Heart and Blood Vessels 
in the Young. 
BY 
A. JACOBI, M. D„ 
NEWYORK. 
Address before the Association of the Alumni of the 
Long Island College Hospital, Feb. 27, 1888. 
Reprinted from The Brooklyn Medical Journal, March, 1888. 
NEW YORK; 
M. J. Rooney & Co., Printers, Broadway & 35th Street. 
1888. HEART AND BLOOD VESSELS 
IN THE YOUNG. 
A. JACOBI, M. D., 
NEWYORK. 
Address before the Association of the Alumni of the Long Island College 
Hospital, February 27, 1888. 
The blood of the advanced foetus and newly born is more concen- 
trated than that of the mother. It contains mainly more haemoglobin; 
therefore, according to the simple rules of osmosis, a surplus will pass 
from the maternal vessels of the placenta to the foetal. These, when 
entering the foetus, will leave some of the blood introduced and re- 
quired for the development of the foetus in its tissues. Thus it is cer- 
tain that the two umbilical arteries cannot export so much blood as the 
single vein imports. 
The haemoglobulin of the blood contained in the umbilical artery 
amounts to 22.2 per cent, of the whole quantity of solid constituents, 
while in the venous blood of the mother it is but 13.99 per cent. The 
first to prove this high percentage was Denis, who found in 1830 the 
correct proportions by determining the quantity of iron contained in 
the blood. 
No less is the blood of the newly born different from that of the 2 
adult and even the infant. Poggiale studied hsemoglobulin in the new- 
born and the full grown dog, and found 16.5 in the solid constitu- 
ents of the blood of the former compared with 12.6 per cent, in that 
of the latter. Wiskeman’s results are similar. It is only in advancing 
age that the haemoglobin which rapidly diminished in infancy, begins 
to increase again, but it does so slowly. In calves and oxen the pro- 
portion is 11.13:13.21 per cent. Denis found it diminishing until the 
age of six months, and increasing slowly up to the thirtieth year, 
Leichtenstern found the following proportions : If the blood of the 
newly born contain hsemoglobulin. 100, that of a child of from six 
months to five years contains 55 ; of from five to fifteen years, 58 ; be- 
tween the ages of fifteen to twenty-five, 64 ; from twenty-five to forty- 
five, 72; from forty-five to sixty, 63. (Subotin also found less in 
young animals than in old ones; also less when the amount of nitro- 
genous food was diminished.) The percentage of hsemoglobulin 
decreases mostly in the very first two weeks. It is lowest at the age of 
from six months to six years ; after that time a slow increase is taking 
place. But even in the very vigor of life, in the third and fourth 
decades, the percentage of hsemoglobulin is smaller than in the newly 
born. 
There are some more differences, depending on age, in the compo- 
sition of the blood, more or less essential. The foetal blood and that 
of the newly born contain but little fibrin, but vigorous respiration 
works great changes in that respect. Nasse found the blood of young 
animals to coagulate but slowly. How this is in the infant, cannot be 
determined until more and better observations will have been made. 
It has struck me, however, in many instances of cerebral apoplexy of 
the newly born that the time for coagulation of the blood must be 
longer than in adult; for the haemorrhages are apt to be most exten- 
sive in the infant. In the sanguineous tumor, kephalhsematoma, of the 
newly born, the blood remains liquid in the sac for many days, and 
not uncommonly will, in apoplexy, spread all over the hemispheres, 
have plenty of time to perforate and penetrate the pia in all directions, 
destroy most of the cerebral tissue, and flow down the spinal cavity. 
These occurrences are so frequent in the infant, and so rare in the 
apoplectic adult, that they can hardly be explained except through the 
insufficient coagulability of the foetal and infant blood. 
There are less salts in the blood of the young, and, according to 
Moleschott, more leucocytes. Its specific gravity in the young is 1045- 
1049; in the adult, 1055. At the same time it is important to recol- 
lect that the total amount of the blood contained in the newly born is 
smaller in proportion than in the adult, the relation of its weight to 
the total weight of the body being in the former, 1:19.5 ; in the latter, 
1:13. 3 
The brief results of the above statements are as follows : The 
young infant (and child) has less blood in proportion to its entire 
weight; this blood has less fibrin, less salts, less haemoglobulin (except 
the newly born), less soluble albumen, less specific gravity, and more 
white blood corpuscles than the blood of advanced age. While these 
facts may require a few considerations later on, a single remark may 
be bestowed on one of the results of an undue amount of blood in the 
circulation of the newly born. 
Weber and Hewitt look for the explanation of many cases of icterus 
in the newly born in the condition of the hepatic circulation. When 
the lungs are in a more or less atelectatic condition, the liver is in a 
state of passive congestion. Then the dilated vessels compress the 
biliary ducts. The same result, that is, jaundice in the newly born, is 
accomplished by an overdue amount of blood in the general circula- 
tion. When the mass of blood circulating in the newly born has been 
increased by pressing out the placenta, and applying the ligature late, 
jaundice will follow. 
The function of the heart begins in the third week after conception. 
Its beats are very irregular at first, become soon regular, but remain 
very frequent until birth. As late as 1822, a surgeon of Geneva, 
Switzerland, Mayor, utilized the knowledge previously obtained, of the 
existence and audibility of foetal heart beats for a practical purpose. 
Until that year no obstetrician knew whether the foetus during parturi- 
tion was still alive or already dead, and the indications for accelerating 
delivery because of danger to the foetal life did not exist. At a later 
period, it was Frank enhauser who tried to predict the sex of the infant 
by counting the number of the foetal heart beats before birth, or rather 
before labor pain had commenced. He believed to have found that 
a foetal pulse, when nearer 124 than 144 in a minute, belonged to a 
male child, and vice versa. I fully believe he was not so often mis- 
taken, as his successors assumed. In a great many cases his experi- 
ence holds good, but the examination must be made before labor sets 
in, and in an afebrile condition of the mother. I know that when I 
still attended a great many obstetrical cases, many years ago, I was 
seldom mistaken in the prediction, based on Frankenhauser’s prin- 
ciple, of the sex of the child, provided I did not make my examina- 
tion when the pulse was disturbed by causes due to changes in either 
the foetus or mother. 
