both to exhibit and disseminate the sense of responsibility to the sick and to the necessities of teaching. The United States has been the last country to participate in these endeavors. The mostly proprietary medical schools did not find pediatric teaching to their advantage, and it took the hearts and purses of the public a long time to be opened. The waves of humanitarianism, sometimes directed by a church, and the demands of science have finally overcome previous indolence. There are many general hospitals that gradually opened special children's wards. You find pediatric hospitals in some of the larger cities New York, Boston, Philadelphia, Albany, St. Louis, and others. It has so happened, however, that real specialties have appealed more to the general sympathy than pediatrics. That is why the number of beds in orthopedic and other special hospitals are mostly favored. Practical teaching has not been extensive. Children's hospitals that should be used for that purpose, and that are directly connected with a medical school, are but few. It has taken the medical faculties, even of universities, too much time to appreciate the necessity of special and wellregulated bedside teaching. In some instances lay trustees, guided by their medical advisers, have opened their wards before faculties have consented to open their eyes. the present time, however, there is hardly a great medical school that does not give amphitheatre or bedside instruction, either in a children's ward of a general hospital or in a special children's or babies' hospital. To a certain extent the teaching of pediatrics in a general hospital has its great advantages. It is not a specialty like that of a special sense or tissue. For the purpose of study it had to be segregated, but it will never be torn asunder from general medicine. Vogel and Gerhardt were both general clinicians.

At

The comparative anatomy and physiology, hygiene, etiology, and nosology of pediatrics have been discussed before you by one of the most prominent pediatrists of our era.* It will be my privilege to explain, as far as time will permit, its relation to general medicine, to embryology and teratology, obstetrics, hygiene, and private and public sanitation, to therapeutics, both pharmacal and operative, and to the specialties of otology, 'ophthalmology, dermatology. and the motor system, to pedagogy, to neurology and psychiatry, forsenic medicine and criminology, and to social politics.

Infancy and childhood do not begin with the day of birth. From conception to the termination of fetal life evolution is gradual.

See abstract of address by Prof. Dr. Escherich on page 848 of November number of Archives of Pediatrics.

The result of the conception depends on parents and ancestor. Nowhere are the laws of heredity more perceptible than in the structure and nature of the child. Physical properties, virtues and sins, and tendencies to disease may not stop even with the third or fourth generation. Hamburger and Osler trace an angioneurosis through six generations, the first case in the series being observed by Benjamin Rush. In many instances, still-births, early diseases, atrophy, and undue mortality of the young depend on antenatal happenings. The condition and diet of the mother influences her offspring. The danger of a contracted pelvis, and the necessity of premature delivery may be obviated by the restriction of the diet, or even by appropriate (thyroid and other) medication of the pregnant woman. Experience and experiment tell the same story. The continued practice of preventing conception causes endometritis. Alcoholism causes chronic placentitis, premature confinement, of still-birth. So does chronic phosphorus and lead poisoning. Fortunately, however, the usual medication resorted to during labor is rarely dangerous, for even morphine or ergot doses given to the parturient woman on proper indications affect the newly-born rarely, and chloroform anesthesia almost

never.

Scanty amniotic liquor, by the prevention of free intrauterine excursions, may cause club-foot; or close contact of the surfaces of the embryo and the membranes give rise to adhesions of the placenta and the head, to filaments and bands whose pressure or traction produces grooving of amputation of limbs, cohesion of toes or fingers, umbilical, meningeal, encephalic, or spinal hernia; not in extra-uterine pregnancy only, where such occurrence are very frequent. Even the majority of harelips and fissured palates have that origin. Arrests of development and fetal inflammation are the headings under which most of the anomalies of the newlyborn may be subsumed; congenital diseases of the ear and of the heart may result from either cause or from both. Obstructions of the intestines. the rare closures of the esophagus, the ureter, the urethra, with hydronephrosis and cystic degeneration of the kidneys are probably more due to excessive cell proliferation in the minute original grooves than to inflammation.

The insufficient closures of normal embryonic fissures or grooves explains many cases of spina bifida, many of encephalocele, most of the split lips and palates, all of porencephalus, bifid uvula and epiglottis, pharyngeal and thyroglossal fistula, the ommunications between the intestinal and urogenital

tracts, and the persistency and patency of the 'urachus.

