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THE HISTORY OF PEDIATRICS AND ITS RELATION TO OTHER SCIENCES AND

ARTS.*

A. JACOBI, M. D., LL. D. (UNIVERSITY OF MICHIGAN AND COLUMBIA),

NEW YORK CITY,

Professor Emeritus, Columbia University, New York.

(Continued from page 10.)

We are building hospitals for the sick of all classes, and insist upon their being supe. rior to the best private residences; asylums for the insane, neuropathics, and drunkards; nurseries and schools for epileptics, cretins and idiots; refuges for the dying consumptives; and sanatoria for incipient tuberculosis. We are bent upon curing and upon preventing. Do we not begin at the wrong end? We allow consumptives and epileptics to marry and to propagate their own curse. We have no punishment for the syphilitic and the gonorrheic who ruins a woman's life and impairs the human race. Man, however, should see that his kind muust not suffer. One-half of us should not be destined to watch, and nurse, and support the other half. Human society and the State have to protect themselves by looking out for a healthy, uncontaminated progency. Laws are required to accomplish this: such laws as will be hated by the epileptic, consumptive, the syphilitic, and the vicious. No laws ever suited the degenerate against whom they were passed, and it is unfortunate that while health and virtue are as a rule not contagious, disease and vice are so to a high degree.

Modern therapeutics, both hygienic and medicinal, has gained much by the close observation of what is permitted or indicated or required in early age. Since it has become more humane (remember it is hardly a century since Pinel took the chains off the insane in their dungeons, and not more than half a century since I was taught to carry my venesection lancet in my vest pocket for ready use) and more scientific, so that whatever is out

side of strict biologic methods is no longer "a system," but downright quackery-the terrible increase of the latter as a worldplague is deemed by rational practitioners and the sensible public an appalling anachronism. It appears that the States of the Union are most anxious (and have been partially successful) to rid themselves of it, while some at least of the nations of Europe are great sufferers than we. According to the latest statistics, there is one quack to every physician in Bavaria and Saxony: ten quacks in Berlin, with its emperor and other accom

Read before the Congress of Arts and Sciences, St. Louis, Mo., September 21, 1904.

plishments, to every forty-six physicians. Its general population has increased since 1879 by 61 per cent; the number of physicians, 1702, per cent; that of the quacks, 1600 per

cent.

One of the main indications in infant therapeutics is to fight anemia, which is a constant danger in the diseases of the young, for the amount of blood at that age is only onenineteenth of the whole body weight, while in the adult it is one-thirteenth. The newlyborn is particularly exposed to an acute anemia. His blood weighs from 200 to 250 grams. It is overloaded with hemoglobin which is rapidly eliminated, together with the original excess of iron. This lively metabolism renders the infant very amenable to the influence of bacteria, and the large number of acute, subacute or chronic cases of sepsis is the result. Besides, the principal normal food is milk, which contains but little iron. That is why pediatrics is most apt to inculcate the lesions of appropriate posture, so as not to render the brain suddenly anemic, and of proper feeding and of timely stimulation before collapse tells us we are too late and of the dangers of inconsiderate depletion. The experience accumulated in pediatric practice has taught general medicine to use small doses only of potassic chlorate; large doses of strychnin and alcohol in sepsis, of mercuric bi-chlorid in croupous inflammations, of heart stimulants, such as digitalis, when a speedy effort is wanted, of arsenic in nervous diseases, of potassi iodid in meningitis; it has warned practical men of the dangers of chloroform in status lymphaticus; it has modified hydrotherapeutic and balneological practice, and the theories of hardening and strengthening according to periods of life, and to the conditions of previous general health.

The appreciation of electricity as a remedy has been enhanced by obstetricians, pediatrists and general practitioners. It is but lately that we have been told (P. Strassmann, Samml. Klin. Vortr., 1903, No. 353) that a newly-born and an infant up to the third week are perfectly insensible to very strong electrical currents. The incompetency of mere experimental work, not corrected or guided by pracice, cannot find a better illustration, for there is no more powerful remedy for asphyxia and atelectasis than the cautious use of the interrupted or of the broken galvanic current.

In the meeting of the Society for the Study of Diseases in Children, May 27, 1904, Mr. Thompson Walker alluded to the collection of 10 cases with status lymphaticus in which death had occurred at the commencement of chloroform administration, or during it, or immediately after the operation. In addition to the usual changes, a hyperplasia of the arteries had been noted, leading to narrowing of the lumen.