The absolute weight of the heart, at different ages, has been studied 
by many observers, mostly by Boyd, who published his investigations 
in 1861. They refer to 1,007 males and 1,038 females in Marylebone 
Infirmary, and 295 males and 233 females in the Insane Asylum of 
Somerset, and extend over the nine years from 1839 t° 1847. 4 
The weights of the heart are, mostly according to Boyd : 
In the new-born, - - - 20.6 grammes. 
1 y2 years, - - - - 44-5 “ 
3 “ - - - - 60.2 “ 
- 72.8 “ 
“ - 122.6 “ 
i 7 “ - ' - 233.7 
24.5 “ - 270.6 “ 
35 - 3°2- 9 
41-50 “ - 303.0 
51-60 “ - 316.6 “ 
61-70 “ - - - - 331.8 £‘ 
71-80 “ - - - -320.8 “ 
81 - 3°3- 5 
Thus the proportion of the weight of the heart to that of the body 
exhibits ■no extraordinary differences in the several ages; and the 
mechanical labor required to supply the body, or any part of it, with 
blood is therefore about the same in the young or old. Still there are 
differences. The yearly increase of the weight of the heart is largest in 
the first few years during the most intense growth, a little less about the 
fourth and fifth years, and again larger about the period of puberty. 
After this time the annual increase becomes smaller, still it continues 
until the time of senility. The absolute weight increases until the 
seventieth or eightieth years, after which it decreases a little, always 
provided that 'the atheromatous changes in the arteries, which occur 
more or less normally about and after the fortieth years, are not of 
such an importance as to result in hypertrophy of the heart. 
Though the limited time at my disposal cannot permit me to refer 
extensively to the literature of the subject, my account would be quite 
incomplete if I did not allude to at least a single book which, by its 
immense material and careful sifting, has vastly added to our knowl- 
edge. I speak of W. Muller’s treatise on “The Proportions of the 
Volume of the Human Heart,” 1883. From the large amount of infor- 
mation contained on its 220 pages, I give a few points full of sugges- 
tions. 
The absolute and proportionate weight of the heart of the embryo 
is very great. As soon as the extensive circulation of the allantois 
ceases, the heart of the embryo increases ’ rapidly. It has not only 
to supply the growth of the body to which it belongs, but also the cord 
and placenta. Thus the increase in weight of the heart is mainly per- 
ceptible in the first half of embryonic life without any difference as to 
sex. The latter does not show its influence before the completion of 5 
the fifth year. Though, however, the increase of the heart is mainly 
noticeable in the earlier months of embryonic existence, it is quite 
marked in the later period also, for it is at this time that the permanent 
organs of the body come in with their claims on circulation and nutri- 
tion. Thus the proportion of the heart to the rest of the body is 
largest about the time of birth, remains stationary for a little while, 
and takes a new start about the end of the second or during the third 
month with the greater extent of the surface of the infant body. The 
increase in weight is mainly confined to the ventricles, for the auricles 
lose in proportion to the ventricles up to the period of completed de- 
velopment of the adolescent. At that time the auricles begin to increase 
noticeably. Still, though the relative weight may diminish, their abso- 
lute weight is growing constantly during life. In the embryo it is the 
muscular mass of the right auricle which predominates over the left. 
From the beginning of the second month after birth, and during the 
whole of the first year, the right and left auricles are equal. After that 
time the right auricle continues to outrank the left, so that during and 
after puberty its weight is larger by 5.5 per cent. The right ventricle 
is extremely active during its embryonic development, because of the 
existence of the placentar circulation, the accumulation of large quan- 
tities of blood, and the patency of the foramen ovale through which 
large amounts of blood are repelled into the right heart. The equality 
of both auricles during infant life is due to the absence of great mus- 
cular exertions, and the renewed increase of the right auricle during 
later life to the effect of muscular action on the distribution of the 
blood. 
The proportion of the size and weight of the heart to the body at 
large is about the same in the later months of the foetus and the earlier 
of the infant. But the relations of the right and left ventricles to each 
other become greatly altered immediately after birth. This change is 
very marked during the first two weeks. Its cause is evident. It is 
true the heart is relieved in the moment of birth of its placentar circu- 
lation, and by the large amount of blood aspirated by the lungs which 
begin their life-long work ; but this relief—which remains permanent 
for the right ventricle—is outbalanced for the left ventricle by the 
organs of the body, whose claims on the action of the heart are either 
increased—thus intestines and the large glands, also the kidneys and 
nervous system—or entirely newr, like the skin with its new function 
of radiation, and the respiratory organs with their rhythmical motion. 
The effect on the function of the left ventricle, and its increase in size, 
becomes particularly great when the involution of the ductus arteriosus 
Botalli has become perfect after the 'first month. The relation between 
the right ventricle and the left becomes permanent about the time of 6 
erect walking. At that time, and later, and without difference as to 
sex, the proportions of the former to the latter is as 507 to 1,000 ; that 
means the right ventricle has half the weight of the left. 
What I said of the predominance of the right heart over the left 
during foetal life, a predominance which is the result of the right heart 
being the principal motor in foetal circulation, gives the simple clue 
to the fact that its physiological action is liable to become pathological. 
The large majority of foetal diseases of the heart are met with in the 
right auricle and ventricle. It is only after birth, and mainly in 
advancing years, when the physiological predominance of the left heart 
has become established that in it cardiac disorders are almost exclu- 
sively found. 
