r*?' r Bethesdo, Md U S Department of Health, Education @? I X^ I jo luauijjodea 5 n „ pw 'opsaifisg -< 0 •n ajMjas u,i|03h $ a C r" l" ru 3i|qnd-aiDjia/^ puo S ,uOi|D3np3 'qiiDan £ jo luaiuijodaa $ fl & pw 'opsauisg £ asiAjaj iil|D3H a 3!|qrv ° O or jo tuauj|jodaa $n £ pw 'opsatjiag < -< 33IAJ35 ij(|oa(-) ^ Jiiqnj'ajojia^vv puo a 'uoiiDjnpg 'hiiosh „ jo luaujuodaa S D a. pw 'Dps3u,iaa ^ ajjAjaj u,i|03H £ :>'|qr>d'ajD)l»M P"° £ Heolth Service Bethesdo. Md US Deportment of Health. Education, ond Welfore. Public I r4?%s\ 5 X^^ I s£Ms\ \ S^S^ o o /* A/ ro ^^^ ^v ° ■uoiiojnpg 'i)i|oaH £ jo juauiiJodaQS D a pw 'opsauiag £ aji/uaj ui|03H £ Di|qnd .3joj|aM puo £ NLM052506126 national library of medicine national library of medicine 3NOIQ3W jo Aavaan tvnouvn 3noiq3w jo Aavasn tvnouvn national library of medicine national library of medicine snidicisw jo Aavaan tvnouvn snidiqsw jo Aavaan tvnouvn national library of medicine national library of MEDICINE NATIONAL LIBRARY OF MEDICINE 3NiDia3w jo Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE SNiDiasw jo Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE aNOiasw jo Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE 3NOIQ3W jo Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE 3Nioia3w jo Aavaan tvnouvn 3NIDIQ3W jo Aavaan tvnouvn 3NOIQ3W jo Aavaan tvnouvn CLINICAL LECTURES ON PEDIATRICS, DELIVERED IN THE VANDERBILT CLINIC DURING THE SESSION OF 1892-93. By aV JACOBI, M.D., Clinical Professor of the Diseases of Children in the College of Physicians and Surgeons of New York, Etc., Etc. (STENOGRAPHIC REPORTS.) Reprinted trom Archives of Pediatrics, Vol. X., 1893. NEW YORK: BAILEY & FAIRCHILD. i893. A „, 1: o PREFACE. Having been informed by the Editor of the Archives of Pediatrics of his intention to collect these clinical lectures for publication, I beg to suggest that they do not claim to furnish complete treatises. They are fair examples of the practical instruction given in the Children's Clinic of the College of. Physicians and Surgeons, both with the merits and demerits of extemporaneous discourses. They are sten- ographic reports exclusively. Still, in spite of all these de- fects and shortcomings, I trust that many of the facts and hints contained in the little book will prove instructive and useful, and many of the cases reported and discussed will compare favorably with those which are made welcome in our medical journals. A. Jacobi. iioW. 34th Street, Dec 25, 1893. t CLINICAL LECTURES ON PEDIATRICS. (Session of 1892-93.) BY A. JACOBI, M.D., Clinical Professer of Pediatrics in the College of Physicians and Surgeons, New York. First:—Delivered Oct. 5th, 1892. (Stenographic Report.) Multiple Sarcoma. Hydrocephalus. Multiple Sarcoma.—It has been my custom to show first the simpler cases at the opening of my clinical course, but we cannot always command our material just when we want it, and therefore I will not let this opportunity pass to show you a very rare case. Here is a baby that certainly looks very sick, and at the same time exhibits an abnormal shape. There is a striking asymmetry between the sides of the cranium ; there is a bulging over the outer part of the right frontal bone, a smaller one on the left, another large one in the occipito- parietal region on the left, and some smaller ones. There is a bulging over the alveolar processes above, on both sides. The abdomen is large, and there are many dilated veins crossing it. There is a tympanitic percussion sound, showing that most of the abdominal swelling is by gas. At the same time there is a circumscribed swelling on the left side which is solid to the feel. Does this tumor belong to one of the mesenteric glands, to the omentum, to the left kidney, or to the spleen ? The tumor has the outline which the enlarged spleen would show; it extends from the normal location of the spleen downward and forward to the median line without interruption. There is dullness on percussion everywhere, no tympanites between the upper and lower end ; but there is some tympanitic per- cussion found between the left kidney and the tumor. It is certainly the spleen. The larger tumor on die head, occupying the outer and upper part of the forehead on the right, is semi-fluctuating. This peculiar semi-fluctation is quite characteristic for large sarcomata, though they be not complicated with cysts. The baby is twelve months old. The first tumor was observed by the parents three months ago, when it was nine months old. Yet it is very probable tumors existed 4 JACOBI: Clinical Lectures on Pediatrics. months before that. It is a peculiarity of congenital tumors that for a long time they are apt to remain dor- mant. That is particularly true of one class, namely, sarcoma. Vet even carcinomy may remain dormant and have passed. Indeed, it has been observed that a tumor present in infancy has sometimes remained in the same condition up to advanced age, and then grew very rapidly and proved itself a malignant growth. Cohnheim, one of the great pathologists of the century, believed that malig- nant tumors, whether appearing early or late in life, resulted from prenatal formation; that inasmuch as malig- nant tumors were of epithelial or cell character he believed the cell formation resulting in malignant growth was but the development of embryonal cells which had not under- gone their proper and timely change into normal tissues. This embryonal origin of tumors appearing in later life cannot, however, be proven to satisfaction in every in- stance. Tumors of various kinds may appear in infants. I have described a number cases {Archives of Pediatrics, vol. i., p. 65), and collected more, of congenital lipoma—not only encysted, as it is mostly found in the adult, but also diffuse, without any capsule. I have also described a number of cases, and collected about forty as early as 1884, in the Transactions of the Copenhagen International Medical Congress, of sarcoma of the kidneys in infants and in the foetus. I have seen carcinoma of the kidney in the foetus, one in the newly-born, and a few more cases have been described. Carcinoma of the liver of sufficient size to seriously interefere with parturition has been de- scribed in a few instances. Congenital osteoma has been seen now and then. Syphilomata, the result of hereditary syphilis, are by no means rare. In this case I believe we have to deal with sarcoma. I conclude this from the fact that a number of the tumors are quite hard. If they were carcinoma, very probably they would be softer by this time, and being so numerous it is likely they would have destroyed life. From the fact that the tumors on the head and face are not of the feel of lipoma, and the further fact that the spleen is involved, lipoma can be excluded. What can be done for the child ? If we had to deal with a single sarcomatous tumor, as of the spleen, we might think of removing the whole organ. But where there are so many tumors as are present in this case and it is probable that many of the internal lymph bodies are JACOBI: Clinical Lectures on Pediatrics. affected which we cannot feel, we can hardly expect to do anything surgically. The one remedy which has proved of much utility to me and also to others is arsenic, com- mencing with small doses, gradually increasing. To this baby, if you thought at all of treating it, you would give half a drop of Fowler's solution three times a day, and slowly increase the dose as far as you would dare go, stopping when there was oedema of the eyelids or face, or vomiting or diarrhoea. In many cases you can increase the dose to four, six, eight times what you began with— always diluting the medicine with plenty of water and giving it only after meals. But to give arsenic with a view of doing this baby much good is a forlorn hope ; the baby will certainly submit to the inevitable. Still, in quite a large number of cases of multiple sarcoma, both in the young and the adult, I have succeeded in reducing the size of the tumors and staying, at least temporarily, the morbid process. There is another medicine which yields some results, perhaps more in carcinoma, however, than in sarcoma. I refer to aniline dyes, which I may speak about more fully at some later clinic. Methylen blue has certainly done a great deal of service, particularly in cases of carcinoma. I do not know that it has cured any cases, but I know it has certainly prolonged life months, and even years, in a num- ber. It may be given by the mouth, or in injections, and is generally well tolerated, particularly in pills and com- bined with small doses of either opium or belladonna. A child of this age would probably begin with four or five daily doses each of one-tenth of a grain. Hydrocephalus.—This is a case of hydrocephalus which visited us first some time ago. At that time the child's head was large, as you see it to-day, and showed wide fontanelles. In the normal baby's head, while the fon- tanelles are open, you can count the pulse there better than at the radial; you can see the pulsations. But as soon as hydrocephalic effusion takes place to any extent this pulsation of the fontanelle ceases. So is was in this case. The child was very dull when it first came. It is now much brighter, the fontanelles are more nearly closed, the physical condition has much improved. It talks some, hears, but the mother says it does not yet see. The cause of the baby not seeing may be different. The eye, the brain, or the optic nerve, may be abnormal. The reaction of the pupils to light seems to be normal. Still, part of the retina may be atrophic. I have now and then seen 6 JACOBI: Clinical Lectures on Pediatrics. restoration of the intellectual and muscular functions in hydrocephalus, yet inability to see remains. This might be explained by the fact that there was degeneration in the optic nerve which persisted, or an effusion in the sheath of the nerve which was not absorbed, or though it were ab- sorbed after all, had meanwhile destroyed the nerve struc- ture by pressure. Here is another baby with a large head. It was the fourth product of conception, and was born at the eighth month, the others at a still earlier date. My assistant says, when asked if there is a history of syphilis, that when he saw the child a month ago the hands were scaly, and there was the story of three miscarriages, which was all the evi- dence of syphilis which he could obtain. You will observe that the child's right pupil is normal ; it is large enough, and contracts and expands. The left pupil is fairly large, but it does not contract, and is drawn to both sides. The eyes are in constant convulsive motion now and then, and again they are quite steady. This constant convulsive (horizontal) twitching of the balls is called nystagmus. It may be due to attempts of the baby to fix che eye-balls in certain directions without having a sufficient muscular strength to steady them. The eye, in which there has been iritis with permanent adhesions, certainly does not admit the rays of light as freely as the other one does. There is also strabismus here. Even normal babies when quite young have some strabismus. While they have strabismus they do not see so well, for they are not able like an adult to shut one eye for the purpose of avoiding double vision. Thus there is in some infants always an uncertainty in the process of seeing, and this uncertainty sometimes produces nystagmus. In a number of cases nystagmus in babies is due to attempts at coordinating the undeveloped muscles of the neck. For instance, the baby while lying on the back tries to hold the head in one direc- tion, but the muscles of the neck may be unequally de- veloped, the head shakes ; meanwhile the baby tries to fix the object with its eyes, and nystagmus develops as a consequence. But as a rule nystagmus is the result of cerebral disease. Now and then it has been found con- nected with a tumor, but usually with some meningitic process—either a simple inflammatory meningitis, or a meningitis connected with infectious disease, such as syphilis. This baby's head is rather large, the fontanelle is still rather wide, but I can cover it with my two fingers. JACOBI: Clinical Lectures on Pediatrics. J The veins on the head are dilated ; as the external vessels so are the internal also large. Such large veins always indicate insufficient circulation. They are not infrequently connected with internal venous hyperaemia and hydro- cephalic effusion. The baby has been developing very slowly. The few teeth which it has been making are breaking down already, so that the nutrition is certainly very poor. Its antecedents are very bad. The mother miscarried three times before it was born, and she carried it only eight months. When first brought here there was an eruption on the palms of the hands and soles of the feet. What could be more positive of hereditary syphilis. The same eruption found all over the body may mean nothing, but when confined to the soles and palms itmeans syphilis. Particularly is that the case with the newly born afflicted with pemphigus. Pemphigus is a superficial inflam- mation, forming large vesicles with serum that raises the epidermis. Pemphigus may exist in the newly born as a re- sult of hot bathing, or a hot bed, or embrocations. In that case it would not be confined to the soles or palms. With the history of syphilis, which is rendered more probable yet by the repeated occurence of miscarriages present in this case, the hydrocephalus can be attributed to the dis- turbed circulation brought about by the disease. The treatment would, then, be principally anti-syphilitic. Hydrocephalus means the presence of "water " in the brain or in the cranial cavity. The serum may be either in the ventricles, or it may cover the surface of the brain. Sometimes it forms great lakes, amounting to eight, six- teen, or more ounces. Sometimes the accumulation of serum is so excessive that the bones will be crowded against the scalp, and local gangrene of the surface will be the result. I have seen such cases. The pressure of the bones against the skin compressed the blood vessels, circulation was cut off, and gangrene resulted. In all cases the scalp, being expanded, is thin, white, and more or less bald. In most cases, hydrocephalus is either congenital or acquired early. When it is congenital, the brain is never fully developed, while the skull may be too large, or nor- mal, or too small, at birth. Such a case may be the result of an embryonal inflammation, though no positive evi- dence of it can be found. The ependyma is often found thickened. The serum contains but little albumen, about one-tenth of a per mille. Many such cases have been attributed to the obstruction of the aquaeductus sylvii, or 8 JACOBI: Clinical Lectures on Pediatrics. to that of the foramen magendie ; in others they have been found normal. Inebrity and syphilis of the parents have been charged with producing congenital hydrocephalus. It is often found in numbers in the same family. Acquired hydrocephalus is inflammatory in most cases ; that appears to be proven by the condition of the serum which—very much like that of transudation and exudation —contains one per mille and much more of albumen. It is the result of interrupted circulation, for instance, by the obstruction of the venar magna Galeni or the sinus recti, brought aboutby exudation or by tumors, or byslowcircu- lation through chronic hyperaemia depending on general rhachitis. In a number of cases it has depended upon the presence of a tumor which has compressed a large vein, thereby giving rise to an effusion of water. In many cases, however, it is an inflammatory product, and the earlier it occurs, say during fcetal development, the more detrimental are the effects. The immature, soft, and flabby brain is com- pressed and injured or destroyed. I have seen a whole hemi- sphere wanting, the meninges being filled with absolutely nothing but water. In a number of cases the lateral ven- tricles are filled to such an extent that while the head is very large, the brain is atrophied,and sometimes nothing is left but a thin layer of cerebral tissue. These are the worst cases ; as I said, the sooner the process begins the worse they are. There are other cases, and this one here may be one of them, in which there is an anomaly of nu- trition in consequence of an abnormal condition of the blood-vessels. Syphilis affects the blood-vessels, particu- larly the arteries, in such a way that their wall, particularly the intima, is thickened, thickened to such an extent that the circulation is impeded, and the result is either abnor- mal nutrition, destruction of cerebral tissue, or hyperaemia and infusion. In a number of cases ofhydrocephalus there is insufficient development of other tissues besides the brain. The bones, for instance, will be found very thin. Not that they have been absorbed again from pressure, but that they were built so from the beginning. You know that there is a difference in the formation of the organs in different people. There are not two gentlemen here who have the same sort of skin, the same color of hair, and so on, or who have the same thickness of the cranial, or other bones. So it is in babies ; the bones are by no means alike. In some, the cranial bones are very thin. All the other tissues maybe thin, especially the connective-tissue system and that means also the blood-vessels. When the JACOBI: Clinical Lectures on Pediatrics. g blood vessels are very thin they are more apt to give rise to effusion. As you can well imagine, a boot made of thin leather will be more likely to leak than a good stout one. Thin-walled blood vessels, particularly those poorly covered with endothelium, will give rise to effusion much more readily than well-developed ones. So this absence of sufficient plastic tissue in the bones, and in the tissues generally, is very probably a frequent cause, if not the most frequent one, of congenital hydrocephalus, partiularly when it can be proven by absence of brain tissue that it has formed very early in life. When it comes to treatment, you can do much more for those that are acquired than you can for those which com- menced in fcetal life. When the commencement was in early fcetal life there is very little brain tissue, and almost every one of such cases will slowly die. Acquired cases may be benefited, particularly when they go with rhachitis. Rhachitical bones of the cranium when soft and succulent can be cut through easily and blood will ooze forth ; the same is true when you cut into the dura mater,, showing that the veins contain considerable blood. The sooner you can relieve the general rhachitis in such cases the more hope will there be of relieving the hydrocephalus. Congenital cases are different, and for them a number of different things have been tried. The tincture of iodine, iodoform ointment, and vesicatories have been applied over the cranium, all to no purpose ; the iodide of potassium has been given without benefit, for where there is no brain there can be little response, new effusion will take place all the while, and the result of treatment is very insignifi- cant. The same must be said of vesicatories, purgatives, and diuretics. It has been proposed to tap the brain. A number of recoveries have been reported from this practice. When you have to deal with a large accumulation of water there is always a temptation to run the trocar in and let it out. There are a few cases on record that got well after such treatment. But as a rule when a man has done something which is promising of success he publishes it, and when he finds, after a year or two, that he was quite mistaken, he is not quite so anxious to publish the fact that he was mistaken. In some of these cases of puncture in hydro- cephalus, the result was published after a month, two months, six months, and in some after a year. Whether there was a return, we are not told. Those that are positively known to have been cured by an operation ro jACOBi: Clinical Lectures on Pediatrics. are not, however, very numerous. I can not say that I have ever succeeded in curing one by this method, with or without the injection of iodine, which has also been proposed and practiced. The aseptic trocar is introduced where you can not hit a sinus, say a little to the right or left of the median line, and a certain quantity of the hydrocephalic fluid is allowed to escape. You should be sure not to remove too much of the fluid. From one to two(rarely three)ounces are suffi- cient. While the fluid is escaping the cranium must be compressed, for you can very well imagine that when you relieve the pressure from inside, the blood vessels will at once dilate and haemorrhage may take place. Not in- frequently when you empty even the pleural cavity too suddenly the result is haemorrhage, simply because the blood vessels, which before had been compressed, are re- lieved of that pressure, they dilate and blood escapes from a weak point in the walls of the vessels. The same thing has happened in the brain. So, use compression with your hand, or with a bandage, while you allow the liquid to escape. Having withdrawn a small amount, withdraw your instrument, but keep up the compression. The child will hardly cry except when you plunge the trocar in; it will look quite placid, and all will be well for a few days, and then the cranium will be likely to swell again, more effusion taking place in spite of your compression bandage, and you will have to repeat the tapping. It is always ex- pected to be done a number of times. There is one peculiarity of such tapping which I noticed not very long ago. When the fluid is withdrawn there may be so little irritation as not even to cause the child to cry, there is no fever afterward, no reaction whatever, still the contents of the cavity change. They appear to assume more and more the character of an inflammatory product. An in- flammatory exudation, as you know, contains a good deal of albumen. I have known the quantity of albumen in the hydrocephalic fluid to increase eight times within a week after tapping. Although then there may apparently be no inflammatory reaction, yet the albumen increases and the condition is not a promising one If the baby be syphilitic, and the hydrocephalus result from that rtis probably better off, as it may respond to anti-syphilitic treatment. [The following remarks on hydrocephalus were added at the next clinical lecture, October 19.] JACOBI: Clinical Lectures on Pediatrics. 11 We were on the subject of hydrocephalus at our last clinic. Here is another case. It does not present anything unusual, but I wish to remind you of the fact that this is a very difficult condition to treat, and many cases have to be managed according to the cause of the hydrocephalus. At first sight this baby appears to be fairly well formed, but when you study it more carefully you find the epiphyses are large, the legs are a little curved, the head is very large, and rather square, facts which point toward rhachitis. While the baby looks intelligent, yet the head is larger than appears to be normal. A baby of twenty months ought to have a head of about eighteen inches in circumference, perhaps even less if a girl, as this one is, but here the circumference is twenty inches, about three inches more than usual. Here the fontanelle is pretty large, whereas in most babies it is closed about the six- teenth month. There is no question about the hydro- cephalic character of the head, but the question is, How much fluid is present ? The pulse can be felt at the fontanelle, which shows that there cannot be a great deal of fluid. It has not interfered much, if at all, with the intellect ; it has not given rise to contractures or paral- ysis. How is its presence to be explained in this case ? Rhachitis, when it affects the cranial more than it does the rest of the bones, will give rise to general hyperaemia of the cranial bones; hyperaemia of the dura mater, effu- sion into the dura, pia, and the brain, and now and then lead to meningitis. With effusion these cases are most amenable to treatment. When taken in time they may get better; they may even get better spontaneously. Hydrocephalus may get well to such an extent as to leave a perfectly intact child. Imagine, for instance, you have a large rhachitic head, with abnormal conjestion of the head and brain and consequent effusion, and the case gets well. Then there is left a large head, a very con- siderable blood supply, which at one time was excessive. Now, a good supply of blood with restored circulation mean good nutrition. So you will not infrequently see that children, who formerly were rhachitic, havinga large, square head in consequence, are the bestscholars at school and become not infrequently the best minds of the nation. Had they been a little more rhachitic, and in a position not to receive good care when children, they might have been half demented, or died idiotic, or in meningitis while young. You see the relationship between a high order of intellect on the one hand and idiocy on the other is 12 JACOBI: Clinical Lect7ires on Pediatrics. very close. A little more or a little less congestion and effusion make all the difference in the world. Now, here is a child with a large head, a cranium that ossified in the course of time, though late. There is some effusion; what can we do for it? We spoke before about tapping. As we see, the effusion is not great here, and tapping, therefore, is not indicated. But if there were a greater accumulation of water, the bones being mostly os- sified, you could not readily compress the skull as the fluid was withdrawn, and a vacuum would result which must be filled, and it would be filled by a determination of blood to the cerebal vessels, and haemorrhage would be more than likely to take place. This baby is getting well spontaneously it seems. General anti-rhachitic treatment, good air, some farina- ceous food with his milk, plenty of beef and eggs, some cod-liver oil, some iron, or hypophosphites with iron, would certainly do good. You know, also, to what ad- vantage we have used phosphorus in cases of rhachitis; this child would take about one-fiftieth of a grain daily. That would mean two minims of the oleum phosphoratum of the Pharmacopoeia, or thirty minims of the liquor phos- phori, or sixty of the elixir phosphori of the National Formulary. The head will become somewhat larger, but not much; if the baby should have in the future a head measuring two, three, or even four inches more in cir- cumference than at present, it may result in no harm, certainly not if it be filled out with cerebral substance. Second:—Delivered October ip, 1892. Hypospadia, Rhachitis, Chronic Pneumonia, Angioma- tous Tumor of Face, Spinal Paralysis. Hypospadia.