The domain of preventive therapeutics expands with the increased knowledge of the cause of disease. That is why immunizing, like curative serums, will play a more beneficent part from year to year, and why the healthy condition of the mucous membrane of the nose, mouth and pharynx, which I have been advising these forty years as a prevention of diphtheria, has assumed importance in the armamentarium of protection against all sorts of infectious diseases.

Amongst the probabiilties of our therapeutical future I also count the prevention of congenital malformations, which, as has been shown, are more numerous than is generally known or presumed, and are often the result of an intrauterine inflammation. In a recent publication F. von Winckel (Samml. Klin. Vortr., 1904, No. 373) emphasizes the fact that the general practitioner or the path ologic anatomist sees only a small number, that indeed the majority is buried out of sight, or is preserved in the specimen jars of the obstetrician. The known number of malformations compared with that of the normal newly-born varies from one to thirty-six, or to one hundred and two or more. They are met with in relatively large numbers on the head, face and neck-altogether in 53.2 per cent of all the 190 cases of malformation observed in Munich during twenty years. A number of them is the result of heredity, of syphilis or other influences. How many are or may be the result of consanguineous marriages will have to be learned. In all such cases the treatment of the parents or the prohibition of injurious marriages should always be insisted upon. The number of those recognized as due to amniotic adhesions or bands is growing from year to year. Kümmel could prove that of 178 cases, 29 were certainly of that nature. External malformations have long been ascribed to them; proximal malformations, such as auricular appendices, harelip, anencephalia, cyclopia, flattening of the face, anophthalmia, hereditary polydactylia (Ahlfeld and Zander, Virchow's Archi., 1891), and lymphangioma of the neck have been found to be caused by amniotic attachments of filaments. Is it too much to believe that the uterus whose internal changes syphilitic or others are known to be ery accessible to local and general medication should be so influenced by previous treatment that malformations and fetal deaths will become less and less frequent?

The problem of the health and hygiene mainly of the older child refers to more than its food. The school question is in the foreground of the study of sanitarians health departments physicians and pedagogues.

Its

importatance is best illustrated by the large convention which was organized in Stuttgart April 1904 as an Inernattional Congress for School Hygiene. Pediatrists pedagogues and statemen formulated their demands and mapped out future discussions. Rational pediatrics would consider the following question: Is it reasonable to have the same rules and the same daily sessions for childern of eight and perhaps of fifteen years and for adolescents? Certainly not. The younger the child the shorter should be the session, the longer and more frequent the recesses. There should be no lessons in the afternoon or only mechaical occupations such as copying or light gymnastics. There should be no home lessons.

The problem of overburdening was carefully considered by Lorinser in 1836, and by many others since. It deals with the number of subjects taught, the strictness and frequency of official examinations, and should consider the overcrowding of schoolrooms. We should try to answer the question whether neuroses are more the result of faunty schooling or of originial debility, heredity, underfeeding, lack of sleep, bad domestic conditions, or all these combined. In Berlin schools they have begun to feed the hungry ones regularly with milk and bread. Νο compulsory education will educate the starving. The child that showed his first symptoms of nervousness when a nursling, the child with pavor nocturnus, or that gets up tired in the morning, or suffers from motor hyperesthesia, pointing or amounting to chorea unless relieved instead of being punished by an uninformed or misanthropic or hysterical teacher gets old or breaks down before the termination of the school term or of school age. There should be separate classes for the feeble, for those who are mentally strong, or weak, or of medium capacity. All of such questions belong to the domain of the child's physician, the physician in general. The office of school physician is relatively new. Whatever we have done in establishing it in America has been preceded by countries to which we are not in the habit of looking for our models. Bulgaria and Hungary have no schools without physicians. On the other hand, Vienna has none for its 200,000 school children. It is reported that the aldermen refused to appoint one. One of them objected for the reason that the doctor might be tempted to examine the Vienna lassies too closely. His business would be, and is, to look out for the healthfulness of the school building, its lighting, warming, cleanliness, the cleanliness of the children and their health, and that of the teachers. A tubercular teacher is a greater

danger to the children than those, who rarely expectorate, to each other. He would take cognizance of the first symptoms of infectious diseases, examine eyes, ears and teeth, and inquire into chronic constitutional diseases, such as rachitis and scrofula in the youngest pupils. He might undertake anthropometrical measurements and benefit science while aiding his wards. He would be helped in all these endeavors by the teachers who must learn to pride themselves on the robust health of their pupils as they now look for the accumulation of knowledge which may be exhibited in public examinations. They will soon learn what Christopher demonstrated that physical development greater weight and larger breathing capacity correspond with increased mental power joining to this the advice that a physical factor as well as, the intellectual one now entirely relied upon should be introduced in the grading of pupils. (Charles (Charles F. Gardiner and H. W. Hoagland Growth and Development of Children in Colorado -Transactions of the American Climatological Association 1903.)