The normal proportion of the weight of the right and left heart— 
-507 : 1,0 o—is disturbed by such morbid conditions only, which 
terminate in unilateral or bilateral actual hypertrophy. This is by 
no means rare in children ; for acute endocarditis and acquired valvu- 
lar diseases are with them quite frequent. If, in your experience, it 
has struck you that they are often encountered about the fifth year, 1 
beg you will remember that this is exactly the time in which the growth 
of the child's heart has become temporarily less, and the disproportion 
between its size and the claims to be satisfied—that is, the necessities 
of circulation and nutrition—are quite as urgent as before. 
However, the temptation to make the diagnosis of cardiac hyper- 
trophy is still greater than its actual occurrence; for the heart’s dull- 
ness is liable to be extensive under normal circumstances. 
In twelve healthy children of from three to eight years, Gerhardt 
found the cardiac dullness almost as large as in adults ; that is, longi- 
tudinally, along the margin of the sternum, centimetres ; trans- 
versely, 5 centimetres. Dullness commenced about the third or fourth 
rib, its height equalled half the length of the sternum ; the impulse was 
often found beyond the mamillary line, and not infrequently in the fourth 
intercostal space, for the diaphragm stands higher in children than in 
adults. Thus the absolute cardiac dullness is proportionately larger 
and higher, the reverse of what is found in old age. This is most per- 
ceptible about the sternum. Along its right margin the cardiac dull- 
ness is very much more marked in children than in adults. Its location 
is changed by turning the child on its side, but not by its sitting up or 
lying down. It is particularly the inferior margin of the dullness which 
is not altered by changes of posture. 
Abnormal shapes of the thorax are frequent causes of increased 
dullness. As soon as the shape of the chest ceases to be elliptical, and 
becomes quadrangular or triangular in consequence of previous pleu- 
ritic adhesions or rhachitic deformity, the heart touches a level surface 7 
instead of an arch, its dullness is apt to give the impression of enlarge- 
ment, and its more distinct impulse that of hypertrophy. 
Diminution or complete absence of cardiac dullness in its normal 
location is found in different conditions : when theu heart is congeni- 
tally situated in the right half of the chest; when there is, on the left 
side, pneumothorax with enlargement of thoracic cavity and changes 
in the location of neighboring organs; in emphysema; in pneumo- 
pericardium. 
Though I am not permitted, in the limited time at my disposal, to 
lose myself in the consideration of pathological subjects, I still be- 
lieve that the allusion to a few anatomical differences in the heart of 
early infancy and more advanced age has been found acceptable. Such 
differences are, however, not confined to the heart; the blood vessels 
share in the peculiarities which render the study of the foetus, infant* 
and child so interesting. It is in the observation of gradual develop- 
ment, and the kaleidoscopic changes of lively growth, wherein lies the 
greatest fascination. 
Quite an abnormal position is reserved by nature to the blood ves- 
sels connecting the mother and foetus in the umbilical cord. The}' are 
two arteries and one vein. The former are the continuations of the 
two hypogastric arteries which ascend—along the urinary bladder—to 
the anterior abdominal wall, in the loose connective tissue of which 
they finally reach the umbilical ring. The vein originates in the pla- 
centa, runs within the cord in spiral convolutions, passes the umbilical 
ring, attaches itself to the loose connective tissue of the anterior aspect 
of the ligamentum suspensorium, and thus reaches the hepatic region. 
Its two ramifications are, firstly, a branch which joins the portal vein 
and enters the liver, and, secondly, the ductus Arantii, which empties 
into the vena cava inferior. 
The anatomical structure of these three blood vessels differs from 
that of all the rest of either arteries or veins. The umbilical arteries 
are thick and strong, both inside and outside the abdominal cavity ; 
particularly so in the proximity of the umbilicus. Inside the ab- 
dominal cavity they are more compact, and of a yellowish red color, 
outside softer and paler. Their muscular layers are mostly circular, 
some longitudinal. Where the latter are found, they are external to 
the former. The muscle extends to the adventitia; its largest size it 
attains near the umbilicus, inside the abdominal cavity. In the cord 
the muscular layer of the arteries is very massive betwen adventitia and 
endothelia. There is no elastic membrane and no intima. Some elastic 
tissue is found near the umbilicus, it gradually increases in the abdom- 
inal cavity; but the intima is not developed in the arteries until they 
are in close proximity to the iliac. Thus, by the massive and powerful 8 
development of the muscular layer, it is explained why there are so few 
hsemorrhages though no ligature have been applied to the cord. 
There are some other peculiarities about the umbilical arteries, viz : 
straight, oblique, or irregular prominences, which cannot be made to 
disappear by stretching, and contain what little elastic tissue is met 
with in this neighborhood. There are also dilatations of the lumen, 
which depend upon differences in the thickness of the walls, and 
longitudinal grooves resulting from occasional local diminution of 
the amount of muscular tissue. Valves there are none. These dila- 
tations and grooves, however, have nothing to do with the contraction 
of the arteries, for after death they remain intact and are replete with 
blood. That contraction is the result of the rigor mortis of the mus- 
cular layer and the reflex action produced by the influence of the cooler 
temperature surrounding the newly-born. Beside these normal pecu- 
liarities, anomalies are also noticed. Three cases of inequal develop- 
ment of the umbilical arteries have been reported by Hausmann. In 
one of them one of the arteries was narrow and terminated inside the 
pelvis, behind the urinary bladder; but the other, with its hypogastric 
artery, and even the common iliac, were considerably dilated. 
The umbilical vein differs from the arteries very much less than is 
usual with veins and arteries in any other parts of the body. The mus- 
cular layer is very large and strong in the vein. There is no intima. 