—This baby is seven weeks old, and has been brought to the clinic because there is something ab- normal about the external genitals. As you see, there is apparently a very large clitoris and immense labia majora. When we come to examine the case more carefully we find a pair of testicles, one on each side, in what are ap- parently the labia majora. We also find that the raphe of the scrotum resembles a constricting band; that the penis is short and drawn down so that it looks like a large cli- toris. We also find that the opening of the urethra is on the under surface of the penis at the fossa navicularis Early in fcetal life the urethra consists of different parts (as does the intestine), which afterward become united JACOBI: Clinical Lectures on Pediatrics. 13 The urethra is formed from outside and inside, the two parts meeting behind the fossa navicularis, but sometimes they fail to meet and may result in an obstruction, though rarely. When this happens the urine will breakthrough at the weakest point, which may be at the end. But that is not the most common form of hypospadia. The spinal cord, the abdominal walls, the intestine, etc., are originally patent in the median line, forming an open groove, and at a later period in embryonic life become closed. Sometimes they do not close. If a part of the abdominal wall does not close in the median line, we may have a congenital umbilical hernia, or lower down an opening into the bladder. If the whole bladder does not close anteriorly, its posterior wall protrudes and con- stitutes what is called exstrophy of the bladder. In bad cases the symphysis pubis may also remain divided and part of the bones undeveloped. In the case before us we have to deal with a condition in which the lower wall of the urethra did not close properly. When the union takes place to only a limited extent, the opening is a large one, and may be found back even as far as the perinaeum. In our case it is between that pointand the fossa navicularis. The open- ing of the urethra is not affected alone, the penis itself is drawn over for want of sufficient development of the cavernous tissue. As long as there are no erections that makes little difference, but as soon as erections take place the penis is bent down and becomes painful and annoying. As the baby is only seven weeks old I would suggest that it be let alone for the present. An operation will be easier to carry out when it becomes older. Rhachitis.—Here is a baby four years of age whose head looks as though it were not so old, while the belly looks as though it might be much older. The legs show a marked curvature outward, allowing enough room for a little dog to pass between. The epiphyses as compared with the diaphyses are large. These bow-legs are the re- sult of rhachitis, of which I mean to speak to-day only in reference to its connection with the intestinal organs. The large belly is due to the same cause. Rhachitis does not mean simply a disease of the bones, it means also faulty or insufficient development of the muscular and even of the nervous tissue. In a number of cases rhachitis begins with insufficient muscular development, and thus we are able to account for the fact that many babies who be- gin to suffer when two or three months old with consti- 14 JACOBI: Clinical Lectures on Pediatrics. pation, do not develop other symptoms of rhachitis until later. This baby has a very big but very soft belly. There is no tumor of any kind. The veins over the abdomen are large, there is tympanitic percussion sound all over, which means gas, either in the peritoneal cavity, or, as in ninety-nine times out of a hundred, in the intes- tine. The gas is formed in the intestine from imperfect digestion, and it is retained there because the muscular layers are not sufficiently developed to expel it. Be- sides, the abdominal walls themselves being flabby, there is no pressure from without to aid in getting rid of the flatulency inside. Besides, no absorption of gas is taking place. The head is normal enough, though a little inclined to the square form. If we had to deal only with sufficient development of muscular tissue in the abdomen and intestines, we could benefit the baby by resorting to massage and friction, friction with the dry hand or by rubbing the abdomen with alcohol and water, or oil. The massage, however, would be the principal thing, and would act by stimulat- ing the muscles. Electricity might do a great deal of good, so also would strychnia. A dose, say, of one one- hundredth of a grain of the sulphate of strychnia, three times daily, would be very effective, but something else will be required. We are told that when the boy was first brought to the clinic he was being fed on weak coffee, sometimes a little milk and bread, and getting that irregularly. There was a gastro-enteritis. Now, it is a very lamentable thing for a boy of four years to be fed on very little milk, very much coffee, with vomiting and diarrhoea. We have here a case of insufficient and faulty nutrition depending upon faulty alimentation, which is a sufficient cause of rhachitis The rhachitis of the bones seems to be only secondary, and is certainly of minor importance compared with what is going on in the abdomen. The improper feeding would account also for the gastro-intestinal catarrh with diarrhoea and vomit- ing. It would result in the formation of gas; in insuf- ficient nutrition of the muscles; in rhachitis. The treatment must be not only strychnia for the stimulation of the intestinal muscles, but also improved diet, which shall improve the condition of the mucous membrane of the alimentary tract and the general nutri- tion of the body. JACOBI: Clinical Lectures on Pediatrics. 15 In selecting food for such a child we must not take our own habits as a guide, for many of us eat too much and of more things than is necessary. If most of us would reduce our diet one-third we should be better off. Chil- dren, as a rule, eat very simply and uniform, and thrive best when they are allowed so to eat. A child at that age might have a piece of beef or mutton once a day; it might have one egg a day, in some shape or other, but not hard; it might have a pint to a quart of boiled milk; it might have some barley, rice, oatmeal, or farina with the milk—and that is all it would want. A baby fed in that way will thrive. Those babies that are costive might have more oatmeal, those that have a tendency to diarrhoea might have more rice or barley with their milk. Fruit will do no harm to older children, particularly boiled fruit. A piece of orange in the morn- ing or after meals, a piece of sugar or two in the course of the day or plain candy, frequently is not only pleasant but useful. But all that depends on the condition of the stomach and general state of the baby. In a case like this we must try to counteract the tendency to fermenta- tion in the intestines. Resorcin, or naphthalin, or salol, or salicin, might be useful, or large doses of bismuth might be given from time to time. If you should give the baby naphthalin he probably would object because of the bad taste. Resorcin is easily taken, it dissolves readily. Bismuth has no taste at all. This baby might take, an hour aftei each meal, three or four grains of sub- nitrate or subcarbonate of bismuth with a half or two- thirds of a grain of resorcin. If there were any tendency to diarrhoea I should add to that some prepared chalk, if any tendency to constipation add two or three grains of calcined magnesia. We have here a similar case. A large stomach, large epiphyses; but the latter appear more prominent than they really are, owing to the thinness of the integuments. Chronic Pneumonia.—This baby gives you the impression at a glance of profound anaemia; it looks exceedingly pale. There is a moaning respiration, which is always indicative of some trouble in the respiratory organs. There is a spasmodic contraction of the diaphragm, which shows that the respiration is impeded. The paleness of the lips and general pallor point to marked anaemia, and probably anaemia of long standing. There is a history of cough which has lasted since the baby was six or eight months old, and it is now two years and four months old. There 16 JACOBI: Clinical Lectures ou Pediatrics. is a history also of expectoration of a purulent character. It has been reported to me that the expectoration was examined, and that no tubercle bacilli were found ; that it consisted principally of pus. Sometime ago the baby would expectorate about a half teacupful at one time. That is certainly a large quantity, and must come from a cavity. The cavity may be in the pleura ; it may be a local or general empyema which has perforated into the lung. It may be in the lung, and if there, it may be of two different characters at least. It may be the result of an abscess, that abscess being either tubercular or simply inflammatory, or it may be due to dilatation of a bronchus. When a bronchus beeomes dilated it may hold a great deal of liquid, an ounce or a number of ounces. Sometimes the fluid which it contains is very fetid if retained long. When the bronchus becomes filled, and an attackof coughing sets in, all the muco-puru- lent fluid may be discharged at once. So that in a num- ber of cases it is very difficult to make the diagnosis between dilatation of a bronchus and a pulmonary cavity. A pneumonia may terminate in an abscess. Such an abscess when lined with a thick pyogenic membrane may not lead to pyaemia or hectic fever at all, just as an ab- scess may exist in the subcutaneous tissue and produce no very bad consequences. Located, however, in so vital an organ as the lungs, the pus cavity would, of course, be more dangerous than if it were subcutaneous. There are pnemonias which sometimes result directly in dilatation ofa bronchus. An interstitial pneumonia, located as itis in the cellular tissue of the lung, not in the alveoli, may run for weeks and months, and finally end in cicatrization and retraction of the whole mass of bronchial tissue with more or less dilatation of the tube walls. There would be an opportunity for the accumulation of a large quantity of muco-pus. In after years, if the patient continues to live, there will be retraction of the chest wall. You will sometimes meet with men who have a chest retracted on one side with diminished respiratory murmur, sometimes bronchial respiration and bronchophony and dullness on percussion. In them, finding these peculiarities under the clavicles, you may make a mistake and suppose there is tuberculosis when it is nothing but the results of a pneumonia of childhood. I warn you of this possibility now because it is the first impressions which one gets in his medical career that stick best. JACOBI : Clinical Lectures on Pediatrics. i1/ Before examining the baby's chest, let me call your at- tention to the fingers. The last phalanx of each finger is large, has a clubbed appearance, and is bluish. Club- bing of the fingers is present when there is chronic inter- ference with the circulation, therefore you will see it in chronic heart disease, in emphysema, in tuberculosis. It is due to interference with the circulation in the distant parts, ending in dilatation and hypertrophy of the small blood vessels and increase of the connective tissue. On examining the chest we find some dullness over the left scapula and diminished respiratory sound. The baby has had a pneumonia which has lasted twenty months. There is no emphysema, no heart disease; simply a chronic pneumonia. You can convince yourselves that (i) there is not much dullness on percussion ; (2) that the voice of the baby is directly under your ear ; (3) that there is bronchial respiration all the way up from the base of the lungs ; (4) that there is a cavity in the lower lobe of the affected lung. In the adult a cavity connected with tuberculosis is usually in the upper lobe ; in the child t is frequently in the lower lobe, but that does not prove that here it is of tubercular origin. If it were tubercular, the probability is there would have been hectic fever long ago and also a fatal termination. There is a peculiar feature about the case to which at- tention should be called. That is a fetor about the breath, which is said to have been worse than it is now. In a baby, that means as a rule, where no cause exists in the mouth or throat, gangrene of the lung ; gangrene of pulmonary tissue from which the circulation has been cut off. That is more likely to occur in babies than in adults, for the pneumonia of adults is usually of the infectious cr fibrinous type, attacks one lobe and runs its course in five to seven days, terminating in recovery ordeath. In babies, on the other hand, the pneumonia is mostly catarrhal, lobular, numerous hepatizations may occur, which means there may be twenty or more centres of the pneu- monic process. When the infiltration is very dense, and the circulation is cut off from intermediate parts, gangrene may take place. For the present I recommend to give the child four or five grains of the sulphate of quinine, or ten grains of the tannate of quinine, in the course of the forenoon to meet the afternoon exacerbation of the fever ; a grain of Dover's powder for the night if there be much cough and restless- ness, and in the course of the twenty-four hours an emul- 18 JACOBI: Clinical Lectures on Pediatrics. sion containing two minims of a good fluid extract of digitalis, and from five to eight grains of camphor. Angiomatous Tumor of the Face.—This baby has an angiomatous tumor of the right side of the face. We are told that it had been operated upon seventeen times in England, and, judging by the numerous scars, we infer that the actual cautery was used. We have employed the cautery six times, always, however, through the same opening, thereby avoiding too much deformity. When the baby was first brought here the mucous membrane of the mouth protruded, was a dark purple in color, while the face outside formed a tumor much larger than its two fists; it extended from the right angle of the mouth to the ear. Vascular tumors and vascular degeneration seen in children and adults are, as a rule, congenital, and mostly very small at birth. Usually they are simply marks, so- called mothers' marks, and very superficial. They are oftenest seen on the face, head, chest and sacrum, now and then on the extremities, sometimes on the mucous membranes, and sometimes we find angiomatous degen- eration of the liver, spleen, kidneys. As already stated, they are usually on the surface, small, not raised, or but little, above the skin at birth. They consist of blood ves- sels which are too numerous, or too numerous and at the same time degenerated. Usually it is the capillaries, or small arteries, sometimes small veins. The color is usually a bright red ; if not, the paler blue depends on the admixture or preservation of connective tissue. The color may also be a little more red or more blue, accord- ing to whether the arterial or venous blood predominates. Angiomatous tumors are apt to grow unless they are situated over bone. When located on the forehead or head they may disappear spontaneously, because of the pressure upon the vessels from growth of the skull. In the case before us, which was not located over a bone, but in the soft tissues of the cheek, the tumor was very small in the beginning, but it went on to grow, and now has been operated upon twenty-five times, and it has not dis- appeared yet. In a number of cases you will have to deal with vas- cular tumors which consist of blood vessels only; while in others you will find a good deal of connective tissue mixed in. The latter are not so arterially red. Some cases are from the beginning complicated with sarcoma, adenoma, or fibroma. I have seen a number of cases in which a small angiomatous tumor was situated in the JACOBI: Clinical Lectures on Pediatrics. 19 subcutaneous tissue, extending outward to the skin, the size of which could be diminished to a slight extent only by pressure. These are the cases which, when the child grows up,sometimesresultinsarcomaoranother malignant growth. When you find such a tumor, partly vascular, partly solid, it is best to remove it to prevent its change into a malignant pseudoplasm. Regarding treatment, removal by excision is indicated only in certain cases, those in which the tumor is pedun- culated or can be rendered so by passing needles through its base, or those which appear more circumscribed than diffuse. By the latter method, passing needles through the base of the tumor, crossing one another, and then constricting with a ligature, the tumor may fall off after some days. The surface should be disinfected with carbolic acid, creo- lin, or other agents. Another very effectual way is the use of the actual cautery in the manner that it was em- ployed in this case. The scars here, although so numer- ous because of the different points of entry made when the patient was treated in England, are very superficial and smooth. But they ought not to have been so numerous. Caustics can be used, fuming nitric acid, bichloride of mercury, etc. Take, for instance, one part of bichloride, eight or ten parts of collodion, one application of which will usually suffice if the naevus be on the head. These are the only methods which I should recom- mend, although a number of others have been employed. You may read in some books of treating naevi by vaccin- ation. It is true that cicatrization following the vaccine ulcer may obliterate the naevus, but it may do too much, or it may do too little. Hydrate of potassium, quicklime and potassium (Vienna paste), have been recommended. Their effect is an uncertainty. Sometimes it goes very deep, and there is more loss of substance than is desired. It has happened to me to have it eat down to the bone and destroy periosteum. In most cases the actual cautery is best. Injections of perchloride or subsulphate of iron must not be employed. They give rise, possibly, to em- bolisms. I have seen a baby die of cerebral embolism from that cause. Infantile Paralysis, Spinal Paralysis, Poliomyelitis.— This boy is nine years of age. You notice something wrong with his right arm. It hangs limp at his side. There is passive mobility in all directions, but no volun- tary movement. There is wasting; the arm is thin, the 20 JACOBI: Clinical Lectures on Pediatrics. fat has disappeared and the muscles are thin and flabby. At the shoulder joint is luxation, with a depression into which you can place your finger. It cannot he an orci- nary luxation retained by muscular force, for the arm can be moved in all directions. We have, then, luxation of the humerus, a very thin arm, especially the humerus, and the muscles over the shoulder joint are emaciated. There is, evidently, paraly- sis, and it must be due to an affection of the nerves or of the muscles. Undoubtedly, in the light of the history of the case, it is in the nerves, not in the muscles. The nerve, having become paralyzed, the question arises whether it is peripheral or central. If central, the lesion must lie in the cervical portion of the cord; if peripheral, in the brachial plexus. It is stated in the history, that when the child was a year old the mother noticed one night that it cried very much, and next morning could not move that arm, and has been unable to move it ever since. It was well, ex- cept for this inability, next day. Now, that does not mean a neuritis; it means a central disease; a cord dis- ease. This case is a rare one, which you will appreciate better after something has been said about the generality of such cases. Now and then babies of a year, or a little older, sometimes younger, will be affected quite suddenly with paralysis. Either they go to bed perfectly well and are taken up in the morning paralyzed, and that is all there is about the history of the case; or they will cry, be feverish, are sick two or three days, and then it is noticed that they are paralyzed. It may be in one, in two, or in three, or all four of the extremities. Or the paralysis may be noticed after the child has had pneumonia, or scarlet fever, or some other of the infectious diseases. Usually it is a lower extremity that is affected, and when the baby is expected to be well of the pneumonia, or scarlet fever, it is found to be paralyzed, and nobody can tell on what day it took place. But the large majority of cases are those in which there are no premonitory symptoms; no fever; simply taken some night with paralysis, nobody knows how. Usually the paralysis is most marked the first day. After five or six days improvement slowly takes place. That may go on three to eight weeks, then the condition re- mains stationary. But in spite of the fact that at first the whole limb seems paralyzed, usually it is only a part that remains affected. If it be the lower extremity, the exten- JACOBI: Clinical Lectures on Pediatrics. 21 sor muscles of the leg are likely to be most affected, and after a while the predominance of the flexors produces so-called paralytic club-foot. The exceptional cases are those in which all four extrem- ities are paralyzed; sometimes the two lower extremities are involved, and one upper; now and then there is a hemiplegia, not, however, including the face; now and then a leg on one side and an arm on the opposite side are involved. It is not common to have one extremity in- volved alone, and when you think it is so there has still been a slight impairment in another. In this case the mother is positive that only the right arm was affected, and we have every reason to believe it. That makes this case a very exceptional one. Regarding the cause: the condition comes on suddenly, and for a number of years, when we knew less of infantile paralysis, I believed the cause was a sudden haemorrhage in the spinal cord. Here in the cervical region and in the lumbar region, where these lesions mostly exist, there is a larger amount of cellular tissue surrounding the cord, and we might suppose haemorrhage would more readily take place in those localities. But after all it is not haemorrhage that produces this form of paralysis, it is a degeneration. Possibly in some few cases a slight haemor- rhage is the actual cause of such degeneration and, there- fore, is the original cause of the paralysis. However that may be, the lesion exists in the anterior horns, which are motor and trophic, and involves the ganglion cells and thereby destroys both motion and nutrition. This has been proven at autopsies where a peculiar degeneration and atrophy of the ganglion cells were found. Regarding treatment, when the case is recent, we have to deal with congestion; when old, we have to deal with cicatrization, anaemia, and atrophy in the interior column of the cord. Therefore the treatment of a recent case and that of an older case is not the same. If you could have seen the case during the period of restlessness and fever, antiphlogistic treatment would certainly have been indi- cated. A few leeches could be applied over the cord, and you would be justified in putting an ice-bag on for some time; you would also give a purgative, and correct the circulation, if necessary, by digitalis, and administer ergot. Ergot will certainly affect the involuntary, the unstriped muscles; thus it affects the blood vessels. The vessels supplying the cord are very short, and although they would themselves be but little affected by the ergot, there JACOB I: Clinical Lectures on Pediatrics. would be through its influence diminished supply through the larger branches from which they arise. I have never found ergot do the slightest amount of good in cerebral disease, whereas it has done a great deal of good in spinal disease,—the difference being that the vessels in the cord are very short and easily influenced from outside, while those supplying the brain are very long, and many have no muscular layers whatever, and are, therefore, not influenced by ergot. You might also use counter irri- tants, such as tincture of iodine; but in spite of this pri- mary treatment, should you see the case early enough, what shall be done for the paralysis that remains after- ward, say after two or three months? In the first part of the disease, in my experience, neither the interrupted nor the continuous electric current will do any good. The time for electricity is when the hyperaemia has passed by and anaemia has set in. After some days the fat begins to disappear; then the muscles become atro- phic, and electricity is indicated to keep up the nutritive process. The defective innervation is shown by the fact that first the interrupted current fails to produce a response; somewhat later, the galvanic current shows the reaction of degeneration, that is, a contracture will take place, but it is not instantaneous; it takes a little time be- fore it becomes visible at all, and then only in installments. Ittakes a long timefor the reaction of degeneration to wear off, if it does at all. Both the galvanic and the interrupted currents ought to be used daily for from five to ten minutes. Apply hot water or cold water and friction, also friction dry or with oil or alcohol. Internal medicines will not do much good. Strychnia is certainly a stimu- lant when given by the mouth, and keeps up the appetite and so on, but it does little or nothing for the paralysis. But given by hypodermic injection I have seen for years that it produces results when its internal administration was useless. This boy is nine years of age; he might receive a fiftieth of a grain twice a day into the tissue of his paralyzed arm, or if he could not be seen that often, get a thirtieth of a grain once a day. In these cases it is best to begin with the full dose and not waste time; if the amount is too great, it can be reduced. But never use strychnia in a recent case. This boy ought also to wear his arm in a sling, for it falls out of the joint by its own weight. The treatment must continue a long time, and may re- quire years. Persistence will render good service, but you will rarely see even a mild case getting entirely well. CLINICAL LECTURES ON PEDIATRICS. (Session of 1892-93.) BY A. JACOBI, M.D., Clinical Professor of Pediatrics in the College of Physicians and Surgeons, New York. Third:—Delivered Oct. 19, 1892. {Stenographic Report.) Scarlet Fever, Spina Bifida, Prolapse of the Rectum. Scarlet Fever.