Our knowledge of the physiology and pathology of the nervous system of all ages

would be defective without lessons derived from the fetus and infant. Amongst newly. born we have often to deal with arrests of development, such as microcephalus, or with that form of fetal meningitis or of syphilitic alterations of blood-vessels which may terminate in chronic hydrocephalus. When the insufficient development of reflex action in the newly-born up to the fifth or sixth week has passed, the very slow development of inhibition during the first half year or more, together with the rapid increase of motor and sensitive irritability explains frequency of eclampsia and other forms of convulsions. Many of them require, however, an additional disposition, which is afforded either by the normal rapid development of the brain, or the abnormal hyperemia of rachitis. The last twenty-five years have increased our knowledge considerably in many directions. Congenital or premature, complete or partial, ossification of the cranial sutures lead mechanically to idiocy, or paralysis, or epilepsy: it is a consolation. however, to know that the victims of surgical zeal are getting less in number since operators have consented to fear death on the operating table, and thoughtful surgeons have come to the conclusion to leave bad enough alone. In the very young the fragility of the blood-vessels, the lack of coagulability of the blood, the large size of the carotid and vertebral arteries, the frequency of trauma during labor and after birth, the vulnerability of the ear

Nose

and scalp, contribute to the frequency of nervous diseases, which before the fifth year amounts to a high percentage of all the cases of sickness. Rapid exhaustion leads to intracranial emaciation and thrombosis, the socalled hydroencephaloid of the gastroenteritis. The large size and number of the lymph vessels of the nasal and pharyngeal cavities facilitate the invasion into the nerve centers of infections which show themselves as tuberculous meningitis, cerebrospinal meningitis, and polioencephalitis, or more so, poliomyelitis, and aschortea of so-called rheumatic-mostly streptococci-origin. and throat specialists, as well as anatomists, have contributed to our knowledge on these points-another proof of the intimate dependency of all parts of medicine upon one another. Now all these conditions are not limited to early life, but their numerical preponderance at that time is so great that it is easy to understand that general nosology could not advance without the overwhelming number of well-marked cases amongst children. Amongst them are the very numerous cases of epilepsy. They escape statistical accuracy, for many an epileptic infant or child dies before his condition is observed, or diagnosticated; a great many cases of petit mal, vertigo, dream-like states and somnambulism, fainting, habit-chorea, truancy, imbecility, incompetency, or occasionally wild attacks of mania, or the perversity of incendiarism, or in older children religious delirium, even hysteric spells, are overlooked or perhaps noticed or suspected by nobody but the family physician; or, in the cases of the million poor, by nobody. They are cared for or neglected at home, and the seizure is taken to be an eclamptic attack due to bowels, worms, colds, and teeth, exactly like three hundred years ago.

Of equal importance in this disease to the pediatrist, the pedagogue, the psychiatrist, the judge, the statesman, no matter whether in office or a thoughtful citizen, is the influence of heredity. The old figures of Echeverria, which have been substantiated by a great many observers, tell the whole story. One hundred and thirty-six epileptics had 553 children. Of these, 309 remained alive; 78 (25 per cent) were epileptic; how many of the 231 that died had some form of epilepsy or would have exhibited it nobody can tell. He observed a dozen cases in one family. While in his opinion 29.72 per cent showed a direct inheritance from epileptic parents, Gowers has a percentage of 35, and Spratling, who has lived among epileptics nearly a dozen years, 66 per cent.

Epilepsy is acknowledged to be one of the causes of imbecility, or genuine idiocy. In

very many instances it should be considered as a coordinate result of congenital or acquired changes in the skull, the brain, and its meninges, and particularly the cortex. In a single idiot institution, that of Langenhagen, 15 per cent to 18 per cent of the 395668 inmates were epileptic; in another, Dalldorf, 18.5 per cent to 24.3 per cent of 167— 344; in a third, Idstein, 36 per cent of 101 (Binswanger, in Nothnagel, Syst. Path. u Ther., Vol. XII, 1,310).

