B888ift'i» BoWmk&ot;: w,;' mas BwPQwfiiwODlKS'!'.'• '* wfloaoft »!?■■■ WY 159 M129d 1916 54530510R NLM D55AA00T 7 NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE LIBRARY. Annex Section — No. 113, MO. .-Cl----1------ W. D. S. G. 0. ' 3—513 NLM052880097 DISEASES of CHILDREN FOR NURSES INCLUDING INFANT FEEDING, THERAPEUTIC MEASURES EMPLOYED IN CHILDHOOD, TREATMENT FOR EMERGENCIES, PRO- PHYLAXIS, HYGIENE, AND NURSING w4 ROBERT S. McCOMBS, M.D. Physician to the Dispensary and Instructor of Nurses at the Children's Hospital of Philadelphia; Associate in Medicine at the Philadelphia Polyclinic and College for Graduates in Medicine THIRD EDITION, THOROUGHLY REVISED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1916 wy \S<\ Copyright, 1907, by W. B. Saunders Company. Revised, reprinted, and recopyrighted January, 1911. Reprinted September, 1912, May, 1914, August, 1915, and January, 1916. Revised, reprinted, and recopyrighted May, 1916 Copyright, 1916, by W. B. Saunders Company V •£,->*.•>■>rr&rt from th.B Library of Cnnfrvene vtju'ev Seo. 59, !>•:•-■-;-is:rit A* of Mcb.. 4, 1999 PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA JUN 10 1916 >CI.A4333f>8C DEDICATED TO THE MEMORY OF MY WIFE WHOSE INSPIRATION MADE THIS BOOK A SUCCESS PREFACE TO THE THIRD EDITION In the preparation of this edition the author has attempted to keep thoroughly abreast of the recent advancement in pediatrics without unduly enlarging the book. Additions have been made to almost all of the chap- ters, and the author feels that everything has been included which has proved to be important. Several articles have been rewritten. New photo- graphs have been added. Such important subjects as pylorospasm, food intoxications, blood-pressure, sporadic typhus, typhoid vaccination, the present treatment of pneumonia, syphilis, and tuberculosis, and the caloric methods of infant feeding have been incorporated. The chapters on nursing have been added to and standardized. The author is indebted to Miss Jennie A. Manly and Miss A. K. Sutton for helpful suggestions upon points in nursing; also to the Henry Phipps Insti- tute of Philadelphia for privilege of making photographs for article on Tuberculosis. He wishes to thank the publishers for their many acts of kindness, the Children's Hospital for the new photo- graphs, and the many friends the book has made for their favorable reviews and their timely advice. He hopes the third edition will receive the approval granted the previous ones. Robert S. McCombs. 21 i i Chestnut Street, Philadelphia, Pa. May, 1916. 5 PREFACE The need for a book on children's diseases for nurses was called to the author's attention while giving a course of lectures to the nurses at The Children's Hospital of Philadelphia. It was his original intention to have only the notes of the lectures printed, so that some form of condensed material might be at hand for purposes of study. This volume has grown from the original notes. Incorporated in it are the methods employed at the Children's Hospital. A short description of each disease found in infancy and childhood has been given. It is hoped that the descrip- tions are clear enough to enable a nurse to know what symptoms to expect and what complications to guard against. The author believes that enough anatomy and pathology have been included to give a clear understanding of. the structure of the body and the changes which take place during disease. Treatment has been included where a thorough knowledge of its underlying reason is neces- sary for intelligent application. Treatment for emer- gencies will be found under the different diseases and in the chapter on Therapeutics. Prophylaxis, infant feeding, and the methods of nursing employed in childhood are dwelt upon. 7 8 PREFACE The author is most deeply indebted to Miss Jennie A. Manly for practically all the points on nursing, together with the receipts for infant feeding used in this book. The original photographs for this volume were taken at the Children's Hospital. In compiling the notes, the author has had frequent recourse to most of the text-books on children's diseases. For many definitions throughout the book, and the descrip- tion of the diseases of the kidney, he has consulted Stevens' Manual 0} Medicine. In the chapters on Gastro-intestinal Diseases and Infant Feeding, Holt's Infancy and Childhood was often consulted. Robert S. McCombs. CONTENTS CHAPTER I PAGE Peculiarities of Children's Diseases............ n CHAPTER II Nursing in Childhood.................. 36 CHAPTER III Diseases of the Respiratory Tract........... . 54 CHAPTER IV Diseases of the Respiratory Tract (continued) ..... gi CHAPTER V Diseases of the Digestive Tract.............112 CHAPTER VI Diseases of the Digestive Tract (continued).......i2g CHAPTER VII Diseases of the Digestive Tract (continued).......140 CHAPTER VIII Diseases of the Circulatory System........... ^g CHAPTER IX Nervous Diseases....................ig7 CHAPTER X Diseases of the Urinary Tract .............231 9 IO CONTENTS CHAPTER XI PAGE Diseases of the Eye, Ear, Skin, and Glandular System . . 249 CHAPTER XII The Infectious Fevers................. 264 CHAPTER XIII Typhoid Fever......................282 CHAPTER XIV Tuberculosis.......................296 CHAPTER XV Contagious Diseases..............••... 314 CHAPTER XVI Constitutional and Nutritional Diseases..... . ,47 CHAPTER XVII Infant Feeding......................356 CHAPTER XVIII Artificial Feeding....................376 CHAPTER XIX Therapeutics.......................4IO CHAPTER XX Weights and Measures; Abbreviations..........474 CHAPTER XXI Medical Terminology.....,........ # 484 Diseases of Children for Nurses CHAPTER I PECULIARITIES OF CHILDREN'S DISEASES A child's life is divided into definite periods, namely, the "newborn," "infancy," "childhood," and "youth." The Newborn.—It is customary to designate a babe as "newborn" until all traces of its prenatal or intra-uterine existence have disappeared. This is usually accom- plished by the end of the first month. Infancy follows the newborn period and continues until the eruption of the first or milk teeth is completed; it is, therefore, limited to the first three years of life. Childhood extends from the third to the seventh year, at which time the permanent teeth make their appearance. Youth includes the years from seven to puberty. Weight.—The normal infant should weigh about seven and a half pounds at birth. During the first week there is a slight loss, but from that time on the increase should be steady. The curve during the first year is represented in the chart and shows approximately the proper weight for the different ages of the infant. ii INFANT'S WEIGHT CHABT. — Omoroii) P CROZKR Months, its* » t 1 a » 10 11 u is 1« is ia 17 is is so 21 n » >< Vfecha 1 1 \> 2 [■> II H3 n n| IS 211 21 IS 27 29 |ll ii {5 ST j) <1 111 « 42j_«» ■:: :- :..........;.....: ■■ ::;:::::::::::::;::::;: \~ . :i:::::. —TTTTT- ,t ^4 -1^1 ::ir: n.:. ::::::/:r tt-t :::^:-:/- -7- Weeks. 1 » » j s ;d. 11 li 1& \7 IV 21 21 U J? 21 |1 T_tiJ:.-iztlzr " »» »' » « « «• « « « m » m 11 n 11 i. h n si J, Fir;, t. PECULIARITIES OF CHILDREN'S DISEASES 13 NAME, Weight Chart ............ ADM.,.................... i MONTH.... | 1 TMofl tTarU-i i Ju-lif !||| 0»Y........ 9!.i > 2> 30 7JVAJ i?. S\ m , ' , i " i ITT" i ' ' 1__[4 _Li- ■ _t± |i 1 1 1 II i " 1 1 II ■■ ■...... M" Fig. 2.—The above chart was designed by Miss Rena C. Fox, Head Nurse, Children's Department of Philadelphia Hospital. It is very useful in cases where it is desirable to keep account of a child's weight over a short period of time. In the larger charts a month's time would appear as a very small line. The heavy lines may represent any pound desired; the figures being given according to first wei;jht of child during period it is to be used. Each subdivision equals two ounces. 14 DISEASES OF CHILDREN FOR NURSES Average Weight. Girls. Boys. Birth................. 7.16 pounds...... 7.55 pounds. 6 months............ 15-05 12 " ............ 20.05 18 " ............ 23.00 2 years.............. 26.00 11 12 13 14 15 31.00 35-o° 39.08 43.08 48.00 52-09 57-Q5 64.01 70.03 81.04 91.02 100.03 108.04 16.00 21.00 24.00 27.00 32.00 36.00 41.02 45.01 49-o5 54-os 60.00 66.06 72.04 79.08 88.03 oa-°3 110.08 Between the ages of twelve and fourteen years girls gain weight faster than boys. Height.—The average height is about twenty and a half inches at birth. The growth during the first year is about eight inches. The growth of the extremities is much more rapid than that of the trunk. The head measures in circumference about thirteen and a half inches. The posterior fontanels should close at the end of the second month and the anterior about the eighteenth month. The special senses of sight, hearing, smell, and touch are developed at birth. A normal infant is able to hold up its head during the second month and sit up about the sixth month. It begins to recognize objects during the fifth month. From the eighth to the sixteenth month it should learn to walk. The age at which an infant begins to talk varies greatly. In the majority of cases by the end of the first year it is able to form certain words, and from this time on the PECULIARITIES OF CHILDREN'S DISEASES 1$ development of the function of speech is rapid. At times perfectly healthy children have made little progress in their ability to talk by the end of the second year. Teeth.—Average table of eruption of the milk teeth: Centrals..................... 5 to 8 months. Laterals..................... 7 to 10 " First molar..................14 to 20 " Cuspid.......................14 to 25 " Second molar................24 to 36 " At three years all of the milk teeth should be in place. The lower teeth usually erupt first. The milk teeth demand the same attention as the per- manent teeth. Average table of eruption of the permanent teeth: First molar.............. 5 to 7 years. Centrals................. 6 to 8 " Laterals................. 7 to 8 " First bicuspid............ 9 to 10 " Second bicuspid..........10 to 12 '' Cuspid..................12 to 13 '' Second molar............12 to 14 " Third molar.............16 to 35, to 40 years. In strumous or rickety children the eruption is fre- quently delayed and the teeth are often brittle and fur- rowed. The enamel may be of poor quality, so that they easily decay. Hutchinson's teeth are seen in hereditary syphilis. The second or permanent upper central incisors have a single shallow crescentic notch in the center of the edge. In 16 DISEASES OF CHILDREN FOR NURSES 5-8 Mon. 7-10 Mon. 14-25 Mon. 24-36 Mon. Fig. 3.—Normal dentition (Friihwald and Westcott). Fig. 4.—Hutchinson's teeth in hereditary syphilis: a, The two upper central in- cisors (second dentition) exhibit deep transverse and longitudinal furrows and a concave notch in the edge. Although the teeth are normal in length, the width is less than normal, thus producing a broad interspace between the central incisors; 6, the upper central incisors (second dentition), immediately after eruption, and the four lower incisors. The lower surface of the upper incisors is rough from the presence of projecting points of dentine. The upper teeth are short and diverge, leaving a broad interval between them. The four lower incisors present a number of small excrescences like nails from imperfect enamel formation. The base of the excrescences is everywhere in the same plane (after Hutchinson). PECULIARITIES OF CHILDREN'S DISEASES iy addition the teeth are small and pegged. They are some- times called "screw-driver" teeth. Laminated and pitted teeth are seen at times after the acute infectious diseases of childhood, such as measles, Fig. 5.—Rachitic teeth. Boy nine and a half years old. The teeth are poorly developed, considerably eroded and grooved. Their position is very irregular; the lower incisors occupy a frontal position (not in the arch of the jaw) and the inferior maxilla makes an angular turn at the canine teeth (Hecker, Trumpp, and Abt). scarlet fever, and diphtheria. When these diseases occur at an early age the formation of the enamel may be affected. This causes such defects as irregular pits upon the crowns of the teeth, particularly the incisors. The pitting is so marked in some cases that it gives a general honey- combed appearance to the crowns. To ascertain if irregularities are due to the eruptive fevers it is necessary to know the age of the child at the period of the disease. Pits upon the incisors caused by the eruptive fevers between 2 I 8 DISEASES OF CHILDREN FOR NURSES the ages of four and five occupy about the central area of the crown face. The enamel about the cutting edge of the teeth has already formed at this age, so that alterations of nutrition would not affect it. The crowns of all the teeth in process of formation at this age are affected in a similar manner. Diseases Peculiar to Children.—Children need differ- ent environments, different management, different medical and surgical care, and different nursing from that required for adults. One-third of a physician's patients are children. Diseases of infancy and of early childhood differ in many respects from those of adult life, but after the seventh year children resemble adults in their ailments more than they do infants. The following diseases are seen chiefly in infancy and childhood: congenital anomalies of the heart, such as "blue babies," due to a patulous foramen ovale; congenital atelectasis or failure of a part of a lung to expand; oph- thalmia neonatorum or a gonorrheal conjunctivitis in the newborn; traumatic hemorrhages and birth paralysis due to injuries during birth; umbilical hernia; noma or gan- grenous stomatitis; cholera infantum; laryngismus stridu- lus; enuresis; chorea; tubercular meningitis; hydro- cephalus; infantile cerebral and spinal paralysis; cox- algia; scarlet fever; measles; rubella; varicella; pertussis; mumps, and diphtheria. Etiology.—Heredity, accidents at birth, infection through the umbilical cord, improper food, and bad hygienic surroundings are the principal causes of disease or of a delicate constitution in the newborn and during infancy. PECULIARITIES OF CHILDREN'S DISEASES 19 Inheritance is a very strong factor in infancy. Such diseases as syphilis and tuberculosis can be directly trans- mitted from the mother to the child. Syphilis very frequently is congenital. While a child is rarely born with tuberculosis, the undermined constitution and the feeble resisting power of an infant born of tubercular parents make it very likely that the disease will develop early in life, at times so soon after birth as to be practically congenital. This is especially so if they breathe the same atmosphere as, or are nursed by, tubercular mothers. Children of parents suffering with rheumatism, gout, Bright's disease, or alcoholism are apt to have poor resist- ing powers and yield easily to infection. Improper food and bad hygiene are the greatest causa- tive factors of disease in infancy. To these are due not only such diseases as rickets, scurvy, and marasmus, but also the great class of gastro-intestinal disorders. Diseases of the Newborn.—The newborn babe faces a series of accidents and infections at birth which may end its career before it is fairly begun. Asphyxia may result during birth. This may be caused by pressure upon the brain or umbilical cord, the winding of the cord about the neck, early separation of the placenta (the after-birth), and various maternal causes, such as prolongation of labor, convulsions, hemor- rhages, and death of the mother. After birth has been accomplished and the child has cried vigorously there usually is no danger, unless there has been some injury or some intra-uterine disease of the organs of respiration, circulation, or the brain. Premature infants may die soon after delivery due to the feeble development of the respiratory mechanism. (For Method of Resuscitation, see page 454.) 20 DISEASES OF CHILDREN FOR NURSES Congenital atelectasis is a failure of the lungs to expand after birth. It is most often seen in babies that have had symptoms of asphyxia at birth, or who are poorly devel- oped. The principal symptoms are cyanosis and pros- tration. These attacks may come on suddenly. They may be mistaken for "blue babies." (See page 159.) It is necessary to have the babe cry vigorously several times a day to fully expand its lungs. It is desirable to stimulate crying if it does not show a tendency in this direction. If sudden cyanosis should occur, the same treatment as is used in asphyxia should be instituted. Icterus, Jaundice.—About one-third of all infants de- velop jaundice within the first few days after birth. It increases in severity for one or two days and then gradu- ally disappears. In cases where it becomes persistently worse and shows no signs of abating, there is probably a congenital obstruc- tion of the bile-ducts or an inflammation of the liver (hepatitis), usually due to syphilis. The acute pyogenic diseases of the newborn are due to infection through the umbilical cord; more rarely, through the mouth or any wound of the skin. After the micro-organism enters the system it may cause a local cellulitis or abscess; it may attack the various serous membranes, giving rise to meningitis, peritonitis, pericarditis, and joint involvements; or it may cause pneumonia, gastro-enteritis, and inflamma- tion of the bones (osteomyelitis). Erysipelas, tetanus, epidemic hemoglobinuria, fatty degeneration of the newborn, and pemphigus neonatorum are diseases which are due to a like method of infection. Ophthalmia neonatorum (see page 251) must be con- PECULIARITIES OF CHILDREN'S DISEASES 21 sidered a pyogenic infection of the newborn, the con- junctiva being the seat of the local infection. Prophylaxis.—As the infection takes place after the child is born, the responsibility rests with the physician and nurse—with the physician at the time of cutting the cord, and more frequently with the nurse in the process of dressing the cord, bathing, or cleansing the mouth or eyes, possibly after having cared for a septic mother or another child. Infection may take place either before or after the separation of the cord. The dressings of the cord should be dry and sterile. If suppuration occurs at the time the cord separates, a wet bichlorid dressing should be applied. Ligatures, instruments, and everything which comes in contact with the umbilical wound should be sterilized. Careful attention should be given to the mouth, genitals, and all surfaces which are liable to chafing or excoria- tion. A nurse in charge of a septic mother should not have the care of the infant. In an institution every septic case should be isolated. This includes all of the above-mentioned diseases. Hemorrhages.—These are frequent during the first days of life. They may be due to injuries at birth or they may be spontaneous. They are primarily due to the fact that the blood-vessels are extremely delicate and that there are great changes transpiring in the blood and the circulation at this period. The most fre- quently seen hemorrhage is that which occurs beneath the scalp (cephalhematoma), which causes a swelling on the vertex of the head. This increases in size gradually for a week or ten days and then slowly disappears 22 DISEASES OF CHILDREN FOR NURSES Hemorrhages may also occur in the various viscera, from the umbilicus, stomach, intestines, mouth, nose, con- junctiva, female genitals, bladder, and subcutaneously. Cerebral hemorrhages are due to pressure upon the child's skull during delivery, which causes a rupture of an artery, with the formation of a clot on the surface of the brain. The pressure of this clot causes paralysis of the parts controlled by the damaged portion of the brain. From this source we may have the various forms of paralysis seen. Facial paralysis is due to an injury of the facial nerve. It is usually caused by pressure of the forceps along the course of the nerve, and not to a hemorrhage in the brain. Erb's paralysis is due to an injury about the shoulder- joint. The affected arm is paralyzed. (See page 214.) Intestinal obstruction may be due to an absence of the anal opening of the rectum (atresia of the anus) or to a strangulated hernia. Every child should be examined carefully immediately after birth to see if the rectum is patulous. If the bowels move, all doubt, of course, is removed. As they should open several times during the first twenty-four hours, any failure to do so should arouse suspicion and a thor- ough examination by the physician should be made. Umbilical hernia and swelling of the breast {mastitis) should be protected by pads. On no account should squeezing of the breast be permitted. Congenital stridor is characterized by noisy inspirations which have been likened to a crowing sound. It may last for six or eight months, when the growth of the larynx causes it to steadily diminish until it entirely disappears, usually by the end of the second year. In spite of the PECULIARITIES OF CHILDREN'S DISEASES 2$ apparent difficulty in breathing the child seems com- fortable. The chief danger is from some intercurrent disease like pneumonia. It may cause pigeon breast, which may persist. Sclerema is a rare condition characterized by hardening of the skin and subcutaneous tissues, together with symptoms of malnutrition. In the treatment of these cases the physician will keep the child in an incubator. Inanition fever is described on page 29. The Most Frequent Diseases of Infancy and Child- hood.—Diseases of the gastro-intestinal tract and broncho- pneumonia are seen more often than any other diseases before the second year. The other common conditions met with during this period are affections of the lymph- glands, tubercular meningitis, pertussis, and measles. After the second year the following diseases are most frequently seen: Disorders of nutrition, such as rickets and scurvy; bone and joint diseases, these being usually tubercular and more rarely syphilitic; diseases of the blood; organic diseases of the heart; pneumonia, typhoid fever, the acute contagious diseases, such as measles, mumps, pertussis, varicella, scarlet fever, and diphtheria. COMPARISON OF CHILDREN'S DISEASES WITH ADULT CONDITIONS The respiratory tract during infancy is undeveloped. The air-cells in the lungs are not so far advanced in their structure, nor so important in the function of respiration, as are the bronchial tubes. This causes an ordinary inflammation of the bronchial tubes, or bronchitis, to be a much more serious condition in infancy than in the 24 DISEASES OF CHILDREN FOR NURSES adult. When the smallest tubes are involved it is called capillary bronchitis or bronchopneumonia. Pneumonia is very common in infancy and childhood. Before two years of age it is usually of the type of a broncho- pneumonia. Next to gastro-intestinal disease this form of pneumonia causes more deaths than any other condition during childhood. After two years of age the pneumonia is usually croupous in type, and, in contradistinction to bronchopneumonia, is very rarely fatal. In this respect it differs from pneumonia in the adult, in whom the mortality ranges from 20 per cent, to 50 per cent. The frequency of empyema as a complication of pneumonia and the frequency of bronchopneumonia as a complication of the acute infectious fevers are peculiarities of children's diseases. Gastro-intestinal disorders in childhood are the most fatal of all diseases. This is in direct contrast to adult life. The reason lies in the delicate digestive power of infants. Toxins or poisons are formed in the intestines from their inability to digest and assimilate properly the food given. This poison is absorbed and produces grave results. During infancy the stomach and intestines are more intimately associated than later in childhood. Hence one is rarely affected without involving the other. This causes an increase in the severity of the symptoms, with consequent deleterious results to the child. Through- out childhood gastro-intestinal conditions are characterized by the severity of the symptoms. The circulatory tract, except for the congenital mal- formations of the heart such as valvular disease and "blue babies," is usually unaffected during infancy. After two years of age heart diseases are common. A murmur should always be looked for in cases of chorea, rheuma- PECULIARITIES OF CHILDREN'S DISEASES 2$ tism, and the acute contagious diseases. A peculiarity of childhood is the development of endocarditis following mild attacks of rheumatism. Aneurysms and arterio- sclerosis are uncommon. Anemia is often present in children. The Genito-urinary Tract.—The kidneys are rarely affected in childhood except as a sequel of scarlet fever. As this is a very common complication of scarlet fever, all those suffering from the disease should be kept under close observation. Enuresis is common in childhood. The various malformations of this tract are common in childhood, especially phimosis. Diseases of the Nervous System.—Hemorrhages are usually on the surface of the brain, and not within its substance. They usually occur at birth. Birth paralysis results. The portion of the cortex at which such hemor- rhages occur fails to develop, and the injury is permanent. Such conditions as chorea (St. Vitus' dance), laryngis- mus stridulus, nodding spasms, tetany, infantile paralysis, and tubercular meningitis are typically children's diseases. One of the peculiarities of children is to have convul- sions from trivial causes, without any lesion of the brain being present. Diseases of the Eyes, Ears, Skin, and Glandular System.—Ophthalmia in the newborn is very often seen in the poorer classes and causes about 30 per cent, of all adult blindness. Conjunctivitis is often seen, espe- cially associated with measles and catarrhal conditions of the nose and throat. Strabismus is not uncommon. Otitis media and mastoid disease are more frequent in childhood than in the adult. Running ears, following 26 DISEASES OF CHILDREN FOR NURSES the contagious diseases, especially measles, is a common complication. Eczema is often observed in artificially fed children. Tubercular adenitis is seen more often in childhood than in the adult. The Acute Infectious Fevers.—Most of the diseases seen in adults attack children. Malaria is common. Hereditary syphilis is observed in childhood, the majority dying before they reach maturity. Typhoid fever is quite a common disease in children living in large cities. It differs from typhoid fever in the adult in that its onset is usually more sudden, manifesting itself as often in the appearance of fever, vomiting, and prostration as in the usual slow, insidious beginning. In the course of the disease constipation is more frequent than diarrhea, tympanites is not so marked, the eruption is less constant, the nervous symptoms are not as apt to be found as in adults, hemorrhage and perforation are also met with less often, and the mortality is lower. Tuberculosis is common in childhood. In infants under two years of age the lung is the part affected; beginning with the second year tubercular meningitis is more often found; and after the third year tuberculosis of the bones, the lymph-glands, peritoneum, and intestines becomes more frequent and are seen throughout childhood. Pott's disease and coxalgia are rarely seen except in childhood. The contagious diseases are typically children's diseases. While they may attack unprotected adults, they are com- paratively rare after fifteen years of age. Constitutional and Nutritional Diseases.—Rheuma- tism is rarely of the acute articular type in children. It is often exhibited only by stiffness and slight aching pains PECULIARITIES OF CHILDREN'S DISEASES 27 in the limbs ("growing pains"). The frequency of endocarditis as a complication of rheumatism, even when no more severe symptoms than growing pains are present, makes it necessary that such cases should be put to bed and receive proper treatment. Diabetes mcllitus is uncommon in childhood, but when it does occur the course is very rapid and fatal. Fig. 6.—Genu valgum. Female child Fig. 7.—Genu varum from rachitis five years old (Napier). (Napier). Scurvy is seen in artificially fed infants. Rickets and marasmus are typical nutritional diseases seen only in childhood. Orthopedics.—Many children have deformities due to rickets, spinal curvatures, congenital dislocation of the hips, and contractions of the tendons. These deformities are overcome by surgical treatment. 28 DISEASES OF CHILDREN FOR NURSES Various terms are given to the different deformities: Clubbed hands; webbed fingers; congenital dislocation of the hips; knock-knees or genu valgum; bow-legs or genu varum; bowing of tibia; club-feet or talipes varus; and talipes valgus; Polydactyly or six fingers. Symptomatology.—In children the onset of disease is usually more sudden, the temperature higher, the pulse and respirations more accelerated, the physical signs more pronounced, the course shorter, and the recovery more rapid than in an adult. Fig. 8.—Talipes valgus (Kerr). Fig. 9.—Talipes varus (Kerr). All temperatures in children are higher than in adult life. Frequently a temperature of 1040 F. to 105° F. is seen in cases of ordinary pharyngitis and mild tonsillitis. Fever in children apparently results from the slightest cause. This is better understood if one realize that the nervous mechanism of a child is more sensitive than that of an adult. Consequently a fever in a child does not indicate as much as in an adult and need not cause anxiety unless prolonged. It is the continuous high temperature which indicates serious illness. On the other hand, the tempera- ture is easily depressed, owing to the great vascularity of the skin, by exposure, by sleep, and by inactivity. PECULIARITIES OF CHILDREN'S DISEASES 29 Inanition fever is a term applied to a peculiar elevation of temperature occurring in the newborn. It is generally seen during the first five days of life, and is apparently due to the fact that the infant gets very little, often nothing at all, from the breast. The temperature may rise to 102° or 1040 F., and is associated with rapid loss of weight. As soon as milk is secreted in abundance, or when the child is placed upon a full breast, artificial food, or even water, if given freely, the temperature falls to normal. It is important that such a fever should be recognized, because it gives at times the first warning of a condition which may prove fatal. The temperature of every child should be taken during the first week. The normal pulse in infancy and childhood is of lower tension than in an adult and varies in frequency according to the age. The first few weeks after birth it beats from 120 to 150 times per minute. In the second year the pulse falls to no; in the third or fourth year to 100; in the seventh to 90; and in the twelfth to 80. Slight causes may produce wide variations of the normal pulse due to the unstable nervous mechanism of a child. The respirations during the same period likewise vary- In the newborn they are from 30 to 60 per minute; in the first year 28 to 30; at five years 22 to 25; at fourteen years 20; and in adult life 18. The peculiar variations of the respiration seen in childhood are due to the same nervous origin which influences the temperature and pulse. The function of digestion in infancy is delicate and undeveloped. Infants are able to digest about 4 per cent. of fat, 6 per cent, of sugar, and 2 per cent, of proteid during the first year. Infants cannot tell their symptoms, so it is necessary to 30 DISEASES OF CHILDREN FOR NURSES study them to find out their ailments. The principal means a child has of explaining its wants, discomforts, or pains is by crying. A child cries from pain, hunger, discomfort, or habit. The cry of hunger is usually fretful, is accompanied by the sucking of its fingers, and ceases when satisfied. The cry of indigestion simulates the cry of hunger, but does not cease when the child is fed. The cry of pain is usually sharp and is accompanied by contractions of the features, drawing up of the legs, and signs of distress. If the child fall asleep from exhaustion it soon awakens, usually with a scream. It is well to remember that a severe pain in infancy may be due either to colic or earache. The child simply moans when the pain is less severe. The cry of weakness is a feeble whine. The cry of temper is prolonged, violent, and is attended with stiffness of the body and the throwing about of the arms and legs. The cry of habit ceases when the child is satisfied and may be caused by a desire for any familiar object, such as a doll, nipple, or rattle. There are also characteristic cries heard in certain diseases such as hydrocephalus, meningitis, marasmus, hereditary syphilis, and pneumonia. In hydrocephalus and meningitis a child will scream out shrilly in the night. This is called the hydrocephalic cry and is also sometimes heard in chronic bone diseases, due to pain. In marasmus there is the feeble. whine; in hereditary syphilis a nasal cry; in pneumonia the cry is short, catching, and suppressed. PECULIARITIES OF CHILDREN'S DISEASES 31 Feeding and Therapeutics.—The entire subject of feeding in infancy and childhood is one of the most im- portant branches of pediatrics. The therapeutic measures employed differ in many respects from adult treatment. Prognosis.—The younger the child, the worse the prog- nosis. This is because of the feeble resisting power and lack of development. On the other hand, many conditions can be outgrown, as the structures and organs increase in size and strength develops. Most deaths in the first year are due to marasmus, affections of the gastro-intestinal tract and to broncho- pneumonia. Practically the only deaths due to nervous origin are from meningitis and convulsions. Of the acute contagious diseases, usually measles and pertussis are the only offenders. Of the chronic diseases, tuberculosis stands alone. Sudden deaths occur from the following causes: mal- formations; internal hemorrhage; asphyxia from overlying; asphyxia from the aspiration of food into the larynx and trachea; asphyxia from enlarged thymus gland; atelec- tasis; convulsions; and marasmus. In the second year there are the same causes of death as in the first, with the exception of marasmus, which for- tunately does not extend into this period. From the second to the fifth year scarlet fever, diph- theria, general diseases of the lungs, and tubercular meningitis are the diseases causing death. From the fifth to the fifteenth year there is low mortality. It is chiefly made up of deaths resulting from diphtheria, scarlet fever, diseases of the lungs, tubercular meningitis, 32 DISEASES OF CHILDREN FOR NURSES diseases of the bones, appendicitis, rheumatism, and cardiac conditions. Quarantine.—The diseases which must be isolated by the regulations of the Boards of Health of different cities vary so that no accurate rule can be given. Scarlet fever, small-pox, diphtheria, epidemic cerebrospinal meningitis, yellow fever, and cholera are universally isolated. In addition, many other diseases must be reported. Sections from the laws of the State of Pennsylvania are given as an example of what regulations must be expected in cases of infectious and contagious diseases. In addition, no one who is suffering from the diseases mentioned, nor anyone who has charge of the persons so suffering, is permitted to ride in a public conveyance, and the patient cannot enter a private vehicle without con- sent of the health authorities and without making pro- vision for thorough fumigation of the vehicle after use. Other provisions are made covering bedding, infected clothing, etc., and renting of rooms which have been occupied by persons suffering from tuberculosis or other infectious diseases, without fumigation. Section i. Be it enacted, etc., That every physician, practicing in any portion of this Commonwealth, who shall treat or examine any person suffering from or afflicted with actinomycosis, anthrax, bubonic plague, cerebrospinal meningitis—epidemic (cerebrospinal fever, spotted fever), chicken-pox, Asiatic cholera, diphtheria (diphtheritic croup, membranous croup, putrid sore throat), epidemic dysentery (bacillary or amebic dysentery), erysipelas, German measles, glanders (farcy), rabies (hydrophobia), leprosy, malarial fever, measles, mumps, pneu- monia (true), puerperal fever, relapsing fever, scarlet fever, (scarlatina, scarlet rash), small-pox (variola, varioloid), tetanus, trachoma, trichinia- sis, tuberculosis in any form, typhoid fever, paratyphoid fever, typhus fever, whooping-cough, yellow fever, anterior poliomyelitis, impetigo PECULIARITIES OF CHILDREN'S DISEASES 33 contagiosa, pellagra, scabies, or uncinariasis shall report the case to the health authorities. Section 2. Upon receipt by the health authorities of any township of the first class, borough, or city, or by the health officer of the State Department of Health, of a report of the existence of a case of anthrax, bubonic plague, cerebrospinal meningitis—epidemic (cerebrospinal fever, spotted fever), chicken-pox, Asiatic cholera, diphtheria (diph- theritic croup, membranous croup, putrid sore throat), German measles, glanders (farcy), leprosy, malarial fever, measles, mumps, relapsing fever, scarlet fever (scarlatina, scarlet rash), small-pox (variola, varioloid), typhoid fever, paratyphoid fever, typhus fever, whooping-cough, or yellow fever, the said health authorities or the health officer of the State Department of Health, as the case may be, will quarantine the residence. Quarantine Periods—// Antitoxin Has Been Used—Cultures. Section 4. The quarantine period for anthrax, bubonic plague, cere- brospinal meningitis—epidemic (cerebrospinal fever, spotted fever), Asiatic cholera, typhus fever, yellow fever, relapsing fever, leprosy, and whooping-cough shall be until the recovery, death, or removal of the patient so suffering, and shall be determined in accordance with the rules and regulations of the health authorities. The quarantine period for small-pox (variola, varioloid) and scarlet fever (scarlatina, scarlet rash) shall be a minimum period of thirty days, or until such time thereafter as the last person in the premises so suffering shall have fully recovered, or until death or removal. The quarantine period for diphtheria (diph- theritic croup, membranous croup, putrid sore throat) shall be a mini- mum period of twenty-one days, or until complete recovery or the death or removal of the patient: Provided, That if antitoxin has been used for curative purposes for the patient, and for the immunizing of all of the inmates of the premises, and two negative bacteriological cultures have been secured from the diseased area of each patient on the premises for two successive days, the minimum period of quarantine may be fourteen days. The quarantine period for measles, German measles, chicken-pox, and mumps shall be for a minimum period of sixteen days, or until the recovery of the last person on the premises so suffering, or until complete recovery or the death or removal of the patient. Exclusion from Places of Amusement, Public Gatherings, Places of Business, Churches, Schools, Etc. Section 7. No child or other person residing in the same premises with any person suffering from anthrax, bubonic plague, cerebrospinal menin- 3 34 DISEASES OF CHILDREN FOR NURSES gitis—epidemic (cerebrospinal fever, spotted fever), Asiatic cholera, small-pox (variola, varioloid), typhus fever, yellow fever, scarlet fever (scarlatina, scarlet rash), relapsing fever, leprosy, diphtheria (diphtheritic croup, membranous croup, putrid sore throat), measles, German measles, chicken-pox, or mumps, shall be permitted to attend any place of amuse- ment, or any church, or other public gathering, or to be exposed, except by permission of the health authorities, on any public street or in any store, shop, factory, or other place of business, or be permitted to attend any public, private, parochial, Sunday, or other schools; and the teachers of public schools, and the principals, superintendents, teachers, or other persons in charge of private, parochial, Sunday, or other similar schools, are hereby required to exclude any and all such persons from said schools; such exclusion to continue until the quarantine is lifted and the premises thoroughly disinfected. Disinfecting Bath, Etc.—Removal—Bath, Ele.—Use of Antitoxin— Admission to School—Removal—Immunes—Admission to School. Section 8. Any child or person residing on the same premises with any person suffering from anthrax, cerebrospinal meningitis—epidemic (cerebrospinal fever, spotted fever), or typhus fever may be allowed after taking a disinfecting bath and putting on disinfected clothing, to remove from the said premises and take up his or her residence on other premises, and may after such removal be admitted into any of the said schools; and any child or person residing on the same premises with any one suffering from diphtheria (diphtheritic croup, membranous croup, putrid sore throat), may be allowed, after taking a disinfecting bath and putting on disinfected clothing, and after antitoxin has been administered for immunizing purposes, to remove from the said premises and take up his or her residence on other premises occupied by adults; and may, after five days from said removal, be admitted into any of the said schools; and any child or person residing on the same premises with any child suffering from scarlet fever (scarlatina, scarlet rash), measles, German measles, mumps, or chicken-pox, may be allowed, after taking a disin- fecting bath and putting on disinfected clothing, to remove from the said premises, and take up his or her residence on other premises occupied only by adults, or by children who are immune to the disease (scarlet fever, scarlatina, scarlet rash, measles, German measles, mumps, or chicken-pox), existing on the said premises from which the said child or person has removed, such immunity being shown by the official health records, and may, fourteen days after such removal, be admitted to any of the said schools: Provided, That if the child or person residing on the PECULIARITIES OF CHILDREN'S DISEASES 35 same premises with any person suffering from any of the said diseases (scarlet fever, scarlatina, scarlet rash, measles, German measles, mumps, or chicken-pox), and removing therefrom as above provided, is himself or herself immune from the disease existing on the said premises, by virtue of a former attack, this fact being shown by the official health records or by other evidence satisfactory to the health authorities, such immune child or person may, on the day following such removal, be admitted to any of the said schools; and any child or person residing on the same premises with any person suffering from relapsing fever may be allowed, after taking a disinfecting bath and putting on disinfected clothing, to remove from the said premises, and take up his or her residence on other premises, and may, after ten days from such removal, be admitted to any of the said schools. CHAPTER II NURSING IN CHILDHOOD The problems which confront the nurse in the manage- ment of children are vastly different from those encoun- tered among adults, but the fundamental principles of nursing are the same. The methods of treatment are in many respects identical, or only slightly altered to adapt them to the young patient. The methods of amusement and entertainment can be appreciated by all who have come in contact with children, and success in handling them depends entirely upon the nurse's temperament. It is the professional side of the nurse, her value to the physician in attendance, which demands the special train- ing in children's diseases. It is necessary to know the symp- toms and to be able to report them intelligently. This calls for careful, trained observation, as the child cannot describe its feelings accurately. The detail of symptoms cannot be recited by the patient, but has to be recognized and tabulated by the nurse. It is necessary to understand the principles of infant feeding and hygiene. These are the two most important subjects of pediatrics. Knowledge of milk mixtures and their preparation is essential. Accuracy is demanded both by the infant's digestion and by the physician. The delicate mechanism of an infant's stomach cannot digest foods unless they contain the proper proportion of fat, sugar, and proteid. The physician's whole plan of treat- 36 NURSING IN CHILDHOOD 37 ment is rendered useless unless he knows the percentage of these ingredients in the mixture the child is getting. The proper methods of feeding in malformations and intubations must be understood. Hygiene is a vast subject in itself. In infancy the sur- roundings and the personal attentions are of greater value than at any other time of life. It is necessary to understand the significance of the stools in infancy. The character of these acts as a guide to the physician in the treatment of the case and in the construction of his milk mixtures. In the same way the character of the vomit is important. The methods of treatment in childhood must be thor- oughly comprehended. The subject of prophylaxis and the care of the contagious cases is the field in which the nurse is in supreme command. By never permitting a lapse in her technic nor carelessness in her methods she does more for the prevention of disease and the health of the human race than any other factor in medicine. GENERAL HYGIENIC MANAGEMENT OF CHILDREN The Newly Born.—Immediately after birth the child should be wrapped in a blanket and placed in a warm room. The eyes should be washed with boric acid or, in cases where there has been a pre-existing vaginal dis- charge one or two drops of a 2 per cent, solution of silver nitrate should be used (Crede's method). The child should then be thoroughly greased and given a warm bath at a temperature of ioo° F. An antiseptic dressing should be applied to the cord and a flannel binder placed around the abdomen. It is preferable to have the child sleep in a crib. 38 DISEASES OF CHILDREN FOR NURSES Care of the Cord—-The cord should be kept dry and disturbed as little as possible until it drops off; this usually occurs on the fifth day. After this has happened an antiseptic dressing and a square pad should be placed over the navel and held firmly in place by the binder, to prevent umbilical hernia. Bathing.—After the separation of the cord the full bath can be given daily. The water should be about ioo° F. The middle of the day and the warmest part of the room are the time and place to select. The bath should take only a few minutes, and vigorous rubbing should be avoided. Clothing.—This should be light in texture, warm, and nonirritating. The chest and arms should be covered with a woolen undershirt, and all clothing should hang from the shoulders. Canton flannel or stockinet make the best diapers. The feet must be warm, as cold feet are responsible for many attacks of colic and indigestion (Holt). The night clothing should consist of a light flannel gown, hung from the shoulders. Too much covering may cause disturbed sleep. In summer the outer clothing should be light and the underclothing of the thinnest flannel or gauze obtainable. Special Hygienic Measures.—The eyes should be washed with boric acid for the first few days and at any time upon the appearance of a discharge from the eye. Infants should be kept in a darkened room. The tem- perature should be taken daily during the first week (see page 29). The mouth should be cleansed with a soft rag wet with sterile water. A solution of bicarbonate of soda, 20 gr. to the ounce, should be employed if there are any signs NURSING IN CHILDHOOD 39 of inflammation or'thrush. In such cases the mouth should be cleansed with this solution after each feeding. The breasts in both sexes often become swollen a few days after birth. If they are not interfered with, this disappears in a short time. Genitals.—In boys the foreskin should be retracted daily and greased. # The skin is very delicate in infants; Fig. io.—The " Children's Hospital Bed." A properly constructed bed for infants. the urine frequently causes scalding and blistering of the surfaces, especially in fat babies. If this occurs the napkins must be removed as soon as soiled; the skin should be bathed only once a day with water (for all other cleansing purposes olive oil should be used); and a powder consisting of balsam of peru, 10 per cent, tal- 40 DISEASES OF CHILDREN FOR NURSES cum, starch, cornmeal, or stearate of zinc, dusted upon the inflamed areas, in all the folds of the skin, and over the diaper. The best dusting powder is probably the balsam of peru, 10 per cent., combined with stearate of zinc. Bran baths are advantageous at times (see page 440). Airing.—In summer a newly bom babe can be taken out at the end of the first week; in winter, at one month. All children should receive all the sunshine and fresh air obtainable. Sleep.—During the first few weeks a child sleeps from twenty to twenty-two hours during the day. An infant should not be allowed to sleep at the breast or with a nipple of a feeding bottle in its mouth. The babe should be awakened every two hours for its feeding. Infant feeding is discussed in Chaps. XVII. and XVIII. Infancy.—Bathing.—By the sixth month the tempera- ture of the bath can be reduced to 95 ° F. and by the end of the first year to 90 ° F. Older children should receive a cold douche with water of about 70 ° F. after the bath, while standing in a tub of warm water. At times infants get blue after the bath, especially if delicate. Under such conditions it is better to discontinue tub bathing and depend upon the bed baths. Clothing.—The abdominal band can be dispensed with after the first few months. In very thin infants it may be continued, to maintain the proper protection to the abdo- men. Low neck and short sleeves should not be allowed. The night clothing should be a light flannel gown hung from the shoulders. The night clothes should be an entirely different set from those worn during the day. Special Hygienic Measures.—The teeth should be kept NURSING IN CHILDHOOD 4* clean to prevent caries. The child should be trained to have its bowel movements and urinate at selected times. Sleep.—During the first six months the child will sleep from sixteen to eighteen hours during the day. At one year it requires from fourteen to fifteen hours of sleep and at two years, thirteen or fourteen hours. An infant's position should be changed often during sleep. Exercise.—An infant usually obtains plenty of exercise from crying and throwing its arms and legs about. Walk- ing should be attempted during the period from the eighth to the sixteenth months, provided there is no tendency to rickets. Talking should be encouraged. Childhood.—Bathing.—During childhood the warm bath should be given at night and the cold bath or sponge in the morning. Clothing.—Woolen undergarments in winter and light textures in summer are the rule. The night clothing should consist of woolen union suits with feet, if there is a tendency to get from under the covers. General Hygienic Measures.—The bowel movements should be kept regular. Any illness or disorder should be immediately attended to. Sleep.—At the age of four years eleven or twelve hours sleep are required. Exercise.—The playroom should be cool—from 60 ° F. to 65 ° F. (Holt). The clothing should be loose, to give the freest possible motion of the muscles. Out-of-door exercises are the most healthful. The proper methods of feeding for children over two years of age is discussed in Chapter XVIII. Youth.—Sleep.—The amount of sleep required from 42 DISEASES OF CHILDREN FOR NURSES the sixth to the tenth year is from ten to eleven hours. From the tenth to the fifteenth year at least nine hours of sleep are necessary. An out-door life with plenty of exercise, frequent bathing, and instant attention to ailments lays the foundation for sturdy manhood and womanhood. The nursery should be the sunniest and the best ventilated room in the house. Nothing which could contaminate the air of the room should be allowed. The temperature should be from 68° F. to 70° F.; no higher. The room should always be thoroughly aired at night. The floors should be covered with rugs, as they are cleaner than carpets. An infant requires about 1000 cubic feet of air, older children about 700 to 800 cubic feet. Premature Babies.—The conditions which have to be combated under these circumstances are the problems of maintaining the body heat, and feeding. Incubators.—These are so arranged that an even tem- perature may be maintained: 98° F. in very delicate in- fants and from 850 F. to 950 F. in more robust babies. At the same time the air is moistened and ventilation is secured. In constructing an incubator the lower portion consists of a hot-water tank (hot-water bottles may be used), above which is an inlet for air. The bed should occupy a position midway in the air chamber and be so arranged as to allow the air to circulate freely around its foot. An exit for the air should exist above the child's head. A moistened sponge should be placed at the foot of the bed. The child is kept in the incubator until it reaches full term. Before removing, the temperature should be gradually lowered. NURSING IN CHILDHOOD 43 In feeding these children, gavage often has to be resorted to. At seven months of age 4 ounce should be given every hour and a half. At eight months f ounce at the same intervals. In small full-term babies it is also necessary to maintain the body heat. This is best accomplished by wrapping Fig. ii.—Cross-section of a wooden incubatqr of simple construction, with glass lid (F): The air enters through the opening A, which can be regulated by means of a damper, passes over the bottles filled with hot water, the saturated sponge, and the ther- mometer, and escapes through the ventilator K. (Friihwald and Westcott). them in cotton and blankets. Hot-water bottles may also be employed. ROUTINE EXAMINATIONS Temperature.—When taking the temperature of the child it is not always possible to teach them to hold the thermometer in the mouth properly, and for young children and infants this method is impracticable. The rectum, the axilla, or the groin are then utilized for this purpose. The thermometer should be greased with ordinary vas- 44 DISEASES OF CHILDREN FOR NURSES elin when introduced into the rectum and the temperature marked "rectal" on the chart or read one degree lower than the mercury indicates, as the local temperature in that part is about one degree higher than in the mouth. If an infant struggles while taking a rectal temperature, turn it on its face, or hold its face downward on your knee. Fig. 12.—Method of taking the rectal temperature of an infant or young child (Kerr). When the thermometer is inserted, with the child in this position, it should be pointed downward, toward the um- bilicus, as the axis of the rectum has been changed. When the rectum is diseased it should not be chosen for the place to take a temperature. In the axilla or groin the temperature should be marked "axillary" on the chart or read one degree higher, as there NURSING IN CHILDHOOD 45 is that much difference in temperature between these localities and the mouth. The skin should be thoroughly dry and the thermometer closely surrounded by folds of skin. Pulse.—The pulse is best obtained in the groin or at the temporal artery in infants. The normal rate for the different ages is given on page 29. Fig. 13—The method of obtaining the temperature at groin. The skin should be free from moisture. The thermometer is laid in the fold of skin between thigh and abdomen and is held in place by crossing thighs. Respiration.—The normal rate for the different ages is given on page 29. COLLECTIONS FOR CLINICAL EXAMINATIONS Method of Collecting Urine.—In males it is a good plan to place the penis in the neck of a bottle which lies between the thighs and is held in position by a square of adhesive plaster, the center of which is pierced, making a hole large enough to grip the neck of the bottle. 46 DISEASES OF CHILDREN FOR NURSES In females a small pan placed under the buttocks will answer, or a bottle can be arranged as described above. If these methods fail, catheterize. The diapers are saved in cases where the stools are to be examined. The blood is examined to determine the number of red and white blood-corpuscles, the percentage of hemo- globin, and for malarial organisms. For method, see page 191. The Wassermann reaction for syphilis and the com- plement fixation test for gonorrhea are also made with the blood. The sputum is examined for tubercle and other bacilli, and should be expectorated into a sterile, wide-mouthed bottle. In children under four years of age, the best method to obtain sputum is as follows: Have an applicator with sterile cotton about the tip. Grasp the tongue, pulling it as far forward as possible, and pass the applicator back to the pharynx, keeping as close to the tongue as possible. The irritation of the pharynx will excite coughing, and the sputum may be swabbed out. The applicator may be placed by the child's bedside, and when the nurse notices a severe attack of coughing the child is picked up and the sputum obtained in the same manner. Another very easy method of obtaining sputum is to insert a large (4-ounce) eye dropper into one end of a catheter, compress the bulb, and pass the catheter back to the pharynx, then allow the bulb to expand, this produces suction and draws the sputum into the catheter. Cerebrospinal fluid is examined for various organisms. For method, see page 210. NURSING IN CHILDHOOD 47 Diphtheria bacilli are looked for in smears taken from the nose and throat. It is at times desirable to have the nurse obtain the culture from a suspected case of diphtheria. To do this she must have a platinum loop and a test- tube containing the proper culture media (Loffler's blood- NAME ^/f^^^&^^L^____ DATS ••J 1 8 a; s STOOLS CHARACTER MEDICINE wmi/m Si REMARKS %ft 3am lool Id 34 /s5 1 Softyrflaw M/Ahkeytt ■AfMfLw 3hr n 6AM m % Z* Wltf&yV; 6 try ism Restless » ?AM 100% lei 26 **} 1 Softbtawn urhiikrullf- Milkfl^ 6*} T^ersb/rifiy // /2AM 5PM 103° 102% 126 116 Zf sy M/lkjLW 6 '•, »v 1 ISO 60 10 h A _J »\ 1 \l I'M SS /t>S •\ ' V 1 ,", >, .130 SO /Of- ' 1 1 A \t 11 ' 1 ' \ 120 *i-S 103 1 1 A V f\ V' \ 1 I/O ■*0 /02- / \ v. A J 1, S\ [ , \ 100 35 10/ 1 J \l V \^ 0 /\ ',/ A \ ,\ ,/v A 90 30 100 V \t f > V \ A r lV V M \, / 80 25" 99 V \J 10 20 98 V 60 15 91 Fig. 2g.—Chart of the temperature (----) and respirations (----) in bronchopneumonia. Child one year old (Kerr). Just before death the temperature often reaches 107 ° F. and 1090 F. The respirations average from sixty to eighty per minute, often they are one hundred per minute, and occasionally a hundred and twenty. There is great short- ness of breath (dyspnea), the child struggles for each breath, the chest is retracted at the base, and the other symptoms of dyspnea are present. The respiratory action is more affected than the heart action, and if the child succumbs it is usually by respiratory failure, the symptoms of which are very rapid, superficial breathing, sometimes IOO DISEASES OF CHILDREN FOR NURSES a hundred to a minute, blueness of the lips and finger-nails, and often a bluish hue to the body. The pulse averages from one hundred and fifty to two hundred per minute. When very rapid it is often irregular. The character of the pulse is more important than the rapidity. At first it is full and strong, but later it becomes weak, thready, compressible, and intermittent. Cough is always present and very persistent, more so than in croupous pneumonia. A good, strong cough is not an unfavorable symptom, as it shows that the reflex irritability of the bronchial tubes is still present. When this is lost the mucus is not removed, the lungs fill up, and respiratory failure threatens. Suppression of cough is, therefore, a bad sign. There is no expectoration before four years of age, the mucus is either swallowed or re-inspired. During severe paroxysms of coughing, if the child be turned on its face or inverted, much of the mucus will run out of the mouth. A blueness (cyanosis) of the skin and mucous membrane is found in severe cases. It is due to a sudden congestion of a portion of the lungs not previously affected. Even when present only at lips and finger-tips, the patient should be very carefully watched, and if further symptoms of respiratory failure develop, they should receive prompt treatment (see pages in and 427). Prostration is progressive; at first it may be moderate, but in the final stages there may be symptoms which are known as the typhoid state. These are delirium, picking at the bed-clothes (carphalogia), twitching of the tendons (subsultus tendinum) rare in childhood, and dry, brown, fissured tongue. Gastro-intestinal Symptoms.—Often there are from four DISEASES OF THE RESPIRATORY TRACT to six green stools a day, containing mucus and undigested food, due to the weakened digestion from the fever and induced by feeding improper food. This same condition may cause vomiting. Vomiting and diarrhea add much to the danger of the attack, and when the result is in doubt, may turn the scales against the patient. In summer this complication is more frequent and more severe. Disten- tion of stomach and intestines from gas may cause attacks of cyanosis, which condition should be relieved as soon as possible. The rectal tube may be employed with care. The urine is scanty. Complications.