Management of the New-born Infant. BY FLOYD M. CRANDALL, M: D., NBW REPRINTED FROM THE Neto yorti fHetocal JJounxal for June 18, 1899. Reprinted from the New York Medical Journal for June 18, 1892. MANAGEMENT OF THE NEW-BORN INFANT.* By FLOYD M. CRANDALL, M. D., NEW YORK. The subject of this paper, lying as it does on the border- line between two departments of medicine-obstetrics and paediatrics-has, as a natural result, received very inadequate attention. Most works on diseases of children contain no reference whatever to the management of the healthy new- born infant, and but slight attention is given to the numer- ous ailments and disorders of the first two weeks of life. Works on obstetrics, while they contain numerous scattered references to the infant, are chiefly concerned with the mother and rarely give connected instructions upon the im- portant matters pertaining to the child. It is a frequent complaint that mothers and nurses follow the physician's directions regarding medicine, but pay no heed to his in- structions concerning diet and the details of management. This is usually the doctor's own fault, for while he gives definite orders regarding treatment, his instructions regard- ing management are vague and indefinite, chiefly because his ideas are vague and indefinite. Clear-cut and definite * Read before the Society of the Alumni of Bellevue Hospital, Feb- ruary 3, 1892. Copyright, 1892, by D. Appleton and OWOK 2 MANAGEMENT OF THE NEW-BORN INFANT. directions upon any subject will usually be followed faith- fully, especially if written. As my professional experience has been to a consider- able degree in these two departments, my attention has been frequently called to the improper treatment which the infant frequently receives. I have ventured to present it to-night, therefore, not because there is anything new or remarkable to offer, but because it is a subject of interest to the general practitioner which is seldom discussed in a connected and compact manner. Tt has seemed almost im- possible for writers who have attempted the subject to confine themselves to their text. In an article upon the new-born infant, recently published in a series of mono- graphs, the writer passes from tying the cord to dentition, both temporary and permanent. This paper is restricted to conditions arising during the first fifteen or twenty days of life. During the progress of labor the interests of the child are to be considered in various ways. General discussion on the use of the forceps is not within the province of this paper. To the child I am convinced that they are less dangerous than ergot. Ergot babies are blue babies, and the more the ergot the bluer the baby. A physician, living in a locality where public opinion is intolerant of instru- ments, who has had considerable experience with ergot, recently expressed to me very strongly the same opinion. From a study of a considerable number of birth-palsies I have been led to the belief that forceps are a less potent factor in their production than prolonged and tedious labor. There seems to me little room for doubt that in- struments in the hands of a reasonably judicious man are less dangerous to the child than the continued compression of the head attendant upon labor prolonged in the second stage, or a prolonged first stage, when the waters have broken. MANAGEMENT OF THE NEW-BORN INFANT. 3 The vaginal douche before delivery is also a matter of importance as regards the child. With ordinary precau- tions it can do no harm, and may save much trouble. A vaginal discharge, even when apparently simple, may be the cause of ophthalmia, and is sometimes the source of serious general septic infection of the child. The douche should certainly not be omitted when the slightest purulent discharge is present, and should be repeated at intervals sufficiently short to insure cleanliness of the parturient canal. Asphyxia may be the result of premature separation of the placenta, certain morbid conditions of the mother, weakness of the child sufficient to prevent respiratory action and expansion of the lungs, or obstruction of the respiratory passages by some foreign substance, but the most common cause is doubtless long-continued compression of the head. When not due to actual organic lesion of the brain it ap- pears under two general forms. In one the head is blue and turgid, the face puffed and swollen, the lips are livid, while the body is of a lighter hue. The heart may usually be heard beating, and sometimes can be felt by the hand, the rate being usually slow. Under these conditions the possibility of resuscitation is good. If, on the other hand, the surface is pale and shrunken, the limbs flaccid, and the muscles without tone, the prognosis is bad, and whatever is done must be done quickly. Fortunately, the infant toler- ates the condition of cyanosis better than the adult, proba- bly from the comparatively low grade of oxidation to which the blood has been accustomed. As long