:&*«■ WY 159 M129d 1921 54530520R NLM DSEfifiDlD 4 NATIONAL LIBRARY OF MEDICINE -J SURGEON GENERAL'S OFFICE LIBRARY. Section No. 113, W.D.S. G.O. No . _2L_£_/.4_7%f~ NLM052880104 DISEASES of CHILDREN FOR NURSES INCLUDING INFANT FEEDING, THERAPEUTIC MEASURES EMPLOYED IN CHILDHOOD, TREATMENT FOR EMERGENCIES, PRO- PHYLAXIS, HYGIENE, AND NURSING BY ROBERT S. McCOMBS, M.D. Physician to the Dispensary and Instructor of Nurses at the Children's Hospital of Philadelphia; Lieut.-Colonel, M.R.C., U. S. Army FOURTH EDITION, THOROUGHLY REVISED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1921 wy /^./,. Copyright, 1907, by W. B. Saunders Company. Revised, reprinted, and recopyrighted January, 1911. Reprinted September, 1912, May, 1914, August, 1915, and January, 1916. Revised, reprinted, and recopyrighted May, 1916. Reprinted April, 1917, January, 1918, August, 1918, June, 1919, January, 1920, and October, 1920. Revised, reprinted, and recopyrighted May, 1921 Copyright, 1921, by W. B. Saunders Company PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA MAY .9 1921 Q-CI.A617075 <7v0 . DEDICATED TO THE NURSES OF THE TRAINING SCHOOL OF THE CHILDREN'S HOSPITAL OF PHILADELPHIA PREFACE TO THE FOURTH EDITION In the preparation of this edition the author has attempted to keep thoroughly abreast of the recent advancement in pediatrics without unduly enlarging the book. Additions have been made to almost all of the chap- ters, and the author feels that everything has been included which has proved to be important. - Several articles have been rewritten. New photo- graphs have been added. The recent progress in infant feeding has been marked, and the latest accepted meth- ods have been incorporated, including the preparation of the foods and mixtures. Articles on acidosis; the mechanical disorders and irregularities of the heart; dehydration; stools; idiocy; encephalitis lethargica; pellagra, etc., have been added. He wishes to thank the publishers for their many acts of kindness, the Children's Hospital for the new photo- graphs, and the many friends the book has made for their favorable reviews and their timely advice. He hopes the fourth edition will receive the approval granted the previous ones. Robert S. McCombs. 124 S. 1 8th Street, Philadelphia, Pa. May, 1921. 5 PREFACE The need for a book on children's diseases for nurses was called to the author's attention while giving a course of lectures to the nurses at The Children's Hospital of Philadelphia. It was his original intention to have only the notes of the lectures printed, so that some form of condensed material might be at hand for purposes of study. This volume has grown from the original notes. Incorporated in it are the methods employed at the Children's Hospital. A short description of each disease found in infancy and childhood has been given. It is hoped that the descrip- tions are clear enough to enable a nurse to know what symptoms to expect and what complications to guard against. The author believes that enough anatomy and pathology have been included to give a clear understanding of the structure of the body and the changes which take place during disease. Treatment has been included where a thorough knowledge of its underlying reason is neces- sary for intelligent application. Treatment for emer- gencies will be found under the different diseases and in the chapter on Therapeutics. Prophylaxis, infant feeding, and the methods of nursing employed in childhood are dwelt upon. 7 8 PREFACE The author is most deeply indebted to Miss Jennie A. Manly for practically all the points on nursing, together with the receipts for infant feeding used in this book. The original photographs for this volume were taken at the Children's Hospital. In compiling the notes, the author has had frequent recourse to most of the text-books on children's diseases. For many definitions throughout the book, and the descrip- tion of the diseases of the kidney, he has consulted Stevens' Manual of Medicine. In the chapters on Gastro-intestinal Diseases and Infant Feeding, Holt's Infancy and Childhood was often consulted. Robert S. McCombs. CONTENTS CHAPTER I PAGE Peculiarities of Children's Diseases....................... n CHAPTER II Nursing in Childhood...................................... 34 CHAPTER III Diseases of the Respiratory Tract......................... 52 CHAPTER IV Diseases of the Respiratory Tract (continued)............ 87 CHAPTER V Diseases of the Digestive Tract............................ 108 CHAPTER VI Diseases of the Digestive Tract (continued)............... 126 CHAPTER VII Diseases of the Digestive Tract (continued)............... 138 CHAPTER VIII Diseases of the Circulatory System........................ 171 CHAPTER IX Nervous Diseases.......................................... 2°° CHAPTER X Diseases of the Urinary Tract .............. 234 9 10 CONTENTS CHAPTER XI PAGE Diseases of the Eye, Ear, Skin, and Glandular System...... 252 CHAPTER XII Diseases of the Bones and Muscles........................ 270 CHAPTER XIII The Infectious Fevers..................................... 278 CHAPTER XIV Typhoid Fever............................................. 297 CHAPTER XV Tuberculosis.............................................. 312 CHAPTER XVI Contagious Diseases........................................ 330 CHAPTER XVII Constitutional and Nutritional Diseases.................... 364 CHAPTER XVIII Infant Feeding............................................ 376 CHAPTER XIX Artificial Feeding......................................... 398 CHAPTER XX Therapeutics.............................................. 435 CHAPTER XXI Weights and Measures; Abbreviations.................... 500 CHAPTER XXII Medical Terminology..................................... 5*° Index............... ..................................... 521 Diseases of Children for Nurses CHAPTER I PECULIARITIES OF CHILDREN'S DISEASES A child's life is divided into definite periods, namely, the "newborn," "infancy," "childhood," and "youth." The Neuborn.—It is customary to designate a babe as "newborn" until all traces of its prenatal or intra-uterine existence have disappeared. This is usually accom- plished by the end of the first month. Infancy follows the newborn period and continues until the eruption of the first or milk teeth is completed; it is, therefore, limited to the first three years of life. Childhood extends from the third to the seventh year, at which time the permanent teeth make their appearance. Youth includes the years from seven to puberty. Weight.—The normal infant should weigh about seven and a half pounds at birth. During the first week there is a slight loss, but from that time on the increase should be steady. The curve during the first year is represented in the chart and shows approximately the proper weight for the different ages of the infant. 1? " S s W i: A \ V £ 2 % OQ 8 & fa 5 go PECULIARITIES OF CHILDREN'S DISEASES 13 NAME, Weight Chan ........... ADM.,.......... ..... Fig. 2.—The above chart was designed by Miss Rena C. Fox, Head Nurse, Children's Department of Philadelphia Hospital. It is very useful in cases where it is desirable to keep account of a child's weight over a short period of time. In the larger charts a month's time would appear as a very small line. The heavy lines may represent any pound desired; the figures being given according to first weight of child during period it is to be used. Each subdivision equals two ounces. 14 DISEASES OF CHILDREN FOR NURSES Average Weight. Girls. Boys. Birth................. 7.16 pounds...... 7.55 pounds. 6 months............ 15.05 " ...... 16.00 " 12 " ............ 20.05 " ...... 21.00 " 18 " ............ 23.00 " ...... 24.00 " 2 years.............. 26.00 " ...... 27.00 " 3 " '.............. 3i-oo " ...... 32.00 " 4 " .............. 35.oo " ...... 36.00 " 5 " .............. 39-o8 " ...... 41-02 6 " .............. 43-o8 " ...... 45-oi " 7 " .............. 48.00 " ...... 49-OS " 8 " .............. 52.09 " ...... 54-Q5 " 9 " .............. 57-05 " ...... 60.00 " 10 " .............. 64.01 " ...... 66.06 11 " .............. 70.03 " ...... 72.04 " 12 " .............. 81.04 " ...... 79-o8 " 13 " .............. 91.02 " ...... 88.03 14 " .............. 100.03 " ...... 99.03 15 " .............. 108.04 " ...... 110.08 " Between the ages of twelve and fourteen years girls gain weight faster than boys. Height.—The average height is about twenty and a half inches at birth. The growth during the first year is about eight incnes. The growth of the extremities is much more rapid than that of the trunk. The head measures in circumference about thirteen and a half inches. The posterior fontanels should close at the end of the second month and the anterior about the eighteenth month. The special senses of sight, hearing, smell, and touch are developed at birth. A normal infant is able to hold up its head during the second month and sit up about the sixth month. It begins to recognize objects during the fifth month. From the eighth to the sixteenth month it should learn to walk. The age at which an infant begins to talk varies greatly. In the majority of cases by the end of the first year it is able to form certain words, and from this time on the PECULIARITIES OF CHILDREN'S DISEASES 15 development of the function of speech is rapid. At times perfectly healthy children have made little progress in their ability to talk by the end of the second year. Teeth.—Average table of eruption of the milk teeth: Centrals..................... 5 to 8 months. Laterals..................... 7 to 10 First molar..................14 to 20 " Cuspid.......................14 to 25 Second molar................24 to 36 At three years all of the milk teeth should be in place. The lower teeth usually erupt first. The milk teeth demand the same attention as the per- manent teeth. Average table of eruption of the permanent teeth: First molar.............. 5 to 7 years. Centrals................. 6 to 8 " Laterals................. 7 to 8 First bicuspid............ 9 to 10 Second bicuspid..........10 to 12 Cuspid..................12 to 13 Second molar............12 to 14 Third molar.............16 to 35, to 40 years. In strumous or rickety children the eruption is fre- quently delayed and the teeth are often brittle and fur- rowed. The enamel may be of poor quality, so that they easily decay. Hutchinson's teeth are seen in hereditary syphilis. The second or permanent upper central incisors have a single shallow crescentic notch in the center of the edge. In 16 DISEASES OF CHILDREN FOR NURSES 5~8 Mon. 7-*° MoN- Fig. 3.—Normal dentition (Friihwald and Westcott). Fig. 4.—Hutchinson's teeth in hereditary syphilis: a, The two upper central in- cisors (second dentition) exhibit deep transverse and longitudinal furrows and a concave notch in the edge. Although the teeth are normal in length, the width is less than normal, thus producing a broad interspace between the central incisors; b, the upper central incisors (second dentition), immediately after eruption, and the four lower incisors. The lower surface of the upper incisors is rough from the presence of projecting points of dentine. The upper teeth are short and diverge, leaving a broad interval between them. The four lower incisors present a number of small excrescences like nails from imperfect enamel formation. The base of the excrescences is everywhere in the same plane (after Hutchinson). PECULIARITIES OF CHILDREN'S DISEASES iy addition the teeth are small and pegged. They are some- times called "screw-driver" teeth. Laminated and pitted teeth are seen at times after the acute infectious diseases of childhood, such as measles, FlG s —Rachitic teeth. Boy nine and a half years old. The teeth are poorly developed, considerably eroded and grooved. Their position is very irregular; the lower incisors occupy a frontal position (not in the arch of the jaw) and the inferior maxilla makes an angular turn at the canine teeth (Hecker, Trumpp, and Abt). scarlet fever, and diphtheria. When these diseases occur at an early age the formation of the enamel may be affected. This causes such defects as irregular pits upon the crowns of the teeth, particularly the incisors. The pitting is so marked in some cases that it gives a general honey- combed appearance to the crowns. To ascertain if irregularities are due to the eruptive fevers it is necessary to know the age of the rhild at the period of the disease. Pits upon the incisors caused by the eruptive fevers between 18 DISEASES OF CHILDREN FOR NURSES the ages of four and five occupy about the central area of the crown face. The enamel about the cutting edge of the teeth has already formed at this age, so that alterations of nutrition would not affect it. The crowns of all the teeth in process of formation at this age are affected in a similar manner. Diseases Peculiar to Children.—Children need differ- ent environments, different management, different medical and surgical care, and different nursmg from that required for adults. One-third of a physician's patients are children. Diseases of infancy and of early childhood differ in many respects from those of adult life, but after the seventh year children resemble adults in their ailments more than they do infants. The following diseases are seen chiefly in infancy and childhood: congenital anomalies of the heart, such as "blue babies," due to a patulous foramen ovale; congenital atelectasis or failure of a part of a lung to expand; oph- thalmia neonatorum or a gonorrheal conjunctivitis in the newborn; traumatic hemorrhages and birth paralysis due to injuries during birth; umbilical hernia; noma or gan- grenous stomatitis; cholera infantum; laryngismus stridu- lus; enuresis; chorea; tubercular meningitis; hydro- cephalus; infantile cerebral and spinal paralysis; cox- algia; scarlet fever; measles; rubella; varicella; pertussis; mumps, and diphtheria. Etiology.—Heredity, accidents at birth, infection through the umbilical cord, improper food, and bad hygienic surroundings are the principal causes of disease or of a delicate constitution in the newborn and during infancy. Inheritance is a very strong factor in infancy. Such diseases as syphilis and tuberculosis can be directly trans- PECULIARITIES OF CHILDREN'S DISEASES 19 mitted from the mother to the child. Syphilis very frequently is congenital. While a child is rarely bom with tuberculosis, the undermined constitution and the feeble resisting power of an infant bom of tubercular parents make it very likely that the disease will develop early in life, at times so soon after birth as to be practically congenital. This is especially so if they breathe the same atmosphere as, or are nursed by, tubercular mothers. Children of parents suffering with rheumatism, gout, Bright's disease, or alcoholism are apt to have poor resist- ing powers and yield easily to infection. Improper food and bad hygiene are the greatest causa- tive factors of disease in infancy. To these are due not only such diseases as rickets, scurvy, and marasmus, but also the great class of gastro-intestinal disorders. Diseases of the Newborn.—The newborn babe faces a series of accidents and infections at birth which may end its career before it is fairly begun. Asphyxia may result during birth. This may be caused by pressure upon the brain or umbilical cord, the winding of the cord about the neck, early separation of the placenta (the after-birth), and various maternal causes, such as prolongation of labor, convulsions, hemor- rhages, and death of the mother. After birth has been accomplished and the child has cried vigorously there usually is no danger, unless there has been some injury or some intra-uterine disease of the organs of respiration, circulation, or the brain. Premature infants may die soon after delivery due to the feeble development of the respiratory mechanism. (For Method of Resuscitation, see page 480.) Congenital atelectasis is a failure of the lungs to expand after birth. It is most often seen in babies that have had 20 DISEASES OF CHILDREN FOR NURSES symptoms of asphyxia at birth, or who are poorly devel- oped. The principal symptoms are cyanosis and pros- tration. These attacks may come on suddenly. They may be mistaken for "blue babies." (See page 174.) It is necessary to have the babe cry vigorously several times a day to fully expand its lungs. It is desirable to stimulate crying if it does not show a tendency in this direction. If sudden cyanosis should occur, the same treatment as is used in asphyxia should be instituted. Icterus, Jaundice.—About one-third of all infants de- velop jaundice within the first few days after birth. It increases in severity for one or two days and then gradu- ally disappears. In cases where it becomes persistently worse and shows no signs of abating, there is probably a congenital obstruc- tion of the bile-ducts or an inflammation of the liver (hepatitis), usually due to syphilis. The acute pyogenic diseases of the newborn are due to infection through the umbilical cord; more rarely, through the mouth or any wound of the skin. After the micro-organism enters the system it may cause a local cellulitis or abscess; it may attack the various serous membranes, giving rise to meningitis, peritonitis, pericarditis, and joint involvements; or it may cause pneumonia, gastro-enteritis, and inflamma- tion of the bones (osteomyelitis). Erysipelas, tetanus, epidemic hemoglobinuria, fatty degeneration of the newborn, and pemphigus neonatorum are diseases which are due to a like method of infection. Ophthalmia neonatorum (see page 254) must be con- sidered a pyogenic infection of the newborn, the con- junctiva being the seat of the local infection. Prophylaxis.—As the infection takes place after the PECULIARITIES OF CHILDREN'S DISEASES 21 chlid is born, the responsibility rests with the physician and nurse—with the physician at the time of cutting the cord, and more frequently with the nurse in the process of dressing the cord, bathing, or cleansing the mouth or eyes, possibly after having cared for a septic mother or another child. Infection may take place either before or after the separation of the cord. The dressings of the cord should be dry and sterile. If suppuration occurs at the time the cord separates, a wet bichlorid dressing should be applied. Ligatures, instruments, and everything which comes in contact with the umbilical wound should be sterilized. Careful attention should be given to the mouth, genitals, and all surfaces which are liable to chafing or excoria- tion. A nurse in charge of a septic mother should not have the care of the infant. In an institution every septic case should be isolated. This includes all of the above-mentioned diseases. Hemorrhages.-—These are frequent during the first days of life. They may be due to injuries at birth or they may be spontaneous. They are primarily due to the fact that the blood-vessels are extremely delicate and that there are great changes transpiring in the blood and the circulation at this period. The most fre- quently seen hemorrhage is that which occurs beneath the scalp (cephalhematoma), which causes a swelling on the vertex of the head. This increases in size gradually for a week or ten days and then slowly disappears. Hemorrhages may also occur in the various viscera, from the umbilicus, stomach, intestines, mouth, nose, con- junctiva, female genitals, bladder, and subcutaneously. Cerebral hemorrhages are due to pressure upon the 22 DISEASES OF CHILDREN FOR NURSES child's skull during delivery, which causes a rupture of an artery, with the formation of a clot on the surface of the brain. The pressure of this clot causes paralysis of the parts controlled by the damaged portion of the brain. From this source we may have the various forms of paralysis seen. Facial paralysis is due to an injury of the facial nerve. It is usually caused by pressure of the forceps along the course of the nerve, and not to a hemorrhage in the brain. ErVs paralysis is due to an injury about the shoulder- joint. The affected arm is paralyzed. (See page 233.) Intestinal obstruction may be due to an absence of the anal opening of the rectum (atresia of the anus) or to a strangulated hernia. Every child should be examined carefully immediately after birth to see if the rectum is patulous. If the bowels move, all doubt, of course, is removed. As they should open several times during the first twenty-four hours, any failure to do so should arouse suspicion and a thor- ough examination by the physician should be made. Umbilical hernia and swelling of the breast (mastitis) should be protected by pads. On no account should squeezing of the breast be permitted. Congenital stridor is characterized by noisy inspirations which have been likened to a crowing sound. It may last for six or eight months, when the growth of the larynx causes it to steadily diminish until it entirely disappears, usually by the end of the second year. In spite of the apparent difficulty in breathing the child seems com- fortable. The chief danger is from some intercurrent disease like pneumonia. It may cause pigeon breast, which may persist. PECULIARITIES OF CHILDREN'S DISEASES 23 Sclerema is a rare condition characterized by hardening of the skin and subcutaneous tissues, together with symptoms of malnutrition. In the treatment of these cases the physician will keep the child in an incubator. Inanition jever is described on page 27. The Most Frequent Diseases of Infancy and Child- hood.—Diseases of the gastro-intestinal tract and broncho- pneumonia are seen more often than any other diseases before the second year. The other common conditions met with during this period are affections of the lymph- glands, tubercular meningitis, pertussis, and measles. After the second year the following diseases are most frequently seen: Disorders of nutrition, such as rickets and scurvy; bone and joint diseases, these being usually tubercular and more rarely syphilitic; diseases of the blood; organic diseases of the heart; pneumonia, typhoid fever, the acute contagious diseases, such as measles, mumps, pertussis, varicella, scarlet fever, and diphtheria. COMPARISON OF CHILDREN'S DISEASES WITH ADULT CONDITIONS The respiratory tract during infancy is undeveloped. The air-cells in the lungs are not so far advanced in their structure, nor so important in the function of respiration, as are the bronchial tubes. This causes an ordinary inflammation of the bronchial tubes, or bronchitis, to be a much more serious condition in infancy than in the adult. When the smallest tubes are involved it is called capillary bronchitis or bronchopneumonia. Pneumonia is very common in infancy and childhood. Before two years of age it is usually of the type of a broncho- pneumonia. Next to gastro-intestinal disease this form DISEASES OF CHILDREN FOR NURSES of pneumonia causes more deaths than any other condition during childhood. After two years of age the pneumonia is usually croupous in type, and, in contradistinction to bronchopneumonia, is very rarely fatal. In this respect it differs from pneumonia in the adult, in whom the mortality ranges from 20 per cent, to 50 per cent. The frequency of empyema as a complication of pneumonia and the frequency of bronchopneumonia as a complication of the acute infectious fevers are peculiarities of children's diseases. Gastro-intestinal disorders in childhood are the most fatal of all diseases. This is in direct contrast to adult life. The reason lies in the delicate digestive power of infants. Toxins or poisons are formed in the intestines from their inability to digest and assimilate properly the food given. This poison is absorbed and produces grave results. During infancy the stomach and intestines are more intimately associated than later in childhood. Hence one is rarely affected without involving the other. This causes an increase in the severity of the symptoms, with consequent deleterious results to the child. Through- out childhood gastro-intestinal conditions are characterized by the severity of the symptoms. The circulatory tract, except for the congenital mal- formations of the heart such as valvular disease and "blue babies," is usually unaffected during infancy. After two years of age heart diseases are common. A murmur should always be looked for in cases of chorea, rheuma- tism, and the acute contagious diseases. A peculiarity of childhood is the development of endocarditis following mild attacks of rheumatism. Aneurysms and arterio- sclerosis are uncommon. Anemia is often present in children. PECULIARITIES OF CHILDREN'S DISEASES 2$ The Genito-urinary Tract.—The kidneys are rarely affected in childhood except as a sequel of scarlet fever. As this is a very common complication of scarlet fever, all those suffering from the disease should be kept under close observation. Enuresis is common in childhood. The various malformations of this tract are common in childhood, especially phimosis. Diseases of the Nervous System.—Hemorrhages are usually on the surface of the brain, and not within its substance. They usually occur at birth. Birth paralysis results. The portion of the cortex at which suchhemor- rhages occur fails to develop, and the injury is permanent. Such conditions as chorea (St. Vitus' dance), laryngis- mus stridulus, nodding spasms, tetany, infantile paralysis, and tubercular meningitis are typically children's diseases. One of the peculiarities of children is to have convul- sions from trivial causes, without any lesion of the brain being present. Diseases of the Eyes, Ears, Skin, and Glandular System.—Ophthalmia in the newborn is very often seen in the poorer classes and causes about 30 per cent, of all adult blindness. Conjunctivitis is often seen, espe- cially associated with measles and catarrhal conditions of the nose and throat. Strabismus is not uncommon. Otitis media and mastoid disease are more frequent in childhood than in the adult. Running ears, following the contagious diseases, especially measles, is a common complication. Eczema is often observed in artificially fed children. Tubercular adenitis is seen more often in childhood than in the adult. The Acute Infectious Fevers.—Most of the diseases 26 DISEASES OF CHILDREN FOR NURSES seen in adults attack children. Malaria is common. Hereditary syphilis is observed in childhood, the majority dying before they reach maturity. Typhoid fever is quite a common disease in children living in large cities. It differs from typhoid fever in the adult in that its onset is usually more sudden, manifesting itself as often in the appearance of fever, vomiting, and prostration as in the usual slow, insidious beginning. In the course of the disease constipation is more frequent than diarrhea, tympanites is not so marked, the eruption is less constant, the nervous symptoms are not as apt to be found as in adults, hemorrhage and perforation are also met with less often, and the mortality is lower. Tuberculosis is common in childhood. In infants under two years of age the lung is the part affected; beginning with the second year tubercular meningitis is more often found; and after the third year tuberculosis of the bones, the lymph-glands, peritoneum, and intestines becomes more frequent and are seen throughout childhood. Pott's disease and coxalgia are rarely seen except in childhood. The contagious diseases are typically children's diseases. While they may attack unprotected adults, they are com- paratively rare after fifteen years of age. Constitutional and Nutritional Diseases.—Rheuma- tism is rarely of the acute articular type in children. It is often exhibited only by stiffness and slight aching pains in the limbs ("growing pains"). The frequency of endocarditis as a complication of rheumatism, even when no more severe symptoms than growing pains are present, makes it necessary that such cases should be put to bed and receive proper treatment. Diabetes mellitus is uncommon in childhood, but when it does occur the course is very rapid and fatal. PECULIARITIES OF CHILDREN'S DISEASES 27 Scurvy is seen in artificially fed infants. Rickets and marasmus are typical nutritional diseases seen only in childhood. Orthopedics.—Many children have deformities due to rickets, spinal curvatures, congenital dislocation of the hips, and contractions of the tendons. These deformities are overcome by surgical treatment. Various terms are given to the different deformities: Clubbed hands; webbed fingers; congenital dislocation of the hips; knock-knees or genu valgum; bow-legs or genu varum; bowing of tibia; club-feet or talipes varus; and talipes valgus; Polydactyly or six fingers. Symptomatology.—In children the onset of disease is usually more sudden, the temperature higher, the pulse and respirations more accelerated, the physical signs more pronounced, the course shorter, and the recovery more rapid than in an adult. All temperatures in children are higher than in adult life. Frequently a temperature of 104 ° F. to 105 ° F. is seen in cases of ordinary pharyngitis and mild tonsillitis. Fever in children apparently results from the slightest cause. This is better understood if one realize that the nervous mechanism of a child is more sensitive than that of an adult. Consequently a fever in a child does not indicate as much as in an adult and need not cause anxiety unless prolonged. It is the continuous high temperature which indicates serious illness. On the other hand, the tempera- ture is easily depressed, owing to the great vascularity of the skin, by exposure, by sleep, and by inactivity. Inanition fever is a term applied to a peculiar elevation of temperature occurring in the newborn. It is generally seen during the first five days of life, and is apparently due to the fact that the infant gets very little, often nothing 28 DISEASES OF CHILDREN FOR NURSES at all, from the breast. The temperature may rise to 102 ° or 1040 F., and is associated with rapid loss of weight. As soon as milk is secreted in abundance, or when the child is placed upon a full breast, artificial food, or even water, if given freely, the temperature falls to normal. It is important that such a fever should be recognized, because it gives at times the first warning of a condition which may prove fatal. The temperature of every child should be taken during the first week. The normal pulse in infancy and childhood is of lower tension than in an adult and varies in frequency according to the age. The first few weeks after birth it beats from 120 to 150 times per minute. In the second year the pulse falls to no; in the third or fourth year to 100; in the seventh to 90; and in the twelfth to 80. Slight causes may produce wide variations of the normal pulse due to the unstable nervous mechanism of a child. The respirations during the same period likewise vary- In the newborn they are from 30 to 60 per minute; in the first year 28 to 30; at five years 22 to 25; at fourteen years 20; and in adult life 18. The peculiar variations of the respiration seen in childhood are due to the same nervous origin which influences the temperature and pulse. The function of digestion in infancy is delicate and undeveloped. Infants are able to digest about 4 per cent. of fat, 6 per cent, of sugar, and 2 per cent, of proteid during the first year. Infants cannot tell their symptoms, so it is necessary to study them to find out their ailments. The principal means a child has of explaining its wants, discomforts, or pains is by crying. A child cries from pain, hunger, discomfort, or habit. PECULIARITIES OF CHILDREN'S DISEASES 29 The cry of hunger is usually fretful, is accompanied by the sucking of its fingers, and ceases when satisfied. The cry of indigestion simulates the cry of hunger, but does not cease when the child is fed. The cry of pain is usually sharp and is accompanied by contractions of the features, drawing up of the legs, and signs of distress. If the child fall asleep from exhaustion it soon awakens, usually with a scream. It is well to remember that a severe pain in infancy may be due either to colic or earache. The child simply moans when the pain is less severe. The cry of weakness is a feeble whine. The cry of temper is prolonged, violent, and is attended with stiffness of the body and the throwing about of the arms and legs. The cry of habit ceases when the child is satisfied and may be caused by a desire for any familiar object, such as a doll, nipple, or rattle. There are also characteristic cries heard in certain diseases such as hydrocephalus, meningitis, marasmus, hereditary syphilis, and pneumonia. In hydrocephalus and meningitis a child will scream out shrilly in the night. This is called the hydrocephalic cry and is also sometimes heard in chronic bone diseases, due to pain. In marasmus there is the feeble whine; in hereditary syphilis a nasal cry; in pneumonia the cry is short, catching, and suppressed. Feeding and Therapeutics.—The entire subject of feeding in infancy and childhood is one of the most im- portant branches of pediatrics. The therapeutic measures employed differ in many respects from adult treatment. 30 DISEASES OF CHILDREN FOR NURSES Prognosis.—The younger the child, the worse the prog- nosis. This is because of the feeble resisting power and lack of development. On the other hand, many conditions can be outgrown, as the structures and organs increase in size and strength develops. Most deaths in the first year are due to marasmus, affections of the gastro-intestinal tract and to broncho- pneumonia. Practically the only deaths due to nervous origin are from meningitis and convulsions. Of the acute contagious diseases, usually measles and pertussis are the only offenders. Of the chronic diseases, tuberculosis stands alone. Sudden deaths occur from the following causes: mal- formations; internal hemorrhage; asphyxia from overlying; asphyxia from the aspiration of food into the larynx and trachea; asphyxia from enlarged thymus gland; atelec- tasis; convulsions; and marasmus. In the second year there are the same causes of death as in the first, with the exception of marasmus, which for- tunately does not extend into this period. From the second to the fifth year scarlet fever, diph- theria, general diseases of the lungs, and tubercular meningitis are the diseases causing death. From the fifth to the fifteenth year there is low mortality. It is chiefly made up of deaths resulting from diphtheria, scarlet fever, diseases of the lungs, tubercular meningitis, diseases of the bones, appendicitis, rheumatism, and cardiac conditions. Quarantine.—The diseases which must be isolated by the regulations of the Boards of Health of different cities vary so that no accurate mle can be given. Scarlet fever, small-pox, diphtheria, epidemic cerebrospinal PECULIARITIES OF CHILDREN'S DISEASES 31 meningitis, yellow fever, and cholera are universally isolated. In addition, many other diseases must be reported. Sections from the laws of the State of Pennsylvania are given as an example of what regulations must be expected in cases of infectious and contagious diseases. In addition, no one who is suffering from the diseases mentioned, nor anyone who has charge of the persons so suffering, is permitted to ride in a public conveyance, and the patient cannot enter a private vehicle without con- sent of the health authorities and without making pro- vision for thorough fumigation of the vehicle after use. Other provisions are made covering bedding, infected clothing, etc., and renting of rooms which have been occupied by persons suffering from tuberculosis or other infectious diseases, without fumigation. Section 1. Be it enacted, etc., That every physician, practicing in any portion of this Commonwealth, who shall treat or examine any person suffering from or afflicted with actinomycosis, anthrax, bubonic plague, cerebrospinal meningitis—epidemic (cerebrospinal fever, spotted fever), chicken-pox, Asiatic cholera, diphtheria (diphtheritic croup, membranous croup, putrid sore throat), epidemic dysentery (bacillary or amebic dysentery), erysipelas, German measles, glanders (farcy), rabies (hydrophobia), leprosy, malarial fever, measles, mumps, pneu- monia (true), puerperal fever, relapsing fever, scarlet fever, (scarlatina, scarlet rash), small-pox (variola, varioloid), tetanus, trachoma, trichinia- sis, tuberculosis in any form, typhoid fever, paratyphoid fever, typhus fever, whooping-cough, yellow fever, anterior poliomyelitis, impetigo contagiosa, pellagra, scabies, or uncinariasis shall report the case to the health authorities. Section 2. Upon receipt by the health authorities of any township of the first class, borough, or city, or by the health officer of the State Department of Health, of a report of the existence of a case of anthrax, bubonic plague, cerebrospinal meningitis—epidemic (cerebrospinal fever, spotted fever), chicken-pox, Asiatic cholera, diphtheria (diph- theritic croup, membranous croup, putrid sore throat), German measles, glanders (farcy), leprosy, malarial fever, measles, mumps, relapsing fever, scarlet fever (scarlatina, scarlet rash), small-pox (variola, varioloid), 32 DISEASES OF CHILDREN FOR NURSES typhoid fever, paratyphoid fever, typhus fever, whooping-cough, or yel- low fever, the said health authorities or the health officer of the State Department of Health, as the case may be, will quarantine the residence. Quarantine Periods—If Antitoxin Has Been Used—Cultures. Section 4. The quarantine period for anthrax, bubonic plague, cere- brospinal meningitis—epidemic (cerebrospinal fever, spotted fever), Asiatic cholera, typhus fever, yellow fever, relapsing fever, leprosy, and whooping-cough shall be until the recovery, death, or removal of the patient so suffering, and shall be determined in accordance with the rules and regulations of the health authorities. The quarantine period for small-pox (variola, varioloid) and scarlet fever (scarlatina, scarlet rash) shall be a minimum period of thirty days, or until such time thereafter as the last person in the premises so suffering shall have fully recovered, or until death or removal. The quarantine period for diphtheria (diph- theritic croup, membranous croup, putrid sore throat) shall be a mini- mum period of twenty-one days, or until complete recovery or the death or removal of the patient: Provided, That if antitoxin has been used for curative purposes for the patient, and for the immunizing of all of the inmates of the premises, and two negative bacteriological cultures have been secured from the diseased area of each patient on the premises for two successive days, the minimum period of quarantine may be fourteen days. The quarantine period for measles, German measles, chicken-pox, and mumps shall be for a minimum period of sixteen days, or until the recovery of the last person on the premises so suffering, or until complete recovery or the death or removal of the patient. Exclusion from Places of Amusement, Public Gatherings, Places of Business, Churches, Schools, Etc. Section 7. No child or other person residing in the same premises with any person suffering from anthrax, bubonic plague, cerebrospinal menin- gitis—epidemic (cerebrospinal fever, spotted fever), Asiatic cholera, small-pox (variola, varioloid), typhus fever, yellow fever, scarlet fever (scarlatina, scarlet rash), relapsing fever, leprosy, diphtheria (diphtheritic croup, membranous croup, putrid sore throat), measles, German measles, chicken-pox, or mumps, shall be permitted to attend any place of amuse- ment, or any church, or other pubhc gathering, or to be exposed, except by permission of the health authorities, on any public street or in any store, shop, factory, or other place of business, or be permitted to attend any public, private, parochial, Sunday, or other schools; and the teachers of public schools, and the principals, superintendents, teachers, or other persons in charge of private, parochial, Sunday, or other similar schools, PECULIARITIES OF CHILDREN'S DISEASES 33 are hereby required to exclude any and all such persons from said schools; such exclusion to continue until the quarantine is lifted and the premises thoroughly disinfected. Disinfecting Bath, Etc.—Removal—Bath, Etc—Use of Antitoxin- Admission to School—Removal—Immunes—Admission to School. Section 8. Any child or person residing on the same premises with any person suffering from anthrax, cerebrospinal meningitis—epidemic (cerebrospinal fever, spotted fever), or typhus fever may be allowed after taking a disinfecting bath and putting on disinfected clothing, to remove from the said premises and take up his or her residence on other premises, and may after such removal be admitted into any of the said schools; and any child or person residing on the same premises with any one suffering from diphtheria (diphtheritic croup, membranous croup, putrid sore throat), may be allowed, after taking a disinfecting bath and putting on disinfected clothing, and after antitoxin has been administered for immunizing purposes, to remove from the said premises and take up his or her residence on other premises occupied by adults; and may, after five days from said removal, be admitted into any of the said schools; and any child or person residing on the same premises with any child suffering from scarlet fever (scarlatina, scarlet rash), measles, German measles, mumps, or chicken-pox, may be allowed, after taking a disin- fecting bath and putting on disinfected clothing, to remove from the said premises, and take up his or her residence on other premises occupied only by adults, or by children who are immune to the disease (scarlet fever, scarlatina, scarlet rash, measles, German measles, mumps, or chicken-pox), existing on the said premises from which the said child or person has removed, such immunity being shown by the official health records, and may, fourteen days after such removal, be admitted to any of the said schools: Provided, That if the child or person residing on the same premises with any person suffering from any of the said diseases (scarlet fever, scarlatina, scarlet rash, measles, German measles, mumps, or chicken-pox), and removing therefrom as above provided, is himself or herself immune from the disease existing on the said premises, by virtue of a former attack, this fact being shown by the official health records or by other evidence satisfactory to the health authorities, such immune child or person may, on the day following such removal, be admitted to any of the said schools; and any child or person residing on the same premises with any person suffering from relapsing fever may be allowed, after taking a disinfecting bath and putting on disinfected clothing, to remove from the said premises, and take up his or her residence on other premises, and may, after ten days from such removal, be admitted to any of the said schools. 3 CHAPTER II NURSING IN CHILDHOOD The problems which confront the nurse in the manage- ment of children are vastly different from those encoun- tered among adults, but the fundamental principles of nursing are the same. The methods of treatment are in many respects identical, or only slightly altered to adapt them to the young patient. The methods of amusement and entertainment can be appreciated by all who have come in contact with children, and success in handling them depends entirely upon the nurse's temperament. It is the professional side of the nurse, her value to the physician in attendance, which demands the special train- ing in children's diseases. It is necessary to know the symp- toms and to be able to report them intelligently. This calls for careful, trained observation, as the child cannot describe its feelings accurately. The detail of symptoms cannot be recited by the patient, but has to be recognized and tabulated by the nurse. It is necessary to understand the principles of infant feeding and hygiene. These are the two most important subjects of pediatrics. Knowledge of milk mixtures and their preparation is essential. Accuracy is demanded both by the infant's digestion and by the physician. The delicate mechanism of an infant's stomach cannot digest foods unless they contain the proper proportion of fat, sugar, and proteid. The physician's whole plan of treat- 34 NURSING IN CHILDHOOD 35 ment is rendered useless unless he knows the percentage of these ingredients in the mixture the child is getting. The proper methods of feeding in malformations and intubations must be understood. Hygiene is a vast subject in itself. In infancy the sur- roundings and the personal attentions are of greater value than at any other time of life. It is necessary to understand the significance of the stools in infancy. The character of these acts as a guide to the physician in the treatment of the case and in the construction of his milk mixtures. In the same way the character of the vomit is important. The methods of treatment in childhood must be thor- oughly comprehended. The subject of prophylaxis and the care of the contagious cases is the field in which the nurse is in supreme command. By never permitting a lapse in her technic nor carelessness in her methods she does more for the prevention of disease and the health of the human race than any other factor in medicine. GENERAL HYGIENIC MANAGEMENT OF CHILDREN The Newly Born.—Immediately after birth the child should be wrapped in a blanket and placed in a warm room. The eyes should be washed with boric acid or, in cases where there has been a pre-existing vaginal dis- charge one or two drops of a 2 per cent, solution of silver nitrate should be used (Crede's method). The child should then be thoroughly greased and given a warm bath at a temperature of ioo° F. An antiseptic dressing should be applied to the cord and a flannel binder placed around the abdomen. It is preferable to have the child sleep in a crib. 36 DISEASES OF CHILDREN FOR NURSES Care of the Cord.—-The cord should be kept dry and disturbed as little as possible until it drops off; this usually occurs on the fifth day. After this has happened an antiseptic dressing and a square pad should be placed over the navel and held firmly in place by the binder, to prevent umbilical hernia. Bathing.—After the separation of the cord the full bath can be given daily. The water should be about 100 ° F. The middle of the day and the warmest part of the room are the time and place to select. The bath should take only a few minutes, and vigorous rubbing should be avoided. Clothing.—This should be light in texture, warm, and nonirritating. The chest and arms should be covered with a woolen undershirt, and all clothing should hang from the shoulders. Canton flannel or stockinet make the best diapers. The feet must be warm, as cold feet are responsible for many attacks of colic and indigestion (Holt). The night clothing should consist of a light flannel gown, hung from the shoulders. Too much covering may cause disturbed sleep. In summer the outer clothing should be light and the underclothing of the thinnest flannel or gauze obtainable. Special Hygienic Measures.—The eyes should be washed with boric acid for the first few days and at any time upon the appearance of a discharge from the eye. Infants should be kept in a darkened room. The tem- perature should be taken daily during the first week (see page 28.) The mouth should be cleansed with a soft rag wet with sterile water. A solution of bicarbonate of soda, 20 gr. to the ounce, should be employed if there are any signs NURSING IN CHILDHOOD 37 of inflammation or thrush. In such cases the mouth should be cleansed with this solution after each feeding. The breasts in both sexes often become swollen a few days after birth. If they are not interfered with, this disappears in a short time. Genitals.—In boys the foreskin should be retracted daily and greased. The skin is very delicate in infants; Fig. 6.—The " Children's Hospital Bed." A properly constructed bed for infants. the urine frequently causes scalding and blistering of the surfaces, especially in fat babies. If this occurs the napkins must be removed as soon as soiled; the skin should be bathed only once a day with water (for all other cleansing purposes olive oil should be used); and a powder consisting of balsam of peru, 10 per cent, tal- 38 DISEASES OF CHILDREN FOR NURSES cum, starch, commeal, or stearate of zinc, dusted upon the inflamed areas, in all the folds of the skin, and over the diaper. The best dusting powder is probably the balsam of peru, 10 per cent., combined with stearate of zinc. Bran baths are advantageous at times (see page 446). Airing.—In summer a newly bom babe can be taken out at the end of the first week; in winter, at one month. All children should receive all the sunshine and fresh air obtainable. Sleep.—During the first few weeks a child sleeps from twenty to twenty-two hours during the day. An infant should not be allowed to sleep at the breast or with a nipple of a feeding bottle in its mouth. The babe should be awakened every two hours for its feeding. Infant feeding is discussed in Chaps. XVIII and XIX. Infancy.—Bathing.—By the sixth month the tempera- ture of the bath can be reduced to 95 ° F. and by the end of the first year to 90° F. Older children should receive a cold douche with water of about 70 ° F. after the bath, while standing in a tub of warm water. At times infants get blue after the bath, especially if delicate. Under such conditions it is better to discontinue tub bathing and depend upon the bed baths. Clothing.—The abdominal band can be dispensed with after the first few months. In very thin infants it may be continued, to maintain the proper protection to the abdo- men. Low neck and short sleeves should not be allowed. The night clothing should be a light flannel gown hung from the shoulders. The night clothes should be an entirely different set from those worn during the day. Special Hygienic Measures.—The teeth should be kept NURSING IN CHILDHOOD 39 clean to prevent caries. The child should be trained to have its bowel movements and urinate at selected times. Sleep.—During the first six months the child will sleep from sixteen to eighteen hours during the day. At one year it requires from fourteen to fifteen hours of sleep and at two years, thirteen or fourteen hours. An infant's position should be changed often during sleep. Exercise.—An infant usually obtains plenty of exercise from crying and throwing its arms and legs about. Walk- ing should be attempted during the period from the eighth to the sixteenth months, provided there is no tendency to rickets. Talking should be encouraged. Childhood.—Bathing.—During childhood the warm bath should be given at night and the cold bath or sponge in the morning. Clothing.—Woolen undergarments in winter and light textures in summer are the rule. The night clothing should consist of woolen union suits with feet, if there is a tendency to get from under the covers. General Hygienic Measures.—The bowel movements should be kept regular. Any illness or disorder should be immediately attended to. Sleep.—At the age of four years eleven or twelve hours sleep are required. Exercise.—The playroom should be cool—from 60 ° F. to 65 ° F. (Holt). The clothing should be loose, to give the freest possible motion of the muscles. Out-of-door exercises are the most healthful. The proper methods of feeding for children over two years of age is discussed in Chapter XLX. Youth.—Sleep.—The amount of sleep required from 40 DISEASES OF CHILDREN FOR NURSES the sixth to the tenth year is from ten to eleven hours. From the tenth to the fifteenth year at least nine hours of sleep are necessary. An out-door life with plenty of exercise, frequent bathing, and instant attention to ailments lays the foundation for sturdy manhood and womanhood. The nursery should be the sunniest and the best ventilated room in the house. Nothing which could contaminate the air of the room should be allowed. The temperature should be from 68° F. to 70 ° F.; no higher. The room should always be thoroughly aired at night. The floors should be covered with rugs, as they are cleaner than carpets. An infant requires about 1000 cubic feet of air, older children about 700 to 800 cubic feet. Premature Babies.—The conditions which have to be combated under these circumstances are the problems of maintaining the body heat, and feeding. Incubators.—These are so arranged that an even tem- perature may be maintained: 98° F. in very delicate in- fants and from 850 F. to 950 F. in more robust babies. At the same time the air is moistened and ventilation is secured. In constructing an incubator the lower portion consists of a hot-water tank (hot-water bottles may be used), above which is an inlet for air. The bed should occupy a position midway in the air chamber and be so arranged as to allow the air to circulate freely around its foot. An exit for the air should exist above the child's head. A moistened sponge should be placed at the foot of the bed. The child is kept in the incubator until it reaches full term. Before removing, the temperature should be gradually lowered. NURSING IN CHILDHOOD 4* In feeding these children, gavage often has to be resorted to. At seven months of age h ounce should be given every hour and a half. At eight months f ounce at the same intervals. In small full-term babies it is also necessary to maintain the body heat. This is best accomplished by wrapping Fig. 7.—Cross-section of a wooden incubator of simple construction, with glass lid (F): The air enters through the opening A, which can be regulated by means of a damper, passes over the bottles filled with hot water, the saturated sponge, and the ther- mometer, and escapes through the ventilator K (Fruhwald and Westcott). them in cotton and blankets. Hot-water bottles may also be employed. ROUTINE EXAMINATIONS Temperature.—When taking the temperature of the child it is not always possible to teach them to hold the thermometer in the mouth properly, and for young children and infants this method is impracticable. The rectum, the axilla, or the groin are then utilized for this purpose. The thermometer should be greased with ordinary vas- 42 DISEASES OF CHILDREN FOR NURSES elin'when introduced into the rectum and the temperature marked "rectal" on the chart or read one degree lower than the mercury indicates, as the local temperature in that part is about one degree higher than in the mouth. If an infant struggles while taking a rectal temperature, turn it on its face, or hold its face downward on your knee. Fig. 8.—Method of taking the rectal temperature of an infant or young child (Kerr), When the thermometer is inserted, with the child in this position, it should be pointed downward, toward the um- bilicus, as the axis of the rectum has been changed. When the rectum is diseased it should not be chosen for the place to take a temperature. In the axilla or groin the temperature should be marked "axillary" on the chart or read one degree higher, as there NURSING IN CHILDHOOD 43 is that much difference in temperature between these localities and the mouth. The skin should be thoroughly dry and the thermometer closely surrounded by folds of skin. Pulse.—The pulse is best obtained in the groin or at the temporal artery in infants. The normal rate for the different ages is given on page 28. Fig. 9.—The method of obtaining the temperature at groin. The skin should be free from moisture. The thermometer is laid in the fold of skin between thigh and abdomen and is held in place by crossing thighs. Respiration.—The normal rate for the different ages is given on page 28. COLLECTIONS FOR CLINICAL EXAMINATIONS Method of Collecting Urine.—In males it is a good plan to place the penis in the neck of a bottle which lies between the thighs and is held in position by a square of adhesive plaster, the center of which is pierced, making a hole large enough to grip the neck of the bottle. 44 DISEASES OF CHILDREN FOR NURSES In females a small pan placed under the buttocks will answer, or a bottle can be arranged as described above. If these methods fail, catheterize. The diapers are saved in cases where the stools are to be examined. The blood is examined to determine the number of red and white blood-corpuscles, the percentage of hemo- globin, and for malarial organisms. For method, see page 194. The Wassermann reaction for syphilis and the com- plement fixation test for gonorrhea are also made with the blood. The sputum is examined for tubercle and other bacilli, and should be expectorated into a sterile, wide-mouthed bottle. In children under four years of age, the best method to obtain sputum is as follows: Have an applicator with sterile cotton about the tip. Grasp the tongue, pulling it as far forward as possible, and pass the applicator back to the pharynx, keeping as close to the tongue as possible. The irritation of the pharynx will excite coughing, and the sputum may be swabbed out. The applicator may be placed by the child's bedside, and when the nurse notices a severe attack of coughing the child is picked up and the sputum obtained in the same manner. Another very easy method of obtaining sputum is to insert a large (jounce) eye dropper into one end of a catheter, compress the bulb, and pass the catheter back to the pharynx, then allow the bulb to expand, this produces suction and draws the sputum into the catheter. Cerebrospinal fluid is examined for various organisms. For method, see page 213. NURSING IN CHILDHOOD 45 Diphtheria bacilli are looked for in smears taken from the nose and throat. It is at times desirable to have the nurse obtain the culture from a suspected case of diphtheria. To do this she must have a platinum loop and a test- tube containing the proper culture media (Loffler's blood- NAME _ /Za&&Jy&KS&u^. _..... DATS. S p 1 ! s STOOLS CHAMcrm MEDICINE NOWISHNDO 5s REMARKS 'Acy 3/IM /M- lOi ty /Sff 5oftyr//o* wAiskyti ■MUHfLw. 6 »x i 1 150 60 IQi> l\ \ /', i \J '. /w 55 /OS M 1 N > ii 11 \ .130 50 tof- 1 \ i 11 A \l i i ;\ i i \ 120 *rS 103 i i A \l l\ V 1_ 1 l ' 110 4-0 102. \ v. A J 1 A 1 1 , \ 100 35 101 \ \J \l V i A >.' A \ /\ ~ a 90 30 too V^ \) r i V V V 80 25 99 ;J 10 20 <78 60 /5 9/ Fig. 2$.— Chart of the temperature (----) and respirations (----) in bronchopneumonia. Child one year old (Kerr). Just before death the temperature often reaches 107 ° F. and 109° F. The respirations average from sixty to eighty per minute, often they are one hundred per minute, and occasionally a hundred and twenty. There is great short- ness of breath (dyspnea), the child struggles for each breath, the chest is retracted at the base, and the other symptoms of dyspnea are present. The respiratory action is more affected than the heart action, and if the child succumbs it is usually by respiratory failure, the symptoms of which are very rapid, superficial breathing, sometimes 96 DISEASES OF CHILDREN FOR NURSES a hundred to a minute, blueness of the lips and finger-nails, and often a bluish hue to the body. The pulse averages from one hundred and fifty to two hundred per minute. When very rapid it is often irregular. The character of the pulse is more important than the rapidity. At first it is full and strong, but later it becomes weak, thready, compressible, and intermittent. Cough is always present and very persistent, more so than in croupous pneumonia. A good, strong cough is not an unfavorable symptom, as it shows that the reflex irritability of the bronchial tubes is still present. When this is lost the mucus is not removed, the lungs fill up, and respiratory failure threatens. Suppression of cough is, therefore, a bad sign. There is no expectoration before four years of age, the mucus is either swallowed or re-inspired. During severe paroxysms of coughing, if the child be turned on its face or inverted, much of the mucus will run out of the mouth. A blueness (cyanosis) of the skin and mucous membrane is found in severe cases. It is due to a sudden congestion of a portion of the lungs not previously affected. Even when present only at lips and finger-tips, the patient should be very carefully watched, and if further symptoms of respiratory failure develop, they should receive prompt treatment (see pages 107 and 453). Prostration is progressive; at first it may be moderate, but in the final stages there may be symptoms which are known as the typhoid state. These are delirium, picking at the bed-clothes (carphalogia), twitching of the tendons (subsultus tendinum) rare in childhood, and dry, brown fissured tongue. Gastro-intestinal Symptoms.—Often there are from four DISEASES OF THE RESPIRATORY TRACT to six green stools a day, containing mucus and undigested food, due to the weakened digestion from the fever and induced by feeding improper food. This same condition may cause vomiting. Vomiting and diarrhea add much to the danger of the attack, and when the result is in doubt, may turn the scales against the patient. In summer this complication is more frequent and more severe. Disten- tion of stomach and intestines from gas may cause attacks of cyanosis, which condition should be relieved as soon as possible. The rectal tube may be employed with care. The urine is scanty. Complications.—Pleurisy is nearly always present. Pur- ulent meningitis sometimes complicates acute broncho- pneumonia, but the most frequent complications are referable to the gastro-intestinal tract. Croupous pneumonia is an acute, infectious, inflam- matory disease of the lungs characterized by a high fever and ending by crisis in from five to nine days. Seventy- five per cent of the cases of croupous pneumonia are caused by the diplococcus pneumoniae. The term lobar pneumonia is generally used for this form of pneumonia, so-called on account of its tendency to involve a whole lobe of the lung in contradistinction to bronchopneumonia, which is sometimes called lobular pneumonia. Croupous pneumonia is one of the oldest recognized diseases; it was described fairly accurately by Hippocrates in 460 B. C. In childhood pneumonia follows, in a general way, the character of an attack in the adult. In speaking of bronchopneumonia it was said that it was the pneumonia of early infancy. This is true until children are about 7 98 DISEASES OF CHILDREN FOR NURSES two years of age, after which they are usually attacked by croupous pneumonia. This disease has a tendency to attack children that were previously healthy; it is especially prevalent in the spring of the year„ Epidemics are not frequent among children, and the disease is rarely fatal. In the order of frequency the disease attacks the following portions of the lungs: left base, right apex, right base, left apex. The complications of pneumonia are pleurisy, otitis, pericarditis, endocarditis, meningitis, neuritis, and neph- ritis. Children rarely have complications, the one most often seen being empyema, which is probably on account of the proneness of children to have severe pleurisy associated with croupous pneumonia. The temperature is generally higher, the pulse more rapid, the duration shorter, and the cerebral symptoms more frequent in children than in adults, otherwise, as has been mentioned before, the disease is the same. The cause of croupous pneumonia is usually exposure. The disease occurs more frequently in males than in females. It is usually primary, occasionally it will com- plicate some form of infectious disease. There are four distinct stages in croupous pneumonia: The stage of congestion or engorgement, seen in the first twenty-four hours. The stage of red hepatization, of from four to five days' duration. The stage of gray hepatization, of from six to ten days' duration. The stage of resolution, of from six to ten days' duration. Congestion is the stage in which the lung is engorged with blood, yet permeable to air. It is an active conges- tion of the lungs. Stage of red hepatization. The term hepatization is DISEASES OF THE RESPIRATORY TRACT 99 given on account of the liver-like appearance of a lung on section. In this stage the lung is dark red in color, and of very firm consistency. This is caused by the air-cells being filled with what is known as a croupous exudate. This exudate is composed of red blood-corpuscles from the capillaries surrounding the alveoli and exfoliated epithelial cells which line the walls of the air vesicles, all massed together by fibrin. The croupous exudate ex- cludes the air from the alveoli affected. This gives rise to a consolidation of the lung, which normally is permeable to air. This condition is called a pneumonic consolidation. The size of the area consolidated depends upon the number of air-cells filled with the croupous exudate. In croupous pneumonia a whole lobe or more is usually affected. It can be understood to what extent the function of the lungs would be impaired under such conditions, and also the tremendous extra strain thrown upon the heart, which has to pump the blood through the consolidation just as through the normal lung. The stage of gray hepatization is so called from the appearance of a lung on section. It is grayish and still firm and liver-like. The grayness is due to the air-cells being filled with white blood-corpuscles, the red blood- corpuscles and fibrin having been withdrawn. The pneumonic consolidation still remains, as the affected area is still impermeable to air. The whole pneumonic con- solidation has become softened in this stage by degener- ation, and is in preparation for the stage of resolution. The stage of resolution is characterized by the lique- faction of the croupous exudate, part of which is expector- ated and part absorbed. Resolution generally begins when the temperature falls to normal and lasts about a IOO DISEASES OF CHILDREN FOR NURSES week. Delayed resolution is the term applied to a slowly resolving pneumonia, which may be prolonged from a week to a month. The pleura adjacent to the pneumonic area is nearly always involved. Symptoms.—The disease is ushered in suddenly with high fever, prostration, acceleration of the respiratory rate, and increase in the pulse-beats. In children vomiting often attends the onset. Pain in the side is also quite p. R. T. 1 Tn.e z. tn.e. 3 m. e trr. e m. e 6 In. C 7 m. e 8 m. e 9 m. e. to fn. e rn. e /J /«■. e. 170 70 108 160 6S lot 150 60 toe \\ 140 55 /OS ; \ 130 50 10* jt h ,\ ' /\. 120 ■4? 103 V/ \ /''' \/? 110 40 loz /A / \ * \ / i \l \ ''1 100 3i /Oi i V V 1 V A/A \ /Nx /-, 90 SO /oo > ^ \ 1- 80 2.5 99 '"' 7o 3.0 98 60 15 97 Fig. 26 —Chart of the temperature (----) and respirations (----) in lobar pneumonia, Child one year old (Kerr). common; a decided chill is not as characteristic as it is in adults. At times the pain is referred to the region of the appendix and appendicitis is simulated. The child appears profoundly sick from the beginning. The skin is hot, the face flushed, often more so on the side corresponding to the pneumonic consolidation. The temperature reaches 1040 to 105 ° F. within twenty-four hours. The pulse is full and strong, averaging 120' to 130 per minute, the respirations are labored and from 40 to 50 per minute, which in severe cases may be as high as 80 to 100. The signs of dyspnea are present, the breathing is not always DISEASES OF THE RESPIRATORY TRACT IOI regular, and there is a characteristic catch of the breath or moan at the end of each expiration. Cough develops early and is hard, catchy, and partially suppressed. There is no expectoration. The urine is scanty. The temperature remains continuously high with slight daily fluctuations. Herpes develops on the lips, the child may be delirious, more often at night than at any other time. Cyanosis may be present, but it is not nearly so frequent as in bronchopneumonia. The danger of respiratory failure is practically absent; on the other hand, the chances of heart failure are vastly increased. In a day or two the cough becomes loose. In children under four years of age there is no expectoration, as the mucus is swallowed. Older children may have the rusty sputum seen in adults. The position in bed (decubitus) is also characteristic; the patient will lie on the side affected to give the sound side a chance for increased expansion. Leukocytosis is present, the white blood-corpuscles being increased from 6000 to 19,000 or 20,000 or more, per cubic millimeter. All these symptoms continue unchanged for from five to nine days, when, if recovery takes place, a sudden drop in the temperature occurs, often accompanied by free perspiration, while a state of comparative comfort succeeds to that of great distress, and it may be followed by a long and refreshing sleep. This is known as the crisis. It may be preceded by a fall of temperature a day or two earlier, which is again followed by a rise. If there is a fall of this description it is called pseudocrisis. The fall in a crisis is sometimes as much as seven degrees in a single twenty-four hours, and the minimum is often slightly subnormal, from which it rises rapidly to the normal. 102 DISEASES OF CHILDREN FOR NURSES Sometimes the temperature falls by lysis. From this point onward convalescence is rapid; in a week the child is out of bed and in a month is out of doors. Pneumonia either ends in resolution, abscess, gangrene, interstitial or fibroid pneumonia, phthisis, or, if fatally, usually by heart failure. Abscess from introduction of pus organisms; gangrene from engorgement of pulmonary vessels; interstitial pneumonia from overgrowth of con- nective tissue from exudate becoming organized; phthisis from introduction of tubercle bacilli. The symptoms of heart failure are coldness of hands and feet, then of the legs and arms, a rapid, compressible, and sometimes irregular pulse, muscular weakness and pallor, but usually no cyanosis. Death usually occurs at the time of the crisis, so if the child can be kept alive until this time has passed, it is practically saved. Prognosis.—Mortality is about 4 per cent. The differ- ence from pneumonia in adults is at once apparent when it is known that the adult mortality is from 20 per cent, to 40 per cent. When complicated by meningitis and endocarditis it is usually fatal. Cerebral pneumonia is a form of the disease character- ized by severe nervous symptoms. Convulsions occur in about 5 per cent, of the cases, and in the more severe forms arching of the back (opisthotonus) may be found. Pleuropneumonia.—Children are especially prone to have pleurisy, and nearly every case of pneumonia could be called pleuropneumonia. Usually under this term are included cases with excessive amount of pleurisy, the two processes uniting to form a single clinical type of disease. There is little to distinguish a case of pleuro- pneumonia except the severity of all the constitutional DISEASES OF THE RESPIRATORY TRACT 103 symptoms. The temperature is often higher, the prostra- tion greater, and the patient in every way impresses one as being more seriously ill than with ordinary pneu- monia. Hypostatic pneumonia, like hypostatic congestion, is caused by the venous stasis, owing to the child's recum- bent position. For this reason the position of a patient in bed should be frequently changed. Aspiration pneumonia is due to the inhalation of some foreign substance into the lungs, which gives rise to an inflammation. Such foreign material may be diphtheric membrane, food, etc. The symptoms are those of bron- chopneumonia. Chronic interstitial pneumonia, as said before, is sometimes a sequel to croupous pneumonia, but in children it is usually associated with phthisis. It is due to an overgrowth of fibrous tissue, with subsequent retraction of the lung tissues. It is generally characterized by chronic cough, slight dyspnea, and scanty expectoration. Bronchiectasis sometimes results when there is the char- acteristic fetid sputum, which occurs in gushes. Gangrene of the lung is sometimes seen following pneumonia. The bacteria of putrefaction gains access to the diseased area and cause necrosis. It is fatal. Symptoms.—Children have the characteristic symptoms of inflammatory disease of the lungs, such as cough and dyspnea, together with profound prostration and the expectoration of very offensive sputum. Abscess of the lungs is more common than gangrene. Small abscess may be seen in bronchopneumonia. Some- times an empyema {purulent pleurisy) will rupture into the lungs, causing a secondary abscess. 104 DISEASES OF CHILDREN FOR NURSES The symptoms here will be those of any lung affection (fever, cough, dyspnea, and expectoration) plus the characteristic symptoms of pus, namely high and irregular fever, rigors, sweats, and pallor. Embolic septic pneumonia or a metastatic abscess of the lung is caused by a septic embolus. Such a septic embolus may arise at the seat of some putrid inflammation or suppuration, such as a wound of an operation or a compound fracture. This embolus lodges in the small capillaries of the lung and starts a point of suppuration, from which there will arise all the symptoms of pus. It is generally only one of the lesions of pyemia. Treatment.—Pneumonia, both bronchopneumonia and the croupous form, are diseases which for a favorable outcome depend not so much on the remedies given as upon the general hygienic measures employed. These measures are grouped under the term general nursing. Since in the treatment of bronchopneumonia very little can be done for the disease and very much can be done for the patient, and since croupous pneumonia is a self-limited disease having a strong tendency in childhood to recovery regardless of the treatment adopted, the plan of treatment of both diseases is practically the same. Serum Treatment of Pneumonia.—It has been found that croupous pneumonia is caused by one of four strains of pneumococci. To determine which strain is present in a given case either the sputum or the fluid withdrawn through an aspirating needle, which is plunged into the pneumonic consolidation, is injected into a mouse. Six hours later a Widal is made with a pure culture of each one of the four strains of pneumococci and the blood of the mouse. The strain that agglutinates when DISEASES OF THE RESPIRATORY TRACT 105 mixed with the blood is the type present in that par- ticular case. Horses have been rendered immune to strains one, two, and three, and their serum can be utilized in prac- tically the same way as in the antitoxin treatment of diphtheria. Strain four is a heterogeneous type and pro- duces no reaction in the horse, so there is no serum avail- able for this form of the disease; it is the mildest form, however, comprising about 30 per cent, of the cases, with a mortality of only 6 per cent. There is really no satisfactory, uncontested evidence that such sera have exerted any influence upon the course of the attack. Cole obtained a serum which seems to have specific action upon the Type I of the pneumococcus, but it is of little service in pneumonia in early life, since the great majority of cases at that time do not depend upon this strain of the germ—75 per cent, being Type IV. Nursing.—The indications are, so far as possible, to make the child comfortable during his illness, to prevent complications, and to treat the individual symptoms as they arise. Bronchopneumonia is frequently a complica- tion of one of the infectious fevers, such as measles, whooping-cough, and influenza; so in the nursing of these conditions prophylactic measures must be employed. Perhaps in the majority of cases of pneumonia in child- hood hygienic treatment is all that is required. The patient should be kept in a large well-ventilated room, and, if possible, changed from one room to another two or three times a day, to allow thorough airing. Some physicians adopt the open-air treatment for pneumonia. The child's bed is then placed on the porch or veranda. 