there any recession of the supraclavicular or suprasternal regions?

The pulse, its volume and rhythm, its rapidity is not of so much importance. A slow, irregular pulse is almost always indicative of meningitis; a rapid, irregular one is not necessarily of serious import.

The condition of the skin is noted. Is it moist or dry? Are the extremities cold or warm? Is there any cyanosis? Are the fingers clubbed, as in tubercular tendencies? Are there any eruptions? And for this purpose the clothing should be removed, as it should be in all careful examinations. The diaper can usually remain on. Oftentimes the only eruption of scarlet fever will be noted on some part of the body covered by the clothing. The degree of emaciation or plumpness can now be noted.

As the cry of the child is its only means of expression, due attention and study should be given to it, as its character is of undoubted assistance as an aid to diagnosis. The cry is strung to a great many different tunes, and each one is significant. The cry of hunger is a short, heartrending one, which is relieved when anything is inserted into the mouth, and ceases when hunger is appeased. When crying from hunger there will be intervals in which the fingers are loudly sucked. The cry of indigestion resembles that of hunger, but is renewed soon after the hunger has been apparently relieved. The cry of intestinal pain is sharp and piercing,, and ends gradually in sobbing, and the child goes to sleep, only to start up suddenly and repeat it, the legs being sharply flexed. In earache, the common disorder of infants, the cry is of the same character, and can only be differentiated by the existence of other symptoms. Then there is the suppressed cry of pleurisy or pneumonia, accompanied by the catchy respiration. I have noticed another peculiarity in children in pneumonia, or in pleurisy, that the pain is often referred to the abdomen; if on the right side it resembles that of appendicitis, and is quite puzzling in the absence of a cough. The cry of weakness is a continuous whine which lasts during most of the waking hours. There is the cry of temper and habit. The former seldom occurs before the sixth or seventh month. It is accompanied by extension of the extremities and retention of the breath, and often frightens the young mother on account of the cyanosis that occurs. The cry of habit is the hardest to estimate. It comes from over-indulgence. The child cries to be held, to be carried, when it is wet to be put down, and from every imaginable cause. The babies in the Babies' Home invariably cry for several days after their admission, but if they receive attention at stated intervals they soon cease crying, but, on the other hand, if they are taken up

every time they cry, they keep it up indefinitely. So the only way to do is to let them cry until they are exhausted for several times, and then it

ceases.

The condition of the pupils and lids is important. If there is intolerance to light without elevation of temperature, or variation of pulse, a simple headache exists. If with these symptoms and added to them a dilatation of the pupils, the meninges are affected. In all febrile conditions of children the pupils are usually dilated. It should be noted if the pupils react to light. Also the presence of corneal ulcers and interstial keratitis, as is so common in hereditary syphilis. The glands at the side of the neck are factors to the diagnosis. They may indicate diphtheria, scarlet fever or simple adenitis, or, if several are inflamed and the others enlarged, probably they are tubercular. In diphtheria and scarlet fever usually the deep cervial are affected. In simple adenitis the superficial, cervical or submaxillary are the ones.

The presence of nasal discharge indicates either influenza, diphtheria or scarlet fever, or if it is chronic, syphilis; bloody mucus or pus from the nose is usually from diphtheria. In a large proportion of cases of diseases of children the history of the illness and intelligent observation by the physician will lead him to form a correct diagnosis, but a physical examination should not be omitted.

In regard to the temperature, I do not depend upon the sense of touch, but use a thermometer in the rectum to the age of five years, when they can hold it safely in the mouth. The heat regulation center in childhood acts so imperfectly that the temperature is affected by trivial causes. By personal observation in most children the daily range is from 98 degrees to 99.5 degrees, so unless the temperature is continuously elevated for a considerable time, it does not indicate anything. A simply rise occurs and in a few hours it is normal. In an illness lasting several days, or a wasting disease, when possibly the temperature is subnormal, the daily use of the thermometer is needful.

The experimenter has succeded in raising infants temperature one to five degrees by the use of artificial heat, hot bottles applied, and I have seen the hot air from a register raise the rectal temperature two degrees. These phenomena are hard to understand.