as cardiac pulsa- tions can be detected by auscultation, efforts at resuscitation should not be abandoned. If the child fails to breathe, the throat should be cleared of mucus by the finger, when one or two slaps upon the back or a sprinkling of cold water are usually sufficient to induce respiratory movements. If 4 MANAGEMENT OF THE NEW-BORN INFANT. this fails, the application of alcohol or whisky to the chest may prove efficacious. If the child still fails to breathe, in- flation of the chest by means of a catheter passed through the glottis is often effectual, and for this purpose the Mer- cier catheter, with its peculiar elbow, is admirably adapted. We are told that attempts to force air into the lungs with- out elevation of the epiglottis are futile. Practically, I have had better results by forcibly blowing into the mouth of the child, a thin handkerchief being spread over the lips and the nostrils being compressed, than by Sylvester's method of artificial respiration. Perhaps the air all goes into the stomach, but I certainly know that I have seen respiratory movements induced by the procedure. As I have thrown the head well back, the oesophagus may have been sufficiently compressed between the vertebrae and larynx to prevent the entrance of air into the stomach. The child is apt to be so relaxed and flabby that little or no expansion of the chest is gained by Sylvester's method. Marked results sometimes follow the alternate dipping of the child into hot and cold water, as described by Playfair. It is a great mistake to allow the child to lie unprotected from cold. If it is evident that prolonged efforts are to be required, the child should be placed in a bath of warm water and not removed until respiration is established. This maintenance of the vital heat, it seems to me, is a matter of the utmost importance. I have recently in a single case had a satisfactory result by the method of inflation described last year by Dr. For- rest. The child is placed in hot water and the head is thrown backward so as to throw the vertebrae of the neck forward. The hands are drawn up and pressed against the sides. This compresses the oesophagus between the larynx and vertebrae, and at the same time the mouth opens. The physician then strongly blows into the mouth of the child. MANAGEMENT OF THE NEW-BORN INFANT. 5 The head is then thrown forward and the arms are brought down to the side so as to compress the air from the lungs. The point of importance is the compression of the oesopha- gus, preventing the entrance of air into the stomach. Under normal conditions, when the child is born the eyes should receive the first attention. They should be carefully washed with a boric-acid solution before the cord is tied. I have never abandoned the old Emergency Hospital prac- tice in this regard, and have never regretted the slight trouble it costs. Tt is very easy to order a saturated solu- tion of boric acid, or to carry a little powder from which a solution may be quickly made. It is placed in a cup with a small, soft handkerchief, or a few squares of cloth ready for use. I now rarely use nitrate of silver. According to Crede's method, a drop of a two-per-cent, solution (ten grains to the ounce) is placed in each eye. The reaction is often severe and, as a routine practice, seems to me entirely un- necessary. In case of purulent vaginal discharge it should invariably be employed, but, as a rule, thorough use of the boric solution is sufficient. The satisfaction of having no ophthalmia to deal with would repay much more trouble than these simple measures cost. The necessity for prompt action when ophthalmia is present, and the method of treat- ment by silver, cold, and perfect cleanliness, is too well known to require comment. While there is no necessity for undue haste in tying the cord, it is best to do so as soon as the eyes have been bathed. I have tried different lengths and have found a cord of about an inch and a half most satisfactory. I have also tried various forms of dressing, and have found noth- ing more satisfactory than the time honored square of soft cloth cut in the center. Charred cloth, although recently commended by a high authority, in this day of antiseptics 6 MANAGEMENT OF THE NEW-BORN INFANT. is a relic of barbarism. Cotton is better than linen, and should be rendered antiseptic by being soaked in a subli- mate solution and dried. As the fluid of the cord exudes rapidly during the first few days, the dressing becomes damp, and should be changed every day. There is no need whatever of odor about the cord, and there will be none if it is kept clean and dry with powder, which for this pur- pose should contain salicylic acid. It will leave a better navel surface and will fall quicker, the average time being about the fifth day. The scar should be healed by the tenth day. With wet dressings, falling of the cord is usu- ally later. The same is true with oily dressings, which some prefer. They are less cleanly and permit more