106 DISEASES OF CHILDREN FOR NURSES When these do not exist, the bed is drawn in front of an open window. The child is protected from the wind, a flannel cap and mittens are worn, it is covered with blankets, and surrounded with hot-water bottles. Whenever it is necessary to change any of the clothing or to give baths, the child is brought into the warm room. The bed is thoroughly warmed with hot-water bottles before the patient is again placed in it. Older children should be kept in bed; infants can be held in the nurse's arms for a considerable part of the time. A frequent change of position is essential. The bed-covers should never be tucked in tightly. Food should be given at regular intervals, and when the child is restless, fretful, sleepless, or nervous, sponging with tepid water usually makes him comfortable. Severe nervous symptoms re- quire the application of ice, either in the form of a cold bath or an ice-bag. Pain is usually relieved by the application of mustard paste or turpentine stupes. In bronchopneumonia an oiled-silk jacket is sometimes worn throughout the attack, and, if necessary, counter- irritation maintained by mustard paste. Hot poultices of flaxseed may be employed. When new poultices are applied the old poultice is first rolled back from one side, and the new one is placed in position; then the other side is covered in the same way. This prevents exposure. Amber oil is also useful. Fever in itself means nothing, as it only indicates the severity of the lesions. Since a temperature of 105 ° F. is characteristic of pneumonia, it is not necessary to do much for it unless it become higher. The nervous symp- toms call more often for treatment than the fever, and as the two go hand in hand, it is customary to keep DISEASES OF THE RESPIRATORY TRACT 107 the fever under control. The best means for this end is cold. It may be used by a graduated bath for small children, a cold pack for older ones, or a simple sponging and an ice-bag. Some physicians use only warm baths (ioo° F.) in their treatment of pneumonia. Iodin is often applied to the chest in unresolved pneu- monia. If the ordinary tincture of iodin causes blistering of the skin, it can be diluted one-half with alcohol. It is the emergencies which arise in pneumonia with which the nurse has to contend. In respiratory failure there is great dyspnea, cyanosis, and signs of collapse. The physician should be immediately summoned; in the meantime, if the child shows great distress in breathing while in the recumbent posture, it should be propped up in bed, oxygen should be administered; gentle friction of the sides of the chest at times stimulates the respiratory mus- cles. He may order a mustard tub and hypodermic in- jections of one or more of the following drugs: atropin, caffein, strychnin, and nitroglycerin. In sudden attacks of great cyanosis a mustard tub is advantageous. At times a moist atmosphere is the best for pneumonia, a croup tent with steam atmosphere medicated with com- pound tincture of benzoin generally relieves the dyspnea, especially if there is much bronchitis associated with the pneumonia. In an ordinary case a child should remain in bed for about a week after the normal temperature has been reached. The temperature, pulse, and respirations should be taken everv three hours. CHAPTER V DISEASES OF THE DIGESTIVE TRACT The digestive tract is composed of the mouth, tonsils and pharynx, the esophagus, stomach and intestines, the pancreas, and the liver. The symptoms of the diseases of the digestive tract are exhibited in the condition of the tongue, breath, ap- petite, and the stools. Vomiting, pain, tenderness, and distention of the abdomen are associated symptoms. The tongue often has a light, uniform coat in health, especially in bottle-fed babies. It becomes heavily coated upon the slightest indication of indigestion. The mucous membrane covering the tongue is the only part of the lining of the alimentary canal visible, and indicates the condition of the mucous membrane in the lower digestive tract. The tongue also becomes coated in fever and catarrhal conditions of the nose and throat. In several diseases there is a characteristic appearance of the tongue. In typhoid fever, in the early stages, the tongue is red and it often trembles upon extrusion, and later becomes dry, brown, and fissured. In scarlet fever, in the first stage, the tongue is heavily coated with a whitish fur, with the exception of the tip, which is red. This whitish fur gradually peels off, so that in a day or two the tongue is a deep red, with the papillae deeply injected. This has given rise to the name strawberry tongue, characteristic of this disease. 108 DISEASES OF THE DIGESTIVE TRACT 109 In gastro-enteritis sometimes the tongue is gray-coated and flabby, with an oval bare spot in the center, which is red and glossy. In older children scars on the tongue are due to tooth-wounds inflicted during epileptic convulsions. Fig. 27. —Illustrating a very good and common position for mouth and throat examina tion (Kerr). Fetor of the breath is frequently due to some local condition, such as chronic rhinitis, tonsillitis; to retained particles of food; to caries of the teeth; to certain lung dis- eases; to dyspepsia; and to the ingestion of certain drugs. The condition of the appetite may be inordinate, lost, or perverted. The following names have been applied to the different varieties of appetite: HO DISEASES OF CHILDREN FOR NURSES Bulimia is the term applied to an inordinate appetite. Anorexia is the term applied to loss of appetite. Pica is a craving for unnatural foods. Dysphagia or difficulty in swallowing may result from local inflammations, stricture of the esophagus, or paral- ysis. Malformations.—In infants these are not uncommon. The conditions most frequently seen are hare-lip, cleft Fig. 28.— Ranuia. The growth lies in the middle of the mouth and seems to be divided into two parts by the constriction of the frenum (from Griinwald, Diseases of the Oral Cavity). palate, and tongue-tie. A large protuberant tongue is seen in cretinism. The principal difficulty experienced in such malformations is in feeding. The child is unable to grasp the nipple and feed properly. Not enough food is obtained, and they die from inanition unless the deform- ity is corrected. Ranuia is a cystic tumor of the floor of the mouth due to degeneration of the sublingual gland or its excretory duct. At times it interferes with swallowing. DISEASES OF THE DIGESTIVE TRACT III Feeding in Malformations of the Mouth.—Hare- lip.—Here it is impossible for the child to suck. Often, if the cleft is held together by the fingers, the child can nurse. If this fails, milk is given by means of a medicine dropper. Cleft Palate.—Here the roof of the mouth is the part lacking; this also makes sucking impossible. At times will be found useful a special nipple consisting of a broad flap of rubber upon the upper surface, which fills the gap in the roof of the mouth and thus makes sucking possible. Sometimes an inverted bowl of a spoon placed in the cleft will answer the same purpose. If these methods fail it is necessary to resort to the medicine dropper. Tongue-tie.—This condition sometimes prevents proper sucking. In the same way the large protuberant tongue of cretinism acts as a barrier. The medicine dropper may have to be resorted to in these cases. If for any reason the medicine dropper is unsuccessful in supplying the child with sufficient nourishment, gavage may be practised (see page 476). Diseases of the Mouth Ulcer of frenum is seen in cases of pertussis. It is a small ulcer on the frenum caused by the propulsion of the tongue against the teeth during coughing. It is easily cured by touching with alum. Glossitis is the name given to inflammation of the tongue. Gingivitis is inflammation of the gums. Herpes is the ordinary "fever blister" seen so often around the lips. It is especially common in croupous pneumonia. 112 DISEASES OF CHILDREN FOR NURSES STOMATITIS This disease is very common among the poorer class of patients. It is due to uncleanliness and to a spongy condition of the mouth seen in ill-nourished children. There are several varieties named according to the appear- ance of the lesions in the mouth. Catarrhal Stomatitis.—This is a swelling of the mucous membrane of the mouth. The membrane is red and injected, the saliva is increased, and either dribbles Fig. 2g.—Ulcerative stomatitis in a child four years of age: Z, Tooth-marks on the tongue and mucous membrane of the lips; g, ulcers (Fruhwald and Westcott). from the mouth or is swallowed. It hurts the child to nurse, and as a consequence food is rejected. There is, in addition, restlessness, languor, and some fever. Aphthous Stomatitis.—In this condition the mucous membrane is swollen and red. There are small, round vesicles on the tip of the tongue, on the inner side of the lips, and on the cheeks. There may be only a dozen vesicles present, or the whole mucous membrane may be covered. These little vesicles break and leave small, DISEASES OF THE DIGESTIVE TRACT 113 shallow ulcers having a red rim. The other symptoms of stomatitis common to all varieties are present. They are dribbling of saliva, heat and pain in the mouth, re- fusal of the child to nurse, restlessness, languor, and fever. Ulcerative Stomatitis.—In addition to the general symptoms of stomatitis there is an ulceration of the mucous membrane beginning at the angle formed at the junction of the cheek and the alveolar processes, which is the portion of the jaw that holds the roots of the teeth. The glands under the jaw are enlarged, but do not suppurate. Fig. 30.—Noma of the face (case of A. T. Bazin). In severe cases necrosis of the jaw may follow, with a subsequent loosening and falling out of the teeth. Parasitic Stomatitis (Thrush).—The general symp- toms of stomatitis are present. On inspection numerous milk-white elevations are found, which on removal leave a raw surface. This is due to a fungous growth introduced through dirty nipples. Gangrenous Stomatitis or Noma.—It is usually seen IT4 DISEASES OF CHILDREN FOR NURSES in debilitated children between the ages of two and six years, and generally follows one of the specific fevers, such as measles or whooping-cough. The symptoms of stomatitis are marked. The chtek, the part affected, is swollen, hard, red, and glazed externally; and internally there is noted an irregular, sloughing ulcer. There is destruction of the tissues and in some cases the skull is exposed. In the large majority of cases the end is death. If there is re- covery, deformity is present except in a few rare cases in which the ulcer does not perforate the skin. Prophylaxis.—Always keep the mouth clean in any illness, especially in infectious fevers. Mercurial stomatitis is caused by the unnatural susceptibility which certain children have toward mercury. It causes soreness of the teeth and redness of the gums. If the mercury is continued, necrosis of the jaw sometimes results. Treatment.—In the treatment of stomatitis the chief thing to do is to keep the mouth clean by the frequent applications of antiseptic washes. In mercurial stomatitis, of course, stop the mercury. Calomel may produce this condition in the very susceptible. The best mouth wash is boric acid, about 10 gr. to the ounce. Care should be taken to sterilize thoroughly the nipples of the bottles before feeding, and a bottle should never be handed from one baby to another. Powdered burnt alum applied to ulcers usually causes prompt recovery. In feeding, the milk should be given cold, by the dropper, if necessary. Cool substances relieve the pain and heat in the mouth; therefore, cracked ice is acceptable. Fruit DISEASES OF THE DIGESTIVE TRACT II5 and vegetables should be given to older children to counter- act the malnutrition, and in children suffering from scurvy orange juice should be given frequently. In severe cases of stomatitis gavage may be necessary (see page 476). TONSILLITIS Tonsillitis is not common in infancy, but throughout childhood it is often seen. It is more common in those of a rheumatic tendency and in children who have enlarged tonsils. One attack predisposes to others. The disease begins from infection of the crypts due to the presence of bacteria in the mouth, which excite an attack whenever conditions are favorable. There are three varieties: simple or catarrhal, follicular, phlegmonous, or quinsy. Fig. 31.—Chronic follicular tonsillitis (Fruhwald and Westcott). Symptoms.—In children the constitutional symptoms are more prominent than the local. The attack comes on suddenly, often with a chill and vomiting. The tem- perature rapidly reaches 102 ° F. to 103 ° F., and in severe forms 1040 F. to 105° F., and there is marked prostration. The tonsils are swollen and red, and there is some pain and difficulty in swallowing. The glands at the angle Il6 DISEASES OF CHILDREN FOR NURSES of the jaw are enlarged, but the swelling is not pro- nounced. In the catarrhal form the tonsils are swollen, red, and covered with tenacious mucus. In the follicular form, sometimes called lacunar angina, in addition to the above symptoms there are numerous yellowish-white spots on the tonsils. These are due to the follicles or crypts being filled with mucus and exfoliated epithelial cells. These can often be pressed out as little plugs (see Fig. 31). In quinsy, which is comparatively rare in childhood, there is an abscess present in the tissues immediately surrounding the tonsils. This causes extreme swelling of the tonsils, often so much so that the space between the two is almost closed. The local symptoms are more promi- nent than the constitutional in this condition. The fever is not apt to be over 102 ° F. and there is not as much prostration as in follicular tonsillitis. At the same time there is much more pain and difficulty in swallowing. The gland affected soon softens, fluctuates, and ruptures. It is almost always unilateral in childhood. At its height swallowing is almost impossible, the voice is lost, and breathing is difficult. Treatment.—Pellets of ice and a gargle of chlorate of potash, 1 dr. to a pint of water, give relief in tonsillitis, and frequently the patient can be rendered more com- fortable by the external application of an ice-bag, a poul- tice, or iodin over the angle of the jaw. CHRONIC HYPERTROPHY OF THE TONSILS Repeated attacks of acute tonsillitis lead to a permanent enlargement of the tonsillar tissues called hypertrophy. The tonsils intrude into the passage leading to the pharynx. In severe cases they may almost meet. This causes ob- DISEASES OF THE DIGESTIVE TRACT struction to the passage of food and leads to a chronic catarrh of the throat. Nearly all cases of enlarged or hypertrophied faucial tonsils have associated with them an overgrowth of the lymphatic tissue in the pharynx behind the posterior openings (nares) of the nose. This is called an adenoid. The two conditions together give rise to characteristic symptoms. Fig. 32.—Diagram (anteroposterior) illustrating by the shaded portion (.4) the situation of adenoid vegetations in the nasopharynx (Kerr). The child sleeps poorly, is restless, and snores. It breathes through the mouth and there is constant catarrh of the nose and pharynx. From the fact that the catarrh can easily extend into the Eustachian tube, which runs from the internal ear to the upper part of the pharynx, attacks of middle-ear disease {otitis media) are quite common, and deafness may result. The child is poorly nourished and is subject to acute attacks of tonsillitis. It also predisposes to diphtheria and scarlet fever. Il8 DISEASES OF CHILDREN FOR NURSES Treatment.—The best plan is to have the tonsils and adenoids removed if the symptoms are sufficiently annoy- ing. Operation.—According to the size of the tonsils and the Fig. 33.— Examination of the nasopharynx for adenoid vegetations. (The examiner in this instance is left-handed.) (Kerr.) preference of the operator, several methods may be em- ployed. The tonsils may be dissected out, removed with a snare, cut off by means of an instrument called a guillo- tine, or by means of "biting" forceps. The pharyngeal tonsils or adenoids are removed at the same time. The DISEASES OF THE DIGESTIVE TRACT I 19 operation is without danger. The complete removal of the faucial tonsils by dissection seems to be the best method. The secondary hemorrhage can be controlled by pellets of ice, pressure, or cotton containing some styptic, like Monsel's solution. It is usually a per- manent cure. Fig. 34.— Typical appearance in adenoid vegetations: Boy ten years old (Friihwald and Westcott). The nasopharynx is usually irrigated with normal salt solution after the operation, and cold things to eat, like ice-cream, are most acceptable. PSEUDODIPHTHERIA OR VINCENT'S ANGINA This is the name given to an ulceromembranous form of inflammation which attacks the mucous membrane of the 120 DISEASES OF CHILDREN FOR NURSES mouth and tonsils. It is characterized by the formation of a membrane, yellowish-gray in appearance, and very offensive. When this membrane is stripped off it leaves a raw, bleeding surface behind. In twenty-four or forty- eight hours a deep, punched-out ulcer forms, with injected edges. The constitutional symptoms are mild. The tem- perature ranges between ioo° F. and 102° F. In three or four days the ulcer gradually heals. Differential Diagnosis.—The appearance of this con- dition is very similar to diphtheria, especially when the fauces and tonsils are the seats of the inflammation. The bleeding which accompanies the stripping of the membrane is very misleading. The differential diagnosis can be de- termined only by an examination, under the microscope, of a smear, properly stained, taken from the lesion. The Klebs-Loffler bacillus is not present, but two characteristic bacilli are found. They are called spirillum and fusiform, from their shape. The disease is only mildly contagious, if at all. The necessity of making an absolute diagnosis, by means of microscopic examination, between Vincent's angina and true diphtheria is of the greatest importance. True diphtheria is subject to quarantine; Vincent's angina is not; diphtheria is a very grave disease; Vincent's angina usually is mild, although in severe cases noma and sep- ticemia may develop. Finally, in diphtheria others should immediately receive antitoxin, as well as the patient. This is not necessary in Vincent's angina. PHARYNGITIS Pharyngitis is an acute sore throat, or, more particu- larly, an acute inflammation of the mucous membrane DISEASES OF THE DIGESTIVE TRACT lining the pharynx. In childhood most of the contagious diseases, such as measles, scarlet fever, etc., are accom- panied by a secondary pharyngitis. Symptoms.—The disease is ushered in suddenly by profuse redness of the mucous membrane of the pharynx and a temperature which may reach 103 ° F. to 1040 F. in a child. The whole vault of the pharynx, uvula, and fauces, may be involved. The inflammation pursues the same course as an inflammation of the mucous membrane anywhere. There is congestion, swelling, dryness, fol- lowed by an oversecretion of mucus, which soon becomes mucopurulent. The surrounding lymph-glands may be slightly enlarged. There is pain at the angle of the jaw and upon swallowing, a hacking cough, and stiffness and tenderness of the muscles of the neck. Extension to the larynx may cause hoarseness; to the ear, deafness (through the Eustachian tube). An inspection of the throat reveals a red and swollen mucous membrane. Simple, rheumatic, follicular, and infectious varieties are found. The first three explain themselves and the last is associated with the infectious fevers. Treatment.— The local treatment is the same as in tonsillitis, with the addition of a steam spray medicated with compound tincture of benzoin, which frequently gives added relief. Pellets of ice may be used to good advantage. All cases of acute sore throat should be looked upon with suspicion, as in most contagious diseases it is the first symptom. This is especially true of measles and diphtheria. If either of these diseases is prevalent, the case should be isolated until the time for the appear- 122 DISEASES OF CHILDREN FOR NURSES ance of the rash has past or the culture from throat is found to be negative. Uvulitis is an inflammation of the uvula or soft palate associated with pharyngitis. At times an elongation of the uvula renders it necessary to remove a small portion. Chronic pharyngitis is not common in childhood. It usually results from repeated acute attacks and the improper use of the voice. Symptoms.—The voice is husky and there is an in- creased secretion, so that there is a constant desire to clear the throat. Disagreeable sensations, such as fulness, tick- ling, and the like are frequently noted. Four forms are found: the hypertrophic pharyngitis in which the membrane has become permanently thickened and causes a constant clearing of the throat. An atrophic pharyngitis, in which the membrane is thinned out and secretion is lacking. Ulcerative pharyngitis, in which the membrane is covered with ulcers due to simple inflammation, or the ulcers of syphilis or tuberculosis. Phlegmonous pharyngitis, or retropharyngeal abscess, is due to a suppuration of the tissues behind the pharynx caused by caries of the cervical vertebrae, the impaction of a foreign body, or as a sequel to one of the infectious fevers. The cases which arise independent of the above causes must be considered (Holt) as a retropharyngeal adenitis (inflammation of the lymph-glands). This may advance to the stage of suppuration, as it does in the majority of cases, when pus is present, or in very rare cases the in- flammation may cease before this stage is reached. DISEASES OF THE DIGESTIVE TRACT 123 Children under one year of age are those most often attacked. It is rarely seen over five years of age. The symptoms are as follows- At first the child may have severe nasal pharyngeal symptoms, accompanied by fever. These symptoms subside, but the fever still remains above normal. Several days later the temperature again rises to 103 ° F. and the local and pressure-symptoms appear. In other cases the onset is sudden and the local and pressure-symptoms are the first to manifest themselves. The characteristic symptoms are due to pressure and are dyspnea from partial closure of the opening of the larynx, difficulty in swallowing from obstruction to the passage of food, mouth-breathing from the closure of the posterior nares, which gives rise to the characteristic "quack." The head is thrown back to elevate the mass and relieve the pressure. There are profound constitu- tional symptoms, the child appears desperately ill, and the appearance of the pharynx on inspection is characteris- tic. There is a bulging of one of the sides of the pharynx, the amount of protrusion varies. In some cases the uvula is pushed to one side and the pharynx filled up. The severity of the symptoms due to pressure depends upon the size of the protruding mass. The tumor soon fluc- tuates, showing the formation of pus, and the temperature becomes hectic (due to pus; high, irregular temperature, accompanied by chills, sweats, and pallor). If left to itself the abscess will rupture, usually in two or three days. Sometimes it is delayed for a week or two. As soon as the fluctuation is discovered the abscess should be incised with a guarded bistoury. This is done so that the pus can be controlled. If allowed to rupture 124 DISEASES OF CHILDREN FOR NURSES itself the pus may be swallowed or inspired. This may cause grave complications, such as aspiration pneumonia or asphyxia. The child should be firmly held in the nurse's lap, with head thrown back. A tongue depressor is used by the physician, as it can be immediately withdrawn, and not a mouth-gag. As soon as the abscess is opened the nurse should bend the child's head forward and thus allow the pus to run out of the mouth. Some surgeons prefer to have the child lie on a table with head hanging backward over the end. After the abscess is lanced the head should be turned to one side to allow pus to escape. The after-treatment is simple, as the symptoms disappear as soon as the pus is removed. Retropharyngeal abscess from Pott's disease is due to the softening of the cervical vertebra? with accumulation of pus behind the pharynx. It is slow in forming and not attended by much fever. Such abscesses are opened externally when the pressure-symptoms become of suf- ficient importance to demand relief. Pseudomembranous Pharyngitis {Septic Sore Throat). —There have been several epidemics of this disease re- ported in Europe and the United States. The symptoms of the epidemic type usually begin abruptly with chilliness, fever, headache, vague general pains, sometimes nausea and vomiting, and occasionally a convulsion. The pharynx and tonsils quickly become covered with a membrane, which usually can be wiped off without difficulty. In two or three'days the glands of the neck become swollen and tender, but rarely suppurate. DISEASES OF THE DIGESTIVE TRACT 125 There may be extensive necrosis of the tissues of the throat, with general sepsis and death. The exciting cause is a germ. It may be the strepto- coccus or staphylococcus, and less rarely the pneumococ- cus or influenza bacillus; but the diphtheria bacillus is never present. In the non-epidemic type the affection is generally milder and is limited to the tonsils. In several of the epidemics the disease has been traced directly to the milk-supply. As this disease so closely resembles diphtheria in its appearance, and can only be distinguished from it by a culture, the child should be isolated and given diphtheria antitoxin anyway, while awaiting the result of the bacteriologic examination. CHAPTER VI DISEASES OF THE DIGESTIVE TRACT (Continued) Diseases of the Esophagus The esophagus is rarely involved in inflammatory processes. The only condition of importance to a nurse is corrosive esophagitis and stricture. Corrosion of the Esophagus.—This is almost always due to the swallowing of strong acids or alkalies. It causes intense pain and burning in the esophagus and swallowing is very painful. Stricture is a secondary result of corrosion. The healing ulcer causes a narrowing of the alimentary canal at its location, and this interferes with swallowing. Symptoms.—A slowly increasing difficulty in deglutition, with regurgitation of food. The esophagus is often much dilated above the stricture, and the food may collect in the pouch thus formed, so that regurgitation may be delayed for several hours. There is much loss of flesh. In bad cases of stricture it is necessary to place the child upon a liquid diet. Diseases of the Stomach In infancy we rarely find the stomach involved alone, being associated with the intestines in nearly all diseases. In older children the stomach conditions may be distinct. Capacity.—At birth the capacity of the stomach is about i -5- ounce. 126 DISEASES OF THE DIGESTIVE TRACT 127 For all practical purposes it is safe to say that the capacity of the stomach increases about 1 ounce for each month, up to eight months; then its development is slower. At one year the capacity is 9 ounces; at eighteen months 12 ounces. As the quantity of food taken at feeding increases, the time it takes the stomach to empty itself lengthens. From two to eight months of age it takes about two hours for mother's milk and two and a half hours for cows' milk. Fig. 35.—Stomach of infant at birth, natural size (J. P. C. Griffith). The position at birth is peculiar in that it is almost vertical instead of being horizontal. This explains the ease with which newly bom babes regurgitate. There is no attending discomfort, being like the running over of a filled bottle. Digestion of Milk.—Mother's milk is coagulated into light, flocculent curds. Cows' milk is coagulated into tough, compact masses, and it takes about a half hour 128 DISEASES OF CHILDREN FOR NURSES longer for the stomach to empty itself of this diet than it does of mother's milk. Vomiting is a condition arising from a large number of sources. It may be watery or mucous; bilious or green, which occurs in any case where vomiting and straining are continued; bloody (hematemesis); or purulent, resulting from the rupture of an abscess into the stomach or esophagus. Fig. 36. —The abdominal regions. The heavy line at the upper border shows the extreme limit of the diaphragm. Imaginary lines divide the abdomen into different regions which, for the sake of clearness and precision, are known as the right and left hypochondriac, the epigastric, the right and left lumbar, the umbilical, the right and left inguinal or iliac, the hypogastric (Kerr). Fecal vomit (stercoraceous) is indicative of intestinal obstruction and is recognized by its odor and appearance. Profuse vomiting, where large quantities of frothy, fermented material are ejected, is significant of gastric dilatation. Vomiting without nausea, distress, or other gastric DISEASES OF THE DIGESTIVE TRACT 129 symptoms occurs in certain neuroses of the stomach, in hysteria, uremia, and in brain diseases, such as tumor or meningitis. This form of vomiting is seen at the onset of many fevers in childhood. Habit vomiting is the name given to that form of emesis in which children vomit from habit alone, no disease of the stomach being present. Cyclic vomiting is characterized by severe attacks of vomiting occurring at more or less regular intervals. It is uncommon and is of nervous origin. Hematemesis is the term applied to vomiting of blood. If the hemorrhage is rapid and the blood immediately vomited, it may be bright red in color. However, it is usually retained for some time in the stomach before ejection, and is then dark brown in color, the so-called coffee-ground appearance. The blood is mixed with food and the subsequent stools are dark and tarry. Hiccough or singultus results from a clonic spasm of the diaphragm. It is often noted as a temporary condition after eating and drinking. Persistent hiccough is fre- quently present in cases of extreme exhaustion following acute or chronic diseases. Malformations and Malpositions of the Stomach.— The cardiac and pyloric ends may be congenitally stenosed (no opening). At times the stomach is found in the thorax, gaining access through a rupture of the diaphragm. Pylorospasm is the name given to a serious condition of early infancy, in which there is a spasmodic affection of the pylorus, with an overgrowth of the circular mus- cular fibers at this point, which produces an obstruction at the outlet of the stomach. It is analogous to the other spasmodic conditions of early infancy, such as constipation due to spasm of the 130 DISEASES OF CHILDREN FOR NURSES sphincter ani; intussusception due to irregular or inter- mittent muscular spasm of the intestines, and the spas- modic affections of the larynx and bronchi. The symptoms begin almost always during the first month. There is occasional vomiting, which soon be- comes habitual, it is very forcible in character; constipa- tion develops, and the child loses weight very rapidly, amounting to 1 or 2 ounces a day. There is no fever, no pain, and no signs of indigestion. There is marked visible gastric peristalsis seen when the stomach is full; it is a slow wave moving from left to right every minute or two. The stomach becomes dilated, and a hard car- tilaginous tumor about the size of a peanut can be felt during peristalsis at the pylorus, due to the hypertrophy of the circular muscular fibers. There is no bile in the vomit and the stools look like meconium. Fifty per cent, of the cases end fatally in from four to six weeks. Treatment.—The medicinal management of pyloro- spasm consists in stomach washing and the employment of proper dietetic methods, consequently a skilful nurse is invaluable. Operation is avoided if possible and is considered only after a careful and thorough trial of this treatment for a period of not more than one to two weeks, without change in the general condition. Diet.—The feedings should not be too near together and small amounts should be given. Breast feedings should be at three-hour intervals and the nursing period from three to eight minutes, according to the amount obtained. A good method is to pump the breast, giving definite amounts, such as 2 ounces at a feeding at one month. The children should not be weaned and arti- DISEASES OF THE DIGESTIVE TRACT 131 ficially fed children often do well with a wet nurse. Where this is impracticable, the fat should be low in the milk formulas; skimmed milk succeeds. The necessary fat can be supplied by olive oil when the fat of milk causes extra vomiting. Egg-albumin and beef-juice are good. Lavage empties the stomach of food and mucus and al- lays the spasm. It should be done two and a half hours after feeding and repeated twice in twenty-four hours. It should be continued for six or eight weeks and once daily for three or four months in the cases that recover. The water should be from 1080 to no° F., rendered alkaline by 1 per cent, of sodium bicarbonate. A meas- ured quantity of water should be used, which should be remeasured when washing is complete, the extra amount obtained will determine the amount of retained food that was in the stomach. Normal salt solution is also used. If much exhaustion follows, the procedure must be abandoned. Weight.—A careful weight chart should be kept, for when there is a slow gain the tide has turned. Operation.—This is a gastroenterostomy (an arti- ficial opening from the stomach into the intestines, thus avoiding the necessity of the food passing through the pyloric valve), or the Rammstedt operation of simple splitting of the hypertrophied mucous membrane. The latter is the one now most commonly employed. After this operation feeding may be commenced almost im- mediately, but only very small amounts given at first, and the full quantity only permitted in a week or more after the operation; \ ounce or less every two hours may be given at first, and this increased in the course of two or three days to 1 ounce every three hours. 132 DISEASES OF CHILDREN FOR NURSES The breast milk should at first be given from a bottle; in about a week nursing directly from the breast may be resumed. Sometimes it is better at the beginning to dilute the breast milk with one-quarter water or lime- water. If breast feeding is found not to agree well, administra- tion of the food from the bottle should be promptly recommenced. Vomiting is liable to occur during the first few days. In many cases hypodermoclysis once or twice a day is of great service when a sufficient amount of liquid cannot be taken or retained. After operation the Murphy method of continuous induction of water into the intestines will probably be employed. (See page 477.) Vomiting may be allayed by placing the child in a semi- erect position. Feeding should be followed by long periods of rest. ACUTE GASTRIC INDIGESTION Acute gastric indigestion is the name applied to a series of symptoms caused by the inability of the stomach to properly digest. The symptoms are vomiting, dulness, or excitement, and at times convulsions. The temperature ranges from ioo° F. to 102° F., sometimes higher. The tongue is coated, the appetite lost, and the abdomen distended. In infants there is an associated diarrhea, the stools con- taining undigested food. From six to twelve hours after the onset the vomiting ceases and the symptoms disappear. DISEASES OF THE DIGESTIVE TRACT 133 GASTRITIS Acute Gastritis is an acute inflammation of the stomach. The mucous membrane is red, sticky, and lusterless; it is swollen and covered with thick mucus. Symptoms.—-They vary much in degree. In severe cases there is moderate fever (102 ° F. to 103° F.) and its associated phenomena. There is loss of appetite, a coated tongue, and intense pain in the epigastric region, which is tender to the touch. In addition there is per- sistent vomiting, thirst, and considerable prostration. Jaundice may follow from the extension of the catarrh to the bile-ducts, and diarrhea from extension to the intes- tines (gastroduodenitis). The treatment is absolute rest. If the stomach is not entirely empty an emetic should be employed. To re- lieve the pain in the stomach local applications such as turpentine stupes or a mustard plaster will be found effective. In severe cases no food should be given by the mouth. To allay the thirst cracked ice may be given, and later milk and lime-water. Chronic Gastritis (Chronic Gastric Indigestion, Dyspepsia).—This is a chronic indigestion and signifies a group of symptoms which accompany every disease of the stomach. When, however, the symptoms depend upon nothing more than simple atony, hypersensitiveness, or chronic catarrh, the condition is spoken of as a distinct affection. Corresponding to this view there are three forms recognized: (1) Atonic, (2) nervous, (3) catarrhal. In infancy chronic gastritis is due to the abundant, tough, adherent mucus lining the stomach. This inter- feres with digestion, even though the stomach secretions are normal. 134 DISEASES OF CHILDREN FOR NURSES The symptoms are: long retention of food, vomiting six to eight hours after eating, signs of general malnutrition, and undigested food in stools. There is also dilatation of the stomach. In infants under three months the prognosis is bad. In older children chronic gastritis is usually caused by gastric irritants such as tea and coffee in excess, by dietetic errors such as insufficient mastication from bad teeth, hurried eating, too much food, insufficient food, coarse or improperly cooked food, excessive dilution of food with liquids, excessive condiments, and irregular eating. Symptoms of chronic gastritis are: coated tongue, per- verted appetite, distress after eating, eructations, flatulence, heart-burn, palpitation, headache, vertigo, disturbed sleep, and lassitude. In atonic dyspepsia the above symptoms are present and the pain usually appears some time after eating. In nervous dyspepsia the above symptoms appear in nervous children. The symptoms vary greatly. At one time there will be anorexia, at another an inordinate appetite, and at still another a perverted taste. Pain and vomiting or retching occur just as frequently when the stomach is empty as when it is full. In catarrhal dyspepsia a condition of chronic inflamma- tion of the stomach exists. Just as in a chronic inflamma- tion of the mucous membrane in any other part of the body, so here there is a thickening of the membrane and the process of digestion is interfered with. The food remains for a long time in the stomach and undergoes fermentation; thus eructations of gas and sour liquids are frequent. There is more or less nausea, with vomiting, at all times, but especially so in the morning when the DISEASES OF THE DIGESTIVE TRACT 135 frothy mucus, which has collected over the mucous mem- brane during the night, is vomited together with much retained, fermented food. In catarrhal dyspepsia the nurse is often instructed to wash the patient's stomach every morning by lavage (see page 474). GASTRALGIA Gastralgia is a painful, paroxysmal (intermittent) affec- tion of the stomach not associated with any organic lesion. Symptoms.—There are paroxysms of severe pain in the epigastrium, usually radiating to the back and occurring when the stomach is empty. It is relieved by pressure and the ingestion of foods or warm, stimulating drinks. Treatment.—The child should be put to bed and hot water or turpentine stupes applied to the epigastrium. If the feet are cold apply hot-water bags there. Hot water containing five or ten drops of brandy and five drops of turpentine should be sipped. GASTRIC ULCER This is a rare condition in childhood. Ulcers may result from follicular gastritis, tuberculosis, or without obvious exciting cause. The latter is probably due to the digestion of a portion of the stomach by its own juices. This occurs when some local disturbance of the circulation shuts off the blood-supply to a portion of the stomach walls, the lowered vitality of that portion permitting the gastric juice to digest it. This produces the ulcer. A gastric ulcer is round or oval and is usually situated at the pylorus on the posterior wall, near the lesser curvature. It is a punched-out ulcer, the apex toward the peritoneum, I36 DISEASES OF CHILDREN FOR NURSES while the floor is usually formed by one of the coats of the stomach. A series of ulcers is not uncommon. Symptoms.—The general symptoms of dyspepsia are present, and in addition the following characteristic symptoms: Pain, which may be severe, appears soon after eating and almost always radiates toward the back. Hem- orrhage is present in one-half of all cases. The bleeding may be profuse and the blood bright red. Localized tenderness, nearly always two or three inches above the umbilicus. Vomiting, occurring an hour or two after eat- ing and at the height of the pain. Hyperacidity, which is an increase in the hydrochloric acid after a test-meal. This is a dangerous affection, demanding absolute rest in bed and rectal feeding. DILATATION OF THE STOMACH Moderate dilatation is often . seen, a very marked dilatation is rare. Causes.—Rickets, chronic gastritis, and pyloric stenosis. The only symptoms present in most cases are those of chronic gastric indigestion. In stenosis of the pylorus there is added vomiting of large quantities of fermented food, which occurs after the lapse of several hours. In some cases of gastric dilatation the stomach is washed daily (see Lavage, page 474). Gastroptosis and enteroptosis is a prolapse or down- ward displacement of the stomach and intestines. TEST-MEALS The ordinary test-meal consists of a dry roll and two- thirds of a pint of water or weak tea, without milk or sugar. DISEASES OF THE DIGESTIVE TRACT 137 In testing for lactic acid the test-meal should consist of a tablespoonful of oatmeal to a liter of water, flavored with a small quantity of salt. Method of Administration.—The child should be given a very light breakfast. Four hours later the stomach- tube should be introduced and the stomach washed (see Lavage, page 474). The meal should then be eaten, and in an hour recovered by means of the stomach-tube. About 40 c. c. should be obtained. NURSING In diseases of the upper gastro-intestinal tract the room should be light and sunshiny, well ventilated, and kept at an even temperature. The clothing should never bind the abdomen. Bathing may be continued, except in the more severe forms of illness and in sore throat. The food should be carefully prepared and given absolutely according to instructions. At times in severe vomiting it is necessary to prohibit food by the mouth. Nothing should then be allowed to enter the stomach. The character of the vomit must be noted; the length of time after eating it occurs is important; and the presence of blood should be immediately reported. Unless there is fever the temperature, pulse, and respira- tions need be taken but once or twice a day. CHAPTER VII DISEASES OF THE DIGESTIVE TRACT (Continued) Diseases of the Intestines The small intestine at birth is about 9 feet long, and the large intestine about 18 inches long. The lower half of this length is occupied by the sigmoid flexure. Feces.—The first stools after birth are called meconium. Four to six stools a day of this discharge are natural. By the fifth day the stools should assume the appearance of milk feces. Milk Feces.—The normal amount discharged by a healthy nursing infant is 2 or 3 ounces. They are soft, yellow, and of good consistency. Mother's milk and cows' milk give practically the same stool. The number of stools during the first two weeks is from three to six daily. After the first month two stools a day is the average. The Feces in Digestive Diseases.—Mucous stools con- sist of grayish or whitish jelly-like masses often streaked through the stool, or a thin mucoid secretion of the in- testines stained a brownish tint if the food has been with- drawn for a day or two. After a purgative, especially castor oil, a large amount of mucus is passed in infancy. Mucus occurs readily, and it may be caused by a func- tional or inflammatory disturbance of the large intestine; if it persists it points to inflammation. Protein Stools.—The odor of putrefaction is discover- able at times. The color is brownish yellow, and mucus 138 DISEASES OF THE DIGESTIVE TRACT 139 is always present. Sometimes tough, yellowish protein curds are found. These are seen in infants where the protein of the food is of high percentage and undigested. They are alkaline in reaction. Fatty Stools.—Fat may show itself either as soap, when they are white or gray, shiny, fairly firm and have a rancid odor, and may be alkaline; or in the form of a smooth, yellow fatty stool of a greasy appearance; and, third, as a curdy stool, soft white curds composed of fat, in a green or yellow diarrheal stool always mixed with mucus and acid in reaction. The soap and curdy stools are of slight consequence unless symptoms of indigestion are present. Carbohydrate stools are of a brown or yellowish-brown tint, homogeneous, and smooth. In other cases there may be decomposition of the carbohydrates in the intes- tine, producing thin, frothy acid stools often green in color, with an odor of acetic acid. Green Stools.—Light pea-green stools need not be con- sidered pathologic. In other cases the color is of deep spinach-green, seen chiefly in the mucus passed in the stool. Green watery stools may be seen in acute intes- tinal indigestion. They may depend either upon an excess of fat or sugar, and may have present the white curdy masses consisting of fat. Blood in the stools is not necessarily a serious matter. Any moderate congestion of the mucous membrane may cause streaks of blood upon the mucus passed. Large quantities and persistent appearance indicate the graver conditions. Symptoms.—The chief symptoms of any disease of the intestines are constipation, diarrhea, and tormina. When the rectum is the seat of lesion we have added tenesmus. 140 DISEASES OF CHILDREN FOR NURSES Constipation is an unnatural retention of fecal matter. Its symptoms are infrequent stools, dyspepsia, fetid breath, headache, vertigo, lassitude, and anemia. In aggravated cases we frequently find hemorrhoids, fissures, fistulae, and prolapse of the rectum accompanying these symptoms. In infancy ordinary constipation nearly always can be corrected by the proper milk mixture, increase in the fats being all that is necessary. A soap-stick, some form of suppository, or introduction of the greased little finger act well in stubborn cases. At times enemas are neces- sary. These should not be used continuously. In older children ordinary constipation can usually be overcome by a regular time for defecation and systematic exercise; abdominal massage and electricity are valuable aids. Encourage the use of water, bran-bread, green vegetables, and stewed fruit. A glass of water before breakfast is often all that is required. Chronic Constipation.—As long as the child has the proper strength food for its age, constipation. should not be troublesome. In artificially fed children, however, cases of chronic constipation are quite frequent. The nurse can correct this fault to a great extent by proper management of the case. In older children the most important measure is to establish a regular time for stool. After breakfast is the best hour. The diet should be mixed, starchy food re- stricted, and fruits encouraged. Meat and green vege- tables should be eaten at least once a day, oatmeal is the best cereal, and orange-juice and stewed prunes the best fruit. Massage should be practised twice a day, after retiring and in the morning. The proper method of giving massage is to use only the hand (without grease of any kind), rubbing the abdomen with a circular motion. The DISEASES OF THE DIGESTIVE TRACT 14I object is to move the skin and muscles upon the intestines, which starts peristalsis, the worm-like movements that force the feces along. Exercise is accomplished during playtime, and is usually sufficient. Suppositories are valuable at times to start the habit of defecation at a regular hour, but should not be continued longer than absolutely necessary. Gluten and glycerin suppositories are the best. If injections are necessary,. 1 dr. of glycerin to \ ounce of water gives the most immediate results. At stool a low chair aids the child better than the high seat for adults. Diarrhea is a condition in which the stools are either too frequent or too loose. Like dyspepsia, it is a symptom of many pathologic conditions. Any condition which tends to lessen the peristalsis of the bowel will cause constipation; any condition which tends to irritate the mucous membrane of the bowel will usually cause diar- rhea. Tormina or intestinal colic is a painful, spasmodic affection of the intestines. It is generally the result of irritating food, flatulence, or fecal accumulation. It is characterized by paroxysms of severe pain of a twisting character centering around the umbilicus and relieved by pressure. The abdomen is usually distended. Severe attacks may lead to incipient collapse, indicated by cold sweats, pinched features, feeble pulse, and vomiting. The attacks often last from a few minutes to several hours, and generally end by a discharge of flatus. In severe attacks enemas, hot applications, aromatic spirits of ammonia, and paregoric are necessary. Tenesmus is a feeling of fulness in the rectum with a constant desire to defecate. 142 DISEASES OF CHILDREN FOR NURSES MALFORMATIONS Congenital atresia of the anus is seen occasionally. It should always be looked for after birth. Through some fault of nature in these cases the rectum becomes con- stricted, or the skin covers its outlet. This prevents any fecal passage. It results in death if prompt relief is not obtained. A baby that does not have a bowel movement in the first twenty-four or forty-eight hours should be examined immediately. DIARRHEA Diarrhea is an acute inflammation of the mucous mem- brane lining the intestines. It is the so-called intestinal catarrh. The different varieties of acute diarrhea are: mechanical, caused by foods which act as foreign bodies; drug, caused by any of the ordinary cathartics in suscep- tible children; acute intestinal indigestion; nervous diarrhea; and diarrhea of certain diseases like uremia. The character of the diarrhea depends upon the seat of the lesion. Inflammation high up in the bowel causes yellow and greenish stools; in the lower bowel more mucus and blood are found and less of the undigested food ele- ments. The lower in the bowel the seat of the inflamma- tion is, the more severe the symptoms become; the tem- perature is higher, the prostration greater, and the stools are mixed with blood. When the lower colon and rectum are involved, in addition, there is tenesmus, which is a sensation of fulness of the rectum, with a constant desire to defecate. Acute Intestinal Indigestion.—In young children an acute attack of indigestion shows both gastric and intes- tinal symptoms; the intestinal symptoms, however, are DISEASES OF THE DIGESTIVE TRACT always the more marked of the two. In older children intestinal indigestion alone is seen. The symptoms are colicky pain, distention, and diarrhea. The pain is localized in the stomach and around the umbilicus. About an hour or two after the onset of the attack diarrhea develops. From four to twelve stools are passed. They are greenish-yellow in infants, and contain undigested food. There is fever, ioo° F. to 102° F. The pulse is rapid and the features pale and pinched. Treatment.—Give castor oil and restrict the diet. In nursing babies give barley-water for twenty-four hours, and at the end of this time return to the breast. The feedings should be at six-hour intervals and the baby allowed to remain at the breast only for five minutes at a feeding. Barley-water is given in the interval. The diet of older children in the acute stage should be similar to that of an infant. Later, broths, eggs, milk, and dried bread or toast can be given. Fruit, vegetables, and cereals should be withheld for several days and then re- turned to slowly. Chronic Intestinal Indigestion.—In infants the symp- toms at times resemble marasmus. The symptoms most often seen are loss in weight, anemia, colicky pain, alter- nating diarrhea and constipation. The bowel movements are characteristic. If there is diarrhea the stools are greenish and often contain white curds. If constipated, the stools are often white. The child cries a great deal, is very restless, and sleeps poorly. Treatment.—It is in these cases that the proper modifica- tion of milk does so much good. In very stubborn cases buttermilk, properly prepared, seems to cure. The proper way to prepare buttermilk is as follows: Flour, 3! dr.; cane sugar, 15 dr.; buttermilk, 1 quart. 144 DISEASES OF CHILDREN FOR NURSES Bring up to the boiling-point, stirring continuously. Then cool rapidly. While the percentage of proteins in this mixture is much higher than is usually given in such conditions, it is more easily and rapidly digested. Often the improvement is remarkable. Buttermilk should not be used for any length of time without the addition of cream. In older children, from four to seven years of age, the symptoms are as follows: The child is under-developed, pale, thin, and has a prominent abdomen. There are dark rings under the eyes, they easily tire, and are fretful and emotional. The stools are foul, there may be con- stipation or diarrhea, and a great deal of gas. Such children frequently grind their teeth, giving rise to the supposition that they have worms. Convulsions are not uncommon. Treatment.—In such cases a trained nurse is invaluable. The chief thing to regulate is the diet. This should be placed entirely in her hands. It is a fact th?t the princi- pal diet of children suffering with this condition usually consists of sugar, potatoes, and oatmeal. These should be interdicted, and for a beginning a diet of rare meat (scraped beefsteak or mutton), and milk instituted. Under the physician's orders, additions will be made, consisting of fruit, kumiss, stale bread, raw oysters, vegetables, etc. Potatoes and oatmeal should be for- bidden for some time in these cases. Proper clothing, cold sponging in the morning, open-air exercise, and cool sleeping-rooms are of equal importance. Summer Diarrhea.—When diarrhea attacks young children in the summer time, it is the so-called summer diarrhea of childhood. This is the most fatal disease of childhood. It occurs in epidemic form regularly every summer in most large cities. The changes in the bowel DISEASES OF THE DIGESTIVE TRACT 145 are slight, amounting in most cases only to a superficial catarrhal mflammation, often bearing no relation to the severity of the symptoms. These are mainly due to the absorption of toxic materials resulting from putrefactive changes in the stomach and intestines (Holt). The chief cause of summer diarrhea is bad milk. The term " milk infection" is frequently used by physicians in defining this condition. Milk which has been delivered to the consumer under the most favorable conditions will show a number of bac- teria on examination. When proper aseptic precautions are taken at a dairy, the herd is proved to be physically sound, the stables are clean and hygienic, the cattle's food is scientifically super- vised, the milk cans and the clothing of the dairymen are sterilized, their hands and the udders of the cows are thoroughly cleansed, the milk is immediately placed in sealed glass quart bottles, packed in ice, and delivered as quickly as possible, still from two to ten thousand bacteria per cubic centimeter will be present. One can imagine the number of bacteria in a cubic centimeter of the ordinary milk which is delivered by the itinerant milk man. A hundred thousand per cubic centimeter is common in the summer time, and in samples of bad milk over a million have been found. The Philadelphia Pediatric Society, which has the super- vision of issuing certified milk certificates in this vicinity, has made ten thousand bacteria to the cubic centimeter the limit for certified milk. As there are only about a half dozen dairies which can comply with this standard in an area which comprises about 2,000,000 people, one can see the difficulty in obtaining good milk. When impure milk is given to an infant the toxins 10 I46 DISEASES OF CHILDREN FOR NURSES generated in its digestive tract produces the symptoms so characteristic of this condition. The symptoms of the milder form are frequent stools, three to twelve a day. They are of yellowish or greenish color and contain undigested food. They are colicky pains with rumbling noises (borborygmi), and slight fever with its attending phenomena These symptoms usually follow an acute attack of indigestion and are accompanied by gastric symptoms which may set in at almost any time after its onset, the principal feature of which is the persistent vomiting. After a time the stools become offensive, mucus is present, the appetite may be normal, but is often impaired and may be almost lost. The tongue is coated, the mucous membrane of the mouth is congested, and in very young infants is often covered with thrush. The general health may not be noticeably affected for several days, but more often the infants become pale, their limbs grow soft and flabby, they lose their spirits, are fretful, sleep badly, and the scales show a decrease in weight of from one to two pounds a week. Relapses are common, especially if the infants are placed upon a milk diet too soon, or by overfeeding. In the more severe form the attack may begin abruptly, or there may have been symptoms of the milder variety for several days. The temperature rises rapidly to 103 ° F., often to 105 ° F. There is great thirst. The children are restless, excited, and may have convulsions, or they may be just the opposite, and lie in a dull stupor. From four to six hours after the onset, vomiting begins, milk appearing as tough curds and very sour. After the stomach is emptied retching continues, and everything given by the mouth is almost immediately rejected. Diarrhea follows. The stools are thin, yellowish, greenish, brownish, or mixed, very DISEASES OF THE DIGESTIVE TRACT 147 offensive, and frequently accompanied by the discharge of large quantities of gas with accompanying colicky pains. In fact, the foul odor, the colic, and the discharge of flatus is the most characteristic symptom of this form of diarrhea. From five to twenty-five fluid stools in twenty-four hours, frequently of good size, and very offensive, are seen after the first day. In a few days mucus may appear. After two or three days there is generally a reaction and the child improves. The stools, however, may continue loose for five or six days, gradually assuming their normal character. If there is no reaction, steadily increasing prostration, continued high temperature, and diarrhea may cause a fatal termination of the case. In other cases the symptoms merge into those of entero- colitis. At times there may be a series of acute attacks a week or ten days apart; in the interval all symptoms are absent except that the stools never become normal. The third or fourth such attack may merge into enterocolitis. Prophylaxis.—As this disease is caused by impure milk, all that is said about the care of the milk in the house and the sterilization of bottles and nipples on page 425 should be carefully read. It is frequently necessary for all milk to be pasteurized during the summer months (see page 383)- ^ During the hot months the infant's clothing should be light flannel; a single-piece dress is the best. Their napkins should be changed immediately after soiling. They should have fresh air, sunlight, and frequent bath- ings. Maternal nursing should be practised in every case where it is possible. Weaning should be avoided during the summer months. Overfeeding should be prohibited. Less food at a feeding by one-third, and more water, is a good rule to follow during the hot weather. Early I48 DISEASES OF CHILDREN FOR NURSES attention should be given to all mild disorders of the gastro-intestinal tract. Finally, if artificial feeding is necessary, the proper modification of cows' milk should be used (see Chapter XLX). Nursing.—Ii possible, children suffering from summer diarrhea should be sent to the seashore. They should not be allowed to walk, but should lie out in the fresh air as much as possible. Fresh air, quiet, proper clothing, and frequent bathing are essential. All soiled diapers should be immediately changed, the buttocks carefully washed, and the move- ments disinfected as described on page 496. The char- acter and frequency of the stools must be reported. It is of the utmost importance to stop the milk, as in the early part of the attack digestion is arrested. Small quantities of cold whey, barley-, or albumin-water should be fre- quently given. If all food is rejected or vomited, the best results are obtained from giving the stomach absolute rest. Maternal nuising should be withheld until twenty-four hours after the vomiting has ceased (which is usually within twelve hours). Then the physician may order a tentative return to the breast. The interval between nurs- ings should then be four hours, and only one-quarter of the usual quantity allowed. This may be regulated by allowing the infant to nurse only for two or three minutes at first. Between nursings whey, barley-, and albumin- water may be given, so that the infant takes something every two hours. If the indications permit, the breast- feeding will be gradually increased. When the child is artificially fed, cows' milk is absolutely withheld during the stage of acute symptoms, and for DISEASES OF THE DIGESTIVE TRACT 149 several days after. When it is begun the physician may have to use various methods to render it digestible. The methods for carrying out any special instruction in this fine, such as peptonizing, etc., will be found in Chapter XIX. During the period when milk is suspended he will use such substitutes for milk as rice- or barley-water, wine-whey, malted soups and foods, albumin-water, fresh beef-juice, animal broths, condensed milk, etc. The methods for preparing these foods will be found in Chapter XVIII. In older children the food is withheld until vomiting ceases, and then broths and beef-juices given. Later, thin gruels made with milk, koumiss, and such foods are substituted. Solid foods should not be allowed for several days after the stools are normal. A proper acquaintance with the appearance and taste of every food ordered is essential, and a careful record of the amounts taken must be kept. At times the physician will order stimulants placed in the foods. No cases do worse than those in which the mother or nurse in charge cannot be made to appreciate the value of starvation, but insist upon giving food, especially milk, in violation of the rules laid down. Lavage and irrigation of the colon are essential adjuncts to the medicinal treatment, and the nurse must be prepared to apply these measures when ordered (see pages 476 and 477)- The graduated cold bath will be ordered at times by the physician (see page 455). At the onset of an attack of diarrhea in summer, give a dose of castor oil and starve the child for twenty-four hours. Barley-water may be used to allay the thirst. ISO DISEASES OF CHILDREN FOR NURSES ENTEROCOLITIS, ILEOCOLITIS, OR DYSENTERY Of this disease there is a catarrhal, an ulcerative, a membranous, and a chronic form. The severity of the symptoms is greater in the ulcerative and membranous forms than in the catarrhal. Enterocolitis may follow one of the intestinal conditions previously discussed, or it may be the initial disease. Its distinguishing symptoms are mucus and blood in the stools, colicky pains, and tenesmus. Often the amount of mucus is quite large, at times the entire movement may be composed of it. The characteristic appearance of mucus is a grayish or whitish jelly-like mass, often streaked through the stool. Blood rarely appears as clots, but is also streaked through the movement. The stools are usually small in size, odorless, and accompanied by a great deal of strain- ing, often only a teaspoonful is passed at one time. After the first acute symptoms are over, the blood usually disap- pears, but the mucus is persistent, and in all cases the recovery is protracted. Relapses are common, and even after the child has fully recovered subsequent attacks are easily excited by errors in diet. This is an important point to keep in mind, as great care must be exercised in supervis- ing the diet of such children; very slight indescretions have produced fatal recurrences of the disease. Impress upon the family the importance of keeping strictly to the physi- cian's orders. A very common complication of enterocolitis is broncho- pneumonia, which usually produces a fatal result. Everything that was said in reference to the cause of summer diarrhea applies to enterocolitis. In the acute catarrhal form the mucous membrane DISEASES OF THE DIGESTIVE TRACT 151 of the colon is red, swollen, edematous, and in some cases ulcerated. Symptoms.—The onset is sudden. There are frequent stools, at first yellow, later green and mixed with curds, mucus, and blood, and sometimes material resembling chopped spinach. Temperature ranges from 102 ° F. to 1030 F. The abdomen is distended and tender along the colon. Vomiting is rarely persistent. In the milder cases the mucus and blood continue to appear in the stools for from four to five days. The diarrhea continues for one or two weeks. In the ulcerative form the mucous membrane is swollen from edema and cellular infiltration. The latter causes superficial necrosis and formation of irregular ulcers which more or less undermine the surrounding mucosa. The symptoms of ulcerative enterocolitis are similar to the simple catarrhal form, but the disease is more pro- tracted and often marked by intermissions and exacerba- tions. The stools are more fluid and the mucus and blood persist. In membranous enterocolitis the mucous membrane is intensely swollen and covered by a false membrane. The separation of the membrane is followed by ulceration and sloughing. The symptoms are the general symptoms of dysentery plus those of the typhoid condition. The stools also contain false membrane and sloughs. The child grows pale, wastes, and assumes a senile appearance. Death may be preceded by coma and convulsions. The prognosis is always grave in membranous entero- colitis, yet recoveries do take place under favorable conditions. 152 DISEASES OF CHILDREN FOR NURSES Nursing of Enterocolitis.—What was said under Summer Diarrhea holds good in enterocolitis. In older children there must be absolute rest, enforced use of the bed-pan, and the proper restriction of the diet. The milk must be stopped immediately and in no instance given without the physician's orders. For the pain apply ex- ternally hot fomentations and mustard poultices. Small pellets of ice introduced into the rectum every two or three minutes for half an hour, or cold compresses applied ex- ternally, will frequently relieve the tenesmus. In severe cases of tenesmus the physician may order thin starch- water injections containing 10 to 20 drops of laudanum to the pint. Irrigation is often practised. In diseases of the intestines the room should be light, cheerful, and well ventilated. Bathing need not be dispensed with unless the child is too sick to stand it. A woolen binder worn around the abdomen is often of use. Cold feet should be avoided in winter, and over- dressing in summer is harmful. The feedings should be carefully prepared and the amount taken accurately recorded; the character of the stools reported, and the bowel movements covered with carbolic acid, 1:20 (see page 309). The temperature, pulse, and respirations should be taken at least twice a day. CHOLERA INFANTUM This is an acute disease of childhood characterized by high fever, vomiting, purging, and collapse. It is now generally taught that the severe symptoms of this disease are produced by the result of a toxemia or poisoning of the system. The poison is produced in the DISEASES OF THE DIGESTIVE TRACT 153 intestinal tract and absorbed. It receives its name from the similarity of the symptoms, in well-marked cases, to Asiatic cholera. In the majority of cases the disease attacks children who have been suffering from some form of intestinal trouble. At times children who have been perfectly well are stricken. Symptoms.—The onset may be gradual or abrupt. Diarrhea is usually the initial symptom. The stools are thin and serous or watery, and have a musty odor. Vomit- ing soon develops, and the irritability is so great that everything is rejected. The thirst is intense, and the temperature is very high, 105° F. to 1080 F.; the pulse is rapid and feeble and the urine scanty. Collapse follows, and is indicated by the pinched features, hollow eyes, sunken fontanels, and the cold surface of the body. Even at this time reaction may set in, but, more commonly, death results from exhaustion. Treatment.—Prophylaxis.—What has been said con- cerning prophylaxis, under previous diseases of the intesti- nal tract, should be practised to avoid such a form of the disease as this. Nursing.—As everything swallowed during an attack only aggravates the vomiting, nothing should be given by the mouth except ice and iced champagne. The physician may find it necessary to wash out the stomach (Lavage, page 476) and irrigate the bowel (page 476). At times hypodermoclysis (see page 484) is resorted to. The serous or watery diarrhea so depletes the fluids of the body that this is necessary. The cold bath or tubbing is used to counteract the fever (page 455). 154 DISEASES OF CHILDREN FOR NURSES In collapse give a mustard tub, no° F., then place the child in a horizontal position, cover with warm blankets, and administer stimulants freely. Cholera morbus is a term given to a disease, similar to cholera infantum, in older children. The symptoms, however, are not so severe. This disease is seen in the summer season, caused by eating unripe fruit, and sudden changes of temperature, such as bathing and swimming. Symptoms.—Intense cramps in the stomach, vomiting, and purging of bilious material, moderate fever, and great prostration. In severe cases the discharge becomes serous, and symptoms of collapse develop. FOOD INTOXICATION (FINKELSTEIN'S) This author has shown that certain nutritional dis- orders resembling profound infection are due mstead to a failure in metabolism, and that the condition is aggra- vated by the ingestion of fat and sugar. In this type of cases it is necessary to stop all foods and give water in as large quantities as can be tolerated with- out vomiting. With cessation of the symptoms, such foods as broths, egg-albumen, beef-juice, buttermilk, albumen-milk, or fat-free milk without additional sugar can be given. DEHYDRATION Many cases of diarrhea in childhood exhibit marked dehydration. It is essential that such patients receive saline solution. Such solutions may be given into the peritoneal cavity instead of by hypodermoclysis. The fluid enters rapidly and from ioo to 250 c.c. can be given in fifteen to twenty minutes. The physician will select a point on the midline (linea alba) just below the umbili- cus for the injection. DISEASES OF THE DIGESTIVE TRACT 155 TUBERCULOSIS OF THE INTESTINES The symptoms closely resemble chronic ileocolitis. Ulceration occurs and the tubercle bacillus is found in the stools. It accompanies general tuberculosis of the body. APPENDICITIS This is an inflammation of the appendix vermiformis. It is a medical condition until an operation is demanded. There are three varieties: catarrhal, ulcerative, and inter- stitial. In mild cases the appearance of the appendix is similar to that of catarrhal inflammation of a mucous membrane elsewhere. In severe forms the appendix is infiltrated with round cells and the mucous membrane is denuded of its epithelium and presents a granular appear- ance. This latter form may eventuate in septic peritonitis, chronic appendicitis with relapses (recurrent appendicitis), or union of the granulating surfaces with complete oblitera- tion (appendicitis obliterans). In ulcerative appendicitis the wall of the appendix is the seat of a more or less localized ulcer. It may be associated with the presence of a fecal concretion or a foreign body, or it may be the result of a typhoid or tubercular infection. In interstitial appendicitis the wall of the appendix is the seat of a necrosis which is not infrequently gangrenous. It terminates by perforation, thereby exciting the most virulent type of peritonitis. The chief causes of appendicitis are exposure, errors in diet, intestinal catarrh with extension to the appendix, traumatism, lodgment in the appendix of fecal concretions or foreign bodies. It may follow some infectious disease, as typhoid, influenza, or tuberculosis. It may be induced by the twisting of the appendix. Any of these conditions 156 DISEASES OF CHILDREN FOR NURSES will interfere with the blood-supply of the appendix, and this is the real reason for the inflammation. Symptoms.—Sudden pain, often general at first, but later most marked in the right iliac fossa. Localized tenderness, most frequently detected over McBurney's point, which is the center of the line drawn between the anterior superior spinous process of the ilium (the anterior prominence on the pelvic bone), and the umbilicus. Fever 103° F. to 104 ° F. There is a localized rigidity in the right iliac fossa and the presence of a definite tumor. Dorsal decubitus with right thigh flexed. Gastro-intes- tinal disturbances, such as anorexia, nausea, vomiting, constipation, or rarely, diarrhea. Terminations: resolution, general peritonitis, localized abscess. Treatment.—Absolute rest and liquid diet. An ice cap should be kept constantly over McBurney's point. Move the bowel only by enema. An operation is necessary at once in cases beginning suddenly with great severity, in ordinary cases where no improvement is noted after the lapse of forty-eight hours, when at any time there should be a sudden increase in the pain or a rapid diffusion of tenderness, and whenever a well-defined tumor can be detected in the right iliac fossa. Nursing.—Previous to operating, spreading tenderness, vomiting, rise or fall in the temperature, and rapidity of the pulse must be reported immediately. If ice-bags are ordered to be applied to McBurney's point, be sure they remain there. If vomiting occurs, the nurse should hold the sides of the abdomen to give as much relief as possible. The room should be well ventilated and kept at an even DISEASES OF THE DIGESTIVE TRACT 157 temperature. Bathing should be dispensed with. Alcohol sponging will relieve, discomfort. After the operation the child should be kept flat on the back. The dressing should be carefully watched. Ab- solutely nothing should be given by the mouth without a physician's orders. The temperature, pulse, and respira- tion should be taken every three hours throughout the attack. In septic cases the surgeon may order the child to be placed in a semireclining or sitting position after operation for purposes of drainage. This can be maintained by a bed-rest and some con- trivance to keep the child from slipping. A simple plan of procedure under these conditions is to take the seat of a swing, bore four holes, one at each corner, through which are passed the ends of four lengths of rope, which are securely knotted on the under side. After the desired position of the seat on the bed has been determined, the two lower ropes are tied to the head of the bed at the level of the mattress. The seat is then tilted to the proper angle, and the two upper ropes are tied to the top of the back of the bed. The seat is then covered with a pillow upon which rests the child's buttocks. His legs are flexed over the edge of the seat, and his feet rest on a hot-water bag. This apparatus gives them a feeling of security and the angle of the seat may easily be changed by loosening or tightening the upper ropes. Continuous saline irrigation of the bowel may be ordered (for method, see page 477). 158 DISEASES OF CHILDREN FOR NURSES INTESTINAL OBSTRUCTION Intestinal obstruction is a condition in which the bowel becomes closed, preventing the passage of fecal material. Causes.—Acute causes are congenital occlusion, intus- susception, internal or external strangulation, and twists. Chronic obstructions are:" stricture from healing ulcer; unnatural accumulations, as of fecal masses; foreign bodies; gallstones; and tumors pressing from within or without. Fig. 37.—Schematic representation of an ileocecal invagination. The mucous mem- brane is indicated by the dotted line (Friihwald and Westcott). Congenital occlusion is usually located at the anus or rectum (see page 142). .Intussusception is the slipping of a portion of the intestines into another portion immediately below it. This usually occurs at the ileocecal valve, the small intestines slipping into the large. This is due to unequal muscular contraction and an elongation of the mesentery (the attachment of the intestines to the abdominal wall). DISEASES OF THE DIGESTIVE TRACT 159 The invagination cuts off the blood-supply, and gangrene occurs. Unless promptly reduced, death occurs from this cause. Symptoms.—The onset is often sudden. There may be a few loose stools, composed mostly of blood and mucus. At first there is paroxysmal pain in the side. Later this becomes continuous. Vomiting almost imme- diately sets in and is at first bilious, but after the obstruc- tion is complete, it becomes fecal (stercoraceous). It is persistent, and everything that enters the stomach is immediately rejected. At first the abdomen is retracted, but it soon becomes distended, and the presence of a sausage-shaped tumor may be detected at the site of the intussusception. Prostration is marked. The tempera- ture ranges between 103 ° F. to 1040 F. If gangrene occurs, the child dies of peritonitis. Treatment.—High rectal enemas of large quantities of water or salt solution at times forces the bowel back and reduces the intussusception. In giving such enemas the buttocks should be well raised and the bottom of the bag four feet above the table. If this does not accom- plish the result, an immediate operation is demanded. Strangulation.—This occurs where there is a hernia or rupture. It may occur externally where the bowel slips through the abdominal ring, or internally if a portion of the gut slips through an opening in the diaphragm or under an adhesion. All of these conditions become strangulations where for any reason the bowel is com- pressed and the passage of feces stopped. Twists or volvulus are found in the sigmoid flexure. They are true twists of the bowel, due to a relaxed mesen- tery. Symptoms of acute obstruction are sudden and at first l6o DISEASES OF CHILDREN FOR NURSES consist of paroxysmal pains, later becoming continuous. There is constipation; vomiting, persistent and becoming stercoraceous; abdominal distention, and collapse. Treatment.—An immediate operation is imperative. Chronic Obstructions. — Healing ulcers form scars which contract and act as a band constricting the intes- tines. Unnatural fecal masses, foreign bodies, and gall- stones may obstruct by their bulk. Tumors may press upon the intestines, in this way compressing them, or tumors growing within the intestines may obstruct by their bulk (uncommon in childhood). The symptoms of chronic intestinal obstructions develop slowly and are the same as those found in the acute form. DILATATION OF THE COLON An enlargement of the colon; usually the distention is very great. It may be congenital or secondary to some stenosis of the bowel. The symptoms consist of great dilation of the colon and obstinate constipation, at times one to two weeks or more passing without a movement. The congenital cases rarely live to adult life; the major- ity die before the age of five of increasing inanition or some complication. DUODENAL ULCER This is a rare condition in childhood, yet distinctly more frequent than was formerly supposed. The condi- tion usually is not recognized during life. The only truly suggestive symptoms suggesting duodenal ulcer is hematemesis and the passage of blood by stool. Nursing.