The examination of the urine should not be neglected. Diabetes is a rare disease in children, but it should not be forgotten that it may occur. I have never seen but two cases occuring in children under ten years of age, but in both it accompanied tubercular meningitis. I think a urinalysis should be made after all exanthemata and diphtheria. Many of those cases that are

so long in convalescing are due to albuminuria, and when I speak of the exanthemata, I mean not only scarletina but varicella, rubella and rubeola, and especially the latter. Measles should receive more careful consideration than is usually accorded it. The sequelæ are nearly as numerous and as severe as those that follow scarlet fever. In New York City last year more children under two years of age died of measles than from any other disease except intestinal troubles. I believe the disease should be quarantined.

Under the head of albumen in the urine I desire to relate a peculiar condition that came under my notice. A child four years old was recovering from an exhausting disease, and owing to some transient stomach trouble, nutrient enemas were given. These were com

posed of milk, egg and beef peptonoids. After the first enema I had cause to examine the urine and found an abundance of albumen, much to my surprise, as none had existed before. This was in the afternoon, the injection having been given at noon. The next morning, no albumen existed. Gave another nutrient enema and the albumen reappeared four hours afterward, tried it the following day with the same result. No more injections were given and there has been no more albuminuria. I do not pretend to explain why the albumen should so quickly appear in the urine after being injected into the bowels, but that it did so is unmistakable, evidently no nephritis existed.

By examination or the napkin one may determine if crystalline uric acid is deposited, or if the urine is highly concentrated. In male infants the urine may be gathered by a condom, and in females by a small dish placed under the diaper and the further elucidation of urinalysis may throw more light on children's diseases, especially the gastro-intestinal variety.

The examination of the thorax will call forth all one's ingenuity, but with a little patience can be accomplished. Of course the clothing should be removed and the atmosphere of the room. should be at least 72 degrees. The condition of the chest is noted, whether there are any deformities, as from rickets. If the expansion is symmetrical, or any bulging of the intercostal spaces. The chest wall is thinner than in an adult, owing to a lack of muscular developement, and more elastic on account of the cartilagenous condition of the framework. For these reasons all pulmonary sounds are puerile or exaggerated. Also the bronchi are relatively larger. A slight bronchial râle may be felt by palpation.

Percussion should be practised with warm hands, and done lightly. The percussion note is usually exaggerated, almost tympanitic, and in the infraclavicular region and between the

The

scapula there may be the cracked pot sound. Ausculation by the use of the ear applied to the chest is preferable to the use of the stethescope, as it does not frighten the child as much, and if one is used to that method it is as efficient. posterior part of the chest should be examined first, as usually the first signs of diseases are found there. Owing to the loud, almost bronchial respiration of children it will be necessary to compare that of both sides to avoid error. It should also be remembered that a child's breathing is often irregular, several long breaths, and then a few shallow, faint, quick ones. It is better that ausculation should be practised before percussion, as it is very difficult to do when the child is crying, and upon it usually depends the diagnosis.

In differentiating a bronchial râle from a pleuritic friction sound, it is sometimes necessary to cause the child to cry and cough and expel the mucus. Areas of consolidation may exist without affecting the percussion note on account of the surrounding emphysematous condition. Flatness always indicates fluid, but when there is fluid usually you also get bronchial breathing, somewhat different from that of consolidation, not quite so distinct.

The apex beat of the heart is usually in the mammary line, or just outside. Heart murmurs are rarely heard before the age of two years unless they are congenital. If the spleen can be felt below the ribs, it is enlarged, unless it is pushed down by a deformity of the chest. In acute diseases enlargement of the spleen means typhoid fever or tuberculosis. In chornic diseases, malaria, anæmia or syphilis. The liver is usually detected a finger's breadth below the ribs.

The condition of the abdomen should be noted; if it is retracted, as in meningitis, or if tympany exists, as in acute intestinal diseases or in rickets. Also determine if phimosis or balanitis is present. I have left the examination of the throat, as it seldom can be done without crying, and, therefore, should be deferred until the last in the examination, and then requires a good light and a quick glance, and often it is necessary to do it forcibly. Often the first signs of the eruption of measles or varicella are seen on the hard palate.

Redness of the fauces indicates either a simple pharyngitis or scarlet fever, although diphtheria may exist without a membrane.