None of the three vessels emits branches; there are no vasa vasorum 
and 710 nerves in their walls. 
To this marked simplicity of the vessels there is but one excep- 
tion, viz., in the neighborhood of and round the navel. Some arterial 
vessels starting from the anterior abdominal wall, bladder, and liver, 
form a circular anastomosis, known by the name of circulus arteriosus 
umbilicalis. It is located in the subperitoneal connective tissue and 
distributed over the adventitia of the intra-abdominal portion of the 
umbilical arteries. Other branches penetrate the ring and linea alba, 
send their capillaries to the subcutaneous connective tissue of the um- 
bilicus, and form a fine vascular circle round the umbilicus as far as 
the starting point of the amnion.* 
It is not surprising that blood vessels which have but temporary 
functions ending with the termination of intra-uterine life should exhibit 
a structure as different from that of the rest of the blood vessels as their 
functions are unique. But the facts are not more interesting than those 
connected with the structure and functions of infantile vessels when 
compared with those of adults. 
*A. Jacobi, in Gerhardt’s Handb. d. Kinderk., 2d ed., I. 2, p. 21, 1882. 
Strawinsky, the same, I. 1, p. 298. 9 
E. Hofmann* discovered the peculiar fact that the arterial pressure 
is very small in the newly born animal. It is but 90 mm. in the newly 
born dog and cannot be raised to more than 160 mm. by suffocation. 
In the grown dog it amounts to 160 or 180 under ordinary circum- 
stances. Even as large arteries as the carotid, when cut, do not spurt 
as in the adult. This is another reason why cords not ligated will 
often not bleed, with the exception of those cases in which the arterial 
pressure is increased by a moderate degree of asphyxia, or the lungs 
are not inflated in consequence of incomplete development of the 
muscular strength in the prematurely born foetus. 
According to a number of actual observations made by R. Thoma, 
the post-foetal growth is relatively smallest in the common carotid, and 
largest in the renal and femoral arteries. Between these two extremes 
there are found the subclavian, aorta, and pulmonary arteries. These 
are differences which correspond with the differences in the growth of 
the several parts of the body supplied by those blood vessels. In re- 
gard to the renal artery and the kidney, it has been found that the 
transverse section of the former grows more rapidly than the volume 
and weight of the latter. Thus it ought to be expected, that congestive 
and inflammatory processes in the renal tissue were almost predestined 
by this disproportion between the size of the artery and the condition 
of the tissue. Moreover, the resistance to the arterial current offered 
by the kidney substance depends also upon the readiness with which 
the current is permitted to pass the capillaries. Now it has been found 
experimentally, that their permeability is greater, and that within a 
given time more water proportionately can be squeezed through them, 
in the adult, than in the child. This anatomical difference may there- 
fore be the reason why renal diseases are so much more frequent in 
infancy and childhood from all causes, with the exception of that one 
which is reserved for the last decades of natural life, viz., atheromatous 
degeneration. 
The blood vessels will, however, not exhibit this stationary propor- 
tion under all circumstances. In certain constitutional disorders the 
proportion of heart and blood vessels is found very much changed. 
As it is not probable that a chronic disorder in its slow progress should 
work a rapid change in the blood vessels, the inference is a sound one, 
that, if the disorder cannot have altered the blood vessels, these must 
have given rise to, or be connected with, the nature of the disorder. 
For instance, in rhachitis, the heart is of average size, but the arteries 
are abnormally large. Great width of arteries lowers blood pressure. 
Thus is best explained the murmur first discovered by Fisher, of Boston, 
over the open fontanelles of rhachitical babies, very much better 
* Oesterr. Jahrb. f. Pad., 1877, p. 189. 10 
indeed than, as Jurasz asserts, by osseous anomalies in the carotid 
canal. Another result of the low blood pressure is the retardation of 
the circulation in the muscles, with flabbiness and incompetency as 
consequences, and still more about the epiphyses which swell and 
soften. It is very much less the cartilaginous condition of the epi- 
physes which gives rise to rhachitis,# (for some of them do not ossify 
before the twentieth year or later, at a time when no rhachitis is ob- 
served) than some constitutional disorders, of which the principal one 
may be, as stated, the unusual size of the blood vessels. There are 
other anomalies in rhachitis which aid in the retardation of circulation, 
viz., the large size of the liver and the smallness of the lungs. Through 
all of these sources ossification becomes defective and irregular, the 
epiphyses exhibit sponge-like softness and hypersemia first, and hard- 
ening, s. c. eburneation of the rhachitical epiphyses afterwards. The 
latter is a natural consequence of the slow circulation, which results in 
a local escape of carbonic acid and thereby to a mechanical deposit of 
phosphate of lime previously kept in solution. 
The condition which has been called scrofula exhibits a different 
condition of the heart. The normal relation of the weight of the heart 
to that of the lungs, between the second and twentieth year, is i :5-y ; 
in scrofula it is i :8-io. That means, the heart is smaller than normal. 
This circumstance, coupled with an acquired debility of the nervous 
system, results in an insufficient supply of blood to the lungs, and to 
the whole body, in defective oxygenization, in oedematous deposits, in 
general ill-nutrition, and peculiar tendency to disintegration of the 
tissue of mucous membranes, bones and the skin, mainly in those 
cases which have been called torpid scrofula by common consent. It 
is in the latter form in which, by virtue of insufficient circulation, the 
lymphatic system pre-eminently participates. This is the more import- 
ant, as the size, patency and number of lymphatics are very great in 
infancy. Sappey found that they could be more easily injected in the 
child than in the adult, and the intercommunication between them and 
the general system is more marked at that, than any other period of 
life.* These facts have been confirmed by S. L. Schenik who, more- 
over, found the network of the lymphatics even in the skin of the 
newly born endowed with open stomata, through which the lymph- 
ducts can communicate with the neighboring tissue and cells. 