—The child must be kept absolutely at rest and fed at first by enema only. An ice-bag, if ordered, DISEASES OF THE DIGESTIVE TRACT l6l should be kept over the region of the duodenum, guarding carefully against depression if the patient is an infant. To prevent the return of hemorrhage the diet must continue light and free from substances of an irritating nature, such as spices or food containing much waste material. Overexercise must be avoided, especially such as would produce undue strain of, or pressure upon, the abdominal region. HERNIA The types of hernia seen most frequently in children are the umbilical and inguinal. Ventral and diaphrag- Fig. 38.—Band of adhesive plaster over an acquired umbilical hernia. The plaster is tensely drawn and applied and fastened over the ribs on both sides, so that a longitudinal fold of the abdominal wall is drawn over the hernia. (Hecker, Trumpp, and Abt.) matic hernias are very rare, and femoral hernia so un- common that it is a curiosity. Umbilical hernia may be congenital. This is a rare condition, or acquired. The latter is a very common and seldom serious affection of infancy. It generally devel- ops in the first few months of life and consists of a slight protrusion at the navel. Strangulation very rarely oc- 11 162 DISEASES OF CHILDREN FOR NURSES curs, and the majority of cases recover spontaneously if such causes as continuous abdominal distention or per- sistent straining efforts are removed. Treatment.—This consists of a band of adhesive plaster tensely drawn and applied and fastened over the ribs on Fig. 39.—Large inguinal hernia. Infant of fourteen months, in the Children's Hospital of Philadelphia. (J. P. C. Griffith.) both sides, so that a longitudinal fold of the abdominal wall is drawn over the hernia. Inguinal Hernia.—This form is much less frequent than umbilical hernia in the first few weeks of life, but more common when developing after this period. The rupture is oftener situated on the right side, and frequently double; sometimes it fills the scrotum. DISEASES OF THE DIGESTIVE TRACT 163 Treatment.—This is very satisfactory and the majority of cases will recover completely under the application of a suitable truss. A truss of hard rubber or a skein of woolen yarn must be worn constantly, and the mother impressed with the importance of never allowing the hernia to descend. The skin under the truss must be kept dry and clean and in a healthy condition. Often a truss will cure in three months. When the use of a truss does not succeed by the end of the first year, and in every case where the hernia is found irreducible after gentle efforts, a radical operation for permanent cure must be employed. ANIMAL PARASITES Animal parasites or intestinal worms are tape-worms (taenia solium and taenia saginata), round worms (ascaris lumbricoides), and seat worms (oxyuris vermicularis.) Tape-worms are formed of white segments. They are flat and may be from ten to fifteen feet in length. They gain entrance to the intestinal canal through un- cooked beef or pork. The taenia saginata or beef-worm is the most common in children. Symptoms.—Various nervous symptoms exist. Anemia, if the worm is not expelled, and at times an inordinate appetite. Segments are seen in the stools. Treatment.—The thorough cooking of all meats. If segments are discovered the child should be treated as follows: a light supper, and the following morning a saline purge, without any breakfast. After the purge has acted give oleoresin of male fern, 15 minims, in capsule, one every hour for four hours. Fifteen minutes after the last dose give castor oil. Milk should be the diet for the rest of the day. 164 DISEASES OF CHILDREN FOR NURSES It is absolutely necessary that the head of the worm should be recovered, for even though all the body is passed if the head remain the worm will grow again. The subsequent stools should be closely watched. The head is very much smaller than the body and is attached to the neck, which gradually grows smaller as the head is ap- proached. At the time of the expected passage of the worm it is well to half fill the receptacle with water. This per- mits the worm to float and avoids the breaking from its own weight. To recover the head a piece of muslin or fine mesh gauze should be stretched over a vessel and the movement poured into this. Fig. 41.— Ascaris lumbricoides (Kerr). segments (Kerr). Ascaris Lumbricoides (Round-worms).—These worms are from five to ten inches in length and about as thick as a slate pencil. They are grayish-pink in color and are DISEASES OF THE DIGESTIVE TRACT 165 pointed at both ends. Usually six to a dozen are present in the bowel. The symptoms are variable, nervous symptoms being the most marked. The worms are often found in the stools. They have a tendency to migrate, and are at times vomited. Treatment.—Santonin, gr. 3, to a child of five, given in three doses at four-hour intervals. The same plan of treatment as described under tape-worms should be fol- lowed, with the exception of santonin being used instead of male fern. Oxyuris Vermicularis (Seat-worms).—These are small thread-worms about one-third inch in length. They occur in great numbers and inhabit the colon and rectum. Symptoms.—Intense itching of anus, especially at night, and the appearance of the worms at anus. Treatment.—The use of bichlorid of mercury, 1 to 10,000 after stool. Wiping the parts thoroughly and the injection of bichlorid of mercury, 1 to 10,000, into the rectum will cure mild cases. Infusion of quassia is also used. Some cases are very troublesome. Blue ointment will relieve the itching. Uncinaria Duodenalis (Hook-worms).—These are small thread-like worms, about three-quarters of an inch long, which attach themselves by means of four teeth to the mucous membrane of the small intestines, especially in the jejunum. The loss of blood due to thousands of these worms being "hooked" to the lining of the intestines causes a severe and at times a fatal anemia. It is one of the most danger- ous parasites met with in the human body. It is found in Egypt, Germany, Italy, Belgium, Switzerland, the West Indies (Jamaica), and through the southern portion of the United States. 166 DISEASES OF CHILDREN FOR NURSES The children affected become dull, listless, emaciated, and profoundly anemic. The ova and embryos are contained in the stools, and are disseminated through dirt. Treatment and Nursing.—Thymol is given to destroy the worms. Following its administration castor oil will usually expel large numbers of dead worms. The stools should be thoroughly disinfected (see page 496). DISEASES OF THE RECTUM Prolapse of Rectum.—This may be partial or complete. A simple eversion of the mucous membrane or a protru- sion of three or four inches of the bowel. It occurs at stool. Treatment.—This can usually be replaced by gentle pressure with oiled fingers. Cold water will reduce Fig. 43.—Toilet-seat for prolapse of the rectum. To be used over the seat of the ordinary nursery-chair. (J. P. C. Griffith.) congestion and assist in an obstinate reduction. To prevent recurrence have the child defecate upon its back, holding buttocks close together. In the more severe forms surgical treatment is demanded. Fissure of the anus is a small linear ulcer of the mucous membrane covering the sphincter. It is very annoying and irritating. DISEASES OF THE DIGESTIVE TRACT 167 Treatment.—Cleanliness and touching the ulcer with a silver stick will promptly cure. Ischiorectal abscess is an abscess in the tissues sur- rounding the rectum. Hemorrhoids or piles are the engorgement of the veins of the rectum. They may be internal or external. They give rise to pain at stool, and are not common in children. Cold-water injections give relief. Incontinence of feces is the name given to the in- ability to control the evacuations. Proctitis.—This is an inflammation of the rectum. When it occurs alone it is caused by the use of suppositories, injections, and seat-worms. The principal symptoms are the passage of mucous and bloody stools with tenesmus. Nursing.—The tenesmus is relieved by the introduc- tion of pellets of ice into the rectum, or by means of a simpler method which is probably just as effective—the application of cold compresses to the anus. Do not take the temperature by way of the rectum if it is diseased. Give rectal irrigations slowly to avoid pain. Diseases of the Liver Jaundice is a pigmentation of the skin and tissues with bile-pigment. It is caused by an obstruction to the flow of bile from the liver, through the common bile-duct, into the intestines. This obstruction in children is usually due to congestion or inflammation of the common bile-duct, the process being an extension from the small intestines. This obstruction prevents the bile from passing through its natural channels, so that it is backed up and thrown 168 DISEASES OF CHILDREN FOR NURSES into the circulatory system and carried to all parts of the body. The symptoms of jaundice are the yellow hue to the skin and conjunctiva of the eye; the latter is distinctive. The urine is dark and the stools are light. Icterus neonatorum is jaundice of the newborn infant. Catarrhal jaundice is the name applied to an acute catarrhal inflammation of the common bile-duct usually caused by extension from the bowel, characterized by the symptoms of gastro-enteritis plus jaundice. Gallstones are concretions formed in the gall-bladder and composed for the most part of bile elements. These stones may lie latent, pass out along the common bile-duct, causing biliary colic, or may become impacted in the duct, giving rise to grave symptoms which demand an operation. This is not common in childhood. Symptoms of biliary colic are sudden and intense pain over the liver, radiating to the right shoulder. This usually occurs an hour or two after eating. A chill with fever may mark the onset. Jaundice may be present from obstruction and the stone may be found in the stool. Cholecystitis is inflammation of the gall-bladder. Congestion of the liver may be active or passive, just. as in the lungs. Active from arterial blood (too much blood from heart to the liver); passive from venous blood (obstruction to return of blood to heart). Cirrhosis of the liver is a chronic disease characterized by an overgrowth of connective tissue and a destruction of the liver-cells. There are two varieties, an atrophic form in which there is general contraction of the connective tissue in the liver and the organ becomes very much reduced in size. DISEASES OF THE DIGESTIVE TRACT 169 A hypertrophic form in which there is no contraction of the connective tissue, but since the connective tissue is largely increased the liver actually enlarges. Abscess and cysts of the liver are seen. Peritonitis This is an inflammation of the peritoneum. It may be primary, or secondary to some inflammation of the surrounding parts. It may be localized or general. It may have a serofibrinous, fibrinous, or purulent exudate. It may be acute or chronic. Acute peritonitis is caused by exposure to cold and wet, traumatism or injury, and by extension of the in- flammation from some adjacent structure, such as typhoid ulcer or appendicitis. It may be secondary to some general disease such as scarlet fever, rheumatism, or tuberculosis. Symptoms.—The disease starts with a chill and fever, 102 ° F. to 103 ° F. There is a rapid, wiry pulse, abdomi- nal pain, and tenderness so intense that abdominal respirations and body movements are inhibited. The child lies on its back with the thighs flexed, the features are pinched, the vomiting is persistent, the bowels are constipated. Hiccough is a common and troublesome symptom, the abdomen is greatly distended and is hard and board-like. In the large majority of cases death occurs in a few days. Nursing.—The room should be kept at an even tem- perature; the bed-clothes should be supported by a frame over the abdomen. The child should be carefully watched; any movement will cause excruciating pain. Bathing should be stopped. 170 DISEASES OF CHILDREN FOR NURSES Champagne is often the only substance which will be re- tained. Cracked ice will alleviate the thirst. Drugs are often administered hypodermically. If the child vomits, hold the sides of the abdomen to give as much relief as possible. The temperature, pulse, and respirations should be taken every three hours. Chronic peritonitis may occur unassociated with tuberculosis. It is usually a localized peritonitis; if gen- eral, it is associated with fluid in the abdomen. Tubercular Peritonitis.—The large majority of cases of chronic peritonitis are tubercular in character. It is usually associated with general tuberculosis or due to tuberculosis of the mesenteric lymph-glands. Symptoms.—The abdomen usually contains fluid and there is an evening rise of temperature; emaciation and weakness are marked. The pain is not so severe as in the acute form of peritonitis, but there is diffuse tenderness. There are evidences of tuberculosis in the other organs. Treatment.—It is in these cases that opening the abdomen is of such value. ASCITES Ascites is a dropsical condition of the peritoneum in which there is a serous effusion into the peritoneal cavity, usually a part of general dropsy. CHAPTER VIII DISEASES OF THE CIRCULATORY SYSTEM Anatomy.—The heart is a hollow, conic muscle nor- mally situated in the left chest. It is divided by muscular and fibrinous partitions into four cavities. The two upper chambers are called the right and left auricles, and the two lower, the right and left ventricles. The right auricle is connected by an opening with the right ventricle called the tricuspid orifice. This passage is closed by the tricuspid valve, so-called because it has three leaflets. The right auricle contains the orifice of the superior and inferior vena cava. This opening is surrounded by a sphincteric muscular band to prevent a back-flow of the blood. The left auricle opens into the left ventricle by the mitral orifice, which is closed by the mitral valve, so called because it resembles a bishop's miter. The function of the valve is to prevent a return flow of blood to the chamber it has left. The left auricle contains the orifice of the pulmonary vein. The right ventricle contains the orifice of the pul- monary artery. This is closed by the pulmonary semi- lunar valves. The left ventricle contains the orifice of the aorta, closed by the aortic semilunar valves. The valves are made of thin fibrous tissue and 171 172 DISEASES OF CHILDREN FOR NURSES covered by the endocardium. They are attached to the heart-muscle walls by the corda tendina; little filaments of muscular tissue. Normally, the valves perfectly close Fig. 44.—Right auricle and ventricle opened : 1, Superior vena cava; 2, inferioi vena cava; 3, right auricle; 4, cavity of right ventricle; 4', papillary muscles; 5', 5", 5'", tricuspid valve; 6, pulmonary artery and semilunar valve; 7, 8, aorta; 10, left au- ricle; 11, left ventricle. (Allen Thomson). the orifice at which they are situated after the column of blood passes that point. The endocardium is the lining. membrane of the heart. It covers the inner walls of all the cavities and both sides of the leaflets of the valves. The pericardium is a serous membrane and forms a sack in which the heart is contained. It is like the pleura and covers the heart in a similar manner as that membrane does the lungs. One portion covers the DISEASES OF THE CIRCULATORY SYSTEM 173 heart-muscle intimately, being firmly attached to it; and the other portion is reflected, forming a closed sack. Between the two layers there is about one ounce of a serous fluid which lubricates the opposing surfaces. The broad upper portion of the heart is called the base and the lower pointed portion, the apex. The heart beats rhythmically from an inherent prop- erty of its muscle and from nervous control. The pneu- mogastric nerve carries the principal fibers to it. When the heart-beat is heard or felt the ventricles empty. This is called systole. The auricles empty be- tween beats. This is called diastole. The Circulation.—The blood enters the right au- ricle from the superior and inferior vena cava. It then passes through the tricuspid orifice to the right ventricle. From the right ventricle the course is through the pulmo- nary artery (the only artery in the body carrying venous blood) to the lungs, where it is purified and changed into arterial blood. It returns to the left auricle through the pulmonary vein, the only vein carrying arterial blood. From the right auricle the blood passes through the mitral orifice to the left ventricle and is then pumped into the aorta. The aorta supplies the general arterial circulation, distributing the blood through its divisions and subdivisions to all parts of the body. The arteries become smaller and smaller, until they become capillaries. Here the arterial blood is changed into venous blood. The venous blood is collected from the capillaries, emptied into veins, which become larger and larger, and finally flows into the superior vena cava (the head, neck, and upper extremities) or into the inferior vena cava (the trunk and lower ex- tremities). The vena cava empties into the right auricle. The time taken for a complete circulation of a drop of 174 DISEASES OF CHILDREN FOR NURSES blood in a newly-born child is twelve seconds; at three months, fifteen seconds; in the adult, twenty-two seconds (Vierordt). The Fetal Circulation.—This is the circulation of the blood in the fetus. It differs from circulation after birth in that the blood is purified in the placenta and not in the lungs of the child. The placenta is attached to the walls of the womb and is expelled at birth, being called the after-birth. Before birth the right and left auricles are connected by an opening called the foramen ovale. A large portion of the blood passes through this foramen directly into the left auricle. A smaller quantity passes through the tri- cuspid valve into the right ventricle. At birth the umbilical cord is ligated and breathing is instituted in the child. The blood then ceases its flow to the placenta and the pulmonary circulation becomes of great importance. The circulation from this moment is the same as in after life. The passage through the foramen ovale and the ductus arteriosus becomes unneces- sary, and, normally, these two openings are closed. The foramen ovale is almost closed at birth and entirely closed within six months after delivery. The ductus arteriosus closes in about ten days. At times these openings remain patulous, they fail to close, and the fetal circulation persists after birth. This allows the venous blood in the right side of the heart to enter the arterial system, giving rise to what are known as blue babies. Before birth the sharp distinction between venous and arterial blood does not exist in the heart. Malformations.—The patulous ductus arteriosus and foramen ovale constitute a deformity of the heart when they persist after birth. The infants affected are more or DISEASES OF THE CIRCULATORY SYSTEM 175 less cyanosed or blue in color, especially about the lips and finger-nails. There are periods when this is more marked than at other times. They are poorly nourished and usually die in the first few months, if not from weakness of the heart, from some intercurrent condition. At times they live, the openings closing late and the normal circula- tion being established. Abnormalities in the origin of the large vessels are sometimes seen. Transposition of the heart is sometimes noted. In this condition the heart is found on the right side instead of the left. Fetal Endocarditis.—This is an inflammation of the lining of the heart which occurs before birth. It is nearly always the right side of the heart that is affected. After birth inflammations of the endocardium attack the left side. The fetal inflammation causes valvular lesions at the tricuspid and the pulmonary orifices, the children being born with these defects. It is safe to say that val- vular lesions of the right side of the heart are always congenital. Phenomena of the Action of the Heart.—The apex- beat is a pulsation caused by the apex of the conic- shaped muscle of the heart coming in contact with the chest wall. After seven years of age it is normally situated in the fifth intercostal space, one-half to one inch inside of the mammary line. Before this time it is found higher and further to the left. The apex-beat may be displaced by such conditions as a pericardial effusion, a hypertrophy or dilatation of the heart, or the pressure from either side from such conditions as a pleural effusion, tumors, etc. Changes 176 DISEASES OF CHILDREN FOR NURSES are noted in the force and extent of the apex-beat under similar conditions. The normal area of heart dulness obtained by per- cussion is from the junction of the third rib, with the sternum on the left side, to the apex-beat which can usually be seen in the fifth interspace, from one-half to one inch inside the mammary line, from the apex-beat to the xiphoid cartilage (the lower end of the sternum or breast- bone), and thence up the right border of the sternum to the level of the third rib. The two sounds heard over the heart upon ausculta- tion are caused as follows: The first results from the contraction of the ventricle and the impact of the heart against the chest wall, and is synchronous with the apex- beat (called the systolic sound). The second sound is caused by the closure of the aortic and pulmonary valves (diastolic). The first sound is long and booming, and between it and the second sound there is a slight pause. The second sound is short and high pitched. After the second sound a long pause follows before the first sound is repeated; characterized by "lubb, tub." Any alteration in the character of either of these sounds is spoken of as a murmur. Accentuation of the sounds does not con- stitute a murmur. If the murmurs are due to a disease of the heart proper they are spoken of as endocardial murmurs. If due to anemia they are called hemic mur- murs. In pericarditis they are called friction sounds, and in aneurism, bruit. A hemic murmur is a soft, blowing sound heard over the base of the heart. They do not indicate any damage to the valves; only an alteration of the blood, such as the diminution of hemoglobin found in anemia. Flint's murmur is the name given to a sound heard in DISEASES OF THE CIRCULATORY SYSTEM IJJ aortic regurgitation, due to the mitral leaflets vibrating between the column of blood passing through the mitral orifice and the column leaking back from the aorta. The locations where the different valve sounds are best heard are: Mitral, at the apex; tricuspid, at the end of the sternum (xiphoid cartilage); aortic, second costal cartilage, about an inch to the right of the sternum; pulmonary, second costal cartilage, about an inch to the left of the sternum. The Pulse.—At birth the pulse is between 130 to 150 per minute, in the second year about 100, and gradually lessens as the child matures. An adult has a pulse of 70 or 80 per minute. There are several changes which take place in the pulse which have received different terms. Tachycardia, an increased frequency of the pulse. Bradycardia, infrequency of the pulse. Intermittent, dropping a beat. Irregular pulse, alternately rapid and slow. A dicrotic pulse is one in which the main beat is quickly followed by a secondary wave or a slight rebound of the vessel. It is seen in the cases where there is a low arterial tension, especially in febrile diseases. It may cause the mistake of counting double the number of beats actually present. A high-tension pulse is one in which the force of the beat is relatively increased. The tension of the pulse may be estimated roughly by noting the amount of pressure of the fingers that is required to arrest the beat. A low tension pulse is just the op- posite. 12 178 DISEASES OF CHILDREN FOR NURSES Venous pulse, when present, is usually found over the jugular vein. It is rare. Asymmetric Radial Pulse.—When the two radial beats are not synchronous it may be due to conditions affecting one side of the circulation, as aortic aneurisms, fractures, luxations, etc. Water-hammer pulse is characterized by short, power- ful beats which suddenly collapse. It is seen in aortic regurgitation (see page 186). Other conditions which are present in diseases of the heart beside the alteration of the apex sounds and pulse above noted, are: Palpitation, which is a rapid tumultuous action of the heart perceptible to the patient. This condition is termed a functional disorder. Mechanical disorders and irregularities of the heart's action can usually be referred to one of the following cate- gories : (1) Sinus arhythmia. (2) Heart-block. (3) Premature contractions. (4) Paroxysmal tachycardia. (5) Auricular flutter. (6) Auricular fibrillation. (7) Pulsus alternans. Sinus arhythmia is an irregularity in the pulse without dropping of beats in which the systoles are of equal dura- tion, but there are variations in the length of the diastolic periods. It is of no pathologic significance. Heart-block may be partial or complete. Here the contraction wave is not transmitted from the auricle to the ventricle (over the bundle of His), and there is a com- DISEASES OF THE CIRCULATORY SYSTEM 179 plete dissociation between the rhythm of the two, usually the auricle beats about twice to the ventricle's once. Premature Contractions of the Ventricles.—This irregu- larity is occasioned by a premature contraction of the ventricle occurring in advance of the arrival of the normal excitation wave from the auricle. It causes extrasys- toles and is of no especial pathologic significance. Paroxysmal tachycardia is a very rapid pulse (200) be- ginning suddenly and ending abruptly. These attacks may last from a few minutes to several days. The fre- quency of the seizures vary widely. These attacks can sometimes be benefited by applying sufficient pressure over the right carotid artery to obliterate the pulse wave in the neck. Auricular Flutter.—A condition in which the auricles may beat as high as 300 to the minute, the ventricle responding to every third or fourth beat of the auricle. It is a rare condition usually seen in advanced periods of life where there is associated degeneration of the heart muscle. Auricular Fibrillation.—Here the auricle ceases to beat as a whole, individual fibers contract, and the ventricle responds with irregular, rapid, haphazard, often incom- plete contractions in response to the shower of stimuli transmitted to it from the contraction of these individual fibers in the auricle. It is always of serious import. Pulsus Alternans.—A regular pulse, but alternately relatively large and small, indicating a partial failure of contractility each alternate beat. It is always of grave prognostic import. Dropsy.—An unnatural collection of serous fluid in the tissues of the body. l8o DISEASES OF CHILDREN FOR NURSES Fig. 45.—The "clubbed fingers" of chronic heart disease. Fig. 46.—Clubbing of toes in chronic heart disease. General Cyanosis.—Blueness of the surface from insufficient oxidation of the blood. Clubbing of the fingers in chronic cases. DISEASES OF THE CIRCULATORY SYSTEM l8l PERICARDITIS This is an inflammation of the pericardium or serous covermg of the heart. It is rare in infancy, but as the child grows older it is not uncommon. It follows pleuro- pneumonia, rheumatism, the acute infectious diseases, pyemia, tuberculosis, and local causes. Fig. 47.—Large pericardial effusion. Area of dulness in solid black. Normal area of absolute cardiac dulness lined (Kerr). Pathology.—The same conditions exist in pericarditis as in inflammations of a serous membrane in any other part of the body. At first the surfaces are red and sticky; they rub together and cause a great deal of pain. In a day or two an effusion appears, which may be serous, serofibrinous, fibrinous, or purulent. In the serofibrinous form there is little - lymph and a great deal of serum, which, in favorable cases, is absorbed. In the fibrinous form, just as in pleurisy, the surfaces 182 DISEASES OF CHILDREN FOR NURSES are covered with a butter-like exudate, which may or- ganize and form adhesions. In the purulent form death is usually the result. Symptoms.—Moderate fever, precardial pain and tenderness, dyspnea, and palpitation. The pulse is at first rapid and forceful, but later weak and irregular. The signs of the effusion will appear on the second or third day, and there will be relief from pain in all but the fibrinous form, where it is apt to be intensified, owing to the adhesion of the two surfaces. The disease lasts from one to three weeks. In the adhesive form of pericarditis, more or less per- manent enlargement of the heart results. Treatment.—The physician may tap the effusion, in which case the nurse should prepare for the operation in the same manner as described for aspirating the chest (see page 83). the precardia being the point of insertion instead of the axilla. Other affections of the pericardium noted are: Hydropericardium, dropsy within the pericardial sac; hemopericardium, blood within the pericardial sac; pneu- mopericardium, air within the pericardial sac. ENDOCARDITIS Endocarditis is an inflammation of the lining mem- brane of the heart. The process is usually confined to the valves. Varieties.—Vegetative, in which are found numerous bead-like vegetations that are especially marked along the free border of the valve. The valve itself is red and swollen. These vegetations are composed of connective tissue and fibrin, the latter derived from the blood. They may be whipped off by the blood current and may be DISEASES OF THE CIRCULATORY SYSTEM 183 carried as emboli to distant organs, such as the brain, kidney, or spleen. But more commonly if life is pre- served they are partially absorbed and fibrous tissue forms, causing a hardening or sclerosis of the valve leaflets. This forms the second variety of endocarditis, the so- called sclerotic or chronic endocarditis. The latter may aiise as a primary disease, and is then characterized by the thickening, curling, and puckering of the valves from an overgrowth of the fibrous tissue. The third variety is the so-called malignant or ulcera- tive endocarditis. Acute endocarditis usually results from acute artic- ular rheumatism, one of the infectious fevers, chorea, or septicemia. Forty per cent, of the cases of articular rheumatism have associated endocarditis. Of the infec- tious fevers, pneumonia and scarlatina are most prone to heart complications. The young are more liable to be attacked than the old. Chronic endocarditis may be congenital, the right side of the heart being then affected. It may follow an acute attack or it may result directly from syphilis, rheu- matism, or Bright's disease. Severe muscular strain some- times induces it in older children. After birth endocarditis most commonly involves the valves of the left side of the heart. Symptoms of Acute Endocarditis.—Subjective phe- nomena, such as pain, fever, cough, and dyspnea, are frequently absent, and auscultation may be the only means of diagnosing the disease, should a murmur be found. In many cases fever, an irregular and rapid pulse, palpitation, precordial distress, and dyspnea are associated symptoms. To understand the conditions which cause valvular 184 DISEASES OF CHILDREN FOR NURSES lesions of the heart the pathologic changes which take place in endocarditis should be kept in mind. It is safe to say that in the majority of cases which survive the acute attack the sclerotic form of endocarditis exists. The sclerotic form is an overgrowth of fibrous tissue which causes the leaflets of the valves to become swollen and permanently thickened. This enlargement of the leaflets obstructs the valvular orifice. This is the case in the so-called stenosis ox obstructive valvular con- ditions. This fibrous tissue sometimes contracts, in which condition the vaive becomes wrinkled, puckered, and curled up. It is then easily discernible that a valve thus affected could not close the valvular orifice completely, and the blood leaks back into the chamber it has just left. This is the condition found in insufficiencies or regurgitations. As there are four valves to the heart—aortic, pul- monary, mitral (left side), and tricuspid (right side)— there may be an aortic stenosis or an aortic regurgitation; a pulmonic stenosis or a pulmonic regurgitation; a mitral stenosis or a mitral regurgitation; a tricuspid stenosis, or a tricuspid regurgitation. Murmurs.—A murmur is any alteration in the nor- mal sound of the heart. (Accentuation of sounds is not considered a murmur.) A murmur is produced by the blood flowing over a roughened or damaged valve. In an obstruction to an orifice the opening is too small, and in forcing the blood through the narrow passage it produces a blowing sound or murmur. In insufficiencies where the valve is not tightly closed there is a leakage back into the chamber of the heart from which the blood has been pumped after the valves are closed. This passage of blood through the leak causes the same blowing sound or murmur. DISEASES OF THE CIRCULATORY SYSTEM 185 The murmur occurs at the time the blood passes through the damaged valve. In obstruction it is at the time the blood is flowing from the chamber into the next portion of the circulation. If the obstruction is at the orifice between the auricle and the ventricle, it is at the moment the auricle is emptying itself into the ventricle. If the obstruction is at the entrance to the aorta or pul- monary artery, the murmur occurs when the ventricle is emptying into the vessels. In regurgitations the orifice is not too narrow, but rather larger than normal, the valves being wrinkled up; so there is no murmur when the blood is passing from one -chamber into the next part of the circulation. When the valves close to prevent back-flow, they do not close the opening entirely; consequently there is leakage into the chamber from which the blood has just passed. This leak is small and it causes a murmur at the time when the valves should be closed. The time when the various phenomena of the heart's action occurs is divided into systole and diastole. Systole is the time when the ventricles empty, the blood flowing into the aorta and the pulmonary artery. The mitral and tricuspid valves are closed to prevent the blood from flowing into the auricles. The auricles fill while this is taking place. The heart-beat occurs at this time, demonstrated by the apex-beat, the pulse wave, and the first sound of the heart. Diastole is the time when the aortic and pulmonary valves close to prevent the blood from flowing back into the ventricle, causing the second sound of the heart; the mitral and tricuspid valves open, and the blood flows 186 DISEASES OF CHILDREN FOR NURSES from the auricles into the ventricles. The time of the different murmurs is as follows: Mitral stenosis or obstruction occurs when the blood is flowing from the left auricle into the left ventricle. The time is diastolic. As the greatest contraction of the auricle occurs late in the diastole the murmur is heard best at that time. It is called a late diastolic murmur, or, more often, presystolic. It is heard just before the first sound of the heart at the apex. Mitral regurgitation or insufficiency occurs when the blood should be flowing from the left ventricle into the aorta. A portion leaks back through the damaged mitral valve. The time is systolic. It is heard instead of the first sound at the apex. Aortic stenosis or obstruction occurs when the blood flows from the left ventricle into the aorta. The time is systolic. It is heard instead of the first sound at the aortic area, the second costal cartilage to the right of the sternum. Aortic regurgitation or insufficiency occurs when the aortic valves should be completely closed. This leak allows the blood to flow back into the left ventricle. The time is diastolic. It is heard instead of the second sound of the heart at the aortic area. Tricuspid stenosis or obstruction occurs when the blood is flowing from the right auricle into the right ven- tricle. The time is late diastolic or presystolic. It is heard just before the first sound at the end of the sternum (xiphoid cartilage). Tricuspid regurgitation or insufficiency occurs when the blood should be flowing from the right ventricle into the pulmonary artery, and the tricuspid valve is closed. A portion leaks through the damaged valve into the right DISEASES OF THE CIRCULATORY SYSTEM 187 auricle. The time is systolic. It is heard instead of the first sound at the end of the sternum. Pulmonary stenosis or obstruction occurs when the blood is flowing from the right ventricle into the pulmonary artery. The time is systolic. It is heard instead of the first sound at the pulmonary area, at the second costal cartilage, one inch to the left of the sternum. Pulmonary regurgitation or insufficiency occurs when the pulmonary valve is closed to prevent the back-flow of blood into the right ventricle. The damaged valve per- mits a portion of the blood to leak back into the right ventricle. The time is diastolic. It is heard instead of the second sound at the pulmonary area. Double murmurs are heard when one or more lesions exist, the valves affected being determined by the time of murmur, and the location where they are best heard. Under such conditions both a systolic and a diastolic murmur can exist. Reduplication of the second sound is due to the fact that the aortic and pulmonary valves do not close simultan- eously, the closure of both valves being heard. Mitral regurgitation is the most common valvular lesion. Table of Heart Murmurs Lesion Systolic Diastolic Presystolic Heard best Mitral stenosis + Apex Mitral regurgitation + Apex Aortic stenosis + Aortic cart. Aortic regurgitation + Aortic cart. Tricuspid stenosis + Xiphoid Tricuspid regurgitation + Xiphoid Pulmonary stenosis + Pul. cart. Pulmonary regurgitation + Pul. cart. The period of compensation means an increase in the size and strength of certain cardiac chambers, sufficient 188 DISEASES OF CHILDREN FOR NURSES to enable the arterial system to receive its normal amount of blood, notwithstanding obstruction or regurgitation at one or more valves. The duration of this period is indefinite, and depends largely upon the amount of damage sustained by the heart and the hygienic conditions to which the patient is subjected. It is Nature's way of overcoming the damage done. In the lung this is accomplished by compensatory emphysema; in the heart the same amount of work has to be continuously accomplished. If a portion of the heart is disabled, the rest of the heart has to do the extra work, and therefore becomes enlarged and hypertrophied. During perfect compensation the murmur is usually the only sign of the endocarditis. People frequently go through life with a murmur and live as long as those who are not so unfortunate. As long as there is perfect com- pensation there is no danger to the life of the patient. Periods of lost compensation usually result from increased damage to the valves, conditions leading to arterial and cardiac degeneration, some intercurrent disease throwing additional strain upon the heart, and undue physical exertion. During this period the subjective symptoms reappear. This loss of compensation gives rise to dilatation of the heart and cardiac insufficiency. No matter what the original valvular lesion may have been, the organ becomes unable to fill the arteries and the blood is dammed back in the lungs and venous congestion of the organs follows. Very frequently the heart will readjust itself and com- pensation will return. Acute ulcerative endocarditis is a rapidly destruc- tive form of endocarditis and is characterized by necrosis DISEASES OF THE CIRCULATORY SYSTEM 189 or ulceration of the valves. It usually follows septicemia or one of the infectious fevers, such as pneumonia, erysipe- las, or scarlet fever. It may arise as a primary condition. The valves are the seat of ulcers, deep abscesses, and soft yellowish vegetations which have undergone partial necrosis. Microscopic examination reveals myriads of micro-organisms. Symptoms.—They are divided into three classes: Gen- eral, cardiac, and embolic. General Symptoms.—There is a high and irregular fever, repeated chills, profuse sweats, great prostration, often delirium and stupor, hurried breathing, a rapid irregular pulse, and a brown, fissured tongue. Jaundice and diarrhea are frequently present. Cardiac Symptoms.—Precordial pain, palpitation, and often murmurs at one or more valves. These may be absent. An embolism is a small portion of the vegetation formed on the valve leaflets which becomes loosened and is swept into the circulation by the force of the blood current. It is carried through the arterial system until it lodges in a vessel of too small caliber to permit its passage. In this position it entirely plugs up the artery and prevents the passage of blood. This causes the part supplied by the arteries to be cut off from its blood-supply. Peripheral emboli yield a petechial rash; renal em- bolism may yield a bloody urine, splenic embolism may yield a painful spleen; cerebral embolism may yield paralysis. The disease lasts from a few days to five 01 six weeks. Death almost invariably results. I90 DISEASES OF CHILDREN FOR NURSES MYOCARDITIS Acute myocarditis is an acute inflammation of the heart muscle. It is rare in childhood. It is almost always secondary to endocarditis or pericarditis. As a primary affection of the heart it may be due to rheumatism or to one of the infectious fevers. The heart muscle becomes degenerated, flabby, and friable. The symptoms are those characteristic of any heart condition, and include pain, dyspnea, a-very rapid and irregular pulse, and since the heart muscle itself is weak- ened, the heart-beats are weak and, in addition, the pulse very small. Fibroid heart is the term given to a chronic myocarditis; it is characterized by an overgrowth of connective tissue, just as in any chronic inflammation elsewhere. HYPERTROPHY OF THE HEART Hypertrophy of the heart is an enlargement of the heart due to an overgrowth of its muscle. It is caused by increased work, and this may be due to too much blood to be removed from the heart, as in regurgitant valvular lesions; obstruction to the outflow of the blood at the valves, as in the stenoses or obstruction in the pulmonary or systemic circulation, as in emphysema or Blight's dis- ease; resistance to ventricular contraction, as in adhe- sions; undue physical exertions, long continued. Varieties.—Simple hypertrophy comprises a thickened muscle with a normal cavity. Eccentric hypertrophy (hypertrophy with dilatation) consists of a thickened muscle and dilated cavities. Concentric Hypertrophy.—There is a thickened muscle and the cavities are diminished in size (always congenital). DISEASES OF THE CIRCULATORY SYSTEM 191 Dilatation of the heart is an enlargement of the heart due to the stretching of its walls. Varieties.—Dilatation with thickening of the walls, which is the same as eccentric hypertrophy; dilatation with thinning of the walls. Dilatation results from excessive pressure within the chambers of the heart, as from sudden extreme exertion; in valvular disease; and in impaired nutrition of the heart muscle, as in low fevers, valvular disease and sclerosis, or hardening of the arteries of the heart. One or both ventricles may be dilated, but usually the right. Symptoms.—As long as the associated hypertrophy keeps pace with the dilatation there are no symptoms, but when the dilatation preponderates, the following symptoms of venous stasis appear: Dyspnea and cough, the blood being dammed back in the venous system causes en- gorgement of the lungs; scanty urine from congestion of the kidneys; dyspepsia from congestion of the stomach. There is general dropsy, and feeble, irregular pulse. Fatty degeneration of the heart is a changing of the heart muscle into fat. When fat is merely deposited upon the heart muscle it is termed fatty infiltration. Fatty degeneration is due to sclerosis of the coronary arteries, valvular diseases, infectious fevers, and to certain poisons, as arsenic, phosphorus, and antimony. Symptoms are those of heart failure: Dyspnea, asthma, cough, weak, irregular pulse, poor digestion, dropsy, syncope, and Cheyne-Stokes respiration. NURSING OF CARDIAC DISEASES Absolute rest is of the greatest importance; light and nutritious diet, improvement of the general condition by 192 DISEASES OF CHILDREN FOR NURSES careful hygienic surroundings. Ice to the precordia will frequently relieve pain. Bathing should be accomplished only by sponge baths. In a severe case of heart disease the child should lie on its back without a pillow. When dyspnea is marked it is necessary to prop up the child in bed so that it can breathe with less discomfort (orthopnea). Fig. 48.— Position in orthopnea. The baby is supported by a frame, a pillow is placed on both sides to support elbows, and a folded sheet is passed around feet to pre- vent child from slipping down. The sheet is held in position by bandages attached to head of bed. The temperature, pulse, and respirations should be taken at least twice a day. It may be necessary to take the pulse more often, and in severe cases the pulse should be under constant observation. Symptoms of heart failure demand instant attention. Whenever the pulse becomes rapid, intermittent, and weak, or the child has sudden attacks of dyspnea, coldness of the extremities, or attacks of syncope, the physician should be immediately informed. While awaiting his arrival the child should be placed flat upon its back and not moved DISEASES OF THE CIRCULATORY SYSTEM 193 for anything. Mustard paste, made of equal parts of mustard and flour, may be applied to front of chest until there is a distinct redness, 15 minims of aromatic spirits of ammonia may be given in water by the mouth, if the child can swallow; hot-water bags may be placed about the extremities, and inhalations of ammonia given. (Be careful not to have concentrated ammonia nor to hold it continuously under the nose; pass it slowly backward and forward.) The physician will probably order a hypoder- mic injection of one of the following drugs: nitroglycerin, strychnin, digitalis, or whisky, all of which should be in readiness. Hypodermoclysis may be ordered and at times he may bleed the child. DISEASES OF THE BLOOD-VESSELS AND THE BLOOD Aneurism is a circumscribed dilatation of an artery. It is uncommon in childhood. The cases reported have been due to hereditary syphilis. The arch of the aorta is the most frequent seat; there may be abdominal aneurisms, and also aneurisms of any artery of the body. Symptoms.—Thoracic aneurisms: Dyspnea, metallic cough, pain, difficulty in swallowing, dilatation of super- ficial veins, unilateral sweating, paralysis of the sympa- thetic nerves, and the presence of a tumor. Arteriosclerosis is a thickening of the arteries due to an overgrowth of connective tissue, associated with more or less fatty degeneration and hardening. Not common in childhood. Phlebitis is an inflammation of the veins due to in- fection. Raynaud's Disease.—A symmetric spasm of the blood- vessels causing at first a whiteness of the skin, with a 13 I94 DISEASES OF CHILDREN FOR NURSES sensation of numbness or tingling, which lasts for a few minutes or a few hours, and is followed by redness and throbbing, and a sensat on of pain. In the more severe cases there may be supe.ficial necrosis or even gangrene from interference with the circulation. The attacks may appear at irregular intervals, some- times several times during the day. Recovery usually takes place after a prolonged course with numerous recurrences. It has a tendency to run in families at times. BLOOD In health the blood amounts to about one-thirteenth of the body-weight. It is composed of serum (a watery fluid), red blood-corpuscles, and white blood-corpuscles. Hemoglobin is the coloring matter of the red blood- corpuscles; it is principally composed of iron. Its function is to carry oxygen to the tissues of the body. Estimation of the Red and White Corpuscles.—The number is obtained by accurate mathematical calculation. The instrument used is called a hemacytometer. The blood withdrawn into the capillary tube is accurately diluted and a drop of this is placed upon a measured glass slide of known dimensions. Under the microscope the number of red and white corpuscles is counted in the measured area. The dilutions being known, the number of corpuscles in a cubic millimeter can be deduced. The hemoglobin is estimated by means of an instrument called a hemoglobinometer. There is a prism of colored glass so arranged that one- half of a small circular receptacle stands above it, con- taining clear water. The other half contains diluted blood. By means of a reflected light and the movable prism, which is graded from a light to a deep reddish hue, DISEASES OF THE CIRCULATORY SYSTEM 195 the two sides are so adjusted that they will be of the same shade. The percentage is read from a small scale attached to the sliding prism. Normal blood will read 100 per cent. on this instrument. The specific gravity of the blood is obtained by placing a drop of blood in a fluid mixture of known specific gravity. When the drop remains stationary the specific gravity is the same as the mixture. Fig. 49.—-Rogers' sphygmomanometer (Morrow). Blood-pressure.—This is taken by means of an apparatus (a sphygmomanometer) which registers in millimeters of mercury the amount of pressure that is present in the arteries during (1) the passage of the pulse wave (systolic pressure), (2) the actual pressure in the arteries during diastole (diastolic pressure). A rubber bag contained in an arm band is placed about the arm above the elbow and air is pumped into this bag until the pressure is sufficient to compress the artery at that point. This, of course, stops the pulse. The air is then allowed to escape until the pulse can be felt at the wrist or heard through the stethoscope placed over the brachial artery below the encirclmg band. At this point the systolic pressure is read off. The diastolic I96 DISEASES OF CHILDREN FOR NURSES pressure is obtained by allowing the air to escape until the pulsations are no longer audible through the stetho- scope; at the point where the sound ceases we read off the diastolic pressure. The difference between the two readings is called the pulse pressure. The normal pressure varies with the age. From three Fig. so.— Thoma-Zeiss hemocytometer : a. Slide used in counting; b, sectional view; c, portion of ruled bottom of well; d, red pipet; e, white pipet. to thirteen the normal systolic pressure is fairly con- stant between 90 and 103 m.m. At the age of puberty it rises rather rapidly toward the adult figures, which normally should be between 115 and 130 m.m. In infants under three years of age it is impracticable to take blood-pressure. Normal blood contains 5,000,000 red blood corpuscles to a cubic millimeter. At birth there are about 18,000, and later in childhood from 6,000 to 12,000 white blood-corpuscles to a cubic millimeter. The specific gravity is about 1.055. DISEASES OF THE CIRCULATORY SYSTEM 197 Anemia is a condition of the blood in which it is de- ficient in quantity or in one or more of its constituents. It is evidenced by pallor of the skin and mucous mem- brane, and by progressive weakness. Iron is used as the remedy, its action tending to increase the percentage of iron in the depleted hemoglobin. Pernicious anemia is a grave form of anemia character- ized by a great deficiency in the number of red blood- corpuscles, and not associated with any definite causal lesion. Plethora is an increase in the whole quantity of blood. Leukocytosis is an increase in the number of white blood-corpuscles. Leukemia is a disease characterized by a great increase in the number of white blood-corpuscles, with lesions of the spleen, lymphatic glands, and bone-marrow. Chlorosis is a disease in which there is a great reduction in the hemoglobin (coloring matter), without any decrease in the red blood-corpuscles. It derives its name from the green tint of the skin. Von Jaksch's disease is characterized by a decrease in the red blood-corpuscles and hemoglobin, and by marked leukocytosis with enlargement of the spleen and at times the liver. HEMOPHILIA OR BLEEDER'S DISEASE This is an hereditary disease characterized by a tendency to bleed excessively from slight wounds or spontaneously. It is probably the worst condition with which a surgeon can be confronted. Children afflicted can bleed to death from a pin scratch, nothing apparently being of use to stop the hemorrhage. It usually runs in families, several 198 DISEASES OF CHILDREN FOR NURSES brothers being affected; the sisters, however, are generally immune. Symptoms.—The symptoms are free and persistent hemorrhage after a trivial injury. Spontaneous hemor- rhages from mucous membranes of the nose, stomach, and bowel, and subcutaneous extravasations of blood are common. Treatment consists in ligation, application of styptics, and plugging of the nose in epistaxis. PURPURA This condition is characterized by extravasations of blood into the skin. When there is likewise hemor- rhage from the mucous membranes it is spoken of as purpura hemorrhagica. Purpura occurs in quite a variety of conditions. It is seen in malignant cases of endocarditis, in severe cases of measles, scarlet fever, variola, and vaccinia, also in epi- demic cerebrospinal meningitis and occasionally in diph- theria, rheumatism, pyemia, and septicemia. Purpura also occurs late in the course of many of the protracted diseases, especially in infancy, such as broncho- pneumonia, empyema, tuberculosis, enterocolitis, menin- gitis, and malignant cases. Certain drugs, such as phosphorus, quinin, and potas- sium chlorate, may produce purpura when long continued. Primary cases of purpura, not associated with any of the previously mentioned causes, occur in children of all ages, being not uncommon in infancy. Symptoms.—The onset may be marked by some fever, headache, malaise, and pain in the limbs, but these may be absent and the disease ushered in by copious crops of small hemorrhages in the skin, followed by bleeding from DISEASES OF THE CIRCULATORY SYSTEM 199 the mucous membrane. Anemia and its associated phe- nomena develop in severe cases. There may also be hemorrhages from the bowel, kidneys, and stomach. It occurs at times in connection with rheumatism, when hemorrhages into the joints are seen, especially the knee- and ankle-joints. In the most severe forms gangrene of the mucous membranes involved is sometimes observed. All forms of purpura have a tendency to relapse. Prognosis.—The appearance of purpuric spots during the course of an infectious disease is always a bad sign, as it usually denotes a very severe infection. In the cachectic varieties it usually heralds the approach of death. Prim- ary cases of purpura simplex generally recover. Primary cases of purpura hemorrhagica usually recover unless the fever is marked. The gangrenous form is fatal. Diseases of the Spleen The spleen is enlarged in a number of conditions, the most frequent of which are malaria, typhoid, rickets, syphilis, and tuberculosis. It is also seen in simple anemia accompanied by moderate leukocytosis, in Banti's disease, in von Jaksch's disease, in leukemia, and Hodgkin's disease. In the last two the liver is also enlarged. It may accompany any of the acute infectious diseases; it is seen in amyloid degenerations; and in cardiac condi- tions in which there is obstruction to the venous circula- tion. The spleen has been removed in cases of pernicious anemia with very good results. CHAPTER IX NERVOUS DISEASES ANATOMY OF THE NERVOUS SYSTEM The central nervous system is composed of the brain, the spinal cord, and their coverings. The brain is contained within the cavity of the skull. It is the center of thought, of the perception of the five senses, and of the voluntary motor activities of the body. Fig. si.—Functional areas of the cerebral cortex, left hemisphere (A. A. Stevens). The brain or cerebrum is divided into the right and left hemispheres by the median fissure. The two hemis- pheres are united by fibers running through the corpus callosum. 200 NERVOUS DISEASES 201 The lower portion is divided into the cerebellum, the crura, the pons, and the medulla. The brain is composed of gray and white matter, the gray matter being external and about a half inch in thickness; it is called the cortex. The rest of the brain is made up principally of white matter and consists of nerve fibers running in various directions. The cortex presents upon its surface deep grooves, which are called fissures or sulci. These fissures are numerous and divide the brain into convolutions. This arrangement gives the greatest area of cortex in the smallest amount of space. The more de- veloped the convolutions, the greater the intellect of the individual. The fissures also divide the brain into different lobes, such as the frontal, temporal, and parietal lobes. The fissure of Sylvius is a large sulcus on the external lateral sur- face of the brain, and it receives a portion of the wing of the sphe- noid bone. _,. r r r» 7 7 t Fig. 52-— General view of the The fiSSUre O] KolandO runs irom cerebrospinal nervous system (after Bourgery ; Schwalbe). the center of the vault of the skull, downward and forward toward the ear. Aiound 202 DISEASES OF CHILDREN FOR NURSES this fissure are located the motor centers of the body; tha«t is, the nerve cells which form the nervous im- pulses, making voluntary motion possible. The arrangement of the motor centers is "upside down"; that is, the center for the legs is uppermost; then, in order, the center for the trunk, the arms, the face, and head, the last-named being the lowest in location. (See Fig. 51). The nerve fibers run from the centers around the fissure of Rolando, through the internal capsule (a pathway in the substance of the brain), to the crura. A hemor- rhage within the internal capsule is the cause of hemi- plegia. The blood-clot, by exerting pressure, prevents any passage of nervous impulses, producing paralysis of the muscles supplied. The crura are two extensions of the brain, one from each hemisphere, which carry motor and sensory fibers. They unite and carry the fibers from both hemispheres as far as the pons. The pons is a bridge of nervous tissues. It not only contains the motor and sensory fibers from the cortex— carrying them from the crura to the medulla, the next portion of the nervous system below—but it also contains fibers running between the two hemispheres of the cere- bellum. The medulla or bulb is the lowest portion of the brain, and at the foramen magnum it becomes the spinal cord. The motor and sensory fibers decussate or cross from one side to the other in the medulla. On account of this crossing of fibers an injury to the left side of the brain produces a paralysis of the right side of the body (hemi- plegia). The medulla contains the center of the involun- tary movements, as respirations, etc. NERVOUS DISEASES 203 The motor fibers run through the anterior and lateral columns of the spinal cord and the sensory fibers through the posterior columns. At the level of the muscle to be supplied the motor fiber leaves the cord by one of the spinal nerves and runs through the branch of this nerve to the muscle. The sensory fibers run from the skin surface and return to the cord through the spinal nerve and enter the posterior columns of the cord. In the cerebellum is located the center of co-ordination. These centers keep all portions of the body working together in unison. The basal ganglia are isolated areas of gray matter within the white matter of the brain, and are associated with the special senses. The ventricles of the brain are cavities within its sub- stance. There are four in number, all connected and containing cerebrospinal fluid. The spinal cord is contained within the spinal column and is a continuation of the medulla. The pathways of the motor and sensory fibers are external, the gray matter being located in the center in the form of an H. The cord is divided into columns. The posterior column receives the sensory filaments through which they run on their way to the brain. The lateral columns and the anterior columns are com- posed of motor filaments running from the brain to the muscle. The central area of gray matter contains trophic cells in addition to motor fibers. Trophic cells supply the tissues with proper nervous tone; when they are injured bed-sores develop and atrophy of the muscles occurs. 204 DISEASES OF CHILDREN FOR NURSES The spinal cord contains most of the centers of reflex action. Since the posterior columns carry only sensory fibers, injury or disease of this part of the cord will cause a loss of sensation below the lesion (locomotor ataxia). Since the anterior and lateral columns carry only motor fibers, injury or disease of this part of the cord will cause paralysis below the lesion (myelitis). Fig. 53.—Lumbar section of spinal cord showing main tracts of white substance and location of principal groups of nerve-cells in gray matter: a. Anterior median fissure; b, posterior median fissure; c, anterior horn of gray matter; d, posterior horn of gray matter; e, central canal; /, anterior white commissure; g, posterior white commissure; h, i, anterior and posterior gray commissures; /, anterior median column; K, lateral column; L, posterior column; m, column of Clarke; n, inner group of nerve-cells; o, anterior group; p, anterolateral group; q, posterolateral group; r, lateral horn (Leroy). The Meninges.—The brain and spinal cord are cov- ered by three membranes: the dura, the arachnoid, and the pia. The dura is a thick, fibrous structure lining the cavities of the skull and spinal canal, dipping into the median fissure and separating the cerebellum from the cerebrum. It also forms the venous sinuses of the brain and surrounds NERVOUS DISEASES 205 the cranial nerves. The function of the dura is to act as a protection to the structure enclosed. The arachnoid is a serous membrane and is very similar to the pleura and the pericardium. It surrounds the brain and cord, and is reflected so that there are two surfaces between which there is a closed sack, con- taining the cerebrospinal fluid. The sack is continuous with the ventricles of the brain. This arrangement not only lubricates the slight movements of the cord and the brain, but permits the central nervous system to rest on a cushion of water, which annuls many shocks. The pia is a thin meshwork of blood-vessels. It closely surrounds the brain and the spinal cord, dipping into the fissures and ventricles, and is the main blood-supply of the cortex and cord. The cranial nerves are twelve in number: (1) olfac- tory, (2) optic, (3) motor oculi, (4) pathetic, (5) trifacial, (6) abducens, (7) facial, (8) auditory, (9) glossopharyn- geal, (10) pneumogastric, (n) spinal accessory, (12) hypoglossal. They supply the organs of the special senses, the structures of the face, the head and the neck, and, through the pneumogastric, the lungs, the heart, and the stomach. The spinal nerves consist of thirty-one pairs. They leave the spinal cord at various levels and carry motor fibers to, and sensory fibers from, the trunk and the upper and lower extremities. The nerves supplying the various structures of the above parts of the body are branches of the spinal nerves. The sympathetic nerves control involuntary actions and keep the different parts of the body working smoothly together (co-ordination). 206 DISEASES OF CHILDREN FOR NURSES TERMINOLOGY The disturbances of motion are paralysis, convulsions, choreiform movements, and tremors. Paralysis may involve one member only, and it is then termed monoplegia; a lateral half of the body, when it is termed hemiplegia; or it may involve the body from the waist down, when it is called paraplegia. A convulsion is a condition in which there are excessive muscular contractions, continued or intermittent, depen- dent upon the involuntary discharge of the motor impulses from the nerve centers. Intermittent contractions are termed clonic; continued contractions, tonic. Convulsions may be general or local. The term spasm is sometimes applied to the latter. Varieties of convulsions: Epileptiform, tetanic, and hysteroidal. Epileptiform convulsions are characterized by uncon- ciousness, and for the most part the movements are clonic. They are preceded by an aura, and the patients bite their tongues. Tetanic Convulsions.—In this form the discharges emanate from the spinal cord and the convulsive move- ments are continuous and not associated with uncon- ciousness. Hysteroidal convulsions are manifestations of hysteria, and in them consciousness is only partially or apparently lost. They are not preceded by an aura, but sometimes by a sensation as of a ball in the throat. The eyes are partially closed, the face expresses some emotion, the tongue is not bitten, the movements are tonic, or, if clonic, NERVOUS DISEASES 207 appear wilful. The paroxysm is of long duration and the patient frequently weeps or laughs. There are various local spasms, such as hiccough, croup, and laryngismus stridulus, etc. Choreiform movements are coarse, jerky, irregular, involuntary movements, which more or less simulate purposeful movements. Athetosis is the term applied to certain movements of the hands and feet in which there is a slow, twisting, interwinding, separation and extension of the fingers and toes. It is frequently observed in the cerebral palsies of children. Tremors are fine, vibratory movements due to the alternate contraction and relaxation of antagonistic groups of muscles. The knee-jerk is obtained by tapping the quadriceps tendon between its insertion and the patella while the legs are crossed. The value of the knee-jerk depends upon the mechanism of its production. This is called the reflex arc. It consists of the sensory nerve running from the patella tendon to the spinal cord, where it enters the reflex center. From this center the motor nerve runs to the muscle, causing it to contract. If the arc is broken by disease or injury to any one of its parts the knee-jerk is lost. When there is any irritating lesion of the cord the reflexes are increased. When there is any destructive lesion of the cord the arc is broken and the knee-jerks are absent. They are, therefore, a very important diagnostic symptom. Ankle clonus consists in a vibratory movement obtained by supporting the tendo Achillis with one hand while the foot is strongly flexed. 208 DISEASES OF CHILDREN FOR NURSES Babinski's reflex is obtained by tickling the sole of the foot; if there is an injury or disease of the central nervous system the great toe will move upward instead of downward, as it does normally. Sensation.—Anesthesia means loss of sensation. Hyperesthesia means exaggerated sensation. Paresthesia is used to indicate certain disagreeable sensations, such as numbness, tingling, itching, creeping, and feeling of "pins and needles." Arthropathies are degenerative changes of the joints. Coma is a condition of unconsciousness from which the patient cannot be aroused. Temporary unconsciousness due to anemia of the brain is termed syncope. Catalepsy is characterized by a peculiar stiffness of the muscles, and when this is overcome by force, the limbs can be placed in unnatural positions, which they retain for a long time. There may or may not be a loss of consciousness and sensation. PECULIARITIES OF DISEASE OF THE NERVOUS SYSTEM IN CHILDREN Owing to the immature development of the central nervous system, and to the great irritability of the per- ipheral or terminal sensory nerves, much more serious nervous symptoms are shown by children from trivial causes than are seen in adult life. The greatest factors in the cause of such conditions are stimulants, such as tea and coffee, and the fact that chil- dren live among exciting surroundings. Plenty of sleep and quiet are essential to the proper development of the nervous system. The effects of such conditions as infantile paralysis and birth palsies last through life. NERVOUS DISEASES 209 Hemorrhage of the brain is usually cortical, on the outside of the hemisphere, and not within its substance. Such diseases as chorea, tetany, and laryngospasm are typical childhood affections. Fig. 54. —Spina bifida (Eisendrath). Malformations.—Meningocele is a protrusion of the covering of the brain (meninges) through some abnormal opening in the skull or spinal canal. It contains cerebro- spinal fluid. When they are spinal in origin they are spoken of as spina bifida. Encephalocele is a protrusion of a portion of the meningus containing brain substance. Hydro-encephalocele contains both brain substance and fluid. Microcephalus is a name given to a small head due to under-development. t4 2IO DISEASES OF CHILDREN FOR A'URSES Hydrocephalus is an enlargement of the skull due to a large amount of cerebrospinal fluid within the ventricles. Other deformities are noted, such as absence of a whole or a part of the brain. Diseases of the Meninges MENINGITIS This term is applied to any inflammation of the mem- branes covering the brain and spinal cord. It may be acute or chronic, and occurs (i) as a complication of the infec- tious diseases, (2) following some local cause, and (3) epidemically. The epidemic variety is also spoken of as epidemic cere- brospinal meningitis or spotted fever, and is described on page 282. When the membranes covering the brain are involved it is called cerebral meningitis; when the spinal cord is the seat of the disease it is spinal meningitis; more often both the brain and spinal meninges are involved, and it is then spoken of as cerebrospinal meningitis. Pathology.—The membranes are serous in character, they surround the cranial nerves as they leave the brain, and the spinal nerves as they emerge from the cord. When a serous membrane is diseased it first becomes very red and inflamed, and later there is an exudate. The first stage produces intense irritation of all the sur- rounding tissues, hence in cerebral meningitis there is severe headache and involvement of the nerves of the spe- cial senses. This causes intolerance of sound and light. Later, when the exudate develops, it produces pressure, and instead of irritation there is paralysis of those parts supplied by the nerves subject to the pressure of the exu- NERVOUS DISEASES 211 date. Deafness and blindness are then found instead of the symptoms of irritation. In spinal meningitis, at first, there is present a spas- modic condition of the muscles due to the irritation of the spinal nerves, this is followed, after the exudate develops, by paralysis due to the pressure. When both the cerebral and spinal meninges are involved we have a combination of the above symptoms. Acute meningitis is most often caused by the diplococcus of pneumonia, by infection from a suppurating wound, by the bacilli of the infectious fevers, by traumatism, and especially by the tubercle bacillus. The prognosis of all forms of meningitis is very grave. The non-tubercular varieties occasionally recover. Tuber- cular meningitis is invariably fatal. In the epidemic variety, Flexner's serum has given wonderful results. The picture of a case of meningitis is complete in the tubercular variety, and only that form will be given here. Tubercular meningitis (cerebral) is an acute inflam- mation of the cerebral meninges excited by the tubercle bacillus. In children the disease may be primary or secondary to a focus of tuberculosis in some other part of the body. The majority of cases are seen between the second and fifth year. The basilar meninges covering the lower part of the brain are especially involved. The pons, crura, and medulla are covered with lymph which mats together in a common mass the adjacent nerves and blood-vessels. The fluid within the ventricles of the brain is increased. Symptoms.—The disease usually begins insidiously with dulness and irritability on the part of the child. 212 DISEASES OF CHILDREN FOR NURSES Sleep is disturbed. The child twitches, grinds its teeth, and starts up with a cry of alarm. When the disease is Fig. 55. —Kernig's sign. The thigh is held at right angles to the body. When an attempt is made to extend the leg, bringing it into a line with' the thigh, there is either marked resistance or an inability to extend the leg, if meningitis is present (Kerr). fully developed headache is intense and causes a shrill scream, known as the hydrocephalic cry. The special senses are extremely acute, bright lights and noises cannot be tolerated; the child becomes irritable when touched. The temperature ranges between 102 ° F. and 103 ° F. The pulse is rapid at first, but later is slow and irregular. The walls of the abdomen are flat. The child lies on its side with the limbs drawn up, the head is bent far back, the fingers are clenched over the thumbs which are turned into the palm of the hand. This is called opisthotonos. Convulsions are common and may be local or general. Toward the* close of the stage the child becomes delirious. When the exudate is of sufficient amount to exert pressure, paralysis develops, especially in the muscles of the face. Coma follows the delirium, the eyes are rolled up, and NERVOUS DISEASES 213 blindness and deafness result. If the finger is drawn across the body a bright red line develops and remains Fig. 56-—Method of introducing needle in lumbar puncture: Child in lying posture (Boston). for some moments; this is called a tache. In the last stage the pulse becomes weak, rapid, and irregular; respirations assume the Cheyne-Stokes characteristics, and the tem- perature falls. The duration is from one to three weeks. Kernig's Sign.—The inability to straighten out the leg when the thigh is bent upon the abdomen. It is present in cases of cerebral meningitis. Lumbar Puncture.—During the course of the disease the physician may find it necessary to relieve the tension in the spinal canal, or he may desire to obtain fluid for diag- nostic purposes. He then will tap the spinal canal by the lumbar puncture method. In preparing for this pro- cedure the skin over the lumbar portion of the spine must be scrupulously sterilized and every aseptic precaution must be absolute. The child is usually held in the posi- tion as shown in Fig. 56 The method consists in inserting a long hypodermic needle between the vertebrae and through 214 DISEASES OF CHILDREN FOR NURSES the membrane; as soon as it enters the spinal canal the cerebrospinal fluid runs out of the needle. Several sterile test-tubes should be in readiness to catch the fluid. When they are filled, plug them with aseptic cotton. The wound in the skin is usually closed with adhesive plaster or a collodion dressing. Diseases of the Brain In diseases of the brain the centers for the various functions, such as motion, sensation, speech, hearing, seeing, smelling, and hearing, are interfered with. The pathways leading from the centers may be involved as they traverse the brain on their way to the spinal cord. Diseases of the brain are usually diagnosed by what are termed pressure symptoms, produced by clots, tumors, abscesses, cysts, etc. The minute anatomy of the brain is almost as well known as that of the spinal cord. The brain centers are definitely located and the direction of the pathways of the fibers from these centers is known. Therefore, it is possible to locate accurately a lesion of the brain, either a tumor, cyst, abscess, or morbid growth, from the pressure-symptoms which they produce. Areas of sclerosis and hemorrhage, destroying or impairing the centers and nerves or the tracts from the centers are determined in the same manner. A lesion in a definite part of the brain will involve certain centers and nerves which will produce paralysis of the parts supplied by those nerves. Thus, if there is a hemor- rhage or a tumor pressing on what is known as Broca's area in the brain, which is the speech center, there will be impairment or loss of the function of speech. If this NERVOUS DISEASES 215 symptom is present with other symptoms of cerebral involvement, such as persistant headache or unconscious- ness, choked disk (a condition of the eye), and paralysis of other parts of the body, there is a tumor involving Broca's area. A more accurate diagnosis than this can be made. The position of the motor areas around the fissures of Rolando are "upside clown," the leg area above, the arm in the center, and the face below. The first symptoms of irri- tation to nervous structures are convulsions. Convulsions due to brain irritation of the motor areas are characteristic. They begin in the part that, corresponds to that portion of the brain which is irritated. If the irritation is in the hand area of the motor region the convulsion will start in the hand, gradually extend up the arm, and then become general. This form of convulsion is termed Jacksonian epilepsy. A finer distinction than locating the lesion in the hand area can be made. If the positions in the different areas in the motor region are known, by watching this convulsion which starts in the hand, and by noting what parts are successively involved, the extent and direction of the convulsion can be determined. If, after the convulsive movements reach the shoulder, they involve the corner of the mouth it is plain that the lesion in the brain extends downward. If, on the other hand, the leg is the next part to become involved the lesion extends upward. This will impress the nurse with the necessity of observing a convulsion carefully so that the diagnosis can be accurately made, for brain surgery demands accuracy, and as so many lesions of the brain can be treated only by surgical means, its importance can be appreciated. 