—Pleurisy is nearly always present. Pur- ulent meningitis sometimes complicates acute broncho- pneumonia, but the most frequent complications are referable to the gastro-intestinal tract. Croupous pneumonia is an acute, infectious, inflam- matory disease of the lungs characterized by a high fever and ending by crisis in from five to nine days. Seventy- five per cent of the cases of croupous pneumonia are caused by the diplococcus pneumoniae. The term lobar pneumonia is generally used for this form of pneumonia, so-called on account of its tendency to involve a whole lobe of the lung in contradistinction to bronchopneumonia, which is sometimes called lobular pneumonia. Croupous pneumonia is one of the oldest recognized diseases; it was described fairly accurately by Hippocrates in 460 B. C. In childhood pneumonia follows, in a general way, the character of an attack in the adult. In speaking of bronchopneumonia it was said that it was the pneumonia of early infancy. This is true until children are about 102 DISEASES OF CHILDREN FOR NURSES two years of age, after which they are usually attacked by croupous pneumonia. This disease has a tendency to attack children that were previously healthy; it is especially prevalent in the spring of the year. Epidemics are not frequent among children, and the disease is rarely fatal. In the order of frequency the disease attacks the following portions of the lungs: left base, right apex, right base, left apex. The complications of pneumonia are pleurisy, endo- carditis, meningitis, and neuritis. Children rarely have complications, the one most often seen being empyema, which is probably on account of the proneness of children to have severe pleurisy associated with croupous pneumonia. The temperature is generally higher, the pulse more rapid, the duration shorter, and the cerebral symptoms more frequent in children than' in adults, otherwise, as has been mentioned before, the disease is the same. The cause of croupous pneumonia is usually exposure. The disease occurs more frequently in males than in females. It is usually primary, occasionally it will com- plicate some form of infectious disease. There are four distinct stages in croupous pneumonia: The stage of congestion or engorgement, seen in the first twenty-four hours. The stage of red hepatization, of from four to five days' duration. The stage of gray hepatization, of from six to ten days' duration. The stage of resolution, of from six to ten days' duration. Congestion is the stage in which the lung is engorged with blood, yet permeable to air. It is an active conges- tion of the lungs. Stage of red hepatization. The term hepatization is DISEASES OF THE RESPIRATORY TRACT 103 given on account of the liver-like appearance of a lung on section. In this stage the lung is dark red in color, and of very firm consistency. This is caused by the air-cells being filled with what is known as a croupous exudate. This exudate is composed of red blood-corpuscles from the capillaries surrounding the alveoli and exfoliated epithelial cells which line the walls of the air vesicles, all massed together by fibrin. The croupous exudate ex- cludes the air from the alveoli affected. This gives rise to a consolidation of the lung, which normally is permeable to air. This condition is called a pneumonic consolidation. The size of the area consolidated depends upon the number of air-cells filled with the croupous exudate. In croupous pneumonia a whole lobe or more is usually affected. It can be understood to what extent the function of the lungs would be impaired under such conditions, and also the tremendous extra strain thrown upon the heart, which has to pump the blood through the consolidation just as through the normal lung. The stage of gray hepatization is so called from the appearance of a lung on section. It is grayish and still firm and liver-like. The grayness is due to the air-cells being filled with white blood-corpuscles, the red blood- corpuscles and fibrin having been withdrawn. The pneumonic consolidation still remains, as the affected area is still impermeable to air. The whole pneumonic con- solidation has become softened in this stage by degener- ation, and is in preparation for the stage of resolution. The stage of resolution is characterized by the lique- faction of the croupous exudate, part of which is expector- ated and part absorbed. Resolution generally begins when the temperature falls to normal and lasts about a 104 DISEASES OF CHILDREN FOR NURSES week. Delayed resolution is the term applied to a slowly resolving pneumonia, which may be prolonged from a week to a month. The pleura adjacent to the pneumonic area is nearly always involved. Symptoms.—The disease is ushered in suddenly with high fever, prostration, acceleration of the respiratory rate, and increase in the pulse-beats. In children vomiting often attends the onset. Pain in the side is also quite p. R. T. I Tn.e z m. e 3 hi. e m. e. s /n. e 6 /n. C 7 m. e 8 rrr.e 9 m-.e. to frr. e r». e /3 nr. e. 170 70 108 160 (>S lot 'SO 60 /Ob n 140 ss /OS ; • 130 so 101 K ,\ '/V 120 ■us 103 \z*> \p 110 4o /OZ /A ' 1 j r cerebrospinal nervous system (after 1 tie fiSSUre 0] KotandO runs from Bourgery; Schwalbe). , , , the center of the vault of the skull, downward and forward toward the ear. Aiound NERVOUS DISEASES l99 this fissure are located the motor centers of the body; that is, the nerve cells which form the nervous im- pulses, making voluntary motion possible. The arrangement of the motor centers is "upside down"; that is, the center for the legs is uppermost; then, in order, the center for the trunk, the arms, the face, and head, the last-named being the lowest in location. (See Fig. 52). The nerve fibers run from the centers around the fissure of Rolando, through the internal capsule (a pathway in the substance of the brain), to the crura. A hemor- rhage within the internal capsule is the cause of hemi- plegia. The blood-clot, by exerting pressure, prevents any passage of nervous impulses, producing paralysis of the muscles supplied. The crura are two extensions of the brain, one from each hemisphere, which carry motor and sensory fibers. They unite and carry the fibers from both hemispheres as far as the pons. The pons is a bridge of nervous tissues. It not only contains the motor and sensory fibers from the cortex— carrying them from the crura to the medulla, the next portion of the nervous system below—but it also contains fibers running between the two hemispheres of the cere- bellum. The medulla or bulb is the lowest portion of the brain, and at the foramen magnum it becomes the spinal cord. The motor and sensory fibers decussate or cross from one side to the other in the medulla. On account of this crossing of fibers an injury to the left side of the brain produces a paralysis of the right side of the body (hemi- plegia). The medulla contains the center of the involun- tary movements, as respirations, etc. 200 DISEASES OF CHILDREN FOR NURSES The motor fibers run through the anterior and lateral columns of the spinal cord and the sensory fibers through the posterior columns. At the level of the muscle to be supplied the motor fiber leaves the cord by one of the spinal nerves and runs through the branch of this nerve to the muscle. The sensory fibers run from the skin surface and return to the cord through the spinal nerve and enter the posterior columns of the cord. In the cerebellum is located the center of co-ordination. These centers keep all portions of the body working together in unison. The basal ganglia are isolated areas of gray matter within the white matter of the brain, and are associated with the special senses. The ventricles of the brain are cavities within its sub- stance. There are four in number, all connected and containing cerebrospinal fluid. The spinal cord is contained within the spinal column and is a continuation of the medulla. The pathways of the motor and sensory fibers are external, the gray matter being located in the center in the form of an H. The cord is divided into columns. The posterior column receives the sensory filaments through which they run on their way to the brain. The lateral columns and the anterior columns are com- posed of motor filaments running from the brain to the muscle. The central area of gray matter contains trophic cells in addition to motor fibers. Trophic cells supply the tissues with proper nervous tone; when they are injured bed-sores develop and atrophy of the muscles occurs. NERVOUS DISEASES 201 The spinal cord contains most of the centers of reflex action. Since the posterior columns carry only sensory fibers, injury or disease of this part of the cord will cause a loss of sensation below the lesion {locomotor ataxia). Since the anterior and lateral columns carry only motor fibers, injury or disease of this part of the cord will cause paralysis below the lesion (myelitis). Fig. 54.—Lumbar section of spinal cord showing main tracts of white substance and location of principal groups of nerve-cells in gray matter: a, Anterior median fissure; b, posterior median fissure; c, anterior horn of gray matter; d, posterior horn of gray matter; e, central canal; /, anterior white commissure; g, posterior white commissure; h, i, anterior and posterior gray commissures; j, anterior median column; K, lateral column; L, posterior column; m, column of Clarke; n, inner group of nerve-cells; 0, anterior group; p, anterolateral group; q, posterolateral group; r, lateral horn (Leroy). The Meninges.—The brain and spinal cord are cov- ered by three membranes: the dura, the arachnoid, and the pia. The dura is a thick, fibrous structure lining the cavities of the skull and spinal canal, dipping into the median fissure and separating the cerebellum from the cerebrum. Tt also forms the venous sinuses of the brain and surrounds 202 DISEASES OF CHILDREN FOR NURSES the cranial nerves. The function of the dura is to act as a protection to the structure enclosed. The arachnoid is a serous membrane and is very similar to the pleura and the pericardium. It surrounds the brain and cord, and is reflected so that there are two surfaces between which there is a closed, sack, con- taining the cerebrospinal fluid. The sack is continuous with the ventricles of the brain. This arrangement not only lubricates the slight movements of the cord and the brain, but permits the central nervous system to rest on a cushion of water, which annuls many shocks. The pia is a thin meshwork of blood-vessels. It closely surrounds the brain and the spinal cord, dipping into the fissures and ventricles, and is the main blood-supply of the cortex and cord. The cranial nerves are twelve in number: (i) olfac- tory, (2) optic, (3) motor oculi, (4) pathetic, (5) trifacial, (6) abducens, (7) facial, (8) auditory, (9) glossopharyn- geal, (10) pneumogastric, (11) spinal accessory, (12) hypoglossal. They supply the organs of the special senses, the structures of the face, the head and the neck, and, through the pneumogastric, the lungs, the heart, and the stomach. The spinal nerves consist of thirty-one pairs. They leave the spinal cord at various levels and carry motor fibers to, and sensory fibers from, the trunk and the upper and lower extremities. The nerves supplying the various structures of the above parts of the body are branches of the spinal nerves. The sympathetic nerves control involuntary actions and keep the different parts of the body working smoothly together (co-ordination). NERVOUS DISEASES 203 TERMINOLOGY The disturbances of motion are paralysis, convulsions, choreiform movements, and tremors. Paralysis may involve one member only, and it is then termed monoplegia; a lateral half of the body, w7hen it is termed hemiplegia; or it may involve the body from the waist down, when it is called paraplegia. A convulsion is a condition in which there are excessive muscular contractions, continued or intermittent, depen- dent upon the involuntary discharge of the motor impulses from the nerve centers. Intermittent contractions are termed clonic; continued contractions, tonic. Convulsions may be general or local. The term spasm is sometimes applied to the latter. Varieties of convulsions: Epileptiform, tetanic, and hysteroidal. Epileptiform convidsions are characterized by uncon- ciousness, and for the most part the movements are clonic. They are preceded by an aura, and the patients bite their tongues. Tetanic Convulsions.—In this form the discharges emanate from the spinal cord and the convulsive move- ments are continuous and not associated with uncon- ciousness. Hysteroidal convulsions are manifestations of hysteria, and in them consciousness is only partially or apparently lost. They are not preceded by an aura, but sometimes by a sensation as of a ball in the throat. The eyes are partially closed, the face expresses some emotion, the tongue is not bitten, the movements are tonic, or, if clonic, 204 DISEASES OF CHILDREN FOR NURSES appear wilful. The paroxysm is of long duration and the patient frequently weeps or laughs. There are various local spasms, such as hiccough, croup, and laryngismus stridulus, etc. Choreiform movements are coarse, jerky, irregular, involuntary movements, which more or less simulate purposeful movements. Athetosis is the term applied to certain movements of the hands and feet in which there is a slowT, twisting, interwinding, separation and extension of the fingers and toes. It is frequently observed in the cerebral palsies of children. Tremors are fine, vibratory movements due to the alternate contraction and relaxation of antagonistic groups of muscles. The knee-jerk is obtained by tapping the quadriceps tendon between its insertion and the patella while the legs are crossed. The value of the knee-jerk depends upon the mechanism of its production. This is called the reflex arc. It consists of the sensory nerve running from the patella tendon to the spinal cord, where it enters the reflex center. From this center the motor nerve runs to the muscle, causing it to contract. If the arc is broken by disease or injury to any one of its parts the knee-jerk is lost. Wiien there is any irritating lesion of the cord the reflexes are increased. When there is any destructive lesion of the cord the arc is broken and the knee-jerks are absent. They are, therefore, a very important diagnostic symptom. Ankle clonus consists in a vibratory movement obtained by supporting the tendo Achillis with one hand while the foot is strongly flexed. NERVOUS DISEASES 205 Babinski's reflex is obtained by tickling the sole of the foot; if there is an injury or disease of the central nervous system the great toe will move upward instead of downward, as it does normally. Sensation.—Anesthesia means loss of sensation. Hyperesthesia means exaggerated sensation. Paresthesia is used to indicate certain disagreeable sensations, such as numbness, tingling, itching, creeping, and feeling of "pins and needles." Arthropathies are degenerative changes of the joints. Coma is a condition of unconsciousness from which the patient cannot be aroused. Temporary unconsciousness due to anemia of the brain is termed syncope. Catalepsy is characterized by a peculiar stiffness of the muscles, and when this is overcome by force, the limbs can be placed in unnatural positions, which they retain for a long time. There may or may not be a loss of consciousness and sensation. PECULIARITIES OF DISEASE OF THE NERVOUS SYSTEM IN CHILDREN Owing to the immature development of the central nervous system, and to the great irritability of the per- ipheral or terminal sensory nerves, much more serious nervous symptoms are shown by children from trivial causes than are seen in adult life. Hence, conditions such as convulsions, tetany, St. Vitus' dance, and enuresis are common. The greatest factors in the cause of such conditions are stimulants, such as tea and coffee, and the fact that chil- dren live among exciting surroundings. Plenty of sleep 206 DISEASES OF CHILDREN FOR NURSES and quiet are essential to the proper development of the nervous system. The effects of such conditions as infantile paralysis and birth palsies last through life. Hemorrhage of the brain is usually cortical, on the outside of the hemisphere, and not within its substance. Fig. 55-—Spina bifida (Eisendrath). Malformations.—Meningocele is a protrusion of the covering of the brain (meninges) through some abnormal opening in the skull or spinal canal. It contains cerebro- spinal fluid. When they are spinal in origin they are spoken of as spina bifida. Encephalocele is a protrusion of a portion of the meningus containing brain substance. Hydro-encephalocele contains both brain substance and fluid. Microcephalus is a name given to a small head due to under-development. NERVOUS DISEASES 207 Hydrocephalus is an enlargement of the skull due to a large amount of cerebrospinal fluid within the ventricles. Other deformities are noted, such as absence of a whole or a part of the brain. Diseases of the Meninges MENINGITIS This term is applied to any inflammation of the mem- branes covering the brain and spinal cord. It may be acute or chronic, and occurs (1) as a complication of the infec- tious diseases, (2) following some local cause, and (3) epidemically. The epidemic variety is also spoken of as epidemic cere- brospinal meningitis or spotted fever, and is described on page 267. When the membranes covering the brain are involved it is called cerebral meningitis; when the spinal cord is the seat of the disease it is spinal meningitis; more often both the brain and spinal meninges are involved, and it is then spoken of as cerebrospinal meningitis. Pathology.—The membranes are serous in character, they surround the cranial nerves as they leave the brain, and the spinal nerves as they emerge from the cord. When a serous membrane is diseased it first becomes very red and inflamed, and later there is an exudate. The first stage produces intense irritation of all the sur- rounding tissues, hence in cerebral meningitis there is severe headache and involvement -of the nerves of the spe- cial senses. This causes intolerance of sound and light. Later, when the exudate develops, it produces pressure, and instead of irritation there is paralysis of those parts supplied by the nerves subject to the pressure of the exu- 208 DISEASES OF CHILDREN FOR NURSES date. Deafness and blindness are then found instead of the symptoms of irritation. In spinal meningitis, at first, there is present a spas- modic condition of the muscles due to the irritation of the spinal nerves, this is followed, after the exudate develops, by paralysis due to the pressure. When both the cerebral and spinal meninges are involved we have a combination of the above symptoms. Acute meningitis is most often caused by the diplococcus of pneumonia, by infection from a suppurating wound, by the bacilli of the infectious fevers, by traumatism, and especially by the tubercle bacillus. The prognosis of all forms of meningitis is very grave. The non-tubercular varieties occasionally recover. Tuber- cular meningitis is invariably fatal. In the epidemic variety, Flexner's serum has given wonderful results. The picture of a case of meningitis is complete in the tubercular variety, and only that form will be given here. Tubercular meningitis (cerebral) is an acute inflam- mation of the cerebral meninges excited by the tubercle bacillus. In children the disease may be primary or secondary to a focus of tuberculosis in some other part of the body. The majority of cases are seen between the second and fifth year. The basilar meninges covering the lower part of the brain are especially involved. The pons, crura, and medulla are covered with lymph which mats together in a common mass the adjacent nerves and blood-vessels. The fluid within the ventricles of the brain is increased. Symptoms.—The disease usually begins insidiously with dulness and irritability on the part of the child. NERVOUS DISEASES 209 Sleep is disturbed. The child twitches, grinds its teeth, and starts up with a cry of alarm. When the disease is Fig. 56.—Kernig's sign. The thigh is held at right angles to the body. When an attempt is made to extend the leg, bringing it into a line with the thigh, there is either marked resistance or an inability to extend the leg, if meningitis is present (Kerr). fully developed headache is intense and causes a shrill scream, known as the hydrocephalic cry. The special senses are extremely acute, bright lights and noises cannot be tolerated; the child becomes irritable when touched. The temperature ranges between 102 ° F. and 103 ° F. The pulse is rapid at first, but later is slow and irregular. The walls of the abdomen are flat. The child lies on its side with the limbs drawn up, the head is bent far back, the fingers are clenched over the thumbs which are turned into the palm of the hand. This is called opisthotonos. Convulsions are common and may be local or general. Toward the close of the stage the child becomes delirious. When the exudate is of sufficient amount to exert pressure, paralysis develops, especially in the muscles of the face. Coma follows the delirium, the eyes are rolled up, and 14 2IO DISEASES OF CHILDREN FOR NURSES blindness and deafness result. If the finger is drawn across the body a bright red line develops and remains Fig. 57.—Method of introducing needle in lumbar puncture: Child in lying posture (Boston). for some moments; this is called a tache. In the last stage the pulse becomes weak, rapid, and irregular; respirations assume the Cheyne-Stokes characteristics, and the tem- perature falls. The duration is from one to three weeks. Kernig's Sign.—The inability to straighten out the leg when the thigh is bent upon the abdomen. It is present in cases of cerebral meningitis. Lumbar Puncture.—During the course of the disease the physician may find it necessary to relieve the tension in the spinal canal, or he may desire to obtain fluid for diag- nostic purposes. He then will tap the spinal canal by the lumbar puncture method. In preparing for this pro- cedure the skin over the lumbar portion of the spine must be scrupulously sterilized and every aseptic precaution must be absolute. The child is usually held in the posi- tion as shown in Fig. 57. The method consists in inserting a long hypodermic needle between the vertebrae and through NERVOUS DISEASES 211 the membrane; as soon as it enters the spinal canal the cerebrospinal fluid runs out of the needle. Several sterile test-tubes should be in readiness to catch the fluid. When they are filled, plug them with aseptic cotton. The wound in the skin is usually closed with adhesive plaster or a collodion dressing. Diseases of the Brain In diseases of the brain the centers for the various functions, such as motion, sensation, speech, hearing, seeing, smelling, and hearing, are interfered with. The pathways leading from the centers may be involved as they traverse the brain on their way to the spinal cord. Diseases of the brain are usually diagnosed by what are termed pressure symptoms, produced by clots, tumors, abscesses, cysts, etc. The minute anatomy of the brain is almost as well known as that of the spinal cord. The brain centers are definitely located and the direction of the pathways of the fibers from these centers is known. Therefore, it is possible to locate accurately a lesion of the brain, either a tumor, cyst, abscess, or morbid growth, from the pressure-symptoms which they produce. Areas of sclerosis and hemorrhage, destroying or impairing the centers and nerves or the tracts from the centers are determined in the same manner. A lesion in a definite part of the brain will involve certain centers and nerves which will produce paralysis of the parts supplied by those nerves. Thus, if there is a hemor- rhage or a tumor pressing on what is known as Broca's area in the brain, which is the speech center, there will be impairment or loss of the function of speech. If this 212 DISEASES OF CHILDREN FOR NURSES symptom is present with other symptoms of cerebral involvement, such as persistant headache or unconscious- ness, choked disk (a condition of the eye), and paralysis of other parts of the body, there is a tumor involving Broca's area. A more accurate diagnosis than this can be made. The position of the motor areas around the fissures of Rolando are "upside down," the leg area above, the arm in the center, and the face below. The first symptoms of irri- tation to nervous structures are convulsions. Convulsions due to brain irritation of the motor areas are characteristic. They begin in the part that corresponds to that portion of the brain which is irritated. If the irritation is in the hand area of the motor region the convulsion will start in the hand, gradually extend up the arm, and then become general. This form of convulsion is termed Jacksonian epilepsy. A finer distinction than locating the lesion in the hand area can be made. If the positions in the different areas in the motor region are known, by watching this convulsion which starts in the hand, and by noting what parts are successively involved, the extent and direction of the convulsion can be determined. If, after the convulsive movements reach the shoulder, they involve the corner of the mouth it is plain that the lesion in the brain extends downward. If, on the other hand, the leg is the next part to become involved the lesion extends upward. This will impress the nurse with the necessity of observing a convulsion carefully so that the diagnosis can be accurately made, for brain surgery demands accuracy, and as so many lesions of the brain can be treated only by surgical means, its importance can be appreciated. NERVOUS DISEASES 213 A nurse will be able to observe convulsions more closely than anybody else; therefore, she should note the kind of convulsion, whether tonic or clonic, where it begins, what parts are successively involved, in which direction the eyes and head turn, for in destructive lesions the head and eyes are usually turned toward the side of the lesion of the brain, and in irritating lesions to the opposite side. Also note what parts of the face are involved, as the nerves supplying the face emerge from the skull at different levels. A lesion at one level might involve a nerve after it had crossed, giving a paralysis on the same side as the lesion instead of the opposite, as is the rule, producing the so- called crossed paralysis; while at another level it may be affected before it has decussated, giving a paralysis on the opposite side of the face. This knowledge gives aid in the determination of the level of the lesion. Also note whether the eyelids are drooped and whether the patient is conscious or unconscious. CONVULSIONS Convulsions occur frequently in childhood. They are due to direct irritation of the cortex or to reflex irritation. The poisons generated by the acute infectious diseases may so irritate the cortex that convulsions occur during the course of these diseases. Convulsions often usher in an attack of illness in children. Reflexly, indigestion, teething, and other trivial causes at times produce general convulsions. This is due to the instability of the nervous system at this early stage. Treatment.—A mustard tub, temperature no° F., for five minutes is the best method to employ (see page 440). The tongue should be protected by inserting some- thing between the teeth and an enema given immediately. 214 DISEASES OF CHILDREN FOR NURSES CEREBRAL PARALYSIS Birth palsy in children is not uncommon. It is caused by a hemorrhage upon the cortex of the brain, rarely within the brain substance. The hemorrhage usually occurs during the birth of the child. The resulting paralysis may be a hemiplegia, half of the body being involved. Contractures occur and the children are usually mentally deficient and crippled. Fig. 58.—Hydrocephalus (side view) (Kerr). Cerebral paralysis may occur after birth, in which case the same symptoms are found. Erb's paralysis is a form of birth paralysis not due to a hemorrhage of the brain. It affects the upper portion of the arm, and is due to an injury around the shoulder-joint during birth. NERVOUS DISEASES 215 Apoplexy is the term applied to a hemorrhage in the brain. Thrombosis of the sinuses of the dura occurs at times, most frequently after an operation upon the mastoid cells. Abscess and tumors are rare in childhood. They cause pressure symptoms. The most common tumors are tubercular in character. r. m A Fig. 59.—Sporadic cretin: before treatment. (From Osier, Sporadic Cretinism m America). Hydrocephalus is a condition in which there is excessive fluid in the ventricles or in the arachnoid cavities. It gives to the head a peculiar shape. It is large and round, the sutures and fontanels are enlarged, the convolutions of the brain are flattened, and usually there is imbecility. Cretinism is a congenital affection characterized by a lack of physical development due to an abnormal condition of the thyroid gland. The symptoms are myxedema (a waxy condition of the subcutaneous tissues), an ab- normally large tongue, and idiocy or imbecility. 2l6 DISEASES OF CHILDREN FOR NURSES The administration of thyroid gland extract to these cases causes a remarkable improvement. Achondroplasia, Chondrodystrophy.—Achondroplasia has been known under the synonyms of "chondrodys- trophia fetalis," "fetal rickets," "fetal cretinism," and "micromelia." Sommering first described it in 1791. Achondroplasia is of great antiquity. Parnet draws attention to the fact that at the British Museum there are a number of glazed earthenware images which are unquestionably models of achondroplastic individuals. They were represented as dwarfs, with big heads, crooked legs, very long arms, etc. It is congenital. These children are dwarfs and there is marked short- ening and bowing of the upper and lower extremities. The spine is also curved. There is prominence of the lower jaw and a "pug-nose"; a peculiar separation of the fingers, called the trident hand, and prominent abdomen. They have normal intellect. Deaf-mutism is due to congenital or early loss of hearing. As the child has never heard spoken words he is unable to imitate the proper sounds. It may also develop in children who have begun to talk, but in whom the deafness occurs at such an early age that they soon lose the memory of what they have accomplished. Congenital myotonia (spasmodic affections) is an affection of the muscles in which a spasmodic rigidity is observed when the child brings them into action after repose. It lasts for a few moments and may recur when voluntary movements are again attempted. It is in- curable, but tends to improve with muscular exercise. Aphasia is a failure of word memory, an inability to utter words, to comprehend them, or to write them. NERVOUS DISEASES 217 Fig. 60.—The "trident hands" in achondroplasia (Fussell, McCombs, deSchweinitz, and Pancoast). Fig. 61.—Achondroplasia. Side view of boy. Curvature of spine, shortness of the extremities, and curvature of bones shown (Fussell, McCombs, deSchweinitz, and Pancoast). 218 DISEASES OF CHILDREN FOR NURSES EPILEPSY The disease apparently depends upon the instability of the motor centers, so that from trivial exciting causes violent discharges occur from time to time. The disease is divided into grand mal and petit mal. Symptoms.—Grand Mal.—A peculiar sensation called an aura sweeps like a wave over the child. This is followed by unconsciousness and violent general con- vulsions, clonic in type. The child bites its tongue and froths at the mouth. The convulsion lasts for a few minutes and is followed by coma and later by automatism, in which the child performs certain automatic acts. Convulsions occur at varying intervals, showing a tendency to increase in number and severity. Petit mal is exhibited by momentary loss of conscious- ness with pallor, without convulsive movements. Treatment.—For the Attack.—This consists in measures to prevent the children from injuring themselves. Some- thing should be placed in the mouth to prevent biting of the tongue; further than this nothing can be done. If they should show any vicious traits after a convulsion, they should be carefully watched, as they are not responsible. Prophylaxis.—Nitrite of amyl inhalations will at times ward off an attack. HYSTERIA Hysteria is a functional disease of the nervous system associated with impaired will power and increased sensi- tiveness to impressions. Hysteric children are ill and should be treated accordingly. The disease is very rare in childhood before the seventh or eighth year, and most cases appear after the tenth year. NERVOUS DISEASES 219 Etiology.—The children most affected are those who have inherited a nervous disposition, or in whose parents insanity, hysteria, or alcoholism have been present. The chief exciting causes are those which lead to a highly nervous condition in children whose general nutri- tion is faulty, such as anemia, chlorosis, or overpressure at school. It may follow the infectious diseases, or result from an injury, fright, or imitation. Symptoms.—These vary so that it is hard to classify them in any definite form. Psychic symptoms usually predominate. The children may have periods of mental depression, indifference to surroundings, a change in disposition, or periods of weeping and laughing without cause. Fits of temper, hallucinations, disturbances of sleep, and a development of a tendency to deception. Older children may actually simulate symptoms of various diseases, which they may have witnessed or about which they have read. Sensory Symptoms.—There may be areas of the body which become highly sensitive (hyperesthesia), so as to simulate inflammation of the various organs. More rarely areas develop of lost sensation (anesthesia). In addition, there may be headache with great tenderness of the scalp, neuralgias of different parts of the body, severe pains in the stomach, sometimes accompanied with vomiting, deafness, and blindness, usually of short dura- tion. Joint Symptoms.—All forms of organic disease of the joints may be simulated. The symptoms are most often referred to the spine and the large joints of the lower extremities. They may develop deformities. Motor Symptoms.—Many varieties of spasm are seen. 220 DISEASES OF CHILDREN FOR NURSES These may affect the eyes, face, mouth, neck, or respira- tion. Hiccup and cough may be severe. General hysteric convulsions may be observed, though these are rare in childhood. In these convulsions consciousness is not fully lost and hallucinations are present. Hysteric paralysis is not common in children. Nursing.-—The best results are obtained by placing the child in a quiet retreat in charge of an intelligent nurse. Every means should be taken to encourage muscular development, keeping the nervous system in the back- ground. They should lead an outdoor life, keep early hours, have regular exercise; their education should be mapped out so as to avoid overpressure. Theaters and exciting books should be avoided. The diet should be plain, and all stimulants, including tea and coffee, forbidden. The nurse should be firm and kind, but must avoid sympathy. Massage and hydrotherapy may be ordered by the physician. CHOREA (ST. VITUS' DANCE) A nervous affection especially common in childhood, and characterized by irregular movements which increase under excitement and cease during sleep. The first manifestations are usually those of awkward- ness in movement, and restlessness. These grow worse until the disease is fully advanced, when there are peculiar jerking, disorderly movements of the various members of the body or involvement of the whole body. The move- ment may be so marked that the child cannot use its arms in eating, it stumbles when walking, and grotesque NERVOUS DISEASES 221 expressions are produced from the involvement of the face. Involvement of the larynx causes stammering, involvement of the muscles of the pharynx causes choking fits and difficulty in swallowing, involvement of the tongue causes its withdrawal to be associated with an audible click. When the child's attention is called to the move- ments they invariably become worse. Frequently a heart murmur develops. The disease lasts from six to ten wxeks. Prognosis is good. Occasionally there are deaths from exhaustion. TETANY A tonic spasm of the muscles of the extremities. It Fig. 62.—Persistent form of tetany in a girl a year and a half old. Tetanic con- tractures of the arms and legs; hands in the "obstetric" position; feet in plantar flexion (Hecker, Trumpp, and Abt). gives rise to a peculiar position of the hand called the obstetric hand, in which the fingers are slightly bent, the thumb held almost at a right angle across the palm, and the whole hand is slightly everted. This spasm lasts for a variable length of time and can be excited by making pressure upon the nerve trunks and blood-vessels of the extremities (Trousseau's sign). The disease is usually associated with laryngismus strid- ulus and recovery nearly always takes place. 222 DISEASES OF CHILDREN FOR NURSES HABIT SPASM A peculiar form of spasm caused by habitual grimaces or movements of the head, finally becoming uncontrollable. This condition is also called tic. NYSTAGMUS A constant movement of the eyes. It may be lateral, horizontal, or rotary. NODDING SPASM OR SPASMUS GYRANS A peculiar form of movement seen in children charac- terized by a continuous nodding of the head. It is asso- ciated with nystagmus. Recovery usually takes place in a month or two. INJURIOUS HABITS Sucking, nail-biting, head-banging, masturbation, in- ordinate appetites for various substances, such as dirt, hair, and threads, are all practices which are injurious and should be controlled immediately. The longer the habit has lasted, the more difficult it is to break. TORTICOLLIS OR WRY-NECK This is a tonic spasm of the sternomastoid muscle. At times it is persistent. Treatment.—If due to rheumatism the neck should be ironed with a hot iron, over a piece of flannel first laid on the skin for protection. Disorders of Speech.—Stuttering or stammering and lisping are the most common. NERVOUS DISEASES 223 Disorders of sleep, such as night terrors, are common. The children awake from sleep with a cry of terror; they Fig. 63.—Torticollis in a child two years of age (Friihwald and Westcott). fail to recognize those around them, and they exhibit symptoms of fright. Diseases of the Spinal Cord The functions of the different columns of the spinal cord are: The anterior and lateral columns—motor; the posterior columns—sensory; the anterior horns of gray matter—trophic and motor. MYELITIS Myleitis is an inflammaton of a segmant of the cord involving the anterior, lateral, and posterior columns and the gray matter. 224 DISEASES OF CHILDREN FOR NURSES Symptoms.—At first there is irritation, producing pain and fever. The pain is a peculiar one called a girdle pain. The reflexes are increased; there are pares- thesias and convulsive movements. Later, when the inflammatory product becomes sufficient • to produce pressure, there is a loss of sensation instead of pain and paresthesias. The reflexes are lost, there is paralysis instead of convulsions, and there is degeneration of the muscles and bed-sores. SCLEROSIS Sclerosis is an atrophy of the structure of the part affected with an overgrowth of connective tissue. Sclerosis in the spinal cord is an atrophy of the nerve elements and an overgrowth of the neurilemma (the connective tissue of the cord). Lateral sclerosis is the term applied when this degen- eration attacks the lateral columns of the cord. This disease does not affect the sensory fibers; the main motor fibers which run through the anterior columns are intact and there are no trophic disturbances. Symptoms.-—Exaggerated knee-jerks, ankle-clonus, and a spastic gait, sometimes spoken of as scissors gait. Acute Anterior Poliomyelitis or Infantile Paralysis. —This is an acute disease which occurs almost exclu- sively in young children, and is characterized by the destruction of nerve-cells in the brain and spinal cord, es- pecially in the anterior horns of gray matter. Since 1907 epidemics of infantile paralysis have been prevalent in Europe and the United States. Flexner and Lewis in their epoch-making studies having proved it to be an infectious and probably a contagious disease. The NERVOUS DISEASES 225 virus of infection most probably gains access to the central nervous system through absorption from the mucous membrane of the nose and throat, from whence it is carried by the lymphatics through the cribriform plate of the Fig. 64 —Scissors gait in a girl two years old (Friihwald and Westcott). ethmoid bone directly into the cranial cavity. The poison is likewise thrown off from the same mucous membrane by a reversed process of elimination. Symptoms.—The paralysis comes on very suddenly. The child goes to bed well and the following morning he is 226 DISEASES OF CHILDREN FOR NURSES cannot move his legs or, at times, his arms. Certain groups of muscles in the upper and lower extremities are involved, chiefly the latter. The paralysis at first is wide- spread, but tends to improve up to a certain point, where it remains stationary. The muscles affected atrophy, and the usefulness of the limb is obtained by an overdevelop- ment of other muscles which perform the function of the muscles which have been destroyed to a limited degree. Fig. 65.—Spinal infantile paralysis in the stage of fully developed palsy. Three-year- old girl (F. Lange). Treatment.—The nose and throat, being the principal points of infection, should be thoroughly douched with antiseptic solutions containing hydrogen peroxid and menthol. This not only applies to the children attacked, but to all children when the disease is epidemic. Flexner urges with emphasis that this should be thoroughly done. All nasal discharges should be dis- infected and destroyed. Adults in contact with the case should use the same precautions. It must also be NERVOUS DISEASES 227 recognized that this infection may last for some time in the affected child, when he may act as a "carrier," so the antiseptic precautions should be continued over a period of several months. In epidemics of the disease it is well to quarantine the case for one month. The most important measure at the onset of the attack is to secure complete rest. Urotropin, in rather large doses, is the drug usually given. The reason it is used is on account of the failure of animals to develop paralysis in many instances when the drug is given simultaneously with or shortly after the injection of the virus. After all acute symptoms have subsided, or at the end of two or three weeks, the nurse may be called upon to give electricity, friction rubs, massage, and manipula- tions to improve the circulation and nutrition of the limb, and they should be faithfully continued twice a day for a long period. The paralyzed children often have to undergo ortho- pedic operation upon tendons and joints, and they fre- quently have to wear braces. Syringomyelia is a disease of the spinal cord in which there is a cavity in the cord. Landry's paralysis is an ascending form of paralysis beginning in the legs and rapidly involving the entire body. Friedreich's ataxia is a form of sclerosis of the spinal cord which develops in childhood and lasts from twenty to thirty years. Atrophies of the muscles of different parts of the body are seen, due to disease of the spinal cord. Pseudohypertrophy of the muscles is a condition in 228 DISEASES OF CHILDREN FOR NURSES which the muscles are apparently enlarged, but actually are degenerating. Diseases of the Nerves NEURITIS Neuritis is an inflammation of a nerve, and is character- ized by pain and tenderness along the course of the nerve. It is associated with various forms of paresthesias. The part supplied by the nerve is at first hyperesthetic, later Fig. 66.—Bell's palsy. The child is crying, only one side of the face shows the emotion, due to paralysis of the muscles of expression on the other. anesthetic. In severe inflammations paralysis of the part supplied by the nerve develops. Sciatica is inflammation of the sciatic nerve character- ized by the above symptoms along its course in the pos- terior part of the thigh. It is worse at night and at the approach of stormy weather. Multiple neuritis is an inflammation of a number of NERVOUS DISEASES 229 nerves. The most common cause in childhood is diph- theria. Symptoms.—There is pain over the deep nerve-trunks, paralysis, and wrist-drop and foot-drop due to paralysis of the extensor muscles. Postdiphtheritic paralysis is a form of multiple neuritis occurring after diphtheria in which the muscles of swallowing are at first attacked, the other muscles of the throat and body being successively involved. Recovery usually follows. If the children die the cause of death is heart failure due to paralysis of the pneumogastric nerve (see page 326). Bell's Palsy.—A paralysis of the muscles of expression (Fig. 66) affecting one side of the face and due to in- jury or disease of the seventh cranial nerve. NURSING IN NERVOUS DISEASES When symptoms of irritation of the central nervous system exist the child should be placed in a dark room, kept as quiet as possible, and the covers should be sup- ported by a frame to prevent the discomfort of their weight. Scrupulous cleanliness must be employed to prevent bed-sores. The position of the child must be frequently changed, parts resting upon the bed must be protected, using air-cushions and water-beds for this purpose. The symptoms developing in the course of nervous diseases must be accurately recorded, convulsions must be observed, and their starting-point, character, extent, and duration reported. In lumbar puncture the fluid is collected in a sterile test-tube with an aseptic cotton stopper. 230 DISEASES OF CHILDREN FOR NURSES At times feeding must be administered by the medicine, dropper, gavage, or enema. In chorea the extremities should be bandaged to protect them from chafing. Pull all sheets very tight and dispense with the "draw sheet." Remove all crumbs immediately and apply powder to bed frequently. The temperature, pulse, and respirations should be taken three times a day. CHAPTER X DISEASES OF THE URINARY TRACT The urinary tract consists of the kidneys, two in number, situated on the right and left side of the body beneath the edge of the ribs, posteriorly; the ureters, which run from the pelvis of the kidneys; the bladder; and the urethra. THE KIDNEYS Anatomy.—The kidney is divided into the cortical area, the medulla or pyramidal, and the pelvis. The uriniferous tubules start in the glomeruli which are situated in the cortical area of the kidney. The glomeruli are tufts of capillaries surrounded by a capsule. The epithelial cells lining the capsule and tubes abstract from the blood current the products which form the urine. The tubes run from the capsules and after pursuing a very tortuous course they empty at the apex of one of the Malpighian pyramids. It is in these tubules that the urinary products are formed. They are emptied from the mouths of the uriniferous tubules, at the apices of these pyramids, into the pelvis of the kidneys, and from here the urine passes through the ureters into the bladder and is voided through the urethra. From these tortuous uriniferous tubules the tube-casts are formed. They are cylindric in shape and usually composed of the lining epithelium in various stages of 231 232 DISEASES OF CHILDREN FOR NURSES degeneration. Their formation is something on this order: The lining epithelium of these tubes is the filter which extracts the uriniferous products from the blood. As long as this epithelial lining is intact the urine is normal; when there is congestion or inflammation of the kidneys the tubules shed this lining membrane. This appears in the urine as casts, and as the wall between the Fig. 67.—A longitudinal section of the kidney, a, Renal artery; c, cortex; m, medulla; u, ureter (Leroy). blood current and the tubules is destroyed there is an outflow of red blood-corpuscles and albumin. This is the condition seen in acute congestion, or acute nephritis, the name for inflammation of the kidneys. In chronic nephritis fatty casts are found. Malformations of the kidneys are not common. Those seen occasionally are horseshoe kidney, where DISEASES OF THE URINARY TRACT 233 the two are fused, forming one large crescentic kidney; supernumerary ureters; floating kidney; and single kidney. THE URINE Normal urine is pale, amber colored, of acid reaction, and has a specific gravity of T015 to 1025. Polyuria is the term applied to an increase in the quan- tity of the urine, and may be a temporary polyuria, such as is seen in excessive ingestion of fluids, the suppresison of perspiration, etc. Permanent polyuria may result from such conditions as diabetes mellitus, diabetes insipidus, chronic interstitial nephritis, and amyloid kidney. Anuria is the term applied to a diminution in the flow of urine. It is seen in the following conditions: Excessive secretion through other channels, such as profuse perspira- tion and diarrhea; in fever; passive renal congestion from obstructive disease of the heart, lung, or liver; organic obstruction in the urinary passages; in acute or chronic parenchymatous nephritis; from nervous causes such as hysteria; and in the reflex inhibition after abdominal injuries or operations. Urea results from the perfect decomposition of the nitrogenous elements of food and tissue. It is, therefore, a normal constituent of the urine. In health the amount excreted varies greatly. Normal urine contains about 2 to 2\ per cent, of urea. When there is imperfect meta- morphosis of tissues and nitrogeous food there is the formation of uric-acid crystals in the urine. When they are in excess the urine is heavy, dark in color, and on cooling throws down a brick-red deposit. When uric acid or urates are found in the urine it is termed lithuria. 234 DISEASES OF CHILDREN FOR NURSES Glycosuria is the name applied to urine containing sugar. It is caused by diabetes mellitus and at times by chorea, tetanus, and functional nervous affections; in- digestion of a large amount of saccharine material, lesions of the pancreas, liver, and base of the brain. Albuminuria is the name applied to the presence of albumin in the urine. It is found in all forms of nephritis and in congestion of the kidneys, resulting from chronic disease of the heart, lung, or liver. Cyclic Albuminuria.—The urine may be albuminous at certain times, as after meals, bathing, or rising in the morning. Accidental albuminuria results from the admixture of albuminous substances with the urine, as pus and blood. It is found in certain nervous diseases, as epilepsy, tetanus, and injuries to the brain, extreme anemia, and the ingestion of large amounts of albuminous foods. Hematuria.—Blood in the urine. Hemoglobinuria.—Blood-pigment in the urine. Choluria.—Bile in the urine. Chyluria.—Chyle in the urine. Pyuria.—Pus in the urine. Indicanuria.—Indican in the urine. It is a symptom of chronic indigestion. Method of Collecting Urine.—In males the penis can be placed in the neck of a bottle which lies between the thighs, and is held in position by a square of adhesive plaster, the center of which is pierced, making a hole large enough to grip the neck of the bottle. In females a small pan placed under the buttocks will answer, or a bottle may be arranged as described above. If these methods fail, catheterize (see page 471). DISEASES OF THE URINARY TRACT 235 Average Daily Quantity of Urine in Health Age Ounces First twenty-four hours............................ o to 2 Second twenty-four hours.......................... J to 3 Three to six days................................. 3 to 8 Seven days to two months......................... 5 to 13 Two to six months................................ 7 to 16 Six months to two years........................... 8 to 20 Two to five years.................................16 to 26 Five to eight years................................20 to 40 Eight to fourteen years............................32 to 48 (Holt). Examination of Urine.—The color is noted and any sediment is recorded. The acidity or alkalinity is deter- mined. The specific gravity is found by means of a urinometer. This is an instrument weighted with mercury and having a scale on the stem graduated from 1000 up. By floating this instrument in a quantity of urine the specific gravity of the specimen can be read off. The point at which the top of the liquid is indicated on the scale is the proper specific gravity. Albumin is tested for by boiling a small quantity of urine in a test tube. It should be clear urine, filtered if necessary. If albumin is present the urine will cloud when boiled, and if upon the addition of a few drops of acetic acid i.t does not clear, albumin is present. If it does clear the precipitate is composed of phosphates. Heller's Test.—Another test used consists in placing a small amount of nitric acid in a test-tube and allowing the urine to run slowly down the sides of tube in such a manner that it will float on the surface of the nitric acid. If albumin is present there will be a white line at the point of contact of the two liquids. A brown line denotes uric acid. 236 DISEASES OF CHILDREN FOR NURSES Sugar is tested for by Fehling's solution. This consists of two parts: One is bluish-green (composed of copper sulphate) and the other is white (composed of rochelle salts and caustic potash). Equal parts of each are added to four times their volume of water and the mixture boiled. If it retains its bluish color it is suitable for a test. A few drops of urine are added to the solution and boiled, and if sugar is present, a reddish-yellow precipitate is thrown down. The test is very accurate. Microscopic examination is necessary to determine the presence or absence of casts, red blood-cells, white blood- cells, and epithelium. Such substances as bile in the urine have special tests. DIABETES INSIPIDUS Diabetes insipidus is a chronic condition characterized by the excretion of large quantities of pale, limpid urine of low specific gravity and free from albumin and sugar. In addition to the urinary symptoms there is an insati- able thirst, good appetite, a harsh, dry skin, a dry tongue, constipation, mental apathy, and emaciation. RENAL HYPEREMIA Active hyperemia is caused by arterial blood and is found in all acute congestions. It is due to exposure when the body is overheated. The same cause, aggra- vated, would cause acute nephritis. Passive hyperemia is due to venous stasis and is found in all chronic congestions. Acute Congestion.—Symptoms of acute congestion are pain over the loins; dark and scanty urine of high specific gravity, and perhaps containing a trace of albumin, a few hyaline casts, and some free blood. DISEASES OF THE URINARY TRACT 237 Passive congestion of the kidneys is caused by condi- tions which obstruct the general circulation, such as chronic disease of the heart, liver, and lung; pressure of tumors upon the renal veins, and, rarely, thrombosis of the renal veins. The kidney is swollen, and in protracted cases becomes hard from an overgrowth of connective tissue. Symptoms.—There is a sensation of weight over the loins; the urine is usually diminished in quantity; rarely increased. Free blood, a trace of albumin, and occa- sionally a few hyaline casts are found. UREMIA Uremia is the name applied to a group of symptoms which result from the retention of toxic materials in the blood which should have been eliminated by the kidneys. Symptoms.—The disease may develop slowly or abruptly and may manifest any of the following phenomena: head- ache, vertigo, delirium, epileptiform convulsions, coma, sudden blindness (unassociated with any retinal change), and transient paralysis from congestion of the brain or cord. Pulmonary symptoms are dyspnea (uremic asthma), and Cheyne-Stokes respiration. Abdominal symptoms are hiccough, obstinate vomiting, and purging. General Symptoms.—The skin is dry, the breath has a urinous odor, the urine is scanty and deficient in urea. The pulse is slow and full, the temperature is subnormal, but during a convulsion the temperature may rise and the pulse become rapid and feeble. Prognosis.—Grave, but always guarded, for recovery 238 DISEASES OF CHILDREN FOR NURSES is possible after the most serious complications and manifestations. Treatment.—The object of the treatment is to eliminate the poison as rapidly as possible. To accomplish this the physician takes advantage of every possible excretory function. He promotes catharsis (purging) and free diaphoresis (sweating). In some cases bleeding and the intravenous injection of normal salt solution is prac- tised. Convulsions may be controlled by inhalations of chloroform. Morphin should be used with great care, as it frequently aggravates the case. NEPHRITIS Acute nephritis is an acute inflammatory disease involving more or less of the whole kidney, but it especially affects the epithelium of the tubes and glomeruli. Other names given to this condition are acute Bright's disease and acute parenchymatous nephritis. Etiology.—Exposure to cold and wet, the specific fevers, especially scarlet fever, and certain poisons. Pathology.—The kidney is swollen, the capsule is nonadherent. At first the organ is bright red in color, but it soon becomes pale and mottled in appearance. Histology.—The epithelium of the tubes and of the glomeruli is the seat of the cloudy swelling and, later, of fatty degeneration. Desquamated epithelium, blood cor- puscles, and an albuminous exudate block up the tubules. Symptoms.—In some cases moderate fever with its associated phenomena, dull lumbar pains, nausea and vomiting, dropsy, beginning in the face and becoming general, and rapid anemia. Uremic symptoms may develop at any time. The urine is scanty and at times DISEASES OF THE URINARY TRACT 239 suppressed. It is smoky in appearance, of high specific gravity, rich in albumin, and throws down a heavy sedi- ment which contains hyaline, blood, and epithelial casts and free blood and epithelial cells. As the general symp- toms are often slight, the diagnosis of the condition must rest upon the urinary analysis. Prognosis.—Guardedly favorable. It may kill by ex- haustion, uremia, or dropsy, and it may become chronic. Treatment.—The disease demands absolute rest in bed until the albumin has entirely disappeared from the urine. Milk is the best food, although butter-milk, gruels, and light broths are admissible. The free use of water should be encouraged. Free action of the skin is secured by means of vapor baths and the bowels are kept loose by concentrated saline draughts, as Rochelle and Epsom salts. Uremia will call for its appropriate treatment. Marked effusions in the serous cavities will sometimes demand aspiration. Convalescence should be protracted. Chronic parenchymatous nephritis may result from acute nephritis or it may be chronic from the beginning. Congestion from heart disease is the usual cause. Pathology.—In the first stage the kidney is large and pale yellow in color, the pallor depending upon the anemia and the fatty degeneration. The tubes are filled with fatty epithelium and casts, and there is always some over- growth of the interstitial connective tissue. In the second stage the organ is small, pale in color, its surface rough, and its capsule somewhat adherent. The reduced size depends upon the destruction of the renal epithelium and the contraction of the overgrown connective tissue. Symptoms.—As the disease usually begins as a chronic 240 DISEASES OF CHILDREN FOR NURSES affection the following symptoms slowly make themselves manifest: progressive loss of flesh and strength, marked anemia, gastro-intestinal disturbances, dropsy, often first noted in the face on arising in the morning; increased arterial tension, some hypertrophy of the left ventricle of the heart so that the second sound at the aortic cartilage is accentuated. Uremic symptoms may develop at any time. The urine is usually diminished although it is often normal in color and appearance. It is highly albuminous and throws down an abundant sediment which contains hyaline, fatty, and granular casts, and fatty epithelium. The process is a chronic one and the epithelium and the casts have undergone fatty degeneration. Complications.—These are numerous and often suggest the diagnosis. The most common are uremia, extensive dropsy into the tissues or serous cavities, valvular heart disease, albuminuric retinitis (an eye condition interfering with vision), and acute exacerbations (an acute paren- chymatous nephritis occurring during the course of the chronic attack). Treatment.—The treatment is largely hygienic and dietetic. Residence in a dry, warm, and equable climate may prolong life or affect a cure. Rest is an essential element in the treatment. The underclothing should be woolen or silk in order to keep the skin constantly active. The diet should be non-nitrogenous and in severe cases an absolute milk diet may be of extreme value. The bowels should be kept active by mineral waters. Chronic Interstitial Nephritis.- This disease, rare in childhood, is a chronic inflammatory condition of the kidney characterized by a reduction in its size due to an DISEASES OF THE URINARY TRACT overgrowth and a subsequent contraction of its connective- tissue elements. It may be associated with general arterio- sclerosis and cardiac hypertrophy. Etiology.—The disease may be secondary to paren- chymatous nephritis or it may result from the chronic congestion of chronic heart disease; but it generally arises as a primary condition and results from the causes which predispose to sclerosis in other organs. Pathology.—The kidneys are small and red in color. The surface is granular and the capsules adherent. Small cysts are often present. The microscope shows a great overgrowth of connective tissue which has contracted, narrowing the lumen of the tubules and interfering with the nutrition of the epithelium, and as a result the epithe- lium may show fatty degeneration with desquamation. The arteries throughout the body may show sclerosis, and from the resistance thus offered hypertrophy of the heart results. Symptoms.—A slow loss of flesh and strength with pro- gressive anemia. Gastric disturbances are very common. The arteries may be rigid and the pulse is of high tension, so that the second sound of the heart is accentuated at the aortic cartilage. Palpitation of the heart is often noted. Dyspnea is a prominent symptom and may result from heart weakness, uremia, or edema of the lungs. Head- ache, vertigo, and insomnia often result from disturbed cir- culation and dimness of vision from albuminuric retinitis. Dropsy is often absent or is slight and appears late in the disease. The urine is increased in quantity, pale in color, and of low specific gravity, 1005 to 1010; it contains but a trace of albumin and a few narrow hyaline casts. 16 242 DISEASES OF CHILDREN FOR NURSES Diagnosis.