■■■; Vj?:
n'r:;.-.
v.'' •. -i..:
- -,,....^ -it'* j.1'
I£B:
.,..,.■35***
&WiP*::.?~ ■■.■■i..v
" I*&.<:>£■':'•■'.::(:; •
j*.&;
.'i-Ji»'
is^jtf^-r; - -
i^^T-:-.;:■.
WY 159 L576n 1918
54530360R
-G
NLM 055fl7 ounce = 15.0 grams
1 ounce = 30.0 grams
1 pound = 450.0 grams
2-/l() pounds = 1000.0 grams = 1 kilogram
Of the articles mostly used in infant feeding we find
the following measures to be most serviceable:
Malt soup extract =
2 scant tablespoonf uls = 1 oz. by weight = 30.0 grams
20 NURSING IN DISEASES OF CHILDREN
Cane sugar —
2 level tablespoonfuls = 1 oz. by weight = 30.0 grams
Milk sugar =
3 level tablespoonf uls = 1 oz. by weight = 30.0 grams
Dextri-maltose =
4 level tablespoonf uls = 1 oz. by weight = 30.0 grams
Flour =
4 level tablespoonf uls = 1 oz. by weight = 30.0 grams
An easy way to figure percentages is this:
5 grains to the ounce = 1% = .3 : 30.0 grams
15 grains to the ounce = 3% = 1.0 : 30.0 grams
In the metric system the percentages are given by
moving the point two figures to the left.
The thermometer scale empirically devised by the
Hollander Fahrenheit and which is still in use in this
country, in Great Britain, and in Holland, is being dis-
placed, at least so far as scientific data are concerned
by the decimal scale, the so-called "centigrade" scale,
in which the freezing point of water or the temperature
of melting snow is taken as zero and the boiling point
of water as 100. Thus we find in comparing the scales of
the Fahrenheit and the centigrade thermometers that
the 100 degrees of the latter correspond to 180 degrees
of the former, and that therefore 5 degrees of centigrade
are equal to 9 degrees of Fahrenheit. We must also
remember that the zero of centigrade corresponds to 32°
F., so that in translating Fahrenheit into centigrade we
must first subtract 32 from the degrees Fahrenheit we
intend to translate, and again that in translating centi-
grade into Fahrenheit we must add 32 to our result.
As an example:
no i' -ci 98.6 - 32 . _ 66.6 _ „ , w _ 0-n
98.6 F. =------\ o =---Y5=''-*X5 = 'J' C.
9 9
37.0 C. = — x 9 4- 32 = 7.4 X 9 + 32 = 66.6 + 32 = 98.6 F.
INTRODUCTION
21
Another point which seems to cause some difficulty is
the elements composing our food and their caloric values.
The food of the animal body, and, therefore, of all of
us, consists first, and most important, of oxygen which
Fahrenheit (F.)
212
98.6"
fC.) Centigrade
100 Boiling Point of Water
-37.0 Normal Body Temperature
32
0
0 Freezing Point of Water
-17.8 Lowest Temperature
observed "by Fahrenheit
in the Winter of 1709
Fig. 1.—Thermometer scales.
is taken into the lungs and without which life can be
maintained for comparatively few seconds only.
Next in importance is water, this has no caloric value,
22 NURSING IN DISEASES OF CHILDREN
but it is so essential for keeping up the functions of the
body that a sudden considerable loss of it Avithout our
administering it by some method or other is sufficient
to cause death from the drying out of the body. This
must be kept in mind especially in the digestive dis-
turbances of infancy, and all considerable losses of water
through diarrhea, vomiting, and perspiration must be
made up at once by the giving of water. This is done,
most conveniently by the natural passage through the
mouth, or by the use of the stomach tube, so-called
"gavage." Should vomiting make the retention of this
water impossible then it should be given through the
rectum; if the water thus given should not be retained,
then it must be administered hypodermically or intra-
venously, when it will surely be utilized. It must be
remembered that even a small baby can live for days
without food as long as it gets sufficient Avater; that is
three ounces to each pound of its weight.
The salts also form an important element in the food.
They have no caloric value but they are indispensable
for life and for the growth, especially of the bones. They
are taken up in the different foods and a deficiency in
these as well as an insufficient retention will cause dis-
eases. The salts form the ash, the inorganic mineral
residue left after the organic parts of the food have
been destroyed by heat.
Some of the salts of the body are continuously dis-
charged in the urine and feces and also in the perspi-
ration and this loss has to be made up by their ingestion,
and further a surplus must be given to the child to
insure its growth. These important minerals are the
salts of calcium, magnesia, sodium, potassium, iron,
chlorine, and phosphorus.
The elements of the food which possess a caloric value,
INTRODUCTION
23
that are necessary as fuel in the body are the proteins,
the carbohydrates and fat.
The value of any material as fuel is expressed in cal-
ories. A (large) calory is the amount of heat required
to raise the temperature of one liter of distilled Avater
one degree centigrade; thus, proteins and carbohydrates
contain 4.1 calories in each gram, that means that one
gram of either is sufficient to raise the temperature of
one liter of distilled water four and one-tenth degrees
centigrade or to raise the temperature of four and one-
tenth liters of distilled water one degree centigrade; the
caloric value of fat is 9.3 calories for each gram of fat,
or more than tAvice that of either proteins or carbo-
hydrates.
For example, the caloric value of coav's milk is in
round figures 700 calories to the liter; for the sake of
convenience we usually say, though this is not quite
exact, but near enough for everyday use, that cow's
milk contains 4 per cent each of protein, carbohydrates
and fat, this Avould give
Proteins 40 grams X 4.1 = 164 calories
Carbohydrates 40 grams X 4-1 = 1Gi calories
Fat 40 grams X 9-3 = 372 calories
700 calories
The proteins, the nitrogenous foods, are many and
vary considerably, those contained in milk are casein
and lactalbumin, of these the casein forms tough hard
curds while the albumin is dissolved in the Avhey and
forms Avhite curds. The proteins are mainly used in the
building up of the body and in growth, but they may
also serve as fuel.
The carbohydrates are the sugars and starches, their
constant components being atoms of carbon and hydro-
24 NURSING IN DISEASES OF CHILDREN
gen, from which these substances derive their name of
carbohydrates; in the act of digestion the starches must
be transformed into sugar before they can be assimilat-
ed. This can also be done before feeding outside of the
body by transforming the starches into maltose, malt-
sugar, by dextrinizing the cooked starch Avith an active
preparation of malt, one containing a considerable
amount of diastase, or by baking, as in the oldfashioned
flour-ball.
The sugars in the foods are milk sugar which is found
in mother's milk as well as in cow's milk, cane sugar
and malt sugar. Though milk sugar is a natural ingre-
dient of milk it is not Avell borne by babies Avhen added
to their food; they digest cane sugar, the ordinary gran-
ulated sugar, much better; malt sugar is the easiest
digested by babies.
The carbohydrates are used in the system as fuel, they
are readily burned up, the end-product being carbonic
acid, and they are used by the body to maintain its
temperature.
Tavo different carbohydrates can be digested much
better when added to the artificial food of babies and
this explains the success of the addition of gruels and
another sugar besides milk sugar Avhich is already pres-
ent in the milk.
The fats in the food haAre a high fuel value, they are
stored up in the body for use in time of need and under
the skin as a protection of the body against the loss of
heat.
In the milk, the fat is present in the form of cream,
AAThich is a suspension of fat globules in the watery liquid
represented by the milk. In making butter the fat is
emulsified, that is the relations of the fat to the Avater
are so changed that Ave now have globules of water sur-
rounded by fat.
INTRODUCTION
25
Other forms of fat used as food are the different oils
and animal fats.
In digestion the fat globules are absorbed as such.
They go through the intestinal mucosa and then the fat
is split up into glycerin, Avhich is an alcohol, and can
easily be burned up, and into fatty acids. If a surplus
of fat should be given to a baby it must be eliminated
in the bowel; it is here split into glycerin and fatty
acids, these latter can not be excreted as such but have
to combine Avith a salt, calcium phosphate, thus forming
a soap. It Avill thus be seen that too much fat in the
food for babies is very liable to deprive the system of a
considerable part of the calcium phosphate Avhich. is
needed in the building up of the bone.
A very important matter in the care and nursing of
babies as Avell as of older children is the keeping of
charts.
These charts, Avhen kept properly can give the initi-
ated at one glance a clear suiwey of the progress of the
child, be it in sickness or in health. Unfortunately very
few are the charts Avhich are kept as they should be and
Avhich are really intelligible.
On a chart Ave represent graphically the changes in
the relation of the clinical phenomena Ave want to
record, be they temperature, pulse, respiration, Aveight,
amount of food taken, caloric value of food, or height,
to a giVen and unchanging unit of time, be this hour or
hours, days, Aveeks, months or years. In order to make
a chart Ave take a sheet of paper plotted in squares. On
this the Arertical lines denote the inteiwal of time intend-
ed to elapse betAveen the taking of the records, and the
horizontal lines indicate the changes in the condition Ave
want, to shoAV. The important point in charting, and
the one which indicates if a chart is good or not, is that
26 NURSING IN DISEASES OF CHILDREN
the intervals in time, that is the unit of time as indicated
by the first tAvo vertical lines, should remain identical
all through the chart; needless to say that the same
holds good also for the spaces between the horizontal
NAME M. ..X AGE It SF,X We NATIONALITY A neritan*
till DATE Dec. a 7 8 9 10 II /Z
Day of Dis MM, u n 12 /* is- /c '7
P. R. T. A.M. P.M. 1 . M. P. M. A. M. M
65 10R
170
107
55 106
50 105
14-0
45 104
130 - — -£- a
40 103 ^3" *" 7*
^zG 7 \ f
^1 it / \
13* 3j 1 / \ \
I*£ - zj_ : 2 A ♦< \
35 102 ZJ s 7 / 1 /
' i_ 4 / | ,_ / _i
. zt^, ? 3i 1 \ t / ;'
S-t ; : jr t - ' / '
ji - ] t L_ / t 3 y
30 101 -t "r-J [t t/ t / Tj 41 /
i - t J ± 31 X EE 1
T -tt ± / It / ± r
r -A- it 3 / ± j L
_t . -3- ii p It Vt
25 100 3_," .^ j n
3 Vf j r'/
13 tf Ii_ /
iM H X
u^ 2 \~^l 53S^ 3 £3 ,** (
20 99 -w *^ =^ V ,\; f rv
i ,, 1 ;Vi
Jt: \ V IE \ \ \ V * •' i jir 1
1
_ _ ~i .1 IJl \
15 98
10 97
5 96
95
. W
3 •Oca 2*~>p.' -
Bowels, No. of movements, Ill 1 /// « / / il i_. //
Urine, quantity, etc., | fa Jx 5*« I? 1" iVJ1 IE £*> 3Z $** 3i_> Jxv 2T Jitf
REM ARK S: 1 Emm II- 1* 0 n 7* p '-
Fig. 2.-—Chart indicating different time intervals.
INTRODUCTION
27
lines. On such a chart we indicate by a dot the height
of the clinical phenomenon to be recorded at the time we
begin the chart Avhere the first vertical line crosses that
horizontal one, another dot on the crossing of the lines
denoting the next record and so on, and then Ave unite
NAME AGE SEX NATIONALITY
DATE
Day If Disease,
P. K. T. A.M. P.M. A.M. P. M. A. M. P. M. A.M. P.M. A M. P. M. A.M. P.M. A.M. P.M.
65 108
170
60 107
160
55 106
150
50 105
45 104
40 103
35 102
30 101
25 100
20 99
15 98
10 97
5 96
95
40
Bowels, No. oi movements.
Urine, quantity, etc.,
REM ARK S:
Fig. 3.—Chart divided into six-hour .intervals.
28 NURSING IN DISEASES OF CHILDREN
these dots v\ith the succeeding one thus plotting a curve.
It is not necessary to take the records at the same
intervals of time as long as Ave indicate this on the chart
by jumping over the corresponding number of vertical
2)>\e\i
f>
33
Fig. 4.—Weight chart,
lines. Let us say, for instance, that during the critical
stage of a case of typhoid fever the temperature was
taken every tAvo hours and the physician had told the
nurse to let the patient sleep all night without disturb-
INTRODUCTION
29
mg him. If the patient sleeps six hours then the nurse
should put doAvn the temperature at the third A^ertical
line after the one before the patient went to sleep. If
the physician should decide that it Avas sufficient to take
the temperatures hoav at four hour intervals then the
£22 '/aMilki5i/qor5% JSS1 Breast milk &% Bvlfermllk
Fig. 5.—Chart in dotted and broken lines.
nurse should make the dots on every second vertical
line, (Fig. 2.)
With some experience the nurse may find it even more
convenient to have only the lines indicating the hours
30 NURSING IN DISEASES OF CHILDREN
of six and tAvelve of the morning and evening and to
shoAv the exact hour at which the record Avas taken by
the proper spacing betAveen these, as indicated on the
accompanying chart Avhich I have used now for more
than twenty years and Avhich nurses find ATery easy to
keep. (Fig. 3.)
On such a chart only one record may be kept in the
Fig. 6.—Monthly chart.
form of a curve, as for instance the weight of a baby
(Fig. 4), or all the different clinical data may be so
shown on the same charts, by marking the curves in dif-
ferent colors (Fig. 5), or by dotted and broken lines.
We can also Avrite in any further data, such as the
number and quality of the stools, the kind of food given,
the medicines, the baths for reducing high temperatures,
any prominent clinical symptoms, etc., so that the chart
INTRODUCTION
31
will take the place of the bedside record which, by the
Avay, I have found to be, as a rule, a most uninteresting
document.
».».,.C.,,,.L:,,,,.:.
DimgnMlM .W.W*>^M«......
Bon, a.,.J.WIS.k-'.iSM>
Hwl:l< fit »m her. I01U I?lb
v..,/5/6 ».....' '"1 Sot.
Weight Pute T,n,p 23 24 2£ 26 27 28 2S 3 03/ / 2 3 (-.5 6 1 8 5 10
230 220 210 &S »0 108 107
4'2r JibT 190 ISO 160 ^ EE|EE:i==l 111=11
7/fa I2n~ 150 Nil 120 30 -*. lplE=Eiz =
^ 2S 20 =
«..„. /? 7 1 1 Ho I II | I o| i 1 0 1 1 1 O 1 0 111 ' O 1 | | I 1 1 1 1 1 < )
f L *--- = ~^:
K,„, ..„..., 6.-7, ✓ Dnt t 4 -BcieJmMJr "V-C nrng^uicj] ft a
/ M« — 6 b e 6 8 b i 8 8 8 I ( 8 8 i 8 8 8
oAM - 6 6 6 6 8 8 6 8 7 7 7 6 7 7 1 7 &
?PM 6 6 6 b 0 8 8 t 7 8 7 6ii 6 6 'I 7 S
s>PH (2) k b i 6 8 8 J 8 8 7 7 t » 7 f> t 7 8
10th ■f 6 6 6 fc 8 8 £ 8 8 8 8 1 i 8 8 t 8 8
T, , _ _
Fig. 7.—Chart indicating quality of stools.
Different forms of charts may be more convenient for
different cases. Thus the chart pictured in Fig. 3 is one
especially adapted for the infectious diseases, each sheet
32 NURSING IN DISEASES OF CHILDREN
being the record of one week. Another chart (Fig. 6)
is one I made and used successfully in a large infant
home, each sheet being the record of one month; on
ffifll J m SS i si a „ „ , ,,, „ M a grams W; ter Total 0.0
Total 100.0% 1000 grams 720.5
This will give us a caloric value of 21.6 calories per
ounce and 691.2 calories per quart.
Mother's milk is, as may be seen from its chemical
composition, the only perfect food for the baby, but,
aside from this it has other perhaps greater advantages
Avhich are not so evident,
It is furnished at the right temperature.
It is practically germ-free, even if the mother should
be suffering from an infectious disease at the time, pro-
vided, naturally that the breasts are not affected.
It is given to the child directly from the breast thus
obviating any handling Avhich is one of the greatest
sources of contamination in animal milk.
It is ahvays to be had at the right time.
Finally, being a transudate to a large extent from
the mother's blood it will contain the protective bodies
of some of the diseases which the mother has overcome
!)() NURSTNG IN DISEASES OF CHILDREN
at some time or other, and it will thus confer a cer-
tain amount of immunity upon the baby; this no other
milk can ever do because it can confer this immunity
only upon the young of the same species.
In short, mother's milk is the only natural food for
the baby and in order to emphasize this still further, we
do not longer speak of artificial feeding when referring
to the other modes of feeding, but Ave call it unnatural
feeding to differentiate it from the only natural kind
of feeding possible.
No other food can take the place of mother's milk.
This Ave see in the mortality statistics Avhich shoAv that
only one breast-fed baby dies during its first year of
life to every ten babies Avho are not given this ad-
vantage.
In practice we meet Avith considerable objection to
nursing on the part of young mothers and their relatives
and friends. Some Avomen do not Avant to nurse be-
cause they are afraid it might spoil their looks or
their shape; these Ave can reassure; many a Avoman be-
comes only really beautiful after she has nursed a baby,
and as to shape this is really of no consequence, as the
shape of the modern Avoman is mostly a matter of
artifice and then shapes change almost Avith the seasons.
Others again object because it Avould interfere with
their pleasures or social duties; this Ave can put aside
as umvorthy of a true Avoman and mother. Or Ave
hear it put forAvard that the mother is nervous and
that the baby might get this nervousness through the
milk. This is one of the most ridiculous arguments we
can hear, and Ave hear it quite often.
Or it is claimed that the mother is weak or anemic.
Any Avoman Avho is strong enough to carry a baby dur-
ing nine months of pregnancy and to nourish it A\dth
FEEDING OF CHILDREN
97
her oavu blood during all this time, A\-ill also, as a rule,
be strong enough to nurse it for a feAv months at least.
In fact, most of the arguments Ave hear put forward
by mothers or their friends Avhy they can not nurse
their baby are nothing but thinly veiled and invalid
excuses.
(hie, and one only, reason do I recognize Avhy a
mother must not nurse her baby and that is Avhen she
is suffering from tuberculosis; this for the reason that
babies are extremely susceptible to this infection and
that hardly any of the babies so infected survive.
Other of the usual diseases on the part of the mother
does not make nursing absolutely impossible, not even
one of the infectious or contagious diseases, and it must
be left entirely to the judgment of the physician, if he
thinks it advisable on account of the mother to stop
her nursing temporarily. I have seen mothers suffer-
ing from typhoid and pneumonia successfully nurse dur-
ing their entire illness Avithout any bad effect either
upon the mother or child.
The nurse should never undertake the grave respon-
sibility of deciding if a Avoman is able to nurse her
child or not, on the contrary she should use her every
effort toAvards the continuance of this one of the noblest
duties of a true Avoman; being with the mother all the
time she can do this much better and more successfully
than the physician Avho of necessity can see his patients
only comparatively rarely.
In order to be successful in this, hoAvever, the nurse
must be acquainted with all the arguments which she
may bring forward in its favor, and she must give them
in a convincing manner, not half-heartedly as if she
did not believe it herself but had only learned these
things by heart like a parrot.
98 NURSING IN DISEASES OF CHILDREN
This is one of the many times when the nurse can
prove her loyalty to her noble profession and to the
physician under avIioiu she is Avorking at the time. The
nurse is the physician's most valued and trusted as-
sistant, he depends upon her and in return he aviU
stand by her through everything. But, he knows that
"loyalty" is the motto of her profession and he ex-
pects it in this as in everything else.
Noav comes the important question: Hoav often should
the baby be nursed and at Avhat intervals?
Naturally, Avhenever the attending physician has
given orders in regard to this they should be carried
out to the very last detail the same as any other
directions Avithout any questioning or hesitation on the
part of the nurse.
But when, as is so often the case, this is left to the
discretion of the nurse, then I Avould adAdse her to
adopt the routine Avhich I haAre tried in a very large
number of cases in prhTate practice, in institutional
Avork, and in my extensive dispensary consultations in
sweral infant av el fare stations Avith A\diich I had the
pleasure of being connected.
I might say right here that I have tried all the dif-
ferent methods advised and that I have finally come to
adopt this routine because I found it almost universally
successful.
To begin Avith the neAvborn. After the active labors
of the mother and the passive labors of the infant dur-
ing childbirth both Avill be exhausted and they Avill re-
quire first and foremost of all a good long refreshing
sleep. The baby is too busy getting accustomed to its
ucav and strange duties of maintaining its oavh body
heat, of providing itself Avith oxygen through respira-
tion and to all the fundamental changes going on in its
FEEDING OF CHILDREN
99
organism to Avasle sonic of its limited energy upon the
fruitless task of trying to obtain unnecessary nourish-
ment Avhich is present at this time in only very minute
quantities. Imagine yourself after a very strenuous day
of Avork feeling sore all over and too tired to eat, when
all you desire and all you need is sleep and some more
sleep. That is the case of the baby after birth. Again
I say put yourself in the baby's place once in a Avhile.
As to the mother she also is exhausted; she has most
likely not had a good undisturbed night's rest for some
time, she wants some food and then rest,
If you leave the baby to itself you a\ ill notice that
it Avill satisfy its need for sleep to its heart's content
and it Avill hardly Avake up for tAveny-four hours. Why
should avc disturb it then; Avhy interfere Avith nature's
Avise provision1?
If the baby should Avake up give it a little warm
Avater, but Avithout sugar—sugar is food and might be
harmful—and above all unless ordered do not give any
of the old-fashioned teas or decoctions Avhich haA-e been
handed doAvn from the dark ages Avithout having any
apparent right of existence. Nor must you offer the baby
any unnatural food in the bottle, it will do no good but
it may do harm.
After the first twenty-four hours Avhen both mother
and baby have been refreshed by sleep and Avhen some
colostrum at least has collected in the breasts, then I
alloAV the baby to nurse twice in the twenty-four hours ;
three times during the third day; four times during the
fourth; and from the fifth day on I have the baby
nursed regularly every four hours in daytime, that is.
at six and ten in the morning, at two and six in the
afternoon and for the last time at ten in the evening;
100 NURSING IN DISEASES OF CHILDREN
nothing is to be given to the baby during the night
from ten in the evening until six the next morning.
Try it a feAv times when you have the chance and
you will be quite as enthusiastic about it as I am myself.
No longer Avill you see the babies Avhich are turning
night into day, Avho Avant to nurse all night because the
Avarm milk soothes their aching little stomachs for a
feAv minutes at least and avIio are too exhausted in day-
time to take even one good nursing. No more AAdll you
have to hustle around to make some fennel, or catnip,
or peppermint, or some other kind of tea for the
colicky baby. No! the baby Avill learn in a very short
time Avhat is expected of it and it Avill soon know Avhen
it is time for nursing; and when it is put to the breast
it Avill be hungry enough to really suck and it Avill not
fall asleep and forget its duty.
Compare the baby on this schedule with one that is
on the old-fashioned tAvo hour feedings which I gave
up years ago because it proved a failure. The four-
hour baby is contented, it sleeps quietly and soundly,
it has no colic, its stools are normal and passed easily;
it does not Avet itself every little Avhile, and it does
not spit up some of its food after nursing. And I must
tell you that this last point is of great importance be-
cause a healthy, Avell-fed baby does not spit up any of
its food, this is an economic waste which would not be
tolerated by nature. Whenever a breast-fed baby spits
up any of its food you can be sure that it is not fed
right and that either it is overfed, which is most fre-
quently the case, or, much more rarely, that it is not
getting enough.
Quite different is the behavior of the hvo-hour baby.
Provided it is not fed too much and too often at night,
it is at its best early in the morning after its first nurs-
FEEDING OF CHILDREN 101
ing; after the second nursing it begins to get somewhat
restless and this Avith every succeeding feeding until
it is spitting up after each nursing and is crying shortly
after it from pains in its overloaded stomach. It soon
Avill not nurse right many times thus instinctively reg-
ulating things to some extent at least; it will either be
constipated or have loose stools Avith particles of un-
digested cream; it will Avet itself frequently and soon it
may get sore buttocks from this; its sleep is light and
easily disturbed; in short its behavior will not be that
of a Avell baby.
What happens in the case of the tAvo-hour baby? An
infant's stomach has a limited capacity and it takes
some time to digest a breast meal. I believe that it
takes three and one-half hours for a baby's stomach to
digest a good generous feeding. The baby's stomach
needs some rest after each meal, the same as ours; it is
not a perpetuum mobile. Noav if you have a baby nurse,
let us say at six in the morning; at eight o'clock when
it is given its next meal there Avill still be some undi-
gested milk in the stomach and the neAV milk Avhich gets
into this w ill at once coagulate into a hard lump. The
same AviU happen at every successive feeding until fin-
ally there is no more room for new food and the baby
must spit it up. Do you Avonder noAV that the baby is
uncomfortable and is cross? Would you care to try
a similar experiment upon yourself? Again, put your-
self sometimes in the baby's place.
Noav I can hear quite a feAv of you ask me : How
is it, that thousands, yea millions of babies have been
brought up on tAvo-hour feedings and have been Avell
and thriving? I shall answer you, that this is quite
true, but that Ave have done many things in the past
differently from the Avay in which we do them now
102 NURSING IN DISEASES OF CHILDREN
and that Ave got aAvay Avith it; considerable numbers
of people lived to ripe old age before Ave kneAV that
bacteria caused certain diseases. Is that any reason
Avhy Ave should not folloAV the mandates of modern hy-
giene? Many people reason that Avay, I knoAV, but this
is no reason AAdiy Ave Avho have been taught better and
Avho can judge of these things should let up on our
continuous AVatchfulness. Furthermore it is a Avell-
knoAAm fact and one Avhich is evident daily Avhen Ave
look at bottle babies, and that is, that some babies Avill
thrfve on any kind of feeding Avhile others will not, and
Ave can neA^er tell Avhen and Avhere Ave shall meet the
latter kind. That "prevention is better than a cure"
is truer in infant feeding than most any other field of
medicine, as the results of bad feeding may sIioav
through the rest of life and be a permanent handicap
to a child.
In order to convince a young mother that it is best
for her to nurse her baby the nurse must knoAV hoAV
to make this as easy as possible, so as to be able to
instruct her.
When the mother Avants to nurse her baby Avhile she
is lying in bed, she turns over to the side correspond-
ing to the breast she is to give and a pilloAv is placed
against her back. Then the baby is placed upon the
loAver arm so that its face is opposite the breast; the
upper, free hand iioav guides the nipple into the baby's
mouth, taking care that not only the nipple but also
part of the areola, the brown ring around it, gets into
the baby's mouth; uoav the first and second fingers
slip over the breast behind the areola from above, one
on each side, and keep the breast away from the infant's
nose. (Fig. 28.)
When the mother sits up to nurse, then she should
FEEDING OF CHILDREN
103
use a Ioav chair, not a rocker, with a comfortable back;
Avhere this is possible a special chair should be found
in the nursery for this purpose, She should put the foot
corresponding to the breast she intends to give upon a
footstool Avhich is just high enough so that Avhen she
iioav places the baby across her lap its mouth will be
p*
^4
*4 m f -
1 t
Fig. 28.—Nursing baby in bed.
Avithin easy reach of the nipple. Then she guides the
nipple into its mouth and holds the breast off its nose
the same as before. (Fig. 29.)
The nurse must know exactly Iioav to do this and she
must be able to place both mother and child in the
right position, then only AviU she be successful in this
104 NURSING IN DISEASES OF CHILDREN
and she Avill be able to save the mother from many
a backache and from many anxious hours. Here, as is
so often the case in nursing, there is only one Avay to
do things and that is the right Avay.
Fig. 29.—Nursing baby sitting up.
If the mother and baby are taught rightly then Ave
shall not have any difficulty in a good many cases, but
still in a considerable number, obstacles offer them-
selves with Avhich the nurse must be acquainted and
Avhich she must knoAV Iioav to meet.
First, she will meet with the Aveakly baby, often it
FEEDING OF CHILDREN
105
is one born prematurely, who still lacks the necessary
reflex to suck; with this it will require time and reg-
ularly repeated efforts before Ave can teach it Avhat to
do. One expedient, which will work in a good many
Fig. 30.—Breast pumps.
cases, is to express a little milk into the baby's mouth
to teach it what is meant by the procedure.
If the baby should be too weak to draw any milk,
then this may be drawn off with the breast pump (Fig.
Fig. 31.—Breck feeder.
30) from which the baby can then draw the milk itself
or the milk may be given to it with a spoon or a Brock
feeder (Fig. 31). In some very weak babies the phys-
ician may order the milk to be given by gavagc through
106 NURSING IN DISEASES OF CHILDREN
a No. 7 soft rubber catheter and naturally the nurse
must knoAV hoAV to do this. It is quite easy after you
have tried it a few times.
Whenever the baby is too Aveak to empty the breast,
or when Ave must resort to the breast pump, great care
must be taken that the breast is ^emptied at each
nursing, otherwise it Avill dry up very soon and this it
Avill do most likely sooner or later anyhoAV. In these
cases and when the family can afford it, it is a good
plan to take a Avet nurse Avith her oavii baby into the
house, so that this healthy, strong baby can stimulate
the young mother's breasts and keep them going until
her baby is strong enough to do this for itself. Fre-
quently Ave meet Avith considerable objection to this;
it is distasteful to many a Avoman to have another baby
at her breast, but the nurse can make this easy Avith
the proper amount of tact and by explaining that this
is only a temporary measure and one Avhich is sure to
work out for the best. Often it takes considerable per-
suasive poAver on the part of both physician and nurse.
Some breasts give up their milk quite readily, too
readily in fact, Avhile others demand a considerable
amount of effort on the part of the baby, but, Avith
patience and perseA-eranee Ave Avill succeed.
The care of the breasts is also of the greatest im-
portance. During the three or four months before con-
finement the mother should be instructed to draAv out
the nipples regularly eA^ery morning and evening and
to Avash them Avith cold Avater or to apply a mixture of
equal parts of glycerin and sweet oil to harden them.
If the nipples should be draAvn in and can not be pulled
out, then a nipple-shield (Figs 32 and 33) Avill often
still make nursing possible.
Before each nursing the nipple should be sponged.
FEEDING OF CHILDREN
107
with some boric acid solution and the same should be
done right after, care being taken, however, that the
nipple is then dried properly.
I knoAV of no more painful condition of the nursing
mother, nor one Avhich more frequently interferes Avith
this duty, than cracked nipples and these can be pre-
vented in a large percentage of the cases by the proper
care of the breasts. Once the cracks in the nipples have
Fig. 32.—Nipple shield. Fig. 33.—Nipple shield.
deA^elopecl only the most painstaking care Avill make
nursing Avith a nipple shield possible; but even then
the pain often interferes Avith the milk; in many cases
I have seen nursing made impossible by this condition.
Lack of care and cleanliness of the breasts Avill often
cause abscesses in one of these to form and then the
nursing at this breast should be given up, temporarily
at least, until it is healed.
Fsually on the fourth day Avhen the milk begins to
shoot into the breasts they become heaATy and tender
108 NURSING IN DISEASES OF CHILDREN
and the glands in the axillae become SAvollen. Great
relief can be given by a properly applied breastbinder,
but few nurses know Iioav to do this properly.
The patient is told to lift her breasts upward and in-
Avard, then the nurse takes a strong piece of cotton or
other cloth, for instance a roller towel, this should be
eight inches Avide, and it is laid from the Avoman's
back and fastened in the middle over the breastbone
Fig. 34.—Breast binder.
quite snugly Avith safety pins from beloAV upwards, so
as to keep the breasts upward and inward. Then a
tuck is made on each side under the breast and held
with safety pins (Fig. 34).
At this time caking of the breasts may also occur,
especially when the baby does not empty them
thoroughly; the milk ducts and glands can then be
felt as hard cords and lumps under the skin and this
condition is frequently quite painful. Gentle massage
of the affected breast from the outer border of the
FEEDING OF CHILDREN
109
areola to the outside of the breast Avill often bring great
relief; but with this the breasts must be thoroughly
emptied by means of the breast pump.
How long should a baby be allowed to nurse? This
is one of the questions which is difficult to ansAver in
a general Avay, because it depends upon the way in
Avhich the breasts give off the milk, and upon the
strength Avith Avhich the baby nurses. As a rule a
nursing should not take longer than from fifteen to
twenty minutes. Careful Aveighing during prolonged
periods in a number of babies has shoAvn that the in-
fant takes three-quarters of its meal in the first ten min-
utes of each nursing.
Frequently Ave wall find that if Ave let the baby nurse
for fifteen minutes it may get too much milk and Avill
spit up some of it, In these cases a reduction of the
time alloAved for the nursing will readily remedy this.
Hoav much should a baby get at each meal? This
we can figure out quite easily. We knoAV from care-
ful investigation that a strong, healthy baby, born at
term, should daily receive at first fifty calories for each
pound it Aveighs. Mother's milk represents at this time
in round figures twenty calories in each ounce and Ave
Avould, therefore, alloAV the baby tAvo and one-half
ounces to each pound daily. The baby is nursed five
times in hventy-four hours and it should then get one-
half ounce for each pound at each nursing. Experience
tells us, hoAvcver, that it is not Aviso to let a baby have
more than seven or at most eight ounces at any nursing,
no matter Avhat its weight may be.
Careful Aveighing has also told us another interesting
fact, namely, that babies do not get the same amounts
at each of the five nursings; and, that the first meal in
the morning is usually the one Avhen they take the most,
110 NURSING IN DISEASES OF CHILDREN
which must naturally be taken into account in determin-
ing Iioav much the baby may have.
A question AAmich seems to be still in dispute, though
I have settled it to my own satisfaction long ago, is:
What shall Ave alloAV the nursing mother to eat and
what shall Ave deny her?
Well do I remember the time Avhen I Avas in college
and Ave Avere taught that the nursing woman should
not haA'e any potatoes, that she should not have salads
nor pickles; in short, her dietary Avas rather limited,
although none of my teachers could ghe us any good
reason for this, they simply repeated one from the
other.
When I Avas still engaged in obstetrics I tried out all
the different diets which I had been taught and of Avhich
I had read later; I have also been guilty of keeping
the young mother during the first feAv days after con-
finement on gruels and large quantities of milk, and
of forcing her later to take milk between meals and
large amounts of liquid altogether; but, let me tell you,
1 have learned from my mistakes—no better school can
be found—-I havre mended my Avays much to the delight
and benefit of my patients.
During the last years I haA'e alloAved the young
mother anything she cared to haA^e right from the time
after her first refreshing sleep.
If the baby Avas born in the middle of the night I
alloAved the mother a full breakfast of fruit, cereals,
meat and eggs and coffee; if it Avas born during the
forenoon I allowed the regular dinner; if in the after-
noon a full supper. I recollect that one of the first
patients whom I permitted this liberal diet Avas a grad-
uate nurse, the AAdfe of a brother physician, and I can
still see her astonishment as Avell as pleasure at this
FEEDING OF CHILDREN
111
innovation, the result of Avhich was, as I expected, a
most happy one.
From the time I alloAved nursing mothers to cat any-
thing and everything they desired, provided they knew
from experience that it Avould agree Avith them,
and since I haAre ceased overloading their stomach with
milk and other liquids so that they could not possibly
have any appetite for their regular meals, I have had
comparatively little trouble with women being unable
to nurse their babies.
Take my advice, subject to physician's orders, let the
nursing mother haAre a good generous diet of Avhole-
some home cooking and, I am sure, your experience will
be the same as mine Avas.
A word here also in regard to the diet for young
mothers in hospitals and similar institutions, because
1 trust that a number of you will succeed in Avinning
the honored and important position of heads of such.
I have frequently found that the diet list in hos-
pitals is rather a rigid affair, and that too little regard
is paid to the tastes of the individual patient and to
their racial and religious likes, dislikes and prejudices.
