■■■; 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 Hi 1 111 f^l !=i Si: "* £ 2! <*) ^ 1 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 WJW.W. WfK t ? 3 4 5 E 1 1 S IB 11 1M3 14 IS It 17 11 19 X 21 32 73 Zl 35 K 11 !l 31 3D 31 I U 34 35 31 31 X 31 « 11 4! 43 44 4S 41 41 41 41 » SI SI 1 ' 811 1' / / 4 at. ...... I A ' - $ lb. / / S ' / 12 ot. / / 1 / T Bet. . £ _ / -/ - / 7 / ' . _ 4k. f -4 X / 1 t 6 us. / it 3 i ' ' 1, / 7 A f v f 2 vt - _ 12 12. \ , <- \ / \ / V / III . \ J ' J 1 \ l 4 ' ^ I Oo i / I___ „ . ft ll\ / / I \ /\/i r t " r 'VI ' 41 7lK" ' . \ ' \\ n *■' to 1 \ / 1 ' n " : k . / " <■■■ C I- 0 ,1 V 1 ? » / IZ «. f> =j ' \^ 3 0 ' / i ' L, n .3 * 1 5 ^?l ' ^5 4, » "-rJBb < "* » "" 3"" 3 Z % i * * 3 3 -i 9 * 5 ' a il*» * * / :i'i-5-s* * * ....../ ij"--.i» - IC 1 ,4 T *« *• ^ . *ub. . k^ ; to, f" r i/l . 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 .1 £ tff 4) c V. O -c v> ~o o A. i CO K <. — NS' ■: - > ■ M < b -■ *• :a "v "0 0 s oc c o CO © 4T c © CO © o o © © 05 03 00 © r~ to © © 143 © 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 I -p" 1 I ' ____L__L_ ~X"II"I II I III llllll Till ; - t tf J 1 -r T]r II ! | | II TT f T XXT - | ^ r T"^ - i \\\ 4-"t 1 II {I) ; | '' - -ij» L.. lr 1 till tiiii i .....;.. LI 1 ILIiiil 1 1' I ^ i T 7 r ' jiii iii ■ [ ' t V\ 1 j t 'ftTT"] 1 M\ ' ; i | ! ft 111 / \w\ i ^ 1111111 X t XX i t j LH I I X xi N 111111 III ^ T itIT x xx3 X T 111111111111 I II ■2 ill 1 r- f4 1 till ^ 1 Tl" 7^fr+~i-"T 11111! - ' 5" - 1 M j . ' ' ~-—T ""^ | 1,1111 •i ■- I L- 111 >> i rf T it fin C ^ 1 fl ^ jTT- ■■■- i II w Q II j_ II rj 5^ c II In 6 tt 1 II Eis (r\ \ _ ^__Tisit- X nXT ! Mil 1 a .......T""T 1 it i f * Q ) . " III ni M t> - jlll ::;^::x:::x XT Iii" ■ e ^X If ■-., , i y J1 £ TT ff""' f 1 ri N •£ \ 11 1 111'ia ■ ' i M ek P f > XX i. _ r - . iJX nTI -2 r X ' X i x ■ tExT lit ^ 1 j i Mill ^ \ . 1 i -- 1 i ! i , _ ifri! i ] \ 1 11' 1 ] i . r lil i «:::t...I. TT > T !-.„,:£._.i. i 11(11 : - TT II 1 11 Mill CM " s :::..:_.::__________________ ^: 1 s "*■' ____-» q* - = ~"- —. -■= . ==:::: * r< " I _____.......... \,...... tt ss -----------------------^___ ^ ::::::_::::::::::::<►:: co r-- co io O O a: C- 02 CT- Oi INFECTIOUS AND CONTAGIOUS DISEASES 219 NAMF c .F. AGE 6 yrs. Sl xf""» e Diehth NATIONAL en'a TY H , fin mer tit*Kl'nj COM DATE Dav of Disease, P. li. T. i"n \ni n #i '1' ni nir. ' SO lor, . 110 4", 10+ 130 s +0 103 \ *• / \ ' d J \,< x - / V / I 110 /.. _ U _j _ v- ldl t N \ \ 10(1 ^ A 09 \ A > 2 s r- > s; s ' S r- 10 5 96 95 Bowels, *o.o[ movements, ITrine. quantity, etc., REM AFiK S: Fig. 61.—Temperature chart in diphtheria with antitoxin. 