—The difference between chronic interstitial nephritis and chronic parenchymatous nephritis is that in the latter the urine is rich in albumin and tube-casts and the disease is seen in earlier life; it lacks much arterial change and produces considerable dropsy. Chronic interstitial nephritis is so insidious that it is scarcely ever discovered except by accident. Either it is discovered in the routine examination or, as frequently happens, not until uremia develops, when often it is too late to do anything. The treatment is practically the same as in chronic parenchymatous nephritis. AMYLOID KIDNEY Amyloid kidney is a name given to the large white kidney found after prolonged suppuration, particularly bone disease; in tuberculosis, syphilis, and malarial cachexia. The urine is increased, there is considerable albumin, and wide hyaline and granular casts. RENAL CALCULUS Renal calculus is a precipitated urinary concretion found in the kidneys. The stone may lie latent indefi- nitely or it may pass out with or without symptoms of colic. It may obstruct the ureter or excite inflammation of the kidney or even abscess. Symptoms of Renal Colic—Sudden onset with sharp pain, starting in the back and radiating down the ureter into the penis, testicle, or thigh. The symptoms of intense pain are present: pallor, cold sweats, weak pulse, and DLSEASES OF THE URINARY TRACT reflex vomiting. The urine subsequently passed may contain the stone, or, as a result of irritation, pus, blood, and desquamated epithelium. An attack may last from a few moments to several hours. Treatment.—The physician will probably use hypo- dermics of morphin and atropin, and inhalations of chloroform if necessary. The free use of water should be encouraged, and hot applications placed over the loins. PYELITIS Pyelitis is the name given to an inflammation of the pelvis of the kidney. HYDRONEPHROSIS This is a dilatation of the pelvis of the kidney with an accumulation of watery fluid resulting from obstruction. It is caused by strictures, tumors, and impacted stones. FLOATING KIDNEY This condition is rare in childhood. The kidney is distinctly mobile, due to a relaxation of the tissues which surround it. The right kidney is the one usually affected and may be found in any part of the abdomen. TUBERCULOSIS OF THE KIDNEY This condition is usually secondary to tuberculosis elsewhere, although it may be primary. It is always grave; the patients may Uve from a few months to three years. 244 DISEASES OF CHILDREN FOR NURSES SARCOMA OF THE KIDNEY Sarcoma of the kidney is a malignant tumor of the kidney which is sometimes seen in children. The organ affected is removed at times by surgical means. It is ultimately fatal. Fig. 68.—Sarcoma of both kidneys in a male child two years of age. The tumors are here outlined to show their extent (Napier). NURSING IN KIDNEY DISEASES In nephritis the room should be warm to facilitate the action of the skin. Vapor baths are necessary at times (see page 436). DISEASES OF THE URINARY TRACT 245 Woolen underwear should be worn to stimulate per- spiration. The child should lie between blankets while in bed. A specimen of the urine should be saved daily, unless otherwise ordered. The total quantity of urine passed in twenty-four hours should be measured. The feeding should be carried out strictly in accordance with instructions. Any symptoms of uremia, such as convulsive move- ments, intense headache, or stupor should be immediately reported. The temperature, pulse, and respirations should be taken at least three times a day. THE BLADDER Enuresis is the inability of a child to hold its urine. In infancy urination is a reflex act beyond the control of the will. After the second year, and often before this age, a child should be able to retain the urine until a suitable time and place for voiding is reached. After two years involuntary urination is spoken of as enuresis. If it occurs at night it is called nocturnal, and if in the day- time, diurnal. In some cases it occurs both during the day and at night. The children suffering from enuresis are usually anemic, underdeveloped, and of a very nervous disposition. Treatment.—Plenty of sleep and a diet of milk, vege- tables, fruits, meats, and cereals should be adhered to. Often a case of nocturnal enuresis can be controlled by awakening a child at eleven or twelve o'clock at night and making him void urine. Another way is to get the child to hold urine as long as possible in the day-time. This accustoms the sphincter to retain the urine. Medical 246 DISEASES OF CHILDREN FOR NURSES treatment is usually necessary. Circumcision at times relieves, if there is a long foreskin. Vesical spasm is a frequent and painful micturition usually due to highly acid urine. Vesical calculus is a stone in the bladder. This gives rise to painful micturition and straining, which at times causes prolapse of the rectum. Occasionally there is sud- den stoppage of the flow and pain in the end of the penis. MALFORMATIONS OF THE GENITAL TRACT Phimosis is a narrowing of the prepuce or foreskin so that it cannot be retracted. This condition gives rise to irritation from accumulation of smegma beneath the skin, obstruction to the flow of urine, enuresis, and masturbation. Treatment.—Circumcision should be done in all cases of phimosis. If the child is vigorous, two years of age is the best time for an operation. Hypospadias.—A malformation of the penis in which the urethra is not continued to the end of the glans, the orifice being on the under surface of the penis. Epispadias.—The opposite of hypospadias, the orifice being on the upper surface of the pents. Exstrophy of the Bladder.—A failure on the part of nature to complete the abdominal wall over the bladder. The bladder is in sight and often fissured so that the urine discharges from it. Undescended Testicle.—Before birth the testicles lie beneath the kidneys. They descend into the scrotum during the ninth month of pregnancy. At times they fail to descend. An undescended testicle usually lies in the inguinal canal. Serious symptoms rarely attend this deformity. DISEASES OF THE URINARY TRACT 247 DISEASES OF THE MALE GENITALS Balanitis.—Inflammation of the prepuce or foreskin. Treatment.—Wash with 1 to 5000 solution of bichlorid of mercury, syringing beneath the foreskin. Urethritis.—Inflammation of the urethra. The chief symptoms are painful urination and a discharge. This discharge may be a simple catarrhal discharge or it may be gonorrheal. If the latter, gonorrheal infection of the eyes (gonorrheal conjunctivitis) must be very carefully guarded against. The parts should be covered and kept clean. Hydrocele.—This is a collection of serous fluid in the testicle or along the inguinal canal. DISEASES OF THE FEMALE GENITAL TRACT Vaginitis.—An inflammation of the vagina. The chief symptom is a yellowish discharge from the vagina. It may be catarrhal or gonorrheal. The gonorrheal form is highly contagious and very obstinate. It may cause gonorrheal conjunctivitis (inflammation of eye) with a loss of sight. Girls suffering from vaginitis should not be allowed to associate with other children and their towels and diapers should be sterilized. The parts should be kept scrupu- lously clean and well protected, and frequent douches of a solution of bichlorid of mercury, 1 to 10,000; potassium permanganate, 1 to 10,000; saturated solution of boric acid, or normal salt solution administered (see page 453). NURSING IN DISEASES OF THE GENITAL TRACT Whenever a discharge exists from the male or female generative organs the nurse should thoroughly sterilize 248 DISEASES OF CHILDREN FOR NURSES her hands after cleansing ihe parts so as to prevent any infection of her eyes. If possible, rubber gloves should be worn. To prevent the spread of vaginitis either in a hospital or in a private family the greatest precautions must be taken. A child affected should have a separate bed-pan, douche-bag, thermometer, eating utensils, playthings, etc. If possible, all articles which come in contact with the dis- charge should be sterilized after using. All linen should be boiled, and all soiled articles, such as cotton, etc., should be soaked in carbolic acid, 1 to 20, before disposal. A pad should be worn, which should be immediately burnt when discarded. Vaginal suppositories are used in treating this disease by many physicians. They must be carefully inserted. CHAPTER XI DISEASES OF THE EYE, EAR, SKIN, AND GLANDULAR SYSTEM THE EYE Anatomy.—The eye is a globe composed of three coats: the sclerotic, the choroid, and the retina. The retina is the sensitive coat; it receives the impressions of the objects seen and transfers them through the optic nerve to the brain. The anterior portion of the eyeball is composed of the cornea, a transparent membrane. Ocular muscle Sclera Choroid Ciliary muscle Iris Conjunct, cul-de-sac Anterior chamber and aqueous humor Crystalline lens Posterior chamber A ngle oj antechamber Suspensory ligament oj the lens Ocular muscle Cornea Vitreous chamber Fig. 69.—Vertical section through the eyeball and eyelids (Pyle). The iris is the curtain behind the cornea which shuts out the unnecessary rays of light. It has an opening in its center called the pupil. The eyeball is moved horizontally and vertically by the 249 250 DISEASES OF CHILDREN FOR NURSES superior, inferior, internal, and external recti muscles; in the oblique directions by the superior and inferior oblique muscles. The conjunctiva covers the eyeball and lines the lid; it is a mucous membrane. The lacrimal apparatus consists of the lacrimal gland which secretes the tears. The tears are poured over the eyeball from a duct at the inner canthus, and drain through a duct leading into the nose. The Meibomian glands are small glands in the upper lids which secrete a lubricating fluid. Definitions.—Photophobia.—Intolerance to light. Lacrimation.—Watering of the eye. Conjunctivitis.—An inflammation of the lining mem- brane of the lids and the covering of the eyeball. Keratitis.—An inflammation of the cornea. Ophthalmia.—An inflammation of the eye. Iritis.—An inflammation of the iris. Strabismus (Cross-eyes).—A paralysis of one of the rectus muscles. Synechia.—Adhesion of the iris to the cornea. Hordeolum.—A stye; a cyst of a Meibomian gland. Accommodation.—The power of the lens to change its form and shape so that objects nearby may be seen as readily and distinctly as those at a distance. Hypermetropic,.—Far-sightedness, as the eyeball is too short. Myopia.—Near-sightedness. The eyeball is too long. Astigmatism.—A flattening of the convexity of a portion of the cornea or lens which blurs the vision. Stenosis of the Lacrimal Duct.—A blocking up of the passage leading from the eye to the nose. DISEASES OF EYE, EAR, SKIN, AND GLANDS 251 Malformations.—Anomalies of the eyes consist of flecks upon the iris, cross-eyes, congenital cataract, and albinism. Care of the Eyes.—Immediately after birth the eyes should be washed with a saturated solution of boric acid. This should be continued during the first week as a part of the daily bath. If the mother has had any vaginal discharge previous to the birth of the child, a drop of a Fig. 70—Examination of the eye. If the patient be a rebellious infant, perfect control may be secured if he is held firmly upon the nurse's lap, the child's head being steadied between the knees of the examiner while the examination is made (Kerr). 2 per cent, solution of nitrate of silver should be placed in each eye immediately after birth (Crede's method). This prevents ophthalmia neonatorum. For the method of syringing the eyes, see page 442. The newborn should be protected from too strong a light as it injures the sight; a dark room is the best. Objects are recognized by the infant when about five months of age. Ophthalmia neonatorum is an inflammation of the 252 DISEASES OF CHILDREN FOR NURSES conjunctiva seen in the newborn. It is due to gonorrhea and is characterized by a purulent discharge from the eye. It very often causes blindness. Conjunctivitis or Pink-eye.—An inflammation of the lining membrane of the eyelids and covering of the eyeball. Symptoms.—Pain in the eye, lacrimation, photophobia, and a discharge which may be catarrhal or purulent. The disease may be acute or chronic. Foreign bodies in the eye can be removed by turning the upper lid, if they are not visible. The lid can be turned by placing a card or match-stick at the center of the upper lid and pulling the anterior portion upward Fig. 71 —Method of everting the upper eyelid (J. P. C. Griffith). by means of the eyelashes (see Fig. 71). A pledget of cotton will remove the speck. Keratitis.—An inflammation of the cornea. It is divided into phlyctenular, ulcerative, and interstitial keratitis. Symptoms.—Pain, lacrimation, and photophobia. In the phlyctenular variety small vesicles appear upon the cornea which may rupture and form shallow ulcers. Scars result from healed ulcers. In the interstitial form the inflammation is not upon the surface, but within the structure of the cornea. This form of the disease is due to hereditary syphilis. DISEASES OF EYE, EAR, SAIN, AND GLANDS 253 Nystagmus consists of vibratory movements of the eyes, horizontally, vertically, or rotary. Nursing of Diseases of the Eye.—When a discharge from the eye exists the lids should be held open and the conjunctiva syringed (see page 442) with a saturated solution of boric acid, repeated often enough to prevent any of the purulent matter from remaining in apposition to the inflamed surfaces for any length of time. The applications used are dropped in the eyes from a medicine- dropper. Cold and hot compresses are employed to combat inflammation and the discharge. Cold compresses are prepared by cutting small disks out of muslin, lint, or gauze and allowing them to lie on a piece of ice until cold. They are then laid over the eyelids. The compress must be changed every two min- utes because it will not remain cold for a longer period. Hot compresses are prepared in the same way, hot water being used instead of ice. Children suffering from inflammation of the eyes should be kept in a dark room. The nurse should always wash her hands in an anti- septic solution after treating ophthalmia, else she may infect her own eyes. THE EAR Anatomy.—The ear is divided into three divisions: the external or pinna, the middle ear, and the internal ear. The external ear or pinna is composed of cartilage, which is so arranged that it collects the air waves, and the auditory canal, which is about one inch long. At the internal end of the external auditory canal is the drum, or tympanic membrane, a small membrane about a half inch in diameter. 254 DISEASES OF CHLLDREN FOR NURSES The middle ear contains three bones: the malleolus, the incus, and the stapes. The malleolus is attached to the drum and articulates with the incus, which in turn articu- lates with the stapes. They are so arranged as to form a system of communication between the drum and the inner ear, by means of which the vibrations of the drum are transmitted to the inner ear. Fig. 72.—Frontal section of the organ of hearing (modified from Politzer). The Eustachian tube connects the middle ear with the pharynx. It is through this duct that inflammation extends from the pharynx and causes middle-ear disease (otitis media). The internal ear contains the organ of hearing called the cochlea. It is so arranged that the vibrations of the drum are transmitted to the terminal filaments of the auditory nerve. The semicircular canals maintain the equilibrium of the DISEASES OF EYE, EAR, SKIN, AND GLANDS 2$$ body. Any disease or injury to them causes intense dizziness. The mastoid cells are in the mastoid process of the temporal bone. They connect with the middle ear. Definitions.—Impacted Cerumen.—The term given to large quantities of wax in the external auditory canal. Furuncle of Canal.—Asmall abscessof the auditory canal. Puncture of Drum.—A rupture of the drum or tympanic membrane. Otitis Media.—Inflammation of the middle ear. It may be catarrhal or purulent. Acute and chronic varieties are seen. Acute Otitis Media (Earache).—This is usually caused by an extension of inflammation from the pharynx along the Eustachian tube. It follows catarrh of the nose and throat, measles, scarlet fever, whooping-cough, and dentition. Symptoms.—There is pain in the ear with congestion of the drum and fever, from 99 ° F. to 102 ° F. The child seems ill without any definite signs of the seat of the lesion. In a great number of cases at the end of twenty-four or forty-eight hours there will be a discharge from the ear. It may be catarrhal or purulent in character. The intense pain improves after the appearance of the discharge, and the condition gradually improves. The discharge is not present without a rupture of the drum. Rupture of the drum does not interfere with hearing. In chronic otitis media the discharge is the character- istic symptom. It may persist for years. The purulent form has a disagreeable odor. Mastoiditis is an inflammation of the mastoid cells. It is caused by an extension of the inflammation from the middle ear. 256 DISEASES OF CHILDREN FOR NURSES Symptoms.—The characteristic symptoms are fever. 103 ° F. to 104 ° F., with swelling and tenderness behind the ear. An operation is demanded in the case of mastoid abscesses. The dangers of mastoiditis are an abscess of the brain and septic thrombosis of the sinus of the brain and jugular Fig. 73-—Mastoid abscess. The characteristic manner in which the external ear is pushed forward by the abscess is here well shown (Kerr). veins. At times during the operation the facial nerve is injured, giving rise to Bell's palsy. Nursing and Treatment of Ear Diseases.—The methods employed are used to keep the ear clean, dry up the discharge, and treat the inflammation. Hot water, 1150 F., is the best agent to use in syringing the ear (for method, see page 443). It not only thoroughly cleanses but it reduces congestion. Nothing else should be used to remove foreign bodies or secretions from the ear. Syringing will be sufficient for all emergencies. DLSEASES OF EYE, EAR, SKIN, AND GLANDS 257 Probing with instruments is dangerous. Powder of some form is used to dry up the discharge. The throat is treated by local applications to cure the primary inflammation or congestion, and a Politzer bag is used to open the Eustachian tubes. This is accom- plished by closing the mouth and nostril, the nozzle of the apparatus being inserted into the other nostril. As the patient swallows, the end of the Eustachian tube is opened, the air is forced from the bag into the nose, and it then passes through the Eustachian tube into the middle ear. At times it is necessary for the surgeon to lance the ear- drum to relieve pain and allow the discharge to escape. When shaving the head for a mastoid operation in girls leave a lock of hair in front which can later be drawn down over the scar. At the time of operation it can be retained beneath adhesive plaster. If the physician per- mits, a shampoo before the operation will afford a great deal of comfort during the weeks the bandage is worn. SKIN DISEASES Anatomy.—The skin is composed of three layers: the epidermis, the true skin, and the subcutaneous or supporting tissue. The epidermis is the external layer and is without blood-vessels or nerves. It acts as a protecting membrane. The true skin lies beneath the epidermis. It is exceed- ingly vascular and contains a meshwork of nerve filaments throughout its extent. The hair and sweat follicles are situated in the true skin. Definitions.—Macules.—Small discolored areas of the skin without elevation. Papules.—Solid elevations of the skin, varying in size from a pin-head to a pea. 17 258 DISEASES OF CHILDREN FOR NURSES Vesicles.—Elevations containing a clear or opaque fluid. Blebs.—Large vesicles. Pustules.—Elevations containing pus. Scales.—Dry exfoliations of the epidermis. Crusts.—Brownish or yellowish masses of dried exuda- tion. Erythema.—A reddish blush to the skin. Miliaria (prickly heat) is caused by a blocking of the ducts leading from the sweat-glands. It produces small vesicles at the orifices of these ducts. Treatment.—Keep the bowels loose, apply a good toilet powder, and prevent irritation by placing silk or linen next to the skin. A saturated solution of bicarbonate of soda, frequently applied, will give much relief. Seborrhea is a disease usually involving the scalp; at times it is universal. It is characterized by the formation of dirty yellow crusts. The crusts should be removed by washing the scalp with warm water and soap and an oint- ment should be applied. Eczema is an inflammation of the true skin. It is caused by chapping of the skin surface from cold or discharges, such as running ears or coryza, and, reflexly, from the gastro-intestinal tract. Symptoms.—Intense burning and itching of the skin with redness and weeping of the surface affected. There are several varieties of eczema: Eczema vesiculosa; principal lesions are vesicles. Eczema papulosa; principal lesions are papules. Eczema pustulosa; principal lesions are pustules. Eczema rubrum, a raw weeping surface. Eczema intertrigo, caused by two moist surfaces rubbing together, such as the thighs. Treatment.—In eczema intertrigo bathe parts only once DISEASES OF EYE, EAR, SKIN, AND GLANDS 259 a day with water; for all other cleansing processes use olive oil and dust parts with a 10 per cent, powder of balsam of Peru made with stearate of zinc. In the other forms of eczema the crusts must be re- moved as soon as they form, and the ointment thoroughly applied. To prevent children from scratching the inflamed skin pasteboard cuffs, well padded, are used. These are made Fig. 74-—Impetigo contagiosa (of one week's duration) in a girl ten years of age, crusting stage already reached; on chin and nose lesions have coalesced (Stelwagon). out of stiff pasteboard cut long enough to extend from the armpit to the wrist and wide enough to encircle the arm. They are held in place by a bandage. This prevents the bending of the elbow and renders it impossible for the child to scratch above the knees (see page 467). Furunculosis is characterized by the formation of numerous small abscesses or boils. 260 DISEASES OF CHILDREN FOR NURSES Onychia is the name given to an inflammation at the root of the nail. Impetigo contagiosa is a contagious skin disease often transmitted through towels, and is characterized by several large, flat pustules which break -early and form crusts. The disease is usually seen on the face. Urticaria or hives is characterized by red elevations which suddenly appear and vary from the size of a pea to that of a hand. They may be multiple. They itch intensely and are soon covered with scratch marks from the finger-nails. They last from one to two hours. Re- peated attacks are common. Treatment.—Apply some soothing lotion and give a laxative. Scabies, or the Itch.—A disease caused by a small "itch mite" or parasite buried under the epidermis. It is most often found between the fingers and the toes. The disease is characterized by intense itching. Tinea Circinata.—A ring-worm of the skin, character- ized by a circular irritation of the skin which fades toward the center. Tinea Tonsurans.—A ring-worm of the scalp. Lupus vulgaris is tuberculosis of the skin. Nevus or Birth-mark.—A collection of blood-vessels in the skin. They are characterized by a raised purplish area. They should be excised if they cause disfiguration. Pediculosis Capitis, or Lice.—Small parasites infest- ing the hair. Pediculosis Pubis.—Small parasites infesting pubic hair. Congenital ichthyosis is a disease of the skin in which there is an overgrowth of the epidermis forming a horny surface resembling parchment. It may last through life. Nursing.—To obtain results in skin diseases it is neces- DISEASES OF EYE, EAR, SKIN, AND GLANDS 261 sary to be patient and to apply the remedies thoroughly. All crusts should be immediately removed and the children prevented from scratching themselves. This may be accomplished by the use of cuffs (see page 467), or by tying the children down by the jacket (see page 467), Impetigo, scabies, tinea circinata, and tinea tonsurans are contagious; therefore, antiseptic precautions must be taken after treating such cases. DISEASES OF THE GLANDULAR SYSTEM Anatomy.—The lymphatic glands are arranged in Fig. 75-—Location of lymphatic glands of face and neck (Kerr). :hains. They are situated along the lymphatic system. Their function is to act as filters, and keep poisonous 262 DISEASES OF CHILDREN FOR NURSES substances and bacteria from entering the general circula- tion. The most important chains of the lymphatic gland in the body are the cervical, axillary, inguinal, bronchial, and mesenteric. They are located in the neck, armpit, groin, back of the bifurcation of the bronchi, and in the posterior part of the abdomen, respectively. Fig. 76.—Location of lymphatic glands (Kerr). Lymphatism is the name applied to a general enlarge- ment of all the lymphatic structures in the body. It is due to an extreme susceptibility of the children affected to inflammation of the lymphoid tissues. The tonsils are enlarged, adenoids are present, and the chains of the lymphatic glands are swollen. DISEASES OF EYE, EAR, SKIN, AND GLANDS 263 Adenitis is an inflammation of a lymphatic gland. Varieties.—Simple adenitis, acute or chronic; tubercular; syphilitic. Adenitis often occurs in the course of the acute infec- tious diseases, especially in measles and scarlet fever. Symptoms.—In simple acute adenitis there is a conges- tion and swelling of the glands. Suppuration is uncommon except after scarlet fever. An infected wound of the extremities may cause adenitis. Suppuration often takes place under such circumstances. Tubercular adenitis is common in childhood; suppura- tion occurs, producing sinuses. The tubercular glands are excised and curetted. Syphilitic glandular enlargements are occasionally seen in childhood. Hodgkin's disease is characterized by a general enlarge- ment of the lvmphatic glands with progressive anemia. ending fatally, CHAPTER XII THE INFECTIOUS FEVERS CHARACTERISTICS OF FEVER Stages.—The febrile stages are invasion, fastigium., and defervescence. Invasion is the gradual rise until it reaches its maximum. Fastigium is the stage in which the temperature shows a tendency to reach again and again its highest point, although there may be marked variations. Defervescence is the gradual fall to normal. Terminations.—Crisis is a fall of temperature from its height to normal or subnormal within twenty-four hours. Lysis is a gradual fall to normal taking several days or a week. Hyperpyrexia is temperature above 1060 F. Febrile Remissions.—All temperatures of fever show a diurnal remission, usually of one degree. The maximum is at 6 p. m. and the minimum at 6 a. m. Types of Fever.—Continued Fever.—The diurnal vari- ation is slight, from i° F. to j.50 F. Remittent.—The diurnal variation is marked and the minimum temperature remains above the normal. Intermittent.—The diurnal variation is marked and the minimum temperature is normal or subnormal. Hectic.—Due to pus. High, irregular fever, with wide fluctuations, accompanied by sweats, chills, and pallor. 264 THE INFECTIOUS FEVERS 265 Pulse and Fever Ratio.—There are about ten extra beats of the pulse for every degree of fever. Simple continued fever without any definite cause is called febricula. F. £ M. £. M. £ M. E. M. £■ M. £ M £■ M £. M. 106 106 104 103 IOZ 101 ZOO 99 98 Fig. 77.—Represents a continued fever. It is observed mostly in erysipelas, acute tuberculosis, lobar pneumonia, and typhoid fever (Kerr). The period of incubation is the period elapsing between the entrance of the poison and the development of the symptoms of the disease. It varies considerably, being F £ M. £ M £ M £. M. £. M. £. M. £. M. £. A/. 106 105 lot A 1 103 A A A A IOZ n A /y i. f\ f 101 / \/ \ V ' \l \ 100 V V v \ 99 V 98 Fig. 78-—Represents the remittent type. This is suggestive of one form of malaria, of tuberculosis (not acute), and suppuration (Kerr). influenced by the susceptibility of the patient and the virulence of the infection. For the following diseases the average period is: Typhoid fever—two to three weeks. 266 DISEASES OF CHILDREN FOR NURSES Measles—two weeks. Rotheln (German measles)—ten to twelve days. Scarlatina—a few hours to a week. Smallpox—one to two weeks. F E M. £ M. E. M £. M F. M. £ M. £ M £ M 106 105 ,1 loH /03 \ , , /oz \ 101 \ /oo i \ 19 J \ \ J 98 l_ J J ^~ ZT \ Fig. 7g—Represents intermittent fever. The left hand half showing the quotidian type while the right hand half shows the tertian type. It is significant of malaria (Kerr). Erysipelas—three to seven days. Diphtheria—two to ten days. Varicella—-ten to fifteen days. F £. M. £ M. £■ M £ M £ M. £ M. £. M. £. M 106 /OS /0/f A A 103 A A A A IOZ A M \ 1) L 101 1 \ \{ 1 \j \ 100 I V V V \ 99 1 93 Fig. 8o.—Represents a hectic and suppurative fever type, which is generally accompanied with sweating (Kerr). Tetanus—a few days to two weeks. Mumps—two to three weeks. The date when rashes appear in various diseases is as follows: THE INFECTIOUS FEVERS 267 Typhoid fever—seventh to ninth day. Smallpox—third or fourth day. Measles—third or fourth day. Scarlatina—first or second day. Rotheln—first or second day. Varicella—first day. Protection from future attacks conferred by various diseases is as follows: Typhoid fever—-relapses are common; second attack are sometimes seen. Measles—second attacks rare. What are supposed to be second attacks are usually rotheln. Rotheln—second attacks rare. Smallpox—second attacks occasionally occur. Mumps—second attacks rare. The following diseases do not confer immunity. Erysipelas, diphtheria, malaria, influenza, and croupous pneumonia. An infectious disease means one due to a specific micro- organism. A contagious disease is one which can be communicated by actual contact, either through the person or by infected clothing. A complication is a condition occurring in the course of a disease. A sequel appears after the attack. CEREBROSPINAL FEVER This disease is also called spotted fever and epidemic cerebrospinal meningitis. It is a specific infectious disease characterized by inflammation of the cerebrospinal men- inges (the membranes covering the brain and spinal cord) 268 DISEASES OF CHILDREN FOR NURSES and usually occurs in the winter and spring. The young are more susceptible than the old. The disease is now considered to be contagious. It is caused by a diplococcus. The mucous membrane lining the nose and pharynx is the portal of entry and dissemination of the disease. Symptoms.—Common Form.—The disease generally begins abruptly with a chill followed by vomiting and excruciating pain in the head, back, and limbs. The muscles of the head, neck, and back become rigid and contracted so that the head is bent backward and the back is straightened. In severe cases the body may be arched in a state of opisthotonos. The mind is soon Fig. 8i —Cerebrospinal meningitis: Tache cere'brale shown on left thigh (Ruhrah). affected, delirium is rarely absent, and in severe cases it is followed by stupor and coma. At first there is intense irritation of the whole nervous system, headache is severe and continuous, twitching of the muscles and actual convulsions are common, all the special senses are extremely acute, and there is pain on the slight- est movement, which often causes the child to cry out shrilly. Later, when the exudate becomes of sufficient amount to exert pressure, paralysis develops; it may be THE INFECTIOUS FEVERS 269 localized, effect one side of the body, or one extremity. Blindness and deafness, disturbed speech, and mental defects are found in the protracted cases. When the finger is drawn oxer the skin a red line develops; this is called the tdche cerebrate (see Fig. 81). The temperature is irregular and indefinite in duration; ordinarily it ranges between 1010 to 103 ° F. In some cases it is almost normal, while in others it is very high. The pulse is rapid and full, the bowels constipated, and there may be polyuria. The eruption is neither constant nor peculiar. In many cases a blotchy, purpuric rash appears over the entire body. Herpes facialis (fever blisters) are also fre- quently observed. In other cases urticaria or a roseolar or erythematous rash appears. The duration ranges from a few hours to several weeks. Treatment.—Within the past two years this dreaded disease has been frequently cured by means of a serum brought to the attention of the world through the work of Flexner and his associates at the Rockefeller Institute in New York. The disease is isolated in most cities under the Board of Health rules. Nursing.—In nursing the disease follows the same routine described under contagious cases (see page 318). Take every antiseptic precaution and spray the nose and throat frequently with some germicide. If a lumbar puncture is made by the physician, several sterile test-tubes properly stoppered with sterile cotton should be ready to receive the fluid. (For a description of Lumbar Puncture, see page 210). Flexner's serum should be kept on ice before use. At the time it is to be injected the bottle should be placed 270 DISEASES OF CHILDREN FOR NURSES for five minutes in water at a temperature of 100 ° F. Do not use boiling water, as it coagulates the serum. When the bottle is opened its edge and neck should be thoroughly wiped with sterile gauze. The physician will introduce a hypodermic needle into the spinal canal, as in making a lumbar puncture. He will then fill the syringe, express all the air, and while a drop or two of the fluid is running from the syringe, attach it to the needle. For this reason it is better to have a needle which fits on the syringe, rather than one which screws on. This care is taken to avoid the introduction of air into the spinal canal. He will then inject the fluid very slowly. When the needle is withdrawn, adhesive plaster or a collodion dressing must be at hand to seal the wound. The child should be prepared for this minor operation in the same way as for a lumbar puncture. The syringe must be absolutely sterile. Injections are usually given every twenty-four hours. MALARIAL FEVER This is a specific non-contagious disease caused by the hematozoa of Laveran. It is characterized by splenic enlargement, by fever with periodic intermissions or re- missions, and by a tendency to extreme anemia. Etiology.—The exciting cause is the hematozoa of Laveran, and the mode of infection is by the bite of a mosquito which has previously sucked the blood of a malarial patient. All ages, from the newborn to the aged, are subject to malaria. Manifestations.—Malaria may manifest itself as in- termittent fever; remittent fever, or chronic malarial cachexia- THE INFECTIOUS FEVERS 27\ Pathology.—The Hematozoa.—A small, colorless ame- boid body enters the red blood-corpuscles, increases in size, and becomes pigmented from the coloring-matter of the corpuscles. When the red blood-corpuscle is destroyed the granules of pigment collect in the center of the organ- ism, which finally divides into a number of small hyaline bodies, each of which begins a new cycle of existence. The chills or paroxysms occur at the time these small Fig. 82.—Some of the principal forms assumed by the Plasmodium of tertian fever in the course of its cycle of development (after Thayer and Hewetson). bodies are thrown into the blood current after the blood- cells are destroyed, and are due to the production of a poison. The parasite of tertian intermittent fever requires forty-eight hours to complete its cycle of existence; there- fore, when a single group of these parasites exist in the blood a paroxysm occurs every other day. If, however, two groups co-exist and sporulate (the term given to the time when the organisms are thrown into the blood-cur- rent) on alternate days, a paroxysm occurs daily (quotidian intermittent fever). The parasite of the quartan intermittent fever requires 2y2 DISEASES OF CHILDREN FOR NURSES seventy two hours in which to develop and undergo sporulation; hence, a single group of these organisms in the blood excites a chill on every fourth day. When two groups co-exist a chill occurs on two successive days and is followed by daily intermission. When three groups co-exist a chill occurs every day and there is quotidian intermittent fever again. The life-history of the parasite of remittent fever within the body is not definitely known. Its cycle of existence occupies from twenty-four to forty- eight hours. In advanced malaria the blood shows a diminished number of red blood-corpuscles and a large quantity of le/nfa. 1 M. £ M £ 3 M.£ ME s ME. 6 M.E. M-£. 8 M.£ 9 M.E. /0 M.E // ME /Z M.£. 108 /07 10b /OS \ lO'f 1 103 A 1 loz A 10/ 100 99 I A / A 1 A 9$ / \ A u ' \_ J Xs V N \/~ *7 Fig. 83—Tertian type of malarial fever. Male child of six years. Quinin begun at X (Kerr). free pigment. The spleen is greatly swollen and deeply pigmented. All the organs, including the brain, are discolored by this free pigment. Intermittent Malarial Fever.—Symptoms.—The char- acteristic features of this form of malaria are the intermit- tent type of fever, the enlargement of the spleen, the hematozoa in the blood, and the occurrence at regular the infectious fevers 273 intervals of the paroxysms divided into three stages— the chill, the fever, and the sweat. Cold Stage.—There is malaise, headache, and great chilliness. The features are pinched, the lips are blue, and the surface of the body is cold and covered with "goose flesh." The rectal temperature is high—1040 F. to 105 ° F. Vomiting may occur. The chill lasts from a few minutes to an hour or two. Hot Stage.—The surface temperature gradually rises, the skin becomes hot, the face flushed, the eyes injected, and the pulse rapid and full. The temperature in the axilla may reach 1060 F. to 1070 F. The child complains of severe pain in the head, back, and limbs, and of thirst. The urine is scanty and dark colored. This stage usually lasts from one to five hours. Sweating Stage.—The fever gradually subsides, the pain grows less, free perspiration follows, and the child falls asleep from which he awakens feeling fairly well. Varieties.—When the disease occurs every day it is termed quotidian intermittent fever; every other day, tertian intermittent; every fourth day, quartan intermittent fever. Prognosis.—Always favorable. Even when no treat- ment is instituted the paroxysms gradually subside. Chronic malarial cachexia may develop. Remittent Malarial Fever or Estivo-autumnal Fever.—In temperate zones remittent fever is observed chiefly in the autumn. It is uncommon in children who live outside of malarial districts. Symptoms.—There is malaise with moderate chilliness followed by a continuous fever which daily remits. The maximum temperature ranges from 1030 F. to 1060 F., 18 274 DISEASES OF CHILDREN FOR NURSES and while this lasts the skin is hot, the face flushed, the eyes injected, the pulse full and strong, the urine scanty, and the patient complains of pain in the head, back, and limbs. Definite paroxysms may or may not be present. Delirium is sometimes noted, vomiting often occurs, and jaundice may appear from the destruction of the red blood- corpuscles and the liberation of their pigment. The spleen is enlarged and the hematozoa are found in the blood. Prognosis.—Favorable. The average duration is from one to three weeks. Chronic malarial cachexia is characterized by anemia, a sallow appearance to the skin, and splenic enlargement. Etiology.—It may result from repeated acute attacks of the disease or it may develop as a primary condition from slow infection. Symptoms.—The child is thin and pale, the complexion is of a dirty yellow or muddy hue, fever is often absent or if present, it is slight and irregular. The spleen is con- siderably enlarged. There is great weakness from the attending anemia. Headache and neuralgia are common symptoms. Hematuria is sometimes observed. Prognosis.—Guarded. With the spleen very large and extreme anemia the patients rarely recover. Malarial infection seems to predispose to certain cases of dys- entery, pneumonia, and amyloid degeneration of the viscera. Treatment.—As malarial fever is contracted by means of infection through mosquito bites, proper measures should be taken to protect children from the mosquitoes. Just as great care should be taken to prevent mosquitoes from biting children who have malaria, and in this way prevent- ing the spread of the disease. Quinin is a specific rem- THE INFECTIOUS FEVERS 275 edy, killing the hematozoa. The dose is from 5 to 10 gr. a day in divided doses (four years), and in ordinary cases in older children is from 15 to 20 gr. a day in divided doses. The drug is given so that the last dose is taken two hours before the expected chill. The cold stage is treated with hot-water bottles and blankets, and the hot stage by sponging. SYPHILIS Syphilis is a communicable disease and may be ac- quired or hereditary. It is caused by the spirochaeta pallida. Syphilis is acquired usually from the mother of the child or from syphilitic wet-nurses. It follows the same course as syphilis in the adult and is divided into three stages. The first is characterized by a chancre, the second by a rash, and the third by a bone lesion and ulcerations. It is now considered contagious in all stages, but especially in the second stage. Hereditary syphilis is more common. When born the child at times has large blebs on the skin surfaces and scars develop around the lips called rhagades. Symptoms.—The Bones.—Epiphysitis, an inflammation of the ends of the bones, is present. Later in the disease chronic osteoperiostitis and syphilitic dactylitis are seen. The liver and the spleen are enlarged. The Respiratory Tract.—Pneumonia is common. Ulcers of the larynx are sometimes observed. Digestive Tract.—A chronic catarrh of the pharynx is present, causing "snuffles." The Organs of Special Senses.—Otitis media and interstitial keratitis are common. DISEASES OF CHILDREN FOR NURSES Nervous Symptoms.—Often absent, but there may be impairment of mentality. The children are weak and sickly and usually die young. If three months pass after a child is born from syphil- itic parents without the appearance of any characteristic symptoms, the child will, in all probability, escape. Fig. 84.—Hereditary syphilis: radiating fissures of the lirs (after A. Fruhinsholz). Hutchinson''s Teeth.—If a child suffering from heredi- tary syphilis lives, the second or permanent teeth are characteristic (see Fig. 4). The teeth most frequently affected are the upper central incisors. They have a dull, opaque color and have a roughly rounded and stunted appearance. The THE INFECTIOUS FEVERS 277 cutting edge of the tooth is narrower than its neck. Over the tips of these stunted and conic teeth the enamel is irregular and forms a semilunar notch. The Wassermann reaction is a test made with blood from an individual suspected of having syphilis. It is reliable in about 80 to 90 per cent, of cases. The physician will take from 4 to 8 c.c. of blood from a vein, or less from a stab of the finger, toe, or ear, and let it stand at the room temperature for one hour until firmly clotted, then it should be put on ice. Be sure and label the tube and reference card, as all blood specimens look the same. If properly taken and kept the specimen will not disintegrate for four or five days. The test consists in mixing the serum of this specimen with a syphilitic antigen, which is a solution of a liver from a syphilitic fetus which has shown the Spirochaeta pallida (the germ that produces syphilis). To this is added blood-serum from a guinea-pig, and the whole is placed in an incubator for three-quarters of an hour at 370 C. After this, rabbit's serum, which has been immunized to red sheep cells, is added, followed by a solution of washed red blood cells from a sheep, and the tube shaken. The whole is again incubated for one to one and a half hours at 370 C. If the test is positive, there is no hemo- lysis; that is, the upper part of the tube is clear and the red corpuscles are precipitated in the lower part. If it is negative, there is complete hemolysis; no cor- puscles are precipitated in bottom of tube. Complement fixation is the same test, except a gono- coccus antigen is used instead of syphilitic liver. Treatment.—The treatment of both hereditary and acquired syphilis consists in giving mercury. This, in 278 DISEASES OF CHILDREN FOR NURSES infants, is given in the form of ointments. Great care must be taken by the nurse to avoid contamination in handling syphilis. Salvarsan, a preparation of arsenic, discovered by Ehrlich, seems to give excellent results. It is injected intravenously or intermuscularly. TETANUS OR LOCKJAW An acute infectious disease excited by the tetanus bacillus and characterized by painful tonic spasms of the voluntary muscles. The bacillus gains an entrance to the system through some wound. Lacerated and punctured wounds, burns, and frost-bites are most likely to become infected. Stables seem to be the breeding ground for the bacillus. Symptoms.—The disease begins with rigidity in the muscles of the neck and lower jaw, by degrees the mus- cles of the back, abdomen, and extremities are similarly involved. The face has a peculiar expression, the brow is wrinkled, the corners of the mouth are drawn up (the sardonic grin) and the jaws are tightly closed (trismus). The body may become arched in a position of opisthot- onos. There is extreme hyperesthesia, and the slightest touch causes an increase in the spasm which is attended by severe pain. If the respiratory muscles are involved there is intense dyspnea. The temperature usually re- mains normal until just before death, when it may rise to 107 ° F. or more. The mind is clear to the end. The duration is from a few days to several weeks. Death occurs in nearly every case. Tetanus occurs sometimes in the newly born from infection of the umbilical cord. THE INFECTIOUS FEVERS 279 Treatment.—There is an antitoxin for tetanus which is injected into the system. HYDROPHOBIA OR RABIES A disease of dogs which at times is communicated to children through a bite of an animal suffering from rabies. It takes about six weeks for the disease to develop after the wound is received. Symptoms.—These consist principally of paralysis of the muscles of the throat, which prevents swallowing. There is fever, and convulsions are present. Treatment.—All dog bites should be immediately washed with antiseptic solutions and a wet bichlorid dressing applied. At the present time cauterization has been discontinued, the bite being treated as an open wound. If the dog is known to have had rabies, treatment by the Pasteur method will prevent the child from develop- ing the disease. Pasteur institutes exist in New York and Chicago. The Boards of Health of some of the larger cities furnish the serum. The treatment, according to this method, consists of hypodermic injections of the serum extending over a period of several weeks. TYPHUS FEVER (BRILL'S DISEASE) An infectious disease which is rarely seen at present except in isolated instances. Formerly it was one of the scourges of the world. When it was found that it was spread by overcrowding and filth, and measures were instituted to improve the hygienic and sanitary conditions of people living under such conditions, the epidemics of the disease were con- trolled. 28o DISEASES OF CHILDREN FOR NURSES Brill, of New York, has lately recognized that a series of symptoms occurring in children to which the name "Brill's disease" had been applied is, in reality, a sporadic form of typhus fever. Symptoms.—Beginning with the usual prodromes, the fever rises rapidly to 1030 or 1040 F. On the fifth or sixth day a rash appears which does not disappear on pressure, and which persists until the crisis, when it rapidly fades. The children are much prostrated, with severe headache, but no abdominal symptoms. Consti- pation is usually marked. After persisting for twelve to fifteen days, the fever usually falls by crisis, and there is a speedy recovery. There is a negative. I Vidal reaction with typhoid organ- isms. The disease is rarely fatal and does not spread to other patients in the ward or in the home. NURSING IN THE ACUTE INFECTIOUS DISEASES The room should be kept at an even temperature; it should be well lighted and ventilated. Bathing should be thorough. The clothing should be of a light woolen texture. Sleep should be encouraged, the urine should be examined routinely, and the temperature, pulse, and respirations taken every three hours where there is fever. The nurse should roll up her sleeves when nursing an infectious disease. Care should be taken by the nurse to prevent the infec- tion of herself. All antiseptic precautions should be employed In malaria the child should be protected against mosquitoes. She should avoid all possibility of being scratched or THE INFECTIOUS FEVERS 28l bitten in hydrophobia. This may occur if it is necessary to feed by gavage. The feedings should be liquid. In tetanus it may be necessary to feed through a catheter placed in the mouth or nose; it may be necessary to chloroform the child while doing this. In syphilis avoid contagion, and when applying mer- curial ointment, to prevent irritation of skin, select a new place each day. For example, the abdomen, right and left axillae, and the right and left thighs can be utilized in rotation. A glass rod is the best means of applying mercurial ointment; 1 dram is used, and is rubbed in for a half hour. CHAPTER XIII TYPHOID FEVER Typhoid fever is an acute infectious fever due to the typhoid bacillus or bacillus of Eberth. The disease is especially characterized by pathologic changes in the lymph-follicles of the intestines and par- ticularly of Peyer's patches, by changes in the mesenteric glands, and by an enlargement of the spleen. The lesions in the intestines and the mesenteric glands are ulcerative in character. Typhoid fever is recognizable in the writings of the ancients four hundred years before Christ, and ever since that period epidemics of this disease have been constantly recorded in medical history. The causes for the frequent epidemics are better understood when it is known that the typhoid bacillus shows great resisting powers. They have remained alive for three months in distilled water, and when buried in the upper layer of the soil they will retain their vitality for six months. Dissemination of the Disease.—The method by which the typhoid bacillus spreads the disease is well understood. The stools of a person suffering from the disease are filled with the germs. Unless these stools are covered with some solution like carbolic acid, ^V; bichlorid of mercury, y^j-; or chlorinate of lime, of equal strength, they pass with the sewage to the nearest water-course. Once in the stream they may pollute an oyster bed or they 282 TYPHOID FEVER 283 may be contained in the water used to sprinkle green vegetables. By far the greatest danger is in swallowing the bacilli in drinking water. Milk may be contaminated by water containing the bacillus. The distances they travel, at times, is almost incredible. Miles down a stream an epidemic will arise traceable to one case at its source. A case occurring in the fall of the year can produce typhoid after the spring thaws, if the stools are carelessly deposited on the upper surface of the soil. The relatively infrequent communication of typhoid fever to physicians and nurses is explained by the fact that the contagion escapes from the child in the stools alone, and as these are promptly disposed of, the chances of dissemination of the poison are few. Carelessness in the disposition of these discharges, such as permitting them to dry upon the linen and in this manner allowing the bacillus to pass into the air of the room, at times occasions the infection of the nurse, the physician, and others attending a typhoid case. Age.—Typhoid fever is seen most often during adoles- cence and in adult life before thirty years of age, although it occurs frequently in childhood. It is rare before two years of age. In the young the duration of the disease is short, and the prognosis very favorable. Sex.—Typhoid fever seems to be more prevalent among boys than among girls, probably because of their more frequent exposure rather than greater susceptibility. Season.—Typhoid fever is more common in the late summer and in the early autumn months than at any other time of the year; hence one of the names for typhoid is autumnal fever. 284 DISEASES OF CHILDREN FOR NURSES Morbid Anatomy.—The principal lesions in typhoid fever are in Peyer's patches in the ileum (the lowermost portion of the small intestines). Peyer's patches are a collection of lymphatic glands in the walls of the intestines and are from one to three inches in length. The typhoid bacilli implant themselves in these glands and cause an inflammation. The Peyer's patch becomes swollen and the superficial tissue sloughs off, leaving a raw, ulcerating surface. This is called a typhoid ulcer. These ulcers may be very small, from an eighth to a quarter of an inch in diameter. More often there is a large, elliptic ulcer, a whole Peyer's patch being involved. At times by the union of one or more ulcers much larger ones are formed, especially at the lower end of the bowel. The borders of the ulcers are raised, the floor of the ulcer is usually the submucous, or muscular coat of the bowel. (The bowel has four coats, the mucous, the submucous, the muscular, and the peritoneal.) If the ulcer eats through all these coats there is a perforation of the bowel. The discharge of the contents of the intestines through the perforation into the peritoneal cavity is often followed by a fatal peritonitis. More commonly the ulcer heals before the bowel is perforated, and the patient recovers, but the normal glandular substance is never restored at the seat of the ulcer. At autopsies ulcers are discovered at different stages of healing, sometimes they are all healed with the exception of the single fatal spot, which has become the seat of perforation. The large intestines are also invaded at times; perhaps in about one-third of the cases perforation may take place here and also in the appendix where the process occasionally extends. Similar infiltration of the TYPHOID FEVER 285 lymph nodules and the lymph cords of the mesenteric glands and of the spleen occurs, contributing to the enlarge- ment of these organs. In the spleen it is associated with active congestion which causes a further enlargement, generally recognizable during life. There has even been known to be a rupture of this organ. Changes in the liver, kidneys, and in the respiratory organs are often found. Hypostatic congestion of the lungs is a frequent complication. Thrombosis of the veins, especially of the femoral, causes the not very rare symptom of milk-leg. Endocarditis is sometimes found. Notwithstanding the intensity of the nervous symptoms in some cases, menin- gitis is rarely met with. Abscess of the parotid gland is a familiar complication. Characteristics of Typhoid Fever in Children.— During childhood the disease is of shorter duration, milder course, has fewer complications, and has a lower mortality than in adult life. The onset is more sudden, fever, vomiting, and prostra- tion being seen as often as slow insidious beginnings. Constipation is more frequent than diarrhea, tympanites is not marked, and the eruption is less constant in child- hood. Nervous symptoms are not as frequently found as in adults; hemorrhage and perforation are also met less often. Noma is sometimes a complication. Death rarely occurs in uncomplicated cases. After ten years of age the symptoms are similar to those seen in adult life. Symptoms and Course.—A certain period of incubation is necessary after the successful implantation of the bacilli before typhoid fever arises. This varies from a few days to two weeks and even longer in some cases. The period of incubation may be without symptoms, but a sense of 286 DISEASES OF CHILDREN FOR NURSES weariness and indisposition to play are usually present. The latter often can be overcome by force of will. A want of appetite and a slight coating of the tongue are not infrequent. In older children the disease itself usually sets in gradually and often is quite advanced before it is suspected; indeed, at times well advanced, constituting the so-called walking typhoid. In children under ten years of age the onset is less gradual. Symptoms of the Attack.—There may be headache, anorexia, a furred tongue, nausea, chilliness, but seldom a decided rigor. The disease may be ushered in by pain in the back or leg muscles and there may be nosebleed (epi- staxis). In older children there may be a looseness of the bowels. There is continuously a slight fever and the child feels wretched. The fever and discomfort increase and finally the child goes to bed. The tendency to loose- ness of the bowels and epistaxis justify a strong suspicion of the existence of typhoid fever. Yet one or both are frequently absent, and in younger children constipation is more often seen than diarrhea. The abdomen soon becomes slightly distended and pressure on the right iliac fossa elicits tenderness with gurgling. Rash.—Usually about the eighth day, rarely later and sometimes a little earlier, the rose-colored spots make their appearance on the skin of the abdomen and chest and at times elsewhere on the body. They are mostly bright red in color, disappear on pressure, and reappear instantly. They are very slightly, if at all, raised. Their number varies greatly. Sometimes they are very numerous, but more often but five to ten are discovered. Herpes are very rarely seen, in contradistinction to pneumonia. TYPHOID FEVER 287 The fever is at once the most important and the most characteristic symptom, and from the temperature alone a diagnosis can be suspected. Initial Stage.—During the first week of the fever there will be found a peculiar tide-like evening rise and morning fall, the temperature of each morning and evening being from one and a half to three degrees higher than that of the morning and evening previous. The fastigium is the stage when the fever again and again reaches the highest point. At the end of a week the height of the fever is reached and then it continues with but little variation, the evening rise and the morning fall still being characteristic, but the remission being less than that seen at the onset—from a half to two degrees being found. It is during this period that the maximum temperatures are found; often 105° F. or a little above are noted. A temperature of 106 ° F. is frequently fol- lowed by recovery, and while temperatures of 107° F., 1080 F., and even 109° F. are sometimes seen, they usually result fatally. The fastigium is succeeded by a third stage or stage of decline in which the reverse of the initial stage is shown by an evening temperature lower than that of the previous evening and the morning temperature lower than that of the previous morning, but the evening temperature still higher than the morning temperature of the same day. This decline continues until the normal is reached, and at times from one to two weeks are consumed before this is attained. The duration of the fever in children, however, is usually shorter than in adult life. Sudden falls of a decided character may occur in conse- quence of hemorrhage from the bowels or even from the 288 DISEASES OF CHILDREN FOR NURSES nose, or from collapse after perforation of the bowels. Sudden rises are produced by indiscretions in diet or by the supervention of some acute inflammatory condition, such as pneumonia. The skin is usually dry, although profuse sweating sometimes occurs most frequently after a bath. Children frequently have higher temperatures than adults. The pulse is not very frequent, 90 to 120 is the usual average. In grave cases it maintains a frequency of 140. 1 2. J ■¥ s £ 7 8 9 10 // IZ /3 /4- /s P. T. m.e. me m. e 777. e. m.e m.e m.e. me. in. e. m. e m.e m.e m.e ir/e me. no 1 08 160 10 7 ISO 106 14-0 105 130 104 A 1 v A A 120 1 03 A A 1 \ r t If. \/ \ N A >'\ '\ ^ 1 I/O IOZ /s 1 \/ V -P yv7 \/v V/N \i \ 1 Y \j \/ 100 101 \t 1 vv' 90 100 /K \/ so 99 1 *^_ 70 98 60 91 Fig. 85 —Chart of the temperature (----) and pulse (---) in typhoid fever of moderate severity in a male child five years old (Kerr). The pulse is often dicrotic (see page 175). The breath- ing rate commonly advances with the rate of the pulse. The heart-sounds at first are normal, but gradually grow less distinct as the prostration increases. As the disease advances the tongue, previously furred, tends to become dry and brown, clearing at the edges, however, and also at the tip as the case improves. In severe cases, especially, if the mouth is not kept clean, sordes form on the teeth, stomatitis sets in, and the lips are covered with black crusts. TYPHOID FEVER 289 Diarrhea, if present, is rarely troublesome. The stools are apt to be grayish-yellow and of about the consistency and frequently likened to pea soup. Hemorrhage from the bowel is always a serious com- plication, but by no means fatal, though large quantities of blood are sometimes discharged. Very rarely a patient will bleed to death. Following the hemorrhage there will be a marked fall in the temperature and a pallor and a faintness such as is common to large hemorrhages else- where. Perforation is suspected when there is a sudden pain in the side with spreading tenderness and vomiting. The temperature falls and the pulse becomes more rapid. If these symptoms occur during the course of typhoid the physician should be immediately informed. Tympanites or distention of the abdomen in a mild degree is at times present in children, but not so often as in adults. The accumulation of gas is commonly ascribed to atony of the bowel. Delirium is rare in childhood. A tendency to drowsiness or even stupor is present, and from this the name of the disease is suggested. Muscular tremor is a symptom in severe cases. Carphalogia or picking at imaginary objects is sometimes present and is merely a symptom of the typhoid state; it is not necessarily of fatal import, as is so often thought by the laity. When this condition, known as the typhoid state, sets in the tongue becomes dry, brown, and fissured. Slight cough usually sets in as the disease advances, due to a hypostatic congestion of the lungs. This can be relieved by frequently changing the position of the child in bed. 19 DISEASES OF CHILDREN FOR NURSES The spleen is always enlarged, reaching in the first half of the second week two or three times its normal size. It then gradually diminishes. Tenderness may accompany the enlargement. The urine in typhoid cases is always dark hued and concentrated, with correspondingly high specific gravity. Often when the fever is high there may be a slight albu- minuria. If there is a nephritis present there will be casts in addition to the albumin. The blood in typhoid fever shows a slight diminution in the white blood-corpuscles in contradistinction to pneu- monia where they are greatly increased. There is also a reduction in the red blood-corpuscles and the hemoglobin, according to the severity of the case. The Widal reaction depends upon the ability of the blood from a typhoid patient to agglutinate a pure culture of typhoid bacilli. It is positive in about 95 per cent, of all cases of typhoid, so it is practically a sure sign of the disease. The diazo reaction is a test made with the urine. Sequelae.