Let us say, for example, that the hospital furnishes
for supper on one evening of the Aveek wieners and
potato salad; this Avill please the German and the
Polish Avoman, but how about the Italian Avho is not
accustomed to this fare, or the Jewish Avoman whose
religion does not permit her to partake of this? Must
they go hungry? Why not give the former her be-
loved spaghetti and the latter a salt herring? Put
yourself in your patient's place occasionally and you
Avill be the better nurse for it.
When a baby does not seem to thrive at the breast
it behooves us to find the cause rather than, as is still
112 NURSING IN DISEASES OF CHILDREN
done so frequently, advise the mother to stop nursing.
First Ave must determine Iioav much food the baby
is getting from its mother. This can be done very
easily by Aveighing the baby before and after each and
every nursing, Avithout undressing, on a good set of
scales, such as I have already described. This Aveigh-
ing should be done for at least three days in succession
in order to eliminate mistakes through any of the daily
Arariations.
What Ave do when the baby is not getting enough Avill
be told later.
Often, hoAvever, Ave Avill ascertain that the baby is
really getting too much and this Ave can easily amend
by reducing the time of nursing, naturally under the
control of the scales.
A special record (Fig. 35) should be kept for this
purpose and the daily Aveight of the naked baby should
be noted on a chart just the same.
Should Ave find that the baby is getting the right
amounts of food and that it still fails to thrive, then
the physician will require samples of milk for exam-
ination. Noav, the quality of the milk varies consider-
ably from the beginning to the end of each nursing.
At the time the baby is put to the breast the milk Avill
contain very little cream, not more than one per cent.
After the nursing it Avill sIioav six and even more per
cent of cream. In order to get a true insight into the
condition of the milk, the nurse should have ten clean
sterile Adals Avith a Avide neck, tAvo for each nursing, and
into one of these she expresses an amount of about five
c.c' before the baby nurses; into the other the same
amount after the baby is through nursing. These ten
samples are then handed to the physician Avho turns
them over to the chemist avIio will take exactly equal
FEEDING OF CHILDREN 113
amounts of each sample, mix these and then subject this
mixed milk, Avhich represents the whole milk for this
particular day, to the same careful analysis Avhich he
employs in testing coav's milk. It is advisable to make
these analyses on three consecutive days to eliminate
the chance of error.
Date Hour Weight Amount ounces ounces
be lbs for^ oz i ai lb a 'ter 03
6 A.M
10 A.M
2 P.M
6 P.M
1U ir5 .LI
Daily Amount
fa A.LI i
10 A.M.
2 P.M
6 P.M
10 P.M,
Daily Amount
6 A.M.
10 A.M.
Z P.M.
6 P.M.
10 P.M.
Daily Amount
Fig. 35.—Three-day nursing record.
Rarely only will the chemist find a faulty composi-
tion of the milk and it is therefore a grave mistake to
wean a baby that is not thriving at the breast. The
nurse should never undertake this on her oavh account,
but she must let the physician take the responsibility
for this truly momentous step.
A feAv times only have I found that the milk was too
Ill NURSING IN DISEASES OF CHILDREN
rich, containing an overabundance of cream, in these
cases 1 was able to mend this by giving the baby one
or tAvo ounces of barley gruel before each nursing in
order 1o dilute the milk.
Combined Feeding
When a mother has not enough milk to satisfy her
baby, it is still of the greatest importance to give it
the benefit of as much breast milk as possible and to
make up the deficiency with some other food from the
bottle.
The same holds also good when a mother of twins
has enough for one baby only, but Avhere Ave Avant both
of them to get at least some breast milk.
Another condition Avhich frequently necessitates com-
bined feeding is in case the mother has to Avork during
the day. In France, Avhich country has the most ex-
cellent laws for the protection of babies, factories AAdio
employ any number of women must set aside a large
room for a nursery Avhere the infants are left in charge
of a trained nurse and Avhere the mothers can nurse
their babies at regular intervals Avithout being docked
in their pay. We, in this country, have, unfortunately,
not yet arrived at this high state of civilization;
mothers Avho are too proud to depend upon charity
must leave their babies in charge of some neighbor or
friend during Avorking hours Avho will have to feed the
baby Avith the bottle at ten in the morning and at tAvo
in the afternoon, and the mother nurses her baby at
six in the morning and at six and ten in the evening.
Mothers of tAvins can administer combined feeding
quite easily as folloAvs: Today baby A is given the
breast at six in the morning and at tAvo in the afternoon
and at ten at night, and it receives the bottle at ten in
FEEDING OK CHILDREN
115
the morning and at six in the evening. Baby B is
nursed at the hour at Avhich baby A Avas given the
bottle and is given the bottle Avhen baby A is at the
breast. Tomorrow baby A -will be nursed only tAvice
and baby B three times, and so on.
In cases in Avhich a mother has not enough milk for
her baby Ave can either alternate the nursings and
bottle feedings; or, and this I have found much more
satisfactory, we have the baby put to the breast at
the regular hour free times a day and after it has taken
all it can, Ave make up the deficiency Avith the bottle
under the control of the scales.
For instance a baby tAvelve Aveeks old, and Aveigh-
ing ten pounds, reeehes on an aA'erage only tAvo ounces
from the breast at each nursing, then it should be given
four ounces in the bottle after each nursing. In this
case it is advisable to leave the baby at the breast not
more than from five to ten minutes; if Ave leave it longer
it may be too tired to take the bottle.
We must also be careful to haA^e the holes in the
nipples of the bottle small enough so that the baby
has to draAv out the milk, otherAvise the baby will soon
learn that it can get its food from the bottle Avith so
much less effort and before long it Avill refuse the breast
altogether as too laborious. You may doubt that small
babies can do this, but, believe me, they know more
than they are gwen credit for.
Bottle Feeding
If you expect in this chapter that I -will give you
recipes for the unnatural feeding of infants or if you
should go eA^en further and expect that I should tell
you what is the best food to give a baby in the bot-
tle, then you are sure to be disappointed.
116 NURSING IN DISEASES OF CHILDREN
For years I have been preaching in meetings of med-
ical men, in my lectures to students and nurses, in
infant Avelfare stations, before mothers' clubs, and at
public gatherings that the unnatural feeding of infants
is one of the most difficult problems of the Avhole field
of scientific medicine. I have also maintained that this
should be left entirely in the hands of the physician,
preferably of the pediatrist, Avho has made a special
study of this, and that it should never be undertaken
by nurses, nor by laymen.
Too much Avrong is done to babies already, and Ave
see daily cases of infants Avho Avere born healthy and
from healthy parents, but aaIio Avere so unfortunate as
to be denied for some good reason or otherwise the
only food intended ever to be placed in a baby's mouth,
namely the milk of its OAvn mother.
How many times am I not forced to pronounce that
most ominous verdict "too late" over some poor little
mite who had been brought up according to the more
or less complicated formulas of some relative or neigh-
bor, or some nurse Avho Avas assuming for herself the
physician's duties, or according to the printed formula
of some ignorant manufacturer of baby foods, or those
contained in books intended as a guide for misguided
mothers ?
I shall be consistent, if anything, in this book and
I shall not bolster up its pages Avith formulae of Avhich
I knoAV that they AAdll do more harm than good.
I shall, hoAvever, give you a few general rules about
the unnatural feeding of babies, so that you -will, as
I trust, understand the general principles underlying
this most complex and complicated scientific work,—
but do not misunderstand me and think that the foods
Ave offer to babies in the bottle should be complicated
FEEDING OF CHILDREN
117
as Avell—and that you may know how to proceed tem-
porarily, should you ever be in a place where a phy-
sician can not be located at once. But again let me
warn you not to attempt this rashly nor Avithout be-
ing forced to do it by circumstances over Avhich you
have no control.
Let us have, first of all, a good look at the one food
Avhich is most frequently used as a substitute for
mother's milk, namely, coav's milk.
AVoman's milk Cow's milk
Ftit 4.0%f 4.0%
Sugar 7.0% 4.5%
Protein 1.5% 3.5%
Salt 0.2% 0.75%;
Water 87.3% 87.25%
If Ave compare the chemical analysis of the two kinds
of milk Ave shall see at once that although the fat and
the water are represented by equal amounts in the tAvo,
material differences exist in the amounts of sugar,
protein and salt. These differences will be readily
understood by you in their AA'hole importance if you
use a little common sense, Avhich, by the Avay, is in
my opinion at the same time the most important and
least used ingredient in the artificial feeding of babies.
Woman's milk, on the one hand, is the physiologic
food for the human baby, an immature organism Avhich
can not move around, is devoid of protective cover-
ing of fur to guard it against climatic changes. It
grows very slowly, taking about twenty years to groAv
to full size. Coav's milk, on the other hand, is also a
baby food, but it is not intended for human babies but
for baby cows Avho can run around soon after birth,
Avho have a natural protection against the cold in their
118 NURSING IN DISEASES OF CHILDREN
furry coat and who are fully groAvn inside of four
short years.
Do you understand now the difference in the chem-
ical composition of the two hinds of milk? AVhy hu-
man milk must contain more sugar to keep the baby
Avarm, and Avhy coav's milk must contain more pro-
tein to build up the muscles for running around and
also more salts to build up the rapidly groAving bones'?
The fat in both kinds of milk is alike in quantity,
but it is a Avell established fact based on a long line
of practical experiments that the cream of coav's milk
is hard to digest for infants av!io even may shoAv the
bad results of a continued overfeeding AAdth the cream
of mother's milk.
FeAv babies are able to stand a food A\diich contains
more than four per cent of cream. Even calves do not
react Avell to this kind of overfeeding and dairymen
Avill tell you that the calves of Jersey cows haA^e to be
taken off their mothers frequently and have to be given
to other breeds of coavs because they can not stand the
extremely high percentage of cream found in the milk
of Jersey coavs. This Avill also explain to you Avhy Ave
do no longer use the milk of Jersey coavs in feeding
babies.
One point stands out in choosing coav's milk for
babies and that is the fact that the best kind of coav's
milk Ave can obtain is just good enough.
The ordinary market milk contains not less than fifty
thousand bacteria in each c.c, many times their number
runs into the million. Even the best, most carefully
obtained and marketed milk, be it certified or so-called
baby's milk, rarely contains less than five thousand
germs in each c.c. You Avill easily understand that this
can not be immaterial to the digestive apparatus, though
FEEDING OF CHILDREN
119
we knoAV iioav that it is not so much the bacteria in the
food as it is the composition of the food Avhich really
makes babies ill.
As to the use of pasteurized milk my opinion differs
from that of a great many pediatricians and sanitariums.
I am fully convinced that Ave can not transform a poor
milk by pasteurization into good milk; Ave can not de-
stroy by this process the poisons formed by the bacteria,
and this is the reason Avhy I stated before that the best
kind of milk is just good enough for the baby.
Still, I have advised for some years to have the milk
quickly brought to the boiling point as soon as it is
received at the home and this for tAvo reasons.
First: pasteurization only kills certain of the germs
and thereby others as Avell as the more resistant spores
have a better chance to groAv, Avhile boiling is more
thorough in its sterilizing effect.
Second: Ave know that the proteins of coav's milk
coagulate in the stomach into hard masses Avhich arc
sometimes found in the baby's stool as tough, leathery,
yelloAvish, bean-shaped curds,—the only real kind of
curds—but by boiling cow's milk Ave succeed in break-
ing up the protein so that it will coagulate into fine
curds, like human milk, in the infant's stomach and that
it can, therefore, be attacked much easier by the gastric
juice and thus digested.
It is not sufficient that coav's milk intended for the
feeding of infants should be produced from a healthy
herd of coavs—Ave do not use one coav's milk any more—
that it be milked in a sanitary stable; that the coavs
be carefully groomed before each milking, that the
milker should wash his hands carefully before milking
each coav, that he don a clean Avhite coat and that he
milk into a covered pail; that the milk be strained right
120 NURSING IN DISEASES OF CHILDREN
after milking, be chilled in ice, filled into sterilized bot-
tles and then kept on ice until delivered at the home.
What is the use of all these precautions, if the de-
liveryman leaves the milk outside the kitchen door be-
fore daylight there to stand in the sun until it is taken
into the house? Have not the germs, no matter hoAV
small their number originally, found ample time to mul-
tiply by the thousands of millions in each bottle? and do
you think that this milk is still good for the baby?
Much better, in my opinion to get a good market milk,
see to it that it is dehVered at a convenient hour, in
summer, best tAvice daily, and have it brought to the
boiling point at once and then cooled quickly.
Suppose noAv that Ave have a good quality of milk,
Iioav are Ave to overcome the differences betAveen it and
human milk?
I haA^e told you before that the fat of coav's milk is
harder to digest for the infant than that of human milk,
and it is for this reason that I have iioav for a number
of years Avhen beginning to feed a sick baby, one Avhose
digestion Avas out of order, started Avith skim milk or
with buttermilk, both of A\iiich contain about one-half
per cent of cream, and then later adding the cream as I
considered it safe in small and sIoavIv increasing doses,
sometimes not more than part of a teaspoonful to a
whole day's feeding. To this I attribute a considerable
amount of my success.
If we give a baby too much cream in its food this has
to be excreted in the stools and avc find in these the so-
called curds Avhich are not at all curds but fatty soaps;
because the cream is split up in the intestine into
glycerin and into fatty acids and these latter draAv an
earthy alkali, usually calcium phosphate, from the sys-
FEEDING OF CHILDREN
121
tem to form this soap; that this is not immaterial to the
organism you Avill see later.
The large amount of protein in cow's milk can easily
be reduced by diluting it, as Ave usually do. But, we
have found out of late that the proteins of coav's milk
have not a harmful effect upon the baby's digestion
and that we can give them in considerable quantities;
on this experience is based the use of the so-called pro-
tein or ehveiss milk.
The salts, though of no caloric value, play an impor-
tant part in the metabolism and giving too much of them
is not immaterial for the organism. They are also re-
duced in quantity by dilution. They are almost entirely
contained in the whey and Ave must think of this Avhen
Ave intend to use Avhey mixtures; these I have given up
long ago as based on erroneous reasoning.
The sugar Avhich is already present in coav's milk in
insufficient quantities is still further reduced by diluting
the milk. This, hoAvever, can be rectified by the addi-
tion of one of the sugars to the food or partly by the
use of cereal gruels.
Do not, hoAvever, conceive the idea that all you have
to do to make a modification of coav's milk Avhich will
agree with a baby is to make the composition of the
food chemically as near as that of human milk as pos-
sible. This has been attempted for decades by physi-
cians and by the manufacturers of proprietary and pat-
ented baby foods, and, though it was a success chem-
ically it was a failure as far as the infants were con-
cerned. In fact avc frequently succeed with foods Avhich
are almost diametrically opposite to human milk in the
composition of their elements.
One important point, it seems to me, has been too
frequently overlooked in the feeding of babies, and that
122 NURSING IN DISEASES OF CHILDREN
is that they are individuals, that they have their likes,
dislikes and idiosyncrasies the same as adults, and that
for this reason they frequently fail to thrive on the
most wonderful formulae Avhich are perfection chemi-
cally. In a piece of machinery we knoAV that Ave have
to feed it so much coal or gasoline, so much oil and so
much water to make it run smoothly; not so the baby
AA'hich Avill insist on its individuality in spite of all our
chemical reasoning and experimentation.
But, you will ask me, Avhat are Ave to do? What are
Ave to give the baby in an emergency! What do you
think of this or that proprietary food of Avhich Ave have
heard so much praise? What about condensed milk or
evaporated milk?
Well as to the first question, take my advice given to
you before, fight shy of undertaking the feeding of in-
fants upon your own responsibility; leave this to the
physician. If, hoAvever, you should be forced to assume
this risk temporarily, then beAvare of mixtures contain-
ing a high percentage of cream, do not use top-milk or
cream mixtures, but start Avith skimmed milk.
You can skim milk by letting it stand until the cream
has risen and then you may dip it off Avith a spoon or
special dipper, or you may syphon out the milk from
underneath the cream.
In an emergency underfeed a baby rather than over-
feed it, then you will be on the safe side at least.
But you must see to it that the baby gets enough Avater
in its food.
Noav as to the proprietary and patented baby foods.
I have often stated that if I could not make a better
food than any one of these manufacturers I Avould haAe
given up the practice of medicine, or at least of pediat-
rics long ago. On this as Avell as on so many other
FEEDING OF CHILDREN
123
points I fully agree Avith Avhat my venerable friend Dr.
Abraham Jacobi of Xcav York stated thirty years ago
and I can do no better than to quote his Avords to you:
"When an adult sits down to a meal and finds placed
before him articles of food -with Avhich he is not familiar,
he makes inquiries in regard to such articles before
eating them. The baby, hoAvever, is credulously fed
upon things Avith Avhich the child, father, mother, or doc-
tor has not the least familiarity; many of Avhich have a
composition unknoAvn to the public, although sold in
large quantities. When some manufacturers deign to
say anything about their merchandise, it is to the effect
that the food offered is the best in the market, that it is
the proper thing and the only thing for children and
invalids of all ages, that the relation of the albuminous
substances to carbohydrates is exactly correct, and that
ci package costs a certain amount of money. In regard
to this subject the public appear to be smitten Avith
absolute blindness. They insist upon forgetting that the
man avIio offers for sale, and advertises at a very heavy
expense, does so, as society is constituted, for his pecu-
niary advantage. To say that if the article offered is not
good, it Avill find no market, is deceiving ourselves,
experimenting on our babies, relying on the character
of a single man or corporation, on the honesty or in-
telligence of the manufacturer's chemist, or his super-
intendent, or his Avorkman, on the nature and condition
of the elements used in the composition of the article,
and on ever so many influences, Avhich can Avork before
the manufactured article gets into the hands of the
consumer. Why the sellers and advertisers of unknoAvn
compounds should be more trusted than those Avho sell
;i simple article of food, such as milk, Avhich is con-
stantly adulterated, can hardly be perceived. Is it
121 NURSING IN DISEASES OF CHILDREN
necessary to say that the factory furnace is lighted more
in the interest of the proprietor than for the benefit of
the public?"
This is the opinion of a man, a humanitarian phy-
sician, a close observer, one Avho believes in uttering his
candid opinions regardless of the hue and cry they may
raise, and Avho at that time was able to look back upon
more than thirty years of practice and teaching of pedi-
atrics. Need I say much more upon this point?
The proprietary foods contain almost universally
large amounts of carbohydrates, either as milk sugar or
as malt sugar, some also as cane sugar, and others as
starch; the amount of fat and proteins A^aries still more
in different brands. None of them are really foods that
may be given to a baby Avith perfect safety, though
some feAv of them could be used achvaiitageously as malt
sugar, if it Avas not for the misleading advertising lit-
erature and the formula accompanying each package.
Concerning the milk preserves, Ave must hold apart
the condensed milks which are SAveetened Avith about
forty per cent of cane sugar and AAdiich are condensed
to about one quarter their original A^olume, from the
evaporated milks Avhich are unsAveetened and are re-
duced only by about one quarter their original volume.
The condensed milks should not be used for babies
under any conditions, the evaporated milks may be used
in an emergency, such as a long trip, especially a sea
voyage, for a specified short time, but as a permanent
food they can not be condemned too severely. They are
often the favorite food given by ignorant foreigners to
their babies and I see their evil results daily in my dis-
pensary Avork.
Little is needed for the successful bottle feeding of
babies; a feAv utensils for measuring the quantities of
FEEDING OF CHILDREN
125
the different ingredients; good clean milk; a few things
which are found in every household or can be bought at
the corner grocery.
Remember in this connection also that nothing is
easier for a nurse than to spend other people's money
lavishly; but that it is in many cases hard enough for
the parents to pay even the nurse's salary.
I Avould advise you also to avoid special measuring
glasses, on which the percentages of the different in-
gredients are indicated, and the rotary indicators recom-
mended for the same purpose. It is much better for
you to learn hoAV to figure out these proportions for
yourselves and you Avill not only be less likely to make
mistakes, but you will be doing your Avork intelligently
because thoughtfully.
The bottles used for feeding babies should have a wide
neck, so that they can be cleaned easily, and they should
not have any sharp edges in the bottom (Fig. 36.) In
hospitals I have frequently seen ordinary medicine bot-
tles used as nursing bottles; this may be economical, but
I consider it ATery bad practice.
New bottles should be boiled for fifteen minutes in
water to anneal the glass thus making it less breakable.
The bottles should be rinsed immediately after feeding
and boiled in soda solution once daily.
The nipples should be big enough so that they can be
turned inside out for cleansing. (Fig. 37.) It is better
to buy imperforated nipples and make the hole of the
desired size with a hot darning needle, The nipples
should be washed immediately after use; they should
be boiled once a day, and when not in use it is better to
keep them dry between a folded toAvel or in a covered
glass jar, than to keep them in a solution of boric acid
all the time, because this will spoil the rubber quickly.
12(5 NURSING IN DISEASES OF CHILDREN
You should have six bottles -with their nipples on
hand, one for each of the five feedings and one in case
of accident.
If the milk is delivered once a day, then you -will best
make up the Avhole day's feeding in the morning and
it is advisable to have the extra bottle also filled, be-
cause one might be broken or spilled. If the milk is
Fig. 36.—Nursing bottles.
delhered tAvice a clay, especially in summer, you -will
have to prepare the food morning and evening.
When the food is ready it should be poured into the
bottles and a sheet of Avhite paper fastened over the top
Avith a rubber band (Fig. 38) and the bottles set in the
ice box; specially small ice boxes for babies are most
convenient.
You must not rely upon the marking upon the bot-
FEEDING OF CHILDREN
127
ties indicating the different quantities Avithout having
this verified by your own measuring.
A baby must not be left alone Avith a bottle, because
it may spill it and then you can not tell hoAV much it
has actually taken. Whenever this is possible, but
surely Avith sick or Aveakly babies, you must hold the
bottle.
Xote on the chart the amount of food the baby has
taken at each feeding, and throw away any food re-
maining in the bottle; this must not be given at a sub-
Fig. 37.—Rubber nipples.
sequent feeding, this would be false economy because
the food may spoil between feedings and make the baby
sick.
When a baby is sick you should also note hoAV it takes
its food, if greedily and very rapidly or slowly with
interruptions; this will help the physician quite often
in making a diagnosis.
If a baby should vomit note how soon after a feeding
this happened and the character not only of the vomited
matter but also of the vomiting itself. Remember also
128 NURSING IN DISEASES OF CHILDREN
that spitting up food is ahvays a sign of something being
wrong and tell the physician about it.
I hope that in the foregoing pages I have impressed
you Avith the difficulties Avith Avhich Ave meet when Ave
have to feed, a baby unnaturally, but I trust that I have
not gone so far as to give you the idea that to do this
successfully is impossible or even rare. It is done daily
and a chart like Fig. 39 will prove this to you.
Fig. 38.—How to keep bottles.
But, because this particular baby did so very well on
the food 1 had prescribed Avas for me not sufficient rea-
son to say that other babies should also thrive on the
same formula and therefore to announce to the world
that I have succeeded in producing a perfect baby food
or to have the formula printed and handed out to
mothers and nurses indiscriminately.
Feeding of children
129
Let me tell you that I do not possess such a thing as
a formula for feeding infants; I have learned years ago
that babies will not thrive on formulas, that every baby
is a laAv unto itself and that we must let it determine
Fig. 39.—Chart of healthy bottle baby.
for itself what is the best food. In order to do this one
must be familiar Avith every one of the ingredients of
the food, with their caloric values, their advantages and
disadvantages, and their physiologic action; then only,
130 NURSING IN DISEASES OF CHILDREN
Avhen avc have these data at the tips of our fingers, to
be used at any moment, shall avc be successful in a rea-
sonable proportion of our cases.
Feeding of Young Children
Under this heading I shall also include the feeding of
infants Avith other foods except those given in the bottle
to aAroid repetition.
When the baby has reached the age of six months it
is usually advisable to give it one spoon feeding instead
of one bottle, usually at tAvo in the afternoon.
Both human milk and coav's milk are deficient in iron.
At birth the infant has a store of iron in its liver Avhich
Avill last it for about six months, but after this period it
requires this mineral from other sources, otherAvise it
-will be pale and anemic as Ave can see every day.
For the first spoon feeding I use either farina pap
made of two teaspoonfuls of farina boiled in eight
ounces of milk, or cream of Avheat prepared the same
way, or zwieback pap made by rolling three zAvieback
or three slices of dry toast Avith a rolling pin and then
boiling this Avith eight ounces of milk. These paps are
sometimes taken by the baby Avithout the least trouble,
other babies object to this unaccustomed kind of food
and mode of feeding quite strenuously; they refuse to
sAvallow it and often spit it out and it -will then take
considerable patience and also strategy to overcome the
baby's strong Avill poAver. But, if Ave only persist long
enough and make the baby understand that it Avill have
to make the best of an unpleasant situation, then Ave
Avill succeed.
Do not get cross Avith the baby, nor scold it, remem-
ber that Avhen you Avere small you did not ahvays like
to take things your mother thought it best for you to
FEEDING OF CHILDREN
131
have. I have found frequently that nurses -will succeed
Avhere the mother has failed, because the baby knows
that it can not impose upon si rangers as it can upon its
mother, who is liable to sIioav in her face that she is
sorry for the baby and that she really Avould rather not
make it take the food.
Orange juice I give iioav quite frequently to very
young babies, as early as six Aveeks of age and even
younger; but, when they have not received this before
they surely should have it when they are six months old.
Oranges not only contain iron but also other valuable
constituents as Ave Avill see later. Should the orange be
sour then Ave SAveeten the juice by adding a little bicar-
bonate of soda.
When the baby has completed its seventh month of
life I give it another spoon feeding, preferably a veg-
etable soup, made Avithout meat stock. A very good
recipe for this is one I haA^e modified from the adAdce of
a French author. Take tAvo ounces of carrots (^one
medium sized carrot), tAvo ounces of potatoes (one small
potato), one ounce of turnips (one-half of a small
turnip), one ounce of spinach or lettuce leaves (one
handful), one ounce (one heaped tablespoonful) of dried
beans, peas, lentils, or of pearl barley, one-half teaspoon-
ful of salt and one quart of fresh Avater, put this into
a stew-pan, cover Avell and alloAV it to simmer on the
back of the stove for four hours or place it into a fire-
less cooker over night; then strain it through a hairsieve
bringing it up to one quart by the addition of boiled
Avater. Before feeding it is thickened by crumbling up
some dry toast in it, This is a very healthful dish not
only for babies but also for young children.
The baby is fed thus until it is nine months old, and
its daily dietary would be like this:
132 NURSING IN DISEASES OF CHILDREN
6 A.M. breast or bottle.
9 a.m. two teaspoonfuls to one tablespoonful
of orange juice.
10 A.M. farina pap.
2 p.m. vegetable soup.
5 p.m. orange juice.
6 p.m. breast or bottle.
10 p.m. breast or bottle.
A few ounces of water are to be given between meals.
At nine months a breast baby should be weaned. This
is best for both mother and infant. A healthy baby
may be weaned to plain cow's milk, in weaker ones it
will be advisable to put them on modified milk; bottle
babies may be kept for some time longer on the modi-
fication on which they have been thriving.
It is not ahvays an easy matter to wean a nursing
baby and in many of my cases have I called upon the
assistance of a nurse for this purpose alone. It is much
easier to succeed when we can keep the mother out of
the sight of the baby for a few days until it has forgot-
ten; frequently I have sent the mother away on a visit.
During the second year of life milk is still one of the
most important parts of the child's diet, but it should
not be used to the exclusion of other foods; nor must we
give too much of it. I have found that one pint of
cow's milk daily is plenty for a child at this age and in
special cases, in which I thought this advisable, young
children got along very nicely on one-half pint only.
We are liable to overlook the fact that coav's milk is,
after all, a baby food the same as mother's milk and
therefore not intended for older organisms.
Another fact Avhich Ave are liable to forget, is that
nature intended the baby's teeth for use and not for
ornament, and this should also be a guidance to us in
the choice of food for a child in the second year. It
FEEDING OF CHILDREN
133
should be given harder articles of diet such as dry toast,
graham wafers, zwieback, Holland rusks, and similar
things. It should also have vegetables in the form of
purees, especially spinach, lettuce, carrots and potatoes.
We may give it steAvcd fruits, of Avhich prune pulp is
one of the best, also raAV grated apples. Strained ce-
reals and well cooked rice, but not thickly covered with
sugar, and Avith milk instead of cream.
My opinion as to eggs for young children has under-
gone a change Avithin the last feAv years. I haA^e seen
so many cases in Avhich I Avas convinced that eggs were
not adAdsable that I have almost entirely given up their
use as an article of diet during the first two years of
life, and adAdse their addition sparingly even after this
age. In my opinion eggs are overestimated as an ar-
ticle of diet, and they are also very expensive, espe-
cially the newly laid kind, the only ones which are fit
for use.
Broth I have also given up in the feeding of young
children. It is essentially a solution of salt, its nour-
ishing qualities are infinitesimal—three pints of broth
contain no more nourishment than one small cup of
milk or one egg. Beef tea is a stimulant and, therefore,
belongs in the same class with tea, coffee and alcohol,
Avhich may be used medicinally upon the physician's
orders for a limited time but should not be given regu-
larly to children.
Meat I also give only rarely during the first two years
of life.
BetAveen the ages of tAvelve and fifteen months, some-
times a little later in Aveakly children, they should get
accustomed to be satisfied with four meals daily, after
the eighteenth month Ave feed them only three times
daily, giving the heaviest meal? containing one-half of
134 NURSING IN DISEASES OF CHILDREN
their daily alloAvance at noon and one-quarter of their
daily alloAvance each at breakfast and supper.
I have seen a good many young children Avho were
brought to me for advice because the mothers thought
they had no appetite. Upon changing their feeding by
reducing it from five meals to three meals daily their
appetite returned and they did Avell again.
A food Avhich has lately come into more general use,
though it has been one of the principal articles of diet
of many Chinese and Japanese for centuries,, is the soy
bean. They contain a large amount, forty-four per
cent, of proteins, tAventy per cent of fat and ten per cent
of sugar, but no starch. I have used them extensively
for some years iioav AAdth very gratifying results. They
may be cooked like ordinary beans or as soup, or one
of the prepared flours may be used in many different
Avays.
The nurse should remember the feAv general rules for
the feeding of young children Avhich I shall iioav give:
1. The proteins in the food are used for groAvth and
for the substitution of the body substance which has
been used up. The child requires not more than ten per
cent of its daily alloAvance in the form of proteins, one-
half of this should be furnished as animal proteins, the
other Avill be supplied in the cereals and vegetables.
2. The carbohydrates Avhich are used up for heat and
energy are the most essential part of the food of the
young child.
3. The fat is used for heat and protection and also is
stored up in the body for future use in times of need
such as long continued illness.
4. The proportion of carbohydrates to fat in the food
should be about six to seven parts of the former by
weight to one part of the latter; this would be in cal-
FEEDING OF CHILDREN
135
ories about twice as many calories from carbohydrates
as from fat.
5. The caloric needs of the child are determined by
its age and weight; the younger the child the more cal-
ories does it require for each pound of weight daily,
about forty calories after the completion of the first year
of life and from twenty-five to thirty calories when it
is two years old.
6. The general condition of the child and its constitu-
tional differences are also of importance in determining
its caloric requirements. Some children do better on
larger amounts of food, others again on small amounts.
7. The keynote in the successful feeding of children
is individualizing; Ave can not feed children according
to any hard and fast rules.
If you will adhere to these rules you will succeed in
a goodly number of cases.
THE FEEDING OF OLDER CHILDREN
With the completion of the second year of life the
main difficulties accruing from the digestive organs are
usually surmounted.
The child may iioav more and more partake of the fare
of the family table with the exception of all dishes
which are highly seasoned.
It may hoav have an occasional egg or a little meat
once a day, but its principal food should still be made
up of cereals, vegetables and fruits.
The cereals need iioav no longer be strained but may
be served Avith the hulls.
Of the vegetables the coarser kinds such as the dif-
ferent members of the cabbage family may be added to
the dietary.
Of the fruits, all those with pits, and the berries, af
136 NURSING IN DISEASES OF CHILDREN
first Avith their seeds strained out may be enjoyed.
StraAA'berries I do not alloAV children to have until they
are six years old on account of the hooked spicules
Avhich may irritate the intestinal mucosa.
The caloric needs of the child Avill gradually come
closer to those of the adult and the nurse should ac-
quaint herself Avith the caloric values of the foods mostly
used so that she can tell if the child's demands are met.
In order to make this easier for you I have made out
a list of some of the commoner foods AAdth their caloric
values, telling Avhich part of the calories is made up of
the proteins, AAdiich of the carbohydrates and also the
fat. The single portions represented in this list are
approximately one hundred calories and I have rounded
them off for the sake of convenience, but they are still
sufficiently accurate for your use.
Whole milk ................. 5 oz.
Skim milk .................. 10 oz.
Cream ...................... 2 oz.
Buttermilk .................. 10 oz.
Whey ....................... 13 oz.
Curds ....................... 2 oz.
Skim milk cheese............. 1% oz.
Cream cheese................ % oz.
Butter ...................... }i> 0z-
01iA?e oil .................... y2 oz.
Egg ........................ one large
Scrambled eggs .............. It 6 oz.
Meat broth.................. 3 pints
Boiled beef ................. 1% oz.
Roast beef or chop........... 1\(2 oz.
Roast pork.................. % oz.
Roast lamb.................. 1% oz.
Roast veal or chicken......... 2 oz.
Boiled chicken ............... 2 oz.
Carbo-
'rotein Fat hydrates
20 50 30
40 10 50
10 SO 10
40 10 50
10 10 S(i
25 70 5
75 25 —
30 70 —
— 100 —
— 100 —
30 70 —
25 75 —
30 70 ■—
40 60 —
05 35 —
20 80 —
50 50 —■
70 30 —■
75 25 —
FEEDING OF CHILDREN
137
FOOD
AMOUNT
Protein
Boiled fish .................. 3 oz. 90
Salted fish .................. 1% oz. 30
Smoked fish ................. IV, oz. 50
Ham....................... % oz. 25
Lean bacon ................. % oz. 10
Potato .................. one medium 5
Bread ...................... one slice 15
Zwieback ................... one 10
Cocoa................ three teaspoonfuls 15
Cooked cereal ............... one cup 10
Rice boiled in water.......... 12 oz. 10
Rice boiled in milk........... 4 oz. 10
Farina boiled in water........ 9 oz. 10
Farina boiled in milk........ ."> oz. 15
Pea or bean soup.......... one-half cup 30
Thick pea soup or white beans. 14 cup 25
Green peas .................. 4i/> oz. 25
String beans ................ 9 oz. 20
Spinach ..................... 7 oz. 30
Cabbn-e .................... 12 oz. 10
Purple cabbage .............. 12 oz. 30
Cauliflower .................. 12 oz. 30
Brussels sprouts ............. s oz. 35
Carrots ..................... 10 oz. 10
Turnips ..................... 8 oz. 10
Oyster plant ................ <• oz. 5
Asparagus .................. 1S oz. 40
Tomatoes ................... 18 oz. 15
Cucumber.................... 24 oz. 30
Radishes .................... IS oz. 20
Rhubarb .................... 18 oz. 10
Chestnuts ................... % oz. 10
Banana ..................... one large 5
Grapes ..................... 4 oz. 5
Cherries .................... 6 oz. 10
Apple, pear, orange.......... one large 5
Dried fruit ............... four prunes 5
Sugar ............... two tablespoonfuls —
Carbo-
Fat hvdrates
10 —
70 —
50 —
75 —
90 —
15 s0
5 80
5 85
30 55
15 75
15 75
20 70
20 70
20 65
15 55
20 55
— 75
— SO
40 30
55 35
10 60
10 60
10 55
5 S5
10 80
5 90
5 55
5 80
10 60
10 70
20 70
10 80
5 90
— 95
— 90
— 95
— 95
— 100
138 NURSING IN DISEASES OF CHILDREN
Milk Avill not be found so prominent in the child's
menu, nor is it so necessary at this stage. Frequently
children will refuse it altogether when they are four or
five years old, because they are tired of it. If the child
should still be Avilling to take it then it should be served
Avith the breakfast and the supper, but not Avith dinner.