—This little girl is about three years old, and the mother says was taken sick yesterday afternoon. She wanted to sleep, and put her hands on the stomach because of pain. The mother gave her licorice powder and she vomited twice. She was inclined to be costive, but the bowels have moved since. Yesterday she was chilly, but last night she was hot. She took only liquid food since, and did not vomit it. On looking at the child there is no noticeable dyspnoea, so that it would seem the fever of last evening was not the result of any respiratory trouble. As she has been walk- ing about, we may exclude any probability of joint dis- ease, rheumatic or otherwise. The most striking thing is the fact that the skin is rather red, and the mother says it has been so since this morning. The tongue is also rather red, whereas its normal color is a pale red. In the eruptive fevers and severe gastritis the tongue is apt to be red because the epithelium has been thrown off, and this is especially likely to take place along the edges, and from there spread all over the organ. This baby's tongue is rather red, although in the middle there is a good deal of epithelium, perhaps more than usual. In the white fur a number of fine red papillae are seen standing out, and in a day or two it is#prdbable more and more will make their appearance as the epithelium falls off, so that the tongue will become red in the centre as it now is on the edges, and we will have the "strawberry tongue" of scarlet fever. • 24 JACOBI: Clinical Lectures on Pediatrics. A number of small eruptions are seen raised above the skin covering the extensor side of the thigh, the hips, the abdomen and chest. If it spreads it will produce an erythematous flush all over the surface, peculiar to scarlet fever. On the left tonsil, which is very much swollen, there is a gray discoloration at one point, while elsewhere it is red—redder than normal. Both tonsils are large, but the left one is the larger of the two and reaches the uvula. This, then, is a case of scarlet fever at a public dispen- sary. While there is a great blessing in dispensaries, they are sometimes also a great curse. If that baby had not been observed at once after its entrance, it might have remained in near contact with other children for from half-an-hour to an hour. That takes place every day. There is whooping cough, there is measles, there is diph- theria, there is scarlet fever. Cases of infectious and contagious diseases come to the dispensaries all the time and remains from an hour to two hours, sowing the disease among other children to carry to their homes and spread it still farther. That is why it is impossible in New York in most cases to trace a given case of contagious or infectious disease to its original source. I have not the slightest doubt that benevolent institutions like this con- tribute a good deal to the spread of these diseases all over the city. So these institutions are not an unmiti- gated blessing. They are liable to spread physical dis- eases as they are sure to spread demoralization amongst the public which is tempted and too eager to take services gratis, though many of them be well able to pay for them. This patient's mother says she has three rooms and three children; one of the children at home has already had scarlet fever, the other has not. I would advise her if she desires to protect the seven-year-old child athome', to have this baby taken to the Willard Parker Hospital where she will be taken care of and be better off than at home. The case is one of utmost importance, both to the baby and to the community at large. But so far as the community is concerned, we will waive that subject for the present. As to the patient, the mother says she gave her lico- rice powder and she vomited. It is not likely the powder had anything to do with the vomitfng. It is very com- mon for scarlet fever, as for many other infectious dis- eases to be ushered in with vomiting, sometimes the vomiting being repeated eight or ten times, or more Jacob I: Clinical Lectures on Pediatrics. 25 There was no pain except an ill feeling at the stomach. There was fever. Then the eruption appeared. The rectal temperature is now 1020 F. We have noticed in this case early participation of the mucous membrane of the mouth. The tongue is red, the tonsils are enlarged and red, and this redness will yet increase. But there is another appearance of the tonsil which is more import- ant than the redness. It is the occurrence of a grayish membrane at so early a time. A grayish membrane in the fauces is of frequent occurrence in scarlet fever. When it comes' on the fourth or fifth day it does not signify much, but when it is present on the first day it means a great deal. Although this baby is not very sick now, I look upon the case as a dangerous one. Where the diphtheritic or pseudo-tliphtheritic membrane appears on the tonsils the first day it will spread within a very short time, and be likely to lead to general sepsis. In all probability within two days that throat if left alone will be gray all over. The glands about the neck will swell, and symptoms of general sepsis will set in. The fever may be very high or not. Sometimes in marked sepsis the tem- perature is quite low. I wish you to remember this in just such cases as this, though we feel like making a good prognosis because the baby appears to be strong and healthy. They run a very bad course if pseudo-mem- brane appears the first day. In a number of cases the membrane is that of what is now called real diphtheria, but in the large majority it is due to what writers are not now inclined to call so. The disposition at present is to call only such cases diphtheria as show the Klebs-Loeffler bacillus in the false membrane. The pseudo-membrane may have the same extent and thickness and general ap- pearance,yet if it do not contain the Klebs-Loeffler bacillus it is spoken of as pseudo-diphtheria. Whether such a division is correct we shall see in a few years. What we can now say is that in not more than about sixteen per cent, of all cases of apparent pseudo-membrane of scar- latinous diphtheria can the genuine Klebs-Loeffler bacillus be found. In other cases the streptococcus or other mi- cro-organisms have been met with. Again in a number of cases in which the Klebs-Loeffler bacillus was found the glandular swelling which is often enormous in diphtheria was not present, or Was present to only a slight degree. On the other hand, in many cases where the streptococ- cus has been found while the bacillus of diphtheria was absent, the glandular swelling has been very intense. 26 JACOBI: Clinical Lectures on Pediatrics. Thus, it would almost appear that we need not be so much afraid of a true diphtheria complicating scarlet fever as of pseudo-diphtheria, especially when the false mem- brane contains the streptococcus. After all as it is neither the streptococcus nor the bacillus that kills, but the ptomaines developed by them, it would be po°r. co.n" solation to know it was not "genuine diphtheria" with its regulation bacillus that destroyed your patient. As long ago as 1884 Gerhardt, of Berlin, called atten- tion at one of the German Medical Congresses, to the probability that diphtheria was the result of different mi- cro-organisms, so that we are not much farther advanced in understanding the causation of this disease now than at that time. That is about all that can be said of it to- day. There are pseudo-membranes; they contain fib- rine, a few blood cells, more leucocytes, broken down epithelium, and on the one hand, a bacillus, and on the other a streptococcus. For the time being I prefer to re- tain the name diphtheria for all such cases alike. More- over, it is claimed, particularly by Kursh, that the very same streptococcus is frequently found in common tonsil- lar angina, and is therefore not characteristic for any special kind of membrane. Thus you see, that after all, the finding of a micro-organism need not prove its etio- logical importance, and that it may after all be but to the secondary infection of, and through the medium of, the blood and the changed chemical and biological condition of the surface. What is to be done with such a case ? The baby has not a very high fever now. If the temperature were 1040 to 1060 F. some antifebrine, phenacetine, or antipyrine, with a stimulant, might be indicated. If that tempera- ture had occured the very first or second day, it would have been safer to adopt such a treatment, for a high fever which breaks out suddenly is not well tolerated. A baby may not tolerate a temperature of 1040 to 1050 the first day, but be thrown into convulsions by it, whereas, after the fever has been present three or four days it may rise to 1050 or 1060 F. and cause no immediate bad results. Therefore, beware of following a rule of treatment based on the temperature alone. When a man tells you that if the temperature rises to i03°or 1040 you must in all haste give an antipyretic, he advises you badly. It depends on the patient's condition whether he ought to have an anti- pyretic or not. Now and then a baby will have a con- vulsion when the temperature rises to 1030 or 1040, and JACOBI: Clinical Lectures on Pediatrics. 27 such a patient ought to receive an antipyretic. Another baby smiles and laughs with the same temperature, and it is not at all necessary to burden its system with an anti- pyretic. The temperature here is only 1020, and the baby certainly does not require an antipyretic. It ought to have good cool air, at 650 F. or not more than jo° F.; it ought to be allowed to drink as much as it pleases, to take liquid food only. It might'be given some alcohol, particularly, as the throat symptoms become threatening. There is no more powerful antiseptic than alcohol in sepsis. In this case I would commence with it early. Probably no other medicine will be necessary so long as the baby is not very sick. You will meet with a great many cases of scarlet fever which will recover without a drop of medicine. Although this baby looks well enough now, I would not, however, leave it without medicine, for it will be very sick to-morrow, and still more sick the day after. If treatment is put off altogether at present, it may afterward prove too late to interfere. Sepsis will set in, there will be heart weakness which ought to be fought this very day. Alcohol will do something. In addition I believe it would be well to give a dose of digitalis now, and as the baby is four years old it might receive half a minim of good fluid extract every three or four hours, commencing perhaps, with a dose every four hours and increasing it to one in three hours if it seems best. The treatment now advised is preventive rather than curative. You can not cure a case of scarlet fever; it will run its full course. You can prevent the heart from be- coming too much enfeebled; you can prevent sepsis from taking place too early and from being too profound. One thing which ought to be done at once in this case, was left unsaid. There is a membrane no matter whether "diphtheritic" or " pseudo-diphtheritic " on the tonsil; there is already a little glandular swelling. This latter is due to the irritation by the poison absorbed not so much from the tonsils as from the naso-pharynx. When you see a false membrane on the tonsil you may be led to suspect that the naso-pharynx participates in the pro- cess. If there be glandular swelling about the angle of the lower jaw you may be assured that the naso- pharynx is already affected. The glandular swell- ing is the result of a local infection. So, what you have to do first, is to disinfect the locality from which the infection is taking place. Disinfection can not often be made by local applications to the tonsil. 28 Jacobi: Clinical Lectures on Pediatrics. Suppose you should try to apply the tincture of the chlo- ride of iron or a solution of nitrate of silver, you would have to forcibly open the mouth, run your swab in and touch the affected parts. The child would scream, strug- gle, and exhaust its strength, yet if there is anything which the patient requires to carry it through the disease it is strength; never, unless you have an older child or an adult to deal with who is willing to have the tonsils touch- ed, try to make local applications with the swab for diphtheria. It is dangerous and I may say criminal, for you cannot succeed without exhausting the child. Again, you can not succeed in an unwilling patient without touch- ing some parts near by which are still well, or which are not covered by membrane. In diphtheria or the so-call- ed pseudo-diphtheria the epithelium at the point of local infection was vulnerable, and sore, and the mucous mem- brane in a catarrhal condition before being attacked by the infectious process. It is only on the tonsils where, according to Stoehr, the epithelia are partly separated from each other by distinct interstices, that diphtheria may take a hold without previous illness. To attempt to make local applications in the young patient you will surely break up epithelium more or less, and within twelve hours there will be extension of the morbid process. But disinfection is desirable, and can be carried out in a way not to injure the surrounding healthy membrane, nor to exhaust the child. It can be done by spraying through the nose, or by gently injecting a small amount of liquid into each nostril. A syringe may be employed, or the liquid may be poured in from a spoon. It will come out through the other nostril or go down the throat. Carried out gently, babies do not mind this procedure much,and they afterward breathe more freely. In a case like this it is desirable that the disinfectant run not always out of the other nostril, but that it touch the throat and disinfect the surface there. This can be ef- fected by closing for a moment the other nostril. If, in- stead of coming out through the mouth, it is swallowed, no harm will be done if the proper fluid be used. Carbolic acid is not appropriate, for babies object to it.and if swallowed in undue quantities it is likely to cause nephritis. If bichlo- ride of mercury be used it should not be stronger than one part in from five to ten thousand of water, in which case a little can be swallowed without harm. Lime water may be used, or boracic acid in a three or four per cent. JACOBI: Clinical Lectures on Pediatrics. 29 solution, or salt water in physiological dilution 1-130. The object is partly to disinfect, partly to cleanse. Frequently within twenty-four hours after commenc- ing these nasal injections and applying them once every hour or two hours the swollen glands will be found dim- inished one half. In a great many cases the selection of the wash is of no account, provided the parts are really cleansed. Be always sure that the injected fluid does not reappear from the nostril you injected. It must return from the other nostril, or enter the posterior nares and pharynx. The latter must be aimed at in most cases. We shall now dismiss the patient to her bed. It was my object to dwell upon the nature and treatment of the case such as it is now. To the general subject of scarlatina we may return when another case presents itself, or you may inform yourself in your text books on the main points. Spina Bifida.—What first strikes our attention in the next patient, a baby of twelve weeks, is a curvature of the long bones, especially of the legs, but this is not mark- ed, and is not more than what is likely to take place in the cramped position occupied by the baby during intra- uterine life. It is probable that the limbs will straigthen and assume the normal shape after a few months. After the clothes have been entirely removed we ob- serve a tumor over the upper part of the sacrum and the lower lumbar portion of thevertebral column. Whenever you find an enlargement at any place, the first question which suggests itself is, what can be the nature of such a growth situated in that particular locality. It must pertain to some of the structures in that neighborhood, and here it must belong to the skin, the subcutaneous tissue, to the muscles or tendons, the periosteum, bone, or that which is beneath the bone—the membranes of the cord, or the cord itself. We notice that the tumor is not of the color or consistency of skin; yet a part of the covering near the edges is still normal skin, while toward the central and most projecting portion it has a shiny, almost trans- parent appearance, and a reddish hue. It is situated in the median line and is about the size of a small orange; light pressure upon it is not painful. It has a cystic feel and seems to contain no hard mass or parts. We are told that it was quite small when the child was born; that all of it was covered with normal skin, there being only a small spot in the centre which looked brighter than the normal skin, and gives us the impres- 30 JACOBI: Clinical Lectures on Pediatrics. sion now of being a scar. There is nothing abnormal about the baby's feet, and both limbs are developed alike. The case is one of spina bifida. That is a tumor-like protrusion from the spinal canal through an abnormal opening in the vertebral column. Usually there is want of development of one or more spinous processes, the tu- mor contains a liquid which is in connection with the cere- bro-spinal fluid in the central canal of the cord, or in the meninges. When the swelling originates in the cord it- self one-half or one-third of this is pushed before it through the opening in the bone. In this case we do not see any- thing of the kind, which is very much more favorable, as it indicates that we have to deal with a hernia of the meninges only. If the cord itself protruded, and was more or less destroyed, it would result in abolition of the function of the nerves supplying the extremities, and cause par- alysis, atrophy, contracture, or deformity. In this case the feet are perfectly formed. What will become of the case if it is left to its own course ? The tissues over the tumor have already be- come greatly stretched and thinned, and doubtless in a short time would burst and let out the fluid. If this would take place only a little fluid could escape at first, but in a few hours it might result in draining off all the cerebro- spinal liquor, hyperaemia of the cord and brain, and death. That is the way in which a fatal result occurs in many cases of spina bifida. If you should puncture the tumor, a part of the fluid might escape and the opening close again, but the fluid would reaccumulate. Puncture and compression at the same time might lead to a good result. If the case were in an adult we might assume from the location of the tumor over the sacrum, that it was below the termination of the spinal cord, but in fetal life and childhood the cord extends lower, and in this case prob- ably to below the tumor, so that whatever we may do, we must be very careful not to injure its structure or excite inflammation. A number of cases have been reported in which the spina bifida tumor was treated by injection of a solution of iodine, iodide of potassium and glycerine. I will give this case some thought and will report to you in a week or two whether I consider it advisable to treat by this method. Meanwhile we will cover and protect the tumor with cotton and a bandage.* *A week afterward the tumor was injected with 15 minims of the solution recommended by Morton containing 1 part of iodine, 3 of iodide i JACOBI: Clinical Lectures on Pediatrics. 31 Prolapsus of the Rectum.—This boy, about four years of age, has been brought here on account of something protruding from the anus. There are several things which can protrude from the anus of normal or abnormal con- stituents above. In the baby the rectum is not curved as it is in the adult. The sacrum in the baby is almost straight and the rectum is, therefore, less well supported mechanically. The protrusion may be of two kinds, viz., one side of the rectum alone being pushed out, or the whole circumference of the gut protrudes. One chief cause of this is tenesmus and straining in consequence of constipation. As the hard masses reach the rectum, the membrane passes out with them and is constricted by the anal sphincter. Again, the object which is seen protruding from the an- us may be a polypus which grows from the mucous mem- brane. Another cause is want of proper development of the anal sphincter. In a number of cases this is found flabby, wanting in tonicity, so that the finger may be very readily introduced. But the most frequent cause is the relaxation of the rectum and sphincter in acute or chronic intestinal catarrh. Where there is catarrh there is hyperaemia and effusion into the mucous membrane and muscular tissue, causing re- laxation and prolapsus. This seems to have been the cause in this case, for the baby has long since had diar- rhoea, and there is no other apparent cause. This may be treated locally as well as by promoting bodily health. Tenesmus may be treated with two or more daily injec- tions of tepid water, the hypertrophied mucous membrane with astringent (alum) injections, in bad cases with the fuming nitric acid or the actual cautery, the paralysis of the muscular layers with suppositories or ointments contain- ing strychnia or extract of nux vomica. Very bad cases may require the subcutaneous injection into the perineum of sulphate of strychnia. of potassium, and 48 of glycerine. Previous to the injection four scruples of the liquid contents were withdrawn. There was hardly any pain, and no disagreeable symptoms followed the operation; no pain, redness, or elevation of temperature. From week to week the size of the tumor decreased, the surface changed in such a way that the integument became more and more cutaneous, until after about four weeks the spina bifida was reduced to less than a quarter of the original size; and it became quite hard. However when a complete success appeared to be only a matter of a short time, the child's death was reported. No reliable account could be obtained, and no autopsy was held. Thus from what could be learned, the baby's death did not appear to be in any way connected with the spina bifida or the opera- tion. A. J. CLINICAL LECTURES ON PEDIATRICS. (Session of 1892-93.) BY A. JACOBI, M.D., Clinical Professor of Diseases of Children in the College of Physicians and Surgeons, New York. Fourth :—Delivered Nov. 2, 1892. (Stenographic Report.) Cracked Lips, Lateral Curvature, Pott's Disease, Adenitis. Cracked Lips.