It is not necessary, however, to look for abnormal constitutional 
conditions as the results or accompaniments of altered blood vessels. 
Under normal circumstances, both the length of arteries and their 
width will change in different periods of life. The common carotid 
o Thus the greater tendency during early age to constitutional symptoms in 
diphtheria, for instance, is easily explained. A Jacobi, Treatise on Diphtheria, p. 31. 11 
has, in the newly born, half the length of the descending aorta, but 
very much less in more advanced age when the vertebral column in- 
creases in length. In other parts of the body the development of 
arteries proceeds inequally, thus the superior thyroid bends downward 
to a considerable extent about the period of puberty, while the larynx 
is becoming larger and the thyroid gland descending. The thoracic 
also descends from the upper end of the dorsal vertebral column, and 
the superior intercostal arteries become steeper. All the large arteries 
are getting enlarged after birth until the twentieth year, after that period 
the increase is slow, but does not cease altogether before the latest 
decade of life. Even the veins change considerably in their anatomical 
structure. There are a hundred valves in the veins of the lower ex- 
tremities of the newly born, which disappear readily afterwards, though 
there may be no anomalous retardation of the venous circulation. 
The width of the arteries does not depend on their congenital pre- 
disposition only,* but also on the degree of blood pressure resulting 
from changes in the heart. A large or hypertrophied heart increases 
the size of the arteries; aortic or mitral incompetency renders them 
gradually smaller. On the other hand, undersize of the arteries pro- 
duces a hypertrophy of the heart and lowers the circulation and blood 
pressure, together with insufficient nutrition in the periphery to such an 
extent as to produce haemophilia, purpura, or gastric ulcerations in the 
chlorotic. Still, there are congenital cases in which the abdominal 
viscera are found perfectly normal when the abdominal arteries are con- 
siderably narrower than normal.* 
Abnormal smallness of the arteries has attracted the attention of 
many observers. Lancerauxf describes an aorta which was thin, yel- 
lowish and fatty, and had a circumference of only five or six centi- 
metres. Long before him, however, Morgagni and Meckel observed a 
deficient development of heart and aorta, and Rokitansky J found at 
the same time smallness of the heart, arteries, sexual organs, and body, 
which he does not look upon as atrophy, but as original hypoplasia, 
but does not connect with chlorosis. Bamberger§ speaks of small 
arteries not interfering with the size of the body, but resulting in chlo- 
rosis without or with haemorrhages. Virchow, who has studied the 
influence of undersized arteries with greater results than anybody, 
found no constant relation between them, the condition of the body, 
and the presence or absence of haemorrhages. The latter have been 
noticed by Trousseau, who describes the haemorrhagic form of chloro- 
sis. Virchow found that smallness of arteries may leave the rest of the 
body now and then intact, and the sexual organs sometimes fully 
* G. Fleischmann, Autopsies, 1815. f Path. Anat. 11., p. 842. 
£ 1., p. 558; 11. 418, 585. § Dis. of the Heart, 1857 
§ Dis. of the Heart, 1857, p. 346. 12 
developed with chlorosis and profuse menstrual flows, sometimes, how- 
ever, of insufficient development. In that case small ovaries and uterus 
are combined with chlorosis. 
The worst forms of the latter conditions have been found by Vir- 
chow, and others since, to depend mainly on the smallness of arteries, 
no matter whether the heart is also small or of normal or large size. 
The latter condition may be either congenital or acquired, and depend 
on either genuine hypertrophy or fatty degeneration. In the latter case 
the heart is flabby and of loose structure. In all these cases chlorosis 
may make its appearance very early and independently of sexual life, 
for Becquerel has the case of a chlorotic child, six years of age, and 
others which developed after confinement. Or it may exhibit its symp- 
toms about the usual time, and prove incurable through all life because 
of the permanence of the congenital insufficiency of the blood vessels. 
See (Lecons de Pathologie Experimentale. Du Sang et des Anemies. 
Paris, 1867, p. 256,) speaks of hereditary and constitutional chlorosis. 
Heredity of chlorosis, in either sex, may not show itself at birth. 
Though not congenital, it may appear between the first few months and 
the second dentition. After it has been once developed, it clings to 
the patient through normal and morbid conditions, as an integral part 
of the general constitution. This hereditary chlorosis is often perceived 
in the male, from infancy to adult age. In a family in which both 
grandmother and mother were eminently chlorotic, he observed a girl 
and two boys, who grew pale in the first few months and long pre- 
served a well-marked discoloration, with functional murmur and all 
the symptoms of chloro-anaemia. Still, all the time a certain amount 
of strength and adiposity remained. Bouillaud called such cases of chlo- 
rosis constitutional ailments, and Trousseau pronounced them mostly 
incurable. 
Still more dangerous conditions may depend upon congenital small- 
ness of the arteries. I have in my possession pieces of the large arte- 
ries, of uncommonly small circumference, and the heart of a little more 
than normal size and in granular degeneration, that were taken from 
the body of a lady who died at the age of thirty-two years. She had 
always been anaemic, suffered from fainting spells during menstruation, 
which was sometimes interrupted for many weeks, and all the symp- 
toms of thorough anaemia all her lifetime; and finally died, with the 
diagnosis confirmed by medical men of the highest professional stand- 
ing, of pernicious “essential” anaemia in consequence of a moderate 
intestinal catarrh. 
Normal growth of the body and its organs depends on active blood 
supply and vigorous circulation. The presence of blood with but little 
propelling power may give rise to swelling and congestion and nutritive 13 
disorders, such as rhachitical epiphysitis, but not to healthy increase and 
function. The size and vigor of the newly born heart offers a ready 
explanation for the rapid growth of the infant body, and mainly those 
organs which are in the most direct communication with the heart by 
straight and fairly large blood vessels. In this condition are the head 
and brain. Thus the latter has an opportunity to grow from 400 
grammes to 800 in one year; after that period its growth becomes less 
marked. At seven, boys have brains of 1,100; girls, of 1,000 grammes. 
