended with complications ; that, moreover, there were
many glandular disturbances without nutritive disorders;
and, finally, that the mesenteric glands were not the sole
roads for the admission of chyle. Besides, in his own
reports, and in those of his followers, and in the experi-
ence of all those who have compared morbid symptoms
during life with the evidences of post-mortem examina-
tions, there are many cases in which, together with the
glandular changes, or independently of them, the acute,
subacute, or chronic inflammation of the peritoneum, either
general or local, and mostly of a tubercular character,
was the only anatomical anomaly underlying the symp-
toms of " mesenteric tabes."

SYMPTOMS

The main symptoms common to every form and case
of " tabes mesenterica " are atrophy and tumid abdomen.
Emaciation and atrophy reach a degree hardly ever met
with in any other morbid condition. The subcutaneous
fat disappears rapidly. The skin is thin, flabby, and in-
elastic; round the limbs it is loose and hangs like a bag;
when taken up between the fingers it retains the fold

1 W. T. Gairdner and Joseph Coats, Lectures to Practitioners,
London, 1888.

422

TABES MESENTERICA

raised in the lifting. In the beginning the muscles can
be recognized; afterward even they emaciate to such an
extent that their outlines disappear, and those of the
bones are distinctly perceptible. The eyes lie deep in
the orbits, and have a peculiarly dry and hungry look;
the bones of the face, with the thin, flaccid, dry and scaly
skin over them, take on a terribly senile expression. The
surface is mostly cool, the limbs are cold, the cutaneous
veins very distinct and blue, much dilated over the chest
and still more so over the abdomen. The voice is thin and
tin-like, the cry mostly tearless, the pulse slow (from ex-
haustion of the heart-muscle), or more frequently rapid,
thin, and compressible. The lymph-bodies of the neck
and the inguinal region, sometimes also the axilla, are
tumefied.

These symptoms are more or less common to all cases.
There are many, however, which exhibit numerous varia-
tions in important particulars. Appetite may be raven-
ous or entirely lost. Some begin with little or no diar-
rhoea, but in all the stools are fetid. The majority, how-
ever, commence with a severe form of intestinal catarrh,
attended with numerous offensive discharges. The pe-
culiar odor, foul, musty, pungent, ammoniacal, is due in
part to acids formed by the fat which has not been ab-
sorbed, sulphides, and other products of putrefaction. In
the further development of the morbid condition there may
be constipation, but diarrhoea is more frequent. It may
not be very copious nor the evacuations very numerous.
There is tenesmus in some, with but little substance; others
are large, and expelled suddenly, in an instantaneous gush.
The temperature is in some cases normal or even sub-
normal, in others elevated; when it is quite high, the
cheeks and scleroticse may become injected. The tumid
belly is absolutely painless in some, very sensitive in
others; the latter mainly in those who have an elevation
of temperature. The large size of the abdomen, with its
nets of dilated veins, contrasts fearfully with the atrophied
condition of the limbs. It is large enough to press the
diaphragm upward and interfere with the functions of
both heart and lungs. The nature of the tumefaction,

4£3

DR. JACOBFS WORKS

however, varies: it is tense or flabby, hard or soft, doughy
or firm, uniform or irregular. Nodules or lumps of differ-
ent shapes and sizes may be discovered by palpation.
They may be spherical; flat, so that the hand can be run
under the cake; superficial, near the abdominal wall; or
deep-seated, in close neighborhood to the vertebral column.
Gentle percussion will reveal tympanites all over, both on
the top of the protruding abdomen while the child is on
his back, and in the flanks; or there are one or more areas
of relative dullness corresponding with a solid mass dis-
covered by palpation; or there is dullness in both flanks,
varying with changes in position, thus indicating the pres-
ence of fluid, which, moreover, can be made out by its
fluctuation. Great care, however, has to be taken lest the
presence of solid tumors in a flank give rise to the diag-
nosis of fluid, or lest intestines containing gas which have
been glued to the abdominal walls disguise entirely
through their lymphatic percussion-sound the presence of
ascites.

Other symptoms may be present, such as cedema,
through thromboses in small veins; extensive dullness be-
longing to fatty liver; albuminuria and the usual micro-
scopic changes of the urine encountered with nephritis ;
local inflammations of the abdominal surface connected
with a})scesses which are occasionally, though rarely, the
final stages of certain forms of peritonitis ; and cough
depending on tubercular disease of the lungs.

The variety of symptoms belonging to " tabes " points
distinctly to different morbid processes. The gradual be-
ginning, slow and feverless course, with but little disturb-
ance of the bowels and other organs ; the connection with
a severe form of enteritis, continuation of diarrhoeal dis-
charges during the beginning and growth of tumidity, and
moderate or high temperatures during the course of the
morbid process ; and the tumidity of the abdomen, with
emaciation following chronic cough and repeated attacks
of catarrh, and terminating either in fatal exhaustion or
in acute peritonitis, appear to prove that there are sev-
eral distinct forms of " tabes," depending on different
causes and attended with varying anatomical alterations.

424

TABES MESENTERICA

PATHOLOGY

Former essays in this work, particularly those of Dr.
Ashby on scrofulosis and my own on tuberculosis and
phthisis, have explained the changes taking place in the
lymph-bodies. Therefore only such brief remarks will be
made here as refer directly to the mesenteric glands.
Most of the first changes occurring in them are of an
inflammatory nature; they are secondary in character;
indeed, the primary changes are mostly neoplasmatic, and
particularly sarcomatous. As in other glands, the inflam-
mation may be a simple one and uncomplicated, or sup-
purative, -or fibrous, or caseous, or tubercular. Simple
adenitis is occasioned by any kind of irritation. Like
an eczema of the head or a nasal catarrh which lights
up adenitis of the neighborhood, a simply intestinal ca-
tarrh, with diarrhoea from any cause whatsoever, produces
it. The first change consists in dilatation of the blood
vessels, with reddening, softening, and succulence of the
tissue, endothelial changes in the lymph-spaces, and new
formation of cells. Afterwards the red discoloration is
replaced by a grayish-white color, now and then inter-
rupted by small blood-points which will turn into pig-
ment, and the difference between the cortical and medul-
lary substances fades or disappears. At the same time
the capsule gets tense over its swelled contents. These
are the cases which are amenable to a complete recovery.
But suppuration, induration, or necrosis of the tissue is
often met with. The latter is a frequent occurrence in
typhoid fever, in which the lymph- bodies of the abdomen
play a similar part to what we observe both more fre-
quently and more extensively in the glands of the neck,
under the influence of diphtheria.

Suppuration of inflamed glands is more frequent near
the surface than in the abdominal cavity, where they are
less exposed. Still, it does occur there, though mostly
in putrid and septic processes. Caseous and calcareous
degeneration is noticed in a certain number of instances.

Fibrous induration of lymph-bodies is of frequent occur-
rence in every region of the body. It is the usual result

425

DH. JACOBrs WOUKS

of repeated irritation. The constant hyperaemia of a
chronic intestinal catarrh or of frequent acute attacks pre-
cludes the return to normal circulation. Then the substance
of the glands becomes hard, dense, and white, the hyper-
plastic connective tissue compresses and atrophies the
cells of the parenchyma, the capsule becomes thick and in-
durated, and the organ retains nothing at all of its former
shape, size and function. In this condition when the
change has gone beyond cell-proliferation, and new tissue
has been fully organized, it is no longer amenable to
treatment.

The tubercular form of inflammation is very seldom of
a primary occurrence. In it the diseased gland is en-
larged, nodulated, and contains small round cells, or flat
epitheliod cells with large nuclei, and frequently giant
cells. The caseous and tubercular forms, while it was
Virchow's original inclination to distinguish between the
two, are considered identical, or mostly so, by Schiippel,
Rindfleisch, Orth, Cornil, and Koch.

Though it is rarely of a primary character, tubercu-
losis of glands, both mesenteric and others, is frequent ;
but to render a gland tubercular there must be an absorb-
ing surface accessible to the virus and ready to admit it.
A healthy mucous membrane absorbs no poison. It re-
quires an open wound, such as a chronic eczema, or a
chronic bronchial catarrh, to permit of a free access to
the neighboring gland. Thus it is that the glands of
the neck and the tracheal and bronchial glands are so
very liable to become tubercular. The mesenteric glands
are less exposed. It is true that the tubercular poison
may pass the stomach undisturbed, but it is certain that
tubercular enteritis and adenitis seldom result from it
directly. Indeed, even the diarrhoeas of phthisical pa-
tients, who swallow their own bacilli constantly, are not
so often of a tubercular nature as they are the mere
result of the local irritation produced by the presence
of copious pulmonary discharges on the intestinal mucous
membrane.

Only when the local irritation has persisted for some
time and produced erosions has a virus an opportunity to

426

TABES MESiENTERICA

locate and fasten itself in the injured epithelial layer.
In that case the tubercular invasion may lead to serious
results though the lesions of the surface have healed.