It is better, when children are likely to drink rapidly
from glass or cup, to have it eaten Avith a spoon, that is
to serve it Avith the cereal or Avith bread.
A very good beverage for children and one which they
like as a rule is cocoa.
We must also see at this age that the child drinks
enough, but not too much, water. Many a child is con-
stipated because it does not get enough Avater and some
cases of constipation respond very nicely to a glass of
fresh Avater taken upon arising in the morning.
After dinner a long nap should still be insisted upon
and will help the active child and save its nervous
system.
Digestive disturbances of older children are fre-
quently due to overeating, especially on holidays and at
children's parties, and then especially the sweets and
candies are to blame. The best treatment for these
simple gastric disturbances is a full dose of castor oil
and tAvo or three days of a diet restricted to gruels
Avithout milk. Should the gastric trouble be accom-
panied by fever, then the physician must be consulted.
You must take care that the child's menu sIioavs suf-
ficient variety as even the best and most Avholesome food
Avill become tiresome and be refused if it is served too
often. Think of the man Avho bet that he could eat
quail thirty days in succession and avIio—lost his bet.
Most children will sIioav an aversion against some
food, frequently some vegetable or other, though some
FEEDING OF CHILDREN
139
children do not like vegetables of any kind because they
have not been brought up rightly. But Avhere they show
an aversion to only a few of these you should find out,
if this is simply in imitation of some older member of
the family or due to some notion; or if it might not be
due to the fact that the child knoAVs either instinctively
or from experience that this particular food does not
agree Avith it.
Within the last few years very interesting studies
have been made Avhich shoAv that certain people are very
susceptible to some of the food proteins which act upon
them as a poison.
You may have seen or at least heard of the, luckily
rare, cases AAdiere coav's milk AAdll produce anaphylactic
shock in even minute quantities. Other cases are simi-
larly affected by the egg proteins and still others by the
proteins of all kinds of vegetables, meats, fruits and
CA^en cereals.
These persons react to the intradermic administration
of even infinitesimal quantities of these proteins in a
similar way as a tuberculous person will react to the
von Pirquet skin test. It has been found out that such
persons may sIioav different kinds of symptoms after
they haA^e partaken of foods containing the particular
protein to Avhich they are sensitive. Whenever you meet
Avith a case in Avhich you suspect this you should call
the physician's attention to this at once.
Quiz
What is colostrum?
When does the milk appear?
What is the composition of mother's milk and its caloric value?
Why is mother's milk best for the baby?
Why do mothers object to nursing?
When must a mother not nurse her baby?
140 NURSING IN DISEASES OF CHILDREN
Should the nurse decide if a mother may nurse her baby?
How often should a baby nurse and at what intervals?
What is the first need after birth, of both mother and baby?
What happens when Ave feed a baby too often?
How should a mother nurse her baby in bed?
How should a mother nurse her baby sitting up?
What is the areola?
What difficulties may the baby offer to nursing?
How do we overcome the difficulties a baby offers to nursing?
How are the breasts cared for?
What causes cracked nipples?
How should you bandage the breasts?
What would you do for caked breasts?
How many minutes should a baby nurse?
How much breast milk does a baby require?
What may a nursing mother eat?
Hoav do we find out how much a baby gets at the breast?
How do we examine the quality of the mother's milk?
What do Ave understand by combined feeding?
How can a working woman nurse her baby?
How can twins be nursed?
What can we do for a mother who has not enough milk?
What is the composition of cow's milk?
What is the difference between mother's milk and cow's milk?
Why do mother's milk and cow's milk differ?
Should you use Jersey milk in infant feeding?
Why do we boil milk and how long?
Is pasteurized milk good for babies?
How should cow's milk for babies be gained?
Which is the most dangerous element in cow's milk?
Is the protein in cow's milk harmful for the baby?
Is it sufficient to make cow's milk chemically like mother's milk
to have the baby thrive?
Why is skim milk safer for babies?
How can you skim the milk?
Are patented and proprietary foods good for babies?
What is the difference between condensed and evaporated milk?
Are milk preserves good for babies?
Which are the best nursing bottles and nipples?
How should you take care of the bottles and nipples?
How many bottles should you have?
FEEDING OF CHILDREN
141
How should you keep the bottles when prepared?
What should you observe when a baby is vomiting?
Can we have a formula for feeding babies?
When should we give a baby other food and why?
When may orange juice be given to a baby?
When should a baby be weaned?
How much milk should a baby get during its second year?
What may be given to a child eighteen months old ?
Are eggs good for young children?
Is broth good for children?
How often should a child fourteen months old and one nineteen
months old be fed?
What are the general rules for feeding young children?
What would you give a child four years old to eat?
Should a child drink water?
What is meant by food idiosyncrasy?
CHAPTER V
THE DISTURBANCES OF NUTRITION IN
INFANTS
We iioav come to the disturbances of nutrition in in-
fants, or, as avc Avould have called them only a feAv years
ago, the gastrointestinal diseases of infancy.
This has ahvays appeared to be a most complex sub-
ject, but since Ave haA^e learned that in these disorders
disturbances of assimilation play the principal role, Ave
have been able to simplify this seeming chaos of path-
ologic conditions, and, in classifying them under differ-
ent heads, to make them easier understood.
In using the term "disturbances of nutrition" Ave ex-
press clearly that Ave consider these conditions iioav to
be due to abnormal digestion Avhich affects the Avhole
organism of the child. At the same time it reminds us
of the fact that the nutrition of the child is of para-
mount importance. We do not, hoAvever, claim that
metabolism must be the primary cause of these dis-
orders, knowing, as Ave do, that it may not be the cause
at all but only a secondary condition.
All attempts to refer these conditions to anatomical
changes in the gastrointestinal canal, or to arrange them
according to our bacteriologic findings, have failed
signally and Ave have iioav, at last, succeeded in classi-
fying them Avithout being obliged to strain our imagina-
tion.
While they may be found occasionally in breast babies
142
DISTURBANCES OF NUTRITION IN INFANTS 143
they comprise mostly those infants Avho have not had
this advantage or for too short a time.
The folloAving classification seems to me to be the best:
I. Children With a Normal Disposition
A. Due to Feeding
1. Simple overfeeding and its consequences.
2. Simple underfeeding and its consequences.
3. One-sided feeding too long continued.
a. With cream.
b. With carbohydrates.
B. Due to Infection
1. Infection of the gastrointestinal canal.
2. Parenteral infection.
a. With normal appetite and consequent relative
overfeeding.
b. With diminished appetite.
C. Due to Heat
1. Direct effect and consequent damage to entire or-
ganism.
2. Indirect effect; relative overfeeding due to dimin-
ished digestion.
II. Children With an Abnormal Disposition
A. Abnormal Constitution
B. Abnormal Formation of the Body
1. Malformations of single organs.
2. Disturbances of the development of the entire body.
Let us first understand Avhat is meant by children Avith
a normal or abnormal disposition.
144 NURSING IN DISEASES OF CHILDREN
Under children Avith a normal disposition we class
those children who Avere born perfectly healthy and Avho
come from healthy stock, but Avhose poAvers of assimi-
lation have been weakened by one of the three causes
mentioned above, either through faulty feeding, or
through infections, or finally through atmospheric con-
ditions.
Children with an abnormal disposition are of two
kinds. They may either be handicapped by constitu-
tional Aveakness such as premature children or children
born from syphilitic or tuberculous parents. Or they
may suffer from some malformations of single organs
only, such as hairlip, cleft palate, partial or total occlu-
sion of some part of the digestive tract, etc., or finally
they may be suffering from disturbance of the develop-
ment of the whole body, they may be excessively large
or small, or the secretions of some of their endocrine
glands may be defective or lacking.
We Avill iioav assume that a perfectly healthy baby
that is getting in the bottle a food Avhich agrees with it,
and which has hitherto been gaining steadih, sud-
denly fails to gain in weight and that its weight remains
stationary. We figure Avhat he is getting and find that
his daily ration does no longer come up to forty-five
calories per pound owing to the fact that he has gained
considerably since his food Avas last changed. We know
from his age, Aveight and behavior that he can readily
take about one-half ounce more in his bottle, and our
reasoning is shoAvn to have been right by the normal
reaction of the baby to this increase in food, he im-
mediately starts to gain again and his stools and tem-
perature remain normal as they Avere before. (Fig. 40,
Chart A).
Noav let us assume that we have another baby of the
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Fig. 40.—The disturbances in nutrition in infants.
146 NURSING IN DISEASES OF CHILDREN
same age and weight, Avhose stools are not good, but are
sometimes a little more frequent and of changing qual-
ity, shoAving that his food is not exactly right for him.
The infant is pale and restless; its abdomen will be
found to be slightly distended Avith gas; nature may
try to mend matters by occasional spitting up ol the
food, the daily excursions of his temperature are a little
larger than normal, though Ave can not call it fever and
his weight is variable, he gains one day to loose this or
even a little more the next. You fully realize that he
is not doing well but upon the urgent demand of the
anxious mother or the grandmother Avho is sure you are
starving the baby anyhow, you increase his food one-
half ounce to each feeding but Avithout result. This
baby is no longer healthy, its nutrition is disturbed,
though only slightly, the balance betAveen the baby and
its food is no longer right, because the assimilation of
the food demands so much Avork from the baby's system
that nothing is left for a gain. This is the lightest form
of digestive disturbance, which has been called "dis-
turbance of balance," to indicate its cause. If you
recognize this in time and call in the physician he will
change the food and reduce its quantity, and lo and be-
hold, the baby's stools get better at once, his tempera-
ture shows no more than the normal excursions and it
begins to gain again. (Fig. 40, Chart B).
Let us assume, however, that the mother Avill not
listen to your request to have the physician called, but
that she listens to the advice of her mother, or of some
neighbor who knoAvs that all that is the matter Avith the
baby is that it is starved, that the food is all right but
that the poor baby never Avas given enough under your
foolish four-hour feeding; "av1io ever heard of letting a
poor baby go for so long Avithout food and then to top
D1STUWUAXCKS OF NUTRITION TN INFANTS 147
it all Avill not give anything at night? We know better
than the doctor Avith his neAvfangled notions, Ave have
had babies of our oavii and avc knoAV all about their
bringing up." They tell you to feed the baby every
Iavo hours and tAvice during the night.
If you are a good nurse and know about these things
you AAdll resign from this case at once; if you are Aveak
you Avill do as told by the family and Avhat is sure to
happen is this: The baby will be quite restless, its sleep
will be disturbed; it -will lose its appetite; its abdomen
Avill be distended Avith gas Avhich comes up at frequent
intervals, it is colicky; its stools also get really bad and
at times diarrheic; the temperature goes up to the verge
of fever, and the Aveight is still variable, the gain of one
day being replaced by the loss of the next.
We noAV have the second stage of nutritional disturb-
ance, a true "dyspepsia." (Fig. 40, Chart C.)
The only remedy is to reduce the amount and the
strength of the food Avhich Avill help in some of the
lighter cases. In the severer ones the food has to be
changed entirely as Avell as reduced in amount, and even
then it will take the infant some time to recoArer from
this illness Avhich, though the principal symptoms are
from the gastrointestinal tract, affects the whole system
as is evidenced by the temperature.
Should this condition still be overlooked, or rather
misunderstood, and should the feeding be still further
increased, then Ave may observe one of tAvo things.
A sudden catastrophe will set in. The child Avill be-
come unconscious, though the mother thinks it is only
tired out and sleepy, Ave can see by the faraAvay look in
its sunken eyes that this is not so; the temperature
takes a sudden jump; the respiration is of a peculiar
character and labored; the urine contains considerable
148 NURSING in DISEASES of children
amounts of albumin; the baby may vomit profusely, this
hoAvever, is not a constant symptom, nor is the profuse
diarrhea Avhich Ave frequently observe at this stage.
From these tAvo last-named symptoms the disease ac-
quired the name of "cholera infantum" or "summer
complaint" because it Avas considered to be more fre-
quent in very hot Aveather; let me assure you, however,
that I see it quite as frequently in Avinter. We iioav call
it "alimentary intoxication," Avhich is a much better
name because it tells us that the food is iioav acting as a
poison and this is also sIioavii in the fact that the ad-
ministration of food makes the baby Avorse. (Fig. 40,
Chart D.)
With, and on account of, the foregoing symptoms the
baby will lose weight suddenly and rapidly, a pound in
tAventy-four hours being nothing unusual; this is due to
increase in the loss of Avater through diarrhea, vomiting,
and the labored respiration. This makes the baby sud-
denly look extremely ill; its eyes are sunken and sur-
rounded by a black ring; its skin is dry, hot and flabby;
it is bluish from the poor circulation; altogether a piti-
ful picture, Avhich is at the same time most ominous.
In other cases Ave do not observe these sudden dis-
astrous changes, but the picture is a more chronic one,
perhaps because the child possesses more natural resis-
tance—let me tell you here that it is truly Avonderful
how much a little baby can oftentimes stand—and does
not succumb so easily. Here Ave observe an entirely
different picture. The baby is extremely thin, nothing
but skin and bones, Avith the face of a very old person;
the mouth is dry and red, and it is mostly open because
the poor infant is dried out and, therefore, extremely
thirsty; the abdomen is much enlarged and distended
with gas; the baby is very restless and sleeps very little;
DISTURBANCES OF NUTRITION IN INFANTS 149
on its skin Ave often find infections in the form of fur-
uncles or abscesses, and intertrigo, soreness around the
anus and buttocks. (Fig. 40, Chart E.)
This is the condition which Ave used to call "maras-
mus" or "atrophy." Noav Ave call it more aptly "de-
composition" to indicate that the child has to live upon
its oavii body substance and must decompose its store
of fat, sugar and even muscular tissue in order to live.
An interesting phenomenon in these cases is the way
in Avhich the little patient reacts to an increase in its
food, be this quantitatively or qualitatively, instead of
the normal reaction of a healthy baby Avhich Avould
sIioav a gain in Aveight, Ave iioav observe a loss of Aveight
folloAAdng this increase, the so-called "paradox reac-
tion."
In Avarning young mothers against overfeeding their
babies Ave frightened some of them into making the op-
posite mistake namely of starving them. This Ave ob-
serve mostly in mothers A\dio have read a great many
books on children and on infant feeding. I have, there-
fore, observed this condition most frequently in the ba-
bies of former nurses and of college graduates. Pro-
vided that the baby is at the breast or that it is get-
ting a sensible food at the right intervals, and that this
underfeeding has not been taking place for too long a
time, so that the baby's organism has really suffered
from it, then it is not dangerous. The baby will be thin,
but not emaciated; its skin will be less elastic than
normal; its abdomen Avill be found caAred in; its stools
are rare and broAvn in color, a so-called starvation stool;
its Aveight is stationary.
Upon proceeding to feed such a baby it -will promptly
react by the disappearance of all these symptoms and
by a steady gain in Aveight. (Fig. 41.)
150 NURSING IN DISEASES OF CHILDREN
Should a baby be Aveakened by this underfeeding,
and still more if its health should have been undermined
by an intercurrent infection, then it may not be able to
assimilate the food Avhen it is finally offered to it and
Fig. 41.—Chart of underfed baby.
it may die from starvation. But, let me tell you, these
cases are quite rare.
We have seen that the quality as Avell as the quan-
tity of the food will cause disturbances and it therefore
DISTURBANCES OF NUTRITION IN INFANTS 151
behooves us hoav to investigate if Ave can tell Avhich one
of the elements of the food is responsible in a given case.
Up to recent times the protein Avas considered the one
component of the milk Avhich Avas usually at the bottom
of all digestive disturbances in bottle babies, most likely
because the large amount of it in coav's milk in com-
parison to mother's milk Was so evident, but, Ave have
learned that the proteins may be given in even larger
amounts than those in cow's milk Avithout doing any
harm, and Ave haA-e learned to look upon this element of
the food as one Avith Avhich Ave need not be particularly
careful.
Everything, even Avater, Avhen given in excess is harm-
ful and you must, therefore, not think that you can Avith
safety proceed to give as much of the proteins as you
want. You should know that a preponderance of albu-
minous material in the food causes an alkaline reaction
of the stool on account of the putrefaction going on in
the intestine during the destruction of the surplus pro-
teins.
The carbohydrates cause a fermentation in the in-
testine and the stools give an acid reaction Avhen they
prevail in the food.
Babies A\dio haA-e been overfed with carbohydrates for
any length of time, as, for instance, those brought up
on any one of the majority of patented and proprietary
foods, Avill look rather well and stout, but upon closer
examination Ave can convince ourselves that they are not
solid and firm, as the healthy baby should be, that on
the contrary they are soft and flabby. This is because
they are Avaterlogged, Avhich means that they look stout
because the large amounts of carbohydrates in their
food cause an abnormal retention of Avater in their sys-
tem. Let their power of assimilating these large
152 NURSING IN DISEASES OF CHILDREN
amounts of carbohydrates break doAvn suddenly, as hap-
pens so often, and their aveight will take a correspond-
ingly sudden drop; the more so as the loose brown
stools which these children void as a rule will become
diarrheic quite readily.
Let me tell you that the pictures Avhich you find in
the booklets sent out by some of the manufacturers of
these foods with high percentages of carbohydrates are
not those of healthy infants; they may look stout
enough, but if you had a chance to see these babies and
look them over carefully you Avould find them big on
account of the Avater retained in their bodies and you
Avould find furthermore that their skin is not a healthy
pink but rather pale and A\dth blemishes due to the
frequent infections from Avhich these babies suffer, and
last, but not least, that they usually have rickets, of
Avhich Ave Avill speak later.
Quite different again is the condition of the babies
Avho receive too much cream in their food.
They are also pale and flabby, but besides this they
are less lively, their sleep is disturbed, their abdomen
distended with gas, their Aveight remains stationary or
their chart shoAvs a steady loss in Aveight; let us increase
their food Avithout changing its quality and they will
present the paradox reaction of Avhich I have spoken be-
fore. Their stools Avill contain large amounts of fat, in
the form of fatty soaps, as much as fifty per cent at
times, and they Avill then be rather hard, dry, yellowish
gray lumps Avhich frequently roll out of the napkin
when you change the baby.
If these babies, Avho are suffering from one-sided over-
feeding, are not taken in hand by the physician in good
time, then those overfed Avith carbohydrates may de-
velop alimentary intoxication at any moment, those
DISTURBANCES OF NUTRITION IN INFANTS 153
overfed Avith fat are the ones Avho Avill frequently pre-
sent the picture of decomposition.
I trust that I have succeeded in the foregoing sketches
in making it clear to you Iioav grave a problem the feed-
ing of babies presents even to the physician.
So far we haA'e been folloAving cases in Avhich the feed-
ing and the metabolism were at fault.
We iioav come to those infants in Avhom the invasion
of the system by bacteria is the primary cause of their
nutritional disturbace.
First Ave Avill speak of those relatively feAV case^ ni
Avhich the bacteria get into the gastrointestinal tract and
here cause an infection of the mucous membranes.
Formerly Ave thought and taught that this Avas of fre-
quent occurrence, but of late Ave have learned that most
of those cases in Avhich Ave blamed the bacteria in spoiled
food or poor milk are due to a Avrong composition of
the food.
Still Ave do see these cases occasionally and the pus
and shreds of mucous membrane in the diarrheic stools
Avill tell the story. Sometimes Ave observe these infec-
tions in the neAvborn, even before food has been gwen,
and then they may be due to the SAvalloAving of infec-
tious amniotic fluid.
Much more frequent and, therefore, of much greater
importance are the cases in which the infection takes
hold in some other part of the body, outside the intes-
tine, and Ave then call them "parenteral."
EA'ery form of infection, no matter in Avhich part of
the body, Avhich makes the child ill Avill exert an unfa-
vorable influence upon the general condition of the body.
Ts it to be wondered at, then, that in infants, in Avhom
nutrition and groAvth are of the utmost importance, even
slight infections Avhich would not distress the older or-
154 NURSING IN DISEASES OF CHILDREN
ganism may be and usually will be a serious matter on
account of the disturbance of nutrition caused by it?
Take, for instance, a slight coryza, which in us would
mean an inconvenience at most, and Avatch its effect
upon the child's metabolism as shown in its chart.
(Fig. 39.)
The first thing Avhich Ave will notice in a case of this
kind will be that the little patient will no longer be
able to digest the same proper amount of a perfectly
suitable food given at the right intervals, not even its
mother's milk, after it has been thriving on this nicely
before. If Ave persist in the same amount and quality of
feeding it Avill soon show the signs of overfeeding or a
dyspepsia.
The baby is feverish from the original infection and
therefore thirsty. Should Ave neglect nature's warning
and quench this thirst with food instead of Avater, then
Ave Avill surely increase the overfeeding and thus make
our little patient Avorse, because Avhere Ave had only rela-
tive overfeeding before from the proper amount of food,
avc will iioav cause positive overfeeding from the exces-
sive quantity of food we are giving.
Let me tell you that in this Avay a good many cases
of dyspepsia in babies find their origin.
Fortunately kind Nature frequently helps us in this
and saves the baby's health by taking aAvay its appetite
and making it refuse all food; Avould you then try to
improve upon Nature.
Only Avhen the infection is of a severe degree and
long continued shall we have to insist upon feeding the
baby and this is then an extremely difficult matter, even
for the physician.
We come now to those disturbances of nutrition which
DISTURBANCES OF NUTRITION IN INFANTS 155
arc due to heat and of these Ave shall first contemplate
the direct effects of heat.
In the densely populated districts of our large cities,
AA-here little air can pass through the canons betAveen
houses, Avhere parks and similar breathing spots are few
and far between; Avhere the fire escape is often the only
means of getting relief; and Avhere, OAving to the
croAvded conditions, and to poverty, the baby spends its
days and nights in the same single room in Avhich the
cooking and Avashing is done, Avhich serves as living
room, Avorkshop and bedroom at the same time, here it
is Avhere Ave will most frequently meet Avith the direct
effect of the high temperatures of the summer months.
This will cause the picture of true sunstroke. The
baby has xevy high fever, it is in coma and suffers from
collapse, it refuses all food, even the much needed Avater,
and if aid is not forthcoming soon it will often die
suddenly.
Quite different from this picture is that of the indirect
effect of heat.
The baby is able to regulate the temperature of its
body eA-en in considerable climatic temperatures, so that
it can maintain its body at the physiologic leA^el. Still
Ave must acknowledge that the extreme summer heat
preArailing at times Avithout any relief at night, espe-
cially Avhen the atmosphere is at the same time sur-
charged Avith moisture, Avill and does influence the di-
gestion of the infant.
Should the baby continue iioav to have a good ap-
petite then it Avill quite readily suffer from the bad ef-
fects of relative overfeeding if Ave persist in giving it
the food in the same strength in Avhich Ave ha\re been
giving it. The baby is naturally quite thirsty from the
loss of water through its skin' and its respirations, by
156 NURSING IN DISEASES OF CHILDREN
which means it is able to stand the heat; should Ave now
make the graA'e mistake of quenching its thirst with
food then Ave Avill make it Avorse because we Avill sub-
stitute positive overfeeding for the relative overfeeding
Avhich injured its nutrition before.
We must not, hoAvever, forget that injudicious cloth-
ing Avhich is practised upon the baby, not only by ig-
norant foreigners, is a contributory cause, as is bad
housing.
I have taught for years that during the hot summer
days the baby should be out on the shady porch or in
the park or some other relathTely cool place as much of
the tAventy-four hours as possible and that all it should
then Avear is a gauze shirt, diaper and a smile, the latter
coming of itself because the baby feels comfortable.
The poor quality of the milk Avhich is liable to con-
tain many more bacteria at this season may be to blame
to some extent, but its importance is not as great as we
used to think.
Undoubtedly these disturbances of nutrition caused
by the effect of heat have something to do Avith the
increase in the mortality among infants in summer; but
Ave must not forget that the babies Avho suffer the most
are those who haAre entered this season Avith an impaired
digestion.
We also know that there is a parallel increase in the
mortality among infants during the winter months due
to poor hygienic conditions, lack of fresh air and fre-
quent infections Avith the so-called "colds" of A\rhich
Ave Avill speak later.
Up to a comparatively short time ago avc thought that
all we had to do in order to be successful in feeding
infants Avas to find the right food for any baby, give it
DISTURBANCES OF NUTRITION IN INFANTS 157
this in the right amounts and at the proper intervals
and the result Avould be good health in the baby.
Of late years Ave have learned, hoAvever, that the feed-
ing of infants is not quite so simple a matter. Not only
have Ave got to find the right food but Ave must also find
out Avhat kind of a baby Ave have to deal Avith, that Ave
are up against that bugbear of algebra the equation
Avith tAvo unknown, the Avrestling Avith Avhich you -will
undoubtedly remember from your high school days.
This is Avhat I mean when I speak of disturbances of
digestion due to an abnormal constitution.
No matter hoAV Avell a baby may look at birth, Ave will
never be able to tell hoAV it Avill thrive, even on breast
milk, and this is due to certain abnormalities of con-
stitution, some of Avhich may be inherited, others ac-
quired.
Of the former Ave haA^e the transmission of an infec-
tion such as syphilis, or the peculiar Aveakness fre-
quently found in the offspring of tuberculous parents;
also a condition predisposing to SAvelling of the lym-
phatic apparatus and to eczema; and many more.
Such as are acquired may be due to poor hygiene, or
to faulty feeding, like, for instance, the case of a baby
tAvo Aveeks old Avho has been given a food containing
large amounts of cream from the day of its birth Avith
the result that its poAver for the assimilation of fat was
so weakened for many months that I had to bring him
up on an almost fat-free food. (Fig. 42.)
Coming iioav to the malformations of single organs, I
need only mention to you the difficulties Avhich you will
haAre Avith infants Avith a cleft palate in whom the food
will return through the nose; or those in whom nature
failed in making the anus meet the lower end of the
rectum; the infants Avith extrophy of the bladder and
15S
NURSING IN DISEASES OF CHILDREN
those with spina bifida, who are so easily infected; and
many more.
Finally the disturbances in the development of the
Avhole body may be due to some arrest of groAvth at a
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Fig. 42.—Chart of intolerance for cream.
more or less early stage of fetal life, or to an over-
secretion or to insufficient secretion of some one or
several of the glands Avith internal secretions such as
the thvroid.
DISTURBANCES OF NUTRITION IN INFANTS 159
Quiz
What do Ave mean by disturbance of nutrition?
What do we understand by the disposition of a child?
What is the normal reaction to an increase in food of a baby?
What is disturbance of balance?
What is dyspepsia in a baby?
What is alimentary intoxication?
What is decomposition in a baby?
What do we understand by paradox reaction S
What do we understand by underfeeding?
What is the result of carbohydrate overfeeding?
What are the results of overfeeding with fat?
Is intestinal infection in babies frequent?
What is meant by parenteral infection?
What is the effect of heat upon the baby?
What should you do during very hot weather?
What do Ave mean by abnormal constitution?
CHAPTER VI
DISEASES CAUSED BY ABNORMAL
METABOLISM
Babies and young children suffer by no means rarely
from diseases Avhich are due to abnormal metabolism
and Avhich are, therefore, also due to a large extent to
the mode of feeding. Of these Ave Avill first take up
rachitis.
Rachitis or, as it is also called, rickets, is a disease
Avhich is not only found in bottle babies, as most of the
textbooks Avill tell you, but Ave observe it quite fre-
quently in breast babies.
It is a disease of the temperate zone, being rare in
the tropics and the frigid zone as Avell as in high moun-
tainous countries.
The disposition toAvard it is inherited, though it is
preventable and does not appear in all the children of
the same parents. I haATe often been able to find the
sure remnants of rickets in mothers avIio brought their
babies to me for this; and when they Avere accompanied
by their oavh mother I Avas able to verify this well-
founded suspicion quite readily.
In the northern states of this country rachitis is very
prevalent, especially among the negroes and Italians;
it is also found very often in the offspring of Polish
immigrants and, though less often, all through the mixed
population of this great country.
In the negro population of our large cities, espe-
cially, Ave rarely see babies who are not affected by this
160
DISEASES CAUSED BY ABNORMAL METABOLISM 161
disease, and this though they arc breast fed for longer
even than necessary. The explanation for this can
readily be found in the fad that these people Avere
transported originally from the tropics to the West
Indies and to our Southern States, Avhere they lived an
outdoor life and Avhere closed doors and avhuIoavs Avere
unknown.
The Italians in this country come mostly from the
Southern provinces and from Sicily, they Avere small
farmers and truck gardeners at home, Avhere they Avere
also living outdoors almost all the time.
Let these people come over here and let them live
herded together in croAvded tenements under the most
unsanitary conditions and you Avill understand that
their babies at least are sure to suffer from this change.
In literature you Avill be able to find many theories
regarding the origin of rachitis, Avhich are too numerous
and contradictory to give, as they Avould only tend to
confuse. From these, hoAvever, I have culled what
seemed to me to be most reasonable and I shall give you
this for Avhat it is worth, it is at least a good Avorking
hypothesis.
I hold that rachitis is a combination of poor hygiene
and bad feeding.
It is then due to ignorance or neglect or a combi-
nation of the tAvo.
Do not think that you will meet Avith rachitis only in
your Avork among the foreigners, or among the poor,
and therefore in your dispensary Avork. Many a baby
in a Avealthy family is neglected even under the, seem-
ingly, best of care, and ignorance is quite as preA^alent
among the Avell-to-do as it is among the loAvly.
The poor hygiene consists in the lack of fresh air,
especially during the Avinter months, when the AvindoAVS
162 NURSING IN DISEASES OF CHILDREN
are kept shut tightly and the poor baby is often not
taken out for an airing from fall until spring.
Have you ever been in a tenement during the Avinter ?
Have you ever had the suffocating experience of enter-
ing one of those one.-room apartments where the cook-
ing and washing Avas done, where the family slept and
ate and worked ? Have you ever looked at the baby left
to itself most of the time and bathed in its oavii dejecta1?
Do you remember that terrible stench which made you
sick and to which you thought you could never get
accustomed1?
Do you Avonder then that rickets is so prevalent?
The poor care consists in the rare changing of the
infant. Did you ever watch an Italian mother bind her
baby "to keep its limbs straight" as she will tell you,
with a band about four inches wide and long enough to
go around the room? Did you notice how long it will
take her to do this? Hoav often do you think this baby
Avill be changed during twenty-four hours?
Or, have you seen a Hungarian baby dressed and then
placed upon a feather pilloAV, Avhich most likely has
served for this purpose for generations, and then tied
up securely in this so that only the face Avas seen?
Or, have you ever called upon a Polish family and
found the mother busy at the Avash tub, with the floor
of the kitchen all wet Avith soapsuds and in midst of
this Avas the baby sitting on the Avet floor, clothed only
in a thin cotton slip, without diapers, but with a heavy
knitted cap on its head, bare-legged, but with patent-
leather shoes on its feet?
Understand me please, I am not making fun of these
poor ignorant people, I am only relating to you what
you Avill be sure to find in your daily work, after you
leave training school, and I am trying to explain to you
DISEASES CAUSED BY ABNORMAL METABOLISM 163
Avhy you meet these babies in the hospital and dis-
pensary.
But look at the reverse side of the medal; go to the
homes of the Avealthy, to the residence streets, and tu
the parks in the fashionable neighborhood, and Avatch
the pale babies in charge of some elderly practical nurse
avIio has ignorance and conceit Avritten all over her face.
If you take a look at these babies you will find that
many of them are perspiring because they are over-
dressed ; they have on a knitted jacket and a heavy coat
over their other clothes. Over their diapers they Avear
rubber draAvers so that they do not Avet the feather bed
upon AAdiich they are resting, their head is buried in a
feather pilloAv, and they are covered with a thick com-
forter, and all this Avhen the temperature is 70° above
zero; but then the nurse -will tell you that it is April
according to the calendar. If you could look into that
baby's home you would find that the baby stays in a
room the temperature of Avhich is never loAver than 70°
and that it is ahvays overdressed and therefore in a
continuous Turkish bath, so to say. Do you understand
noAv Avhat I mean Avhen I state that these babies also
are neglected?
Of course these babies perspire all the time and are
naturally Aveakened by this, and OAving to their thirst
they wall also most likely be overfed.
The other babies Avho are alloAved to lie in their dis-
integrating urine, inhale the ammonia thus formed. On
approaching one of these infants and getting a whiff of
this ammoniacal odor you Avill frequently be able to
foretell that the baby will most likely be suffering from
rachitis.
Poor hygiene and neglect are really only contributory
164 NURSING IN DISEASES OF CHILDREN
causes of this disease, Avhile the most potent factor in its
production is bad feeding.
Overfeeding, the most frequent form of bad feeding,
is to be held responsible for it.
The breast baby, Avhich is fed every tAvo hours or
every time it Avants to, is quite as much overfed as the
bottle baby Avhich gets too much food. The element of
the food AA'hich, in my opinion is to blame as the cause
of rickets is the fat.
One of two things may happen, either the food is too
rich in cream altogether, or the food contains an over-
supply of carbohydrates, and this interferes Avith the
proper digestion of the fat, as Ave haA'e seen before.
Noav, what happens? The fat Avhich can not be
digested, has to be excreted. In order to be excreted,
the fat has to be split up in the intestine into the in-
nocuous glycerin and into fatty acids. These latter can
not be excreted as such, but are transformed into a fatty
acid soap by uniting with an earthy alkali. This earthy
alkali is found in the body mostly in the form of phos-
phate of calcium in the bones. In case of need the body
Avill draw upon these deposits of phosphate of calcium
and rickets results. You wdll readily understand hoAV
this is more likely to happen in children who haArc in-
herited a predisposition toAvard this disease, and hoAV
the contributory causes Avill further this abnormal
process.
Rachitis usually appears during the second half of
the first year of life, the time Avhen the effects of bad
feeding are mostly in evidence.
The principal signs of it are in the bones Avhich are
softened by it and then may become deformed. The
pathologic condition in the bones causes considerable
pain, and rickety babies have a peculiar yelling cry.
DISEASES CAUSED BY ABNORMAL METABOLISM 165
They perspire a great deal, especially over the back of
the head, then the perspiration irritates the skin here
and they rub their head on the pilloAV Avhich produces
the characteristic baldness, or at least thinness of the
hair, over the back of the head of these little patients.
Rachitis is a disease Avhich can easily be prevented or
cured in its lighter forms by proper hygiene, care and
feeding.
In my opinion one of the most important results in our
Avork in infant welfare stations, consists in our teaching
mothers that it does not kill the baby to bring it to us
there, even in winter, and thus to teach them the ad-
vantage of fresh air.
All these severe cases of rickets, as Ave see them so
frequently on our streets are a damaging testimony of
somebody's ignorance or neglect.
That rickets can be prevented quite easily has been
shown recently by the most meritorious Avork of one of
my medical friends in New York City. He succeeded in
teaching the colored mothers inhabiting the Columbus
Hill district the value of prophylaxis and early treat-
ment and his results Avere so evident even to them that
many brought their children on their own account or on
the advice of some happy neighbor, to have their babies
made well and straight again.
Another form of disturbance of the metabolism is
infantile scurvy.
If an infant should be fed exclusively on coav's milk
Avhich has been pasteurized repeatedly, or Avhich has
been sterilized by prolonged boiling—bringing the milk
rapidly to the boiling point and then cooling it, does not
seem to have the same effect—it may develop this
disease.
The heat applied to the milk destroys certain hypo-
166 NURSING IN DISEASES OF CHILDREN
thetic substances in it to which the name "vitamines"
has been given. Tliese Adtamines are necessary for the
health of babies and they are present also in mother's
milk, and for this reason breast babies are free from
this affection.
The disease consists in hemorrhages under the peri-
osteum, in the skin and mucous membranes. The gums
are a favorite site for hemorrhages, but only around the
teeth.