In more advanced life its weight is relatively less, 1,424 in the male 
and 1,272 in the female. At the same early period the whole body 
grows in both length and weight. The original length of 50 centi- 
metres of the newly born increases to no with the seventh year, the 
greatest increase after that time amounts to 60 (in the female 50) centi- 
metres only. In the same time the weight increases from 3. 2 kilo, to 
20.16 in the boy, from 2.9 to 18.45 in the girl. That gives a propor- 
tion of 1 to 6 or 7, while after that time the increase is but three or 
four fold. 
As I have stated, the large blood vessels do not grow equally. At 
first, the pulmonary artery is from two to four .centimetres larger than 
the ascending aorta. That means for the lungs more active work, but 
also more tendency to disease, particularly as, since the closure of the 
ductus Botalli, the aorta which gives off the bronchial arteries, assumes 
considerable proportions within a short time. 
The labor required of both heart and lungs is greater than in the 
adult; thus fatigue is more easily experienced, and the necessity of 
sleep, the interruption or absence of which adds to exhaustion and 
waste, is readily explained. More physiological work is done by these 
two organs, and, moreover, in a manner somewhat different from what 
we notice in those fully developed. In these, nothing is required but 
the substance’ or rather constant reproduction of the bulk of the body ; 
in the child, not only reproduction, but a new development of tissues 
must go on, and perpetual growth. And all this has to be accom- 
plished at the expense of a blood, which, after having been drained of 
its surplus of solid constituents immediately after life, contains less 
solid constituents than the blood of the old. Thus the normal oligae- 
mia of the child is in constant danger of increasing from normal 
physiological processes. The work before a baby has to be per- 
formed with, so to speak, a scarcely sufficient capital. The slightest 
mishap reduces the equilibrium between that capital and the labor to 
be performed, and the chances for the diminution of the amount of 
blood in possession of the child are very frequent indeed. 
Thus, the vulnerability of the young being great, and diseases in 
early infancy and childhood so very frequent, cases of anaemia are met 14 
with in every day’s practice, and in every form, complicated and un- 
complicated, with great emaciation or without it, and either curable or 
not. 
The slowness of the circulation and its insufficiency in all cases 
where the normal relation between heart and blood vessels is disturbed, 
as for instance, in rhachitis and the watery condition of the blood, are 
apt to give rise to catarrh of the pharynx and larynx and the respiratory 
organs in general. Besides, the walls of the blood vessels are known 
to suffer in anaemia. They become thin, and undergo fatty degenera- 
tion, which Ponfick has found in the heart, and in the intima of the 
larger blood vessels and in the capillaries. In consequence of the 
thinness of the blood and the changed condition of the blood vessels, 
serous transudation, and, now and then, extravasations will take place. 
The same occurrence is noticed in the adult in conditions of anaemia. 
It not infrequently occurs that those who have least blood, lose it most 
easily. Anaemic women are very apt to have copious menstruation, 
and when their general condition has been improved, both blood and 
blood vessels resist this tendency to haemorrhage. 
Haemorrhages, again, result in anaemia in a number of instances. 
They are of different character and importance. There is true melaena ; 
umbilical haemorrhage; haemophilia; primary or secondary purpura; 
internal haemorrhages of the newly born; cephalhaematoma; haemor- 
rhages from rectal polypi; epistaxis depending on coryza; episfaxis at 
a more advanced age from heart disease and abdominal stagnation ; 
haemorrhages in diphtheritic angina; and such as take place during or 
in consequence of operations for hare-lip or ritual circumcision. Death 
may result from many of them, such as melaena, haemophilia, pharyn- 
geal haemorrhages, or circumcision ; others are of but little gravity, 
such as the sanguineous tumor of the newly born ; others are apt to 
result in permanent ailing. As a rule, however, an acute anaemia is 
more easily overcome than one that is of a more chronic nature, and 
thereby undermines the vitality and strength of the organs while it 
slowly robs them of their nutriment. Infants who are thus stricken 
recover but slowly or not at all. Young animals resist starvation to a less 
degree than old ones. A dog of two days bore starvation in Magendie’s 
laboratory but two days; a dog of six years, thirty. Similar results 
were obtained by Chossat in his experiments on pigeons. Thoroughly 
anaemic and delicate babies seldom recover entirely, like starving young 
animals which never attained their normal condition though they were 
carefully fed afterward. 
Even in such instances, however, murmurs in the jugular veins are 
not very frequent in infancy and early childhood. Murmurs in the 
carotids and over the large fontenelles, however, are by no means rare. 15 
It is not true that these murmurs, audible over the brain, belong to 
rhachitis only. They are found in every condition in which the blood 
pressure in the large arteries of the cranial cavity is lessened. 
The heart itself exhibits functional murmurs but seldom. When- 
ever there are murmurs present, it is safer to attribute them to organic 
disease rather than to merely functional disorder. In most cases it is 
not difficult, with the restrictions detailed before, to diagnosticate the 
consecutive hypertrophy. Besides, it is now well known that acquired 
endocarditis is by no means rare, and, moreover, that it occurrs even 
more frequently ; for acute articular rheumatism is by no means infre- 
quent in the infant and child. Although the brain be not so liable to 
suffer from emaciation, dependent upon anaemia, as other organs, still 
there are a number of cases in which headaches, attacks of syncope, 
sleepiness, etc., or, on the contrary, sleeplessness and hysterical 
attacks, are the result of anaemia alone, and disappear when this condi- 
tion is relieved. Not a few of the babies and children who cry the 
greater part of the night have no other ailment besides general anaemia, 
and such children are frequently relieved by a meal or some stimulant 
before they are put to bed, or given during the interruption of their 
sleep. The pulse of such children is sometimes very much accelerated ; 
sometimes, however, it is slow, and sometimes irregular. I have 
known such children, in whom for months, and occasionally for years, 
I have feared the development of cerebral affections from the very fact 
that their pulse was both slow and weak and irregular; and yet, when 
their general condition was improved, both the regularity and the fre- 
quency of the pulse were increased. 