—The first case rs a baby of nineteen months which was nursed by the mother for thirteen months, since which time it has steadily fallen away. Evidently it has not been properly fed, but that for which the child has been brought to the clinic to-day is an open sore at the angle of the mouth which refuses to heal. The open wound at the side of the mouth is covered with a whitish membrane upon a granulating surface. The pseudo-membrane in this case might suggest diphtheria, but there is no reason to believe that such is its true na- ture ; for there is no other membrane anywhere else, though we be told this is of long standing. If examined under the microscope it would be found to contain albumen and fibrous exudate, some pavement epithelium, leucocytes, but probably no bacilli, perhaps streptococci or the numer- ous micro-organisms which are found everywhere. It will likely require some time for healing, as the child is in poor health and has a tendency to break the granula- tions by rubbing the face with the hands. The surface should be kept disinfected and clean, should be dried with absorbent cotton and treated with an ointment of oxide of zinc or bismuth, with balsam of Peru ; or with the dry bismuth subnitrate powder to be applied every few hours. Improvement of the general health will also improve the ulceration. While waiting for the next case to come in, I wish to refer to a case you have seen previously. A child was presented lately, nine years of age, which nineteen months before had had swollen knees. This JACOBI: Clinical Lectures on Pediatrics. had recurred once or twice. When presented she was suffering from insufficiency of the mitral valve and hyper- trophy of the left ventricle. For the endocarditis ice bags over the cardiac region were advised, while digi- talis was to be taken internally, and it was urged that she be kept in bed a month without being once permitted to leave it. We are told she feels much better. Lateral Curvature.—The history of this case, taken by the assistant, reads as follows : Almost to the end of the second year the child, a boy of about seven, suffered from what is described as a vesicular eruption accom- panied with fever and restlessness. On being raised and when the spinal column was touched it cried out. De- formity was observed when the child was one year old. It began to walk at two. No history of tuberculosis. Curvature of the spine, scoliosis, may be the result of different causes. We are told that it began in this case when the baby was quite young, so there may have been a congenital disposition. A congenital disposition to scoliosis might rest in the bones or in the muscles. If the scoliosis began very early, it probably was not the mus- cles that were at fault, but the bones, for the baby is not called upon to use its muscles much the first three or four months. It is really wonderful that most of us are tolerably straight. The spinal column is composed of seven cer- vical, twelve dorsal, and five lumbar vertebrae, making twenty-four bones, and it is really a wonder, that we are not all more or less scoliotic, for any change in the shape of any of the bones would result in more or less deviation of the vertebral column from its normal outline. Now and then such an anomaly does take place,and scoli- osis is the result. The history is not very clear as to the time of com- mencement of the curvature in this case. If it did not occur until after six months of age the cause was prob- ably muscular; the result of debility. External causes may have acted. When nurses carry a baby on one arm as they generally do, particularly when the baby is quite young, you may expect some scoliosis. You should see to it that babies are not carried on one arm exclusively and that they be not carried in an erect posture too early' Rarely can they sit up straight, or hold the head erect before the third or fourth month. Mothers and nurses being proud of the baby, often carry it on the arm with- out a proper support for the trunk before it is six or eight JACOBI: Clinical Lectures on Pediatrics. 35 weeks old, and often thereby cause scoliosis which is liable to become worse afterwards. Girls and boys are compelled to go to school when only six or eight years of age. In school they have to sit up from five to eight hours on a badly shaped bench, perhaps one which has no back to rest the hips and spine against, the muscles become fatigued and the children lean over to one side, usually the right. They have to enter the room in file, there is little room between the benches, they are compelled to crowd in sidewise, and girls thereby push the bulk of their garments to one side where it raises the gluteal region as on a cushion, while the other side is not supported. The result is lateral deviation of the spine. Then they may rest one arm on the desk with the back twisted laterally, while the other arm is lower, and this, again, leads to misshape. There are other causes of muscular mal-development. In rachitis it is not the bones alone that are affected ; there is also insufficient development of the muscles. The dorsal muscles are weak, and scoliosis will follow. The ribs and vertebrae are frequently the seat of rachitic softening. Very often it is the lumbar vertebrae that give way in such children, because of the very consider- able weight put upon them. Both the vertebrae and the muscles failing to keep the spine erect, we have scoliosis. This case is a pretty marked one, the primary and principal deviation of the vertebral column being to the right in the dorsal region, while there is a compensatory curve to the left in both the cervical and lumbar regions. Usually the curve is to the right, and if not marked there is no or very little compensatory curve to the left in other regions. How can we tell that this is a case of rachitical de- formity ? Look at the baby, first at its square, bulging head, then at the groove about the lower part of the chest, which is the result of softening of the ribs, against which the diaphragm and respiratory muscles are pulling harder than they can withstand. As long as the ribs are normally hard they can not be influenced by the atmospheric pressure, but when softened this pressure and the action of the diaphragm cause a sinking and a groove, such as you see here. This will remain even after the disappearance of the bone-softening mostly for life. As a further proof of rickets, we have here the pigeon-breast. The normal chest is elliptic, while this one is triangular, the cartilages of the ribs being pushed 36 JACOB I: Clinical Lectures on Pediatrics. forward by atmospheric pressure on the side of the chest, and afterwards hardened and solidified in that position. The rachitical deformity produces effects upon the in- ternal organs. It compresses the heart and lungs, and presses the liver downward. Owing to compression of the lung the patient in later life is apt to suffer from dyspnoea even though there be no acute trouble. The spleen and liver being pressed downward encroach upon the other abdominal and the pelvic organs. In such a compressed state, one could not expect the internal organs to per- form their functions properly; the lungs do not get enough air ; the heart's action is interfered with directly and by want of pulmonary function ; the abdominal organs being cramped and displaced, digestion is often interfered with ; the urinary secretion does not go on normally. Is it, then, any wonder that hunchbacks fre- quently have a bad temper, are peevish and morose ? I mention that to call your attention to the direct depend- ence of our temper, our character upon anatomical dis- orders. In cases of this kind interference with the func- tion of the viscera may be sufficient to account for the peculiar mental and emotional state of the individual. Twenty years ago we had here in this country very few cases of this kind ; ten years ago they began to be more common, and now, I am sorry to say, they are not at all infrequent. Rachitis was a very rare disease in its worst forms thirty years ago in America. The reason why it is so common now is easily found ; it depends upon over- population, bad air indwellings, insufficient and improper food and so on. Wherever there is a large influx of poor people there is rachitis, there is scrofula, and kindred dis- eases. We have not seen the end of it here yet. Pott's Disease.—This little girl, about nine years of age, has a swelling in the upper and inner aspect of the thigh. You notice discoloration over the swelling, en- larged blood vessels, bluish tint. What can it be ? It might be a large hernia, an inflammatory swelling, an ab- scess, enlarged glands, and so on. Hernia is excluded at once because of the situation of the tumor. The dilatation of the veins is due to some impediment of the circulation. I cannot say that there is fluctuation, but I get a feeling of semi-fluctuation indicating a good deal of fluid beneath, as if there might be a cyst or abscess deeply situated! The thickness of the tissues lying over the fluid prevents fluctuation from becoming more distinct. JACOBI: Clinical Lectures on Pediatrics. 37 If there be pus, as we think there is, it might arise from that neighborhood, or have travelled from a distance. There is no local trauma to account for it, and the glands are not affected. It would be possible, had the child been lying long in bed, with the leg raised, for the con- tents of an abscess above the knee to have travelled to this part of the thigh, but there is no history pointing in that direction. It is more than likely the pus has come from above. That does not mean from the abdominal walls, for these seem normal enough ; it means rather from within the pelvis. An abscess inside the pelvis may reach the thigh anteriorly or posteriorly. In children we find abscesses mostly along the psoas or iliac muscles as a result of inflammation of the vertebral column (spondy- litis.) The abscess starts as a rule in the centre of the vertebra and gradually breaks through. When it reaches the surface it affects the intra-vertebral cartilage, and may cause breaking down of most of the tissues near by, and may also result in change of shape of the spinal col- umn. The pus increasing, makes its way to a distance, usually along the fascia until it reaches the pelvis. It may travel along the psoas and iliac muscles and finally reach the femur. Now and then the abscess will break through the pelvis posteriorly. Or it may follow down the muscles of the back to the deep tissues in the gluteal region. Sometimes after reaching the thigh, it travels down to the knee. This baby has been complaining of her back twelve months. When playing with other children she gets tired and sits down. She walks stiffly. One test of vertebral trouble is the patient's ability to stoop and take this penny from the floor. When she holds the vertebral column stiffly, bends the knee and thigh, and reaches down with the arm close to the side to pick up the ob- ject, and perhaps in rising puts one hand on the knee, or moves along until she can raise herself by a chair, you may pretty safely diagnosticate spondylitis. Spinal dis- ease may exist when it is yet difficult to find any deform- ity or swelling. While there is scarcely any apparent deformity in the case we find, when the child is turned upon the face, that pressure over the spinal column causes pain in one spot in the lumbar region. Probably at this locality the abscess had.formed in the vertebra, broke in- teriorly and thus found its way along the fascia, psoas and iliac muscles and made its appearance on the thigh. 38 JACOBI: Clinical Lectures on Pediatrics. One reason why the girl's condition is now so bad is the fact that the mother had not sense enough to know that she was sick, and even at this moment she tells me that she does not think the child has much the matter with it. When the patient is placed on the back she dislikes to extend the affected limb, but keeps it slightly flexed, probably because there is a certain amount of inflamma- tion of the psoas muscle. When the limb is forcibly straightened it causes the whole pelvis to rise. There probably was more pain over the iliac region anteriorly at one time, but the pus having escaped below the pain has now largely disappeared. The first requisite for her recovery is absolute rest. She must remain in bed. It is a question whether that abscess should be opened very soon. A number of years ago every surgeon would have told you to wait, not to open it, for it was known that most cases turned out badly after the abscess had been drained, but with the facility which we now have of keeping the parts perfectly clean the results are much better than they used to be, and if this baby were in a hospital, under good super- vision, I would not object to opening the abscess at once; I would keep it drained and wash it once a day, or every other day, and it is likely the result would be a very fair one if the bone would heal. I say if it would, and there is the main difficulty. We must, if we can, attend to the original cause of the abscess and the general condition of the child. Most cases are of tubercular nature, but it may have resulted from trauma, from a fall, for instance. If the cause be tubercular, the disease may remain local in some form for years and then perhaps become general. We are told that this child's father died of tuberculosis and a younger child in the family died of marasmus, which probably meant tuberculosis of the mesenteric glands. It is very likely, therefore, that we need not look to trauma in this case, but rather to tuberculosis of the bone. What can be done for that ? Probably but little, for we can hardly cut down to the vertebra and remove it as we might do if the disease were situated in some other bone. As to the tuberculosis, I have felt encouraged to continue these twenty-five or thirty years the use of arse- nic, and in addition to this I would give the baby guaiacol, in the beginning only one drop four times a day in sweet- ened water or in milk; it is better that creasote, for the JACOBI: Clinical Lectures on Pediatrics. beneficial effect of the latter depend upon the amount of. guaiacol it contains, about fifty or sixty per cent. I have been better satisfied with my results since I used guaiacol in addition to arsenic. Besides in protracted bone dis- eases, both in tubercular and non-tubercular, the tissue- building property of phosphorus comes in very beneficially. One-hundreth of a grain of phosphorus may be given three or four times a day, that means one drop of the oleum phosphoratum of the Pharmacopoeia, or from 10 to 30 minims of the elixir of phosphorus of the National Formulary. It was only a few years ago that Lannelongue recom- mended the treatment of local tuberculosis by the injec- tion of a ten per cent, solution of zinc chloride in the sur- rounding ligaments and soft structures. He claimed a cure as a result in every instance, as positively as usual in the enthusiastic introduction of a new mode of treat- ment. A local irritation would be set up with produc- tion of so much new connective tissue that the bacteria of tuberculosis would be annihilated or rendered innocu- ous. I speak of this treatment and the wonderful re- sults claimed for it because Lannelongue's name has been before the profession at least thirty years. He is well known as a surgeon, and you know we are inclined to believe whatever we are told, as we expect others to be- lieve what we have to tell. However, I saw a number of Lannelongue's cases and can say that quite some of them were not very well, in fact they were far from being so. Another local treatment, however, I will eulogize, and I think with reason, that is, injection of iodoform in oil and ether, or in oil only, into the tubercular cavity, either in the abscess cavity alone or in the bone containing cavities. Absolutely trustworthy observers speak well of it. If this abscess in the vertebra were within reach I would be very much in favor of injecting it with that agent. But again, in order to afford the slightest chances for any therapeutical success the patient ought to be in a hospital. Adenitis.—This little boy has some enlargements under the jaw. One of them is intimately connected with the periosteum. Which is it ? One of you replies the tumor on the left side; another one, the tumor on the right side. I must have been mistaken myself; it was another case, not this one, in which the growth was closely attached to the periosteum, for here, as all of you may perceive, the bodies are moveable. Moral, do not trust your neighbor- 4° JACOBI: Clinical Lectures on Pediatrics. ino- practitioner. He may be mistaken, or may wish to lead you astray. Besides these larger swellings under the maxilla there are a number of swollen lymph bodies in the neck and also under the arm and elsewhere ; there are also dilated veins just below the clavicle, which means that there is an impediment to the circulation, and that impediment may exist in the vena cava or in the heart. It is probably not in the heart, otherwise there would be obstruction of the circulation manifest else- where; it is more likely in the vena cava or in the sub- clavian. If the swelling were limited to the glands about the neck, we would expect to find some local cause or the history of one, such as inflamed mucous membrane in that neighborhood, stomatitis, catarrh of the mouth ; eczema of the head would cause a swelling of the glands back of the neck. A large majority of the so-called scrofulous glands of the neck are the result of catarrh or other local irritation of the mucous membrane of the mouth or nose, or eczema of the scalp. But here the glands are enlarged at a dis- tance in the axilla and elsewhere, so that we have to look for a general cause. We do not attach so much import- ance to enlargement of glands in the inguinal region for they are often slightly enlarged without special signifi- cance. It is possible that there are enlarged glands in- side the chest which impede the circulation and cause the dilatation of the veins in the clavicular region of the surface. These mediastinal glands may have been af- fected gradually, by the three tiers of lymphatic glands which are located from the jaw to the clavicular region, from above downward. Thus, there are many cases in which the tumefaction of the lymph bodies does not appear to result from any irritation of the neighborhood. Thus, for instance, in leukaemia or leucocythaemia, and also in pseudo-leucocythaemia (Hodgkin's disease.) The next patient, a girl of about eight years, isbrought in with a mechanical apparatus. She looks rather pale. You suggest that she probably has joint disease, and that the condition may be inflammation of the soft tissues or bone—caries, necrosis, ulceration of some kind. Further, that the form of inflammation in the joints of children is apt to be tubercular. What would you look for as further proof that the joint trouble is tubercular ? Yes there might be involvement of the lungs and glands. In most children tuberculosis will first show itself in the J AC OBI: Clinical Lectures on Pediatrics. 41 glands. Here there is a scar under the neck and some remaining enlarged glands. You should also examine those under the arms. Some enlargement of the inguinal glands may exist and be of less significance. The mother says the child limped three months before a brace was put on, and that she used to have fever. Dr. Huber tells us there is some hoarse respiration at the right apex. The patient coughs a good deal, worse at night, so that the mother thinks she may have whooping- cough. I had the boy come to my office where his blood was examined and found to contain the normal number of red blood cells, and nearly the normal number of leu- cocytes. Thus leucocythaemia was ruled out. The boy says he coughs a good deal, but the lungs seem normal. There were no glandular enlargements except about the neck. We have, then, several cases before us of glandular swellings. Are we entitled to use the term gland in this connection ? What is a gland ? We have been told that it is a body which has the physiological function of secreting. Now, a lymph gland, so-called, does not secrete at all. Besides an outer wall, and a good deal of cellular and elastic tissue, it contains lymphoid cells which have great similar- ity to embryonal cells. It also contains lymph ducts which enter and others which leave it, blood vessels that go in and out, and small cavities lined with epithelium. But it secretes nothing. It is only a depot for lymph ducts to deposit their contents in and take them up again to be carried farther. There is no secretion and there- fore it should not be called a gland. Anatomically speaking, the term lymph body would be very much the better one. Now, such a lymph body is in most intimate connection with the ducts and large trunks of the lymphatic system, and finally with the blood circulation. It is, in- deed, in intimate connection with almost every substance. Ducts lead to lymph bodies from every mucous mem- brane, from the skin, and from every other lymph body. I do not know of a more beautiful sight than that of in- jected lymph bodies. They are very numerous and con- stitute an immense net, no matter where one examines— in the skin, in the mucous membrane, even in the young bone. Imagine, then, that there is some irritation going ■on at the surface, say on the skin or the mucous mem- brane. It must result also in irritation of lymph bodies 42 JACOBI: Clinical Lectures 071 Pediatrics. or ducts. If there be within reach a foreign substance they are ever ready to carry it away, whatever may be its nature. Large numbers of them are open, and when there is a poison on the mucous membrane they quickly absorb it. They are open for instance on the upper and under surface of the diaphragm, which best explains, per- haps, the fact that local peritonitis or perihepatitis and pleurisy are frequently found together. A perihepatitis will make a pleurisy, a pleurisy will make a perihepatitis simply because the lymph stomata keep up a constant communication. If the irritation be on the skin, the lymph bodies become likewise irritated, hyperaemic and swollen. Babies and adults who have a catarrh, have the neighboring lymph bodies swollen soon afterward. Cure the nasal catarrh and you cure the hyperaemic and en- larged lymph bodies; or, if there be a diphtheritic de- posit in the naso-pharynx, all the lymph ducts originat- ing there will carry the poison to the lymph bodies to which they belong at the angle of the jaw, and they will swell immensely. Wash and disinfect the diphtheritic surface very thoroughly and the lymph bodies will be found to diminish in size very rapidly. Or, take a case of common eczema of the head of a baby, the lymph bodies of the neck will be swollen the first day or in a few days. Cure the eczema as soon as you can and the lymph bodies will diminish in size and be cured. No iodide of potassium, no massage, no ointment will be of the same service. So elsewhere, suppose, for instance, you have to deal with a common diarrhoea, a common in- testinal catarrh, the lymph bodies of the mesentery will swell and become hyperaemic. When such a baby dies you will find the lymph bodies hyperaemic, the blood vessels engorged. In order to diminish the size of the swollen lymph bodies you have to cure the diarrhoea. There is no such thing as a morbid process running its full course without implicating the neighboring tissues. Whenever you do not cure the diarrhoea, the eczema the nasal catarrh, the lymph bodies remain swollen! In the beginning these bodies are simply hyperaemic, a condition which by itself is not dangerous It may f'TC Tf/ \ndT and 2° awa^ in as short a time After a while, however, when the blood circula- tion has been interfered with for some time, there will be effusion, a proliferation of cells in the connective tissue and when the swelling has lasted three, four or six weeks the gland, if cut through, will be found no longer hyper JACOBI: Clinical Lectures on Pediatrics. 