Heredity need not show itself in the production of a fully developed disease. It exhibits itself normally either in equality or resemblances, either total or partial, of the body, or some one or more of its external or internal organs. In this way it may affect the nervous, the muscular, the osseous, or other tissues. That is why dystrophies in different forms, obesity, achondroplasia, hyperplasia, or atrophy may be directly inherited, while in other cases the disposition to degeneration only is transmitted.

Hereditary degeneracy is often caused by social influences. The immoral conditions created by our financial system make women select not the strong and hearty and the young husband, but the rich and old, with the result of having less vigorous children. Certain professions, the vocations of soldiers and mariners, and subordinate positions of employees in general, enforce complete or approximate celibacy, with the same result. The nations that submit to the alleged necessity of keeping millions of men in standing armies, are threatened with a degenerated offspring, for not only do they keep the strongest men from timely marriages, but they increase prostitution and venereal diseases, with their dire consequences for men, women, an progeny. Wars lead to the same result in increased proportion, for tens and hundreds of thousands of the sound men are slain or crippled, or demoralized. Those who are inferior and unfit for physical exertions remain behind and procreate an inferior race. Those who believe with Lord Rosebury that an empire is of but little use without an imperial race will always, in the interests of a wholesome civilization, object to the untutored enthusiasm which denounces the "weakling," and the "craven cowardice" of those who believe in the steady evolution of peace and harmony amongst men, and, in sympathy with the physical and moral health of the present and future generation, will prefer the cleanly and washed sportmanship of an educated youth to that of the mud-streaked and blood-stained manhunter.

A great many diseased conditions cannot be thoroughly understood unless they be studied in the evolving being. Tumors are rarely inherited, but many of them are observed in early life. Lymphonma, sarcoma, also lipoma and carcinoma, and cystic degeneration, are observed at birth, or within a short time after, and seem to favor Cohnheim's theory, according to which many owe their origin to the persistence in an abnormal location of embryonic cells. This theory does not exclude the fact that congenital

tumors my remain dormant for years or decades and not destoy the young.

So much on some points connected with embryology and teratology. The connection with obstetrical practice is equally intimate. Three per cent of all the mature living fetuses are not born into postnatal life this very day. To reduce the mortality even to that figure, it has taken much increase of knowledge and improvement in the art of obstetrics to such an extent that it has become possible by Cesarean section not only to save the fetus of a living, but also of a dead mother, for the fetus in her may survive the dying woman.

But after all, many a baby would be better off, and the world also, if it had died during labor. There are those, and not a few, who are born asphyxiated on account of interrupted circulation, compression of the impacted head, or meningeal or encephalic hemorrhage, which destroys many that die in the first week of life. Those who are not so taken away may live as the result of protracted asphyxia only to be paralytic, idiotic, or epileptic. Many times in a long life have I urged upon the practitioner to remember that every second added to the duration of asphyxia adds to the dangers either to life or to an impaired human existence. Besides fractures, facial or brachial paralysis, cephalhematoma and hematoma of the sternocleidomastoid muscle, gonorrheal ophthalmia, with its dangers to sight and even to life, may be daily occurrences in an obstetrician's life. All such cases prove the insufficiency of knowledge without art, or of art without knowledge, and the grave responsibility of the practical obstetrician. To close a newlyborn by death causes at least dire bereavement: to cripple his future is not rarely criminal negligence.

Within a few days after birth the obstetrician or the pediatrist has the opportuniy of observing all sorts of microbic infections, from tetanus to hemorrhages or gangrene, and the intense forms of syphilis. Not an uncommon disease of the newly-born and the very young is nephritis. It is the consequence, in many cases, of what appears to be a common jaundice, or of uric acid infarction, which is the natural result of the sudden change of metabolism. The diverticula of the colon, as described by Hirschsprung and Osler, and what nearly forty years ago I characterized as congenital constipation, which depends on the exaggeration of the normally excessive length of the sigmoid flexure, belong to the same class. Their dangers may be avoided when they are understood. the infectious diseases of the embryo and the fetus, it is principally syphilis that

Of

should be considered; amongst the acute forms variola and typhoid are relatively rare.

What I have been permitted to say is enough to prove the intimate interdependence and connection between pediatrics and the diseases of the fetus, with embryology and teratology, obstetrics, and some parts, at least, of social economics.