It is this class of cases which is so frequently neglected by both 
parents and physicians. If this condition of anaemia and ill-nutrition 
be allowed to continue, the first attack of an acute febrile or infectious 
disease will extinguish the light that never burned brightly. What 
might have been done to avert that calamity, is the question we pro- 
pose to ourselves when it is too late. There are many indications, of 
which I mention but one. As the greatest labor of living has to be 
performed by the heart, which is suffering from ill-nutrition more than 
the rest of the body because of the hard and constant work to be per- 
formed, let the heart be stimulated and strengthened while you attend 
to the rest of the indications; for the heart stimulants will not only 
whip the heart into action, they do very much more—they invigorate 
the circulation in the heart muscle and reinforce it, while they stimulate. 
There are blood vessels so thin and incompletely developed, and 
integuments so poorly formed, that bleeding will now and then make 
its appearance spontaneously. I remember two such cases, particu- 
larly one in which blood would trickle from the surface of the lower 16 
extremities like perspiration, in drops, day after day, until the baby 
died of exhaustion. That, in babies who die within the first week, or 
later even, the pericardium and pleura are covered with scores and 
hundreds of smaller or larger blood points, which give no rise to any 
prominent symptoms, is not at all uncommon. In all these cases the 
haemorrhage need not be the result of a deterioration of the blood ves- 
sel tissue by constitutional diseases at all. Of the latter, however, it is 
principally hereditary syphilis which gives rise to such a haemorrhagic 
diathesis. It is in these cases not so much an endocarditis which can be 
charged, as in advanced age, with the production of haemorrhages, but 
the defective general tissue formation and the presence of gummata and 
white hepatization of the lungs. 
Still, endocarditis and atheromatous degeneration are not unheard 
of in the young. Moutard Martin* reports the case of a boy who died 
of small-pox at the age of two years. At the autopsy there were found : 
pericarditis sicca, hypertrophy of the heart, and atheromatous deposits 
of a diameter of from two to five millimetres, about an inch below the 
origin of the aorta. Sanne, in an article on the aneurism of the aorta 
and atheromatous degeneration during infancy, f has four cases of aneu- 
ism from that cause, one in a foetus, and three in children of two, ten, 
and thirteen years. I have in my possession the descending aorta of a 
girl who died, at the age of seven years, with an aneurism. After all, 
however, atheromatous degeneration in the young is but an exceptional 
occurrence. But ruptures of blood vessels are very frequent, the more 
so the younger the individual. Congenital thinness of the blood ves- 
sels, without atherosis, is by no means rare ; a certain grade is the rule. 
Voigtel refers also to a deficiency of original formation as a probable 
cause of aneurisms ; Cruveilhier| refers to cirsoid aneurisms as resulting 
from congenital thinness of the median layer, and says that now and 
then arteries and veins cannot be distinguished from each other. 
Virchow, as related before, explains the worst cases of lifelong chloro- 
sis by the thin walls and narrow lumen of the arterial vessels. Klebs 
met with thin blood vessels in a dropsical baby that died when thirty- 
two weeks old. C. O. Weber reports congenital atrophy and weakness 
of the arterial walls. Balassa claims them as the causes of spontaneous 
aneurisms; so does Gull in a case of aneurism of the arteria cerebelli; 
and Dieulafoy describes the case of a girl of seventeen years, in which 
the cerebral haemorrhage was due to miliary aneurisms resulting from 
hereditary predisposition. 
As may be inferred from what has been said, the vascular debility 
may be of two kinds. It may be local, and then give rise to miliary or 
’'Bull. Soc. Anatom., 1875, p. 775. f Revue Mens, fev., 1887. 
t Traite, 1., p. 735. 17 
larger aneurism; or it may be general, and exist while all the mem- 
branes constituting the wall are present. 
In the arteries of medium and small calibre, the elastic membrane 
is a thin and simple membrane; it is only in larger arteries that elastic 
fibres will also extend into, and mix with, the adjoining layers. The 
elastic membrane is particularly thin where the branches are given olf 
from the arteries. It is here where spontaneous haemorrhages are most 
apt to take place. It is here also where, in later life, aneurisms are 
found, such as find no ready explanation by an injury. Not only has the 
elastic membrane been found thin, but entirely absent in such places, 
and there it is where Eppinger* looks for the seat of what he calls con- 
genital aneurisms ; that is, those which, though they make their appear- 
ance in later life only, still owe their original source to that congenital 
anatomical defect. 
From the physician’s standpoint the combined action of the heart 
and arteries—the pulse—is particularly interesting. 
The pulse of the infant and child offers a great many differences 
from that of the adult, both in frequency and volume. As already 
stated, the pulse of the foetus varies from 124 to 144 or 150 and more. 
Immediately after birth it is very much less frequent. Within an hour 
it assumes a certain regularity, and still the figures furnished by a large 
number of competent authors appear to prove the greatest difficulties in 
obtaining uniform results. From what I have observed, ]. L. Smith is 
correct in fixing the number of heartbeats in a minute at 136, his lowest 
figure being 96, his highest 164. According to some, the average figure 
rises during the second half of the first month, and then proceeds slowly 
to decrease. From the first to the sixth month the pulse is 120 during 
sleep, 130 to 135 while awake. It is 100 at six years, 88 at thirteen, 
72 in the adult. Tall children exhibit less frequency than short ones; 
girls, after the fifth year, and more so about puberty, more than boys. 