2l6 DISEASES OF CHILDREN FOR NURSES A nurse will be able to observe convulsions more closely than anybody else; therefore, she should note the kind of convulsion, whether tonic or clonic, where it begins, what parts are successively involved, in which direction the eyes and head turn, for in destructive lesions the head and eyes are usually turned toward the side of the lesion of the brain, and in irritating lesions to the opposite side. Also note what parts of the face are involved, as the nerves supplying the face emerge from the skull at different levels. A lesion at one level might involve a nerve after it had crossed, giving a paralysis on the same side as the lesion instead of the opposite, as is the rule, producing the so- called crossed paralysis; while at another level it may be affected before it has decussated, giving a paralysis on the opposite side of the face. This knowledge gives aid in the determination of the level of the lesion. Also note whether the eyelids are drooped and whether the patient is conscious or unconscious. CONVULSIONS Convulsions occur frequently in childhood. They are due to direct irritation of the cortex or to reflex irritation. The poisons generated by the acute infectious diseases may so irritate the cortex that convulsions occur during the course of these diseases. Convulsions often usher in an attack of illness in children. Reflexly, indigestion, teething, and other trivial causes at times produce general convulsions. This is due to the instability of the nervous system at this early stage. Treatment.—A mustard tub, temperature no° F., for five minutes is the best method to employ (see page 466). The tongue should be protected by inserting some- thing between the teeth and an enema given immediately. NERVOUS DISEASES 217 CEREBRAL PARALYSIS Birth palsy in children is not uncommon. It is caused by a hemorrhage upon the cortex of the brain, rarely within the brain substance. The hemorrhage usually occurs during the birth of the child. The resulting paralysis may be a hemiplegia, half of the body being involved. Contractures occur and the children are usually mentally deficient and crippled. Fig. 57.—Hydrocephalus: Side view. (Kerr.) Cerebral paralysis may occur after birth, in which case the same symptoms are found. Encephalitis Lethargica (Sleeping Sickness).—A dis- ease which has lately made its appearance in the United States, and which has as its most characteristic symptom profound lethargy. 2l8 DISEASES OF CHILDREN FOR NURSES There is at first an irresistible desire for sleep, which later becomes so profound that the patients can only be aroused at intervals. There is also a marked tendency to ptosis (drooping) of the upper eyelids. This state may last for weeks. So far it has been very fatal in its results, and the cause is undiscovered. It is necessary to main- tain the nourishment of these children by various meth- ods, as in all unconscious states. By many authorities it is thought to be a sequel of influenza. Apoplexy is the term applied to a hemorrhage in the brain. Thrombosis of the sinuses of the dura occurs at times, most frequently after an operation upon the mastoid cells. Abscess and tumors are rare in childhood. They cause pressure symptoms. The most common tumors are tubercular in character. Hydrocephalus is a condition in which there is excessive fluid in the ventricles or in the arachnoid cavities. It gives to the head a peculiar shape. It is large and round, the sutures and fontanels are enlarged, the convolutions of the brain are flattened, and usually there is imbecility. Deaf-mutism is due to congenital or early loss of hearing. As the child has never heard spoken words he is unable to imitate the proper sounds. It may also develop in children who have begun to talk, but in whom the deafness occurs at such an early age that they soon lose the memory of what they have accomplished. Aphasia is a failure of word memory, an inability to utter words, to comprehend them, or to write them. Disorders of Speech.—Stuttering or stammering and lisping are the most common. Disorders of sleep, such as night terrors, are common. NERVOUS DISEASES 219 The children awake from sleep with a cry of terror: they fail to recognize those around them, and they exhibit symptoms of fright. IDIOCY A condition in which there is a failure in the normal development of the mind. It has been defined as a mental feebleness, depending upon a disease or defect of the brain, congenital or ac- quired during its development, which has arrested the growth of the mental powers; while insanity is the disease of the mind previously sound, coming on after mental power has been fairly well attained (Peterson). The usual classification employed to designate the various degrees of mental deficiency recognizes in order: (1) The moron, but little separated from the normal individual. (2) Imbecility, in which a high and low grade are found, the latter being the worse of the two. (3) Idiocy, which shows numerous types: {a) The paralytic, dependent upon some lesion produc- ing infantile cerebral paralysis. {b) The Mongolian, with the protruding tongue and Mongolian cast to the eyes. {c) The microcephalic, the most striking anatomic fea- ture is the remarkable smallness of the skull. {d) The hydrocephalic, due to the pressure of the fluid in this disease. (e) The epileptic, of slow development, usually does not appear before puberty, in those who suffer with epileptic mental disturbances of a more active form. (/") Amaurotic Family Idiocy.—Usually seen in He- 220 DISEASES OF CHILDREN FOR NURSES brew children, often several in a family are subject to it, and the children are blind. (g) Idiot-savants.—This includes a class of idiots who may have remarkable aptitude in certain limited directions, yet the individual is not above a condition of feeble-mindedness (moron), or even imbecility, in all other directions. In addition, there are a large number of idiots belong- ing to no definite type. The cretin is an idiot due to disease of the thyroid gland, who can be cured. There are many degrees of backwardness in children which can be remedied, which are not considered as feeble-mind edness. EPILEPSY The disease apparently depends upon the instability of the motor centers, so that from trivial exciting causes violent discharges occur from time to time. The disease is divided into grand mat and petit mat. Symptoms.—Grand Mai.—A peculiar sensation called an aura sweeps like a wave over the child. This is followed by unconsciousness and violent general con- vulsions, clonic in type. The child bites its tongue and froths at the mouth. The convulsion lasts for a few minutes and is followed by coma and later by automatism, in which the child performs certain automatic acts. Convulsions occur at varying intervals, showing a tendency to increase in number and severity. Petit mal is exhibited by momentary loss of conscious- ness with pallor, without convulsive movements. Treatment.—For the Attack.—This consists in measures to prevent the children from injuring themselves. Some- thing should be placed in the mouth to prevent biting of NERVOUS DISEASES 221 the tongue; further than this nothing can be done. If they should show any vicious traits after a convulsion, they should be carefully watched, as they are not responsible. Prophylaxis.—Nitrite of amyl inhalations will at times ward off an attack. At times a salt-free diet may be ordered. HYSTERIA Hysteria is a functional disease of the nervous system associated with impaired will power and increased sensi- tiveness to impressions. Hysteric children are ill and should be treated accordingly. The disease is very rare in childhood before the seventh or eighth year, and most cases appear after the tenth year. Etiology.-—The children most affected are those who have inherited a nervous disposition, or in whose parents insanity, hysteria, or alcoholism have been present. The chief exciting causes are those which lead to a highly nervous condition in children whose general nutri- tion is faulty, such as anemia, chlorosis, or overpressure at school. It may follow the infectious diseases, or result from an injury, fright, or imitation. Symptoms.—These vary so that it is hard to classify them in any definite form. Psychic symptoms usually predominate. The children may have periods of mental depression, indifference to surroundings, a change in disposition, or periods of weeping and laughing without cause. Fits of temper, hallucinations, disturbances of sleep, and a development of a tendency to deception. Older children may actually simulate symptoms of various diseases, which they may have witnessed or about which they have read. Sensory Symptoms.—There may be areas of the body which become highly sensitive (hyperesthesia), so as to 222 DISEASES OF CHILDREN FOR NURSES simulate inflammation of the various organs. More rarely areas develop of lost sensation (anesthesia). In addition, there may be headache with great tenderness of the scalp, neuralgias of different parts of the body, severe pains in the stomach, sometimes accompanied with vomiting, deafness, and blindness, usually of short dura- tion. Joint Symptoms—AW. forms of organic disease of the joints may be simulated. The symptoms are most often referred to the spine and the large joints of the lower extremities. They may develop deformities. Motor Symptoms.-—Many varieties of spasm are seen. These may affect the eyes, face, mouth, neck, or respira- tion. Hiccup and cough may be severe. General hysteric convulsions may be observed, though these are rare in childhood. In these convulsions consciousness is not fully lost and hallucinations are present. Hysteric paralysis is not common in children. Nursing.—The best results are obtained by placing the child in a quiet retreat in charge of an intelligent nurse. Every means should be taken to encourage muscular development, keeping the nervous system in the back- ground. They should lead an outdoor life, keep early hours, have regular exercise; their education should be mapped out so as to avoid overpressure. Theaters and exciting books should be avoided. The diet should be plain, and all stimulants, including tea and coffee, forbidden. The nurse should be firm and kind, but must avoid sympathy. Massage and hydrotherapy may be ordered by the physician. NERVOUS DISEASES 223 SPASMOPHILIA Under this term various spasmodic affections of child- hood are grouped in which there is a peculiar tendency to convulsive disorders. The disturbance is a functional one, based upon no known pathologic lesion, and ap- parently not connected with the imperfect development of the nervous system characteristic of all children in early life. The chief affections of this group are laryngo- spasms, chorea, tetany and the various tics, and habit spasms. LARYNGISMUS STRIDULUS Laryngismus stridulus, also called child crowing, is purely of nervous origin (a neurosis), and does not depend upon a catarrhal condition of the larynx, like spasmodic croup. It is due to a complete spasmodic closure of the larynx, making it impossible, for a time, for the child to breathe at all. The spasm then relaxes and the air is drawn through the contracted larynx with a shrill, crowing sound. It is seen in children of a rachitic tendency between the ages of six and eighteen months and seems to be more common in males than females. The attacks are frequently seen in children who have been closely confined in warm, stuffy rooms, and are often associated with enlarged tonsils and adenoids. The attack may be excited by a sudden draught of cold air, or, reflexly, from teething and gastro-intestinal disorders. Symptoms.—The child may have a few mild attacks during the day or extending over a period of several days. This condition is very often confounded with whooping- cough, the "crowing" of the mild attacks closely simu- lating the whoop of pertussis. When the attack is fully developed the child is awakened from sleep by a sudden arrest of the breathing and a tonic 224 DISEASES OF CHILDREN FOR NURSES spasm of the muscles. (Tonic spasms are continuous spasms in which the patient remains rigid until the spasm relaxes.) The face is at first pale and later bluish, the neck rigid, the eyes rolled up, the body arched, the thumbs turned into the palms of the hands, the legs extended, and there is a complete absence of breathing. In about fifteen or twenty seconds the spasm relaxes and the air is drawn through the larynx with a shrill, crowing sound. At times the spasm is longer, and in a few instances asphyxia has resulted before it has relaxed. Several such attacks may occur on the same night, and, gradually decreasing in severity, they may extend over a period of one to two weeks unless proper medicinal measures are instituted. To distinguish this affection from spasmodic croup remember that in laryngismus stridulus there is no croupy cough, hoarseness, or fever, but there is present a tonic spasm and the peculiar crowing sound. Treatment and Prophylaxis.—Fresh air and cold sponging unless the shock of the sponging frightens the child into an attack; the rachitis should be treated, hy- per trophied tonsils and adenoids should be removed, and gastro-intestinal disorders corrected. For the attack the best treatment is to dash cold water on the face and neck, in an attempt to break the spasm. Mustard tubs (no° F.) may be resorted to, and inhala- tions of chloroform in severe cases. At times it is neces- sary to perform intubation. HOLDING-BREATH SPELLS This condition begins in early infancy and may con- tinue until the child is four or five years old. It is of nervous origin and in susceptible children tem- per or fright may precipitate an attack. It occurs while NERVOUS DISEASES 225 the child is crying, when it suddenly holds its breath until its face becomes livid, the trunk and extremities are rigid, and there may be convulsive twitchings. The rigidity is followed by complete relaxation and often loss of consciousness. The entire attack usually lasts about one-half minute. There may be a crowing sound as the child catches its breath. After a few minutes of quiet the child ap- parently is as well as ever. While these attacks are alarming, they never seem to be followed by any serious complications, and as the child gets older they gradually cease. Treatment consists in the adoption of measures to break the attack, and the same methods should be fol- lowed as described under laryngismus stridulus. Arti- ficial respiration is useful, for after the child is breathing normally recovery is quick. CHOREA (ST. VITUS' DANCE) A nervous affection especially common in childhood, and characterized by irregular movements which increase under excitement and cease during sleep. The first manifestations are usually those of awkward- ness in movement, and restlessness. These grow worse until the disease is fully advanced, when there are peculiar jerking, disorderly movements of the various members of the body or involvement of the whole body. The move- ment may be so marked that the child cannot use its arms in eating, it stumbles when walking, and grotesque expressions are produced from the involvement of the face. Involvement of the larynx causes stammering, in- volvement of the muscles of the pharynx causes chokmg 15 226 DISEASES OF CHILDREN FOR NURSES fits and difficulty in swallowing, involvement of the tongue causes its withdrawal to be associated with an audible click. When the child's attention is called to the move- ments they invariably become worse. Frequently a heart murmur develops. The disease lasts from six to ten weeks. Prognosis is good. Occasionally there are deaths from exhaustion. Children suffering from chorea should be immediately taken from school and not allowed to return for several weeks after recovery. TETANY A tonic spasm of the muscles of the extremities. It Fig. 58. —Persistent form of tetany in a girl a year and a half old. Tetanic con- tractures of the arms and legs; hands in the "obstetric" position; feet in plantar flexion (Hecker, Trumpp, and Abt). gives rise to a peculiar position of the hand called the obstetric hand, in which the fingers are slightly bent, the thumb held almost at a right angle across the palm, and the whole hand is slightly everted. This spasm lasts for a variable length of time and can be excited by making pressure upon the nerve trunks and blood-vessels of the extremities (Trousseau's sign). The disease is usually associated with laryngismus strid- ulus and recovery nearly always takes place. NERVOUS DISEASES 227 HABIT SPASM A peculiar form of spasm caused by habitual grimaces or movements of the head, finally becoming uncontrol- lable. This condition is also called tic. NYSTAGMUS * A constant movement of the eyes. It may be lateral, horizontal, or rotary. NODDING SPASM OR SPASMUS GYRANS A peculiar form of movement seen in children charac- terized by a continuous nodding of the head. It is asso- ciated with nystagmus. Recovery usually takes place in a month or two. INJURIOUS HABITS Sucking, nail-biting, head-banging, masturbation, in- ordinate appetites for various substances, such as dirt, hair, and threads, are all practices which are injurious and should be controlled immediately. The longer the habit has lasted, the more difficult it is to break. Diseases of the Spinal Cord The functions of the different columns of the spinal cord are: The anterior and lateral columns—motor; the posterior columns—sensory; the anterior horns of gray matter—trophic and motor. MYELITIS Myelitis is an inflammation of a segment of the cord involving the anterior, lateral, and posterior columns and the gray matter. Symptoms.—At first there is irritation, producing pain and fever. The pain is a peculiar one, called a girdle pain. The reflexes are increased; there are pares- 228 DISEASES OF CHILDREN FOR NURSES thesias and convulsive movements. Later, when the inflammatory product becomes sufficient to produce pressure, there is a loss of sensation instead of pain and paresthesias. The reflexes are lost, there is paralysis instead of convulsions, and there is degeneration of the muscles and bed-sores. SCLEROSIS Sclerosis is an atrophy of the structure of the part affected with an overgrowth of connective tissue. Sclerosis in the spinal cord is an atrophy of the nerve elements and an overgrowth of the neurilemma (the connective tissue of the cord). Lateral sclerosis is the term applied when this degen- eration attacks the lateral columns of the cord. This disease does not affect the sensory fibers; the main motor fibers which run through the anterior columns are intact and there are no trophic disturbances. Symptoms.—Exaggerated knee-jerks, ankle-clonus, and a spastic gait, sometimes spoken of as scissors gait. Acute Anterior Poliomyelitis or Infantile Paralysis. —This is an acute disease which occurs almost exclu- sively in young children, and is characterized by the destruction of nerve-cells in the brain and spinal cord, es- pecially in the anterior horns of gray matter. Since 1907 epidemics of infantile paralysis have been prevalent in Europe and the United States. Flexner and Lewis in their epoch-making studies having proved it to be an infectious and probably a contagious disease. The virus of infection most probably gains access to the central nervous system through absorption from the mucous membrane of the nose and throat, from whence it is carried by the lymphatics through the cribriform plate of the NERVOUS DISEASES 229 ethmoid bone directly into the cranial cavity. The poison is likewise thrown off from the same mucous membrane by a reversed process of elimination. Symptoms.—The paralysis comes on very suddenly. The child goes to bed well and the following morning he Fig. 59.—Scissors gait in a girl two years old (Friihwald and Westcott). cannot move his legs or, at times, his arms. Certain groups of muscles in the upper and lower extremities are involved, chiefly the latter. The paralysis at first is wide- spread, but tends to improve up to a certain point, where it remains stationary. The muscles affected atrophy, and 230 DISEASES OF CHILDREN FOR NURSES the usefulness of the limb is obtained by an overdevelop- ment of other muscles which perform the function of the muscles which have been destroyed to a limited degree. Treatment.—The nose and throat, being the principal points of infection, should be thoroughly douched with antiseptic solutions containing hydrogen peroxid and menthol. This not only applies to the children attacked, but to all children when the disease is epidemic. Fig. 60. —Spinal infantile paralysis in the stage of fully developed palsy. Three-year- old girl (F. Lange). Flexner urges with emphasis that this should be thoroughly done. All nasal discharges should be dis- infected and destroyed. Adults in contact with the case should use the same precautions. It must also be recognized that this infection may last for some time in the affected child, when he may act as a "carrier," so the antiseptic precautions should be continued over a period of several months. In epidemics of the disease it is well to quarantine the case for one month. The most important measure at the onset of the attack NERVOUS DISEASES 231 is to secure complete rest. Urotropin, in rather large doses, is the drug usually given. The reason it is used is on account of the failure of animals to develop paralysis in many instances when the drug is given simultaneously with or shortly after the injection of the virus. After all acute symptoms have subsided, or at the end of two or three weeks, the nurse may be called upon to give electricity, friction rubs, massage, and manipula- tions to improve the circulation and nutrition of the limb, and they should be faithfully continued twice a day for a long period. The paralyzed children often have to undergo ortho- pedic operation upon tendons and joints, and they fre- quently have to wear braces. Syringomyelia is a disease of the spinal cord in which there is a cavity in the cord. Landry's paralysis is an ascending form of paralysis beginning in the legs and rapidly involving the entire body. Friedreich's ataxia is a form of sclerosis of the spinal cord which develops in childhood and lasts from twenty to thirty years. Atrophies of the muscles of different parts of the body are seen, due to disease of the spinal cord. Diseases of the Nerves NEURITIS Neuritis is an inflammation of a nerve, and is character- ized by pain and tenderness along the course of the nerve. It is associated with various forms of paresthesias. The part supplied by the nerve is at first hyperesthetic, later anesthetic. In severe inflammations paralysis of the part supplied by the nerve develops. 232 DISEASES OF CHILDREN FOR NURSES Sciatica is inflammation of the sciatic nerve character- ized by the above symptoms along its course in the pos- terior part of the thigh. It is worse at night and at the approach of stormy weather. Multiple neuritis is an inflammation of a number of Li... - "i. l.....».>. »-• ■. /o<; tot A -K- 10* A /\ A A /oz f\ A / , \ L ^\ i 101 ! \J f \ \ V 1 J \ 100 V V v \ 99 98 -1 Fig. 88.—Represents the remittent type. This is suggestive of one form of malaria, of tuberculosis (not acute), and suppuration (Kerr). influenced by the susceptibility of the patient and the virulence of the infection. For the following diseases the average period is: Typhoid fever—two to three weeks. 2So DISEASES OF CHILDREN FOR NURSES Measles—two weeks. Rotheln (German measles)—ten to twelve days. Scarlatina—a few hours to a week. Smallpox—one to two weeks. F E M. £ M E. M. E. M F. M. £ M. E. M EM 106 105 1 10/r I 1 /03 f J /oz / I , 101 / \ /oo / \ y? / \ 98 L. J J S~ IX Fig. 89.—Represents intermittent fever. The left hand half showing the quotidian type while the right hand half shows the tertian type. It is significant of malaria (Kerr). Erysipelas—three to seven days. Diphtheria—two to ten days. Varicella—ten to fifteen days. F E. M. E M. £■ M E M £ At. £ M. £. M £. M 106 /OS 10/f A A 103 A A A A /OZ n 1 n L n \ L 101 ' \ \i ! \l \ 100 / V V V \ 99 1 98 Fig. 90.— Represents a hectic and suppurative fever type, which is generally accompanied with sweating (Kerr). Tetanus—a few days to two weeks. Mumps—two to three weeks. The date when rashes appear in various diseases is as follows: THE INFECTIOUS FEVERS 281 Typhoid fever—seventh to ninth day. Smallpox—third or fourth day. Measles—third or fourth day. Scarlatina—first or second day. Rotheln—first or second day. Varicella—first day. Protection from future attacks conferred by various diseases is as follows: Typhoid fever—relapses are common; second attack are sometimes seen. Measles—second attacks rare. What are supposed to be second attacks are usually rotheln. Rotheln—second attacks rare. Smallpox—second attacks occasionally occur. Mumps—second attacks rare. The following diseases do not confer immunity. Erysipelas, diphtheria, malaria, influenza, and croupous pneumonia. An infectious disease means one due to a specific micro- organism. A contagious disease is one which can be communicated by actual contact, either through the person or by infected clothing. A complication is a condition occurring in the course of a disease. A sequel appears after the attack. Method of Dissemination,—The chief source of infec- tion is close contact with or proximity to the patient himself, the disease being given to others before it is recognized and the individual isolated, or given after quarantine has been removed and the patient believed to be well. Often the infection has been so mild that it has 282 DISEASES OF CHILDREN FOR NURSES not been recognized at all, and the child has remained an undiscovered source of infection. Carriers also are a source of infection. These are per- sons who have recovered from the disease, but still carry active infectious germs upon their mucous membranes, or another class who have not suffered, but who have been in close contact with patients, and who carry the germs on their mucous membranes. Certain diseases are transmitted by dust (tuberculosis), water (typhoid), and insects (malaria and yellow fever). CEREBROSPINAL FEVER This disease is also called spotted fever and epidemic cerebrospinal meningitis. . It is a specific infectious disease characterized by inflammation of the cerebrospinal men- inges (the membranes covering the brain and spinal cord) Fig. 91.—Cerebrospinal meningitis: Tache cer^brale shown on left thigh (Ruhrah), and usually occurs in the winter and spring. The young are more susceptible than the old. The disease is now considered to be contagious. It is caused by a diplococcus. The mucous membrane lining the nose and pharynx is the portal of entry and dissemination of the disease. THE INFECTIOUS FEVERS 283 Symptoms.—Common Form.—The disease generally begins abruptly with a chill followed by vomiting and excruciating pain in the head, back, and limbs. The muscles of the head, neck, and back become rigid and contracted so that the head is bent backward and the back is straightened. In severe cases the body may be arched in a state of opisthotonos. The mind is soon affected, delirium is rarely absent, and in severe cases it is followed by stupor and coma. At first there is intense irritation of the whole nervous system, headache is severe and continuous, twitching of the muscles and actual convulsions are common, all the special senses are extremely acute, and there is pain on the slight- est movement, which often causes the child to cry out shrilly. Later, when the exudate becomes of sufficient amount to exert pressure, paralysis develops; it may be localized, effect one side of the body, or one extremity. Blindness and deafness, disturbed speech, and mental defects are found in the protracted cases. When the finger is drawn over the skin a red line develops; this is called the tdche cerebrate (see Fig. 91). The temperature is irregular and indefinite in duration; ordinarily it ranges between 1010 to 103 ° F. In some cases it is almost normal, while in others it is very high. The pulse is rapid and full, the bowels constipated, and there may be polyuria. The eruption is neither constant nor peculiar. In many cases a blotchy, purpuric rash appears over the entire body. Herpes facialis (fever blisters) are also fre- quently observed. In other cases urticaria or a roseolar or erythematous rash appears. The duration ranges from a few hours to several weeks. 284 DISEASES OF CHILDREN FOR NURSES Treatment.—Within the past few years this dreaded disease has been frequently cured by means of a serum brought to the attention of the world through the work of Flexner and his associates at the Rockefeller Institute in New York. The disease is isolated in most cities under the Board of Health rules. Nursing.—In nursing the disease follows the same routine described under contagious cases (see page 334). Take every antiseptic precaution and spray the nose and throat frequently with some germicide. If a lumbar puncture is made by the physician, several sterile test-tubes properly stoppered with sterile cotton should be ready to receive the fluid. (For a description of Lumbar Puncture, see page 213.) Flexner's serum should be kept on ice before use. At the time it is to be injected the bottle should be placed for five minutes in water at a temperature of 100 ° F. Do not use boiling water, as it coagulates the serum. When the bottle is opened its edge and neck should be thoroughly wiped with sterile gauze. The physician will introduce a hypodermic needle into the spinal canal, as in making a lumbar puncture. He will then fill the syringe, express all the air, and while a drop or two of the fluid is running from the syringe, attach it to the needle. For this reason it is better to have a needle which fits on the syringe, rather than one which screws on. This care is taken to avoid the introduction of air into the spinal canal. He will then inject the fluid very slowly. When the needle is withdrawn, adhesive plaster or a collodion dressing must be at hand to seal the wound. The child should be prepared for this minor operation in THE INFECTIOUS FEVERS 285 the same way as for a lumbar puncture. The syringe must be absolutely sterile. Injections are usually given every twenty-four hours. The injection of the serum may cause urticaria similar to that seen following the use of antidiphtheric serum. MALARIAL FEVER This is a specific non-contagious disease caused by the hematozoa of Laveran. It is characterized by splenic enlargement, by fever with periodic intermissions or re- missions, and by a tendency to extreme anemia. Fig. 92.—Some of the principal forms assumed by the Plasmodium of tertian fever in the course of its cycle of development (after Thayer and Hewetson). Etiology.—The exciting cause is the hematozoa of Laveran, and the mode of infection is by the bite of a mosquito which has previously sucked the blood of a malarial patient. All ages, from the newborn to the aged, are subject to malaria. Manifestations.—Malaria may manifest itself as in- termittent fever; remittent fever, or chronic malarial cachexia- Pathology.—The Hematozoa.—A small, colorless ame- boid body enters the red blood-corpuscles, increases in 286 DISEASES OF CHILDREN FOR NURSES size, and becomes pigmented from the coloring-matter of the corpuscles. When the red blood-corpuscle is destroyed the granules of pigment collect in the center of the organ- ism, which finally divides into a number of small hyaline bodies, each of which begins a new cycle of existence. The chills or paroxysms occur at the time these small leinf}. / m. e. z M £-. 3 M-E M-E s M-E. 6 M.E. V 8 M.£ 9 ME /O M.E // M.E /Z M.E. 108 /07 10b /OS 11 /O^r 1 103 1 /oz 101 . 100 99 L A , ) A I A 9$ ' N vA 1/ ' \_ ■J xv j > \/~ ■V 1 \ Fig. 93-—Tertian type of malarial fever. Male child of six years. Quinin begun at X (Kerr). bodies are thrown into the blood current after the blood- cells are destroyed, and are due to the production of a poison. The parasite of tertian intermittent fever requires forty-eight hours to complete its cycle of existence; there- fore, when a single group of these parasites exist in the blood a paroxysm occurs every other day. If, however, two groups co-exist and sporulate (the term given to the time when the organisms are thrown into the blood-cur- rent) on alternate days, a paroxysm occurs daily (quotidian intermittent fever). The parasite of the quartan intermittent fever requires seventy-two hours in which to develop and undergo THE INFECTIOUS FEVERS 287 sporulation; hence, a single group of these organisms in the blood excites a chill on every fourth day. When two groups co-exist a chill occurs on two successive days and is followed by daily intermission. When three groups co-exist a chill occurs every day and there is quotidian intermittent fever again. The life-history of the parasite of remittent fever within the body is not definitely known. Its cycle of existence occupies from twenty-four to forty- eight hours. In advanced malaria the blood shows a diminished uumber of red blood-corpuscles and a large quantity of free pigment. The spleen is greatly swollen and deeply pigmented. All the organs, including the brain, are discolored by this free pigment. Intermittent Malarial Fever.—Symptoms.—The char- acteristic features of this form of malaria are the intermit- tent type of fever, the enlargement of the spleen, the hematozoa in the blood, and the occurrence at regular intervals of the paroxysms divided into three stages— the chill, the fever, and the sweat. Cold Stage.—There is malaise, headache, and great chilliness. The features are pinched, the lips are blue, and the surface of the body is cold and covered with "goose flesh." The rectal temperature is high—1040 F. to 105 ° F. Vomiting may occur. The chill lasts from a few minutes to an hour or two. Hot Stage.—The surface temperature gradually rises, the skin becomes hot, the face flushed, the eyes injected, and the pulse rapid and full. The temperature in the axilla may reach 1060 F. to 107° F. The child complains of severe pain in the head, back, and limbs, and of thirst. 288 DISEASES OF CHILDREN FOR NURSES The urine is scanty and dark colored. This stage usually lasts from one to five hours. Sweating Stage.—The fever gradually subsides, the pain grows less, free perspiration follows, and the child falls asleep from which he awakens feeling fairly well. Varieties.—When the disease occurs every day it is termed quotidian intermittent fever; every other day, tertian intermittent; every fourth day, quartan intermittent fever. Prognosis.—Always favorable. Even when no treat- ment is instituted the paroxysms gradually subside. Chronic malarial cachexia may develop. Remittent Malarial Fever or Estivo-autumnal Fever.—In temperate zones remittent fever is observed chiefly in the autumn. It is uncommon in children who live outside of malarial districts. Symptoms.—There is malaise with moderate chilliness followed by a continuous fever which daily remits. The maximum temperature ranges from 103 ° F. to 1060 F., and while this lasts the skin is hot, the face flushed, the eyes injected, the pulse full and strong, the urine scanty, and the patient complains of pain in the head, back, and limbs. Definite paroxysms may or may not be present. Delirium is sometimes noted, vomiting often occurs, and jaundice may appear from the destruction of the red blood- corpuscles and the liberation of their pigment. The spleen is enlarged and the hematozoa are found in the blood. Prognosis.—Favorable. The average duration is from one to three weeks. Chronic malarial cachexia is characterized by anemia, a sallow appearance to the skin, and splenic enlargement. Etiology.—It may result from repeated acute attacks of THE INFECTIOUS FEVERS 289 the disease or it may develop as a primary condition from slow infection. Symptoms.—The child is thin and pale, the complexion is of a dirty yellow or muddy hue, fever is often absent or if present, it is slight and irregular. The spleen is con- siderably enlarged. There is great weakness from the attending anemia. Headache and neuralgia are common symptoms. Hematuria is sometimes observed. Prognosis.—Guarded. With the spleen very large and extreme anemia the patients rarely recover. Malarial infection seems to predispose to certain cases of dys- entery, pneumonia, and amyloid degeneration of the viscera. Treatment.—As malarial fever is contracted by means of infection through mosquito bites, proper measures should be taken to protect children from the mosquitoes. Just as great care should be taken to prevent mosquitoes from biting children who have malaria, and in this way prevent- ing the spread of the disease. Quinin is a specific rem- edy, killing the hematozoa. The dose is from 5 to 10 gr. a day in divided doses (four years), and in ordinary cases in older children is from 15 to 20 gr. a day in divided doses. The drug is given so that the last dose is taken two hours before the expected chill. The cold stage is treated with hot-water bottles and blankets, and the hot stage by sponging. SYPHILIS Syphilis is a communicable disease and may be ac- quired or hereditary. It is caused by the spirochaeta pallida. Syphilis is acquired usually from the mother of the child or from syphilitic wet-nurses. It follows the same course 19 29O DISEASES OF CHILDREN FOR NURSES as syphilis in the adult and is divided into three stages: The first is characterized by a chancre, the second by a rash, and the third by a bone lesion and ulcerations. It is now considered contagious in all stages, but especially in the second stage. Hereditary syphilis is more common. When born the Fig. 94.—Hereditary syphilis: radiating fissures of the lips (after A. Fruhinsholz). child at times has large blebs on the skin surfaces and scars develop around the lips called rhagades. Symptoms.—The Bones.—Epiphysitis, an inflammation of the ends of the bones, is present. Later in the disease chronic osteoperiostitis and syphilitic dactylitis are seen. The liver and the spleen are enlarged. THE INFECTIOUS FEVERS 291 The Respiratory Tract.—Pneumonia is common. Ulcers of the larynx are sometimes observed. Digestive Tract.—A chronic catarrh of the pharynx is present, causing "snuffles." The Organs of Special Senses.—Otitis media and inter- stitial keratitis are common. Nervous Symptoms.—Often absent, but there may be impairment of mentality. The children are weak and sickly and usually die young. If three months pass after a child is born from syphil- itic parents without the appearance of any characteristic symptoms, the child will, in all probability, escape. Hutchinson's Teeth.—If a child suffering from heredi- tary syphilis lives, the second or permanent teeth are characteristic (see Fig. 4). The teeth most frequently affected are the upper central incisors. They have a dull, opaque color and have a roughly rounded and stunted appearance. The cutting edge of the tooth is narrower than its neck. Over the tips of these stunted and conic teeth the enamel is irregular and forms a semilunar notch. The Wassermann reaction is a test made with blood from an individual suspected of having syphilis. It is reliable in about 80 to 90 per cent, of cases. The physician will take from 4 to 8 c.c. of blood from a vein, or less from a stab of the finger, toe, or ear, and let it stand at the room temperature for one hour until firmly clotted, then it should be put on ice. Be sure and label the tube and reference card, as all blood specimens look the same. If properly taken and kept the specimen will not disintegrate for four or five days. 292 DISEASES OF CHILDREN FOR NURSES The test consists in mixing the serum of this specimen with a syphilitic antigen, which is a solution of a liver from a syphilitic fetus which has shown the Spirochaeta pallida (the germ that produces syphilis). To this is added blood-serum from a guinea-pig, and the whole is placed in an incubator for three-quarters of an hour at 370 C. After this, rabbit's serum, which has been immunized to red sheep cells, is added, followed by a solution of washed red blood cells from a sheep, and the tube shaken. The whole is again incubated for one to one and a half hours at 370 C. If the test is positive, there is no hemo- lysis; that is, the upper part of the tube is clear and the red corpuscles are precipitated in the lower part. If it is negative, there is complete hemolysis; no cor- puscles are precipitated in bottom of tube. Complement fixation is the same test, except a gono- coccus antigen is used instead of syphilitic liver. In infancy the blood for these reactions is often with- drawn from the longitudinal sinus of the brain through the fontanel. Injection of salvarsan can also be given by this route. Treatment.—The treatment of both hereditary and acquired syphilis consists in giving mercury. This, in infants, is given in the form of ointments. Great care must be taken by the nurse to avoid contamination in handling syphilis. Salvarsan (arsphenamine and neo-arsphenamine), a preparation of arsenic, discovered by Ehrlich, seems to give excellent results. It is injected intravenously or intramuscularly. The injection can also be made into the sinuses of the brain through the fontanel, which seems to cause practically no pain to the infant; in older THE INFECTIOUS FEVERS 293 children this method, of course, is impracticable. From four to six injections are usually required, two weeks apart'. In hereditary syphilis the use of mercurial ointment still seems to give the best results. TETANUS OR LOCKJAW An acute infectious disease excited by the tetanus bacillus and characterized by painful tonic spasms of the voluntary muscles. The bacillus gains an entrance to the system through some wound. Lacerated and punctured wounds, burns, and frost-bites are most likely to become infected. Stables seem to be the breeding ground for the bacillus. Symptoms.—The disease begins with rigidity in the muscles of the neck and lower jaw, by degrees the mus- cles of the back, abdomen, and extremities are similarly involved. The face has a peculiar expression, the brow is wrinkled, the corners of the mouth are drawn up (the sardonic grin) and the jaws are tightly closed (trismus). The body may become arched in a position of opisthot- onos. There is extreme hyperesthesia, and the slightest touch causes an increase in the spasm which is attended by severe pain. If the respiratory muscles are involved there is intense dyspnea. The temperature usually re- mains normal until just before death, when it may rise to 107 ° F. or more. The mind is clear to the end. The duration is from a few days to several weeks. Death occurs in nearly every case. Tetanus occurs sometimes in the newly born from infection of the umbilical cord. Treatment.—There is an antitoxin for tetanus which is injected into the system. All wounds into which any 294 DISEASES OF CHILDREN FOR NURSES powder, manure, or cultivated soil has gained entrance are especially likely to be infected by the tetanus bacilli, as are wounds received around stables and horses. Children receiving such wounds should be immedi- ately inoculated with a prophylactic dose of the serum. It was used to great advantage in the wounded during the World War. HYDROPHOBIA OR RABIES A disease of dogs which at times is communicated to children through a bite of an animal suffering from rabies. It takes about six weeks for the disease to develop after the wound is received. Symptoms.—These consist principally of paralysis of the muscles of the throat, which prevents swallowing. There is fever, and convulsions are present. Treatment.—All dog bites should be immediately washed with antiseptic solutions and a wet bichlorid dressing applied. At the present time cauterization has been discontinued, the bite being treated as an open wound. If the dog is known to have had rabies, treatment by the Pasteur method will prevent the child from develop- ing the disease. Pasteur institutes exist in New York and Chicago. The Boards of Health of some of the larger cities furnish the serum. The treatment, according to this method, consists of hypodermic injections of the serum extending over a period of several weeks. TYPHUS FEVER (BRILL'S DISEASE) An infectious disease which is rarely seen at present except in isolated instances. Formerly it was one of the scourges of the world. THE INFECTIOUS FEVERS 295 When it was found that it was spread by overcrowding and filth, and measures were instituted to improve the hygienic and sanitary conditions of people living under such conditions, the epidemics of the disease were con- trolled. Brill, of New York, has lately recognized that a series of symptoms occurring in children to which the name "Brill's disease" had been applied is, in reality, a sporadic form of typhus fever. Symptoms.—Beginning with the usual prodromes, the fever rises rapidly to 1030 or 1040 F. On the fifth or sixth day a rash appears which does not disappear on pressure, and which persists until the crisis, when it rapidly fades. The children are much prostrated, with severe headache, but no abdominal symptoms. Consti- pation is usually marked. After persisting for twelve to fifteen days, the fever usually falls by crisis, and there is a speedy recovery. There is-a negative Widal reaction with typhoid organ- isms. The disease is rarely fatal and does not spread to other patients in the ward or in the home. NURSING IN THE ACUTE INFECTIOUS DISEASES The room should be kept at an even temperature; it should be well lighted and ventilated. Bathing should be thorough. The clothing should be of a light woolen texture. Sleep should be encouraged, the urine should be examined routinely, and the temperature, pulse, and respirations taken every three hours where there is fever. The nurse should roll up her sleeves when nursing an infectious disease. 296 DISEASES OF CHILDREN FOR NURSES Care should be taken by the nurse to prevent the infection of herself. All antiseptic precautions should be employed. In malaria the child should be protected against mosquitos. She should avoid all possibility of being scratched or bitten in hydrophobia. This may occur if it is necessary to feed by gavage. The feedings should be liquid. In tetanus it may be necessary to feed through a catheter placed in the mouth or nose; it may be necessary to chloroform the child while doing this. In syphilis avoid contagion, and when applying mer- curial ointment, to prevent irritation of skin, select a new place each day. For example, the abdomen, right and left axillae, and the right and left thighs can be utilized in rotation. A glass rod is the best means of applying mercurial ointment; 1 dram is used, and is rubbed in for a half hour. CHAPTER XTV TYPHOID FEVER Typhoid fever is an acute infectious fever due to the typhoid bacillus or bacillus of Eberth. The disease is especially characterized by pathologic changes in the lymph-follicles of the intestines and par- ticularly of Peyer's patches, by changes in the mesenteric glands, and by an enlargement of the spleen. The lesions in the intestines and the mesenteric glands are ulcerative in character. Typhoid fever is recognizable in the writings of the ancients four hundred years before Christ, and ever since that period epidemics of this disease have been constantly recorded in medical history. The causes for the frequent epidemics are better understood when it is known that the typhoid bacillus shows great resisting powers. They have remained alive for three months in distilled water, and when buried in the upper layer of the soil they will retain their vitality for six months. Dissemination of the Disease.—The method by which the typhoid bacillus spreads the disease is well understood. The stools of a person suffering from the disease are filled with the germs. Unless these stools are covered with some solution like carbolic acid, 2V; bichlorid of mercury, ^; or chlorinate of lime, of equal strength, they pass with the sewage to the nearest water-course. Once in the stream they may pollute an oyster bed or they 297 298 DISEASES OF CHILDREN FOR NURSES may be contained in the water used to sprinkle green vegetables. By far the greatest danger is in swallowing the bacilli in drinking water. Milk may be contaminated by water containing the bacillus. The distances they travel, at times, is almost incredible. Miles down a stream an epidemic will arise traceable to one case at its source. A case occurring in the fall of the year can produce typhoid after the spring thaws, if the stools are carelessly deposited on the upper surface of the soil. The relatively infrequent communication of typhoid fever to physicians and nurses is explained by the fact that the contagion escapes from the child in the stools alone, and as these are promptly disposed of, the chances of dissemination of the poison are few. Carelessness in the disposition of these discharges, such as permitting them to dry upon the linen and in this manner allowing the bacillus to pass into the air of the room, at times occasions the infection of the nurse, the physician, and others attending a typhoid case. Age.—Typhoid fever is seen most often during adoles- cence and in adult life before thirty years of age, although it occurs frequently in childhood. It is rare before two years of age. In the young the duration of the disease is short, and the prognosis very favorable. Sex.—Typhoid fever seems to be more prevalent among boys than among girls, probably because of their more frequent exposure rather than greater susceptibility. Season.—Typhoid fever is more common in the late summer and in the early autumn months than at any other time of the year; hence one of the names for typhoid is autumnal fever. TYPHOID FEVER 299 Morbid Anatomy.—The principal lesions in typhoid fever are in Peyer's patches in the ileum (the lowermost portion of the small intestines). Peyer's patches are a collection of lymphatic glands in the walls of the intestines and are from one to three inches in length. The typhoid bacilli implant themselves in these glands and cause an inflammation. The Peyer's patch becomes swollen and the superficial tissue sloughs off, leaving a raw, ulcerating surface. This is called a typhoid ulcer. These ulcers may be very small, from an eighth to a quarter of an inch in diameter. More often there is a large, elliptic ulcer, a whole Peyer's patch being involved. At times by the union of one or more ulcers much larger ones are formed, especially at the lower end of the bowel. The borders of the ulcers are raised, the floor of the ulcer is usually the submucous, or muscular coat of the bowel. (The bowel has four coats, the mucous, the submucous, the muscular, and the peritoneal.) If the ulcer eats through all these coats there is a perforation of the bowel. The discharge of the contents of the intestines through the perforation into the peritoneal cavity is often followed by a fatal peritonitis. More commonly the ulcer heals before the bowel is perforated, and the patient recovers, but the normal glandular substance is never restored at the seat of the ulcer. At autopsies ulcers are discovered at different stages of healing, sometimes they are all healed with the exception of the single fatal spot, which has become the seat of perforation. The large intestines are also invaded at times; perhaps in about one-third of the cases perforation may take place here and also in the appendix where the process occasionally extends. Similar infiltration of the 300 DISEASES OF CHILDREN FOR NURSES lymph nodules and the lymph cords of the mesenteric glands and of the spleen occurs, contributing to the enlarge- ment of these organs. In the spleen it is associated with active congestion which causes a further enlargement, generally recognizable during life. There has even been known to be a rupture of this organ. Changes in the liver, kidneys, and in the respiratory organs are often found. Hypostatic congestion of the lungs is a frequent complication. Thrombosis of the veins, especially of the femoral, causes the not very rare symptom of milk-leg. Endocarditis is sometimes found. Notwithstanding the intensity of the nervous symptoms in some cases, menin- gitis is rarely met with. Abscess of the parotid gland is a familiar complication. Characteristics of Typhoid Fever in Children.— During childhood the disease is of shorter duration, milder course, has fewer complications, and has a lower mortality than in adult life. The onset is more sudden, fever, vomiting, and prostra- tion being seen as often as slow insidious beginnings. Constipation is more frequent than diarrhea, tympanites is not marked, and the eruption is less constant in child- hood. Nervous symptoms are not as frequently found as in adults; hemorrhage and perforation are also met less often. Noma is sometimes a complication. Death rarely occurs in uncomplicated cases. After ten years of age the symptoms are similar to those seen in adult life. Symptoms and Course.—A certain period of incubation is necessary after the successful implantation of the bacilli before typhoid fever arises. This varies from a few days to two weeks and even longer in some cases. The period of incubation may be without symptoms, but a sense of TYPHOID FEVER 301 weariness and indisposition to play are usually present. The latter often can be overcome by force of will. A want of appetite and a slight coating of the tongue are not infrequent. In older children the disease itself usually sets in gradually and often is quite advanced before it is suspected; indeed, at times well advanced, constituting the so-called walking typhoid. In children under ten years of age the onset is less gradual. Symptoms of the Attack.—There may be headache, anorexia, a furred tongue, nausea, chilliness, but seldom a decided rigor. The disease may be ushered in by pain in the back or leg muscles and there may be nosebleed (epi- staxis). In older children there may be a looseness of the bowels. There is continuously a slight fever and the child feels wretched. The fever and discomfort increase and finally the child goes to bed. The tendency to loose- ness of the bowels and epistaxis justify a strong suspicion of the existence of typhoid fever. Yet one or both are frequently absent, and in younger children constipation is more often seen than diarrhea. The abdomen soon becomes slightly distended and pressure on the right iliac fossa elicits tenderness with gurgling. Rash.—Usually about the eighth day, rarely later and sometimes a little earlier, the rose-colored spots make their appearance on the skin of the abdomen and chest and at times elsewhere on the body. They are mostly bright red in color, disappear on pressure, and reappear instantly. They are very slightly, if at all, raised. Their number varies greatly. Sometimes they are very numerous, but more often but five to ten are discovered. Herpes are very rarely seen, in contradistinction to pneumonia. 302 DISEASES OF CHILDREN FOR NURSES The fever is at once the most important and the most characteristic symptom, and from the temperature alone a diagnosis can be suspected. Initial Stage.—During the first week of the fever there will be found a peculiar tide-like evening rise and morning fall, the temperature of each morning and evening being from one and a half to three degrees higher than that of the morning and evening previous. The fastigium is the stage when the fever again and again reaches the highest point. At the end of a week the height of the fever is reached and then it continues with but little variation, the evening rise and the morning fall still being characteristic, but the remission being less than that seen at the onset—from a half to two degrees being found. It is during this period that the maximum temperatures are found; often 105° F. or a little above are noted. A temperature of 106° F. is frequently fol- lowed by recovery, and while temperatures of 107° F., 108° F., and even 1090 F. are sometimes seen, they usually result fatally. The fastigium is succeeded by a third stage or stage of decline in which the reverse of the initial stage is shown by an evening temperature lower than that of the previous evening and the morning temperature lower than that of the previous morning, but the evening temperature still higher than the morning temperature of the same day. This decline continues until the normal is reached, and at cimes from one to two weeks are consumed before this is attained. The duration of the fever in children, however, is usually shorter than in adult life. Sudden falls of a decided character may occur in conse- quence of hemorrhage from the bowels or even from the TYPHOID FEVER 303 nose, or from collapse after perforation of the bowels. Sudden rises are produced by indiscretions in diet or by the supervention of some acute inflammatory condition, such as pneumonia. The skin is usually dry, although profuse sweating sometimes occurs most frequently after a bath. Children frequently have higher temperatures than adults. The pulse is not very frequent, 90 to 120 is the usual average. In grave cases it maintains a frequency of 140. 1 2 J 4- s (, 7 8 9 10 // ii /3 /« IS P. T. m.e. me in. e m.e. m.e m.e. m.e. me. m.e. m. e m.e. m.e m.e me me. no 1 03 160 10 7 ISO 106 /■9-0 105 '30 104- A ,\ A IZO 1 03 A 1 \ /: \> \ 1 \ > / \ A I/O 1 OZ r 1 y ■'// \lr y \ \7> \i \ / V \j \/ 100 101 \/ Y Vy' 90 100 v/ 80 99 1 >v 70 98 GO 91 .. _ Fig. 95.—Chart of the temperature (----) and pulse (----) in typhoid fever of moderate severity in a male child five years old (Kerr). The pulse is often dicrotic (see page 177). The breath- ing rate commonly advances with the rate of the pulse. The heart-sounds at first are normal, but gradually grow less distinct as the prostration increases. As the disease advances the tongue, previously furred, tends to become dry and brown, clearing at the edges, however, and also at the tip as the case improves. In severe cases, especially, if the mouth is not kept clean; sordes form on the teeth, stomatitis sets in, and the lips are covered with black crusts. 304 DISEASES OF CHILDREN FOR NURSES Diarrhea, if present, is rarely troublesome. The stools are apt to be grayish-yellow and of about the consistency and frequently likened to pea soup. Hemorrhage from the bowel is always a serious com- plication, but by no means fatal, though large quantities of blood are sometimes discharged. Very rarely a patient will bleed to death. Following the hemorrhage there will"be a marked fall in the temperature and a pallor and a faintness such as is common to large hemorrhages else- where. Perforation is suspected when there is a sudden pain in the side with spreading tenderness and vomiting. The temperature falls and the pulse becomes more rapid. If these symptoms occur during the course of typhoid the physician should be immediately informed. Tympanites or distention of the abdomen in a mild degree is at times present in children, but not so often as in adults. The accumulation of gas is commonly ascribed to atony of the bowel. Delirium is rare in childhood. A tendency to drowsiness or even stupor is present, and from this the name of the disease is suggested. Muscular tremor is a symptom in severe cases. Carphalogia or picking at imaginary objects is sometimes present and is merely a symptom of the typhoid state; it is not necessarily of fatal import, as is so often thought by the laity. When this condition, known as the typhoid state, sets in the tongue becomes dry, brown, and fissured. Slight cough usually sets in as the disease advances, due to a hypostatic congestion of the lungs. This can be relieved by frequently changing the position of the child in bed. TYPHOID FEVER 305 The spleen is always enlarged, reaching in the first half of the second week two or three times its normal size. It then gradually diminishes. Tenderness may accompany the enlargement. The urine in typhoid cases is always dark hued and concentrated, with correspondingly high specific gravity. Often when the fever is high there may be a slight albu- minuria. If there is a nephritis present there will be casts in addition to the albumin. The blood in typhoid fever shows a slight diminution in the white blood-corpuscles in contradistinction to pneu- monia where they are greatly increased. There is also a reduction in the red blood-corpuscles and the hemoglobin, according to the severity of the case. The Widal reaction depends upon the ability of the blood from a typhoid patient to agglutinate a pure culture of typhoid bacilli. It is positive in about 95 per cent, of all cases of typhoid, so it is practically a sure sign of the disease. The diazo reaction is a test made with the urine. Sequelae.—Insanity in the form of acute mania some- times occurs. Aphasia and chorea have been reported. Phthisis, post-typhoid bone lesions and typhoid spine (a severe pain in the back aggravated by motion) follow the disease. As a rule sequela? are uncommon in children. Relapses often occur following upon the relaxation of diet. The symptoms of a relapse are those of the primary disease, excepting that the symptoms are less severe, the duration shorter, and recovery the rule. Relapses may be multiple. Recrudescence is a simple return of fever, also often induced by lapses in diet. 20 306 DISEASES OF CHILDREN FOR NURSES Prognosis.—In children under fifteen recovery almost invariably takes place. Hemorrhage and perforation occur less often than in the adult. A mistake is often made in using the term typhoid pneumonia, meaning typhoid fever complicated by pneu- monia. Typhoid pneumonia means pneumonia with typhoid symptoms, such as the brown, dry tongue, delir- ium, twitching of the tendons, and picking at the bed- clothes. These occur in fevers when patients are ex- hausted, and are not seen in typhoid fever alone. In typhoid pneumonia, typhoid fever does not exist. If the two are present at the same time use the title typhoid and pneumonia. Vaccination Against Typhoid.—This prophylactic measure has proved efficient in almost every case where proper inoculation has been made. It is important that the nurse in training and in active practice should be inoculated. The method consists in giving hypodermicaliy a cul- ture of typhoid bacilli which has been rendered prac- tically non-virulent through long cultivation of a single strain, and then killed by heat. The first inoculation consists of 500,000,000 dead bac- teria in salt solution. The second and third doses, each given at intervals of ten days, contain 1,000,000,000 dead bacilli. The best time to give the injection is in the afternoon, so that its effects will wear off during the night. The immediate effect of the inoculation is a smarting pain last- ing for only a minute or two. Nothing further is noted until four or five hours later, when headache and malaise may develop, and at the site of the inoculation a red and TYPHOID FEVER 307 tender area the size of the palm of the hand. The headache and other symptoms are rarely severe enough to interfere with sleep, and by next morning all symptoms usually have disappeared. The introduction of these dead bacteria causes the blood to develop antibodies similar to those formed in true typhoid. We have the same reaction taking place that would follow the presence of living typhoid bacilli, and the same units of defence are organized. As the bacilli are dead, they do no harm, but the resistance developed by their introduction lasts over a period of several years, during which time any typhoid bacillus which should lodge in the body would be immediately destroyed. This immunity to typhoid lasts about three years, at the end of which time fresh vaccination is advisable. Treatment and Nursing.—Absolute rest and restriction of diet are essential. Many physicians use a liquid diet, others a more liberal one. It is usually governed by the amount of emaciation and tympanites. The treatment of typhoid fever by graduated baths is far better than by any other method. It not only reduces the temperature, but controls the delirium, the diarrhea, and keeps the mouth and tongue in good condition. It also lessens the severity of every symptom. The method of giving these baths is described on page 455). The effect of the bath on the temperature varies with the stage of the disease, it being frequently the case in the first week that the fall in temperature is less than one degree; in the second and third week, however, the fall will be from one to three degrees. In addition to lowering the temperature the immediate effect of the baths is to add strength to the heart and volume to the pulse (Holt). 308 DISEASES OF CHILDREN FOR NURSES Contra-indications.—Practically the only contraindica- tions to this plan of treatment are: (i) When there is an almost absolute pulselessness with a blue, cyanosed appearance of the skin occurring while giving the tub, in which case the child should be immediately removed, put to bed, and hot-water bags applied to the extremities and whiskey given. (2) Hemorrhage. (3) Perforation. None of the complications excepting hemorrhage from the bowel and perforation are allowed to interfere with the carrying out of this treatment. The reason they are discontinued in hemorrhage is the fear that the necessary movements in the bath would excite further bleeding; and in perforation, to avoid the danger of unnecessary contam- ination of the peritoneum with feces. Delirium is con- trolled by a soothing voice and touch in conjunction with the bromids. Constipation should be relieved by the enemas alone. Hemorrhage from the bowel should be treated by absolute rest, cold to the abdomen, the food should be reduced to a minimum, and be of the mildest character. In severe cases the foot of the bed can be raised. The physician should be immediately notified. Perforation.—Symptoms of perforation, such as spread- ing tenderness, sudden pain in the side and vomiting, demand absolute quiet and the immediate notification of the physician. Tympanitic distention may be relieved by the careful passage of the rectal tube, and the pain relieved by tur- pentine stupes. One of the dangers of protracted cases is bed-sores. These can generally be averted by careful attention to cleanliness, by thoroughly drying the patient after washing, TYPHOID FEVER 309 by removing all traces of urine or other discharges, and by sponging the patient daily with alcohol or whisky. Above all, the position in bed should be changed frequently and all inequalities in the bed-clothes should be kept smoothed out, while the bed should be kept clear of crumbs and other particles of food. Should a sore appear, anti- septic dressings should be applied and the part relieved from pressure by an air-cushion. Convalescence.—In no disease is watchfulness during convalescence more important. Relapses and the per- foration of an ulcer may occur during this period. The ulcers are not necessarily healed when the temperature reaches the normal. Therefore, absolute rest and a liquid diet should be kept up for at least ten days after the tem- perature has reached normal. The hair is very apt to fall out and, therefore, should be cut short. By no means is it necessary to shave the head. Prophylaxis.—When typhoid is epidemic all drinking- water should be boiled for one-half hour before using. Since the contagion of typhoid fever resides solely in the stools, vomited matter, urine, and other discharges from the body, it is important that these should be thoroughly and properly disinfected, also that the linen which has been in the least degree soiled by them should be imme- diately removed and sterilized. Stools may be disinfected in the following manner: Place in the bed-pan, before using, a small quantity of car- bolic acid solution, 1 : 20, or chlorinated lime of the same strength. Cover the evacuation with another quantity of the disinfectant, mix thoroughly, stand aside for one-half hour, then empty the whole into the water-closet hopper. 3IO DISEASES OF CHILDREN FOR NURSES Then thoroughly rinse out the vessel with disinfectant solution and hot water. Linen may be immersed in carbolic acid, i : 20, until boiled. Boiling for half an hour disinfects it. After the bowels have been moved the buttocks and anus of the patient should be thoroughly washed with 1 : 40 carbolic acid or bichlorid, 1 to 2000, followed by hot water and soap. Door-knobs or parts of 'the door touched with the soiled hands should be washed with the same disinfectants, since drying of the fecal matter causes it to disseminate and gives rise to a source of infection. The nurse should wash her own hands with soap and water and then rinse them in a solution of bichlorid. It is by soiled hands or floating bacteria from dried feces that nurses are infected. Where tub-bathing is employed, it is possible that the water of the bath that has been used several times may be a source of infection. The nurse should, therefore, wash her hands after tubbing a patient, and watchful care should be exercised not to carry them to the mouth during the bath. After death or discharge of the patient the mattress, which should be well protected during use by a rubber sheet, should be thoroughly aired. The rubber sheet itself should be washed in carbolic acid, rinsed in cold water, and dried in the open air. PARATYPHOID FEVER This is a condition which almost exactly resembles typhoid fever, except that its course is not so severe. It TYPHOID FEVER 3H is caused by bacilli, known as paratyphoid "A" and "B," the latter being the most frequent. In prophylactic moculations against typhoid fever, as employed by the United States Army during the World War, both of the above strains of germs were included. Whenever inoculations are to be given the same pro- cedure should be adopted. The treatment and nursing are the same as that recom- mended in typhoid fever. CHAPTER XV TUBERCULOSIS Tuberculosis is an infectious, communicable disease due to the bacillus tuberculosis of Koch. It is a disease that may occur at any time of life, most frequently in childhood and between the ages of twenty and thirty. It may be local or general and may involve any organ and almost any structure of the body. The predisposing causes to tuberculosis are divided into general and local. General predisposition to the disease may be inherited directly from the parents, who have themselves suffered from tuberculosis, or from those who, in consequence of syphilis, alcoholism, or any other constitutional vice, have transmitted a feeble constitution to their children. Actual congenital tuberculosis is rare; that is, a child is rarely born with tuberculosis, although cases are sometimes seen. The surroundings in which a child is reared plays an important part in the general predisposition to tuberculosis, cramped quarters and exposure being the chief causes. In childhood marasmus, intestinal diseases, in fact any debilitating general or local disease, may predispose to tuberculosis. A local predisposition is created by any diseased condi- tion of the mucous membranes or organs most exposed to the infection. The most important are repeated attacks of bronchitis, bronchopneumonia or pleurisy, and chronic 312 TUBERCULOSIS 313 catarrhal inflammations of the nose and pharynx so frequently associated with enlarged tonsils or adenoid growths of the pharynx. The role played by other diseases in the development of tuberculosis is important and, until recently, little under- stood. In a very large number of cases tuberculosis develops as a sequel of one of the acute infectious dis- eases, particularly measles, pertussis (whooping-cough), or epidemic influenza. In such cases there probably has existed a previously latent tuberculosis, usually an involve- ment of the bronchial lymph-nodes. An acute disease, like pertussis, lowers the general vitality of the body and gives the tubercular process a chance to light up. As long as the constitution of the child is robust and the resisting powers of the tissues are up to par there is slight danger of contracting any form of tuberculosis. It is when the resisting powers of the tissues are faulty that the bacilli gain a foothold, and this may be in the mucous membrane of the throat, lungs, or bowel. The bacilli are taken up by the lymphatics and carried to the nearest lymph-gland, where they are arrested. The glands involved may be the cervical lymph-glands or the bronchial lymph-glands which are back of the bifurcation of the bronchi and receive the lymphatics from the lungs; or the mesenteric lymph-glands which are retroperitoneal (behind the abdominal viscera) may be involved. When the bacillus enters one of these glands it starts an inflammation which, if allowed to run its course, will be the typical inflammation produced by the tubercle bacillus; namely—congestion, swelling, cell proliferation, and caseation. Or if the vitality of the body is regained this process may be arrested at any point and the product of the inflammation will 314 DISEASES OF CHILDREN FOR NURSES become encapsulated by a wall of fibrous tissue (the way a tubercular lesion is cured), in which condition they may lie latent in the body for an indefinite number of years and possibly for a life-time. Tubercular cervical adenitis is frequently seen in the hospital wards; tubercular lymph- glands, both bronchial and mesenteric, are met with as often in the autopsy-room. If for any reason the vitality of the part is not strong enough to resist the tubercular inflammation, or if some intercurrent disease lowers the vitality sufficiently to permit a lighting-up of the old tubercular inflammation, sooner or later these lymph-glands will caseate and rupture. In the cervical glands such a condition leads to the sinuses of the neck so frequently seen, while in the bronchial glands such a condition leads to a tubercular infection of the lungs known as phthisis. In the mesenteric glands the rupture leads to abscess formation, peritonitis, or tubercular enteritis. Any structure of the body may be involved by the tu- bercle bacillus. When the spine is affected there is Pott's disease, when the bones and joints are affected there is tubercular osteomyelitis, coxalgia, and other surgical con- ditions. The liver, spleen, pleura, kidneys, and all other organs may be involved, usually secondarily. The bacillus does not always take the above course. It may enter the lungs directly by inhalation and set up a tubercular lesion, or it may be swallowed in the milk and meat from tubercular cattle. In young children under two years of age the lung is the part of the body usually affected; beginning with the second year tubercular meningitis is more frequently found; and after the third year tuberculosis of the bones, TUBERCUL OS IS 315 of the cervical and mesenteric lymph-glands, and of the peritoneum and intestines become more frequent and are seen throughout childhood. That the disease is communicable is proved by large numbers of individual cases in which a person closely associated with the tubercular patient has contracted the disease and died. It is sometimes hard to trace the origin of a given case of tuberculosis on account of its tendency to lie latent for so long a period. In addition to the above predisposing causes residence in a low, damp, and badly drained locality, and physique contribute to the tendency toward developing tuberculosis. ' The physique of the child is important. Children who suffer with tuberculosis of the lungs usually have a flat chest with prominent shoulder-blades and a narrow angle of the ribs at the lower border of the anterior portion of the chest. This is called the phthisic chest. It seems to predispose to tuberculosis of the lungs on account of the poor expansion of the lungs which results from such a formation. Many children have phthisic chests who are not suffering from the disease. Phthisis is the name ap- plied to tuberculosis of the lungs. The varieties of tuberculosis seen in children are tuberculous bronchopneumonia, miliary tuberculosis, tuberculosis of the bronchial lymph-glands, tubercular meningitis, and tubercular bone and joint diseases. TUBERCULOUS BRONCHOPNEUMONIA Pathology.—If the tubercle bacillus does not gain access to the lungs from the rupture of the bronchial lymph-node the bacillus entering the respiratory tract through the inspired air lodges in the terminal bronchioles 316 DISEASES OF CHILDREN FOR NURSES and excites a proliferation or overgrowth of the fixed cells. The new cells are termed epithelioid and frequently contain bacilli. Giant-cells are often formed by a fusion or overgrowth of these cells. This aggregation of new cells acts as an irritant and is soon surrounded by a wall of leukocytes, the whole forming a gray, translucent mass, the so-called gray tubercle. In a short time the bacillus excites a necrosis or softening which starts in the center, spreads to the periphery and converts the tubercle into a yellow, cheesy mass called the yellow tubercle. The degen- erated tubercles fuse and form the uniform cheesy masses commonly observed at the autopsies. At this stage one or two things may occur. Either the mass may soften, break into a bronchial tube, and leave behind a cavity with ulcerating walls, or it may become encapsulated by an overgrowth of connective tissue and later calcify. In addition to the tubercular process other changes are noted. The lung tissue in the neighborhood of the tuber- culous deposits is the seat of a true bronchopneumonic inflammation, the connective tissue is always more or less proliferated, the bronchial tubes are inflamed, and the pleura over the affected area is always adherent. In infants the disease resembles marasmus, and it is very hard to distinguish the two conditions. In older children the disease follows one of three courses: namely, a rapid, acute course, a subacute course, and a chronic course. Symptoms.