Scurvy appears in babies betAveen the ages of six and
eighteen months. The baby is anemic, and it cries from
pain Avhenever it is touched or moved; it is especially
frequent in infants Avith rickets, because the deficient
hygiene in these Avill act as a contributory cause.
The vitamines are present not only in raAv milk, but
also in fruits and vegetables, and giving these to babies
early, as for instance orange juice, acts as a prophy-
lactic.
I have not seen it develop in any of the infants I have
had under my care in infant Avelfare stations, and in a
large orphan asylum, because I insist on their getting
orange juice at a very early age.
A constitutional abnormality, peculiar to infants and
young children, is a condition AAdiich we now call
spasmophilia and which shoAvs up first at about five
months of age.
It is observed in three forms.
First and most frequent of these is the so-called spasm
of the larynx, also called staying aAvay or internal con-
vulsions. The child stops breathing suddenly and then
after some seconds Avill resume breathing with a loud
crowing noise.
Second the infant may shoAv peculiar spasms in some
of its muscles, affecting at times one or more extremities,
DISEASES CAUSED BY ABNORMAL METABOLISM 167
Avhich Avill then assume peculiar positions. At the same
time its nervous system -will be in a state of irritability,
and responds to electrical irritation Avith characteristic
reactions.
Third the infant may have general convulsions with
loss of consciousness, and these may affect the Avhole
body or only a part of it.
Spasmophilia appears usually at the end of the winter
and in bottle babies AAdio are given large amounts of
coav's milk Avhich contains much cream. It is also ob-
served in overfed breast babies.
It is, in my opinion, due to a faulty calcium metabol-
ism and it is for this reason often observed in infants
suffering from rachitis.
A case of spasmophilia must never be considered as
light; a child may be attacked by spasm of the larynx
out of apparent good health, and it may die in the first
or in any one of the subsequent attacks.
You must handle these little patients with great care;
they must be saved from eArery kind of excitement and
must not be crossed.
During the general convulsions nothing is better than
absolute rest and good air, to see to this is all you
should do until the arrival of the physician.
"What usually happens however is this:
Let us say a baby Avhich has, as the mother believed,
been in good health, is taken suddenly Avith convulsions.
The first thing the frantic mother will do is to go out
on the front porch or in the back yard and shout for
help, to which the Avomen in the neighborhood respond
Avith alacrity.
If you are living in the neighborhood you will be
surely sent for, and by the time you arrive this picture
will strike your eyes: The baby is lying in the hot
168 NURSING IN DISEASES OF (-HILDREN
kitchen on the lap of Mrs. A. who strokes and rubs its
limbs; Mrs. B. insists on opening the hands because the
thumbs must not be draAvn in; Mrs. C. applies cold Avct
cloths to the little patient's head; Mrs. D. is preparing a
mustard bath; Mrs. E, a fountain syringe for an enema;
other Avomen are doing something else, eA^erybody is
very busy crowding the little kitchen Avhich is like a
steam bath.
The first thing for you to do is to get the poor baby
out of all this hubbub as quickly as possible; get rid of
all these Avell-meaning, but officious Avomen, Avho Avill
only hinder you, the mother included, take the baby into
an airy bedroom, put it into a bed to Avarm its body
which has been chilled by all the handling it has been
subjected to and quietly aAvait the arrival of the
physician.
Formerly Ave met Avith many conditions in infants and
children Avhich Ave Avere not able to explain anatomically,
but of the presence of Avhich Ave Avere aAvare by many
symptoms. Many of these Ave are iioav able to group
under what is called exudative diathesis or lymphatism.
These children are subject to enlargement of the
lymph glands and Avhen they get older they Avill fre-
quently have enlarged tonsils and adenoids. They show
very little resistance to infections; they haAre frequent
"colds," attacks of bronchitis, and by no means rarely
Avill they develop asthma. They also are subject to
eczema.
The predisposition to this constitutional disturbance
is inherited, but as it is favored by overfeeding with
animal food, it can be overcome by careful regulation
of the diet, and by hygienic living.
DISEASES CAUSED BY ABNORMAL METABOLISM 169
Quiz
What is the other name for rickets?
Is rickets frequent in breast fed babies'"
What causes rickets?
Has clothing anything to do with rickets?
Has feeding anything to do with rickets?
In what part of the body does rickets show mostly?
Can rickets be preA-ented?
What is infantile scurvy?
What is deficient in the food in infantile scurvy?
Can Ave prevent infantile scurvy, and how?
What do Ave mean by internal convulsions?
What causes convulsions?
What should you do for a baby in convulsions?
CHAPTER VII
THE EXAMINATION OF THE CHILD
In no Avay can you better fit yourself for your profes-
sion than by developing your poAvers of observation and
by training your senses in such a Avay that you Avill not
only be able to tell the normal functions and behavior
of your patients, but, that you will also be accustomed
to tell, sometimes at a glance, that everything is not
Avell Avith your charge.
If you haA'e dcA^eloped these faculties and are in the
habit of using them every second, you will be in a posi-
tion to call the physician's attention to any, eATen the
slightest change from the normal, you AAdll many times
save your patient from serious illness and from suffer-
ing. What more noble duties can be imagined?
You must also knoAV beforehand Iioav you Avill be en-
abled to help the physician in his examination of the
child, a thing not always easy, and to anticipate his
slightest moA^e and intention; thus only will he be in a
position to perfect his diagnosis.
To aid you in learning these details, and to perfect
yourself the following chapter is devoted.
After the baby is born you should look it over most
carefully, and this is best done during its first bath.
Do not be afraid of ridicule but call the physician's
attention to every detail, no matter hoAV slight, Avhich
does seem to you to vary from the normal. He is the
one to decide if it is of any importance or not.
Your inspection .should cover the entire body, front
as Avell as back.
170
EXAMINATION OF THE CHILD
171
You should note any abnormalities of the skin, if
there are any blemishes, marks or scars.
Are the normal openings of the body present or has
the infant an imperforated anus, or a deformity of the
eyes, the ears, the nose, mouth, or has it a cleft palate?
Note any abnormal sAvellings, not only those caused
by the birth, but also those it might have brought into
the Avorld.
Pay attention to the size, position and shape of the
extremities; if the baby moves them all equally Avell or
not,
\Yatch if the baby passes meconium or urine, also
if it A'omits.
Listen to its breathing and also to its cry, if it is
lusty or only a moan.
Inspect the stump of the cord and find out that there
is no bleeding from it and that it is tied securely; also
that there are no abnormalities around the navel.
Then, Avhen the baby is dressed and in its bed go over
frequently and ascertain that it is all right and com-
fortable; if it is sleeping soundly, if it assumes the
normal position similar to the one it occupied in the
uterus, Avith the knees slightly bent and the arms up-
Avard, and the hands above the head.
The daily inspections should be repeated every time
you undress the baby.
You must Avatch for a possible discharge from its eyes
during the first week and report its presence to the
physician at once.
It is of great importance, too, to know if the baby
has the snuffles during its first two weeks. Do not make
light of this and think it is only "a slight cold."
The child's skin should be red or pink, not blue;
especially not during its crying ■ even the slightest erup-
172 NURSING IN DISEASES OF CHILDREN
tion deserves attention, some of these you Avill perceive
better Avhen you are not too near the part you Avant to
inspect, Soreness around the anus and buttocks must
be reported to the physician at once.
The motions of the limbs should also be Avatched very
carefully at this time, sometimes you Avill notice that the
baby does not move one of these at all, and the physi-
cian will find the cause for this.
Let me Avarn you again not to keep any of these ob-
servations of yours to yourself, no matter hoAV trivial
they may appear to you. If you do you Avill Avrong your
patient and the physician as well. The latter is the only
one Avho can determine the importance and cause of
any abnormal phenomena.
In older babies it is equally important for you to be
most observant.
A great deal can be learned from the baby's cry-
It is his only means of expressing himself. It is his
language.
A continuous cry, perhaps Avith the fist in its mouth
may indicate hunger, and Avill stop Avhen food is given.
Do not, hoAvever, explain every crying spell in this
Avay; it is not as frequent as you may have thought.
This kind of a cry may also indicate that the baby is
thirsty and really Avants a drink of Avater and not
food. Do not forget this, as is so often done.
The baby may cry from pain. A colicky cry is spas-
modic and during it the legs -will be drawn upon the
abdomen. If from other pain such as earache, Avhich
is very frequent, or from a pin pricking it, the cry
will be loud, sharp and continuous.
A frequent cause of the baby's crying is that it is
wet or otherAvise uncomfortable. Whenever a child
cries you should examine its diapers, and if these
EXAMINATION OF THE CHILD
173
should be dry take the baby up and sti'aighten out its
clothes.
A sleepy baby v\ill cry because it does not want to
go to sleep, then it aa ill give a feAv cries, loud at first,
then Aveaker, finally a sigh or two and it is asleep.
Babies learn soon that Avhen they Avant attention
all they have to do is to cry, and to cry long enough.
As soon as they are taken up they will stop, to renew
their demands Avhenever they are put back to bed.
This is most frequently observed in spoiled babies, or
in those avIio have been sick, or have not had the right
training from the very first.
Older infants and young children Avill cry from fear.
They are afraid Avhen they Avake up in the dark, and
Avhen you have soothed them Avith a feAv kind words
they -will sleep again.
The cry from bad temper can hardly be mistaken
for anything else, it is usually a sign of a spoiled baby.
Premature babies usually do not cry loudly but moan
or AA-himper; so do other Aveakly infants, especially those
Avith atelectasis.
In babies who are ill, principally those suffering from
pneumonia, the cry is very significant, a loud, lusty
cry will usually indicate a favorable prognosis, while
a hoarse whine is a bad sign.
The temperature of young children must be taken in
the rectum Avith a thermometer the bulb of which has
been greased with vaseline. See to it that the ther-
mometer is really introduced far enough, and that at the
same time it does not strike the Avail of the rectum.
Its pressure thus hurts the child. Young babies may
stay in their bed during this procedure, older infants
you should lay across your lap on their stomach, so
that they can not break the instrument should they
174 NURSING IN DISEASES OF CHILDREN
squirm. If you acquire sufficient practice in this im-
portant procedure, and learn hoAV to do it gently, the
child Avill usually not mind it at all.
Very important too is that you should note the qual-
ity of cough, if it is loose or dry, barking or croupy,
how long each attack lasts, if it is repeated soon and
comes at frequent intervals, or is rare; also if it is more
liable to come at certain times of the day.
The respirations of babies should be counted, espe-
cially during illness, by laying the hand upon the in-
fant's chest; you should also note the type of breath-
ing and any change in this. Be especially careful to
watch for the employment of the auxiliary respiratory
muscles, such as movements of the nostrils during in-
spiration and in older children if they lean upon their
hands to aid breathing.
The pulse should be counted for a full minute, this
you can do by placing your finger upon the radial
artery or over the heart, but still more coiweniently
over the carotid or the fontanel.
Watch also the condition of the fontanel; if it should
be tense or bulging or sunken in, this should be reported
to the physician at once.
Keep track of the number of times the baby wets
itself, also if it is scalded by the urine and still more
important if it cries every time it urinates.
I haA'e spoken before of the way in Avhich you should
note the number and quality of the stools. It is also
necessary to observe any peculiar odor; hoAV they are
passed if forced out or squirted out, or Avith gas, and
further if they are of a normal quantity or only enough
to soil the napkin slightly each time you change it.
Look for slight lumps under the skin A\diich may
mean SAvollen glands due to a local or general infec-
EXAMINATION OF THE CHILD
175
tion. They Avill sIioav especially on the neck, in the
nape, under the chin and jaAvs, in the groins and above
the elboAvs.
Look into the infant's mouth and find out if there are
any Avhite spots.
Be very careful to report to the physician at once
when a discharge comes from either ear, or if the child
should put its hand frequently to one side of the head,
and also if one cheek is reddened more than the other.
Watch if the baby holds its head straight, or habit-
ually more to one side, and keep a record of the phys-
iologic processes such as holding up the head AAdien
carried, sitting up, the first tooth and so on. Every-
one of these data may mean much to the physician; es-
pecially if the infant should lose the faculty or the in-
clination of doing any of these things.
You should also be aAvare of it if the baby should
be afraid of being touched or moved; and also if it
should then cry as from pain.
The condition of the abdomen is also Avorthy of your
continuous attention; if it is abnormally distended or
large, if it is sunken and flat, or if large veins are to
be seen upon it; also if it is unevenly distended.
In girl babies you should be on the lookout for a
vaginal discharge, especially in institutional children,
where these cases must be called to the attention of
the physician at once so that they can be isolated and
green special care.
In boys the genitals should also be regularly in-
spected and abnormalities, such as a SAvelling, etc.,
reported.
Nor should you be satisfied AAdth carefully examin-
ing babies Avhen undressed, but you should be contin-
uously watching its every movement.
176 NURSING IN DISEASES OF CHILDREN
You should be present as often as possible when the
mother nurses it and see if it can swalloAV Avell and
how it nurses. If it nurses right through Avithout let-
ting the nipple go, or if it has to interrupt the act
every feAv seconds to get its breath, this latter fact
should be told the physician at once.
I do not claim that this list of the things and condi-
tion Avhich you should Avatch is by any means com-
plete; the careful nurse can undoubtedly add many
more. But, Avhat I intended to bring out, and I trust
I have done so, is to teach you hoAV many things you
should be thinking of Avhen entrusted Avith the care of
a baby and that you must not perform your work
automatically and unthinkingly.
When you expect the physician's Adsit be sure to have
everything that you knoAV from experience he might
need in readiness, so that you do not have to hustle
around Avhen you hear him coming and thus Avaste his
valuable time.
HaA^e the room Avarm and the AvindoAVS and doors
closed, but the air must be good all the same, remem-
ber that it is not only cold air that is fresh air.
Upon a small table which must be solidly built, not
a card table or a seAving table, you have placed a soft
pilloAV and a blanket, so that the child can be put on
this and partially covered for examination.
In a coArered pail you haAre the last napkins soiled by
the baby's stools; and, if necessary have a clean bottle
filled Avith about one ounce of its urine.
I have frequently found it very difficult to obtain
a sample of the baby's urine for the simple reason that
the nurse did not know Iioav to collect it, although this
is really quite simple.
In boys you take a solid test tube of fair size, fold
EXAMINATION OF THE CHILD
177
some adhesixc plaster around the edge of it and then
fasten it over the penis Avith a couple of strips of ad-
hesive plaster and leave it inside the diaper until you
have succeeded in getting your sample.
In girls you take the same kind of test tube and fas-
Fig. 43.—Holding baby for examination of back of chest.
ten it Avith strips of plaster over the vulva; this is
ever so much better than collecting the urine in ab-
sorbent cotton and then Avringing this out, or to take
a sample from the chamber Avhere it is likely to be con-
taminated by germs and also by stool.
178 NURSING IN DISEASES OF CHILDREN
Your chart should be lying upon the table brought
up to the minute. Any medicines the baby has been
getting should be within easy reach, also the last pre-
scription for the baby's food and one of the bottles Avith
the food ready for feeding.
Fig. 44.—Holding baby for examination of front of chest.
Should the baby have vomited recently this must also
be preserved in a clean boAAd or the pieces of clothing
soiled by it should be on hand.
Get the vaseline for the thermometer, a bottle of al-
cohol and a cloth to clean it; a wash bowl, soap and
toAvel—but please not a new one Avhich will not take
EXAMINATION OF THE CHILD
179
up moisture—for the physician's hands. Now after un-
dressing the baby until all it Avears is its shirt, napkin
and nightgown, wrap it up in a blanket and you can
iioav serenely await the physician's arrival.
Every physician will appreciate greatly if you know
Fig. 45.—Holding baby for examination of throat.
how to hold the baby during his examination, and dur-
ing minor surgical operations, or for the administra-
tion or application of medicines.
For the examination of the back of the chest the
baby should be sitting on your forearm, its face over
your shoulder, your free hand should hold its head
180 NURSING TN DISEASES OF CHILDREN
(Cig. 4:$). For that of the front of the chest your
one arm should press the baby against you, Avhile the
free hand holds its arms above its head which is pressed
against your shoulder (Fig. 44).
When the throat is to be examined hold the baby
Fig. 46.—Holding baby for examination of ear.
against you, pinning down the arms, the other hand
steadying the head (Fig.. 45) or the physician may Avant
to hold the infant's head and then you use your free
hand to hold its body.
When the physician desires to examine the baby's
ear vou hold it Avith one hand sideAvays against you and
EXAMINATION OF THE CHILD
181
hold its head tightly against your shoulder, but keep
your arm out of the Avay of the light (Fig. 46).
For all this you Avill either stand up or sit down, as
the physician may desire.
For the inspection of the eyelids you will place the
Fig. 47.—Examination of baby's eye.
baby across your lap, its head resting upon your knee,
or upon the pilloAV on the table. (Fig. 47).
It is very important for you to know how to hold
the baby for a lumbar puncture, a slight and painless
method of investigation Avhich may be of inestimable
Aalue not only for diagnosis but also as a therapeutic
measure.
182 NURSING IN DISEASES OF CHILDREN
A small baby, or an older infant that is unconscious,
is placed -with its back well over the edge of the pil-
Ioav, hoav you stand on the opposite side of the table,
facing the baby, grasp its buttocks Avith one hand and
the upper part of its back Avith the other and then
Fig. 48.—Holding infant for lumbar puncture.
hold it tightly so that it can not movre, and at the same
time arch its spine toAvard the physician. You should
always ha\re three sterile test tubes Avith sterile cot-
ton stoppers standing ready in a tumbler at the physi-
cian's elboAV, when you expect him to do this (Fig. 48).
For older and stronger babies, and also for older
EXAMINATION OF THE CHILD
183
children it -will be better to hold them in a different
Avay, in Avhich you Avill have a firmer grip upon the
child. You iioav stand at one side of the child facing
it, as it is sitting upon the edge of a firm table, its
back slightly over it. Noav you pull its hands through
betAveen its legs, grasp each of its hands Avith one of
Fig. 49-A.—Holding older child for lumbar puncture, sitting.
Front view.
your own from outside its thighs, and catch its head
under your armpit Avhich is nearest to it, and hold it
there tightly betAveen your upper arm and your body.
In this way you can hold the child perfectly still for
the comparatively feAv seconds Avhich are consumed in
a lumbar puncture Avithout any aid (Figs. 49 A and B)
If you do not hold the child firmly, as I have told
184 NURSING IN DISEASES OF CHILDREN
you, so that it can not move its spine, you may be re-
sponsible for the breaking off of the needle in the spine,
and it will then sometimes be rather difficult to recover
the broken end. But let me tell you when one of these
accidents should happen,—and they -will, and do hap-
pen to the most experienced physician—then comes
49-B.—Holding older child for lumbar puncture, sitting.
Back view.
the time Avhen you can sIioav your true loyalty to him
and thus to your noble profession. No matter Avhat
happens, you must never shoAv any surprise or any ex-
citement by your expression or by your gestures, you
must act as if this Avere an everyday occurrence, yes, as
if it Averc a part of the operation. Remember that many
EXAMINATION OF THE CHILD
185
people, not only the so-called ignorant ones, are natur-
ally suspicious of everything the physician does, espe-
cially Avhen it is something of Avhich they may not have
heard before. They will be Avatching him and you still
more, and your slightest indication of surprise or excite-
ment may forever destroy their faith in your friend, the
physician.
Let me tell you here further, that you should be, if
possible, eAren more careful in guarding your tongue;
an indication of doubt in the physician's ability or judg-
ment, even by a single Avord, or the belittling of one of
the measures ordered by him Avill only too quickly end
his usefulness in this case, and thereby may endanger
your patient's life.
So remember, keep yourself in hand, be loyal to the
last ditch; then only -will you be Avorthy of the name
of a "trained nurse."
In older children you may require a sheet to overcome
their greater muscular poAvers, and knoAving hoAV to hold
them Avill help you materially, it will save your temper
and will prevent a disgraceful fight. (Fig. 50.)
Never try to deceive the child, it will never forget if
you have lied to it. Should you knoAV that the examina-
tion, or the slight operation, is going to be disagreeable
or even painful, warn the child of this beforehand. W7hat
is the use of telling the child a lie when he is sure to
feel the evidence in his oavii body that you have de-
ceived him? And do not let the mother, nor the grand-
mother, tell him that he is not to be hurt. Many a time
have I been obliged to give them a scolding right before
the child. But when they were sensible they saw that
I was right, and I kept their friendship as well as that
of the child, even if I did hurt it.
To hold an older, perhaps unruly child, for an ex-
186 NURSING IN DISEASES OF CHILDREN
animation or slight operation upon its mouth, throat or
nose, you take it upon your lap with its back towards
you, take its legs betAveen your oavii, locking the feet,
then put your arms under the child's holding them be-
tAveen your upper arm and forearm, and your hands
holding its head against your chest, (Fig. 51.)
You may also roll the child in a blanket Avith its arms
Fig. 50.—Holding older child for lumbar puncture, lying down.
at its side, and this is especially good for the examina-
tion of the ear. (Fig. 52.)
When holding a child for the physician, avIio is using
a reflector, you must be careful not to get any part of
your body betAveen this and the source of light.
For the examination of its abdomen the physician Avill
want the child to be placed upon the table, and you
EXAMINATION OF THE CHILD
187
can then make it much easier for him by keeping the
legs slightly flexed in the knees to relax the abdominal
muscles.
For gavage, washing out of the stomach, roll the child
Fig. 51.—Holding older child for examination of throat.
in a blanket, its legs betAveen yours, its head against
your chest. Babies are laid upon the table. The phys-
ician will now take a small stomach tube, or in babies a
soft rubber catheter, he dips this into warm water,
188 NURSING IN DISEASES OF CHILDREN
keeps the tongue of the patient doAvn Avith the first fin-
ger of one hand, Avhile the other inserts the tube into
the esophagus by a slightly rotary motion. The tube
will usually slide into the proper passage quite readily,
Fig. 52.—Rolling child in blanket for examination of ear.
especially Avhen the child is crying, but should it go in-
to the larynx you can hear this by the Avhistling sound
made by the air going through the rubber tube.
EXAMINATION OF THE CHILD
189
When the tube has been pushed in so as to be in the
stomach a small piece of glass tubing is put into the end
of the stomach tube, then over this is slipped a rubber
tube of the proper size and into the other end of this
Fig. 53.—Gavage.
is slipped a funnel. Wratch the physician very carefully
how he proceeds in this because he will frequently ask
you to do this by yourself in his absence. (Fig. 53.)
For intubation of the larynx you hold the child in the
same way, but one of your hands must be kept free to
190 NURSING IN DISEASES OF CHILDREN
grasp the mouth gag used in this procedure. (Fig. 54.)
When the physician has to open an abscess on the pos-
terior pharyngeal wall, a so-called retropharyngeal
abscess, which is by no means rare in babies, you hold
Fig. 54.—Holding child for intubation.
the child tightly as for an examination of the throat
but as soon as the abscess has been opened the physician
will usually expect you to niOAre the child forAvard so
that the pus Avill run out of its mouth and will not be
aspirated.
EXAMINATION OF THE CHILD 191
Naturally every physician Avill have his oavii method,
and you should folloAv his every slightest suggestion or
change; but he may also leave it to you to see hoAV you
can hold the child most coiweniently and at the same
time most securely and then you must not hesitate, but
you must knoAV at once Avhat to do.
Noav one Avord about the giving of an enema. This
simple everyday procedure is done so often Avrongly by
nurses that I shall better describe it.
For this you should use a soft rubber catheter, not
the hard rubber tip of the ordinary fountain syringe,
and a funnel, best of glass, connected Avith it.
Place the child upon a blanket on a table or on a hard
bed. It should be lying upon its back, or on its left
side, with the legs slightly flexed in the groins and
knees. Noav fill your funnel Avith the liquid to be used
let the catheter fill up then squeeze it together, dip the
end of it into Avarm oil or vaseline and slowly as Avell
as gently insert it into the anus, letting the liquid run
a little as you get into the lower part of the rectum.
The catheter Avill then be floated past the loAver and
middle sphincter muscle Avithout having to employ any
force. (Fig. 55).
The pressure of the liquid should not be more than
six inches in babies and tAvehre inches in older children;
that means that the funnel should not be held higher
than this distance above the child's anus. Only if you
observe this rule will you be successful and at the same
time not hurt your patient.
I have often seen nurses climb on a chair to hang a
fountain bag up on the Avail or have somebody hold it
Avay above his head. This is wrong and will hurt the
patient because the pressure of the liquid will be directed
]f)2 NURSING IN DISKASKS OP CHILDREN
against the middle sphincter muscle, this Avill con-
tract and thus close the upper boAvel against the enema,
Avhich will then have to remain in the loAver part of the
Fig. 55.—Enema.
boAvel and balloon this up. This Avill not only counter-
act the purpose of the enema but it Avill also make the
child A^ery uncomfortable and cause it pain. I also be-
lieve that the method just mentioned is the only one by
AAdiich you can administer a so-called "high enema."
EXAMINATION OF THE CHILD
193
Quiz
Why should you look a newborn over?
For what should you look when inspecting the newborn?
How should the skin of a baby look?
Can you learn anything from the baby's cry?
Do premature babies cry loudly?
How should you take a baby's temperature?
Can you learn anything from a baby's cough?
Can you learn anything from a baby's respirations?
How may you count a baby's pulse?
What differences may you observe in the fontanel?
What should you observe in a baby's stools?
What should you observe on a baby's abdomen?
Why should you watch a baby nursing?
How should you prepare for the physician's arrival?
How can you get a sample of a baby's urine?
How should you hold a baby for the examination of its chest?
How should you hold a baby for the examination of its ears?
How would you hold a baby for lumbar puncture?
What is lumbar puncture?
Should you tell a child that it is not going to be hurt?
What is gavage?
How is gavage done?
How should you hold a child for intubation?
How should you give an enema?
CHAPTER VIII
THE INFECTIOUS AND CONTAGIOUS DISEASES
By the term "infectious disease" we indicate that a
pathologic change of the vital functions of the body is
caused by the action of one or more kinds of parasitic
organisms which have invaded the body of the patient.
These parasites may belong to the vegetable kingdom,
the so-called bacteria, or to the animal kingdom, the so-
called protozoa; of some of them Ave are, hoAvever, not
quite sure as yet how Ave should classify them.
Again while we know which parasites cause certain
of these diseases, such as diphtheria, syphilis and mala-
ria for instance, of others we are still in ignorance of
the specific organism which is the cause of the disease,
though Ave are certain that it is caused by an infection,
as, for instance, measles.
If one of these diseases should be transmitted through
indirect means, such as articles of food, etc., we speak
of it as an infectious disease; if on the other hand it
should be transmitted directly from one person to an-
other Ave call it contagious. In the latter case it is,
hoAvever, by no means necessary that the person who is
thus transmitting the disease should be sick himself, it
is sufficient that he harbors the germs someAvhere in his
system. A typical example of an infectious disease is
typhoid fever, which we knoAV to be transmitted either
directly or indirectly through water; of the contagious
diseases a typical example is diphtheria.
You Avill readily understand that a disease which is
usually of an infectious nature may at times be trans-
194
INFECTIOUS AND CONTAGIOUS DISEASES 195
mitted by contagion and also that a contagious disease
may be carried indirectly and thus be transmitted by
infection.
To illustrate this latter point I may state that I have
repeatedly seen mothers Avho Avere taking care of one
of their children Avhen it Avas ill from typhoid fever
acquire the disease by close contact; and I have also
been able to trace tAvo epidemics, one of diphtheria and
another of scarlet fever, to milk.
In the folloAving pages I shall refer to these diseases
collectively as infectious diseases, because I trust that
1 haA'e made it sufficiently clear to you that they must
be one and all infectious and that only some of them are
at the same time contagious.
When the body of a human being is invaded by one
of these parasites one of three conditions must arise.
Either the body is able to make them innocuous before
they haATe had time to attack the system; or the parasite
attacks the system, thereby making the person ill, but
the latter is able in time to overcome the former and
the patient recovers; or, finally, the parasites are too
strong for the patient Avho succumbs to his illness after
a longer or shorter time.
You -will see from this that an infectious disease
represents a fight to the finish betAveen the parasite and
its host. The factors Avhich determine the outcome of
this fight are: the pathologic action of the parasites
and the more or less deA'eloped poAver of the body to
overcome the parasitic disturbance.
AVe are also able to notice a difference at certain times
in the same kind of parasites. At one time they may be
entirely innocuous to the human being, Avhile at another
they Avill be extremely dangerous for it; in this case Ave
196 NURSING IN DISEASES OF CHILDREN
speak of them as "virulent," in the former as "avir-
ulent."
Some of these parasites fortunately possess only a
very slight virulency for the human race.
This faculty of resisting the attack of certain para-
sites is called immunity. It may be born in the body, or
it may be acquired by overcoming the disease caused by
them. It is for this latter reason that some of these dis-
eases attack the human body only once in a lifetime.
Other parasites again leaAre the body in such a con-
dition, though in good health, that it Avill be an easy
prey to a subsequent attack of the same parasite; as ex-
amples for these diseases I may mention pneumonia,
erysipelas and polyarthritis, commonly called inflam-
matory rheumatism.
Age and sex will frequently determine if and how the
body can overcome a parasitic attack, and so -will the
fact if the individual has been suffering from another
illness, or is still suffering from it, also Avhat organs are
mostly affected by the parasites, or Avhat poison they
produce.
Let us iioav investigate the question which will in-
terest us most here, whether children OAving to their
youth shoAv a special disposition toAvards infectious dis-
eases, and, if so, Avhy.
We shall find that the young body, on account of its
immaturity, is much less adapted for a fight against
parasites than the adult; and experimental Avork in
special laboratories teaches us that it is much more dif-
ficult to immunize, that is to make nonsusceptible, very
young animals than older ones, because the former can
produce the antibodies, the antidote to the poison pre-
pared by the parasite, in much less amounts and that
to do this is a much greater strain upon their system,
INFECTIOUS AND CONTAGIOUS DISEASES 197
WTe must therefore state most emphatically that child-
hood, as such, forms a special disposition toward para-
sitic diseases.
Some of these parasites produce in children and
especially in infants, diseases of a severity such as we
shall rarely obseiwe in adults.
Furthermore, the least diminution in the natural re-
sistance of the body of the child, be it from faulty feed-
ing, or from climatic changes, Avill aid the parasites and
will cause an infectious disease of much greater severity
than Ave would observe in the adult.
Aside from this the young infant brings into the
world a certain amount of immunity against some of
the infectious diseases, because its mother has had them
before conception, and she Avas thus in a position to
transmit some of the immune bodies from her oavii blood
to that of the fetus. The breast baby receives a further
amount of these antibodies in the mother's milk and it
Avill thereby be still more fortified against the invasion
by parasites. Later in life these antibodies acquired in
this AAray by the baby Avill be an aid in overcoming some
of these diseases, as for instance measles Avhich is rightly
considered a disease of little danger, though the acci-
dental infection Avith other germs during its course Avill
influence this.
The fact that children are so very susceptible to many
of these infections Avill account for their having these
diseases during childhood as a rule and Ave call some of
these, as for instance measles, chicken pox and AA'hoop-
ing cough, "diseases of childhood" because almost
everybody Avill have had them in youth and -will there-
fore be immune against them later in life.
Let, hoAvever, one of these diseases, as for instance
measles, be brought amongst a population where it had
198 NURSING IN DISEASES OF CHILDREN
been unknown before and where for this reason nobody
carries any of the antibodies for this disease in his blood,
and the disease AAdll no longer be confined to the young
but it will spread amongst the whole population and it
will be correspondingly severe.
Sometimes we are able to immunize a large propor-
tion of a population artificially against one of these dis-
eases, so that it will become quite rare and that for this
reason children are no longer exposed to it, and this
disease will then be no longer figured among the dis-
eases of childhood, as was smallpox, for instance, only
a little over one hundred years ago.
Some of these diseases appear continuously here and
there in single cases when we call their occurrence
"sporadic."
They are also with us all the time, and are liable to
appear grouped together in a community at a certain
time, and Ave then speak of it as " endemic.''
Let this same disease spread from one of these centers
over large areas and we will call it "epidemic."
If a disease should circle the globe, as did epidemic
influenza in the last two decades of the last century,
then Ave shall speak of a "pandemic" disease.
Some of the sporadic diseases, as for instance measles,
scarlet fever, and diphtheria will appear in endemic and
epidemic form every feAv years, because in the interval
between this and the last epidemic not sufficient sus-
ceptible children were present in a community to permit
of its Avider spread.
Seasonal changes also seem to have considerable to do
with the appearance of such diseases; some of them, as
for instance diphtheria, are more prevalent in winter,
Avhile others appear to be more frequent at other sea-
sons of the year.
INFECTIOUS AND CONTAGIOUS DISEASES 199
Another factor Avhich should not be overlooked, is
the increased chance for infection given by the congre-
gation of susceptible indiAdduals in schools and similar
institutions. WTe are often able to observe hoAV an epi-
demic Avill almost disappear Avith the closing of the
schools in summer to reappear Avith the beginning of
school in the fall of the year.
Formerly Ave thought that climate, as such, had con-
siderable to do Avith the spread of diseases, such as for
instance malaria and yelloAV feATer. Comparatively re-
cent adA-ances in sanitary science have taught us, hoAV-
eA^er, that these diseases are transmitted by insects, cer-
tain species of mosquitoes, and they haAre thus been
proATed to be confined to the region Avhere these insects
flourish the most.
Quite a number of the infectious diseases are prevent-
able and therefore unnecessary; typical of these is
typhoid fever AAdiich is due to a contamination of the
Avater supply of a certain community or region, and
AAdiich Avill disappear as if by magic with a change in
the source of the Avater, or with its purification by arti-
ficial means.
Others again are preventable by sanitation, that is by
folloAving the laws of hygiene and by the isolation of
everyone of the first cases appearing in a community.
Still others can be prevented by special measures
such as ATaccination against smallpox.
Let us iioav consider Avhat happens in the body AAdien
these parasites enter it.
For some the portal of entry is knoAAm, and they may
begin their Avork of destruction at the site of entry, for
others Ave can only surmise it because they travel
through the system to do their damage aAvay from the
site of infection, for still others Ave are as yet in igno-
rance as to their way of entering the body.
200 NURSING IN DISEASES OF CHILDREN
First of all let me Avarn you that in order to under-
stand this rather complex idea of infection you must ad-
here to one fact, namely, that even Avhere the parasite
appears to remain localized to his portal of entry, Avhere
as avc say only a local infection takes place, still the ef-
fect of this infection Avill be felt all through the body
because the Avhole organism is called upon to resist this
invasion.
Let us assume that some bacteria enter one of the
hair-follicles in the skin and groAV here. Do not think
that all the body does is to throw a zone of leucocytes
around this focus and that it can then retire upon its
laurels. The AAdiole body will be astir at once. The
neighboring lymph-glands AAdll throw out detachments
of leucocytes, the so-called phagocytes, AAdiose business
it Avill be to attack the germs and to devour them if
possible. The activity in these lymph-glands will be
tremendously increased, they begin to SAvell. Should
they be successful in their attack the invasion will be
repelled, the germs will be destroyed, the fight is Avon,
and the glands Avill return to their former size.
If the lymph-glands should fail in their Avork they
Avill sacrifice their own lives in order to save the rest
of the body, they will be changed into pus, a glandular
abscess will be formed. Wre Avill then observe not only
the local destruction at the site of the original infection,
but Ave Avill also find some of the glands destroyed and
the body saved.
What Avould our body be Avithout these faithful guar-
dians, the lymph-glands? The first invasion of bacteria
in the body Avould mean general infection and death.
Nature, hoAvever, does not intend that the body should
take any chances and that it should rely entirely upon
the lymph-glands. As I have said before the Avhole
INFECTIOUS AND CONTAGIOUS DISEASES 201
system is in alarm. The blood making apparatus is
stimulated in furnishing still further leucocytes for the
fight. The blood is furnished Avith bodies to bind and
thus neutralize the poison prepared by the bacteria.