—Insanity in the form of acute mania some- times occurs. Aphasia and chorea have been reported. Phthisis, post-typhoid bone lesions and typhoid spine (a severe pain in the back aggravated by motion) follow the disease. As a rule sequela? are uncommon in children. Relapses often occur following upon the relaxation of diet. The symptoms of a relapse are those of the primary disease, excepting that the symptoms are less severe, the duration shorter, and recovery the rule. Relapses may be multiple. Recrudescence is a simple return of fever, also often induced by lapses in diet. TYPHOID FEVER 29I Prognosis.—In children under fifteen recovery almost invariably takes place. Hemorrhage and perforation occur less often than in the adult. A mistake is often made in using the term typhoid pneumonia, meaning typhoid fever complicated by pneu- monia. Typhoid pneumonia means pneumonia with typhoid symptoms, such as the brown, dry tongue, delir- ium, twitching of the tendons, and picking at the bed- clothes. These occur in fevers when patients are ex- hausted, and are not seen in typhoid fever alone. In typhoid pneumonia, typhoid fever does not exist. If the two are present at the same time use the title typhoid and pneumonia. Vaccination Against Typhoid.—This prophylactic measure has proved efficient in almost every case where proper inoculation has been made. It is important that the nurse in training and in active practice should be vaccinated. The method consists in giving hypodermically a cul- ture of typhoid bacilli which has been rendered prac- tically non-virulent through long cultivation of a single strain, and then killed by heat. The first inoculation consists of 500,000,000 dead bac- teria in salt solution. The second and third doses, each given at intervals of ten days, contain 1,000,000,000 dead bacilli. The best time to give the injection is in the afternoon, so that its effects will wear off during the night. The immediate effect of the inoculation is a smarting pain last- ing for only a minute or two. Nothing further is noted until four or five hours later, when headache and malaise may develop, and at the site of the inoculation a red and DISEASES OF CHILDREN FOR NURSES tender area the size of the palm of the hand. The headache and other symptoms are rarely severe enough to interfere with sleep, and by next morning all symptoms usually have disappeared. The introduction of these dead bacteria causes the blood to develop antibodies similar to those formed in true typhoid. We have the same reaction taking place that would follow the presence of living typhoid bacilli, and the same units of defence are organized. As the bacilli are dead, they do no harm, but the resistance developed by their introduction lasts over a period of several years, during which time any typhoid bacillus which should lodge in the body would be immediately destroyed. This immunity to typhoid lasts about three years, at the end of which time fresh vaccination is advisable. Treatment and Nursing.—Absolute rest and restriction of diet are essential. Many physicians use a liquid diet, others a more liberal one. It is usually governed by the amount of emaciation and tympanites. The treatment of typhoid fever by graduated baths is far better than by any other method. It not only reduces the temperature, but controls the delirium, the diarrhea, and keeps the mouth and tongue in good condition. It also lessens the severity of every symptom. The method of giving these baths is described on page 429). The effect of the bath on the temperature varies with the stage of the disease, it being frequently the case in the first week that the fall in temperature is less than one degree; in the second and third week, however, the fall will be from one to three degrees. In addition to lowering the temperature the immediate effect of the baths is to add strength to the heart and volume to the pulse (Holt). TYPHOID FEVER 293 Contra-indications.—Practically the only contra-indica- tions to this plan of treatment are: (1) When there is an almost absolute pulselessness with a blue, cyanosed appearance of the skin occurring while giving the tub, in wrhich case the child should be immediately removed, put to bed, and hot-water bags applied to the extremities and whiskey given. (2) Hemorrhage. (3) Perforation. None of the complications excepting hemorrhage from the bowel and perforation are allowed to interfere with the carrying out of this treatment. The reason they are discontinued in hemorrhage is the fear that the necessary movements in the bath would excite further bleeding; and in perforation, to avoid the danger of unnecessary contam- ination of the peritoneum with feces. Delirium is con- trolled by a soothing voice and touch in conjunction with the bromids. Constipation should be relieved by the enemas alone. Hemorrhage from the bowel should be treated by absolute rest, cold to the abdomen, the food should be reduced to a minimum, and be of the mildest character. In severe cases the foot of the bed can be raised. The physician should be immediately notified. Perforation.—Symptoms of perforation, such as spread- ing tenderness, sudden pain in the side and vomiting, demand absolute quiet and the immediate notification of the physician. Tympanitic distention may be relieved by the careful passage of the rectal tube, and the pain relieved by tur- pentine stupes. One of the dangers of protracted cases is bed-sores. These can generally be averted by careful attention to cleanliness, by thoroughly drying the patient after washing, 294 DISEASES OF CHILDREN FOR NURSES by removing all traces of urine or other discharges, and by sponging the patient daily with alcohol or whisky. Above all, the position in bed should be changed frequently and all inequalities in the bed-clothes should be kept smoothed out, while the bed should be kept clear of crumbs and other particles of food. Should a sore appear, anti- septic dressings should be applied and the part relieved from pressure by an air-cushion. Convalescence.—In no disease is watchfulness during convalescence more important. Relapses and the per- foration of an ulcer may occur during this period. The ulcers are not necessarily healed when the temperature reaches the normal. Therefore, absolute rest and a liquid diet should be kept up for at least ten days after the tem- perature has reached normal. The hair is very apt to fall out and, therefore, should be cut short. By no means is it necessary to shave the head. Prophylaxis.—When typhoid is epidemic all drinking- water should be boiled for one-half hour before using. Since the contagion of typhoid fever resides solely in the stools, vomited matter, urine, and other discharges from the body, it is important that these should be thoroughly and properly disinfected, also that the linen which has been in the least degree soiled by them should be imme- diately removed and sterilized. Stools may be disinfected in the following manner: Place in the bed-pan, before using, a small quantity of car- bolic acid solution, i : 20, or chlorinated lime of the same strength. Cover the evacuation with another quantity of the disinfectant, mix thoroughly, stand aside for one-half hour, then empty the whole into the water-closet hopper. Then thoroughly rinse out the vessel with disinfectant TYPHOID FEVER 295 solution and hot water. Linen may be immersed in carbolic acid, 1 : 20, until boiled. Boiling for half an hour disinfects it. After the bowels have been moved the buttocks and anus of the patient should be thoroughly washed with 1 : 40 carbolic acid or bichlorid, 1 to 2000, followed by hot water and soap. Door-knobs or parts of the door touched with the soiled hands should be washed with the same disinfectants, since drying of the fecal matter causes it to disseminate and gives rise to a source of infection. The nurse should wash her own hands with soap and w^ater and then rinse them in a solution of bichlorid. It is by soiled hands or floating bacteria from dried feces that nurses are infected. Where tub-bathing is employed, it is possible that the water of the bath that has been used several times may be a source of infection. The nurse should, therefore, wash her hands after tubbing a patient, and watchful care should be exercised not to carry them to the mouth during the bath. After death or discharge of the patient the mattress, which should be well protected during use by a rubber sheet, should be thoroughly aired. The rubber sheet itself should be washed in carbolic acid, rinsed in cold water, and dried in the open air. CHAPTER XIV TUBERCULOSIS Tuberculosis is an infectious, communicable disease due to the bacillus tuberculosis of Koch. It is a disease that may occur at any time of life, most frequently in childhood and between the ages of twenty and thirty. It may be local or general and may involve any organ and almost any structure of the body. The predisposing causes to tuberculosis are divided into general and local. General predisposition to the disease may be inherited directly from the parents, who have themselves suffered from tuberculosis, or from those who, in consequence of syphilis, alcoholism, or any other constitutional vice, have transmitted a feeble constitution to their children. Actual congenital tuberculosis is rare; that is, a child is rarely born with tuberculosis, although cases are sometimes seen. The surroundings in which a child is reared plays an important part in the general predisposition to tuberculosis, cramped quarters and exposure being the chief causes. In childhood marasmus, intestinal diseases, in fact any debilitating general or local disease, may predispose to tuberculosis. A local predisposition is created by any diseased condi- tion of the mucous membranes or organs most exposed to the infection. The most important are repeated attacks of bronchitis, bronchopneumonia or pleurisy, and chronic 296 TUBERCULOSIS 297 catarrhal inflammations of the nose and pharynx so frequently associated with enlarged tonsils or adenoid growths of the pharynx. The role played by other diseases in the development of tuberculosis is important and, until recently, little under- stood. In a very large number of cases tuberculosis develops as a sequel of one of the acute infectious dis- eases, particularly measles, pertussis (whooping-cough), or epidemic influenza. In such cases there probably has existed a previously latent tuberculosis, usually an involve- ment of the bronchial lymph-nodes. An acute disease, like pertussis, lowers the general vitality of the body and gives the tubercular process a chance to light up. As long as the constitution of the child is robust and the resisting powers of the tissues are up to par there is slight danger of contracting any form of tuberculosis. It is when the resisting powers of the tissues are faulty that the bacilli gain a foothold, and this may be in the mucous membrane of the throat, lungs, or bowel. The bacilli are taken up by the lymphatics and carried to the nearest lymph-gland, where they are arrested. The glands involved may be the cervical lymph-glands or the bronchial lymph-glands which are back of the bifurcation of the bronchi and receive the lymphatics from the lungs; or the mesenteric lymph-glands which are retroperitoneal (behind the abdominal viscera) may be involved. When the bacillus enters one of these glands it starts an inflammation which, if allowed to run its course, will be the typical inflammatidn produced by the tubercle bacillus; namely—congestion, swelling, cell proliferation, and caseation. Or if the vitality of the body is regained this process may be arrested at any point and the product of the inflammation will 298 DISEASES OF CHILDREN FOR NURSES become encapsulated by a wall of fibrous tissue (the way a tubercular lesion is cured), in which condition they may lie latent in the body for an indefinite number of years and possibly for a life-time. Tubercular cervical adenitis is frequently seen in the hospital wards; tubercular lymph- glands, both bronchial and mesenteric, are met with as often in the autopsy-room. If for any reason the vitality of the part is not strong enough to resist the tubercular inflammation, or if some intercurrent disease lowers the vitality sufficiently to permit a lighting-up of the old tubercular inflammation, sooner or later these lymph-glands will caseate and rupture. In the cervical glands such a condition leads to the sinuses of the neck so frequently seen, while in the bronchial glands such a condition leads to a tubercular infection of the lungs known as phthisis. In the mesenteric glands the rupture leads to abscess formation, peritonitis, or tubercular enteritis. Any structure of the body may be involved by the tu- bercle bacillus. When the spine is affected there is Pott's disease, when the bones and joints are affected there is tubercular osteomyelitis, coxalgia, and other surgical con- ditions. The liver, spleen, pleura, kidneys, and all other organs may be involved, usually secondarily. The bacillus does not always take the above course. It may enter the lungs directly by inhalation and set up a tubercular lesion, or it may be swallowed in the milk and meat from tubercular cattle. In young children under two years of age the lung is the part of the body usually affected; beginning with the second year tubercular meningitis is more frequently found; and after the third year tuberculosis of the bones, TUBERCULOSIS 299 of the cervical and mesenteric lymph-glands, and of the peritoneum and intestines become more frequent and are seen throughout childhood. That the disease is communicable is proved by large numbers of individual cases in which a person closely associated with the tubercular patient has contracted the disease and died. It is sometimes hard to trace the origin of a given case of tuberculosis on account of its tendency to lie latent for so long a period. In addition to the above predisposing causes residence in a low, damp, and badly drained locality, and physique contribute to the tendency toward developing tuberculosis. The physique of the child is important. Children who suffer with tuberculosis of the lungs usually have a flat chest with prominent shoulder-blades and a narrow angle of the ribs at the lower border of the anterior portion of the chest. This is called the .phthisic chest. It seems to predispose to tuberculosis of the lungs on account of the poor expansion of the lungs which results from such a formation. Many children have phthisic chests who are not suffering from the disease. Phthisis is the name ap- plied to tuberculosis of the lungs. The varieties of tuberculosis seen in children are tuberculous bronchopneumonia, miliary tuberculosis, tuberculosis of the bronchial lymph-glands, tubercular meningitis, and tubercular bone and joint diseases. TUBERCULOUS BRONCHOPNEUMONIA Pathology.—If the tubercle bacillus does not gain access to the lungs from the rupture of the bronchial lymph-node the bacillus entering the respiratory tract through the inspired air lodges in the terminal bronchioles 300 DISEASES OF CHILDREN FOR NURSES and excites a proliferation or overgrowth of the fixed cells. The new cells are termed epithelioid and frequently contain bacilli. Giant-cells are often formed by a fusion or overgrowth of these cells. This aggregation of new cells acts as an irritant and is soon surrounded by a wall of leukocytes, the whole forming a gray, translucent mass, the so-called gray tubercle. In a short time the bacillus excites a necrosis or softening which starts in the center, spreads to the periphery and converts the tubercle into a yellow, cheesy mass called the yellow tubercle. The degen- erated tubercles fuse and form the uniform cheesy masses commonly observed at the autopsies. At this stage one or two things may occur. Either the mass may soften, break into a bronchial tube, and leave behind a cavity with ulcerating walls, or it may become encapsulated by an overgrowth of connective tissue and later calcify. In addition to the tubercular process other changes are noted. The lung tissue in the neighborhood of the tuber- culous deposits is the seat of a true bronchopneumonic inflammation, the connective tissue is always more or less proliferated, the bronchial tubes are inflamed, and the pleura over the affected area is always adherent. In infants the disease resembles marasmus, and it is very hard to distinguish the two conditions. In older children the disease follows one of three courses: namely, a rapid, acute course, a subacute course, and a chronic course. Symptoms.—In the acute form the disease resembles bronchopneumonia. The characteristic symptoms of phthisis are absent. The temperature remains high, without intermission, and there is a gradual loss of flesh and strength. Death results in every case. TUBERCUL OS IS 301 In the subacute variety the principal symptoms are fever and wasting. The temperature is irregular. Cough and dyspnea are present, expectoration is absent before four years of age. Hemoptysis is rare, respirations are accelerated, the spleen is often enlarged, anemia is marked, dropsy is rare, and then only late in the disease. Sweating is also seen late in the disease. The chronic cases resemble protracted bronchopneu- monia. Often periods of freedom from the disease are observed. At the first fresh cold the symptoms reappear. This condition of affairs may continue over an indefinite period. It may terminate by becoming acute or subacute in form, when the symptoms observed in those conditions will be found. It may cause general miliary tuberculosis or tubercular meningitis. The presence of the tubercle bacillus in the sputum makes the existence of the disease positive. ACUTE MILIARY TUBERCULOSIS OR ACUTE GENERAL TUBERCULOSIS This is an acute infectious disease excited by the tubercle bacilli and characterized anatomically by the simultaneous formation of miliary tubercles in many parts of the body. The disease usually develops in early life and is secondary to some primary lesion, as a tubercular gland. The bacilli are probably disseminated by the veins. All the organs may be uniformly infiltrated with the tubercles, but more commonly certain organs, like the lungs and brain, are more affected than the others. Symptoms.—There is debility, loss of flesh and strength, the temperature ranges between 102 ° F. and 103 ° F., and is characterized by an evening rise. There is cough, 302 DISEASES OF CHILDREN FOR NURSES rapid respirations, and symptoms of the typhoid state are present. Tubercle bacilli are rarely found. If the lungs are chiefly affected, dyspnea, cough, and expec- toration will be marked. When the intestines and the peritoneum are mainly involved, pain, distention, abdom- inal tenderness and diarrhea will be the most prominent symptoms. TUBERCULOSIS OF THE BRONCHIAL LYMPH-GLANDS This condition is frequent in childhood. The general symptoms of tuberculosis are present; namely, fever and wasting. The other symptoms are lacking. The usual result of such an inflammation is a rupture of the gland with subsequent involvement of the lungs. Eustace Smith's sign is supposed to be diagnostic of enlarged bronchial glands. It is demonstrated as follows: A stethoscope is placed over the large blood-vessels of the chest (at the base of the heart), with the child's head forward on the chest; then bend the child's head as far back as possible, and, if a murmur is then heard which was previously absent, enlarged bronchial glands exist. The murmur is caused by the pressure of the enlarged glands upon the vessels, the position of the head bringing them into apposition with these vessels. Bronchial glands that are not enlarged will not produce this sign. TUBERCULAR MENINGITIS Tubercular meningitis is fully described under diseases of the nervous system (see page 208). TUBERCULAR DISEASE OF THE BONES AND JOINTS Pott's disease is tuberculosis of the spine. It may be located in the cervical, dorsal, or lumbar regions of the TUBERCULOSIS 303 spinal column. It causes a necrosis or caries of the ver- tebrae. Symptoms.—The disease comes on insidiously. The earliest symptoms are due to irritation of the spinal nerve roots. Pain is the most prominent of these and is referred to various parts of the body supplied by the distribution of the nerves affected. Fig. 86.—Pott's disease of the upper dorsal vertebrae. Sharp-angled kyphosis. (Clinic of von Ranke-Herzog, Munich.) In a short time there is a rigidity of the spine and the child assumes various postures to prevent the diseased surfaces of the vertebrae from rubbing together. If he stoops to pick anything from the floor he does so without bending his back. Jumping from elevations hurts him and pulling the head away from the body relieves him. 304 DISEASES OF CHILDREN FOR NURSES Soon an angular deformity called kyphosis appears at the seat of the disease in the spine. This progressively becomes worse, making a permanent deformity commonly called hunch-back. The tubercular process causes softening of the vertebrae and abscess formation. These abscesses vary in their location according to the seat of the lesion. In cervical Pott's disease they may be retropharyngeal; in dorsal and lumbar Pott's disease they may point in the small of the back or burrow through the sheath of the psoas muscle and point in the thigh at the lower attachment of the muscle. This is called a psoas abscess. In addition to these symptoms there is fever, wasting, pain, insomnia, and paralysis. Prognosis.—If the children are made to rest, given proper care and attention, and their backs immobilized, a cure will result in a large number of cases. Plaster jackets and other mechanisms are applied to keep the back rigid. Abscesses have to be opened and drained. Coxalgia or coxitis is a tubercular inflammation of the hip-joint. It causes necrosis of the bones of the joint. Symptoms. First Stage.—The disease begins insid- iously. The first symptom noted is slight lameness or the fact that the child wears out one shoe quicker than its mate. In a short time pain develops, due to muscular spasms. The pain is referred to the knee, often causing this joint to be suspected when the hip is really at fault. These symptoms may last a few weeks or even longer. Second Stage.—During this period the leg is in a char- acteristic position. The foot is everted, the thigh is TUBERCULOSIS 305 slightly flexed and rotated outward, and the leg is appar- ently lengthened, due to the tilting of the pelvis. The joint is locked from constant muscular spasm and abscesses form about the hip-joint. The duration of this stage is indefinite. Third Stage.—In this stage the joint has been destroyed. The thigh is flexed on the abdomen, it is rotated inward, the foot is inverted, there is shortening of the leg, and a Fig. 87.—Hip-joint disease showing tilting of the pelvis in abduction, and apparent lengthening (left leg) (Moore). curvature of the spine. Ankylosis or a permanent union of the bones may result, which prevents any movement of the head of the femur. Treatment.—Coxalgia demands absolute rest in bed with an extension apparatus (see Fig. 114, page 461) applied to the affected leg. This draws the bone down- ward so that the head of the femur does not come in contact with the acetabulum or socket of the hip-joint; 20 306 DISEASES OF CHILDREN FOR NURSES it also immobilizes the joint. Abscesses are opened and drained. Tubercular arthritis is a tubercular inflammation of a joint. Almost any joint in the body may be involved. The knee, ankle, and elbow are probably the most often affected. Symptoms.—This consists of a spindle-shaped swelling of the joint without any signs of inflammation. It has a Fig. 88.—Tubercular dactylitis of the right thumb and left middle finger of a three-year- old child (Hecker, Trumpp, and Abt). doughy feeling and a whitish appearance. It has been called white swelling. Later it may break down, the joint be destroyed, and ankylosis result. Treatment.—This consists of immobilization of the joint by plaster casts. At times curetment is necessary. Tubercular Osteomyelitis.—This is an inflammation of the shaft of the bone characterized by swelling and necrosis of the bone. The dead portion of the bone has to be removed. TUBERCULOSIS 307 Epiphysitis is an inflammation of the ends of the bones. Tubercular dactylitis is an inflammation of the bones of the hands and feet. TUBERCULAR ADENITIS This is seen chiefly in the cervical lymph-glands, and is characterized by swelling, softening and breaking down of the glands, sinuses resulting. TREATMENT OF TUBERCULOSIS Prophylaxis.—Sputum of consumptive children should be received in suitable vessels which contain antiseptic solutions, and subsequently destroyed. Phthisic mothers should not nurse their offspring. The healthy should not sleep in the apartments of those affected. The treatment of tubercular children aims to strengthen their vitality and resisting powers and to destroy or disable the tubercular bacillus. This is brought about by good food, fresh air, frequent bathing, sunlight, avoidance of exposure, graduated exercise, a dry, well- ventilated house and plenty of sleep and recreation. In bone and joint diseases absolute immobility of the part affected is essential. Hemorrhage from the lung in childhood is infrequent. If it should occur, the child should be kept absolutely quiet and an ice-bag applied to the chest. The physician should be immediately notified. Immobilizing the lung by induction of pneumothorax is a plan of treatment which gives good results in many cases of pulmonary tuberculosis. Sterile nitrogen is introduced into the pleural cavity through a thin hollow needle. A special apparatus is 308 DISEASES OF CHLLDREN FOR NURSES used, and at intervals of a day or two measured quantities are injected until the lung is completely collapsed. The pleural cavity requires refilling every month or two. Nursing.—The room should be sunny, cheerful, and well ventilated. In tuberculosis of the lungs the child Fig. 89.—Proper clothing for outdoor schools and for open-air treatment. The child is holding a paper napkin in front of face while coughing. should live in the fresh air. If it is too cold or stormy to stay out of doors, the windows in the nursery should fre- quently be raised to keep the atmosphere thoroughly TUBERCULOSIS 309 fresh. At night the windows should be wide open, the child thoroughly covered, and not exposed to the draught. It is important that patients be convinced of the great benefits to be derived from outdoor treatment. Even 3IO DISEASES OF CHILDREN FOR NURSES dispensary patients living in the slums may sleep on housetops, laundry-flats, or in tents in yards. To meet the out-of-door sleeping problems the Klon- dike bed has been devised. Klondike Bed.—This bed is made in the regular way, with a sheet of asbestos over the wire spring mattress. Heavy brown paper may be substituted for the asbestos. The foundation of the bag is first, a double blanket folded in half, crosswise, and then a single wash blanket to serve as a sheet. Over this foundation a single wash blanket is used and over this a double red blanket. At the foot of the bag may be placed hot-water bottles or hot bricks. Over this mattress army blankets or horse blankets may be used, well tucked. Next, have a piece of canvas, a canvas envelope, or a rubber sheet with the rubber side out to keep off rain and snow. Place the pillows in an inverted position to keep the shoulders warm. Sleeping-out clothing may consist of bed shoes, flannel pajamas, and a sleeping hood with cape attached, made of double thicknesses of flannel having elastic sewed at bottom to allow the arms to go through. This makes the cape fit snugly over the shoulders. After arising in the morning the patient should always dress in a warm room. Cleanliness must be insisted on in tuberculosis. Brooms or other appliances which raise dust should not be used in the sick-room. Proper conditions may be maintained by the use of damp cloths and washing up the floors. It is advisable to remove all unnecessary furni- ture and hangings as they accumulate dust. It is always well in private and hospital nursing to keep separate dishes for the use of the patient. The TUBERCUL OS IS 3 11 visiting nurse may instruct the family to mark and boil the dishes, forks, and spoons which the patient uses. Frequent bathing and friction of the skin are essen- tial. The bowels should be kept regular. Exercise should be taken only upon physician's permission. Fig. 91.—Improvised inexpensive ice-chest. It consists of a wooden box with lid covered with four or five layers of newspapers, all of which may be covered with oil-cloth. A bucket is placed in the box with sawdust under and surrounding it. The bottles of milk and the ice are placed in the bucket and all is covered with a lid. In tuberculosis of the bones and joints the part should be kept absolute immobile. The method of applying" extension will be found on page 460. Any pus from 312 DISEASES OF CHILDREN FOR NURSES tubercular lesions should be covered with carbolic acid, i to 20, and allowed to stand for half a day before dis- posal. The diet should be wholesome. Raw eggs and milk should be taken to build up the system. Plenty of sleep and exercise without exertion are beneficial. Reference to the caloric value of foodstuffs will be helpful. (See page 392). Disinfection of Excreta.—For this purpose chlorid of lime is the best disinfectant. It should be thoroughly mixed with stools, urine, and sputum and allowed to stand in order to become saturated. If through careless- ness or ignorance of a patient sputum accidentally es- capes to the floor, lye in full strength should be used, as this disinfectant destroys the mucus as well as the bacilli. Bed-pans and urinals should always be boiled. Care of Soiled Bed Linen.—Bedding soiled with feces or urine should be washed in formalin and then boiled immediately. Boiling is a safe procedure for destroying tubercle bacilli. After drying, all bedding and clothing should be placed in a room and fumigated with formalin. The proper proportions are one quart of formalin to six ounces of permanganate of potash. It should be al- lowed to stand twenty-four hours. It is well in private nursing to have bed and body clothing boiled separately before placing with the family laundry. Disposal of the Sputum.—Tissue-paper napkins are used in preference to cups or flasks. The children should be carefully instructed in their use, collecting them in small paper bags to be burned. They have the advan- tages of low cost, cleanliness, and burn readily on disposal after use. TUBERCULOSIS 313 The sputum for examination should be collected in a sterile bottle with a wide mouth. In children under four years of age the best method to obtain sputum is as fol- lows: Place cotton about the end of an applicator. Grasp the tongue and pass the applicator close to it back to the pharynx; this should excite a cough, when the sputum can be swabbed out, or the applicators may be placed by the child's bedside and when the nurse notices a severe attack of coughing the child is picked up and, if possible, the sputum is obtained in the same way. Another easy method of obtaining sputum is to place a large (^-ounce) eye-drop- per in one end of a catheter. The bulb should be com- pressed and the catheter passed to the pharynx. The bulb is then allowed to expand; the suction then draws the sputum into the catheter. CHAPTER XV CONTAGIOUS DISEASES A contagious disease is one that can be transmitted through contact with the patient. SCARLET FEVER OR SCARLATINA This is an acute contagious disease characterized by high fever, rapid pulse, a scarlet rash, and an unusual tendency to nephritis. The germ that causes scarlet fever has not been discovered. The contagion is carried by the clothes, bed-clothing, or other articles which have come in contact with a patient suffering from scarlet fever. Milk is suspected of sometimes being a means of dis- semination. The disease can be transmitted by direct inoculation and, therefore, is characterized as a contagious disease. The poison is extremely tenacious to life, infected clothes unused for years being known to lead to fresh outbreaks. The young are especially predisposed, but not equally so. One attack practically gives immunity, as second attacks are uncommon. Period of incubation is from a few hours to a week. Symptoms.—Mild Cases.—At times the symptoms of scarlet fever are so mild that the disease may escape notice. There is fever, a slight sore throat and a very faint rash, often escaping proper diagnosis; a hot bath will cause such a rash to show plainly. It may fade away very 314 CONTAGIOUS DISEASES 315 quickly and the character of the rash not be suspected until slight desquamation appears. This form is con- tagious and is especially dangerous, as it is often not isolated. Ordinary Case.—The disease begins suddenly with vomiting or it may be ushered in with convulsions. Throat Symptoms.—There is pain and difficulty in swallowing, fulness and tenderness under the jaw, and enlargement of the lymphatic glands. The tongue is at 1 z 3 * 5 t> 7 8 9 10 // /Q Ii p. T. m.e In. e fn.e. m. e m. e. tn. e. m. e. in. e m. e. tn. e m. e. ftt- e. m, e. 170 /OS 160 167 r. ^, A /SO (0(, rN ' \, A ,'\ ifa /of 1 V N' '>' V "\ ,» 130 /09 1 V \ A V .\ iSfi /03 _ \, * s ^ I/O IOZ, 1 \ ~J \r *\ loo /Ol 1, 1/ S/ A \ 90 166 V \ So 99 > k 70 98 t r* s_ 60 17 Fig. 92.—Pulse (----) and temperature (----) of a simple uncomplicated scarlet fever. The acme in this case was reached somewhat late; the defervescence is rather marked (Kerr). first heavily coated, red at the tip and edges. This white coat peels off, beginning at the edges, and in a few days it disappears and the papillae of the tongue become bright red and swollen. This appearance has given rise to the name strawberry tongue. The whole posterior portion of the mouth and pharynx are deeply injected and may show a punctiform erythema before the rash appears on the skin. In severe cases the tonsils may be the seat of follicular inflammation or they may be covered with false membrane. 3 16 DISEASES OF CHILDREN FOR NURSES Eruption.—A scarlet punctiform rash appears, at the end of the first or the beginning of the second day, on the neck and chest and spreads over the entire body. Some- times the appearance of the rash is delayed. It disappears on pressure and if the finger-nail be drawn through it a white line will remain for a second or two. It may be a uniform rash or it may appear in patches with healthy skin surrounding it. In five or six days the rash gradually disappears and a scaly desquamation or peeling follows. A bright rash shows a strong heart; sudden fading of the rash may mean heart failure. In some cases the rash is slightly papular or vesicular (scarlatina miliaris). Febrile Symptoms.—The fever rises abruptly, reaching the maximum temperature of 1040 F. to 105° F. in twenty- four or forty-eight hours, and remaining at about this height for three or four days and then falling by lysis. The duration of the febrile period is from seven to nine days. The pulse is rapid, out of all proportion to the fever, and the respirations are accelerated. The appetite is lost, the bowels are constipated, and the urine is scanty and high colored and often contains albumin. Nervous Symptoms.—Restlessness, headache, insomnia, delirium, and convulsions may occur. Convulsions occur- ring late in the disease are very significant of uremia. More Severe Cases.—Anginoid Scarlet Fever.—This form is characterized by severe throat symptoms. The tonsils are much swollen and often covered with a false membrane. The fever is high and the prostration is profound. Ulceration, and, at times, gangrene of the throat occur; the carotid artery may be involved. In this form death may result from exhaustion, aspiration pneu- MM *-'A- The eruption of scarlet fever on the third day (Hecker, Trumpp, and Abt). CONTAGIOUS DISEASES 317 monia, or hemorrhage from an ulceration of the carotid artery. Malignant Scarlet Fever.—This is a very severe form of the disease. The onset is abrupt, with a chill, vomiting or a convulsion. The fever is very high (1060 F. to 107° F.). The pulse is rapid and feeble. Delirium sets in and is followed by coma. Death may result before the appear- ance" of the rash in twenty-four or forty-eight hours. The rash, if present, may become hemorrhagic. Complications.—Nephritis.—This usually develops during convalescence and, as it may be unattended by subjective symptoms, the urine in a case of scarlet fever should be examined daily in order to detect immediately the presence of albumin. In other cases the onset of nephritis is recognized by the suppression of urine, the development of uremia, and the appearance of dropsy. Nephritis may be the immediate cause of death, but more commonly the case ends in recovery or in chronic nephritis. Among other complications may be mentioned hyper- pyrexia, endocarditis, pericarditis, pneumonia, suppura- tion of the lymphatic glands, ophthalmia, inflammation of the middle ear, chorea, and a peculiar inflammation of the joints resembling rheumatism. Prognosis.—Always guarded. The mortality varies in different epidemics from five to forty per cent. Treatment and Nursing.—A case of scarlet fever should be immediately isolated. It is kept in isolation for at least six weeks, for it takes that length of time for the peeling to be completed. Children should not mingle with others for a month following their release from quaran- tine and should not sleep with others for three months. 318 DISEASES OF CHILDREN FOR NURSES Cases of scarlet fever should be kept absolutely at rest to avoid complications and should be given a liquid diet as long as the fever lasts. The rash and the peeling which follows render it necessary to anoint the surface of the body with cold cream or carbolized vaselin two or three times a day. This relieves the itching and irritation of the skin and controls the desquamation. To avoid the danger of nephritis the children should be encouraged to drink water or lemonade freely. The nose and throat should be sprayed with antiseptic solutions. Nervous symptoms are relieved with ice-caps and cool sponges. Cardiac weakness should be combated by heart stimulants. Isolation and Disinfection in Contagious Cases.—Pro- phylaxis should be complete, as the disease is highly contagious and is prone to leave many serious complica- tions. The room selected should be at the top of the house if practicable, and it should have plenty of ventila- tion and be bright and sunshiny. All upholstered furni- ture should be removed, curtains and hangings taken down, and the carpets taken up. Where possible, two rooms and a bath should be set aside for the nurse and the patient. They must be iso- lated from the rest of the house, and no one should be allowed in the room except the physician and the nurses, unless he gives permission. The nurse should not eat her meals in the room with the patient. The room should be wiped up daily with a duster moist- ened with carbolic, bichlorid, or a 2 per cent, formalin solutions. The floor should be swept with a broom Scarlatinal angina (third day) (Hecker, Trumpp, and Abt). Follicular tonsillitis (Hecker, Trumpp, and Abt) CONTAGIOUS DISEASES 319- covered with a duster also moistened with the disinfecting solutions. After use, all dusters should be thoroughly soaked in disinfectant and then washed. The dishes and linen should be placed in separate metallic vessels containing water; these vessels should be draped in sheets wet with disinfecting solution. They should be removed daily. Unused food can be put into a similar receptacle, which should be removed three times a day. The contents should be burnt. Sheets wet with carbolic acid, 1140, should be hung over the doorways. All desquamation should be immediately burned or immersed in carbolic acid. The thorough disinfection of all articles which come in contact with the child is absolutely necessary. The nurse should be protected by a gown and cap, and before going out should take an antiseptic bath (see page 470) and change all of her clothing. The physician should be protected by a gown and cap while in the room and before leaving should wash his face and hands in an antiseptic solution. The contagium is contained in the secretions such as the urine, bowel movements, "perspiration, and discharges from the nose and ear. All of these should be disinfected by covering with carbolic acid, 1: 40. The mildest cases should receive the same treatment and care, and isolation should be for the same length of time. The stools should be received in a vessel containing a disinfectant. An equal quantity of disinfectant to the size of the excreta should be added, the whole thoroughly mixed, and allowed to stand for a half-hour before emptying into the water-closet hopper. The bed-pan should contain disinfectant when not in use. It should be thoroughly 320 DISEASES OF CHILDREN FOR NURSES rinsed in warm water before placing it beneath the child, otherwise the disinfectant might burn the buttocks. After recovery the child should be given a warm bath and shampoo with bichlorid, i: 5000, rolled in a clean sheet which has not been in the isolation rooms, and carried to another room, where he can be dressed. The rooms should then be sealed, all articles in the iso- lation rooms hung over lines, and the rooms fumigated with formaldehyd. The disinfection of the nurse is practically the same as for the patient. A discharging nose or ear may be capable of causing the disease after the desquamation has ceased. Cases of empyema following scarlatina have caused outbreaks in surgical wards. MEASLES OR RUBEOLA This is an acute contagious disease characterized by catarrh of the respiratory tract, moderate fever, and a papular eruption appearing on the fourth day, lasting two or three days, and disappearing by fine desquamation. The rash also has the tendency to form crescents. Measles is a highly contagious disease. The poison is transmitted through the clothing and other articles which have come in contact with the person suffering from the disease; it can also be contracted by direct contact. The contagium is apparently associated with the nasal and bronchial secretions, but has not been isolated. Measles is most commonly observed in children, but unprotected adults are very liable to be attacked. It is essentially an epidemic disease, but now and then sporadic cases are seen. One attack is fairly protective, but does not give absolute immunity. The eruption of measles two days after its first appearance (Hecker, Trumpp, and Abt). CONTAGIOUS DISEASES 321 The period of incubation is two weeks. Symptoms.—Prodromal.—There is chilliness, coryza, watering of the eyes, photophobia (the inability to stand light), cough, and drowsiness. The Fever.—The temperature rises rapidly to 102 ° F. or 1030 F., but on the second day there is decided remission, the temperature remaining down until the appearance of the rash on the fourth day when it again rises to or beyond the first range of temperature. It remains at this height for two or three days and then falls by crisis. FAHR. 1 z 3 4 5 6 7 8 M. . £M M. e. M. E. M. E M. E. M. E M . C. M. c. 107 106 105- 1 oh- 1 03 102 1 0 1 I 00 1 99 7 98 I 97 Ca tarrhal Stage. Exanthematous Stage. Com/. Fig. 93.—Temperature chart of rubeola of moderate severity in a child of four and one-half years (Kerr). The Catarrh.—There is redness of the conjunctiva, lacrimation, sneezing, hoarseness, cough, and expectora- tion. There may be vomiting and diarrhea. A slight adenitis of the cervical glands is common. Rash.—This appears on the fourth day on the face and rapidly spreads over the entire body. It is composed of 21 322 DISEASES OF CHILDREN FOR NURSES small, dark red, velvety papules which form groups having crescentic borders. There is an eruption on the mucous membrane of the throat one day before the rash appears on the skin. In two or three days the eruption begins to fade and a fine desquamation soon follows. Koplik's Sign.—This consists in minute bluish-white specks surrounded by a red areola, appearing on the mucous membrane lining the cheeks and lips one or two days before the rash appears. Malignant or hemorrhagic measles is a form of the disease which occurs under bad hygienic conditions and is characterized by a petechial rash, hemorrhages from the mucous membranes, and by profound prostration. Complications and Sequelae.—By far the most prevalent are capillary bronchitis or catarrhal pneumonia and otitis media. Gastro-intestinal disturbances, cancrum oris, tuberculosis, and paralysis are also seen. Prognosis.—Guardedly favorable. Complications are apt to occur and render the prognosis grave. The usual mortality is low. In epidemics and in hospitals at times it is as high as 30 or 40 per cent. The majority of the deaths are due to bronchopneumonia. Treatment and Nursing.—Measles must be isolated. The quarantine is not so rigid as in scarlet fever, for six- teen days only is the length required. A dark room must be chosen on account of the photophobia, or intolerence to light. The methods for isolation and disinfection are described on page 318. The treatment is symptomatic. Inunctions of carbolized vaselin are used to allay the irritation and help the des- Koplik's spots in measles (Hecker, Trumpp, and Abt). Appearance of the throat in measles (Hecker, Trumpp, and Abt). CONTAGIOUS DISEASES 323 quamation. Warm baths are given after the rash dis- appears to facilitate desquamation. The most important complications to guard against in measles are bronchopneumonia and otitis media. To avoid these children should remain in bed and a flannel or cotton jacket should be worn. The chest should be rubbed daily with some counterirritant, such as camphor- ated oil or amber oil. Earache should be treated by syr- inging the ear with hot water (see pages 443 and 444). It is advisable for the child to wear some form of pro- tection over the ears throughout the attack. A simple expedient is to place cotton in the external auditory meatus and cover the head and ears with a snugly fitting cap. The nose and throat must be frequently cleansed with antiseptics or normal salt solution. ROTHELN OR RUBELLA This is an acute contagious disease resembling both scarlet fever and measles, but differing from both in its short course, slight fever, and freedom from sequelae. The disease is highly contagious; the poison may be carried in the clothes or may be directly transmitted. Symptoms.—Prodromal symptoms are slight or absent. The disease begins with drowsiness, slight fever, and sore throat. The eruption appears on the first or second day and varies greatly in character. In some cases the rash is composed of small, red, slightly elevated papules resem- bling measles; in others the rash is bright red and diffuse, resembling scarlet fever. It begins on the face and spreads rapidly over the entire body, but it fades so quickly that the face may be clear before the extremities become involved. Slight desquamation frequently follows, though 324 DISEASES OF CHILDREN FOR NURSES it is often absent. Apart from the sore throat the catarrhal symptoms are slight. The superficial cervical and pos- terior auricular lymph-glands are more swollen than in measles. The duration is from three to five days. The prognosis is good. Isolation for five or six days is advisable, though not imperative. Nursing.—The disease does not require much attention. The room should be darkened, the nose and throat washed with antiseptic sprays, and the temperature, pulse, and respiration taken twice a day. DIPHTHERIA This is an acute contagious disease excited by the Klebs-Loffler bacillus and characterized by moderate fever, great prostration, glandular enlargement, and a fibrinous exudate which is usually located in the throat. Etiology.—Diphtheria is most common between the ages of three and six in children who suffer from catarrhal conditions of the nose and throat. The poison is contained in the secretions of the throat and may be transmitted through the atmosphere and through the clothing. One attack does not protect the child from a second. The Klebs-LofBer bacillus is found in the membranous exudate and the constitutional symptoms result from the poison generated by this bacillus. The membrane is not a true membrane, but a necrosis of the superficial cells of the mucous membrane caused by the Klebs-Lofiier bacillus. It is grayish-white in appearance and more or less adherent, so that when it is stripped off it leaves a raw, bleeding surface. Sometimes the necrosis extends to the deeper tissues, causing wide- spread ulceration and gangrene. The membrane is CONTAGIOUS DISEASES 325 usually found on the tonsils, pillars, and pharynx, but it may extend to the mouth, larnyx, and nose. It is then called laryngeal diphtheria or membranous croup, and nasal diphtheria, respectively. The lymphatic glands are considerably swollen; the spleen is engorged. The lungs frequently show bronchopneumonia. Types.—According to location, there may be faucial, laryngeal, nasal, and cutaneous diphtheria. According to the severity of the attack the disease may be mild, grave, and malignant. The period of incubation is from two to ten days. A condition, resembling faucial diphtheria, called Vincent's angina has already been described on page 123. Symptoms.—Catarrhal diphtheria, so-called because there is an absence of membrane, is only a catarrhal con- dition of the nose and throat; the secretions, however, contain the Klebs-Loffler bacillus. The symptoms are mild, but the risk of spreading the contagion is great. Faucial Diphtheria of Ordinary Severity.—The disease commonly begins with a chill, moderate fever, malaise, and sore throat. The fever, as a rule, is not very high, 102° F. to 1040 F., and its course is quite irregular. The pulse soon becomes rapid and feeble, the bowels are con- stipated, the urine is scanty and frequently albuminous, and the prostration is out of proportion to the severity of the febrile symptoms. Local Phenomena of Faucial Diphtheria.—The child complains of difficulty in swallowing, the muscles of the neck feel stiff, and there is tenderness under the jaw. The lymphatic glands are considerably enlarged and the tonsils are covered with grayish-white membrane which, when stripped off, leaves a raw, bleeding surface. The 326 DISEASES OF CHILDREN FOR NURSES membrane soon forms again and may extend to the larynx and into the nose. The average duration of the disease is from one to two weeks. Laryngeal Diphtheria.—This is usually secondary, by extension from the faucial diphtheria, but it may be primary. It is recognized by hoarseness, aphonia (loss of voice), croupy cough, progressive dyspnea, and stridu- lant breathing. The wings of the nose play, the sterno- mastoid muscles are prominent, and other signs of dyspnea are present. Shreds of false membrane are sometimes expectorated during violent fits of coughing. The febrile symptoms are usually slight. Death often results from suffocation, but recovery is not impossible in the most unpromising cases. Intubation is necessary at times (see page 332). Nasal Diphtheria.—This is nearly always secondary. It is recognized by an offensive discharge from the nose, epistaxis, and excoriation of the lips and wings of the nose. The false membrane may be detected within the nasal chambers upon inspection. Cutaneous Diphtheria.—This may be primary or secon- dary. The constitutional symptoms are similar to those of faucial diphtheria. The membrane may appear at any point where there is excoriation. Complications.—Capillary bronchitis, pneumonia, myocarditis, otitis media, nephritis, and paralysis. The most prevalent are bronchopneumonia, nephritis, and postdiphtheritic paralysis, the latter generally occurring during convalescence and being observed in about 15 per cent, of all cases. Post-diphtheritic Paralysis.—There is no relation be- tween the severity of the attack of diphtheria and the Diphtheria of the lips (Hecker, Trumpp, and Abt). Pharyngeal diphtheria (Hecker, Trumpp, and Abt). CONTAGIOUS DISEASES 327 liability to paralysis. Mild cases which are thought to be simple pharyngitis at times are followed by troublesome paralysis. The pharynx is usually the principal seat of the paralysis, which can be recognized by difficult swallowing and imperfect speech, and frequently the regurgitation through the nose of liquids. Next in fre- quency the eyes are involved and there is strabismus (cross-eyes), and ptosis (dropping of the, upper lids). The heart may be affected and in such cases, if death does not immediately result, there may be a remarkable slowing of the pulse. In some cases there is an extensive involve- ment of the extremities. Recovery from the paralysis usually occurs. Prognosis.—Always guarded. The mortality of diph- theria is from 10 to 50 per cent. In true faucial diphtheria the prognosis is usually good. In laryngeal and nasal it is grave. Three-fourths of the cases which end fatally die of exhaustion. Treatment.—Prophylaxis.-—In no other disease are prophylactic measures so imperative as in diphtheria. All cases of recognized diphtheria, as well as all cases of suspected diphtheria, should be immediately isolated. Other children in the family should not be allowed to attend school. The suspected cases of diphtheria should be kept in isolation until two or three negative cultures are obtained. If diphtheria is not present this means only two or three days' isolation. In true cases of diphtheria the quarantine should be kept up until a negative culture is obtained, after the throat symptoms are well. This is usually in from ten days to two weeks. At times it is necesssary for the nurse to obtain the 328 DISEASES OF CHILDREN FOR NURSES culture from a case of diphtheria. To do this she must follow the instructions as given on page 47- Special attention should be paid to all attacks of croup in children, especially to those attacks which do not come on suddenly in the night. It may be laryngeal diphtheria. Do not examine an infant's throat immediately after feeding. Antitoxin is obtained from selected horses. The method by which it is produced is as follows: The horse is given a mild case of diphtheria by injecting a few Klebs- Loffler bacilli into its system. The horse recovers from the attack. A second attack is induced by the same methods. It takes a larger number of bacilli to cause a reaction than it did at first, showing that a certain resist- ance to the poison has developed in the blood of the horse. Other injections are made, each more powerful than the preceding, and are continued until the horse fails to develop any symptoms of diphtheria, even though doses are used which would have killed him at first. This proves that the blood contains sufficient resistance to the poison or the toxin of diphtheria to destroy the bacilli as soon as they enter the system. The blood is then withdrawn, and the serum alone is used. It is standardized and called antitoxin, because it contains the principle which overcomes the toxin of diphtheria. The only annoying symptom attending its administra- tion is the appearance of hives. The reason for giving antitoxin is to throw into the human system at once a large amount of resistance to the growth and development of the Klebs-Loffler bacilli. The same resistance or antitoxin is manufactured in the human system, but it takes days for it to become of suffi- CONTAGIOUS DISEASES 329 cient strength to combat the bacilli which are developing with almost equal rapidity. The immense advantage of throwing fully developed antitoxin into the system to combat the early and unorganized attack of the bacilli is p,G 94.—Position for intubation. The child's legs are wrapped in a blanket, and grasped between knees of nurse. Her arms are passed beneath child's and her hands fix the head. evident. It is like having a standing army to quell in- cipient revolts. To obtain the best results large quantities of antitoxin should be used early in the disease; even before the diagnosis is made in suspicious cases. If no improvement 33O DISEASES OF CHILDREN FOR NURSES is noticed within twelve hours the dose is repeated. The dose of antitoxin for children is from 2000 to 4000 units. It is given hypodermically. It is influenced by the weight of the child; heavier children require larger doses. Nursing.—The room should be selected as in scarlet fever, and the methods for isolating and nursing contagious Fig. gs-—Position for intubation. The child's head is allowed to fall backward and is firmly held in position behind edge of table. cases as described on page 318 should be followed. A moist atmosphere should be maintained. All cases which have been exposed to the contagium should be immunized with about 1000 units of antitoxin; this immunity will last for about one month. The nurse in charge of the case should also receive an CONTAGIOUS DISEASES 331 immunizing dose of antitoxin. As the contagion is not contracted through the atmosphere of the room or through the air we breath, but through the discharges from the patient's nasopharynx, care should be taken in this direc- tion. The hands should be thoroughly washed and immersed in carbolic-acid solution, and all instruments which are used in connection with the patient should be Fig. 96.—Position for tracheotomy. The rolled blanket beneath shoulders and neck makes trachea prominent. immersed in the same solution. For this purpose a basin of carbolic solution, 1:40, should be kept constantly in the room. All linen and gauze which has been contaminated by the discharges of the patient should be immediately sterilized or burned. No one but the physician should be allowed in the room and he should be protected by cap and gown. The nurse should not leave the sick-room without changing her garments and washing thoroughly in carbolic or bichlorid solution. The nurse should 332 DISEASES OF CHILDREN FOR NURSES spray her nose and throat three or four times a day with some antiseptic solution, and when out should not visit any houses, particularly where there are children. After a patient is well, all articles should be thoroughly fumi- gated and the patient should receive two disinfectant baths. Irrigation of nose with normal salt solution from a foun- tain syringe is often used in cases of nasal diphtheria. In faucial diphtheria the spraying of the throat with antiseptic or normal salt solution must be thoroughly done. In cases where the children are prone to eject pieces of membrane during irrigation, it is well for the nurse to protect her eyes with glasses and tie a piece of gauze over her mouth and nose. She should thoroughly disinfect her person, the bed, or the floor if they become contaminated with discharges. The pulse should be under observation at frequent intervals throughout the attack and during convalescence. Intubation.—In laryngeal diphtheria it is necessary at times to perform intubation. The operation consists in the introduction of a tube into the larynx. It opens the larynx and allows free breathing in cases where the larynx has become almost closed from the diphtheritic membrane. Different caliber tubes are used for the various ages. During the operation it is necessary for the nurse to hold the child's head in the following manner: The child is wrapped in a blanket to secure the arms and legs. The nurse's legs being crossed, her knees should firmly grasp the child's legs, her arms should hold the child's upper extremities, and her hands fix the head. At times the child is placed on a table, the head extending over the end and firmly held by a nurse. The child should be wrapped in a blanket. CONTAGIOUS DISEASES 333 Tracheotomy.—An incision of the trachea. It is neces- sary at times to open the trachea below the larynx to save the child from suffocation. A tube is introduced through the opening and the breath is drawn into the lungs through this passage. Fig. 07.—Position for feeding in intubation. The head is allowed to drop over side of lap. Junket or semifluid food is most eisily swallowed. Nursing.—Intubation and tracheotomy demand con- stant nursing and watching. In tracheotomy if a piece of membrane or mucus plugs up the openings in the tubes suffocation results. If it becomes necessary to remove the inner tracheotomy tube, it is unlocked and drawn out; it should be cleansed in boric acid. Long feathers are passed through the opening and the mucus dislodged. 334 DISEASES OF CHILDREN FOR NURSES After the air-passages are free the inner tube is reinserted. A moist atmosphere should be maintained. After the attack is over the tube is removed, the opening closed, and the child resumes breathing through the natural passages. In intubation, after the physician has introduced the tube, he may cut the silk thread immediately or he may loop it over the ear. If he does the latter, it must be held fast by a strip of adhesive plaster. It is also wise to tie the children's arms in such a way that they cannot reach the string and pull out the tube; cuffs may answer this purpose (see page 467). When the silk thread is to be removed, always cut the knot off first. If this is not done, the wrong end may be pulled and the knot will then catch in the hole through which the thread passes, causing the tube to be dislodged. Feeding in Intubation.—The child should be placed on its back across the nurse's lap and the head allowed to drop slightly lower than the body. This allows the food to pass into the pharynx and not into the larynx. Semi- liquids, such as gruels, junket, thickened broths, etc., are more easily swallowed by older children than liquid food. SMALLPOX OR VARIOLA This is an acute contagious disease characterized by an eruption which is at first papular, then vesicular, and finally pustular. Etiology.