43- aemic, but white, and in a few months there will be induration and thickening. The cellular tissue in the gland becomes hypertrophied, indurated, and in- curable. Imagine, further, that the cellular tissue has not only become changed, but that there is also a real hypertrophy of the lymph body; that the lymphoid cells have accumulated, forming a large mass, with the con- stituent parts crowding upon one another until granular degeneration takes place in the centre and finally sup- puration. This breaking down into pus may remain central for some time, gradually it extends, the frail wall may become perforated, the surrounding tissue become involved, constituting peri-adenitis and going frequently on to the formation of a very large abscess. When the external skin participates in the process you have that peculiar large, soft red or purple swelling which after awhile will either rupture spontaneously or, which is bet- ter, fall under some surgeon's knife. When you incise such a peri-adenitis, or large abscess which came origin- ally from a small source, you let out a good deal of pus, but you do not let out all and the abscess does not heal, for the lymphoid cells and tissues which participate in the process but have not softened are still there. They are not discharged when you make the incision. Such cases may go on a month, a year or ten years before the annoying mass is thrown out. Or you will have to go in and scrape it out, burn it out, or remove it with a knife— all of which might have been avoided had a simple nasal catarrh, eczema of the head, or diphtheria been treated correctly. In a number of cases this simple process of glandular swelling and suppuration gives rise to important compli- cations. The most serious one is invasion by tubercle bacilli. The bacilli entering one gland may pass on until they reach the lungs or invade the bones. In a number of cases tuberculosis is first visible in the glands, but in a number, particularly in children, it is first mani- fest in the bones. We must not identify the bones of a child with those of an adult. In children the bones are not at first a uniformly solid body. Long bones consist first of three parts—the diaphysis, the epiphysis, and the cartilaginous layer from which the growth takes place. Such bones are very succulent, and it is in the epiphysis and under the cartilage covering the epiphysis that tuber- culosis is frequently seen, particularly in the bones which remain soft a long time. Thus it is that we frequently t JACOBI: Clinical Lectures on Pediatrics. see tubercular ostitis at the knee, at the hip, sometimes in the long bones of the fingers, etc. Those peculiar swellings that we see now and then constituting round or spheroidal bodies on the phalanges, the so-called spina ventosa, are ostitis, mostly of tubercular nature. In such cases the tuberculosis frequently remains in the bones a long time, and then may either heal up or become general. I return to the lymph bodies. We only have to remem- ber how numerous are the lymph bodies in order to judge how dangerous they can be. In the neck we have the jugular trunk, and nearby the subclavian and the broncho- mediastinal trunks. To them belong a large number of bodies and plexuses. The trunks finally take up all the lymph from the lymph bodies and empty it into the blood circulation. Irritation may at first affect but a single body, but from here it may extend gradually to others until about all in the body are involved. We often find, when there is a swollen gland in the neck, that a few weeks or a month afterward those lower down are involved, including the subclavian and perhaps the mediastinal. The latter are found enlarged, particularly in babies who are affected with rachitis at an early period. Sometimes the mediastinum is so far filled with enlarged so-called bronchial " glands " that you can detect their presence by percussion, some- times on the left side anteriorly, but mostly posteriorly be- tween the scapulae about the hilus of the two lungs. When they are small they have little influence except that they cause secondary bronchitis. Babies of four, five, or eight months who have a catarrh all the time, generally have such enlarged glands. They may be numerous enough to give you the impression of a large tumor, and may com- press the large bronchi and cause bronchial respiration without there being any disease of the lung or pleura. In some cases they even so far compress the large bronchi as to give rise to symptoms of suffocation. In a number of conditions the lymph bodies swell from some general rather than from a local cause. That is seen in scarlet fever and typhoid fever; in leprosy, sy- Pu IM ^ocythaemia. The latter is a condition in which the blood is so changed that, instead of having one leucocyte to three hundred or three hundred and fifty red blood cells, there are twenty, or one hundred and sometimes even one hundred and fifty leucocytes That life can continue with one leucocyte to two red blood cells is out of the question. The seat of this disease may be JACOBI: Clinical Lectures on Pediatrics. 45 three-fold. It may first appear in the lymph bodies them- selves, or show itself mostly in the liver, or spleen, or in the bones. Leucocythaemia in the bones is most decep- tive and treacherous. Very frequently it cannot be diag- nosed unless the blood be examined. When the liver, spleen, or lymph bodies are enlarged you can atleastsus- pect the disease, and of course you will in that case be in- duced to examine the blood. Leucocythaemia is mostly found in the adult, but I have seen at least ten, probably more cases in children under three or four years. I also remember a case in a baby of seven months and, through the kindness of a colleague, one that terminated fatally at four weeks. It is very apt to run a fatal course in a few months in children, while in adults it may last years. I have seen a boy with it who had an immense spleen and ascites and lived seven or eight months, which was a long time for a child. There are some cases, usually originat- ing in the bones, in which it ends fatally in a few days. I believe the whole number of recorded cases of leukaemia in children is about twenty-two, and in a few of these the patients died within eleven days, and in one in four days. Such cases show not only rapid increase of leucocytes compared with the red blood cells, but also symptoms of sepsis and acute purpura. There are haemorrhages of dif- ferent kinds, haemorrhage from the nose, from the con- junctiva, into the brain, from the mucous membrane of the intestinal tract, and so on. In this boy I did not find any such difficulty at all; the blood was normal. There were no misshapen blood cells. In what has been called pernicious anaemia, where there is no disproportion between the leucocytes and red blood cells, there is a peculiar change in the red cells so that, instead of being spherical, they become irregular in shape, some very small, some angular. 1 did not find that, and consequently could exclude pernicious anaemia. There are other diseases in which the lymph bodies will swell pseudo-leukaemia, Hodgkin's disease,in that state in which, without originally a change in the condition of the blood, the lymph bodies of the whole body or the larger part of it slowly increase in size. There is no fever, no general irritation connected with it. I have lately seen a young lady about two weeks before her death, in whom the lymph bodies of the neck were so swollen that she was absolutely unrecognizable. The face was pale and formed a huge uniform mass,so great was the enlargement of the lymph bodies, the face was embedded in a mass of 46 JACOBI: Clinical Lectures on Pediatrics. them. The arms were raised, the lymph bodies in the axilla being swollen to such a degree that it was impos- sible for her to get her elbows near the trunk. The in- guinal region was also padded with larged masses. There she was, propped up, and had been a number of months, waiting patiently until her last hour should come. For- tunately it has come since. When I saw her there was very little change in the blood, there was nothing to be found except the enormously swollen lymph bodies. There is another cause for swelling of the lmyph bodies. We have already spoken of syphilis. Compared with some others, that is a very favorable cause, for we have remedies against it. Pseudo-plasms are the other cause to which I refer. Among children we most fre- quently find sarcoma and adenoma, or adeno-sarcoma. An adenoma means a large swelling in which the lymph bodies are much increased in size and contain a large number of round cells such as are seen in sarcoma. In sarcoma there is either a swelling which consists of round cells exclusively, small round cells mixed with spindle-shaped cells, or spindle-shaped cells lined with a large amount of connective tissue, or all three, round and spindle-shaped cells and connective tissue- stroma, increased. These are frequent, and are access- ible to some treatment. The best treatment for a single sarcoma is the knife. That is, extirpate it and have done with it. But that is seldom possible; there generally are a number. On making an incision into the neck for the removal of perhaps four sarcomatous tumors which could be recognized, you will find still others below, and have to stop finally because the blood vessels will not permit of going further down. Next to the knife in treatment comes arsenic Arsenic will certainly reduce sarcomata a great deal, and some- times will cure the case. In a number of cases, however, after quiescence or,apparent absence a number of months or years, the sarcoma would reappear and run a fatal course. This boy has taken arsenic about six weeks and is evidently better than he was; I am positive the lymph bodies are only about half the size they were some time ago. It will be continued. Fowler's solution has been given, two drops at first, now three drops three times a day, largely diluted, after meals. It is wonderful some- times to what extent arsenic can be increased I should not wonder if in time the boy can take four, five or even ten drops three times a day. The dose should be carried JACOB I: Clinical Lectures on Pediatrics. 47 up, if the effect is not obtained before, even to the pro- duction of intestinal symptoms, as diarrhoea or vomiting, or the production of erythema, or dropsical symptoms. Always remember the remedy must be given after meals and largely diluted. CLINICAL LECTURES ON PEDIATRICS. (Session of 1892-93.) BY A. JACOBI, M.D., Professor of Diseases of Children, College of Physicians and Surgeons, New York. Delivered November 9, 1892. {Stenographic Report.) Diphtheria, Rachitis, Congenital Syphilis. Diphtheria.—The following history has been obtained in this case. The girl is seven years old. Six days ago she complained of pain in the throat. This morning she cannot speak on account of hoarseness. The temperature is 1030 in the rectum. On looking at the throat one sees some patches, and the enlarged tonsils. The glands under jaw are also swollen. The child was here before and the mother was told not to bring her again because of the danger to other pa- tients. Still, here she is again. You will remember what I said at a previous clinic, that dispensaries are expected to do a good deal of good, that is what they do, but they also do much harm. Doubtless hundreds go there to be infected with contagious disease from those that ought not to go to a clinic at all, but should be isolated. For the purpose of diagnosis your attention is called to the following points: The patient has a temperature of 103° F. On both tonsils there are a number of isolated, grayish spots. The tonsils and the general mucous membrane are not unusually red at all. Earlier, how- ever, there has been redness, but it has disappeared, which shows that the local irritation is much improved. Not every membranous deposit is associated with an exces- sive hyperaemia. On the contrary, not infrequently do we see a whitish membrane without much hyperaemia. Some- times such spots appear upon a mucous membrane which seems to be intact. Yet remember that a mucous mem- brane which becomes diphtheritic cannot, with one ex- ception, be intact; there must first have been an abrasion, although it may have been a very small one. That is why 50 JACOBI: Clinical Lectures on Pediatrics. I warn you against using swabs, against cauterizing, and so on in any form of diphtheria, for unless you touch the exact spot and only the exact spot of the false membrane, you will destroy epithelium, and then, a new diphtheritic invasion or dissemination will take place. The one excep- tion alluded to is the tonsil, where Stoehr demonstrated minute interstices between the superficial epithelia; into these interstices diphtheria may find its way and involve the system without there being a sore or break of the sur- face in the ordinary sense of the word. But as a rule it gets a hold only where there is a superficial lesion. A surface which is very hyperaemic may be attacked by diphtheria afterward, but it is not always so; hyperaemia by no means always precedes diphtheria. A very high degree of pharyngitis may run its course, and even lead to suppuration without being attended by diphtheria. As a rule diphtheria and suppuration do not go together. The cases in which diphtheria is complicated with abscess are very rare indeed. When abscess does occur it is usu- ally situated in the deeper tissues, say at the side of or be- low the tonsil which then is raised, and the seat of a good deal of pain and accompanied by fever. While you may not see such a case in the course of a year's active prac- tice, yet it is necessary to know that it may occur. In this girl's case there is one peculiar symptom; she is absolutely hoarse. Hoarseness implies an abnormal con- dition of the vocal cords. Is there a membrane in the larynx, or is there simply a catarrh? For a catarrh will give rise to the same hoarseness as a membrane. A great many of us when we have a laryngeal catarrh cannot make ourselves heard. This girl cannot; she speaks in a whisper. This condition has existed only since this morn- ing. Observe the chest. Is the respiratory movement such as to indicate dyspnoea and laryngeal obstruction? No. The movements of the chest are fairly normal. It would seem, then, that there is no considerable obstruc- tion in the larynx; that the simple hyperaemia which had previously existed above has descended into the larynx and caused aphonia. If there were a dense membranous deposit in the larynx, difficulty would be experienced in getting sufficient air into the lungs and the respiratory muscular action would be increased to force the air through the narrowed glottis. There is, in such cases, violent action of the diaphragm and the other respiratory muscles, the movements are especially noticeable above and below the clavicle; here in genuine croup there is a J AC OBi: Clinical Lectures on Pediatrics. 51 considerable amount of retraction, the breathing becomes labored, and the exertion to fill the lung becomes very great. The inspiration is drawn and protracted, besides being noisy. You can hear such a child's breathing and can see changes in the external aspect of the chest above and below very distinctly at a distance. Nothing of this diagnostic sign is visible in this case. The change in the vocal cords cannot, therefore, be considerable, although there must be some change to account for the hoarseness. There may be, however, a thin film of membrane, and I should decidedly be of this opinion if there had not previously been a hyperaemia above and fever. Some years ago, before diphtheria had become so constant and extensive in the city, isolated croup of the larynx was more common, the deposit on the vocal cord with the signs I have just described, being the only diagnostic symptom. Such cases were attended by no fever because there are very few lymphatics on the vocal cord to absorb the virus. It was, and often is now, a lo- cal disease only,and destroyed life simply by strangulation. Thus as long as you have to deal with a larynx which is filled with pseudo-membrane, with no diphtheria of the nose, naso-pharynx or pharynx or other complication, the disease proceeds without fever. But when you meet with a case of obstruction of the larynx with fever and nothing else, it is an inflammatory trouble, maybe a sim- ple catarrh. Such are the cases of supposed croup to v which you may be called in the night and before you get to the house the attack of hoarseness and croupous dysp- noea is gone. They are accompanied by fever. If there be no fever they are dangerous, because probably pseudo- membranous and not simply catarrhal. When I made this distinction many years ago I was laughed down, but now I have the satisfaction of knowing that it is taught in many text-books. Once more: long drawn, slow in- spiration, and absence of fever mean in most cases pseudo-membrane; increased number of respirations and increased temperature mean inflammatory disease of the respiratory organs which it is true, may be complicated with pseudo-membrane. As to the nature of the case before us, I think we would be derelict in our duty if we did not treat it as one of diphtheritic laryngitis. There has been diphtheria of the pharynx, and the probability is that the trouble with the vocal cord is diphtheritic and if let alone it may form a massive membrane which will lead to strangulation and JACOBI: Clinical Lectures on Pediatrics. necessitate either tracheotomy or intubation. Since 1880 xvhen I began to give mercury in so-called membra- nous croup I had the satisfaction of seeing many cases get well which formerly would die whether with or with- out tracheotomy. Since the introduction of intubation I have also observed that cases with this operation do much better if mercury be administered before and afterward. The preparation which I have always used is the bichlor- ide. A child of this age ought to take about one-fiftieth of a grain every half hour for the first day, and every hour the next day. Some of it is always lost, so that if you prescribe one-fiftieth of a grain every half hour the child will probably get about two-thirds of a grain in the twenty-four hours. The younger the child the more it can take proportionately, so that if it be half a year old it may take about one sixtieth of a grain every hour with- ou being troubled by mouth or intestinal symptoms. Perhaps in one of thirty cases there will be a little vomit- ing or diarrhoea. When that takes place a few drops of tinct. opii camphorata will correct it. Be sure, however that the mercury is given sufficiently diluted, say one, part to eight or ten thousand, or even more, of water. The one-fiftieth of a grain in a tablespoonful of water would be about right, making a dilution of about one to twelve thousand. Babies that have no teeth will show less mercurial influence when so treated than older chil- dren, but these too, are perfectly safe. It takes children longer than adults to get under the full influence of mer-, cury as far as over-dosing is concerned. The child should be kept in a room of even tempera- ture, above rather than below 700 F; say 720. Water should boil on the stove all the time. It would also be well to pour some crude oil of turpentine into the water, using, say, a tablespoonful every hour, thus filling the room with the vapor of turpentine and water. We have just learned something more about the sur- roundings of the case. The mother of the patient was confined only a few days ago, and therefore is liable in the small rooms they occupy to get diphtheria and die. Then there is the newly born baby with the stump of the cord which can very readily become infected by the diph- theritic poison. Yet the woman who has brought the child here refuses to have it sent to the hospital If we were a civilized people the child would be taken away from the woman whether she wished it or not, and be sent to the hospital where there would be a chance to Jacobi: Clinical Lectures on Pediatrics. 53 save it by performing intubation or tracheotomy should it become strangulated, and where it could not infect the puerperal mother and newly born baby, or the whole neighborhood. But what can we do under the circum- stances? Absolutely nothing. We can simply wait for the time when in a hundred years or more we will be more civilized and can protect ignorant people against themselves. Rachitis.—Our next patient is a little girl with rachitis. We have already seen some cases of this disease, and I will try to avoid repetition, yet when cases come that are very instructive I would like to present them. What I said of curvature of the long bones is particularly well illustrated in the bones of the leg here. The epiphyses , are very large and the softening also involves the diaph- yses. There is curvature of the tibia both forward and outwards. Babies who contract rachitis in their second year, while trying to stand and walk on their softened bones will have not only lateral but also anterior cur- vature, as this one has. We notice in this patient a peculiar flabbiness of the muscles, especially of those of the abdomen. The belly is big, owing not so much to the size of the internal vis- cera as to the gaseous distention. In some cases, how- ever, the spleen and liver are enlarged. The spleen may be found a little below the border of the ribs while the liver, which is always large in babies,may reach down to near the navel. That is due less to hypertrophy of the organ than to contraction of the chest, for the chest in rachitis is not elliptical as in the normal state, but triangular and compressed. The enlargement of the belly in children is, therefore, due to several causes: 1. The viscera may be a little hypertrophied; 2. They are dislodged downward; 3. Distention by gas. The gaseous distention is greater than usual for two reasons, namely, that the abdominal walls are flabby and do not exert the normal compression upon the intestine, and also because usually the muscular layers of the bowels themselves are feeble, flabby and do not cause expulsion of the gas. Nor does absorption of gas take place readily. Constipation may be an early symptom of rachitis, being due to inactivity of the mus- cular layers of the bowels; indeed in many cases it is the first symptom of rachitis. Congenital Syphilis.—The history of the little baby now presented to you reads as follows: The mother has been married a little more than three years, and has been pregnant three times. The first pregnancy terminated from 54 JACOBI: Clinical Lectures on Pediatrics an unknown cause at the eighth month. The child ac- cording to the physician's statement, was somewhat of a yellowish or of copper color. The second child is twenty months old; this is the third one, now five months old. Not having milk herself the mother put it on the bottle. At first she gave it condensed milk, diluted so that a bot- tle of water contained one teaspoonful of the milk. Of that the baby received not more than six teaspoonfuls in the twenty-four hours. A diarrhoea developed which con- tinued a number of weeks. At the age of two months the diet was changed ; it was put on sterilized milk, one part milk to three of water. Now it occasionally gets a little oatmeal. Thus you see the baby has had a hard time. A hard time for different reasons. First, a child was previously born at the eighth month ; it showed some suspicious eruptions, and if the history were fully known it probably would have given evidence of syphilitic taint. Rachitis being a disease of general ill-nutrition rather than of the osseous system alone, it is not infrequently the result of hereditary syphilis. Indeed there are some who insist that every case of rachitis is of syphilitic origin. But our time being limited, I can only say to-day that the assertion that every case of rachitis is of syphilitic origin is a gross exaggeration. This baby at first received a teaspoonful of condensed milk a day, and afterwards sterilized milk. The first was improper and insufficient; the second was insufficient. To feed a baby on cow's milk mixed with water exclus- ively is certainly erroneous, not being based on physio- logical facts, and sterilized cow's milk is always cow's milk; it is not more. No matter how carefully you steri- lize cow's milk, it is never woman's milk, and is never, in that shape, a thing which the baby will bear as well' as mother's milk. This baby has been illy nourished; it has a quadrangular chest instead of an elliptical one. The cartilages of the ribs are very prominent simply because the sides of the rachitical ribs are flattened by the at- mospheric pressure during the process of respiration The result of the lateral compression is that the anterior ends are pushed forward. This is one of the signs of rachitis Then the tibiae are beginning to curve considerably more than normal. I have already reminded you of the fact that a part of the curvature of the long bones is the re- sult of the baby's position in the uterus. But the bend is too great here to be accounted for in that way alto gether. Then there is swelling of the epiphyses N CLINICAL LECTURES ON PEDIATRICS. (Session of 1892-93.) BY A. JACOBI, M.D., Professor of Diseases of Children, College of Physicians and Si-.rgeons, New York. Delivered November id, 1892. (Stenographic Report.) Epispadia and Exstrophy of the Bladder. Pneumonia. Constipation. Epispadias and Extrophy of the Bladder—At the close of the Clinic otlast week some of you saw a boy of about eleven years who had hypospadias and complained con- siderably of pain while urinating, and it took him a long time to empty his bladder. Besides that case we had seen one in a baby, the glans being large and the penis bent upon itself, the spongy substance poorly developed, so that had an erection taken place the organ would surely have been turned down. As the baby was very young, we decided to wait a time before proposing an operation. To-day we have another baby with an arrest of develop- ment different from that seen in the former cases. I alluded to the fact that in fcetal life many organs of the human body are formed in grooves or open channels, which gradually become closed. I alluded to the fact that hernia of the brain, and hypospadias, spina bifida, umbilical hernia begin in such a way. The same thing is true of exstrophy of the bladder. The bladder is formed at a very early time, beginning to assume shape about the fourth week of uterine gestation. Until that time it is a part of what is called the cloaca, a large cavity into which the lower part of the intestines also terminate. Later a wall is thrown out, separating the rectum and bladder. The abdominal cavity and the bladder being originally an open groove, closure may be delayed or may not take place at all. Now and then closure so far takes place that only a small opening remains, extending through the abdominal walls into the bladder, through 6 JACOBI: Clinical Lectures on Pediatrics. which you may be able to introduce a pencil or your finger. Unfortunately the cases in which no closure over the bladder takes place at all are more frequent. In this event there is no anterior wall of the bladder; only the posterior wall is present and protrudes, being uncovered by the abdominal walls, so that the surface looks raw and hyperaemic. What you see here is simply the mucous membrane of the posterior wall of the bladder, the sur- rounding skin showing gradual transition into the texture of the mucous membrane. The upper part of the mucous surface is seen always to be dry, while the lower part is moist. That is the condition observable in this case. Looking more closely we observe two little spots from which urine squirts forth from time to time; the stream is not constant, but interrupted. That fact is best seen in the normal bladder with the cystoscope. When looking through that instrument there are periods when nothing special is seen, but every ten, fifteen, or twenty seconds an undulating movement will be noticeable in the liquid contained in the bladder caused by urine coming down from the ureters. Besides bladder exstrophy, there is in this case a condi- tion of epispadias. The penis has not closed on top. In very bad cases the symphysis pubis does not close, and in a few instances the bones have shown an arrest of de- velopment. The mother has applied a hard compress where the urine escapes, such as is used for hernia. Certainly it did not keep the urine in. and I cannot imagine the indication for such an instrument. It has been attempted to con- struct a box to apply over the abdomen, which was to take the place of the bladder and from which the urine could be allowed to escape from time to time. But only an adult could wear it with any degree of success. The only thing which can be done for this child is an opera- tion. Operations have proven successful a number of times. In such cases there was a good deal of tissue to draw upon the edges were freshened and sewed together. Now and then ,t was necessary even to separate th? pubic bones in order to get enough tissue to draw from, just as sometimes in doing a hare-lip operation it is necessary ?o waT ButVo ^ ?