This sets up a reaction in the Avhole system, which is
further evidenced in the rise in temperature. This may
not be sufficient in a slight infection to be measured, but
in one of any magnitude it -will be considerable and Avill
then be a further means of defense for the body because
the germs do not groAV as Avell in a medium the temper-
ature of which is above that of the normal body.
If this is Avhat takes place in our body if a compara-
tively trivial infection should attack it, can you imagine
Avhat will happen Avhen one of the infectious diseases
should hwade it and overrun the system Avith parasites?
As I have indicated above some of the parasites do not
only damage the body by the haAToc they Avork at the
site of their entrance into the body, but even more 10 be
dreaded is the systemic effect of the poison or poisons
Avhich they produce, and Avhich the body at times finds
it very hard to overcome.
For an example let me tell you the effect of the action
of the bacteria causing diphtheria. The Klebs-Loffler
bacillus usually makes its entrance into the body
through the throat Avhere it will cause an exudative
inflammation A\rhich may be so severe as to interfere with
respiration. But it also produces tAvo kinds of poison,
toxin. One of these AAdiich is always present in large
quantities affects the blood vessels and the heart; the
other has a specific action upon the nervous system and
causes more or less localized paralysis in some parts of
the body.
Still other bacteria like the tetanus bacillus, the germ
causing lockjaAV, do not cause any evident local injury
202 NURSING IN DISEASES OF CHILDREN
at their site of entrance but the poison it produces per-
meates the nervous system and it is thus responsible for
the typical attacks.
A germ like the tubercle bacillus may cause destruc-
tion in all the tissues of the body wherever it is carried,
while the parasite causes malaria attacks and destroys
the red blood-corpuscles.
Of some of these infections Ave do not yet knoAV their
mode of action, nor can Ave fully understand as yet if
the symptoms Ave observe in or upon the body are the
effects of the action of the germs or if they may not
rather be the answer of the body to the Invasion. As
an example for this I might mention the rash in scarlet
fever.
In its fight against the poison prepared by the in-
Araders the body of the host, the patient, produces an
antidote which will neutralize this poison someAvhat in
the same manner as an alkali will neutralize an acid
and thus combine Avith it to form an innocuous salt. If
the body is strong enough to produce these so-called
antibodies in sufficient quantities the life of the patient
Avill be preseiwed, he Avill recover; if not, serious dam-
age Avill be suffered by it and the patient Avill eventually
die.
This fact, though suspected, and made use of empir-
ically for some time, has only comparatively recently
been brought upon a scientific basis so that it can be
made use of not only in the treatment but also in the
prevention of these diseases.
Take as a typical example the administration of anti-
toxin in diphtheria.
In the preparation of this antitoxin ^ye make an
animal, usually a young healthy horse, slightly ill, by
INFECTIOUS AND CONTAGIOUS DISEASES 203
the injection of a small dose of living Klebs-L6ffler
bacilli.
During this illness the system of the animal defends
itself against this hwasion by producing the antidote,
the so-called antitoxin, against this germ.
After the animal has recovered from this first injec-
tion, it will be able to stand a larger dose with impunity,
because this antitoxin will be circulating in its blood
ready to neutralize a certain amount of poison.
It is now injected in repeated increasing doses, ahvays
short of making it seriously ill, until finally its blood
can neutralize many times a dose of poison fatal to an
animal not so prepared.
Noav the horse is bled; the blood serum, Avhich con-
tains the antibodies is drawn off and prepared for use.
Let us now assume that a susceptible child has been
exposed to an infection with the diphtheria germs. These
lodge in its throat and begin the work of producing
their poison, the toxin.
If the physician can see this child early enough, that
is before the bacteria have had time to make up too
much toxin, he will be able by the injection of the anti-
toxin to do two things. First the antitoxin will make
the toxin innocuous and second the injection will stimu-
late the body of the child in preparing an oversupply of
antitoxin itself, so that it can take care of any further
toxin which the germs should produce.
The parasites will find the body of this child an un-
suitable medium to groAV in; they Avill die and the child
is saved.
But, this child has brothers and sisters who are also
susceptible but Avho have not yet been exposed and the
physician wants to make them insusceptible, that means
he desires to place them into the position of persons Avho
204 NURSING IN DISEASES OF CHILDREN
have overcome the disease and Avho, for this reason, still
carry enough antitoxin in their blood to neutralize the
toxins should they be hwaded by the germs.
He will proceed to give these children smaller, so-
called immunizing, doses of the antitoxin. These are
frequently sufficient to stimulate their systems to make
up enough antitoxin themselves to be saved from an
infection.
Quite recently another most interesting fact has been
found, one by Avhich Ave can tell if the body of a certain
person contains enough antitoxin to make him immune
should he be exposed to these germs.
We have learned that persons Avho have some anti-
toxin in their systems, be this by inheritance or by over-
coming the disease, or lastly by artificial means, will
react by the application of some of the toxin to a de-
nuded small surface of skin in a peculiar manner; and
that the strength of this reaction w ill also indicate the
amount of antitoxin present in the body.
By this simple method Ave will be able to tell if a per-
son is sufficiently protected against this disease, so that
an exposure to these germs -will be, in all probability,
harmless, or if he should be immunized.
But, we have also learned from this another fact,
namely that some people seem to be unable to produce
any appreciable amount of antitoxin, and that they are
the ones who will have this disease more than once.
Quite naturally if this should be a nurse she will bet-
ter avoid as far as possible all chances of infection.
We possess, hoAvever, still another means of protect-
ing the body against infection.
It has been found out by experiments on animals that
the injection of dead germs causing some of these dis-
eases will also stimulate the body to prepare larger
3B • • 'p
pjg 56.__Tuberculin reactions. (Pottenger, Tuberculin).
] Conjunctival reaction of left eye.
2A Von Pirquet reaction, well marked; B, control site.
2>A. Von Pirquet reaction, moderate; B, control site.
4. Moro reaction, well marked.
5. Moro reaction, slight.
INFECTIOUS AND CONTAGIOUS DISEASES 205
amounts of antitoxin, even after it has been invaded by
these same germs, and thus protect the person against
their ravages.
Of this principle Ave make use in the injection of the
so-called vaccines, that is of liquids containing known
numbers, usually so many millions, of the dead bodies
of these particular germs.
After the body has been invaded by a certain germ,
when the person is, therefore, suffering from this disease
caused by it, Ave have in many cases the means at our
disposal to ascertain this fact and thus to make a diag-
nosis of the illness when it Avas otherAvise doubtful.
We may then either take a drop of the blood of the
patient, which will contain, quite naturally some amount
of antibodies and add this to some of the living germs
which Ave suspect. If the patient is really suffering from
this disease the antitoxin in the blood will numb and
paralyze the germs and they will clump together inertly,
this is the so-called agglutination test as exemplified by
the so-called Widal test for typhoid.
Or, Ave take some of the crushed bodies of a germ con-
taining the toxin produced by it and administer it upon
the skin, Moro's reaction (Fig. 56-4 and 5), or mucous
membranes, Calmette's reaction (Fig. 56-1), or into the
skin, von Pirquet's reaction (Fig. 56-2 A and 3 A) and
the body of the patient will react in a typical manner to
this, provided it harbors these germs. This is frequently
made use of in cases of suspected tuberculosis.
In this disease Ave are also able to produce a general
systemic reaction by the injection of minute doses of
the same material, and Ave are then in a position to tell
by the measures of defense set up by the body if that
person is suffering from the disease.
I trust that after these general remarks about infec-
206 NURSING IN DISEASES OF CHILDREN
tion you will be able to understand the different diseases
due to this cause of Avhich I shall speak hoav.
I shall first take up the acute infectious diseases,
especially the so-called diseases of childhood and then
the chronic infections.
Perhaps the most frequent contagious diseases of
childhood are the exanthemata, so called because a rash,
an exanthema, is the most prominent symptom of the
infection. These are measles, scarlet fever, rubeola and
chicken pox, formerly Ave Avould have classed with tliese
also smallpox.
Before I give you a short description of these diseases
it Avill be necessary for me to familiarize you with cer-
tain technical terms which Ave usually apply in connec-
tion Avith them.
Incubation is the time AAdiich elapses betAveen the tak-
ing into the system the specific germ until the first
symptoms of illness appear. This time of incubation is
peculiar to each one of these infections and varies con-
siderably as Ave shall see.
Prodromal stage is the period from the first symptoms
of the disease to the appearance of the rash.
Stage of efflorescence is the time from the appearance
of the rash until this fades.
Desquamation means the scaling of the skin which is
observed after some of these diseases.
Measles (morbilli, Latin), is caused by a germ which
is still unknoAvn. Its incubation is about eleven days.
The prodromal or so-called catarrhal stage lasts three
or four days and consists in the gradual onset of coryza,
a peculiar, dry, metallic cough and conjunctivitis. About
tAventy-four hours before the stage of eruption Ave will
be able to see the so-called Koplik's spots on the inside
of the cheeks. The eruption appears first on the face
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208 NURSING IN DISEASES OF CHILDREN
and spreads to the Avhole body; it consists at first in
isolated red papules Avhich coalesce Avith intervals of
healthy skin giAdng a blotchy appearance; the rash looks
as if it had been put on the skin Avith a calcimining
brush. The fever corresponds to the rash, they both last
about six days Avhen the rash will disappear and the
temperature come doAvn by crisis. (Fig 57.) Then a
fine desquamation will take place, the scales looking
like bran.
Tavo symptoms Avhich may trouble the child consider-
ably at times are the photophobia, the fear of bright
light, and the dry harsh cough.
Measles is as a rule not a dangerous disease, especially
not in a Avell regulated household, but in the crowded
tenements and in the slums it demands many a victim.
During the stage of coiwalescence, after the acute
symptoms of the disease have disappeared, you should
be very careful Avith these little patients, because they
are very susceptible to the accidental infection Avith the
germs of the grippy infections and in my opinion the
broncho-pneumonia Avhich Ave observe so frequently in
neglected cases mostly, is not part of the measles but
is due to this secondary infection.
The poison of measles is also liable to acthrate any
tubercle bacteria Avhich are lying dormant in the system
and Ave Avill quite frequently hear that a child developed
tuberculosis in some form or other after this disease.
Infection of the middle-ear is by no means rare in
measles, the germs being carried from the nose through
the Eustachian tube, but this also is, in my opinion not a
part of the original disease but a secondary infection.
The kidneys should be carefully watched because Ave
see occasionally that the poison Avill damage these im-
portant organs.
INFECTIOUS AND CONTAGIOUS DISEASES 209
Scarlet Fever (scarlatina, Latin), is also caused by a
parasite Avhich has not yet been found Avith any cer-
tainty. The stage of incubation is short, usually from
tAvo to four days. The prodromata last about tAventy-
four hours; they come on suddenly, are intense, and
most prominently consist in vomiting and sore throat;
in some children Ave often obseiwe convulsions.
The eruption appears first on the chest, spreading to
the rest of the body. The face shows it with the least
intensity. The rash consists in minute specks forming
into a uniform erythema, it looks as if it had been
painted upon the skin with a fine camel's-hair brush.
In the throat Ave find intense hyperemia and also the
typical rash, this also gives the tongue its peculiar ap-
pearance.
The iever Avhich is high even in uncomplicated cases
comes doAvn by lysis and the temperature may be normal
again in about nine or ten days. (Fig. 58.)
Desquamation is in large flakes and sheets, in which
we can see the openings of the hair-follicles as pin holes.
Scarlet fever is the one infectious disease Avhich I
dread more than any other. It is a disease .of surprises,
and not only is the original infection frequently an ex-
tremely dangerous one but the many complications
which are liable to arise add greatly to this danger.
Most to be feared is the infection in the throat and
here it is often difficult to tell how much of this is due
to the scarlatina and Iioav much to the accidental septic
infection.
From these affections of the throat Ave haAe in only
too many eases, an infection of one or both ears; this
middle-ear disease may leave the child partially or to-
tally deaf and children under seven-years of age will then
210 NURSING IN DISEASES OF CHILDREN
Typical 5 carlerfever Chart aae-svn female. : Russian
tit 2n4 3rd Temp. Day: cf D is ea S ♦* sn. 6th. 7m 6th , 9 th
108 107 106 --
103 I 102 | 101 wTrr — --
100 "T pi L TO
! \ \ .
99 T l\ V
98 ---
?7 :
96
95
Fig. 58.—Temperature chart in scarlet fever.
INFECTIOUS AND CONTAGIOUS DISEASES 211
also most likely be mutes because the faculty of speech
is not yet sufficiently fixed in their brains.
After the child has apparently recovered from the
attack of the disease Ave observe in many cases that the
poison has Aveakened the kidneys and has left them in a
damaged condition. This is why the careful physician
will insist on keeping the patient in bed for four Aveeks,
and why he will require you to watch the amount of
urine passed and to supply him daily Avith samples
of this.
Numerous other complications may be observed.
I Avant to Avarn you not to be misled by an erroneous
popular opinion which still makes of scarlatina, Avhich
is really nothing but a mild case of scarlet fever, a sep-
arate disease. This may lead to carelessness and many
cases of the most severe type may be traced to one of
these light ones.
German Measles (rubeola, Latin) is another one of the
exanthemata of Avhich avc do not knoAV the cause. It is
comparatively a very mild disease and only a small
number of children are susceptible to this infection.
The incubation is long, seventeen to twenty-one days.
The prodromal stage, if any, may last twenty-four
hours and offers nothing characteristic.
The rash appears first on the face and spreads to the
rest of the body; it consists in slightly raised spots
Avhich do not run together; sometimes the rash Avill
more approach in appearance that of scarlatina; at
other times that of measles, it comes on in several suc-
cessive crops.
Scaling is frequently absent, but Avhen present it is
slight. Complications are not to be feared.
Chicken Pox (varicella, Latin), Ave have not yet suc-
ceeded in finding the germ causing this disease.
212 NURSING IN DISEASES OF CHILDREN
Incubation is long, from two to three Aveeks.
The prodromata are slight and do not last more than
twenty-four hours, they consist in a slight feeling of
illness.
The rash comes in successive crops all over the body
so that one can observe the different stages of it within
a small area of skin. First conies a small red swelling
of the skin which will develop into a blister within a
feAv hours. This blister will remain for about two days,
then a crust will form which falls off without leaving
any scar.
Whenever the child scratches itself it is liable to in-
fect one or more of these blisters and they will then
leave permanent pitted scars on the skin. It is the rule
to find at least one of these scars on the face of every
person who had varicella in childhood.
Though chicken pox is a mild disease as a rule it may
attack the kidneys. In weakly infants and in those who
are suffering from a severe digestive disturbance the
eruption may become gangrenous, and this is a most
fatal complication.
Smallpox (variola, Latin). As I have told you before
this used to be counted among the diseases of childhood
and it was so prevalent everywhere that it was regarded
as a special sign of beauty if somebody's face was not
disfigured by the pitted scars.
The English physician Edward Jenner, a name you
should never forget as that of one of the greatest ben-
efactors to humanity, had obserA^ed that people who had
been milking cows which Avere suffering from so-called
coAvpox and Avho had thus acquired this infection Avere
immune to smallpox. In the year 1798 he published
these observations which attracted widespread attention.
Other physicians have verified this observation and
INFECTIOUS AND CONTAGIOUS DISEASES 213
since then vaccination, that is, the innoculation with cow-
pox has been practiced more or less in all the civilized
countries and thousands, yea millions of lives have thus
been saved.
Strange to say there were, from the very beginning
and are still, some queer people who doubt the efficacy
of vaccination, in the same way as these or similarly
misguided people try to block every advance made in
the medical sciences. WTould you believe that in this
year of Grace, nineteen hundred and eighteen, numerous
people can still be found Avho would rather save a few
animals than hundreds of thousands of children? Who
do not "believe" in germs, nor in antitoxin? That some
of this same class object to having our soldiers vac-
cinated against typhoid fever and would rather see them
die by the thousands than to give up their preconceived
notions 1
This is the class of people who still object to the pro-
tection of the population of this country by universal
vaccination against smallpox. Our federal government
has insisted for years that every immigrant has to be
freshly vaccinated, and successfully at that, before he
can be landed on our shores; but anyone who was born
here has a right to carry the contagion as much as he
Avants to. Unfortunately these queer people usually find
equally queer representath^es in the different state legis-
latures who are Avilling to lend themselves to the block-
ing of scientific advance and to the curtailing of the
poAvers of our sanitary officers.
I have long maintained that the only way we can
stamp out smallpox in this country, is to vaccinate every-
body avIio is willing; then to abolish all other preven-
tative measures against this disease and to trust to it
that all those who do not believe in prophylaxis get
214
NURSING IN DISEASES OF CHILDREN
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INFECTIOUS AND CONTAGIOUS DISEASES 219
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hours later I Avas called on the telephone to come at
once. When I arrived the child Avas dead.
Do not, therefore, alloAV yourself to be misled by the
truly remarkable result of the administration of anti-
220 NURSING IN DISEASES OF CHILDREN
toxin. Though all outAvard symptoms may have disap-
peared in twenty-four hours or so you must remember
that the poison affects the Avhole body.
Whooping1 Cough (pertussis, Latin), is a peculiar dis-
ease. It is very common and in cities only feAv children
escape it. Its cause has been recently found to be the
so-called Bordet-Gengou bacillus.
It is spread mostly through attendance at school, and
endemics of it are frequently observed in orphanages.
Summer resorts at the seaside and in the mountains are
also places Avhere children are likely to be infected, be-
cause people are inconsiderate enough to take these
little patients to such places thinking of their own com-
fort and convenience AAdthout giving thought to others.
The stage of incubation lasts usually about one week.
If an exposed child should not shoAv any symptoms after
tAvo Aveeks Ave have a right to assume that it escaped the
infection.
For the sake of convenience Ave have divided the dis-
ease into three stages: the catarrhal, the spasmodic and
that of recession. You must remember, however, that
clinically you can not separate these stages distinctly.
The catarrhal stage shows nothing more than indef-
inite symptoms Avith coryza and a bronchial cough
which at times may be croupy in character and is se-
verer at night. This is a time A\dien it will be quite dif-
ficult for the physician to make a diagnosis, except in
time of an epidemic or endemic, or when other children
in the same house or school suffer from whooping cough.
The physical examination of the child will not give him
any indication; the fever is irregular and slight.
When finally the nurse or the experienced mother
hears the first typical attack, which is usually after two
weeks, the diagnosis can readily be made.
INFECTIOUS AND CONTAGIOUS DISEASES 221
It seems to me to be superfluous to describe to you
one of these attacks, once you have seen and heard one,
you will neArer forget it.
The spasmodic stage usually lasts from four to six
Aveeks, though it may last much longer. The severity of
Whoopinq Cough. N- of attacks ^vomiting
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Fig. 62.—Chart of whoops and vomiting.
the disease is determined by the original condition of
the little patient, the number of attacks in twenty-four
hours and the amount of vomiting with these, and you
should keep a chart of this. (Fig. 62.) As a rule there
will be no fever.
Finally the attacks will become less and less, until all
222 NURSING IN DISEASES OF CHILDREN
that is left is a loose cough A\diich may sometimes last
for quite a considerable time and may return the fol-
loAving Avinter.
Whooping cough, the same as measles, is a disease in
Avhich the social circumstances of the family of the pa-
tient determine the outcome to a great extent. In the
sanitary chvelliiigs of the better classes it is hardly to
be feared, but in the slums and in orphanages it is quite
frequently fatal. This is not due to any greater severity
of the infection under these poor conditions, but it is
due to accidental infection Avith the germs causing the
so-called "colds"; A\diich will then in many cases lead
to the justly dreaded bronchopneumonia. Also you AviU
remember that in this disease as Avell as in measles any
dormant tubercle bacilli in the body Avill be stimulated
to reneAved groAvth and this explains the frequency Avith
Avhich tubercular infection seems to folloAV upon whoop-
ing cough.
Mumps, or Epidemic Parotitis.—This is a contagious
disease the cause of Avhich is not knoAvn.
The period of incubation is long, tAvo or three Aveeks,
then conies a stage of prodromata Avhich offers nothing
more than a .slight feeling of illness and then conies the
characteristic SAvelling of the parotid glands, usually
first on one side and a feAv days later on the other. This
is accompanied by slight fever, a feeling of tenseness
over the SAvollen regions and difficulty in mastication.
After increasing for tAvo or three days the SAvelling
begins to soften and then disappears in a feAv more days.
As a rule the child does not feel ill enough to stay in
bed and Avill be well soon.
Epidemic Cerebrospinal Meningitis.—This disease
Avhich is caused by the meningococcus intracellularis of
Weichselbaum is not transmitted by contagion from pa-
INFECTIOUS AND CONTAGIOUS DISEASES 223
tients suffering from it as much as from carriers Avho do
themselves suffer only from a slight pharyngitis.
The disease appears usually in epidemic form during
the colder months, reaching its height during the months
from February to May, and it is rather rare in summer.
It is a typical disease of childhood, 90 per cent of all
the cases are obsen^ed in children, and of these 25 per
cent Avill be infants. The cases Avhich are observed
amongst adults occur as a rule in barracks, camps and
prisons.
The disease begins usually suddenly Avith vomiting,
high fever, seA-ere headache; this Avill soon be folloAved
by convulsions. (Fig. 63.)
The most characteristic symptom is the stiffness and
retraction of the neck.
The duration of the disease varies considerably from
a feAv hours to about six weeks.
Only after convalescence has set in AAdll Ave be able to
tell if and how much damage has been done to the ner-
vous system.
Fortunately Ave iioav possess a remedy for this dread-
ful disease in an antitoxin. But this is only serviceable
in this specific type of infection and has to be used as
early as possible and then intraspinally.
The slight operation, if Ave can dignify it by this name,
of spinal puncture is still comparatively unknoAvn among
the laity. It is in this, as well as in some other diseases,
of tremendous value both as a diagnostic and a thera-
peutic measure and the nurse can be of invaluable aid
to the physician and she may at the same time be able
to saAre the patient's life if she impress upon the family
of the sick child the triviality of the procedure in com-
parison to its p04ssible beneficial effect; the more so as
even in fatal cases it can not do any harm, but on the
224 NURSING IN DISEASES OF CHILDREN
contrary, by relieving the pressure upon the nervous
apparatus it Avill undoubtedly lessen the suffering.
."1 5 T 111 iii 11 mill
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Fig. 63.—Temperature chart in epidemic meningitis.
Anterior Poliomyelitis, or Infantile Paralysis.—This
disease which has been seen sporadically for a long time
and which was first described by two physicians under
INFECTIOUS AND CONTAGIOUS DISEASES 225
whose name it is also known as Heine-Medin's disease,
has of late appeared in endemic and epidemic form in
this and other countries. The germ causing it has been
found in all probability, but not yet with absolute cer-
tainty.
The prodromal stage lasts usually three days. Dur-
ing these Ave observe sudden high fever, restlessness,
sleepiness, headaches, pain in the limbs and, A\diat I con-
sider most characteristic, vomiting with constipation.
After the disappearance of these acute prodromal
symptoms develop the typical paralyses which will in-
crease in extent for one or tAvo days, and Avill then fre-
quently disappear to a greater or lesser extent in the
course of days, Aveeks or months.
Most to be dreaded in this disease is the paralysis of
the respiratory muscles which is usually fatal.
Recent investigations have shown that our efforts to
overcome the paralysis which is left in about eighty per
cent of these cases should begin about six weeks after
the onset of the disease and that they should be con-
tinued for many months. This offers a wide and useful
field for nurses AAdio are Avilling to undergo the special
training required for the analysis and treatment of these
poor crippled children.
We have noAv finished the diseases peculiar to child-
hood. Before taking up the nursing and care of these
Ave will haA^e to consider some of the other infectious
and contagious diseases which may be found frequently
in children and which may then offer different problems
from the same disease in the adult.
Epidemic Influenza.—Few of you will remember the
pandemic of this disease which, coming from Asia in
the year 1889, traveled across Europe, thence across the
Atlantic Ocean to this country where it appeared first
226 NURSING IN DISEASES OF CHILDREN
in New York, later in Chicago, and then in other cities
of our Eastern States. It then crossed this continent
following ahvays the lines of travel, and thence returned
to its place of origin in 1891. By this mode of its spread
it is proved to be a typical contagious disease Avhich is
communicated through persons ill or recovered from it.
Since then only smaller epidemics have been observed.
The period of incubation is extremely short, from
twelve hours to three days.
Its cause is the bacillus influenzae of Pfeiffer, the portal
of entry of which is the mucous membrane of the throat
and nose, Avhere it AAdll frequently remain localized,
though it AAdll by no means rarely descend into the
deeper respiratory passages.
If you had undergone one of the attacks of this great
pandemia you would be sure to remember that, though
the disease lasts as a rule only from one to three days,
from the high feA^er, the intense pain in every muscle in
the body, the distressing backache and splitting head-
ache which accompany the coryza, the pharyngitis and
conjunctivitis that it is a general infection. In children
and especially in infants it leads very readily to an
otitis media Avith suppuration and also to a retropharyn-
geal abscess, bronchitis and pneumonia.
The Grippy Infections.—While the infection in in-
fluenza, as Ave have seen, is due solely to the bacillus
Pfeiffer, that in the so-called grippy infections, which
are often confounded Avith influenza, may be due to a
number of different germs. These grippy diseases, or as
they are usually called "colds," are endemic and they
represent not only the most frequent form of infection
in our climate but they are also most frequently ob-
served in childhood; some children seem to have a spe-
cial predisposition toward this kind of infection.
INFECTIOUS AND CONTAGIOUS DISEASES 227
The grippy infections are the most contagious of all
diseases. They are spread by everyone AAdio is suffering
from Avhat is still considered by too many people a sim-
ple cold and Ave can Avatch its spread through a family,
a school, a hospital or through a Avhole community.
The mode of infection is very easy to understand when
Ave remember that every time Ave open our mouth to talk
Ave propel a cloud of droplets for some distance from
our person every one of Avhich will hold a number of
these germs; Avhen Ave cough or sneeze these droplets
Avill be driven a good deal further.
Let me illustrate to you some of the ways by which
this contagion is most frequently spread.
A mother takes her baby out for an airing and meets
a friend AAdio has just bloAvn her nose because she has a
"cold." Her gloves are contaminated Avith the germs
and she immediately proceeds to pat the baby in the face.
Or, AAdiich is still Avorse, she proceeds to hug the baby
and most likely kisses it on the mouth. Do you Avonder
if this baby Avill have a coryza in tAvo or three days?
You may yourself have a coryza Avhile you are on duty
in the baby's Avard, or the attending physician, or in-
terne, Avill be so afflicted, A\diat more natural than that
the close contact into AA'hich you and they come with
the patients AviU infect some if not all of them?
A child goes to school and the teacher is coughing and
sneezing; she AAdll infect a large number of her pupils
Avho will come home and in due time spread the disease
all through the family.
I shall leave it to your OAvn imagination to picture for
yourself other modes of contagion, but I trust that this
Avill suffice to put you on your guard and that it
Avill teach you to be extremely careful AAdien you carry
this infection; that you should also protect your patients
228 NURSING IN DISEASES OF CHILDREN
at all times from the approach of Adsitors, even of mem-
bers of their own family whom you suspect of this.
You yourself should keep away from the patients when
you have even a slight'' cold,'' and where this is not pos-
sible you should wear a gauze mask before your mouth
and nose when around your duties. You may also re-
mind the physician to do so, when needed and he will
frequently thank you for your thoughtfulness.
In children's hospitals, orphanages and similar insti-
tutions every newly admitted case should be isolated for
about two Aveeks. Should one of the inmates show the
least sign of this infection he should be isolated by a
gauze tent being placed over his bed or by screens ar-
ranged around it and the beds should never be nearer
to each other than six feet. Still better is the most
modern Avay by which wards are cut up into cubicles
Avith glass partitions, so that you can supervise all the
children at once and that they can see each other with-
out being able to infect their neighbors. Where the ex-
pense of these glass partitions is prohibitive I have seen
excellent results from gauze screens.
Let me also Avarn you against using your handkerchief
on one of your little wards, and still more against the
Avorst of all offenders, the family handkerchief.
Now we shall see what may happen Avhen the con-
tagion reaches a child.
The period of incubation is very short, from one to
four days.
Then the child Avill have a dry swelling of the an-
terior part of the nose, AAdiich will last for about two
days, the nose is stuffed so that the child can hardly
breathe through it; in babies this may be entirely impos-
sible. Tavo days later the nose begins to run, Ave observe
a mucous discharge from the nostrils Avhich- will soon
INFECTIOUS AND CONTAGIOUS DISEASES 229
become mucopurulent and the eyes are reddened and
show an increased conjunctival secretion. The child has
Fig. 64.—The grippy infections.
a '' cold in the head,'' a coryza or anterior rhinitis. (Fig.
64, 1).
In some cases the disease Avill stop here, especially
230 NURSING IN DISEASES OF CHILDREN
Avhen measures are taken at once to arrest its extension.
Let me tell you right here that by the proper methods
we are able in a good many cases to arrest a further
spread of the germs in our patients by using energetic
means of treatment at any of the stages Avhich I shall
now describe.
Let us, however, assume that the disease is permitted
to folloAV its course, Avhich only too often is the case,
and we shall see hoAv the infection creeps into the back
part of the nasal cavity, we have a posterior rhinitis.
(Fig. 6-1, 2.)
Look at the anatomy of the postnasal space and note
the close proximity of the Eustachian tube and you will
at once find the explanation of the frequent compli-
cations in the middle ear.
This posterior rhinitis is quite liable to become sub-
acute or chronic.
The infection descends farther and the nasopharyn-
gitis (Fig. 64, 3) which results makes the child haAvk
and cough, in its efforts to remove the tough secretion
which avc may now see behind the soft palate. Also, es-
pecially in babies the tissues under the mucous mem-
brane in front of the cervical spine may become infected
and produce a retropharyngeal abscess.
In some cases the infection takes place through the
mouth, it settles upon the soft palate and the tonsils,
Ave have a pharyngitis. (Fig. 64, 4).
On the tonsils Ave will observe two forms of this in-
vasion, Avhich is also called angina. Either Ave observe
stripes of exudate so-called lacunar tonsillitis, or the
tonsils are studded AAdth one or more purulent cores, so-
called follicular tonsillitis. In severe infections the tis-
sues back of or above the tonsil are attacked, an abscess
forms, this is a quinzy.
INFECTIOUS AND CONTAGIOUS DISEASES 231
From the pharynx and the nasopharynx the disease
may go farther doAA'n into the larynx, a real sore throat,
laryngitis (Fig. 64, 5) with its dry, irritating cough,
and in some children pseudocroup.
Next it Avill attack the Avindpipe, tracheitis (Fig.
64, 6). Do you remember the last severe cold you had,
when you had that distressing cough and one morning
you Avoke up and you felt tight, and a burning sensation
behind the sternum at every inspiration and a pain
there"? Well, you then had a tracheitis.
Then the larger branches of the bronchial tree will
be inArolved, this is a bronchitis. (Fig. 64, 7).
When the smaller bronchi are included in the infec-
tion avc have to deal Avith a bronchiolitis. (Fig. 64, 8).
And finally the lung vesicles will be infected here and
there at the ends of these bronchioli we now have the
picture of that most dangerous condition found in babies
and young children and also in those suffering from
measles or Avhooping cough, a bronchopneumonia. (Fig.
G4, 9).
In cases Avhich go through all these stages usually two
Aveeks will elapse from the original coryza until the
bronchopneumonia. But let me tell you again that we
are able in a considerable number of cases to prevent
this progress and to arrest it at any one of the inter-
mediate points.
Pneumonia.—Croupous pneumonia differs consider-
ably from bronchopneumonia, in the former small lob-
ules of the lungs are infected here and there in widely
distributed areas, for this we call it also lobular, in the
latter either part or all of one lobe is attacked, this is
lobar pneumonia.
Lobar pneumonia is by no means as rare in babies as
232 NURSING IN DISEASES OF CHILDREN
we used to think, and in older children it is a very fre-
quent disease.
It is caused by the pneumococcus, of Avhich Ave noAV
recognize four different types. We have also learned
recently that the type of germ causing the infection de-
termines to a large extent the outcome of the disease;
some being more virulent than others.
In young children the beginning of the disease is not
characteristic, they appear ill, have fever, vomiting and
sometimes convulsions. In older children it starts often
with a chill as in the adult.
Quite frequently it is a very difficult matter to find
out the cause of this illness until the disease has reached
the outer parts of the lung so that Ave can find the
physical signs of it in our examination.
The inspection of the sputum is not of great help in
younger children because they do not expectorate until
they are about seven years old. We are, however, able
to obtain this sputum by making a child cough and then
catching it before the little patient has had time to
swallow it; this is of great importance when we want
to determine the type of the germ, as we have an efficient
vaccine against at least one of these types.
In both forms of pneumonia the infection upon reach-
ing the outer parts of the lung may attack the pleura
and we Avill then have a pleurisy. This may be ot the
dry kind, which is very painful or we may have a trans-
udate of serum, the so-called pleuritic exudate. Should
this latter become infected, perhaps by some suppurative
focus somewhere else in the body, thus as an otitis me-
dia, Ave will find pus in the chest, an empyema.
When the disease is in parts of the lung adjoining the
diaphragm the child may complain of a severe abdominal
pain as its most prominent symptom. This may make us
INFECTIOUS AND CONTAGIOUS DISEASES 233
think of abdominal conditions, as for instance appendi-
citis, and it is liable to be very misleading.
Typhoid Fever.—This disease is caused by the bacillus
of Eberth, AAdiich is transmitted by means of infected
water, either directly or indirectly, thus as milk and
other articles of diet which are liable to contamination
and are consumed raw. It is also transmitted by per-
sons who have recovered from the disease and who may
harbor the germs for years, so-called carriers.
I have stated before that this infection is preventable
and therefore a gauge of the hygienic as Avell as the
sanitary standard of a community.
We used to think that it was rather rare in infancy
and infrequent in childhood. We have learned, how-
ever, that this is not the case.
In babies the gastric symptoms may be so prominent
that the fever will run its course as a so-called gastric
fever; the older the child, the more will the type of the
disease approach that of the adult.
The temperature in a case of typhoid is usually quite
characteristic, the fever continues Avith more or less
severity for three weeks. (Fig. 65.)
From the tenth day of the disease Ave are able to make
a sure diagnosis from an examination of the blood, the
so-called Widal reaction of which I have spoken before.
In this disease, perhaps more than in any other, the
nurse must be on the lookout continuously, it is a disease
of surprises. She must examine every stool for the
least vestige of blood which may mean a hemorrhage
into the bowel. This may also be indicated by a sudden
drop in the temperature. (Fig. 66.) A rapid remission
of the fever with severe pains in the abdomen and signs
of collapse may be indicative of a perforation of the
boAvels,
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236 NURSING IN DISEASES OF CHILDREN
that she should overlook a danger signal and thus jeop-
ardize the patient's life.
Inasmuch as you can never tell Avhen you Avill be called
upon to take charge of a case of typhoid fever, you
should keep yourself immune by the preventive inoc-
ulation which is at the most an inconvenience for a day
or two, but which has proved itself to be a great boon
to humanity. Look, for instance at the statistics of the
morbidity and mortality from this disease in our huge
army now and compare it with that of the comparatively
few men in the Spanish-American Avar of 1898!
The Rheumatic Infections.—These infections Avhich
are due to a germ which has not yet been isolated appear
in three forms: The so-called acute articular rheuma-
tism, also called inflammatory rheumatism or polyar-
thritis (this is an inflammation of many joints); chorea
minor or St. Vitus' dance; purpura rheumatica.
Polyarthritis is rather rare in the first period of child-
hood; it is also frequently overlooked at this age and
the pains attributed to some trivial cause. We will hear
that a child which is very ill has had "growing pains"
for some time. The disease affects one joint after an-
other, sometimes returning to the same one several times
during its course. The child has high fever and suffers
greatly from pain.