odor. The scar should be kept clean, and be dressed with the same powder. If a so-called umbilical polypus forms, it should be removed by means of a tight ligature. Smaller masses of granulation should be cut down with nitrate of silver and dressed antiseptically. The antiseptic care of the umbilicus can not be too strongly insisted upon. Sim- ple moist antiseptic dressings or, still better, antiseptic pow- ders are preferable to ointments. The various diseases at and about the umbilicus are ex- tremely rare when proper antiseptic treatment has been carried out. They require active surgical treatment and are beyond the scope of this paper. Tetanus neonatorum, now known to be of microbic origin, is, happily, a rare disease in this city, and will probably never occur under strict anti- septic management of the umbilicus and of abrasions upon the child's body. The radical changes which take place at birth should not be forgotten. The child is suddenly transferred from an unvarying temperature of 100° F., where surface evapo- ration is impossible, to a varying temperature twenty de- grees to foity degrees lower, where evaporation from sur- MANAGEMENT OF THE NEW-BORN INFANT. 7 face and lungs is constant, and where it must rely wholly upon heat generated within its own body. It is wonderful that such a change is as well tolerated as it is. We should certainly do nothing to reduce the vital forces, and should take every precaution for preserving the vital heat. The child should be removed from exposure as soon as possible and wrapped in a warm flannel blanket. It is best not to put the baby into the bath-tub at first. The vernix caseosa is soluble in fat, which should be em- ployed for its removal. An animal oil is best, and every nurse will tell you that lard removes it more readily than any other substance. After thoroughly anointing every portion of the body, especially the folds and creases, the oil should be wiped away with a soft towel, a sponge, with a little warm water and soap, being used in places. On the following day, when the child has become more accustomed to its new surroundings, a more thorough bath may be given, but it is best not to use the tub until the cord has fallen. Absolute cleanliness throughout the whole period of in- fancy is of the most vital importance to the well-being of the child. The daily bath should be omitted only for the most serious reasons. The use of powder is a necessity, but is often overdone, the nurse depending upon it rather than upon care in drying the surface. Some powders are irritating and cause eruptions. Rice powder does nicely; starch is often improperly prepared; lycopodium is all that some skins will bear, and it may be advantageously added to most powders. If there is excoriation, two per cent, of salicylic acid or five per cent, of boric acid may be added. Salicylic acid is especially adapted to such use, and in some conditions, as for the cord, may be employed in the strength of twenty per cent, to eighty per cent, of starch. For ordinary purposes the compound talcum powder has been the most satisfactory preparation I have used. 8 MANAGEMENT OF THE NEW-BORN INFANT. The napkins should be changed as soon as soiled, even if it is every hour, and the child should not only be dried, but washed with water. Some nurses dry the napkins and use again without washing. Erythema is almost certain to follow such practice. In treating this disorder, it is best to question upon these points, and also as to the method of washing the napkins. If washed with strong soda or harsh soaps, without thorough rinsing, they will irritate the skin when wet and prolong the disorder, which is at best rebel- lious to treatment. The parts should be very gently washed with water and perhaps a little borax, but no soap. If mild, a dusting powder containing salicylic acid or oxide of zinc may be used. If there is excoriation or much discharge, the pow- der may form into little masses and irritate. On the whole, I have obtained the best results from an oily preparation, which may not only be curative, but protects from dis- charges. The following, proposed by Fox, has been very satisfactory : Acidi salicylici, gr. x ; bismuthi subnitra- tis, 3 ij ; corn starch, 3 jss.; ung. aq. rosae, ad 3 j. M. In some cases boric acid, or zinc oxide, in ointment with resorcin, seems to be more efficacious. Before the child is dressed it should be inspected by the physician, and any birth mark or abnormity had better be reported to the father or some friend. Nurses are in- clined to make capital upon such matters at the expense of the physician, using a discovery of some abnormity as proof of their superior knowledge of infants. The average male child, according to Dr. Smith's observation, weighs seven pounds eleven ounces; the average female, seven pounds four ounces. During the first three days there is usually a loss of weight, which has been regained before the end of the week. If the child does well, it should gain an ounce a day to three months, the original weight being MANAGEMENT OF TIIE NEW-BORN INFANT. 