—The poison of smallpox is extremely tenacious to life, remaining alive in clothes for a long time, and another attack of the disease may start from this source. Unless protected by vaccination or a previous attack the whole race is susceptible, from the child in utero to the very aged. The negro race is especially prone to the disease. CONTAGLOUS DISEASES 335 Symptoms.—The disease usually begins with a chill followed by vomiting and intense lumbar pains. The fever rises rapidly, reaching 1040 to 105 ° F. in twenty-four hours. It continues at this height until about the end of the third or fourth day, when it drops several degrees. It remains at this new level until the vesicles become pustules, when a hectic fever develops which may be higher than the original temperature, and like all hectic temperatures it is marked by wide fluctuations. The temperature finally falls by lysis about the eighteenth day of the disease. All the symptoms which attend fever are present. The eruption is first noticed about the third or fourth day, appearing as small red spots on the face, forehead, and wrists. These small red spots are rapidly converted into small round papules which feel like shot under the skin. This eruption rapidly spreads over the entire body. About the third day of the eruption the papules are converted into clear vesicles, divided by small filaments into several parts, something like the divisions ot an orange. This is termed loculation. When they are pricked with a needle the entire contents is not dis- charged, but only the fluid in the divisions opened is obtained. The vesicles have a small impression at their summit which is termed umbilication, and are surrounded by a red ring of inflammation. In two or three days the fluid in the vesicles becomes turbid and they become pustules. The loculation and the umbilication disappear. Between the lesions the skin is swollen and edematous, so that the features are unrecog- nizable. In three days more the pustules rupture, soft yellow crusts form which have an offensive odor, and 336 DISEASES OF CHILDREN FOR NURSES adhere to the skin for a week or more. WThen the crusts fall off, pockmarks (small scars) remain as a permanent deformity. Confluent smallpox is a severe form of variola in which the pustules coalesce and the symptoms are severe. Malignant smallpox is associated with hemorrhages; at times there is bleeding into the pustules, constituting what is sometimes called black smallpox. Varioloid is a modified smallpox occurring in one who has been previously protected by vaccination. Prophylaxis.—Universal vaccination. Treatment.—The child should be immediately isolated. The room should be selected and the same precautions practised as described under Scarlet Fever (see page 318). The treatment is symptomatic. Nursing.—The instructions for isolating and disinfect- ing in contagious cases as described on page 318 must be followed. The temperature of the room should be maintained at 68° F. It should be darkened to prevent pitting as much as possible. The diet should be liquid, and plenty of water or lemonade given at frequent intervals. It is absolutely necessary that the nurse should have been successfully vaccinated before attending a case of smallpox. If she has been exposed to the disease while unprotected by vaccination she should be immediately inoculated. All others who have come in contact with the disease should likewise be immediately vaccinated. She should not go out without taking a full bichlo- rid bath, and then should not visit other families. The child's urine should be examined frequently and the temperature, pulse, and respiration taken every three hours. The eruption of varicella on the fourth day (Hecker, Trumpp, and Abt). CONTAGIOUS DISEASES 337 Itching may be relieved by frequent sponging and soak- ing the crusts with oil. The child's hands should be cov- ered with mittens, preferably wet with normal salt solution. The children should not be permitted to scratch themselves; cuffs may be necessary (see page 467). The eyes should be frequently syringed, and the nose and throat sprayed. To prevent marked pitting: (1) The vesicles should be broken up with a fine sterile needle. (2) The base of the vesicles, after they are broken, should be cauterized with a sharp stick of silver nitrate. (3) The papules should pe painted with iodin. (4) Light and air should be excluded by covering the exposed skin surface with sweet oil and dusting upon this a powder composed of equal parts of bismuth subnitrate and prepared chalk twice daily. This forms a mask. VARICELLA OR CHICKEN-POX An acute contagious disease of short duration character- ized by slight fever and a vesicular eruption which dis- appears in two or three days. Symptoms.—There is slight fever and before the end of the first twenty-four hours there is an eruption usually appearing on the face and chest. At first the eruption consists of widely scattered papules which soon become vesicles. The vesicles are superficial. They are neither umbilicated nor loculated and usually are not surrounded by a red inflammatory ring. At times a small red areola occurs. The eruption appears in crops lasting over two or three days and rarely pustulates or leaves scars. The vesicles dry up and form crusts which adhere for a few days. Sometimes the drying starts at the center and thus gives the appearance of umbilication. 22 S3^ DISEASES OF CHILDREN FOR NURSES Erysipelas occasionally complicates the disease. Treatment.—The disease is contagious, but it rarely requires isolation. As long as the crusts are present the disease can be transmitted. Nursing.—For the itching, mild solutions of carbolic acids can be applied. To remove the crusts nothing is better than applications of ichthyol ointment. Mittens should be placed on the child's hands to prevent them from scratching themselves. VACCINIA (COWPOX) Cowpox is a general disease with a local manifestation acquired by vaccination. VACCINATION The value of vaccination was first shown by Edward Jenner, in 1798. He noticed that the dairymen who came in contact with the disease in cattle were rarely affected by smallpox. At that time smallpox was univer- sal, the person who was not pock-marked being the exception, for terrible epidemics depopulated towns and villages. Jenner reasoned that cowpox had rendered these men immune to smallpox; therefore, arbitrary inoculation of individuals with the scabs from affected cows would produce the same immunity in others. He was fortunate in establishing his claims and soon vaccina- tion became a fixed custom. To realize the immense benefit it has been to the human race it is only necessary to compare existing conditions with those of a hundred years ago. Now the pock-marked individual is the exception and epidemics are controlled. Antivaccination societies reason ignorantly, confuse CONTAGIOUS DISEASES 339 syphilis, sometimes called pox, with vaccination, exhibiting pictures of syphilitic ulcers as the dire results of vaccination, and harp on the few instances of deaths following vaccina- tion which have been reported. A few bad results have occurred from improper technic and impure serum. This is not the fault of the method, it is due to the carelessness of the physician who vaccinates or of the manufacturers Fig. 98.—Normal vaccination pustule on the sixth day after vaccination (Friihwald and Westcott). in making the serum. The risk at present is practically nil with modern methods of asepsis. In Prussia, where compulsory vaccination has existed since 1874, the death rate per 100,000 of population has dropped from 24.45 per cent., the average previous to 1874, to 1.51 per cent. A child, if healthy, should be vaccinated during the first two months of life, as the symptoms are very slight 34O DISEASES OF CHILDREN FOR NURSES at that time. If delicate, wait until the child is in good condition and gaining in weight. A successful vaccination gives immunity for five years. Should the vaccination be unsuccessful, it should be repeated until a result is obtained. Method.—The skin surface is washed clean and rubbed with alcohol. Do not use antiseptic solutions, as they kill the germ before it enters the system and a nega- tive result follows. The upper layers of the skin are scraped off with a sharp bistoury until an exudation of serum takes place. Bleeding is to be avoided if possible. The serum is then introduced into the wound from the sterile tubes and thoroughly rubbed in by some flat instrument. The wound should be allowed to dry thoroughly before applying an aseptic dressing. This dressing should be renewed as long as there is an open wound and during the course of the local inflammation. It is as necessary to keep dirt and clothing out of this wound as any other. Severe ulcerations result from infection. The course of the local manifestation is similar to that taken by the eruption of smallpox. First a papule, then a vesicle, umbilicated and loculated, followed by a pustule and a scab. It requires about the same time for develop- ment as the typical rash of variola. Three days is about the average for each stage. ERYSIPELAS An acute contagious disease excited by the streptococci and characterized by a peculiar inflammation of the skin and subcutaneous tissues. The germs can be carried in the clothes. Certain children are more predisposed than others. Those suffering from wounds or from diseases which lower the vitality are especially susceptible. CONTAGLOUS DISEASES 341 The poison usually gains access through some wound or abrasion. In the newborn erysipelas starting at the navel is sometimes seen. Symptoms.—The disease is ushered in with a chill and there is fever, 1040 F., with all its symptoms. The inflammation usually begins in the neighborhood of the nose and spreads upward and laterally over the head to the neck, where it frequently stops. The affected part has a crimson hue, is swollen and tense, and is limited by a very sharp line or a well-defined ridge, beyond which, however, projections can be felt creeping out into the adjacent subcutaneous tissue. The surface of the inflamed area is first smooth and glazed, but later it is covered with minute vesicles and blebs. The child complains of burning and tingling and the surrounding skin may be so edematous that the features are almost unrecognizable. In four or five days the redness begins to fade and the swelling disappears; desquamation follows and the fever falls by crisis. The average duration is from a week to ten days. Relapses are extremely common. Nursing.—The dressings should be kept fresh, changing them at least twice a day. The patient should be kept quiet and the urine should be examined. The clothing and articles which come in contact with the patient must be disinfected. Never put a case of erysipelas in a surgical ward. PERTUSSIS OR WHOOPING-COUGH A contagious disease characterized by catarrh of the respiratory tract and peculiar paroxysms of cough, ending in a prolonged, whooping inspiration. The disease is 342 DISEASES OF CHILDREN FOR NURSES highly contagious, proximity to the child with whooping- cough being sufficient to contract the disease. One attack protects from others. Symptoms.—There are three stages, the catarrhal stage, the paroxysmal stage, and the stage of decline. Half of the cases appear in the first two years of life. Catarrhal Stage.—The disease begins with the symptoms of coryza and bronchial catarrh. It is similar to other cases of bronchitis, but does not respond to the ordinary remedies for catarrh. After two or three weeks it passes into the paroxysmal stage. In the paroxysmal stage the cough becomes more violent and is paroxysmal. During a paroxysm the face becomes cyanosed, the eyes are injected, and the veins distended. The cough frequently induces vomiting and in severe cases hemorrhages. The close of the paroxysm is marked by a long-drawn whooping inspiration due to the spasmodic closure of the glottis. The number of paroxysms varies; there may be from ten to twelve or, in severe forms, from forty to fifty in twenty-four hours. Ulcers frequently form on the frenum (the small attachment of the tongue to the floor of the mouth) from forcible propulsion of the tongue against the lower teeth during a paroxysm. This stage lasts about three or four weeks. Stage of Decline.—The paroxysms gradually grow less frequent and less violent and finally cease. Complications.—Pertussis is very prone to be followed by some complication. Bronchopneumonia probably ranks as the most frequent and fatal complication, causing two thirds of the deaths. Convulsions occur in some cases. Prognosis.—During the first year the mortality is CONTAGLOUS DISEASES 343 about twenty-five per cent. From this time on it rapidly decreases. Treatment.—Children suffering from pertussis should be isolated so far as possible. They should be kept from school and any other children in the family sent away. Delicate children should be particularly protected against the disease. The isolated period should be continued as long as the spasmodic stage lasts. Inhalations of menthol, amyl nitrite, or a few whiffs of chloroform will frequently control a violent paroxysm. Nursing.—The child should have plenty of fresh air. During the day it is of benefit to take it out of doors. This is permissible if its temperature is not over ioo° F. At night the windows should be opened. Frequent changes of atmosphere and clothing seem to have a beneficial effect upon the spasms of cough. The seashore seems to aid in the cure of the disease. If a child vomits a meal a short time after eating it, another meal should be given. It is best to make the diet as liquid as possible. Infants should receive their milk diluted more than usual, and in severe cases it should be peptonized (see page 367). Light flannel underwear should be worn. The chest should be anointed with camphor oil daily, and inhalations of medicated steam should be employed. A practical measure which may be adopted in those cases in which vomiting occurs frequently during the paroxysm is to place a binder around the abdomen. This should be drawn tight, as it is the support which it gives to the abdominal muscles which is desired. By preventing these large muscles from being brought into full play during the paroxysm vomiting is frequently 344 DISEASES OF CHILDREN FOR NURSES avoided, as it is usually due to their violent contraction making pressure on the filled stomach. Before disposing of the sputum and vomited material it should be disinfected. PAROTITIS OR MUMPS This is an acute contagious disease characterized by inflammation of the parotid and other salivary glands. Fig. q,4).—Epidemic parotitis. Second day. The picturp shows the uniform swell- ing in the region of the left ear, which has spread to the face and the submaxillary areas; also the characteristic elevation of the auricular lobule. The filling of the fossa between the mastoid process and the ramus of the lower jaw is, unfortunately, not visible (Hecker, Trumpp, and Abt). The bacilli of the disease are probably contained in the sputa. One attack confers immunity. Symptoms.—The disease is ushered in with chilliness, moderate fever, malaise, and a swelling of one of the CONTAGIOUS DISEASES 345 parotid glands. The swelling is seen below and in front of the ear; the surrounding tissues are edematous and the submaxillary glands are soon involved. The features are swollen and distorted, the movements of the jaw are restricted and painful, and there is a decrease in the flow of saliva, making the mouth dry and uncomfortable. The other parotid is usually soon affected. The swelling lasts five or six days. Complications are not often seen. Abscess of the parotid gland and deafness have been reported. Some- times the testes in the male and, more rarely, the breasts or ovaries in the female are involved, but these complica- tions are not common in childhood. Treatment.—This consists of the applications of ichthyol ointment. The sputum should be disinfected. INFLUENZA OR LA GRIPPE An acute contagious disease characterized by fever, extreme prostration, pain in the head and back, and generally by catarrh of the respiratory or gastro-intestinal tract. Etiology.—The disease occurs in epidemics. The exciting cause is a small bacillus found in the sputum. When prevalent no age or sex is exempt. One attack does not confer immunity from others. Influenza does not kill except by its complications. The most frequent are catarrhal pneumonia, croupous pnuemonia, anemia, and otitis media. Tuberculosis of the lungs, nephritis, neuritis, and meningitis are also seen. Symptoms.—The disease begins with languor, chilli- ness, severe pain in the head and neck, and fever ranging 346 DISEASES OF CHILDREN FOR NURSES from ioi° to 1030 F. There is extreme prostration. In some cases the principal symptoms are those of the respiratory tract, in others the gastro-intestinal symptoms are most important, and in the third variety the nervous symptoms are most prominent. In simple cases the temperature falls in two or three days by crisis, but com- plications not infrequently prolong the case for two or three weeks. Respiratory Symptoms.—There may be coryza, laryn- gitis, or bronchitis. This gives rise to a nasal discharge, cough, expectoration, sneezing, and watering of the eyes. Tonsillitis and otitis media are often associated conditions. Gastro-intestinal Symptoms.—There is vomiting and diarrhea with their attending symptoms. Nervous Symptoms.—Neuralgic pains in the head, back, and limbs. In some children the nervous symptoms appear alone in conjunction with the fever. One set of symptoms only may be present, but more often two or more tracts are involved. Skin eruptions occur at times. Prognosis.—Uncomplicated cases nearly always recover in from five to seven days. Treatment and Nursing.—The disease is communi- cable. The child should be put to bed and kept there until the fever is normal. A liquid diet should be given. The temperature, pulse, and respiration should be taken three times a day. If there is catarrh, the nose and throat should be systematically sprayed. Earache should be treated by syringing the ear with water at a temperature of no° F. The sputum should be disinfected. CHAPTER XVI CONSTITUTIONAL AND NUTRITIONAL DISEASES CONSTITUTIONAL DISEASES RHEUMATISM Rheumatism, as a whole, has varied manifestations in childhood. It may be articular, muscular, and neural. Rheumatic affections of the serous membranes, of the mucous membranes, and of the skin are found. The disease is uncommon under five years of age. The two most prominent types of rheumatism are articular rheumatism and muscular rheumatism. Acute articular rheumatism or inflammatory rheu- matism is an acute general disease characterized by irregular fever, inflammation of joints, and a marked tendency to affect the heart. In children the acute course with marked inflammation of the joints is uncommon. The cause of the disease is unknown. Some writers attribute acute articular rheumatism to bacterial infection, the germ being undiscovered. Poor hygienic surroundings, damp houses, and a sudden chilling of the body are the factors concerned in the onset of the disease. Symptoms.—In children under ten years of age the disease begins slowly. There is fever (ioo° to ioi° F.) and stiffness in several joints. Marked inflammation with swelling and pain of the joints involved is uncommon. 347 DISEASES OF CHILDREN FOR NURSES The ankles, knees, wrists, elbows, and small joints of the feet are the ones most often affected. The stiffness may move from joint to joint or one alone may be involved. At times the joints are so stiff that they make the child lame; more often these pains are designated as "grow- ing pains." Sweats are uncommon. The muscles are painful and there may be rigidity in more severe cases. The duration is from a few days to several weeks. One attack seems to predispose to others and anemia may result. After ten years of age the symptoms closely resemble rheumatism in the adult. Complications.—Endocarditis is the most common complication and may occur in very mild cases. About 40 per cent, of all cases of rheumatism have this com- plication. Pleurisy, pericarditis, pneumonia, chorea, iritis, meningitis, and certain cutaneous phenomena, such as pur- pura and urticaria, are also seen. Pharyngitis, tonsillitis, laryngitis, and bronchitis are sometimes caused by rheumatism. Muscular rheumatism is an affection of the voluntary muscles characterized by pain, tenderness, and rigidity. Types.—Different names have been applied, according to the location. Torticollis or wry-neck, when it involves the sterno- mastoid muscle. Lumbago when it involves the lumbar muscles. Pleurodynia when it involves the intercostals. Cephalodynia when it involves the occipitofrontalis. Exposure to the cold and wet, combined with muscular strain, usually excites it. Symptoms.—Pain is the chief symptom, aggravated by CONSTITUTIONAL AND NUTRITIONAL DISEASES 349 the use of the muscles, and is associated with tenderness. Sometimes the muscles are rigid and contracted, such a condition being frequently seen in torticollis. Torticollis.—The head is fixed and inclined to one side, every effort to turn it being accompanied with severe pain. The recovery is spontaneous in a few days. Treatment.—Ironing the neck gives great relief. A small iron, not too hot, is the best implement to use. A piece of flannel should be laid upon the skin for protection. Lumbago.—There is a dull, aching pain across the loins which is aggravated by turning the body or attempting to rise from a sitting posture. Pleurodynia.—The pain is felt in the side and is increased by deep breathing, coughing, or twisting of the body. The respirations are restricted on the affected side and there is tenderness to the touch. The absence of fever will serve to distinguish it from pleurisy. Cephalodynia is characterized by superficial head pains which are increased by movements of the scalp and are associated with tenderness on pressure. Rheumatism frequently appears to be the cause of neuritis. Treatment.—The salicylates and the alkalies are the remedies used in rheumatism. Nursing.—The room should be kept warm and at an even temperature. On account of the danger of endo- carditis the child should be kept in bed as long as there is fever. "Growing pains" should never be allowed to explain stiffness and discomfort in children. Involve- ment of the heart may follow such trivial symptoms, rheumatism not being suspected until a heart lesion is found. 350 DLSEASES OF CHILDREN FOR NURSES The child should be placed between blankets while in bed. If applications to the joints are necessary, it must be done in a way to avoid pain. DIABETES MELLITUS This disease is characterized by the presence of sugar in the urine, polyuria, and loss of flesh and strength. The exact cause of diabetes is not known. It is uncom- mon in childhood, but when it exists the course is very rapid. Symptoms.—■ Urinary.—The urine is increased in quantity, varying from three or four pints to six or eight quarts in twenty-four hours. It is light in color and of high specific gravity, 1030 to 1040, and leaves a whitish residue. In summer it attracts flies and has an aromatic odor. The total amount of sugar excreted in twenty-four hours can be from a few ounces to half a pound or more. General.—The most prominent symptoms in childhood are loss of flesh and strength. The temperature is normal or subnormal and the thirst is unquenchable. The tongue and mouth are dry, the bowels are constipated, the skin is dry and harsh, and frequently the seat of intense itching. This is especially observed at the genitalia and may be the first symptom of the disease. There are also attending nervous symptoms, such as headache, disturbed sleep, enuresis, and abscess formations. The course of diabetes mellitus in childhood is very rapid, much more so than in the adult, from two to four months being the average duration. The disease ends in a condition, analogous to uremia, called acetonemia, which is characterized by epigastric pain, dyspnea, a CONSTLTUTIONAL AND NUTRITIONAL DISEASES 351 fruity odor to the breath, headache, delirium, stupor, and coma. Nursing.—The room should be light and cheerful. Bathing should be frequent. Thirst should be.satisfied. A specimen of urine should be saved daily unless otherwise ordered, and the amount voided in twenty-four hours measured. Symptoms of acetonemia must be reported immediately. The temperature, pulse, and respirations should be taken once a day. Diet.—In diabetes the diet is of the utmost importance, all sugars and starches must be eliminated as far as possible. Food-stuffs permissible in diabetes are: cream, curds, milk, eggs, buttermilk, fish, oysters, clams, all meats except liver, all green vegetables, unsweetened jellies, almonds, walnuts, butternuts, and pecans, tea and coffee with cream, but without sugar, and plenty of water. The bread should be made of gluten flour. The food-stuffs that must be avoided are: all sugar, potatoes, white and sweet, rice, beets, carrots, turnips, peas, and beans. Pastry, unless made with gluten flour, and liver. It is not necessary that the children should remain in bed, unless so ordered by the physician. NUTRITIONAL DISEASES SCURVY, SCORBUTUS, OR BARLOW'S DISEASE This is characterized by bleeding, spongy gums, swelling and extravasations of blood around the joints, especially the knees and the ankles. There may be pseudoparalysis, immobility of the legs, extreme tenderness of the skin 352 DISEASES OF CHILDREN FOR NURSES surface with swelling of the body and extremities, a thickening of the bones, marked anemia, and weakness. Cause.—Prolonged use of condensed milk, sterilized milk, and proprietary foods. The symptoms may come on slowly and last over several months. If the character of the disease is not recognized it may prove fatal. Treatment.—The disease yields readily to treatment. This consists in giving orange juice to the babies; in older children lemon juice is used. RACHITIS OR RICKETS This is a nutritional disease of early childhood, charac- terized chiefly by defective formation of the bony struc- tures. It usually develops during the first or second year; it is not congenital. Poverty, artificial food, and bad hygienic surroundings are the predisposing causes. Breast-fed children rarely have rickets. The bones are soft, being extremely deficient in lime salts, and when ossification finally results the bones become heavy, large, and irregular in outlines. This causes such deformities as bow-legs, knock-knees, spinal curvature, pigeon-breast, and square cranium. The liver and spleen are often enlarged. The negro race is especially prone to the disease. Symptoms.—The early symptoms are restlessness and slight fever at night, free perspiration about the head, diffuse soreness and tenderness of the body, prominence of the abdomen, pallor, slight diarrhea, delayed dentition, and the eruption of badly formed teeth. Skeletal Phenomena.—The head is large and more or less square in outline; careful palpation may detect soft CONSTITUTIONAL AND NUTRITIONAL DISEASES 353 Fig. ioo.—Rachitic boy of three years. A large and somewhat angular head. The typic posture of a rachitic child, with the arms supported at his side. Curvature of the clavicles and the spine causes the neck to appear short. Contraction of the lateral di- ameter of the thorax; abdomen protrudes; curvature of the bones of the forearm (Hecker, Trumpp, and Abt). areas in the skull. The fontanel closes late. The sides of the chest are flattened, the sternum is prominent; nodules can be felt at the sternal end of the ribs called "rachitic rosary." There may be a distinct transverse 23 354 DISEASES OF CHILDREN FOR NURSES groove at the level of the ensiform cartilage called "Harri- son's groove." The spinal column is frequently curved anteroposteriorly called kyphosis; or latterly when it is termed scoliosis. The long bones are curved and promi- nent at the extremities. This prominence leads to en- largements at the wrists and ankles. The deformities of the legs may be marked. At times it is impossible for the child to stand erect and at others the whole skeleton is so deformed as to produce rachitic dwarfs. The usual deformities are knock-knees, bow-legs, and anterior bowing of the tibia. These are corrected by operative measures. The bones are broken, set straight, and kept in place by the use of plaster casts. Prognosis.—Rickets in itself is rarely fatal. Some intercurrent disease, like pneumonia, may cause death. Treatment.—This consists in giving the affected children the best milk obtainable and all the fresh air and sunshine they can get. Salt baths, prepared by placing three to five ounces of rocksalt in a gallon of water in the baby's tub, and rubbing the child until the skin glows, is advantageous. Rachitic children should be taught to sit and to lie straight on account of the possibility of deformity. For the same reason they should not be permitted to walk until this danger has passed. MARASMUS OR INFANTILE ATROPHY When a child is unable to digest and assimilate food for any length of time a pathologic condition sets in. The symptoms arising from this are grouped under the names of malnutrition and marasmus. Marasmus is the extreme form of malnutrition, occurring so far as is known, CONSTITUTIONAL AND NUTRITIONAL DISEASES 355 without any constitutional or local disease. It is a re- sult of faulty nutrition only. The symptoms of marasmus are the same as those of malnutrition, only in a more advanced form. They are loss of weight until the child literally becomes skin and bones, pallor, anemia, and subnormal temperature. The appetite in severe cases is almost entirely lost. The stools are sometimes normal, but more often contain curds and undigested food and are large in comparison to the amount of food taken. Bed-sores frequently develop and the children die of exhaustion. Treatment.—This consists in discovering the food which is most easily assimilated and gradually increasing the strength of it until the normal percentages are properly digested. Such a diet may consist of egg-water, barley, arrowroot, and oat-meal water, malted soups, whey, buttermilk and milk mixtures, or, in a word, the entire subject of artificial feeding. Gavage may be necessary. Nursing.—Nutritional diseases are due to a lack of proper food, consequently the careful preparation and administration of the proper diet is of the utmost impor- tance. The character of the stools and vomit should be accurately reported and a careful chart of the child's weight kept. Bed-sores and pneumonia should be guarded against, and the temperature, pulse, and respira- tion taken at least twice a day. CHAPTER XVII INFANT FEEDING Nutrition is the most important branch of pediatrics. The question whether a child will be strong and robust or a weakling is often determined by its food in the first three months of its life. The corner-stone of the con- stitution is laid during that period. The largest part of the immense mortality of the first year is traced directly to disorders of nutrition. At times temporary success may mean ultimate failure. This is illustrated in the use of many of the proprietary foods. The results seem to be satisfactory at first, the infant gains in weight remarkably, and the absence of certain vital elements from the food may not be noticed for months. It is finally discovered that the child has rachitis or some allied condition and it starts life handi- capped by an undermined constitution. Another mistake often made is the prolonged use of predigested foods. The child is unable to digest naturally the simplest foods after prolonged use of such methods, this function being undeveloped. Some children with very robust con- stitutions seem to thrive on almost any food, but they are the exception. THE FOOD CONSTITUENTS AND THE PART THEY PLAY IN NUTRITION This is well described by Holt and in part his descrip- tion is given below. "In infancy and childhood, as in 356 INFANT FEEDING 357 adult life, the elements of the food are five in number: Proteids, fats, carbohydrates, mineral salts, and water. The forms in which they must be served to a child and the relative quantities in which they are demanded, are different from those required by an adult. One of the reasons for this difference is the delicate condition of the organs of digestion in infancy, and the inability to assimi- late certain forms of food. Another reason is that pro- vision must be made not only for the natural waste of the body, but for its rapid growth, as it nearly trebles in size in the first twelve months. " Proteids.—These are essential to life since they are the only kind of food that is capable of replacing the continuous nitrogenous waste of the cells of the body, upon the healthy condition of which the digestion and assimilation of other elements of food depend. The proteid is furnished by the casein and other albuminoids found in both the woman's and the cows' milk. It is also found in muscle fiber, white of eggs, gluten of wheat, etc. The proteids most easily digested by infants are those of woman's milk. The greatest difficulty in artifi- cial feeding has been to find other proteids to take their place. It is the difference in the digestibility of the proteids which causes most of the trouble in the substitu- tion of cows' milk for woman's milk. The average amount of proteid furnished in a good sample of woman's milk is 1.5 per cent. " Fats.—The uses of fats in the body are intimately associated with those of proteids. Fat possesses the important property of saving nitrogenous waste, so that when this is supplied in the food in proper proportions the entire energy of the proteid may be expended upon 358 DISEASES OF CHILDREN FOR NURSES growth and nutrition of the cells of the body, without being used up in the production of animal heat. The demands upon the proteid by rapid growth of the body during infancy make it desirable that whenever possible the fats should do the work of the proteid. "In addition to their use as a source of animal heat the fats add to the body weight by storing up fat in the body. They are needed for the growth of the nerve cells and fibers and are essential to the proper growth of bone. Fat also fills the role of a natural laxative. The produc- tion of fat required in infancy is greater than at other periods of life. Probably the most common mistake in artificial feeding is to give too little fat. This is one of the chief reasons for the failure of proprietary infant foods, all being insufficient in fat. Woman's milk of good quality contains from three to five per cent, of fat. "Carbohydrates.—Although these, like the fats, cannot replace the nitrogenous waste of the body, they are impor- tant aids to the proteids, and in this respect they are even more valuable than fats. The carbohydrates are partially changed into fat and may thus increase the body weight. They are capable of replacing the fat waste of the body, and are one of the most important sources of animal heat. The form in which carbohydrates are furnished to infants is milk sugar. "In building up the cells of the body the proteids are first in importance, the carbohydrates second, and the fats third. In production of animal heat the neces- sity to maintain life, the fats come first and the carbo- hydrates second. The proteids should never be called upon for this purpose. In a proper diet all of the ele- ments are represented. INFANT FEEDING 359 "Mineral salts are of greater importance in infancy than later in life, on account of the rapid building up of the bony system which is going on at this period. The most important for this purpose are the phosphate of lime and magnesium. These are furnished in abundance in both woman's milk and cows' milk. The salts are also necessary for cell growth, forming the mineral con- stituents of the blood and digestive fluids, and facilitating absorption, excretion, and secretion. "Water.—The food of all young mammals consists of from 80 to 90 per cent, of water. This is needed for the solution of certain parts of the food, such as the sugars and some of the proteids and for the suspension of other proteids and emulsified fats. All the food is thus dis- solved and very finely divided, so as to be more readily acted upon by the feeble digestive organs of the infant. Water is also needed in large quantities for the rapid elimination of waste in the body. When the diet of the infant is entirely fluid, additional water between feeding is unnecessary, but when solids are added and the feedings are at longer intervals, water should be given freely between feedings at all seasons, but more especially in summer." WOMAN'S MILK This is the ideal infant food. It is the secretion of the mammary gland. A few drops may be squeezed from the breasts before parturition. Generally speaking, how- ever, it is only present after delivery. During the first two days the secretion is scanty, but usually upon the third or fourth day it becomes established. It is bluish- white in color, usually alkaline, sometimes neutral, never acid in reaction. The specific gravity is 1031, and when 360 DISEASES OF CHILDREN FOR NURSES precipitated it forms light flocculi, never precipitating in large masses, like cows' milk. Colostrum.—The secretion in the first two or three days differs quite markedly from the later milk. It is Fig. roi.—Cremometer: The instrument is filled to the mark o with unskimmed milk and allowed to stand for from eighteen to twenty-four hours at the temperature of the room, when the depth of the layer of yellow cream can be read off in degrees. The num- ber of degrees corresponds to the cream percentage, which in good milk should never fall below 10 per cent, (after Chevalier). of high specific gravity and very rich in proteids and mineral salts. Composition of Woman's Milk.—Proteids are usually present in proportion of one to two per cent. The amount of proteid is larger in the first few days; after the third week it is stationary to the end of lactation, when it falls very markedly. Fat: 4 per cent, is the average. INFANT FEEDING 361 Sugar : The ordinary variations are between 6 per cent. and 7 per cent. Fig. 102.—Scheme showing the composition of human and of cows' milk: i, Proteid; 2, fat; 3, carbohydrates; 4, salts (Friihwald and Westcott). Salts : The average proportion is about 20 per cent. or about one-fourth that of cows' milk. EXAMINATION OF MILK The quantity is determined by weighing the baby be- fore and after feeding. The average amount of milk taken at one feeding by a child is an ounce for each month of its age until the eighth month. Reaction is obtained by means of litmus paper; specific gravity is obtained by means of a small hydrometer. Fats.—A cream gauge holding 10 cc. is filled to the zero mark, and allowed to stand for twenty-four hours at the temperature of the room. Then read off the per- centage of cream. The ratio of cream to fat is, woman's 5 to 3. Cows', after eight to ten hours, 4 to 1. The sugar and salts are constant. Proteids can only be approximately determined by the specific gravity and by the percentage of fats. A specific gravity higher than 1031 shows increase in proteids; 362 DISEASES OF CHILDREN FOR NURSES lower, a decrease, if percentage of fats is normal. In- creased percentage of fats will lower the specific gravity, and a decreased percentage will raise it. Microscopic examination shows the presence of bacteria, etc. COWS' MILK This is the only milk of lower animals practically available for infant feeding. It must be fresh, clean, from healthy animals, preferably of a mixed herd rather than from a single cow. It is then more apt to be uniform, as a single cow is subject to daily variations. Animals should have fresh food and transportation should be as short as possible. For all practical purposes it is necessary that one should know only the amount of fat in the milk being used, as this is the only variable factor. The Difference between Cows' Milk and Woman's Milk.—Cows' milk is more opaque, slightly acid, or neutral, but never alkaline in reaction, as is woman's milk. There is less sugar in cows' milk, and the proteids in cows' milk are not only two or three times as great in amount, but they differ in their character. This latter is best shown by the digestibility of both proteids by the infant's stomach. Cows' milk in the stomach is coagulated into large, firm clots, which dissolve slowly, while woman's milk forms loose flocculent curds which dissolve readily. Cows' milk contains bacteria; woman's milk is sterile. Cream.—A great misapprehension exists as to the composition of cream. It is often spoken of as if it were entirely different from milk. It should be regarded as milk which contains an excess of fat, for the addition of cream to a mixture does not change the proteid percentage, but only the percentage of fat. INFANT FEEDING 363 In infant feeding it is convenient to make use of cream containing a definite percentage of fat. This may be either 8, 12, or 16 per cent. Sixteen per cent, is most often employed. METHODS EMPLOYED TO KILL THE BACTERIA IN MILK Pasteurized Milk.—-The bottles, after having been thoroughly boiled, should be filled with the prescribed quantity of milk and corked with sterilized nonabsorbent cotton. Place the bottles in the cells of the pasteurizer and fill the cells with cold water. The cells are then Fig. 103.—Freeman's pasteurizer. placed in the pasteurizer, leaving out the middle set for the convenience of pouring in the boiling water. Next turn the faucet of the pasteurizer so that it will be open; then pour boiling water into the pasteurizer until it reaches the iron rods or until the water begins to run from the faucet; then turn off the faucet. Place in position the center cells and put the cover on securely. In a half hour remove the cover. Attach a hose to cold water faucet over the sink and another one to the faucet of the pasteur- izer. Place the hose from the cold-water pipe inside the 364 DISEASES OF CHILDREN FOR NURSES pasteurizer between the cells and the sides, turn on the cold water, and at the same time turn on the faucet of the pasteurizer, so that the water will run out at the bottom at the same time that it is running in at the top, thus causing a sudden cooling of the bottles, which is very important. After the bottles are thoroughly cold remove and place in the ice-chest. The pasteurizer should then be emptied by the hose attached to the faucet. Three important facts must be remembered in pas- teurizing milk. First, that the pasteurizer must stand on wood or on some other nonconductor of heat. Second, that the water poured into the pasteurizer must be boiling hot so that the temperature of the milk will be raised to 1670 F. in ten minutes. Third, that the bottles must be rapidly cooled. To pasteurize milk when no regular apparatus is at hand, the bottles should be placed in a basket, preferably one made of wire, of which variety there are many on the market. A block of wood or a saucer should be placed in the bottom of a pan of cold water, and upon this stand the basket containing the bottles. This raises the bottles from actual contact with the bottom of the pan. The water is then heated until the sterile thermometer placed in one of the bottles of milk reads 1670 F. This temperature should be maintained for one-half hour, when the bottles should be rapidly cooled under running water and placed on ice. When sterilizing a thermometer by boiling, be sure to have one which will indicate 212 ° F., otherwise it will break. Sterilized Milk.—Prepare and fill bottles the same as Tor pasteurizing. The bottles are then set on a block of INFANT FEEDING 365 wood about one inch thick which is placed in a boiler so that the bottles do not touch the bottom. The water in the boiler should be then closely covered and allowed to steam for one hour. The bottles should then be removed, cooled, and put on ice. RECEIPTS FOR THE PREPARATION OF INFANT FOODS Barley Water.—Cover two tablespoonfuls of pearl barley with boiling water, let it boil five minutes, drain, and throw water away. Cover with two quarts of boiling water and simmer gently until reduced about one quart, which takes about two hours. Then strain through four thicknesses of gauze. The prepared barley flour of the "Health Food Com- pany of New Vork" or Robinson's Barley, two drams to each twelve ounces of water, and cooking for fifteen minutes is almost identical with the ordinary barley water (Holt). Starch............... 1.63 1 Fat.................. 0.05 Proteid............... 0.09 Inorganic salts........03 Water................ 08.20 contained in barley water (Holt). Total 100.00 , Rice and Oatmeal Water.—Cover two tablespoonfuls of rice or oatmeal with boiling water. Let it boil five minutes, drain, and throw water away. Cover with two quarts of boiling water and simmer gently until reduced about one quart. Then strain through four thicknesses of gauze. If used alone, add a little salt. Rice Milk.—Wash a tablespoonful of the best rice and boil it one and a half hours in a pint of new milk. Rub it through a fine sieve. Add two tablespoonfuls of granulated sugar, heat, and serve. 366 DISEASES OF CHILDREN FOR NURSES Albumin and Milk.—Put the white of one egg into eight ounces of cold milk. Pour the whole into a fruit jar, screw on the top and shake vigorously for half a minute. It is then ready to serve. It should be light and smooth. Albumin Water.—Put the white of one egg into eight ounces of cold water. Pour the whole into a fruit jar and shake vigorously for half a minute, when it is ready to serve. Whey.—Heat one pint of milk to ioo° F. (no higher), add one teaspoonful of rennet and stir gently, stand aside to set, but not on ice. After the milk has been thoroughly coagulated, stir up the curds with a fork or spoon, and strain through a flannel cloth. One quart of milk will make about two-thirds or three-fourths of a quart of whey. In acute indigestion whey will often be retained when other foods are rejected. Whey and White of Egg.—To every 7 oz. of whey add the beaten white of one egg. Whey and Milk or Cream.—In adding milk, cream, or a milk mixture to whey, the whey"should be made as directed above and after all the curds have strained off the whey should be heated to a temperature of 1500 F. and the milk, cream, or milk mixture must have been pasteurized before adding. Whey, Milk, or Cream and White of Egg.—Add the quantity of pasteurized milk or cream at the temperature and in the manner stated above; then the mixture must be cooled or quite cold before adding the beaten whites of the eggs, the number of whites being one to every seven ounces of whey used, and not one to every seven ounces of the mixture. INFANT FEEDING 367 Wine Whey.—Heat a half pint of milk in a saucepan, and when steaming hot add, quickly, four tablespoonfuls of sherry wine. Let the mixture stand for a few minutes on the stove, then take from the fire, break up the curds, and strain through flannel or four thicknesses of gauze. It may be served with or without sugar. Fully Peptonized Milk.—One pint of milk, 4 oz. of cold water, 1 peptonizing powder (5 gr. extract of pan- creatis, 15 gr. soda bicarbonate). Dissolve the powder in 4 oz. of water and to each bottle of milk of 4 oz. (previously pasteurized) add 1 oz. of the mixture. Stand the bottle in a pan of water 1200 F. and allow it to remain there for a half hour, when it should be used at once. Peptonize each bottle to be used just before it is time for the feeding. Milk, fully peptonized, should only be given by gavage or by the rectum on account of its bitter taste. All milk ordered peptonized and given by gavage or rectum must be fully peptonized. Partially Peptonized Milk.—One pint of milk, 4 oz. of cold water, 1 peptonizing powder (5 gr. extract of pancreas, 15 gr. soda bicarbonate). Dissolve the powder in 4 oz. of water and to each bottle of milk of 4 oz. (previously pasteurized) add 1 oz. of the mixture. Stand the bottle in a pan of water, 1200 F., and allow it to stand for ten minutes, when it is ready to be used at once. Feedings of more or less than 4 oz. must be worked on the basis of 1 oz. of peptonizing solution to 4 oz. of milk. Peptonized milk is valuable when there is feeble proteid digestion. It is not advisable to continue its use indefin- itely, as the stomach gradually becomes less and less able 368 DISEASES OF CHILDREN FOR NURSES to do its work. At the most it should be used only for a month or two at one time; when stoppage of this method is desirable, gradually diminish the amount of powder used. Method of Peptonizing Mixtures.—First, make up mixture according to the formula. Then add the pep- tonizing fluid (made according to the formula) and allow the whole quantity of milk to stand in a bottle or pitcher in a pan of water, 1200 F., for the prescribed length of time, say ten minutes or a half hour, according to the order. Then quickly raise the water around the milk to the boiling-point and allow it to boil for three or four minutes. Remove the milk, cool, and bottle, and place on ice. The boiling of the water around the milk will stop the peptonization which, if not stopped, will cause the milk to become very bitter; it also sterilizes the milk and does away with the necessity of pasteurizing. Oatmeal Gruel.—Mix two rounding tablespoonfuls of Bethlehem oatmeal with a little cold water; add a quarter teaspoonful of salt. Pour over it one pint of boiling water and stir over the fire until it boils. Then stand it where it will bubble slowly for a half hour, add a lump of sugar and a tablespoonful of whipped cream or a tablespoonful of sherry wine, and serve. Children seldom care for foods prepared with wine. Apple Gruel.—Good in irritation of the bowels. Core and quarter a large apple. Pour over it one pint of boiling water and simmer until it is reduced to a pulp. Strain. Mix two level tablespoonfuls of arrow-root with a little cold water and add to the hot apple water. Stir until it boils; then move back and let it cook slowly for ten minutes. Do not serve too hot and preferably without sugar. INFANT FEEDING 369 Farina Gruel.—Put a pint of milk into a double boiler. When it comes to the boiling-point sprinkle into it two level tablespoonfuls of Hecker's farina. Stir until it thickens and then let it cook for twenty minutes. Add a quarter of a teaspoonful of salt and a lump of sugar, and serve. Flour Gruel or Pap.—Put a pint of milk into a double boiler and let it come to the boiling-point. Moisten two level tablespoonfuls of flour with a little cold water and stir into the boiling milk. Add one-fourth of a teaspoonful of salt and let it cook for twenty minutes. Add a lump of sugar and a little nutmeg if desired. German Gruel made with Flour Ball.—Put one pint of flour into a strong bag and tie tightly with twine. Put into a kettle of boiling water and boil for five hours. When done take off the cloth and peel off the outside moist portion. Grate the ball and then put the flour into a baking pan and dry in a moderate oven for two hours, being careful not to brown. Moisten two tablespoonfuls of this flour with a little cold water and pour over it one pint of boiling water and simmer for three minutes. Add a small pinch of salt and a lump of sugar and 4 oz. of warm milk, and serve. Barley Gruel Liquefied or Dextrinized with Cereo or Maltine.—One heaping tablespoonful of barley flour, one pint of boiling water. Mix the flour in a small part of water and add to the rest. Boil fifteen minutes, then add enough cool water to make up the original pint. Cool to ioo° F. or 105° F. and liquefy with one teaspoon- ful of cereo or maltine. This predigests the gruel. Barley Gruel.—Moisten one tablespoonful of Robin- son's Patent Barley with 4 oz. of cold water; pour over 24 370 DISEASES OF CHILDREN FOR NURSES it 4 oz. of boiling water and add a half teaspoonful of salt. Let it simmer for five minutes; then add 4 oz. of hot milk. Let it come to a boil. Stir in a teaspoonful of sugar and serve. Arrow-root Gruel.—Moisten an even tablespoonful and a half of arrow-root in a little cold water. Pour over it a pint of boiling milk, stir over the fire until it thickens and let it boil slowly for ten minutes. Take from the fire and add a teaspoonful of sugar and one-fourth tea- spoonful of salt. When this gruel is made for a child who is on a weak milk mixture, like 3.6.1. or weaker, the gruel should be made with two-thirds water and a third milk instead of a pint of full strength milk. Arrow-root Gruel with Egg.—Separate an egg, beat the white and yoke until light; then mix them carefully. Add slowly one pint of plain freshly made arrow-root gruel, and serve. Rice Flour Gruel.—Mix a tablespoonful of rice flour with a little cold milk and add it to a pint of scalding milk. Cook for fifteen minutes. Add one-fourth teaspoonful of salt, a teaspoonful of sugar, one-fourth teaspoonful of ground cinnamon, and a teaspoonful of brandy. This is especially beneficial as a food in cases of diarrhea. Barley Jelly.—Put two tablespoonfuls of washed pearl barley into one and a half pints of water and slowly boil down to one pint. Strain and let the liquid settle into a jelly. Barley Jelly made with Robinson's Barley Flour.— Dissolve slowly two rounding tablespoonfuls of Robinson's barley flour with two ounces of cold water. Add one pint of boiling water and simmer gently for fifteen minutes, INFANT FEEDING 371 stirring all the time. Strain and let the liquid settle into a jelly. Beef Juice.—A piece of lean steak is slightly broiled on each side and the juice pressed out by a meat press or a lemon squeezer. Two or three ounces can ordinarily be obtained from one pound of beef. This is seasoned with salt and given cold or warm, but not heated suffi- ciently to coagulate the albumin in solution. If heated above 1600 F. it will be unfit for use. Beef Juice and Milk.—When beef juice is added to milk the milk should never be heated above ioo° F. before the addition of the beef juice. Barley Jelly, Maltine, and Milk Mixture.—Dissolve two teaspoonfuls of barley jelly (made with Robinson's flour) by adding one-fourth teaspoonful of Maltine and stirring. After the jelly has become a liquid add to the milk mixture in the proportion of the above quantity of liquid to every 4 oz. of mixture. Preparation of Gelatin in the Treatment of Infan- tile Diarrhea.—Five hundred grams (—17 oz., 3 dr. — 10 grs.) of chemically pure gelatin are dissolved in a liter (~33h oz- ) °f boiled water; the solution is filtered, and after being sterilized for an hour in an autoclave at a temperature of 248° F., is poured into tubes having a capacity of 10 cc. (— 2i| fldr.), each tube thus con- taining 1 gm. (about 15 gr.) of gelatin. When it is desired to use this preparation, it is liquefied by plac- ing the tubes in hot water. As much as 12 gm. or 14 gm. have been given in the course of twenty-four hours. Weill commences with 3 gm. a day and increases at the rate of 1 gm. a day until a decided effect is produced. Oatmeal Jelly.—Soak two ounces of coarse oatmeal for 372 DISEASES OF CHILDREN FOR NURSES twelve hours in one quart of cold water, then boil the mixture down to one pint, and strain while hot through a fine cloth or several thicknesses of gauze. Malt Soup Mixture.—To make a 40 oz. mixture: 20 oz. of milk, 20 oz. of water, 3 oz., by measure, of wheat flour (measured loosely and not packed), i| oz., by measure, of malt soup. Number 1.—Mix the flour with the 20 oz. of milk and suspend it so as to make a uniform mixture. After as much of the flour is dissolved or suspended as possible strain through gauze (two thicknesses) to strain out all the lumps or excess. Number 2.—Dissolve the iioz. of malt in 20 oz. of water. Number 3.—Take the first mixture and the second mixture, that is, the flour and the milk mixture and the malt and the water mixture, and stir them together thoroughly. Place the whole in an enamel pot (or double boiler) and put over a slow fire, allowing the mixture to come to 1600 F. and keeping it at that temperature for twenty minutes, stirring all the time. At the end of the twenty minutes bring the mixture to a boil and remove from the fire. If there is a loss in the bulk through the cooking make up the full amount (40 oz.) by adding sterile water; then place in the bottles and cool down slowly to the temperature of running water. When the mixture is finished it has a light yellow color, smells of malt, and when it cools becomes quite thick, but when again heated becomes fluid and easily taken through the ordinary nipple if the holes are large. When the malt soup mixture is ordered one-half or one-third strength, it means that instead of taking the full amount of milk (that is, the 20 oz.) half or only INFANT FEEDING 373 10 oz. of milk is to be used and the other half is to be water, making in the whole mixture, milk 10 oz., water 30 oz., instead of 20 oz. The extra 10 oz. of water is to be added to the 10 oz. of milk, and then the flour is dissolved or suspended in the half strength milk or pro- ceed as directed above. Buttermilk.—At times the proteid in plain cows' milk is indigestible even when given in very small percentages. Large curds continually appear in the stools. In such cases buttermilk often cures the indigestion in remarkably short periods of time. It should be prepared as follows: Flour................................ 3! dr. by weight. Sugar................................15 " " Buttermilk.......................... i quart. The mixture should be brought to the boiling-point, stirring continuously. Just as it is about to boil it should be removed from the stove and cooled rapidly under running water. The mixture should then be placed upon the ice. The proper amount for the age is poured into a nursing bottle at feeding time and slightly heated. This mixture contains a much higher percentage of proteid than diluted cows' milk, but some change takes place in it which renders the mixture easily digestible. It should not be given for any length of time without the addition of cream. Buttermilk Conserve.—This is a condensed form of buttermilk. One part is added to three or four parts of water. It is a very good method of serving buttermilk. It should be slightly heated before adding the water. Buttermilk tablets are on the market under various trade names. If neither fresh buttermilk nor the conserve can be obtained, the tablets may be used. 374 DISEASES OF CHILDREN FOR NURSES Condensed Milk.—It is made by heating milk to 2120 F. to destroy the bacteria and then evaporating in a vacuum at a low temperature to less than one-fourth its volume. Condensed milk contains, after diluting six times, about i per cent, of fat, 1.20 per cent, of proteid, 7.23 per cent. of sugar, and .17 per cent, of salts (Holt). As the usual dilution is from twelve to eighteen times it is evident how it lacks in fats and proteid. Knowing how necessary fats and proteids are to the infant it can be appreciated why condensed milk should not be used as a permanent food. It sometimes works well as a slight change for a short period in acute indigestion, but it should not be used permanently without the addition of cream, and never if good milk and accurate milk mixture can be obtained. Junket.—To one pint of fresh luke-warm cows' milk add two teaspoonfuls of essence of pepsin or liquid rennet. Stir for a moment and then allow to stand until firmly coagulated. It is served cold. Kumiss and Bean Flour.—These are preparations sometimes used in infant feeding. Kumiss is a fermented form of cows' milk. It is more useful for older children than for infants. Bean flour has been recommended by Edsall for feedings in cases of difficult proteid digestion. Especially prepared flour must be obtained, and prepared according to the physician's instructions. The mixture has a nauseating odor, but it has given good results in a limited number of cases. Protein Milk (Eiweissmilch of Finkelstein).