Thus it becomes evident not only why it is that a pri-
mary tuberculosis of the intestine, and the secondary tu-
berculosis of the mesenteric glands, by the introduction
of tuberculous food, may take place, but also why they
are relatively rare. Indeed, the cases which appear to be
conclusive are by no means so. For, while we may sus-
pect that infected meat or milk has occasioned a tuber-
culosis, that very case may have been infected either
through a wound of the lips, mouth, or throat, or by
simultaneous inhalation. Thus the suspicion that a case
is one of intestinal contagion is more readily entertained
than it can be proved. Schottelius^ fed ten families, con-
sisting of one hundred and thirty persons, on tuberculous
meat, which was taken raw sometimes, for two years; in
eleven years none of them died of tuberculosis. Thus,
while there is no doubt as to the occasional occurrence of
tubercular infection by meat or milk, the cases must be
well weighed before they are decided affirmatively.

Besides the simple secondary hyperplasia of the mesen-
teric glands resulting in obstruction, and the tubercular in-
filtration terminating in the same disturbance of function —
besides its infectious character — there is a third condition
which leads to the symptoms called " tabes mesenterica,''
viz., chronic tubercular peritonitis. It is quite frequent,
but its symptoms may vary in duration and severity. While
the child is emaciated, sometimes to a fearful extent, the
abdomen is tumid, elliptic, its surface shining, the surface-
veins dilated, the umbilicus expanded and flattened. There
is sometimes ascites; sometimes hard and circumscribed
tumors, or the intestinal convolutions, may be distinctly
felt or seen. This tumid condition is even liable to per-
sist when tubercular meningitis makes its appearance in
the course of time. There may be colic and diarrhoea,
or they may be absent. The temperature may be normal.
Slight changes in the afternoon ought to be ascertained
by inserting the instrument into the rectum. This con-

2 Virchow's Archiv, vol. xci.

427

DR. JACOBI'S WORKS

dition may last many months, even a year; it is capable
of vast improvement, and may terminate in recovery,
though with a low standard of vitality. This capability
of recovery, with which the experienced practitioner and
pathologist has long been acquainted, has surprised the
surgeons, now and then, who opened the abdomen under
a mistaken diagnosis, found tubercular peritonitis, sewed
up again, and concluded that when the patient recovered
it was because, and not in spite of, their uncalled-for
operation. At the present time, however, we are justified
in the belief that only those cases of chronic peritoneal tu-
berculosis will have a chance which are local, and not the
result of general tubercular infection.

Diagnosis. — In estimating the size and tumidity of a
child's abdomen, we must not lose sight of the fact that
it is normally larger in proportion than that of the adoles-
cent or the adult. The child's pelvis and chest are less de-
veloped, its liver large. The shape of the abdomen is
tun-like, its vertical length one-third of the length of the
body, while in the adult the proportion is one-fifth. A
high degree of tumidity may be due to constipation, mainly
that form which originates in oversize of the sigmoid flex-
ure, or in expansion of the intestine depending on mus-
cular weakness. The main cause of the latter is rachitis,
the first principal features of which, when developed at
an early date, are costiveness, meteorism, and flabby mus-
cular texture. Other causes are flatulence depending on
improper food and fermentation-processes in the bowels,
or insufficient peristalsis, or the presence of scybala; also
the presence of ascites depending either on cirrhosis or
perihepatitis or generalized peritonitis, the first of which
is the less frequent cause; or oversize of abdominal or-
gans, such as the liver or bladder; also either cystic
(urachus or echinococcus) or solid tumors. Among the
latter fibroma, enchondroma, myxoma, and lipoma are quite
rare and therefore not of clinical importance; carcinoma
is not uncommon, but sarcoma is more frequent. There
were, up to 1884,^ forty-three cases of sarcoma of the kid-

3 A. Jacob!, Sarcoma of the Foetal and Infant Kidney, Trans-
act. Internat. Congress, Copenhagen, 1884.

428

TABES MESENTERICA

ney on record. Tubercular disease and tubercular tume-
faction are very much more common. It is true that iso-
lated tubercular tumors, mainly those of the mesenteric
glands, are quite rare, but they do occur, uncomplicated
or, mostly, complicated with other lesions of an inflamma-
tory character. This complication of glandular enlarge-
ment with peritonitis may lead to very serious results,
even beyond the tubercular infection. A girl of two and
a half years, of healthy family, who previously suff"ered
from aural discharges and measles, and afterwards from
anaemia and general malaise, was taken with abdominal
pain and distention, constipation, and vomiting of mucus
and purulent material. She died after an illness of three
days. The autopsy revealed caseous mesenteric and retro-
peritoneal glands of the size of pigeon's eggs, bending
upon itself and gangrene of the sigmoid flexure, peritonitic
adhesions along the descending colon, the sigmoid flexure,
and the rectum, and complete obstruction, by compression,
of the ileum.* Similar occurrences are not at all rare,
though mostly not so striking as the one just related.
Indeed, adhesions between the intestines themselves, or
the intestines and the parietal peritoneum, or peritonitic
exudation with hemorrhages, or infiltrations of the omen-
tum which result in hard nodulated tumors located above
the umbilicus, are quite common, and form large masses
together with the infiltration of the gland themselves.
Such peritonitic exudations may be either simply inflam-
matory or tubercular, small or large, hard or soft, local or
generalized to such an extent as to fill the whole abdomen.
The diagnosis of tubercular peritonitis, or peritoneal
tuberculosis, is apt to be quite difficult. There are many
chronic cases which cannot be difl'erentiated from non-
infectious peritonitis and other inflammatory processes.
Besides, many of the caseous tuberculizations are small,
and thereby inaccessible to an accurate physical exami-
nation. They, and the rare cases of primary tuberculosis
of spleen, liver, bile-ducts, peritoneum, and intestines, are
to be inferred rather than diagnosticated. But there are

* Th. Pauli, Jahrb. f. Kinderheilkunde, 1889, xxix. 77.

429

DR. JACOBI'S WORKS

cases of tumid belly with atrophy of both an acute and a
chronic character, in which the nature of the affection can
be made out with some degree of certainty. When the
distention of the stomach appears after an intestinal ca-
tarrh, when it continues after diarrhcea has ceased in fre-
quency, the stool either improving in character or remain-
ing offensive, when the temperature remains high and the
symptoms (occasionally) exhibit a " typhoid " character,
with (now and then) delirium and frequently a dry tongue,
the existence of an acute attack of tubercular peritonitis
is probable. This diagnosis is rendered the more probable
by the presence of some other symptoms. Among them
are cough, sometimes slight, short, and hacking, some-
times moist and frequent ; the presence of pulmonary symp-
toms or dulness over the manubrium sterni or below one or
both of the clavicles, pointing to swelling of the trachea]
or bronchial glands; a concomitant history of tuberculosis
in the family; and a more intense degree of emaciation
than the brief duration of an intestinal catarrh would
justify. Still, mistakes are possible even then. The fre-
quent complication of peritoneal tuberculosis with fatty
liver and parenchymatous nephritis may obscure the clear
comprehension of the case. " Scrofulous " glands occur-
ring round the neck may be, and mostly are, non-tuber-
cular, being the result of non-infectious irritation of the
scalp or nasal cavities; the tumefaction of the inguinal
glands is too frequent to be of much account.

Prognosis. — The prognosis is always uncertain except
in the very worst cases. It is absolutely fatal when the
" tabes mesenterica " means peritoneal and glandular tu-
berculosis complicated with, or depending on, generalized
tuberculosis; when the temperature is permanently high,
and exhaustion extreme; when diarrhoea remains copious
and offensive, the heart very feeble, and the intra-abdom-
inal exudation has resulted in very extensive induration.
A case occurring in a healthy family, in a child that does
not suffer from cough or other pulmonary complication,
but develops its emaciation and tumid abdomen after a
protracted, though uncomplicated, diarrhoea, furnishes a
more favorable prognosis. For in such the diagnosis of

430

TABES MESENTERICA

a mere — non-infectious — hyperplasia of the mesenteric
glands can be made with great probability. In such, even
large indurations will be absorbed gradually. When the
diagnosis of chronic peritoneal tuberculosis has been made,
the case is less promising; still, in it the possibility of re-
covery, or partial recovery, is not excluded. Indeed, the
results of laparotomies, such as have been alluded to be-
fore, hold out a certain amount of hope even in those cases
in which the diagnosis could be made with perfect ac-
curacy.

Treatment. — A healthy infant or child cannot fall sick
with any of the symptoms of " tabes mesenterica." Thus
prevention consists in taking all the measures calculated
to preserve the general health of the baby. Foremost
among them is the selection of proper food: all the rules
and regulations detailed in other parts of this work, which
refer to the raising on breast-milk and appropriate artificial
food, must be conscientiously obeyed; farinaceous sub-
stances allowed in but moderate quantities; casein, which
is a frequent irritant of the intestinal mucous membranes,
limited to its proper percentage; and fat administered in
no greater quantity than is contained in the natural nutri-
ment of the nursling. Weaning is to take place at the
legitimate time, which has mostly arrived when a few
teeth have made their appearance. Good air and atten-
tion to the condition of the skin (cool bathing and fric-
tion, protection by warm clothing, and avoidance of
draughts) aid in enabling the young to resist injurious in-
fluences.