9 doubled at six months and trebled at one year. The aver- age length is nineteen inches, which is doubled at four years. The temperature at birth is 100°, which soon falls to 98-6°, and then returns to 99°. The pulse is about 130, which may be increased twenty or thirty beats by crying, or decreased ten or fifteen beats during sleep. Even in perfect health the pulse is often irregular and is practically of no value as a symptom. The respirations are about 44, and fall to 30 at one year. The eyes are almost invariably of a greenish or bluish-gray color, and no opinion can be formed at birth as to what their permanent color will be. The pupils are large and sensitive to light. The auditory canal, owing to swelling of the mucous membrane, is usu- ally closed, and there may be a slight discharge which might mislead the unwary. The abdomen, owing to the frequency of digestive disorders in infants, is an important region. The peculiarities in the relations of the abdominal organs are due chiefly to the great size of the liver, which displaces the stomach and colon to the left, the caecum be- ing extremely variable in position. The sigmoid flexure is long, sometimes reaching well into the right iliac fossa, and is the cause in some instances of persistent constipation. The bladder is almost wholly an abdominal organ, and its de- tection above the pubes does not necessarily mean undue distention. While the physician is rarely consulted regarding the clothing of the infant, it is a subject upon which he should have some knowledge. Tight bands and waists are fortu- nately being superseded by more rational methods of dress- ing, though but slowly. The unfortunate infant is bound about the chest and waist by layer after layer, while the arms, legs, and neck have but half the covering. Each layer has its own array of buttons and safety pins always at the back. The baby protests, and a new reef is taken in 10 MANAGEMENT OF THE NEW-BORN INFANT. his bandages, already too tight, and he is put back in the cradle to lie on the same buttons, safety-pins, and lumps he has been complaining of. The Gertrude suit, of which so much has been said in Babyhood, is a vast improvement over old methods. The original suit has been considerably modified and improved, and does away with the bands and waists and all constriction about the body. The band for the baby as well as for the mother is a dis- puted point. I can see no real objection when properly ap- plied, but several advantages in a light tlannel band during the first few months. It should be four inches wide, with- out a hem, and long enough to go once and a half about the body. Pieces of tape fastened to one end make a better fastening than pins. The shirt should be cut high in the neck and have long sleeves. Flannel should be used, for it is a necessity in this climate. The Jaeger flannel is by all means the best. It is rare that it can not be worn next the skin. In hot weather flannel should still be used, the thin- nest possible being employed. The napkins are usually too thick and bungling. Soft cotton cloth is the best material. They should be cut a yard long and half a yard wide and folded once so as to make two thicknesses, the napkin when ready for use being eighteen inches square. If thicker and larger they are uncomfortable and may distort or deform the child. Rubber napkins and shields are objectionable from their tendency to overheat the parts. They are only admissible for short periods or when traveling. The stockings should be long enough to fasten to the napkin and should always be kept on the feet. The outer garments, one of which should be of flannel, should not be so long and heavy as to obstruct the limbs. All the clothes should be opened in front. I need not here urge the importance of breast feeding, but would urge more careful attention to the numerous de- MANAGEMENT OF THE NEW-BORN INFANT. 11 tails in the care and management of the breasts, neglect of which deprives many children of the food to which they are justly due. The breasts should receive attention at least six weeks before the birth of the child. Cracking of the nip- ples is to a large degree a preventable misfortune. The most efficient preventive measure is the gentle drawing out and manipulation of the nipple night and morning for sev- eral weeks before the beginning of lactation. Certain me- dicinal applications may be made with advantage at the same time. The usual application of astringents frequently fails utterly. I have seen a primipara who had faithfully applied solutions of alum, borax, and alcohol for two months obliged to stop nursing entirely on the fifth day because of deep fis- suring of the nipples. They were certainly tough-as tough as sole-leather; and, like sole-leather, when pinched, bent, and squeezed, they cracked. They were not pliable ; but plia- bility is as necessary as toughness. It is to be gained