Its main causes are central. External irritations, worms, calculi, genital or nasal reflexes, may be occasional proximate causes. But cauterization of the nares, and still more, circumcision, and clitoridectomy prove more the helplessness or recklessness of the attendant than the possibility of a cure The individual cases of recovery by the removal of clots, wounds, or tumors, are great and comforting results, but if epilepsy and its relations are ever to disappear, it is not the knife of the surgeon, but the apparatus of human foresight and justice that will accomplish it. Most of the causes of epilepsy are preventable. To that class belong syphilis and alcoholism in various generations, rachitis, tuberculosis and scrofula, many cases of encephalo-meningitis, and most cases of otitis. A question is attributed to a royal layman, "If preventable, why are they not prevented?" If there is a proof of what Socrates and Kant said, namely, that statesmanship cannot thrive without the physician, it is contained in the necessities of epilepsy. Prevention, preventives, and hygienic, medicinal, and surgical aids have to be invoked, unfortunately with slim results so far.

The influence of hereditary syphilis on the diseases of the nervous system has been studied these twenty years, both by neurologists and pediatrists. Its results are either direct -that means characteristically syphilitic or metasyphilitic that means merely degenerative. Hoffmann cured a case of syphilitic epilepsy in a girl of nine years in 1712. Plenk describes convulsions and other nervous symptoms depending on hereditary syphilis, and Nils Rosen de Rosenstein describes the same in 1781. The literature of the latter part of the eighteenth, and of the first half of the nineteenth century, is silent on that subject, though the cases of affections of the nervous system depending on hereditary syphilis are very frequent (13 per cent of all the cases, according to Rupmf, die Syph. Erk. d. Nervens, 1889). Jullien (Arch. Gen. 1901) reports 206 pregnancies in forty-three syphilitic matrimonies. Of the children, 162 remained alive. Half of them had convulsions or symptoms of meningitis.

According to Nonne (die Syph. d. Nervens. 1902) hereditary syphilis differs from the acquired form in this-that several parts of the nervous system are affected simultaneously; and that arteritis, meningitis, gummata, and simple sclerosis occur in combination. Simple cerebral meningitis and apoplexies are very rare. Encephalitis is more frequent. frequent. Probably spinal diseases are more frequent, according to Gilles de la Tourette, Gasne, Sachs, and others. Tabes dorsalis is not often found, but may rather depend on an atavistic syphilitic basis; for altogether the nerve syphilis of the second previous generation as a cause of disease in the young is not very rare. (E. Finger, W. Klin. Woch., 13. 1900.)

What we call neuroses are infrequent in infants and children. Neuralgias are not so common as in the adult, but would be more frequently found if sought for. Even adipositas dorosa has been observed in childhood. Hysteria is by no means rare, and its mono-symptomatic character, so peculiar to early age, adds to its nosological importance. Its early appearance is of grave import. Its often hereditary origin makes it a serious problem; under-alimentation or ill-nutrition, rachitis and scrofula, frequentiy connected with and underlying it, may make it dangerous and a fit subject for the study of educators, psychologists, judges, and all those whose direct office it is to study social and socialistic problems. Hysteria is not quite unknown amongst males, though the large majority are females.

Some of the vaso-niotor and trophic disturbances are less, others more frequent, in the young than in the adult. Amongst 129 cases of akroparesthesia there is only one of Frankl Hochwart in a girl of twelve years, and one of Cassirer in a girl of sixteen. Scleroderma is met with mostly in mature life, but the cases of Neumann at thirteen days, and those of Cruse, Herxheimer, and of Haushalter and Spillmann, who observed two cases in one family, all of them when infants were only a few weeks old, prove that the same influences which are at work in advanced age, namely. hereditary disposition, neuropathic family influence, low general nutrition, colds, trauma, and so on, may play their role in infant life. Nor are infant erythromelalgias numerous. Henoch saw one in a teething infant, Baginsky in a boy of ten, Heimann one in a girl of thirteen, Graves one in a girl of sixteen that means 3 or 4 cases below thirteen or sixteen years of age, out of a number of 65 collected by Cassirer in his monograph. (Die Vasomotorisch-trophische n Neurose, Berlin, 1901.) In half a century I have seen but one that occurred in early age,