—In the acute form the disease resembles bronchopneumonia. The characteristic symptoms of phthisis are absent. The temperature remains high, without intermission, and there is a gradual loss of flesh and strength. Death results in every case. TUBERCULOSIS 317 In the subacute variety the principal symptoms are fever and wasting. The temperature is irregular. Cough and dyspnea are present, expectoration is absent before four years of age. Hemoptysis is rare, respirations are accelerated, the spleen is often enlarged, anemia is marked, dropsy is rare, and then only late in the disease. Sweating is also seen late in the disease. The chronic cases resemble protracted bronchopneu- monia. Often periods of freedom from the disease are observed. At the first fresh cold the symptoms reappear. This condition of affairs may continue over an indefinite period. It may teirninate by becoming acute or subacute in form, when the symptoms observed in those conditions will be found. It may cause general miliary tuberculosis or tubercular meningitis. The presence of the tubercle bacillus in the sputum makes the existence of the disease positive. ACUTE MILIARY TUBERCULOSIS OR ACUTE GENERAL TUBERCULOSIS This is an acute infectious disease excited by the tubercle bacilli and characterized anatomically by the simultaneous formation of miliary tubercles in many parts of the body. The disease usually develops in early life and is secondary to some primary lesion, as a tubercular gland. The bacilli are probably disseminated by the veins. All the organs may be uniformly infiltrated with the tubercles, but more commonly certain organs, like the lungs and brain, are more affected than the others. Symptoms.—There is debility, loss of flesh and strength, the temperature ranges between 102 ° F. and 103 ° F , and is characterized by an evening rise. There is cough, 318 DISEASES OF CHILDREN FOR NURSES rapid respirations, and symptoms of the typhoid state are present. Tubercle bacilli are rarely found. If the lungs are chiefly affected, dyspnea, cough, and expec- toration will be marked. When the intestines and the peritoneum are mainly involved, pain, distention, abdom- inal tenderness and diarrhea will be the most prominent symptoms. TUBERCULOSIS OF THE BRONCHIAL LYMPH-GLANDS This condition is frequent in childhood. The general symptoms of tuberculosis are present; namely, fever and wasting. The other symptoms are lacking. The usual result of such an inflammation is a rupture of the gland with subsequent involvement of the lungs. Eustace Smith''s sign is supposed to be diagnostic of enlarged bronchial glands. It is demonstrated as follows: A stethoscope is placed over the large blood-vessels of the chest (at the base of the heart), with the child's head forward on the chest; then bend the child's head as far back as possible, and, if a murmur is then heard which was previously absent, enlarged bronchial glands exist. The murmur is caused by the pressure of the enlarged glands upon the vessels, the position of the head bringing them into apposition with these vessels. Bronchial glands that are not enlarged will not produce this sign. TUBERCULAR MENINGITIS Tubercular meningitis is fully described under diseases of the nervous system (see page 211). TUBERCULAR DISEASE OF THE BONES AND JOINTS Pott's disease is tuberculosis of the spine. It may be located in the cervical, dorsal, or lumbar regions of the TUBERCUL OSIS 319 spinal column. It causes a necrosis or caries of the ver- tebrae. Symptoms.—The disease comes on insidiously. The earliest symptoms are due to irritation of the spinal nerve roots. Pain is the most prominent of these and is referred to various parts of the body supplied by the distribution of the nerves affected. Fig. 96.—Pott's disease of the upper dorsal vertebrae. Sharp-angled kyphosis. (Clinic of von Ranke-Herzog, Munich.) In a short time there is a rigidity of the spine and the child assumes various postures to prevent the diseased surfaces of the vertebras from rubbing together. If he stoops to pick anything from the floor he does so without bending his back. Jumping from elevations hurts him and pulling the head away from the body relieves him. 320 DISEASES OF CHILDREN FOR NURSES Soon an angular deformity called kyphosis appears at the seat of the disease in the spine. This progressively becomes worse, making a permanent deformity commonly called hunch-back. The tubercular process causes softening of the vertebrae and abscess formation. These abscesses vary in their location according to the seat of the lesion. In cervical Pott's disease they may be retropharyngeal; in dorsal and lumbar Pott's disease they may point in the small of the back or burrow through the sheath of the psoas muscle and point in the thigh at the lower attachment of the muscle. This is called a psoas abscess. In addition to these symptoms there is fever, wasting, pain, insomnia, and paralysis. Prognosis.—If the children are made to rest, given proper care and attention, and their backs immobilized, a cure will result in a large number of cases. Plaster jackets and other mechanisms are applied to keep the back rigid. Abscesses have to be opened and drained. Coxalgia or coxitis is a tubercular inflammation of the hip-joint. It causes necrosis of the bones of the joint. Symptoms. First Stage.—The disease begins insid- iously. The first symptom noted is slight lameness or the fact that the child wears out one shoe quicker than its mate. In a short time pain develops, due to muscular spasms. The pain is referred to the knee, often causing this joint to be suspected when the hip is really at fault. These symptoms may last a few weeks or even longer. Second Stage.—During this period the leg is in a char- acteristic position. The foot is everted, the thigh is TUBERCULOSIS 321 slightly flexed and rotated outward, and the leg is appar- ently lengthened, due to the tilting of the pelvis. The joint is locked from constant muscular spasm and abscesses form about the hip-joint. The duration of this stage is indefinite. Third Stage.—In this stage the joint has been destroyed. The thigh is flexed on the abdomen, it is rotated inward, the foot is inverted, there is shortening of the leg, and a Fig. 97.—Hip-joint disease showing tilting of the pelvis in abduction, and apparent lengthening (left leg) (Moore). curvature of the spine. Ankylosis or a permanent union of the bones may result, which prevents any movement of the head of the femur. Treatment.—Coxalgia demands absolute rest in bed with an extension apparatus (see Fig. 125, page 487) applied to the affected leg. This draws the bone down- ward so that the head of the femur does not come in contact with the acetabulum or socket of the hip-joint; 21 322 DISEASES OF CHILDREN FOR NURSES it also immobilizes the joint. Abscesses are opened and drained. Tubercular arthritis is a tubercular inflammation of a joint. Almost any joint in the body may be involved. The knee, ankle, and elbow are probably the most often affected. Symptoms.—This consists of a spindle-shaped swelling of the joint without any signs of inflammation. It has a Fig. 98. —Tubercular dactylitis of the right thumb and left middle finger of a three-year- old child (Hecker, Trumpp, and Abt). doughy feeling and a whitish appearance. It has been called white swelling. Later it may break down, the joint be destroyed, and ankylosis result. Treatment.—This consists of immobilization of the joint by plaster casts. At times curetment is necessary. Tubercular Osteomyelitis.—This is an inflammation of the shaft of the bone characterized by swelling and necrosis of the bone. The dead portion of the bone has to be removed. TUBERCULOSIS 323 Epiphysitis is an inflammation of the ends of the bones. Tubercular dactylitis is an inflammation of the bones of the hands and feet. TUBERCULAR ADENITIS This is seen chiefly in the cervical lymph-glands, and is characterized by swelling, softening and breaking down of the glands, sinuses resulting. THE VON PIRQUET CUTANEOUS TEST It is made by washing the skin of the arm with ether or alcohol, applying a drop of undiluted old tuberculin, and then scarifying slightly through this with a steril- ized needle. A control scarification is made a couple of inches distant for comparison, no tuberculin being used here. A positive reaction develops within twenty-four hours, sometimes longer, and consists of a red, slightly indurated papule 5 mm. or more in diameter; a papule of smaller size is not considered certainly positive. If the reaction is negative a second test should be made within a few days. A positive reaction indicates that the patient has or has had tuberculosis. TREATMENT OF TUBERCULOSIS Prophylaxis.—Sputum of consumptive children should be received in suitable vessels which contain antiseptic solutions, and subsequently destroyed. Phthisic mothers should not nurse their offspring. The healthy should not sleep in the apartments of those affected. The treatment of tubercular children aims to 324 DISEASES7 OF CHILDREN FOR NURSES strengthen their vitality and resisting powers and to de- stroy or disable the tubercular bacillus. This is brought about by good food, fresh air, frequent bathing, sunlight, avoidance of exposure, graduated exercise, a dry, well- ***. -'-H FlG. 99.— Proper clothing for outdoor schools and for open-air treatment. The child is holding a paper napkin in front of face while coughing, ventilated house and plenty of sleep and recreation. In bone and joint diseases absolute immobility of the part affected is essential. Hemorrhage from the lung in childhood is infrequent. TUBERCULOSIS 325 If it should occur, the child should be kept absolutely quiet and an ice-bag applied to the chest. The physician should be immediately notified. Immobilizing the lung by induction of pneumothorax is a plan of treatment which gives good results in many cases of pulmonary tuberculosis. Sterile nitrogen is introduced into the pleural cavity through a thin hollow needle. A special apparatus is used, and at intervals of a day or two measured quantities are injected until the lung is completely collapsed. The pleural cavity requires refilling every month or two. Nursing.—The room should be sunny, cheerful, and well ventilated. In tuberculosis of the lungs the child should live in the fresh air. If it is too cold or stormy to stay out of doors, the windows in the nursery should fre- quently be raised to keep the atmosphere thoroughly fresh. At night the windows should be wide open, the child thoroughly covered, and not exposed to the draft. It is important that patients be convinced of the great benefits to be derived from outdoor treatment. Even dispensary patients living in the slums may sleep on housetops, laundry-flats, or in tents in yards. To meet the out-of-door sleeping problems the Klon- dike bed has been devised. Klondike Bed.—This bed is made in the regular way, with a sheet of asbestos over the wire spring mattress. Heavy brown paper may be substituted for the asbestos. The foundation of the bag is first, a double blanket folded in half, crosswise, and then a single wash blanket to serve as a sheet. Over this foundation a single wash blanket is used and over this a double red blanket. At the foot of the bag may be placed hot-water bottles or 326 DISEASES OF CHILDREN FOR NURSES hot bricks. Over this mattress army blankets or horse blankets may be used, well tucked. Next, have a piece of canvas, a canvas envelope, or a rubber sheet with the rubber side out to keep off rain and snow. Place the TUBERCULOSIS 327 pillows in an inverted position to keep the shoulders warm. Sleeping-out clothing may consist of bed shoes, flannel pajamas, and a sleeping hood with cape attached, made Fig. 101.—Improvised inexpensive ice-chest. It consists of a wooden box with lid covered with four or five layers of newspapers, all of which may be covered with oil-cloth. A bucket is placed in the box with sawdust under and surrounding it. The bottles of milk and the ice are placed in the bucket and all is covered with a lid. of double thicknesses of flannel having elastic sewed at bottom to allow the arms to go through. This makes the cape fit snugly over the shoulders. After arising in the morning the patient should always dress in a warm room. 328 DISEASES OF CHILDREN FOR NURSES Cleanliness must be insisted on in tuberculosis. Brooms or other appliances which raise dust should not be used in the sick-room. Proper conditions may be maintained by the use of damp cloths and washing up the floors. It is advisable to remove all unnecessary furni- ture and hangings as they accumulate dust. It is always well in private and hospital nursing to keep separate dishes for the use of the patient. The visiting nurse may instruct the family to mark and boil the dishes, forks, and spoons which the patient uses. Frequent bathing and friction of the skin are essen- tial. The bowels should be kept regular. Exercise should be taken only upon physician's permission. In tuberculosis of the bones and joints the part should be kept absolute immobile. The method of applying extension will be found on page 486. Any pus from tubercular lesions should be covered with carbolic acid, 1 to 20, and allowed to stand for half a day before dis- posal. The diet should be wholesome. Raw eggs and milk should be taken to build up the system. Plenty of sleep and exercise without exertion are beneficial. Reference to the caloric value of foodstuffs will be helpful. (See page 417.) Disinfection of Excreta.—For this purpose chlorid of lime is the best disinfectant. It should be thoroughly mixed with stools, urine, and sputum and allowed to stand in order to become saturated. If through careless- ness or ignorance of a patient sputum accidentally es- capes to the floor, lye in full strength should be used, as this disinfectant destroys the mucus as well as the bacilli. Bed-pans and urinals should always be boiled. TUBERCULOSIS 329 Care of Soiled Bed Linen.—Bedding soiled with feces or urine should be washed in formalin and then boiled immediately. Boiling is a safe procedure for destroying tubercle bacilli. After drying, all bedding and clothing should be placed in a room and fumigated with formalin. The proper proportions are one quart of formalin to six ounces of permanganate of potash. It should be al- lowed to stand twenty-four hours. It is well in private nursing to have bed and body clothing boiled separately before placing with the family laundry. Disposal of the Sputum.—Tissue-paper napkins are used in preference to cups or flasks. The children should be carefully instructed in their use, collecting them in small paper bags to be burned. They have the advan- tages of low cost, cleanliness, and burn readily on disposal after use. The sputum for examination should be collected in a sterile bottle with a wide mouth. In children under four years of age the best method to obtain sputum is as fol- lows: Place cotton about the end of an applicator. Grasp the tongue and pass the applicator close to it back to the pharynx; this should excite a cough, when the sputum can be swabbed out, or the applicators may be placed by the child's bedside and when the nurse notices a severe attack of coughing the child is picked up and, if possible, the sputum is obtained in the same way. Another easy method of obtaining sputum is to place a large Q-ounce) eye-drop- per in one end of a catheter. The bulb should be com- pressed and the catheter passed to the pharynx. The bulb is then allowed to expand; the suction then draws the sputum into the catheter. CHAPTER XVI CONTAGIOUS DISEASES A contagious disease is one that can be transmitted through contact with the patient. SCARLET FEVER OR SCARLATINA This is an acute contagious disease characterized by high fever, rapid pulse, a scarlet rash, and an unusual tendency to nephritis. The germ that causes scarlet fever has not been discovered. The contagion is carried by the clothes, bed-clothing, or other articles which have come in contact with a patient suffering from scarlet fever. Milk is suspected of sometimes being a means of dis- semination. The disease can be transmitted by direct inoculation and, therefore, is characterized as a contagious disease. The poison is extremely tenacious to life, infected clothes unused for years being known to lead to fresh outbreaks. The young are especially predisposed, but not equally so. One attack practically gives immunity, as second attacks are uncommon. Period of incubation is from a few hours to a week. Symptoms.—Mild Cases.—At times the symptoms of scarlet fever are so mild that the disease may escape notice. There is fever, a slight sore throat and a very faint rash, often escaping proper diagnosis; a hot bath will cause such a rash to show plainly. It may fade away very 330 CONTAGIOUS DISEASES 331 quickly and the character of the rash not be suspected until slight desquamation appears. This form is con- tagious and is especially dangerous, as it is often not isolated. Ordinary Case.—The disease begins suddenly with vomiting or it may be ushered in with convulsions. Throat Symptoms.—There is pain and difficulty in swallowing, fulness and tenderness under the jaw, and enlargement of the lymphatic glands. The tongue is at 1 z 3 * 5 6 7 8 9 10 II IS Ii p. T. in. e In. e. m.e. m. e. m. e in. e. m. e. In- e m. e. m- e m. e. m- e. m. e. 170 108 IdO 107 r. Ax /SO fo(, ». fN \ '\ ifo lOi r> A 'w ^' N>' N ,\ 130 109 < V \ A \' \ A I2P 103 t f \, A s " no IOZ 1 \^ -\ 100 101 1, it \ 90 166 Y^ *• ■ ^ So 99 70 ?* 60 V Fig. 102.—Pulse (----) and temperature (----) of a simple uncomplicated scarlet fever. The acme in this case was reached somewhat late; the defervescence is rather marked (Kerr). first heavily coated, red at the tip and edges. This white coat peels off, beginning at the edges, and in a few days it disappears and the papillae of the tongue become bright red and swollen. This appearance has given rise to the name strawberry tongue. The whole posterior portion of the mouth and pharynx are deeply injected and may show a punctiform erythema before the rash appears on the skin. In severe cases the tonsils may be the seat of follicular inflammation or they may be covered with false membrane. 332 DISEASES OF CHILDREN FOR NURSES Eruption.—A scarlet punctiform rash appears, at the end of the first or the beginning of the second day, on the neck and chest and spreads over the entire body. Some- times the appearance of the rash is delayed. It disappears on pressure and if the finger-nail be drawn through it a white line will remain for a second or two. It may be a uniform rash or it may appear in patches with healthy skin surrounding it. In five or six days the rash gradually disappears and a scaly desquamation or peeling follows. A bright rash shows a strong heart; sudden fading of the rash may mean heart failure. In some cases the rash is slightly papular or vesicular (scarlatina miliar is). Febrile Symptoms.—The fever rises abruptly, reaching the maximum temperature of 1040 F. to 105 ° F. in twenty- four or forty-eight hours, and remaining at about this height for three or four days and then falling by lysis. The duration of the febrile period is from seven to nine days. The pulse is rapid, out of all proportion to the fever, and the respirations are accelerated. The appetite is lost, the bowels are constipated, and the urine is scanty and high colored and often contains albumin. Nervous Symptoms.—Restlessness, headache, insomnia, delirium, and convulsions may occur. Convulsions occur- ring late in the disease are very significant of uremia. More Severe Cases.—Anginoid Scarlet Fever.—This form is characterized by severe throat symptoms. The tonsils are much swollen and often covered with a false membrane. The fever is high and the prostration is profound. Ulceration, and, at times, gangrene of the throat occur; the carotid artery may be involved. In this form death may result from exhaustion, aspiration pneu- / A •- X^S ■*■ A - .-• ... ■ » 'v The eruption of scarlet fever on the third day (Hecker, Trumpp, and Abt). CONTAGIOUS DISEASES 333 monia, or hemorrhage from an ulceration of the carotid artery. Malignant Scarlet Fever.—This is a very severe form of the disease. The onset is abrupt, with a chill, vomiting or a convulsion. The fever is very high (1060 F. to 107° F.). The pulse is rapid and feeble. Delirium sets in and is followed by coma. Death may result before the appear- ance of the rash in twenty-four or forty-eight hours. The rash, if present, may become hemorrhagic. Complications.—Nephritis.—This usually develops during convalescence and, as it may be unattended by subjective symptoms, the urine in a case of scarlet fever should be examined daily in order to detect immediately the presence of albumin. In other cases the onset of nephritis is recognized by the suppression of urine, the development of uremia, and the appearance of dropsy. Nephritis may be the immediate cause of death, but more commonly the case ends in recovery or in chronic nephritis. Among other complications may be mentioned hyper- pyrexia, endocarditis, pericarditis, pneumonia, suppura- tion of the lymphatic glands, ophthalmia, inflammation of the middle ear, chorea, and a peculiar inflammation of the joints resembling rheumatism. Prognosis.—Always guarded. The mortality varies in different epidemics from five to forty per cent. Treatment and Nursing.—A case of scarlet fever should be immediately isolated. It is kept in isolation for at least six weeks, for it takes that length of time for the peeling to be completed. Children should not mingle with others for a month following their release from quaran- tine and should not sleep with others for three months. DISEASES OF CHILDREN FOR NURSES Cases of scarlet fever should be kept absolutely at rest to avoid complications and should be given a liquid diet as long as the fever lasts. The rash and the peeling which follows render it necessary to anoint the surface of the body with cold cream or carbolized vaselin two or three times a day. This relieves the itching and irritation of the skin and controls the desquamation. To avoid the danger of nephritis the children should be encouraged to drink water or lemonade freely. The nose and throat should be sprayed with antiseptic solutions. Nervous symptoms are relieved with ice-caps and cool sponges. Cardiac weakness should be combated by heart stimulants. Isolation and Disinfection in Contagious Cases.—Pro- phylaxis should be complete, as the disease is highly contagious and is prone to leave many serious complica- tions. The room selected should be at the top of the house if practicable, and it should have plenty of ventila- tion and be bright and sunshiny. All upholstered furni- ture should be removed, curtains and hangings taken down, and the carpets taken up. Where possible, two rooms and a bath should be set aside for the nurse and the patient. They must be iso- lated from the rest of the house, and no one should be allowed in the room except the physician and the nurses, unless he gives permission. The nurse should not eat her meals in the room with the patient. The room should be wiped up daily with a duster moist- ened with carbolic, bichlorid, or a 2 per cent, formalin solutions. The floor should be swept with a broom Scarlatinal angina (third day) (Hecker, Trumpp, and Abt). Follicular tonsillitis (Keeker, Trumpp, and Abt), CONTAGIOUS DISEASES 335 covered with a duster also moistened with the disinfecting solutions. After use, all dusters should be thoroughly soaked in disinfectant and then washed. The dishes and linen should be placed in separate metallic vessels containing water; these vessels should be draped in sheets wet with disinfecting solution. They should be removed daily. Unused food can be put into a similar receptacle, which should be removed three times a day. The contents should be burnt. Sheets wet with carbolic acid, 1140, should be hung over the doorways. All desquamation should be immediately burned or immersed in carbolic acid. The thorough disinfection of all articles which come in contact with the child is absolutely necessary. The nurse should be protected by a gown and cap, and before going out should take an antiseptic bath (see page 496) and change all of her clothing. The physician should be protected by a gown and cap while in the room and before leaving should wash his face and hands in an antiseptic solution. The contagium is contained in the secretions such as the urine, bowel movements, perspiration, and discharges from the nose and ear. All of these should be disinfected by covering with carbolic acid, 1: 40. The mildest cases should receive the same treatment and care, and isolation should be for the same length of time. The stools should be received in a vessel containing a disinfectant. An equal quantity of disinfectant to the size of the excreta should be added, the whole thoroughly mixed, and allowed to stand for a half-hour before emptying into the water-closet hopper. The bed-pan should contain disinfectant when not in use. It should be thoroughly 336 DISEASES OF CHILDREN FOR NURSES rinsed in warm water before placing it beneath the child, otherwise the disinfectant might burn the buttocks. After recovery the child should be given a warm bath and shampoo with bichlorid, i: 5000, rolled in a clean sheet which has not been in the isolation rooms, and carried to another room, where he can be dressed. The rooms should then be sealed, all articles in the iso- lation rooms hung over lines, and the rooms fumigated with formaldehyd. The disinfection of the nurse is practically the same as for the patient. A discharging nose or ear may be capable of causing the disease after the desquamation has ceased. Cases of empyema following scarlatina have caused outbreaks in surgical wards. Serum-treatment may be employed by the physician. MEASLES OR RUBEOLA This is an acute contagious disease characterized by catarrh of the respiratory tract, moderate fever, and a papular eruption appearing on the fourth day, lasting two or three days, and disappearing by fine desquamation. The rash also has the tendency to form crescents. Measles is a highly contagious disease. The poison is transmitted through the clothing and other articles which have come in contact with the person suffering from the disease; it can also be contracted by direct contact. The contagium is apparently associated with the nasal and bronchial secretions, but has not been isolated. Measles is most commonly observed in children, but unprotected adults are very liable to be attacked. It is essentially an epidemic disease, but now and then sporadic V. >'^ *s\ The eruption of measles two days after its first appearance (Hecker, Trumpp, and Abt). CONTAGIOUS DISEASES 337 cases are seen. One attack is fairly protective, but does not give absolute immunity. The period of incubation is two weeks. Symptoms.—Prodromal.—There is chilliness, coryza, watering of the eyes, photophobia (the inability to stand light), cough, and drowsiness. The Fever.—The temperature rises rapidly to 102 ° F. or 103° F., but on the second day there is decided remission, the temperature remaining down until the appearance of the rash on the fourth day when it again rises to or beyond the first range of temperature. It remains at this height for two or three days and then falls by crisis. FAHR. 1 z 3 4 5 6 7 8 M . E. M. E . M. e. M. E M. e:. M. E. M . E\ M. E. 107 106 (of 1 04- <03 A 102. A 1 0 1 I 00 1 99 7 98 X 97 Ca, tarr/rcd - ......-~............................ ,............ a:.:.^,.__„,_£_ ... * -A...... Fig. 105.—Position for intubation. The child's head is allowed to fall backward and is firmly held in position behind edge of table. The Schick Test.—A valuable skin reaction to de- termine the necessity of giving inmunizing doses of anti- toxin to those exposed to diphtheria. The Test.—A small amount of diphtheria toxin in normal salt solution is injected into the skin by a special needle. If the individual has no antitoxin present in his circulation there will develop a red, slightly swollen spot of erythema, with a brownish tinge, at the sight of the CONTAGIOUS DISEASES 347 inoculation within twenty-four to forty-eight hours, which lasts from seven to ten days. This is a positive reaction and shows he needs diphtheria antitoxin. A negative reaction shows the individual is already pro- tected by antitoxin in his blood. The average immuniz- ing dose is iooo units, and it gives protection for a short period only, not over four weeks, and sometimes only for ten days. Nursing.—The room should be selected as in scarlet fever, and the methods for isolating and nursmg contagious cases as described on page 334 should be followed. A moist atmosphere should be maintained. All cases which have been exposed to the contagium should be immunized with about 1000 units of antitoxin; this immunity will last for about one month. The nurse in charge of the case should also receive an immunizing dose of antitoxin. As the contagion is not contracted through the atmosphere of the room or through the air we breath, but through the discharges from the patient's nasopharynx, care should be taken in this direc- tion. The hands should be thoroughly washed and immersed in carbolic-acid solution, and all instruments which are used in connection with the patient should be irirmersed in the same solution. For this purpose a basin of carbolic solution, 1:40, should be kept constantly in the room. All linen and gauze which has been contaminated by the discharges of the patient should be immediately sterilized or burned. No one but the physician should be allowed in the room and he should be protected by cap and gown. The nurse should not leave the sick-room without changing her garments and washing thoroughly in carbolic or bichlorid solution. The nurse should 348 DISEASES OF CHILDREN FOR NURSES spray her nose and throat three or four times a day with spme antiseptic solution, and when out should not visit any houses, particularly where there are children. After a patient is well, all articles should be thoroughly fumi- gated and the patient should receive two disinfectant baths. Irrigation of nose with normal salt solution from a foun- tain syringe is often used in cases of nasal diphtheria. In faucial diphtheria the spraying of the throat with antiseptic or normal salt solution must be thoroughly done. In cases where the children are prone to eject pieces of membrane during irrigation, it is well for the nurse to protect her eyes with glasses and tie a piece of gauze over her mouth and nose. She should thoroughly disinfect her person, the bed, or the floor if they become contaminated with discharges. The pulse should be under observation at frequent intervals throughout the attack and during convalescence. Intubation.—In laryngeal diphtheria it is necessary at times to perform intubation. The operation consists in the introduction of a tube into the larynx. It opens the larynx and allows free breathing in cases where the larynx has become almost closed from the diphtheritic membrane. Different caliber tubes are used for the various ages. During the operation it is necessary for the nurse to hold the child's head in the following manner: The child is wrapped in a blanket to secure the arms and legs. The nurse's legs being crossed, her knees should firmly grasp the child's legs, her arms should hold the child's upper extremities, and her hands fix the head. At times the child is placed on a table, the head extending over the end and firmly held by a nurse. The child should be wrapped in a blanket. CONTAGIOUS DISEASES 349 Tracheotomy.—An incision of the trachea. It is neces- sary at times to open the trachea below the larynx to save the child from suffocation. A tube is introduced through the opening and the breath is drawn into the lungs through this passage. Nursing.—Intubation and tracheotomy demand con- stant nursing and watching. In tracheotomy if a piece of membrane or mucus plugs up the openings in the tubes Fig. 106.—Position for tracheotomy. The rolled blanket beneath shoulders and neck makes trachea prominent. suffocation results. If it becomes necessary to remove the inner tracheotomy tube, it is unlocked and drawn out; it should be cleansed in boric acid. Long feathers are passed through the opening and the mucus dislodged. After the air-passages are free the inner tube is reinserted. A moist atmosphere should be maintained. After the attack is over the tube is removed, the opening closed, and the child resumes breathing through the natural passages. In intubation, after the physician has introduced the 350 DISEASES OF CHILDREN FOR NURSES tube, he may cut the silk thread immediately or he may loop it over the ear. If he does the latter, it must be held fast by a strip of adhesive plaster. It is also wise to tie the children's arms in such a way that they cannot reach the string and pull out the tube; cuffs may answer this purpose (see page 493). Fig. 107.—Position for feeding in intubation. The head is allowed to drop over side of lap. Junket or semifluid food is most easily swallowed. When the silk thread is to be removed, always cut the knot off first. If this is not done, the wrong end may be pulled and the knot will then catch in the hole through which the thread passes, causing the tube to be dislodged. Feeding in Intubation.—The child should be placed on its back across the nurse's lap and the head allowed to drop • CONTAGIOUS DISEASES 351 slightly lower than the body. This allows the food to pass into the pharynx and not into the larynx. Semi- liquids, such as gruels, junket, thickened broths, etc., are more easily swallowed by older children than liquid food. SMALLPOX OR VARIOLA This is an acute contagious disease characterized by an eruption which is at first papular, then vesicular, and finally pustular. Etiology.—The poison of smallpox is extremely tenacious to life, remaining alive in clothes for a long time, and another attack of the disease may start from this source. Unless protected by vaccination or a previous attack the whole race is susceptible, from the child in utero to the very aged. The negro race is especially prone to the disease. Symptoms.—The disease usually begins with a chill followed by vomiting and intense lumbar pains. The fever rises rapidly, reaching 1040 to 105 ° F. in twenty-four hours. It continues at this height until about the end of the third or fourth day, when it drops several degrees. It remains at this new level until the vesicles become pustules, when a hectic fever develops which may be higher than the original temperature, and like all hectic temperatures it is marked by wide fluctuations. The temperature finally falls by lysis about the eighteenth day of the disease. All the symptoms which attend fever are present. The eruption is first noticed about the third or fourth day, appearing as small red spots on the face, forehead, and wrists. These small red spots are rapidly converted into small round papules which feel like shot under the 4 352 DISEASES OF CHILDREN FOR NURSES skin. This eruption rapidly spreads over the entire body. About the third day of the eruption the papules are converted into clear vesicles, divided by small filaments into several parts, something like the divisions ol an orange. This is termed loculation. When they are pricked with a needle the entire contents is not dis- charged, but only the fluid in the divisions opened is obtained. The vesicles have a small impression at their summit which is termed umbilication, and are surrounded by a red ring of inflammation. In two or three days the fluid in the vesicles becomes turbid and they become pustules. The loculation and the umbilication disappear. Between the lesions the skin is swollen and edematous, so that the features are unrecog- nizable. In three days more the pustules rupture, soft yellow crusts form which have an offensive odor, and adhere to the skin for a week or more. When the crusts fall off, pockmarks (small scars) remain as a permanent deformity. Confluent smallpox is a severe form of variola in which the pustules coalesce and the symptoms are severe. Malignant smallpox is associated with hemorrhages; at times there is bleeding into the pustules, constituting what is sometimes called black smallpox. Varioloid is a modified smallpox occurring in one who has been previously protected by vaccination. Prophylaxis.—Universal vaccination. Treatment.—The child should be immediately isolated. The room should be selected and the same precautions practised as described under Scarlet Fever (see page 334). The treatment is symptomatic. Nursing.—The instructions for isolating and disinfect- CONTAGIOUS DISEASES 353 ing in contagious cases as described on page 334 must be followed. The temperature of the room should be maintained at 68° F. It should be darkened to prevent pitting as much as possible. The diet should be liquid, and plenty of water or lemonade given at frequent intervals. It is absolutely necessary that the nurse should have been successfully vaccinated before attending a case of smallpox. If she has been exposed to the disease while unprotected by vaccination she should be immediately inoculated. All others who have come in contact with the disease should likewise be immediately vaccinated. She should not go out without taking a full bichlo- rid bath, and then should not visit other families. The child's urine should be examined frequently and the temperature, pulse, and respiration taken every three hours. Itching may be relieved by frequent sponging and soak- ing the crusts with oil. The child's hands should be cov- ered with mittens, preferably wet with normal salt solution. The children should not be permitted to scratch themselves; cuffs may be necessary (see page 493). The eyes should be frequently syringed, and the nose and throat sprayed. To prevent marked pitting: (1) The vesicles should be broken up with a fine sterile needle. (2) The base of the vesicles, after they are broken, should be cauterized with a sharp stick of silver nitrate. (3) The papules should pe painted with iodin. (4) Light and air should be excluded by covermg the exposed skin surface with sweet oil and dusting upon this a powder composed of equal parts of bismuth subnitrate and prepared chalk twice daily. This forms a mask. 23 354 DISEASES OF CHILDREN FOR NURSES VARICELLA OR CHICKEN-POX An acute contagious disease of short duration character- ized by slight fever and a vesicular eruption which dis- appears in two or three days. Symptoms.—There is slight fever and before the end of the first twenty-four hours there is an eruption usually appearing on the face and chest. At first the eruption consists of widely scattered papules which soon become vesicles. The vesicles are superficial. They are neither umbilicated nor loculated and usually are not surrounded by a red inflammatory ring. At times a small red areola occurs. The eruption appears in crops lasting over two or three days and rarely pustulates or leaves scars. The vesicles dry up and form crusts which adhere for a few days. Sometimes the drying starts at the center and thus gives the appearance of umbilication. Erysipelas occasionally complicates the disease. Treatment.—The disease is contagious, but it rarely requires isolation. As long as the crusts are present the disease can be transmitted. Nursing.—For the itching, mild solutions of carbolic acids can be applied. To remove the crusts nothing is better than applications of ichthyol ointment. Mittens should be placed on the child's hands to prevent them from scratching themselves. VACCINIA (COwTOX) Cowpox is a general disease with a local manifestation acquired by vaccination. The eruption of varicella on the fourth day (Hecker, Trumpp, and Abt). CONTAGIOUS DISEASES 355 VACCINATION The value of vaccination was first shown by Edward Jenner, in 1798. He noticed that the dairymen who came in contact with the disease in cattle were rarely affected by smallpox. At that time smallpox was univer- sal, the person who was not pock-marked being the Fig. 108.—Normal vaccination pustule on the sixth day after vaccination (Fruhwald and Westcott). exception, for terrible epidemics depopulated towns and villages. Jenner reasoned that cowpox had rendered these men immune to smallpox; therefore, arbitrary inoculation of individuals with the scabs from affected cows would produce the same immunity in others. He was fortunate in establishing his claims and soon vaccina- tion became a fixed custom. 356 DISEASES OF CHILDREN FOR NURSES To realize the immense benefit it has been to the human race it is only necessary to compare existing conditions with those of a hundred years ago. Now the pock-marked individual is the exception and epidemics are controlled. Antivaccination societies reason ignorantly, confuse syph- ilis, sometimes called pox, with vaccination, exhibiting pictures of syphilitic ulcers as the dire results of vaccination, and harp on the few instances of deaths following vaccina- tion which have been reported. A few bad results have occurred from improper technic and impure serum. This is not the fault of the method, it is due to the carelessness of the physician who vaccinates or of the manufacturers in making the serum. The risk at present is practically nil with modem methods of asepsis. In Prussia, where compulsory vaccination has existed since 1874, the death rate per 100,000 of population has dropped from 24.45 per cent., the average previous to 1874, to 1.51 per cent. A child, if healthy, should be vaccinated during the first two months of life, as the symptoms are very slight at that time. If delicate, wait until the child is in good condition and gaining in weight. A successful vaccination gives immunity for five years. Should the vaccination be unsuccessful, it should be repeated until a result is obtained. Method.—The skin surface is washed clean and rubbed with alcohol. Do not use antiseptic solutions, as they kill the germ before it enters the system and a nega- tive result follows. The upper layers of the skin are scraped off with a sharp bistoury until an exudation of serum takes place. Bleeding is to be avoided if possible. The serum is then introduced into the wound from the sterile tubes and thoroughly rubbed in by some flat instrument. The wound should be allowed to dry thoroughly before CONTAGIOUS DISEASES 357 applying an aseptic dressing. This dressing should be renewed as long as there is an open wound and during the course of the local inflammation. It is as necessary to keep dirt and clothing out of this wound as any other. Severe ulcerations result from infection. The course of the local manifestation is similar to that taken by the eruption of smallpox. First a papule, then a vesicle, umbilicated and loculated, followed by a pustule and a scab. It requires about the same time for develop- ment as the typical rash of variola. Three days is about the average for each stage. ERYSIPELAS An acute contagious disease excited by the streptococci and characterized by a peculiar inflammation of the skin and subcutaneous tissues. The germs can be carried in the clothes. Certain children are more predisposed than others. Those suffering from wounds or from diseases which lower the vitality are especially susceptible. The poison usually gains access through some wound or abrasion. In the newborn erysipelas starting at the navel is sometimes seen. Symptoms.—The disease is ushered in with a chill and there is fever, 1040 F., with all its symptoms. The inflammation usually begins in the neighborhood of the nose and spreads upward and laterally over the head to the neck, where it frequently stops. The affected part has a crimson hue, is swollen and tense, and is limited by a very sharp line or a well-defined ridge, beyond which, however, projections can be felt creeping out into the adjacent subcutaneous tissue. The surface of the inflamed 358 DISEASES OF CHILDREN FOR NURSES area is first smooth and glazed, but later it is covered with minute vesicles and blebs. The child complains of burning and tingling and the surrounding skin may be so edematous that the features are almost unrecognizable. In four or five days the redness begins to fade and the swelling disappears; desquamation follows and the fever falls by crisis. The average duration is from a week to ten days. Relapses are extremely common. Nursing.—The dressings should be kept fresh, changing them at least twice a day. The patient should be kept quiet and the urine should be examined. The clothing and articles which come in contact with the patient must be disinfected. Never put a case of erysipelas in a surgical ward. Serum treatment at times is used. PERTUSSIS OR WHOOPING-COUGH A contagious disease characterized by catarrh of the respiratory tract and peculiar paroxysms of cough, ending in a prolonged, whooping inspiration. The disease is highly contagious, proximity to the child with whooping- cough being sufficient to contract the disease. One attack protects from others. Symptoms.—There are three stages, the catarrhal stage, the paroxysmal stage, and the stage of decline. Half of the cases appear in the first two years of life. CatarrhaLStage.—The disease begins with the symptoms of coryza and bronchial catarrh. It is similar to other cases of bronchitis, but does not respond to the ordinary remedies for catarrh. After two or three weeks it passes into the paroxysmal stage. CONTAGIOUS DISEASES 359 In the paroxysmal stage the cough becomes more violent and is paroxysmal. During a paroxysm the face becomes cyanosed, the eyes are injected, and the veins distended. The cough frequently induces vomiting and in severe cases hemoipfiages. The close of the paroxysm is marked by a long-drawn whooping inspiration due to the spasmodic closure of the glottis. The number of paroxysms varies; there may be from ten to twelve or, in severe forms, from forty to fifty in twenty-four hours. Ulcers frequently form on the frenum (the small attachment of the tongue to the floor of the mouth) from forcible propulsion of the tongue against the lower teeth during a paroxysm. This stage lasts about three or four weeks. Stage of Decline.—The paroxysms gradually grow less frequent and less violent and finally cease. Complications.—Pertussis is very prone to be followed by some complication. Bronchopneumonia probably ranks as the most frequent and fatal complication, causing two thirds of the deaths. Convulsions occur in some cases. Prognosis.—During the first year the mortality is about twenty-five per cent. From this time on it rapidly decreases. Treatment.—Children suffering from pertussis should be isolated so far as possible. They should be kept from school and any other children in the family sent away. Delicate children should be particularly protected against the disease. The isolated period should be continued as long as the spasmodic stage lasts. Inhalations of menthol, amyl nitrite, or a few whiffs of chloroform will frequently control a violent paroxysm. Vaccine treatment is being extensively employed. The 360 DISEASES OF CHILDREN FOR NURSES greatest interest centers around the employment of vac- cines of the Bordet-Gengou bacillus. Vaccines at times undoubtedly do good, at other times they are disap- pointing. Nursing.—The child should have plenty of fresh air. During the day it is of benefit to take it out of doors. This is permissible if its temperature is not over ioo° F. At night the windows should be opened. Frequent changes of atmosphere and clothing seem to have a beneficial effect upon the spasms of cough. The seashore seems to aid in the cure of the disease. If a child vomits a meal a short time after eating it, another meal should be given. It is best to make the diet as liquid as possible. Infants should receive their milk diluted more than usual, and in severe cases it should be peptonized (see page 387). Light flannel underwear should be worn. The chest should be anointed with camphor oil daily, and inhalations of medicated steam should be employed. A practical measure which may be adopted in those cases in which vomiting occurs frequently during the paroxysm is to place a binder around the abdomen. This should be drawn tight, as it is the support which it gives to the abdominal muscles which is desired. By preventing these large muscles from being brought into full play during the paroxysm vomiting is frequently avoided, as it is usually due to their violent contraction making pressure on the filled stomach. Before disposing of the sputum and vomited material it should be disinfected. CONTAGIOUS DISEASES 361 PAROTITIS OR MUMPS This is an acute contagious disease characterized by inflammation of the parotid and other salivary glands. Fig. log.—Epidemic parotitis. Second day. The picture shows the uniform swell- ing in the region of the left ear, which has spread to the face and the submaxillary areas; also the characteristic elevation of the auricular lobule. The filling of the fossa between the mastoid process and the ramus of the lower jaw is, unfortunately, not visible. (Hecker, Trumpp, and Abt.) The bacilli of the disease are probably contained in the sputa. One attack confers immunity. Symptoms.—The disease is ushered in with chilliness, moderate fever, malaise, and a swelling of one of the parotid glands. The swelling is seen below and in front of the ear; the surrounding tissues are edematous and the submaxillary glands are soon involved. The features are swollen and distorted, the movements of the jaw are restricted and painful, and there is a decrease in the 362 DISEASES OF CHILDREN FOR NURSES flow of saliva, making the mouth dry and uncomfortable. The other parotid is usually soon affected. The swelling lasts five or six days. Complications are not often seen. Abscess of the parotid gland and deafness have been reported. Some- times the testes in the male and, more rarely, the breasts or ovaries in the female are involved, but these complica- tions are not common in childhood. Treatment.—This consists of the applications of ichthyol ointment. The sputum should be disinfected. INFLUENZA OR LA GRIPPE An acute contagious disease characterized by fever, extreme prostration, pain in the head and back, and generally by catarrh of the respiratory or gastro-intestinal tract. Etiology.—The disease occurs in epidemics. The exciting cause is a small bacillus found in the sputum. When prevalent no age or sex is exempt. One attack does not confer immunity from others. Influenza does not kill except by its complications. The most frequent are catarrhal pneumonia, croupous pnuemonia, anemia, and otitis media. Tuberculosis of the lungs, nephritis, neuritis, and meningitis are also seen. Symptoms.—The disease begins with languor, chilli- ness, severe pain in the head and neck, and fever ranging from 1010 to 1030 F. There is extreme prostration. In some cases the principal symptoms are those of the respiratory tract, in others the gastro-intestinal symptoms are most important, and in the third variety the nervous symptoms are most prominent. In simple cases the CONTAGIOUS DISEASES 3^3 temperature falls in two or three days by crisis, but com- plications not infrequently prolong the case for two or three weeks. Respiratory Symptoms.—There may be coryza, laryn- gitis, or bronchitis. This gives rise to a nasal discharge, cough, expectoration, sneezing, and watering of the eyes. Tonsillitis and otitis media are often associated conditions. Gastro-intestinal Symptoms.—There is vomiting and diarrhea with their attending symptoms. Nervous Symptoms.—Neuralgic pains in the head, back, and limbs. In some children the nervous symptoms appear alone in conjunction with the fever. One set of symptoms only may be present, but more often two or more tracts are involved. Skin eruptions occur at times. Prognosis.—Uncomplicated cases nearly always recover in from five to seven days. In the epidemic of 1918 the large number of deaths was due chiefly to pneumonia complicating the disease. This was principally bronchopneumonia in children. Treatment and Nursing.—The disease is communi- cable. The child should be put to bed and kept there until the fever is normal. A liquid diet should be given. The temperature, pulse, and respiration should be taken three times a day. If there is catarrh, the nose and throat should be systematically sprayed. Earache should be treated by syringing the ear with water at a temperature of no° F. The sputum should be disinfected. CHAPTER XVII CONSTITUTIONAL AND NUTRITIONAL DISEASES CONSTITUTIONAL DISEASES RHEUMATISM Rheumatism, as a whole, has varied manifestations in childhood. It may be articular, muscular, and neural. Rheumatic affections of the serous membranes, of the mucous membranes, and of the skin are found. The disease is uncommon under five years of age. The two most prominent types of rheumatism are articular rheumatism and muscular rheumatism. Acute articular rheumatism or inflammatory rheu- matism is an acute general disease characterized by irregular fever, inflammation of joints, and a marked tendency to affect the heart. In children the acute course with marked inflammation of the joints is uncommon. The cause of the disease is unknown. Some writers attribute acute articular rheumatism to bacterial infection, the germ being undiscovered. Poor hygienic surroundings, damp houses, and a sudden chilling of the body are the factors concerned in the onset of the disease. A great deal has been said lately of bad teeth and ton- sils as a causative factor of rheumatism. This undoubt- edly is true in many instances, but is not the only cause. 364 CONSTITUTIONAL AND NUTRITIONAL DISEASES 365 However, such conditions should be sought for and properly treated if they exist. Symptoms.—In children under ten years of age the disease begins slowly. There is fever (ioo° to ioi° F.) and stiffness in several joints. Marked inflammation with swelling and pain of the joints involved is uncommon. The ankles, knees, wrists, elbows, and small joints of the feet are the ones most often affected. The stiffness may move from joint to joint or one alone may be involved. At times the joints are so stiff that they make the child lame; more often these pains are designated as "grow- ing pains." Swreats are uncommon. The muscles are painful and there may be rigidity in more severe cases. The duration is from a few days to several weeks. One attack seems to predispose to others and anemia may result. After ten years of age the symptoms closely resemble rheumatism in the adult. Complications.—Endocarditis is the most common complication and may occur in very mild cases. About 40 per cent, of all cases of rheumatism have this com- plication. Pleurisy, pericarditis, pneumonia, chorea, iritis, meningitis, and certain cutaneous phenomena, such as pur- pura and urticaria, are also seen. Pharyngitis, tonsillitis, laryngitis, and bronchitis are sometimes caused by rheumatism. Muscular rheumatism is an affection of the voluntary muscles characterized by pain, tenderness, and rigidity. Types.—Different names have been applied, according to the location,, Torticollis or wry-neck, when it involves the sterno- mastoid muscle. 366 DISEASES OF CHILDREN FOR NURSES Lumbago when it involves the lumbar muscles. Pleurodynia when it involves the intercostals. Cephalodynia when it involves the occipitofrontalis. Exposure to the cold and wet, combined with muscular strain, usually excites it. Symptoms.—Pain is the chief symptom, aggravated by the use of the muscles, and is associated with tenderness. Sometimes the muscles are rigid and contracted, such a condition being frequently seen in torticollis. Torticollis.—The head is fixed and inclined to one side, every effort to turn it being accompanied with severe pain. The recovery is spontaneous in a few days. Treatment.—Ironing the neck gives great relief. A small iron, not too hot, is the best implement to use. A piece of flannel should be laid upon the skin for protection. Lumbago.—There is a dull, aching pain across the loins which is aggravated by turning the body or attempting to rise from a sitting posture. Pleurodynia.—The pain is felt in the side and is increased by deep breathing, coughing, or twisting of the body. The respirations are restricted on the affected side and there is tenderness to the touch. The absence of fever will serve to distinguish it from pleurisy. Cephalodynia is characterized by superficial head pains which are increased by movements of the scalp and are associated with tenderness on pressure. Rheumatism frequently appears to be the cause of neuritis. Treatment.—The salicylates and the alkalies are the remedies used in rheumatism. Nursing.—The room should be kept warm and at an even temperature. On account of the danger of endo- CONSTITUTIONAL AND NUTRITIONAL DISEASES 367 carditis the child should be kept in bed as long as there is fever. "Growing pains" should never be allowed to explain stiffness and discomfort in children. Involve- ment of the heart may follow such trivial symptoms, rheumatism not being suspected until a heart lesion is found. The child should be placed between blankets while in bed. If applications to the joints are necessary, it must be done in a way to avoid pain. ACIDOSIS This is a distinct condition in which acid substances are present in the blood, due apparently to a decrease in alkalinity of the blood, as indicated by diminished car- bonic dioxid tension of the alveolar air in the lungs. The symptoms may arise during an attack of summer diarrhea, pneumonia, nephritis, and diabetes, or they may develop without any discoverable reason whatever. It has a tendency to run in families at times. The only constant symptom apart from the laboratory tests of the alveolar air is a deep, exaggerated inspiration and expira- tion, usually not increased in rapidity and constantly present. Early restlessness and excitement are later dis- placed by prostration and coma. It is a dangerous condition; when the symptoms are well developed death is liable to occur. Treatment is directed toward re-establishing at once the normal alkalinity of the blood by the administration of bicarbonate of soda solution in sufficient quantities to render the urine alkaline. This is often done intrave- nously. 368 DISEASES OF CHILDREN FOR NURSES In addition to the treatment by alkalis the administra- tion of water in large amounts is important in all cases. If it cannot be given by the mouth or retained by the rectum, it may be administered by hypodermoclysis in the form of normal saline solution or, better, by intraperi- toneal injection. Starvation is the procedure indicated at the beginning of the treatment. Nursing.—In testing the carbonic dioxid tension of the alveolar air it is necessary for the patient to breathe into a rubber bag for twenty to thirty seconds; in infants a special mask has been devised by Marriott. The bicarbonate of soda solution must be sterilized in the following way: Bring a liter (331 fl. oz.) of distilled water to the boiling- point. Remove from the flame. Add immediately 30 grains of sodium bicarbonate (C. P.) taken directly from the original container and weighed in a sterilized vessel. Cool the solution to a temperature of no° F. and use what is required at once. DIABETES MELLITUS This disease is characterized by the presence of sugar in the urine, polyuria, and loss of flesh and strength. The exact cause of diabetes is not known. It is uncom- mon in childhood, but when it exists the course is very rapid. Symptoms.— Urinary.—The urine is increased in quantity, varying from three or four pints to six or eight quarts in twenty-four hours. It is light in color and of high specific gravity, 1030 to 1040, and leaves a whitish CONSTITUTIONAL AND NUTRITIONAL DISEASES 369 residue. In summer it attracts flies and has an aromatic odor. The total amount of sugar excreted in twenty-four hours can be from a few ounces to half a pound or more. General.—The most prominent symptoms in childhood are loss of flesh and strength. The temperature is normal or subnormal and the thirst is unquenchable. The tongue and mouth are dry, the bowels are constipated, the skin is dry and harsh, and frequently the seat of intense itching. This is especially observed at the genitalia and may be the first symptom of the disease. There are also attending nervous symptoms, such as headache, disturbed sleep, enuresis, and abscess formations. The course of diabetes melfitus in childhood is very rapid, much more so than in the adult, from two to four months being the average duration. The disease ends in a condition, analogous to uremia, called acetonemia, which is characterized by epigastric pain, dyspnea, a fruity odor to the breath, headache, delirium, stupor, and coma. Nursing.—The room should be light and cheerful. Bathing should be frequent. Thirst should be satisfied. A specimen of urine should be saved daily unless otherwise ordered, and the amount voided in twenty-four hours measured. Symptoms of acetonemia must be reported immediately. The temperature, pulse, and respirations should be taken once a day. Diet.—In diabetes the diet is of the utmost importance, all sugars and starches must be eliminated as far as possible. Food-stuffs permissible in diabetes are: cream, curds, milk, eggs, buttermilk, fish, oysters, clams, all meats except liver, all green vegetables, unsweetened jellies, 24 370 DISEASES OF CHILDREN FOR NURSES almonds, walnuts, butternuts, and pecans, tea and coffee with cream, but without sugar, and plenty of water. The bread should be made of gluten flour. The food-stuffs that must be avoided are: all sugar, potatoes, white and sweet, rice, beets, carrots, turnips, peas, and beans. Pastry, unless made with gluten flour, and liver. It is not necessary that the children should remain in bed, unless so ordered by the physician. PELLAGRA A disease endemic in certain parts of the world, the exact cause being undetermined. By certain investiga- tors it is supposed to be due to nutritional causes, a poor quality of cornmeal being especially blamed, and by others to a protozoon transmitted by the bite of certain flies or mosquitos. The weight of evidence at the pres- ent time seems to support the view that it is caused by a deficiency in the vitamins. Children are often affected where the disease is prev- alent. The symptoms are divided into the cutaneous, digestive, and nervous groups. The skin exhibits the most characteristic symptoms, which consist of an erythema, usually of the hands, feet, or neck, which becomes dark red and livid and is followed in about two weeks by drying, scaling, and pigmenta- tion. Along with the cutaneous symptoms are digestive dis- turbances (most marked under four years of age), such as dysentery, stomatitis, abdominal pains, and vomiting; also nervous symptoms, such as headache, vertigo, de- CONSTITUTIONAL AND NUTRITIONAL DISEASES 3/1 pression, insomnia, and cramps in various parts of the body. The disease has a tendency to improvement and sub- sequent recurrence. Sometimes several years may pass without an attack. Other parts of the body become in- volved and there is a gradual decline. Loss in weight becomes marked, the nervous symptoms more pronounced, and there is profound prostration. Severe cases may be fatal in two to three years, but usually the disease lasts a longer time. Recovery in fully developed cases is very unusual. Treatment.—The diet should be made abundant and nourishing and changed in some way from that which has been employed, especial care being taken to diminish the carbohydrates and increase the animal and vegetable protein. Infants should not nurse from pellagrous mothers. Hydrotherapy has proved valuable, and exposure to sunshine should be avoided, as it tends to increase the eruption. NUTRITIONAL DISEASES SCURVY, SCORBUTUS, OR BARLOW'S DISEASE This is characterized by bleeding, spongy gums, swell- ing and extravasations of blood around the joints, especi- . ally the knees and the ankles. There may be pseudoparal- ysis, immobility of the legs, extreme tenderness of the skin surface with swelling of the body and extremities, a thickening of the bones, marked anemia, and weakness. Cause.—Prolonged use of condensed milk, sterilized milk, and proprietary foods. The symptoms may come on slowly and last over sev- 372 DISEASES OF CHILDREN FOR NURSES eral months. If the character of the disease is not recog- nized it may prove fatal. Treatment.—The disease yields readily to treatment. This consists in giving orange-juice to the babies; in older children lemon-juice is used. Prune-juice and canned tomato-juice can also be employed. Potatoes and fresh vegetables can be given with advantage in children over one year, or even somewhat younger. RACHITIS OR RICKETS This is a nutritional disease of early childhood, charac- terized chiefly by defective formation of the bony struc- tures. It usually develops during the first or second year; it is not congenital. Poverty, artificial food, and bad hygienic surroundings are the predisposing causes. Breast-fed children rarely have rickets. The bones are soft, being extremely deficient in lime salts, and when ossification finally results the bones become heavy, large, and irregular in outlines. This causes such deformities as bow-legs, knock-knees, spinal curvature, pigeon-breast, and square cranium. The liver and spleen are often enlarged. The negro race is especially prone to the disease. Symptoms.—The early symptoms are restlessness and slight fever at night, free perspiration about the head, diffuse soreness and tenderness of the body, prominence of the abdomen, pallor, slight diarrhea, delayed dentition, and the eruption of badly formed teeth. Skeletal Phenomena.—The head is large and more or less square in outline; careful palpation may detect soft areas in the skull. The fontanel closes late. The sides of the chest are flattened, the sternum is prominent; nodules can be felt at the sternal end of the ribs called CONSTITUTIONAL AND NUTRITIONAL DISEASES 373 Fig. no.—Rachitic boy of three years. A large and somewhat angular head. The typic posture of a rachitic child, with the arms supported at his side. Curvature of the clavicles and the spine causes the neck to appear short. Contraction of the lateral di- ameter of the thorax; abdomen protrudes; curvature of the bones of the forearm (Hecker, Trumpp, and Abt). urachitic rosary." There may be a distinct transvere groove at the level of the ensiform cartilage called "Har- rison's groove." The spinal column is frequently curved anteroposteriorly, called kyphosis; or latterly, when it is 374 DISEASES OF CHILDREN FOR NURSES termed scoliosis. The long bones are curved and promi- nent at the extremities. This prominence leads to en- largements at the wrists and ankles. The deformities of the legs may be marked. At times it is impossible for the child to stand erect and at others the whole skeleton is so deformed as to produce rachitic dwarfs. The usual deformities are knock-knees, bow-legs, and anterior bowing of the tibia. These are corrected by operative measures. The bones are broken, set straight, and kept in place by the use of plaster casts. Prognosis.—Rickets in itself is rarely fatal. Some intercurrent disease, like pneumonia, may cause death. Treatment.—This consists in giving the affected children the best milk obtainable and all the fresh air and sunshine they can get. Salt baths, prepared by placing three to five ounces of rocksalt in a gallon of water in the baby's tub, and rubbing the child until the skin glows, is advantageous. Diet.—Beef-juice, orange-juice, cooked fruit, and broths may be added to the diet. Fresh vegetables must be tried as soon as the age permits. If no cereal food has been given, its administration may be begun. In fact, a varied diet is an excellent means for the cure of rickets;. and this should be commenced earlier than is commonly done with normal children. Rachitic children should be taught to sit and to lie straight on account of the possibility of deformity. For the same reason they should not be permitted to walk until this danger has passed. CONSTITUTIONAL AND NUTRITIONAL DISEASES 375 MARASMUS OR INFANTILE ATROPHY When a child is unable to digest and assimilate food for any length of time a pathologic condition sets in. The symptoms arising from this are grouped under the names of malnutrition and marasmus. Marasmus is the extreme form of malnutrition, occurring, so far as is known, without any constitutional or local disease. It is a re- sult of faulty nutrition only. The symptoms of marasmus are the same as those of malnutrition, only in a more advanced form. They are loss of weight until the child literally becomes skin and bones, pallor, anemia, and subnormal temperature. The appetite in severe cases is almost entirely lost. The stools are sometimes normal, but more often contain curds and undigested food and are large in comparison to the amount of food taken. Bed-sores frequently develop and the children die of exhaustion. Treatment.—This consists in discovering the food which is most easily assimilated and gradually increasing the strength of it until the normal percentages are properly digested. Such a diet may consist of egg-water, barley, arrowroot, and oat-meal water, malted soups, whey, buttermilk and milk mixtures, or, in a word, the entire subject of artificial feeding. Gavage may be necessary. Nursing.—Nutritional diseases are due to a lack of proper food, consequently the careful preparation and administration of the proper diet is of the utmost impor- tance. The character of the stools and vomit should be accurately reported and a careful chart of the child's weight kept. Bed-sores and pneumonia should be guarded against, and the temperature, pulse, and respira- tion taken at least twice a day. CHAPTER XVIII INFANT FEEDING Nutrition is the most important branch of pediatrics. The question whether a child will be strong and robust or a weakling is often determined by its food in the first three months of its life. The corner-stone of the con- stitution is laid during that period. The largest part of the immense mortality of the first year is traced directly to disorders of nutrition. At times temporary success may mean ultimate failure. This is illustrated in the use of many of the proprietary foods. The results seem to be satisfactory at first, the infant gains in weight remarkably, and the absence of certain vital elements from the food may not be noticed for months. It is finally discovered that the child has rachitis or some allied condition and it starts life handi- capped by an undermined constitution. Another mistake often made is the prolonged use of predigested foods. The child is unable to digest naturally the simplest foods after prolonged use of such methods, this function being undeveloped. Some children with very robust con- stitutions seem to thrive on almost any food, but they are the exception. THE FOOD CONSTITUENTS AND THE PART THEY PLAY IN NUTRITION This is well described by Holt and in part his descrip- tion is given below. " In infancy and childhood, as in adult life, the elements of the food are five in number: Proteids, fats, carbohydrates, mineral salts, and water. 376 INFANT FEEDING 377 The forms in which they must be served to a child and the relative quantities in which they are demanded, are different from those required by an adult. One of the reasons for this difference is the delicate condition of the organs of digestion in infancy, and the inability to assimi- late certain forms of food. Another reason is that pro- vision must be made not only for the natural waste of the body, but for its rapid growth, as it nearly trebles in size in the first twelve months. " Proteids.—-These are essential to life since they are the only kind of food that is capable of replacing the continuous nitrogenous waste of the cells of the body, upon the healthy condition of which the digestion and assimilation of other elements of food depend. The proteid is furnished by the casein and other albuminoids found in both the woman's and the cows' milk. It is also found in muscle fiber, white of eggs, gluten of wheat, etc. The proteids most easily digested by infants are those of woman's milk. The greatest difficulty in artifi- cial feeding has been to find other proteids to take their place. It is the difference in the digestibility of the proteids which causes most of the trouble in the substitu- tion of cows' milk for woman's milk. The average amount of proteid furnished in a good sample of woman's milk is 1.5 per cent. "Fats.—The uses of fats in the body are intimately associated with those of proteids. Fat possesses the important property of saving nitrogenous waste, so that when this is supplied in the food in proper proportions the entire energy of the proteid may be expended upon growth and nutrition of the cells of the body, without being used up in the production of animal heat. The demands upon the proteid by rapid growth of the body 378 DISEASES OF CHILDREN FOR NURSES during infancy make it desirable that whenever possible the fats should do the work of the proteid. "In addition to their use as a source of animal heat the fats add to the body weight by storing up fat in the body. They are needed for the growth of the nerve cells and fibers and are essential to the proper growth of bone. Fat also fills the role of a natural laxative. The produc- tion of fat required in infancy is greater than at other periods of life. Probably the most common mistake in artificial feeding is to give too little fat. This is one of the chief reasons for the failure of proprietary infant foods, all being insufficient in fat. Woman's milk of good quality contains from three to five per cent, of fat. "Carbohydrates.—Although these, like the fats, cannot replace the nitrogenous waste of the body, they are impor- tant aids to the proteids, and in this respect they are even more valuable than fats. The carbohydrates are partially changed into fat and may thus increase the body weight. They are capable of replacing the fat waste of the body, and are one of the most important sources of animal heat. The form in which carbohydrates are furnished to infants is milk sugar. "In building up the cells of the body the proteids are first in importance, the carbohydrates second, and the fats third. In production of animal heat the neces- sity to maintain life, the fats come first and the carbo- hydrates second. The proteids should never be called upon for this purpose. In a proper diet all of the ele- ments are represented. "Mineral salts are of greater importance in infancy than later in life, on account of the rapid building up of the bony system which is going on at this period. The most important for this purpose are the phosphate of INFANT FEEDING 379 lime and magnesium. These are furnished in abundance in both woman's milk and cows' milk. The salts are also necessary for cell growth, forming the mineral con- stituents of the blood and digestive fluids, and facilitating absorption, excretion, and secretion. "Water.—The food of all young mammals consists of from 80 to 90 per cent, of water. This is needed for the solution of certain parts of the food, such as the sugars and some of the proteids and for the suspension of other proteids and emulsified fats. All the food is thus dis- solved and very finely divided, so as to be more readily acted upon by the feeble digestive organs of the infant. Water is also needed in large quantities for the rapid elimination of waste in the body. When the diet of the infant is entirely fluid, additional water between feeding is unnecessary, but when solids are added and the feedings are at longer intervals, water should be given freely between feedings at all seasons, but more especially in summer." WOMAN'S MILK This is the ideal infant food. It is the secretion of the mammary gland. A few drops may be squeezed from the breasts before parturition. Generally speaking, how- ever, it is only present after delivery. During the first two days the secretion is scanty, but usually upon the third or fourth day it becomes established. It is bluish- white in color, usually alkaline, sometimes neutral, never acid in reaction. The specific gravity is 1031, and when precipitated it forms light floccufi, never precipitating in large masses, like cows' milk. The best method to maintain the quantity and quality of mother's milk is to have the breast thoroughly emptied 380 DISEASES OF CHILDREN FOR NURSES at each nursing; this stimulates its function. The ad- herence to regular feeding intervals is essential. If there is a failing supply, often the taking of large amounts of fluid will improve the quantity; water acts well if it does not cause the milk to become too thin. There does not seem to be any special value in drinking milk, as it has a tendency to make the mother unduly fat, and water is just as good. Undoubtedly, malted Fig. in.— Cremometer: The instrument is filled to the mark o with unskimmed milk and allowed to stand for from eighteen to twenty-four hours at the temperature of the room, when the depth of the layer of yellow cream can be read off in degrees. The num- ber of degrees corresponds to the cream percentage, which in good milk should never fall below 10 per cent, (after Chevalier). liquors help. Exercise, freedom from nervous tension, and open-air walks are beneficial. Colostrum.—The secretion in the first two or three days differs quite markedly from the later milk. It is of high specific gravity and very rich in proteids and mineral salts. INFANT FEEDING 381 Composition of Woman's Milk.—Proteids are usually present in proportion of one to two per cent. The amount of proteid is larger in the first few days; after the third week it is stationary to the end of lactation, when it falls very markedly. Fat: 4 per cent, is the average. Sugar : The ordinary variations are between 6 per cent. and 7 per cent. Fig. 112.—Scheme showing the composition of human and of cows' milk: i, Proteid; 2, fat; 3, carbohydrates; 4, salts (Fruhwald and Westcott). Salts : The average proportion is about 20 per cent. or about one-fourth that of cows' milk. EXAMINATION OF MILK The quantity is determined by weighing the baby be- fore and after feeding. The average amount of milk taken at one feeding by a child is an ounce for each month of its age until the eighth month. Reaction is obtained by means of litmus paper; specific gravity is obtained by means of a small hydrometer. Fats.