—The object of this preparation is to secure a milk for infant feeding which is low in sugar, high in protein, with a INFANT FEEDING 375 moderate amount of fat. It is made as follows: To i quart of whole milk is added a half ounce of rennet or enough to coagulate the casein. The whey is strained off through muslin by suspending the curd for one hour. The curd is then rubbed through a fine wire sieve. One pint of fermented milk (buttermilk, lactic acid milk, koumiss, or matzoon) is now added, also i pint of water. It is easier to rub the curd through the sieve if the fer- mented milk is gradually added during this process. The average composition of protein milk is fat, 2.5 per cent.; sugar, 1.5 per cent.; protein, 3 per cent.; salts, 0.5 per cent. For prolonged use, maltose should be added. INFANT FOODS These are not in any way substitutes for mother's or properly modified cows' milk. They are capable of doing and have done much positive harm. They are the greatest exciting cause of rickets and scurvy. At times some of the preparations may be of considerable value, but chiefly for temporary use in pathologic conditions. Here they should be prescribed like drugs. The majority of the preparations are rich in sugar and lacking in fats and proteids. Children may gain weight, but they do so on the carbohydrates alone. The result of such develop- ment leads to the waxy appearance which children develop, when about a year of age, who have been fed on these foods. CHAPTER XVIII ARTIFICIAL FEEDING The various elements, necessary for proper food in infancy, the difference between mother's milk and cows' milk, the various ways of preparing cows' milk to render it sterile or more easily digestible, and the various other preparations that may be used as substitutes for milk were discussed in the previous chapter, so that it is in order to discuss the subject of infant feeding proper. The different methods of feeding which are available are breast-feeding, either by the mother or by a wet- nurse; mixed feeding, or a combination of artificial feeding and nursing; and artificial feeding exclusively. The first choice should always be maternal nursing. This is nature's food for the infant and nature cannot be improved upon. " While recent advances in artificial feeding have greatly diminished the necessity for wet-nursing, there are still many instances where, objectionable though they may be, they are indispensable for saving the life of the child, as the perfect substitute for good breast-milk is as yet un- discovered" (Holt). By mixed feeding is meant a combination of breast and artificial feeding. This may be resorted to when the milk supply of a mother is insufficient, or when the strain upon her health is unduly great. The same care must be 376 ARTIFICIAL FEEDING 377 exercised to keep the nipples clean and to have the feeding at regular intervals in breast feeding as in artificial diets. Weaning should always be done gradually, when possible, for the sake of both mother and child. "While there are many women, especially of the lower classes, who are able to nurse their children advantageously throughout the first year, the number of such among the better classes is certainly very small. By the latter nursing can rarely be continued beyond the ninth, and often not beyond the sixth month, without unduly draining the vitality of the mother and at the same time harming the child. Weaning in hot weather is usually to be avoided. " In cases of sudden weaning the food must be very much weaker in the beginning than for an artificially fed child of the same age. If weaned at six months the child should be put on a mixture suitable for a child of one month of age; if at nine or ten months, upon a food appropriate for a child of three or four months. If this is done the change can be made without causing much disturbance. When the infant has become somewhat accustomed to cows' milk, the strength can be gradually increased " (Holt). ARTIFICIAL FEEDING In artificial feeding there are several fundamental principles which must be constantly borne in mind; they are well described by Holt and his work is quoted, in part, below: "The food must contain the same con- stituents as mother's milk: namely, fat, proteid, sugar, inorganic salts, and water; the constituents must be pres- ent in about the same proportions as in good mother's milk; as nearly as possible the different constituents should 378 DISEASES OF CHILDREN FOR NURSES resemble those of mother's milk both in their chemical composition and in their behavior in the digestive fluids; the addition to foods of very young infants of substances not found in mother's milk, like starch, is unnecessary, contrary to the best physiology, and if used in consider- able quantities may be positively harmful. " In the artificial feeding of infants, cows' milk is selected because it furnishes all the necessary elements, although not in proportions required by young infants. In feeding mfants according to this plan the attempt is made so to modify cows' milk as to make it conform in composition to woman's milk, and so to adjust the proportions of the various constituents to meet the individual cases. "In modifying cows' milk for infant feeding our calculations are based upon the composition of good breast milk, as determined by the latest analyses: Woman's milk, Cows' milk, per cent. per cent. Fat............4 3-5 to 4 Sugar............7 4-5 Proteids..........1.5 4 Salts.............2 .7 Water...........87.3 87.3 (Holt.) "In cows' milk there is an excess of proteids and salts, too little sugar, and about the quantity of fat required. Other conditions which must be considered are the pres- ence of bacteria in cows' milk, its acid reaction, and the fact that its proteids are more difficult of digestion. " Fats.—The average amount of fat that an infant can digest varies from 2 to 4 per cent. It is rarely necessary in health to go above or below these proportions. Be- ginning with the 2 per cent, in the early days of life, this can be increased to 3 per cent, in a month, and to 4 per ARTIFICIAL FEEDLNG 379 cent, at the age of five or six months. No other mod- ification in the fat is necessary. " Sugar.—In woman's milk the percentage of sugar is constant in all instances, between 6 and 7 per cent. In feeding cows' milk it is seldom necessary to have the sugar less than 5 per cent, and never more than 7 per cent. It should be distinctly understood that the purpose of adding sugar to milk is not to sweeten it, but to furnish the proper proportion of soluble carbohydrate necessary for the infant's nutrition. However, when good milk sugar cannot be obtained, cane sugar may be used. The amount added must be but little more than half that of milk sugar on account of its sweeter taste and its greater liability to ferment in the stomach. " Proteids.—The modification of the proteids is the most important change necessary in cows' milk, for it is the proteids which give the greatest difficulty in infant digestion. In ordinary cases in health, a reduction in the amount of proteids present is all that is necessary. The normal amount of proteids in woman's milk is 1.5 per cent. In very young infants it is necessary to reduce it even more than this, sometimes to .75 per cent, and even to .50 per cent. By the end of the first month the average child can take 1 per cent, and by the fourth month 1.5 per cent, and by the sixth month 2 per cent. The reduction of the proteids is effected by dilution with water." The meaning of such terms as 3.6.1. mixtures etc., is 3 per cent, fat, 6 per cent, sugar and 1 per cent, proteid mixture. Mixtures should always be expressed in the sequence of fat, sugar, proteid. " Inorganic Salts.—These, like the proteids, are exces- 380 DISEASES OF CHILDREN FOR NURSES sive in cows' milk and to nearly the same degree. There- fore, when milk is diluted as required by the proteids, the salts will be nearly in their proper proportion and they may be dismissed from separate consideration. " Reaction.—The acidity of cows' milk may be over- come by the addition of either lime-water or bicarbonate of soda. Of the former, 5 per cent, of the total quantity is required; of the latter, one grain to each ounce of food." The subject of heating milk for the destruction of bacteria was considered on page 363. Fat is furnished by cream; proteid by milk. Cream containing 16 per cent, fat is usually taken as a working basis, and a standard solution of milk-sugar of 20 per cent, strength should be used. Maltose, either in the form of malt soups or in com- bination with dextrin, "dextrimaltose," can be substi- tuted for milk-sugar. The quantity of dextrimaltose added is the same as would be required when milk-sugar is the carbohydrate used. It is very much more easily assimilated than other sugars. It will, however, break down more readily. It should be weighed in determining the proper amount to add. A rounded tablespoonful will weigh about \ ounce. CREAM In the larger cities it is possible to obtain certified half-pints of cream of 16 and 12 per cent, strengths. When these are not available and the nurse has to de- pend upon an ordinary quart bottle of milk to obtain the cream, she will find the following table of service. ARTIFICIAL FEEDING 381 After a quart of milk, containing 4 per cent, fat, has stood for at least twelve hours, The top 2 ounces represent 24 per cent, cream. The " 6 " " 20 " " The " 7 " " 16 " " The " 9 " " 12 " " If a pint of milk is used, one-half of the above quantities represent the percentages of fat; for example, 3I ounces would equal a 16 per cent, cream, and 4^ ounces a 12 per cent, cream. Milk containing 4 per cent, fat is about the average quality served to the public. It is not the richest milk obtainable, as this is not desired. The cream line of certified 4 per cent, milk in the ordinary shaped quart milk bottle is about 4 inches below the top, and when the visible cream is dipped off it will amount to about 5 ounces. Four per cent, fat milk means that if the quart should be shaken until an even distribution of the cream is ob- tained there would be 4 per cent, of fat in every ounce of milk in the bottle, whether the first or the thirty-second is used. When milk stands the fat rises to the top of the bottle and only the upper ounces contain it; if these should be dipped off, the bottom ounces would be entirely free from fat ("skimmed milk"). It must also be remembered that in obtaining definite strength creams, it is not meant that the top 7 or 9 ounces should be entirely composed of cream. Both the cream and the milk below the cream line must be used. This is obtained by two methods: (1) by siphoning, (2) by dipping. 382 DISEASES OF CHILDREN FOR NURSES Method for Siphoning.—A sterile glass tube long enough to reach to the bottom of a quart jar and curved at its upper extremity is placed in the bottle of milk. To its outer end a sterile rubber tube is attached, which runs to the sterile receptacle which is to receive the bottom milk. The bottom of the bottle of milk must be on a higher level than the receptacle. To start the flow of milk introduce a large jounce sterile eye-dropper into the free end of the rubber tube. The bulb of the dropper must be tightiy squeezed Fig. 104.—Apparatus for siphoning. between the fingers when this is done. As soon as the dropper is in position release the bulb and the suction will draw the milk up the glass tube. Withdraw the dropper as soon as the milk has turned the curve of the glass tube. If, for any reason, the first attempt at suction is not suc- cessful, do not squeeze the bulb again without withdrawing the dropper, for if the bulb should be squeezed while still in position it would disturb the cream layer. Do not start the flow under any circumstances by suck- ing with the mouth over the free end of the tube. The ARTIFICIAL FEEDING 3§3 mouth is not sterile and would contaminate the end of the tube through which the milk flows. The milk is allowed to flow until all of the bottom milk is removed from the bottle and only the desired amount of top milk remains. For instance, to get a 16 per cent, cream, 25 ounces of the bottom milk would be siphoned off, leaving 7 ounces of 16 per cent, cream. Method for Dipping.—A special dipper is necessary, the best being a Chapin dipper. Fig. 105.—The Chapin dipper (improved form). The dipper is introduced open. When the top is on a level with milk the bottom is drawn upward, closing the dipper, and the first ounce can then be removed without spilling or disturbing the cream layer. The dipper contains 1 ounce, and the amount of top milk desired is removed by successive dipperfuls. Method for Changing Percentages of Cream.—To make 12 per cent, cream, take two parts of 16 per cent, cream 384 DISEASES OF CHILDREN FOR NURSES and one part of whole milk. Example: To make 9 dr. of 12 per cent, cream, take 6 dr. of 16 per cent, cream and 3 dr. of whole milk. Eight per cent, cream contains one part 16 per cent. cream and two parts of whole milk. Example: To make 8 per cent, cream, take 2 oz. of 16 per cent: cream and add 4 oz. of whole milk to make 6 oz. Fats. Sugars. Proteids. 16 per cent, cream.........16 4 3.60 12 per cent, cream.........12 4.20 3.80 8 per cent, cream......... 8 4.20 3-9° The fats alone are increased in cream, the sugar and proteid remain practically the same. Cream is the same as milk, with the addition of all the fat in the bottle which has floated to the surface. METHODS BY WHICH MILK CAN BE MODIFIED There are several formulas to expedite this work. At the Children's Hospital in Philadelphia the nurses construct the milk mixtures from the following: Baner's Formula.— Q = Total quantity to be used in twenty-four hours. F = The per cent, of fat desired in the mixture. S = The per cent, of sugar desired in the mixture. P = The per cent, of proteid desired in the mixture. M = milk. C = cream. L. W. = lime-water. Qx(F-P) ---------;— ----= cream. percentage 01 cream — 4 QxP ^ •„, ----— the cream = milk. 4 5 per cent, of the total quantity = lime-water. Q - M - C - L. W. = sterile water, Qx(S-P) --------= milk sugar. ARTIFICIAL FEEDING 385 Example.—A 4.7.2. mixture is ordered, 40 oz. to be given in twenty-four hours. The percentage of the cream used is 16. Q = 4o. F = 4. S=7. P=2. 4ox(4-2) 40 v 2 ---r = — = of oz. cream. 16-4 12 i 4°X2 « 1 -n ----— Of = 13I oz. milk. 4 Tjj7 of 40 = 2 oz. lime-water. 40 — 6f — 13J — 2 = 18 oz. of sterile water. 4ox(7-2) 40x5 ---------=----=2 oz. milk sugar. 100 100 The proper proportions for a 4-7-2 mixture, 40 oz. to be given in twenty-four hours, based upon 16 per cent, cream are: Cream.......................... 6§ oz. Milk...........................i3| " Sterile water.....................18 " Lime-water...................... 2 " 40 " Two ounces of dry milk sugar are dissolved in this mixture. Short Cuts.—In a 3.6.1. mixture the cream equals one-sixth of the total quantity, if 16 per cent, cream is used; and the milk equals one-fourth of the total quantity. In a 3.6.1. mixture if a 12 per cent, cream, both the fat and the proteid are furnished by the cream and the addition of milk is unnecessary. Example.—Total quantity 32 oz., a 3.6.1. mixture made with 12 per cent, cream. 32 X(? — i) 32 X 2 *---^--- = „~ = 8 oz. cream. 12 — 4 8 32x1 O -11 0-----8 = 0 = milk. 4 2S 386 DISEASES OF CHILDREN FOR NURSES In a mixture where citrate of soda is used the powder is added in the proportion of i gr. to each ounce of milk or cream. The 5 per cent, of lime-water is not used in such a mixture, the citrate of soda giving the necessary alkalinity. In using a solution where 2 gr. = 1 dr., or any other solution, the amount of water used to dissolve the necessary number of grains should be subtracted from the total quantity of sterile water. Whenever milk is mentioned, it means whole milk, that is, milk that has not been skimmed, and in which a thor- ough distribution of the cream has been obtained by shak- ing the bottle. In diluting the whole milk to reduce the proteid, the fats are equally reduced. Therefore, it is necessary to add an extra amount of fat to the mixture to bring up its percent- age to the proper strength, which is higher than the per- centage of proteid desired; for this reason the cream is always added to whole milk. TOP-MILK MIXTURES In private practice it is often more convenient and less expensive to use top-milk mixtures instead of adding separate standard cream (like 16 per cent, cream) to a quantity of whole milk, in order to increase the amount of fat in a mixture of cows' milk. Cows' milk contains, for all practical purposes, 4 per cent. of fat, 4 per cent, of sugar, and 4 per cent, of proteid. If 1 per cent, of proteid is desired, it is readily obtained by diluting the whole milk with three times its volume of water, this makes the milk one-quarter of its original strength or 1 per cent, proteid. If 2 per cent, proteid is desired, the ARTIFICIAL FEEDING 387 whole milk is diluted with an equal quantity of sterile water. This makes the proteid one-half its original strength or 2 per cent. The fats and sugars are neces- sarily reduced in the same ratio. As was said before, the top 7 ounces of a quart of milk contain a 16 per cent, cream after standing twelve hours, and the top 9 ounces a 12 per cent, cream. The fats alone are increased in cream. The proteids are still approxi- mately 4 per cent. If a 3-6-1 mixture is ordered by the physician, and the child is taking ten bottles of 2 oz. each during the twenty- four hours, the total quantity for the day would be 20 oz. Therefore, it is necessary to make 20 oz. of a mixture containing 3 per cent, fat, 6 per cent, sugar, and 1 per cent. proteid. Method.—The top 9 oz. should be dipped, or the lower 23 oz. siphoned, off. This must be carefully done to avoid the risk of shaking up the cream and not obtaining the full strength of fat. This gives 9 oz. of milk containing 12 per cent, fat, 4 per cent, sugar, and 4 per cent, pro- teid. If this quantity should be diluted with three times its volume of water it would represent 3 per cent, fat, 1 per cent, sugar, and 1 per cent, proteid, as the milk would be only one-fourth of the whole mixture. If a 12 per cent, cream is used, and 3 per cent, fat is desired, the total quantity should be divided by one- fourth. Therefore, \ of 20 = 5. Hence, 5 oz. of the original 9 ounces of the 12 per cent, cream is the proper amount in this example. To this must be added the proper amount of lime-water and sugar of milk, which may be worked out by Baner's formula, and enough 388 DISEASES OF CHILDREN FOR NURSES sterile water to make the mixture the proper total quan- tity. Example: \ of 20 = 5 ounces of 12 per cent, cream. Trt^ of 20 = 1 ounce of lime-water. 20 X (6 — 1) 20 X S t t -n u- x. a- ------------ X ------ = 1 ounce of sugar of milk, which dis- 100 100 solves and does not increase the quantity of the mixture. Subtracting 6 oz. (top milk and lime-water) from 20 equals 14 oz. of sterile water necessary to complete the mixture. Thus: Top milk.............. 5 ounces Lime-water............ 1 ounce Sterile water........... 14 ounces 20 " Sugar of milk.......... 1 ounce, which dissolves. The 5 oz. represent \ of 20, the dilution being 15 oz., so the fat is 3 per cent, and the proteid is 1 per cent. The sugar, which was reduced to 1 per cent, by this dilu- tion, is raised to 6 per cent, by the addition of the ounce of sugar of milk. That the top 9 oz. contain practically all the fat in the quart of milk can be proved by multiplying 9 by the percentage of fat and dividing by 100:-----— = 1.08 ounces of fat in 9 ounces, and then subtracting this amount from the total quantity of fat in 32 oz. of a 4 per cent, milk, —^q— -=1.28 ounces of fat in a quart, which subtraction leaves .20 oz. of fat in the remaining 23 oz. of bottom milk, which is practically skimmed milk, and the addition of any amount of these bottom 23 oz. to a mixture would not raise the percentage of fat, but only ARTLF1CIAL FEEDING 3«9 the proteid. Therefore, if a 3-6-2 mixture is desired, it is only necessary to add some of the bottom milk to bring up the percentage of the proteid. Thus, 20 oz. of a 3-6-2 mixture are desired. From the previous example we know the quantities necessary to make a 3-6-1 mixture. By dividing the total quantity by \ we get the proper dilution of the fat to 3 per cent., but the proteid is likewise reduced to 1 per cent. Here it is necessary to raise the proteid to 2 per cent. This can be done as follows: If whole milk contains 4 per cent, of proteid, diluting with an equal amount of sterile water would give a 2 per cent, proteid, but we have already diluted with three parts of water, reducing the proteid to 1 per cent., therefore, by adding an amount of skimmed milk equal to the quantity of top milk used, we will double the percentage of proteid without disturbing the fat, consequently the result would be: Top milk......... ....... 5 ounces Bottom milk.............. 5 " Lime-water............. 1 ounce Sterile water ............ 9 ounces 20 " Sugar of milk............. 1 ounce, which dissolves. One-half the mixture is milk and cream and one-half water. In this same manner any percentage of proteid can be worked out if it is remembered that one-quarter of the total quantity represents i per cent, of proteid. Thus, if 1J per cent, of proteid is ordered in a 20-oz. mixture, and 5 oz. represent 1 per cent., it would be necessary to add 2\ oz. of bottom milk. As it is only possible to obtain 9 oz. of 12 per cent. cream from 1 quart of milk, anything above 36 oz. of total 390 DISEASES OF CHILDREN FOR NURSES mixture will require the purchase of an extra pint or quart of milk. For fat percentages lower than 3 per cent., it would be necessary to take smaller fractions; thus, one-sixth of the total quantity would represent a 2 per cent, fat if a 12 per cent, cream is used. The proteid would be reduced to two-thirds of 1 per cent., and sufficient bottom milk would have to be added to bring up the percentage. Example.—If 24 oz. of a 2-6-1 mixture is ordered: One-sixth of 24 oz. equals 4 oz. of top 12 per cent, milk, representing 2 per cent, of fat and twro-thirds of 1 per cent. of proteid. If two-thirds of 1 per cent, is contained in 4 oz., 1 per cent, will be represented in 6 oz. |:i::4:x=4^-§ = 6 ounces. Therefore, 2 oz. of bottom milk must be added. The formula would then read: Top milk................. 4 ounces Bottom milk.............. 2 " Lime-water............... 1^ " Sterile water..............i6| " "24^ Sugar of milk............ \\ ounces, which dissolves. The quantity of lime-water and sugar of milk are de- termined by Baner's formula. Another method which can be used to arrive at the same result is to work with two bottles of milk. If the amount to be used is small, two pint bottles will answer. The top 3 J- oz. of milk in a pint represent a 16 per cent. cream. This amount can be dipped off and the quantity of 16 per cent, cream found necessary by Baner's formula ARTLFICIAL FEEDING 39J can be added to the amount of whole milk required. The whole milk is obtained from the second bottle, which has been thoroughly shaken to get a uniform distribution of the cream. A 12 per cent, cream can be obtained by using 4-2 oz. Two quart bottles can also be used when the quantities required cannot be furnished by the pints. Example.—Forty ounces of a 4-7-2 mixture are desired: The top 7 oz. of a quart give a 16 per cent, cream. Working with Baner's formula we find that 6§ oz. of a 16 per cent, cream are necessary; therefore this amount is taken from the top 7 oz. and added to 13J oz. of whole milk taken from the second bottle, which amount is found to be the proper quantity to add to this mixture by working the formula (see page 384). CALORIC METHOD OF INFANT FEEDING This is a method based upon the energy requirements of the average infant in health. Calorie is the term used to represent units of energy; it is the amount of heat required to raise 1 kilogram of water i° C. in temperature. In feeding infants and children the practical value of this method lies in the fact that it enables one to see if he is feeding far above or below the physical re- quirements, and it furnishes a good check to other methods. The caloric values of the different ingredients in an infant's diet have been carefully calculated; the factors 9.3 represent fat; 4.1, sugar; and 4.1, proteid. Multiply- ing these known values by the amount of each ingredient taken, the total caloric value of the diet can be estimated. The results will be approximately as follows: 392 DISEASES OF CHILDREN FOR NURSES i ounce of 7 per cent, milk has a caloric value of............... 27.5 1 ounce of 6 per cent, milk has a caloric value of............... 25.0 1 ounce of 5 per cent, milk has a caloric value of............... 22.5 1 ounce of 4 per cent, milk has a caloric value of............... 20.0 1 ounce of 3 per cent, milk has a caloric value of............... 17-5 1 ounce of 2 per cent, milk has a caloric value of............... i5-° 1 ounce of 1 per cent, milk has a caloric value of............... 12.5 1 ounce of fat-free milk has a caloric value of.................. 10.0 1 ounce of whey has a caloric value of........................ 10.o 1 ounce of milk-sugar, by weight, has a caloric value of......... 116.0 1 ounce of milk-sugar, by volume, has a caloric value of......... 72.0 1 even tablespoonful of milk-sugar has a caloric value of........ 44.0 1 ounce of barley flour, by weight, has a caloric value of......... 100.0 1 ounce of barley water (1 tablespoonful to a pint) has a caloric value of............................................. 2.0 1 ounce of malt soup extract has a caloric value of............. 80.0 1 ounce of condensed milk has a caloric value of............... 132.0 1 ounce of olive oil, by volume, has a caloric value of........... 245.0 —{Holt). The caloric value of any modification of cows' milk of known percentages may be calculated as follows: An infant is taking six feedings of 6 ounces, or 36 ounces daily, of a milk containing fat, 3.5 per cent.; sugar, 7 per cent.; protein, 1.75 per cent.: .035 (fat %) X 9.3 (caloric value of fat) = .07 (sugar %) X 4.1 (caloric value of sugar) = .0175 (protein %) X 4.1 (caloric value of protein) = .325 caloric value of fat in 1 gram of food. .287 caloric value of sugar in 1 gram of food. .072 caloric value of protein in 1 gram of food. .684 caloric value of 1 gram of food. .684 X 100 = 684 (caloric value of 1 liter of food); 36 ounces = 1.06 liters; 1.06 X 684 = 725 (number of calories in food taken daily). The average infant in health requires about 100 calories for each kilo (2^ pounds) of body weight from the third week to the sixth month. These gradually diminish until at the end of the first year they are about 75 to 80 calories per kilo. The caloric requirements are greater in very active infants, premature babies, and those much below the ARTIFICIAL FEEDING 393 average weight. For such infants 125 to 150 calories per kilo may be necessary. Throughout the years of childhood they need about 80 calories per kilogram. The adult, moderately active, 35 to 40 calories per kilogram, and the very aged about 27 calories per kilogram. In the undernourished child a higher caloric require- ment, is needed. This may follow an illness or be due to improper dieting. Appended is a table worked out by Dr. Clifford B. Farr, of Philadelphia, which is especially useful, since it is con- structed on the basis of a definite caloric valuation. He gives the weight of the substances described which it re- quired to produce 100 calories, or fractional parts thereof. In a given case, knowing the total caloric requirement, it is easy to calculate from this table how much of each article of food must be given to gain the desired result, and by adding together the caloric values of the quantities of each ingredient used the total caloric value is quickly estimated. The first column represents the weight in grams; the figures in parentheses, ounces avoirdupois. In the case of liquids the bulk in fluidounces is added: Calories. Article. Weight. 100 Steak, Tenderloin* . ................. 35 gr. (1.3) 100 Beef, scraped. \ (Round, cooked, lean). 54 (2) 100 Panopepton.J Largest dose recom- mended, 15 c.c..................... 140 c.c. 5 oz 100 Chicken, Roast f.................. 55 (2) 100 Halibutf............................ 83 (3) 50 Oysters (raw on shell)................ 96 (3.4) 100 Bacon (raw)........................ 15 (.5) 25 Consomme......................... 207 (7.3)—7 fl. oz. * Locke, Food Values, New York, 1911. f Atwater and Bryant, Bull. 28, Dept. Agriculture. (Also indirectly for analyses given by Fisher and Locke.) % New and non-official remedies. 394 DISEASES OF CHILDREN FOR NURSES Calories. Article. Weight. 25 Beef-juice........................... 150 Warm process*.................... 5.3 oz.—55 fl. oz. 12.5 Beef-broth*......................... 312 P. 1.02............................. II.I OZ/—IOj fl. oz. 25 Beef-juice........................... 200 Cold process*....................... 7.1 oz. P. 3.00............................. 7 fl. oz. 100 Yolks (a)........................... 27 (1)—\ fl. oz. (a) \ bulk, 6 to 7 caloric value. 75 Boiled egg (small) (b).........._...... 45 (i-°) (b) Shell, 11 per cent, gross weight. 100 Egg white (c) from 7 eggs, 26 gm. each. . 181 (6.4)—6j fkoz. (c)| bulk, 1-7 caloric value. 25 Albumen-water,* double strength...... 200 2 whites to 8 oz...................... 7.1 oz. (52 g: egg white)..................... 7 fl. oz. 25 Asparagus (canned).................. 135 (4.9) 50 Green peas (canned).................. 89 (3.1) 25 Lettuce............................. 126 (4.5) 100 Lima beansf (cooked)................ 62 (2.2) 100 Potato (baked)...................... 86 (3.0) 50 Spinach (cooked)..................., 87 (3.0) 25 Tomatoes (canned).................. 108 (3.8)—3.5 fl. oz. 100 Baked beansf (home-made)........... 50 (1.8) 100 Pea soupf (split).................... 77 (2.8)—2f fl. oz-. 100 Figs............................... 31 (1.1) 50 Apples (raw)........................ 103 (3.6) 100 Bananas............................ 100 (3.5) 50 Orange juice....................--- 94 (3.3)—3§fl. oz. ioo- Olives (green)....................... 32 (1.1) 100 Almonds............................ 15 (0.5) 100 Peanuts............................ 18 (0.6) 100 Olive oil............................ 11 (0.4)—| fl. oz. 100 Sponge cake........................ 25 (0.9) 100 Baked custard,f egg, milk, sugar 2, 2 tablespoonfuls, | cup............... 73 (2.6) 100 Sugar, granulated or lump............ 24 (0.86) 100 Maple syrup........................ 35 (1.2)—ij fl. oz. 100 Milk-sugar, 2 even tablespoonfuls...... 25 (0.9) 100 Home-made white bread............. 38 (1.3) 100 Rolls, French or Vienna.............. 35 (1.2) 100 Shredded wheat..................... 27 (0.9) 100 Zwiebach........................... 23 (0.8) 100 Graham crackers (3)................. 23 (0.8) 100 Soda biscuits (4)! (Uneeda)........... 24 (0.9) 100 Rice (raw).......................... 28 (1.0) 100 Rice (boiled) (5 fl. oz.). 100 Rice (flaked) (9 fl. oz. by bulk). * Holt, Diseases of Infancy and Childhood, 5th ed. t Locke, Food Values, New York, 1911. ARTIFICIAL FEEDING 395 Calories. Article. Weight. ioo Cream of wheat (wheat flour)......... 27 (i.o) 100 Cream of wheat (prepared) (6 fl. oz. by bulk). 100 Oatmeal (flaked)..................... 25 (0.9) 100 Oatmeal (prepared). 25 Barley water*....................... 337 Tablespoonful to pint.............. 12 oz.; 11 fl. oz. ioo- Wheat or barley flour................ 27 (1.0) 100 Cheese, American.................... 22 (0.8) 100 Butter............................ . . 13 (0.5) 100 Woman's milk,* 1.50; 457............ 140 c.c; 5 oz. Av.; 5 fl. oz. 100 Cows' milk* (average)................ 140 c.c. 3.50; 4; 4.50........................ 5 oz.; 5 fl. oz. 100 Cows' milk (rich)*................... 127 c.c. 3.50; 5; 4.50........................ 4.5 oz.; \\ fl. oz. 100 Cream, 16 per cent.*................ . 56g. 3.25; 16; 4.05....................... 2 oz.; 2 fl. oz. 100 Cream, 20 per cent.*............... 47 c.c. 3.o"5; 20; 3.90....................... 1.7 oz.; if fl. oz. 100 Cream, 40 per cent.*................. 25 c.c. 2.20; 40; 3.00....................... 0.9 oz.; 1 fl. oz. 100 Top-milk, 7 per cent.*................ io2g. 3-5o;. 7; 4.50........................ 3-6 oz.; 3! fl.-oz-. 100 Skimmed milk* (1.80 per cent.)........ 2oog. (6 oz. removed from a quart of 4 per cent.), 3.60; 1.80; 4.50........... . . . 7.1 oz.; 7 fl. oz. From 10 per cent, milk, with addition of milk-sugar,* 100 0.50; 1.50; 5.50...................... 256 c:c:; 9.1 oz.; 8| fl. oz. From 7 per cent, milk, with addition of sugar,* 100 1.25; 2.50; 6.50...................... i8ig.; 6.5 oz.; b\ fl. oz. From 4 per cent, milk, with addition of sugar,* 100 2.50; 2.80; 5.50...................... 169; 6 oz.; 6 fl. oz. From skimmed milk (1.80), with sugar,* 100 1.20; 0.60; 7.00...................... 256g.;9.ioz.;82fl.oz. 100 Condensed milk*.................... 33S- (Eagle brand)....................... 1.2 oz. 8.43; 6.94; 50.69..................... 1 fl. oz. 100 1 with 6 of water.................... 231 (8.3) 1.20; 0.99; 7.23...................... 7§ fl. oz. 100 1 with 9 of water.................... 322 0.84; 0.69; 5.1....................... n-5 °z-;IO? "• oz- 100 Koumiss from cows' milk............ 220 2.66; 1.83; 4.09...................... 8 oz.; 7! fl. oz. 100 Buttermilk*........................ 278 3.60; 0.50; 4.06...................... 9-9 oz-; 9 "• oz- 100 Whey (from whole milk)*............. 285; 10 oz.; 93 fl. oz. 396 DISEASES OF CHILDREN FOR NURSES METHODS FOR DETERMINING THE PERCENTAGES OF VARIOUS MIXTURES Whole cows' milk contains 4 per cent, of fat, 4.5 per cent, of sugar, and 4 per cent, of proteid. Milk and Lime-water, 5 to 1.— \ of the mixture is milk. f of 4 per cent. = -2S° = 3^ per cent, of fat. \ of 4\ per cent. = \\ = 3I per cent, of sugar. f of 4 per cent. = -2g° = 3$ per cent, of proteid. Therefore, this mixture contains 3\ per cent, of fat, 3f per cent, of sugar, and 3^- per cent, of proteid. Milk and Lime-water, 3 to 1.—The percentages are determined in the same way, three-fourths of the whole quantity being milk. Whey, 5 oz. + 1 oz. of a 16 Per Cent. Cream.— Whey contains 0.32 per cent, of fat, 4.79 per cent, of sugar, and 0.86 per cent, of proteid. Cream contains 16 per cent, of fat, 4 per cent, of sugar, and 3.6 per cent. of proteid. In this mixture one-sixth of the total quantity is cream. \ of 16 per cent. = \6-=2.66 per cent, of fat contained in cream. f of .32 per cent. = -' = .26 per cent, of fat contained in whey. 2.92 per cent, of fat contained in mixture. \ of 4 per cent. = £ ■•= 0.66 per cent, of sugar contained in cream. % of 4-79 Per cent- = ^f5 = 3-99 per cent, of sugar contained in whey. 4.65 per cent, of sugar contained in mixture. I of 3.60 per cent. = 3-° --= .60 per cent, of proteid contained in cream. £ of .86 per cent. = 4^° = .71 per cent, of proteid contained in whey. 1.31 per cent, of proteid contained in mixture. The mixture contains 2.92 per cent, of fat, 4.65 per cent, of sugar, and 1.31 per cent, of proteid. Rule for Determining the Percentage of Fat in a ARTLFICIAL FEEDING 397 Mixture.—Add the quantities of the ingredients together. Multiply the percentage of the fat in the cream by the quantity of cream in the mixture and divide by the total quantity. Multiply the percentage of fat in the milk by the quantity of milk in the mixture and divide by the total quantity. The sum of the two results gives the percentage of fat in the mixture. Example.—In a mixture containing 5 oz. of a 16 per cent, cream, 11 oz. of milk (4 per cent, fat) and 24 oz. of water, the total quantity is 40 oz. 16x5 = f % = 2 per cent, of fat in the cream. -----= is = 1.1 per cent, of fat in the milk. 40 3.1 per cent, of fat in the mixture. Therefore, the mixture would contain 3.1 per cent. of fat. CARE OF MILK IN THE HOUSE The best milk may be absolutely spoiled by carelessness in the methods employed for keeping it in the house. Too often in the large cities the bottles are left at the front or back door by the distributor at a very early hour in the morning. Two or three hours often pass before the milk is placed on ice; this may be during the hottest days of summer, and often after it has stood in the direct rays of the sun. Necessarily the milk should be placed imme- diately in the refrigerator. Some very ingenious devices are constructed by many to receive the milk and save the early morning rising, at the same time having the milk in proper surroundings. If the milk is not delivered in hermetically sealed bottles then nothing is better to keep it in than an ordinary mason jar which has been properly 398 DISEASES OF CHILDREN FOR NURSES sterilized. The milk should not be allowed to stand in the refrigerator uncovered; nor should it be placed in the same compartment with the food. The best method to employ, if a separate compartment is not available, is to have a small refrigerator for the milk alone; many of these are on the market. However, a very satisfactory one can be improvised from an ordinary bread-box. The refrigerators must be kept scrupulously clean. If at any time there is a disagreeable odor perceptible upon opening the box, it is either due to neglect or to a leak into the packing between the walls of the refrigerator. As this packing is often hair, wool, or some similar substance, the water renders it mouldy and consequently unhealthy; when such a contingency occurs the refrigerator should be immediately abandoned. After the milk is on the ice it should be disturbed as little as possible, hence it is better to prepare the milk for the day at one time. Each feeding should be placed in a separate nursing bottle properly sterilized, and stoppered with aseptic cotton. These bottles are placed in the refrigerator immediately. It is better to have the ice in a separate compartment from the milk, as the water which collects fom the melting of the ice is not pure, often containing dirt, and if from artificial ice, traces of ammonia. If, for any reason at all, a nursing bottle should topple over into this water, the milk within it may become contaminated. It is well to have the bottles stand in a wire frame. Milk left uncovered for fifteen minutes may render all the care and aseptic measures practised at the dairies useless. The same care must be used in handling condensed milk and buttermilk. All can openers used to open tins ARTIFICIAL FEEDLNG 399 containing the commercial varieties of these products must first be boiled. The entire contents of the can must be emptied into a sterile nursing bottle or some similar receptacle and kept on ice. Precautions must be taken to prevent contamination by placing sterile cotton in the mouth of the bottle and covering other forms of receptacles thoroughly. If a can of condensed milk is slightly warmed, by placing it in hot water for five minutes, the contents will run easily into a nursing bottle. Con- densed milk that has been open for more than two days should not be used. Be careful to keep the cotton stoppers sterile while filling the bottles; do not carelessly place them where they may be contaminated. All vessels in which milk has stood for any length of time should be thoroughly scalded before refilling. Milk should not be kept warm in Thermos bottles or by any other method for any length of time. It favors the growth of bacteria. Even when pasteurized milk is so kept it permits the spores to develop. When milk is pasteurized all living bacteria are killed, but the spores ("the eggs" from which bacteria develop) are not de- stroyed. The nurse's hands should be thoroughly scrubbed before preparing milk mixtures and before feeding the children. BOTTLES AND NIPPLES The best style of bottle is that which can be most easily cleaned. On no account should bottles with any complicated apparatus be allowed. The cylindric bottles with wide mouths are generally preferred. The best nipples are those of plain black rubber which slip over the 400 DISEASES OF CHILDREN FOR NURSES' neck of the bottle. Those with long rubber tubes going to the bottom of the bottle should not be used, as it is practically impossible to keep them clean. The hole in the nipple should be large enough to allow the milk to drop rapidly when the bottle is inverted, but not so large as to permit the milk to run through in a stream. The bottles should first be rinsed with cold water, then washed with hot soapsuds and a bottle-brush. When not in use they should stand full of water. Before the milk is put into them they should lie for twenty minutes in boiling water. After the bottles have been sterilized they should not remain uncovered, but should be stoppered immediately with sterile cotton. Nipples should be boiled for five minutes daily, and when not in use they should be kept in a receptacle con- taining a saturated solution of boric acid. To prevent nipples from collapsing, the nursing bottle should be held at such an angle so that the nipple is con- stantly filled with milk. If for any reason a nipple is removed while feeding, do not put it down carelessly; it is better to drop it into the receptacle containing boric acid. RULES FOR FEEDING A child should not be more than twenty minutes taking its food, and should not be allowed to sleep with the nipple in its mouth. The bottle should be placed so that the child sucks milk, and not air. The bottle of milk should always be warmed to a temperature of ioo° F. before feeding. This is done by placing the bottle in water, which is heated until the de- sired temperature is obtained. One of the handiest and ARTIFICIAL FEEDING 401 quickest methods of heating milk is by using a "Bubble quick." This is a patented apparatus which can be ob- tained in most of the large cities. If there is regurgitation immediately after feeding, sit the infant upright. Often there will be an eructation of gas which will eliminate this tendency. A child should never be jumped up and down or rocked while it is being fed or immediately afterward. Children should be kept quiet after their evening meals to avoid the occurrence of night terrors. Schedule for Feeding Healthy Infants During the First Year. Number of Interval be- Night feed- Ounces Ounces a feedings in tween meals ings: 10 p.m. for one for twenty- 8 ' twenty-four by day. to 7 a.m. feeding. four hours. hours. Hours. 3d to 7th day.......10 2 2 1 to 1 \ 10 to 15 2d to 3d week.......10 2 2 1 \ to 3 15 to 30 4th to 5th week..... 9 2 1 i\ to 3^ 22 to 32 6th week to 3d month. 8 2\ 1 3 to 4^ 241036 3d to 5th month..... 7 3 1 4 to 5^ 28 to 38 5th to 9th month. ... 6 3 o 5^ to 7 33 to 42 9th to 12th month___ 5 3^ o 7i to 9 37 to 45 (Holt.) Usually the child's food in health should be increased in strength just as fast as the child's digestion will permit. An infant much above the average in weight must have its food graded accordingly. With this knowledge artifi- cial feeding in health resolves itself into an easy problem. Indications for Varying Mixture.—In regard to the exact indications when the fats, sugar, and proteids of milk are to be varied in infant feeding, much is yet to be learned; however, the following are the chief points: Sugar.—If the sugar is too low, the gain in weight is slower than when it is furnished in proper amounts. Excess of sugar is shown by colic, or thin, green, and 26 402 DISEASES OF CHILDREN FOR NURSES very acid stools, which cause irritation of the buttocks. Sometimes eructations and regurgitations of small quan- tities of food take place. Fat.—Excess of fat is shown by vomiting or regurgita- tion of food in small quantities, usually one or two hours after feeding; sometimes by frequent stools which are almost normal. There may be fat lumps in the stools. Too little fat causes constipation, and dry and hard stools. Proteids.—Excess of proteids is shown by the presence of curds in the stools, by colic, constipation, and vomiting. Excess in quantity of milk given at a feedmg causes immediate regurgitation. It is not practicable to modify the milk so as to meet every temporary symptom of discomfort an infant may have. The general rules are: If they are not gaining in weight without special signs of indigestion, increase the proportions of all the ingre- dients. If there is habitual colic, reduce the proteids. For frequent vomiting, soon after eating, reduce the quantity. For the regurgitation of sour masses of food reduce the fat and also sometimes the proteids. For obstinate constipation increase both fat and proteid. THE USE OF FOODS OTHER THAN MILK DURING THE FIRST YEAR The addition of other foods should be deferred until after the eighth or ninth month. Starch can then be added, usually in the form of barley. As starch is added, ANTLFICIAL FEEDING 403 sugar should be gradually withdrawn. The only other thing to be advised during the first year is beef juice; this may be given after the tenth or eleventh month to weak infants; at first only \ oz. daily; later 3 oz. In difficult cases of feeding the problem is essentially the same: that the food must be adapted to an infant whose powers of digestion are very feeble and easily dis- turbed. The general principles to be followed in these cases are to give larger quantities of diluted food after three months of age, to feed at more frequent intervals, and since the proteids give the most trouble, the fats coming next, to reduce the strength of these elements. Sugars rarely cause trouble; therefore, it is seldom necessary to reduce them. Hence such formulae as 2, 6, .75 are often seen. Another plan that may be followed when the infant has great trouble in digesting the proteids of cows' milk is to peptonize it, or to add some such ingredients as oatmeal, arrowroot, or barley. These may take the place of some of the plain boiled water of the formulae previously given. The number of cases that cannot be managed by simply varying the elements of cows' milk is small. The scales are the best means of deciding whether a child is progressing favorably. At first the gain in weight will be slow—2 or 3 oz. a week; later, however, they should gain about 8 oz. a week. For those children who do not thrive on intelligent modification of cows' milk sometimes the substitution, for a short period, of condensed milk succeeds; sometimes they thrive upon sterilized milk, malted soups, or broths and bean flour, withholding the milk for a time. In every instance the 404 DISEASES OF CHILDREN FOR NURSES general principle must be to begin with something which the child can digest and assimilate, and return to the usual proportions of the milk ingredients gradually, but just as soon as possible. Most proprietary foods are composed almost entirely of carbohydrates and are insufficient in fats. Throughout childhood, in all acute febrile diseases, the rule should be less food and more water. When a child for any reason refuses to take its food, and there is danger of death from inanition, gavage should be practised. In acute diarrhea in infancy stop the mixture and give barley water for twenty-four hours; purge and return slowly to normal mixture. FEEDING DURING AND AFTER THE SECOND YEAR OF LIFE The average child, when it reaches the age of twelve months, can take plain milk without any addition of water, or milk with the addition of small quantities of water. The child should weigh about twenty pounds, be about twenty-nine inches in length, have six teeth, and during the second year begin to walk around a chair. The child should be vaccinated during the second year, if this has not been done earlier. It should be taught to make known when it desires to urinate or to have a bowel movement, and to have them at convenient and regular periods five or six times a day. The foreskin of a boy should be retracted daily until there is no trouble in pulling it back. This prevents trouble later. A child should have a healthy complexion, a clean tongue, and well-digested bowel movements. ARTIFICIAL FEEDING 405 To feed children too often, with too many kinds of food and with too little milk, during the second year, is a mistake. A child of twelve months should be fed five times a day, say at 6 o'clock in the morning, 10, 1, 5 and 9 p. m. Often a simple milk diet will be sufficient, the milk being given plain or with small quantities of water added. Eight ounces at a feeding is enough. In addition to this 4 oz. (eight tablespoonfuls) of gruel and two teaspoonfuls of orange juice can be added to the 1 o'clock meal. Orange juice is always a good thing to give children, as it prevents scurvy. It can be given after the age of six months. The best gruel is oatmeal. Do not give this instead of milk, but in addition to the milk. At twelve months a child's diet should be: 6 A. M., 8 oz. of milk. 10 A. M., 8 oz. of milk. 1 p. m., 8 oz. of milk, 4 oz. of gruel, \ oz. of orange juice. 5 p. M., 8 oz. of milk. 9 p. M., 8 oz. of milk. Other food than milk should be taken from a spoon. The teeth that a child has at twelve months are not chewing teeth; therefore, no solid food should be given. Children do not have chewing teeth until they are twenty months old. At fifteen months of age a soft boiled egg can be added at the 1 o'clock meal, and the gruel increased to 6 oz., given twice a day, say at the 8 a. m. and the 5 p. m. meals. At fifteen months a child's diet should be as follows: 406 DISEASES OF CHILDREN FOR NURSES 8 A. M., 8 oz. of milk, 6 oz. of gruel. io A. m., 8 oz. of milk. i P. M., 8 oz. of milk, a soft boiled egg, \ oz. orange juice. 5 p. M., 8 oz. of milk, 6 oz. of gruel. 9 P. M., 8 oz. of milk. A child should not have potatoes until it is eighteen months old. Rice in small quantities may be given at intervals after fifteen months. At eighteen months clear chicken or mutton soups may be added to the mid-day meal; also dried bread and a little butter. The other meals should be the same as at fifteen months. Do not give beef juice except when the child is in poor health, at which time it acts as a tonic. It will do no harm, but, on the other hand, it will do no good in health. At twenty-one months a child can digest meat in small amounts. Scraped beef from the inside of rare steak is the best, a tablespoonful of this may be added to the mid-day meal. The diet at twenty-one months will be as follows: 8 A. m., 8 oz. of milk, 6 oz. of gruel, soft boiled egg, bread and butter. io A. ji., 8 oz. of milk. i p. M., 6 oz. of clear soup, \ oz. of scraped beef, orange juice, bread and butter. 5 P. M., 8 oz. of milk, 6 oz. of gruel, bread and butter. 9 P. m., 8 oz. of milk. The milk is discontinued when the meat is given. Always give a child water between each meal; the best time is one hour before feeding. Let it have all it wishes. Milk should be pasteurized if scarlet fever is epidemic. At the beginning of the third year the 9 p. m. bottle of milk can be discontinued. At this age a child can go without food for twelve hours and it is a better plan to have it retire with an empty stomach. ARTIFICIAL FEEDING 407 The orange juice should be continued; vegetables may be added, but should always be put through a colan- der and served as a pulp. Potatoes, peas, squash, and spinach may be used. A dessert, such as junket, may be added. The diet during the third year will be as follows: 8 A. m., orange juice, 10 oz. of milk, 6 oz. of gruel, soft boiled egg, bread and butter. 10 A. m., 8 oz. of milk. 1 p. M., 6 oz. of soup, meat, vegetables, bread and butter, dessert. 5.30 p. m., 10 oz. of milk, 6 oz. of gruel, bread and butter. After three years of age three meals are sufficient. The food may be slowly increased in amount with a few additions until ten years of age. The diet will be as follows: Breakfast: Fruit, cereals, milk, bread and butter, one or two eggs. Dinner: Soup, meat, bread and butter, vegetables, and dessert. Supper: Cereals, milk, bread and butter. The foods which may be given during this period are milk, cream, eggs, rare beef, mutton, lamb, white meat of chicken, and well-cooked fish. Vegetables: Potatoes, asparagus tips, spinach, stewed celery, string beans, and fresh peas. Cereals: The best are the hominy grits, split wheat, and oatmeal. They should be cooked at least six hours. The prepared cereals should be cooked about.four times as long as the directions say. Broths and soups. Bread and biscuits. Desserts: Junket, plain custards, rice pudding without 408 DISEASES OF CHILDREN FOR NURSES raisins, and, not oftener than once a week, good ice cream. Fruits: Oranges, baked apples—never raw apples until ten years of age, and then with caution. Jams and preserved fruits cause trouble. Do not give fat or greasy food to children. Only the meats and vegetables mentioned are feasible. Also hot bread, griddle cakes, all nuts, candies, pies, tarts, salads, jellies, pastry of every description, tea, coffee, cocoa, beer, cider, bananas, and dried fruits should never be given to children. A light lunch at 10.30 or 11 o'clock spoils the appetite for dinner. It is better not to change the child's food during the hot weather. ADJUNCTS TO FEEDING The principal adjuncts to feeding during childhood are rest, exercise, and ventilation. Rest.—Young children about two years of age require a great deal of rest. They should sleep twelve hours at night, with a nap in the morning and one in the after- noon; the afternoon nap should be at least two hours in length. As the child becomes older the morning nap may be dropped. At ten years of age they should have at least from ten to eleven hours rest a day. Children should never be too active in the afternoon, as this is frequently the cause of bed-wetting. Exercise.—During the first year the baby gets enough exercise from waving its legs and arms about. During the second year a "baby jumper" is helpful. From it the child obtains sufficient exercise without hurting and unduly tiring itself. If the child walks from room to ARTIFICIAL FEEDING 409 room or about the chairs it should rest often to preserve the arch of the foot. Boys usually obtain sufficient exercise from their play. Exercise is the best cure for constipation. Ventilation.—Give children all the fresh air they can get, do not have their clothing too tight, and have a window open in the room at night. An infant requires 1000 cubic feet of fresh air. Older children should have between 700 and 800 cubic feet. CHAPTER XIX THERAPEUTICS In the treatment of children more can be accomplished by good hygienic surroundings, careful feeding, and proper nursing than by the administration of drugs. Drugs are necessary under certain conditions, when it is better to give divided doses frequently than a large amount at one time. Drugs well borne by children include alcoholic stimulants, which should be diluted eight times before administration, quinin, calomel, iodids, cod-liver oil, bromids, chloral, and belladonna. Belladonna often causes an erythema or redness of the skin even when given in small quantities, but this does not necessarily mean that the drug is producing deleterious effects. Chloral should be given by the rectum. When given by the mouth it causes irritation of the mucous mem- branes. Drugs poorly borne by children include opium, usually given in the form of Dover's powder, salicylates, iron, and acids. Children are more susceptible to opium than adults. The other drugs mentioned have a tendency to derange the digestion. Mixtures containing arsenic should be diluted with at least eight parts of water when administered. 410 THERA PE UTICS 411 RULES FOR DOSAGE IN CHILDHOOD Several rules for dosage in childhood have been devised, founded on the fact that drugs influence the human organ- ism somewhat in proportion to the body weight. Young's Rule.—Add twelve to the age of the child and divide the sttm into the age. This gives the pro- portionate quantity of an adult dose. Thus, the age of a child being two years, two plus twelve would be fourteen, and fourteen divided into two would be T2f or \ of the adult dose, being the proper dose for a child of two years. Crowling's Rule.—Divide the age of the child at the following birthday by twenty-four, and the result is the proportionate dose for that child. Thus, the following birthday of a child being four years, /T or \ of the adult dose would be the proper quantity for a child at three years. THE THERAPEUTIC LIMIT The therapeutic limit of a drug is the furthest point to which a drug can be pushed, with safety, in the treat- ment of a disease. The therapeutic limit of the following drugs is: Aconite. Tingling of the mucous membrane of the mouth and lips and a weak, compressible pulse. Antipyrin. Cyanosis, languor, and a weak pulse. Arsenic. Nausea and diarrhea. Puffiness under the eyes. Aspirin. Ringing in the ears. Belladonna. Dilation of the pupil, dryness of the mouth, and a rapid, corded pulse. Bromids. Mental torpor and an acne rash (bromism). 412 DISEASES OF CHILDREN FOR NURSES Carbolic acid. Smoky urine. Cimicifuga. Frontal headache. Colchicum. Serous diarrhea. Digitalis. A slow, full pulse. Iodids. Headache, coryza, and sore throat. Mercury. Salivation, sore gums, and fetid breath (ptyalism). Oil of Wintergreen. Ringing in the ears. Opium. Contraction of the pupils and sleep. Phosphorus. Matchy taste. Quinin. Ringing in the ears. Salicylates. Ringing in the ears. Salol. Ringing in the ears. Strychnin. Stiffness of the muscles of the neck, twitch- ing of the muscles, and nervousness. Sulphonal. Pinkish urine. Tartar Emetic. Nausea and a slow pulse. Thyroid Extract. Loss of weight and strength, fever, and a rapid pulse. CONTRA-INDICATIONS Aconite. Contra-indicated in weak heart. Alcohol. Contra-indicated in typhoid if odor is present on breath. Chloral. Contra-indicated in hypertrophied heart and disease of heart muscle. Chloroform. Contra-indicated in heart disease. Digitalis. Contra-indicated in hypertrophied heart and disease of heart muscle. Ether. Contra-indicated in disease of the bronchi and lungs. Hyoscin. Contra-indicated in sore throat. THERAPEUTICS 413 Iodid. Contra-indicated in cavity formation in phthisis. Mercury. Contra-indicated in inflammations of a serous membrane with serous exudate. Nitrous Oxid Gas. Contra-indicated in aneurysm and arteriosclerosis. Opium. Contra-indicated in Bright's disease. Quinin. Contra-indicated in middle-ear disease. Strychnin. Contra-indicated in inflammations of the spinal cord. Tartar Emetic. Contra-indicated in infancy. Thyroid Extract. Contra-indicated in exophthalmic goiter. Tonics (Bitter). Contra-indicated in inflammations of gastro-intestinal tract. Veratrum Viride. Contra-indicated in gastric inflam- mations and weak heart. DOMINANT ACTION OF DRUGS Aconite depresses the heart directly. Amyl nitrite depresses the motor portion of the spinal cord. Bromids depress the motor portion of the spinal cord. Chloral depresses the motor portion of the spinal cord. Digitalis stimulates every portion of the circulation. Strychnin stimulates the motor portion of the spinal cord. DRUGS WHICH QUICKEN THE PULSE Alcohol. Ammonia. Atropin. Ether. Nitroglycerin. 414 DISEASES OF CHILDREN FOR NURSES DRUGS WHICH SLOW THE PULSE Aconite. Digitalis. Chloroform. Opium. Veratrum Viride. DRUGS WHICH RAISE BLOOD PRESSURE Alcohol. Cocain. Ammonia. Digitalis. Atropin. Ergot. Strychnin. CHARACTERISTIC PULSES Aconite. Slow, weak pulse. Amyl Nitrite. Rapid, soft pulse. Digitalis. Slow, full pulse. Opium. Slow, full pulse. Veratrum Viride. Slow, weak pulse. DRUGS WHICH DILATE THE PUPIL Belladonna. Cocain. DRUGS WHICH CONTRACT THE PUPIL Eserin. Opium. DRUGS WHICH CAUSE SKIN REACTIONS Erythematous Eruptions: Antipyrin. Belladonna (resembles scarlet fever). Chloral. Quinin. THERAPEUTICS 415 Acneif orm Eruption: Arsenic. Bromids. Iodids. Drugs causing Cyanosis: Antipyrin. Potassium chlorate. Hydrocyanic acid. Nitrites. DRUGS WHICH COLOR THE URINE Carbolic acid. Smoky urine. Creosote. Olive-green urine. Methylene-blue. Blue-green urine. Resorcin. Olive-green urine. Salicylates. Olive-green urine. Santonin. Yellow urine. Sulphonal. Pinkish urine. Thymol. Olive-green urine. Turpentine and eucalyptus give an odor of violets to urine. DRUGS WHICH COLOR THE STOOLS Bismuth. Black stool. Hematoxylin. Red stool. Iron. Black stool. Silver. Black stool. VACCINES These are dead bacteria suspended in normal salt solution and are used in the treatment of a large variety of conditions. In children the best results are obtained in cases of furunculosis and multiple abscesses. In most of the other conditions they have not been very successful, though occasionally cases may show marked improvement. 416 DISEASES OF CHILDREN FOR NURSES DRUGS OF THE U. S. PHARMACOPEIA MOST COMMONLY EMPLOYED IN CHILDREN'S DISEASES, TOGETHER WITH THEIR DOSES FOR CHILDREN TWO YEARS OLD Acetanilid, gr. ss-j. Aceta. Acetum opii, Tit ss-j. scillae, Tfli-v. Acida. Acidum aceticum dil., TTlv-xv. carbolicum, gr. J. gallicum, gr. ss-ij. hydrocyanicum dil., TTti-i- hydrochloricum dil., Tfl,i~v- nitricum dil., Tfl.i-iij. nitrohydrochloricum dil.,Tit i-v. phosphoricum dil., Tfl,i_v. salicylicum, gr. j. sulphuricum dil., TTLi-v. aromaticum, TTti-v. tannicum, gr. ss-ij. jEtherea. /Ether, Tflii-x. Chloroformum, TTfi-v. Ammonia. Ammonii bromidum, gr. i-v. carbonas, gr. ss-j. chloridum, gr. i-v. Antimonium. Antimonii et potassii tartras, gr. Antipyrin, gr. ss-ij. Aspirin, gr. ss-iss. Aquae. Aqua ammoniae. (External.) camphorae, f^j. cinnamomi, f.^i-ij. menthae piperitae, f3i_VJ- rosse. (External.) Argentum. Argenti nitras, gr. ^j—jV nitras fusa. (External). Atropin Sulph., gr. -gU^fa- Bismuthum. Bismuthi subcarbonas, gr. i-v. subnitras, gr. i-v. Calcium. Creta praeparata, gr. ii-x. Testa praeparata, gr. ii-x. Carbo Ligni, gr. i-v. Cerata. (External.) Ceratum canthar. cetacei. ext. canth. plumbi sub. resinas. resinae com. sabinae. saponis. zinci carbon. Charta;. (External.) Charta sinapis. Chloral, gr. i-v. Codein, gr. &-&. Collodium. (External.) Collodium cum cantharide. flexile. Confectiones. Confectio sennae, gr. x-xx. Decocta. Decoctum haematoxyli, f^i^ij- hordei, f^i-iv. quercus. (External.) Digitalin, ttjjss-v. Emplastra. (External.) Emploastrum assafoetidae. belladonnae. hydrargyri. opii. THERAPEUTICS 4*7 Emplastra. (External.) Emploastrum picis burgundicae. cum cantharide. resinae. saponis. Extracta. Extractum belladonnas, gr. ^-jV cinchonae, gr. i-iv. colocynthidis C, gr. J-j. gentianae, gr. £-j. glycyrrhizae, gr. i-v. haematoxyli, gr. i-iv. hyoscyami, gr. yg-4. krameriae, gr. £-ij. malti, TTtxv-f^ss. nucis vomicae, gr. ?j~ij. taraxaci, gr. ii-x. Extracta Fluida. Extractum buchu fluid., Tttii-v. cascara sagrada fld., Tltii_x. cimicifugae fluid., TTtiv-viij. ergotae fluid., TflJ-ij. gelsemii fluid., Tttl-i. grindeliae fluid., (External.) pilocarpi fluid., TTtx. pruni virg. fluid., Tit*. rhei fluid., Tit i-v. sennae fluid., TTtx_xxx- spigeliae et sen. fluid., f^j- uvae ursi fluid., Tltii-v. Valerianae fluid., TTLii—x. Ferrum. Ferri citras, gr. ss-ij. et ammonii citras, gr. ss-ij. et potassii tartras, gr. ss-ij. et quininae citras, gr. ss-ij. lactas, gr. ss-ij. pyrophosphas, gr. J-j. subcarbonas, gr. i-ij. sulphas exsiccata, gr. {-j. Ferrum reductum, gr. ss-ij. Glycerita, (External.) Glycerinum acidi carbolici. gallici. tannici. Heroin, gr. &-&. 27 Hydrargyrum. Hydrargyri chloridum corros., gr- ifor. mite, gr. ^j-iss. Hydrargyrum cum creta, gr. ss-iss. Infusa. Infusum buchu, f.^i-ij. calumbaa, f.^i-ij- digitalis, TTtx~f3ss. lini, f^ss-ij. Kamala, gr. v-xv. Linimenta. (External.) Linimentum ammoniae. calcis. camphorae. cantharidis. chloroformi. plumbi subacetatis. saponis. terebinthinae. Liquores. Liquor acidi arseniosi, TflM-h]- ammonii acetatis, fgss-j. arsenici et hydrarg. iodidi, TTlss-j. calcis, f.^i-f^iij. ferri nitratis, Tlti-iij- subsulphatis, Tltss-j. magnesii citratis, f^ii-f^ss. pepsini, f^ss-fgj. plumbi subacetat. dil. (Ex- ternal.) potassii arsenitis, Tlti_iij- citratis, f^ss-j. sodae chloratae. (External.) Magnesium. Magnesia, gr. v-gr. xl. Magnesii carbonas, gr. v-gr. xl sulphas, gr. v-xv. Manna, gr. xx-^j. Mellita. (External.) Mel despumatum. rosae. boracis. 4i8 DISEASES OF CHILDREN FOR NURSES Misturae. Mistura ammoniaci, fgss-ij. amygdalae, f^i-^fj. assafcetidae, f^i-ij. chloroformi, fji-ij. cretae, f.^ss-j. ferri comp., f^i-ij. ferri et ammonii acetatis, f,5 ss-j. glycyrrhizae comp., Tfl.xv-f3ss- potassii citratis, f^ss-j. rhei et sodae, fgss-j. Morphina. Morphinae acetas, gr. ^j-jV- murias, gr. ?VsV- sulphas, gr. ^j-sV Moschus, gr. i-ij. Mucilagines. Mucilago acacias, ad lib. sassafras medullae, ad lib. tragacanthae, ad lib. ulmi, ad lib. Nitroglycerin, gr. 5£„. Olea. Oleum chenopodii, TTfii-iv. cinnamomi, Ttti- gaultheriae, Tfli-ij- menthas piperitae, Tltss-j. morrhuae, Tflxv-f^j. olivae, f3i-ij. ricini, f^ss-ij. succini. (External.) terebinthinae, TTX.ii-v. Oleoresinae. Oleoresina aspidii, Tftv-xx. Opium, gr. TV-J. Pelletierine tannas, gr. i-v. Pepo, 3i-ij. Petrolatum (External). Phenacetin, gr. ss-j. Phosphorus, gr. vnrrrtff- Plumbum. Plumbi acetas, gr. \-\. Potassium. Potassii acetas, gr. ii-v. bicarbonas, gr. ii-v. bitartras, gr. x-xv. bromidum, gr. ii-v. chloras, gr. ii-v. citras, gr. ii-v. et sodii tartras, gr. xv-^j. iodidum, gr. ss-iij. nitras, gr. iss-viij. permanganas. (External.) Pulveres. Pulvis aromaticus, gr. i-ij. glycyrrhizae comp., gr. iv-viij. ipecacuanhas et opii, gr. \-\%%. rhei comp., gr. v-x. Quinina. Quininas bisulphas, gr. ss-iv. sulphas, gr. ss-iv. valerianas, gr. J-ss. Resinae. Resina jalapae, gr. £-ss. podophylli, gr. ■&-??. scammonii, gr. ^-iss. Rheum, gr. ss.