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 <.4,(, VWr ^r'Week 4th. £th £th jth Qth 70 — — — —' — 35 &c 30 so 25 _ 40 20 - n^ " 30 1 r 1 1 t 4-,4- is_____________J_£L-42£_____________________________ 20 1 ^ 1£^ t %**t -i\t 3£ A 4 V 10________i______________s,_________________ 10 ----------r -------- s"-------------- _> n v c 1 ^t 5 t I ■*--,' X X A S____t-?_______j,_________J__I J,_____,_______ ---1 ?----------5----- 'lir -5-----'-------- t ? 5__Z!v S^V 4- s>t-.Z j__„ 3Z-W 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 T j j i ii i ii jii 11111Tit III T no II T 1 HjiTI Lii4xrl I 1 1111 11 T Tl 111111 l4i 111111 II J T i, 11! 1 1111 11 111 I 1 3 T X ^ T °. |t| 40 T K X 11 1 1 1 11 1 1 1 1 1 1 1 1 VS T | | J J | | I 10 T It 1 T + 44 T III «i* X ill II .4* "TT IT T | -1 || 1J 1J11 111 1111 1 1 11 I 1 § I sl l] :lj s o| || g] g| fe| s| s 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, Naaaimo iio sasvasia ni dnishjin Vol CD c r^ n> ~- a. 0" SB 4 ^ H-, 73 fa CD H f/3 r+- ti- £s" ro fa e+ 3 71 CD H- ra xn po 05 |—I P Pj Ha O f-h >-d O P" 4 B r-f-E3J CD o p « ra t^ 0> ^ o n P O P Ha r+ pa P r+ r+ O PT- 3 - O ti CD B i- 2. *■ U4 C4 ~] 00 » © o o o c 40 O *- tO CO 4* Jl O O O C © 3 = i 1 I j .■« 0 B < 0 g 3' p 0 > B | ► 3 R g U1 C Ut © tO CO CO *■ *■ 'Jl 41 Oi © Cn © U4 © Ji 5 Six i % j. a i " ro ~' °° <° O © O © © © 3 © M to to 4* ^ - -4 C 1 .' ;* **' [«'" 4- > >J .-']■" Jt * "^ •'' ZI ".» i *££ * - ^ S 4" 06 "1 4' i' ~ n.. ,Sli __________ -*--- -- ^ > 1 ' "•» \ ^v ._-,.___..,.--..,.___-_-------------j > vS u ____ ' •* \ "" '> """.T i f.. 1 ^ m ::: n::::::::::::::"J::::::::::H: ?" |\5 X _- -^ .......T -e--- * 3 ■^ * _____?s____9j___: T\\T ' H' ^ A ' Jfl S5 "\~"i==,. " c- " "" » N> s--;-" v^"~-—. 1 fl 1 r» !» Nn ITiTt I ^ O fa 4 ^■f- r+ o f=- S- CD V. cn? CD 2! s» P -a rz^ P^ —h a n pu CD y; ^t- ^ > H O l-i r+ n CD -3- CD n K 4 o O ^ Pi Ci H o l> 3 p 2 (3- -i o CD CD P p 73 SB CI CD 0 p GO ^i rt- M f=- > c CD 02 CD £ C/J O Hs 4 72 CD ^t- ^. f=- P= CD Pi 73 71 236 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 MK I i ) < s i i ■ ■ n n n n ii is H n u i a n a n » n n „-»-.. »-»»J»--J«.-J-.«..... -.-■,- 4 kw<; i ~ A* tS: : " *< »> 1 1 01 l ^ ? 1 _," 1 - " * 1 X ^£ ?■■- 41- 4 oi "• _ ,. __±__ £_______C-- - - i 7--- — r .=> , / ,i P' ? 7 + j^,---------------f--------»--7----- _*-----n------^------- E~E - -t - . . ♦. ' " _ . : » E - / ::: nfh-.-j--------£__ [ . ' 3E2---n___j ». | :5~—:-:::: :::i::"::::: £ 1 2 _j---------------1-------------- -•EEEElE E5EEE|EEEEjEEEEEE -nr§:_;:::::£:::::::_:*:::::: I if ri_UL.______;:___.- '»' '« '< » ' 7 mm umimiiiiiii^ Fig. 67.—Weight chart of premature. 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 1?18 NLM052879900