Chorea minor is a peculiar infection which is usually
seen after the fourth year of life. It consists in gro-
tesque purposeless movements of different parts of the
body and it is at times so severe that we have to pad
the bed to prevent the patient from injuring himself.
In lighter cases these motions cease during sleep, in the
severe ones they are incessant.
Purpura rheumatica is a hemorrhagic affection of the
skin accompanied by high fever,
INFECTIOUS AND CONTAGIOUS DISEASES 237
These three forms of the rheumatic infection may at
times replace one another; the more so as one attack of
this infection predisposes for others. They are not local
but general diseases, and the most dreaded complication
is the inflammation of inner lining of the heart, the
endocarditis, which is observed in about seventy-five per
cent of the cases and will usually damage the valves in
the heart, leaving the patient handicapped for the rest
of his life.
Sepsis.—The septic infections are caused by the om-
nipresent germs of the streptococcus and staphylococcus
strains. With the knowledge we now possess of prophy-
laxis, of asepsis, and of antisepsis, we have been able to
reduce the number of these unnecessary and preventable
infections to a very large extent, but, Ave still do observe
them far more frequently than we should.
The younger the child and the more it has been weak-
ened, the more frequent will Ave observe these infections,
and the more dangerous will we find them to be.
I have told you before that infants suffering from
severe digestive disturbances, especially those who had
been overfed with carbohydrates, show a great disposi-
tion towards these infections.
Though these may at first seem to be localized, mostly
in the skin, the infection is a systemic one and its effects
may be far-reaching.
Sepsis is also a frequent complication of other infec-
tious diseases such as scarlatina and diphtheria, and they
will then make the prognosis much more doubtful.
We iioav come to the chronic infections in childhood.
Syphilis.—This disease is also often called lues and I
advise you to use this latter term when speaking to the
physician of the disease before the family of the patient,
238 NURSING IN DISEASES OF CHILDREN
but not to them, because this name is not understood by
the laity.
Syphilis is caused by a parasite, the Spirochaeta pal-
lida. In children Ave usually find it as a congenital hered-
itary disease; though the acquired may also be ob-
served, for instance A\dien it has been transmitted
through the Avet-nurse.
The most frequent early symptoms of congenital lues
are eruptions of all kinds upon the skin and a persistent
coryza during the first weeks of life which is accompa-
nied by a loud saAving noise at inspiration.
Sometimes the early symptoms may be so slight as to
be overlooked and then the disease will appear later in
childhood; then especially as an affection of the eyes,
deformities of the permanent upper middle incisors and
deafness.
The most important thing for these poor children Avith
congenital syphilis is that they should receive persistent
and long-continued treatment.
You should always be on the lookout for this disease
and you should call the attention of the physician to any
suspicious symptom, both for the sake of your patient
Avho may be saved considerable suffering by your Avatch-
fulness; and also for your oavii sake to guard yourself
against contagion.
Do not imagine that syphilis is a disease of the poor
and the slums only. You Avill be surprised how often
you will meet Avith it in the so-called best families.
Therefore, be on your guard all the time.
Tuberculosis.—This disease is caused by the bacillus
of Koch and it is usually taken into the body through
the respiratory tract.
It is very frequent in infancy and childhood, much
more so than Ave used to believe.
INFECTIOUS AND CONTAGIOUS DISEASES 239
You knoAV hoAV often Ave see young adults die from this
disease, but I do not think that you knoAV that twue as
many infants die from the same cause during their first
tAvo years of life.
Children are very susceptible to this form of infection,
the more so the younger they are, and unfortunately
the chances for their being exposed to it are A^ery great.
It is not necessary that a child be near the source of
infection for any length of time, one single exposure of
a A'ery short duration Avill often suffice.
Hoav many people do you think are going around un-
aAvare of the fact that they are thus infected?
Hoav many people Avho do know that they are afflicted
by this disease have taken the pains to acquire even the
first principles of hygiene and prophylaxis, so as to be
enabled to prevent their spreading this scourge of hu-
manity ?
Look at our public thoroughfares soAvn with expec-
torations, in spite of the signs prohibiting this filthy
habit. Sit in the street car and have the person on the
seat across from you cough Avithout guarding his mouth.
Go to visit a patient in the last stages of the disease and
Avatch him expectorate all over the floor. Observe these
and many other similar and equally unsanitary condi-
tions and you will no longer Avonder that tuberculosis is
prevalent and that those most susceptible to it, the
children, are its prey.
You aauII ask me how do babies get tuberculosis, do
they bring it into the Avorld, is it inherited?
No, it is not a congenital disease and only the disposi-
tion toAvards this infection is inherited.
Hoav do babies get it then?
Usually from the mother, or the nurse or some other
person that handles it. I have just come from a consul-
210 NURSING IN DISEASES OF CHILDREN
tation to see a baby seven weeks old which is dying from
tubercular meningitis acquired from its unsuspecting
mother.
The older infant learns to walk and it will then quite
naturally fall. Who was living in that house or flat be-
fore; has the father ascertained this before the family
moved in?
Not long ago I saw in one of my dispensaries four
children from one family. They had always been well,
and their father and mother were strong, healthy, clean
working people, the best kind of people we have in this
country, according to my opinion. Lately the children
had been ailing and one child had died; good reason for
them to worry. I found that everyone of these four
children had tuberculosis in some form or other, the two
other children were found to be suspicious upon exami-
nation. Where did they get it? I did a little investigating
and found that a feAv months before they had moved into
their present abode and that they inhabited the whole
cottage. Further investigation revealed the fact that be-
fore this family moAred in, a family of foreigners, one of
the unsanitary kind, had been living there and that the
head of this family had died there from tuberculosis. Do
you wonder any longer? Will you also believe me if I
tell you that the Health Department saw to it that this
cottage was disinfected and renovated?
A feAv days ago I saAV a child three years old die from
tubercular meningitis. It was sick only eight hours, so
the mother told me; her sister has been suffering from
a tubercular spine for several years.
The different forms in which we observe tuberculosis
in childhood do not vary from that in the adult except in
the lungs. We do not see anyAvhere near as much of this
in children, and then it is more in the bronchial glands
INFECTIOUS AND CONTAGIOUS DISEASES 241
than in the lung tissue. The glands are a favorite site
for tuberculosis in children anyhoAv, and you will now
easily understand this from Avhat has been said about
the function of the glands in infectious diseases.
Tubercular disease of the bones and joints, peritonitis
and meningitis are also preeminently affections of young
people. So is also the so-called miliary tuberculosis
(from milium the millet seed), meaning a sudden sow-
ing out of the infection all through the body when we
Avill find these small foci of the disease in large numbers.
Quiz
What is meant by the terms infectious and contagious?
What may happen when a germ invades the body?
What do we mean by the terms virulent and avirulent?
What is immunity?
Can we suffer from an infectious disease once only?
Are children predisposed to infections?
What is an antibody?
Which babies are more immune?
Why do we call a disease a disease of childhood?
What do we mean by the terms: sporadic, endemic, epidemic and
pandemic?
Does climate alone produce infectious diseases?
Are infectious diseases preventable?
May any infection remain localized?
Why do lymph-glands swell?
Why do Ave have fever in infections?
How may bacteria act upon the body?
What is antitoxin?
How does the injection of antitoxin act?
What do Ave understand by immunizing doses of antitoxin?
Can we tell if a person has antitoxin in his blood?
What are vaccines?
What is the agglutination test?
What is an exanthematous disease?
What is incubation?
What is the prodromal stage?
What is the stage of efflorescence?
What is the stage of desquamation?
Which are the most troublesome symptoms in measles?
242 NURSING IN DISEASES OF CHILDREN
What should we guard against in measles?
How is the desquamation in measles?
How is the desquamation in scarlet fever?
Which is the most dangerous part of scarlet fever?
For which complications must you watch in scarlet fever?
How long should a scarlet fever patient stay in bed?
What is scarlatina?
How would you describe chicken pox?
Should a child with varicella be permitted to scratch itself?
What is variola?
Is vaccination successful?
Should you be vaccinated?
How long does vaccination protect?
What is the lasting effect of smallpox?
What causes diphtheria?
Where do we observe the principal symptoms of diphtheria?
What is most to be feared in diphtheria?
Which are the stages of whooping cough?
What is most to be feared in whooping cough?
Why do we perform lumbar puncture in epidemic meningitis?
What is the other name of infantile paralysis?
What do we understand by grippy infections?
How do the grippy infections spread?
How can you prevent the grippy infections?
Which are the forms of pneumonia?
How would you get the sputum in a baby?
What is pleurisy?
What is empyema?
What should you look out for in typhoid?
How should you protect yourself against typhoid?
What is the scientific name for inflammatory rheumatism?
What are growing pains?
What is understood by chorea minor?
What should we fear in the rheumatic infections?
How can we prevent sepsis?
Which are the chronic infections?
What other name do you know for syphilis?
Can we see syphilis in babies?
How is tuberculosis transmitted?
What causes tuberculosis?
What precautions would you advise against the spread of tuber-
culosis ?
CHAPTER IX
THE NURSING OF SICK CHILDREN
The Premature.—The infant born before the normal
end of pregnancy is called premature.
It is placed into extrauterine existence in a stage of
development Avhich should normally still be passed in-
side the uterus.
The functional insufficiency shoAvn physiologically
even by the mature newborn is, therefore, more pro-
nounced in the premature, and this corresponding to the
stage of its development at birth. It shoAvs thus a lack
of vitality and an insufficient poAver of resistance toward
the demands of extrauterine life. This lack of vitality
is, hoAveA-er, only relative and it must not be confounded
Avith the absolute AA'hich is based upon a morbid dis-
position.
If Ave measure the groAvth of these infants not ac-
cording to the time of their birth, but according to the
time elapsed since conception Ave will find that it is about
the same as we would expect it to be in a normal infant.
In consequence avc aa ill see that the earlier the fetus is
born, the greater will be its relative lack of vitality and
the less will be its viability. The organs are, however,
fully able to perform their functions.
But, we must not forget that in many of these cases
an absolute debility or a morbid disposition will also be
found because the prematurity was due to sickness of
the mother of the fetus, with the result that it also may
then ha\re been born suffering from some illness.
The causes of premature birth are many and it may
243
244 NURSING IN DISEASES OF CHILDREN
not always be possible to determine with certainty
which one was at work.
The most frequent cause is syphilis. Other chronic
diseases of the mother are: tuberculosis, alcoholism, dis-
eases of the heart or kidneys, infectious diseases; also
local disease of the uterus, injury, or tAvin pregnancy.
Nor must we forget that the physician is at times
forced out of consideration for the health of the mother
to induce premature labor.
Clinically the temperature curve is of the greatest im-
portance in these cases as it indicates the weakness of
the whole organism. These infants usually show a con-
siderable drop in their temperature soon after birth,
down to about 85° F., they may then feel icy cold to
the touch, but this must only be regarded as a danger
signal if you should not succeed in bringing the tempera-
ture up to about 95° F. on the second day by artificial
heat.
Your first consideration should then be to keep these
babies warm, but not too warm, because they will very
quickly suffer from this.
As soon as the premature is born it should be quickly
wrapped in blankets and surrounded by hot water
bottles.
You should not bathe it, as the exposure in the first
bath may be fatal, but you oil it, and then wrap it either
in cotton batting or in a heated blanket.
In a hospital, or similar institution, you will often find
automatic incubators for these cases, or even incubator
rooms; but, the former are not quite easy to regulate and
are liable to get out of order; the latter are rather hard
upon the nurse. Still, Avhen obtainable and in Avorking
order they should be used.
We have found out experimentally that the most suit-
THE NURSING OF SICK CHILDREN 245
able temperature to keep these babies in is 86° F. and
never more, because this may prove dangerous for the
child.
In the private house, where these incubators can not
be obtained, you have to be satisfied by a makeshift of
your own, you can do this Avith a little ingenuity and
you will be pleasantly surprised hoAV Avell you may
succeed.
An easy way to do this is to take the child wrapped in
a blanket or in cotton, put it in its crib, or into a basket,
and then to place on each side of it tAvo hot Avater bottles
or quart fruit jars. One of these is changed every hour,
day and night, Naturally, you must be informed of the
child's body temperature by frequent measurements
Avith the thermometer.
Next in importance conies the respiration of the pre-
mature. Its center of respiration is underdeveloped,
and, for this reason, respiratory failure is a frequent
cause of danger or even death. Asphyxia and cyanosis
may set in suddenly at any moment during the first Aveek
of life. They are especially liable to set in after feeding.
You should, therefore, Avatch your little charge con-
tinuously so as to be ready to stimulate the Aveak res-
piration, either by taking the baby up and slapping it
and, if possible, making it cry, or by stronger measures,
such as a warm bath at 104° with cold showers over its
nape and back.
Atelectases, that is failures of parts of the lung to ex-
pand, are also frequently found in the premature.
Noav comes the grave question hoAV we should feed
these babies and what amounts.
They need a food of a high caloric value, because
their requirements are also high; depending upon the
stage of development at which they were born their de-
246 NURSING IN DISEASES OF CHILDREN
mand for food may be as high as 150 calories for each
kilogram they Aveigh.
In smaller prematures especially you will find it quite
difficult at first to administer any food at all. Giving the
breast is usually out of the question. When possible you
give the breast milk in the bottle, otherAvise you will have
to use the medicine dropper, Breck feeder (Fig. 31,
page 105), or gavage.
During the first few days you will sometimes have the
greatest difficulties in administering as much as two
ounces during the day and often you will have to be
satisfied if you can fulfill the baby's caloric requirements
by the end of the second or third week.
Mother's milk is the only food for these infants, but
unfortunately, oAving to the premature birth and to the
conditions which led to it the mother will, in quite a
considerable number of cases, not be able to furnish
even the small amounts needed. In such an event we
must try to get milk from some other woman. This is
comparatively easy in institutions but in private prac-
tice it is frequently very difficult, but possible.
About one year ago I was called into the country to
see the surviving one of eight months premature twins.
The little girl had weighed four pounds at birth, but
had gone down to three and one-quarter pounds AAdien I
first saAv her, Avhen she Avas seven weeks old.
The mother did not have any milk for her. On inquiry
I found that there were three nursing mothers Avithin a
radius of about three miles AAdio had strong healthy
babies.
When the urgency of the case was put before these
kind hearted women they gladly promised to let us have
all their milk they could spare.
For the next sixteen Aveeks the father of my little pa-
THE NURSING OF SICK CHILDREN 247
tient drove ten miles every morning to collect this milk
Avhich was given boiled in the bottle.
When the baby was thirteen Aveeks old these women's
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milk did not suffice any longer and we gave modified
cow's milk in addition after each feeding. At tAventy-
three weeks Ave could dispense Avith the human milk
altogether and the result of our feeding is illustrated in
the accompanying chart. (Fig. 67.)
248 NURSING IN DISEASES OF CHILDREN
If breast milk is unobtainable then we shall have to
resort to unnatural feeding, but this will lessen the
chances of the baby considerably.
What are the chances of the premature to survive?
Those weighing four pounds or more are relatively easy
to raise; those weighing between two and one-half and
four pounds offer some chance, the more the higher the
Aveight; under two and one-half pounds they Avill be
saved only very rarely.
Still, you must never give up hope and you must set
your pride in succeeding even against the heaviest odds.
I knoAV a young lady, iioav the mother of a family, who
only Aveighed tAvo pounds and two ounces at birth. The
loAvest Aveight I knoAV of in a premature that survived,
Avas in an institution where I had the pleasure of work-
ing ; this baby Aveighed one pound and nine ounces at
birth.
Next to feeding the greatest difficulty Avill be found in
guarding these babies against infection of any kind.
Even a mild coryza may prove fatal to them. You must,
therefore, insist upon it that visitors should be kept
aAvay from them. These poor little mites should never
be placed upon exhibition for the gratification of the
idle curious, and you must never lend yourself to attend
these infants in show places, no matter hoAV attractive
the offer of remuneration should seem to you.
Everything you use for the baby or which comes in
contact with it should be surgically clean, and you must
prepare your hands as if you were to assist at a lapa-
rotomy before you touch it. Then only may you expect
to be successful.
You will now ask me how long one of these babies
requires artificial heat, or how long it should stay in the
THE NURSING OF SICK CHILDREN 249
incubator. As soon as the infant is able to maintain its
body temperature and is at the same time gaining stead-
ily, though perhaps slightly, so soon may you gradually
begin to reduce the temperature surrounding it.
This must be done under the regular control by the
thermometer and the scales and if you should notice at
any time that the baby is losing in Aveight or that its
temperature falls beloAV the normal, then you must give
it more artificial heat at once.
I knoAV from obseiwation that some nurses have a spe-
cial aptitude in raising the premature AAdiich seems to be
lacking in others. I know one Avoman in an institution,
a practical nurse at that, avIio Avas so expert in this work
that all the premature sent there Avere placed under her
care, and the way she did succeed, even in seemingly des-
perate cases, Avas truly marvelous.
Infectious Diseases.—Except where the physician
takes these matters in his oavii hands, you Avill have to
take full charge of a little patient suffering from a con-
tagious or infectious disease and you have to make all
the arrangements in the house Avith tAvo points in vieAV.
First, you desire to give the greatest comfort and quiet
to your Avard; second, you Avant to prevent the trans-
mission of the infection to the other members of the
household.
When you are called to a case of this nature you should
take as nearly as possible everything with you which yOu
expect to use during the next feAv weeks, or even months,
for your own comfort and for your patient.
Do not forget to take a warm dressing gown and slip-
pers along; most likely you will have to get up at night
a good many times and you will require them.
Arrange your affairs so that you can stay any length
of time without worrying. I have often been able to
250 NURSING IN DISEASES OF CHILDREN
observe that a patient was made restless because the
nurse was getting fidgety in her anxiety to get through.
Remember that once you are on one of these cases you
can not leave until the patient has fully recovered and
the quarantine has been lifted; that you can not take
even a Avalk in the streets, much less enter a store, so
have a list ready of the things you knoAV from experience
you may require.
If you should be engaged for a maternity case for
about this time you should either refuse to go to an in-
fectious case or you should notify the prospective mother
that it will be impossible for you to take care of her.
You must not approach a maternity case for at least two
Aveeks after you have been looking after an infectious
disease, especially scarlet fever, or diphtheria, for fear
that you might transmit it to the young mother. You
must be familiar with the health laws of the state and
the community AAdiere you are nursing and you should
observe them faithfully.
When you arrive at the patient's house, first ask to be
shoAvn to a room Avhere you can change from your street
clothes to your uniform. Not only does the uniform
shoAv the family that you are ready for work, but it is,
and rightly so, a badge of authority; you also should
keep your street clothes free from contagion.
Noav, when properly arrayed, you approach your little
patient Avith a pleasant greeting and a smile. In children
even more than in adults, the first impression they get
of a stranger Avill determine their future attitude to-
ward him. You Avill haAre to live with the child for some
time; you will have to minister to him and most likely
have to do things to Avhich he will object, so try to be
on the best of terms Avith him from the very first moment
and show that you Avant to be his friend.
THE NURSING OF SICK CHILDREN 251
You Avill best not touch the child right away, but give
him a chance to look you over and get accustomed to
your presence. There is plenty of other work for you
to do as a rule.
If the physician has not done so before your arrival,
you must now proceed to choose a room for yourself and
the patient. In doing this remember that this will be
the only abode for you and your patient and that the rest
of the family have all the other rooms at their disposal
and also the porch and yard. Therefore you should pick
out the best room in the house. It should be located as
near the bathroom as possible and should be separate
from the rooms occupied by the rest of the family. It
should preferably be a corner room Avith a south and
east exposure and tAvo windoAvs. You should ask to have
Iavo rooms at your disposal if possible, so that the pa-
tient can be kept in one in daytime, and in the other at
night, and that one can ahvays be aired.
After choosing your room or rooms you proceed to
remove all the pictures, hangings, and upholstered fur-
niture, carpets, rugs, in short eA^erything which can not
be easily washed or disinfected.
Whenever possible you should try to get a so-called
hospital bed, otherwise pick out a high single bed for
your patient, Have a table or two in the room, also a
chair for the physician, an easy chair for yourself and
also a lounge or a bed for you to rest on; this is about
all the furniture you Avill require. For a case of measles
you should also have a screen to place betAveen the bed
and the Avindows to protect the eyes of the child against
bright light.
Of other things you require I may mention the bedpan,
a covered pail, some paper bags, gauze, absorbent cotton,
glasses, cups and drinking tubes for the patient.
252 NURSING IN DISEASES OF CHILDREN
Quite naturally you have brought along your oavii cer-
tified thermometer, bath thermometer and charts.
When attending your first case of an infectious disease
in a private house you will learn that a great difference
exists betAveen working in an institution Avhich offers
every facility, and the average household. If you should
find that you should need other things as the case pro-
ceeds do not hesitate to ask for them, provided you can
not get along without them. But, as I think I have told
you before, do not spend other people's money foolishly.
Learn to improvise, your patrons will surely appreciate
this and you will be astonished yourself to see how well
you can often get along Avithout a great many things
Avhich you thought were indispensable.
In this respect you should follow the example set by a
very able surgeon AAdio, in order to teach his students
that they did not require a lot of instruments for an
operation, removed an appendix having no other instru-
ment but a pair of scissors and a needle. Perhaps you
have yourself made the observation that he AAdio brings
the greatest array of instruments is not necessarily
also the best operator.
For the disinfection of the excreta have plenty of
a good antiseptic on hand, like crude carbolic acid, or
chloride of lime, they are better than many a one with
a high-sounding name and a corresponding price. You
may also Avring a sheet out of a solution of one of these
and hang it over the door of the sickroom or over that
part of the hallway which leads to it. Not that I think
that it will pre\~ent contagion, but it Avill serve as a re-
minder to the rest of the household to keep out of the
room.
Outside your room you should have a table on which
the food for yourself and the patient is to be deposited.
THE NURSING OF SICK CHILDREN 253
You should eat at this table and you must make it a
rule never to taste anything, not even drink a glass of
water in the sickroom. This is the only way in which
you can guard your oavii person against infection.
You should also never touch any of the dainties des-
tined for your patient, you would be shocked if you
heard the remarks made, usually unjustly, about a
nurse who does not heed this advice.
All the dishes, glasses, spoons, etc., used by your pa-
tient must remain in the sickroom and you should wash
them yourself.
Now, after you have seen to all these details, during
Avhich time your little charge has had a good chance to
look you over, you may approach him, smooth his pil-
low, perhaps as your first ministration and see to it
that his bed is comfortable.
The skin of children is much more sensitive than that
of adults; the slightest wrinkle in the sheet may make
them uncomfortable and cause decubitus, bedsores.
Pin the sheet doAvn at the corners, so that it will
stay smooth when the child throws itself around. Have
a draAvsheet under the buttocks so that you must not al-
ways change the whole bed and disturb your patient, in
case the child soils its body. Above all see to it that no
crumbs are left in the bed Avhen the patient is allowed
to eat breadstuff's.
Then you take the child's pulse, respiration and tem-
perature, note these on your chart and also all spe-
cial symptoms of the case, which may be of interest to
the physician.
Remember always that you are with the patient all
the time and that you have, therefore, a much better
chance to observe and study the case than the physician
who sees his patient only at intervals. You can be of
254 NURSING IN DISEASES OF CHILDREN
great help to him and at the same time best serve your
patient, if you note everything, even the slightest change
on your history. If you trusted to your memory you
might forget some essentials. Should any question occur
to you at any time note this on a pad, so that you are
sure to ask the physician about it, who will be only too
glad to explain any point of the case.
Your charts and bedside notes must always be written
up to the minute so that the physician can tell at a
glance what the condition of the patient has been since
his last visit. But, do not write doAvn any unessential
matters or things Avhich are self-evident. Let me tell
you confidentially, naturally, that the bedside notes
which I see daily are almost uniformly the most un-
interesting pieces of literature that I can imagine, they
bring so many unnecessary particulars that it is quite
difficult at times to find what I am really interested in
and Avhat I should know. Write your bedside notes
clearly and concisely, as you would write a telegram.
Remember that these notes are proof of your under-
standing of the condition of the patient and that they
should not be like the diary of a boarding school miss.
At the visit of the physician make your report in a
businesslike Avay and hand him your chart and notes.
Then help him in his examination so that he may proceed
rapidly and Avith the least disturbance of the child.
You should always have your pad ready so that you
can write down his orders exactly as he gives them, and
make sure that you have understood every one of them.
If you should be in doubt about any point do not hesitate
to ask questions; the physician will not mind your asking
these, but he will be annoyed if he is called on the phone
every little while to explain something Avhich he thought
he had made clear to you before.
THE NURSING OF SICK CHILDREN 255
I have found it to be a very good idea if the nurse
has such headings as food, medicines, baths, etc., written
on her pad so that she will not overlook a single im-
portant point.
It is also of the greatest importance that you should
report to the physician any unexpected or undesirable
effect of one of his orders. Remember we have to do
Avith individuals, not Avith cases, and that we can never
foretell hoAV a certain patient will react to any one
measure, no matter hoAV beneficial Ave have found it in a
large number of cases.
I can not impress upon your mind too often the les-
son that you must never degrade your noble profession
by working mechanically and making of it a mere handi-
craft, going on doing things because you have acquired
the habit of doing them. Especially if you nurse for
different physicians, and not for one only AAdll you soon
perceive that there are different Avays of getting iden-
tical results and that you may harm your patient by in-
sisting upon your accustomed method.
Another point which I consider of the very greatest
importance is that you should do your Avork right and
that you should Avatch your patient but that you must
not overAvork. Nothing is more annoying than to have a
nurse's health give out in the midst of a serious case
and to have a sick child get accustomed to a strange
face.
The physician may be so interested in his patient
that he does not realize that he is overtaxing your
strength. Insist, except it should be during the critical
stage of the disease and only for a day or two, that you
have eight hours out of the tAventy-four for yourself.
Take an airing daily and get sufficient sleep. From what
I have told you of infections you will realize, I trust,
256 NURSING IN DISEASES OF CHILDREN
that you will only be able to resist the invasion of the
germs if you keep yourself in good health.
Should your case prove to be a very difficult one and
should it require continuous attention and watching then
you should request the physician to give you aid by send-
ing a second nurse to relieve you.
When iavo nurses are on one case I have found it best
to suggest to them to take alternate eight-hour shifts.
For instance nurse A. is on duty from 10 p. m. to 6 a. m.,
nurse B. from 6 a. m. to 2 p. m., nurse A. again from 2
p. m. to 10 p. m., and so on; in this Avay each nurse gets
one full night's rest eA~ery second night and she is still
at hand in case of urgency.
Let us noAV rapidly pass before our mind's eye the
different infectious diseases and the special care each one
of them may require.
Measles.—This disease requires special attention to
the respiratory organs. The most prominent symptom
and the one Avhich distresses the child most is the dry
cough which usually racks its body and prevents sleep.
If you find that your little patient is getting exhausted
ask the physician for a narcotic; a good sound sleep Avill
often do more good than anything else. Also get the
permission of the physician to employ a croup kettle and
a steam tent over the bed, this Avill frequently relieve
this cough quickly.
Keep the nostrils and upper lip Avell greased with some
simple ointment such as zinc oxide salve or cold cream.
The discharge from the nose causes excoriations, sores.
The eyes should be bathed frequently and the dis-
charge from them be removed carefully; the eyelids
should also be covered with the same kind of ointment.
See to it that the temperature of the room is ahvays
about seventy degrees and avoid any chilling of the
THE NURSING OF SICK CHILDREN 257
child, but the air in the room should ahvays be good;
and remember that fresh air does of necessity mean cold
air.
Do not pull the shades down and have the room en-
tirely dark, as I have found it so often; as I have told
you before a screen around the bed to keep out the direct
light is sufficient; you can not do your work well, nor
keep things clean in the dark, and it also makes many
children restless. ■
In this disease you should be quite sure that neither
you nor anybody else Avho comes near the child is suf-
fering from a coryza.
Watch the patient's breathing, note any sign of dysp-
nea or any change in the cough.
If the rash should not come out well, a condition
greatly dreaded by the laity, you may bring it out by
the administration of hot drinks and a Avarm bath or a
hot bath; this Avill tend quite frequently to relieve the
minds of the family.
Do not be afraid of bathing these children, though
this should be done cautiously Avithout exposing them.
Formerly measles Avas often mistaken for smallpox on
account of the filthy condition in Avhich patients were
kept as a rule owing to the fear of the external applica-
tion of Avater which still possessed the people.
The hardest time in this as in many other infectious
diseases will be during the period of convalescence Avhen
the careful physician insists on keeping his patients in
bed while they feel entirely Avell and want to get up
and play.
Noav aa ill be the time when you can show if you are
a good nurse for children or not. You Avill have to think
up all kinds of innocent, quiet entertainments for the
benefit of your little charge. You must be a good story-
258
NURSING IN DISEASES OF CHILDREN
teller and you must be able to tell long forgotten fairy-
tales, or make these up on the spur of the moment.
Learn how to cut out paper dolls and such things. In
older children spelling "bees" between you and them
are a source of great amusement especially if you let
the child beat you occasionally. In short you should be
able to keep the child quiet, and at the same time in-
terested so as to make it forget that it has to be in bed,
but that it will rather dread the time when it has to get
up for fear that these amusing hours will be no longer
his.
Many a friendship can you thus form for life, and
how many a time have I seen hot tears coursing down
the little faces at the parting of the dear nurse.
Scarlet Fever.—Here your first and principal attention
should be directed toward the affection of the throat.
Watch its condition and inform the physician at once
of any change for the worse. Be as gentle and at the
same time as thorough as possible in swabbing or spray-
ing out the throat, as the physician may have ordered.
Naturally the child will not like these procedures, but
with some tact and the proper amount of sympathy it
will let you do anything not so much for its own sake,
but rather because it is afraid of hurting your feelings
and thus losing your friendship or respect.
The pulse must be carefully counted and the slight-
est irregularity or change in its quality reported.
Be on the lookout for any puffiness or SAvelling around
the eyes, or at the ankles which may be the first sign of
a disturbance in the function of the kidneys.
Keep an exact record of the amount of urine passed
in each twenty-four hours, a lessening of this should be
reported to the physician at once. You have learned in
your training how to examine the urine; do this every
THE NURSING OF SICK CHILDREN 259
day in these cases. If you should not have a test-tube
nor any chemicals, an old spoon and a candle, also a
little vinegar, will make it possible for you to make a
rough test for albumin.
When the child appears to be sleepy make sure that
this is really not coma from heart failure or uremic
poisoning, also that it is not due to a beginning un-
consciousness, the first sign of an affection of the brain.
If the child should complain of pains in its joints this
may be due to a peculiar form of arthritis observed in
this disease. Wrap the affected joints carefully, and
place them in the most comfortable position upon pil-
lows, this AAdll saA^e your patient considerable suffering.
In this disease you must be prepared at any moment
for sudden and unexpected complications which may
set in at any time when the case seems to be progressing
very nicely and you least expect anything to happen.
Do not be caught napping.
When scaling begins you can further the act of des-
quamation by warm baths and by anointing the skin
Avith cocoa butter or sAveet almond oil.
Chicken-pox.—Chicken-pox may become hemorrhagic,
but do not alloAV yourself to get frightened by this, it
does not influence the course of the disease.
Watch carefully for any symptoms from the kidneys,
though this does not often arise in this mild infection.
Most important is that you should prevent the child
from scratching itself and thus to avoid secondary in-
fection. This is not always quite easy. But make the
child as comfortable as possible, keep its skin clean and
well anointed to lessen the itching. Above all keep its
mind occupied to turn it aAvay from its oavii body.
For the mucous membranes have simple antiseptic
washes. In girls you should place a pledget of ab-
260 NURSING IN DISEASES OF CHILDREN
sorbent cotton soaked in one of these between the vulva,
because secondary infection is here more "difficult to
prevent, and nasty ulcers may form.
Smallpox.—In a case of smallpox of even medium
severity you Avill be kept more than busy in trying to
make your patient at least tolerably comfortable.
Most annoying is the development of the eruption on
the palms of the hands and the soles of the feet and also
on the mucous membranes.
Watch the eyes very carefully, not infrequently one
or more pustules Avill deA'elop on the cornea AA'hich may
not only mean defective vision but permanent blindness.
Before and during the stage of suppuration antiseptic
baths, especially with potassium permanganate, may
make the patient a great deal more comfortable and
lessen the chance of pitting.
We do not see of late the really severe cases of this
disease as older writers used to report them.
Diphtheria.—In your anxiety to overcome the symp-
toms in the upper respiratory passages you should not
forget that this is a very severe general infection in
which of the internal organs the heart and kidneys suf-
fer most severely.
Naturally you must be most assiduous in carrying out
the physician's orders as to the spraying or swabbing
out of the nose and throat thoroughly and to the minute.
But, you must also Avatch the child's respirations care-
fully so as to call the physician at once when you notice
any interference with this. He may be able to relieve
the obstruction by intubation or tracheotomy and thus
save even desperate and seemingly hopeless cases.
You will also have great difficulty with the apathy
and aversion for food in these patients and you must
use all your ingenuity in making them eat. Put only
THE NURSING OF SICK CHILDREN 261
small amounts of attractive food on the plate, a floAver
or a little bit of green Avill often make the food more
attractive and the patient Avill taste it from curiosity.
A little milk served in a new cup Avith a picture at its
bottom may help you; also food cut up into curious
figures and patterns, anything to aAvaken the child from
his apathy and to arouse his lagging appetite.
Watch the pulse very carefully and note even the
slightest change in it. Also look out for danger signals
from the kidneys and keep a record of the amount of
urine passed daily.
In children avIio have been intubated you must guard
against their pulling out the tube and you must notify
the physician at once. I, personally, believe that cases
AAdiich have been intubated should either be in the hos-
pital or a physician should be in attendance at the home
all the time.
I do not expect you to be as experienced in diphtheria
as is one reATered Sister in an institution abroad, AAdio
has been in charge of the diphtheria Avards for more
than thirty years. Upon the day of the two-thousandth
case of diphtheria, the life of which had been pre-
served by intubation, all during her term of service, the
medical director of the hospital placed upon the Avail of
the building a bronze tablet in memory of the late Doc-
tor O'Dwyer of New York, who introduced this life-sav-
ing operation. This Sister knoAvs exactly the time when
intubation is urgent. And further than this, once when
one of her little charges had pulled out the tube and
there Avas danger of his suffocating before the arrival of
the physician, she performed the intubation herself and
thus saved the child.
You must, hoAvever, be familiar Avith the instruments
262 NURSING IN DISEASES OF CHILDREN
used in intubation (Fig. 68), so that you can clean them
and you must know what assistance is required from
you.
You must also knoAV thoroughly the instruments
Fig. 68.—Instruments for intubation.
Fig. 69.—Tracheotomy tube.
needed for tracheotomy and the way this operation is
performed, and it is necessary that you can take out the
inner tube and keep it clean or remove obstructions
from it. (Fig. 69.)
THE NURSING OF SICK CHILDREN 263
After intubation and tracheotomy, and also if there
should be a paralysis of the soft palate, you must be
very careful Avith the feeding. These little patients
often can not take liquids; these may go into the wrong
passage or may come out through the nose, because the
soft palate can not close the nasopharynx during the
act of SAvalloAving.
You must feed these children Avith semisolid foods.
You will ask me, Iioav are Ave going to give them water
or other liquids A\diich they are surely in need of?
All you have to do is to make the liquids semisolid
by the addition of gelatin or agar-agar and the child
AAdll not only be able to sAvalloAv them but will also
enjoy them.
Remember that convalescence from this disease is very
sIoav, and that these patients must be kept upon their
backs for at least tAvo weeks after the disappearance of
all symptoms.
In some cases the blood vessels may be so severely
damaged that the slightest injury, as from a hypodermic,
will leave a black spot. Do not fail to tell this to an
anxious mother.