The early symptoms of rachitis indicate a thorough
anti-rachitical treatment (animal food, phosphorus, and
iron), and diarrhoea, no matter from what cause, must be
relieved immediately. Again I insist upon the danger in-
curred by allowing the catarrhal or inflammatory irritation
of the mucous membrane to remain unchecked; for it is
because of this that the neighboring glands begin to swell,
or that bacteric invasion takes place. But not diarrhoea
alone is connected with hypersemia and its dangers; con-
stipation also may be both the result and a cause of ex-
tensive congestion and irritation. Sometimes glandular

431

DR. JACOBI'S WORKS

swelling may appear without an apparent cause. In a
healthy family the thirteenth baby, after having been
subject to habitual costiveness, was laparotomized because
of intussusception. Thus it happened that the mesenteric
glands could be leisurely inspected and examined; they
were swelled to the size of beans and hazel-nuts.

To prevent the tubercular form, cow's milk and meat
must not be administered unless exposed to boiling heat.
It is true that there are not many cases of infection by
these agents, but the few ought to be avoided. Cream,
buttermilk and cheese cannot be submitted to the same pre-
ventive measure, and must be used with some caution. The
different forms of scrofula (" erethic " and " torpid ")
must be treated according to the methods discussed in other
essays; it is in them that animal foods, malt, iron, cod-liver
oil, and cereals without or with milk, are indispensable.
Whenever possible, a change of climate ought to be ad-
vised. Local tuberculosis in glands or in bones must be
extinguished by an operative procedure; and a chronic
eczema should be made to heal.

In chronic cases, in which changes in the mesenteric
glands can be safely diagnosticated and the existence of
tuberculosis excluded, iodides largely diluted may be ad-
ministered for a long time. The potassium, sodium, and
iron salts have their own indications, and may be com-
bined. They are particularly demanded in patients who
have previously suffered from the torpid, or adipose, form
of scrofula. They may be used externally, in baths regu-
larly given. It is here that natural springs, such as St.
Catherine's and Kreuznach, can be employed to advan-
tage. In the tubercular form arsenic ought to be admin-
istered in small doses for weeks or even months. Fat
(cream, cod-liver oil) does better here than in the simple
hyperplastic form, but in every instance we ought to re-
member that indurated mesenteric glands absorb but a
small quantity. Whenever enteritis remains active, the
eroded or ulcerated mucous membranes require antifer-
mentative treatment. In that chronic form small doses
of calomel are less efficient than bismuth, with or without
resorcin, and small doses of opium. Naphthalin and salol

432

TABES MESENTERICA

may be tried, but generally are not well tolerated. Nitrate
of silver, one-fortieth to one twentieth of a grain every
two or three hours, may be given for a week. Counter-
irritants have a less happy effect than warm applications
(moist or dry) and warm bathing. As may be judged
from the remarks I made on laparotomy in connection with
peritoneal tuberculosis, it cannot be recommended as a
remedy until many more unbiased observations shall have
been gathered. In ascites paracentesis must not be per-
formed unless urgently required, for many a case has been
absorbed without any surgical interference.

433

CASE OF SEPSIS IN A NEWBORN INFANT

G.^ MALE, 862 Park Avenue, was seen at 9 p. m., April 5,
1905, with Dr. Baran. Is the third child of the family.
No miscarriage. First child was an eight months baby;
died on the second day. Mother had been sick and under
treatment for several months previously. Second child
was delivered by Dr. Baran, and is in good health. No
family disease, particularly no hemophilia.

History. — No written records were kept. The follow-
ing history was elicited from the physician: Nothing was
noticed until the fourth day. Then heavy uric acid infarc-
tions were discharged. That lasted until the eighth day.
It recommenced on the ninth and lasted to the tenth day.
Urine was pale on the eleventh. No examination was
made. Quantity fair. Circumcision on the eighth, with
no accident. Purpuric spots of small size were seen on
the extremities on the ninth day.

Hematuria appeared on the twelfth and continued. On
that day a consultant was called in. He found what has
been described, and both kidneys swollen. Is reported to
have diagnosticated tumors of both kidneys.

The cord fell off on the fifteenth day, April 4th, Was
seen by me on the sixteenth, April 5th, 9 P- m. Air of
room good; window had been kept open; bedding clean;
plumbing appears to be in order. Mother in fair health;
sitting up; has no fissures in her nipples. No history of
tuberculosis, or syphilis. Baby still weighs nearly six
pounds ; is said to have lost considerably. Mouth and
nose normal; lips dry; somewhat fissured in the corners.
Ears appear negative. No diarrhoea. No malformation.
Purpuric spots, small and large; some with slight elevation
of the surface, over chest and epigastrium; some on face,
shoulders, arms, fingers. Some painful livid elevations
(suggesting the presence of pus in the deeper tissue).
Icteric discoloration not noticeable in gaslight; is reported

435

DR. JACOBI'S WORKS

to be trifling. The liver large, as usual at that age. The
spleen was not felt; percussion negative. The right kid-
ney was not felt. The left kidney felt like the size of a
hen's egg, hard and smooth. Respirations about 60; pulse
200; temperature 104.5° F. Heart negative. Umbilical
stump has some bloody oozing; is covered with some boracic
acid, with which it has been dressed all along. The con-
dition of the child appeared to warrant no close examina-
tion of the lungs, nor of the blood; no vein being in view
or accessible under the circumstances. The baby died the
next day.

Autopsy at 9 p. m., six hours after death. Surface
as described in the living; some of the spots paler; some
more livid. A moderate amount of serum, tinged with
blood, in the pericardium. On it numerous petechiae.
Heart negative; thymus small, negative. Four of the lobes
of the lungs have disseminated hemorrhages; some quite
superficial, pleural and subpleural; some infarctions, mostly
triangular of ^-f cm. in depth. Some atelectatic places
in both sides posteriorly. Peritoneum holds a few ounces
of blood-tinged serum, and shows a few petechiae on the
abdominal wall. Both costal pleurae covered with petechiae,
and a few extensive extravasations. Liver as large as nor-
mal; negative. Umbilical vein and ductus Arantii, nor-
mal; not ulcerated. Spleen small; negative. Stomach
exhibits circumscribed blood points in the mucous mem-
brane. Many extend down to the submucous tissue.
These changes are mostly found in the pyloric part.

Umbilical stump large; slightly eroded; covered with
a scab of coagulum and boric acid. The pelvic connective
tissue is black with blood. Both adrenals small; rather
more so than normal.

Left kidney enlarged to almost twice its size; dislodged
downwards from 4 to 5 cm. ; capsule penetrated with blood ;
some clots between capsule and kidney; no open blood ves-
sel found; capsule also thickened with fat. The upper
part of the kidney forms a black, almost uniform-looking
mass, which so swells the tissue that fetal lobulation be-
comes indistinct. The right kidney is similarly changed,
but to a far less degree. Section of the left kidney ex-

436

CASE OF SEPSIS IN INFANT

hibits some small uric acid infarctions which are still held
in the pyramids.

A few points are of unusual interest:

1. Uric acid was discharged in large quantities from
the fourth to the eighth day; then again from the ninth
to the tenth. Small hemorrhages, with or without secondary
nephritis, are not very rare after uric acid infarction, but
the suspicion that the foreign bodies might have caused the
hematuria was soon dismissed.

2. It is certain that almost every floating kidney found
in early age is congenital. As this baby had been lying
down all the few days of his life, the increase in size
should not be charged to the dislodgment of the left kid-
ney.

3. The diagnosis of intra-abdominal tumors, until it
be quite positive, should be suspended even in infants and
children in whom intestinal contents are rarely misleading.
Besides, what we feel inside is exaggerated by the mass
at least of abdominal wall which has to be grasped on
both sides of the questionable body. The left kidney was
enlarged by hemorrhage, and was abnormally accessible,
and the tumor of a kidney might be suggested by the find-
ings. Still, very few tumors of a kidney ever bleed. Car-
cinoma does bleed sometimes; sarcoma very rarely; cal-
culi in later life; tuberculosis not in the newborn; cysts
and hydronephrosis not at all.

4. The bacteric cause of this sepsis is not known; nor
can we know the mode of its invasion. The amniotic
liquor and the milk and lochia of the mother should not be
accused as long as she was well and other causes cannot
be found. The skin exhibited so many changes that its
condition one or two weeks previously can only be guessed.
The lips were sore at a late date. The umbilical stump
was sore and bleeding. The cord had not fallen off before
the fourteenth day; invasion is quite possible during that
long time of the cutting of the cord (even the very tissue
of the cord, unchanged, may admit microbes, or toxins) ;
and boracic acid is probably not a sufficient antiseptic to
be applied as a protection to a vulnerable surface like
that of the navel.