by frequent manipulation and the use of an oil. The best oil in my experience is lanolin, with a little cold cream added (one part to three) to render it less waxy and more readily applicable. It should be gently and thoroughly applied after each application of the astringent to counteract its tendency to stiffen and harden. Both the nipple and the mouth of the infant should be washed with plain cool water, to which a few drops of lis- terine may be added, before and after each nursing. De- composing milk on the nipple excoriates and favors fissur- ing; in the mouth of the child it irritates and forms a cult- ure medium for bacteria. Without this care germs and spores which have lodged on the nipple and in the mouth are carried into the stomach during nursing and may de- velop serious digestive disorders. Fissures, when they occur, try the physician's resources to the utmost. Not to enumerate the scores of drugs that 12 MANAGEMENT OK THE NEW-BORN INFANT. have been proposed, I would simply say that on the whole I have had the most satisfactory results from the use of dry tannic acid. The nipple is cleansed with boric-acid solu- tion and dried and the tannin dusted well into the fissures. It should be repeated after each nursing. It forms a coat- ing that does not readily come off, and relief is usually ex- perienced at the next nursing. The nipple should be af- forded all the rest possible, and a shield should be used if practicable. Sometimes, in addition to the fissures, or even when no fissure can be detected, the whole nipple becomes eroded and extremely sensitive. For this condition balsam of Peru is very effectual, or a one-per-cent, ointment of resorcin. In other cases there is a hypersensitiveness far out of pro- portion to the apparent seriousness of the fissures or ero- sion. The mother falls into an extreme nervous condition, and looks ahead with apprehension to every nursing. I saw a marked case of this character last year. The mother was anxious to nurse her child, but would fall into such a condition of nervous excitement before every nursing that bottle-feeding seemed inevitable. An application of a four- per-cent. solution of cocaine on a piece of cotton for five minutes was finally tried, and relieved the pain. The inter- vals of nursing were extended as far as possible, and the cocaine used each time. The nipples were washed before and after each nursing and balsam of Peru applied. The mother was reassured, the strength of the cocaine was re- duced, and in a week she was nursing the child without seri- ous discomfort, and continued to do so during the summer. For various reasons, nursing should be discontinued from a breast in which pus has formed or is forming. In mastitis, or any' condition accompanied by fever, the con- stitutional disturbance alone often renders nursing im- possible. MANAGEMENT OF THE NEW-BORN INFANT. 13 Unless the mother is especially exhausted, the child may be put to the breast at the end of four or five hours. During the first two days six hours is a sufficiently short interval for nursing. The child will get all the breasts con- tain, and will obtain no more by more frequent attempts. 1 can not say that I never give anything but the breast during the first two or three days. The child gets very little from the breast during the second day, and the stomach must become empty. A baby will wail and cry and show every evidence of hunger, and will drop quietly to sleep upon re- ceiving a little warm fluid. If it is restless and crying on the second day, you may be quite sure that the nurse will give it something before night-it may be milk, broth, gruel, syrup, or sugar. It is better for the physician to prescribe what shall be given. I have seen no bad results from weak oatmeal water. You thus give water that has been boiled, with sufficient nourishment to satisfy the scruples of the mother and nurse. But let the nurse feed indiscriminately with the score of things that tradition demands, and you will find about the fourth day that the family has been awake with a crying child. The bowels are usually loose, the passages being of bad odor, and perhaps greenish. With a mild laxative and exclusive breast feeding, the symptoms usu- ally disappear in a few days, but the baby is subject to attacks of colic for a much longer time, and may have formed the pleasant habit of lying awake and crying at night. Sometimes, I believe quite frequently, the mother's milk is too rich in fat during the first two or three weeks, causing colic, indigestion, and irregular bowels. Order outdoor exercise for the mother, increase the amount of fluid she takes and decrease the meat, for proteids in the mother's diet increase the fat in the milk. Give the baby a 14 MANAGEMENT OF THE NEW-BORN INFANT. teaspoonful or two of Vichy water before each nursing, and the indigestion will probably disappear. The most important matter in this whole subject of breast-feeding is regularity. It is even more important than in