By no means rarely do Ave see a rash appear about
ten days to tAvo Aveeks after the administration of anti-
toxin. This is called serum-exanthema; it may be itchy
and trouble the child for a few days, but is nothing
more than an inconvenience, Avhen we think of the bene-
fit derived by the antitoxin.
Whooping Cough.—The convulsive stage of this dis-
ease should run its course Avithout any fever, any eleva-
tion of temperature should, therefore, very carefully be
watched for, as this will be the first sign of a complica-
tion by a secondary accidental infection such as an
otitis media or bronchopneumonia or the recrudescence
264 NURSING IN DISEASES OF CHILDREN
of an old tubercular focus. You must for this reason
take the temperature regularly all through the disease.
During the attacks of coughing, and the vomiting
Avhich frequently accompanies them, you should hold the
child's head, remove the mucus from the mouth, and
otherAvise make it as easy for the child as you can.
Should the child vomit immediately after eating or
the administration of medicine then this should be re-
peated at once when the attack is over. You will be
astonished at first to observe hoAV a child after passing
through one of these paroxysms and the severe vomiting,
Avill be quite happy again at once and relish its food.
The number of these attacks is determined, to some
extent at least, by the nerArous makeup of the child. By
your quiet demeanor in telling the child to resist the
impulse, you A\dll often be able to reduce their fre-
quency.
In severe cases with sixty or more paroxysms the
sleep of your charge will quite naturally be seriously
disturbed and you should make the child go to sleep as
often as possible to preserve its strength.
The heart may also suffer an acute dilatation in severe
cases, and you must observe the pulse very carefully.
Pure air is one of the first things needed by every
case of whooping cough.
Mumps.—This is usually such a light disease that you
Avill rarely be called upon except in an institution.
Keep the patient and especially the affected regions
of the face Avarm and Avatch out for possible, though
rare, complications on the part of the genital glands.
Epidemic Cerebrospinal Meningitis.—In this disease
Ave observe a condition of extreme irritability of the
sensitive and motor nerves. The child may resist the
lightest touch as unpleasant, or even painful. Strong
THE NURSING OF SICK CHILDREN 265
light, or a loud noise, Avill affect it similarly and the
little patient is Avorried every time anybody approaches
his bed. He is restless on account of the headache and
neuralgic pains he suffers.
You must keep these children extremely quiet; Avear
slippers, and walk on tiptoe, so as not to cause any
jarring of the bed. The rustle of starched clothes, or a
silk petticoat Avill annoy him. The room must be in
semidarkness and at night the lights should be shaded
toAvard his bed.
The skin is very sensitive and the lightest touch will
leaA'e a red mark.
Feeding is very difficult in this disease. Not only is
it interfered with by the nervous vomiting, but the child
has entire lack of appetite and usually severe diarrhea.
One case I remember Avell; the people Avere poor and
could not afford a nurse and I kept this patient from
starvation by administering food by rectum and through
the stomach tube during six weeks.
An ice cap to the head is often of benefit and also hot
packs and hot baths to reduce the nervous irritability.
Pneumonia.—Both forms of this disease, broncho-
pneumonia, as Avell as croupous pneumonia will demand
a great deal of your attention.
The primary location of the disease will necessitate
your Avatching the respirations and observing if the
child gets enough oxygen. On your chart you must note
the number of respirations per minute very carefully,
because an increase in the rate may mean a further in-
volvement of lung tissue, Avhile a decrease may be due
to increasing Aveakness of the patient.
The pulse aa ill tell you the condition of the heart,
which AAdll be affected both by the interference with the
circulation and aeration of the blood and by the poison
266 NURSING IN DISEASES OF CHILDREN
absorbed from the lungs which permeates the Avhole
body.
The temperature is a good indication of the condition
of the child in croupous pneumonia. Do not, however,
regard the first drop in the temperature as a sign of the
beginning crisis. Frequently you will see a remission of
the fever, a so-called pseudocrisis, followed by a renewed
rise, and then the real crisis with its rather sudden drop
from high temperature to a subnormal one.
This is the time when you must watch the heart even
more carefully because collapse may set in due to the
weakened condition of the whole system.
In bronchopneumonia the fever is quite irregular and
does not offer any indication of the condition of the
patient, except that a normal or subnormal temperature
may indicate to you a critical condition, especially if
the pulse and respiration should remain rapid, as this
Avill indicate that the child is so low that it can no longer
get up the normal reaction to the infection, namely the
fever.
The position in bed of children with pneumonia should
be changed frequently in order to prevent, if possible,
further involvement of the lung by hypostatic conges-
tion. Babies should be carried around and they will be
very grateful for the relief offered by this. Older
children may be propped up with a back rest.
The pain Avhich accompanies pneumonia is relieved
best by wet packs, and by the application of mustard
packs, which also ease the respirations.
These measures are also ATery useful in those cases in
which the poisoning of the whole system may simulate
a meningitis.
The air in the room should be of the purest but not
cold. Young and weakly children, especially, do not
THE NURSING OF SICK CHILDREN 267
stand cold air well. The atmosphere in the room should
be moist, this helps the breathing of the patient and
lessens the racking cough. You can do this by having
a steam kettle going in the room or by erecting a steam
tent over the bed.
Typhoid Fever.—Perhaps in no other disease is nurs-
ing of so great an importance as in typhoid. You must
be Avatching all the time.
You must note the number and quality of the stools;
the amount of food the patient takes; how much liquid
you are able to administer; Iioav much and how soundly
he sleeps; if his mind is clear, or if he is apathetic
or delirious.
We have given up the full baths in this disease which
Avere in ATogue a feAv years ago and we employ now
sponge baths to reduce the temperature and to stimulate
the patient. Children, that is most of them, object
strenuously to cold sponges and the excitement caused
by them may defeat our purpose. Sponge baths given at
a temperature of 5° F. below that of the body of the
patient, are quite as efficacious and not in the least
obnoxious to children.
These and an ice cap to the head will also often
diminish the restlessness so characteristic of this disease,
which has also been called nervous fever.
The patient should take considerable amounts of liq-
uid to keep the kidneys flushed out and to carry aAvay
the toxins by these means.
Nowadays avc feed these children a good deal more
than we used to do and we see them get up less
weakened. Sugar is the best food here to raise the
caloric Aralue and it is borne well.
When the temperature has come down, which it does
by lysis, you can never tell if this is the end of the
268 NURSING IN DISEASES OF CHILDREN
disease. One or more relapses may set in and protract
the disease considerably.
The Rheumatic Infections.—In rheumatic infections
your principal duty consists in making the patient as
comfortable as possible and in Avatching the pulse.
The former you succeed in by placing the affected
joints in the position which will best relieve the pain;
Avrapping them in cotton or flannel cloth and by ap-
plying heat.
The slightest irregularity or change in the quality or
rate of the pulse must be reported to the physician at
once, because this may mean the onset of an endocar-
ditis, which may either be fatal or leave your patient
an invalid for life.
At the slightest indication of an affection of the heart,
perhaps indicated only by an uncomfortable feeling,
or a pain in the region of this organ, you should, Avith
the permission of the physician, apply an ice bag over
this organ.
Let me tell you here that beneficent as the ice bag
often is in children it may be very dangerous if ap-
plied directly to the skin. Parts of the skin may be-
come frozen and later gangrenous. Ahvays place a
thick piece of flannel betAveen the skin and the ice bag
to prevent this unnecessary occurrence.
Children suffering from chorea minor should be kept
in bed and must be very quiet, as any excitement may
increase the choreatic motions, which Avhen severe will
exhaust the child.
No visitors should be alloAved. In the hospital these
patients should be placed in a private room, or their
bed be surrounded by screens; this is not only for the
sake of the patient himself; but also for the protection of
the other inmates Avho may acquire an imitation chorea.
THE NURSING OF SICK CHILDREN 269
The chorea may also make cheAving impossible, or at
least difficult, and Ave Avill have to be satisfied to ad-
minister liquids and semisolids. I believe that these
children should have a strict vegetarian diet.
AVarm baths folloAved by hot packs are very beneficial.
Tuberculosis.—An entire volume could be written on
the nursing and care of this infection and for this rea-
son I shall be rather short, though I fully realize the
importance of this subject. I think, however, that you
should either receive special instruction in this or that
you should take a postgraduate course.
Except Avhere the child is suffering from an acute
exacerbation of the disease, the object of your minis-
trations should be to strengthen its body and to make it
more resistant against the germ by the liberal applica-
tion of the two supreme remedies for this affliction:
Fresh Air and Sunshine.
These can be best procured in properly equipped in-
stitutions at the seaside or in the mountains. Day-
camps, floating hospitals and similar arrangements nave
also accomplished a great deal of good. But, unfortu-
nately, the accommodation in all these places is so woe-
fully below the number of those who really should be
able to enjoy them that Ave have to be satisfied Avith
makeshifts at the home.
Young children should be out of doors as much of the
day as possible and the mother should be taught that
they must sleep in a room the AvindoAv of Avhich is kept
open. Older children can spend their time on an im-
provised sleeping porch, Avhich can be erected at com-
paratively little expense, or they should sleep with a
AvindoAv tent.
The skin should be kept in the best of condition by
270 NURSING IN DISEASES OF CHILDREN
the liberal application of Avater, in older children cool
Avater.
In tubercular disease of the lungs you must be teacher
as well as nurse. You must imbue these children with the
principles of hygiene. You must impress upon them that
they must not endanger the lives of those dearest to them
by their carelessness; that they must dispose of their spu-
tum so that it can not do any further harm; and that
above all they must keep their hands as free from the
germs as possible.
I have a great admiration for those noble Avomen
among the nurses who have taken up the work of visit-
ing nurses to these poor unfortunates and I know from
observation how much they can do to brighten these
lives, blighted in the bud, so to say, and what splendid
results they achieve, many times against the heaviest
odds. I consider this one of the finest callings for some
of you Avho feel not only that you can do this work, but
also that you can love it.
Little can be done for the poor children with tuber-
cular meningitis, except to make them as comfortable
as possible.
I want to give you a Avord of warning, however. It
happens not infrequently that these little patients, after
days of unconsciousness Avill Avake up some morning,
sit up in bed, talk to you quite naturally and begin to
play. Do not let yourself be deceived, and above all do
not instill even a ray of hope in the poor, despairing par-
ents. This is not a sign of recovery. It only means that
the brain has become accustomed to the increased pres-
sure. This stage of brightening may last twenty-four,
or even thirty-six hours, then comes a relapse into un-
consciousness Avhich Avill soon be folloAved by death.
Quite different is the prognosis in tuberculosis of the
THE NURSING OF SICK CHILDREN 271
glands and to some extent of the bronchial glands.
Tliese children will be benefited greatly by your care
and by the right feeding. They require plenty of fresh
air and, where the family can afford it, a change of
climate at the seashore or in the mountains.
For these cases as well as for those of tuberculosis of
the bones or joints and of the peritoneum we have
learned during the last fifteen years that the sun treat-
ment, worked out by the Swiss physician Doctor Rollier,
has really done wonders in a great many cases when
employed in time; but you should not undertake this
Avithout special instruction in its application, and after
some institutional experience.
Other Diseases.—Though the care of infants and the
nursing of children suffering from one of the infectious
diseases will form by far the greater number of cases
in which you are called upon to take care of children,
they are, naturally, subject to other diseases as well, and
I shall noAv proceed to give you a fe\v salient points
avoiding as much as possible all repetition.
Medical Cases.—These will include chronic diseases of
the heart, either congenital or acquired during one of
the infectious diseases, of the kidneys, the digestive
organs, the respiratory organs and metabolic disturb-
ances such as diabetes.
In all these disorders your powers of observation will
many times aid the physician materially in arriving at
a diagnosis and in pronouncing his prognosis. The lat-
ter function, especially, is one Avhich is entirely within
the province of the physician and you should never al-
Ioav yourself to utter a single Avord about the possible
outcome of any illness no matter how light or severe it
may appear to you.
Do not give in to temptation, nor be coaxed into an
272 NURSING IN DISEASES OF CHILDREN
unguarded utterance by the anxious mother. Refer her
to the physician as the only one avIio may give her this
information, and even he will often find this impossible.
A rashly given opinion may and often will hamper
the physician in his Avork and also many times destroys
the confidence of the family in him.
As to your making a diagnosis and speaking of this
to the family, that is too preposterous to discuss even
here.
But be sure to communicate to the physician all your
observations, no matter how trivial they may appear to
you. Do not be afraid of being laughed at. An expe-
rienced physician will always appreciate your efforts to
help him and he will be only too glad to explain to you
the importance or unimportance of any symptom, be-
cause he realizes that you can do your best work only
Avhen you fully knoAV what is expected of you.
In diseases of the heart the pulse is of the greatest
bearing upon the case. Watch it carefully and note any
change in its rate, quality and fullness; also if it is
irregular or not.
In these cases as well as in diseases of the kidneys
the urine should also be measured carefully, its daily
quantity and the number of times it is voided must be
noted on your chart. Tell also about its color, its odor,
if it is clear or turbid, or if it contains any abnormal
admixtures. Also if its passage seems to cause pain or
irritation. Have a sample ready for the physician every
day.
In disturbances of the digestive organs you will have
to Avatch the amount of food taken, if it causes any
distress or eructations of gas. Watch for nausea, A\diich
is not quite easy in children. If the child vomits you
should knoAV Iioav soon this happens after taking food;
THE NURSING OF SICK CHILDREN 273
if it Avas Avith retching or without any effort, how it
smelled and looked; if it showed any undigested food
or Avas only bile-stained mucus. Also keep it for the
inspection of the physician.
The stools also deserve your closest attention. Their
color, odor, reaction, if acid or alkaline, the frequency
of their passage, if they demand considerable effort, or
are squirted out or run off at all times; the amount of
gas passed Avith them or independently; if they contain
mucus, blood, undigested food, particles Avhich look like
parasites, or shreds of mucous membranes; also if they
are passed involuntarily. Keep the last stool passed, or
anyone Avhich seems to you abnormal for the inspection
of the physician.
In respiratory diseases the character and rate of res-
pirations must be noted; if they are easy, labored, deep,
or superficial, regular or intermittent; if there appears
to be any obstruction, and where this seems to be
located; if they are equal on both sides or if one side
hangs back.
A very important sign is if the child can rest equally
Avell on both sides or only on one side.
We can learn a great deal from the cough of our pa-
tients ; if it is dry or loose, or changes from the one into
the other; if it is painful, labored, or Avithout effort,
the duration of coughing spells and when these occur;
if they are massed together at certain times of the day
or night, or come at all times; if they awaken the little
patient or do not let him sleep.
Much may also be told from the examination of the
sputum. In small children it is SAvallowed, but you may
obtain it in these even as I have told you before. Its
color, odor, quantity, quality, if mucous or purulent, if
it comes in gushes, or only occasionally, all these condi-
274 NURSING IN DISEASES OF CHILDREN
tions you must observe. The physician Avill also often
require a sample of this for microscopic examination;
you should then make sure that it is really sputum and
not saliva which you have put into a Avide-necked bottle
for him to take along. Be also sure that none of it ad-
heres to the outside of the bottle.
Should there have been a hemorrhage from the lung
keep it and the bedclothes, etc., AAdiich have been soiled,
so that the physician may learn of the amount of blood
lost.
In metabolic disorders and also in the disturbances of
the digestive organs the quality and quantity of the food
is of the greatest importance. The nurse must be a good
cook as Avell, so that she can make even the most limited
diet attractive to the child. Many times Avill you be
required to Aveigh every bit of food AAdiich you give and
how much of it the child takes and to keep a careful
record of this.
Let me tell you that I have found really good die-
titians rather rare among nurses, and I think more at-
tention should be paid to this branch in training schools.
Do not forget that children get tired very easily when
they are given about the same things day after day. Use
your ingenuity and if you can not change the things you
are allowed to offer, you can at least alter their appear-
ance and thus deceive the child, and make it take the
same things which it has refused before.
Surgical Cases.—The care of children after operations
is about the same as in adults. Only remember that dur-
ing the operation their bodies must be exposed as little as
possible and that they suffer from shock the more the
younger they are.
They do not stand prolonged operations very well but
the effect of the general anesthetic wears off in them
THE NURSING OF SICK CHILDREN 275
much quicker, nor does it cause as much vomiting as in
the adult.
You must be an expert in bandaging and you must be
able to reneAv this at once A\dien soiled without disturb-
ing the site of the operation. The bandage should be
applied snugly and still must not press upon any part of
the child's body.
Use only zinc oxide adhesive plaster in children, and
as little as possible of this because it produces irritation
quite readily.
See to it that the child is placed in the most comfort-
able position and that it is turned over whenever this
is permitted.
When plaster of Paris casts have been applied to a
limb Avatch the color of the fingers and toes, if they
should get blue and numb or cold, notify the surgeon at
once because this is an indication that the cast is too
tight, and has interfered with the circulation.
Also Avatch the edges of the cast that they do not cut
into the tender skin and flesh; and report to the physi-
cian as soon as you notice a bad odor arising from under-
neath the cast.
The child must remain in bed quietly and it must not
be permitted to throAV itself around or to change its
position Avithout your aid.
If Aveights should have been employed you must be
Arery careful that they really have the desired effect and
that the little patient has not changed its position in
bed, so that the Aveights can no longer exert their trac-
tion.
After operations on the nose or throat one must look
out for secondary hemorrhage. Even after as slight an
operation as that for the removal of adenoids or en-
276 NURSING IN DISEASES OF CHILDREN
larged tonsils the child's life may be endangered by the
continued flow of blood which the child will swallow.
Should a tampon have been placed into the nostril
children are very apt to remove this unbeknown to you.
Nervous diseases are perhaps the most difficult cases
you will be called upon to take care of. No other dis-
turbance will demand so much of your attention, so
much tact and judgment on your part.
Watch the child's every move. Be on the lookout for
even the slightest spasm, change in speech or in dispo-
sition. The mental attitude of the child may undergo
strange involutions. Frequently a child av!io has 'been
your pet and Avho seemed to be very fond of you Avill
suddenly turn against you so that you can do nothing
with it any longer. Do not let this hurt your feelings,
but remember that the child is ill and, therefore, not in
his right mind.
With these nervous children you must be firm and
quiet, do not lose your temper, hold yourself well in
hand, and you will eventually Avin.
You must be acquainted Avith the different forms of
delirium and of convulsions, so that you can describe
everything that happened to the physician.
Diseases of the eyes demand frequently the instillation
of drops or the application of ointments into the con-
junctival sac' and this is not ahvays easy to perform;
the child may fight you off or shut its eyelids so tightly
that you can hardly open them. Still it is essential that
this should be done and done Avell. Do not hesitate to
ask some member of the family to help you, and be sure
that the drug is really applied where it should be.
In infections of the eye you must make all applica-
tions exactly as ordered by the physician and by the
THE NURSING OF SICK CHILDREN 277
Avatch to the minute. Any neglect on your part may
mean permanent blindness for the little patient.
If the eyeball itself should have been injured or at-
tacked by the disease be very gentle and most careful
for fear the eye may rupture in a struggle.
Skin diseases require most of all that you prevent
the child from scratching itself. This may not only
aggravate the original lesion but it is almost sure to
cause secondary infection Avith pus cocci, or, if the dis-
ease of the skin should itself be of an infectious nature,
it may be the means of spreading it to other parts of
the body.
It is useless to apply ointments to scabs or crusts on
the skin. You might just as Avell put the stuff on the
Avail. Soak off the crusts first Avith oil, or remove them
Avith a forceps, and then apply your medication.
If an ointment should have been ordered to be applied,
put it on thick enough. It has been placed into your
hands to be used for the patient, not to be preserA^ed.
Medicated baths are often administered in these cases.
Make sure Avhat kind of bathtub Avill be best for the
particular bath to be given. Some drugs attack metals
and are changed by these and become inert or form
entirely different compounds.
Be careful of your oavii hands and person that you
do not become infected yourself. Better Avear rubber
gloves when taking care of infectious skin diseases.
Quiz
What is a premature?
Which are some of the most frequent causes of premature birth?
What must you watch most carefully in premature?
How should you care for a premature newborn?
What is the best temperature to keep the premature in?
Why should you watch the respirations of the premature?
What is the caloric demand of the premature?
278 NURSING IN DISEASES OF CHILDREN
How may you feed a premature?
What is the best food for the premature?
How would you determine the chances of a premature to survive?
Why and how should you prevent infection of the premature?
How long does a premature require artificial heat?
How would you choose a room and prepare it for the care of a
child suffering from an infectious disease?
Should you take care of a maternity case after one of the in-
fectious cases?
How would you protect the eyes of a child ill of measles?
What do you need in the patient's room?
Where should you keep the patient's dishes, etc.?
How should you prepare the bed?
Wliat should go into your charts and bedside notes?
Why should we individualize?
Why should you look after your own health?
How would you care for a child ill with measles?
What is the best room temperature for a case of measles?
What should you do for a child during its convalescence?
How would you care for a case of scarlet fever?
How would you care for a child ill with chicken pox?
How would you care for a child suffering from smallpox?
How would you care for a child ill with diphtheria?
What is intubation and when is it done?
How would you feed a child which has a paralyzed palate?
What is serum exanthema?
How would you care for a case of whooping cough?
What would you do for a child with mumps?
What would you do for a child with cerebrospinal meningitis?
How would you care for a child ill Avith pneumonia?
Could you tell from the temperature chart if a child has broncho-
pneumonia or croupous pneumonia?
Would you keep the windows open when taking care of a young
child ill with pneumonia?
How would you take care of a case of typhoid fever?
How would you take care of a child ill with inflammatory rheu-
matism?
How should you apply the ice bag to a child?
How would you care for a case of chorea?
What have you to observe when taking care of a child suffering
from tuberculosis?
THE NURSING OF SICK CHILDREN
279
What is the Rollier treatment?
Should you pronounce the diagnosis of a case?
What should you observe about the pulse?
What must you know of the urine of a sick child?
For what should you examine a child's stools?
What should you observe in a child which vomits?
What is important in the respirations of a sick child?
What is important about the cough of a sick child?
How should you preserve the sputum for the physician?
How can a physician estimate the amount of hemorrhage from
the lungs?
What must you know about the diet of a sick child?
What must you observe in a child which has been operated?
How would you take care of a child which has a plaster cast on?
For what should you watch after an operation for adenoids or
removal of the tonsils?
What is to be observed in children suffering from some nervous
disorder?
What is your duty in children with eye diseases?
What should you do for a child with skin disease?
CHAPTER X
PUBLIC HEALTH NURSING OF CHILDREN
By Mrs. A. L. Hansen, R.N.
Modern public health nursing is an outgrowth of the
simple form of charity practiced in the centuries before
the Christian era in India, Greece and Rome, by the
early Christians and the JeAvs of that day, Avhen it be-
came incumbent on all religious persons to visit the sick
in their homes and to offer aid and sympathy.
It is a far cry from the crude services of the early
days to the efficient nursing and instruction given in
homes by the modern public health nurse, but the great
underlying qualification for the nurses has remained the
same.
Miss Gardner, superintendent of the Baltimore Visit-
ing Nurse Association, in her book on Public Health
Nursing says: "Every public health nurse would do
Avell to know by heart St. Vincent de Paul's beautiful
description of the calling of the visiting sisters given in
the middle of the seventeenth century, for it is ap-
plicable to our modern nurse. 'Their convent must be
the home of the sick; their cell the chamber of suffering;
their chapel the parish church; their cloister the streets
of the city; in the place of the rule AAdiich binds nuns to
one enclosure there must be the general vow of obedi-
ence ; the grating through Avhich they speak must be the
fear of God; the veil Avhich shuts out the Avorld must
be holy modesty.' "
The nurse Avho seeks to do public health Avork because
280
PUBLIC HEALTH NURSING OF CHILDREN 281
it is steady and part time duty, or because she dislikes
night Avork, is not going to make a success of it.
The public health nurse must have good health and
great poAver of endurance Avhich enables her to con-
tinue her daily rounds through the storms of Avinter and
the relentless heat of .summer. She must have executive
ability, be resourceful and cooperative, have such edu-
cation as Avill enable her to meet Avith the college gradu-
ate in social Avork on common ground; she must possess
teaching qualifications, be enthusiastic, have a keen
sense of humor, be tactful, firm and determined.
The public health nurse must be graduated from a
hospital of the first class and must be registered in the
state in Avhich she nurses. The standard is high, but
not too high for qualification for one av!io must occupy
the position of trust given to a public health nurse.
The salary paid the public health nurse is not so large
as that paid institutional or piwate nurses, so no one
Avill go into the service for financial reasons alone. There
is usually a period of tAvo or three months' probation
asked by Adsiting nurse associations, during AAdiich time
the salary is Ioav and at the end of the period the nurse
if she chooses or is acceptable to the association is placed
on the regular staff. The salary for staff nurses ranges
from $840 to $1,080 yearly, for supervisors $1,200 to
$1,500 yearly, and superintendents from $1,800 up.
Superintendent.—In visiting nurse associations there
is a superintendent in charge Avho is Avell trained in
general public health nursing, and Avho should possess
great poAver of diplomacy. The duties of a superin-
tendent vary from those toAvard the board of managers
and the nursing staff, to those connected Avith other
social agencies and the general public. She must be
282 NURSING IN DISEASES OF CHILDREN
able to speak at public meetings, and tactfully represent
her association at community gatherings.
Supervisors.—The supervising or head nurses come
in direct daily contact with the staff and patients. Where
substations are used in addition to the general office,
the supervisor there meets her group of nurses for daily
conference and receives reports. She is directly respon-
sible to the superintendent for all matters concerning
the districts in her charge. The supervisors are usually
postgraduates from a school of public health nursing.
They must have had a varied experience in public health
Avork.
Office.—The general clerical work of the office is done
by an ordinary clerical force. It shows great lack of ef-
ficiency to employ nurses for this purpose. In very large
associations a nurse office supervisor is sometimes em-
ployed, but, as a rule, a professional woman is not
needed and of much more use on the nursing staff.
Postgraduate Courses.—Many of the larger associa-
tions noAv offer a postgraduate course in public health
work, usually in connection Avith a university. Nurses
desiring information in regard to these courses can ob-
tain it from the National Organization of Public Health
Nursing in New York City.
To one ignorant of public health Avork it would seem
that such intricate organization is not necessary for the
care of the sick in their homes. Actual bedside care is
only a fraction of the work done, the duties are so
numerous that Avithout good organization and system
the work could not be done efficiently.
Equipment.—The uniform most generally adopted for
visiting nurses is a dress of blue gray, with turned down
collar and soft linen cuffs; a long blue coat, heavy in
Avinter, light Aveight for spring and autumn, and a plain
PUBLIC HEALTH NURSING OF CHILDREN 283
black hat. (Fig. 70.) The nurse carries a bag equipped
with packages of sterile gauze and cotton, adhesive
plaster, roll of old clean linen, two sizes of bandages, two
bottles of alcohol (one used only for sterilizing the
thermometer), lysol, boric acid crystals, permanganate
Fig. 70.—District nurse in uniform.
of potash, sweet oil, zinc oxide ointment and powder,
and green soap. A linen case is provided to hold cathe-
ters, douche nozzles, etc., a fountain syringe is kept in
another bag of stout linen and a small pus basin goes
into another. Two aprons, towels and paper napkins,
284 NURSING IN DISEASES OF CHILDREN
together Avith a supply of bedside note forms and infor-
mation cards complete the equipment. (Fig. 71.)
Records.—The information required by a district
nursing association includes much in regard to the fam-
ily as Avell as the patient. The Avork of the visiting
nurse is not alone for the individual, but, to benefit the
community, and her statistics must, therefore, include
Fig. 71.—Contents of district nurse's bag.
much information in regard to ventilation, general sani-
tary condition of homes, milk supply, etc.
Case Work.—Prenatal instruction to, and supervision
of the expectant mother may be considered first. The
nurse is frequently called into the home ahead of the
doctor, and it is her first duty to get a doctor for her
patient. In the case of foreign-born Avomen it is often
difficult to get the consent to employ a doctor, or at
least a male doctor. A midwife is usually chosen,
though a woman physician is not refused. The nurse
PUBLIC HEALTH NURSING OF CHILDREN 285
advocates the employment of a good physician and
frequently succeeds.
If a midAvife is to deliver the case the nurse tells the
patient that she can not have both nurse and midAvife,
but, as the latter is usually not called until labor, the
nurse Avill continue during the prenatal period. This is
the only instance Avhere a nurse may hold a case AAdthout
a physician in attendance.
The nurse calls every tAvo Aveeks during the first seven
or eight months of pregnancy, and every Aveek during
the last month. She endeavors to have the patient Avorry
as little as possible, and presses upon her attention the
consideration of outside things to take her mind away
from her condition. If any abnormal symptoms develop,
the doctor is at once advised, but, every care is taken
to make as light of them as possible to the patient.
The special points to be noticed are:
1. Urine, tAventy-four hour specimen taken every tAvo
Aveeks, examination can be made by nurse Avith doctor's
consent.
2. Condition of bowels, if constipated advise laxative
diet and more fluids, and shoAv hoAV to prepare.
3. Care of the skin, frequent bathing.
4. Exercise, moderate and in open air, or, if Avoman
does her oavii houseAVork advise rest in afternoons in
open air.
5. Ventilation, especially of sleeping rooms.
6. Drainage. This is a good opportunity for the
nurse to inspect all the drains and to advise as to care.
7. Clothing, light weight, but warm, and if possible
hang from shoulders. A nurse may make a Avarm friend
in a prospective mother by merely showing her how to
make a maternity gown, especially to one who objects
286 NURSING IN DISEASES OF CHILDREN
to going on the street for necessary fresh air because of
feeling conspicuous.
8. Food, meat only once a day, more water than usual,
avoid tea and coffee and try to form the habit of drink-
ing milk as a good preparation for nursing the baby.
Alcohol in any form is forbidden.
9. Care of breasts, nipples examined, if small and flat
gentle traction can be made with the fingers to draw
them out; if the nipples are dry, they should be washed
AAdth Avarm water at night and a little cold cream on lint
placed over them.
10. Abnormal conditions such as swelling of legs, vari-
cose veins, hemorrhoids, cramps, leucorrhea, persistent
vomiting, headaches, dizziness, puffiness of face or hands,
neuralgic pains, muscular twitchings, or signs of hemor-
rhage from uterus must be at once reported to the
physician.
11. If patient is to be confined at home the nurse
should make all arrangements for room for delivery
and lying-in period.
12. Clothing for baby must be examined and sufficient
quantity obtained.
13. Necessary bedding, etc., not forgetting plenty of
clean neAvspapers, must be arranged for.
Superstitions.—The public health nurse necessarily
comes in contact Avith much ignorance and superstition,
and at no time more than with a pregnant woman. The
Avidespread superstition regarding maternal impressions
will have to be combated, and the nurse will do well to
have her mind well stored with information to prove
there is no basis in fact for these opinions.
Baby Care.—During prenatal visits the nurse takes
the opportunity to instruct the mother in the care of
babies.
PUBLIC HEALTH NURSING OF CHILDREN 287
Two points on which to lay emphasis, because seldom
thought of by the usual district mother, are, the tub
used for the baby's bath must be used for no other pur-
pose ; and diapers must be Avashed after every urination.
Mothers are in the habit of using the baby's bathtub for
all kinds of household purposes, and then, without ster-
ilizing, it is used to bathe the baby, and when the child
gets some infection Avonder is expressed as to how it
came. The visiting nurse in foreign families never needs
to be told of the presence of a child in the house, for
she is greeted at the door Avith the foul fumes of diapers
dried Avithout Avashing.
Method.—Before commencing work, the nurse makes
certain that all she requires is in the room, that there is
sufficient heat, and then she closes the door and, if pos-
sible, locks it to make sure no neighbors get in to in-
terrupt or let in cold air.
After removing her coat and cuffs and putting on her
apron, the nurse proceeds to scrub her hands, and then
takes from her bag a paper napkin and spreads it on a
bedside table or a chair. On this she places from her
bag every article to be used in care of the case, then
closes the bag. (Fig. 72.)
In maternity Avork the baby is bathed and dressed
first. Care is taken in placing the child in the Avater
that it may not be frightened. The face is not Avashed
in the tub, but with clean Avater after the baby is taken
from the tub and wrapped in a Avarm toAvel. The mother
is asked to Avatch the nurse, and her attention is draAvn
to special points, as the care of the eyes; each eye being
washed with sterile Avater or saturated solution of boric
acid, Avith clean cotton, and on no account must the
cotton be dipped tAvice in the solution or the same solu-
tion used for cleansing the mother's nipples.
288 NURSING IN DISEASES OF CHILDREN
The nurse must shoAv how to Avash the baby's ears and
nose, and teach that it is not necessary to Avash the
mouth, but, that things placed in the mouth must be
sterile. The mother is taught to cleanse her nipples
carefully before and after each nursing.
If it is necessary to take a child's temperature, the
thermometer must be Avashed Avith soap and running
water, and then placed in the thermometer alcohol for
five minutes.
Fig. 72.—District nurse ready for baby's bath.
The district nurse must not expect to find equipment
to her hand for treatments as she has been accustomed to
in her institutional or private Avork. She will haAre to
improvise most of the time. NeAvspapers or table oil-
cloths will be used for rubber sheeting, shawls and com-
forters for blankets, and packs may be made by sewing
PUBLIC HEALTH NURSING OF CHILDREN 289
together several small pieces of material instead of
sheets. To cover a moist compress the nurse must use
the oiled paper in which the bread has been delivered
instead of oil silk. Flatirons or stove lids take the place
of hot water bottles, etc.
A case of sore throat or suspicious contagious disease
found by the nurse must be isolated until seen by the
doctor.
Tuberculosis.—One of the principal duties of the nurse
is to teach the family in the care of contagious and in-
fectious diseases. Hospital care is urged, or in the case
of tuberculosis sanitorium care is urged. If the parent
of a tuberculous child refuses to alloAV its care aAvay
from the home, the nurse must then visit frequently, and
persistently insist on fresh air, cleanliness, good diet
and care of the sputum.
If a bone case she must see that all dressings are care-
fully destroyed, and in any case see that the patient and
all his belongings are isolated from the rest of the fam-
ily. Failure of the family to comply should be sufficient
grounds for the health department to remove patients
by force in states Avhere laws covering this exist.
Infant Welfare.—"Keep the baby well," is the slogan
of the infant Avelfare nurse. She visits the homes and
teaches mothers the care of their babies, and unless she
is a good teacher, as Avell as a good nurse, and has a
pleasing personality and is fond of babies, she can not
hope to succeed in this work.
Once or tAvice a week clinics for the examination of
well babies are held at a babies' dispensary. In all pro-
gressive cities and rural communities there are now suf-
ficient of these dispensaries to be within reach of all.
An infant specialist is medical director; he examines the
babies brought to the clinic, advises the mothers, and
290 NURSING IN DISEASES OF CHILDREN
issues orders to the nurse for her direction in her week's
work.
Many cities iioav have a central clinic Avhich is a clear-
ing-house for any sick babies brought into a Avell baby
dispensary. Central clinic is held daily and in connec-
tion there is usually a diet-kitchen Avhere a nurse from
the visiting nurse staff is detailed to prepare special
diets for sick babies, which are later distributed to the
homes.
Little Mothers' Leagues.—Another activity conducted
at the well baby dispensary is a "Little Mothers' League."
Here the sisters of babies gather for instruction in the
care of infants, and much of the teaching desired for
the mothers has to be delivered through one of these
girls. The future mothers of the community are thus
also being instructed. The teaching is mostly done by
district nurses.
School Nurse.—Medical inspectors examine school
children and find certain physical defects Avdiich are re-
ported to the parents, but, the carrying out of the doc-
tor's order and the correction of the defect lies in the
hand of the school nurse. Her duty is to visit the home
and continue visiting until the child is in good condition.
The nurse also makes frequent examinations of the
children and refers necessary cases to the medical in-
spector. Small dressings and minor injuries are treated
in the school building by the school nurse. She also
lectures and demonstrates on hygiene and home nursing
to the various classes.