°m ?e b°neS and draW them re- ward. But no operations have been undertaken so far as LZhLtt:1? ^ I™ *— °ld- Meanwhile th^ motner nas to get alone the best ra-n t^ : to keen thp «£« f i. • n' it: ls necessary to keep the skin from becoming irritated by the urine, JACOBI: Clinical Lectures on Pediatrics. 57 and that can be done by applying vaseline alone or with bismuth. The scrotum is normal in this case, and the testicles have descended at the proper time. The bones are well developed. The case is interesting enough, especially when con- sidered in connection with the one of hypospadias which some of you saw last week. That boy, aged about eleven years, complained as an adult will who has stricture of the urethra. That is, he had slow urination accompanied by pain, and for that reason had retained his urine a num- ber of times for quite a while. You know what a stric- ture in the adult will lead to by interfering with the free flow of the urine: the urine being retained in the bladder longer than it should becomes alkaline, irritates the mucous surface, produces a subacute and afterward a chronic cystitis, there may be ulceration, and inflammation may extend up the ureters to the kidneys and produce pyelitis. All that might happen to this boy should he go without treatment. His hypospadias terminates about the fossa navicularis, where there is only a very small open- ing, and the doctor who saw him said he was able to in- troduce a probe into the anterior part of the urethra, but that it would not go beyond. I found the same difficulty. He was kept under observation until he would stay no longer; he wanted to go home. During his stay 1 had opportunity to learn that it was impossible by ordinary means to pass a probe but a very short distance into the urethra. The opening was very small and a probe could be introduced about two-thirds of an inch, but there it would stop. Then it was attempted to introduce a probe while the boy was urinating, and that succeeded. It was one of the cases in which the usual development of the urethra was not completed in fcetal life. Normally, the urethra is formed from outward in, and from inward out, so that the two parts join behind the glans penis, simi- larly to what occurs in the rectum, where the lumen of the intestine is formed by the two separate parts of the intes- tine joining each other. The outer part of the urethra failed to join evenly with the inner part. They overlapped, forming a pocket into which the probe would enter and stop, until finally its introduction was effected while the urine was passing outward, opening up the continuous channel and closing the pocket. In that case the best treatment would probably be to dilate gradually and per- sistently. 58 JACOBI: Clinical Lectures on Pediatrics. Pneumonia.—This colored baby., two years old, was taken sick last Sunday, three days ago. It was noticed that it could not sleep at night, that it was thirsty, had poor appetite, was feverish, had a cough, and yesterday vomi- ted once. It has lost strength. The temperature in the rectum was ioi° F. The rectum is the only reliable place to take the temperature of a baby, and it is the quickest. An average thermometer will take the tem- perature in the rectum in a minute and a half, whereas if placed in the axilla it requires five minutes, and then the result is very uncertain. The child being restless the air gets to the thermometer; the surface, too, is perspiring more in one case than in another and lowers the temper- ature. The mother can be instructed to take the temper- ature by the rectum, and the result will be just as reli- able as if obtained by yourself. There being fever and cough, you would suspect an acute or subacute inflammatory disease of a respiratory organ. Cough maybe produced in the pharynx by reflex action, but it generally originates in the larynx or upper or lower part of the bronchial tubes. When inflamma- tory disease develops in the respiratory organs, particu- larly in the lungs, the result must be immediately a change in the respiration. The respirations are less deep and therefore they must be more frequent in order to give a sufficient amount of air. When the temperature rises there is also an increase in the number of respirations and heart-beats. There is a certain normal relation be- tween the heart-beats and respirations. In the child the normal relation between the two is about ten respirations to thirty-seven or thirty-eight heart-beats. When there is a variation of this proportion there must be some reason for it. In disease of the brain the heart-beats are often reduced in frequency, while in inflammatory disease of the respiratory organs the number of respirations is in- creased. For instance, if the pulse in a baby were found 120 the normal respiration would be a little more than 30, perhaps 32 or 33. If then there be fever and a pulse of 150 it should correspond to 40 respirations, but if the actual number of respirations be 50 or 60 you'may infer that there is some inflammatory disease in the thoracic cavity. In a large number of cases, therefore you can make the diagnosis of an intense bronchitis of a broncho-pneumonia or a genuine croupous pneumonia simply from disturbance of the normal proportion between the respiration and heat-beats. This baby, for instance JACOBI: Clinical Lectures on Pediatrics. has 60 respirations a minute, and in order to maintain the normal proportion there should be about 225 heart- beats in the same period. Instead of that the number is only 150 or 160, or 10 respirations to 25 heart-beats, in- stead of 37. That points to inflammation of the respira- tory organs. On examining the chest we find dulness on the leftside behind, and bronchi very perceptible near the chest wall, pointing to pneumonia. What kind of pneumonia? If there were genuine croupous pneumonia there should be by this time not only moderate dulness but decided flatness. Further, instead of coarse respiration and a few rales, there should be by this time bronchial respiration, for there would probably be a good deal of induration throughout the whole pulmonary tissue. The air would go in and out of the tubes but would not pass into the air cells, and you would hear it as you do in the trachea. That is what is called bronchial or tubular respiration. If the baby cried you would hear the voice just under your ear, producing what is called bronchophony. That is not present here except to a slight degree. A broncho- pneumonia or lobular pneumonia, the result of the exten- sion of a bronchial catarrh, is usually bilateral; it is seldom limited to one side only. In most cases it begins beneath the scapula and is found on both sides. We shall have to consider the subject of pneumonia more fully at a future time. To-day we can speak further only of treat- ment. When you treat a case do not treat the name of the disease but rather the patient. I have seen many cases treated according to the book very beautifully indeed and everything went quite well according to the notion of the doctor, until all at once the patient was dead. Why was it so ? Simply because so many of us are more likely to treat the disease by name than to treat the patient. We have to deal with a single child, man or woman, and we must study that person. According to whether we have to treat a pneumonia in a child which previously was healthy or sick, robust or delicate, will the prognosis differ, and the treatment must be different. Many a case of pneumonia will run its full course without any medicinal treatment, while many a case requires very active treat- ment from the very beginning. That is especially so in regard to local and general stimulants. It has become the fashion to begin the treatment not only of infectious diseases, but also of common inflammatory diseases, with 6o JACOBI: Clinical Lectures on Pediatrics. very strong stimulants, particularly alcohol Nothing is mo7e-I will put it mildly-erroneous. While a number of cases which do not survive the second or third day mieht be saved with active stimulating treatment, others are worse off when alcohol is given them than they were before Therefore every case should be studied. This child is emaciated and not capable of withstanding a siege which an ordinary child could do. Therefore it requires good nutrition and some stimulation at once. Whether alcohol should be given is another question. Babies do not stand alcohol very well unless in infectious diseases. Considering the facility with which they de- velop hyperaemic conditions of the brain, it is better to abstain from alcohol as long as may be. It would prob- ably be better to give a patient of this kind benzoic acid, or camphor, or ammonia from the beginning. At the same time a general stimulant is not what is wanted, but rather a local one. The epiphyses are large in this baby, being an evidence of some degree of rickets, and that means that the heart muscle as well as other muscles are not well developed and easily exhausted. I should give such a baby a grain of carbonate of ammonia every hour or two, and also some digitalis. It might receive half a minim of Squibb's fluid extract of digitalis every three or four hours. Good nourishment, but not an excess of it, should be given, and the temperature of the room should be kept at about 690 to 72°F„ the air a little moist, and under such circumstances the baby's chances of re- covery are very fair. Do not forget, however, that in these cases you have not to deal with a genuine pneu- monia, which will take just six or eight days to run its course, but rather a broncho-pneumonia which may last as many weeks, for a bronchial catarrh may develop into a pneumonia here and there in certain limited areas which may be quite well within a week, but meanwhile new sets of pneumonic inflammation will develope this process repeating itself until six or eight weeks pass before re- covery takes place. It is, therefore, more necessary to commence stimulation early than it is in genuine pneu- monia, which runs its course in a definite and much shorter time. There are no complications here, at least at present, with the exception of the general debility of the patient; therefore no indications for any other treat- ment. Particularly no antipyretics are to be given so long as the temperature will not prove excessively high. You JACOBI: Clinical Lectures on Pediatrics. 61 cannot extinguish a fire by preventing yourselves from observing it. Constipation.—This baby is six weeks old, and is said to have weighed fourteen pounds when born. Since two weeks ago it has lost a great deal in weight. At the same time it began to have small, pin-head whitish vesicles on the forehead. The vesicles spread peripherally. It has had a cough for three days. It is habitually constipated. The mother denies having had syphilitic symptoms. The father admits having had some variety of venereal disease eleven years ago. There have been no miscarriages. The mother has another child two years and a half old, which has purulent ophthalmia and a discharge from the right ear. Her milk is not good and she has fed this baby chiefly on paregoric and anise-seed tea. We learn, then, that the baby was very large when born. The mother is large and fleshy. The baby is very much emaciated now, its skin is hyperaemic; there is an eruption on the head, scabs are present all over it, the surfaces are oozing as most hyperaemic and sore surfaces do. The scabs are composed of serum which has dried up, of epithelium, of dirt, and of hair matted together. Had the baby been washed well from the beginning the scabsnever would have formed. I can find no local disease in this baby further than what has been mentioned. There is no apparent reason why it should be so emaciated. There is not much reason for suspecting syphilis. There has been no roseola, there are no ragged edges about the mouth or anus, the soles of the feet and palms of the hands are clear; there is not even a nasal catarrh or ulcer. But there is something else to account for its condition. Yes, the baby is constipated; it goes three or four days without a passage, and then the mother gives it oil. But there is still an important point in the history. " The baby lives on anise-seed tea and paregoric." Yes, and that is not a very nourishing diet. The baby had the breast a few days or a week, and since that time the poor unfortunate waif has been living on five-drop doses of paregoric and ample quantities of anise-seed tea; and it has been starved. Of course there can be no faeces if there is no food. She said the baby was constipated. Certainly it was; nothing getting into the intestine, nothing could get out of it. The mother is amused at this remark, but the saddest thing of it all is that such a woman should have charge of a human being at all. But 62 JACOBI: Clinical Lectures on Pediatrics. there is no one to care; certainly no one to interfere. If the baby were kicked into the street by a bystander or by the mother, some policeman would come, perhaps, and see that justice was done to both parties, but there is here a human being absolutely in the power of this woman and she does with it and does not with it as she pleases. She starves it, the baby will certainly be buried if she goes on like that, and there is nobody to care, nobody to hold her responsible; no justice, no humanity, no society that cares anything for one in its helpless position. If that is not a sad thing at the end of the nineteenth century, I do not know what is. For you, it is well enough to see this case of "constipation," which indeed is no constipation in the exact meaning of the word, but is frequently mistaken for it. The way to get rid of the constipation in the case is to give the baby food. It must receive something more substantial. Before closing 1 will add a few more remarks to what I have before said about constipation in general. I have spoken of what I call congenital constipation. The sig- moid flexure in the newly born and in the infant is bent upon itself, not only once, but sometimes twice, or even three times. Indeed that part of the colon is so long that the sigmoid flexure is found in the right side often enough to have led surgeons to operate on the right side for arti- ficial anus, instead of on the left. It is the great length of the colon at this end which causes the flexures, and these sometimes cause congenital constipation. The downward course of the contents is delayed; the faeces dry out and accumulate, and when passed finally they constitute hard whitish or yellowish balls. I have met with a number of cases where they had to be spooned out. I described a case twenty-five years ago in which a baby had no discharges at all, and believing there was imper- forate rectum I operated. The baby died, unfortunately, and then I found that I was entirely mistaken; there was only just that condition of things which I have just de- cribed. Since that time it has been better appreciated, and is recognized as a cause of serious constipation. This form of constipation will last until the fifth or seventh year, when the lower part of the intestine assumes the shape generally described in adults. Until then such babies ought not to be given purgatives, as a regular thing, but should receive one or two rectal injections a day. JACOBI: Clinical Lectures on Pediatrics. 63 Besides the want of food as a cause for constipation in the baby just seen, there is still another cause, namely, opium. A large number of babies are constipated because they receive paregoric. Then I have before spoken of constipation in connection with rhachitis, and I will not repeat those remarks. Another cause is im- proper feeding. Many babies are fed on cow's milk, which contains a good deal more casein than mother's milk. This coagulates in the stomach; the coagulum is not dissolved again, the masses go down into the intestine and there act either as an irritant, producing diarrhoea, or obstruct the lumen of the gut and cause constipation. Farinaceous food, when given exclusively or in large quan- tity, may have the same effect, clog up the intestine and set up irritation and diarrhoea or produce constipation. A number of medicines besides opium, which has already been mentioned, have the same effect. Tannic acid, large quantities of bismuth, phosphate of lime, and lime gener- ally, which are given against a sour stomach, etc., will cause constipation unless they are withdrawn at the right time. Another cause is inactivity of the muscular layers of the intestine resulting from inflammatory trouble. Enteritis, which in the beginning gives rise to diarrhoea, afterwards gives rise to constipation,because of an cedem- atous effusion into the muscular tissue which results in a paretic condition. The same can be said of peritonitis. This is not by any means an infrequent disease in infancy and childhood, it leads to an oedematous effusion into the tiss les and inertia of the muscular layers, besides in- fluencing the sympathetic nerves. Thus, every case of constipation ought to be studied by itseif, and the treatment should be in accord with the cause. If there be no passages because the child receives no food, it must be fed. If the casein of cow's milk is the cause, the quantity of milk must be reduced and some farinaceous or animal food be mixed with it. Where medicine is the cause, it must be discontinued. If there be rhachitis, treat that. Where there has been peri- tonitis you must at least avoid the dangers which would attend the administration of medicines that would irritate the intestine and make likely another attack. Where there has been muscular paresis from the causes already named, it will be well to support the abdomen and facili- tate muscular action by applying a bandage around the abdomen. In such cases, too, injections will probably do much more service and be safer than medicines. CLINICAL LECTURES ON PEDIATRICS. (Session of 1892-93.) BY A. JACOBI, M.D., Professor of Diseases of Children, College of Physicians and Surgeons, New York. Delivered November jo, 1892. {Stenographic Report.) Whooping- Cough. Whooping-Cough.—This girl, about six years of age, had, we are told, measles in July and a cough ever since she was a baby. The mother brings her here because of a cough which she thinks is whooping-cough, and doubt- less she has been told that it is. She has severe attacks of coughing at night, is a little better during the day. The cough to which the mother refers must be the re- sult of some actual change extending over a longtime. Very likely there have been intermissions, more or less complete, until a new catarrhal attack would develop on a subacute or chronic form. We meet with a great many such cases, either in children who for some reason once had an acute bronchitis and never got well, or who had a tendency to rickets or so-called "scrofula" from infancy. Those children who have a tendency to glandular swell- ings, not only in the neck but also in the mediastinum, are very apt to have an irritation, a hyperaemia of the bronchial tube. This is very apt to pass into a subacute, and from a subacute back into an acute bronchitis, and occasionally into a broncho-pneumonia. Evidences of the latter are often found. Such babies are very apt to perish finally of an acute extensive attack of broncho- pneumonia or to pass into tubercular consumption. The latter is particularly apt to occur where, as is true of many cases, there is a family history of glandular swellings and tuberculosis. Now, this child had measles in July, having already been a sufferer from bronchitis, and under those circumstances an attack of measles is very apt to lead to broncho-pneumonia. Doubtless it did so in this case and the child has not been well since. The mother thinks the child coughs differently from what it used to; that 66 JACOBI: Clinical Lectures on Pediatrics. now it has whooping-cough. It is well to bear in mind that whooping-cough does frequently follow measles, for the reason, we may suppose, that the active agent of whooping-cough, probably a germ, takes hold more readily when there is morbid condition of the bronchial mucous membrane than when the respiratory tract is in a normal condition. In children who have been coughing for weeks from bronchitis, it is very difficult in the begin- ning to make a differential diagnosis from whooping- cough. You can reach a conclusion only when the pecu- liar crowing inspiration takes place from spasm of the glottis, especially at night time. When there is a severe cough and no previous broncho-pneumonia or marked bronchitis to account for it, you may be justified in mak- ing an early diagnosis of whooping-cough, or before the whoop becomes so striking as to be absolutely diagnos- tic. To be able to do this safely, however, it is necessary to examine many so-called trifling cases, for the more important cases often present in the beginning pnly such symptoms as are found in the comparatively unimportant ones. It is the so-called trifling cases which often try the practitioner. Not to know whether a cough will prove to be a whooping-cough or only the cough of a light bron- chitis, may cost you a family and your good reputation, for any old woman can make the diagnosis of whooping- cough as well as you when the whoop has declared itself in a definite way. Now and then it is expected that the doctor know a little more than the old woman of the neighborhood. That means that he must study his tri- fling cases over and over again, and as he does so he will find them growing constantly more interesting. And they sharpen his wits. The attacks of whooping-cough occur most frequently at night. Sometimes during a single night there are only two or three, sometimes twenty or thirty attacks. They are most apt to come at night, because, first, the children are then locked up in bad air, which irritates the bronch- ial mucous membrane; second, the patient lies usually on the back, and whatever there is in the nares or upper pharynx runs off into the larynx, or at least to the ary- tenoid cartilage and sets up irritation; third, whatever ac- cumulates in the bronchi and larynx is expectorated as it is in the day time and it leads to cough. The general cause of the disease, however, is probably a germ and acts by day as well as by night. Still the attacks in the day are not only less frequent but are also less violent. JACOBI: Clinical Lectures on Pediatrics. 