The

After birth there are anomalies and diseases which are encountered in the infant and child only. There are also, common to all ages, though mostly found in children. such diseases as exhibit a symptomatology and course peculiar to them. The first class, besides those which are seen in the newlyborn, is made up mostly of developmental diseases-scrofula, rachitis, chlorosis. actual or alleged ailments connected with dentition, most forms of stomatitis, Bednar's so-called aphthae, the ulceration of "epithelial pearls" along the raphe, amygdalitis, pharyngitis, adenoid proliferations, lateroand retro-pharyneal abscesses belong here. Infectious diseases, such as variola, diphtheria, scarlatina, measles, pertussis, and tuberculosis of the glands, bones, joints, and peritoneum have been most successfully studied by pediatrist or those clinicians who paid principal attention to pedology. Meissner prints the titles of more than 200 actual monographs on scarlet fever published in Europe before 1884. Pleurisy and pneumonia of the young have their own symptomatoloy. Empyema is more frequent and requires much more operative interference. Tracheotomy and intubation are mostly required by the young, both on account of their liability to edema of the larynx and to diphtheria, and of the narrowness of the larynx. Of invagination, 25 per cent occur under one year, 53 per cent under ten. Appendicitis, sometimes hereditary and a family disease, would long ago have been recognized as a frequent occurrence in the young if it had not been for the difficult, mainly encountered in the young, and sometimes impossibility of its diagnosis. That is what we have been taught by Hawkins and by Treves, and lately by McCosh. Operations on glandular abscesses, osteotomies, and other operations on the bones and joints, particularly in tuberculosis, and on malformations, such as have been mentioned, require the skilful hand of the operating physician in a great many instances. Omphalocele, exstrophy of the bladder, undescended testicle, spermatic hydrocele, multiple exostoses, imperforate rectum, atresia of the vagina, or an occasional case of stenosed pylorus, belong to that class, some requiring immediate operation, some permitting of delay. It is principally infancy that demands removals of anigoma,

which are almost all successful, and of hygroma, mostly unsuccessful, mainly when situated on the neck and resulting from obstruction of the thoracic duct sometimes connected with thrombosis of the jugular vein. Childhood requires correction of kyphosis and scoliosis, and operations for adenoids and hypertrophied tonsils, and furnishes the opportunities for lumbar puncture and for laparotomy in tubercular peritonitis; also suprapubic cystotomy, and mastoid operations. That gum-lancing is no operation indicated or permissible in either the young or adult, and not any more so in the former than in the latter, is easily understood by those who acknowledge its necessity only in the presence of a morbid condition of the gums or teeth, and not when the physiological process of dentition exhibits no anomaly. It scarcely ever does. Altogether, operating specialists would work and know very much less if a large majority of the cases were not entrusted to them by the pediatrist, who recognizes the principle that those who are best fitted to peform it should be trusted with important medical work. So well is the seriousness and difficulty of operative procedures, that 1,500 pages of Gerhardt's handbook are dedicated to external pathology and operations, and that special work, besides many monographs by hundreds of authors, have been written by such masters as Guersant, Forster, Bryant, Graldes, Holmes, St. German, Karewski, Lannelongue, Kirmisson, and

Broca.

Ear specialists recognize the fact that otology is mostly a specialty of the young. The newly-born exhibit changes of epithelial detritus, to the aspiration of foreign material, or to an edema ex vacuo occasioned by the separation of formerly adjacent mucous surfaces. Pus is found in the middle ear of 75 per cent of the still-born, or of dead nurslings. It contains meconium, lanugo, and vernix. Aschoff* examined fifty still-born, or such as had lived less than two hours; twenty-eight of them had, pus in the middle ears 55 (per cent). He also examined thirty-five infants that had lived longer than two hours; twenty-four had pus (70 per cent). Evidently the latter class had been exposed to a microbic invasion. The diagnosis in the living infant is very difficult, mostly impossible, on account of the large size of the Eustachian tube, which, after having admitted the infection, allows the pus to escape into the pharynx and the rest of the alimentary canal. Many of the newly-born that die with unexplained fevers perish from the septic material, or its toxins, absorbed in the middle ear or the intestines. Nor are Aschoff, Zeit. f. Ohrenh. Vol. xxxi.

older children exempt. Geppert (Jahrb. f. Kind., Vol. xlv, 1897) found a latent otitis media in 75 per cent of all the inmates of the children's hospitals. Both latent and known otitis is often connected with pneumonia, or with pneumonia and enteritis. In individual cases it may, however, be difficult to decide which of the two or three is the primary, which the secondary affection.