Another important item in an examination is the rectum. It is very common for an ulcer or a fissure to exist. With a history of constipation, and especially if the child is restless and in pain after defæcation, the rectum should be examined. It often escapes the mother's notice, and she is surprised when it is pointed out. The

insertion of the finger and scraping the ulcer with your finger nail is usually all that is needed to effect a cure.

In the examination of children, trifles should be considered. The relative age, weight, size of cranium, mentality, etc. No harsh measures should be used if they can be avoided, and by tact as satisfactory a diagnosis can be made as in adults.

I feel as though I ought to offer an apology for this rambling talk. Some of it I have read, and most of it I have jotted down from observation, but it is only by telling such clinical experiences that they are of any benefit to others, so I may be pardoned.

PRESENT STATUS OF HEREDITY AND ITS RELATION TO TUBERCULOSIS.*

By W. A. Jones, M. D.,

Minneapolis.

By heredity is meant the tendency manifested by an organism to develop in the likeness of its progenitor, demonstrating the transmission of physical and mental characteristics from parent to offspring, regarded as the conservative factor in evolution, opposing the tendency to variation under conditions of environment.

Wilson says: "In its physiological aspect, therefore, inheritance is the recurrence in successive generations of like forms of metabolism, and this is effected through the transmission from generation to generation of a specific substance or idioplasm which we have seen reason to identify with cromotin."

The study of heredity involves study of cell growth and development, and the original germ is a single cell similar in its essential nature to any of the tissue cells composing the body.

Huxley says: "It is certain that the germ is not merely a body in which life is dormant or potential, but that it is itself simply a detached portion of the substance of a preëxisting living body."

That such a cell can carry with it properties or power to develop into a man or a mollusk, is one of the unexplained wonders of biological science.

Various theories have been advanced to clear up the mystery, and yet it is now but speculative.

The early theory of preformation, in which it was believed that the egg contained an embryo fully formed in miniature, was too absurd to last,

*Read before the Hennepin County Medical Society, December 6, 1897.

and it was not until 1839 that Schwann demonstrated the fact that the egg is a cell having the same essential structure as the other cells of the body.

The preformation theory, however, was not entirely discarded, but simply changed to a predetermined idea, or to what is now called germinal localization, in which His believed that every point in the embryonic region of the blastoderm must represent a later organ or part of an organ, and, on the other hand, that every organ developed from the blastoderm has a preformed germ in a definitely located region of the flat germ-disc or cytoplasm, with a definite molecular organism directly handed down from the parent.

Roux, in 1888, believed that he had demonstrated by his experiments that if one-half of a blastomere were destroyed, the uninjured half in some cases developed into a perfectly formed half larva. Later Roux, together with other writers, including De Vries, Hertwig and Weismann, sought for a final explanation of germinal localization, and narrowed the cytoplasmic theory down to the nucleus, and from this developed the

IDIOPLASM THEORY.

Nägeli considered inheritance as effected by the transmission, not of a cell, considered as a whole, but of a particular substance, the idioplasm contained within a cell and forming the basis of heredity. The idioplasm is supposed to have definite, peculiar, selective and dynamic properties, causing reaction on the part of surrounding structures, leading to definite chemical and plastic changes, i. e., to differentiation and development. This idioplasm is conceived to be a net-work which extends through the entire cell and from cell to cell throughout the body, and is identified with chromotin. It is also claimed that the idioplasm has its origin in the nucleus of a cell, and this is derived from both sexes, while the cytoplasm is derived from the female.

These two theories, germinal localization and idioplasm, can be traced back to Darwin's idea of pangenesis, in which he maintained that the germ-cell contained innumerable gemmules, each of which predetermined one of the adult cells; that they accumulated in reservoirs, and he thus explained the transmission of acquired characteristics.

The Roux-Weismann theory contends that the idioplasm or chromotin is a highly complex mixture of different substances beyond microscopic demonstration, representing different qualities and quantities, with a fixed architecture, which is transmitted from generation to generation and determines the development of the embryo in a definite and specific manner. This means that the original germ plasm is carried on unchanged in its final delivery to the nucleus.