67 Whooping-cough is liable to last a number of months. During the attacks the child coughs violently, the face becomes flushed because of the interruption of the circu- lation, the diaphragm contracts on the heart and lungs and interferes with the circulation; the muscles of the neck constrict the jugular veins and the blood is retained in the face and brain. In a number of cases the restric- tion of the circulation in the small vessels causes haemor- rhages, especially on the conjunctiva, nose and lungs. Such children are sometimes seen going about with one or both eyes bloodshot. That may last a week or two weeks, and recurrence take place repeatedly. There may be haemorrhage from the nose; there are haemorrhages from the lungs. Such babies vomit a good deal; bringing up the contents both of the stomach and of the bronchial tubes. Now and then they have haemorrhages into the meninges, but before this there is simple hyperaemia. The hyperaemia or congestion may lead to convulsion. I have seen patients that would have a convulsion with every attack of cough. I have seen as many as twenty or twenty-five convulsions in a day, and have been com- pelled to give chloroform as soon as an attack would begin in order to prevent a convulsion. The haemorrhage into the brain may lead not only to convulsion, but also to paralysis, local or hemiplegic. The cases of local par- alysis due to whooping-cough are by no means infre- quent, and therefore to let a whooping-cough alone be- cause it is expected to run its course in three or four months, more or less, is a great mistake. It is not a ques- tion whether it is necessary to treat such cases; it is rather a question'whether it should not be regarded as criminal not to treat them. It is not a question whether you shall give a placebo; you must give an active medi- cine. Still, the treatment in most instances is very unsatisfac- tory, the best proof of the difficulty of controlling a whooping-cough is seen in the hundreds of quack and regular medicines recommended for it. The whole phar- macopoeia has been pilfered for the purpose. A large number of remedies have been tried and given up. There are very few that stand the test of time and experience. For.many years I have, after trying for a time some new remedy that might arise, always returned to my old love, which is belladonna. Belladonna is, in my opinion, still the best thing which we can give in the treatment of whooping-cough. I give it in three daily doses, one in 68 JACOBI: Clinical Lectures on Pediatrics. the morning, one at noon, one at night. Every dose must show an effect. The first sign of an incipient overdose in the adult is dilatation of the pupil. In a child it is a pecu- liar erythematous flush of the cheeks. A blush makes its appearance say fifteen or thirty minutes after the dose has been given. This effect should be visible at every dose, otherwise the belladonna will have no effect on the whooping-cough. This child might receive ten drops of the tincture three times a day, and if there be not the effect just mentioned, the dose may be increased a drop until the effect is observable. Anyway, after a few days it will fail to produce the flush, and I find that as a rule the dose has gradually to be increased until about in a fortnight it has been doubled. I again repeat that, unless you obtain the flushing of the cheek, the belladonna will have no effect on the whooping-cough, and you might just as well have not given any treatment at all. Sometimes the attacks of coughing are very severe, and may lead to convulsions, so that you are compelled to do something else, give some immediate relief. This is par- ticularly true at night. Opium or chloral might be given. This child which is six years of age might receive six or eight grains of chloral hydrate at one dose. If the effect should wear off, another dose might be given in from three to six hours. Sometimes it is necessary to give a good dose of chloral at bed-time every night in order to secure sound sleep. A number of medicines have been recommended in whooping-cough, as already stated. Bromides have been recommended, and of late bromoform in three or six drop doses two to four times a day. I cannot say that my ex- perience with it has been sufficient to confirm the urgent recommendations made in its favor. Delivered December 14., 1892. {Stenographic Report?) Cranio tabes and Hydrocephalus. Purpura. Tubercular Peritonitis. Retarded Mental Development. Craniotabes and Hydrocephalus.—-Here is a skull which belongs to the museum of the college. It is a beautiful illustration of rhachitical softening of the occipital bones. I have already spoken to you about craniotabes, but as this is such a fine specimen I could not resist exhibiting it. It is the skull of a child of three or four years. There are many perforations of the occipital bone and an im- JACOBI: Clinical Lectures on Pediatrics. 69 mense anterior fontanel. The peculiar shape of the fore- head strikes you at once, being bulging and square in consequence of the hydrocephalic effusion. The holes in the occipital bone are to be accounted for in the line of my remarks at a previous clinic. A large amount of soft osseous structure is deposited under the periosteum in a rhachitical bone; the bone becomes thick, soft, hyperaemic, and when cut through, a large amount of blood oozes forth. The same hyperaemic state is present in the dura, pia, and brain, and all the tissues give rise to effusion. Thus it is that the rhachitical cranium is often complicated with hydrocephalus, of that form which under treatment will frequently get practically well. But imagine in a baby such newly-formed, thickened and softened bones of the cranium, the baby lying on one side or the other, or squarely on its back, and constant pressure being thus exerted, causing absorption of the soft osseous structure. After a time the entire thickness of the bone may disap- pear in places. In the same way ribs or other bones are sometimes absorbed under a pulsating aneurism. This skull is so large that it undoubtedly has been the seat of hydrocephalic effusion. Purpura.—Do you see anything abnormal about that nose? Girl of about ten years. Student : " It is hyper- aemic—shows some red spots." Is it a hyperaemic red- ness ? " Only the lower part of it." Do you see any- thing on the forehead or cheek? "There are some re- mains of such spots on the cheek." Yes, and there are some similar red spots on the hands, arms and forearms, on the legs and all over—isolated red spots. Do you still think it is hyperaemia ? " No, it is purpura." You answer the question by making a diagnosis. What is the differ- ence between hyperaemia and haemorrhage ? " The hy- peraemia is more uniform, and would not be present all over the body." The latter is not likely, but still it is possible. And you would draw the finger over the skin; if it were hyperaemia the pressure would cause it to dis- appear, which it would not do if it were haemorrhage. Here pressure has very little effect if any, which would point to a real haemorrhage. What very probably is the history of such a spot as this ? " It comes out, lasts a few days or a few hours and disappears. It disappears grad- ually I think." Does it change its color? Have you ever seen the results of a street fight ? " Yes, it does change its color." You see the spots, then, in different stages of jo JACOBI: Clinical Lectures on Pediatrics. development. In a street fight you see immediately after a blow haemorrhage under the skin which is red; now and then if it is in deeper tissue, or venous blood only has been extravasated, it is bluish. But usually it is red, and it will remain red for some time; a change will soon take place, the serum will be absorbed while the solid parts of the extravasated blood will remain, the haematin will change to bluish or purple, green, yellow, and then dis- appear. Thus you can say in this and other cases which of the haemorrhagic spots is the older and which the newer. When the spots first come they are more or less red. According to the patient's statement it has been so in this case, for the redder spots have come very recently, while the darker, yellowish or greenish ones are older. According to the history the child has had several of these attacks, the first one occurring in July last. About three weeks ago toward evening a fresh crop of petechiae was noticed, preceded by a slight chill, then by moder- ate febrile movement, after which the eruption showed itself. She also had pains in the various joints. The child says the spots first appeared principally over the forearms, not so much over the joints . Closer in- quiry elicits the fact that she first noticed petechial spots about two years and a half ago, in the winter, and they have appeared off and on each winter since, and again last July when successive crops came out for a period of about six weeks, then there was none until three weeks ago. The present attack is the only one, it seems, which was accompanied by fever, but in all there has been more or less pain in the joints. The spots are mostly at a dis- tance from the heart over the hands, arms, and lower extremities, but few over the shoulders and face. That would seem to show that they are connected either with insufficient heart power or a peculiar condition of the peripheral blood-vessels, or want of innervation of the outlying provinces. That is at least a justifiable suppos- ition. Although the heart may be at fault in some way, yet the haemorrhages could not take place unless the blood-vessels were modified either in structure or inner- vation. Haemorrhage may take place from fright or very severe emotion, but as a rule when there are repeated haemorrhages which come in just the same way, you must conclude that the blood-vessels through which it takes place, it being always in the same localities must be changed. I believe I have already spoken of the fa- cility with which haemorrhage takes place in the newly- JACOBI: Clinical Lectures on Pediatrics. J\ born and in small infants. There also it is the result of the blood-vessels being insufficient in structure. At the time the baby is born the tissues are still in a peculiarly soft, fragile, embryonal state, and the blood-vessels are very liable to rupture. We must assume that when haemorrhages take place so frequently it must be the fault of the blood-vessels themselves. We can imagine that they were not well formed in the beginning; that, for in- stance, the elastic layer was not well developed. In many cases, for instance, we can prove that an aneurism will take place in just such a part of a larger or smaller artery as has been congenitally deprived of a good deal of elastic tissue. Such an aneurism will frequently be found just where a smaller branch leaves off, and it is in just such places where the elastic tissue has been found wanting. That might also explain why haemorrhages sometimes take place in a certain part of the body. At the same time that there may be incompetent structure there may also be insufficient innervation, or there may be insufficient heart power which allows venous stagna- tion. There may also be at the same time some foreign invasion. That leads me to what has been said of late years of the recurrence of such haemorrhages. Purpura, it has been claimed by some, particularly Babes, of Buchar- est, to be the result of bacteric invasion. He claims to have found one and the same bacillus in every case of acute purpura. Now, it is possible there is such a thing here, but it may strike you as difficult to suppose the in- vasion by one and the same bacillus in a case like this where the attacks have extended over years. It is very much more probable in my mind that in such a case we have not to deal with an acute bacteric condition, but rather an original weakness of cardiac function and very probably an insufficient development of the blood-vessel walls.' At the same time the patient has told us that she has rheumatic pains in most cases when she has had these attacks. So-called rheumatic pains may be acute articu- lar rheumatism, yet it may be the result of nothing else than such haemorrhages taking place into the joints or the articular ligaments. One form of purpura has been called peliosis rheumatica. It is accompanied with rheumatic fever and a good deal of pain about the joints and the pur- pura is present through the joint and about the joints. Now, is it fair to assume, particularly as such cases are not transformed into a real attack of acute articular rheu- matism, that the synovial membranes are involved in the JACOBI: Clinical Lectures on Pediatrics. haemorrhages as well as the surfaces. Besides the two forms mentioned, purpura, and peliosis rheumatica, there is a third one of similar appearance, acute purpura, or morbus maculosus Werlhof. What is the difference be- tween morbus maculosus and purpura ? The former is said to be an acute disease attended with a great deal of fever. There is frequently haemorrhage from the mucous membrane of the nose, from the intestinal canal, some- times from the kidneys (bloody urine), into the brain,and so on. Though it be called a disease suigeneris, the an- atomical conditions are probably the same as in the others just mentioned. Another form of the same affection is so-called scurvy. Here you have small and large haem- orrhages under the skin, haemorrhages from the nose, from the intestine, into the brain, with all the results of cerebral haemorrhage; convulsions and so on. That means a repetition of all the previously enumerated symp- toms. In "scurvy," bleeding from the gums also takes place. But in all there is " purpura." When the bleed- ing has been from the gums it has been called scurvy; when there have been rheumatic pains it has been called rheumatic purpura, etc. I think it safe to say that all these different forms belong to one and the same class of phenomena, relating in part to the condition of the blood- vessels, in part to innervation, and perhaps in part or now and then to bacteric invasion. The identity of these forms becomes clearer when they are compared with what is known of scurvy in the infant. Scurvy in the infant need not exhibit any bleeding from the gums at all. Haemorrhages usually take place in the lower extremities, under the periosteum, etc., to such an extent as to cause the limb to swell to twice or three times its normal size. Babies that have no teeth seldom bleed from the gums, even some in whom teeth have formed do not bleed at the gums. So that scurvy in in- fants in one sense is quite different from that in adults, which was seen particularly in former times when voy- ages at sea were long and the diet mainly salt food. But what I wish to impress upon your mind is that scurvy, purpura haemorrhagica, or morbus maculosus, and rheu- matic purpura are one and the same thing, a fact of great importance in diagnosis and treatment. The names, however, are useful in description, although describing conditions which depend upon the same causes. What can we do in a case of this kind ? The fever has certainly gone down by this time. We ought to examine JACOBI: Cinical Lectures on Pediatrics. 73 the heart. There is no murmur in this case. If we should find incompetency of the mitral valve we should conclude there was a good deal of stagnation in the outlying prov- inces. And that explains in part perhaps the facility with which haemorrhages often take place. But there is no evi- dence of it here; there is no murmur, thereis but little en- largement. But it seems the heart impulse is rather strong compared with the very feeble pulse. Here I may remark that you should examine as many normal people as you can, for one cannot judge of an abnormal condition unless he knows the normal. I have yet to say something about the probable condi- tion of the blood-vessels in this case, and it is one of the most interesting subjects in pathology. It strikes me that her heart is fairly normal in size and that its impulse, al- though she looks weak, is rather strong. It strikes me that the radial artery is small, and even the carotid is unusually small. If the carotid and radial are small, it is fair to assume that all the arteries in her body are small. Now, what would be the immediate result of the heart being of normal size while the arteries are small? The heart is contracting and there is not sufficient lumen in the arteries to allow the blood to pass along. Therefore, the heart exerts a greater impulse upon the arteries than is usual. It may also have struck you, as it did me on lis- tening to her heart that its sound was muffled and not as clear as normal. That muffled sound is» heard when the muscular tissue of the heart is changed, as when there is a slight degree of fatty degeneration, or some chronic myocarditis. It is not the sound produced by endocard- itis or the murmur of mitral insufficiency or stenosis of the ostium, for there you have to deal with a distinct murmur. It is probable that she is given to attacks of weakness if not to fainting spells, because the brain is insufficiently supplied with blood; that she passes a smaller quantity of urine than the normal because the renal arteries do not carry sufficient blood, and so on. In such a case there probably would be venous stag- nation, although there is no valvular incompetency, but simply because the arteries are so small. That would be an additional reason why in her case there should be pur- pura month after month for two or three years. We know not only clinically but also from autopsies, that in many of these cases there is smallness of the arteries. And if the case has lasted for some time the heart is apt to be JACOBI: Clinical Lectures on Pediatrics, found in a state of fatty change, although it may not be much enlarged. The same anatomical conditions have been found in some cases of puerperal endocarditis and in chlorosis. The incurable forms of chlorosis in the female, and also in the male, are those that depend on insufficient size of the arteries, the heart being either also small or in some abnormal condition. This condition of things was studied by Virchow, thirty years ago. See, of Paris, has followed him, and a number of observations have been made in which chlorosis, pernicious anaemia, essential anaemia, have been found to depend on absolutely nothing but insufficient size of the arteries with fair or insufficient development of the heart. At any rate, all these con- ditions would seem to have to do with this girl's pur- pura. Question, what to do with such a heart and such arter- ies ? She wants first absolutely good nourishment. She must have some exercise, but not to fatigue. She must have some heart stimulant to enable the heart to get a little more blood into the arteries and make the insuffi- cient arteries do their duty. What heart stimulant ? Is it digitalis ? It does not strike me that digitalis is the proper thing, for it is known to exert a stimulating effect on the heart and arteries at the same time. While thus stimulating, some spasm might be excited in the smaller arteries so that the circulation would be made worse than it was before. That is the reason why digi- talis is so dangerous in atheromatous degeneration of the arteries. You never know when you are safe in giving digitalis. Some will tolerate it, but the large majority will not, because it stimulates not only the heart to con- traction, but also the inelastic hardened arteries when these are atheromatous, so that not infrequently you will find your case getting worse instead of better. In that event you will have to select something which will act on the heart more than on the arteries. Strophanthus is one, spartein another, and nitroglycerin will do. If she take a heart stimulant I would advise strophan- thus at first. She might take five or six drops of the tincture three times a day, and if it were found that the pulse got a little stronger and she, however, needed more, she might take four or five doses. Do not forget it is not the blood that gives rise to haemorrhage, it is the condition of the blood-vessels. Yet the condition of the vessels depend upon the nutrition furnished by the state of the blood, and thus a person may be more apt to bleed JACOBI: Clinical Lectures on Pediatrics. 75 who has less or insufficient blood. A person with an- aemia or hyperaemia is more apt to bleed than one in health. Not because the blood escapes more easily, but because the blood-vessel walls have become incompetent to hold it. Iron is likely to do her good, but phosphorus and ar- senic would probably do better. She might take the one seventy-fifth of a grain of arsenious acid after meals and four doses a day of one minim each of the oil of phosphor- ous of the pharmacopoeia. Instead of arsenious acid one might give her two or three drops of Fowler's solution after meals, largely diluted, and instead of the oleum phosphoratum of the Pharmacopoeia, the elixir of phos- phorus of the National Formula, half a teaspoonful three or four times a day. Tubercular Peritonitis.—This boy is three years and-a- half old. His abdomen is much enlarged, dating back six months to an attack of measles complicated with pneu- monia. There is no history of alcoholic excess, but there is of excessive coffee drinking. He has had a moderate temperature for several weeks past. Physical examination of the thorax shows dulness over right side anteriorly above the liver. As there is ascites it probably has pushed the liver up, which crowds upon the lung, compresses it, thus perhaps causing the dulness. There is ascites, without dropsy of the lower extremities, of the face, or upper extremities. What should we con- clude from that fact is the cause of the ascites ? An as- cites may be due to a process in the liver, to a tubercular, carcinomatous, or other form of peritonitis, to heart dis- ease, to kidney disease, and so on. It cannot be due here to heart disease, for that would cause dropsy of the whole body, as of the face and lower extremities. Nor is a local dropsy due to kidney disease. A local dropsy must have a local cause, and it being here an ascites, the cause must be below the diaphragm. It is either in the liver or in the peritonaeum. It has been suggested by the gentle- man who sent the case for our investigation, that it may be cirrhosis, and I may state here that cirrhosis of the liver is not so infrequent in little children as you may •suppose. We generally find cirrhosis due to alcohol. Cirrhosis of the liver or interstitial hepatitis, is commonly spoken of as gin drinker's liver. And it has been estab- lished that a number of cases even in children were really due to alcoholism. Some boys will drink, and babies y6 JACOBI: Clinical Lectures on Pediatrics. have sometimes had cirrhosis because of *e Painstaking care of the medical practitioner who supplied them with sufficient stimulants during a protracted illness. it is well to bear such facts in mind. But there are other cases in which ascites has been due to liver disease exc u- sively and of a different nature. For instance syphilo- mata and atrophy of the liver in consequence of heredi- tary or acquired syphilis will lead to ascites. That is it will obstruct the hepatic circulation, cause blocking up in the portal vein, splenic swelling and peritonaeal effusion the cause may be and is in some instances, cirrhosis, but in many where that diagnosis has been made the autopsy has shown a different state. In rare instances it has been carcinoma of the liver, but more frequently it has been tuberculosis. Tuberculosis will frequently affect a single locality and remain there for years. For instance, tuber- culosis of bone is very frequent in children, and it may stay in one joint or bone for months, and even for years, before it spreads. So it may take place in the peritonaeum and remain there without affecting neighboring organs at all, particularly without affecting the lungs. A num- ber of such cases as the present one heal, no matter what you do if only you give the patients rest in bed and feed them well. Some bear iodide of potassium or iron very well. This patient should have some arsenic, cod liver oil, plenty of beef and other suitable food, abundance of fresh air. A number of these local cases of tubercular peritonitis have got well of late years by simply having the abdomen opened, the ascitic fluid discharged, and the abdomen closed again. That can be done whenever no evidence of the disease elsewhere can be discovered and other treatment has failed. But the unfortunate part is that tubercular peritonitis need not remain local long; other parts will become affected, and in the case presented to you the child had measles six months ago, pneumonia on that, and coughed for some time afterward. That history makes me very suspicious of the slight dulness which now exists over the right lung. The child is very pale, too, so that it is not unlikely it has tubercular peritonitis, pul- monary and glandular tuberculosis. It is possible that a part of the dulness over the lung is due to swelling of the mediastinal lymph bodies. To repeat the treatment briefly, it would be for this baby rest in bed, fresh air, good food, watching the tem- perature, not allowing it to go up too high; a little d" ieri- JACOBI: Clinical Lectures on Pediatrics. yy talis to keep the heart in good working order, a little arsenic as a tissue builder, guiacol rather than creasote, say one drop three times a day and later four, five, or even six times a day in water or milk. If the ascites increase, paracentesis must be practiced, but if the lungs should be found in healthy condition laparotomy should take the place of paracentesis. Unless the child improve some operation should be done to let the fluid out of the ab- domen soon. It is very probable the circulation is much interfered with now, as is the action of the lungs and heart from pressure on the diaphragm. Retarded Mental Development.