Working Papers.—The passage of Child Labor LaAvs
has made it necessary for children under the compulsory
school age to appear for medical examination if it be-
comes necessary for them to Avork. None are examined
before completion of the sixth grade Avork and then only
PUBLIC HEALTH NURSING OF CHILDREN 291
Avith a recommendation from the school principal. A
thorough physical examination is made of each ap-
plicant by a doctor of the department of health, assisted
by a public health nurse. The nurse is responsible for
issuing correct papers perndtting the child to Avork, and
she is the custodian of all the office files.
Quiz
What are the requirements of a public health nurse?
What is the organization of public health nursing?
What are the duties of the different grades?
What are your duties in prenatal work?
What special points should you notice in prenatal work?
What about maternal impressions?
What should you teach about the baby's tub and diapers?
How would you prepare for the baby's bath?
How do you take care of the thermometer?
How may you improvise equipment?
What should you do in a case of tuberculosis?
What is infant welfare?
How is infant welfare work carried on?
What is a Little Mothers' League?
What are the duties of a school nurse?
What are the duties of the nurse in connection with the giving
out of working papers?
CHAPTER XI
MENTAL HYGIENE
By H. G. Matzinger, M.D.
In primitive times, when life Avas simple and competi-
tion did not exist, when there was room for everybody
and it was a comparatively easy matter to obtain the
necessities and comforts of life, there was no need for
mental hygiene. But as soon as people began to live in
larger groups it became increasingly more difficult to
live and the problems of the individual became more
and more complex. Essentially they did not change
much, but there Avas less and less freedom in solving
them, because there were others in the same quest whose
interests had to be considered.
Now as then these efforts resolved themselves, in the
last analysis, into the acquisition of happiness, which
means primarily enough to eat, a comfortable home and
as little interference as possible.
As life became more complex there was less freedom,
less happiness, with a growing number of people whose
claims had to be considered and so there came a need
for a faculty of adjustment to the eA^er-increasing dif-
ficulties which blocked the way. Thus it happened that
the very growth of what is called civilization, far from
making life easier, in reality interfered with freedom,
made life much more complex and created a need for
the individual to fit himself easier and more satisfac-
torily to the difficulties which surrounded him.
Just as physical hygiene assists in the maintenance of
292
MENTAL HYGIENE
293
physical health in the midst of all sorts of possibilities
of disease, so mental hygiene teaches the individual how
he may adjust himself most satisfactorily to the life
conditions in Avhich he happens to find himself and thus
to attain the highest degree of happiness, with as little
danger of mental disorders and conflict as possible.
It stands to reason that mental hygiene has a larger
import for the adult than for the child, but fundamental
training for the happiest adjustment to life conditions
has to be begun in childhood, if the best results in
character development and usefulness are to be attained.
The career of many a child is ruined by failure of
parents in properly assisting it to fit itself to its en-
vironment. A little reflection will shoAv that the child is
seriously handicapped in meeting these requirements
from its ATery entrance into life. It is born into home
conditions and discipline which are the result and out-
come of ages of progressive development in family life.
Its great-grandparents had no such demands made upon
them AAdien they Avere infants, as the modern child is
required to fit itself to. The difference between their
childdife and that of today is vast.
Take for instance the simple matter of clothing, which
very early becomes a real test of its ability to adjust
itself to the standards of the family. It must not do the
very things Avhich it naturally desires to do because of
the clothes and the taste of the mother or other members
of the family with whom it is obliged to live. Early it
must learn to respect the rights and comforts of others.
It must not take Avhat it has a liking for, nor must it
romp nor shout AAdien others want quiet. At every turn
it meets AAdth restrictions, many of them normal and
important, but all calling for the development of re-
294 NURSING IN DISEASES OF CHILDREN
straint and adjustment Avhich Avould try and irritate a
groAvn-up.
The demands of education are also vastly more serious
than tAvo generations ago. The modern highly organized
and scientific methods of getting an education make
very early demands upon the child. All too frequently
the intellectual training of a child is begun at a very
tender age when the physical development is much more
important.
These conditions Avith so many others make child-life
very complex, and there is from the very beginning a
real need of mental hygiene if the child is not to be dis-
couraged and embittered and its outlook upon life
Avarped. It is an established fact that much of queerness
and strange conduct, as Avell as the failure of normal
character development, are the result of failure on the
part of the child to adjust itself in a normal way to its
environment, and in this the management of the parent
is often more to blame than the child.
It must be admitted that many children are handi-
capped by poor heredity, but eA^en so, there is all the
more need for thoughtful assistance in the trying times
so common in the life of a child, Avhen it is called upon
to fit itself in an easy and normal Avay to AvhateA^er seems
hard and troublesome.
The normal child and not infrequently the one not
overburdened by heredity is far more likely to develop
a healthy mental attitude towards its surroundings by
its oavii efforts, wisely assisted and directed by the par-
ent, than by any amount of precept or other Avell-meant
activities of the adults with Avhom it has to live. We can
not get away from the fact that nature is able at all
times to obtain better results if she is not hampered too
much.
MENTAL HYGIENE
295
The greatest assistance Ave can give a child in the
formation of a type of character which will enable it
to get along Avithout clash or failure in any situation
which may obtain in its life, is to develop its own re-
sources to the fullest extent, to find out Avhat the
child's stock in trade is as to natural equipment. It
must of all things have abundant opportunity to come in
contact Avith external conditions, otherwise it can not
reveal itself.
One of the earliest accomplishments of the infant is
the acquisition of consciousness of its OAvn separate ex-
istence, apart from other people and things. This is
usually a simple process, if the parents are not too eager
in guarding the child and in anticipating all its wants.
First the child becomes tremendously interested in its
oavii body. It examines its hands and feet and other
parts of its body whenever opportunity presents. It
should have much time for this, in order that its interest
may soon be transferred to other things. If left to itself
Avith sufficient leisure this is soon accomplished, and the
child announces the fact by calling itself "I" and not
by the baby name which the parents use. This ability
to clearly distinguish between the "I" and the "not I"
is a very important step in the mental life of the child
and the development of full consciousness. The greatest
mischief is here done by keeping the infant constantly
occupied and handling it too much.
As soon as the interest is tranferred to the environ-
ment the child further increases its stock of ideas. It
must be remembered that the number and kind of ideas
which the child manages to accumulate determine the
kind of judgment Avhich it will show. It is manifestly
important that as many right ideas about the outside
Avorld should be acquired as it is possible to do, in order
296 NURSING IN DISEASES OF CHILDREN
that the child may learn to fit itself most fully to its
environment.
Here too it becomes important that the child learn
early to distinguish betAveen "mine" and "not mine."
How easy and common is it that the child does not get a
fair chance in this. The parents spend hours in guarding
him and planning for all his Avaking hours. All sorts
of fancy toys and so forth are thrust upon him so that
he is robbed of the chance to get experiences of his oavii.
He gets everything he cries for, and as a result he
emerges from early infancy with but a vague notion of
what contact with the outside Avorld normally brings in
the way of experiences.
Unfortunately, the modern child is much too carefully
guarded and protected during this period to get the
right ideas, and in this imperfect state of deATelopment
it is carried into the next stage, Avhen it is called upon
to begin to gradually detach itself from the parental
supervision. Nothing is more important in the life and
character formation of a child than this early detach-
ment. Irreparable damage is done by postponing it. A
great majority of the failures of individuals to measure
up to the demands that life-conditions make upon them
originate here. Yet how common it is to see well-mean-
ing parents endeavor in every way to put it off and to
prolong the dependency of the period of early childhood.
The normal child shows a desire for this independence
by revolt against parental authority and by freedom of
action whenever opportunity presents. Simultaneously
it sublimates its desire to be mothered into a sort of
chivalrous protectorate over its mother. It is a common
mistake of parents to misinterpret this rebellion, and the
natural evolution of the child is disturbed and made
MENTAL HYGIENE
297
difficult by intimidation and unjust restraint and pun-
ishment.
If the evolution of the child-mind is normal and un-
hampered, he iioav shoAvs a great desire for omniscience.
He inquires into everything, he wants to know "how it
works," and every opportunity should be given to gain
this added knowledge about things. It is usually inter-
preted as meddlesomeness and his desire to show supe-
rior knoAvledge to that of the parents, unfortunately,
brings him into conflict Avith them, that results much too
often in his being misjudged and injudiciously curbed.
So often this is the beginning of a surly, shut-in person-
ality, Avhich ultimately results in a feeling that every-
thing is Avrong and that no one can be trusted.
Of all the periods in a child's life this is the most
critical and calls for most sympathetic and resourceful
management. Fortunately, its requirements are to a
large extent met by normal and plentiful intercourse
a\ ith other children of the same age. Many of the finer
traits of manliness and fair play originate in the rough
and tumble adjustment of child play under normal con-
ditions. The attitude of the parent to the difficulties
Avhich arise, no matter how petty they may be, is of the
greatest importance. A certain judicious "hands off"
policy is most valuable in accomplishing independence
and resourcefulness and in paAdng the Avay to a whole-
some detachment of the child.
There is another feature, and one of very great im-
portance, in the evolution of the child mind as well as
of his physical development. This is the matter of sex.
It does not require much reflection to become aware of
the fact that the most important function of the living
organism is to reproduce itself, and so to aid in the con-
tinuation of the race. All activities of the human being
298 NURSING IN DISEASES OF CHILDREN
have no better object than to make possible a more satis-
factory and more useful life for his descendants. Better
home conditions, better educational advantages, better
prospects for a happy and ^successful career for the child.
Physically all the development is directed toAvard
maturing the best possible physique for that epoch in
the evolution of the body which we call puberty. Every-
thing becomes secondary to the groAvth and full de-
velopment of those parts and organs of the body whose
only use is reproduction. False modesty and prudish-
ness have interfered Avith the full realization of this on
the part of the parents, indeed it almost seems as though
many parents had lost sight of it entirely.
In the normal child, Avith normal opportunities, the
love, or sex-feeling, first shows itself as the greater at-
tachment of the girl for the father and the boy for the
mother. This is often so marked that it leads to poorly
disguised partiality. This partiality is, of course, to be
avoided in every Avay possible. Before long a change is
noticed and Avith the growing detachment of the child
its love and affection becomes Avhat is called homosexual.
In other Avords, there is now sIioavii a very strong attach-
ment for individuals of the same sex. A boy will have
a boy friend for whom he will sacrifice anything, even
displeasure of the parents. A girl will have a girl friend
Avith whom she Avishes to be whenever there is any free
time, whom she emulates and who is the only companion
A\dio will satisfy her. Of course, childlike, this imperfect
love attachment may and does change often from one
person to another, but it is ahvays some one of the same
sex. Noav Avhen puberty approaches there is a more or
less sudden reversal of this love or sex feeling, and it
becomes heterosexual, that is love for the opposite sex
appears, with a complete change in the individual from
MENTAL HYGIENE
299
being an OA'ergroAvn child to a desire to be groAvn up.
The normal child has little, if any, trouble in passing
through these changes, but very frequently umvise and
prudish methods of parents and nurses or other groAvn-
ups, especially those groAvn-ups Avith abnormal sex in-
clinations and vicAA-s, lead the groAving child into think-
ing about its sexual parts as something to be ashamed of.
By this and by constant AAdiispering and mysterious ad-
monitions and injunctions, the child-mind becomes cen-
tered on the matter, and being naturally in an investi-
gating attitude toAvards everything, evil thinking and
evil practices often develop. The entire matter of sex
should be dealt Avith in an open free way, whenever it
comes up in such a way as to require attention, by the
parents, and should neA'er be left to any other person,
not even to the physician.
The accidental exposures so common in the home child
life, up to let us say the tenth year, should never be
treated as indecent, but like the ordinary things AAdiich
the child should learn not to do, because no one else does
them. In this Avay Ave avoid the possibility of making
the matter prominent in the child-mind and thus aA^oid
the danger of opening the Avay to unnatural and ab-
normal sex developments.
Children's nurses and the regular nurses should bear
this in mind, for it is they, more than the average par-
ent, Avho are most likely to err in this important matter.
So far Ave have been concerned Avith the normal child
and the most important life conditions which call for
guidance in adjustment or mental hygiene. The problem
becomes much more complex, hoAvever, when we are
dealing with the abnormal child. Unfortunately a large
proportion of children everywhere are more or less ab-
normal, physically and mentally. An altogether reliable
300 NURSING IN DISEASES OF CHILDREN
investigator has estimated that 75 per cent of all school
children in the United States are not entirely well. Eyes,
ears, teeth, stomachs, feet, backs, skins, etc., are the seat
of trouble of development as often if not oftener than
of disease.
As to mental abnormality no trustworthy figures can
be given, for the reason that the tests which can be
applied do not give the same results with all investi-
gators; and for the further reason that, after all, the
best criterion of a normal mental equipment is the man-
ner in which an individual fits himself into the social and
economic conditions of the group in which he lives. It
is at once apparent that the standards of reaction or
conduct differ widely in different communities and dif-
ferent walks of life. If a child is born into a group in
Avhich the rule is that at the age of four it knows whether
it is a boy or a girl, can name ordinary objects, and can
repeat sentences of three or four words, and it fails to
be able to show such progress, we have a right to assume
that something is wrong.
There are, of course, delays in mental development
Avhich are due to such unfavorable conditions as ill
health, but the normal child soon fills up the gap when
it gets the proper chance. But, unfortunately, in many
children the development of the intellectual faculties is
backAvard from the start and continues to be so all
through the period of life in which the mind should
reach its normal growth. Such children do not only fail
to keep up Avith their school studies, but fail to de-
velop the proper moral sense, the knowledge of right
and Avrong, of responsibility and of justice, and all
through their further life they, consequently, shoAv lack
of judgment.
It is not saying too much to state that the delinquents,
MENTAL HYGIENE
301
paupers, criminals and prostitutes belong to this class
of individuals Avho never get the right ideas of life be-
cause of lack of mental equipment, and so are constantly
in conflict Avith society and law and order. They are
usually called feeble-minded and can be detected in
childhood because their defect sIioavs itself very early in
failure of acquisition of the ordinary knoAvledge of the
average child. If their difficulties are met Avith patience
and the most made of the stock of mind Avhich they have,
much can be done Avith such children. They need espe-
cially to be guarded from discouragement, misunder-
standing and temptation.
There are many degrees of feeble-mindedness. The
higher grade in AAdiich the defect is not so marked are
often called morons. Their defect shows itself more
in the Avay of instability. If conditions of life are favora-
ble and everything goes well, they do well enough; but,
Avhen difficulties arise they are found wanting in the
ability to adjust themselves to the adverse conditions
and they then do the antisocial thing. Very often they
do not get the proper assistance to regain their balance,
and discouraged and out Avith things, they noAV follow
the course of least resistance and become a menace to
society.
Many of them make up the large group of so-called
ne'er-do-wells who have constantly to be assisted to get
along at all, while others run the gamut from delin-
quency to crime. It must not be forgotten that among
this feeble-minded class there are a large number of
individuals Avho are not altogether deficient, but may
show peculiar brightness and aptness at some one
faculty. To this group belong the infant prodigies, who
while unable to keep up with normal children in their
mental development, nevertheless show almost wonder-
302 NURSING IN DISEASES OF CHILDREN
ful capacity in some one direction or other. Here you
have the musical genius, the wonder at figures, and so
forth.
A safe rule to go by is that the normal child is the
least conspicuous child, because it is at all times able
to fit itself to surroundings and conditions in such a
normal and satisfactory way that it is not noticed.
We take special note only of the unusual and the excep-
tional in children as well as in groAvn-ups, and the same
rule applies to them.
We often hear and read of the menace of the feeble-
minded, and there is a common feeling that the real
danger from them is exaggerated. This may be true in
some localities and among some people, but the fact re-
mains and is noAV generally admitted that the feeble-
minded individual is a potential criminal in that it is so
easy for him to do antisocial things. Moreover, he usually
has to be constantly assisted and guarded to maintain
himself. Often he becomes entirely dependent in his early
adult life. Besides this, we now know that the bulk of
feeble-mindedness is hereditary and so is handed down
to future lives. The poor judgment of this group makes
them prolific, and so their number is increasing out of
proportion. Many of their descendants are illegitimate.
In fact, the whole matter of illegitimacy has more to do
with feeble-mindedness than with any other factor or
group of factors.
The lower grades of feeble-mindedness merge into
imbecility. The imbeciles themselves vary very much as
to the degree and kind of their defect. As a rule they
never learn more in all their developmental period than
the average normal child knows when it is six or seven
years old. The lower types do not accomplish as much
as that. While the higher types may be able to reach
MENTAL HYGIENE
303
the mental development of ten years, in some intellectual
capacities, their mental groAvth is not symmetrical,
and usually the moral sense of right and wrong and the
ability to protect and defend themselves remain primi-
tive and infantile, no matter how many years they may
live.
The imbecile group merges into the idiot group. In
a general Avay it is fair to say that the idiot never
learns more in all his life than the normal child knows
at a year and a half or at two years. Often they do
not eA^en learn to talk more than a few words. Many
of xhem haATe a language of their own, by means of
Avhich their parents are able to understand their simple
Avants. Many never learn to feed themselves, as, or-
dinary children do, and, of course, never can be left to
themselves because they do not learn enough to take
care of themselves in the simplest matters. Idiots rarely
live long, but, together with imbeciles, they make up a
surprisingly large number of the population.
In the State of New York a fairly reliable census of
these two groups, including of course many low-
grade feeble-minded persons, sIioavs as large a num-
ber as thirty-three thousand, only seven thousand of
AAdiich are in custodial institutions. There is no reason
to believe that the proportion varies in other states
where a careful census is taken. It must be remem-
bered in this connection that the existence of some such
individuals neA'er becomes publicly known. They are
carefully secreted and cared for by the parents Avho
are able to do so.
Of course this Ioav type of mental defect rarely has
descendants. They are never desired in marriage and
are usually sterile, so they do not become a menace;
but, they are a care and expense to the public in that an
304 NURSING IN DISEASES OF CHILDREN
increasingly large number of them sooner or later be-
come a public charge.
Fortunately the loAver grades do not live long be-
cause their viability is Ioav and they are constantly ex-
posed to accident and the development of disease. Many
of the higher grades of imbeciles and the Ioav grades oi
feeble-minded can, hoAvever, under institutional care and
training, become partially self-supporting, under com-
petent supeiwision, and so are not as heaATy a burden to
the public.
The Avhole matter of mental defect is being better
understood each year. Private and public schools for
backAvard children are increasing in number. Private
and public institutions for the defective are also be-
coming more numerous. EveryAvhere public officials
and organizations Avhich have to do Avith correction and
charity are realizing more and more that the individuals
Avho come under their care are defective mentally, and
require thoughtful training and proper institutional
care, rather than punishment and financial support. It
\Adll not be long before every state AAdll not only have
sufficient and proper institutions for the care of this
dependent class, but aa ill also have its educational de-
partment equipped Avith the facilities and the means of
early detecting the feeble-minded and so arranging the
intellectual and physical training by proper mental and
physical hygiene as to save many from failure, depend-
ency and crime.
There is, hoAvever, little prospect that the number of
mentally defective people Avill decrease, because it is
hereditary, and there is at present no legal Avay of deter-
mining that they shall not have offspring.
MENTAL HYGIENE
Quiz
What is mental hygiene?
What is meant by adjustment of the child?
What are the first accomplishments of the child?
Which is the most critical period of child-life?
What about the sex feeling of children?
What is homosexual love?
What is heterosexual love?
How should the matter of sex be dealt with?
How should accidental exposures be dealt with?
How do we determine a normal mental equipment?
Can feeble-mindedness be detected in childhood?
Which are the degrees of feeble-mindedness?
Is feeble-mindedness hereditary?
What is imbecility?
Wliv is institutional care needed for the feeble-minded?
INDEX
A
Abdomen, examination of, 186
inspection of, 175
of infant, 54
Abnormal child, 299
Abscesses, 149
glandular, 200
retropharyngeal, 190
Acid reaction of stool, 151
Advantages of breast milk,
95
Agglutination, 205
Airing, 64
Alimentary intoxication, 148
Alkaline reaction of stool, 151
Amount of breast feeding, 112
117
of breast milk, 94
Amusement of children, 257
Antibodies, 196, 202
Antitoxin, in diphtheria, 217
preparation of, 201
Areola, 102
Arteries, umbilical, 45
Arterious duct, 44
Arthritis in scarlet fever, 259
Artificial respiration, 43
Asphyxia, 42
in premature, 245
Ash, 22
Atelectasis, 42
in premature, 245
Atrophy, 149
Aversion to some foods, 138
Avirulency, 196
B
Baby scales, 52
shows, 54
yard, 63
Backache in smallpox, 214
Bag of public health nurse,
283
Balance,' disturbance of, 146
Baldness, in rickets, 165
Band, 85
Bath thermometer, 65
Bathing, baby in public
health nursing, 287
in measles, 257
of newborn, 47
Bed, breast feeding in, 102
for infants, 90
Bedside notes, in infectious
diseases, 254
records, 31
Body surface of newborn, 40
Boiled milk, 119
Bolus alba, 68
Bones of infant, 55
Bottle feeding, 115
Bracing legs, 63
Breast binder, 108
feeding, 94
of newborn, 48
pump, 105
stool, 42
Breck feeder, 105
in premature, 246
Bronchiolitis, 231
Bronchitis, 231
Bronchopneumonia, in grippy
infections, 231
in measles, 207
in whooping cough, 222
Broth for young children, 133
Butter, 24
C
Caking of breast. 108
Calmette's reaction, 205
308
INDEX
Caloric demand of infant,
135
of newborn, 41
of premature, 245
values, 23
of breast milk, 85
of foods, 136
Calory, 23
Cane sugar, 24
Canines, 56, 71
Caput succedaneum, 38
Carbohvdratcs as food, 2.3
in food, 134
overfeeding with, 151
Care of breasts, 106
of teeth, 71
Casein, 23
Casts, plaster of Paris, 27:1
Centigrade, 20
Centigram, 19
Centimeter, 18
Cephalhematoma, 40
Cerebrospinal meningitis, 222
Changing position of baby, 63
Charts, in infectious diseases,
254
keeping of, 25
Chest, examination of, 177
Chickenpox, 211
care of, 259
Child, examination of, 170
Childhood, 69
diseases of, 206
Chorea minor, 236
Cilia, 74
Circulation, fetal, 44
Circumference of chest, 70
of head, 70
Cholera infantum, 148
Clothes basket as bed, 89
Clothing and mental hygiene,
293
of newborn, 85
Colds, 226
Colostrum, 48, 94
Combined feeding, 114
Comedones, 76
Coinparison of mother's milk
and cow's milk, 117
Composition of breast milk,
95
Condensed milk, 124
Constitution, 144
as cause of disturbances of
nutrition, 157
Contagious disease, 194
Convalescence from diph-
theria, 263
from measles, 257
Convulsions, 167
in meningitis, 223
Coryza, 229
as cause of disturbances of
nutrition, 154
in measles, 206
in premature, 247
in whooping cough, 220
Cough observation of, 273
quality of, 174
whooping, 220
Cowpox, 212
Cow's milk, caloric value of,
23
quality of, 118
('racked nipples, 107
Cradle, 77
Crawling of baby, 63
Cream, 24
overfeeding with, 152
Croup kettle in measles, 256
Croupous pneumonia, 2.31
Cry of babies, 172
Crving in rickets, 164
Curds, 119
D
Decagram, 19
Decameter, 18
Deciduous teeth, 55
Decigram, 19
Decimeter, 18
Decomposition, 149
Desquamation, 206
Dcxtrinizing, 24
Diapers, 84
Diastase, 24
Diathesis, exudative, 168
Diet, of nursing mother, 110
Digestive disturbances of
older children, 138
Diphtheria, 216
care in, 260
INDEE5
Discharge, vaginal, 175
Diseases of childhood, 206
Disinfection, 252
Disposition of child, 144
of infant, 62
of newborn, 50
toward infections, 196
Disturbance of balance, 146
of nutrition, 142
due to heat, 155
due to infection, 153
Drying of infant, 66
Drooling, 59
Duration of bath of infant,
66
Dyspepsia, 147
E
Ear, examination of, ISO, 186
in scarlet fever, 209
Eczema cuff, 60
Efflorescence, stage of, 206
Eggs, for young children, 133
Elements of food, 21
Empyema, 232
Endemic diseases, 198
Endocarditis, 237
in rheumatism, 268
Enema, 191
Epidemic cerebrospinal men-
ingitis, 222
diseases, 198
Equipment of public health
nurse, 282
Erythema of neAvborn, 47
Eustachian tube, 230
Evaporated milk, 124
Examination of breast milk,
112
of child, 170
Exanthema, serum, 263
Exanthemata, 206
Exercise for infant, 91
Exudate, pluritic, 232
Exudative diathesis, 168
Eyes, diseases of, 276
examination of, 181
in measles, 256
in smallpox, 260
infection of, 276
K 309
F
Fahrenheit, 20
Farina pap, 130
Fats, as food, 24, 1.34
overfeeding as cause of
rickets, 164
Fatty acids, 25
Feebleminded, 301
Feeding, in chorea minor, 269
in diphtheria, 260, 263
in meningitis, 265
in metabolic disorders, 274
in second year, 132
in typhoid, 267
in whooping cough, 264
of infants, 66, 74
of older children, 135
of premature, 245
of young children, 130
Feet, position of, 77
Fetal circulation, 44
Fever of suppuration, 214
Fixation, 63
Flannels, 84
Flour-ball, 24
Follicular tonsillitis, 230
Fontanel, 55
observation of, 174
Food elements of, 21
idiosyncrasies, 139
proprietary, 127
Foramen ovale, 44
Furuncles, 149
G
Gain, of infant, 53
Gas metabolism, of newborn,
42
Gastric fever, 233
Gauze mask, 228
Gavage, 22, 105, 187
General behavior of infant,
61
German measles, 211
(iertrnde skirt, 88
Glands, enlargement oft 175
tuberculous, 241, 271
Glandular abscess, 200
Gram, 18
310
INDEX
Inoculation against typhoid,
236
Insensible perspiration, 37
Inspection, daily of infant,
171
of teeth, 73
Internal convulsions, 166
Intertrigo, 149
Intestinal infection, 153
Intervals between breast
feedings, 98
Intoxication, alimentary, 148
Intubation, 189, 261
Grasping, 63
Grippy infections, 226
in measles, 207
in whooping cough, 222
Growing pains, 236
Growth of child, 69
Gums, rubbing of, 59
H
Hair, care of, 75
Hearing, in newborn, 49
Heart disease, as cause of pre-
maturity, 244
in diphtheria, 217, 260
in disturbance of nutrition,
155
Heetagram, 19
Hectameter, 18
Heine-Medin's disease, 225
Holding up head, 63
Hospital diets, 111
Hygiene, mental, 292
I
Icterus, 48
Idiosyncrasies, to foods, 139
Idiots, 303
Imbeciles, 302
Immaturity, 36
Immunity, 196
Immunization, 196
Immunizing doses, 204
Incisors, 56, 71
Incubation, 206
Incubator, for premature, 244
Infancy, 50
Infant, bathing of, 65
clothing of, 83
disturbance of nutrition in,
142
welfare work, 289
Infection, 200
as cause of disturbance of
nutrition, 153
as cause of prematurity,
244
intestinal, 153
parenteral, 153
Infectious diseases, 194
care of, 249
Influenza, epidemic, 225
J
Jaundice of newborn, 48
Jersey milk, 118
K
Kidney disease, as cause of
prematurity, 244
Kidneys in chickenpox, 212,
259
in diphtheria, 217, 260
in measles, 207
in scarlet fever, 211, 258
Kilogram, 19
Kilometer, 18
Kimono, 88
Knitted jacket, 88
Koplik's spots, 206
L
Lactalbumin, 23
Lacunar tonsillitis, 230
Lanugo, 48
Laryngitis, 231
Larynx, spasm of, 166
Layette, 92
Length of breast feeding,
109
of newborn, 38
Lifting head, 63
Liter, 18
Little mothers' leagues, 290
Lobar pneumonia, 231
Lobular pneumonia, 231
Loss of weight, in newborn,
136
INDEEI
Love, 298
Lovalty, 98, 184
Lues, 237
Lumbar puncture, 181
in meningitis, 223
Lymphatism, 168
Lymph glands in infections,
200
M
Malformations, as cause of
disturbance of nutri-
tion, 157
Malt sugar, 24
Maltose, 24
Marasmus, 149
Massage, 77
of caked breast, 108
Maturity, 36
Measlesj 206
care in, 256
German, 211
Meat in young children, 133
Meconium, 42
Medical cases, care in, 271
Meningitis, care in, 264
epidemic cerebrospinal, 222
tubercular, 240, 270
Mental hygiene, 292
Metabolic disorders, feeding in,
274
Metabolism, abnormal as
cause of disease, 160
Meter, 18
Metric system, 17
Middle ear, in grippy infec-
tion, 230
in influenza, 226
in measles, 207
in scarlet fever, 209
Aliliary tuberculosis, 241
Milk for older children, 138
sugar, 24
teeth, 55
Milligram, 19
Millimeter, 18
Modification of cow's milk,
120
Molars, 71
Moro's reaction, 205
x 311
Morons, 301
Mosquitoes, as carriers of dis-
ease, 199
Mother's milk, in premature,
246
Mouth, inspection of, 74
washes, 73
wiping of, 54
Muscles, of infant, 54
Mumps, 222
care of, 264
N
Nails, care of, 74
Nasopharyngitis, 230
Natural foocl, 96
Nervous child, 78
diseases, care in, 276
Newborn, 36
examination of, 170
breast feeding of, 98
Night gown for infant, 88
Nipple shield, 106
Nipples, cracked, 107
Nose, care of, 73
in diphtheria, 216
operations on, 275
washing out of, 74
Number of breast feedings, 98
Nursing bottles, 125
mother, diet of, 110
observation of, 176
record, 112
Nursling, stage of, 51
Nutrition, disturbances of,
142
O
Objections to breast feeding,
96
Only child, 78
Orange juice, 131
Orthopedics, 17
Overfeeding, 151
as cause of rickets, 164
one sided, 152
Oxygen, as food, 21
312
INDEX
P
Pacifier, 61
Pajamas, 88
Pandemic diseases, 198
Paradox reaction, 149, 15L
Paralysis, infantile, 224
Parenteral infection, 153
Parotitis, epidemic, 222
Pasteurized milk, 119
Pediatrics, 17
Peritonitis, tubercular, 241
Perspiration in rickets, 165
insensible, 37
Phagocytes, 200
Pharyngitis, 230
Pharynx, inspection of, 74
Photophobia, 74
in measles, 207
Physician, visit of, 176
Pirquet, von, reaction, 205
Pinning blanket, 87
Plaster of Paris casts, 275
Pleurisy, 232
Pneumonia, care in, 265
croupus, 231
Poliomyelitis, 224
Polyarthritis, 236
Postgraduate courses for pub-
lic health nurses, 282
Powdering of infant, 68
Premature, 243
Prematurity, 36
Premolars, 56, 71
Prenatal instruction, 284
Pre\7entable diseases, 199
Prevention of cooling of new-
born, 47
Princess slip, 89
Prodromal stage, 206
Proprietary foods, 122
Proteins, as food, 23
in digestive disturbances,
151
in food, 134
Pseudocrisis, 266
Pseudocroup, 231
Public health nursing, 280
Pulse, counting of, 174
in diphtheria, 261
in newborn, 46
in pneumonia, 265
in rheumatism, 268
in scarlet fever, 258
in whooping cough, 264
watching of, 272
Puncture, lumbar, in menin-
gitis, 223
Purpura, 236
Q
Quinsy, 230
R
Rachitis, 160
Reaction, normal, 144
paradox, 149, 152
Records, of public health
nurse, 284
Regularity, in infants, 64
Respirations, artificial, 43
observation of, 174, 273
of newborn, 44
of premature, 245
Resuscitation in asphyxia, 43
Retropharyngeal abscess. 190
in grippy infections, 230
in influenza, 226
Rheumatic infections, 236
care in, 268
Rhinitis, 229
Rickets, 160
Rollier treatment, 271
Room, in infectious diseases,
251
Routine, for infants, 65
Rubber nipples, 125
S
St. Vitus' dance, 236
Salts as food, 22
Scales, 52
Scarlet fever, 209
care in, 258
School nurse, 290
Sculptor's clay, 68
Scurvy, 165
Sebum, 76
INDE
Seeing in newborn, 49
Sense of pain, in newborn, 50
of temperature in newborn,
50
Sepsis, 237
Serum exanthema, 263
Sex, 297
Shower, 76
Sitting up, 63
at breast feeding, 102
Size of shirt, 84
Skin, blood vessels in, 75
care of, 75
diseases, care in, 277
exercise of, 75
in scarlet feA7er, 259
of infant, 54
oiling of, 76
Sleep, in whooping cough, 264
of infant, 62
position during, 63
Sleeping bag, 83
outdoors, 64
Smallpox, 212
care in, 260
Smelling, in newborn, 50
Smile, first, 63
Snuffles, in newborn, 171
Soap, 66
Soy bean, 134
Spasmophilia, 166
Spinal puncture, in meningi-
tis, 223
Spitting up of food, 100
Spoiled child, 78
Sponge bath, 76
for infant, 68
in typhoid, 267
Spoon feeding, 130
Sporadic infections, 198
Spots, Koplik's, 206
Sputum, observation of, 27.3
obtaining of, 232
Standing, 63
Starches, 23
Starvation stool, 149
Steam tent, in bronchopneu-
monia, 267
in measles, 256
Stearate of zinc, 68
ix 313
Stools, number of, in infants,
68
observation of, 174, 27.3
signs for, 33
starvation, 149
Sugar, 23
Summer complaint, 148
Sunstroke, 155
Sun treatment, 271
Superintendent of public
health nurses, 281
Supervisor of public health
nurses, 282
Surgical cases, care of, 274
Syphilis, 237
as cause of prematurity,
244
T
Tactile sense, in newborn, 50
Taste, in newborn, 49
Teeth, milk, 55
second dentition, 71
Teething, 56
Temperature, in infection,
201
in pneumonia, 266
in typhoid, 233
in whooping cough, 26.3
of newborn, 46
of living room, 76
of premature, 244
of room in measles, 256
of sponge bath, 267
taking of, 173
Thermometer scale, 20
Throat, examination of, 180,
186
in diphtheria, 216
in scarlet fever, 209, 258
operations on, 275
Thumb sucking, 60
Time intervals, on chart, 28
Toilet basket, 92
Tonsillitis, 230
Toxins, 201
Tracheitis, 231
Tracheotomy, 262
Tube, Eustachian, 230
Tuberculin reaction, 205
314
Tuberculosis, 238
after measles, 207
after whooping cough, 222
as cause of prematurity,
244
care in, 269
in breast feeding, 97
public health nursing in,
289
Twins, breast feeding of, 114
Typhoid fever, 233
care in, 267
U
Underfeeding, 149
Unnatural feeding, 96, 115
in premature, 247
Urination, 174
of infant, 68
Urine, collection of, 176
in scarlet fever, 258
measuring of, 272
V
Vaccination, against small-
pox, 213
Vaccines, 205
Vaginal discharge, 175
Vegetable soup, 131
Vein, umbilical, 44
Venous duct, 44
Vernix caseosa, 47
Virulency, 196
Vitamines, 166
Vomiting, 127
observation of, 272
Pirquet, von, reaction, 205
W
Walking, 63
pen, 63
Washing, of flannels, 84
of face of infant, 66
Water, as food, 21
for bath, 65
for older children, 138
Weakly babies, breast feed-
ing in, 104
Weaning, 132
Weighing, 51
Weight of child, 69
of newborn, 36
Wet nurse, 106
Whooping cough, 220
care in, 263
Widal test, 205, 233
Wisdom teeth, 71
Wooden forms for flannels, 85
Working papers, 290
Z
Zwieback pap, 130
;ep
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NLM052879900