—A cream gauge holding 10 cc. is filled to the zero mark, and allowed to stand for twenty-four hours at the temperature of the room. Then read off the per- 382 DISEASES OF CHILDREN FOR NURSES centage of cream. The ratio of cream to fat is: woman's 5 to 3; cows', after eight to ten hours, 4 to 1. The sugar and salts are constant. Sugar is estimated by Fehling's method. Proteins can only be approximately determined by the specific gravity and by the percentage of fats. A specific gravity higher than 1031 shows increase in proteins; lower, a decrease, if percentage of fats is normal. In- creased percentage of fats will lower the specific gravity, and a decreased percentage will raise it. Microscopic examination shows the presence of bacteria, etc. COWS' MILK This is the only milk of lower animals practically available for infant feeding. It must be fresh, clean, from healthy animals, preferably of a mixed herd rather than from a single cow. It is then more apt to be uniform, as a single cow is subject to daily variations. Animals should have fresh food and transportation should be as short as possible. For all practical purposes it is necessary that one should know only the amount of fat in the milk being used, as this is the only variable factor. The Difference between Cows' Milk and Woman's Milk.—Cows' milk is more opaque, slightly acid, or neutral, but never alkaline in reaction, as is woman's milk. There is less sugar in cows' milk, and the proteids in cows' milk are not only two or three times as great in amount, but they differ in their character. This latter is best shown by the digestibility of both proteids by the infant's stomach. Cows' milk in the stomach is coagulated into large, firm clots, which dissolve slowly, while woman's milk forms loose flocculent curds which dissolve readily. Cows' milk contains bacteria; woman's milk is sterile. INFANT FEEDING 3«3 Cream.—A great misapprehension exists as to the composition of cream. It is often spoken of as if it were entirely different from milk. It should be regarded as milk which contains an excess of fat, for the addition of cream to a mixture does not change the proteid percentage, but only the percentage of fat. In infant feeding it is convenient to make use of cream containing a definite percentage of fat. This may be either 8, 12, or 16 per cent. Sixteen per cent, is most often employed. METHODS EMPLOYED TO KILL THE BACTERIA IN MILK Pasteurized Milk.—The bottles, after having been thoroughly boiled, should be filled with the prescribed quantity of milk and corked with sterilized nonabsorbent cotton. Place the bottles in the cells of the pasteurizer and fill the cells with cold water. The cells are then Fig. 113.—Freeman's pasteurizer. placed in the pasteurizer, leaving out the middle set for the convenience of pouring in the boiling water. Next turn the faucet of the pasteurizer so that it will be open; then pour boiling water into the pasteurizer until it reaches the iron rods or until the water begins to run from the faucet; 384 DISEASES OF CHILDREN FOR NURSES then turn off the faucet. Place in position the center cells and put the cover on securely. In a half-hour remove the cover. Attach a hose to cold-water faucet over the sink and another one to the faucet of the pasteur- izer. Place the hose from the cold-water pipe inside the pasteurizer between the cells and the sides, turn on the cold water, and at the same time turn on the faucet of the pasteurizer, so that the water will run out at the bottom at the same time that it is running in at the top, thus causing a sudden cooling of the bottles, which is very important. After the bottles are thoroughly cold remove and place in the ice-chest. The pasteurizer should then be emptied by the hose attached to the faucet. Three important facts must be remembered in pas- teurizing milk. First, that the pasteurizer must stand on wood or on some other nonconductor of heat. Second, that the water poured into the pasteurizer must be boiling hot so that the temperature of the milk will be raised to 167 ° F. in ten minutes. Third, that the bottles must be rapidly cooled. To pasteurize milk when no regular apparatus is at hand, the bottles should be placed in a basket, preferably one made of wire, of which variety there are many on the market. A block of wood or a saucer should be placed in the bottom of a pan of cold water, and upon this stand the basket containing the bottles. This raises the bottles from actual contact with the bottom of the pan. The water is then heated until the sterile thermometer placed in one of the bottles of milk reads 167 ° F. This temperature should be maintained for one-half hour, when the bottles should be rapidly cooled under running water and placed on ice. When sterilizing a thermometer by boiling, be sure to INFANT FEEDING 385 have one which will indicate 2120 F., otherwise it will break. Sterilized Milk.—Prepare and fill bottles the same as for pasteurizing. The bottles are then set on a block of wood about one inch thick which is placed in a boiler so that the bottles do not touch the bottom. The water in the boiler should be then closely covered and allowed to steam for one hour. The bottles should then be removed, cooled, and put on ice. RECEIPTS FOR THE PREPARATION OF INFANT FOODS Barley Water.—Cover two tablespoonfuls of pearl barley with boiling water, let it boil five minutes, drain, and throw water away. Cover with two quarts of boiling water and simmer gently until reduced about one quart, which takes about two hours. Then strain through four thicknesses of gauze. The prepared barley flour of the "Health Food Com- pany of New York" or Robinson's Barley, two drams to each twelve ounces of water, and cooking for fifteen minutes is almost identical with the ordinary barley water (Holt). Starch............... 1.63 Fat.................. 0.05 Proteid............... 0.09 Inorganic salts........03 Water................ 08.20 contained in barley water (Holt). Total ioo.c Rice and Oatmeal Water.—Cover two tablespoonfuls of rice or oatmeal with boiling water. Let it boil five minutes, drain, and throw water away. Cover with two quarts of boiling water and simmer gently until reduced about one quart. Then strain through four thicknesses of gauze. If used alone, add a little salt. Rice Milk.—Wash a tablespoonful of the best rice 25 386 DISEASES OF CHILDREN FOR NURSES and boil it one and a half hours in a pint of new milk. Rub it through a fine sieve. Add two tablespoonfuls of granulated sugar, heat, and serve. Albumin and Milk.—Put the white of one egg into eight ounces of cold milk. Pour the whole into a fruit jar, screw on the top and shake vigorously for half a minute. It is then ready to serve. It should be light and smooth. Albumin Water.—Put the white of one egg into eight ounces of cold water. Pour the whole into a fruit jar and shake vigorously for half a minute, when it is ready to serve. Whey.—Heat one pint of milk to ioo° F. (no higher), add one teaspoonful of rennet and stir gently, stand aside to set, but not on ice. After the milk has been thoroughly coagulated, stir up the curds with a fork or spoon, and strain through a flannel cloth. One quart of milk will make about two-thirds or three-fourths of a quart of whey. In acute indigestion whey will often be retained when other foods are rejected. Whey and White of Egg.—To every 7 oz. of whey add the beaten white of one egg. Whey and Milk or Cream.—In adding milk, cream, or a milk mixture to whey, the whey should be made as directed above and after all the curds have strained off the whey should be heated to a temperature of 1500 F. and the milk, cream, or milk mixture must have been pasteurized before adding. Whey, Milk, or Cream and White of Egg.—Add the quantity of pasteurized milk or cream at the temperature and in the manner stated above; then the mixture must be cooled or quite cold before adding the beaten whites of the eggs, the number of whites being one to every seven INFANT FEEDING 387 ounces of whey used, and not one to every seven ounces of the mixture. Wine Whey.—Heat a half pint of milk in a saucepan, and when steaming hot add, quickly, four tablespoonfuls of sherry wine. Let the mixture stand for a few minutes on the stove, then take from the fire, break up the curds, and strain through flannel or four thicknesses of gauze. It may be served with or without sugar. Fully Peptonized Milk.—One pint of milk, 4 oz. of cold water, 1 peptonizing powder (5 gr. extract of pan- creatis, 15 gr. soda bicarbonate). Dissolve the powder in 4 oz. of water and to each bottle of milk of 4 oz. (previously pasteurized) add 1 oz. of the mixture. Stand the bottle in a pan of water 1200 F. and allow it to remain there for a half hour, when it should be used at once. Peptonize each bottle to be used just before it is time for the feeding. Milk, fully peptonized, should only be given by gavage or by the rectum on account of its bitter taste. All milk ordered peptonized and given by gavage or rectum must be fully peptonized. Partially Peptonized Milk.—One pint of milk, 4 oz. of cold water, 1 peptonizing powder (5 gr. extract of pancreas, 15 gr. soda bicarbonate). Dissolve the powder in 4 oz. of water and to each bottle of milk of 4 oz. (previously pasteurized) add 1 oz. of the mixture. Stand the bottle in a pan of water, 1200 F., and allow it to stand for ten minutes, when it is ready to be used at once. Feedings of more or less than 4 oz. must be worked on the basis of 1 oz. of peptonizing solution to 4 oz. of milk. Peptonized milk is valuable when there is feeble proteid digestion. It is not advisable to continue its use indefin- 388 DISEASES OF CHILDREN FOR NURSES itely, as the stomach gradually becomes less and less able to do its work. At the most it should be used only for a month or two at one time; when stoppage of this method is desirable, gradually diminish the amount of powder used. Method of Peptonizing Mixtures.—First, make up mixture according to the formula. Then add the pep- tonizing fluid (made according to the formula) and allow the whole quantity of milk to stand in a bottle or pitcher in a pan of water, 1200 F., for the prescribed length of time, say ten minutes or a half hour, according to the order. Then quickly raise the water around the milk to the boiling-point and allow it to boil for three or four minutes. Remove the milk, cool, and bottle, and place on ice. The boiling of the water around the milk will stop the peptonization which, if not stopped, will cause the milk to become very bitter; it also sterilizes the milk and does away with the necessity of pasteurizing. Oatmeal Gruel.—Mix two rounding tablespoonfuls of Bethlehem oatmeal with a little cold water; add a quarter teaspoonful of salt. Pour over it one pint of boiling water and stir over the fire until it boils. Then stand it where it will bubble slowly for a half hour, add a lump of sugar and a tablespoonful of whipped cream or a tablespoonful of sherry wine, and serve. Children seldom care for foods prepared with wine. Apple Gruel.—Good in irritation of the bowels. Core and quarter a large apple. Pour over it one pint of boiling water and simmer until it is reduced to a pulp. Strain. Mix two level tablespoonfuls of arrow-root with a little cold water and add to the hot apple water. Stir until it boils; then move back and let it cook slowly for ten minutes. Do not serve too hot and preferably without sugar. INFANT FEEDING 389 Farina Gruel.—Put a pint of milk into a double boiler. When it comes to the boiling-point sprinkle into it two level tablespoonfuls of Hecker's farina. Stir until it thickens and then let it cook for twenty minutes. Add a quarter of a teaspoonful of salt and a lump of sugar, and serve. Flour Gruel or Pap.—Put a pint of milk into a double boiler and let it come to the boiling-point. Moisten two level tablespoonfuls of flour with a little cold water and stir into the boiling milk. Add one-fourth of a teaspoonful of salt and let it cook for twenty minutes. Add a lump of sugar and a little nutmeg if desired. German Gruel made with Flour Ball.—Put one pint of flour into a strong bag and tie tightly with twine. Put into a kettle of boiling water and boil for five hours. When done take off the cloth and peel off the outside moist portion. Grate the ball and then put the flour into a baking pan and dry in a moderate oven for two hours, being careful not to brown. Moisten two tablespoonfuls of this flour with a little cold water and pour over it one pint of boiling water and simmer for three minutes. Add a small pinch of salt and a lump of sugar and 4 oz. of warm milk, and serve. Barley Gruel Liquefied or Dextrinized with Cereo or Maltine.—One heaping tablespoonful of barley flour, one pint of boiling water. Mix the flour in a small part of water and add to the rest. Boil fifteen minutes, then add enough cool water to make up the original pint. Cool to ioo° F. or 105 ° F. and liquefy with one teaspoon- ful of cereo or maltine. This predigests the gruel. Barley Gruel.—Moisten one tablespoonful of Robin- son's Patent Barley with 4 oz. of cold water; pour over 39° DISEASES OF CHILDREN FOR NURSES it 4 oz. of boiling water and add a half teaspoonful of salt. Let it simmer for five minutes; then add 4 oz. of hot milk. Let it come to a boil. Stir in a teaspoonful of sugar and serve. Arrow-root Gruel.—Moisten an even tablespoonful and a half of arrow-root in a little cold water. Pour over it a pint of boiling milk, stir over the fire until it thickens and let it boil slowly for ten minutes. Take from the fire and add a teaspoonful of sugar and one-fourth tea- spoonful of salt. When this gruel is made for a child who is on a weak milk mixture, like 3.6.1. or weaker, the gruel should be made with two-thirds water and a third milk instead of a pint of full strength milk. Arrow-root Gruel with Egg.—Separate an egg, beat the white and yoke until light; then mix them carefully. Add slowly one pint of plain freshly made arrow-root gruel, and serve. Rice Flour Gruel.—Mix a tablespoonful of rice flour with a little cold milk and add it to a pint of scalding milk. Cook for fifteen minutes. Add one-fourth teaspoonful of salt, a teaspoonful of sugar, one-fourth teaspoonful of ground cinnamon, and a teaspoonful of brandy. This is especially beneficial as a food in cases of diarrhea. Barley Jelly.—Put two tablespoonfuls of washed pearl barley into one and a half pints of water and slowly boil down to one pint. Strain and let the liquid settle into a jelly. Barley Jelly made with Robinson's Barley Flour.— Dissolve slowly two rounding tablespoonfuls of Robinson's barley flour with two ounces of cold water. Add one pint of boiling water and simmer gently for fifteen minutes, INFANT FEEDING 391 stirring all the time. Strain and let the liquid settle into a jelly. Beef Juice.—A piece of lean steak is slightly broiled on each side and the juice pressed out by a meat press or a lemon squeezer. Two or three ounces can ordinarily be obtained from one pound of beef. This is seasoned with salt and given cold or warm, but not heated suffi- ciently to coagulate the albumin in solution. If heated above 1600 F. it will be unfit for use. Beef Juice and Milk.—When beef juice is added to milk the milk should never be heated above ioo° F. before the addition of the beef juice. Barley Jelly, Maltine, and Milk Mixture.—Dissolve two teaspoonfuls of barley jelly (made with Robinson's flour) by adding one-fourth teaspoonful of Maltine and stirring. After the jelly has become a liquid add to the milk mixture in the proportion of the above quantity of liquid to every 4 oz. of mixture. Preparation of Gelatin in the Treatment of Infan- tile Diarrhea.—Five hundred grams (—17 oz., 3 dr. — 10 grs.) of chemically pure gelatin are dissolved in a liter (—33I oz. ) of boiled water; the solution is filtered, and after being sterilized for an hour in an autoclave at a temperature of 248° F., is poured into tubes having a capacity of 10 cc. (—21 \ fldr.), each tube thus con- taining 1 gm. (about 15 gr.) of gelatin. When it is desired to use this preparation, it is liquefied by plac- ing the tubes in hot water. As much as 12 gm. or 14 gm. have been given in the course of twenty-four hours. Weill commences with 3 gm. a day and increases at the rate of 1 gm. a day until a decided effect is produced. Oatmeal Jelly.—Soak two ounces of coarse oatmeal for 392 DISEASES OF CHILDREN FOR NURSES twelve hours in one quart of cold water, then boil the mixture down to one pint, and strain while hot through a fine cloth or several thicknesses of gauze. Malt Soup Mixture.—To make a 40 oz. mixture: 20 oz. of milk, 20 oz. of water, 3 oz., by measure, of wheat flour (measured loosely and not packed), i| oz., by measure, of malt soup. Number 1.—Mix the flour with the 20 oz. of milk and suspend it so as to make a uniform mixture. After as much of the flour is dissolved or suspended as possible strain through gauze (two thicknesses) to strain out all the lumps or excess. Number 2.—Dissolve the ijoz. of malt in 20 oz. of water. Number 3.—Take the first mixture and the second mixture, that is, the flour and the milk mixture and the malt and the water mixture, and stir them together thoroughly. Place the whole in an enamel pot (or double boiler) and put over a slow fire, allowing the mixture to come to 1600 F. and keeping it at that temperature for twenty minutes, stirring all the time. At the end of the twenty minutes bring the mixture to a boil and remove from the fire. If there is a loss in the bulk through the cooking make up the full amount (40 oz.) by adding sterile water; then place in the bottles and cool down slowly to the temperature of running water. When the mixture is finished it has a light yellow color, smells of malt, and when it cools becomes quite thick, but when again heated becomes fluid and easily taken through the ordinary nipple if the holes are large. When the malt soup mixture is ordered one-half or one-third strength, it means that instead of taking the full amount of milk (that is, the 20 oz.) half or only INFANT FEEDING 393 10 oz. of milk is to be used and the other half is to be water, making in the whole mixture, milk 10 oz., water 30 oz., instead of 20 oz. The extra 10 oz. of water is to be added to the 10 oz. of milk, and then the flour is dissolved or suspended in the half strength milk or pro- ceed as directed above. Buttermilk.—At times the proteid in plain cows' milk is indigestible even when given in very small percentages. Large curds continually appear in the stools. In such cases .buttermilk often cures the indigestion in remarkably short periods of time. It should be prepared as follows: Flour................................ 3! dr. by weight. Sugar................................15 " Buttermilk........................... i quart. The mixture should be brought to the boiling-point, stirring continuously. Just as it is about to boil it should be removed from the stove and cooled rapidly under running water. The mixture should then be placed upon the ice. The proper amount for the age is poured into a nursing bottle at feeding time and slightly heated. This mixture contains a much higher percentage of proteid than diluted cows' milk, but some change takes place in it which renders the mixture easily digestible. It should not be given for any length of time without the addition of cream. Buttermilk Conserve.—This is a condensed form of buttermilk. One part is added to three or four parts of water. It is a very good method of serving buttermilk. It should be slightly heated before adding the water. Buttermilk tablets are on the market under various trade names. If neither fresh buttermilk nor the conserve can be obtained, the tablets may be used. 394 DISEASES OF CHILDREN FOR NURSES Bean or Pea Soup.—Two tablespoons uncooked beans or peas. One-quarter teaspoon salt. One cup milk. Wash and soak beans or peas in cold water over night. Cook slowly. Add salt, and when soft mash through fine sieve. Add milk slowly till mixture is smooth. Cook over hot water for thirty minutes, beat for three minutes. Strain and serve. Thick Split Pea Soup.—One-half cup split peas; four cups cold water. One pint milk; one-half onion (if de- sired). One tablespoon fat; four tablespoons flour. One teaspoon salt; dash of pepper. Small piece of salt pork or bacon end. May be cooked with peas if desired. Pick over peas and wash in cold water. Soak for several hours or over night. Cook slowly with pork or bacon and onion until soft. Rub through sieve. Heat milk over hot water. Mix flour and seasoning in enough cold water to pour, and stir in milk. Cook, stir- ring constantly until thick and smooth. Add fat and pea pulp and more milk if too thick. Serve hot. Spinach Soup.—One-half cup cooked spinach (one quart uncooked). One cup milk (shake bottle thor- oughly). One-quarter teaspoon salt. Pick over and wash fresh young spinach in several waters. Put in small kettle without water—and let cook slowly until soft. Spinach will cook in its own juice. Mash through fine strainer, add milk, and stir till smooth; add salt and cook over hot water for five min- utes. Strain again before serving. Potato Soup.—Two medium-sized potatoes. One- quarter cup celery cut fine. One-quarter teaspoon salt. One cup milk. INFANT FEEDING 395 Wash and pare potatoes, cook slowly with celery in enough water to cover, add salt, and when soft mash through fine sieve. Add milk slowly till mixture is per- fectly smooth. Heat over hot water for fifteen minutes, beat for a few minutes, and strain for serving. Condensed Milk.—It is made by heating milk to 2120 F. to destroy the bacteria and then evaporating in a vacuum at a low temperature to less than one-fourth its volume. Condensed milk contains, after diluting six times, about 1 per cent, of fat, 1.20 per cent, of proteid, 7.23 per cent. of sugar, and .17 per cent, of salts (Holt). As the usual dilution is from twelve to eighteen times it is evident how it lacks in fats and proteid. Knowing how necessary fats and proteids are to the infant it can be appreciated why condensed milk should not be used as a permanent food. It sometimes works well as a slight change for a short period in acute indigestion, but it should not be used permanently without the addition of cream, and never if good milk and accurate milk mixture can be obtained. Junket.—To one pint of fresh luke-warm cows' milk add two teaspoonfuls of essence of pepsin or liquid rennet. Stir for a moment and then allow to stand until firmly coagulated. It is served cold. Kumiss and Bean Flour.—These are preparations sometimes used in infant feeding. Kumiss is a fermented form of cows' milk. It is more useful for older children than for infants. Bean flour has been recommended by Edsall for feedings in cases of difficult proteid digestion. Especially prepared flour must be obtained, and prepared according to the 396 DISEASES OF CHILDREN FOR NURSES physician's instructions. The mixture has a nauseating odor, but it has given good results in a limited number of cases. Protein Milk (Albumin Milk; Eiweissmilch of Finkel- stein).—The object of this preparation is to secure a milk for infant feeding which is low in sugar, high in protein, with a moderate amount of fat. It is made as follows: To 1 quart of whole milk is added a half ounce of rennet or enough to coagulate the casein. The whey is strained off through muslin by suspending the curd for one hour. The curd is then rubbed through a fine wire sieve. One pint of fermented milk (buttermilk, lactic acid milk, koumiss, or matzoon) is now added, also 1 pint of water. It is easier to rub the curd through the sieve if the fer- mented milk is gradually added during this process. The average composition of protein milk is fat, 2.5 per cent.; sugar, 1.5 per cent.; protein, 3 per cent.; salts, 0.5 per cent. For prolonged use, maltose should be added. Larosan Milk.—Two-thirds of an ounce of larosan powder is added to one-half pint of milk, and mixed thor- oughly. Another whole pint of milk is heated to the boiling- point. When it has come to a boil it is added to the larosan milk mixture, and the whole is placed on the flame and allowed to boil for five minutes. This may be diluted with water in the proportion of one-half or two- thirds larosan milk. This mixture, because of its high protein content and comparative ease of preparation, can be used as a substitute for albumen-milk. INFANT FEEDING 397 INFANT FOODS These are not in any way substitutes for mother's or properly modified cows' milk. They are capable of doing and have done much positive harm. They are the greatest exciting cause of rickets and scurvy. At times some of the preparations may be of considerable value, but chiefly for temporary use in pathologic conditions. Here they should be prescribed like drugs. The majority of the preparations are rich in sugar and lacking in fats and proteids. Children may gain weight, but they do so on the carbohydrates alone. The result of such develop- ment leads to the waxy appearance which children develop, when about a year of age, who have been fed on these foods. CHAPTER XIX ARTIFICIAL FEEDING The various elements necessary for proper food in infancy, the difference between mother's milk and cows' milk, the various ways of preparing cows' milk to render it sterile or more easily digestible, and the various other preparations that may be used as substitutes for milk were discussed in the previous chapter, so that it is in order to discuss the subject of infant feeding proper. The different methods of feeding which are available are breast-feeding, either by the mother or by a wet- nurse; mixed feeding, or a combination of artificial feeding and nursing; and artificial feeding exclusively. The first choice should always be maternal nursing. This is nature's food for the infant and nature cannot be improved upon. " While recent advances in artificial feeding have greatly diminished the necessity for wet-nursing, there are still many instances where, objectionable though they may be, they are indispensable for saving the life of the child, as the perfect substitute for good breast-milk is as yet un- discovered" (Holt). By mixed feeding is meant a combination of breast and artificial feeding. This may be resorted to when the milk supply of a mother is insufficient, or when the strain upon her health is unduly great. The same care must be 398 ARTIFICIAL FEEDING 399 exercised to keep the nipples clean and to have the feeding at regular intervals in breast feeding as in artificial diets. Weaning should always be done gradually, when possible, for the sake of both mother and child. "While there are many women, especially of the lower classes, who are able to nurse their children advantageously throughout the first year, the number of such among the better classes is certainly very small. By the latter nursing can rarely be continued beyond the ninth, and often not beyond the sixth month, without unduly draining the vitality of the mother and at the same time harming the child. Weaning in hot weather is usually to be avoided. " In cases of sudden weaning the food must be very much weaker in the beginning than for an artificially fed child of the same age. If weaned at six months the child should be put on a mixture suitable for a child of one month of age; if at nine or ten months, upon a food appropriate for a child of three or four months. If this is done the change can be made without causing much disturbance. When the infant has become somewhat accustomed to cows' milk, the strength can be gradually increased " (Holt). Recent Progress in Artificial Feeding.—A short review of the various methods employed in infant feeding, and the progress made in recent years, would seem to be neces- sary, so that the nurse will have a more comprehensive idea of what the physician is doing, and by what plan he is working. The percentage method of feeding, first advocated by Rotch, of Boston, and later made far more practical by 400 DISEASES OF CHILDREN FOR NURSES simplification, is really a method of calculation, and a means of obtaining relative accuracy in the preparation of infant foods. Bauer's formula is the standard plan by which this is accomplished. By this method cows' milk can be changed to any desired percentage strength in fat, car- bohydrate, and protein. Top milk feeding is another plan of arriving at per- centage mixtures. It is necessary, to successfully carry out this method, to know the percentages of fat at various levels in 32 ounces (quart) of milk containing 4 per cent, of fat, and which has stood for six hours or longer. Upper 7 ounces has 16 per cent. fat. " 9 " " 12 " 16 " " 7 " 20 " " 6 " 24 " " 5 " " The caloric method, by which the number of heat units required by the infant is sought, is not now used as a method of feeding, but as a check on the caloric contents of the food. It is of inestimable use in determining the caloric value of our mixtures in avoiding over- and under- feeding. More recently Czerny and Finkelstein have taught us the dangers of overfeeding with whole milk, and also its individual ingredients, fat, sugar, and salts, individually and in combination; buttermilk, albumen-milk (eisweiss- milk of Finkelstein), skimmed milk, larosan milk, and malt soups are frequently substituted by their disciples for cows' milk in certain intestinal conditions. During the past few years there has been an increasing tendency to boil cows' milk before feeding it to infants. ARTIFICIAL FEEDING 401 This has long been customary in Continental clinics. Its value lies in the fact that it renders the curd more fragile, and at the same time destroys the bacteria present in milk. It can be boiled over a flame or in a double boiler, the latter plan probably being the better, although the naked flame gives the finer curd. The changes caused in milk by boiling make it necessary to administer fruit and vegetable juices, non-dextrinized cereals, and other foods, such as cod-liver oil, to prevent a retarded devel- opment on the part of the infant. Citrate of soda, and the use of cereal diluents instead of water, prevent the formation of tough curds. Mixed Diet for Young Infants.—Perhaps the greatest change in infant feeding has been the earlier date at which mixed feeding is started. As early as the third month one to two teaspoonfuls of orange-juice are given. At five months a little well-cooked cereal can be added to one of the meals. From six to nine months infants readily take a broth and vegetable meal as a substitute for one of the milk feedings, in the form of a vegetable or meat soup. All of these additions must be started gradually. At the ninth month farina, a vegetable soup, or a clear broth (chicken, lamb, or veal) and toast or zweiback crumbs, with an additional portion of stewed fruit (apples, prunes) or a strained vegetable (potato, spinach, carrots, peas) can be added. As a rule, when more than one quart of milk mixture is needed to properly nourish the infant the age is reached when a mixed diet can be instituted. Dried milk has also received a great deal of favorable consideration, and where the physician desires a clean 26 DISEASES OF CHILDREN FOR NURSES milk, this form undoubtedly is serviceable. It is manu- factured as powdered whole milk and skimmed milk (Dryco, Klim, etc.). Larosan, a powdered milk prepara- tion, because of its high protein content and comparative ease of preparation, can be used as a substitute for albumin milk in the home. Cane-sugar, milk-sugar, and dextrin-maltose are used for the addition of carbohydrate to the mixture, the last perhaps being the best. The addition of potassium car- bonate or bicarbonate to the compound renders it laxa- tive. Saccharine is used to sweeten when sugars are with- drawn. Whole milk mixtures are also used by many physicians. In artificial feeding there are several fundamental principles which must be constantly borne in mind; they are well described by Holt and his work is quoted, in part, below: "The food must contain the same con- stituents as mother's milk: namely, fat, protein, sugar, inorganic salts, and water; the constituents must be pres- ent in about the same proportions as in good mother's milk; as nearly as possible the different constituents should resemble those of mother's milk both in their chemical composition and in their behavior in the digestive fluids; the addition to foods of very young infants of substances not found in mother's milk, like starch, is unnecessary, contrary to the best physiology, and if used in consider- able quantities may be positively harmful. " In the artificial feeding of infants, cows' milk is selected because it furnishes all the necessary elements, although not in proportions required by young infants. In feeding infants according to this plan the attempt is made so to ARTIFICIAL FEEDING 403 modify cows' milk as to make it conform in composition to woman's milk, and so to adjust the proportions of the various constituents to meet the individual cases. "In modifying cows' milk for infant feeding our calculations are based upon the composition of good breast milk, as determined by the latest analyses: Woman's milk, Cows' milk, per cent. per cent. Fat............4 3.5 to 4 Sugar...........7 4.5 Proteids..........1.5 4 Salts.............2 .7 Water...........87.3 87.3 (Holt.) "In cows' milk there is an excess of proteids and salts, too little sugar, and about the quantity of fat required. Other conditions which must be considered are the pres- ence of bacteria in cows' milk, its acid reaction, and the fact that its proteids are more difficult of digestion. " Fats.—The average amount of fat that an infant can digest varies from 2 to 4 per cent. It is rarely necessary in health to go above or below these proportions. Be- ginning with the 2 per cent, in the early days of life, this can be increased to 3 per cent, in a month, and to 4 per cent, at the age of five or six months. No other mod- ification in the fat is necessary. " Sugar.—In woman's milk the percentage of sugar is constant in all instances, between 6 and 7 per cent. In feeding cows' milk it is seldom necessary to have the sugar less than 5 per cent, and never more than 7 per cent. It should be distinctly understood that the purpose of adding sugar to milk is not to sweeten it, but to furnish the proper proportion of soluble carbohydrate necessary for the infant's nutrition. However, when good milk 404 DISEASES OF CHILDREN FOR NURSES sugar cannot be obtained, cane-sugar may be used. The amount added must be but little more than half that of milk sugar on account of its sweeter taste and its greater liability to ferment in the stomach. " Proteids.—The modification of the proteids is the most important change necessary in cows' milk, for it is the proteids which give the greatest difficulty in infant digestion. In ordinary cases in health, a reduction in the amount of proteids present is all that is necessary. The normal amount of proteids in woman's milk is 1.5 per cent. In very young infants it is necessary to reduce it even more than this, sometimes to .75 per cent, and even to .50 per cent. By the end of the first month the average child can take 1 per cent, and by the fourth month 1.5 per cent, and by the sixth month 2 per cent. The reduction of the proteids is effected by dilution with water." The meaning of such terms as 3.6.1. mixtures etc., is 3 per cent, fat, 6 per cent, sugar and 1 per cent, proteid mixture. Mixtures should always be expressed in the sequence of fat, sugar, proteid. " Inorganic Salts.—These, like the proteids, are exces- sive in cows' milk and to nearly the same degree. There- fore, when milk is diluted as required by the proteids, the salts will be nearly in their proper proportion and they may be dismissed from separate consideration. "Reaction.—The acidity of cows' milk may be over- come by the addition of either lime-water or bicarbonate of soda. Of the former, 5 per cent, of the total quantity is required; of the latter, one grain to each ounce of food." ARTIFICIAL FEEDING 405 Lime-water can be made by placing a piece of unslaked lime the size of an egg in a gallon of water; stir vigorously and allow to settle. The first water is poured off and fresh added. It should be kept covered. The subject of heating milk for the destruction of bacteria was considered on page 383. Fat is furnished by cream; protein by milk. Cream containing 16 per cent, fat is usually taken as a working basis, and a standard solution of milk-sugar of 20 per cent, strength should be used. Maltose, either in the form of malt soups or in com- bination with dextrin, "dextrimaltose," can be substi- tuted for milk-sugar. It is very much more easily assimilated than other sugars. It will, however, break down more readily. It should be weighed in determining the proper amount to add. Sugar Measure.—The most convenient method of measuring sugar is to employ a Chapin dipper. Level tablespoonsful can also be utilized. Chapin Level dipper. tablespoonsful 1 ounce sugar (cane) = 1 2| 1 ounce milk-sugar = \\ 3! 1 ounce dextrin-maltose =2 4 CREAM In the larger cities it is possible to obtain certified half-pints of cream of 16 and 12 per cent, strengths. When these are not available and the nurse has to de- pend upon an ordinary quart bottle of milk to obtain the cream, she will find the following table of service. 406 DISEASES OF CHILDREN FOR NURSES After a quart of milk, containing 4 per cent, fat, has stood for at least six hours, The top 2 ounces represent 24 per cent, cream. The " 6 20 a u The " 7 " 16 n n The " 9 " 12 a a The " 16 " 7 The " 20 " 6 n n If a pint of milk is used, one-half of the above quantities represent the percentages of fat; for example, 3\ ounces would equal a 16 per cent, cream, and \\ ounces a 12 per cent, cream. Milk containing 4 per cent, fat is about the average quality served to the public. It is not the richest milk obtainable, as this is not desired. The cream line of certified 4 per cent, milk in the ordinary shaped quart milk bottle is about 4 inches below the top, and when the visible cream is dipped off it will amount to about 5 ounces. Four per cent, fat milk means that if the quart should be shaken until an even distribution of the cream is ob- tained there would be 4 per cent, of fat in every ounce of milk in the bottle, whether the first or the thirty-second is used. When milk stands the fat rises to the top of the bottle and only the upper ounces contain it; if these should be dipped off, the bottom ounces would be entirely free from fat ("skimmed milk"). It must also be remembered that in obtaining definite strength creams, it is not meant that the top 7 or 9 ounces should be entirely composed of cream. Both the cream and the milk below the cream line must be used. This is obtained by two methods: (1) by siphoning, (2) by dipping. ARTIFICIAL FEEDING 407 Method for Siphoning.—A sterile glass tube long enough to reach to the bottom of a quart jar and curved at its upper extremity is placed in the bottle of milk. To its outer end a sterile rubber tube is attached, which runs to the sterile receptacle which is to receive the bottom milk. The bottom of the bottle of milk must be on a higher level than the receptacle. To start the flow of milk introduce a large ^-ounce sterile eye-dropper into the free end of the rubber tube. The bulb of the dropper must be tighdy squeezed Fig. 114.—Apparatus for siphoning. between the fingers when this is done. As soon as the dropper is in position release the bulb and the suction will draw the milk up the glass tube. Withdraw the dropper as soon as the milk has turned the curve of the glass tube. If, for any reason, the first attempt at suction is not suc- cessful, do not squeeze the bulb again without withdrawing the dropper, for if the bulb should be squeezed while still in position it would disturb the cream layer. Do not start the flow under any circumstances by suck- ing with the mouth over the free end of the tube. The 408 DISEASES OF CHILDREN FOR NURSES mouth is not sterile and would contaminate the end of the tube through which the milk flows. The milk is allowed to flow until all of the bottom milk is removed from the bottle and only the desired amount of top milk remains. For instance, to get a 16 per cent, cream, 25 ounces of the bottom milk would be siphoned off, leaving 7 ounces of 16 per cent, cream. Method for Dipping.—A special dipper is necessary, the best being a Chapin dipper. Fig. 115.—The Chapin dipper (improved form). The dipper is introduced open. When the top is on a level with milk the bottom is drawn upward, closing the dipper, and the first ounce can then be removed without spilling or disturbing the cream layer. The dipper contains 1 ounce, and the amount of top milk desired is removed by successive dipperfuls. Method for Changing Percentages of Cream.—To make 12 per cent, cream, take two parts of 16 per cent, cream ARTIFICIAL FEEDING 409 and one part of whole milk. Example: To make 9 dr. of 12 per cent, cream, take 6 dr. of 16 per cent, cream and 3 dr. of whole milk. Eight per cent, cream contains one part 16 per cent. cream and two parts of whole milk. Example: To make 8 per cent, cream, take 2 oz. of 16 per cent, cream and add 4 oz. of whole milk to make 6 oz. Fats. Sugars. Proteids. 16 per cent, cream.........16 4 3.60 12 per cent, cream.........12 4.20 3.80 8 per cent, cream......... 8 4.20 3.90 The fats alone are increased in cream, the sugar and proteid remain practically the same. Cream is the same as milk, with the addition of all the fat in the bottle which has floated to the surface. METHODS BY WHICH MILK CAN BE MODIFIED There are several formulae to expedite this work. At the Children's Hospital in Philadelphia the nurses construct the milk mixtures from the following: Baner's Formula.— Q = Total quantity to be used in twenty-four hours. F = The per cent, of fat desired in the mixture. S = The per cent, of sugar desired in the mixture. P = The per cent, of proteid desired in the mixture. M = milk. C = cream. L. W. = lime-water. Qx(F-P)____ -----*—!'—---*-----= cream. percentage of cream — 4 -*=---— the cream = milk. 4 5 per cent, of the total quantity = lime-water. Q — M-C — L. W. = sterile water. Qx(S-P) ... 56—*-----i = milk sugar. 410 DISEASES OF CHILDREN FOR NURSES Example.—A 4.7.2. mixture is ordered, 40 oz. to be given in twenty-four hours. The percentage of the cream used is 16. Q = 4o. F = 4. S=7. P=2. 4qx(4-2) 40x2 ---j-----' =---- = of oz. cream. 16-4 12 J 40x2 ----— Oj = 13^ oz. milk. 4 Y55 of 40 = 2 oz. lime-water. 40 - 6§ — 13 J — 2 = 18 oz. of sterile water. 40 x (7 — 2) 40x5 ----^---- = ~---- = 2 oz. milk sugar. 100 100 The proper proportions for a 4-7-2 mixture, 40 oz. to be given in twenty-four hours, based upon 16 per cent, cream are: Cream.......................... 6§ oz. Milk...........................i3| " Sterile water.....................18 " Lime-water...................... 2 " 40 " Two ounces of dry milk sugar are dissolved in this mixture. Short Cuts.—In a 3.6.1. mixture the cream equals one-sixth of the total quantity, if 16 per cent, cream is used; and the milk equals one-fourth of the total quantity. In a 3.6.1. mixture if a 12 per cent, cream, both the fat and the proteid are furnished by the cream and the addition of milk is unnecessary. Example.—Total quantity 32 oz., a 3.6.1. mixture made with 12 per cent, cream. 32X(? —i) ?2X2 „ *---^---L = ,5-r— = 8 oz. cream. 12 — 4 8 3~- 8 = 0 = milk. 4 ARTIFICIAL FEEDING 411 In a mixture where citrate of soda is used the powder is added in the proportion of 1 gr. to each ounce of milk or cream. The 5 per cent, of lime-water is not used in such a mixture, the citrate of soda giving the necessary alkalinity. In using a solution where 2 gr. = 1 dr., or any other solution, the amount of water used to dissolve the necessary number of grains should be subtracted from the total quantity of sterile water. Whenever milk is mentioned, it means whole milk, that is, milk that has not been skimmed, and in which a thor- ough distribution of the cream has been obtained by shak- ing the bottle. In diluting the whole milk to reduce the proteid, the fats are equally reduced. Therefore, it is necessary to add an extra amount of fat to the mixture to bring up its percent- age to the proper strength, which is higher than the per- centage of proteid desired; for this reason the cream is always added to whole milk. TOP-MILK MIXTURES In private practice it is often more convenient and less expensive to use top-milk mixtures instead of adding separate standard cream (like 16 per cent, cream) to a quantity of whole milk, in order to increase the amount of fat in a mixture of cows' milk. Cows' milk contains, for all practical purposes, 4 per cent. of fat, 4 per cent, of sugar, and 4 per cent, of proteid. If 1 per cent, of proteid is desired, it is readily obtained by diluting the whole milk with three times its volume of water, 412 DISEASES OF CHILDREN FOR ATURSES this makes the milk one-quarter of its original strength or i per cent, proteid. If 2 per cent, proteid is desired, the whole milk is diluted with an equal quantity of sterile water. This makes the protein one-half its original strength or 2 per cent. The fats and sugars are neces- sarily reduced in the same ratio. As was said before, the top 7 ounces of a quart of milk contain a 16 per cent, cream after standing six hours, and the top 9 ounces a 12 per cent, cream. The fats alone are increased in cream. The proteids are still approxi- mately 4 per cent. If a 3-6-1 mixture is ordered by the physician, and the child is taking ten bottles of 2 oz. each during the twenty- four hours, the total quantity for the day would be 20 oz. Therefore, it is necessary to make 20 oz. of a mixture containing 3 per cent, fat, 6 per cent, sugar, and 1 per cent. proteid. Method.—The top 9 oz. should be dipped, or the lower 23 oz. siphoned, off. This must be carefully done to avoid the risk of shaking up the cream and not obtaining the full strength of fat. This gives 9 oz. of milk containing 12 per cent, fat, 4 per cent, sugar, and 4 per cent, pro- teid. If this quantity should be diluted with three times its volume of water it would represent 3 per cent, fat, 1 per cent, sugar, and 1 per cent, proteid, as the milk would be only one-fourth of the whole mixture. If a 12 per cent, cream is used, and 3 per cent, fat is desired, the total quantity should be divided by one- fourth. Therefore, \ of 20 = 5. Hence, 5 oz. of the original 9 ounces of the 12 per cent, cream is the proper ARTIFICIAL FEEDING 413 amount in this example. To this must be added the proper amount of lime-water and sugar of milk, which may be worked out by Baner's formula, and enough sterile water to make the mixture the proper total quan- tity. Example: \ of 20 = 5 ounces of 12 per cent, cream. T§7 of 20 = 1 ounce of lime-water. ------------ X —^-^ = 1 ounce of sugar of milk, which dis- 100 100 solves and does not increase the quantity of the mixture. Subtracting 6 oz. (top milk and lime-water) from 20 equals 14 oz. of sterile water necessary to complete the mixture. Thus: Top milk.............. S ounces Lime-water............ i ounce Sterile water..........■ 14 ounces 20 " Sugar of milk.......... 1 ounce, which dissolves. The 5 oz. represent \ of 20, the dilution being 15 oz., so the fat is 3 per cent, and the proteid is 1 per cent. The sugar, which was reduced to 1 per cent, by this dilu- tion, is raised to 6 per cent, by the addition of the ounce of sugar of milk. That the top 9 oz. contain practically all the fat in the quart of milk can be proved by multiplying 9 by the percentage of fat and dividing by 100: 9 IOO = 1.08 ounces of fat in 9 ounces, and then subtracting this amount from the total quantity of fat in 32 oz. of a 4 per cent, milk, 32 x 4 - 1.28 ounces of fat in a quart, which 414 DISEASES OF CHILDREN FOR NURSES subtraction leaves .20 oz. of fat in the remaining 23 oz. of bottom milk, which is practically skimmed milk, and the addition of any amount of these bottom 23 oz. to a mixture would not raise the percentage of fat, but only the proteid. Therefore, if a 3-6-2 mixture is desired, it is only necessary to add some of the bottom milk to bring up the percentage of the proteid. Thus, 20 oz. of a 3-6-2 mixture are desired. From the previous example we know the quantities necessary to make a 3-6-1 mixture. By dividing the total quantity by \ we get the proper dilution of the fat to 3 per cent., but the proteid is likewise reduced to 1 per cent. Here it is necessary to raise the proteid to 2 per cent. This can be done as follows: If whole milk contains 4 per cent, of proteid, diluting with an equal amount of sterile water would give a 2 per cent, proteid, but we have already diluted with three parts of water, reducing the proteid to 1 per cent., therefore, by adding an amount of skimmed milk equal to the quantity of top milk used, we will double the percentage of proteid without disturbing the fat, consequently the result would be: Top milk................. 5 ounces Bottom milk.............. 5 " Lime-water .............. 1 ounce Sterile water.............. 9 ounces 20 Sugar of milk............. 1 ounce, which dissolves. One-half the mixture is milk and cream and one-half water. In this same manner any percentage of proteid can be worked out if it is remembered that one-quarter of the total quantity represents i per cent, of proteid. ARTIFICIAL FEEDING 415 Thus, if 1^ per cent, of proteid is ordered in a 20-oz. mixture, and 5 oz. represent 1 per cent., it would be necessary to add 2\ oz. of bottom milk. As it is only possible to obtain 9 oz. of 12 per cent. cream from 1 quart of milk, anything above 36 oz. of total mixture will require the purchase of an extra pint or quart of milk. For fat percentages lower than 3 per cent., it would be necessary to take smaller fractions; thus, one-sixth of the total quantity would represent a 2 per cent, fat if a 12 per cent, cream is used. The proteid would be reduced to two-thirds of 1 per cent., and sufficient bottom milk would have to be added to bring up the percentage. Example.—If 24 oz. of a 2-6-1 mixture is ordered: One-sixth of 24 oz. equals 4 oz. of top 12 per cent, milk, representing 2 per cent, of fat and two-thirds of 1 per cent. of proteid. If two-thirds of 1 per cent, is contained in 4 oz., 1 per cent, will be represented in 6 oz. |:i::4:x = 4-v-f = 6 ounces. Therefore, 2 oz. of bottom milk must be added. The formula would then read: Top milk................. 4 ounces Bottom milk.............. 2 " Lime-water............... \\ " Sterile water..............i6f " l4~ « Sugar of milk............ \\ ounces, which dissolves. The quantity of lime-water and sugar of milk are de- termined by Baner's formula. 416 DISEASES OF CHILDREN FOR NURSES Another method which can be used to arrive at the same result is to work with two bottles of milk. If the amount to be used is small, two pint bottles will answer. The top 3 \ oz. of milk in a pint represent a 16 per cent. cream. This amount can be dipped off and the quantity of 16 per cent, cream found necessary by Baner's formula can be added to the amount of whole milk required. The whole milk is obtained from the second bottle, which has been thoroughly shaken to get a uniform distribution of the cream. A 12 per cent, cream can be obtained by using 4^ oz. Two quart bottles can also be used when the quantities required cannot be furnished by the pints. Example.—Forty ounces of a 4-7-2 mixture are desired: The top 7 oz. of a quart give a 16 per cent, cream. Working with Baner's formula we find that 6§ oz. of a 16 per cent, cream are necessary; therefore this amount is taken from the top 7 oz. and added to 13^ oz. of whole milk taken from the second bottle, which amount is found to be the proper quantity to add to this mixture by working the formula (see page 409). CALORIC METHOD OF INFANT FEEDING This is a method based upon the energy requirements of the average infant in health. Calorie is the term used to represent units of energy; it is the amount of heat required to raise 1 kilogram of water i° C. in temperature. In feeding infants and children the practical value of this method lies in the fact that it enables one to see if he is feeding far above or below the physical require- ments, and it furnishes a good check to other methods. ARTIFICIAL FEEDING 417 The caloric values of the different ingredients in an infant's diet have been carefully calculated; the factors 9.3 represent fat; 4.1, sugar; and 4.1, proteid. Multiply- ing these known values by the amount of each ingredient taken, the total caloric value of the diet can be estimated. The results will be approximately as follows: 1 ounce of 7 per cent, milk has a caloric value of............... 27.5 1 ounce of 6 per cent, milk has a caloric value of............... 25.0 1 ounce of 5 per cent, milk has a caloric value of............... 22.5 1 ounce of 4 per cent, milk has a caloric value of............... 20.0 1 ounce of 3 per cent, milk has a caloric value of............... 17.5 1 ounce of 2 per cent, milk has a caloric value of............... 15.0 1 ounce of 1 per cent, milk has a caloric value of............... 12.5 1 ounce of fat-free milk has a caloric value of.................. 10.0 1 ounce of whey has a caloric value of........................ 10.0 1 ounce of milk-sugar, by weight, has a caloric value of......... 116.0 1 ounce of milk-sugar, by volume, has a caloric value of......... 72.0 1 even tablespoonful of milk-sugar has a caloric value of........ 44.0 1 ounce of barley flour, by weight, has a caloric value of......... 100.0 1 ounce of barley water (1 tablespoonful to a pint) has a caloric value of............................................. 2.0 1 ounce of malt soup extract has a caloric value of............. 80.0 1 ounce of condensed milk has a caloric value of............... 132.0 1 ounce of olive oil, by volume, has a caloric value of........... 245.0 —(Holt). The caloric value of any modification of cows' milk of known percentages may be calculated as follows: An infant is taking six feedings of 6 ounces, or 36 ounces daily, of a milk containing fat, 3.5 per cent.; sugar, 7 per cent.; protein, 1.75 per cent.: .035 (fat %) X 9.3 (caloric value of fat) = .07 (sugar %) X 4.1 (caloric value of sugar) = .0175 (protein %) X 4.1 (caloric value of protein) = .325 caloric value of fat in 1 gram of food. .287 caloric value of sugar in 1 gram of food. .072 caloric value of protein in 1 gram of food. .684 caloric value of 1 gram of food. .684 X 100 = 684 (caloric value of 1 liter of food); 36 ounces = 1.06 liters; 1.06 X 684 = 725 (number of calories in food taken daily). 27 418 DISEASES OF CHILDREN FOR NURSES Fraley's Formula.—A very simple formula has been suggested by Fraley to calculate the total number of calories furnished by the day's food: (2F + S + P) X it Q = C Twice the fat percentage plus the sugar percentage plus the protein percentage, multiplied by one and a quarter times the total quantity of food mixture given in the day equals the number of calories furnished by the day's food. Example.—Forty-eight ounces of a 3 per cent, fat, 6 per cent, sugar, and 2 per cent, protein mixture are being given in twenty-four hours. Substituting these figures the formula reads: (2 X 3 + 6 + 2) X ii X 48 = 14 X 60 = 840 calories. The average infant in health requires about 100 calories for each kilo {2% pounds) of body weight from the third week to the sixth month. These gradually diminish until at the end of the first year they are about 75 to 80 calories per kilo. The caloric requirements are greater in very active infants, premature babies, and those much below the average weight. For such mfants 125 to 150 calories per kilo may be necessary. Throughout the years of childhood they need about 80 calories per kilogram. The adult, moderately active, 35 ARTIFICIAL FEEDING 419 to 40 calories per kilogram, and the very aged about 27 calories per kilogram. In the undernourished child a higher caloric require- ment is needed. This may follow an illness or be due to improper dieting. Appended is a table worked out by Dr. Clifford B. Farr, of Philadelphia, which is especially useful, since it is con- structed on the basis of a definite caloric valuation. He gives the weight of the substances described which it required to produce 100 calories, or fractional parts thereof. In a given case, knowing the total caloric requirement, it is easy to calculate from this table how much of each article of food must be given to gain the desired result, and by adding together the caloric values of the quantities of each ingredient used the total caloric value is quickly estimated. The first column represents the weight in grams; the figures in parentheses, ounces avoirdupois. In the case of liquids the bulk in fluidounces is added: Calories. Article. Weight. 100 Steak, Tenderloin*.................. 35 gr- (J-3) 100 Beef, scraped, f (Round, cooked, lean). 54. (2) 100 Panopepton.J Largest dose recom- mended, 15 c.c..................... 140 c.c. 5 oz. 100 Chicken, Roastf..................... 55 (2) 100 Halibutf.....................■...... 83 (3) 50 Oysters (raw on shell)................ 96 (3.4) 100 Bacon (raw)............1........... 15 (.5) 25 Consomme......................--- 207 (7.3)—7 A- oz. * Locke, Food Values, New York, 1911. t Atwater and Bryant, Bull. 28, Dept. Agriculture. (Also indirectly for analyses given by Fisher and Locke.) % New and non-official remedies. 420 DISEASES OF CHILDREN FOR NURSES Calories. Article. Weight. 25 Beef-juice........................... 150 Warm process*.................... 5.3 oz.—5^ fl. oz. 12.5 Beef-broth*......................... 312 P. 1.02............................. 11.1 oz.—io| fl. oz. 25 Beef-juice........................... 200 Cold process*....................... 7.1 oz. P. 3.00............................. 7 fl. oz. 100 Yolks (a)........................... 27 (1)—f fl. oz. (a) ^ bulk, 6 to 7 caloric value. 75 Boiled egg (small) (b).........._...... 45 (1.6) (b) Shell, 11 per cent, gross weight. 100 Egg white (c) from 7 eggs, 26 gm. each. . 181 (6.4)—65 fl. oz. (c)| bulk, 1-7 caloric value. 25 Albumen-water,* double strength...... 200 2 whites to 8 oz...................... 7.1 oz. (52 gt egg white)..................... 7 fl. oz. 25 Asparagus (canned).................. 135 (4.9) 50 Green peas (canned).................. 89 (3.1) 25 Lettuce............................. 126 (4.5) 100 Lima beanst (cooked)................ 62 (2.2) 100 Potato (baked)...................... 86 (3.0) 50 Spinach (cooked).................... 87 (3.0) 25 Tomatoes (canned).................. 108 (3.8)—3.5 fl. oz. 100 Baked beansf (home-made)........... 50 (1.8) 100 Pea soupf (split).................... 77 (2.8)—2! fl. oz-. 100 Figs............................... 31 (1.1) 50 Apples (raw)........................ 103 (3.6) 100 Bananas............................ 100 (3.5) 50 Orange juice........................ 94 (3.3)—3§fl. oz. 100 Olives (green)....................... 32 (1.1) 100 Almonds............................ 15 (0.5) 100 Peanuts............................ 18 (0.6) 100 Olive oil............................ 11 (0.4)—\ fl. oz. 100 Sponge cake........................ 25 (0.9) 100 Baked custard,f egg, milk, sugar 2, 2 tablespoonfuls, \ cup............... 73 (2.6) 100 Sugar, granulated or lump............ 24 (0.86) 100 Maple syrup........................ 35 (1.2)—1\ fl. oz. 100 Milk-sugar, 2 even tablespoonfuls...... 25 (0.9) 100 Home-made white bread............. 38 (1.3) 100 Rolls, French or Vienna.............. 35 (1.2) 100 Shredded wheat..................... 27 (0.9) 100 Zwiebach........................... 23 (0.8) 100 Graham crackers (3)................. 23 (0.8) 100 Soda biscuits (4)f (Uneeda)........... 24 (0.9) 100 Rice (raw).......................... 28 (1.0) 100 Rice (boiled) (5 fl. oz.). 100 Rice (flaked) (9 fl. oz. by bulk). * Holt, Diseases of Infancy and Childhood, 5th ed. t Locke, Food Values, New York, 1911. ARTIFICIAL FEEDING 421 Calories. Article. Weight. 100 Cream of wheat (wheat flour)......... 27 (1.0) 100 Cream of wheat (prepared) (6 fl. oz. by bulk). 100 Oatmeal (flaked)..................... 25 (0.9) 100 Oatmeal (prepared). 25 Barley water*....................... 337 Tablespoonful to pint.............. 12 oz.; 11 fl. oz. ioo- Wheat or barley flour................ 27 (1.0) 100 Cheese, American.................... 22 (0.8) 100 Butter.............................. 13 (0.5) 100 Woman's milk,* 1.50; 4; 7............ 140 c.c; 5 oz. Av.; 5 fl. oz. 100 Cows' milk* (average)................ 140 c.c. 3.50; 4; 4.50........................ 5 oz.; 5 fl. oz. 100 Cows' milk (rich)*................... 127 c.c. 3-5o; 5; 4-5°........................ 4-5 oz.; 4^ fl. oz. 100 Cream, 16 per cent.*................. 56g. 3.25; 16; 4.05....................... 2 oz.; 2 fl. oz. 100 Cream, 20 per cent.*................. 47 c.o. 3.0-5; 20; 3.90....................... 1.7 oz.; if fl. oz. 100 Cream, 40 per cent.*................. 25 c:o. 2.20; 40; 3.00....................... 0.9 oz.; 1 fl. oz. 100 Top-milk, 7 per cent.*................ io2g. 3-5o;. 7; 4.50........................ 3-6 oz.; 3! fl.-oz-. 100 Skimmed milk* (1.80 per cent.)........ 2oog. (6 oz. removed from a quart of 4 per • cent.), 3.60; 1.80; 4-50. • •.......: ; • • 7-i oz.; 7 fl. oz. From 10 per cent, milk, with addition of milk-sugar,* 100 0.50; 1.50; 5.50...................... 256 etc:; 91 oz.; 8| fl. oz. From 7 per cent, milk, with addition of sugar,* 100 1.25; 2.50; 6.50...................... i8ig.; 6.5 oz.; 65 u. oz. From 4 per cent, milk, with addition of sugar,* 100 2.50; 2.80; 5.50...................... 169; 6 oz.; 6 fl. oz. From skimmed milk (1.80), with sugar,* 100 1.20; 0.60; 7.00...................... 256g.;9.ioz.;85fl.oz. 100 Condensed milk*.................... 33g- (Eagle brand)....................... 12 oz. 8.43; 6.94; 50.69..................... 1 \oz- 100 1 with 6 of water.................... 231 (8.3) 1.20; 0.99; 7.23...................... 72 n. oz. 100 1 with 9 of water.................... 322 0.84; 0.69; 5.1....................... "-S oz.; iof fl. oz. 100 Koumiss from cows' milk............ 220 2.66; 1.83; 4.09...................... 8oz-; 7f n-oz. 100 Buttermilk*........................ 278 3.60; 0.50; 4-06...................... 9-9 oz.; 9 A- oz. 100 Whey (from whole milk)*............. 285; 10 oz.; 93 fl. oz. 422 DISEASES OF CHILDREN FOR NURSES METHODS FOR DETERMINING THE PERCENTAGES OF VARIOUS MIXTURES Whole cows' milk contains 4 per cent, of fat, 4.5 per cent, of sugar, and 4 per cent, of proteid. Milk and Lime-water, 5 to 1.— \ of the mixture is milk. % of 4 per cent. = -2s° = 33 per cent, of fat. f of 4\ per cent. = ff = 3! per cent, of sugar. f- of 4 per cent. =-■§-=?& Per cent, of proteid. Therefore, this mixture contains 3I per cent, of fat, 3f per cent, of sugar, and 3J per cent, of proteid. Milk and Lime-water, 3 to 1.—The percentages a^e determined in the same way, three-fourths of the whole quantity being milk. Whey, 5 oz. + 1 oz. of a 16 Per Cent. Cream.— Whey contains 0.32 per cent, of fat, 4.79 per cent, of sugar, and 0.86 per cent, of proteid. Cream contains 16 per cent, of fat, 4 per cent, of sugar, and 3.6 per cent. of proteid. In this mixture one-sixth of the total quantity is cream. J of 16 per cent. f of .32 per cent I of 4 per cent. | of 4.79 per cent I of 3.60 per cent, § of .86 per cent, The mixture contains 2.92 per cent, of fat, 4.65 per cent, of sugar, and 1.31 per cent, of proteid. Rule for Determining the Percentage of Fat in a = 6 = 2.66 per cent, of fat contained in cream. = •■■"- = .26 per cent, of fat contained in whey. 2.92 per cent, of fat contained in mixture. = f = 0.66 per cent, of sugar contained in cream. = ~i~ = 3.99 per cent, of sugar contained in whey. 4.65 per cent, of sugar contained in mixture. = - = -6o per cent, of proteid contained in cream. = ' °= .71 per cent, of proteid contained in whey. 1.31 per cent, of proteid contained in mixture. ARTIFICIAL FEEDING 423 Mixture.—Add the quantities of the ingredients together. Multiply the percentage of the fat in the cream by the quantity of cream in the mixture and divide by the total quantity. Multiply the percentage of fat in the milk by the quantity of milk in the mixture and divide by the total quantity. The sum of the two results gives the percentage of fat in the mixture. Example.—In a mixture containing 5 oz. of a 16 per cent, cream, n oz. of milk (4 per cent, fat) and 24 oz. of water, the total quantity is 40 oz. ----"* = M = 2 per cent, of fat in the cream. 40 ■---- = #4 = i. i per cent, of fat in the milk. 4° ___ 3.1 per cent, of fat in the mixture. Therefore, the mixture would contain 3.1 per cent. of fat. CARE OF MILK IN THE HOUSE The best milk may be absolutely spoiled by carelessness in the methods employed for keeping it in the house. Too often in the large cities the bottles are left at the front or back door by the distributor at a very early hour in the morning. Two or three hours often pass before the milk is placed on ice; this may be during the hottest days of summer, and often after it has stood in the direct rays of the sun. Necessarily the milk should be placed imme- diately in the refrigerator. Some very ingenious devices are constructed by many to receive the milk and save the early morning rising, at the same time having the milk in proper surroundings. If the milk is not delivered in hermetically sealed bottles then nothing is better to keep it in than an ordinary mason jar which has been properly DISEASES OF CHILDREN FOR NURSES sterilized. The milk should not be allowed to stand in the refrigerator uncovered; nor should it be placed in the same compartment with the food. The best method to employ, if a separate compartment is not available, is to have a small refrigerator for the milk alone; many of these are on the market. However, a very satisfactory one can be improvised from an ordinary bread-box. The refrigerators must be kept scrupulously clean. If at any time there is a disagreeable odor perceptible upon opening the box, it is either due to neglect or to a leak into the packing between the walls of the refrigerator. As this packing is often hair, wool, or some similar substance, the water renders it mouldy and consequently unhealthy; when such a contingency occurs the refrigerator should be immediately abandoned. After the milk is on the ice it should be disturbed as little as possible, hence it is better to prepare the milk for the day at one time. Each feeding should be placed in a separate nursing bottle properly sterilized and stoppered with aseptic cotton. These bottles are placed in the refrigerator immediately. It is better to have the ice in a separate compartment from the milk, as the water which collects fom the melting of the ice is not pure, often containing dirt, and if from artificial ice, traces of ammonia. If, for any reason at all, a nursing bottle should topple over into this water, the milk within it may become contaminated. It is well to have the bottles stand in a wire frame. Milk left uncovered for fifteen minutes may render all the care and aseptic measures practised at the dairies useless. The same care must be used in handling condensed milk and buttermilk. All can openers used to open tins ARTIFICIAL FEEDING 425 containing the commercial varieties of these products must first be boiled. The entire contents of the can must be emptied into a sterile nursing bottle or some similar receptacle and kept on ice. Precautions must be taken to prevent contamination by placing sterile cotton in the mouth of the bottle and covering other forms of receptacles thoroughly. If a can of condensed milk is slightly warmed, by placing it in hot water for five minutes, the contents will run easily into a nursmg bottle. Con- densed milk that has been open for more than two days should not be used. Be careful to keep the cotton stoppers sterile while filling the bottles; do not carelessly place them where they may be contaminated. All vessels in which milk has stood for any length of time should be thoroughly scalded before refilling. Milk should not be kept warm in Thermos bottles or by any other method for any length of time. It favors the growth of bacteria. Even when pasteurized milk is so kept it permits the spores to develop. When milk is pasteurized all living bacteria are killed, but the spores ("the eggs" from which bacteria develop) are not de- stroyed. The nurse's hands should be thoroughly scrubbed before preparing milk mixtures and before feeding the children. BOTTLES AND NIPPLES The best style of bottle is that which can be most easily cleaned. On no account should bottles with any complicated apparatus be allowed. The cylindric bottles with wide mouths are generally preferred. The best nipples are those of plain black rubber which slip over the 420 DISEASES OF CHILDREN FOR NURSES' neck of the bottle. Those with long rubber tubes going to the bottom of the bottle should not be used, as it is practically impossible to keep them clean. The hole in the nipple should be large enough to allow the milk to drop rapidly when the bottle is inverted, but not so large as to permit the milk to run through in a stream. The bottles should first be rinsed with cold water, then washed with hot soapsuds and a bottle-brush. When not in use they should stand full of water. Before the milk is put into them they should lie for twenty minutes in boiling water. After the bottles have been sterilized they should not remain uncovered, but should be stoppered immediately with sterile cotton. Nipples should be boiled for five minutes daily, and when not in use they should be kept in a receptacle con- taining a saturated solution of boric acid. To prevent nipples from collapsing, the nursing bottle should be held at such an angle so that the nipple is con- stantly filled with milk. If for any reason a nipple is removed while feeding, do not put it down carelessly; it is better to drop it into the receptacle containing boric acid. RULES FOR FEEDING A child should not be more than twenty minutes taking its food, and should not be allowed to sleep with the nipple in its mouth. The bottle should be placed so that the child sucks milk, and not air. The bottle of milk should always be warmed to a temperature of ioo° F. before feeding. This is done by placing the bottle in water, which is heated until the de- sired temperature is obtained. One of the handiest and ARTIFICIAL FEEDING 427 quickest methods of heating milk is by using a " Bubble quick." This is a patented apparatus which can be ob- tained in most of the large cities. If there is regurgitation immediately after feeding, sit the infant upright. Often there will be an eructation of gas which will eliminate this tendency. A child should never be jumped up and down or rocked while it is being fed or immediately afterward. Children should be kept quiet after their evening meals to avoid the occurrence of night terrors. Schedule for Feeding Healthy Infants During the First Year. Number of Interval be- Night feed- Ounces Ounces Age feedings in tween meals ings: 10 p.m. for one for twenty- twenty-four by day. to 7 a.m. feeding. four hours. hours. Hours. 3d to 7th day.......10 2 2 1 to 1J 10 to 15 2d to 3d week.......10 2 2 i\ to 3 151030 4th to 5th week..... 9 2 1 2$ to 3^ 22 to 32 6th week to 3d month. 8 2§ 1 3 to 4$ 241036 3d to 5th month..... 7 3 1 4 to 5 J 28 to 38 5th to 9th month. ... 6 3 o 5J to 7 33 to 42 9th to 12th month--- 5 3$ o 7 J to 9 371045 (Holt.) Usually the child's food in health should be increased in strength just as fast as the child's digestion will permit. An infant much above the average in weight must have its food graded accordingly. With this knowledge artifi- cial feeding in health resolves itself into an easy problem. Indications for Varying Mixture.—In regard to the exact indications when the fats, sugar, and proteids of milk are to be varied in infant feeding, much is yet to be learned; however, the following are the chief points: Sugar.—If the sugar is too low, the gain in weight is slower than when it is furnished in proper amounts. Excess of sugar is shown by colic, or thin, green, and 428 DISEASES OF CHILDREN FOR NURSES very acid stools, which cause irritation of the buttocks. Sometimes eructations and regurgitations of small quan- tities of food take place. Fat.—Excess of fat is shown by vomiting or regurgita- tion of food in small quantities, usually one or two hours after feeding; sometimes by frequent stools which are almost normal. There may be fat lumps in the stools. Too little fat causes constipation, and dry and hard stools. Proteids.—Excess of proteids is shown by the presence of curds in the stools, by colic, constipation, and vomiting. Excess in quantity of milk given at a feeding, causes immediate regurgitation. It is not practicable to modify the milk so as to meet every temporary symptom of discomfort an infant may have. The general rules are; If they are not gaining in weight without special signs of indigestion, increase the proportions of all the ingre- dients. If there is habitual colic, reduce the proteids. For frequent vomiting, soon after eating, reduce the quantity. For the regurgitation of sour masses of food reduce the fat and also sometimes the proteids. For obstinate constipation increase both fat and proteid. THE USE OF FOODS OTHER THAN MILK DURING THE FIRST YEAR The addition of other foods should be deferred until after the sixth to the ninth month, with the exception of orange-juice, which can be given from the third month on, and gruel, which may be started at five months. ARTIFICIAL FEEDING 429 NINE TO TWELVE MONTHS DIET 6.00 A. m. Milk mixture, 8 ounces. 8.30 a. m. Orange or prune juice, \ to 1 tablespoonful. Can be given with 10 a. m. or 2 p. m. meal. 10.00 a. m. Milk mixture, 8 ounces, cereal (farina, oatmeal, etc.), 1 to 2 tablespoonsful. 2.00 p. m. Vegetable soup (spinach, bean, split pea, potato, carrots, etc.) or a clear broth (chicken, lamb, or veal). When starting soup feedings, first replace 1 ounce of 2 p. m. bottle by 1 ounce of soup in another bottle; then give 7 ounces of milk mixture. Gradually increase soup and diminish milk until an entire bottle of milk is replaced by soup. 6.00 p. m. Milk mixture, 8 ounces, and bread, zweiback, or cereal. 10.00 p. m. Milk mixture, 8 ounces, if needed. The scales are the best means of deciding whether a child is progressing favorable. At first the gain in weight will be slow—2 or 3 oz. a week; later, however, they should gain about 8 oz. a week. Most proprietary foods are composed almost entirely of carbohydrates and are insufficient in fats. Throughout childhood, in all acute febrile diseases, the rule should be less food and more water. When a child for any reason refuses to take its food, and there is danger of death from inanition, gavage should be practised. In acute diarrhea in infancy stop the mixture and give barley water for twenty-four hours; purge and return slowly to normal mixture. FEEDING DURING AND AFTER THE SECOND YEAR OF LIFE The average child, when it reaches the age of twelve months, can take plain milk without any addition of water, or milk with the addition of small quantities of water. The child should weigh about twenty pounds, be about twenty-nine inches in length, have six teeth, and during the second year begin to walk around a chair. 430 DISEASES OF CHILDREN FOR NURSES The child should be vaccinated during the second year, if this has not been done earlier. It should be taught to make known when it desires to urinate or to have a bowel movement, and to have them at convenient and regular periods five or six times a day. The foreskin of a boy should be retracted daily until there is no trouble in pulling it back. This prevents trouble later. A child should have a healthy complexion, a clean tongue, and well-digested bowel movements. TWELVE TO FIFTEEN MONTHS DIET 6.00 A. M. Milk, 8 ounces. 8.30 A. m. Orange juice, prune juice, or apple sauce (1 ounce). Can be given with 10 a. m. or 2 p. m. meal. 10.00 a. m. Milk, 8 ounces, and cereal (farina, oatmeal, etc.), 1 or 2 tablespoonfuls, slice of crisp bacon. 2.00 p. m. Vegetable (spinach, beans, potato, peas, carrots) or cream soup and zweiback, toast, etc., or a clear broth (chicken, lamb, or veal). The broth is usually given in the same quantity as the bottle. A little scraped beef or beef juice may occasionally be added. 6.00 p. m. Milk, 8 ounces, and bread, zweiback, or cereal, Gustard, or pap. 10.00 p. m. Milk, 8 ounces, if needed. DIET FROM FIFTEEN MONTHS TO TWO YEARS Breakfast (7.30-8.00 a. m.) : Fruit—Stewed prunes, orange juice, stewed peaches, baked apple, apple sauce. Cereal—Oatmeal, barley, cornmeal, hominy, pettijohn, farina, cream of wheat. Milk—Warm milk to drink. Bread—One slice of day-old toast or zweiback. Mid-morning Lunch (10.30 a. m.) : Milk—One cup. Bread—Day-old or toast. Dinner (12.30 p. m.): Main Dish: 1—Soup—Spinach, split pea, lima bean, asparagus, celery or carrot; or 2—Egg—Boiled, poached, coddled, or scrambled; or 3—Minced chicken and rice; or 4—Scraped lamb chop or rare roast beef and baked or mashed potato; or 5—Baked or mashed potato and chopped green vegetable. ARTIFICIAL FEEDING 431 Bread—One slice (one day old). Milk—One cup. Dessert—Egg custard, junket, cornstarch, rice, bread, or cereal puddings. Mid-afternoon (3.00-3.30 p. M.): Milk—One cup. Bread—(Day-old) or zweiback. Supper (5.00-5.30 p. m.): Cereal with milk. Rice with milk. Soup or eggs (if not served at noon). Milk and dry bread. Stewed fruit (if constipated). Always give a child water between each meal; the best time is one hour before feeding. Let it have all it wishes. Milk should be pasteurized if scarlet fever is epidemic. At the beginning of the third year the 9 p. m. bottle of milk can be discontinued. At this age a child can go without food for twelve hours and it is a better plan to have it retire with an empty stomach. The orange juice should be continued; vegetables may be added, but should always be put through a colan- der and served as a pulp. Potatoes, peas, squash, and spinach may be used. A dessert, such as junket, may be added. The diet during the third year will be as follows: 8 A. M., orange juice, 10 oz. of milk, 6 oz. of gruel, soft boiled egg, bread and butter. 