437

CATALEPSY IN A CHILD THREE YEARS OLD

Fannie C, aged three years; admitted to Mount Sirrai
Hospital, New York, September 4, 1879. Some weeks
previous to her admission she suft'ered from headache,
for which she was given castor oil. Diarrhoea then set
in, and continued; at her admission her pulse was 136,
respiration 30, and temperature 103|° F. The tongue
was red at its edges; the spleen was enlarged; she had
roseola, very slightly tympanites, and diarrhoea. These
symptoms of her typhoid fever continued for some time,
with a temperature ranging from 105° down to 101° F.
She coughed a good deal.

September lOth. It was recognized that she had whoop-
ing-cough, and she was removed from the ward.

l6th. It was noted that the diarrhoea was better, and
on the 17th she was without fever. On the 23rd her pulse
was stronger, and it was hoped that she would then go on
to recovery. On that day, however, a slight spasm of the
eyelids was noticed. She coughed but little, but cried a
great deal. There were rales with slight dulness at the
right apex. At 5 p. m. she urinated quite freely, the
twitching continued, and her pulse was 102 and weak.
She spoke only a little, but cried a good deal during the
next few days.

2ith, She had passages which contained some undi-
gested milk. Her appetite was good, and she took milk,
soup, egg, etc.

25th. At 10 A. M. there was a good deal of twitching
of the lids, and also the eyeballs turned upward, tonically;
occasionally there was divergent strabismus; but in the
night she slept with her eyes closed.

When the arms were lifted up they would remain in
any position in which they were placed. When she was
directed, in a loud voice, to drop the arms she would

439

DR. JACOBI'S WORKS

slowly do so. Her legs were in a similar condition, and
would remain in the position in which they were placed.
The fourth finger, taken separately, remained extended
or flexed when placed in either position. The arm could be
partly extended, partly flexed with some force, and re-
mained in that position. Still there was some volun-
tary action left; for when her arms and hands were in a
natural position, she would attempt to take a penny from
the bedclothes. Her muscular action in general was very
deficient. When she was set up in bed, her head fell
forward, and then, again, when the arm was lifted verti-
cally, it would remain in that position for minutes, and
then slowly come down. During the last three days she
passed a large quantity of urine, with a specific gravity of
1020. Her extremities were very cold, and she was in-
diff'erent to everj'thing about her; but when she was
aroused by strong impressions, even the twitchings of the
eyelids would, for a moment, cease.

27th. The patient was a little stronger and sat up in
bed. She held her head erect while being fed. The
twitching of the muscles persisted. W^hen the extrem-
ities were placed forcibly in the cataleptic position, re-
duction was attended with little pain. The lower extrem-
ities were less abnormal than the upper ones. She could
stand and walk two or three steps. Sensibility to con-
tact, pain, and temperatures entirely lost. A needle could
be run through the skin without eliciting any evidence
whatever that it produced pain; tickling the soles of the
feet yielded only slight reflex movements; the patella ten-
don reflex was greatly diminished; her eyes were star-
ing, and her appetite was ravenous.

28th. Easily awakened from sleep; one passage from
the bowels; answered questions; anaesthesia and analgesia
persistent; conjunctivae, eyeballs, eyelashes could be
touched without giving rise to twitching; sight good; ap-
petite ravenous, and swallowing easy. Pennies occasion-
ally taken from the bedclothes; bowels more constipated
than they were yesterday.

29/^. Pulse 88; respiration 26; temperature 97° F.
Less twitching of the eyelids; patient appeared brighter,

440

CATALEPSY IN CHILD THREE YEARS OLD

but anaesthesia and analgesia persisted, and the arms
were strongly cataleptic; appetite continued ravenous; the
pupils were equal, and responded to light; the urine was
passed in large quantity, and had a specific gravity of
1020.

30th. Pulse 84; respiration 30; temperature 98° F.
Two stools; a small ulceration existing upon one arm
began to extend; the patient was very cross; the Schnei-
derian membrane was very sensitive; slight touch produced
sneezing.

October 1st. Pulse 92; respiration 22; temperature 99°
F. The cataleptic position of arm was sustained one
minute; there was no twitching of the eyelids, and the pa-
tient appeared brighter; anaesthesia and analgesia remain
unchanged. When an arm was flexed a good deal of
strength was required to extend it. Urinated once or
twice every hour.

2d. Loss of sensation complete; surface of body and
extremities warmer, quantity of urine less, and strength
of patient increased.

3d. When an arm was extended or flexed it dropped at
oirce. Reflex movements on pricking with needles.

4!th. Pulse 84; temperature 99° F. Four passages from
the bowels, for which tinct. opii camphorata was given;
anaesthesia and analgesia as before. Four more passages.

6th. Cataleptic position held out one minute. Three
passages from the bowels, and opium was increased.

7th. Slept well. Passed a large quantity of urine;
slight reflex movements oir tickling and pricking the feet.
The opium was suspended, and camphor and whiskey
given.

8th. Less diarrhoea, and surface warmer. Ulceration
on arm looked better. Again Schneiderian membrane and
conjunctiva gave reflex movements orr tickling.

Qth. Patient brighter; anaesthesia and analgesia as be-
fore; arm and fingers retained cataleptic position forty-
five seconds; urine 1015; no albumen. Pulse 76; respira-
tion 18; and temperature 99° F. A good deal of strength
was required, on the part of the attendant, to overcome
the cataleptic position while it lasted.

441

DR. JACOBFS WORKS

13th. Pulse regular; surface warmer; feet still cold;
called for drink frequently. Cataleptic condition un-
changed.

I'ith. Sat in a rocking-chair.

15th. Asked for chamber. On tickling, no reflex; no
patella reflex. Cataleptic condition persisted to a slight
degree; no twitching of the eyelids.

After this time the general condition of the patient im-
proved, and at about the 20th of October the cataleptic
symptoms had entirely disappeared. She was still in bed
November 5th, but sat up occasionally; her appetite was
ho longer ravenous; urine less copious.

The child recovered, but remained anaemic and weak
longer than patients recovering from typhoid fever are
liable to do.

The only case of catalepsy in a child which has come
to my notice besides the one reported by me occurred in
a boy of thirteen, who suff'ered from chorea magna during
the space of two years before he died irr an insane asy-
lum. His attacks of chorea were very violent indeed,
interrupted by intervals of several weeks, in which his
convulsive efforts and his psychopathic condition would
improve, and would alternate sometimes with brief attacks
of catalepsy, with but partial consciousness, diminished
or destroyed will power, and the waxy flexility, all of
which symptoms were present in my other case, and are
claimed to be those of the morbid condition under consid-
eration.

The literature of the subject is by no means inconsid-
erable, but the cases observed during childhood are but
few in number. In his paper, published in Gerhart's
Handb. d. Kinderh., vol. v. 1. p. 186 et seq., Monti quotes
but eleven cases met with in children, male and female
in about equal numbers, of from five to fifteen years,
the average age being nine years. I know of no case pre-
viously reported of a child of three years; in it all the
symptoms, psychic indolence, normal or abnormal tem-
perature, cold surface, anaesthesia, analgesia, flexihilitas
cerea, and diminished patellar reflex (the latter is fre-
quently found intact) were found combined. The increase

442

CATALEPSY IN CHILD THREE YEARS OLD

of urine during a good part of the catalepsy was a re-
markable feature, such as is seen in hysteria of both
adults and children. But while it contained no sugar, and
nothing abnormal, except large quantities of phosphates,
it had the, in children, unusual spec. grav. of 1015-1020.

443

CONCERNING THE NEGLECTED CAUSES OF

INFANT MORTALITY IN THE CITY

OF NEW YORK

To the Editor of the Medical Record:

The paper of Dr. Rogers on " Neglected Causes of In-
fant Mortality in New York," read before the Medi-
cal Society of the County of New York, September 14th,
has been published in your number of October 1st. The
discussion on the same paper, which took place in the same
Society in the adjourned stated meeting of October 12th,
I find reported in your number of November l6th. Now,
Mr. Editor, I take the liberty of addressing you on the
same subject, begging your pardon for so doing, inasmuch
as I might have had an opportunity of discussing the
paper for its merits or faults before the members of the
Society. But it so happened that I could not be present
at either of those meetings; and therefore, as my name
has been mentioned in connection" with the subject, and,
moreover, as I take a deep and personal interest in the
topic discussed, I ask you to publish a few remarks which,
perhaps, may be found available.