The great vascularity of the middle ear, but still more the accessibility of the funnel-like Eustachian tube in the infant, renders otitis media very frequent. Schwartze's assertion that otitis media furnishes 22 per cent of all ear cases in general or special practice surely is correct. Besides, difficult hearing is very frequent in the young, a fact of the greatest import to pedagogy. As early as 1886 Bezold found that of 1,900 school children 25. per cent had only one-third, and 11 per cent of the others only one-fifth of normal hear. The frequent affections of the nose and pharynx in the young explain these facts and exhibit the possibilities of preservation. Finally, the immature condition of the mastoid process and of the floor of the external canal is best appreciated by the practitioner, general or special, who deals with their abscesses.

Whether deafmutism is the result consanguineous marriage cannot be definitely asserted. It is not often hereditary, quite often it appears to be the result of family alcoholism, it sometimes depends on arrest of development and fetal inflammation, but is more frequently an aquired condition. Not rarely children are affected after they have been able to speak. The majority of cases are caused by cerebral or cerebrospinal inflammation. According to Biedert, 55 per cent are of that class, 28 per cent are caused by infectious diseases (cerebrospinal meningitis, scarlatina, typhoid fever, diphtheria, also variola and measles), 33. per cent by injuries, and only 2.5 per cent are original ear affections. Thus many of the congenital cases, and most of the acquired, are preventable. More and more will our deaf-mute institutions avail themselves of this knowledge, and will learn how to teach their children not only how to read and write, but also how to hear.

Not to the same, but to a great extent, pediatrics and ophthalmology join hands. Infectious diseases, such as diphtheria, affect the conjunctiva and sometimes the cornea. Syphilis of the cornea with or without chronic iritis, is known in the form of parenchymatous or diffuse keratitis. A frequent tumor in the eye of the young is glioma, and frequent symptomatic anomalies are strabismus and nystagmus-both of them results of a great many and various external or in

ternal causes, with sometimes difficult diag

noses.

The connection of pedology with dermatology is more than skin deep; some of the most interesting problems of the latter must be studied on antenatal and postnatal lines. The congenital absence of small or large parts of the surface is probably due to amniotic adhesions; seborrhea and the mild form of lichen, also the furunculosis of infant cachexia and atheroma, to the rapid development, in the second half of intrauterine life, of the sebaceous follicles; ichthyosis to the same and to a hypertrophy of the epidermis and the papillae of the corium sometimes with dilatation of their blood-vessels and with sclerosis of the connective tissue. Congenital anomalies such as lipoma, sarcoma, nevus pigmentosus open all the questions of the embryonal origin of neoplasms; and the eruptions on the infant surface unclose to the specialist the subject of infectious diseases. We recognize in the pemphigus of the palms and soles syphilis; in herges, gangrene, and what I have described as chronic neurotic pemphigus, the irritable nervous system; in eczema, constitutional disturbances of the nutrition; in erythema, local irritation or intestinal autoinfection; in isolated or multiple forms, ranging between hyperemia and exudation, the effect of local irritation or the acute or chronic influence of drugs. A dermatologist who knows no embryology or pedology, a pediatrist who knows no dermatology, is anything but a competent and trustworthy medicla practitioner.

The diseases of the muscles interest the pediatrist, the surgical specialist, the orthopedist, the neurologist, to an equal extent.

Many forms of myositis are of infectious origin. Amongst the special forms of muscular atrophy it is the hereditary variety which concerns the first. The spinal neuritic atrophy, the myogenous progressive dystrophy, including the so-called pseudo-hypertrophy, Thomson's congenital myotonia, and (atrophy) the defects of muscles-mainly of the pectoral, but also the trapezius, quadriceps and others-no matter whether they are primary or myogenous (this probably always when there is is a complication with progressive dystrophy), are of special interest to all. I need not do more than mention torticollis in order to prove that neither the special pediatist, nor the special orthopedist, nor the general surgeon, can raise the claim of ownership.