-ij. Salol, gr. ss-iss. Santoninum, gr. £-ss. Scammonium, gr. i-ij. Senna, gr. iii-v. Sinapis (Emetic), gr. viii-xx. Sodium. Sodii acetas, gr. ii-v. arsenias, gr. x\rrik- bicarbonas, gr. ii-v. boras. (External.) bromidi, gr. i-v. salicylici, gr. ss-iss. Spiritus. Spiritus aetheris comp., TTtii—x. nitrosi, Tftv-xx. ammoniae aromat., Tit "-v. camphorae, Til ss-iv. chloroformi, Tit i-v. THERAPEUTLCS 419 Spiritus. cinnamomi, Tlti-ij- frumenti, Tftv-f.^j- juniperi comp., Tit v-xv. menthae piperita;, Tit ss-ij. vini gallici, Tttv-f3J. Strychnina. Strychninae sulphas, gr. Tiff—riff- Sulfonal, gr. iss. Sulphur. Sulphur praecipitatum, gr. x -xv. Syrupi. Syrupus acacias, ad lib. allii, f^ss-^ij. ferri iodidi, Tftii-v. ipecacuanhas, TfiMi-fSij- krameriae, Tftxx-f3j- lactucarii, Tftxx_f3J- limonis, ad lib. pruni virginianas, Tftxv-f3ss. rhei, f^ss-j. aromat., fgss-j. sarsaparillae comp., Tflxv-f^ss. scillas, Tftii-vj- comp., Tftii-vj- senegas, Tftii-v. tolutani, Tltii-vj. zingiberis, Tftv-x. Tincturae. Tinctura aconiti, TTfi-ss. belladonnas, Tit i-ij- calumbas, Tftiii-xv- cannabis indicae, Tfti-ij- cardamomi comp., Tftv-xv. catechu comp., Tftv-xv. cinchonas comp., Tftx-xv. cinnamomi, TTTii—xv. colchici, TT|.i-iij. digitalis, TT\ss—iij. ferri chloridi, Tit i-v. gelsemii, Tfti-ij- gentianas comp., Tftv-xv. guaiaci ammon, Tltv-xv. hyoscyami, Tfti-iv. iodi, TTfi-iv. ipecac, et opii, Tlti-iss- kino, Tftii-xx- kramerias, Tftn-^- lavendulae comp., Tflv-xx,, Tincturas. nucis vomicae, Tit ss-ij- opii, Tlti-iij- camphorata, Tftv-xx. deodorata, Tlti-iij. rhei dulcis, Tftv-x. saponis viridis. (External.) scillae, Tit i-v. strophanthus, Tftss-j. Valerianae ammoniata, TTLV—xv- zingiberis, Tft"-vij- Trional, gr. iss. Unguenta. (External.) Unguentum acidi carbolici. acidi tannici. aquae rosas. belladonnas. cantharidis. creasoti diachylon. gallas. hydrargyri. ammoniati. iodidi rubri. nitratis. oxidi flavi. rubri. iodi ichthyol. mezerei. picis liquidae. plumbi carbonatis. iodidi. potassii iodidi. stramonii. sulphuris. iodidi. veratrinae. zinci oxidi. Veronal, gr. iss. Vina. Vinum ergotae, Tttv-x. ferri amarum, Tftxx-f^ss. ipecacuanhas, Tftii-viij. opii, Tftss-j. rhei, Tftv-f^ss. Zincum. Zinci oxidum, gr. f-ss. sulphas, gr. |-v. valerianas, gr. J-ss. Zingiber. Pulv. zingiberis, gr. J-ij. 420 DLSEASES OF CHILDREN FOR NURSES Normal Salt Solution.—One and one-half drams of sodium chlorid (ordinary table salt) are added to two pints of sterile water, thoroughly mixed with a sterile glass rod, and filtered into a sterile bottle. If normal salt solution is to be used for hypodermoclysis it should be sterilized for a half hour on three successive days. In emergencies it may be boiled steadily for one hour. A sterile thermometer should be used to take the temperature of the solution. POISONS AND THEIR ANTIDOTES Acids, Mineral.—Alkalies in di- lute solution; lime; whitewash; magnesia; soap. Quickness of administration essential. Avoid emetics and stomach-pump. Acids, Vegetable.—Soap; soda or potassa in dilute solution; except for oxalic acid, for which give lime, whitewash, chalk, or mag- nesia. Atropin.—See Belladonna. Belladonna.—Emetics; stomach- pump; tannic acid; morphin hypodermically. Bismuth and Its Compounds.— Albumen; milk. Bromin.—Soap; oils. Aconite.—Emetics; stomach- r pump; tannic acid; digitalis; ^anna/>is Indica.—Emetics; lem laudanum; warmth; stimulation- recumbent position. on juice; quiet; if exhaustion, stimulants. Alkalies and Their Salts.—Vine- gar; weak acids; oil freely; opium. Alum.—Albumen.* Antimony and Its Salts.—Tannic acid; opium; external warmth. Arsenic and Its Salts.—Emetics; stomach-pump; recently made hydrated sesqui-oxid of iron; (made by adding water of ammo- nia to solution of trisulphate of iron); magnesia; dialyzed iron and salt; oil or fat. Carbolic Acid.—Stomach-pump; solution of saccharate of lime; sulphate of sodium; hot and cold douche. Chloral and Chloroform.—Alter- nate hot and cold douche; artifi- cial respiration; cardiac stimu- lants. Cocculus Indicus.—E m e t i c s; stomach-pump; at first, give opium; chloral; chloroform; later, stimulants. No chemical anti- dote. * Albumen is furnished by whites of eggs. THERAPEUTICS 421 Colchicum.—Emetics; stomach- pump; tannic acid; opium; stim- ulants. Conium.—Emetics; stomach- pump; artificial respiration; tan- nic acid; opium. Copper and Its Salts.—Albumen; milk; calcined magnesia; yellow prussiate of potash. Croton Oil and Other Drastic Purgatives.—Emetics; albumi- nous drinks; bismuth; external heat. Cyanid of Potassium.—See Hy- drocyanic Acid. Digitalis.—Emetics; stomach- pump; tannic acid; stimulants. Gelsemium.—Same as Aconite. Hydrocyanic Acid.—Alternate hot and cold douche; intravenous injection of aqua ammonias; atropin hypodermically. Hyoscyamus.—Same as Bella- donna. Iodin.—Starch, freely; if this can- not be obtained, then soap. Iron, Salts of.—Soap; alkalies; albumen. dilute Lead, Salts of.—Emetics; stomach- pump; alkaline sulphates; soap; albumen; milk; purge. Mercury, Salts of (Bichlorid of Mercury).—Emetics; albumen; milk; wash out stomach Opium.—Stomach-pump; atropin hypodermically; coffee; flagella- tion; artificial respiration; elec- tricity. Phosphorus.—Emetics; sulphate of copper in small doses; crude oil of turpentine; stomach-pump; avoid oils or fats. Potash Salts.—No distinct anti- dote. Santonin.—Emetics; purges; stim- ulants; artificial respiration. Silver, Salts of. freelv; albumen. -Common salt, Soda Salts.—No distinct antidote. Stramonium.—Same as Belladon- Strychnin.—Emetics; stomach- pump (at first only) tannic acid; chloral; bromid of potash; ether; chloroform; rest. Veratrum Viride.—Same as Aco- nite. Zinc, Salts of.—Albumen in the form of white of egg; carbonate of soda; milk, freely. DISEASES OF CHILDREN FOR NURSES TREATMENT OF EMERGENCIES The following treatments are given so that the nurse may know what to do in cases of extreme emergency, where it is impossible to obtain a physician immediately and where delay might result in the death of the child. In every emergency case send for the physician at once, and while awaiting his arrival do as much for the patient as can be done without exercising his prerogatives, and at the same time have everything prepared so that his orders may be anticipated and the patient receive immedi- ate medication. When the nurse knows what orders to expect, the detail can be worked out before the physician arrives. Asphyxia.—Give artificial respiration (see page 454). Oxygen, atropin, ?foj gr., and strychnin, g'g gr., hypo- dermically, to a child four years of age, will probably be ordered. Asthma.—Prompt relief often follows the inhalation of a few drops of chloroform. Bites should be treated as open wounds and not cau- terized. They should be thoroughly washed with hydro- gen peroxid and a wet bichlorid dressing applied. Burns.—The burned area should be covered with lint saturated with normal salt solution or carron oil, which is composed of equal parts of linseed oil and lime-water. Chills.—The child should be surrounded with hot- water bottles and covered with a blanket. Hot drinks may be administered. If this plan of treatment is fol- lowed by a sweat, the skin should be sponged with water containing a tablespoonful of alcohol to the basin. The temperature should be taken. THERAPEUTICS 423 Collapse.—Place the child in a mustard' tub at a temperature of no° F. for five minutes, vigorously rubbing the extremities and the skin surfaces during this time. After removal from the tub place it in a horizontal posi- tion, cover with warm blankets; heart and respiratory stimulants will probably be ordered. Croup.—A sponge moistened with hot water may be applied to the throat, or the child may be placed in a hot bath or mustard tub at a temperature of no° F. If these simple remedies fail, an emetic will often bring relief, the best being the wine of ipecac administered in dram doses until effective; or a little powdered alum mixed with honey or molasses given in teaspoonful doses. In severe cases it may be necessary to resort to the inhalation of a few drops of chloroform. A croup tent with moist atmosphere is advantageous. An umbrella covered with a blanket may be substituted for the regulation croup tent. Convulsions. —Epileptiform. — Measures should be taken to prevent the child from injuring itself. Some- thing should be placed between the teeth to prevent biting of the tongue. An enema should be given. Uremic— The same precautions must be taken as in epileptiform convulsions. The inhalation of a few drops of chloroform may control the seizures until the physician arrives. Reflex Convulsions.—The child should be placed in a mustard tub, at no° F., for five minutes. Dislocations.—Apply cold to the joint. Drowning.—The child should be forced to vomit to relieve the stomach of the swallowed water; this can be accomplished by pressure over the stomach. Artificial respiration should then be practised (see page 454). 424 DISEASES OF CHILDREN FOR NURSES Dyspnea.—Dyspnea may be due to a number of causes. If the child is suffering from heart disease, it should be propped up in bed. If due to some disease of the respira- tory tract, a croup tent with a moist atmosphere may help; oxygen should be administered if at hand, or the child should be kept in a room filled with fresh air or even carried out of doors. If due to diphtheria, intubation will probably be necessary. Heart or respiratory stimu- lants will probably be ordered. Epistaxis or Nosebleed.—The child should sit upright in the chair, the clothing should be loosened about the neck, firm pressure made over the bridge of the nose by holding it between the fingers, and ice should be applied to the bridge of the nose and back of the neck. Small pellets of ice may be introduced into the nostrils or held in the mouth. If this does not answer, plugging the nostrils with absorbent cotton may be resorted to. Com- pound tincture of benzoin, diluted lemon-juice, and adre- nalin chlorid, 1:2000, may be introduced into the nose. No astringent powders should be used locally on account of their tendency to produce sneezing, thus starting the nose- bleed afresh. Earache.—Douche the ear with warm water at a tem- perature of no° F. for about five minutes (see page 443). Then introduce a pledget of cotton saturated with sweet oil and a drop of laudanum. Fainting.—Loosen the clothing; place the child on its back with the head on a lower level than the feet; use smelling salts and aromatic spirits of ammonia, ten drops in a tablespoonful of water for a child four years of age. Foreign Bodies.—Eye.—If possible remove the body with a wisp of cotton; if it cannot be discovered turn the THE RAPE UTICS 425 lid as described on page 252, when, in most cases, it can readily be found. Ear.—Nothing should be used except hot-water douch- ings; on no account attempt to probe with any instrument; the douching will be sufficient for all cases. Nose.—Douching the nose with warm water is usually sufficient, the nozzle of the syringe being placed in the nostril which is free. Throat.—Often a sharp slap on the back will cause the expulsion of the foreign body. If it is impossible to recover the object and it seems to be lodged in the throat, send immediately for the physician. If it has been swal- lowed give the child bread and potatoes to eat, and a dose of oil. Fractures.—If simple, apply a temporary dressing and splint to avoid unnecessary laceration of the tissues. If compound (communicating with the air) wash thor- oughly with a solution of bichlorid of mercury, 1 to 4000, and apply a wet bichlorid or normal salt solution dressing. In fractures of skull, apply an ice-cap. Heart Failure.—Symptoms of heart failure demand instant attention. Whenever the pulse becomes rapid, intermittent, and weak, or the child has sudden attacks of dyspnea, coldness of the extremities, or attacks of syncope, the physician should be immediately informed. While awaiting his arrival the child should be placed flat upon its back and not moved for anything. Mustard paste, made of equal parts of mustard and flour, may be ap- plied to front of chest until there is a distinct redness, 15 minims of aromatic spirits of ammonia may be given in water by the mouth, if the child can swallow; hot-water bags may be placed about the extremities, and inhala- 426 DISEASES OF CHILDREN FOR NURSES tions of ammonia given. (Be careful not to have con- centrated ammonia nor to hold it continuously under the nose; pass it slowly backward and forward.) The phys- ician will probably order a hypodermic injection of one of the following drugs: nitroglycerin, strychnin, digitalis, or whisky, all of which should be in readiness. Hypodermo- clysis may be ordered and at times he may bleed the child. Hemorrhage.—Hemoptysis (Spitting of Blood).—Mor- phin should be administered in profuse hemorrhages, the dose being -£% gr. to a child four years of age. Ice- bag to chest. Hematemesis (Vomiting of Blood).—An ice-bag should be placed over the stomach and all food by the mouth prohibited. If profuse, morphin, -^ gr., to a child of four years can be administered hypodermically. Typhoid.—The hemorrhage from the bowel should be treated by absolute rest, ice-bag to the abdomen, the food should be reduced to the minimum and of the mildest character. In severe cases the foot of the bed can be raised and morphin, dose ^ gr- t0 tV Sr- t0 a child of four years, should be administered hypodermically. Laryngismus Stridulus.—Dash cold water on the face and neck in an attempt to break the spasm. Mustard tubs at a temperature of no° F. may be resorted to, and in severe cases inhalations of chloroform. Nervousness.—Warm baths at a temperature of no° F. will usually allay nervousness. Pain can usually be relieved by the application of heat; that is, hot-water bag, turpentine stupe, etc. Perforation.—Typhoid.—Absolute quiet; no food or liquids by mouth or rectum. The physician should be immediately notified. THERAPEUTICS 427 Appendicitis.—The same plan of treatment should be followed. Poisons.—If possible wash out the stomach, give a large dose of oil, and administer the proper antidote (see page 420). Prolapse of the Rectum.—The prolapsed portion of the bowel should be greased with vaselin, cold cloths applied, and gently pushed within the sphincter. Respiratory Failure.—In respiratory failure there is great dyspnea, cyanosis, and signs of collapse. The physician should be immediately summoned; in the mean- time, if the child shows great distress in breathing while in the recumbent posture, it should be propped up in bed, oxygen should be administered; gentle friction of the sides of the chest at times stimulates the respiratory muscles. He may order a mustard tub and hypodermic injections of one or more of the following drugs: atropin, caffein, strychnin, and nitroglycerin. In sudden attacks of great cyanosis a mustard tub is advantageous. Shock.—Hot (no°F.) normal salt solution or hot coffee may be injected into the rectum; about a pint should be used. Heart and vasomotor stimulants will be ordered; like strychnin, ammonia, and digitalis. Sunstroke.—-The child's clothing should be removed and cool drinks administered. The child should be placed in the coolest part of the room, ice-bags applied to the head, and cool sponging given. At times it is necessary to give cold baths and cold irrigations of colon (see page 429). Stimulation should be resorted to if necessary. Urine.—Suppression of the urine may be overcome by giving the child plenty of water to drink and administering sweet spirits of niter, dose ten drops in water every three 428 DISEASES OF CHILDREN FOR NURSES hours to a child of two years, until the kidneys become active. Retention of the urine at times may be overcome by a hot sitz bath or a warm tub. If this fails and the child is suffering, catheterization is necessary (see page 471). Persistent Vomiting.—Usually a mustard plaster applied for ten minutes over the stomach will relieve the vomiting. No food should be given by the mouth. Cracked ice will relieve the thirst. Wounds.—All wounds should be thoroughly cleansed (all the dirt removed, washed with peroxid of hydrogen or a solution of bichlorid of mercury, 1 : 4000) and covered with a wet bichlorid or sterile normal salt solution dressing. Therapeutic Measures Employed in Childhood TO REDUCE TEMPERATURE Ice-cap.—Ice is placed in a canvas bag and beaten with a mallet until broken in small pieces. It is then transferred to a rubber ice-bag. Express all air from the bag by twisting the unfilled portion. Carefully apply metal cap; then cover with towel or gauze. Sponge Bath.—The temperature of the water should be from 85 ° F. to 90° F. Equal parts of water and alcohol or water and vinegar can be used. The clothes should be removed from an infant with the exception of the diaper. In older children the portions of the body not being sponged may be kept covered. The sponging should be continued for five to fifteen minutes and the child then wrapped in a blanket without further dressing. The temperature of a child should be taken half an hour after sponging. THERA PE UTICS 429 Cold Pack.—The child is stripped of all its clothing, laid upon a blanket, and the entire trunk wrapped in a sheet which has been wrung out of water at a temperature of ioo° F., the sheet should be so applied that one part of the body does not come in contact with another. Small pieces of ice are rubbed over the sheet, first in front and then behind. The head should be sponged with cold water and a hot-water bottle applied to the feet during this procedure. After the ice has been rubbed upon the sheet for ten minutes the child is enveloped in the blanket without removing the wet pack. The applications of ice should be made every fifteen or thirty minutes if ordered, and may be continued at these intervals for one or twenty- four hours. Graduated Cold Bath.—The child is placed in a tub of water at a temperature of 100 ° F. The temperature is then gradually reduced by the addition of ice wrapped in towels or by cold water until the temperature of the water is 85° F. or 8o° F. While in the tub the child's body should be vigorously rubbed and an ice-bag or cold cloths should be applied to the head. The bath may be continued for ten or fifteen minutes. Upon removal the child's body should be quickly dried and wrapped in a warm blanket. The temperature of the child should be taken half an hour after removal from the bath. Cold Irrigation of the Colon.—Water of 400 F. to 50° F. is injected through a catheter into the rectum. About a pint should be injected at one time. When introducing the catheter, if the end is placed immediately within the sphincter and then a small amount of water al- lowed to run, the rectum will dilate and permit the further introduction of the catheter to be accomplished easily. 43O DISEASES OF CHILDREN FOR NURSES Measures to reduce temperature should be stopped if the child becomes very blue. COUNTER-IRRITATION Cantharides Blister.—The surface of the skin which is to be blistered is thoroughly scrubbed and washed with alcohol. The cantharides plaster should be cut to the proper size and its surface oiled. It should then be applied and allowed to remain in position for six hours. The plaster should be removed carefully, and if the skin is raised cut the lowest portion of the bleb and allow the fluid to run out, carefully protecting the sound skin. Do not tear the blistered skin, as it causes a great deal of pain. Apply zinc-oxid ointment. If the blister is not raised at the expiration of the six hours apply boric-acid ointment covered with a thick layer of cotton; this will cause it to raise in a few hours. Mustard Paste or Mustard Plaster.—Take one part of powdered mustard and six parts of wheat flour, mix with white of egg or lukewarm water, and spread between two layers of old linen or muslin. White of egg is used in preference to water, as it prevents blistering. In pulmonary diseases the mustard paste should sur- round the chest, and in heart failure it should cover the entire trunk. Mustard Poultice.—One part of mustard added to six parts of flaxseed and thoroughly mixed in lukewarm water. When ordered the strength can be increased up to one part of mustard to three parts of flaxseed. It is a very useful method of applying mustard over longer periods. Mustard Bath (Heubner's).—An extremely heroic mustard bath given in some cases of collapsed lung. THERA PE UTLCS 4 31 The proportions are one pound of mustard to one and a half quarts of water. A sheet is wrung out in the above and wrapped about the child from the axillae to the feet; it is allowed to remain in this dressing for from fifteen to thirty minutes. The mouth, nose, and eyes must be protected from the mustard fumes. After removing the sheet the child must be given a warm tub in order to thoroughly remove all traces of the mustard. The real object of this procedure is to get the child to cry vigorously from the irritation of the mustard, and in this way to expand the collapsed portion of the lung. (For Mustard Tub, see page 440.) Mustard Pack.—The child should be stripped and laid upon a blanket; the trunk should be surrounded with a sheet dipped in mustard water. This is prepared by adding one tablespoonful of mustard to a quart of tepid water. After the wet sheet is applied the child should be wrapped in a blanket. It should be removed in from ten to fifteen minutes. Turpentine Stupe.—A teaspoonful of turpentine is mixed with a pint of boiling water. A flannel cloth is dipped in this mixture and wrung out very tightly in a stupe wringer. It is then applied to the part affected and covered with oiled silk or wax paper. A thick layer of cotton should be placed over all, to retain the heat. Camphorated oil, amber oil, and olive oil, four parts, mixed with turpentine, one part, are liniments which may be applied to the chest. They are either rubbed in with the hand or applied by means of flannel cloths wet with the preparation. Dry Cups.—A small medicine glass is selected, the edges of which should be carefully oiled before using. 432 DISEASES OF CHILDREN FOR NURSES One or two drops of alcohol are placed in the glass, it is then manipulated so that the alcohol covers the sides of the vessel with a thin film, care being taken that no drops of the liquid are present. The alcohol is then lighted, and, while burning, the glass is inverted and the mouth is held firmly against the skin. The skin will be sucked up into the glass on account of the vacuum, and the cup will be firmly held in place. They are allowed to remain in position for fifteen or thirty minutes. To remove, press the skin down at one side of the glass in such a way that air is allowed to enter. The greatest care is necessary in the application of cups to prevent burning of the skin. This is caused by a drop of burning alcohol running down the sides of the glass and falling on the skin, or by over- heating the edges of the glass. Wet Cups.—The skin should be scrubbed. The phys- ician will then scarify the part to be cupped and apply the cups in the same way as described above. POULTICES Antiseptic Poultices.—Absorbent cotton wet with a solution of bichlorid of mercury, i to 4000; potassium permanganate, 1 to 4000; or carbolic solution, 1 to 40, and covered with green protective or wax paper. Charcoal poultice is used as a deodorizer. One part of powdered charcoal is added to two parts of linseed and prepared like a flaxseed poultice. Powdered charcoal is spread over the surface. Digitalis Poultice.—Make a flat bag and fill with leaves of digitalis. The bag should be steeped in boiling water and applied, or soak digitalis leaves, 2 oz. to 3 pint, in warm water, until they are soft, drain off the THERAPEUTICS 433 water, and boil them. The decoction can then be added to flaxseed. Flaxseed Poultice.—According to the size of the poultice which is required, a quantity of flaxseed is added to boiling water until the mixture is thick enough to stir. It is then thoroughly beaten over a flame to fill the poultice with air, this makes the poultice light. A layer half an inch thick is spread over old linen, applied to the affected part, and covered with wax paper. In some conditions, such as pneumonia and peritonitis, the lightest possible poultices are necessary; layers less than half an inch are then applied. Spice Poultice.—Equal parts of allspice, cinnamon, ginger, and cloves are placed between two layers of flannel or gauze, which are then quilted. It is then wrung out of hot whiskey or brandy, applied to the part affected, and covered with 'wax paper. In heating whiskey or brandy they should never be placed upon the stove or near a flame. They should be poured into a cup which is then placed in a receptacle containing boiling water. Starch Poultice.—The starch is first mixed with a little cold water, and then enough boiling water is added to make a paste. It is spread on old linen or muslin, covered with a layer of gauze, and applied like other poultices. A few drops of laudanum may be sprinkled over the surface of the poultice before applying, if there is much pain. A preferable form of starch poultice for skin diseases is to make a flat bag and fill with dry potato starch; then dip in boiling water and allow to cool. Technic.—All poultices should be beaten until they are thoroughly filled with air; this renders them light in 28 434 DISEASES OF CHILDREN FOR NURSES weight. They should be covered with wax paper or oiled silk and a thick layer of cotton to keep them warm. News- papers may be used in emergencies. A margin of i inch of the linen should be left to turn in, the surface of the poultice should be anointed with oil to protect the skin, and one poultice should not be removed until another is ready for application, the skin being wiped dry before the new one is put in place. Before applying a poultice, test its temperature by holding it to your face. Do not leave one poultice on over an hour. COMPRESSES Cold compresses are made by wringing cloths out of cold water and applying to the body. For the eyes small disks are cut from muslin or lint and placed upon a cake of ice. When they are thoroughly cold they are laid over the closed eyelids. They should be changed constantly. Hot compresses for the eyes are prepared in the same manner, boiling water being used instead of ice. The disk should be tested upon the back of the hand before application. HOT APPLICATIONS Hot-water bags are filled with water as hot as can be borne. All the air should be expressed before screwing on the top, and the bag should be placed in a properly fitting flannel cover to prevent burning of the skin. Hot Foot-baths.—The bed should be protected with a rubber mackintosh, which in turn is covered with a towel. A small foot-tub is placed upon this, containing enough water to cover the child's feet at a temperature of 115° F. The exposed portions of the child's legs should be covered THERAPEUTICS 435 with towels. After three minutes a quart of hotter water is added, care being taken not to allow it to come in contact with the child's extremities. The addition of hotter water is continued at these intervals until the water is as hot as can be borne by the hand. The child's feet should remain in the water at this temperature for about fifteen minutes, when they are quickly dried and wrapped in a warm blanket. Hot Bath.—The child is placed in a tub of water at a temperature of ioo° F. The temperature is gradually raised to no° F. by the addition of hot water. A ther- mometer should be used so that the temperature of the water is not raised too high. The body should be vigor- ously rubbed and an ice-cap or cold cloths should be applied to the head while the child is in the bath. The bath should last for ten to fifteen minutes. Hot Pack.—The clothes are removed and the child is wrapped in a blanket wrung out of water at a temperature of no° F. The child should then be rolled in a second dry blanket covering the first. Hot-water bottles should surround the child and an ice-cap or cold cloths should be applied to the head. These hot applications can be applied every twenty or thirty minutes until free per- spiration is produced. Hot water or lemonade may be given to induce sweating; the sweat may be continued as long as desirable. At the expiration of the necessary time the moist blanket is removed, care being taken not to expose the child, a warm, dry blanket taking its place. The child is then sponged with warm water and alcohol to remove the perspiration. The undershirt and night- gown are then replaced and the ice-cap removed, the child always remaining between warm blankets. 436 DISEASES OF CHILDREN FOR NURSES Modified Hot Pack.—The child is wrapped in dry hot blankets. Hot-water bottles are placed under the arms, knees, and feet. An ice-cap over the head. Hot lemon- ade should be given and the pack terminate as above. Vapor Bath.—The bed should be covered with a mack- intosh and blanket. The clothing is removed and a Fig. 106.—Vapor bath. The covers are held above patient by means of a frame. They are tightly tucked in all around bed. The steam is introduced from kettle at foot of bed. An ice-cap is applied to head. Warm or cold beverages are administered to induce perspiration. blanket is placed loosely over the child. A frame reaching from the neck to well below the feet is placed over the patient. All metal parts of the frame must be covered by a bandage or old muslin to prevent condensation of the THERA PEUTLCS 437 steam. Over the frame, in the following order, are placed, first, a blanket, then a mackintosh with the rubber side toward the patient, completely covering the frame, and, finally, several blankets covering the whole apparatus. A thermometer should be placed on the chest of the child where it can be readily obtained. The covers are then tucked in securely at the top and both sides of the frame. If desired the blanket which loosely covers the child can now be withdrawn from the opening at the foot. This blanket is usually allowed to remain in giving vapor baths to children. The covers are then tucked in about the foot of frame, a small opening being left which should be of sufficient size to allow the introduction of the spout or hose leading from the steam kettle. Before applying the steam an ice-cap is placed on the child's head, boiling water is placed in the kettle, and the alcohol lamp beneath is lighted. When steam appears, the spout or hose is placed through the opening left for that purpose, care being taken not to place the spout over the child's feet, as the drip from its end is liable to scald the skin. The thermometer should be read every five minutes, care being exercised not to expose the chest. When the thermometer reads 1200 F. the kettle should be removed and the child allowed to remain exactly as before for twenty or thirty minutes. If the thermometer at no time registers 1200 F. the steam is kept up for thirty minutes. During the bath give hot or cold water freely; hot lemonade is also used at times to induce perspiration. At the end of twenty or thirty minutes after the ther- mometer has reached 1200 F. the frame is carefully 438 DISEASES OF CHILDREN FOR NURSES removed from under its covering in such a way that there is no exposure nor disturbance of the covering, the steam thus being retained. The child remains in this position for twenty minutes. At the expiration of this time the moist blankets and mackintosh are carefully removed, warm, dry blankets taking their place. The child is then sponged with warm water and alcohol to remove the perspiration. The undershirt and night-gown may then be replaced and the ice-cap removed. The child should always remain between warm, dry blankets. In private houses an attachment at times can be made to the steam-heat radiators; this saves a great deal of trouble in chronic cases. A tea kettle with a garden hose attached to its spout, the other end placed at the foot of the bed, will answer very well when no special apparatus is at hand. A piece of stove-pipe covered with asbestos can be fitted up to answer the same purpose. Holes should be punched through its sides for ventilation, and it should have an " elbow," so that it can be directed over the foot of the bed. Inside of the stove-pipe, standing on a piece of asbestos, place an alcohol lamp over which can be placed a tin cup filled with water. In the country or where it is impossible to generate steam by any of the above methods, hot bricks plunged into a basin half-filled with cold water may answer. Hot-air Bath.—The child and bed are prepared as in the vapor bath, only the steam is omitted. Hot air is introduced beneath the blanket by placing the alcohol lamp beneath the spout of an open kettle. This generates heat at this point, which passes into the bed. THE RAPE UTICS 439 The stove-pipe, as described above, can be used here, the cup of water being unnecessary. In many modern houses the electric light can be taken advantage of to give hot-air baths. A 30-candlepower electric bulb should be purchased. The child and bed can be prepared as in the vapor bath, except for an opening, which should be left over the upper portion of frame, through which the bulb can be passed and securely tied to the frame in such a way that there will be no danger of burning the child or the blankets. After the bulb is in place the opening can be closed. All the adjunct meas- ures as described under the vapor bath should be carried out. A sitting hot-air bath can be given by placing the child wrapped in a blanket on a chair, with his feet in hot water. Blankets draped from his shoulders should cover the child and the chair. Beneath the chair place an alco- hol lamp in a bucket, or the 30-candlepower lamp may be used. In any of the above baths, if pilocarpin has been ordered by the physician, it should be given at the time the nurse is about to begin the preparation for the bath. Then it will be fully active during the bath. Sitz Bath.—Useful when there is retention of urine, pain in pelvic region, or rectal congestion. A simple method is to place the child in the sitting posture in a tub of water at 115 ° to 120 ° F. The water should come to the level of the umbilicus. Salt Baths.—Prepared by adding from 3 to 5 oz. of sea salt to a gallon of water at a temperature of 900 F. to ioo° F., the number of gallons used in a 44O DISEASES OF CHILDREN FOR NURSES bath varying. When the solution of salt is of sufficient strength the water causes the skin to glow. The baths are useful in rickets. Mustard Bath.—The bath is prepared by placing four or five tablespoonfuls of dry mustard in a gauze bag, which is shaken in four or five gallons of water until it is thoroughly saturated with the mustard. The water should be at a temperature of 105 ° F. when the child is put into the tub, after which it should be slowly raised to no° F. by the addition of hot water. An ice-cap or cold cloths should be applied to the head and the body vigor- ously rubbed while the child is in the tub. It may be continued for ten minutes, at the expiration of which time the child should be quickly removed and wrapped in a blanket without drying. Mustard Foot-bath.—At times it is impracticable to put children in a tub; then a mustard foot-bath is useful. The bed is protected by a rubber blanket covered with towels. Cloths are wrung out of mustard water made by adding a teaspoonful of mustard to a quart of water and heated to no° F. These are wrapped about the child's feet, the rest of the body being covered. They are applied until the skin becomes red. BATHS USED IN TREATING SKIN DISEASES Bran Baths.—Place one quart of ordinary wheat bran in a gauze bag and place in four or five gallons of water. The bag should be shaken and squeezed until the water resembles a thin porridge. The temperature should be maintained at 95 ° F. Alkaline Baths.—The quantity of water should be THERAPEUTICS 441 twenty-two and a half gallons, at a temperature of 95 ° F. In this is placed: Carbonate of soda, 3 oz. Bicarbonate of soda, 3 oz. Carbonate of potassium, 3 oz. Borax, 3 oz. Compound Glycerin Bath.—Water, twenty-two and a half gallons, at a temperature of 95° F. Ingredients: Glycerin, 2 oz. Tragacanth, 1 oz. The bath must be used immediately, as this mixture forms glue. Compound Sulphur Bath.—Water, twenty-two and a half gallons, at a temperature of 95° F. Ingredients: Precipitated sulphur, 1 lb. Sodium hyposulphite, 1 oz. Acid sulphuric (strong), 1 dr. Water, 1 pt. To be mixed and then added to tub. Linseed Bath.—Add one pound of linseed to twenty- two and a half gallons of water at a temperature of 95 ° F. Starch Bath.—Take four tablespoonfuls of crushed starch and make a paste by adding cold water. Then add two quarts of boiling water, stirring over a fire until it makes an ordinary laundry starch. To twenty gallons of water at a temperature of 95 ° F. add 4 oz. of wash- ing soda and then add the cooked starch. If especially ordered, 4 oz. of glycerin and 4 oz. of borax may be added to the above, or the following: Sodium biborate, \ oz. Sodium carbonate, 2 oz. Potassium carbonate, 3 oz. 442 DISEASES OF CHILDREN FOR NURSES Two to four teaspoonfuls of this mixture are added for every gallon of water, with double the amount of dry starch. Tar Bath.—The patient is rubbed with oil of cade on the diseased patches and then is given a warm bath or a plain starch bath. Vinegar-and-Mercury Baths.—Water, twenty-two and a half gallons, at a temperature of 95 ° F. Ingredients: Vinegar, i pt. Glycerin, 1 pt. Bichlorid of mercury, i dr. HYGIENIC BATHS Tepid Bath.—Given at a temperature of from 95° to ioo° F. It is useful in nervous conditions and to induce sleep. Shower Baths or Sponge Baths.—The child should stand in a foot-tub containing warm water. A large sponge holding about a pint of water at from 40 ° to 60 ° F. should be squeezed three or four times over the chest, shoulders, and spine of the child, the skin being vigorously rubbed meanwhile. The bath should not last more than half a minute, and should be followed by a brisk rubbing until a thorough reaction is established. SYRINGING Eye Syringing.—The lids should be massaged to remove pus, then held apart by the fingers, and any dis- charge dislodged from beneath them. A soft-rubber ear syringe is filled with saturated solution of boric acid heated to 100 ° F., and the nozzle is placed at the inner canthus of the eye. The solution should be wiped away THERA PEUTLCS 443 with antiseptic cotton. Always wipe toward the external canthus, to avoid contamination of the other eye. Medi- cine which is to remain in the eye is dropped in at the external canthus. The rubber ear syringe is safer to use Fig. 107.—Method of syringing eye. The cotton held against the nose should prevent any infection of other eye. than the ordinary glass eye-dropper, as children are prone to struggle. Ear Syringing.—An ear syringe is filled with water at a temperature of no° F. The soft-rubber nozzle is placed within the external auditory canal and the bulb gently squeezed. A half pint to a quart of water is used. A fountain syringe held on a level with the ear can be substituted for the small syringe. The bag should be filled with a quart of water at no0 F., and a small nozzle held in the auditory canal. Do not raise bag above level of ear as it causes too great a pressure. 444 DISEASES OF CHILDREN FOR NURSES Nasal Syringing.—A soft-rubber nasal syringe is filled with an antiseptic solution. The same syringe should Fig. 108.—Method for syringing ear with fountain syringe. The lower end of bag should not be above level of auditory canal. not be used for more than one child unless thoroughly disinfected. Two positions may be used in nasal syringing. In diphtheria, scarlet fever, or any severe illness the child should not be removed from the bed. In such cases the head should be held on one side, the syringe being placed THERA PE UTICS 445 in the upper nostril. Then the child's head should be turned to the other side and the other nostril syringed. The alternate syringing should be continued until the nose is clean. When syringing, the water should run out of the opposite nostril or out of the mouth. The other method is to hold the child erect on the lap with the head inclined a little forward, the syringing being done by a person who stands behind. Fig. 109.—Method for syringing nose. The syringe is introduced into upper nostril, the solution escaping from opposite nostril or mouth. Just as small an amount of pressure should be exerted when syringing the nose as possible, on account of the danger of forcing the infection into the Eustachian tube and causing an otitis media. At times a fountain syringe is used to irrigate the nose. 446 DISEASES OF CHILDREN FOR NURSES The bottom of the bag should not be over two feet above the child's head. Syringing of the Mouth and Pharynx.—A Davidson syringe may be used. If the pharynx is to be reached the nozzle is used as a tongue depressor. This should be placed at the angle of the mouth between the back teeth. The child should be held in the sitting posture, with the head inclined forward. INHALATIONS Croup Tent.—A croup tent is made by placing a blanket over a frame in such a way that the entire bed is Fig. no.—Croup tent (J. P. C Griffith). covered except for a small aperture at the side of the bed near the head which is required for ventilation. THERAPEUTICS 447 Blankets are used instead of sheets, as the latter are liable to catch fire. If a regular frame is not available, a good substitute can be made by erecting broom-sticks at the four corners of the bed and stretching a cord around the tops of the sticks. A very good tent can be improvised by throwing a large blanket over an umbrella. A croup kettle heated by a safety alcohol lamp should be placed upon the floor or on a low box beside the crib, Fig. m.-Croup kettle (J. P. C. Griffith). so that the end of the spout is just inside the tent at a level, of the surface of the bed. The kettle is filled with boiling water and a dram of the compound tincture of benzoin may be added. The medicated steam vapor is very soothing in inflammations of the respiratory tract. Great care must be taken to prevent the tent or bed-clothes from catching fire. 448 DISEASES OF CHILDREN FOR NURSES STOMACH WASHING OR LAVAGE A soft rubber catheter, size 16, American scale (24 French), with a large eye, is attached to rubber tubing by a glass joint. A funnel holding from 4 to 6 oz. is inserted in the end of the tube. The child should be held in a sitting posture, the body protected by a rubber sheet and the catheter moistened. While the tongue is depressed with the forefinger of the left hand the catheter is rapidly passed into the pharynx and down the esophagus. About ten inches of the catheter should be passed beyond the lips. When it has reached the stomach the funnel is Fig. 112.—Lavage. raised higher than the level of the infant's stomach and from 4 to 6 oz. of water poured into it from a pitcher. When this has run into the stomach the funnel is lowered and raised three or four times to remove any stomach contents, and then lowered below the level of THERA PE UTICS 449 the infant's stomach, which siphons out the water and stomach contents. This should be repeated until water runs clear. In older children the funnel should be refilled several times before siphoning out the contents, as the capacity of the stomach is greater. The water should be boiled and be at a temperature of no° F. when used. When Fig. 113.—Gavage. the siphoned water runs clear remove the catheter from the stomach. To siphon successfully there must be some water remaining in the funnel when it is lowered. Care must be taken in giving both lavage and gavage that the child does not bite off and swallow the tube, for if such an accident happens there is nothmg to do but open the stomach. 2g 45O DISEASES OF CHILDREN FOR NURSES GAVAGE (FEEDING BY STOMACH-TUBE) Gavage (Feeding by Stomach-tube).—The same appara- tus is used as in stomach washing. The child should be wrapped in a blanket. Sometimes, where there is great resistance to the introduction through the mouth, it may be passed through the nose. In older children a mouth gag is often necessary. A good substitute is a large spool, the catheter being passed through the hole in the spool. After the tube has entered the stomach the funnel should be raised to allow the gas to escape. The food is then poured into the funnel; as soon as it has disappeared the tube is tightly pinched and quickly withdrawn to prevent food from trickling into the pharynx, which often causes vom- iting. In young infants, after removing the tube, it is well to keep the jaws open for a few moments to prevent gagging. Food given by gavage is often predigested; the intervals between feedings must be longer than under other cir- cumstances, and at times the stomach should be washed first. IRRIGATION OF THE COLON The child is placed upon its back, brought to the edge of the bed with the thighs flexed, and the buttocks slightly elevated. A soft rubber catheter is attached to an ordinary fountain syringe, the bag containing the water being hung 4 or 5 feet above the bed. The water should be at a temperature of 85 ° or 90° F. in ordinary cases; when there is shock normal salt solution at a tem- perature of no° F. is used. The catheter should be greased before introduction and a small quantity of the water allowed to run off. It should then be placed within the sphincter when the water is allowed to flow. THERAPEUTICS 451 This distends the rectum and allows further insertion to be accomplished easily. The catheter is pushed in slowly to a distance of 12 or 14 inches. Usually a pint and often a quart will be introduced before any water returns. The irrigation should be continued until the water returns clear; at times a gallon of water is used for a single irrigation. Gentle kneading of the abdomen should be continued during the procedure. At the end of the irrigation the rubber tube is detached and the water allowed to escape through the catheter. CONTINUOUS SALINE INJECTION This is used by many surgeons following operations on septic cases, especially appendectomy. It is useful when- ever children are greatly depleted. An ordinary fountain syringe is filled with normal salt solution at a temperature of 115 ° to 120 ° F. This is tied to the foot of the bed not over a foot above the level of the buttocks. Two hot-water bags, tied together, are sus- pended over the bag containing the salt solution, one on either side, and a blanket is wrapped around them. The hot-water bags can be refilled from time to time as they cool. The tube is then carried under the bed-covers and over hot-water bags, which lie on the bed, to the child's buttocks, which are elevated. Here it is attached to a specially prepared rectal tube (Murphy's tube). A cath- eter can be used in place of a Murphy tube if the latter is not at hand. The catheter should be inserted from four to six inches in the rectum. If the tube is expelled it must be strapped in with adhesive plaster. The flow of the salt solution is controlled by a stop-cock or, better, a hemostat. The solution should drip (a drop at 452 DISEASES OF CHILDREN FOR NURSES a time) into the rectum. By shutting off one-half or more of the caliber of the tube by means of the hemostat this can be regulated. The idea of giving the solution so slowly is to have it all absorbed. Usually, however, there is leakage, and the clothes must be changed frequently and the bed protected. The system of hot-water bottles will keep the solution at the proper temperature. When the solution is not retained a good plan is to give it for two hours, then dis- continue for the same length of time. ENEMATA An enema consists in the injection of soapy water into the rectum. The water should be at a temperature of 85° or 900 F High Enema.—A catheter should be attached to the nozzle of the fountain syringe and thoroughly greased. A small amount of water should be allowed to run off before introduction; then place the catheter within the sphincter and start the flow; this allows it to be pushed in further without doubling up. Where an immediate effect is desired the most efficient enema contains one teaspoonful of glycerin. Oil enemas are useful where the fecal mass is hard and dry and expelled with difficulty. Low enemas are given in the same manner; the water is injected by the introduction of the nozzle of syringe within sphincter, the catheter being unnecessary. Nutrient enemata are sometimes used. They should be peptonized. When drugs are given by enemata milk is sometimes used as the fluid. THERAPEUTICS 453 HYPODERMICS The skin should be rubbed with alcohol and then pinched between the thumb and forefinger, and the needle plunged firmly into the subcutaneous tissue. Veins must be avoided. The solution is injected slowly. After the withdrawal of the needle the part should be kneaded with the fingers. If the drugs used are of an irritating nature hot sponges of cotton should be applied to the part. The hypodermic needle must be sterile. For the administration of gelatin solutions sterile "horse hypodermics" are used. The preparations must be injected slowly and the punctured wound covered with collodion. Antitoxin is sold in sterile hypodermic tubes. The method of introduction is the same. BACTERINES AND VACCINES These are emulsions of dead bacteria which are injected into the patient to stimulate phagocytosis, based on Wright's opsonic theory. Phagocytosis is the property of the white blood cor- puscles to destroy germs and to eliminate toxins or poisons. In many conditions it does a great deal of good. The technic of administration is the same as for any hypodermic injection. VAGINAL DOUCHING A fountain syringe with a catheter attached to the nozzle is used. The catheter should be sterile and greased before introduction into the vagina. The solutions used for douching are bichlorid of mercury, i: 10,000; potassium permanganate, 1:10,000; saturated solution of boric acid; and salt solution. They should be at a tern- 454 DISEASES OF CHILDREN FOR NURSES perature of no° F., and from one to two quarts are used. VAGINAL INJECTIONS Argyrol is the drug most often used. Three drams of a io or 20 per cent, solution of argyrol are placed in a glass syringe having a sterile rubber catheter attached to the nozzle. The parts are thoroughly cleaned and the solution injected. The catheter is quickly with- drawn and the vulva is held together for several minutes, when the solution is allowed to run out. Argyrol deeply stains all linens. It is sometimes administered in the form of vaginal suppositories. METHODS OF RESUSCITATION* When a person is shocked by electricity, overcome by coal or illuminating gas, rescued from drowning, poisoned by certain drugs or fumes, severely injured, or in a state of collapse from one of many other causes, he may ap-< parently be dead, but if there is. some one at hand who can start the proper methods of resuscitation at once, a human life may be saved. It is practically impossible for a person to recover if certain cells in the brain have been deprived of oxygen for a period exceeding ten minutes, so within that space, of time lies his chance of life or death. A person dies from one of two causes: in the first class, failure of the heart is primarily-responsible for death, and in the. second, failure of the respirations. Heart Failure.—If the heart has ceased to beat there is no known practical agency by which it may be started ♦Robert S. McCombs in The Nurse, October, 1015. THERA PE UTICS 455 again. However, though the patient is apparently dead, the heart may make a weak attempt at beating, so weak that respiration ceases from failure of the supply of oxygen to reach the respiratory center in the central nervous system. The oxygen, of course, is carried to this center by the blood and, when the failing heart can- not propel the blood-stream at its normal rate and volume the supply of fresh oxygen is diminished and the respira- tory center shuts down. Cessation of respiration itself will soon stop any attempts of the heart to beat. There- fore the most important single expedient in this class of cases is to re-establish respiration by means of arti- ficially forcing the victim to breathe, for in this way the vicious circle is broken. Respiratory Failure.—In collapse due to electric shock, coal or illuminating gas poisoning, and drowning, the function of respiration is either suddenly paralyzed or progressively depressed. The heart may not be affected at first to a degree which in itself would prove dangerous, but the interruption of the oxygen supply to the body will soon stop its action. In this class of cases artificial respiration is again indicated as the most im- portant factor in the treatment. The principal thing that we attempt to accomplish in all methods employed, for inducing artificial respiration is to force air in and out of the lungs in sufficient quanti- ties to supply enough oxygen to maintain life and to stimulate the respiratory center to resume its function. Inhalation of oxygen in itself is always a good adjunct to artificial respiration; likewise rubbing the extremities, slapping the skin surface, passing gauze saturated with ammonia beneath the nose (not so close that burning 456 DISEASES OF CHILDREN FOR NURSES from the fumes may be a danger), assist in stimulating the respiratory center. It is also vital in every method to loosen the clothing so that movement of the chest will not be restricted and to clear mucus from the mouth, also to pull the tongue forward so as to give the air free passage. If necessary the jaw should be forced open, and it is always best to put some hard object between the teeth that the patient may not bite the tongue. Hot-water bottles should be placed about the victim if the temperature is subnormal or if other symptoms of shock are present after recovery takes place. In case of drowning, the water should be expelled from the stomach and lungs by placing the victim face downward across a barrel or similar object; thus, com- pression of the abdomen forces the water out. No method of artificial respiration, manually applied, will ventilate the lungs with as large an amount of air as is obtained in normal breathing. The Schafer, Silvester, Hall, and Howard methods, however, will sustain life. There are also on the market several machines for per- forming artificial respiration. These include the pul- motor, Doctor Brat's apparatus, the lungmotor, and the salvator. Doctor Meltzer of the Rockefeller Institute has published a description of an apparatus which he has given to the medical profession. Manual Methods of Artificial Respiration.—Artificial respiration has been given a great deal of scientific study during the past few years in an effort to standardize the methods to be employed and to simplify the manipu- lations required. It has been felt that the old Silvester method, which has proved its efficiency over a long THERAPEUTICS 457 period of time, is too complicated for the average layman to grasp immediately; it is too difficult to apply correctly and, if not properly performed, it loses its value. This, together with the fatigue engendered by the necessary exertion on the part of the person manipulating the arms of the victim, makes a more simple and less tiresome method desirable. Through actual experience the Schafer or "prone- pressure" method has been found just as efficient and is very much easier to apply. Scientific experiments have proved its value, and now it is being advocated as the proper method to employ. It was devised by Sir E. A. Schafer, of Edinburgh, and consists in laying the victim on his belly and applying pressure rhythmically on the loins and lower ribs. To get the best results the arms should be stretched forward above the head, and the face turned to one side so that breathing through the mouth and nose will not be embarrassed, and the operator should stand or kneel across the victim's back. In this position he places his hands over the lowermost ribs and upper portion of the loins and by bending forward, and in this, way throwing the weight of his body on his wrists, the victim's chest is compressed against the ground and the air is squeezed out of the lungs; then by assuming the erect posture the pressure is removed and the natural elasticity of the chest causes it to expand spontaneously and respiration results. By repeating these movements rhythmically twelve times to the minute, a person can be kept alive almost indefinitely. The pressure should be applied evenly, without sudden forcible movements, so that no injury to the ribs or liver will occur. The following figures, obtained by Henderson, show 458 DISEASES OF CHILDREN FOR NURSES the amount of air interchanged in Silvester's and Schafer's methods, compared with the amount in natural breathing at the same rate as the artificial: Silvester's, 150-200 c.c; Schafer's (with arms stretched forward), 200-300 c.c; natural breathing, 500-600 c.c. Summed up, the advantages claimed for the Schafer method are (1) greater simplicity and ease of adminis- tering, (2) absence of trouble from the tongue falling backward and blocking the air-passages, (3) little danger of injuring the liver or breaking the ribs if pressure is gradually and not violently applied, and (4) larger ventilation of the lungs. In performing artificial respiration, if the child does not show any signs of returning vitality, do not be dis- couraged, but continue the motion regularly for at least one hour, summoning such assistance as you may need. ASPHYXIA IN THE NEWBORN At times the child fails to breathe after birth. Under such conditions it is necessary to stimulate the respiratory centers. This usually can be accomplished by slapping the child, pouring ether or cold water over the chest, and removing mucus from the mouth; or if these methods fail, by grasping the base of the ribs between the thumb and fingers, the thumb on one side of the body and the remaining fingers on the other; by firmly squeezing the fingers together the air is forced out of the lungs, and upon relaxing the fingers the chest expands, filling the lungs. The base of the ribs should be forced together in this manner at the rate of about thirty times to the minute. THERAPEUTICS 459 HYPODERMOCLYSIS This is the introduction of normal salt solution under the skin. For this purpose is used a sterile fountain syringe or glass reservoir with a special needle attached to the end of the rubber tube. The needle of a "horse hypodermic" can be used. The bag is filled with the necessary quantity of normal salt solution, at a temperature of 1200 F., which has been sterilized on three successive days. After the cold water has run off, the needle is plunged through the skin. The pectoral and gluteal regions are usually selected as the places for injections. When the needle is in place the normal salt solution is allowed to run slowly, and continued until the amount ordered, varying from i to 8 oz., has entered the sub- cutaneous tissues. A small collodion dressing is applied to the puncture. Use a sterile thermometer for taking temperature of salt solution. INTRAVENOUS INJECTIONS This consists of the introduction of normal salt solution into a vein. The physician usually selects a vein at the inner side of the elbow-joint. A bandage is tied tightly around the arm above the joint to engorge the vein. He dissects the vein away from the surrounding tissue and places a grooved director beneath it. A ligature of catgut is thrown around the vein, below the point of inserting the needle, and tied. A second ligature is placed in position above the point of insertion, but it is not tied until after the injection has been given. A sterile fountain syringe or glass reservoir is filled with the required amount (usually a quart) of normal salt solution, which has been sterilized on three successive days, and a hypodermoclysis 460 DISEASES OF CHILDREN FOR NURSES or horse hypodermic needle attached to the end of the rubber tube. The normal salt solution should be at a temperature of no° to 1200 F. (use sterile ther- mometer). When the physician is ready to introduce the needle into the vein the solution is allowed to run; it should be running when it is introduced into the vein, as this avoids the entrance of air into the vessels, which is a very dangerous accident. The bandage should be cut as soon as the needle enters the vein. When the solution has run into the vein the upper ligature is tied before the needle is removed. The skin wound is then stitched and an aseptic dressing applied. The instruments needed in this operation are a scalpel, forceps, hemostats, grooved director, ligatures, and a foun- tain syringe with proper needle; also roller bandage. The arm should be prepared as for an operation. EXTENSIONS FOR FRACTURES AND COXALGIA A strip of adhesive plaster, 2 inches wide, is cut long enough to extend from the outer portion of the knee or middle of the thigh to a point 2 inches below the sole of the foot and from there to the middle of the thigh or knee on the opposite side of the leg. The adhesive is applied to the outer portion of the leg, as far as the ankle- joint. It is not attached to the foot, and 4 inches are allowed for the loop around the foot. It is then carried to the opposite ankle-joint and applied to the inner side of the leg. A bandage starting at the ankle- joint is applied to the leg as far as the adhesive strips extend. A small block of thin wood, 3 inches long and 2 inches wide, is covered with adhesive, a hole bored in the center, and the board placed in the middle of the loop THERAPEUTICS 461 below the foot and held in place by a strip of adhesive. Through the perforation in the block a wire is passed, which is firmly attached to the inner side of the block. The wire should run over a pully at the foot of the bed and have a four or five-pound weight attached at the base which should clear the floor by several inches. A wad of cotton is placed beneath the tendo Achillis to prevent pressure at this point. The foot of the bed is elevated to obtain counter-extension. Fig. 114.