namely, in a boy of twelve, who got well with the loss of two toes. On the other hand the symmetrical gangrene of Raynaud and the acute circumscribed edema of Milton and Quincke, 1882 (treated of by Collins in 1892), are by no means relatively rare in infancy and childhood. There are a few cases of the former that occurred in the newly-born. Two I have seen myself. There are those which have been observed at six months (Friedel), at nine months (De France), at fifteen months (Bjering), at eighteen months (Dick). In the year 1889 Morgan collected 93 cases, 13 of which occurred from the second to the fifth, 11 between the fifth and tenth, and 15 between the tenth and twentieth years. Amongst the 168 cases collected by Cassirer, 20 occurred below the fifth, 8 between the fifth and tenth, and 25 between the tenth and twentieth years of life. most nervous diseases, these cases had either congenital or acquired causes, amongst which a general neuropathic constitution, and the hereditary influence of alcohol, chlorosis, and anemia are considered prominent. Of acute circumscribed edema. 28 cases are found below nine years of age in Cassirer's collection of 60 cases, one of which at the age of one and a half months is reported by Crozer Griffith, one at three months by Dinckelacker. Again, hereditary influence is found powerful. Osler could trace the disease through five generations.

Like

The connection of pediatrics with psychiatry is very intimate. Insane children are much more numerous than the statistics of lunatic asylums would appear to prove, for there are, for obvious reasons, but few insane children in general institutions. It is only those cases which become absolutely unmanageable at home that are entrusted to or forced upon an asylum. The example of the French, who more than fifty years ago had a division in the Bicetre for mentally disturbed children, as seldom or not at all been imitated. Thus it happens that though not even minority of the cases of idiocy become known, its statistics are more readily obtained than that of dementia of early life. Some of its physical causes or accompaniments have been mentioned-asphyxia with its consequences, ossification and asymmetrical shape of the cranium, accidents during infancy and childhood, neuroses that may be the beginning or proximate causes of graver trouble. Infectious diseases play an important part in the etiology of intellectual disorders. Althaus collected 400 such cases. They were mainly, influenza 113, rheumatism 96, typhoid fever 87, pneumonia 43, variola, 41, cholera 19, scarlatina 16, erysipelas 11. In most of the cases there were predisposing

elements, such as heredity and previous diseases, or over-exertion of long duration. The overworked brains of school children were complained of as adjuvant causes of lunacy by Peter Frank as early as 1804. We are as badly off, or worse, a hundred years later.

There is one ailment, however, that appears to hurt children less than it does adolescents or adults, that is masturbation. There are those cases, fortunately few, which depend on cerebral disease and original degeneracy, but in the large majority of instances masturbation, frequent though it be, has not in the very young the same perils that are attended by it later on when the differentiation of sex has been completed and is recognized. Babies under a year, and children under eight or ten will outlive their unfortunate habit, and do not appear to suffer much from its influence. Whatever is said to the contrary is the exaggeration of such as like to revel in horrors. The same exorbitant imagination is exhibited in other statements. What Lom. broso and his followers have said of the faulty arrangement of the teeth, prognathic skulls, retracted nose, short and attached lobes of the auricle, as distinct symptoms of mental degeneracy, belongs to that class, and need not always be taken as the positive signs of insane criminality. There is so much poetical exaggeration and word painting in them that Lombroso and also Karfft-Ebing are the pets of the prurient lay public. In its midst there must be many who are anxious to believe with Lombroso that brown hair and eyes, brachycephalic heads, and medium size of the body characterize the insane criminal, if only for the purpose of scanning the hair and eyes and heads of their near friends and their mother-in-law's relatives.

It is certainly not true that, as Lombroso will have it, children are cruel, lazy, lying, thievish, just as little as according to him all savages are like carnivorous animals, and essentially criminal, while others are convinced that by nature they are amiable, like Uncas, and virtuous like Chingacook, and have been rendered savage only by the strenuuousness of conquering immigrants. Nor is it true that the idiot brain is merely arrested at a stage similar to anthropoid, or even saurian development, for it is less arrest of development than the influence of embryonal or fetal disease, beside maniotic anomalies that cause the irregularities of the encephalion.

Amongst the worst causes of idiocy is cretinism, both the endemic and the sporadic. Every cretin is an idiot, not vice versa. The endemic form could be prevented by State interference which would empty the stricken valleys; the sporadic depends on thyroidism,

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