Dr. Harris speaks of the paper in anything but a com-
mendatory manner. He says that " the discourse itself
fails to supply the groundwork that is requisite for a
proper discussion of the subject. It deals with the most
important questions in an ex cathedra style; it deals largely
in denunciations ; and many of its statements are incor-
rect, its use of statistics is inaccurate, its deductions are
unjust, and its arguments, like its style, are calculated
to do harm." These are severe imputations, and, if true,
every lover of scientific facts and public welfare has to
be sorry for the publication of the essay in a scientific
journal, and a number of secular papers which I have
been told have been supplied with long and elaborate ex-

445

. DR. JACOBI'S WORKS

tracts right after the paper had been read before the
Society. However, Mr. Editor, I do not mean to blame
you for the literal publication of Dr. R.'s paper, no mat-
ter whether Dr. Harris is wrong or right. Every one
who would undertake to underestimate the importance of
your publishing it would certainly be quieted by the vote
of thanks to the editor of the New York Medical Record,
moved by the author of the paper himself.

After the discussion had taken place I was told by
good authority that " never a paper was riddled like this."
That may be, as far as the discussion went; still, a large
portion of the paper, I find, has not been discussed at all.
Thus, if this undiscussed portion is beyond fault and
blame. Dr. Rogers may take his share of the blame and
still rest on his laurels. Nobody, it appears, touched a
number of subjects brought forward by the author, and
still they are of a nature to require discussion. Maybe
that they are unimpeachable or that the discussion ap-
peared either useless or untimely in such a connection.

My reason for interfering with the natural death of
the paper of Dr. Rogers is partially a personal one; more,
however, am I compelled to address you from a feeling of
duty toward the medical public and the County Medical
Society. If, as I hope to show, the paper was unworthy
of the Society or any member thereof, such a fact ought
to be stated and proved; and if I have been mentioned as
the author of (part at least of) the " Rules for the Man-
agement of Infants," which Dr. Rogers attempts at ridicul-
ing, I believe I have a right to defend my views. I as-
sume this right for the further reason that Dr. Stone is
reported, on page 427, to have, as it were, tried to excuse
the existence and publication of those " Rules." I shall
try my hand at no excuse, but shall explain and justify.

I should not express my correct opinion if I did not
emphasize the fact that I consider Dr. Rogers' lecture on
" Neglected Causes of Infant Mortality " a remarkable
paper. The pathological effect of heat, the importance
or non-importance of malarial effluvia, the efficacy of dis-
infectants, the sprinkling of streets, a discourse on the
proper food for infants and on the " Rules for the Man-

446

NEGLECTED CAUSES OF INFANT MORTALITY

agement of Infants," the physiology of infant digestion,
the physical history and the theory of the articles and
mode of dressing, the comparison of cow's and condensed
milk, ventilation, " canards," the Infant Hospital, and
grand-jury presentments on private nurseries — all in one
paper, read in a single meeting and published, with the
publicly voted thanks of the author, in a small part of a
single number of the New York Medical Record — I must
confess that I stand aghast at the historical fact that all
these subjects can be discussed in one dictatorial, pro-
phetical, sneering article. If all these themes can be dis-
cussed with this p.Trticular air of an almost religious per-
suasion, in a single paper, subjects each of which has
strained the minds of acute and learned authors for many
years, I expect the rest of the sciences and arts (say,
astronomy, theology, law, Nicolson pavement, fire escapes,
and tubariaiT pregnancy) thoroughly exhausted in the next
to appear. And why not.'' The doctor spends half an hour
in the Infant Hospital and knows it all by heart, while I
must confess, Mr. Editor, that after I had spent many
an hour, on twelve or fifteen different days in the course
of a month, in the same institution, I felt almost unwilling
and not thoroughly enabled to write the report required
by and promised to the Commissioners of Charities and
Correction. The doctor finds in literature the report of
an infant perishing while being fed on plain arrowroot,
and he concludes that he and Divine Providence in their
wisdom ought to prescribe cow's milk. The doctor learns
that the Board of Health emphasizes, because it is " the
fashion," the pernicious influence of malarial effluvia, and
from this fact he " more than suspects " that these aerial
causes are overrated by the authorities.

It is my intention, Mr. Editor, to confine my remarks
especially to that part of Dr. Rogers' paper which is
meant to controvert the rules for the management of in-
fants. It has been stated publicly that I was the author.
Now, most of the nine rules are mine, some of them verb-
ally. It was the intention — mine and that of others — that
these rules should be spread on handbills and through the
newspapers " among the poor and the working classes,"

447

DR. JACOBFS WORKS

as directions from the Board of Health. I have good
reason to believe that some objection was made to them,
not, however, from a scientific point of view; neverthe-
less they were spread in the well-known form, through the
papers, without my doing anything in the matter, and I
know they have done some good. As these rules were not
the result of a whim, but of study, experience, and scien-
tific facts, and as every one of them has been attacked and
ridiculed by Dr. Rogers on the pretence of their being
urrscientific and injurious; as, further, physiology, chem-
istry, and literature have been pressed into the service of
the reviewer, I hold it my sacred duty to explain and to
refute. I hold it also my sacred duty to investigate the
physiological knowledge of a medical man who sneers at
every thing and every fact he has not done or stated. If
I shall succeed in proving, as I mean to do in a short
review, that Dr. Rogers has stated his imagination as facts,
his wishes as chemistry, and his mistakes as physiology,
I think I shall have done my duty and nothing else.

Before applying to my task, Mr. Editor, let me allude
to some specimens of Dr. Rogers' physiology, in order
to show the manner of his reasoning and the thoroughness
of his views. The doctor speaks, on page 337, of " solar
heat as the cause of disease and death," which " ought to
be studied in, first, its relation to our annual infant mor-
tality, and, second, in its destructive effect upon the adult
and uport the lower animals," on the latter of which he
promises future elucidations. Now, Mr. Editor, I do not
see why the effect of a single agent, with mostly well-
known qualities, why solar heat should act on different
principles in the infant or in the adult or in the brute ani-
mal. These qualities can be imagined to show minor dif-
ferences, according to the bodies acted upon, but their
physical effects must necessarily be the same. The doctor
states himself that the depression of the vital forces pro-
duced by heat is equally applicable to feeble adults as to
infants. But let us see how, according to Dr. Rogers,
heat destroys the life of our infants: First, by directly
depressing their vital forces. Second, by producing haras-
sing and exhausting cutaneous diseases which torture and

448

NEGLECTED CAUSES OF INFANT MORTALITY

" poison to death " the already enfeebled frame of " the
little sufferer." Third, by its deteriorating effect upon
much of the food habitually given to the infant and young
child, whether taken from its mother's or other breasts or
from the markets. Fourth, by the generation of malarial
agents. The latter Dr. Rogers thinks but little of as a
cause of death, because it is " the fashion " of the Board
of Health and others to exaggerate it. The third may be
obviated, I believe, unless the heat of the summer inter-
feres more with the wholesome nature of the food " taken
from the mother's breast " than I am aware of, or Dr.
Rogers is able to prove. The second sounds more senti-
mental than scientific, is more apt to touch feminine hearts
with the " poisoning to death " the " little sufferers," and
the " enfeebled frame," than it will convince the medical
reader of the truth of the assertion that children are killed
by solar eczema, or strophulus, or any kin form of der-
matitis from the same cause. And the first injury and
death by " direct depression of the vital forces " reminds
me of a certificate of death I had the intense pleasure of
seeing a number of years ago, which stated the cause of
death in a given case to be " deficiency of life."

Physiological experiments and physical science happen
to prove a little more than Dr. Rogers appears to be willing
to teach. In a temperature of 104°, animals, unless they
are given water and food, will die within two or four hours.
Their own temperature would first sink, then rise up to
113°, and death would set in after the symptoms of lan-
guor, sleepiness, convulsions, sometimes tetanic, and coma
would have made their appearance (Obernier). Such are
the symptoms when the high temperature is combined with
moisture (Delaroche), the animal temperature being apt
to rise beyond the external temperature.

By moderate increase of temperature all organic pro-
cesses, especially those of the nerves, are stimulated and
excited, but, beyond a certain limit, the physiological fuirc-
tions are disturbed. It requires but a few degrees above
the normal temperature of the blood to destroy the func-
tions of nerves, muscles, blood corpuscles, and glandula^
cells, in consequence of partial coagulation of the soluble

449

DR. JACOBI'S WORKS

albuminous substances (myosin and others) contained in
the fluid constituents of the tissues. This occurrence takes
place at 104° in fish, at 120°-122° in mammalia, at 127° in
birds.

Such degrees of temperature, however, are not observed
under common circumstances. But the modus operandi of
heat is regulated exclusively by its physical qualities, the
principal one of which is expansion — expansion of every-
thing, both inorganic and organic. Expansion of the air
we inhale results in the lessened supply of oxygen to the
lungs in the deficient oxygenation of the blood, in reten-
tion of carbonic acid and other excrementitious matter, in
the getting up of poisonous symptoms, first of an excitant,
then of a depressing order. In fact, we observe a number
of cases, depending on heat only, which look very much
like uraemia. For every one of my professional readers
remembers cases of death with no signs of haemorrhage
or inflammation of the brain to be found on the post-
mortem table; they are positive proofs of the fact that in
many of them the cerebral symptoms are but secondary
to the primary disintegration of the blood. Moreover, we
do know that in many of such cases of coup de chaleur
the lungs are the first to be aff"ected.