10 A. M., 8 oz. of milk. i p. M., 6 oz. of soup, meat, vegetables, bread and butter, dessert. 5.30 P. M., 10 oz. of milk, 6 oz. of gruel, bread and butter. After three years of age three meals are sufficient. The food may be slowly increased in amount with a few additions until ten years of age. The diet will be as follows: 432 DISEASES OF CHILDREN FOR NURSES Breakfast: Fruit, cereals, milk, bread and butter, one or two eggs. Dinner: Soup, meat, bread and butter, vegetables, and dessert. Supper: Cereals, milk, bread and butter. The foods which may be given during this period are milk, cream, eggs, rare beef, mutton, lamb, white meat of chicken, and well-cooked fish. Vegetables: Potatoes, asparagus tips, spinach, stewed celery, string beans, and fresh peas. Cereals: The best are the hominy grits, split wheat, and oatmeal. They should be cooked at least six hours. The prepared cereals should be cooked about four times as long as the directions say. Broths and soups. Bread and biscuits. Desserts: Junket, plain custards, rice pudding without raisins, and, not oftener than once a week, good ice cream. Fruits: Oranges, baked apples—never raw apples until ten years of age, and then with caution. Jams and preserved fruits cause trouble. Do not give fat or greasy food to children. Only the meats and vegetables mentioned are feasible. Also hot bread, griddle cakes, all nuts, candies, pies, tarts, salads, jellies, pastry of every description, tea, coffee, cocoa, beer, cider, bananas, and dried fruits should never be given to children. A light lunch at 10.30 or n o'clock spoils the appetite for dinner. It is better not to change the child's food during the hot weather. ARTIFICIAL FEEDING 433 DIET LIST MUST NOT TAKE Hot bread, rolls, or griddle cakes. Fresh bread. Ready-to-serve cereals. Cakes. Ham. Sausage. Pork. Salt fish; smoked, canned, dried, or preserved meats or other food of same character. Corned beef. Dried beef. Kidney. Liver. Bacon. Stews. Dressing and Sauces. All fried foods. Fried eggs. Cabbage. Onions (raw). Radishes. Cucumbers. Tomatoes. Baked beans. Beets. Egg plant. Corn. Nuts. Pastry. Salads and pickles. Syrups. Preserves. Dried fruits. Canned fruits. Bananas. Pears, grapes, raw apples, berries, watermelon. Cantaloupes. Tea. Coffee. ' Beer. Wine. Tarts. Pies. Candy. Soda water. MAY TAKE Fresh fish, broiled or boiled. Mutton chops. Chicken. Chicken broth. Mutton broth. Veal broth. Roast beef and lamb—meats roasted or broiled and cut into small pieces. Beefsteak, scraped beef. Beef juice. Oatmeal Wheaten grits. Hominy. Rice. Cornmeal. Farina. Arrowroot. Cream of wheat. Barley gruel. Oat gruel. Milk and cream. Buttermilk. 28 Thoroughly cooked for three hours. Butter. Bread (24 hours old) toast. Whole wheat bread. Zweiback. Crackers, soda, oatmeal, and gra- ham. Milk toast. Potaotes, baked or mashed. Asparagus tips. Carrots, mashed. Squash. Spaghetti, plain, boiled. Macaroni, plain, boiled. Onions, boiled. Green peas, fresh and well boiled. String beans, fresh and well boiled. Beet tops. Spinach. Stewed celery. Boiled rice. Soup. Eggs, fresh, plain, omelette, soft boiled, poached, scrambled. 434 DISEASES OF CHILDREN FOR NURSES MAY TAKE Orange juice. Oranges, peaches, Junket. Cornstarch. stewed fruit, baked apples. Plain custard. Apple sauce. Puddings, rice (without raisins), Stewed prunes. tapioca, sago, bread. Vanilla ice-cream (no hokey pokey). Cocoa. All meals must be given at regular hours and nothing given between meals unless ordered by the doctor. Children must eat slowly and chew well before swallowing. Never give eggs unless you know they are fresh. Never feed a child milk unless you know it is clean and sweet. All vegetables should be well boiled. No seasoning except salt. ADJUNCTS TO FEEDING The principal adjuncts to feeding during childhood are rest, exercise, and ventilation. Rest.—Young children about two years of age require a great deal of rest. They should sleep twelve hours at night, with a nap in the morning and one in the after- noon; the afternoon nap should be at least two hours in length. As the child becomes older the morning nap may be dropped. At ten years of age they should have at least from ten to eleven hours rest a day. Children should never be too active in the afternoon, as this is frequently the cause of bed-wetting. Exercise.—During the first year the baby gets enough exercise from waving its legs and arms about. During the second year a "baby jumper" is helpful. From it the child obtains sufficient exercise without hurting and unduly tiring itself. If the child walks from room to room or about the chairs it should rest often to preserve the arch of the foot. Boys usually obtain sufficient exer- cise from play. Exercise is the best cure for constipation. Ventilation.—Give children all the fresh air they can get, do not have their clothing too tight, and have a window open in the room at night. An infant requires iooo cubic feet of fresh air. Older children should have between 700 and 800 cubic feet. CHAPTER XX THERAPEUTICS In the treatment of children more can be accomplished by good hygienic surroundings, careful feeding, and proper nursing than by the administration of drugs. Drugs are necessary under certain conditions, when it is better to give divided doses frequently than a large amount at one time. Drugs well borne by children include alcoholic stimulants, which should be diluted eight times before administration, quinin, calomel, iodids, cod-liver oil, bromids, chloral, and belladonna. Belladonna often causes an erythema or redness of the skin even when given in small quantities, but this does not necessarily mean that the drug is producing deleterious effects. Chloral should be given by the rectum. When given by the mouth it causes irritation of the mucous mem- branes. Drugs poorly borne by children include opium, usually given in the form of Dover's powder, salicylates, iron, and acids. Children are more susceptible to opium than adults. The other drugs mentioned have a tendency to derange the digestion. Mixtures containing arsenic should be diluted with at least eight parts of water when administered. 435 436 DISEASES OF CHILDREN FOR NURSES RULES FOR DOSAGE IN CHILDHOOD Several rules for dosage in childhood have been devised, founded on the fact that drugs influence the human organ- ism somewhat in proportion to the body weight. Fig. 116.—Medicine-dropper. Showing the correct method of dropping from the thicker portion of the tube. (J. P. C Griffith.) Young's Rule.—Add twelve to the age of the child and divide the sum into the age. This gives the pro- portionate quantity of an adult dose. Thus, the age of a child being two years, two plus twelve would be fourteen, and fourteen divided into two would be ^ or \ of the adult dose, being the proper dose for a child of two years. THERAPEUTICS 437 Cowling's Rule.—Divide the age of the child at the following birthday by twenty-four, and the result is the proportionate dose for that child. Thus, the followmg birthday of a child being four years, -fa or I of the adult dose would be the proper quantity for a child at three years. THE THERAPEUTIC LIMIT The therapeutic limit of a drug is the furthest point to which a drug can be pushed, with safety, in the treat- ment of a disease. The therapeutic limit of the following drugs is: Aconite. Tingling of the mucous membrane of the mouth and lips and a weak, compressible pulse. Antipyrin. Cyanosis, languor, and a weak pulse. Arsenic. Nausea and diarrhea. Puffiness under the eyes. Aspirin. Ringing in the ears. Belladonna. Dilation of the pupil, dryness of the mouth, and a rapid, corded pulse. Bromids. Mental torpor and an acne rash (bromism). Carbolic acid. Smoky urine. Cimicifuga. Frontal headache. Colchicum. Serous diarrhea. Digitalis. A slow, full pulse. Iodids. Headache, coryza, and sore throat. Mercury. Salivation, sore gums, and fetid breath (ptyalism). Oil of Wintergreen. Ringing in the ears. Opium. Contraction of the pupils and sleep. Phosphorus. Matchy taste. 43^ DISEASES OF CHILDREN FOR NURSES Quinin. Ringing in the ears. Salicylates. Ringing in the ears. Salol. Ringing in the ears. Strychnin. Stiffness of the muscles of the neck, twitch- ing of the muscles, and nervousness. Sulphonal. Pinkish urine. Tartar Emetic. Nausea and a slow pulse. Thyroid Extract. Loss of weight and strength, fever, and a rapid pulse. CONTRA-INDICATIONS Aconite. Contra-indicated in weak heart. Alcohol. Contra-indicated in typhoid if odor is present on breath. Chloral. Contra-indicated in hypertrophied heart and disease of heart muscle. Chloroform. Contra-indicated in heart disease. Digitalis. Contra-indicated in hypertrophied heart and disease of heart muscle. Ether. Contra-indicated in disease of the bronchi and lungs. Hyoscin. Contra-indicated in sore throat. Iodid. Contra-indicated in cavity formation in phthisis. Mercury. Contra-indicated in inflammations of a serous membrane with serous exudate. Nitrous Oxid Gas. Contra-indicated in aneurysm and arteriosclerosis. Opium. Contra-indicated in Bright's disease. Quinin. Contra-indicated in middle-ear disease. Strychnin. Contra-indicated in inflammations of the spinal cord. THERAPEUTICS 439 Tartar Emetic. Contra-indicated in infancy. Thyroid Extract. Contra-indicated in exophthalmic goiter. Tonics (Bitter). Contra-indicated in inflammations of gastro-intestinal tract. Veratrum Viride. Contra-indicated in gastric inflam- mations and weak heart. DOMINANT ACTION OF DRUGS Aconite depresses the heart directly. Amyl nitrite depresses the motor portion of the spinal cord. Bromids depress the motor portion of the spinal cord. Chloral depresses the motor portion of the spinal cord. Digitalis stimulates every portion of the circulation. Strychnin stimulates the motor portion of the spinal cord. DRUGS WHICH QUICKEN THE PULSE Alcohol. Ammonia.- Atropin. Ether. Nitroglycerin. DRUGS WHICH SLOW THE PULSE Aconite. Digitalis. Chloroform. Opium. Veratrum Viride. 440 DISEASES OF CHILDREN FOR NURSES DRUGS WHICH RAISE BLOOD PRESSURE Alcohol. Cocain. Ammonia. Digitalis. Atropin. Ergot. Strychnin. CHARACTERISTIC PULSES Aconite. Slow, weak pulse. Amyl Nitrite. Rapid, soft pulse. Digitalis. Slow, full pulse. Opium. Slow, full pulse. Veratrum Viride. Slow, weak pulse. DRUGS WHICH DILATE THE PUPIL Belladonna. Cocain. DRUGS WHICH CONTRACT THE PUPIL Eserin. Opium. DRUGS WHICH CAUSE SKIN REACTIONS Erythematous Eruptions: Antipyrin. Belladonna (resembles scarlet fever). Chloral. Quinin. Acneiform Eruption: Arsenic. Bromids. Iodids. Drugs causing Cyanosis: Antipyrin. Potassium chlorate. Hydrocyanic acid. Nitrites. THERA PE UTICS 44 J DRUGS WHICH COLOR THE URINE Carbolic acid. Creosote. Methylene-blue. Resorcin. Salicylates. Santonin. Sulphonal. Thymol. Smoky urine. Olive-green urine. Blue-green urine. Olive-green urine. Olive-green urine. Yellow urine. Pinkish urine. Olive-green urine. Turpentine and eucalyptus give an odor of violets to urine. DRUGS WHICH COLOR THE STOOLS Bismuth. Black stool. Hematoxylin. Red stool. Iron. Black stool, Silver. Black stool. VACCINES These are dead bacteria suspended in normal salt solution and are used in the treatment of a large variety of conditions. /-.2 DISEASES OF CHILDREN FOR NURSES DRUGS OF THE U. S. PHARMACOPEIA MOST COMMONLY EMPLOYED IN CHILDREN'S DISEASES, TOGETHER WITH THEIR DOSES FOR CHILDREN TWO YEARS OLD Acetanilid, gr. ss-j. Aceta. Acetum opii, TTLss-j. scillae, JTti-v. Acida. Acidum aceticum dil., Tfyv-xv. carbolicum, gr. \. gallicum, gr. ss-ij. hydrocyanicum dil., Tfl|-i. hydrochloricum dil., Tfl,i-v. nitricum dil., Ttti-iij. nitrohydrochloricum dil.,T)Xi-v. phosphoricum dil., Tfl,i-v. salicylicum, gr. j. sulphuricum dil., TTU-v. aromaticum, TILi-v. tannicum, gr. ss-ij. ^therea. ^ther, TTlii-x. Chloroformum, JJIi-v. gr. l-v. Ammonia. Ammonii bromidum, carbonas, gr. ss-j. chloridum, gr. i-v. Antimonium. Antimonii et potassii tartras, gr. 3T~¥- Antipyrin, gr. ss-ij. Aspirin, gr. ss-iss. Aquae. Aqua ammoniae. (External.) camphorae, f^j. cinnamomi, f.^i-ij. menthae piperitae, f3i~ij- rosae. (External.) Argentum. Argenti nitras, gr. 3^—gV nitras fusa. (External). Atropin Sulph., gr. ^-^,. Bismuthum. Bismuthi subcarbonas, gr. i-i subnitras, gr. i-v. Calcium. Creta praeparata, gr. ii-x. Testa praeparata, gr. ii-x. Carbo Ligni, gr. i-v. Cerata. (External.) Ceratum canthar. cetacei. ext. canth. plumbi sub. resinae. resinae com. sabinae. saponis. zinci carbon. Charts;. (External.) Charta sinapis. Chloral, gr. i-v. Codein, gr. &-£. Collodium. (External.) Collodium cum cantharidft. flexile. Confectiones. Confectio sennae, gr. x-xx. Decocta. Decoctum haematoxyli, f^i-ij hordei, f3 i-iv. quercus. (External.) Digitalin, tijjss-v. Emplastra. (External.) Emploastrum assafoetidae. belladonnae. hydrargyri. opii. THERAPEUTICS 443 Emplastra. (External.) Emploastrum picis burgundicse. cum cantharide. resinaa. saponis. Extracta. Extractum belladonnas, gr. 3*2 ~fV cinchonae, gr. i-iv. colocynthidis C, gr. \-\. gentianae, gr. \-y glycyrrhizae, gr. i-v. haematoxyli, gr. i-iv. hyoscyami, gr. ^g-J. krameriae, gr. \-\\. malti, Tllxv-f^ss. nucis vomicae, gr. -^x"Ti- taraxaci, gr. ii-x. Extracta Fluida. Extractum buchu fluid., Tttii-v. cascara sagrada fid., Tttii-x. cimicifugae fluid., HXiv-viij. ergotae fluid., TTli-ij. gelsemii fluid., fili-^. grindeliae fluid., (External.) pilocarpi fluid., Tttx. pruni virg. fluid., ITlx. rhei fluid., Tfti-v. sennae fluid., TTLX-XXX- spigeliae et sen. fluid., fgj. uvae ursi fluid., TTlii-v. Valerianae fluid., Tit ii-x. Ferrum. Ferri citras, gr. ss-ij. et ammonii citras, gr. ss-ij. et potassii tartras, gr. ss-ij. et quininae citras, gr. ss-ij. lactas, gr. ss-ij. pyrophosphas, gr. \-y subcarbonas, gr. i-ij. sulphas exsiccata, gr. J-j. Ferrum reductum, gr. ss-ij. ■alycerita, (External.) Glycerinum acidi carbolici. gallici. tannici. Heroin, gr. 5V5V Hydrargyrum. Hydrargyri chloridum corros., gr- Tib". mite, gr. 55-iss. Hydrargyrum cum creta, gr. ss-iss. Infusa. Infusum buchu, f.^i-ij. calumbae, f.^i-ij- digitalis, TTLx-f^ss. lini, f^ss-ij. Kamala, gr. v-xv. Linimenta. (External.) Linimentum ammoniae. calcis. camphorae. cantharidis. chloroformi. plumbi subacetatis. saponis. terebinthinae. Liquores. Liquor acidi arseniosi, TU\i-iij. ammonii acetatis, fgss-j. arsenici et hydrarg. iodidi, Tltss-j. calcis, fji-f^iij. ferri nitratis, TTLi_iij-. subsulphatis, TTtss-j. magnesii citratis, fgii-f^ss. pepsini, f^ss-f.^j. plumbi subacetat. dil. (Ex- ternal.) potassii arsenitis, TuJ-iij- citratis, f^ss-j. sodae chloratae. (External.) Magnesium. Magnesia, gr. v-gr. xl. Magnesii carbonas, gr. v-gr. xl. sulphas, gr. v-xv. Manna, gr. xx-^j. Mellita. (External.) Mel despumatum. rosae. boracis. 444 DISEASES OF CHILDREN FOR NURSES Misturae. Mistura ammoniaci, f^ss-ij. amygdalae, f^i-^fj. assafoetidae, f^i-ij. chloroformi, f^i-ij. cretae, f.^ss-j. ferri comp., f^i-ij. ferri et ammonii acetatis, f£ ss-j. glycyrrhizae comp., ITLxv—f^ss. potassii citratis, f^ss—j. rhei et sodae, f^ss-j. Morphina. Morphinae acetas, gr. -fa—£5. murias, gr. ¥Y-*V sulphas, gr. ^"To- Moschus, gr. i-ij. Mucilagines. Mucilago acaciae, ad lib. sassafras medullae, ad lib. tragacanthae, ad lib. ulmi, ad lib. Nitroglycerin, gr. ^ Olea. Oleum chenopodii, Tttii-iv. cinnamomi, Till. gaultheriae, TTLi-ij. menthae piperitae, Tfl_ss-j. morrhuae, TTLxv—f^j. olivae, f^i-ij- ricini, f^ss-ij. succini. (External.) terebinthinae, Tflii-v. Oleoresinae. Oleoresina aspidii, TTLv-xx. Opium, gr. TV-J. Pelletierine tannas, gr. i-v. Pepo, 3i-ij. Petrolatum (External). Phenacetin, gr. ss-j. Phosphorus, gr. i^-rh- Plumbum. Plumbi acetas, gr. §-§. Potassium. Potassii acetas, gr. ii-v. bicarbonas, gr. ii-v. bitartras, gr. x-xv. bromidum, gr. ii-v. chloras, gr. ii-v. citras, gr. ii-v. et sodii tartras, gr. xv-^j. iodidum, gr. ss-iij. nitras, gr. iss-viij. permanganas. (External.) Pulveres. Pulvis aromaticus, gr. i-ij. glycyrrhizae comp., gr. iv-viij. ipecacuanhas et opii, gr. £-iss. rhei comp., gr. v-x. Quinina. Quininae bisulphas, gr. ss-iv. sulphas, gr. ss-iv. valerianas, gr. J-ss. Resinae. Resina jalapas, gr. J-ss. podophylli, gr. -fa-rg. scammonii, gr. J-iss. Rheum, gr. ss.-ij. Salol, gr. ss-iss. Santoninum, gr. J-ss. Scammonium, gr. i-ij. Senna, gr. iii-v. Sinapis (Emetic), gr. viii-xx. Sodium. Sodii acetas, gr. ii-v. arsenias, gr. Thrwi- bicarbonas, gr. ii-v. boras. (External.) bromidi, gr. i-v. salicylici, gr. ss-iss. Spiritus. Spiritus aetheris comp., ITLii-x. nitrosi, TTLv-xx. ammoniae aromat, Tflii-v. camphorae, TTJss-iv. chloroformi, TTU-v. THERAPEUTICS 445 Spiritus. cinnamomi, TTLi-ij. frumenti, TTLv-f^j. juniperi comp., TTLv-xv. menthae piperita;, TTtss-ij. vini gallici, TTLv-f3J. Strychnina. Strychninae sulphas, gr. T^-y^. Sulfonal, gr. iss. Sulphur. Sulphur prsecipitatum, gr. x -xv. Syrupi. Syrupus acaciae, ad lib. allu, f3ss-3ij. ferri iodidi, TIT ii-v. ipecacuanhas, TTLii-f3J. krameriae, Tlixx-f^j. lactucarii, TTLxx-fgj. limonis, ad lib. pruni virginianae, TTLxv-f^ss. rhei, f^ss-j. aromat., fjss-j. sarsaparillae comp., TTLxv-f^ss. scillae, TTLii-vj. comp., TTLii-vj. senegas, TIT ii-v. tolutani, TTLii-vj. zingiberis, TTLv-x. Tincturae. Tinctura aconiti, TfLi-ss. belladonnae, TTLi-ij • calumbae, TTLiii-xv. cannabis indicas, TTLi-ij. cardamomi comp., TTLv-xv. catechu comp., TTLv-xv. cinchonae comp., TTLx-xv. cinnamomi, TT\ii-xv. colchici, TTli-iij- digitalis, Tltss-iij. ferri chloridi, TILi-v. gelsemii, TTLi-ij- gentianae comp., TTLv-xv. guaiaci ammon, TTLv-xv. hyoscyami, TTLi-iv. iodi, TTLi-iv. ipecac, et opii, TTLl-iss. kino, Tfl.ii-xx- krameriae, TTLii-xx. lavendulae comp., TTtv-xx. Tincturae. nucis vomicae, TTLss-ij. opii, TTLi-iij- camphorata, TTLv-xx. deodorata, TTLi-iij- rhei dulcis, TTLv-x. saponis viridis. (External.) scillae, TTLi-v. strophanthus, TTLss-j. Valerianae ammoniata, TTLv-xv. zingiberis, TTLii-vij. Trional, gr. iss. Unguenta. (External.) Unguentum acidi carbolici. acidi tannici. aquae rosae. belladonnae. cantharidis. creasoti. diachylon. gallae. hydrargyri. ammoniati. iodidi rubri. nitratis. oxidi flavi. rubri. iodi ichthyol. mezerei. picis liquidas. plumbi carbonatis. iodidi. potassii iodidi. stramonii. sulphuris. iodidi. veratrinas. zinci oxidi. Veronal, gr. iss. Vina. Vinum ergotae, TTLv-x. ferri amarum, TTLxx-f^ss. ipecacuanhas, TTLh-viij. opii, TTLss-j. rhei, Ttlv-f^ss. Zincum. Zinci oxidum, gr. |-ss. sulphas, gr. J-v. valerianas, gr. J-ss. Zingiber. Pulv. zingiberis, gr. J-ij. 446 DISEASES OF CHILDREN FOR NURSES Normal Salt Solution.—One and one-half drams of sodium chlorid (ordinary table salt) are added to two pints of sterile water, thoroughly mixed with a sterile glass rod, and filtered into a sterile bottle. If normal salt solution is to be used for hypodermoclysis it should be sterilized for a half hour on three successive days. In emergencies it may be boiled steadily for one hour. A sterile thermometer should be used to take the temperature of the solution. Dakin's Solution.—A germicidal solution which de- pends upon the formation of nascent chlorin for its action. It came into great prominence during the war and is the solution used in the Carrel-Dakin method of treatment of infections. Large quantities of a very dilute solution are employed. POISONS AND THEIR ANTIDOTES Acids, Mineral.—Alkalies in di- Antimony and Its Salts.—Tannic lute solution; lime; whitewash; acid; opium; external. warmth. magnesia; soap. Quickness of administration essential. Avoid Arsenic and Its Salts.—Emetics; emetics and stomach-pump. stomach-pump; recently made hydrated sesqui-oxid of iron Acids, Vegetable.—Soap; soda or (made by adding water of ammo- potassa in dilute solution; except nia to solution of trisulphate of for oxalic acid, for which give jron). magnesia; dialyzed iron lime, whitewash, chalk, or mag- and sait; 0ij or fat- nesia. Aconite.-Emetics; stomach- Atropin.-See Belladonna. pump; tannic acid; digitalis; laudanum; warmth; stimulation; Belladonna.—Emetics; stomach- recumbent position, pump; tannic acid; morphin hypodermically. Alkalies and Their Salts.—Vine- gar; weak acids; oil freely; Bismuth and Its Compounds.— opium. Albumen; milk. Alum.—Albumen.* Bromin.—Soap; oils. * Albumen is furnished by whites of eggs. THERAPEUTICS 447 Cannabis Indica.—Emetics; lem- on juice; quiet; if exhaustion, stimulants. Carbolic Acid.—Stomach-pump; solution of saccharate of lime; sulphate of sodium; hot and cold douche. Chloral and Chloroform.—Alter- nate hot and cold douche; artifi- cial respiration; cardiac stimu- lants. Cocculus Indicus.—E m e t i c s ; stomach-pump; at first, give opium; chloral; chloroform; later, stimulants. No chemical anti- dote. Colchicum.—Emetics; stomach- pump; tannic acid; opium; stim- ulants. Conium.—Emetics; stomach- pump; artificial respiration; tan- nic acid; opium. Copper and Its Salts.—Albumen; milk; calcined magnesia; yellow prussiate of potash. Croton Oil and Other Drastic Purgatives.—Emetics; albumin- ous drinks; bismuth; external heat. Cyanid of Potassium.—See Hy- drocyanic acid. Digitalis.—Emetics; stomach- pump; tannic acid; stimulants. Gelsemium.—Same as Aconite. Hydrocyanic Acid.—Alternate hot and cold douche; intravenous injection of aqua ammoniae; atropin hypodermically. Hyoscyamus.—Same as Bella- donna. Iodin.—Starch, freely; if this can- not be obtained, then soap. Iron, Salts of.—Soap; dilute al- kalies; albumen. Lead, Salts of.—Emetics; stom- ach-pump; alkaline sulphates; soap; albumen; milk; purge. Mercury, Salts of (Bichlorid of Mercury).—Emetics; albumen; milk; wash out stomach. Opium.—Stomach-pump; atropin hypodermically; coffee; flagella- tion; artificial respiration; elec- tricity. Phosphorus.—Emetics; sulphate of copper in small doses; crude oil of turpentine; stomach-pump; avoid oils or fats. Potash Salts.—No distinct anti- dote. Santonin.—Emetics; purges; stim- ulants; artificial respiration. Silver, Salts of.—Common salt, freely; albumen. Soda Salts.—No distinct antidote- Stramonium.—Same as Belladon- na. Strychnin.—Emetics; stomach- pump {at first only); tannic acid; chloral; bromid of potash; ether; chloroform; rest. Veratrum Viride.—Same as Aco- nite. Zinc, Salts of.—Albumen in the form of white of egg; carbonate of soda; milk, freely. 448 DISEASES OF CHILDREN FOR NURSES TREATMENT OF EMERGENCIES The following treatments are given so that the nurse may know what to do in cases of extreme emergency, where it is impossible to obtain a physician immediately and where delay might result in the death of the child. In every emergency case send for the physician at once, and while awaiting his arrival do as much for the patient as can be done without exercising his prerogatives, and at the same time have everything prepared so that his orders may be anticipated and the patient receive immedi- ate medication. When the nurse knows what orders to expect, the detail can be worked out before the physician arrives. Asphyxia.—Give artificial respiration (see page 480). Oxygen, atropin, 4^ gr., and strychnin, gS gr-> hypo- dermically, to a child four years of age, will probably be ordered. Asthma.—Prompt relief often follows the inhalation of a few drops of chloroform. Bites should be treated as open wounds and not cau- terized. They should be thoroughly washed with hydro- gen peroxid and a wet bichlorid dressing applied. Burns.—The burned area should be covered with lint saturated with normal salt solution or carron oil, which is composed of equal parts of linseed oil and lime-water. Chills.—The child should be surrounded with hot- water bottles and covered with a blanket. Hot drinks may be administered. If this plan of treatment is fol- lowed by a sweat, the skin should be sponged with water containing a tablespoonful of alcohol to the basin. The temperature should be taken. THERAPEUTICS 449 Collapse.—Place the child in a mustard tub at a temperature of no° F. for five minutes, vigorously rubbing the extremities and the skin surfaces during this time. After removal from the tub place it in a horizontal posi- tion, cover with warm blankets; heart and respiratory stimulants will probably be ordered. Croup.—A sponge moistened with hot water may be applied to the throat, or the child may be placed in a hot bath or mustard tub at a temperature of no° F. If these simple remedies fail, an emetic will often bring relief, the best being the wine of ipecac administered in dram doses until effective; or a little powdered alum mixed with honey or molasses given in teaspoonful doses. In severe cases it may be necessary to resort to the inhalation of a few drops of chloroform. A croup tent with moist atmosphere is advantageous. An umbrella covered with a blanket may be substituted for the regulation croup tent. Convulsions.—Epileptiform. — Measures should be taken to prevent the child from injuring itself. Some- thing should be placed between the teeth to prevent biting of the tongue. An enema should be given. Uremic.—The same precautions must be taken as in epileptiform convulsions. The inhalation of a few drops of chloroform may control the seizures until the physician arrives. Reflex Convulsions.—The child should be placed in a mustard tub, at no° F., for five minutes. Dislocations.—Apply cold to the joint. Drowning.—The child should be forced to vomit to relieve the stomach of the swallowed water; this can be accomplished by pressure over the stomach. Artificial respiration should then be practised (see page 480). 29 45° DISEASES OF CHILDREN FOR NURSES Dyspnea.—Dyspnea may be due to a number of causes. If the child is suffering from heart disease, it should be propped up in bed. If due to some disease of the respira- tory tract, a croup tent with a moist atmosphere may help; oxygen should be administered if at hand, or the child should be kept in a room filled with fresh air or even carried out of doors. If due to diphtheria, intubation will probably be necessary. Heart or respiratory stimu- lants will probably be ordered. Epistaxis or Nosebleed.—The child should sit upright in the chair, the clothing should be loosened about the neck, firm pressure made over the bridge of the nose by holding it between the fingers, and ice should be applied to the bridge of the nose and back of the neck. Small pellets of ice may be introduced into the nostrils or held in the mouth. If this does not answer, plugging the nostrils with absorbent cotton may be resorted to. Com- pound tincture of benzoin, diluted lemon-juice, and adre- nalin chlorid, i: 2000, may be introduced into the nose. No astringent powders should be used locally on account of their tendency to produce sneezing, thus starting the nose- bleed afresh. Earache.—Douche the ear with warm water at a tem- perature of no° F. for about five minutes (see page 469). Then introduce a pledget of cotton saturated with sweet oil and a drop of laudanum. Fainting.—Loosen the clothing; place the child on its back with the head on a lower level than the feet; use smelling salts and aromatic spirits of ammonia, ten drops in a tablespoonful of water for a child four years of age. Foreign Bodies.—Eye.—If possible remove the body with a wisp of cotton; if it cannot be discovered turn the THE RAPE UTICS 451 lid as described on page 255, when, in most cases, it can readily be found. Ear.—Nothing should be used except hot-water douch- ings; on no account attempt to probe with any instrument; the douching will be sufficient for all cases. Nose.—Douching the nose with warm water is usually sufficient, the nozzle of the syringe being placed in the nostril which is free. Throat.—Often a sharp slap on the back will cause the expulsion of the foreign body. If it is impossible to recover the object and it seems to be lodged in the throat, send immediately for the physician. If it has been swal- lowed give the child bread and potatoes to eat, and a dose of oil. Fractures.—If simple, apply a temporary dressing and splint to avoid unnecessary laceration of the tissues. If compound (communicating with the air) wash thor- oughly with a solution of bichlorid of mercury, 1 to 4000, and apply a wet bichlorid or normal salt solution dressing. In fractures of skull, apply an ice-cap. Heart Failure.—Symptoms of heart failure demand instant attention. Whenever the pulse becomes rapid, intermittent, and weak, or the child has sudden attacks of dyspnea, coldness of the extremities, or attacks of syncope, the physician should be immediately informed. While awaiting his arrival the child should be placed flat upon its back and not moved for anything. Mustard paste, made of equal parts of mustard and flour, may be ap- plied to front of chest until there is a distinct redness, 15 minims of aromatic spirits of ammonia may be given in water by the mouth, if the child can swallow; hot-water bags may be placed about the extremities, and inhala- 452 DISEASES OF CHILDREN FOR NURSES tions of ammonia given. (Be careful not to have con- centrated ammonia nor to hold it continuously under the nose; pass it slowly backward and forward.) The phys- ician will probably order a hypodermic injection of one of the following drugs: nitroglycerin, strychnin, digitalis, or whisky, all of which should be in readiness. Hypodermo- clysis may be ordered and at times he may bleed the child. Hemorrhage.—Hemoptysis (Spitting of Blood).—Mor- phin should be administered in profuse hemorrhages, the dose being -^ gr. to a child four years of age. Ice- bag to chest. Hematemesis (Vomiting of Blood).—An ice-bag should be placed over the stomach and all food by the mouth prohibited. If profuse, morphin, -^ gr., to a child of four years can be administered hypodermically. Typhoid.—The hemorrhage from the bowel should be treated by absolute rest, ice-bag to the abdomen, the food should be reduced to the minimum and of the mildest character. In severe cases the foot of the bed can be raised and morphin, dose -^ gr. to -^ gr. to a child of four years, should be administered hypodermically. Laryngismus Stridulus.—Dash cold water on the face and neck in an attempt to break the spasm. Mustard tubs at a temperature of no° F. may be resorted to, and in severe cases inhalations of chloroform. Nervousness.—Warm baths at a temperature of no° F. will usually allay nervousness. Pain can usually be relieved by the application of heat; that is, hot-water bag, turpentine stupe, etc. Perforation.—Typhoid.—Absolute quiet; no food or liquids by mouth or rectum. The physician should be immediately notified. THERAPEUTICS 453 Appendicitis.—The same plan of treatment should be followed. Poisons.—If possible wash out the stomach, give a large dose of oil, and administer the proper antidote (see page 446). Prolapse of the Rectum.—The prolapsed portion of the bowel should be greased with vaselin, cold cloths applied, and gently pushed within the sphincter. Respiratory Failure.—In respiratory failure there is great dyspnea, cyanosis, and signs of collapse. The physician should be immediately summoned; in the mean- time, if the child shows great distress in breathing while in the recumbent posture, it should be propped up in bed, oxygen should be administered; gentle friction of the sides of the chest at times stimulates the respiratory muscles. He may order a mustard tub and hypodermic injections of one or more of the following drugs: atropin, caffein, strychnin, and nitroglycerin. In sudden attacks of great cyanosis a mustard tub is advantageous. Shock.—Hot (no°F.) normal salt solution or hot coffee may be injected into the rectum; about a pint should be used. Heart and vasomotor stimulants will be ordered? like strychnin, ammonia, and digitalis. Sunstroke.—The child's clothing should be removed and cool drinks administered. The child should be placed in the coolest part of the room, ice-bags applied to the head, and cool sponging given. At times it is necessary to give cold baths and cold irrigations of colon (see page 455). Stimulation should be resorted to if necessary. Urine.—Suppression of the urine may be overcome by giving the child plenty of water to drink and administering sweet spirits of niter, dose ten drops in water every three DISEASES OF CHILDREN FOR NURSES hours to a child of two years, until the kidneys become active. Retention of the urine at times may be overcome by a hot sitz bath or a warm tub. If this fails and the child is suffering, catheterization is necessary (see page 497). Persistent Vomiting.—Usually a mustard plaster applied for ten minutes over the stomach will relieve the vomiting. No food should be given by the mouth. Cracked ice will relieve the thirst. Wounds.—All wounds should be thoroughly cleansed (all the dirt removed, washed with peroxid of hydrogen or a solution of bichlorid of mercury, 1 : 4000) and covered with a wet bichlorid or sterile normal salt solution dressing. Therapeutic Measures Employed in Childhood TO REDUCE TEMPERATURE Ice-cap.—Ice is placed in a canvas bag and beaten with a mallet until broken in small pieces. It is then transferred to a rubber ice-bag. Express all air from the bag by twisting the unfilled portion. Carefully apply metal cap; then cover with towel or gauze. Sponge Bath.—The temperature of the water should be from 85 ° F. to 900 F. Equal parts of water and alcohol or water and vinegar can be used. The clothes should be removed from an infant with the exception of the diaper. In older children the portions of the body not being sponged may be kept covered. The sponging should be continued for five to fifteen minutes and the child then wrapped in a blanket without further dressing. The temperature of a child should be taken half an hour after sponging. THERAPEUTICS 455 Cold Pack.—The child is stripped of all its clothing, laid upon a blanket, and the entire trunk wrapped in a sheet which has been wrung out of water at a temperature of ioo° F., the sheet should be so applied that one part of the body does not come in contact with another. Small pieces of ice are rubbed over the sheet, first in front and then behind. The head should be sponged with cold water and a hot-water bottle applied to the feet during this procedure. After the ice has been rubbed upon the sheet for ten minutes the child is enveloped in the blanket without removing the wet pack. The applications of ice should be made every fifteen or thirty minutes if ordered, and may be continued at these intervals for one or twenty- four hours. Graduated Cold Bath.—The child is placed in a tub of water at a temperature of ioo° F. The temperature is then gradually reduced by the addition of ice wrapped in towels or by cold water until the temperature of the water is 85 ° F. or 8o° F. While in the tub the child's body should be vigorously rubbed and an ice-bag or cold cloths should be applied to the head. The bath may be continued for ten or fifteen minutes. Upon removal the child's body should be quickly dried and wrapped in a warm blanket. The temperature of the child should be taken half an hour after removal from the bath. Cold Irrigation of the Colon.—Water of 400 F. to 50° F. is injected through a catheter into the rectum. About a pint should be injected at one time. When introducing the catheter, if the end is placed immediately within the sphincter and then a small amount of water al- lowed to run, the rectum will dilate and permit the further introduction of the catheter to be accomplished easily. 456 DISEASES OF CHILDREN FOR NURSES Measures to reduce temperature should be stopped if the child becomes very blue. COUNTER-IRRITATION Cantharides Blister.—The surface of the skin which is to be blistered is thoroughly scrubbed and washed with alcohol. The cantharides plaster should be cut to the proper size and its surface oiled. It should then be applied and allowed to remain in position for six hours. The plaster should be removed carefully, and if the skin is raised cut the lowest portion of the bleb and allow the fluid to run out, carefully protecting the sound skin. Do not tear the blistered skin, as it causes a great deal of pain. Apply zinc-oxid ointment. If the blister is not raised at the expiration of the six hours apply boric-acid ointment covered with a thick layer of cotton; this will cause it to raise in a few hours. Mustard Paste or Mustard Plaster.—Take one part of powdered mustard and six parts of wheat flour, mix with white of egg or lukewarm water, and spread between two layers of old linen or muslin. White of egg is used in preference to water, as it prevents blistering. In pulmonary diseases the mustard paste should sur- round the chest, and in heart failure it should cover the entire trunk. Mustard Poultice.—One part of mustard added to six parts of flaxseed and thoroughly mixed in lukewarm water. When ordered the strength can be increased up to one part of mustard to three parts of flaxseed. It is a very useful method of applying mustard over longer periods. Mustard Bath (Heubner's).—An extremely heroic mustard bath given in some cases of collapsed lung. THERAPEUTICS 457 The proportions are one pound of mustard to one and a half quarts of water. A sheet is wrung out in the above and wrapped about the child from the axillae to the feet; it is allowed to remain in this dressing for from fifteen to thirty minutes. The mouth, nose, and eyes must be protected from the mustard fumes. After removing the sheet the child must be given a warm tub in order to thoroughly remove all traces of the mustard. The real object of this procedure is to get the child to cry vigorously from the irritation of the mustard, and in this way to expand the collapsed portion of the lung. (For Mustard Tub, see page 466). Mustard Pack.—The child should be stripped and laid upon a blanket; the trunk should be surrounded with a sheet dipped in mustard water. This is prepared by adding one tablespoonful of mustard to a quart of tepid water. After the wet sheet is applied the child should be wrapped in a blanket. It should be removed in from ten to fifteen minutes. Turpentine Stupe.—A teaspoonful of turpentine is mixed with a pint of boiling water. A flannel cloth is dipped in this mixture and wrung out very tightly in a stupe wringer. It is then applied to the part affected and covered with oiled silk or wax paper. A thick layer of cotton should be placed over all, to retain the heat. Camphorated oil, amber oil, and olive oil, four parts, mixed with turpentine, one part, are liniments which may be applied to the chest. They are either rubbed in with the hand or applied by means of flannel cloths wet with the preparation. Dry Cups.—A small medicine glass is selected, the edges of which should be carefully oiled before using. 458 DISEASES OF CHILDREN FOR NURSES One or two drops of alcohol are placed in the glass, it is then manipulated so that the alcohol covers the sides of the vessel with a thin film, care being taken that no drops of the liquid are present. The alcohol is then lighted, and, while burning, the glass is inverted and the mouth is held firmly against the skin. The skin will be sucked up into the glass on account of the vacuum, and the cup will be firmly held in place. They are allowed to remain in position for fifteen or thirty minutes. To remove, press the skin down at one side of the glass in such a way that air is allowed to enter. The greatest care is necessary in the application of cups to prevent burning of the skin. This is caused by a drop of burning alcohol running down the sides of the glass and falling on the skin, or by over- heating the edges of the glass. Wet Cups.—The skin should be scrubbed. The phys- ician will then scarify the part to be cupped and apply the cups in the same way as described above. POULTICES Antiseptic Poultices.—Absorbent cotton wet with a solution of bichlorid of mercury, i to 4000; potassium permanganate, 1 to 4000; or carbolic solution, 1 to 40, and covered with green protective or wax paper. Charcoal poultice is used as a deodorizer. One part of powdered charcoal is added to two parts of linseed and prepared like a flaxseed poultice. Powdered charcoal is spread over the surface. Digitalis Poultice.—Make a flat bag and fill with leaves of digitalis. The bag should be steeped in boiling water and applied, or soak digitalis leaves, 2 oz. to 3 pint, in warm water, until they are soft, drain off the THERAPEUTICS 459 water, and boil them. The decoction can then be added to flaxseed. Flaxseed Poultice.—According to the size of the poultice which is required, a quantity of flaxseed is added to boiling water until the mixture is thick enough to stir. It is then thoroughly beaten over a flame to fill the poultice with air, this makes the poultice light. A layer half an inch thick is spread over old linen, applied to the affected part, and covered with wax paper. In some conditions, such as pneumonia and peritonitis, the lightest possible poultices are necessary; layers less than half an inch are then applied. Spice Poultice.—Equal parts of allspice, cinnamon, ginger, and cloves are placed between two layers of flannel or gauze, which are then quilted. It is then wrung out of hot whiskey or brandy, applied to the part affected, and covered with wax paper. In heating whiskey or brandy they should never be placed upon the stove or near a flame. They should- be poured into a cup which is then placed in a receptacle containing boiling water. Starch Poultice.—The starch is first mixed with a little cold water, and then enough boiling water is added to make a paste. It is spread on old linen or muslin, covered with a layer of gauze, and applied like other poultices. A few drops of laudanum may be sprinkled over the surface of the poultice before applying, if there is much pain. A preferable form of starch poultice for skin diseases is to make a flat bag and fill with dry potato starch; then dip in boiling water and allow to cool. Technic.—All poultices should be beaten until they are thoroughly filled with air; this renders them light in 460 DISEASES OF CHILDREN FOR NURSES weight. They should be covered with wax paper or oiled silk and a thick layer of cotton to keep them warm. News- papers may be used in emergencies. A margin of 1 inch of the linen should be left to turn in, the surface of the poultice should be anointed with oil to protect the skin, and one poultice should not be removed until another is ready for application, the skin being wiped dry before the new one is put in place. Before applying a poultice, test its temperature by holding it to your face. Do not leave one poultice on over an hour. COMPRESSES Cold compresses are made by wringing cloths out of cold water and applying to the body. For the eyes small disks are cut from muslin or lint and placed upon a cake of ice. When they are thoroughly cold they are laid over the closed eyelids. They should be changed constantly. Hot compresses for the eyes are prepared in the same manner, boiling water being used instead of ice. The disk should be tested upon the back of the hand before application. HOT APPLICATIONS Hot-water bags are filled with water as hot as can be borne. All the air should be expressed before screwing on the top, and the bag should be placed in a properly fitting flannel cover to prevent burning of the skin. Hot Foot-baths.—The bed should be protected with a rubber mackintosh, which in turn is covered with a towel. A small foot-tub is placed upon this, containing enough water to cover the child's feet at a temperature of 1150 F. The exposed portions of the child's legs should be covered THERAPEUTICS 461 with towels. After three minutes a quart of hotter water is added, care being taken not to allow it to come in contact with the child's extremities. The addition of hotter water is continued at these intervals until the water is as hot as can be borne by the hand. The child's feet should remain in the water at this temperature for about fifteen minutes, when they are quickly dried and wrapped in a warm blanket. Hot Bath.—The child is placed in a tub of water at a temperature of ioo° F. The temperature is gradually raised to no° F. by the addition of hot water. A ther- mometer should be used so that the temperature of the water is not raised too high. The body should be vigor- ously rubbed and an ice-cap or cold cloths should be applied to the head while the child is in the bath. The bath should last for ten to fifteen minutes. Hot Pack.—The clothes are removed and the child is wrapped in a blanket wrung out of water at a temperature of no° F. The child should then be rolled in a second dry blanket covering the first. Hot-water bottles should surround the child and an ice-cap or cold cloths should be applied to the head. These hot applications can be applied every twenty or thirty minutes until free per- spiration is produced. Hot water or lemonade may be given to induce sweating; the sweat may be continued as long as desirable. At the expiration of the necessary time the moist blanket is removed, care being taken not to expose the child, a warm, dry blanket taking its place. The child is then sponged with warm water and alcohol to remove the perspiration. The undershirt and night- gown are then replaced and the ice-cap removed, the child always remaining between warm blankets. 462 DISEASES OF CHILDREN FOR NURSES Modified Hot Pack.—The child is wrapped in dry hot blankets. Hot-water bottles are placed under the arms, knees, and feet. An ice-cap over the head. Hot lemon- ade should be given and the pack terminate as above. Vapor Bath.—The bed should be covered with a mack- intosh and blanket. The clothing is removed and a Fig. 117.—Vapor bath. The covers are held above patient by means of a frame. They are tightly tucked in all around bed. The steam is introduced from kettle at foot of bed. An ice-cap is applied to head. Warm or cold beverages are administered to induce perspiration. blanket is placed loosely over the child. A frame reaching from the neck to well below the feet is placed over the patient. All metal parts of the frame must be covered by a bandage or old muslin to prevent condensation of the THERAPEUTICS 463 steam. Over the frame, in the following order, are placed, first, a blanket, then a mackintosh with the rubber side toward the patient, completely covering the frame, and, finally, several blankets covering the whole apparatus. A thermometer should be placed on the chest of the child where it can be readily obtained. The covers are then tucked in securely at the- top and both sides of the frame. If desired the blanket which loosely covers the child can now be withdrawn from the opening at the foot. This blanket is usually allowed to remain in giving vapor baths to children. The covers are then tucked in about the foot of frame, a small opening being left which should be of sufficient size to allow the introduction of the spout or hose leading from the steam kettle. Before applying the steam an ice-cap is placed on the child's head, boiling water is placed in the kettle, and the alcohol lamp beneath is lighted. When steam appears, the spout or hose is placed through the opening left for that purpose, care being taken not to place the spout over •the child's feet, as the drip from its end is liable to scald the skin. The thermometer should be read every five minutes, care being exercised not to expose the chest. When the thermometer reads 1200 F. the kettle should be removed and the child allowed to remain exactly as before for twenty or thirty minutes. If the thermometer at no time registers 1200 F. the steam is kept up for thirty minutes. During the bath give hot or cold water freely; hot lemonade is also used at times to induce perspiration. At the end of twenty or thirty minutes after the ther- mometer has reached 1200 F. the frame is carefully 464 DISEASES OF CHILDREN FOR NURSES removed from under its covering in such a way that there is no exposure nor disturbance of the covermg, the steam thus being retained. The child remains in this position for twenty minutes. At the expiration of this time the moist blankets and mackintosh are carefully removed, warm, dry blankets taking their place. The child is then sponged with warm water and alcohol to remove the perspiration. The undershirt and night-gown may then be replaced and the ice-cap removed. The child should always remain between warm, dry blankets. In private houses an attachment at times can be made to the steam-heat radiators; this saves a great deal of trouble in chronic cases. A tea kettle with a garden hose attached to its spout, the other end placed at the foot of the bed, will answer very well when no special apparatus is at hand. A piece of stove-pipe covered with asbestos can be fitted up to answer the same purpose. Holes should be punched through its sides for ventilation, and it should have an " elbow," so that it can be directed over the foot of the bed. Inside of the stove-pipe, standing on a piece of asbestos; place an alcohol lamp over which can be placed a tin cup filled with water. In the country or where it is impossible to generate steam by any of the above methods, hot bricks plunged into a basin half-filled with cold water may answer. Hot-air Bath.—The child and bed are prepared as in the vapor bath, only the steam is omitted. Hot air is introduced beneath the blanket by placing the alcohol lamp beneath the spout of an open kettle. This generates heat at this point, which passes into the bed. THE RAPE UTICS 465 The stove-pipe, as described above, can be used here, the cup of water being unnecessary. In many modern houses the electric light can be taken advantage of to give hot-air baths. A 30-candlepower electric bulb should be purchased. The child and bed can be prepared as in the vapor bath, except for an opening, which should be left over the upper portion of frame, through which the bulb can be passed and securely tied to the frame in such a way that there will be no danger of burning the child or the blankets. After the bulb is in place the opening can be closed. All the adjunct meas- ures as described under the vapor bath should be carried out. A sitting hot-air bath can be given by placing the child wrapped in a blanket on a chair, with his feet in hot water. Blankets draped from his shoulders should cover the child and the chair. Beneath the chair place an alco- hol lamp in a bucket, or the 30-candlepower lamp may be used. In any of the above baths, if pilocarpin has been ordered by the physician, it should be given at the time the nurse is about to begin the preparation for the bath. Then it will be fully active during the bath. Sitz Bath.—Useful when there is retention of urine, pain in pelvic region, or rectal congestion. A simple method is to place the child in the sitting posture in a tub of water at 115 ° to 120 ° F. The water should come to the level of the umbilicus. Salt Baths.—Prepared by adding from 3 to 5 oz. of sea salt to a gallon of water at a temperature of oo° F. to ioo° F., the number of gallons used in a 30 466 DISEASES OF CHILDREN FOR NURSES bath varying. When the solution of salt is of sufficient strength the water causes the skin to glow. The baths are useful in rickets. Mustard Bath.—The bath is prepared by placing four or five tablespoonfuls of dry mustard in a gauze bag, which is shaken in four or five gallons of water until it is thoroughly saturated with the mustard. The water should be at a temperature of 105 ° F. when the child is put into the tub, after which it should be slowly raised to no° F. by the addition of hot water. An ice-cap or cold cloths should be applied to the head and the body vigor- ously rubbed while the child is in the tub. It may be continued for ten minutes, at the expiration of which time the child should be quickly removed and wrapped in a blanket without drying. Mustard Foot-bath.—At times it is impracticable to put children in a tub; then a mustard foot-bath is useful. The bed is protected by a rubber blanket covered with towels. Cloths are wrung out of mustard water made by adding a teaspoonful of mustard to a quart of water and heated to no° F. These are wrapped about the child's feet, the rest of the body being covered. They are applied until the skin becomes red. BATHS USED IN TREATING SKIN DISEASES Bran Baths.—Place one quart of ordinary wheat bran in a gauze bag and place in four or five gallons of water. The bag should be shaken and squeezed until the water resembles a thin porridge. The temperature should be maintained at 95 ° F. Alkaline Baths.—The quantity of water should be THERAPEUTICS 467 twenty-two and a half gallons, at a temperature of 95 ° F, In this is placed: Carbonate of soda, 3 oz. Bicarbonate of soda, 3 oz. Carbonate of potassium, 3 oz. Borax, 3 oz. Compound Glycerin Bath.—Water, twenty-two and a half gallons, at a temperature of 95° F. Ingredients: Glycerin, 2 oz. Tragacanth, 1 oz. The bath must be used immediately, as this mixture forms glue. Compound Sulphur Bath.—Water, twenty-two and a half gallons, at a temperature of 95° F. Ingredients: Precipitated sulphur, 1 lb. Sodium hyposulphite, 1 oz. Acid sulphuric (strong), 1 dr. Water, 1 pt. To be mixed and then added to tub. Linseed Bath.—Add one pound of linseed to twenty- two and a half gallons of water at a temperature of 95 ° F. Starch Bath.—Take four tablespoonfuls of crushed starch and make a paste by adding cold water. Then add two quarts of boiling water, stirring over a fire until it makes an ordinary laundry starch. To twenty gallons of water at a temperature of 95 ° F. add 4 oz. of wash- ing soda and then add the cooked starch. If especially ordered, 4 oz. of glycerin and 4 oz. of borax may be added to the above, or the following: Sodium biborate, \ oz. Sodium carbonate, 2 oz. Potassium carbonate, 3 oz. 468 DISEASES OF CHILDREN FOR NURSES Two to four teaspoonfuls of this mixture are added for every gallon of water, with double the amount of dry starch. Tar Bath.—The patient is rubbed with oil of cade on the diseased patches and then is given a warm bath or a plain starch bath. Vinegar-and-Mercury Baths.—Water, twenty-two and a half gallons, at a temperature of 95 ° F. Ingredients: Vinegar, 1 pt. Glycerin, 1 pt. Bichlorid of mercury, i dr. HYGIENIC BATHS Tepid Bath.—Given at a temperature of from 95° to ioo° F. It is useful in nervous conditions and to induce sleep. Shower Baths or Sponge Baths.—The child should stand in a foot-tub containing warm water. A large sponge holding about a pint of water at from 40° to 60 ° F. should be squeezed three or four times over the chest, shoulders, and spine of the child, the skin being vigorously rubbed meanwhile. The bath should not last more than half a minute, and should be followed by a brisk rubbing until a thorough reaction is established. SYRINGING Eye Syringing.—The lids should be massaged to remove pus, then held apart by the fingers, and any dis- charge dislodged from beneath them. A soft-rubber ear syringe is filled with saturated solution of boric acid heated to 100° F., and the nozzle is placed at the inner canthus of the eye. The solution should be wiped away THERA PE UTICS 469 with antiseptic cotton. Always wipe toward the external canthus, to avoid contamination of the other eye. Medi- cine which is to remain in the eye is dropped in at the external canthus. The rubber ear syringe is safer to use Fig. 118.— Method of syringing eye. The cotton held against the hose should prevent any infection of other eye. than the ordinary glass eye-dropper, as children are prone to struggle. Ear Syringing.—An ear syringe is filled with water at a temperature of no° F. The soft-rubber nozzle is placed within the external auditory canal and the bulb gently squeezed. A half pint to a quart of water is used. A fountain syringe held on a level with the ear can be substituted for the small syringe. The bag should be filled with a quart of water at no° F., and a small nozzle held in the auditory canal. Do not raise bag above level of ear as it causes too great a pressure. 470 DISEASES OF CHILDREN FOR NURSES Nasal Syringing.—A soft-rubber nasal syringe is filled with an antiseptic solution. The same syringe should Fig. 119.—Method for syringing ear with fountain syringe. The lower end of should not be above level of auditory canal. not be used for more than one child unless thoroughly disinfected. Two positions may be used in nasal syringing. In diphtheria, scarlet fever, or any severe illness the child should not be removed from the bed. In such cases the head should be held on one side, the syringe being placed THE RAPE UTICS 471 in the upper nostril. Then the child's head should be turned to the other side and the other nostril syringed. The alternate syringing should be continued until the nose is clean. When syringing, the water should run out of the opposite nostril or out of the mouth. The other method is to hold the child erect on the lap with the head inclined a little forward, the syringing being done by a person who stands behind. Fig. 120.—Method for syringing nose. The syringe is introduced into upper nostril, the solution escaping from opposite nostril or mouth. Just as small an amount of pressure should be exerted when syringing the nose as possible, on account of the danger of forcing the infection into the Eustachian tube and causing an otitis media. At times a fountain syringe is used to irrigate the nose. 472 DISEASES OF CHILDREN FOR NURSES The bottom of the bag should not be over two feet above the child's head. Syringing of the Mouth and Pharynx.—A Davidson syringe may be used. If the pharynx is to be reached the nozzle is used as a tongue depressor. This should be placed at the angle of the mouth between the back teeth. The child should be held in the sitting posture, with the head inclined forward. INHALATIONS Croup Tent.—A croup tent is made by placing a blanket over a frame in such a way that the entire bed is Fig. 121.—Croup tent (J. P. C Griffith). covered except for a small aperture at the side of the bed near the head which is required for ventilation. THERA PE UTICS 473 Blankets are used instead of sheets, as the latter are liable to catch fire. If a regular frame is not available, a good substitute can be made by erecting broom-sticks at the four corners of the bed and stretching a cord around the tops of the sticks. A very good tent can be improvised by throwing a large blanket over an umbrella. A croup kettle heated by a safety alcohol lamp should be placed upon the floor or on a low box beside the crib, Fig. 122.—Croup kettle (J. P. C Griffith). so that the end of the spout is just inside the tent at a level of the surface of the bed. The kettle is filled with boiling water and a dram of the compound tincture of benzoin may be added. The medicated steam vapor is very soothing in inflammations of the respiratory tract. Great care must be taken to prevent the tent or bed-clothes from catching fire. 474 DISEASES OF CHILDREN FOR NURSES STOMACH WASHING OR LAVAGE A soft rubber catheter, size 16, American scale (24 French), with a large eye, is attached to rubber tubing by a glass joint. A funnel holding from 4 to 6 oz. is inserted in the end of the tube. The child should be held in a sitting posture, the body protected by a rubber sheet and the catheter moistened. While the tongue is depressed with the forefinger of the left hand the catheter is rapidly passed into the pharynx and down the esophagus. About ten inches of the catheter should be passed beyond the lips. When it has reached the stomach the funnel is Fig. 123. —Lavage. raised higher than the level of the infant's stomach and from 4 to 6 oz. of water poured into it from a pitcher. When this has run into the stomach the funnel is lowered and raised three or four times to remove any stomach contents, and then lowered below the level of THERAPEUTICS 475 the infant's stomach, which siphons out the water and stomach contents. This should be repeated until water runs clear. In older children the funnel should be refilled several times before siphoning out the contents, as the capacity of the stomach is greater. The water should be boiled and be at a temperature of no0 F. when used. When Fig. 124.—Gavage. the siphoned water runs clear remove the catheter from the stomach. To siphon successfully there must be some water remaining in the funnel when it is lowered. Care must be taken in giving both lavage and gavage that the child does not bite off and swallow the tube, for if such an accident happens there is nothing to do but open the stomach. 476 DISEASES OF CHILDREN FOR NURSES GAVAGE (FEEDING BY STOMACH-TUBE) Gavage (Feeding by Stomach-tube).—The same appara- tus is used as in stomach washing. The child should be wrapped in a blanket. Sometimes, where there is great resistance to the introduction through the mouth, it may be passed through the nose. In older children a mouth gag is often necessary. A good substitute is a large spool, the catheter being passed through the hole in the spool. After the tube has entered the stomach the funnel should be raised to allow the gas to escape. The food is then poured into the funnel; as soon as it has disappeared the tube is tightly pinched and quickly withdrawn to prevent food from trickling into the pharynx, which often causes vom- iting. In young infants, after removing the tube, it is well to keep the jaws open for a few moments to prevent gagging. Food given by gavage is often predigested; the intervals between feedings must be longer than under other cir- cumstances, and at times the stomach should be washed first. IRRIGATION OF THE COLON The child is placed upon its back, brought to the edge of the bed with the thighs flexed, and the buttocks slightly elevated. A soft rubber catheter is attached to an ordinary fountain syringe, the bag containing the water being hung 4 or 5 feet above the bed. The water should be at a temperature of 85 ° or 90 ° F. in ordinary cases; when there is shock normal salt solution at a tem- perature of no° F. is used. The catheter should be greased before introduction and a small quantity of the water allowed to run off. It should then be placed within the sphincter when the water is allowed to flow. This distends the rectum and allows further insertion to be accomplished easily. The catheter is pushed in THERAPEUTICS 477 slowly to a distance of 12 or 14 inches. Usually a pint and often a quart will be introduced before any water returns. The irrigation should be continued until the water returns clear; at times a gallon of water is used for a single irrigation. Gentle kneading of the abdomen should be continued during the procedure. At the end of the irrigation the rubber tube is detached and the water allowed to escape through the catheter. CONTINUOUS SALINE INJECTION This is used by many surgeons following operations on septic cases, especially appendectomy. It is useful when- ever children are greatly depleted. An ordinary fountain syringe is filled with normal salt solution at a temperature of 1150 to 1200 F. This is tied to the foot of the bed not over a foot above the level of the buttocks. Two hot-water bags, tied together, are sus- pended over the bag containing the salt solution, one on either side, and a blanket is wrapped around them. The hot-water bags can be refilled from time to time as they cool. The tube is then carried under the bed-covers and over hot-water bags, which lie on the bed, to the child's buttocks, which are elevated. Here it is attached to a specially prepared rectal tube (Murphy's tube). A cath- eter can be used in place of a Murphy tube if the latter is not at hand. The catheter should be inserted from four to six inches in the rectum. If the tube is expelled it must be strapped in with adhesive plaster. The flow of the salt solution is controlled by a stop-cock or, better, a hemostat. The solution should drip (a drop at a time) into the rectum. By shutting off one-half or more of the caliber of the tube by means of the hemostat this can be regulated. 478 DISEASES OF CHILDREN FOR NURSES The idea of giving the solution so slowly is to have it all absorbed. Usually, however, there is leakage, and the clothes must be changed frequently and the bed protected. The system of hot-water bottles will keep the solution at the proper temperature. When the solution is not retained a good plan is to give it for two hours, then dis- continue for the same length of time. ENEMATA An enema consists in the injection of soapy water into the rectum. The water should be at a temperature of 85°or90° F High Enema.—A catheter should be attached to the nozzle of the fountain syringe and thoroughly greased. A small amount of water should be allowed to run off before introduction; then place the catheter within the sphincter and start the flow; this allows it to be pushed in further without doubling up. Where an immediate effect is desired the most efficient enema contains one teaspoonful of glycerin. Oil enemas are useful where the fecal mass is hard and dry and expelled with difficulty. Low enemas are given in the same manner; the water is injected by the introduction of the nozzle of syringe within sphincter, the catheter being unnecessary. Nutrient enemata are sometimes used. They should be peptonized. When drugs are given by enemata milk is sometimes used as the fluid. Suppositories of gluten or of glycerin of small size are serviceable for the relief of constipation, as is often a simple "soap stick." They are inserted into the rectum by pushing them through the anus. THERAPEUTICS 479 HYPODERMICS The skin should be rubbed with alcohol and then pinched between the thumb and forefinger, and the needle plunged firmly into the subcutaneous tissue. Veins must be avoided. The solution is injected slowly. After the withdrawal of the needle the part should be kneaded with the fingers. If the drugs used are of an irritating nature hot sponges of cotton should be applied to the part. The hypodermic needle must be sterile. For the administration of gelatin solutions sterile " horse hypodermics" are used. The preparations must be injected slowly and the punctured wound covered with collodion. Antitoxin is sold in sterile hypodermic tubes. The method of introduction is the same. BACTERINES AND VACCINES These are emulsions of dead bacteria which are injected into the patient to stimulate phagocytosis, or the forma- tion of antibodies. Phagocytosis is the property of the white blood corpus- cles to destroy germs and to eliminate toxins or poisons. The technic of administration is the same as for any hypodermic injection. VAGINAL DOUCHING A fountain syringe with a catheter attached to the nozzle is used. The catheter should be sterile and greased before introduction into the vagina. The solutions used for douching are bichlorid of mercury, 1:10,000; potassium permanganate, 1:10,000; saturated solution of boric acid; and salt solution. They should be at a tem- perature of no° F., and from one to two quarts are used. 480 DISEASES OF CHILDREN FOR NURSES VAGINAL INJECTIONS Argyrol is the drug most often used. Three drams of a 10 or 20 per cent, solution of argyrol are placed in a glass syringe having a sterile rubber catheter attached to the nozzle. The parts are thoroughly cleaned and the solution injected. The catheter is quickly with- drawn and the vulva is held together for several minutes, when the solution is allowed to run out. Argyrol deeply stains all linens. It is sometimes administered in the form of vaginal suppositories. METHODS OF RESUSCITATION* When a person is shocked by electricity, overcome by coal or illuminating gas, rescued from drowning, poisoned by certain drugs or fumes, severely injured, or in a state of collapse from one of many other causes, he may ap- parently be dead, but if there is. some one at hand who can start the proper methods of resuscitation at once, a human life may be saved. It is practically impossible for a person to recover if certain cells in the brain have been deprived of oxygen for a period exceeding ten minutes, so within that space, of time lies his chance of life or death. A person dies from one of two causes: in. the first class, failure of the heart is primarily responsible for death, and in the second, failure of the respirations. Heart Failure.—If the heart has ceased to beat there is no known practical agency by which it may be started again. However, though the patient is apparently dead, the heart may make a weak attempt at beating, so weak that respiration ceases from failure of the supply of * Robert S. McCombs in The Nurse, October, 1915. THERAPEUTICS 481 oxygen to reach the respiratory center in the central nervous system. The oxygen, of course, is carried to this center by the blood and, when the failing heart can- not propel the blood-stream at its normal rate and volume the supply of fresh oxygen is diminished and the respira- tory center shuts down. Cessation of respiration itself will soon stop any attempts of the heart to beat. There- fore the most important single expedient in this class of cases is to re-establish respiration by means of arti- ficially forcing the victim to breathe, for in this way the vicious circle is broken. Respiratory Failure.—In collapse due to electric shock, coal or illuminating gas poisoning, and drowning, the function of respiration is either suddenly paralyzed or progressively depressed. The heart may not be affected at first to a degree which in itself would prove dangerous, but the interruption of the oxygen supply to the body will soon stop its action. In this class of cases artificial respiration is again indicated as the most im- portant factor in the treatment. The principal thing that we attempt to accomplish in all methods employed, for inducing artificial respiration is to force air in and out of the lungs in sufficient quanti- ties to supply enough oxygen to maintain life and to stimulate the respiratory center to resume its function. Inhalation of oxygen in itself is always a good adjunct to artificial respiration; likewise rubbing the extremities, slapping the sTrin. surface, passing gauze saturated with ammonia beneath the nose (not so close that burning from the fumes may be a danger), assist in stimulating the respiratory center. It is also vital in every method to loosen the clothing so that movement of the chest will not be restricted and 31 482 DISEASES Of CHILDREN FOR NURSES to clear mucus from the mouth, also to pull the tongue forward so as to give the air free passage. If necessary the jaw should be forced open, and it is always best to put some hard object between the teeth that the patient may not bite the tongue. Hot-water bottles should be placed about the victim if the temperature is subnormal or if other symptoms of shock are present after recovery takes place. In case of drowning, the water should be expelled from the stomach and lungs by placing the victim face downward across a barrel or similar object; thus, com- pression of the abdomen forces the water out. No method of artificial respiration, manually applied, will ventilate the lungs with as large an amount of air as is obtained in normal breathing. The Schafer, Sylvester, Hall, and Howard methods, however, will sustain life. There are also on the market several machines for per- forming artificial respiration. These include the pul- motor, Doctor Brat's apparatus, the lungmotor, and the salvator. Doctor Meltzer of the Rockefeller Institute has published a description of an apparatus which he has given to the medical profession. Manual Methods of Artificial Respiration.—Artificial respiration has been given a great deal of scientific study during the past few years in an effort to standardize the methods to be employed and to simplify the manipu- lations required. It has been felt that the old Sylvester method, which has proved its efficiency over a long period of time, is too complicated for the average layman to grasp immediately; it is too difficult to apply correctly and, if not properly performed, it loses its value. This, together with the fatigue engendered by the necessary exertion on the part of the person manipulating the arms THERA PE UTICS 483 of the victim, makes a more simple and less tiresome method desirable. Through actual experience the Schafer or "prone- pressure" method has been found just as efficient and is very much easier to apply. Scientific experiments have proved its value, and now it is being advocated as the proper method to employ. It was devised by Sir E. A. Schafer, of Edinburgh, and consists in laying the victim on his belly and applying pressure rhythmically on the loins and lower ribs. To get the best results the arms should be stretched forward above the head, and the face turned to one side so that breathing through the mouth and nose will not be embarrassed, and the operator should stand or kneel across the victim's back. In this position he places his hands over the lowermost ribs and upper portion of the loins and by bending forward, and in this, way throwing the weight of his body on his wrists, the victim's chest is compressed against the ground and the air is squeezed out of the lungs; then by assuming the erect posture the pressure is removed and the natural elasticity of the chest causes it to expand spontaneously and respiration results. By repeating these movements rhythmically twelve times to the minute, a person can be kept alive almost indefinitely. The pressure should be applied evenly, without sudden forcible movements, so that no injury to the ribs or liver will occur. The following figures, obtained by Henderson, show the amount of air interchanged in Sylvester's and Schafer's methods, compared with the amount in natural breathing at the same rate as the artificial: Sylvester's, 150-200 c.c; Schafer's (with arms stretched forward), 200-300 c.c; natural breathing, 500-600 c.c. Summed up, the advantages claimed for the Schafer 484 DISEASES OF CHILDREN FOR NURSES method are (1) greater simplicity and ease of adminis- tering, (2) absence of trouble from the tongue falling backward and blocking the air-passages, (3) little danger of injuring the liver or breaking the ribs if pressure is gradually and not violently applied, and (4) larger ventilation of the lungs. In performing artificial respiration, if the child does not show any signs of returning vitality, do not be dis- couraged, but continue the motion regularly for at least one hour, summoning such assistance as you may need. ASPHYXIA IN THE NEWBORN At times the child fails to breathe after birth. Under such conditions it is necessary to stimulate the respiratory centers. This usually can be accomplished by slapping the child, pouring ether or cold water over the chest, and removing mucus from the mouth; or if these methods fail, by grasping the base of the ribs between the thumb and fingers, the thumb on one side of the body and the remaining fingers on the other; by firmly squeezing the fingers together the air is forced out of the lungs, and upon relaxing the fingers the chest expands, filling the lungs. The base of the ribs should be forced together in this manner at the rate of about thirty times to the minute. HYPODERMOCLYSIS This is the introduction of normal salt solution under the skin. For this purpose is used a sterile fountain syringe or glass reservoir with a special needle attached to the end of the rubber tube. The needle of a "horse hypodermic" can be used. The bag is filled with the necessary quantity of normal salt solution, at a temperature THE RAPE UTICS 48 5 of 1200 F., which has been sterilized on three successive days. After the cold water has run off, the needle is plunged through the skin. The pectoral and gluteal regions are usually selected as the places for injections. When the needle is in place the normal salt solution is allowed to run slowly, and continued until the amount ordered, varying from 1 to 8 oz., has entered the sub- cutaneous tissues. A small collodion dressing is applied to the puncture. Use a sterile thermometer for taking temperature of salt solution. INTRAPERITONEAL INJECTIONS Saline solutions are given by this method when there is marked dehydration of the infant. The skin and sub- cutaneous tissues are picked up between the thumb and finger and the injection given in the linea alba just below the umbiHcus. From 100 to 250 c.c. can be given in fifteen to twenty minutes. INTRAVENOUS INJECTIONS This consists of the introduction of normal salt solution into a vein. The physician usually selects a vein at the inner side of the elbow-joint. A bandage is tied tightly around the arm above the joint to engorge the vein. He dissects the vein away from the surrounding tissue and places a grooved director beneath it. A ligature of catgut is thrown around the vein, below the point of inserting the needle, and tied. A second ligature is placed in position above the point of insertion, but it is not tied until after the injection has been given. A sterile fountain syringe or glass reservoir is filled with the required amount (usually a quart) of normal salt solution, which has been sterilized on three successive days, and a hypodermoclysis 486 DISEASES OF CHILDREN FOR NURSES or horse hypodermic needle attached to the end of the rubber tube. The normal salt solution should be at a temperature of no° to 1200 F. (use sterile ther- mometer). When the physician is ready to introduce the needle into the vein the solution is allowed to run; it should be running when it is introduced into the vein, as this avoids the entrance of air into the vessels, which is a very dangerous accident. The bandage should be cut as soon as the needle enters the vein. When the solution has run into the vein the upper ligature is tied before the needle is removed. The skin wound is then stitched and an aseptic dressing applied. The instruments needed in this operation are a scalpel, forceps, hemostats, grooved director, ligatures, and a foun- tain syringe with proper needle; also roller bandage. The arm should be prepared as for an operation. EXTENSIONS FOR FRACTURES AND COXALGIA A strip of adhesive plaster, 2 inches wide, is cut long enough to extend from the outer portion of the knee or middle of the thigh to a point 2 inches below the sole of the foot and from there to the middle of the thigh or knee on the opposite side of the leg. The adhesive is applied to the outer portion of the leg, as far as the ankle- joint. It is not attached to the foot, and 4 inches are allowed for the loop around the foot. It is then carried to the opposite ankle-joint and applied to the inner side of the leg. A bandage starting at the ankle- joint is applied to the leg as far as the adhesive strips extend. A small block of thin wood, 3 inches long and 2 inches wide, is covered with adhesive, a hole bored in the center, and the board placed in the middle of the loop THERA PE UTICS 487 below the foot and held in place by a strip of adhesive. Through the perforation in the block a wire is passed, which is firmly attached to the inner side of the block. The wire should run over a pully at the foot of the bed and have a four or five-pound weight attached at the base which should clear the floor by several inches. A wad of cotton is placed beneath the tendo Achillis to prevent pressure at this point. The foot of the bed is elevated to obtain counter-extension. FlG. 125.