The pulse is more rapid in the infant while awake, sitting up, or stand- 
ing, than while asleep or lying down; more in excitement, exercise, or 
fever. Thus it is difficult to arrive at a safe estimation of the frequency 
of the pulse in case of sickness. In the radial artery it is sometimes 
impossible to obtain it; the femoral or carotid is often more accessible, 
the basilar, through the open fontanelle, very much more so. When 
frequency alone is the object of examination, it is always better not to 
touch the baby at all. The beats of the fontanelle or the carotid can 
be distinguished and counted easily, up to a frequency of 240 a minute. 
But it is not always, or not only the frequency we wish to notice, but 
the character of the pulse. In the latter respect the young have their 
peculiarities. The expansion of the artery is very much more percep- 
tible and prolonged than the contraction, and the rhythm is by no means 
* Langenbeck’s Arch., vol. xxxv., Suppl., 1887. 18 
stationary. The pulse is very apt to be irregular, even during the regu- 
lar respiration of sleep. The slightest deviation from the normal 
standard of health renders it slightly but perceptibly irregular; anaemia 
does the same, and either increases or diminishes its frequency. When 
the latter takes place, the differential diagnosis between anaemia and 
incipient meningitis, with its pneumogastric irritation, becomes quite 
difficult. 
The examination of the pulse was, in the absence of the modern 
methods of diagnosticating, which are liable to render us more exact, 
though less observing and circumspect, a source of study and instruc- 
tion in ancient times. In Daremberg’s “ History of Medicine,” Paris, 
.1879, !•> P- 224, I find the following remarks quoted from two Greek 
authors on the pulse of the young. Rufus, of Ephesus, speaks of it as 
small, and yielding no perceptible difference between diastole and sys- 
tole. Herophilus calls it ’aXoyoS'; that is, deprived of sense, or 
rules, or proportion. It is known to increase in volume with advan- 
cing age, and to accommodate itself to metric measurements. That of 
the newly born is pyrrhic, UU, two short beats; the child, trochaic, 
—U, one long and one short beat, with three tempi, two of which 
belong to the diastole, one to the systole; the adult, spondaic, 
two long beats; senility, iambic, U—, one short and one long beat. 
Such observations are more than merely interesting through their in- 
geniousness and poetical flavor; they are correct. It is too seldom 
that we modern men look for instruction and edification amongst our 
ancient or more recent predecessors; it is too often that we forget how 
much we could each of us learn directly from Hippocrates and Celsus, 
or Sydenham and Peter Frank. 
Both the biologist and the practicing physician—l wish they were 
identical—are interested in the condition of the pulse of the young. 
Some of its anomalies I have alluded to before. To what extent it will 
guide us in our diagnosis of incipient meningeal disturbances, every 
practitioner has experienced many times. In normal children, after 
the fourth or fifth, certainly after the seventh year, the pulse is regular, 
rhythmical, and of equal strength. When there is irregularity in 
strength and rhythm, it proves impaired condition either of the heart 
or its innervation ; and in connection with other symptoms, like those 
of Josef Hofmann, incipient neurasthenia and physical and intellectual 
dangers ahead. 
In which way it may lead us to a rapid, at least preliminary, diag- 
nosis of inflammatory lung diseases, has not appeared to me to be suffi- 
ciently appreciated. At least I find, in my daily rounds, that the 
proportion of pulse to respiration is not always watched. What I mean 
is this : the normal relation of heartbeats to the number of respirations 19 
is 37 or 38 to io. When this relation is disturbed, there is a reason 
for it. When the number of respirations is increased compared with 
the pulse, say ten to thirty, twenty-five, or even less, and particularly 
when the change took place rather suddenly, with fever and all the 
other signs of an acute disease, there is inflammation of the organs of 
respiration. Mistakes are very rare. They may be, it is true, the result 
of an occasional—though very uncommon—actual complication with 
meningitis (I do not speak of the secondary meningitis of pneumonia). 
That may retard the pulse even in a pneumonia, as it does without it; or 
the mistake may be due to an old heart disease, or unusual degree of 
cardiac debility, which increases the pulse beyond expectation. 
Here, Mr. President, I must finish my remarks. lam aware, and 
gratefully so, that you have consented to listen to them with forbearing 
patience, like kind hosts. They have been quite extensive, perhaps too 
much so ; but how fragmentary they were after all, struck me only 
when I felt they were too prolonged. Still, the subject is one of vast 
importance and great interest, though its discussion had to be cur- 
tailed. I might have drawn many more conclusions based upon the 
facts touched upon, evolved indications for treatment, and pointed 
out the way to remedy some of the evils alluded to, and their conse- 
quences. I had to omit this, I must say, rather unwillingly ; for Ido 
not belong to the class of those who look upon the practice of medicine 
as inferior to its study, as a trade, as a necessary evil, as a failure, or 
a placebo. On the contrary, I rejoice in knowing and learning more 
profoundly and feeling more keenly, from year to year, that there is no 
nobler aim for even the most abstruse study and abstract science, than 
their utilization in the service of mankind, and that every intellectual 
effort, every scientific gain, ought to and finally will, be ennobled by 
being made subservient to a practical end. That practical end of all 
investigations and studies of anatomical and physiological questions is 
the prevention and cure of disease. It is this combination of intellec- 
tual labor and practical result, undertaken and accomplished in the 
interest at the same time of scientific research, and the moral elevation 
and physical welfare of both the individual and the commonwealth, 
wherein lies the fascination of our professional calling. None under- 
stands and appreciates that better than an academic assembly such as 
favored me with the invitation to be present to-night, and with the 
honor of the permission to address them.