—Will you observe the appearance of that child's face ? A boy of three years. The face and head are broad, without great height, and the head is flat. That would mean there is probably not room enough in the cranium for a normal brain, or rather that the normal brain may be compressed. The nose is broad, retracted, not elevated as it should be. The vomer being short, and being in contact with the base of the brain, you may imagine at least, not having seen it, that the distance to the brain from the flattened nose is short. Then there are certain indications of rhachitical develop- ment with premature ossification of the cranial sutures. In a number of cases general rhachitis is accompanied by premature ossification of the bones at the base of the skull, so that the base of the brain has not opportunity to expand, and the distance from the occipital spine to the root of the nose remains short. The flatness of the nose is accompanied by a hardened, flat, and broad palate. Thus we have in the case a flatness of the hard palate, a short vomer and retracted nose, synostosis, especially be- tween the sphenoid and occipital bones, flat parietal bones, a short skull and a narrow skull above. The re- sult is insufficient development of the cranial cavity, and a mild case of so-called cretinism. Cases of cretinism which you read about occurring in Switzerland and elsewhere are usually more marked than this one, and are apt to be accompanied by goitre. Here we probably have to deal with only an accidental degen- eration. The mother says she has one more child, a baby of seven months, and that it is doing well. She says this child was eighteen months old when it had its first tooth. That is one indication of insufficient development or of rhachitic development. As you probably know, babies us- ually have the first tooth between the seventh and eighth 7 ^ s^^r &. rnTt^Ta^c^yTs left There is no doubt but that this case is of syphilitic na chiMandZVTTn to ^e question of what to do Th child ought to have absolute rest. She ought not to wal na- e walk JACOBI: Clinical Lectures on Pediatrics. 81 on the limb, for we cannot tell to what extent there is gummatous degeneration and when the bones may break down. She has already been put under antisyphilitic treatment. Iodide of potassium ought certainly to be given, but it may be a question whether mercury should be given at the same time. When I do not see the pa- tient for sometime,say not oftener than in intervals of four or six weeks, I guard against possible evil effects of iod- ide of potassium by alternating it with corrosive sublim- ate every week or ten days, giving one drug at a time. The baby is old enough to take from fifteen to twenty- five grains of iodide of potassium a day. As a rule the iodide of potassium is well tolerated by children, but if for any particular reason it could not be given the iodide of sodium might be substituted. Iodism is very rare in little children. Whenever iod- ism occurs, that is a severe attack of conjunctivitis or rhinitis attending the administration of iodide of potassi- um, you can mostly limit it, if not cure it, by giving at the same time chlorate of potassium. This child might take from fifteen to twenty grains of chlorate of potassium in the twenty-four hours and suffer less iodism. If the stomach should not bear iodide of potassium you might, as I have said, try iodide of sodium, and if this should also prove obnoxious you might add some bicarbonate of sodium or a little strychnine. I have frequently found that strych- nine in fair doses, say for this baby the fortieth of a grain in twenty-four hours,makes the iodide of potassium much more endurable. In alternating bichloride with iodide of potassium every six or ten days, this baby might receive from a fifteenth to a twentieth of a grain of the corrosive sublimate three times a day according to the effect pro- duced. That the interruption of the iodides for a few days is safe may be shown by the fact that iodide is still present in the urine from three to six days after the ad- ministration of the drug has been omitted. Syphilitic Lesions.—Here are two children which have been brought by their mother. The first is a baby of eighteen months. It is natural for every normal tongue to be somewhat "furred," but this one is not so at all; there is only a streak of fur at the sides and a triangular space behind where the epithelium has not yet been cast off. But you notice that where the coat still remains it is too thick, it is abnormal. So there seems to be some- thing abnormal not only in the loss of epithelium but al- so in the retention of it. This particular condition, where 82 JACOBI: Clinical Lectures on Pediatrics. there is an unusual amount of epithelium in irregular spots and denudation at other places, has been called psoriasis of the tongue. A large majority of the cases are not syphilitic, but there are undoubtedly cases in which syphilis is the cause. Here our attention is directed to the fact that a good deal of the scaly hair has been lost; there is alopecia, not "areata" as the spots are not particularly circumscribed, but there is loss of hair almost complete in some places. A more marked alopecia is frequently seen in the syphilis of adults, and it sometimes is present from parasitic disease. I should advise the mother to cut the child's hair frequently; by so doing she will undoubtedly improve the vigor of its growth. The other baby is about ten months old. It had lost its finger nails, but they have grown again since it was under treatment. On the lips and in the mouth there are granulations and perforations of the mucous membrane and some sessile papillomata, so-called mucous patches which are characteristic of specific infection. The child has been under treatment since its birth by the doctor who attended the mother's confinement. We are told that when the baby was a month and a half old the mo- ther noticed its finger nails become black, and about the third month they fell off. Later an eruption developed over the body which lasted about a month and disap- peared under treatment. Since last July the mother has noticed a patch on the lips which is present yet. Regarding the treatment, we are told that the older child was given a tenth of a grain of calomel since Octo- ber, probably three times a day; this is also the amount it has received of late. It is said the child improved un- til a short time ago and then there was a relapse. But the evidence of a relapse, we are told, is that the de- nuded patch on the tongue became more diffuse. Re- garding that point I have already said that psoriasis of the tongue is sometimes specific, more often it is not. Even in cases where it started out specific, it may remain as an independent affection, and be due to debility of the epithelial surface or to a microorganism; still a micro- organism is said to be the cause more often than can be proven. The psoriasis, when it persists, is a low inflam- matory process, is very obstinate, resisting all treatment for years, and you may meet with patients who never get rid of it. Diseases of the mouth are liable to be very ob- stinate. A man was in my office this morning whom I have known ten or twelve years, and once or twice a year he will come with a disease of the tongue which some JACOBI: Clinical Lectures on Pediatrics. 83 times looks like herpes, sometimes like eczema, and after it has lasted a few days ulcers appear which are very painful. They also appear on his lips, on the gums, on the inner side of his cheeks down into his throat. Frequent- ly they come in half a day or a day like an acute disease, sometimes with a little fever, sometimes with no fever, and they go away very slowly. He says he has at times suffered with it for months in succession. In this child's case the psoriasis of the tongue is proba- bly now the result of two factors: First, a peculiar debil- ity of the tissues which are subject to frequent inflamma- tions and break down very easily; second, it is at the same time a neurosis. A neurosis will frequently show itself as an acute eczema of the skin, still more frequently as an acute herpes. So it shows itself in the mouth in this case. In the case of the man whom I saw this morn- ing there is a peculiar complication; that is, he is sexual- ly very poorly developed. The testicles are very small, the pubes very little raised and covered with hair but very sparsely. Very frequently brain and nerve diseases are attended with insufficient development of the testi- cles and genital organs generally. In this case I believe the neurosis depends a good deal upon insufficient inner- vation shown by imperfect development of the genitals. The man says he is perfectly well otherwise, but when he works he all at once gives out; he may be feeling per- fectly well and yet have to give up to sleep. That oc- curs very frequently, several times a day, particularly the first weeks when his eruption is out. So that it seems there is insufficient development and insufficient resist- ance of the nervous system in a man who, though well formed, has a peculiarly pale, thin skin over the whole surface of the body. Vascular Tumor of the Cheek.—We are told that the trouble of this boy, who is twelve years of age, dates back one year. The whole left cheek appears to be larger than the right, and a circumscribed, slightly mov- able tumor, at this examination not of large size, can be felt in the cheek. But when he leans forward the swell- ing becomes much larger and more tense. As ■he rises from the stooping posture and you hold the finger against the tumor in the mouth,it is noticed to gradually become smaller, and you are able to accelerate its reduction in size by gentle pressure. The tumor, whatever it is, must be connected with the tissues in the cheek. There we have mucous membrane, J AC OBi: Clinical Lectures on Pediatrics. submucous tissue, some fat, muscles, blood-vessels, ner- ves, lymphatics, skin. If the tumor were connected with Steno's Duct, as one of you suggests, it would not swell on stooping and diminish on rising. No, it is evidently a vascular tumor, the blood-vessels being dilated and the surrounding tissues elastic enough to allow of enlarge- ment when the blood runs in and to contract when the blood runs out by posture or otherwise. It is a very interesting case, and you will not be likely to see many like it. It is not superficial, for neither the skin nor the mucous membrane of the cheek is specially changed in color. So there is a circumscribed angioma, which very probably was quite small at birth and has increased to considerable dimensions since. The mother did not notice it until about a year ago, two months after a tooth was drawn. While she seems to think there was some connection be- tween the pulling of the tooth and the appearance of the tumor, it is probably about as baseless a supposition as that all the numerous diseases attributed to dentition are really due to the cutting of the first teeth. Regarding treatment, excision would, I believe, be a very poor procedure in this case and it would not be at- tended by less deformity than the use of the actual cau- tery. Excision, too, would probably be a very bloody operation. We will see the boy again before resorting to treatment and will have time to think about the case, but it is my impression it can best be treated by the actual cautery, introducing the cautery point and turning it about in the interior of the cheek at the seat of the tu- mor, thus destroying a large mass internally while leav- ing but a small scar externally. Sarcoma of the Spleen.—This baby, an Italian child about ten months old, has a swollen spleen. You will remember what I said upon this subject when speaking of leukaemia and pseudo-leukaemia, and that I spoke of counting the number of the blood cells. I have done that in this case, and found there are still four million, four hun- dred thousand blood cells in a cubic millimeter of blood, the normal amount being five million and a half, in the adult, and less in the child. Besides not being reduced much in quantity considering that the baby is emaciated the cells are also of normal size and shape. There were a few more than the usual number of leucocytes twenty- four thousand instead of twenty thousand to the cubic millimeter of blood, as found in the adult, and about half JACOBI: Clinical Lectures on Pediatrics. 85 as many in the child,so we can say positively that we have not to deal with leucocythaemia, and that we have not to deal with pernicious anaemia. The spleen here is large and feels hard. It is very dif- ficult to percuss the spleen in the child when it is only slightly enlarged. As a rule it is found on the left at about the eighth and ninth intercostal spaces extending backward and downward to about the level of the eleventh rib. But in a number of cases, the liver being large, the intestines are very tympanitic and extend over the spleen, so that there will be a tympanitic percussion sound and the outlines of the spleen cannot in that way be deter- mined. Moreover, you cannot well palpate it in many cases in children, whereas in the adult by pressing gently and firmly under the ribs on the left side during deep in- spiration the spleen can be readily felt descending and rising again with expiration. It is more noticeable in proportion to the degree of enlargement when it exists, as in typhoid fever, malarial fever, etc. In this baby's case the spleen is very much enlarged and can be both percussed and palpated below the free border of the ribs. The question arises, what is the cause of the splenic enlargement ? We have excluded leucocythaemia. There is no history of malaria. Let me say a few words here of other anomalies of the spleen. One of the rarest anom- alies is absence of the spleen. Now and then there are seemingly two or three spleens, the fcetal lobulation of the spleen persisting in after life. Indeed as many as fifteen and even twenty-seven lobulations have been ob- served. The lobulations remain so deep sometimes that they give you the impression of supernumerary spleens, just as it sometimes occurs with the liver. In a few cases it has been found that the spleen was enlarged at birth. It has been observed in babies when the mother had been affected for months with intermittent fever. In this case, however, there has been no history of malaria. It might result from a previous typhoid fever or relapsing fever, but these, again, are excluded from the history. As we cannot fall back on any acute disease we shall have to turn to a neoplasm as the explanation of the case. Neo- plasms of the viscera are not very infrequent. Cohnheim, because he saw so many cases of tumor in infancy and childhood, attributed them to the persistence of a num- ber of embryonic cells, or their failure to undergo a change into the normal tissue of the parts in which they might be situated. Imagine what takes place in the em- 86 JACOBI: Clinical Lectures on Pediatrics. bryo: The embryo in the beginning is only a compound of a number of embryal cells. Not until a little later is tissue formed out of them. Now, through faulty growth a number of these cells may be prevented from undergo- ing the normal changes. A nest of them may then be wrapped up and concealed in the normal tissue which has since developed. Then in after years through some means or other new life gets into such cells and they pro- liferate into a neoplasm, such as carcinoma or sarcoma. Most of the tumors which we find in early life are either carcinoma or sarcoma. That, then, was the theory of Conheim, which may be true for a number of instances but which certainly is not the explanation for all cases. Undoubtedly we have in this case a tumor of the spleen not of benign nature. In some instances the tumor, even when congenitally present, has remained dormant for weeks, months, or years. I have seen sarcoma, particu- larly of the kidney, remain dormant for years and after- ward take a start and grow very fast. This is not a case of perisplenitis, as the child never complained of pain. When acute inflammation of the covering of the spleen exists it is very painful. Some- times it results from a blow or an embolus, or some other cause of haemorrhage which results in rapid in- crease of the organ. Again, there is no cystic degeneration nor abscess in the tumor in this case; no fluctuation can be discovered; the tumor is hard. We have then to decide between car- cinoma and sarcoma. If it were carcinoma the baby probably would have died ere this; or at least, if it were carcinoma there probably would be by this time numer- ous metastatic deposits in various parts, especially in the glands. The latter are not swollen. The baby, then, has sarcoma. If good care is taken of him it may be a number of months before the end will come. We may even influence the tumor to a certain extent by treat- ment. I have not found that the aniline dyes, particularly methyl blue, which is sometimes beneficial in carcinoma have much influence on sarcoma. Arsenic is the drug which we shall have to depend upon. The baby should take a drop of Fowler's solution largely diluted three times a day, increasing the amount every few days by a sixth to a quarter of a drop at each dose, so that in time two, three, or even four drops will be taken At the same time good food and general hygiene will lengthen the child s days more or less. 8 CLINICAL LECTURES ON PEDIATRICS. (Session of 1892-93.) BY A. JACOBI, M.D., Professor of Diseases of Children, College of Physicians and Surgeons, New York. Delivered January 4, 1893. {Stenographic Report.) Angioma of the Face. Cardiac Disease. Malarial Fever. Stomatitis. Angioma of the Face.—This little girl is presented again to show the results of the treatment of an angioma of the face by the actual cautery. You will remember the statement that she had been thus treated a large number of times in England, and seven or more times here. Since the last time you saw her and several weeks since we last used the cautery, the tumor has continued to con- tract, to diminish in size, and we will postpone further treatment for a time yet. You observe that there is great joy exhibited by this little one as she is told she can go ; you will find on going out into practice that the little show great joy when the doctor leaves the house. Therefore do not make long calls if you can help it. Cardiac Disease.—If you wish to learn all that you ought about clinical medicine you must see your cases more than once. This little girl, ten years of age, was presented here five weeks ago for excessive ascites and a moderate degree of oedema of the lower extremities. At that time cardiac disease was discovered There was a mitral regurgitant murmur ; that meant insufficiency of the mitral valve. You have answered correctly that the natural result of mitral insufficiency joined to a high de- gree of hydraemia would be a weak pulse, may be a thready and irregular one, that the venous circulation would be slow, the veins entering the heart would be- come dilated and in bad cases the veins all over the body would be dilated ; that the organs to be first affected would be the lungs. There we would first have hyperae- mia and a pulmonary or bronchial catarrh. The occur- ance of bronchitis or pneumonia in mitral disease is very bad because of the degree of venous obstruction present even without and before this occurrence. Again 88 JACOBI: Clinical Lectures on Pediatrics. you have answered correctly in saying that beyond the lungs the first effect would be upon the vena cava in- ferior; this would obstruct the return flow from the liver, produce enlargement of that organ and dilatation of its vessels. The parenchyma of the liver and the structure of its peritoneal covering is very expansive; the liver will swell like a sponge, if not, then the tension will be so greatthat there will be pain and also a certain degree of perihepatitis. Thus it is that in a number of cases in which the liver swells considerably there is no pain what- ever, whereas in some cases in which the swelling is small in proportion to the disturbance, there is considerable pain because of want of expansibility of the parenchyma. In this patient's case there has not been much pain. The circulation of the liver being interfered with,the blood backs up in the portal vein and this causes congestion of the organs from which it collects the venous blood. In the stomach there will be produced different forms of gastritis and indigestion. This accounts for the fact that very frequently gastritis is benefited, though not cured, by cardiac stimulants. Instead of giving only bi- carbonate of socjium or other remedies intended to act upon the stomach directly, you would also give digitalis, strophanthus or others. The same would be true of the pulmonary symptoms; instead of giving remedies intended to influence the respiratory organs alone, you would give a heart stimulant. In a large number of cases there is not only gastric catarrh, bur. also intestinal catarrh. In some cases there is constipation, but more frequently the intestinal catarrh leads to diarrhoea. Diarrhoea following and depending upon disease of the lungs or heart is a very ominous symptom. Going a step further, we may see the hemorrhoidal veins affected, and in adults especially we often find local treatment ineffectual, whereas by emptying the bowel and then relieving the venous obstruction by treatment directed to the heart the so-called haemorrhoids, as long as they are merely varicose dilatations of the veins, are caused to disappear more or less completely. In the case of the patient before us, treatment has been directed to the heart and she has been given rest in bed, with the result that the oedema of the lower extremities has disappeared, her ascites is much less, and the liver not so large. Normally in the foetus the liver can be felt down about on aline with the umbilicus, while in the new- ly born it can easily be felt below the ribs, and in an in- fant of a year, though the organ be considerably reduced JACOBI: Clinical Lectures on Pediatrics. 89 in relative size, it can only yet easily be felt by pressing the fingers beneath the ribs. In the present case there is sufficient enlargement to enable us to map out the liver easily an inch below the level of the ribs. In a liver which is the seat of amyloid degeneration or the infiltrated form of cancerous disease you can hardly ever run the finger underneath its edge as you can do here. As to treatment, aside from rest and food, it will have to be directed chiefly to the heart. The infusion of digi- talis might be given, and be replaced after a time by stro- phantus, or spartein, or convallaria, permanently or un- til any gastric symptoms arising from digitalis had sub- sided. But the principal remedy in her case must be absolute rest. You ought never to treat an acute or sub- acute heart disease without enjoining absolute rest. The patient ought not to be allowed to leave the bed a single instant. The most dangerous cases are those in which the muscle of the heart rather than the endocardium is affected, and the greatest pains must be taken to prevent unnecessary exercise. Such a patient as this one ought not to be allowed to leave the bed even during defecation and micturition. A number of cases that have died sud- denly from heart disease might have been saved had they not been allowed for several weeks to leave the bed. This girl, then, ought to be kept in bed for some time; her bowels should be moved by a daily enema. She should have digitalis. In the short time during which this treatment has been applied her ascites has become much reduced and she has improved in every way. In such cases you will always be asked about the prog- nosis. Of course, the heart lesion is incurable, but the symptoms may decidedly improve or entirely disappear until further provocation. In the case of this patient the heart is not markedly enlarged, and what enlargement there is is due to hypertrophy. It is possible, therefore, that the compensatory increase in the heart muscle will facilitate the circulation in the future so that the liver will become still more diminished in size. I think that the very fact that her liver tissue is expansible, that the peri- tonaeum has given way over the swelled organ, has pre- vented her condition from becoming worse. You can imagine that if there had been more resistance in the liver the heart would have been exerted more than it has been in trying to overcome the obstruction, so that the spongy condition of the liver was really the safeguard of the heart. Insufficiency of the mitral valve and moderate hypertro- 90 JACOBI: Clinical Lectures on Pediatrics. phy of the left ventricle is not so dangerous after all, par- ticularly when it takes place about this time of life. About puberty, when the heart grows fast, and the arte- ries