This theory leaves out the possibility of regeneration. Repeated experiments have shown that if the power of regeneration is proven, the germ cell has not the qualitative properties claimed by these investigators.

Driesch, Hertwig and Wilson now agree that the initial cytoplasmic localization of the formative conditions is of limited extent, and determines only the earlier stages of development. With each forward step, new conditions, chemical differentiations and the like are established, which form the basis for the ensuing change, and so on in ever increasing complexity.

During this initial period various conditions may modify the nutrition or positon of the cell or its contents, thus accounting for stability and defect. The primary determining cause lies in the nucleus, the secondary in the metabolic changes in the cytoplasm, and the regularity or irregularity in its subsequent operations.

Various theories have been advanced as to the changes in the nucleus. Driesch has suggested that the nucleus is a storehouse of ferments which pass out into the rest of the cell, and perhaps set up or incite activity, growth and differentiation. It is also supposed that the nucleus loses in volume, or at least a portion of its chromotin, while the germ nucleus itself retains the ancestral heritage. At all events, the nucleus primarily incites changes in the cytoplasm, beginning in the youngest ovarian egg and proceeding continuously until the cycle of adult life has run its course.

"Every living organism at every stage of its existence reacts to its environment by physiological and morphological changes. The developing embryo, like the adult, is a moving equilibrium, a product of the response of the inherited organism to the external stimuli working If these stimuli be altered, developupon it. ment is altered." (Wilson.)

For the development to proceed in a normal and regular manner, the organism must be surrounded by normal conditions, and yet the external conditions are not always the cause of specific forms of development, and in some instances we are forced to conclude that an unusual stimulus will not change the fixed and apparently preformed and predestined character of the organism. The cell has two roles to perform, one morphological and inherent, the other constructive, and yet both are different phases of one process. If Nägeli's hypothesis is correct, that the nucleus is a complex, molecular substance made up of crystaline, doubly reflecting particles, each consisting of numerous atoms and impermeable by water, it would not be unreasonable to suppose that one cell or class of cells was destined to form the structure or framework of the body, while another set was to

It has been

preside over the various functions. supposed also, that if this latter class predominated, the individual so endowed would have less resistance, and thus be more apt to acquire tuberculosis. We might then explain some of the inherent qualities or characteristics which are the groundwork for latent possibilities. Although the entire cell body is essential in development, the nucleus alone suffices for the inheritance of specific possibilities.

When the question is asked as to the nature or structure of the cell and how it has been acquired, it is impossible to get away from some of the old ideas of heredity. To the first part of the question, all the hypotheses, or any of them, may seem to fit an individual case-the pangen theories of Darwin, Huxley, De Vries and Weisman, all of which are at bottom the theory of predetermination.

Driesch says: "What lies beyond our reach at present is to explain the ordinary rhythm of development, the coördinating power that guides development to its predestined end." But whatever theory we advance, Weismann believes that we are simply substituting for one difficulty, another of the same kind.

* *

"The truth is, that an explanation of development and inheritance is at present beyond our reach. What we know is, that a specific kind of living substance derived from the parent, tends to run through a specific cycle of changes, during which it transforms itself into a Dody like that of which it formed a part. The second question, regarding the historical origin of the idioplasm, brings us to the side of the evolutionists. The idioplasm of every species has been derived, as we must believe, by the modification of a preëxisting idioplasm through variation and the survival of the fit* We are utterly ignorant of the manner in which the idioplasm of the germ cell can so respond to the play of physical forces upon it as to call forth an adaptive variation, and the study of the cell has, on the whole, seemed to widen, rather than to narrow, the enormous gap that separates even the lowest forms of life from the inorganic world."

test.

*

*

However ignorant we are of the cell processes, we must admit that certain characteristics and defects are transmitted from one generation to another. The transmission may skip one generation and appear in the second or third, and this, we know, is the atavistic theory; but we cannot explain, nor is it necessary, perhaps, to know, how a cell can be transmitted through one generation without the development of its latent possibilities.