bottle-feeding, for the breast milk changes decidedly according to the frequency of nursing. If the interval is too long, it becomes thin and watery ; if too short, con- centrated and rich and causes indigestion. The first week is not too early to begin the formation of regular habits If the child is asleep, wake it when the time for nursing arrives. It will soon form the habit of waking at regular intervals, and will go to sleep as soon as the nursing is fin- ished. Above all things, warn the mother against con- tinuous and everlasting night nursing. It wears on the mother, impairs the milk, and ruins the digestion of the child. A discussion of the subject of artificial feeding would occupy far more space than this paper will permit. To state the matter briefly, I would feed a child of average weight half an ounce of food every four hours during the first two days, soon increasing to an ounce every two hours, and an ounce and a half at the end of the second week. With one feeding between eleven at night and seven in the morning the child receives ten feedings a day during the first three months. As to the composition of the food, let it be cow's milk by all means. Allow the milk to stand in a bottle or pitcher for two hours and pom1 off the upper half. For the first feedings take of this rich milk four parts, lime water one part, and water seven parts. After a few days the milk may be increased and the water decreased. In warm weather the milk should be sterilized. Urine is usually passed during the first twelve hours, and thereafter about an ounce is passed ten or twelve MANAGEMENT OF THE NEW-BORN INFANT. 15 times a day, ten ounces being the normal average amount for the new-born infant. It is at first cloudy from the ad- mixture of epithelial cells and uric acid and of very low gravity (1'003 to 1'006). Later it becomes clearer and pale, but the gravity continues low during childhood. When the urine does not pass, the distended bladder may be readily felt, as it lies very high. Usually hot applica- tions over the hypogastrium, a sprinkling of cold water, or a warm bath are sufficient to start the flow. The catheter is very rarely required, and should be used only as the last resort. The bowels usually act within a few hours after birth, the passages during the first two days, and sometimes longer, being greenish-black in color and tarry in consist- ency. If there is no passage, a teaspoonful of sweet oil is often sufficient, to which a few drops of castor oil may be added. In certain cases constipation is obstinate and per- sistent, and is due to an excessively long sigmoid flexure. In such cases a daily enema may be required until the child is several months old. Constipation is occasionally present from the first, the passages being hard and dry; more frequently it is acquired. The treatment is often discouraging. The attention must be directed first and chiefly to the milk which the child receives, whether it is cow's milk or breast milk, and any error in digestion should be corrected as far as possi- ble. Give plenty of cool water. This, I believe, is very important, for the infant usually requires more fluid than it obtains in the milk. Instruct the nurse to gently massage the abdomen daily, not by simply rubbing the surface, but by grasping the abdominal wall with the flattened hand and causing it to move upon the bowels beneath. If these measures fail, try a small soap suppository at the same time every day, or in more extreme cases part of a small-sized 16 MANAGEMENT OF THE NEW-BORN INFANT. glycerin suppository, or half a teaspoonful of pure glycerin by syringe. Drugs should be the last resort. Among these, cascara has, on the whole, served me best, but some- times fails completely. Two drops of cascara cordial may be given twice a day as the initial dose, to be increased if necessary. When the passages are white or pasty and the child does not thrive, a few grains of phosphate of soda, given three times a day, often yield most satisfactory results. It may be added to the milk if the child is bottle- fed. Whatever drug is given, an attempt should be made to reduce the dose very slowly, relying more on diet and other measures. Mild measures at first are often sufficient, but if the bowels are neglected during the first few weeks a habit of constipation may develop which will be very hard to break. Two errors are common in the treatment of chronic constipation. The first is reliance on a single measure-a single article of diet, a single mechanical measure, or a single drug. No one of these is of itself sufficient if the case is obstinate. The diet must be corrected and the at- tack must be made from several points at once. The sec- ond error is the attempt to cure a continuous and persistent condition by intermittent and spasmodic treatment. No matter how good the treatment, it is sure to fail unless per- sistently applied. Jaundice in the infant, as in the adult, is symptomatic of numerous conditions. In the vast majority of cases it appears on the second or third day without assignable cause, continues about a week, and is unaccompanied by symptoms. The sclerotic is not discolored, the urine does not stain, and the stools retain their normal color. In rare instances acute obstructive jaundice marked by the usual symptoms occurs during the first week. The cause of the disorder has not been satisfactorily explained. There may MANAGEMENT OF THE NEW-BORN INFANT. 