Expansion of the blood vessels will result in local hyper-
aemia and in generally retarded and feeble circulation, in
(Edematous effusion and consecutive paralysis of the mus-
Cjjlar tissue.

Expansion of the blood itself and the gases contained
in it must interfere with the nutrition of the body as a
whole, and of every single organ.

Above 80 '^ of atmospheric temperature the radiation of
animal heat from the surface is stopped, the normal and
requisite refrigeration of the system does no longer take
place from this source, and this prerequisite for normal
naetamorphosis is gone.

Thus, Mr. Editor, the eff'ects of heat on the animal
system might be counted up to some greater length. I
might do so from the usual stock of physiological knowl-
edge at the disposal of every fairly informed medical
maft; but what I have said will be deemed sufficient to

450

NEGLECTED CAUSES OF INFANT MORTALITY

prove that Dr Rogers might have improved upon his etio-
logical explanations.

To what extent the " Rules for the Management of In-
fancy," if spread amongst the population, could have been
beneficial, I must leave to the profession to judge. In my
original copy they read as follows — I print them here for
comparison with those copied in Dr. Rogers' paper:

//' you nurse your baby:

Do not nurse your baby oftener than every two or three
hours.

Do not nurge a baby of more than six months oftener
than five times in twenty-four hours.

When thirsty in the meantime, give it cold water; in
hot weather mix a teaspoonful of whiskey with a tumbler-
ful 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 lukewarm from a nursing bottle.

Bottle and mouthpiece 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.

Where the bowels are costive, take farina instead of
barley floui*.

Where they are very costive, take oatmeal gruel, strain
it before mixing with milk.

When you have but half enough breast milk, use the
same food. Give the food and the breast 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 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.

Summer complaint:

451

DR. JACOBI'S WORKS

When babies throw off and purge, give nothing to eat
and nothing 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.

Thus I do not deserve any credit for the second " rule,"
as appearing in Dr. Rogers' paper. It is evidently added
by some thoughtful mind, and reads as follows : " Use
light flannel covering of chest and bowels at all times,
and other clothing to suit the change of weather." Dr.
Rogers is indignant at such an advice and flings at it the
following "neglected" physiology:

1st. Nature's means of preventing the overheating of
the blood and structures of the body is the evaporation
of perspiration from the surface.

2d. Woollen fabrics directly oppose the process of cool-
ing. Therefore they oppose Nature, are unscientific and
inhumane.

3d. The true condition of an infant in very hot weather
is perfect nudity.

4th. As a compromise it may endure a covering of the
lightest linen or well-worn cotton fabric, which readily be-
comes moistened by the perspiration, and thus by evapora-
tion acts as a cooling wet sheet.

I state at once that his further advice of sponging the
children from head to foot in tepid water during the hot
season cannot be objected to. It is. a fact that such ad-
vice has not been given in the " Rules," which, however,
were not meant to contain all the rules necessary or avail-
able in the management of infants. Nor are the doctor's
rules all-comprehending and thoroughly satisfactory. For
I must confess that I should not feel capable of sustain-
ing his order that the child, at all ages, " were allowed
an unrestrained run to iced Croton water " as a drink.
My criticism would be as long as Dr. R.'s paper if I should

452

NEGLECTED CAUSES OF INFANT MORTALITY

attempt at here ventilating tliis question, but I may be
permitted to ask why the surface, which needs cooling by
all means, should be sponged with tepid and the stomach
be drowned in ice-cold water.

But we have to deal with " Rule No. 2 " and its criticiser.
To the doctor's first sentence I take no exception. Those
objections, however, which I entertain to the rest will be-
come apparent by the following considerations and their
comparison with Dr. Rogers' autodidactic ideas on per-
spiration, evaporation, flannel, and linen "or" cotton:

The purpose to be obtained by dressing consists in the
regulation of the normal cooling process, the radiation of
heat. This purpose is obtained in cold weather by moder-
ating and equalizing the motion of the atmosphere near
the surface of the body, and further by the low conducting
property of many of the materials used as wearing ap-
parel. But these are not the only physical conditions which
determine the differences of the action and value of our
clothing. I allude to the hygroscopic qualities of different
articles.

Equal weights of wool, cotton, and linen harbor differ-
ent quantities of water; wool more than cotton and twice
as much as linen. Moreover, linen allows the water it
contains to evaporate much sooner than wool.

Thus the perspiration of the surface is slowly soaked
up by flannel, is slowly and uniformly evaporated on the
outside of the flannel, and leaves the skin nearly dry. No
perspiration collects on the skin; but little evaporation
takes place on the skin itself; no sudden change in its tem-
perature is observed. Nothing is more dangerous than
these sudden changes of the temperature of the surface;
and my professional readers will admit that cases of bron-
chitis and pneumonia, not to speak of intestinal catarrh,
are never more frequent than during the very liottest sea-
son. It is not the perspiration which results in sickness,
but the rapid refrigeration taking place on the very sur-
face of the skin in consequence of rapid evaporation. Flan-
nel covering the human surface acts like another cutaneous
integument for the protection of the original one.

Linen is not so hygroscopic as flannel. It does not soak

453

DR. JACOBI'S WORKS

up and retain, for a slow and uniform evaporation on its
own surface, the perspiration of the skin. Moreover, evap-
oration takes place more rapidly from linen, and therefore,
it cools more suddenly than flannel or cotton also. For
this reason it is worn in summer. It is agreeable and com-
fortable for tlie moment, and when you have a good reason
for believing in the constancy of the weather and the high
temperature and the absence of wind or draught. As
soon as, by a sudden change of temperature or by a
draught, evaporation will take place on the skin as well as
on the linen, the cooling process is too rapid and results in
disease. Therefore, many people with common sense will
compromise between flannel and linen, and select cotton in
the hot season, as it modifies the extreme qualities of either.
Whoever is subject to copious perspiration will not be
satisfied with cotton, but select flannel to cover his surface.
Much of the comfort and advantage obtained by our
articles of dressing depend on their permeability by the
atmosphere. Flannel is nearly twice as permeable as
linen. Now add to this that this permeability by air is
interrupted by soaking the articles in water, and remem-
ber the fact that linen is so easily soaked. If you do j'ou
find an explanation for the uncomfortable sensation and
the unwholesome consequences of a wet linen sheet on
your body. It is the same sensation which is felt on ren-
dering the skin impermeable by shellac or india rubber,
or noticed even by expert swimmers after they have been
in water for hours. Perspiration is checked and con-
gestion to internal organs — lungs, liver, and intestines —
commences. The use of the oil-silk jacket, too, in in-
ternal diseases appears injudicious, for the moistness of
the skin is not the result of increased cutaneous action,
but it is due to local condensation and consecutive suppres-
sion of perspiration from the impermeability of the cov-
ering.

The sudden refrigeration of the wet skin and the wet
linen is dangerous because of the sudden diminution of
the body's temperature. Pettenkofer has studied the ef-
fects of wet feet, with the following result: If you get
your woollen stockings wet to the amount of only 1^

454

NEGLECTED CAUSES OF INFANT MORTALITY

ounces of wool, tlie amount of heat necessary to dry this
small quantity, which must be supplied by the system un-
less you change your stockings at once, would be sufficient
to melt half a pound of ice or to heat half a pound of
water from 32° to 212°.

I hope, Mr. Editor, Dr. Rogers will look at his linen
or cottojt theory with a little less satisfaction than before.
At all events, even they diff'er greatly in their qualities;
and, further, a fabric which " becomes readily moistened
by the perspiration " will no longer. " thus by evapora-
tion," act as a cooling sheet, nor will flannel henceforth
" check perspiration arrd directly oppose Nature."

I have tested Dr. R.'s physiology in some important
points, and it has appeared that there was something
" neglected " in his solar-heat and flannel theories. I have
now to turn my attention to some other " rules," three of
which have attracted the good or ill will of the critic.
Now, No. 9 is approved of. The advice given to a mother
to send for a doctor in case of necessity evidently strikes
him as good and practical, " as it is just what the parents
would do in any case." I hope the parents will ring the
bell of a practitioner with a tolerable stock of physiology.

Rule No. 3 is an abomination in itself. No matter
whether that printed on page 339 or the one proposed by
me is in question, the doctor is disinclined to obey it, be-
cause " a model mother and estimable lady," who, not hav-
ing breast milk enough for the baby, fed her child on
Winslow's soothing syrup instead of additional nourish-
ment, had " the absurd impression " that infants ought
to wait two hours before taking another meal, and kept
the infant hungry until the doctor, who was sent for as
Rule No. 9 ordains, told her that the fact of the baby
having taken food an hour and a half before had nothing
to do with the child's desires. And thus the child's " colic "
was cured at once.