It seems hardly necessary here to call attention to the heredity of instincts, sense qualities, memory, imagination, intellect or passions, to

gether with a host of subordinate characteristics, or to dilate upon the indirect or collateral laws of heredity. There are a sufficient number of cases, familiar to us all, that illustrate this special line of heredity; but when it comes to the transmission of disease, there should be nothing strange or unexpected. Perhaps the difference is only in degree as to disease being, strictly speaking, hereditary or transmissible, and this brings us to the theory of predisposition. This cannot be strictly defined, neither is it of equal importance for all diseases. The fact that some individuals are attacked, and others equally exposed to danger escape, is not due to any special predisposition on the part of the former. Predisposition to disease, and particularly infectious disease, may mean that the germ has in some cases hit, and in others missed; but for diseases other than infectious, the supposition is that there is an inherent structural foundation, influenced only by succeeding environment. The assumption is clear that children born of psycho-neurotic parents may entirely escape mental or nervous diseases, if the early environment is changed or altered. In its broad sense, predisposition may be defined as a defect in the constitution which lessens resistance and is more liable to invasion of disease. Whether or not this predisposition is peculiar or applicable to tuberculosis, is still an unsettled question. Various authors with voluminous statistics have attempted to show that tuberculosis is inherited, and Goldsmith argues that "as the world was created, so is tuberculosis inherited."

Baumgarten advocates vigorously the doctrine that heredity as a casual faculty in tuberculosis is mainly inheritance of the bacilli, and not, as usually believed, inheritance of the soil or predisposition. Rare instances tend to prove this assumption, but the author cited fails to say definitely whether the disease was transmitted by the mother or from the father.

Gärtner has published some very extensive investigations, and he believes that there is inheritance of the specific germ of the disease; and, second, inheritance of a peculiar predisposition which favors the acquisition of the disease in after life, and that the predisposition is increased by all causes which produce a general or local weakness. It may depend upon mechanical causes, or upon chemical constituents of the cells and fluid and body. In opposition to Baumgarten, he maintains that there is a possibility only of fœtal infection in which the bacillus is transmitted from the mother to the foetus; but he furthermore concludes that tuberculosis is not transmitted directly from the father to the child, although it has been claimed by other authorities that the bacilli have been found in

the spermatozoa, and may thus directly affect the ovum.

Ribbert concludes that we must admit that a large number of interesting statistics may be utilized as points of support of the possibility of congenital transmission of bacilli, but that strict proof has been brought only for placental infection to account for congenital human tuberculosis. Infection in this way, however, is only a possibility, and that it does not occur as a rule, is proved by the fact that the offspring of tuberculous mothers are commonly born sound and free.

Klebs has shown that the intrauterine transmission of tuberculosis from an infected mother is one of the rarest occurrences, and as to transmission from the father, which alone can constitute demonstrable neredity, there is no proof at all. Gärtner showed in his inoculation experiments only one bacillus to be present in fourteen million spermatozoids, so that the chances for infection in this way are reduced to a minimum. It could not further be shown that spermatozoids ever incorporate bacilli. When it is considered that, on the one hand, the tubercle bacilli are so rarely found in the semen, and, on the other hand, that primary congenital tuberculosis is itself so rare, it may be concluded that tuberculosis is never conveyed to the foetus by the spermatozoids. Thus, practically, tuberculosis is not an inherited disease. I am aware that there are many opponents to this theory, and there are some claims which are apparently incontestable, that go to show that the spermatozoid may convey the bacillus, and that the tuberculous process may remain latent in the body a long time. This is the essential part of the hypothesis, that tuberculosis is often due to bacillar heritage; but, notwithstanding the increasing plausibility of this theory, there is a vast array of facts which tend to disprove it.

Solly, American Journal Medical Sciences for August, 1895, in his studies of two hundred and fifty cases, shows that there is a family history in one hundred and thirty-nine cases (parental seventy-two, grandparental nineteen, and collateral forty-eight), one hundred and eleven of acquired. He maintained that the connection between phthisis in an individual and phthisis in the family may be derived in one of three ways: First, inheritance of the bacilli; second, by way of susceptibility, and, third, by contagion.

If we look at inheritance from Nägeli's standpoint, that the nucleus is a complex substance, and that each part of the cytoplasm has a destiny to perform, how do we know that this substance may not contain the latent tubercular germ? or at least if it does not contain the germ, it is reasonably certain that the nucleus which