17 be truth in the theory of Quincke, which attributes it to non-closure of the ductus venosus, which permits portal blood containing bile pigment to pass at once into the gen- eral circulation. As the condition naturally disappears, it rarely requires treatment. The clothing should be investi- gated, but it is extremely doubtful if bands could be so tight as to cause mechanical congestion of the liver. If the bowels are not free, gray powder is, perhaps, the most ap- propriate cathartic. Thrush is a disease of young infants and marasmic chil- dren. It is rarely seen in healthy children when proper cleanliness of the mouth and nipples has been maintained, for it does not develop on a perfectly healthy membrane. Digestive disorders, while common in connection with thrush, are not necessarily a part of that disease, but result more from the swallowing of acrid secretions than from actual extension of the thrush. It is best combated by an alkaline wash. Borax is a time-honored remedy, and a good one. I have seen better results by adding to the mixture an equal amount of bicarbonate of sodium. Honey or syrup should not be used as a vehicle, for their decompo- sition adds to the disease. A simple solution in water is best, to which a little glycerin and tincture of myrrh may be added. Gentle but thorough removal of the exudation should be practiced three times a day by means of a soft cloth saturated with the solution, and wrapped on the finger or a lead-pencil. Unless this is done with extreme gentle- ness, more harm than good will result. If the disease is localized, the spots may be touched to advantage with a two- per-cent. solution of sulphate of copper. Colic is most common between the second and fourth months, but not infrequently appears during the first week, and may be severe and very troublesome, the attacks being periodical, with a tendency to recur at the same time each 18 MANAGEMENT OF THE NEW-BORN INFANT. day. The causes and preventive treatment have already been considered. It seems sometimes almost impossible to prevent it, and treatment for its relief is demanded. The feet will usually be found cold, and should be made warm at once. This simple precaution is sometimes followed by relief of the pain. Heat should also be applied to the ab- domen, the warm hand of the nurse sometimes being suf- ficient. A little plain warm water may be given, to which peppermint may advantageously be added. Three or four drops of rhubarb and soda mixture in a teaspoonful of warm water is extremely effective. Aniseed cordial (elixir anisi) is frequently used, and is quite efficient. It contains twenty-five per cent, of deodorized alcohol. Dalby's car- minative, so largely used, it should be remembered, as com- monly dispensed, is an opium mixture of half the strength of paregoric. Equal parts of lime water and cinnamon water, or equal parts of camphor water and compound tincture of cardamom, are effective mixtures. The mother should never be allowed to suppose that she can use pare- goric for these attacks. The temptation to overuse it is altogether too great. So little is said of snuffles in the text-books, except as a symptom of syphilis, that many a young practitioner has been worried by a simple and very common disorder. Cold in the head is common in infants, and is more serious than in older children. Frequently it amounts only to snuffling or rattling, and perhaps sneezing without much closure of the passages. It can not become very severe, however, without preventing nursing by obstructing the breathing, and this is the serious aspect of the disorder. Syphilitic coryza begins with a watery, somewhat acrid discharge which soon becomes muco-purulent, is frequently streaked with blood, and forms excoriations and thick scabs upon the lip. It persists and becomes steadily worse, and MANAGEMENT OF THE NEW-BORN INFANT. 