The relations of pediatrics to forensic medicine are very close. Nothing is more apt to demonstrate this than the immense literature in every language on infanticide and the questions of physiology, physics, and chem

istry connected with that subject. The mon-. orgaphs and magazine essays of the last two centuries written on the value or the fallacy of the lung test in the dead newly-born would fill a small library. Much attention has been paid by physicians and by forensic authors to lesions and fractures of the newly-born head, and to anomalies of the female pelvis causing them. Apparent death of the newly-born and the causes of sudden death in all periods of life have been studied to such an extent as to render negative results of police investigation and of autopsy reports less numerous from year to year. Most sudden deaths receiving attention of the authorities occur in the young. There were (Wm. Wynn Westcott in Brit. Med. Jour., November 7, 1903) in England and Wales during ten years 150,009 overlain infants; in 1900, 1,774. In Liverpool, out of 960 inquests there were 143 on babies that had died of such suffocation by accident or malice aforethought; in London, in 1900, 615; in 1901, 511; in 1902, 588 In London they had annually 8,000 official inquests, one of fourteen of which was on overlain infants. The etiology of sudden deaths would be far from complete, indeed the most difficult questions could not be solved except by the facilities furnished by the observations on the young. Foreign bodies in the larynx, beans, shoe-buttons, and playthings generally, even ascaries (Bouchut,) bones and pieces of meat, aspirated during vomiting, acute edema of the glottis, aspiration of a long uvula, or of the retracted tongue, the rupture of a pharyngeal abscess or of a suppurating lymphoid body into the trachea, a sudden swelling of the thymus in the narrow space between the manubrium and vertebral column, which at best measures only 2.2 cm., even a corzya in the narrow nose of a small infant filled or not with adenoids are causes of sudden death.

The nervous system furnishes many such cases. It is true there is no longer a diffuse interstitial encephalitis, such as Jastrowitz would have it, nor is the hypertrophy of the brain so frequent by far as Hüttenbrenner taught, but there are sudden collapses and deaths by falls on the abdomen, by sudden stragulation of large herniae and other shocks of the splanchnic nerve. There are sudden and unexplained deaths in unnoticed attacks of convulsions, in the first paralytic stage of laryngismus stridulus, in glottic spasms from whatever cause, in the paralysis-or, according to Escherich, laryngospasm of what Paltauf has been denominated status lymphaticus, in cerebral anemia, no matter whether it is the result of exhaustion or, as Charles West taught us sixty years ago, from the mere change of position of a pneumonic or other

wise sick baby, when suddenly raised from its bed. its bed. Or, death may occur suddenly (a very frequent occurrence) in the heart failure of parenchymatous degeneration of the heart muscle as it occurs in and after diphtheria, influenza, and other infectious diseases, or in the acute sepsis of appendicitis and other intraperitoneal affections, whether recognized or not. For the absorbing power, even of the normal peritoneum, is enormous. Of a very acute infection ("infectio acutissima"), Wernich spoke as early as 1883.

In gastroenteritis, the terminating bronchopneumonia may destroy life quite suddenly; there is a capillary bronchitis of the very young with no cry, no moan, and no cough, but with sudden death; there are in extreme atrophy fatal emboli into the pulmonary, sometimes renal, more often cerebral, arteries. There are the cases of uremic convulsions, sudden, with sudden death, which are often taken to be merely reflected or "providential," because the frequency of acute nephritis in the newy-born and the infant, with is fever and itts uremia, in spite of the publications of Martin and Ruge, Virchow, Orth, Epstein, and my own, is not yet fully appreciated. That is so much the more deplorable as the diagnosis of nephritis at any age is readily made by the examination of the urine, which is so easy to obtain in the young. Other suddenly fatal conditions, such as the acute or chronic sepsis I mentioned before, often quite unsuspected, entering through the umbilicus, the intestine, or the middle ear, are quite frequent.

I have been careful not to mention any cause of death that may just as well be and has been studied in the adult; hemorrhages, the many forms of sepsis of later periods of life, poisons, such as carbolic acid and iodoform, intense cold or heat, insolation, etc., for it is my duty to exhibit the relation to forensic medicine of pediatrics only. Forensic medicine has to guard the interest of all. Nothing in all medicine is more difficult than the discovery of the cause of death. The best knowledge of the advanced practitioner, of the pathologist, of the chemist, of the bacteriologist, of the obstetrician, should be at the service of the people. Every European country understands that and acts on that knowledge. Our own Massachusetts has broken away from the coroner's institution, which was a fit authority for a backwoods municipality, but is so no longer, even an expert, or a body of experts, does not succeed in discovering the cause of death. What shall we say of a system which now and then does discover the hidden cause of a sudden death? When the New York State Legislature half a year ago passed a bill abolishing