—Buck's extension apparatus. The foot of the bed is elevated to obtain c< extension. Care must be taken in the removal of old adhesive strips that the skin is not pulled off with the plaster. Alcohol or ether will render this task easier. DRESSING FOR FRACTURE OF THE FEMUR IN CHILDREN OVER TWO YEARS OF AGE Hamilton Splint.—This is the best dressing to apply in childhood. It consists of (1) two long splints; the ex- 488 DISEASES OF CHILDREN FOR NLRSES ternal reaches rrom the axilla to the sole of the foot and the internal extends from the groin to the sole. They are 4 or 5 inches wide at the hip-joint and taper to 3 inches at the ankle. (2) Two long bags filled with bran, the external reaching from the axilla to the ankle and the internal extending from the groin to the internal malleolus. (3) A Buck's extension apparatus applied as described above. (4) A sand-bag reaching from the axilla to the ankle along the uninjured side. Method.—A piece of unbleached muslin of sufficient length to reach from the axilla to the sole and a yard wide Fig. 126.—Hamilton splint. First apply a Buck's extension. The injured leg is held in position by bran-bags between wooden side-splints, a long sand-bag balances the dressing on the sound side, to which is tied the uninjured ankle. A shot-bag is placed over upper fragment of fractured bone. is placed beneath the child. At a point corresponding to the level of the groin the muslin, is cut through half its width. The extension apparatus is applied and the bran-bags put in their proper places in close apposition to the leg. The splints are then laid on the edge of the muslin and folded in until they fit close to the bran-bags and hold them snugly to the leg. Three or four strips of bandage placed around the dressing keep the splints THERAPEUTICS 489 in place. The sand-bag is placed along the uninjured side. The upper portion of the unbleached muslin, which has not been folded in by the internal splint, is then carried around the body, including the sand-bag, and over the external splint, to hold the upper end in position. A weighted shot-bag is placed over the upper fragment of the bone and the foot of the bed is elevated. The necessity of frequent changing of the dressings and clothing of the child, from contamination with urine and the stools, renders it necessary, at times, to apply a moulded pasteboard splint beneath the fractured thigh, which should extend upward as far as the waist and be firmly held in place. This method of dressing does away with the pain from motion which always attends the process of redressing. MOLDED PASTEBOARD SPLINTS Technic.—The pasteboard is cut in the proper shape and of the proper length, and dipped in hot water. When C______J Fig. 127.—Jaw-cup, unfolded. A moulded pasteboard splint (Da Costa). thoroughly wet it can easily be moulded to the part, which shape it holds when dry. It should be padded with cotton before application. SPLINTS Splints are used to keep the broken fragments of bone in apposition after a fracture. According to the location of the fractured bone different 49° DISEASES OF CHILDREN FOR NURSES kinds of splints have been devised. The principal forms are as follows: shoulder-cap, for fracture of the upper portion of the humerus; the internal angular and anterior angular splints for fractures of lower end of humerus Fig. 130.—Anterior angular splint Fig. 131.—Shoulder-cap (Da Costa). (Da Costa). and upper portion of the bones of the forearm; and the Bond splint for fracture of the lower portion of the bones of the forearm. FRACTURE-BOX This is a special box used for fractures of the lower portion of the leg. It is so constructed that the sides are movable and the foot-piece perforated. THERAPEUTICS 491 A pillow is placed upon the bottom of the box, while the sides are down, upon which is rested the fractured leg in such a manner that the foot is held firmly at a right angle against the foot-piece of the box, being secured in this position by a strip of bandage through the perforations. A wad of cotton should be placed beneath the heel and sole of the foot. The sides of the box are then turned Fig. 132.—Fracture-box (Da Costa) up and held in the upright position by three or four strips of bandage surrounding the box. This causes the .leg to be held firmly between the two sides of the pillow. AIR-BEDS AND CUSHIONS Air-beds are useful at times in injuries to the back. Water-beds are also used. Air-cushions are very useful in relieving a part from pressure. PLASTER CASTS Plaster casts are very useful in childhood. They are used for fractures, for keeping joints immobile, and for keeping the bones straight after an osteotomy. Specially prepared bandages are used, which should be soaked in luke-warm water immediately before application. 492 DISEASES OF CHILDREN FOR NURSES FRAMES Frames are used in Pott's disease, in order that the backbone may be kept immobile. The child is placed upon the frame in such a position that the buttocks are situated at the opening in the canvas. This permits bowel movement without removal from frame. The child is held in position by unbleached muslin, which is attached to the two side bars of the frame and cut of sufficient length to extend from the axilla to the base of Fig. 133.—Modified Bradford frame. Devised by Dr. Fauntleroy. The daily tightening of the nuts A and B keeps apparatus rigid. the frame. This covering should be tightly drawn across the child and firmly attached to the opposite bar. The Bradford frame, or some of its modifications, is the best. Fauntleroy's modification permits of the taking up of the slack by daily tightening the nuts in the upper and lower bars. This saves the trouble of constant tightening of unbleached muslin. OILED-SILK JACKET This is a very good method of obtaining a mild, con- stant counter-irritation of the chest, formerly used exten- sively in cases of pneumonia and bronchitis. The jacket is prepared by cutting out three layers, according to the pattern shown in Fig. 134. THERAPEUTICS 493 The outer layer is oiled silk, the middle layer is cotton batting, and the inner layer gauze. For a child one year m Fig. 134 —Pattern for oiled-silk jacket. of age the dimensions should be 12 by 12 inches. A properly prepared jacket should last about two weeks. STRAIT-JACKET When it is necessary, in very restless children, to con- trol their movements the strait-jacket is of use. It is made of unbleached muslin, double thickness, a yard wide and cut long enough to reach from one side of the bed to the other. It is attached to the frame of the bed on both sides and fastened securely enough to hold the child flat upon its back. Two armholes are cut at the proper level and distance apart, and these should be bound. A wad of cotton should protect the skin of the axillae from chafing. CUFFS AND HAND COVERS Some form of protection is necessary in children who have a tendency to pick at their dressings or to scratch irritating lesions of the skin. Celluloid cuffs can be purchased which should be well padded before being applied. Pasteboard cuffs are made by cutting stiff pasteboard of sufficient length to extend from the armpit, or axilla, to the wrist, and wide enough to encircle the arm. 494 DISEASES OF CHILDREN FOR NURSES They should be well padded with cotton and held in place by a bandage. This form of dressing prevents the child from bending the elbow. A light metal covering for the hands is the best form Fig. 135.—A light metal covering for hands which prevents children from scratching sores. of protection. The illustration (Fig. 135) shows this metal covering and the same applied. MASKS Masks are useful in the treatment of skin diseases of the face. They are made so as to cover completely the head and face, small apertures being cut for the eyes, nose, and mouth. It is the only means by which applica- tions to the face can be properly applied. THERAPEUTICS 495 MASSAGE Massage is useful in infancy after attacks of infantile paralysis. The affected limbs should be massaged daily to increase the circulation to the part, so that the unaf- fected muscles will be under the most favorable conditions for hypertrophying or overdeveloping, upon which de- pends a fairly good use of the leg. In childhood, massage is one of the best measures to employ in chronic constipation. It should be practised twice a day, after retiring and in the morning. The proper method of giving massage in these cases is to use only the hand, without grease of any kind, rubbing the abdomen with a circular motion, the idea being to move the abdominal wall over the intestine, and in this way to excite peristalsis. In older children the same causes for massage exist as in the adult. ELECTRICITY Electricity has a limited scope in childhood. In paralytic conditions it is useful and should be applied in the same manner as in the adult. SKIAGRAPHY For' the purposes of diagnosis, especially of fractures, the Rontgen ray is of the greatest use. Medicinally it is employed in the treatment of enlargement of the thyroid and thymus glands; cervical and bronchial ade- nitis; in some forms of splenic hypertrophy, notably leu- kemia; and in eczema, tinea tonsurans, nevi, and other skin affections. 496 DISEASES OF CHILDREN FOR NURSES DISINFECTION All discharges should be immersed in carbolic acid, 1:40; bichlorid of mercury, 1:2000; or chlorinated lime of equal strength, and allowed to stand fifteen minutes. All bed-clothing should be thoroughly boiled for a half hour. Disinfection of Hands.—Remove all dirt from under and around nails. Nails and hands should be thoroughly scrubbed with soap and hot water. Immerse them in 95 per cent, alcohol for not less than one minute, then plunge the hands in a solution of bichlorid of mer- cury, 1: 2000, or carbolic solution, 1:40, and thoroughly wash them for at least a minute. A clean wound should never be dressed after an infected wound. The hands should be disinfected between each dressing. Full bichlorid baths, 1:4000, should be taken while nursing contagious cases, and given to the patient before release from quarantine. Fumigation of the apartments, mattresses, hangings, clothing, etc. is accomplished by thoroughly sealing the room and introducing formalin gas through the keyhole. Disinfection of Excreta.—The stools and urine should be received in a vessel containing a disinfectant. An equal quantity of disinfectant to the size of the excreta should then be added and the whole thoroughly mixed, and allowed to stand for half an hour before emptying into the water-closet hopper. The bed-pan should contain disinfectant when not in use. It should be thoroughly rinsed in warm water before placing it beneath the child, otherwise the disinfectant might burn the buttocks. THERA PE UTICS 497 DRESSING OF BURNS AND WOUNDS The burned or scalded area should be covered with lint saturated with a normal salt solution. All lacerated and punctured wounds should be thor- oughly cleansed with hot water and peroxid of hydrogen. They should be covered with a wet bichlorid or sterile normal salt solution dressing and wax-paper. PREPARATION FOR OPERATION Thoroughly scrub the part with tincture of green soap, shaving first, if necessary; rinse with sterile water and alcohol; then a solution of bichlorid of mercury, 1:2000. Cover with gauze wrung out of 1:4000 bichlorid of mercury, wax paper, and bandage. At the time of operation this process is repeated. Many surgeons use tincture of iodin spray to sterilize the skin. This is usually prepared by adding one part of tincture of iodin to three parts of water. It is sprayed upon the skin by means of an atomizer. The skin thus treated peels off with the dressings. CATHETERIZATION The hands should be thoroughly scrubbed and dis- infected. The external genitals should be scrubbed with tincture of green soap and water; washed with sterile water; then with 1:4000 bichlorid solution; then a second time with sterile water to remove all traces of bichlorid. Soft rubber catheters should be boiled for ten minutes. English and silk catheters should be immersed in 1:20 carbolic solution for ten minutes; then thoroughly rinsed in sterile water before introduction. 32 498 DISEASES OF CHILDREN FOR NURSES When ready to catheterize, dip' the end of the catheter in carbolized oil, i: 40. If the catheter touches any part before entering the urethra it must be resterilized. This care is taken to avoid infection of the bladder. When removing catheter it should be pinched to prevent the urine remaining in it from running out. If a glass catheter is used the finger should be placed over the opening. ASPIRATION OF THE CHEST A large needle, or trocar, and cannula is used to pierce the chest-wall. The instrument used is attached by means of a rubber tube to a vacuum pump from which all the air must have been removed before the operation. The child should be prepared for operation in the usual way, the point of the proposed puncture having been previously determined. The instruments used should be sterilized. A small dressing is placed over the puncture. Fig. 136.—Paquelin's cautery. Note that the benzene is contained in the handle of the apparatus (W. E. Ashton). PAQUELIN CAUTERY The metal reservoir, containing a sponge, should be about one-third full of benzene. The platinum point to THE RAPE UTICS 499 be used is screwed into position, the tube from the reser- voir is slipped over the handle, the point is heated in the lamp, is removed from the flame, and by compressing the bulbs previously connected with the reservoir, benzol vapor is forced into the point, which will heat up and can be maintained at any temperature by the rapidity with which the bulb is worked. METABOLIC BED The metabolic bed is a name applied to a specially arranged bed in which the child is suspended in such a way that every drop of urine and feces is saved. The quantitative analysis of the excreta, compared with the known intake, gives the results of metabolism in the body and determines the nitrogen balances. CHAPTER XXI WEIGHTS AND MEASURES; ABBREVIATIONS SCALES OF WEIGHTS AND MEASURES APOTHECARIES* WEIGHT The pound (libra) ounce (uncia) dram (drachma) scruple (scrupulum) grain (granum) lb. contains 12 ounces. § "8 drams. 3 " 3 scruples. 9 " 20 grains. WINE MEASURE The gallon (congius) C contains 8 pints. pint (octarius) 0 " 16 fluidounces. fluidounce (uncia fluida) il n 8 fluidrams. fluidram (drachma fluida) ft a 60 minims. minim (minimim) m TABLE OF MUTUAL EQUIVALENTS OF WEIGHTS AND MEASURES lb. I 3 9 gr- 1 = 12 = 06 = = 288 = :576c 1 = 8 = = 24 = : 480 1 = = 3 = 1 = : 60 20 c 0 I 3 m 1 = = 8 = 128 = 1024 = 61,440 1 = 16 = 128 = 7,680 1 = 8 = 1 = 480 60 500 WEIGHTS AND MEASURES; ABBREVIATIONS .50I In prescription writing the scruple is rarely used at the present time. THE METRIC SYSTEM When the metric system is used, the quantities of liquids, as well as solids, are expressed by weight. The meter is the unit of length; the gram, of weight; and the liter, of volume. The prefixes, deca, hecto, kilo, derived from Greek numerals, are used to denote increase, and the prefixesj deci, centi, milli, derived from the Latin numerals, to denote decrease. IOOO. = 1 kilometer. 100. = 1 hectometer. 10. = 1 decameter. I. = 1 meter. .1 = 1 decimeter. .01 = 1 centimeter. .001 = 1 millimeter. The cube of a centimeter is called a cubic centimeter, and is written cc, which term is used to denote capacity. It is used almost exclusively. Thus, instead of saying 1 decimeter, we say 100 cc, and instead of 1 deciliter, we say 100 cc. Relation Between the Apothecaries and the Metric System.— 1 meter = 39-39 inches. 25 millimeters = 1 inch. x i;ter = 33.81 fluidounces, slightly over a quart. 1 gram = 15I Srains .065 " = 1 grain- 29.37 cubic centimeters = 1 fluidram. . » " = 15 minims. 502 DISEASES OF CHILDREN FOR NURSES Rule for Converting Troy Weights into Grams.— (a) Reduce each quantity to grains, move the decimal point one place to the left, and subtract one-third. (b) Reduce each quantity to drams and multiply by four. To Estimate a Dose of a Different Fractional Part of a Grain from the Drug on Hand.—You are often ordered to give a dose of medicine of a different frac- tional part of a grain from the drug you have. Thus, you may be ordered to give gr. ?V of strychnin when the only solution on hand is one in which 10 minims equals gr. -fa. To find out how much to give, multiply the denominator of the fraction of the solution on hand by the number of minims in which it is held in solution, and divide the result by the amount ordered. Thus, 1 SIS IO 40)600(15 40 200 200 Give 15 drops. If quantity in a tablet is greater than required. The given dose is used as the numerator and the re- quired dose as the denominator, thus: The dose of a tablet is marked T^-T gr., and the re- quired dose is y^- gr. 100 — 2 T50 — 3 Therefore, two-thirds of the tablet is the required dose. The tablet should be dissolved in fifteen drops of distilled water and two-thirds, or ten drops, administered as the dose. WEIGHTS AND MEASURES; ABBREVIATIONS 503 To Obtain a Fractional Part of a Minim.—hi times \, \, or f minim may be ordered. To obtain the amount correctly, it is necessary to take 5 minims of the drug and add 20 minims of water, making 25 minims in all; then 5 minims of this quantity will represent 1 minim of the drug. If \ minim is desired, 15 minims of water should be added to the 5 minims representing 1 minim of the drug, making 20 minims in all; then 15 minims of this quantity will represent £ minim of the drug. If \ minim is desired, 5 minims of the above will rep- resent the proper amount. If | minim is desired, it is necessary to add 5 minims of water to the original 5 minims representing the drug, making 10 minims in all; then 5 minims of this quantity will represent \ minim of the drug. In emergencies, 2 drops of a drug can be estimated as representing 1 minim. By adding 6 drops of water, making 8 drops in all, and then taking 6 drops of this quantity, f minim may be obtained. Two drops of the above would represent \ minim of the drug. By adding 2 drops of the water to the 2 drops of the drug and taking 2 drops of this quantity, \ minim may be obtained. If fractional parts of a drop are ordered, one-half of the above dilutions would represent the proper number of drops to use. Rule for Making Solutions of Definite Strengths.— (a) A 1 per cent, solution contains 5 (4.80) grains of the drug to each ounce of the solution. Therefore, a 2 per cent. solution contains 10 grains to the ounce; a 5 per cent. solution, 25 grains; a 10 per cent, solution, 50 grains, etc. (b) A 1:1000 solution contains 8 grains to a pint. 504 DISEASES OF CHILDREN FOR NURSES Therefore, a 1:2000 solution contains 4 grains to a pint, a 1:4000 solution 2 grains and a 1:8000 solution 1 grain. The drugs are usually dissolved in water and labeled so many grains to the dram. DOMESTIC MEASURES 1 teaspoonful = 1 dram or 4 cc. 1 dessertspoonful = 2 drams or 8 cc. 1 tablespoonful = 4 drams or 16 cc. 1 wine glass -= 2 ounces. 1 tea cup = 5 ounces. 1 tumbler =11 ounces. TEMPERATURE There are two methods of expressing degrees of heat and cold, Centigrade and Fahrenheit, expressed by the symbols C. and F., respectively. The zero point of the Centigrade scale is the freezing- point of water, equal to 32° F.; and the ioo° point Cen- tigrade is the boiling-point of water, equal to 212 ° F. Rule for Changing Centigrade Temperatures to Fahrenheit.— Cx 9 ■-----z x 32 5 f Example : 100 C. (boiling-point of water). C. ioo° X 9 =900 h-5 =180 +32 = 212° F. To change Fahrenheit to Centigrade: F-32X5 _c 9 Example : 212 ° F. (boiling-point of water). F. 2120 — 32 = 180 X 5 =900 -5-9 = ioo° C. WEIGHTS AND MEASURES; ABBREVIATIONS 505 Abbreviation. aa. A. c. Ad Add. Ad lib. Ad part. dolent. Alt. dieb. Alt. hor. Alt. noct. A. p. Aq. Aq. astr. Aq. bull. Aq. bull. Aq. dest. Aq. ferv. Aq. font. Aq. pluv. Aq. pur. Aq. tep. Bisind., b.i.d. Bull. C, Cent. C, cong. Cap. Capsul. C.c. Cg., Cgm. Chart. Chartul. Cib. C. m. Cm. C. n. C. n. s. Coch. Coch. ampl. Coch. infant. Coch. mag. Coch. med. ABBREVIATIONS* Foreign word.or phrase. English equivalent. ana Of each (i. e., equal parts). ante cibum Before meals. ad To, up to. adde, addatur, addantur Add, let there be added. ad libitum As much as desired. ad partes dolente,s To the painful (aching) parts. alternis diebus alternis horis alternis noctibus ante prandium aqua aqua astricta aqua bulliens aquae bullientis aqua destillata aqua f ervens aqua fontana aqua pluvialis aqua pura aqua tepida bis in die bulliat Celsius, Centigrade congius cape, capiat capsula cubic centimeter centigram charta chartula cibus eras mane centimeter eras nocte eras nocte sumendus cochleare cochleare amplum cochleare infantis cochleare magnum cochleare medium Every other day, alternate days. Every other hour. On alternate nights, every other night. Before meals. Water. Frozen water, ice. Boiling water. Of boiling water. Distilled water. Hot water. Spring water. Rain water. Pure water. Tepid water. Twice a day, twice daily. Let it boil. Thermometer scale with 100 degrees between the melting- point of ice and the boiling- point of water. A gallon. Take (thou), let him take. A capsule. A metric measure (16.23 min- ims). One-hundredth of a gram (£ gr.). Paper. A small paper. Food, victuals. Tomorrow morning. One-hundredth of a meter (0.3937 inch). Tomorrow night. To be taken tomorrow night. A spoonful. Heaping spoonful. A child's spoonful. A tablespoonful. A dessertspoonful. * Reprinted from The Nurse, October, 1915. 506 DISEASES OF CHILDREN FOR NURSES Abbreviation. Coch. parv. Coct. Col. Colet. Collun. Collut. Collyr. Comp. Conf. Contin. Coq. Crast. Cras mane sumend. Cum C. V. Cyath. Cyath. vin. D. Decoct. Decub. De d. in d. Deglut. Det. in dup. Dieb. alt. Dieb. tert. Dil. Dim. D. in p. aeq. Divid. Dolor, dur. Dr., 3 D. t. d. Ejusd. Empl. En., Enem. Et F. F., Fahr. Feb. dur. Ferv. F. h. Filt. Fluid., Fid. Fldr. Flor. Fl. oz. F. m. Foreign word or phrase. cochleare parvum coctio cola coletur collunarium collutorium collyrium compositus confectio continuetur coque, coquantur crastinus cras mane sumendus cras vespere cyathus cyathus vinarius dies; dosis, . libra Linim. linimentum Liq. Lot. liquor lotio M. misce, meter, meridies mistura Mac. macera Man. manipulus Man. pr. mane primo M. ft. mistura fiat Mg., Mgm. milligramme Mic. pan. mica panis Min., ttjj minimum Mist. mistura Mm., mm. millimeter N. B. nota bene No. numero, numerus Noct. nocte Noct. nocte maneque maneq. Non repetat. non repetatur 0. octarius 01. oleum Omn. bih. omni bihora Omn. hor. omni hora English equivalent. Leaves. Let a potion be made. Let pills be made. In divided doses. Let it or them be made. Let a pill-mass be made and divided into pills. Let a powder be made. A gargle. A metric weight (15.437 grains). A grain, grains. A drop, drops. By drops. An hour. A draft. At bedtime. At the hour of sleep. Daily. An infusion. An injection. A metric weight (33.816 fluid- ounces). A pound. A liniment. A solution. A lotion. , Mix (thou), French unit of length (39.37 inches), noon, mixture. Macerate. A handful. Early in the morning. Let a mixture be made. A metric weight (g^ grain). Bread crumb. A minim. A mixture. A metric linear measure (£5 inch). Note well. In number, a number. At night. At night and in the morning. Do not repeat. A pint (5xvj). Oil. Every two hours. Every hour. 508 DISEASES OF CHILDREN FOR NURSES Abbreviation. Foreign word or phrase. English equivalent. Omn. mane, 0. m. Omn. noct. 0. n. Omn. quar. omni mane Every morning. omni nocte Every night. omni quadrante hora Every quarter of an hour. hor. Ov. ovum An egg. Oz., 5 uncia Ounce. P. ae. partes aequales In equal parts. Part. vie. partitis vicibus In divided doses, divided by turn. Per per Through, by means of, very. Pil. pilula A pill. Pocul. poculum A cup. Post cib. post cibum After meals. Pot. potio A potion. P.p. post prandium After meals. Ppt. praecipitatum Precipitate. P. r. n. pro re nata When required. Pulv. pulvis A powder. q. i h. quaque hora Every hour. q. 2 h. quaque secunda hora Every two hours. q. 3 h. quaque tertia hora Every three hours. q. 4h. quaque quarta hora Every four hours. Q. s. quantum sufficit A sufficient quantity. Quotid. quotidie Daily. R recipe Take (thou). Rad. radix Root. Redig. in redigatur in pulverum Let it be reduced to powder. pulv. Red. in pulv. reductus in pulverum Reduced to powder. Rep. repetatur Let it be repeated. S. A. secundum artem According to art. Sat. saturatus Saturated. Scat. scatula A box. Scr., 9 scrupulus A scruple (20 grains). Sem. semen Seed. Seq.luce sequenti luce The following day. Sp. fr. spiritus frumenti Whisky. Sig. signa, signetur Write (thou), let it be marked. Sin. sine Without. Sinap. sinapis Mustard. Solut. solutio A solution. S. o. s. si opus sit. If necessary. Sp. gr. gravitas specificus Specific gravity. Spt., spir. spiritus Spirit. Ss. semis, semissis, semi- A half. St. stet, stent Let it or them stand. Stat. statim Immediately. Su. sumet Let him take. Sum. sumatur, sumantur Let it (them) be taken. WEIGHTS AND MEASURES; ABBREVIATIONS 509 Abbreviation. Foreign word or phrase. S. v. spiritus vini S. v. g. spiritus vini gallici S. v. r. spiritus vini rectificatus S. v. t. spiritus vini tenuis Syr. syrupus Tab. tabella Tal. talis, tales T. d., t. i. d. ter die, ter in die Tinct., Tr. tinctura Trit. tritura Troch. trochiscus, trochisci Una, 0 uncia Ung. unguentum Ut diet. ut dictum Ves. vesica Vesic. vesicula, vesicatorium Vin. vinum Vitel. ov. vitellus ovi V. S. solutio + volume -f- metric English equivalent. Alcoholic spirit. Brandy. Alcohol. Proof spirit. Syrup. A tablet. Such a one, such ones. Three times a day, thrice daily. " Tincture. Triturate. A lozenge, troche, lozenges. An ounce. An ointment, unguent. As directed. The bladder. A blister. Wine. Yolk of egg. Volumetric solution (one con- taining in each liter [quartl a definite amount of any re- agent), also called standard solution. CHAPTER XXII MEDICAL TERMINOLOGY Prefix Definition Example A absence of asepsis. dys painful dyspepsia. end the lining endocarditis. he mo blood hemothorax. hydro water hydrocele. hyper above hyperacidity. hypo beneath hypodermic. macro large macroglossia. micro small microscope. peri around pericardium. pneumo air pneumothorax. pyo pus pyogenic. Suffix Definition Example Algia pain neuralgia cele a tumor hydrocele. ectomy cutting out appendectomy. esthesia feeling hyperesthesia. gogue drugs causing in- crease of flow cholagogue. itis inflammation of appendicitis. lithiasis stone in nephrolithiasis. odynia painful pleurodynia. ology study of bacteriology. orrhea copious discharge diarrhea. otomy cutting into gastrotomy. phagia swallowing dysphagia. pepsia digestion dyspepsia. phonia speech aphonia. Name Root Word Inflammation of Brain encephalos encephalitis. ear ous, otos otitis. gland aden adenitis. heart cardia endocarditis. intestine (large) colon colitis. intestine (small) enteron enteritis. kidney nephron nephritis. 610 MEDICAL TERMINOLOGY 5" Name Root Word liver hepar mouth stoma muscle mys, myos nerve neuron nose rhis, rhinos rectum procto skin derma stomach gaster tongue glossa Inflammation of hepatitis. stomatitis. myositis. neuritis. rhinitis. proctitis. dermatitis. gastritis. glossitis. GLOSSARY Abdomen.—The portion of the trunk extending from the chest to the pelvis. Abnormal.—Not conforming to the general rule of nature. Abduct.—To draw from median line. Adduct.—To draw toward center. Abrasion.—The rubbing off of the skin or mucous surfaces by injury. Adenitis.—Inflammation of a gland. Adenoid.—A polypoid growth in the pharynx, back of the nose. Adipose.—Consisting of fat. Adolescence.—The period between puberty and full development. Aerated.—Exposed to the action of fresh air. Albumen.—White of egg. Alkaline.—Having properties the opposite to those of an acid. Alopecia.—Baldness. Alveoli.—Air cells of the lungs. Analyze.—To ascertain the composition of. Anasarca.—General dropsy. Anatomy.—The study of the different tissues and organs of the body. Anemia.—A decrease in the blood constituents. Anesthetic—Pertaining to the loss of sensation. Ankylosis.—A locking of a joint from injury or disease. Anomalies.—Marked deviation from the normal. Anorexia.—Loss of appetite. Antiseptic—Having the power to destroy bacteria and to prevent their growth. AnUS.—-The external opening of the rectum. Areola.—A colored ring around an object. Arthrepsia.—Marasmus. Asepsis.—Absence of bacteria. Asphyxia.—Suffocation. Assimilate.—The process of transforming food into such a nutrient condition that it may be taken up by the blood. 512 DISEASES OF CHILDREN FOR NURSES Atony.—Want of power, especially muscular power. Atresia.—The absence of the natural opening to a normal canal. Auricle.—The external ear. Autopsy.—An examination of the organs and tissues of the body made after death. Bacteria.—Germs. A low form of plant life. They multiply very rapidly. Batting.—Cotton or wool arranged in layers for quilting. Bicuspids.—The fourth and fifth teeth from the middle. Bladder.—The reservoir for the urine. Bronchial Tubes.—The air-passages from the windpipe or trachea to the air-cells of the lungs. Cachexia.—A very low condition of nutrition due to some serious disease. Calorie.—The amount of heat required to raise i gram of water ta i° of heat Centigrade. Canine Teeth.—The eye teeth, third from the middle. Canthus.—The angle formed by the upper and lower eyelids at the internal and external extremity of the palpebral fissure. Carbohydrates.—Sugars. Caries.—Death of a bone. Caseate.—To break down and form a cheese-like mass, seen in tuber- cular processes. Casein.—The ingredient of milk which constitutes most of the curd, and is the chief source of proteid. Catharsis.—To purge. Catheter.—A hollow, flexible rubber tube used to draw off the urine from the bladder (catheterization). Cell.—The smallest division of animal life. The entire body is composed of millions of cells. Cereals.—The grain plants, such as wheat, rye, barley, etc. The seed is used for food. Cerumen.—The wax of the ear. Cicatrix.—Scar tissue. Circulation.—The flowing of the blood through the body. Clonic.—The term given to intermittent convulsions. Coagulate.—To thicken, clot, or curdle. Coalescence.—The union of two or more parts of a thing. To flow together. Colic—Severe griping pain in the abdomen. MEDICAL TERMINOL OGY 5J3 Colostrum.—The milky fluid which can be pressed from the breasts of a pregnant woman, and which flows for the first three days after the birth of the child. Communicable.—Contagious. Complication.—A condition occurring during the course of a disease. Compound.—Composed of two or more ingredients. Compress.—A folded cloth, wet or dry, applied to a part for the relief of inflammation, or to prevent a hemorrhage. Condiment.—Substances used to give relish to food. Congenital.—Being present at the time of birth. Congestion.—An abnormal accumulation of blood in an organ or part of the body. Constipation.—Difficult or infrequent bowel movements. Constriction.—The state of being squeezed. Contagious.—Capable of direct communication. Contaminated.—Rendered impure by contact. Contusion.—A bruise. Convalescence.—The gradual return to health after sickness. Convulsion.—A violent and involuntary muscular contraction, or series of contractions. Cornea.—The transparent anterior portion of the eyeball. Coryza.—Cold in the head. Coxalgia.—Tubercular hip-joint disease. Crepitus.—A grating, crackling sound. Curdle.—The formation of curds. Curds.—The thickened portion of milk. Curetment.—Scraping of a part to remove diseased tissue. Cyst.—A cavity containing fluid and surrounded by a capsule. Cystitis.—Inflammation of the bladder. Dandruff.—Small scales from the scalp. Deaf-mutism.—The condition of being both deaf and dumb. Debilitated.—Weakened. Decoction.—The water in which a substance has been boiled. Decubitus.—The position of a patient in bed. Defecate.—The act of having a bowel movement. Deformity.—Unnatural shape. Degeneracy.—The tendency to deteriorate. Deglutition.—The act of swallowing. Deleterious.—Injurious. Delivery.—The birth of a child. Dentition.—The process of cutting teeth. 33 514 DISEASES OF CHILDREN FOR NURSES Dermatitis.—Inflammation of the skin. Desquamate.—To shed the skin. Development.—A gradual growth through progressive changes. Diagnosis.—Recognition of a disease. Diastole.—The period when the chambers of the heart dilate after the period of contraction. Occurs after each heart-beat. Digestion.—The process of changing the food from the form in which it enters the body to that in which it is absorbed by the blood. Disinfection.—Rendering free from germs. Diurnal.—Daily. Douche.—A jet of water entering a cavity of the body. Dyspepsia.—Chronic indigestion. Ecchymosis.—Extravasation of blood into surrounding tissues. Edema.—Dropsical swelling. Effervescent.—Bubbling up, with the giving off of gas bubbles. Effusion.—The pouring out of a serous or bloody fluid into the tissues or cavities of the body. Embolus.—A particle of fibrin or other material brought by the blood current and forming an obstruction within an artery at its place of lodgment. Embryo.—The unborn child before the fourth month of pregnancy. Emulsion.—A mixture of an oily substance with a liquid. Enema.—An injection into the rectum. Epidermis.—The outer layer of the skin. Epistaxis.—Nose-bleed. Eruption.—A rash. Eustachian Tube.—A duct running from the middle ear to the pharynx. Evaporation.—Converting into vapor. Excretion.—A discharge of waste products. Exhale.—To breath out. Expiration.—The emptying of the lung of air. Fat-free Milk.—Milk from which all the fat has been removed. Feces.—-The stools. Matter expelled from the intestines by way of the rectum. Fetus.—The unborn child after the fourth month of pregnancy. Fissures.—Cracks in the skin, or mucous membrane. Flatulence.—The presence of gas in the stomach and intestines. Flocculent.—Flaky. Fomentation.—Flannel cloths rung out of hot water and placed on the body as a means of applying moist heat. MEDICAL TERMINOLOGY 515 Fontanel.—The soft spot in a child's head, caused by the non-union of the bones. Formula.—A list of the names and quantities of the ingredients of a mixture. Function.—The mode of action of an organ. Furuncle.—A boil. Genital.—Pertaining to the organs of reproduction. Gland.—An organ of the body that secretes substances of use to the system or casts off waste matter. Hemorrhage.—Bleeding. Hemorrhoids.—Piles. Hepatization.—Liver-like. Used in describing the lung in pneu- monia. Hernia.—A rupture. The protrusion of the internal organs from their natural position. Hydrotherapy.—Treatment by means of water. Hygiene.—The science of preserving health. Hypertrophy.—To enlarge by overgrowth. Icterus.—Jaundice. Idiocy.—A lack of mental understanding. Imbecile.—One who is mentally weak. Incisors.—The four front teeth of each jaw. Incubator.—An apparatus for preserving the life of a premature infant. Infected.—Brought in contact with bacteria. Inherent.—Instinct. The ability to perform certain acts without knowledge of the reason and without previous training of the individual. Insomnia.—Sleeplessness. Inspiration.—The act of filling the lungs with air. Intermittent.—Ceasing at intervals. Interstitial Tissue.—The supporting tissue or framework of an organ or structure of the body. Isolation.—The complete separation from other individuals. Kumiss.—Fermented milk. Labor.—Childbirth. Laceration.—A cut. Lancinating.—Shooting. 516 DISEASES OF CHILDREN FOR NURSES Latent.—Hidden. Laxative.—A medicine that moves the bowels gently. Leukocytosis.—An increase in the number of white blood corpuscles in the circulation. Ligament.—A band of tissue binding two parts together. Lime-water.—A solution of lime in water. Loins.—The lower part of the back and region of the hips. Lubricant.—An oily material used to make two surfaces glide smoothly over one another. Malaise.—A feeling of weakness. Listlessness. Manipulation.—The act of handling or working with the hands. Massage.—A rubbing or kneading of the muscles. Mastication.—The act of chewing. Membrane.—A thin lining tissue. Membranous Croup.—Diphtheria of the larynx. Meningitis.—An inflammation of the membranes covering the brain and spinal cord. Microbe.—A germ. Micturition.—The act of urinating. Milk Sugar.—A sugar made by the evaporation of the whey of milk. Milk Teeth.—The first set of teeth. Minim.—About a drop. One-sixtieth of a fluid dram. Molars.—The back teeth. Morbid.—Diseased. Morbid Anatomy.—The study of diseased tissues. Mortality.—The frequency of death. Mucous Membrane.—The lining membrane of all passages and cavities that come in contact with the air. Mucus.—A slimy fluid from the mucous membrane. Navel.—The umbilicus. Necrosis.—Death of a structure or tissue. Nephritis.—Inflammation of the kidney. Bright's disease. Neural.—Pertaining to a nerve. Neuralgia.—Pain along the course of a nerve. Neurosis.—A nervous functional disease. Neurotic—Nervous. Nevus.—A birth-mark. Nitrogenous Food-stuffs.—Meats, potatoes, and similar foods. Nocturnal.—Pertaining to night. Normal.—According to the rule of nature. MEDICAL TERMINOLOGY 517 Obstetrics.—The management of childbirth. Occluded.—Closed. Opaque.—Not transparent. Organism.—The body as a whole. Organize.—The conversion into living tissue. Palatable.—Agreeable to the taste. Parasites.—Insects living on animals, such as lice. Paroxysm.—A spasm. Paroxysmal.—Spasmodic. Parturition.—Childbirth. Pasteurization.—The heating of milk to 167 ° F. to destroy germs. Pathology.—The science of the changes which take place in the structure of the body in disease. Patulous.—Open. Pelvis.—The bony basin supporting the abdominal viscera. Percentage.—Rate per hundred. Perforation.—Used to denote the occurrence of a hole into an organ or through the bowel. Period of Incubation.—The time elapsing between the introduction of bacteria into the body and the appearance of the symptoms of the disease. Periodic—Recurring at intervals. Peristalsis.—The worm-like movements of the intestines by which the feces are moved. Peritonitis.—An inflammation of the membrane lining the abdominal cavity. Pertussis.—Whooping-cough. Petechiae.—Hemorrhagic spots in the skin. Phenomenon.—A thing that is observed. Physiology.—The science of the functions of the different organs. Placenta.—The attachment of the umbilical cord to the inner side of the womb. The "after-birth." Pneumonia.—Inflammation of the lungs. Polyp.—A tumor composed of mucus. Pores.—The openings of the sweat-glands in the skin. Poultice.—A hot, soft mass, used to apply moist heat or to remove odor. Predisposition.—A tendency to. Pregnancy.—The carrying of the child by mother before birth. Premature.—Before full term. 518 DISEASES OF CHILDREN FOR NURSES Prophylaxis.—Measures to prevent the development or spread of disease. Proteid.—The albuminous foods; the nourishing part of milk, eggs, and meat. Pruritus.—Itching. Puberty.—The period of life at which an individual becomes capable of producing children. Pubic—Pertaining to the front of the pelvis. Puerperium.—The period immediately following childbirth. Pulse-rate.—The number of beats per minute. Purgative.—A medicine that cleans out the bowels. Quarantine.—The guarding of a building which houses a contagious case, so that no one can enter or leave. Rash.—A breaking out on the skin. Ratio.—Proportion. Reaction.—The return to normal after collapse. The return to warmth after a chill. Rectum.—The lower end of the intestines. Regurgitai on.—Vomiting of mouthfuls. Relax.—To make less rigid. Remittent.—Temporary disappearance. Respiration.—The act of breathing. Respiratory Rate.—The number of respirations per minute. Resuscitate.—To revive. Rickets.—A disease of childhood characterized by deformity of the bones and changes in the liver and spleen. Rigor.—Chill. Rigor Mortis.—The stiffening of the muscles after death. RStheln.—German measles Rubella.—Measles. Rubeola. —Measles. Saliva.—Secretion present in the mouth. Saturated Solution.—A solution of a substance in which no more of that substance can be dissolved. Sclerosis.—Hardening of a part due to overgrowth of fibrous tissue. Scrofulous.—Tubercular. Scurvy.—A disease due to a lack of nourishing diet. Secretion.—The substance produced by glandular action. MEDICAL TERMINOLOGY 519 Sedentery.—Sitting. Sepsis.—Poisoning by germs. Sequel.—A condition which appears after a disease. Shock.—The period of collapse following an accident or operation. Sinus.—Discharging channel from an abscess cavity. Sitz Bath.—Sitting in water covering the hips. Sordes.—Crusts that accumulate on the teeth. Spasmodic.—Occurring in spasms. Specific Remedy.—One that has a distinct curative influence on an individual disease, as quinin in malaria. Sputum.—Spittle. Sprain.—A tearing of the ligaments around a joint. Stenosis.—Constriction or narrowing of a channel. Sterilize.—To render free from germs. Sterile.—Absence of germs. Stimulate.—To excite action. Stomach Teeth.—The two milk teeth on either side of the four lower incisors. Striae.—Lines or furrows. Structure.—Construction of parts. Stupe.—A cloth rung out of hot water and used for applying moist heat. Suppression.—A stoppage of a discharge. Symptom.—A sign of a disease. Temperature.—The degree of heat. Tetanus.—Lock-jaw. Tissue.—A collection of cells of the body doing the same work. Toxin.—A poison. Traumatism.—An injury. Tumor.—An abnormal swelling. Umbilical Cord.—The cord by which the infant is attached to the placenta. It enters the child's body at the umbilicus or navel. Unhygienic—Contrary to the laws of health. Urine.—The excretion of the kidneys. Uterus.—The womb. Vapor Bath.—A bath in vapor used to produce sweating. Vagina.—The opening in the female which extends from the womb to the outer parts. 520 DISEASES OF CHILDREN FOR NURSES Varicose Veins.—Swollen, thickened veins. Venous Stasis.—Engorgement of the veins with blood. Ventilation.—The process of replacing foul air with pure. Viscera.—The organs of the body. Vitality.—Vigor. Vulva.—The external genitals of the female. Weaning.—Removing the nursing infant permanently from the breast. Whey.—The part of milk which remains fluid after the curds have formed. INDEX Abbreviations, 505 Abscess, cerebral, 218 in Pott's disease, 320 ischiorectal, 167 of liver, 169 of lung, 106 psoas, 320 retropharyngeal, 122 Accommodation, 253 Achondroplasia, 273 Acidosis, 367 Addison's disease, 269 Adenitis, 266 tubercular, 25, 323 Adenoid, 117 Air-beds, 491 Air-cushions, 491 Airing of newborn babe, 38 Albumin and milk, 386 in urine, test for, 238 water, 386 Albuminuria, 237 Alkaline baths, 466 Amaurotic family idiocy, 219 Amyloid kidney, 245 Amyotonia congenita, 277 Anemia, 24, 197 Anesthesia, 208 in hysteria, 222 Aneurysm, 24, 193 Angina, follicular, 116 Vincent's, 119 Anginoid scarlet fever, 332 Animal parasites, 207 Ankle clonus, 207 Ankylosis, 321 Anorexia, 124 Antidotes of poisons, 446 Antigen, syphilitic, 292 Antiseptic poultices, 458 Antitoxin in diphtheria, 344 Anuria, 236 Anus, atresia of, 22, 142 fissure of, 166 Aortic insufficiency, 186 stenosis, 186 Apex-beat, 175 Aphasia, 218 Aphthous stomatitis, 112 Apoplexy, 331 Apothecaries' weight, 500 and metric system, relation be- tween, 501 Appendicitis, 155 Appetite in digestive diseases, 109 Apple gruel, 388 Arachnoid, 205 Arhythmia, sinus, 178 Arrow-root gruel, 390 with egg, 391 Arsphenamine, 292 Arteriosclerosis, 24, 193 Arthritis, tubercular, 322 Arthropathies, 208 Artificial feeding, 398 Baner's formula, 400 caloric method, 400 percentage method, 399 recent progress in, 399 respiration, 480 manual methods, 482 Ascaris lumbricoides, 164 Ascites, 170 Asphyxia, emergency treatment, 448 in newborn, 19, 484 Aspiration in empyema, 84 of chest, 498 pneumonia, 103 Asthma, 74 emergency treatment, 448 thymus, 269 521 522 INDEX Astigmatism, 253 Atelectasis, 77 congenital, 19 Athetosis, 207 Atmosphere, moist maintaining of, 5° . Atomizers, 48 Atresia of anus, 22, 142 Atrophic rhinitis, 61 Atrophy, infantile, 375 muscular, 231 Auricular fibrillation, 179 flutter, 179 Auscultation of heart, 176 Autogenous vaccines in pyelitis, 246 Autumnal fever, 298 Babies, blue, 24, 174 Babinski's reflex, 208 Backwardness in children, 220 Bacterines, 479 Balanitis, 250 Baner's formula, 400 for cream mixtures, 409 Banti's disease, 199 Barley gruel, 389 jelly, 390 maltine, and milk mixture, 391 water, 385 Barlow's disease, 371 Bath, alkaline, 466 bran, 466 compound glycerin, 467 sulphur, 467 for skin diseases, 466 graduated cold, 455 hot, 461 hot-air, 464 sitting, 465 hygienic, 468 linseed, 467 mustard, 468 prevention of chills after, 49 salt, 465 shower, 468 sitz, 465 sponge, 454, 468 starch, 467 tar, 468 tepid, 468 vapor, 462 Bath, vinegar and mercury, 468 Bathing in childhood, 48 in infancy, 48 of newborn, 36 Bean soup, 394 Bed, Children's Hospital, 37 Klondike, 325, 326 linen, soiled, care of, 329 metabolic, 499 Bed-sores, 308 Beef juice, 391 and milk, 391 Bell's palsy, 233 Bichlorid baths, 496 Birth-marks, 264 Birth-palsy, 25, 217 Bites, treatment of, 448 Bladder, diseases of, 248 exstrophy of, 249 inflammation of, 246 Blebs, 261 Bleeders' disease, 197 Blindness, adult, 25 Blister, cantharides, 456 fever, in, 262 Block, heart-, 178 Blood, diseases of, 193 in stools, 139 specific gravity of, 195 Blood-pressure, determination of, 195 Blood-vessels, diseases of, 133 Blue babies, 24, 174 Bones, diseases of, 270 malformations of, 270 tuberculosis of, 318 Borborygmi, 146 Bottles, feeding, 425 sterilization of, 48 Bottom milk, 407 Bowing of tibia, 27, 272 Bow-legs, 27, 272 Bradford frame, Fauntleroy's modi- fication of, 492 for fractures, 492 Bradycardia, 177 Brain, 200 abscess of, 218 diseases of, 214 hemorrhage of, 25 malformations of, 209 Bran baths, 466 INDi Brat's apparatus for artificial res- piration, 482 Breast, pigeon-, 22, 271 Breasts of newborn, 37 Breath in digestive diseases, 109 Breathing, stridulous, 64 Bright's disease, 241 Brill's disease, 294 symptoms, 295 Bronchi, foreign bodies in, 67 Bronchiectasis, 73 Bronchitis, 23, 67 acute, 70 capillary, 23 chronic, 72 Bronchopneumonia, 23, 90 acute, 93 tuberculous, 315 Bubble quick, 427 Buck's extension, application of, 486 Bulimia, no Burns, dressing of, 497 emergency treatment, 448 Buttermilk, 393 care of, in house, 424 conserve, 393 Calculus, renal, 245 vesical, 249 Caloric method of artificial feeding, 400 of infant feeding, 416 values, table of, 417-421 Calorie, 416 Camphorated oil, 457 Cane-sugar in artificial feeding, 402 Cantharides blister, 456 Capillary bronchitis, 23 Carbohydrate stools, 139 Carbohydrates, 378 Care of milk in house, 423 Carriers, 282 Catalepsy, 208 Catarrhal laryngitis, 62 stomatitis, 112 Catheterization, 497 Cautery, Paquelin, 498 Cephalhematoma, 21 Cephalodynia, 366 Cerebral hemorrhages in newborn, 21 EX 523 Cerebral localization, 215 meningitis, 210 paralysis, 217 pneumonia, 102 Cerebrospinal fever, 282 meningitis, 210, 282 Chapin dipper, 408 Characteristic cry, 29 Charcoal poultice, 458 Chest, aspiration of, 498 funnel-, 271 Cheyne-Stokes respiration, 57 Chicken-pox, 354 Child, crowing, 223 Childhood, general hygiene of, 39 nursing in, 34 period of, 11 Children's Hospital bed, 37 Chills, emergency treatment, 448 prevention of, after baths, 49 Chlorosis, 197 Cholecystitis, 168 Cholera infantum, 152 morbus, 154 Choluria, 237 Chondrodystrophia fetalis, 273 Chondrodystrophy, 273 Chorea, 25, 209, 225 heart murmur in, 24 Choreiform movement, 207 Chyluria, 237 Circulation, 173 fetal, 174 Circulatory system, anatomy of, 171 diseases of, 24 Cirrhosis of liver, 168 Cleanliness in tuberculosis, 328 Cleft palate, in Clothing for outdoor sleeping, 327 in childhood, 39 in infancy, 39 of newborn, 36 Clubbed fingers in heart disease, 180 hands, 27, 270 toes in heart disease, 180 Club-feet, 27, 270 Coffee-ground vomit, 129 Cold bath, graduated, 455 compress to rectum, 48 in the head, 58 DEX 524 INI Cold pack, 455 Colic, intestinal, 141 renal, 245 Collapse, treatment of, 448 Colon, dilatation of, 160 irrigation of, 476 Colostrum, 380 Coma, 208 Compensation, cardiac, 187 period of, 187 Complement fixation test, 44, 292 Compresses, 460 cold, to rectum, 48 Condensed milk, 395 care of, in house, 424 Congenital dislocation of hip-joint, 270 laryngeal stridor, 66 Congestion of liver, 168 of lungs, 89 Conjunctivitis, 25, 255 Constipation, 140 Constitutional diseases, 26 Contagious diseases, 26, 330 acute, heart murmur in, 24 definition of, 281 nurse in, 49 Continuous saline injection, 477 Contraindications for various drugs,_ 438 Convulsions, 25, 206, 216 emergency treatment, 449 Cord, care of, 36 Corrosion of esophagus, 126 Coryza, 58 Cough, 52 Counter-irritation, 456 Cowling's rule for dosage, 437 Cowpox, 354 Cows' milk, 382 Coxa vara, 272 Coxalgia, 320 extensions for, 486 Coxitis, 320 Cradles, improvised, 50 Cranial nerves, 205 Cream, 383 dipping for, 408 in artificial feeding, 410 method for changing percentage , of, 413 siphoning for, 411 Cretinism, 220, 268 fetal, 273 Crossed paralysis, 216 Croup, emergency treatment, 448 kettle, 473 spasmodic, 63 tent, 472 Croupous exudate, 99 pneumonia, 24, 90, 97 Crowing child, 223 Crusts, 261 Cry, characteristic, 29 Cuffs, 473 Cups, dry, 457 wet, 458 Curdy stools, 139 Curvature of spine, 271 Cutaneous test, von Pirquet's, for tuberculosis, 323 Cyclic vomiting, 129 Cystitis, 246 Dactylitis, tubercular, 323 Dakin's solution, 446 Deaf-mutism, 218 Death, cause of, 30 Defervescence, 278 Deformities, 27 Dehydration, 154 Dextrimaltose, 405 Dextrin-maltose in artificial feed- ing, 402 Diabetes insipidus, 239 melfitus, 26, 368 Diaphragmatic hernia, 161 pleurisy, 86 Diarrhea, 142 in typhoid fever, 304 saline solution in, 154 summer, 144 Diastole, 185 Dicrotic pulse, 177 Diet, fifteen months to two years, 43° in pylorospasm, 130 list, 433 mixed, for young infants, 401 nine to twelve months, 429 twelve to fifteen months, 430 Digestion, 28 Digestive diseases, feces in, 138 tract, diseases of, 108 INDEX 525 Digitalis poultice, 458 Dilatation of colon, 160 of heart, 191 of stomach, 136 Diphtheria, 340 Schick test, 346 Dipper, Chapin, 408 Dipping for cream, 408 Diseases, inheritance in, 18 peculiar to children, 18 Disinfection, 496 in scarlet fever, 333 of excreta, 328, 496 of hands, 496 of stools in typhoid fever, 300 Dislocation, congenital, of hip, 27, 270 emergency treatment, 449 Dissemination of disease, 281 Dosage, rule for reduction of, 502 rules for, 436 Douching, vaginal, 479 Draughts, avoidance of, 47 Dried milk, 402 Dropsy in heart disease, 179 Drowning, emergency treatment, 449 Drugs, characteristic pulses of, 440 dominant action of, 439 poorly borne by children, 435 used in children's diseases, with dose, 442 well borne by children, 435 which cause eruptions, 440 color stools, 441 urine, 441 contract pupil, 440 dilate pupil, 440 quicken pulse, 439 raise blood-pressure, 440 slow pulse, 439 Dry cups, 457 Ductless glands, diseases of, 267 Ductus arteriosus, 174 Duodenal ulcer, 160 Dura mater, 204 Dwarfs, 269 Dysentery, 150 Dyspepsia, atonic, 134 catarrhal, 134 chronic, 133 Dyspepsia, nervous, 133 Dysphagia, no Dyspnea, 54 emergency treatment, 450 Dystrophy, muscular, 276 pseudohypertrophic, 276 Ear, diseases of, 25, 256 nursing in, 259 examination of, 49 foreign bodies in, 450 running, 25 syringing, 469 Earache, 258 emergency treatment, 450 Eczema, 25, 261 Edema of glottis, 66 pulmonary, 77 Ehrlich's salvarsan, 292 Eiweissmilch, 396 Electricity, 495 Embolism, 189 Emergencies, treatment of, 448 Emphysema, pulmonary, 77 Empyema, 81 Encephalitis lethargica, 217 Encephalocele, 209 Endocarditis, 182 after rheumatism, 24 complicating rheumatism, 26 fetal, 175 ulcerative, 188 Endocardium, 172 Enemata, 478 Enlargement of thymus glands, 268 Enterocolitis, 150 membranous, 151 Enuresis, 248 Epilepsy, 220 Jacksonian, 215 Epileptic idiocy, 219 Epileptiform convulsions, 206 Epiphysitis, 323 Epispadias, 249 Epistaxis, 61 treatment, 450 Erb's paralysis, 22, 233 Erysipelas, 20, 357 Erythema, 261 Esophagus, corrosion of, 126 diseases of, 126 stricture of, 126 526 INDEX Eustace Smith's sign, 318 Examination, method of holding child for, 47 Examinations, general, 41 Excreta, disinfection of, 328, 496 Exercise, 434 in childhood, 39 in infancy, 39 Exophthalmic goiter, 267 Expectoration, 54 Exstrophy of bladder, 249 Extension, Buck's, 487 Extensions for fractures, 486 Extremities, growth of, 14 Eye, care of, 254 compresses for, 460 diseases of, 25, 252 foreign bodies in, 255 malformations of, 254 syringing, 468 Eyelid, everting, 255 Fainting, treatment, 450 Family idiocy, amaurotic, 219 Farina gruel, 389 Fastigium, 278 Fat percentages in mixtures, rules for, 422 Fats, 377 in artificial feeding, 403 Fatty degeneration of heart, 191 of newborn, 20 stools, 139 Fauntleroy's modification of Brad- ford's frame, 492 Febricula, 279 Feces, 138 blood in, 139 carbohydrate, 139 curdy,139 fatty, 139 green, 139 in digestive diseases, 138 incontinence of, 167 milk, 138 mucous, 138 protein, 138 soapy, 139 Feeble-mindedness, 219, 220 Feeding, adjuncts to, 434 artificial, 398 Baner's formula, 400 Feeding, artificial, caloric method, 400 percentage method, 399 recent progress in, 399 by stomach-tube, 476 during first year, 428 schedule for, 427 second year, 429 infant, 376 regurgitation after, 49 rules for, 426 top milk, 400 Feet, care of, 49 club-, 270 flat-, 271 Fehling's solution, 239 Female genitals, diseases of, 250 Femoral hernia, 161 Fetal circulation, 174 cretinism, 273 rickets, 273 Fever blisters, 262 cerebrospinal, 282 characteristics of, 278 continued, 278 hay-_, 75 hectic, 278 inanition, 27 infectious, 278 intermittent, 278 malarial, 285 remittent, 278 scarlet, 330 types of, 278 typhoid, 297 Fibrillation, auricular, 179 Fibrinous bronchitis, 72 Fibroid heart, 190. Finger-sucking, 227 Fingers, six, 27 supernumerary, 273 webbed, 27, 273 Finkelstein's eiweissmilch, 396 food intoxication, 154 Fissure of anus, 166 Fixation, complement, 292 Flat-feet, 271 Flaxseed poultice, 459 Flexner's serum, 284 Flint's murmur, 176 Floating kidney, 246 I Flour gruel, 389 INDEX 527 Flutter, auricular, 179 Fontanels, anterior, closing of, 1 posterior, closing of, 14 Food, constituents of, 376 intoxication, 154 Foot-baths, hot, 460 mustard, 466 Foramen ovale. 174 patulous, 174 Foreign bodies in bronchi, 67 in larynx, 67 in nose, 67 in respiratory tract, 67 Fracture of femur, dressing for, 487 Fracture-box, 490 Fractures, emergency treatment, 45i. extensions for, 486 Fraley's formula, 418 Frames, 492 Frenum, ulcer of, in Friction sound, 176 Friedreich's ataxia, 231 Fumigation, 496 Funnel-chest, 271 Furuncle of auditory canal, 258 Furunculosis, 262 Gait, scissors, 228 waddling, 271 Gall-stones, 168 Gangrene of lung, 103 Gastralgia, 135 Gastric ulcer, 135 Gastritis, 133 chronic, 133 Gastro-enteritis, 20 Gastro-enterostomy for pyloro- spasm, 237 Gastro-intestinal disorders, 24 Gavage, 476 Gelatin, preparation of, for infan- tile diarrhea, 391 Genital tract, malformation of, 249 Genitals, diseases of, 249 of newborn, care of, 37 Genito-urinary system, diseases of, 25 malformations of, 25 Genu valgum, 28, 272 Genu varum, 28, 272 German gruel, 389 Gingivitis, in Girdle pain, 227 Glandular system, diseases of, 25, 265 Glomeruli of kidneys, 234 Glossary, 511 Glossitis, in Glottis, edema of, 66 Glycerin bath, compound, 467 Glycosuria, 237 Goiter, 267 exophthalmic, 267 Gonorrhea, 250 complement fixation test for, 44 Grand mal, 220 Graves' disease, 267 Gray tubercle, 316 Green stools, 139 Griffith's weight chart, 12 Growing pains, 26 Growth during first year, 14 of extremities, 14 Gruel, apple, 388 arrow-root, 390 barley, 389 farina, 389 flour, 389 German, 389 oatmeal, 390 rice flour, 392 Gums, inflammation of, in Habit, cry of, 29 spasm, 227 vomiting, 129 Habits, injurious, 227 Hamilton squint, 487 Hands, clubbed, 27, 270 covers for, 493 disinfection of, 496 trident, in achondroplasia, 273 Hare-lip, in Harrison's groove, 373 Hay-fever, 75 Head, circumference of, 14 Head-banging, 227 Hearing, development of, 14 Heart, action of, 175 mechanical disorders and ir- regularities of, 178 528 INDEX Heart, anatomy of, 171 congenital malformations of, 24 dilatation of, 191 diseases of, 24 clubbed fingers in, 180 toes in, 180 nursing in, 191 failure, 480 emergency treatment, 451 fatty degeneration of, 191 fibroid, 190 hypertrophy of, 190 malformations of, 174 murmur in chorea, rheumatism, and acute contagious diseases, 24 sounds of, 176 transposition of, 175 Heart-block, 178 Height, 14 at birth, 14 Heller's test, 238 Hematemesis, 129 treatment, 452 Hematozoa, 285 Hematuria, 237 Hemiplegia, 206 Hemocytometer, 194 Hemoglobin, 194 Hemoglobinometer, 194 Hemoglobinuria, 237 epidemic, 20 Hemopericardium, 182 Hemophilia, 197 Hemoptysis, 76 treatment, 452 Hemorrhage from bowel, treatment, 452 from mouth, treatment, 452 from nose, treatment, 450 in newborn, 21 of brain, 25 Hemorrhoids, 167 Hepatitis, 20 Hepatization, gray, 91 red, 98 Hereditary syphilis, 26, 290 cry of, 29 Hernia, 161 diaphragmatic, 161 femoral, 161 Hernia, inguinal, 161, 162 treatment of, 163 umbilical, 161 acquired, 161 congenital, 161 in newborn, 22 treatment of, 162 ventral, 161 Herpes, in simplex, 262 zoster, 262 Heubner's mustard bath, 456 Hiccough, 129 Hip, congenital dislocation of, 28, 270 Hives, 263 Hodgkin's disease, 169, 267 Holding-breath spells, 224 treatment, 225 Hook-worm, 165 Hordeolum, 253 Horseshoe kidney, 235 Hospital bed, children's, 37 Hot applications, 460 bath, 461 foot-baths, 460 pack, 461 modified, 462 Hot-air bath, 464 sitting, 465 Hot-water bags, 460 care of, 48 Human milk, 379 Hunger, cry of, 29 Hutchinson's teeth, 16, 291 Hydrocele, 250 Hydrocephalic cry, 212 idiocy, 219 Hydrocephalus, 210, 218 cry of, 29 Hydro-encephalocele, 209 Hydronephrosis, 246 Hydropericardium, 182 Hydrophobia, 294 Hydrothorax, 86 Hygienic management of children in general, 35 Hyperemia, renal, 239 Hyperesthesia, 208 in hysteria, 221 Hypermetropia, 253 Hypernephroma, 269 Hyperpyrexia, 278 Hypertrophic rhinitis, 61 Hypertrophy of heart, 190 Hypodermics, 479 Hypodermoclysis, 484 Hypospadias, 249 Hypostatic pneumonia, 103 Hysteria, 221 etiology, 221 nursing in, 222 symptoms, 221 joint, 222 motor, 222 psychic, 221 sensory, 221 treatment, 222 Hysteroidal convulsions, 206 Ice-cap, 454 Ichthyosis, congenital, 264 Icterus neonatorum, 20, 168 Idiocy, 219 amaurotic family, 219 epileptic, 219 hydrocephalic, 219 microcephalic, 219 Mongolian, 219 paralytic, 219 Idiot-savants, 220 Ileocolitis, 150 Imbecility, 219 Impacted cerumen, 258 Impetigo contagiosa, 263 Impure milk, 145 Inanition fever, 27 Incontinence of feces, 167 Incubation, period of, 279 Incubators, 40 Indicanuria, 237 Indigestion, acute gastric, 132 cry of, 29 intestinal, 142 Infancy, general hygiene of, 38 period of, 11 Infant feeding, 376 caloric method, 416 foods, proprietary, 397 receipes for, 385 young, mixed diet for, 401 Infantile atrophy, 375 paralysis, 228 Infantilism, 269 34 EX 529 Infectious disease, definition, 281 nurse in, 49 fevers, 278 acute, 25 nursing in, 295 Inflammation of bladder, 246 of liver, 20 of muscle, 273 of testicle, 250 Inflammatory rheumatism, 364 Influenza, 362 Inguinal hernia, 161, 162 treatment, 163 Inhalations, technic of, 472 Inheritance in diseases, 18, 19 Injections, intravenous, 485 vaginal, 479, 480 Injurious habits, 227 Insanity, 219 Inspiration, noisy, 67 Insufficiency, aortic, 186 mitral, 186 pulmonary, 187 tricuspid, 186 Intermittent fever, quartan, 286 quotidian, 286 malarial fever, 287 Internal secretion, disorders of, 269 Intestinal colic, 141 indigestion, 142 obstruction, 158 in newborn, 22 perforation in typhoid fever, 299, 300 Intestines, diseases of, 138 malformations of, 142 obstruction of, 158 tuberculosis of, 155 Intoxication, food, 154 Intraperitoneal injections, 485 Intravenous injections, 485 Intubation, 348 Intussusception, 158 Invasion stage of fever, 278 Iritis, 253 Irrigation of colon, 476 cold, 455 rectal, 48 Ischiorectal abscess, 167 Itch, 264 INL 530 INDEX Jacksonian epilepsy 215 Jaundice, 20, 167 catarrhal, 168 Joints, malformations of, 270 tuberculosis of, 318 Junket, 395 Keratitis, 253, 255 Kernig's sign, 213 Kidney, amyloid, 245 anatomy of, 234 after scarlet fever, 25 diseases of, nursing in, 248 floating, 246 horseshoe, 235 malformations of, 235 sarcoma of, 247 tuberculosis of, 247 Klondike bed, 325, 326 Knee-jerks, 207 Knock-knee, 27, 272 Koplik's sign, 338 Kumiss and bean flour, 395 Kyphosis, 320, 373 Lacunar angina, 116 La grippe, 362 Laminated teeth, 17 Landry's paralysis, 231 Larosan milk, 396 Laryngeal stridor, congenital, 66 Laryngismus stridulus, 25, 223, 225 emergency treatment, 452 treatment and prophylaxis, 224 Laryngitis, 62 acute catarrhal, 62 syphilitic, 63 tubercular, 63 Laryngospasm, 209 Larynx, foreign bodies in, 67 morbid growths of, 66 papilloma of, 66 Lavage of stomach, 474 in pylorospasm, 131 Legs, bow-, 272 Lethargic encephalitis, 217 Leukemia, 197 Leukocytosis, 197 Lice, 264 Lime-water, 405 Linea alba, 154 Linseed bath, 467 Lisping, 227 Lithuria, 236 Liver, cirrhosis of, 168 congestion of, 168 diseases of, 107 inflammation of, 20 Lobar pneumonia, 90, 97 Lockjaw, 292 Lumbago, 366 Lumbar puncture, 213 Lung, abscess of, 103 anatomy of, 87 diseases of, 87 congestion of, 89 gangrene of, 103 immobilization in tuberculosis, 325 Lungmotor, 482 Lupus vulgaris, 264 Lymphatism, 265, 269 Lymph-glands, bronchial, tubercu- losis of, 318 Lysis, 278 Macules, 261 Malaria, 285 Malarial fever, 26, 285 Male genitals, diseases of, 250 Malformations of bones and joints, 270 Malt soup mixture, 392 Maltose, 405 Marasmus, 27, 375 cry of, 29 Marks, birth-, 264 Masks for skin diseases, 474 Massage, 495 Mastitis in newborn, 22 Mastoid disease, 25 Mastoiditis, 259 Masturbation, 227 Measles, 336 Measure, sugar, 405 Mechanical disorders and irregu- larities of heart's action, 178 Meconium, 138 Medical terminology, 510 Medicine-dropper, 436 Meninges, diseases of, 210 of brain, 204 Meningitis, 210 INDEX 53* Meningitis, cerebral, 210 cerebrospinal, 210, 282 cry of, 29 tubercular, 25, 211 Meningocele, 209 Mercurial stomatitis, 114 Metabolic bed, 499 Metric system, 501 Microcephalic idiocy, 219 Microcephalus, 209 Micromelia, 273 Miliaria, 261 Miliary tuberculosis, 317 Milk, bottom, 407 care of, in house, 423 condensed, 395 care of, in house, 424 cow's, 382 digestion of, 127 dried, 402 examination of, 381 feces, 139 impure, 145 infection, 145 larosan, 396 methods of modifying, 409 pasteurized, 383 peptonized, 387 protein, 396 rice, 385 siphoning, 407 skimmed, 406 sterilized, 385 teeth, average age of eruption of, IS . . whole mixtures of in artificial feeding, 402 woman's, 379 Milk-sugar in artificial feeding, 402 Mineral salts in food, 378 Minim, method of obtaining frac- tional part, 503 Mitral insufficiency, 186 stenosis, 186 Mixed diet for young infants, 401 Mixtures, top-milk, 411 Modifying milk, methods of, 409 Moist atmosphere, maintaining, 50 Mongolian idiocy, 219 Monoplegia, 206 Morbid growths of larynx, 66 Moron, 219, 220 Mouth, diseases of, iii inflammation of, 112 malformation of, no of newborn, care of, 36 syringing of, 472 Mucous stools, 138 Mumps, 361 Murmur, cardiac, 176 heart, in chorea, rheumatism, and acute contagious diseases, 24 Murmurs in endocarditis, 184 Muscles, diseases of, 270, 273 inflammation of, 273 Muscular dystropfiy, 276 pseudohypertrophic, 276 rheumatism, 365 Mustard bath, 466 Heubner's, 456 foot-bath, 466 pack, 457 paste, 456 plaster, 456 poultice, 456 Myelitis, 227 Myocarditis, 190 Myopia, 253 Myositis, 273 ossificans, 275 simple, 273 suppurating, 273 Myotonia, congenital, 277 Nail-biting, 227 Nasal syringing, 470 Nebulizers, 48 Neo-arsphenamine, 292 Nephritis, 241 chronic interstitial, 243 parenchymatous, 242 Nerves, cranial, 205 diseases of, 231 spinal, 205 sympathetic, 205 Nervous system, anatomy of, 200 diseases of, 25 peculiar in children, 208 nursing in, 233 Nervousness, treatment of, 452 Neuritis, 231 multiple, 232 Nevus, 264 532 INDEX Newborn, acute pyogenic diseases of, 20 asphyxia of, 19, 484 bathing of, 36 care of, 35 cerebral hemorrhages in, 21 clothing of, 36 diseases of, 19 prophylaxis in, 20 facial paralysis in, 22 fatty degeneration of, 20 hemorrhages in, 21 intestinal obstruction in, 22 mastitis in, 22 period of, 11 umbilical hernia in, 22 Night terrors, 218 Nipples, 425 babies', care of, 49 Nodding spasm, 25, 227 Noisy inspiration, 67 Noma, 113 Normal salt solution, 446 Nose, foreign bodies in, 67, 451 Nosebleed, treatment, 450 Nursery, general hygiene of, 39 Nursing in childhood, 34 in duodenal ulcer, 160 Nutrient enemata, 478 Nutrition, 376 Nutritional diseases, 26, 367 Nystagmus, 227, 256 Oatmeal gruel, 388 jelly, 391 water, 385 Obesity, 269 Obstetric hand, 226 Obstruction, intestinal, 158 chronic, 160 Oiled silk jacket, 492 Onychia, 263 Operation, preparation for, 497 Ophthalmia, 25 neonatorum, 20, 254 Opisthotonos, 212 Orchitis, 250 Orthopedics, 27 Orthopnea, 55 Osteomyelitis, 20, 273 tubercular, 322 Osteoperiostitis, 273 Otitis media, 25, 258 Outdoor sleeping, clothing for, 327 treatment of tuberculosis, 326 Oxyuris vermicularis, 165 Pack, hot, 461 Pain, cry of, 29 Palpitation of heart, 178 Palsy, Bell's, 233 Pap, 389 Papilloma of larynx, 66 Papules, 261 Paquelin cautery, 498 Paralysis, 25 birth, 25 cerebral, 217 crossed, 216 definition of, 206 Erb's, 22, 233 facial, 22' infantile, 228 Landry's, 231 post-diphtheric, 232, 342 Paralytic idiocy, 219 Paraplegia, 206 Parasites, animal, 163 Paratyphoid fever, 310 Paresthesia, 208 Parotitis, 361 Paroxysmal tachycardia, 179 Pasteurized milk, 383 Pea soup, 394 thick split, 394 Peculiarities of children's diseases, 11 Pediculosis capitis, 264 pubis, 264 Pellagra, 370 Pemphigus neonatorum, 20 Pennsylvania quarantine laws, 30- 33 Peptonized milk, 387 Peptonizing mixture, 388 Percentage method of artificial feeding, 399 of cream, method for changing, 408 of mixtures, methods of deter- mining, 422 Percussion of heart, 176 Perforation, emergency treatment, 452 IND. Perforation in typhoid fever, 299, 3°4 Pericarditis, 20, 181 Pericardium, 172 Peritonitis, 20, 169 Pernicious anemia, 197 Pertussis, 358 Petit mal, 220 Peyer's patches, 299 Phagocytosis, 479 Pharyngitis, 120 atrophic, 122 chronic, 122 hypertrophic, 122 phlegmonous, 122 pseudomembranous, 124 Phimosis, 25, 249 Phlebitis, 193 Photophobia, 253 Pia, 204 Pica, no Pigeon-breast, 22, 271 Pigeon-toes, 271 Piles, 167 Pink-eye, 255 Pirquet's cutaneous test for tuber- culosis, 323 Pitted teeth, 17 Pitting in small-pox, preventing of, 353 Plaster casts, 491 Plethora, 197 Pleurisy, 78 hemorrhagic, 85 Pleurodynia, 86, 366 Pleuropneumonia, 104 Pneumohydrothorax, 86 Pneumonia, 90 aspiration, 103 cerebral, 102 chronic interstitial, 90 croupous, 24 cry of, 29 embolic septic, 104 hypostatic, 103 lobar, 97 serum treatment, 104 treatment of, 104 typhoid, 306 Pneumonic consolidation, 99 Pneumopericardium, 182 Pneumothorax, 86 EX 533 Pneumothorax, artificial, in tuber- culosis, 325 Poisons and their antidotes, 446 Poliomyelitis, acute anterior, 228 Polydactylism, 273 Polydactyly, 27 Polyuria, 236, 237 Post-diphtheric paralysis,-232, 342 Potato soup, 394 Pott's disease, 318 Poultices, 458 Precocity, 269 Premature babies, 40 contractions of ventricles, 179 Pressure symptoms, 214 Prognosis in diseases of children, 30 Proctitis, 167 Prolapse of rectum, 166 emergency treatment, 453 Promises to child, 50 Prone-pressure method of artificial respiration, 483 Proteids, 377 in artificial feeding, 404 Protein milk, 396 stools, 138 Pseudocrisis in pneumonia, 101 Pseudodiphtheria, 119 Pseudohypertrophic muscular dys- trophy, 276 Pseudomembranous pharyngitis, 124 Psoas abscess, 320 Psoriasis, 262 Pulmonary insufficiency, 187 edema, 77 emphysema, 75 stenosis, 187 Pulmotor, 482 Pulse, 28, 177 dicrotic, 177 taking of, 43 venous, 178 water-hammer, 178 Pulsus alternans, 179 Purpura, 198 hemorrhagica, 198 Pustules, 261 Pyelitis, 246 Pylorospasm, 129 diet in, 130 gastro-enterostomy for, 131 DEX 534 in Pylorospasm, lavage in, 131 operation in, 131 symptoms of, 130 treatment of, 130 weight-chart in, 131 Quarantine, regulations of, 30 Quinsy, 116 Rabies, 294 Rachitic rosary, 373 Rachitis, 372 Rammstedt's operation for pyloro- spasm, 131 Ranuia, no Rashes, dates when they appear, 280 Raynaud's disease, 193 Reaction, Wassermann, 44 Rectal irrigation, 48 Rectum, cold compresses to, 48 diseases of, 166 inflammation of, 167 prolapse of, 166 emergency treatment, 453 Reduplication of heart sounds, 187 Regurgitation, 185 after feeding, 49 aortic, 186 mitral, 186 Remittent malarial fever, 288 Renal calculus, 245 hyperemia, 239 Resolution, stage of, 99 Respiration, 28, 55 artificial, 480, 481 Respiratory failure, 481 emergency treatment, 453 tract, diseases of, 23, 52 foreign bodies in, 67 Rest, 434 Resuscitation, methods of, 480 Retropharyngeal abscess, 122 Rhagades, 290 Rheumatism, 26, 364 acute articular, 364 endocarditis after, 24 complicating, 26 heart murmur in, 24 inflammatory, 364 muscular, 365 Rhinitis, 58 Rhinitis, acute, 58 atrophic, 61 Lhronic, 59 hypertrophic, 61 Rice and oatmeal water, 385 flour gruel, 390 milk, 375 Rickets, 27, 47, 372 fetal, 273 Rickety children, eruption of teeth in, 15 Rogers' sphygmomanometer, 105 Roentgen rays, 495 Rose cold, 75 Round worms, 164 Rubella, 339 Rubeola, 336 Running ears, 25 Rusty sputum, 54 Saccharine in artificial feeding, 4°2 Saline solution in diarrhea, 154 Salt bath, 465 solution, normal, 446 continuous injection, 477 Salvarsan, 292 Salvator, 482 Sarcoma of kidney, 247 Sardonic grin, 293 Scabies, 264 Scales, 261 Scarlatina, 330 miliaris, 332 Scarlet fever, 330 anginoid, 332 kidneys after, 25 malignant, 333 Schafer method of artificial respira- tion, 483 Schick test of diphtheria, 346 Sciatica, 232 Scissors gait, 228 Sclerema, 23 Sclerosis, 228 Scoliosis, 271, 274 Scorbutus, 370 Screw-driver teeth, 17 Scurvy, 27, 370 Seat-worms, 165 Seborrhea, 261 Secretion, internal, disorders of, 269 INDEX 535 Septic sore throat, 124 Serum, Flexner's, 284 treatment of pneumonia, 104 of scarlet fever, 336 Shingles, 262 Shock, emergency treatment, 453 Shower bath, 467 Sickness, sleeping, 217 Sight, development of, 14 Singultus, 129 Sinus arhythmia, 178 Siphoning milk, apparatus for, 407 method for, 407 Sitting hot-air bath, 465 Sitz bath, 465 Six fingers, 27 Skiagraphy, 495 Skimmed milk, 406 Skin, diseases of, 25, 261 masks for, 494 test, von Pirquet's, for tuber- culosis, 323 Sleep, disorders of, 218 in childhood, 39 in infancy, 39 in newborn babe, 38 Sleeping sickness, 217 Small-pox, 351 black, 352 malignant, 352 Smell, development of, 14 Soap stick, 478 Soapy stools, 139 Solutions, percentage, rules for, 503 Sore throat, septic, 124 Soup, bean,394 pea, 394 thick split, 394 potato, 394 spinach, 394 Spasmodic croup, 63 Spasmophilia, 223 Spasms, nodding, 25, 227 Spasmus gyrans, 25, 227 Speech, disorders of, 218 Sphygmomanometer, 195 Spice poultice, 459 Spinach soup, 394 Spinal cord, anatomy of, 203 diseases of, 227 nerves, 205 Spine, curvature of, 271 observation of, 47 Spirochaeta pallida, 292 Spitting of blood, treatment, 452 Spleen, diseases of, 199 removal of, 199 Splint, Hamilton, 487 Splints, 489 Sponge bath, 454, 468 Spotted fever, 282 Sputum, 54 collecting, for examination, 329 disposal of, 329 in tuberculosis, 329 Starch bath, 467 poultice, 459 Status lymphaticus, 269 Stenosis, aortic, 186 mitral, 186 of lacrimal duct, 253 pulmonary, 187 tricuspid, 186 Sterilization of bottles, 48 of thermometer, 50 Sterilized milk, 385 Stomach, capacity of, 126 dilatation of, 136 diseases of, 126 nursing in, 137 inflammation of, 133 malformations of, 129 washing, 474 Stomach-tube, feeding by, 476 Stomatitis, 112 aphthous, 112 gangrenous, 113 parasitic, 113 mercurial, 114 ulcerative, 113 Stools, disinfection of, in typhoid fever, 309 Strabismus, 25, 253 Strait jacket, 493 Strangulation of intestine, 159 Strawberry tongue, 108, 331 Stricture of esophagus, 126 Stridor, congenital, 22 laryngeal, 66 Stridulous breathing, 64 Strumous children, eruption of teeth in, 15 Stuttering, 218 536 INDEX St. Vitus' dance, 25, 225 Stye, 253 Subsultus tendinum, 96 Sugar in urine, 239 measure, 405 Sulphur bath, 467 Summer diarrhea, 144 Sunstroke, treatment, 453 Supernumerary fingers, 273 toes, 273 Suppositories, 478 Suppurating myositis, 273 Sylvester's method of artificial res- piration, 482 Sympathetic nerves, 205 Symptomatology of children's dis- eases, 27 Syncope, 208 Syndactylism, 273 Synechia, 253 Syphilis, 289 hereditary, 26 cry of, 29 Wassermann reaction in, 44 Syphilitic laryngitis, 63 Syringing, 468 ear, 469 eye, 468 mouth, 472 nose, 470 Syringomyelia, 231 Systole, 185 Systolic sound, 176 Tache cerebrale, 283 Tachycardia, 177 paroxysmal, 179 Taenia saginata, 163 solium, 163 Talipes valgus, 27, 270 varus, 27, 270 Talking, 15 Tape-worms, 163 Tar bath, 468 Teeth, 15 eruption of, 15 in strumous or rickety children, 15 Hutchinson's, 16 laminated, 17 milk, average age of eruption of, 15 Teeth, permanent, average age of eruption of, 15 pitted, 17 screw-driver, 17 Temper, cry of, 29 Temperature, 27 changing Centigrade to Fahren- heit, 504 methods of reduction, 454 sudden rise of, 49 taking of, 41, 42, 48 Tenesmus, 141 Tepid bath, 468 Testicle, inflammation of, 250 undescended, 249 Test-meals, 136 Tetanic convulsions, 206 Tetanus, 20, 293 Tetany, 25, 209, 226 Therapeutic limit, 437 Therapeutics, 435 Thermometer, sterilization of, 50 Throat, examination of, 49 foreign bodies in, 451 septic sore, 124 Thrombosis, 218 Thrush, 113 Thymus asthma, 269 gland, enlargement, 268 Tibia, bowing of, 27, 272 Tinea circinata, 264 tonsurans, 264 Toes, pigeon-, 271 supernumerary, 273 Toilet-seat for prolapse of rectum, 166 Tongue in digestive diseases, 108 inflammation of, in strawberry, 108 Tongue-tie, in Tonsillectomy, 118 Tonsillitis, 115 Tonsils, hypertrophy of, 116 Top-milk feeding, 400 mixtures, 411 Tormina, 141 Torticollis, 275, 366 treatment of, 276 Touch, development of, 14 Tracheotomy, 349 Tremors, 207 Tricuspid stenosis, 186 INDEX 537 Trident hand in achondroplasia, ?73 Trismus, 293 Trousseau's sign, 226 Tubercular adenitis, 25, 323 arthritis, 322 dactylitis, 323 laryngitis, 63 meningitis, 25, 211 osteomyelitis, 322 Tuberculosis, 26, 312 acute miliary, 317 care of soiled bed linen in, 329 cleanliness in, 328 disinfection of excreta in, 328 lung immobilization in, 325 nursing in, 325 of bones, 318 of bronchial lymph-glands, 318 of intestines, 155 of joints, 318 of kidney, 247 outdoor treatment, 326 treatment of, 323 von Pirquet's cutaneous test for, 323 Tuberculous bronchopneumonia, 3i5 Tumors, cerebral, 218 Turpentine stupe, 457 Tympanites in typhoid fever, 304 Typhoid fever, 26, 297 pneumonia, 306 spine, 305 state in bronchopneumonia, 96 ulcer, 299 vaccination against, 306 walking, 297 Typhus fever, 294 symptoms, 295 Ulcer, duodenal, 160 gastric, 135 of frenum, in typhoid, 299 Ulcerative stomatitis, 113 Umbilical hernia, 161 acquired, 161 congenital, 161 treatment, 162 Uncinaria duodenalis, 165 Undescended testicle, 250 Urea, in Uremia, 240 Urethritis, 250 Urinary tract, diseases of, 234 Urine, 237 collecting of, 23 7 examination of, 238 method of collecting, 43 retention of, treatment, 454 suppression of, treatment, 453 Urotropin, 231 Urticaria, 263 Uvulitis, 122 Vaccination, 355 against typhoid, 306 Vaccines, 441, 479 autogenous, in pyelitis, 246 in whooping-cough, 359 Vaccinia, 354 Vaginal douching, 479 injections, 480 Vaginitis, 250 Vapor bath, 462 Varicella, 354 Variola, 351 Varioloid, 352 Ventilation, 434 Ventral hernia, 161 Ventricles, premature contractions, 179 Vesical calculus, 249 spasm, 249 Vesicles, 261 Vincent's angina, 119 Vinegar and mercury bath, 468 Volvulus, 159 Vomiting, 128 cyclic, 129; habit, 129 of blood, treatment, 452 persistent, treatment, 454 Vomitus, disinfection of, in per- tussis, 50 Von Jaksch's disease, 197 Von Pirquet cutaneous test for tuberculosis, 323 Waddling gait, 271 Walking, 14 typhoid, 301 Wassermann reaction, 44, 291 538 Water, drinking of, 46 in food, 379 Water-hammer pulse, 178 Weakness, cry of, 29 Weaning, 399 Webbed fingers, 27, 273 Weight, 11 chart, 13 Griffith's, 12 in pylorospasm, 131 table, 14 Weights and measures, 500 Wet cups, 458 Whey, 386 and milk, 386 and white of egg, 386 milk, and white of egg, 386 Whole milk mixtures in artificial feeding, 402 Whooping-cough, 358 INDEX Widal reaction, 305 Wine measure, table of, 500 whey, 387 Woman's milk and cows' milk. difference between, 382 Worms, intestinal, 163 round,164 seat-, 165 tape-, 165 Wounds, dressing of, 497 emergency treatment, 454 Wry-neck, 275 treatment of, 276 x-Rays, 495 Yellow tubercle, 316 Young's rule for dosage, 436 Youth, general hygiene in, 39 period of, n /J/ ft 4 jur: 1 is?,' WY 159 M129d 1921 54530520R NLM DSEflflDlD M NATIONAL LIBRARY OF MEDICINE NLM052880104