19 is rarely present for any length of time without other syphilitic manifestations. Simple coryza rarely continues longer than a week or ten days; the discharge is not as acrid, but frequently becomes so thick as to wholly occlude the nasal passages, which are comparatively small in the infant. Treatment, when the disease is mild, consists in apply- ing warm camphorated oil over the bridge of the nose and introducing a little cold cream into the nostrils with a camel's-hair brush. In more severe cases the nostrils must be as thoroughly cleaned as possible with a brush or piece of cotton wrapped on a probe, or an attempt may be made to gently syringe the nostrils with Seiler's solution, after which the cold cream may be applied. Gentleness here, as in treating diseases of the mouth, is of the first impor- tance. Bronchitis at this early age is an extremely serious dis- ease, for if marked it virtually means broncho-pneumonia. The term used by some of the older writers-suffocative catarrh-expresses very well the clinical aspect which the disease is inclined to assume. Treatment does not differ materially from that of the same disease in older children. Bronchitis is important also from another point of view. In a recent study of congenital heart disease, I found that a large percentage of the cases suffered from bronchitis dur- ing the first week. The foetal openings of the heart and vessels do not fully close until the seventh or eighth day, and it has been suggested that bronchitis, by causing pul- monary obstruction, may be a factor in causing their con- tinued patency. Every precaution should certainly be taken to prevent the disease, and it should be removed with the greatest possible dispatch. 20 MANAGEMENT OF THE NEW-BORN INFANT. Cerebral haemorrhage, due to venous congestion and rupture of the capillaries of the pia mater; the various forms of obstetrical paralysis; haemorrhages from the vari- ous cavities ; trismus neonatorum-are all serious conditions of great interest, but their consideration is prohibited from lack of space. Numerous minor ailments or abnormal conditions occur which require attention. Cephalaematoma is a collection of blood commonly subperiosteal. It forms a tense, some- what elastic tumor, situated, in the great majority of cases, over the right parietal bone. Unless evidence of suppura- tion appears, it should be let entirely alone, for it rarely happens that the blood is not absorbed. Swelling of the breasts is sometimes marked and causes considerable discomfort. They should be simply protected from pressure. Sometimes warm camphorated oil very gently applied seems to give relief. If suppuration occurs, which is rarely the case, they should be treated like any abscess. If vomiting of blood occurs, the breasts should be ex- amined, for a surprisingly large amount of blood may flow from a fissured nipple. Congenital teeth are not, as a rule, attached to the bone and soon loosen and fall. They should be at once removed. Vaccination, unless there is some definite reason for haste, had better be postponed until the child is at least six months old. It does not " take " well before that age, and it may be necessary to repeat the operation several times. The baby may be wailing and puny, with low vitality and apparently little hold on life; the asphyxia may be deep ; the convulsions long and severe ; the indigestion ob- stinate, and yet the case may not be necessarily hopeless. In no condition is the truism that while there is life there MANAGEMENT OF THE NEW-BORN INFANT. 21 is hope more true than in that of early infancy. Vigorous and healthy children not infrequently develop from the most unpromising infants. Many a strong man is to-day engaged in the active affairs of life whose first days prom- ised nothing but speedy death. While an infant breathes it is never wise to wholly abandon hope or to relax one's efforts. 113 West Ninety-fifth Street. S @ REASONS WHY Physicians Should Subscribe foh The New York Medical journal, Edited by FRANK P. FOSTER, M. D., Published by D. APPLETON & CO., 1, 3, & 5 Bond St I. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE: It is the exponent of the most advanced scientific medical thought. 3. BECAUSE : Its contributors are among the most learned medical men of this country. 4. BECAUSE : Its "Original Articles" are the results of scientific observation and research, and are of infinite practical value to the general practitioner. 5. BECAUSE : The "Reports on the Progress of Medicine," which are published from time to time, contain the most recent discov- eries in the various departments of medicine, and are written by practitioners especially qualified for the purpose. 6. BECAUSE: The column devoted in each number to " Therapeu- tical Notes" contains a resume of the practical application of th® most recent therapeutic novelties. 7. BECAUSE : The Society Proceedings, of which each number con- tains one or more, are reports of the practical experience of prominent physicians who thus give to the profession the results of certain modes of treatment in given cases. 8. BECAUSE : The Editorial Columns are controlled only by the desire to promote the welfare, honor, and advancement of the sci- ence of medicine, as viewed from a standpoint looking to the best interests of the profession. 9. BECAUSE : Nothins is admitted to its columns that has not some bearing on medicine, or is not possessed of some practical value. IO. BECAUSE: It is published solely in the interests of medicine, and for the upholding of the elevated position occupied by th© profession of America. Subscription Price, $5.00 per Annum. Volumes begin in January and July.