An infant is entitled to a sufficient supply of food.
Therefore, if breast milk is secreted in insufficient quan-
tity, artificial food has to be given. If the baby is hungry
it will cry, surely. But when the baby does cry it is not
always from hunger. To the contrary, the causes of a

455

DR. JACOBI'S WORKS

baby's crying are very numerous, so numerous, indeed, that
many an author has thought it worth his while to write
elaborate articles on that subject. Nothing is more cus-
tomary than to mistake every crying spell of an infant
for the expression of hunger, and nothing more common
than that the mouth of an uneasy, frightened, annoyed,
pinched, pin-stuck, rachitic, wet, dirty, sore, or feverish
baby is closed with the nipple. Nothing more common
than that the thirst of an infant is made the pretext for
feeding it as if an adult who requires water, and asks
for it, was satisfied with corned beef or beef tea.

The cases where babies have to wait for their meals
too long are certainly the exception; those where they are
fed too frequently, the rule. If a mother has not got
enough for her baby, if the baby has to go to sleep half-
satisfied, it will awake and cry and require the breast, and
certainly is entitled to it. But this is altogether wrong,
as the supply itself ought to be made satisfactory. It is
the more wrong as direct injury will follow the too fre-
quent sucking. Mr. Thomas Ballard has written a book^
to present his theory of the cause of the diseases of infants
and puerperal women, in which he states that in his opinion
a large portion of the diseases of young infairts — viz.,
affections of the skin (erythema and urticaria from gastro-
intestinal disturbance), thrush, nervous disorders of all
kinds, and intussusception of the bowels — are due to
" fruitless sucking." One mode of fruitless sucking is
the nursing from empty or incompetent mammary glands.
And whoever knows that " the excitation of the nerves
of taste produces an abundant reflex secretion of gastric
juice and also a flow of bile and pancreatic juice in the
bowels" (Bro^vn-Sequard), will admit that Dr. Ballard
is right in many respects. And, moreover, it is a well-
known fact that, the whole alimentary canal being a single
and coherent tract, motory efforts of the upper portion
give rise to peristaltic action in the lower. Thus the ali-

1 " A New and Rational Explanation of the Diseases pecu-
liar to Infants and Mothers, with obvious sujrgestions for their
prevention or cure." Bv Thomas Ballard. London, 1860, pp.
128.

456

NEGLECTED CAUSES OF INFANT MORTALITY

mentary organs of a baby who, no matter whether to
its satisfaction or dissatisfaction, is fed too frequently,
will never be at rest, and, no matter whether the con-
sistence and constituents of the food are correct or not,
the very existence of increased peristaltic motions gives
rise to diarrhoea and consecutive disorders. Thus if there
be a child that claims more food than the mother's breast
can afford to give, it will not suffice to give it possession
of the nipple to drink from it thin milk and muscular ex-
haustion, but the indication is to so add artificial nourish-
ment to the natural one that the baby will have enough
each time, and after each meal will require a normal time
for rest and digestion.

The normal time for rest between meals and for the
digestion of a satisfactory meal in a young infant experi-
ence shows to be from two to three hours. Habit may
change this to a certain extent. You may prolong the in-
tervals, for instance, in the night, or you may shorten
them by compelling the infant to take food whenever it
shows any sign of uneasiness. A child may have " colic,"
not from hunger, as in Dr. Rogers' case, but from flatu-
lence depending upon the incomplete digestion of the too
copious food, and scream. It will be fed to stop its crying,
and oil is thrown into the fire. Such things are so thor-
oughly known as, unfortunately, the common rule that I
save my readers further remarks on my part. But I insist
upon the fact that the " desires " of the infants are gen-
erally either no desires or their character is misunder-
stood; that, more than heat and hunger and changes of
temperature together, overfeeding, too frequent feeding,
is the cause of the large majority of the digestive and
consecutive disorders of infants. I have to stop here, be-
cause the further elucidation might fill a volume. There-
fore, a rule is necessary and ought to exist for timing the
intervals in which infants are to be fed, provided the food
is normal and in sufficient quantity. A rule may have its
exceptions, but it is given for the most possible good of
the largest possible number.

It will hardly be denied that irregular feeding is
mostly overfeeding; that it may and will result in vomit-

457

DR. JACOBI'S WORKS

ing, catarrh of stomach and intestines, subsequent con-
gestion and swelling of the mesenteric glands, flatulence,
enlargement and hypertrophy of stomach, with all the con-
sequences of impaired digestion; for the rest of the physi-
cal and mental functions need no particular illustration.
But this is not all. If there is danger in irregular feeding
and overfeeding (simply because a child has or appears
to have the desire) to its physical welfare, there is just
as great a danger to its moral development. The time and
mode of feeding infants is the first means of their train-
ing, their education ; in fact, education has to begin with
the first day of life. It is not true that there is plenty
of time in later life to commence education, for the
groundwork of all our education, all our morals, is habit.
The attentive observer, professional or unprofessional, is
aware of the facility and rapidity with which bad habits
are contracted, and how soon infants will learn how much
they can gain by screaming and naughtiness, or whether
they can influence their attendants by the expression of
their desires or caprices. The preparatory stage of men-
tal actions, the function of the senses, is to a considerable
degree developed with the moment of birth, and the old
" nihil est in intellectu quod non antea fuerit in sensu "
requires early attention to the first simple rule — regularity
and punctuality in the management of the newborn or
young infants in order to develop their " intellect " and
morals on a sound basis. I hope, however, to discuss at
some other time the question of the necessity of early
training and of the beginning of infant education on the
very first day of life, in connection with the peculiarly
rapid and interesting development of the concourse and
centre of the sensory and all other nerves — the brain.
My readers will pardon me, therefore, for dropping this
subject here and directing their attention to the " delect-
able " (cf. Medical Record, page 341) physiology dis-
played in Dr. Rogers' criticism on " Rule No. 4."

A number of questions, commencing with " we wish to
know," and followed by " let us see " (p. 340), I shall
answer after having examined, in a few words, Dr.
Rogers' fitness for the place of criticising apostle of infant

458

NEGLECTED CAUSES OF INFANT MORTALITY

diet, " Let us see." Dr. Rogers — who, by the bye, is
still clinging to the antiquated theory of Liebig's, of ex-
clusively heat-making and exclusively tissue-building ma-
terials, proteinous substances being the first, and amylum
amongst the latter — declares " barley to be a vegetable
substance very poor in plastic or building material." This
is ludicrously wrong, as the doctor might have learned from
any text-book on organic chemistry or physiology in the
hands of a first-course student of medicine. I quote from
one. There are (in 1,000 parts):

Albuminous substances: In wheat, 135; barley, 123; rye, 107;
oatmeal, 90; Indian corn, 79; rice, 31.

Amylum: In rice, 823; Indian corn, 637; wheat, 569; rye, 555;
oatmeal, 503; barley, 483.

Fat: Indian corn, 48; oatmeal, 40; barlev, rve, wheat, rice,
but little.

Salts (principally phosphates): Barley, 27; oatmeal, 26;
wheat, 20; rye, 15; Indian corn, 13; rice, 5.

Potassa is mostly found in wheat, magnesia irf wheat
and Indian corn, lime in oatmeal and barley, iron in bar-
ley, phosphoric acid in barley and wheat. From these fig-
ures Professor Moleschott (of Zurich, Switzerland; Turin
and Florence, Italy) concludes that amongst all the vege-
table substances fit for digestion and assimilation, and the
support of the human organism, none is more so than bar-
ley. It is true he had not read Dr. Rogers' assertion,
based upon " experience, physiology, and common sense "
(p. 340), that " barley is a vegetable substance poor in
plastic or building material." From his investigations
Professor Moleschott arrives at the conclusion that eleven
hundred grammes of barley (thirty-six ounces) are suffi-
cient to sustain a hard-working adult man. I will add at
once a very important advantage of barley over the rest
of the above-mentioned vegetables, which is this : that it
bears the removal of the husk after grinding better than
any other. The large proportion of the proteinous sub-
stances in wheat and rye is deposited in the inner layer
of the husk, which generally is not used (Payen). It is
different in barley, where the protein is spread in equal

459

DR. JACOBI'S WORKS

proportion through the whole grain. Thus the husk can
be removed, the consistence finer, without diminishing the
nutritive value of the constituents. Evidently the results
of modern chemistry and " phj'siology " have now and
then confirmed the " experience and common sense " of
olden times, for even old Van Swieten (iv., p. 644) speaks
of " potus nutrierrs dilutus, ut hordei vel avence decoctum,
tertia parte lactis recentis admixti."

" Let us see " further. Dr. Rogers says that " barley
contains dextrin, a substance which even in the adult is
difficult of digestion, and, a fortiori, must be so in an in-
fant " (p. 340). And again he emphasizes dextrin as
" indigestible." Physiology says, to the contrary, that
fresh saliva has the faculty of transforming starch and
dextrin into sugar. The transformation of dextrin into
sugar is so rapid, indeed, that hardly any dextrin is ever
found unchanged below the duodenum. ^loreover. the ex-
istence of dextrin, not only of such as is performed in
the food, but also that which is transformed from starch,
is both so important and so easily influenced that the facil-
ity of stomach digestion greatly depends on it. The ex-
periments of Maurice SchifF, of Florence,- prove that the
formation of gastric acid, especially lactic acid, prin-
cipally devolves on dextrin.

Again, Dr. Rogers assures us that the casein of barley
is " insoluble." What this means we are at a loss to un-
derstand. For physiology teaches that the cellulose of
the casein of the leguminosae. and of the albuminate of the
cerealiae, are rendered soluble by fine grinding and dis-
solved by cooking, and that both the casein and the album-
inate are digested in the gastric juice. In fact, the casein
is probably nothing else, according to the investigation of
F. Hoppe, but an albuminate of potassa.

Further, Dr. Rogers, speaking of some observations
of Guillot's concerning artificial feeding, alludes to sub-
stituting " for the milk some farinaceous substance, made
fluid by boiling arrowroot, gum arabic, rice, or some simi-

2 " Lemons sur la Physiologic de la Digestion, f aites au Museum
d'Histoire naturelle de Florence." 2 vols., 1868.

460

NEGLECTED CAUSES OF INFANT MORTALITY

lar substance in water." Where the similarity is to be
found between arrowroot (amylum, mostly) and gum
arabic. Dr. Rogers is surely unable to determine. Physiol-
ogists know that gum is not absorbed, or in a very small
quantity only, and that the lining membrane of the in-
testine is simply covered and smoothed by it. But still
Dr. Rogers has the naivete to assure us that Dr. Guillot
" was struck with the uniform presence in the bowels of
a jelly-like substance. Upon analysis this substance was
found to be nearly pure starch." I confess that I also
am " struck " with the novelty of the fact that gum, when
introduced into the intestine and analyzed, is recognized
as pure starch. It requires an innocent mind, and one
not spoiled by chemistry, to believe it.

From the supposed results of Dr. Guillot's experiments,
made oit sick children, while Dr. Rogers speaks of the diet
of the healthy, he concludes that " it would therefore ap-
pear that the infant, whose salivary apparatus and whose
teeth are not developed, has neither his gastric, nor duo-
denal, nor other intestinal glands ready to digest the
starchy substances of a farinaceous diet." From this re-
mark it is evident that Dr. Rogers believes that the reason
why amylum is not digested by the gastric, or duodenal,
or intestinal glands — they being not " ready " yet — must
be sought for in the tender age. But, as far as I know,
these glands have neither in the infant nor in the adult
anything to do with the digestion of starch. Physiology
sustains me in this opinion. And here again it is the doc-
tor who makes a serious mistake; for it is more than doubt-
ful that anywhere the intestine contributes to the diges-
tion of starchy material. To the contrary, whatever amy-
lum has not been transformed into sugar by saliva, either
in the mouth or in the stomach, is thus changed by the
pancreatic juice.

The secretion of the pancreas has three distinct func-
tions :

1. Transmutation of albuminous substances into pep-
tone.

2. Changing fat into an emulsion fit for absorption.

3. Transformation of starch into sugar.

461

DR. JACOBI'S WORKS

The fact that a writer of Dr. Rogers' experience and
knowledge is not acquainted with this fact does not dis-
prove the results of Claude Bernard's and others' experi-
ments. The pancreatic juice is, in fact, much more effi-
cient thart saliva; it digests amylum as well raw as cooked;
and while for an immediate action it requires a temperature
of 95°, a lower temperature will not be an impediment
to its efficacy. Even the presence of bile and acid gastric
juice cannot stop its action.

" The salivary secretion of the child is little or noth-
ing." Which of the two it is — " little " or " nothing " —
Dr. Rogers does not say ; but in order to carry his point,
he appears to believe " nothing," and reasons accordingly.
But the fact is, that it is " none " in very young infants
under four months ; the youngest infants in whom saliva
has been found being forty-one days old. After that period
there is plenty. Thus the pancreas iit very young infants,
pancreas and salivary glands in infants over four months,
perform the function of transforming into dextrin and
sugar such amylum as will be introduced, in limited quan-
tities, into the system of an infant. The physiological
effect of the saliva, as it is shown in the transmutation of
amylum into sugar, is due to a substance — first, I believe,
isolated by Cohnheim — called ptyalin. It acts rapidly and
on proportionately large masses, like a fermenting agent,
not only as long as the mixture is alkaline, but also when
it gets slightly acid. Thus its action is not interrupted
by the normally acid secretion of the stomach. Ptyalin
is found in all the salivary glands of man (not in the
parotid of the dog), and it is not decomposed by acting
on the substances undergoing digestion, exactly like the
rest of fermenting agents.

Thus, there can be no doubt in any unprejudiced mind
that a reasonable amount of amylum will be digested in the
salivary and pancreatic secretions of the infant. It re-
quires an unusual straining of logic to deny it, just as it
manifests a singular desire for levelling nature, which
is so much in the habit of diversifying and multiplying, to
look upon barley, arrowroot, rice, gum arabic, and other
" farinaceous " substances as similar or equivalent.

462

NEGLECTED CAUSES OF INFANT MORTALITY

In consequence of such a " deep-rooted delusion " (p.
341), Dr. Rogers, in order to present the most forcible
aspect of his pleading, relates the case, reported by Routh,
of a woman who succeeded in systematically killing her
sixth child by feeding it on nothing but " the best arrow-
root that could be procured." Neither the physiology of
infant digestion nor the " Rules for the Management of
Infants " claim any blessing or advantages for unmitigated
amylum poisoning; and the somewhat malicious unction
with which the case has been reproduced speaks for (or
against) the reasoning of a man in whose good-will I
have the courage to believe, and " whose heart is in the
case" (p. 344), unpolluted by physiology and chemistry.

Now, Mr. Editor, I believe I have tried your patience
long enough; but, for a consolation, I think I have done,
at last, with the author of " Neglected Causes of Infant
Mortality." I " exonerate our respected friend, however,
for his utterances of manifest falsehoods, for he undoubt-
edly supposed that the sources for his data were reli-
able" (v. Dr. Rogers on p. 343, first column). But I
do not exonerate him for contradicting himself on his own
ground, and, moreover, committing the same sins for which
he blames the Board of Health, and the " Rules." For
instance,, he protests against such " loose direction " as
" a little salt " and " a lump of sugar," and complains at
not receiving any instructions how much a little salt to
a pint of food would be, or how big " a lump of sugar "
must be added. This is all very well. But then a man who
has nothing but blame to express and nothing but fault to
find, must not, " of course, recognize the appropriate ad-
dition of water to the milk of cow, and the addition of a
proper amount of sugar, especially the sugar of milk, and
of common salt, and of lime or other alkalies." For he
exposes himself to retaliation by being questioned about
what is the " appropriate addition of water," or the " proper
amount of sugar," of " common salt," of " lime," and of
" other alkalies," and which alkalies he means. Moreover,
the very same writer, who first protests against " loose
instructions," and, secondly, has nothing but loose instruc-
tions to give, has the ingenuity, or the weakness, to in-

463

DR. JACOBFS WORKS

sist upon the " freshest and most natural milk/' without
any addition or admixture. Nor do I see more consistency
in the fact that one and the same writer should absolutely
insist upon the Infant Hospital to have milk which not
even should be transported, and on the other hand assures
us that " no thinking being need be told that the very
mixing of the milk is the only true way to secure an aver-
age good milk," and that " there certainly never was any
material transported into a city of a more desirable char-
acter for the food of infants than the Orange County milk
and cream supplied by . . . and . . . and . . . and
several smaller parties." You will permit me, Mr. Editor,
not to copy the names and firms of those business men;
they might feel like sending me a Christmas present if I,
though im'oluntarily, gave them " a lift."

If I meant to go on, there would hardly be an end
to the list of mistakes, incongruities, and " fallacies "
which have slipped into Dr. Rogers' paper. There may be
a good many good points in t]ie essay, but Dr. Harris
says its animus is mischievous; Dr. Castle asserts its facts
are misrepresented; and I say its physiology is rather
imaginary, its chemistry tolerably antediluvian, and the
whole effort " a lamentable failure " (vide Rogers, " neg-
lected," etc.. Medical Record, p. 343).

Finally, Mr. Editor, I beg your pardon for once more
addressing you for a special purpose. A criticism is nat-
urally mostly of a negative character. I have tried, though,
to alternate my negative expositions and some positive
facts, not believing myself justified in trespassing too
much, and to no use, upon your space and your readers'
time. As I have repeatedly blamed Dr. Rogers' paper for
its absolute barrenness, as far as its scientific value is con-
cerned, I request the privilege of being permitted to lay
before your readers, in your next number, such facts and
opinions concerning the diet of infants and children as
have given rise to part of the " Rules for the Management
of Infants."

Yours truly,

A. Jacobi.

464

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