—Buck's extension apparatus. The foot of the bed is elev.Ued to obtain counter- extension. Care must be taken in the removal of old adhesive strips that the skin is not pulled off with the plaster. Alcohol or ether will render this task easier. DRESSING FOR FRACTURE OF THE FEMUR IN CHILDREN OVER TWO YEARS OF AGE Hamilton Splint.—This is the best dressing to apply in childhood. It consists of (1) two long splints; the ex- 462 DISEASES OF CHILDREN FOR NORSES ternal reaches "rom the axilla to the sole of the foot and the internal extends from the groin to the sole. They are 4 or 5 inches wide at the hip-joint and taper to 3 inches at the ankle. (2) Two long bags filled with bran, the external reaching from the axilla to the ankle and the internal extending from the groin to the internal malleolus. (3) A Buck's extension apparatus applied as described above. (4) A sand-bag reaching from the axilla to the ankle along the uninjured side. Method.—A piece of unbleached muslin of sufficient length to reach from the axilla to the sole and a yard wide Fig. us-—Hamilton splint. First apply a Buck's extension. The injured leg is held in position by bran-bags between wooden side-splints, a long sand-bag balances the dressing on the sound side, to which is tied the uninjured ankle. A shot-bag is placed over upper fragment of fractured bone. is placed beneath the child. At a point corresponding to the level of the groin the muslin is cut through half its width. The extension apparatus is applied and the bran-bags put in their proper places in close apposition to the leg. The splints are then laid on the edge of the muslin and folded in until they fit close to the bran-bags and hold them snugly to the leg. Three or four strips of bandage placed around the dressing keep the splints THERAPEUTICS 4^3 in place. The sand-bag is placed along the uninjured side. The upper portion of the unbleached muslin, which has not been folded in by the internal splint, is then carried around the body, including the sand-bag, and over the external splint, to hold the upper end in position. A weighted shot-bag is placed over the upper fragment of the bone and the foot of the bed is elevated. The necessity of frequent changing of the dressings and clothing of the child, from contamination with urine and the stools, renders it necessary, at times, to apply a moulded pasteboard splint beneath the fractured thigh, which should extend upward as far as the waist and be firmly held in place. This method of dressing does away with the pain from motion which always attends the process of redressing. MOLDED PASTEBOARD SPLINTS Technic.—The pasteboard is cut in the proper shape and of the proper length, and dipped in hot water. When Fig. 116.—Jaw-cup, unfolded. A moulded pasteboard splint (Da Costa). thoroughly wet it can easily be moulded to the part, which shape it holds when dry. It should be padded with cotton before application. SPLINTS Splints are used to keep the broken fragments of bone in apposition after a fracture. According to the location of the fractured bone different 464 DISEASES OF CHILDREN FOR NURSES kinds of splints have been devised. The principal forms are as follows: shoulder-cap, for fracture of the upper portion of the humerus; the internal angular and anterior angular splints for fractures of lower end of humerus Fig. 117.—Bond's splint (Da Costa). Fig. 119.—Anterior angular splint Fig. 120.—Shoulder-cap (Da Costa). (Da Costa). and upper portion of the bones of the forearm; and the Bond splint for fracture of the lower portion of the bones of the forearm. FRACTURE-BOX This is a special box used for fractures of the lower portion of the leg. It is so constructed that the sides are movable and the foot-piece perforated. THERAPEUTICS 465 A pillow is placed upon the bottom of the box, while the sides are down, upon which is rested the fractured leg in such a manner that the foot is held firmly at a right angle against the foot-piece of the box, being secured in this position by a strip of bandage through the perforations. A wad of cotton should be placed beneath the heel and sole of the foot. The sides of the box are then turned Fig. 121.—Fracture-box (Da Costa) up and held in the upright position by three or four strips of bandage surrounding the box. This causes the leg to be held firmly between the two sides of the pillow. AIR-BEDS AND CUSHIONS Air-beds are useful at times in injuries to the back. Water-beds are also used. Air-cushions are very useful in relieving a part from pressure. PLASTER CASTS Plaster casts are very useful in childhood. They are used for fractures, for keeping joints immobile, and for keeping the bones straight after an osteotomy. Specially prepared bandages are used, which should be soaked in luke-warm water immediately before application. 30 466 DISEASES OF CHILDREN FOR NURSES FRAMES Frames are used in Pott's disease, in order that the backbone may be kept immobile. The child is placed upon the frame in such a position that the buttocks are situated at the opening in the canvas. This permits bowel movement without removal from frame. The child is held in position by unbleached muslin, which is attached to the two side bars of the frame and cut of sufficient length to extend from the axilla to the base of I ■ 1 Fig. 122.—Modified Bradford frame. Devised by Dr. Fauntleroy. The daily tightening of the nuts A and B keeps apparatus rigid. the frame. This covering should be tightly drawn across the child and firmly attached to the opposite bar. The Bradford frame, or some of its modifications, is the best. Fauntleroy's modification permits of the taking up of the slack by daily tightening the nuts in the upper and lower bars. This saves the trouble of constant tightening of unbleached muslin. OILED-SILK JACKET This is a very good method of obtaining a mild, con- stant counter-irritation of the chest, formerly used exten- sively in cases of pneumonia and bronchitis. The jacket is prepared by cutting out three layers, according to the pattern shown on the following page. THERA PE UTICS 467 The outer layer is oiled silk, the middle layer is cotton batting, and the inner layer gauze. For a child one year ffl Fig. 123.—Pattern for oiled-silk jacket. of age the dimensions should be 12 by 12 inches. A properly prepared jacket should last about two weeks. STRAIT-JACKET When it is necessary, in very restless children, to con- trol their movements the strait-jacket is of use. It is made of unbleached muslin, double thickness, a yard wide and cut long enough to reach from one side of the bed to the other. It is attached to the frame of the bed on both sides and fastened securely enough to hold the child flat upon its back. Two armholes are cut at the proper level and distance apart, and these should be bound. A wad of cotton should protect the skin of the axillae from chafing. CUFFS AND HAND COVERS Some form of protection is necessary in children who have a tendency to pick at their dressings or to scratch irritating lesions of the skin. Celluloid cuffs can be purchased which should be well padded before being applied. Pasteboard cuffs are made by cutting stiff pasteboard of sufficient length to extend from the armpit, or axilla, 468 DISEASES OF CHILDREN FOR NURSES to the wrist, and wide enough to encircle the arm. They should be well padded with cotton and held in place by a bandage. This form of dressing prevents the child from bending the elbow. A light metal covering for the hands is the best form Fig. i 24.—A light metal covering for hands which prevents children from scratching sores. of protection. The illustration (Fig. 124) shows this metal covering and the same applied. MASKS Masks are useful in the treatment of skin diseases of the face. They are made so as to cover completely the head and face, small apertures being cut for the eyes, THERAPEUTICS 469 nose, and mouth. It is the only means by which applica- tions to the face can be properly applied. MASSAGE Massage is useful in infancy after attacks of infantile paralysis. The affected limbs should be massaged daily to increase the circulation to the part, so that the unaf- fected muscles will be under the most favorable conditions for hypertrophying or overdeveloping, upon which de- pends a fairly good use of the leg. In childhood, massage is one of the best measures to employ in chronic constipation. It should be practised twice a day, after retiring and in the morning. The proper method of giving massage in these cases is to use only the hand, without grease of any kind, rubbing the abdomen with a circular motion, the idea being to move the abdominal wall over the intestine, and in this way to excite peristalsis. In older children the same causes for massage exist as in the adult. ELECTRICITY Electricity has a limited scope in childhood. In paralytic conditions it is useful and should be applied in the same manner as in the adult. SKIAGRAPHY For the purposes of diagnosis, especially of fractures, the Rontgen ray is of the greatest use. Medicinally it is not employed. 470 DISEASES OF CHILDREN FOR NURSES DISINFECTION All discharges should be immersed in carbolic acid, 1:40; bichlorid of mercury, 1:2000; or chlorinated lime of equal strength, and allowed to stand fifteen minutes. All bed-clothing should be thoroughly boiled for a half hour. Disinfection of Hands.—Remove all dirt from under and around nails. Nails and hands should be thoroughly scrubbed with soap and hot water. Immerse them in 95 per cent, alcohol for not less than one minute, then plunge the hands in a solution of bichlorid of mer- cury, 1: 2000, or carbolic solution, 1:40, and thoroughly wash them for at least a minute. A clean wound should never be dressed after an infected wound. The hands should be disinfected between each dressing. Full bichlorid baths, 1:4000, should be taken while nursing contagious cases, and given to the patient before release from quarantine. Fumigation of the apartments, mattresses, hangings, clothing, etc. is accomplished by thoroughly sealing the room and introducing formalin gas through the keyhole. Disinfection of Excreta.—The stools and urine should be received in a vessel containing a disinfectant. An equal quantity of disinfectant to the size of the excreta should then be added and the whole thoroughly mixed, and allowed to stand for half an hour before emptying into the water-closet hopper. The bed-pan should contain disinfectant when not in use. It should be thoroughly rinsed in warm water before placing it beneath the child, otherwise the disinfectant might burn the buttocks. THERA PE UTICS 471 DRESSING OF BURNS AND WOUNDS The burned or scalded area should be covered with lint saturated with a normal salt solution. All lacerated and punctured wounds should be thor- oughly cleansed with hot water and peroxid of hydrogen. They should be covered with a wet bichlorid or sterile normal salt solution dressing and wax-paper. PREPARATION FOR OPERATION Thoroughly scrub the part with tincture of green soap, shaving first, if necessary; rinse with sterile water and alcohol; then a solution of bichlorid of mercury, 1:2000. Cover with gauze wrung out of 1:4000 bichlorid of mercury, wax paper, and bandage. At the time of operation this process is repeated. Many surgeons use tincture of iodin spray to sterilize the skin. This is usually prepared by adding one part of tincture of iodin to three parts of water. It is sprayed upon the skin by means of an atomizer. The skin thus treated peels off with the dressings. CATHETERIZATION The hands should be thoroughly scrubbed and dis- infected. The external genitals should be scrubbed with tincture of green soap and water; washed with sterile water; then with 1:4000 bichlorid solution; then a second time with sterile water to remove all traces of bichlorid. Soft rubber catheters should be boiled for ten minutes. English and silk catheters should be immersed in 1:20 carbolic solution for ten minutes; then thoroughly rinsed in sterile water before introduction. 472 DISEASES OF CHILDREN FOR NURSES When ready to catheterize, dip the end of the catheter in carbolized oil, 1:40. If the catheter touches any part before entering the urethra it must be resterilized. This care is taken to avoid infection of the bladder. When removing catheter it should be pinched to prevent the urine remaining in it from running out. If a glass catheter is used the finger should be placed over the opening. ASPIRATION OF THE CHEST A large needle, or trocar, and cannula is used to pierce the chest-wall. The instrument used is attached by means of a rubber tube to a vacuum pump from which all the air must have been removed before the operation. The child should be prepared for operation in the usual way, the point of the proposed puncture having been previously determined. The instruments used should be sterilized. A small dressing is placed oyer the puncture. Fig. 125.—Paquelin's cautery. Note that the benzene is contained in the handle of the apparatus (W. E. Ashton). PAQUELIN CAUTERY The metal reservoir, containing a sponge, should be about one-third full of benzene. The platinum point to THE RAPE UTICS 473 be used is screwed into position, the tube from the reser- voir is slipped over the handle, the point is heated in the lamp, is removed from the flame, and by compressing the bulbs previously connected with the reservoir, benzol vapor is forced into the point, which will heat up and can be maintained at any temperature by the rapidity with which the bulb is worked. METABOLIC BED The metabolic bed is a name applied to a specially arranged bed in which the child is suspended in such a way that every drop of urine and feces is saved. The quantitative analysis of the excreta, compared with the known intake, gives the results of metabolism in the body and determines the nitrogen balances. CHAPTER XX WEIGHTS AND MEASURES; ABBREVIATIONS SCALES OF WEIGHTS AND MEASURES APOTHECARIES' WEIGHT The pound (libra) It), contains 12 ounces. ounce (uncid) f, " 8 drams. dram (drachma) 3 " 3 scruples. scruple (scrupulum) 9 " 20 grains. grain (granum) gr. WINE MEASURE The gallon (congius) C contains 8 pints. pint (octarius) O " 16 fluidounces. fluidounce (uncia fluida) f§ " 8 fluidrams. fluidram (drachma fluida) f£ " 60 minims. minim (minimim) ITf TABLE OF MUTUAL EQUIVALENTS OF WEIGHTS AND MEASURES K>. I 7> 9 gr- 1 = 12 = 96 = 288 = 5760 r = 8 = 24 --- 480 1 = 3 = 60 1 = 20 ' c o 1 z m 1=8 = 128 = 1024 = 61,440 1 = 16 = 128 = 7,680 1 = 8 = 480 1 = 60 474 WEIGHTS AND MEASURES; ABBREVIATIONS 475 In prescription writing the scruple is rarely used at the present time. THE METRIC SYSTEM When the metric system is used, the quantities of liquids, as well as solids, are expressed by weight. The meter is the unit of length; the gram, of weight; and the liter, of volume. The prefixes, deca, hecto, kilo, derived from Greek numerals, are used to denote increase, and the prefixesj deci, cenli, milli, derived from the Latin numerals, to denote decrease. rooo. = 1 kilometer. 100. = 1 hectometer. 10. = 1 decameter. 1. = 1 meter. .1 = 1 decimeter. .01 = 1 centimeter. .001 = 1 millimeter. The cube of a centimeter is called a cubic centimeter, and is written cc, which term is used to denote capacity. It is used almost exclusively. Thus, instead of saying 1 decimeter, we say 100 cc, and instead of 1 deciliter, we say 100 cc. Relation Between the Apothecaries and the Metric System.— 1 meter = 39-39 inches. 25 millimeters = 1 inch. T liter = 33-8i fluidounces, slightly over a quart. 1 gram = 15 £ grains .065 " = 1 grain. 29.37 cubic centimeters = 1 fluidram. a " " =15 minims. 476 DISEASES OF CHILDREN FOR NURSES Rule for Converting Troy Weights into Grams.— (a) Reduce each quantity to grains, move the decimal point one place to the left, and subtract one-third. (b) Reduce each quantity to drams and multiply by four. To Estimate a Dose of a Different Fractional Part of a Grain from the Drug on Hand.—You are often ordered to give a dose of medicine of a different frac- tional part of a grain from the drug you have. Thus, you may be ordered to give gr. 4V of strychnin when the only solution on hand is one in which 10 minims equals gr. gV To find out how much to give, multiply the denominator of the fraction of the solution on hand by the number of minims in which it is held in solution, and divide the result by the amount ordered. Thus, 1 65 IO 40)600(15 40 200 200 Give 15 drops. If quantity in a tablet is greater than required. The given dose is used as the numerator and the re- quired dose as the denominator, thus: The dose of a tablet is marked TlT gr., and the re- quired dose is 3-^ gr. Therefore, two-thirds of the tablet is the required dose. The tablet should be dissolved in fifteen drops of distilled water and two-thirds, or ten drops, administered as the dose. WEIGHTS AND MEASURES; ABBREVIATIONS 477 To Obtain a Fractional Part of a Minim.—At times \, \, or | minim may be ordered. To obtain the amount correctly, it is necessary to take 5 minims of the drug and add 20 minims of water, making 25 minims in all; then 5 minims of this- quantity will represent 1 minim of the drug. If | minim is desired, 15 minims of water should be added to the 5 minims representing 1 minim of the drug, making 20 minims in all; then 15 minims of this quantity will represent \ minim of the drug. If \ minim is desired, 5 minims of the above will rep- resent the proper amount. If \ minim is desired, it is necessary to add 5 minims of water to the original 5 minims representing the drug, making 10 minims in all; then 5 minims of this quantity will represent \ minim of the drug. In emergencies, 2 drops of a drug can be estimated as representing 1 minim. By adding 6 drops of water, making 8 drops in all, and then taking 6 drops of this quantity, f minim may be obtained. Two drops of the above would represent \ minim of the drug. By adding 2 drops of the water to the 2 drops of the drug and taking 2 drops of this quantity, \ minim may be obtained. If fractional parts of a drop are ordered, one-half of the above dilutions would represent the proper number of drops to use. Rule for Making Solutions of Definite Strengths.— (a) A 1 per cent, solution contains 5 (4.80) grains of the drug to each ounce of the solution. Therefore, a 2 per cent. solution contains 10 grains to the ounce; a 5 per cent. solution, 25 grains; a 10 per cent, solution, 50 grains, etc. (b) A 1:1000 solution contains 8 grains to a pint. 478 DISEASES OF CHILDREN FOR NURSES Therefore, a i: 2000 solution contains 4 grains to a pint, a 1:4000 solution 2 grains and a 1:8000 solution 1 grain. The drugs are usually dissolved in water and labeled so many grains to the dram. DOMESTIC MEASURES 1 teaspoonful = 1 dram or 4 cc. 1 dessertspoonful = 2 drams or 8 cc. i tablespoonful =4 drams or 16 cc. 1 wine glass = 2 ounces. 1 tea cup = 5 ounces. 1 tumbler =11 ounces. TEMPERATURE There are two methods of expressing degrees of heat and cold, Centigrade and Fahrenheit, expressed by the symbols C. and F., respectively. The zero point of the Centigrade scale is the freezing- point of water, equal to 32° F.; and the ioo° point Cen- tigrade is the boiling-point of water, equal to 212 ° F. Rule for Changing Centigrade Temperatures to Fahrenheit.— Cx 9 ------ X 7.2 5 6 Example : 100 C. (boiling-point of water). C. ioo° x 9 = 900 h- 5 = 180 + 32 = 212° F. To change Fahrenheit to Centigrade: F~32X5 = 9 Example : 2120 F. (boiling-point of water). F. 2120 — 32 =180 X 5=900=9 = 100° C. WEIGHTS AND MEASURES; ABBREVIATIONS 479 ABBREVIATIONS* Abbreviation. aa. A. c. Ad Add. Ad lib. Ad part. dolent. Alt. dieb. Alt. hor. Alt. noct. A. p. Aq. Aq. astr. Aq. bull. Aq. bull. Aq. dest. Aq. ferv. Aq. font. Aq. pluv. Aq. pur. Aq. tep. Bisind., b.i.d. Bull. C, Cent. C, cong. Cap. Capsul. C.c. Cg., Cgm. Chart. Chartul. Cib. C. m. Cm. C. n. C. n. s. Coch. Coch. ampl. Coch. infant. Coch. mag. Coch. med. Foreign worcUor phrase. English equivalent. ana Of each (i. e., equal parts). ante cibum Before meals. ad To, up to. adde, addatur, addantur Add, let there be added. ad libitum As much as desired. ad partes dolente.s To the painful (aching) parts. alternis diebus alternis horis alternis noctibus ante prandium aqua aqua astricta aqua bulliens aquae bullientis aqua destillata aqua fervens aqua fontana aqua pluvialis aqua pura aqua tepida bis in die bulliat Celsius, Centigrade congius cape, capiat capsula cubic centimeter centigram charta chartula cibus eras mane centimeter eras nocte eras nocte sumendus cochleare cochleare amplum cochleare infantis cochleare magnum cochleare medium Every other day, alternate days. Every other hour. On alternate nights, every other night. Before meals. Water. Frozen water, ice. Boiling water. Of boiling water. Distilled water. Hot water. Spring water. Rain water. Pure water. Tepid water. Twice a day, twice daily. Let it boil. Thermometer scale with 100 degrees between the melting- point of ice and the boiling- point of water. A gallon. Take (thou), let him take. A capsule. A metric measure (16.23 min- ims). One-hundredth of a gram (£ gr.). Paper. A small paper. Food, victuals. Tomorrow morning. One-hundredth of a meter (0.3937 inch). Tomorrow night. To be taken tomorrow night. A spoonful. Heaping spoonful. A child's spoonful. A tablespoonful. A dessertspoonful. ♦Reprinted from The Nurse, October, 1915. 480 DISEASES OF CHLLDREN FOR NURSES Abbreviation. Foreign word or phrase. English equivalent. Coch. parv. cochleare parvum A teaspoonful. Coct. coctio Boiling. Col. cola Strain. Colet. coletur Let it be strained. Collun. collunarium A nasal douche or wash. Collut. collutorium Mouth-wash. Collyr. collyrium An eye-wash. Comp. compositus Compound. Conf. confectio Confection. Contin. continuetur Let it be continued. Coq. coque, coquantur Boil, let them be boiled. Crast. crastinus Tomorrow. Cras mane cras mane sumendus To be taken tomorrow morning, sumend. Cum cum With. C. V. cras vespere Tomorrow evening. Cyath. cyathus A glassful. Cyath. vin. cyathus vinarius A wineglassful. D. dies, dosis, -da A day, a dose, give. Decoct. decoctum A decoction. Decub. decubitus Lying down. De d. in d. de die in diem From day to day. Deglut. deglutiatur Let it be swallowed. Det. in dup. detur in duplo Let twice as much be given. Dieb. alt. diebus alternis On alternate days. Dieb. tert. diebus tertiis Every third day. Dil. dilue, dilutus Dilute (thou), diluted. Dim. dimidius One-half. D. in p. aeq. divide in partes aequales i Divide into equal parts. Divid. dividendus To be divided. Dolor, dur. dolore durante While the pain lasts. Dr., 3 drachma A dram (60 grains). D. t. d. dentur tales doses Let such doses be given.. Ejusd. ejusdem Of the same. Empl. emplastrum Plaster. En., Enem. enema A clyster or enema. Et et And. F. fac Make. F., Fahr. Fahrenheit Thermometer scale with 180 degrees between the melting-point of ice and the boiling-point of water. Feb. dur. febre durante While the fever lasts. Ferv. fervens Boiling. F. h. fiat haustus Let a draft be made. Filt. filtra Filter. Fluid., Fid. fluidus Liquid. Fldr. drachma fluida Fluidram. Flor. Mores Flowers. Fl. oz. uncia fluida Fluidounce. F. m. fiat mistura Let a mixture be "made. WEIGHTS AND MEASURES; ABBREVIATIONS 481 Abbreviation. Foreign word or phrase. Fol. folia F. pot. fiat potio F.-pil. fiant pilulae Fract. dos. fracta dosi Ft. fiat, fiant (pi.) Ft. mas. div. fiat massa dividenda in pil. in pilulas Ft. pulv. fiat pulvis Garg. gargarisma Gm. gram, gramme Gr. granum, grana Gtt. gutta, guttae Guttat. guttatim H. hora Haust. haustus Hor. decub., hora decubitus H. d. Hor. som., hora somni H. s. Ind. in dies Infus. infusio Injec. injectio L. liter Lb., lb. libra Linim. linimentum Liq. liquor Lot. lotio M. misce, meter, meridies mistura Mac. macera Man. manipulus Man. pr. mane primo M. ft. mistura fiat Mg., Mgm. milligramme Mic. pan. mica panis Min., tie minimum Mist. mistura Mm., mm. millimeter N. B. nota bene No. numero, numerus Noct. nocte Noct. nocte maneque maneq. Noii repetat. non repetatur 0. octarius 01. oleum Omn. bih. omni bihora Omn. hor. omni hora English equivalent. Leaves. Let a potion be made. Let pills be made. In divided doses. Let it or them be made. Let a pill-mass be made and divided into pills. Let a powder be made. A gargle. A metric weight (15.437 grains). A grain, grains. A drop, drops. By drops. An hour. A draft. At bedtime. At the hour of sleep. Daily. An infusion. An injection. A metric weight (33.816 fluid- ounces). A pound. A liniment. A solution. A lotion. Mix (thou), French unit of length (39.37 inches), noon, mixture. Macerate. A handful. Early in the morning. Let a mixture be made. A metric weight (gV grain). Bread crumb. A minim. A mixture. A metric linear measure (^§ inch). Note well. In number, a number. At night. At night and in the morning. Do not repeat. A pint (§xvj). Oil. Every two hours. Every hour. 3i 482 DISEASES OF CHILDREN FOR NURSES Abbreviation. Foreign word or phrase, Omn. mane, omni mane 0. m. Omn. noct. omni nocte 0. n. Omn. quar. omni quadrante hora hor. Ov. ovum Oz., 3 uncia P. ae. partes aequales Part. vie. partitis vicibus Per per Pil. pilula Pocul. poculum Post cib. post cibum Pot. potio P.p. post prandium Ppt. praecipitatum P. r. n. pro re nata Pulv. pulvis q. 1 h. quaque hora q. 2 h. quaque secunda hora q. 3h. quaque tertia hora q. 4h. quaque quarta hora Q.s. quantum sufficit Quotid. quotidie 3 recipe Rad. radix Redig. in redigatur in pulverum pulv. Red. in pulv. reductus in pulverum Rep. repetatur S. A. secundum artem Sat. saturatus Scat. scatula Scr., 9 scrupulus Sem. semen Seq.luce sequenti luce Sp. fr. spiritus frumenti Sig. signa, signetur Sin. sine Sinap. sinapis Solut. solutio S. 0. s. si opus sit. Sp. gr. _ gravitas specificus Spt., spir. spiritus Ss. semis, semissis, semi- St. stet, stent Stat. statim Su. sumet Sum. sumatur, sumantur English equivalent. Every morning. Every night. Every quarter of an hour. An egg. Ounce. In equal parts. In divided doses, divided by turn. Through, by means of, very. A pill. A cup. After meals. A potion. After meals. Precipitate. When required. A powder. Every hour. Every two hours. Every three hours. Every four hours. A sufficient quantity. Daily. Take (thou). Root. Let it be reduced to powder. Reduced to powder. Let it be repeated. According to art. Saturated. A box. A scruple (20 grains). Seed. The following day. Whisky. Write (thou), let it be marked. Without. Mustard. A solution. If necessary. Specific gravity. Spirit. A half. Let it or them stand. Immediately. Let him take. Let it (them) be taken. WEIGHTS AND MEASURES; ABBREVIATIONS 483 Abbreviation. Foreign word or phrase. English equivalent. S. v. spiritus vini Alcoholic spirit. S. v. g. spiritus vini gallici Brandy. S. v. r. spiritus vini rectificatus Alcohol. S. v. t. spiritus vini tenuis ' Proof spirit. Syr. syrupus Syrup. Tab. tabella A tablet. Tal. talis, tales Such a one, such ones. T. d., t. i. d. ter die, ter in die Three times a day, thrice daily. Tinct., Tr. tinctura Tincture. Trit. tritura Triturate. Troch. trochiscus, trochisci A lozenge, troche, lozenges. Una, 5 uncia An ounce. Ung. unguentum An ointment, unguent. Ut diet. ut dictum As directed. Ves. vesica The bladder. Vesic. vesicula, vesicatorium A blister. Vin. vinum Wine. Vitel. ov. vitellus ovi Yolk of egg. V. S. solutio + volume -J- Volumetric solution (one con- metric taining in each liter [quartl a definite amount of any re-agent), also called standard solution. CHAPTER XXI MEDICAL TERMINOLOGY Prefix Definition Example A absence of asepsis. dys painful dyspepsia. end the lining endocarditis. he mo blood hemothorax. hydro water hydrocele. hyper above hyperacidity. hypo beneath hypodermic. macro large macroglossia. micro small microscope. peri around pericardium. pneumo air pneumothorax. pyo pus pyogenic. Suffix Definition Example Algia pain neuralgia cele a tumor hydrocele. ectomy cutting out appendectomy. esthesia feeling hyperesthesia. gogue drugs causing in- crease of flow cholagogue. itis inflammation of appendicitis. lithiasis stone in nephrolithiasis. odynia painful pleurodynia. ology study of bacteriology. orrhea copious discharge diarrhea. otomy cutting into gastrotomy. phagia swallowing dysphagia. pepsia digestion dyspepsia. phonia speech aphonia. Name Root Word Inflammation of "Brain encephalos encephalitis. ear ous, otos otitis. gland aden adenitis. heart cardia endocarditis. intestine (large) colon colitis. intestine (small) enteron enteritis. kidney nephron nephritis. 484 MEDICAL TERMINOLOGY 485 Name Root Word Inflammation of liver mouth hepar stoma hepatitis. stomatitis. muscle nerve nose mys, myos neuron rhis, rhinos myositis. neuritis. rhinitis. rectum skin procto derma proctitis. dermatitis. stomach tongue gaster glossa gastritis. glossitis. GLOSSARY Abdomen.—The portion of the trunk extending from the chest to the pelvis. Abnormal.—Not conforming to the general rule of nature. Abduct.—To draw from median line. Adduct.—To draw toward center. Abrasion.—The rubbing off of the skin or mucous surfaces by injury. Adenitis.—Inflammation of a gland. Adenoid.—A polypoid growth in the pharynx, back of the nose. Adipose.—Consisting of fat. Adolescence.—The period between puberty and full development. Aerated.—Exposed to the action of fresh air. Albumen.—White of egg. Alkaline.—Having properties the opposite to those of an acid. Alopecia.—Baldness. Alveoli.—Air cells of the lungs. Analyze.—To ascertain the composition of. Anasarca.—General dropsy. Anatomy.—The study of the different tissues and organs of the body. Anemia.—A decrease in the blood constituents. Anesthetic.—Pertaining to the loss of sensation. Ankylosis.—A locking of a joint from injury or disease. Anomalies.—Marked deviation from the normal. Anorexia.—Loss of appetite. Antiseptic—Having the power to destroy bacteria and to prevent their growth. Anus.—The external opening of the rectum. Areola.—A colored ring around an object. Arthrepsia.—Marasmus. Asepsis.—Absence of bacteria. Asphyxia.—Suffocation. Assimilate.—The process of transforming food into such a nutrient condition that it may be taken up by the blood. 486 DISEASES OF CHILDREN FOR NURSES Atony.—Want of power, especially muscular power. Atresia.—The absence of the natural opening to a normal canal. Auricle.—The external ear. Autopsy.—An examination of the organs and tissues of the body made after death. Bacteria.—Germs. A low form of plant life. They multiply very rapidly. Batting.—Cotton or wool arranged in layers for quilting. Bicuspids.—The fourth and fifth teeth from the middle. Bladder.—The reservoir for the urine. Bronchial Tubes.—The air-passages from the windpipe or trachea to the air-cells of the lungs. Cachexia.—A very low condition of nutrition due to some serious disease. Calorie.—The amount of heat required to raise i gram of water tc i° of heat Centigrade. Canine Teeth.—The eye teeth, third from the middle. Canthus.—The angle formed by the upper and lower eyelids at the internal and external extremity of the palpebral fissure. Carbohydrates.—Sugars. Caries.—Death of a bone. Caseate.—To break down and form a cheese-like mass, seen in tuber- cular processes. Casein.—The ingredient of milk which constitutes most of the curd, and is the chief source of proteid. Catharsis.—To purge. Catheter.—A hollow, flexible rubber tube used to draw off the urine from the bladder (catheterization). Cell.—The smallest division of animal life. The entire body is composed of millions of cells. Cereals.—The grain plants, such as wheat, rye, barley, etc. The seed is used for food. Cerumen.—The wax of the ear. Cicatrix.—Scar tissue. Circulation.—The flowing of the blood through the body. Clonic.—The term given to intermittent convulsions. Coagulate.—To thicken, clot, or curdle. Coalescence.—The union of two or more parts of a thing. To flow together. Colic.—Severe griping pain in the abdomen. MEDLCAL TERMINOLOGY 487 Colostrum.—The milky fluid which can be pressed from the breasts of a pregnant woman, and which flows for the first three days after the birth of the child. Communicable.—Contagious. Complication.—A condition occurring during the course of a disease. Compound.—Composed of two or more ingredients. Compress.—A folded cloth, wet or dry, applied to a part for the relief of inflammation, or to prevent a hemorrhage. Condiment.—Substances used to give relish to food. Congenital.—Being present at the time of birth. Congestion.—An abnormal accumulation of blood in an organ or part of the body. Constipation.—Difficult or infrequent bowel movements. Constriction.—The state of being squeezed. Contagious.—Capable of direct communication. Contaminated.—Rendered impure by contact. Contusion.—A bruise. Convalescence.—The gradual return to health after sickness. Convulsion.—A violent and involuntary muscular contraction, or series of contractions. Cornea.—The transparent anterior portion of the eyeball. Coryza.—Cold in the head. Coxalgia.—Tubercular hip-joint disease. Crepitus.—A grating, crackling sound. Curdle.—The formation of curds. Curds.—The thickened portion of milk. Curetment.—Scraping of a part to remove diseased tissue. Cyst.—A cavity containing fluid and surrounded by a capsule. Cystitis.—Inflammation of the bladder. Dandruff.—Small scales from the scalp. Deaf-mutism.—The condition of being both deaf and dumb. Debilitated.—Weakened. Decoction.—The water in which a substance has been boiled. Decubitus.—The position of a patient in bed. Defecate.—The act of having a bowel movement. Deformity.—Unnatural shape. Degeneracy.—The tendency to deteriorate. Deglutition.—The act of swallowing. Deleterious.—Injurious. Delivery.—The birth of a child. Dentition.—The process of cutting teeth. 488 DISEASES OF CHILDREN FOR NURSES Dermatitis.—Inflammation of the skin. Desquamate.—To shed the skin. Development.—A gradual growth through progressive changes. Diagnosis.—Recognition of a disease. Diastole.—The period when the chambers of the heart dilate after the period of contraction. Occurs after each heart-beat. Digestion.—-The process of changing the food from the form in which it enters the body to that in which it is absorbed by the blood. Disinfection.—Rendering free from germs. Diurnal.—Daily. Douche.—A jet of water entering a cavity of the body. Dyspepsia.—Chronic indigestion. Ecchymosis.—Extravasation of blood into surrounding tissues. Edema.—Dropsical swelling. Effervescent.—Bubbling up, with the giving off of gas bubbles. Effusion.—The pouring out of a serous or bloody fluid into the tissues or cavities of the body. Embolus.—A particle of fibrin or other material brought by the blood current and forming an obstruction within an artery at its place of lodgment. Embryo.—The unborn child before the fourth month of pregnancy. Emulsion.—A mixture of an oily substance with a liquid. Enema.—An injection into the rectum. Epidermis.—The outer layer of the skin. Epistaxis.—Nose-bleed. Eruption.—A rash. Eustachian Tube.—A duct running from the middle ear to the pharynx. Evaporation.—Converting into vapor. Excretion.—A discharge of waste products. Exhale.—To breath out. Expiration.—The emptying of the lung of air. Fat-free Milk.—Milk from which all the fat has been removed. Feces.—The stools. Matter expelled from the intestines by way of the rectum. Fetus.—The unborn child after the fourth month of pregnancy. Fissures.—Cracks in the skin, or mucous membrane. Flatulence.—The presence of gas in the stomach and intestines. Flocculent.—Flaky. Fomentation.—Flannel cloths rung out of hot water and placed on the body as a means of applying moist heat. MEDICAL TERMINOLOGY 489 Fontanel.—The soft spot in a child's head, caused by the non-union of the bones. Formula.—A list of the names and quantities of the ingredients of a mixture. Function.—The mode of action of an organ. Furuncle.—A boil. Genital.—Pertaining to the organs of reproduction. Gland.—An organ of the body that secretes substances of use to the system or casts off waste matter. Hemorrhage.—Bleeding. Hemorrhoids.—Piles. Hepatization.—Liver-like. Used in describing the lung in pneu- monia. Hernia.—A rupture. The protrusion of the internal organs from their natural position. Hydrotherapy.—Treatment by means of water. Hygiene.—The science of preserving health. Hypertrophy.—To enlarge by overgrowth. Icterus.—Jaundice. Idiocy.—A lack of mental understanding. Imbecile.—One who is mentally weak. Incisors.—The four front teeth of each jaw. Incubator.—An apparatus for preserving the life of a premature infant. Infected.—Brought in contact with bacteria. Inherent.—Instinct. The ability to perform certain acts without knowledge of the reason and without previous training of the individual. Insomnia.—Sleeplessness. Inspiration.—The act of filling the lungs with air. Intermittent.—Ceasing at intervals. Interstitial Tissue.—The supporting tissue or framework of an organ or structure of the body. Isolation.—The complete separation from other individuals. Kumiss.—Fermented milk. Labor.—Childbirth. Laceration.—A cut. Lancinating.—Shooting. 49O DISEASES OF CHILDREN FOR NURSES Latent.—Hidden. Laxative.—A medicine that moves the bowels gently. Leukocytosis.—An increase in the number of white blood corpuscles in the circulation. Ligament.—A band of tissue binding two parts together. Lime-water.—A solution of lime in water. Loins.—The lower part of the back and region of the hips. Lubricant.—An oily material used to make two surfaces glide smoothly over one another. Malaise.—A feeling of weakness. Listlessness. Manipulation.—The act of handling or working with the hands. Massage.—A rubbing or kneading of the muscles. Mastication.—The act of chewing. Membrane.—A thin lining tissue. Membranous Croup.—Diphtheria of the larynx. Meningitis.—An inflammation of the membranes covering the brain and spinal cord. Microbe.—A germ. Micturition.—The act of urinating. Milk Sugar.—A sugar made by the evaporation of the whey of milk. Milk Teeth.—The first set of teeth. Minim.—About a drop. One-sixtieth of a fluid dram. Molars.—The back teeth. Morbid.—Diseased. Morbid Anatomy.—The study of diseased tissues. Mortality.—The frequency of death. Mucous Membrane.—The lining membrane of all passages and cavities that come in contact with the air. Mucus.—A slimy fluid from the mucous membrane. Navel.—The umbilicus. Necrosis.—Death of a structure or tissue. Nephritis.—Inflammation of the kidney. Bright's disease. Neural.—Pertaining to a nerve. Neuralgia.—Pain along the course of a nerve. Neurosis.—A nervous functional disease. Neurotic.—Nervous. Nevus.—A birth-mark. Nitrogenous Food-stuffs.—Meats, potatoes, and similar foods. Nocturnal.—Pertaining to night. Normal.—According to the rule of nature. MEDICAL TERMINOLOGY 491 Obstetrics.—The management of childbirth. Occluded.—Closed. Opaque.—Not transparent. Organism.—The body as a whole. Organize.—The conversion into living tissue. Palatable.—Agreeable to the taste. Parasites.—Insects living on animals, such as lice. Paroxysm.—A spasm. Paroxysmal.—Spasmodic. Par turi tion.—C hildbirth. Pasteurization.—The heating of milk to 167 ° F. to destroy germs. Pathology.—The science of the changes which take place in the structure of the body in disease. Patulous.—Open. Pelvis.—The bony basin supporting the abdominal viscera. Percentage.—Rate per hundred. Perforation.—Used to denote the occurrence of a hole into an organ or through the bowel. Period of Incubation.—The time elapsing between the introduction of bacteria into the body and the appearance of the symptoms of the disease. Periodic—Recurring at intervals. Peristalsis.—The worm-like movements of the intestines by which the feces are moved. Peritonitis.—An inflammation of the membrane lining the abdominal cavity. Pertussis.—Whooping-cough. Petechias.—Hemorrhagic spots in the skin. Phenomenon.—A thing that is observed. Physiology.—-The science of the functions of the different organs. Placenta.—The attachment of the umbilical cord to the inner side of the womb. The "after-birth." Pneumonia.—Inflammation of the lungs. Polyp.—A tumor composed of mucus. Pores.—The openings of the sweat-glands in the skin. Poultice.—A hot, soft mass, used to apply moist heat or to remove odor. Predisposition.—A tendency to. Pregnancy.—The carrying of the child by mother before birth. Premature.—Before full term. 492 DISEASES OF CHILDREN FOR NURSES Prophylaxis.—Measures to prevent the development or spread of disease. Proteid.—The albuminous foods; the nourishing part of milk, eggs, and meat. Pruritus.—Itching. Puberty.—The period of life at which an individual becomes capable of producing children. Pubic.—Pertaining to the front of the pelvis. Puerperium.—The period immediately following childbirth. Pulse-rate.—The number of beats per minute. Purgative.—A medicine that cleans out the bowels. Quarantine.—The guarding of a building which houses a contagious case, so that no one can enter or leave. Rash.—A breaking out on the skin. Ratio.—Proportion. Reaction.—The return to normal after collapse. The return to warmth after a chill. Rectum.—The lower end of the intestines. Regurgitation.—Vomiting of mouthfuls. Relax.—To make less rigid. Remittent.—Temporary disappearance. Respiration.—The act of breathing. Respiratory Rate.—The number of respirations per minute. Resuscitate.—To revive. Rickets.—A disease of childhood characterized by deformity of the bones and changes in the liver and spleen. Rigor.—Chill. Rigor Mortis.—The stiffening of the muscles after death. Rotheln.—German measles Rubella.—Measles. Rubeo la. —Measles. Saliva.—Secretion present in the mouth. Saturated Solution.—A solution of a substance in which no more of that substance can be dissolved. Sclerosis.—Hardening of a part due to overgrowth of fibrous tissue. Scrofulous.—Tubercular. Scurvy.—A disease due to a lack of nourishing diet. Secretion.—The substance produced by glandular action. MEDLCAL TERMINOLOGY 493 Sedentery.—Sitting. Sepsis.—Poisoning by germs. Sequel.—A condition which appears after a disease. Shock.—The period of collapse following an accident or operation. Sinus.—Discharging channel from an abscess cavity. Sitz Bath.—Sitting in water covering the hips. Sordes.—Crusts that accumulate on the teeth. Spasmodic.—Occurring in spasms. Specific Remedy.—One that has a distinct curative influence on an individual disease, as quinin in malaria. Sputum.—Spittle. Sprain.—A tearing of the ligaments around a joint. Stenosis.—Constriction or narrowing of a channel. Sterilize.—To render free from germs. Sterile.—Absence of germs. Stimulate.—To excite action. Stomach Teeth.—-The two milk teeth on either side of the four lower incisors. Striae.—Lines or furrows. Structure.—Construction of parts. Stupe.—A cloth rung out of hot water and used for applying moist heat. Suppression.—A stoppage of a discharge. Symptom.—A sign of a disease. Temperature.—The degree of heat. Tetanus.—Lock-jaw. Tissue.—A collection of cells of the body doing the same work. Toxin.—A poison. Traumatism.—An injury. Tumor.—An abnormal swelling. Umbilical Cord.—The cord by which the infant is attached to the placenta. It enters the child's body at the umbilicus or navel. Unhygienic.—Contrary to the laws of health. Urine.—The excretion of the kidneys. Uterus.—The womb. Vapor Bath.—A bath in vapor used to produce sweating. Vagina.—The opening in the female which extends from the womb to the outer parts. 494 DISEASES OF CHILDREN FOR NURSES Varicose Veins.—Swollen, thickened veins. Venous Stasis.—Engorgement of the veins with blood. Ventilation.—The process of replacing foul air with pure. Viscera.—The organs of the body. Vitality.—Vigor. Vulva.—The external genitals of the female. Weaning.—Removing the nursing infant permanently from the breast. Whey.—The part of milk which remains fluid after the curds have formed. INDEX Abbreviations, 479 Abscess, cerebral, 215 in Pott's disease, 304 ischiorectal, 164 of liver, 166 of lung, 107 psoas, 304 retropharyngeal, 126 Accommodation, 250 Achondroplasia, 216 Adenitis, 263 tubercular, 26, 307 Adenoid, 121 Air-beds, 465 Air-cushions, 465 Airing of newborn babe, 40 Albumin and milk, 366 in urine, test for, 255 water, 366 Albuminuria, 234 Alkaline baths, 440 Amyloid kidney, 242 Anemia, 25, 192, 193 Anesthesia, 205 in hysteria, 219 Aneurysm, 25, 190 Angina, follicular, 120 Vincent's, 123 Anginoid scarlet fever, 316 Animal parasites, 204 Ankle clonus, 204 Ankylosis, 305 Anorexia, 114 Antidotes of poisons, 410 Antigen, syphilitic, 277 Antiseptic poultices, 432 Antitoxin in diphtheria, 3 28 Anuria, 233 Anus, atresia of, 22, 142 fissure of, 164 Aortic insufficiency, 183 stenosis, 183 Apex-beat, 173 Aphasia, 216 Aphthous stomatitis, 116 Apoplexy, 315 Apothecaries' weight, 474 and metric system, relation be- tween, 475 Appendicitis, 155 Appetite in digestive diseases, 113 Apple gruel, 368 Arachnoid, 202 Arrow-root gruel, 370 with egg, 371 Arteriosclerosis, 25, 190 Arthritis, tubercular, 306 Arthropathies, 205 Artificial feeding, 376 respiration, 454 manual methods, 456 Ascaris lumbricoides, 162 Ascites, 168 Asphyxia, emergency treatment, 422 in newborn, 19, 458 Aspiration in empyema, 87 of chest, 472 pneumonia, 107 Asthma, 77 emergency treatment, 422 Astigmatism, 250 Atelectasis, 80 congenital, 20 Athetosis, 204 Atmosphere, moist, maintaining of, 52 Atomizers, 50 Atresia of anus, 22, 142 Atrophic rhinitis, 63 495 DEX 496 Atrophy, infantile, 354 muscular, 227 Auscultation of heart, 174 Autumnal fever, 283 Babies, blue, 24, 173 Babinski's reflex, 205 Bacterines, 453 Balanitis, 247 Baner's formula for cream mixtures, 3»4 Barley gruel, 369 jelly, 370 maltine, and milk mixture, 371 water, 365 Barlow's disease, 351 Bath, alkaline, 440 bran, 440 compound glycerin, 441 sulphur, 441 for skin diseases, 440 graduated cold, 429 hot, 435 hot-air, 438 sitting, 439 hygienic, 442 linseed, 441 mustard, 442 prevention of chills after, 51 salt, 439 shower, 442 sitz, 439 sponge, 428, 442 starch, 441 tar, 442 tepid, 442 vapor, 436 vinegar and mercury, 442 Bathing in childhood, 40 in infancy, 40 of newborn, 38 Bed, Children's Hospital, 39 Klondike, 309, 310 linen, soiled, care of, 312 metabolic, 473 Bed-sores, 293 Beef juice, 371 and milk, 371 Bell's palsy, 229 Bichlorid baths, 470 Birth-marks, 260 Birth palsy, 25, 214 Bites, treatment of, 422 Bladder, diseases of, 245 exstrophy of, 246 Blebs, 258 Bleeders' disease, 194 Blindness, adult, 25 Blister, cantharides, 430 fever, 115 Blood, diseases of, 190 specific gravity of, 191 Blood-pressure, determination of, 192 Blood-vessels, diseases of, 190 Blue babies, 24, 173 Bones, tuberculosis of, 302 Borborygmi, 147 Bottles, feeding, 399 sterilization of, 50 Bottom milk, 382 Bowing of tibia, 28 Bow-legs, 28 Bradford frame, Fauntleroy's modi- fication of, 466 for fractures, 466 Bradycardia, 175 Brain, 197 abscess of, 215 diseases of, 211 hemorrhage of, 25 malformations of, 206 Bran baths, 440 Brat's apparatus for artificial res- piration, 456 Breasts of newborn, 39 Breath in digestive diseases, 113 Breathing, stridulous, 66 Bright's disease, 238 Brill's disease, 279 symptoms, 280 Bronchiectasis, 76 Bronchitis, 23, 70 acute, 70 capillary, 24 chronic, 75 Bronchopneumonia, 24, 94 acute, 97 tuberculous, 299 Bubble quick, 401 Buck's extension, application of, 460 Bulimia, 114 IND Burns, dressing of, 471 emergency treatment, 422 Buttermilk, 373 care of, in house, 398 conserve, 373 Calculus, renal, 242 vesical, 246 Caloric method of infant feeding, 39i values, table of, 392-395 Calorie, 391 Camphorated oil, 431 Cantharides blister, 430 Capillary bronchitis, 24 Carbohydrates, 358 Care of milk in house, 397 Catalepsy, 205 Catarrhal laryngitis, 64 stomatitis, 116 Catheterization, 471 Cautery, Paquelin, 472 Cephalhematoma, 21 Cephalodynia, 349 Cerebral hemorrhages in newborn, 22 localization, 212 meningitis, 207 paralysis, 214 pneumonia, 106 Cerebrospinal fever, 267 meningitis, 207, 267 Chapin dipper, 383 Characteristic cry, 30 Charcoal poultice, 432 Chest, aspiration of, 472 Cheyne-Stokes respiration, 59 Chicken-pox, 337 Child, crowing, 68 Childhood, general hygiene of, 41 nursing in, 36 period of, n Children's Hospital bed, 39 Chills, emergency treatment, 422 prevention of, after baths, 51 Chlorosis, 194 Cholecystitis, 166 Cholera infantum, 153 morbus, 155 Choluria, 234 Chondrodystrophy, 216 32 EX 497 Chorea, 25, 220 heart murmur in, 24 Choreiform movement, 204 Chyluria, 234 Circulation, 171 fetal, 172 Circulatory system, anatomy of, 169 diseases of, 24 Cirrhosis of liver, 167 Cleanliness in tuberculosis, 310 Cleft palate, 115 Clothing for outdoor sleeping, 310 in childhood, 41 in infancy, 41 of newborn, 38 Clubbed fingers in heart disease, 177 hands, 28 toes in heart disease, 177 Club-feet, 28 Coffee-ground vomit, 132 Cold bath, graduated, 429 compress to rectum, 50 in the head, 60 pack,429 Colic, intestinal, 142 renal, 242 Collapse, treatment of, 422 Colon, irrigation of, 415, 450 Colostrum, 360 Coma, 205 Compensation, cardiac, 184 period of, 184 Complement fixation test, 46, 277 Compresses, 434 cold, to rectum, 50 Condensed milk, 374 care of, in house, 398 Congestion of liver, 166 of lungs, 93 Conjunctivitis, 25, 255 Constipation, 140 Constitutional diseases, 26 Contagious diseases, 26, 314 acute, heart murmur in, 25 definition of, 267 nurse in, 51 Continuous saline injection, 451 Contra-indications for various drugs, 412 Convulsions, 25, 203, 213 498 INDEX Convulsions, emergency treatment, 423 Cord, care of, 38 Corrosion of esophagus, 129 Coryza, 60 Cough, 54 Counter-irritation, 430 Cowpox, 338 Cows' milk, 362 Coxalgia, 304 extensions for, 460 Coxitis, 304 Cradles, improvised, 52 Cranial nerves, 202 • Cream, 362 dipping for, 387 in artificial feeding, 385 method for changing percentage of, 388 siphoning for, 386 Cretinism, 215 fetal, 216 Crossed paralysis, 213 Croup, emergency treatment, 422 kettle, 447 spasmodic, 65 tent, 446 Croupous exudate, 103 pneumonia, 24, 94, 101 Crowling's rule for dosage, 411 Crusts, 258 Cry, characteristic, 30 Cuffs, 447 Cups, dry, 431 wet, 432 Cyclic vomiting, 132 Dactylitis, tubercular, 307 Deaf-mutism, 216 Death, cause of, 31 Defervescence, 264 Deformities, 27 Dextrimaltose, 380 Diabetes insipidus, 236 mellitus, 27, 350 Diaphragmatic pleurisy, 89 Diarrhea, 132, 133 in typhoid fever, 289 summer, 145 Diastole, 182 Dicrotic pulse, 175 Diet in pylorospasm, 133 Digestion, 29 Digestive tract, diseases of, 112 Digitalis poultice, 432 Dilatation of heart, 188 of stomach, 138 Diphtheria, 324 Dipper, Chapin, 383 Dipping for cream, 383 Diseases, inheritance in, 18 peculiar to children, 18 Disinfection, 470 in scarlet fever, 317 of excreta, 312, 470 of hands, 470 of stools in typhoid fever, 294 _ Dislocation, congenital, of hip, 28 emergency treatment, 423 Dosage, rule for reduction of, 476 rules for, 411 Douching, vaginal, 453 Draughts, avoidance of, 49 Dropsy in heart disease, 176 Drowning, emergency treatment, 423 . . Drugs, characteristic pulses of, 414 dominant action of, 413 poorly borne by children, 410 used in children's diseases, with dose, 416 well borne by children, 410 which cause eruptions, 414 color stools, 415 urine, 415 contract pupil, 414 dilate pupil, 414 quicken pulse, 413 raise blood-pressure, 414 slow pulse, 414 Dry cups, 421 Ductus arteriosus, 173 Dura mater, 201 Dysentery, 151 Dyspepsia, atonic, 136 catarrhal, 136 chronic, 135 nervous, 135 Dysphagia, 114 Dyspnea, 56 emergency treatment, 424 INDEX 499 Ear, diseases of, 25, 250 nursing in, 256 examination of, 51 foreign bodies in, 424 running, 25 syringing, 443 Earache, 255 emergency treatment, 424 Eczema, 26, 258 Edema of glottis, 70 pulmonary, 80 Ehrlich's salvarsan, 278 Eiweissmilch, 374 Electricity, 469 Embolism, 186 Emergencies, treatment of, 422 Emphysema, pulmonary, 80 Empyema, 84 Encephalocele, 206 Endocarditis, 179 after rheumatism, 25 complicating rheumatism, 27 fetal, 173 ulcerative, 185 Endocardium, 170 Enemata, 452 Enterocolitis, 151 membranous, 152 Enuresis, 25, 245 Epilepsy, 218 Jacksonian, 212 Epileptiform convulsions, 203 Epiphysitis, 307 Epispadias, 246 Epistaxis, 63 treatment, 424 Erb's paralysis, 22, 214 Erysipelas, 20, 340 Erythema, 258 Esophagus, corrosion of, 129 diseases of, 129 stricture of, 129 Eustace Smith's sign, 302 Examination, method of holding child for, 49 Examinations, general, 43 Excreta, disinfection of, 312, 470 Exercise, 408 in childhood, 41 in infancy, 41 Expectoration, 56 Exstrophy of bladder, 246 Extension, Buck's, 461 Extensions for fractures, 460 Extremities, growth of, 14 Eye, care of, 251 compresses for, 434 diseases of, 25, 249 foreign bodies in, 252 malformations of, 251 syringing, 442 Eyelid, everting, 252 Fainting, treatment, 424 Farina gruel, 369 Fastigium, 264 Fat percentages in mixtures, rules for, 396 Fats, 357 in artificial feeding, 378 Fatty degeneration of heart, 188 of newborn, 20 Fauntleroy's modification of Brad- ford's frame, 466 Febricula, 265 Feces, 140 incontinence of, 164 milk, 140 Feeding, adjuncts to, 408 artificial, 376 by stomach-tube, 450 iduring first year, 402 schedule for, 401 second year, 404 infant, 356 regurgitation after, 51 rules for, 400 Feet, care of, 51 Fehling's solution, 236 Female genitals, diseases of, 247 Fetal circulation, 172 cretinism, 216 rickets, 216 Fever, cerebrospinal, 267 characteristics of, 264 continued, 264 hay-, 78 hectic, 264 inanition, 30 infectious, 264 intermittent, 264 malarial, 270 remittent, 264 500 INDEX Fever, scarlet, 314 types of, 264 typhoid, 282 Fibrinous bronchitis, 75 Fibroid heart, 187 Finger-sucking, 222 Fingers, six, 28 webbed, 28 Finkelstein's eiweissmilch, 374 food intoxication, 155 Fissure of anus, 164 Fixation, complement, 277 Flaxseed poultice, 433 Flexner's serum, 269 Flint's murmur, 175 Floating kidney, 243 Flour gruel, 369 Fontanels, anterior, closing of, 14 posterior, closing of, 14 Food, constituents of, 356 intoxication, 155 Foot-baths, hot, 414 mustard, 440 Foramen ovale, 172 patulous, 173. Fracture of femur, dressing for, 461 Fracture-box, 464 Fractures, emergency treatment, 425 extensions for, 460 Frames, 466 Frenum, ulcer of, 115 Friction sound, 175 Friedreich's ataxia, 227 Fumigation, 470 Furuncle of auditory canal, 255 Furunculosis, 259 Gait, scissors, 224 Gall-stones, 165 Gangrene of lung, 107 Gastralgia, 137 Gastric ulcer, 137 Gastritis, 135 chronic, 135 Gastro-enteritis, 20 Gastro-enterostomy for pyloro- spasm, 134 Gastro-intestinal disorders, 24 Gavage, 450 Gelatin, preparation of, for infan- tile diarrhea, 371 Genital tract, malformation of, 246 Genitals, diseases of, 246 of newborn, care of, 39 Genito-urinary system, diseases of, 25 malformations of, 25 Genu valgum, 28 varum, 28 German gruel, 369 Gingivitis, 115 Girdle pain, 224 Glandular system, diseases of, 25, 261 Glomeruli of kidneys, 231 Glossary, 485 Glossitis, 115 Glottis, edema of, 70 Glycerin bath, compound, 441 Glycosuria, 234 Gonorrhea, 247 complement fixation test for, 46 Grand mal, 218 Gray tubercle, 300 Griffith's weight chart, 12 Growing pains, 27 Growth during first year, 14 of extremities, 14 Gruel, apple, 368 arrow-root, 370 barley, 369 farina, 369 flour, 369 German, 369 oatmeal, 370 rice flour, 372 Gums, inflammation of, 115 Habit, cry of, 30 spasm, 222 vomiting, 132 Habits, injurious, 222 Hamilton squint, 461 Hands, clubbed, 28 covers for, 467 disinfection of, 470 Hare-lip, 115 Harrison's groove, 354 Hay-fever, 78 Head, circumference of, 14 Head-banging, 222 Hearing, development of, 14 Heart, action of, 173 anatomy of, 169 congenital malformations of, 24 dilatation of, 188 diseases of, 24 clubbed fingers in, 177 toes in, 177 nursing in, 188 failure, 454 emergency treatment, 425 fatty degeneration of, 188 fibroid, 187 hypertrophy of, 187 malformations of, 173 murmur in chorea, rheumatism, and acute contagious diseases, 24 sounds of, 174 transposition of, 173 Height, 14 at birth, 14 Heller's test, 235 Hematemesis, 132 treatment, 426 Hematozoa, 271 Hematuria, 234 Hemiplegia, 203 Hemocy tome ter, 191 Hemoglobin, 191 Hemoglobinometer, 191 Hemoglobinuria, 234 epidemic, 20 Hemopericardium, 179 Hemophilia, 194 Hemoptysis, 79 treatment, 426 Hemorrhage from bowel, treatment, 426 from mouth, treatment, 426 from nose, treatment, 424 in newborn, 21 of brain, 25 Hemorrhoids, 164 Hepatitis, 20 Hepatization, gray, 103 red,102 Hereditary syphilis, 26, 275 cry of, 30 Hernia, umbilical, in newborn, 22 Herpes, 115 INDEX 501 Heubner's mustard bath, 430 Hiccough, 132 Hip, congenital dislocation of, 28 Hives, 260 Hodgkin's disease, 166, 263 Holding-breath spells, 69 treatment, 70 Hook-worm, 163 Hordeolum, 250 Horseshoe kidney, 232 Hospital bed, Children's, 39 Hot application, 434 bath, 435 foot-baths, 434 pack, 435 modified, 436 Hot-air bath, 438 sitting, 439 Hot-water bags, 434 care of, 50 Human milk, 359 Hunger, cry of, 30 Hutchinson's teeth, 16, 276 Hydrocele, 247 Hydrocephalic cry, 209 Hydrocephalus, 207, 215 cry of, 30 Hydro-encephalocele, 206 Hydronephrosis, 243 Hydropericardium, 179 Hydrophobia, 279 Hydro thorax, 89 Hygienic management of children in general, 37 Hyperemia, renal, 236 Hyperesthesia, 205 in hysteria, 219 Hypermetropia, 250 Hyperpyrexia, 264 Hypertrophic rhinitis, 63 Hypertrophy of heart, 187 Hypodermics, 453 Hypodermoclysis, 459 Hypospadias, 246 Hypostatic pneumonia, 107 Hysteria, 218 etiology, 219 nursing in, 220 symptoms, 219 joint, 219 motor, 219 psychic, 219 502 INDEX Hysteria, symptoms, sensory, 219 treatment, 220 Hysteroidal convulsions, 203 Ice-cap, 428 Ichthyosis, congenital, 260 Icterus neonatorum, 20, 165 Ileocolitis, 151 Impacted cerumen, 255 Impetigo contagiosa, 260 Impure milk, 146 Inanition fever, 23, 29 Incontinence of feces, 164 Incubation, period of, 265 Incubators, 42 Indicanuria, 234 Indigestion, acute gastric, 134 cry of, 30 intestinal, 143 Infancy, general hygiene of, 40 period of, 11 Infant feeding, 356 caloric method, 391 foods, proprietary, 375 recipes for, 365 Infantile atrophy, 354 paralysis, 224 Infectious disease, definition, 267 nurse in, 51 fevers, 264 acute, 26 nursing in, 280 Inflammation of liver, 20 Inflammatory rheumatism, 347 Influenza, 345 Inhalations, technic of, 446 Inheritance in diseases, 19 Injections, intravenous, 459 vaginal, 453 Injurious habits, 222 Insufficiency, aortic, 183 mitral, 183 pulmonary, 184 tricuspid, 183 Intermittent fever, quartan, 271 quotidian, 271 malarial fever, 272 Intestinal colic, 142 indigestion, 143 obstruction, 159 in newborn, 22 Intestinal perforation in typhoid fever, 284, 285 Intestines, diseases of, 140 malformations of, 142 obstruction of, 159 tuberculosis of, 156 Intoxication, food, 155 Intravenous injections, 459 Intubation, 332 Intussusception, 159 Invasion stage of fever, 264 Iritis, 250 Irrigation of colon, 450 cold, 429 rectal, 50 Ischiorectal abscess, 164 Itch, 260 Jacksonian epilepsy, 212 Jaundice, 20, 165 catarrhal, 165 Joints, tuberculosis of, 302 Junket, 374 Keratitis, 350, 352 Kernig's sign, 210 Kidney, amyloid, 242 anatomy of, 231 after scarlet fever, 25 diseases of, nursing in, 244 floating, 243 horseshoe, 232 malformations of, 232 sarcoma of, 244 tuberculosis of, 243 Klondike bed, 309, 310 Knee-jerks, 204 Knock-knee, 28 Koplik's sign, 322 Kumiss and bean flour, 374 Kyphosis, 304, 354 Lacunar angina, 120 La grippe, 345 Laminated teeth, 17 Landry's paralysis, 227 Laryngismus stridulus, 25, 68, 70 emergency treatment, 426 Laryngitis, 64 IND Laryngitis, acute catarrhal, 64 syphilitic, 65 tubercular, 65 Lavage of stomach, 448 in pylorospasm, 134 Leukemia, 194 Leukocytosis, 194 Lice, 260 Linseed bath, 441 Lisping, 222 Lithuria, 233 Liver, cirrhosis of, 166 congestion of, 166 diseases of, 165 inflammation of, 20 Lobar pneumonia, 94, 101 Lockjaw, 278 Lumbago, 349 Lumbar puncture, 210 Lung, abscess of, 107 anatomy of, 91 diseases of, 91 congestion of, 93 gangrene of, 107 immobilization in tuberculosis, 307 Lungmotor, 456 Lupus vulgaris, 260 Lymph-glands, bronchial, tubercu- losis of, 302 Lymphatism, 262 Lysis, 264 Macules, 257 Malaria, 270 Malarial fever, 26, 270 Male genitals, diseases of, 247 Malt soup mixture, 372 Maltose, 380 Marasmus, 27, 354 cry of, 30 Masks for skin diseases, 468 Massage, 469 Mastitis in newborn, 22 Mastoid disease, 25 Mastoiditis, 255 Masturbation, 222 Measles, 320 Meconium, 140 Medical terminology, 484 Meninges, diseases of, 207 EX 503 Meninges of brain, 201 Meningitis, 20, 207 cerebral, 207 cerebrospinal, 207, 267 cry of, 30 tubercular, 25, 208 Meningocele, 206 Mercurial stomatitis, 118 Metabolic bed, 473 Metric system, 475 Microcephalus, 206 Micromelia, 216 Miliaria, 258 Miliary tuberculosis, 301 Milk, bottom, 382 care of, in house, 397 condensed, 374 care of, in house, 398 cows', 362 digestion of, 130 examination of, 361 feces, 140 impure, 146 infection, 146 methods of modifying, 384 pasteurized, 363 peptonized, 367 protein, 374 rice, 365 siphoning, 382 skimmed, 381 sterilized, 364 teeth, average age of eruption of, IS woman's, 359 Mineral salts in food, 359 Minim, method of obtaining frac- tional part, 477 Mitral insufficiency, 183 stenosis, 182 Mixtures, top-milk, 386 Modifying milk, methods of, 384 Moist atmosphere, maintaining, 52 Monoplegia, 203 Mouth, diseases of, 115 inflammation of, 116 malformation of, 114 of newborn, care of, 38 syringing of, 446 Mumps, 344 Murmur, cardiac, 174 504 INDEX Murmur, heart, in chorea, rheu- matism, and acute contagious diseases, 24 Murmurs in endocarditis, 181 Muscular rheumatism, 348 Mustard bath, 440 Huebner's, 430 foot-bath, 440 pack, 431 paste, 430 plaster, 430 poultice, 430 Myelitis, 223 Myocarditis, 187 Myopia, 250 Nail-biting, 222 Nasal syringing, 444 Nebulizers, 50 Nephritis, 238 chronic interstitial, 240 parenchymatous, 239 Nerves, cranial, 202 diseases of, 228 spinal, 202 sympathetic, 202 Nervous system, anatomy of, 197 diseases of, 25 peculiar in children, 205 nursing in, 229 Nervousness, treatment of, 426 Neuritis, 228 multiple, 228 Nevus, 260 Newborn, |acute pyogenic diseases of, 20 asphyxia of, 19, 458 bathing of, 38 care of, 37 cerebral hemorrhages in, 22 clothing of, 38 diseases of, 19 prophylaxis in, 21 facial paralysis in, 22 fatty degeneration of, 20 hemorrhages in, 21 intestinal obstruction in, 22 mastitis in, 22 period of, n umbilical hernia in, 22 Night terrors, 223 Nipples, 399 babies', care of, 51 Nodding spasm, 25, 222 Noma, 117 Normal salt solution, 420 Nose, foreign bodies in, 425 Nosebleed, treatment, 424 Nursery, general hygiene of, 41 Nursing in childhood, 36 Nutrient enemata, 452 Nutrition, 356 Nutritional diseases, 26, 351 Nystagmus, 222, 253 Oatmeal gruel, 368 jelly, 371 water, 365 Obstetric hand, 221 Obstruction, intestinal, 158 chronic, 160 Oiled silk jacket, 466 Onychia, 260 Operation, preparation for, 471 Ophthalmia, 25 neonatorum, 20, 251 Opisthotonos, 209 Orthopedics, 27 Orthopnea, 57 Osteomyelitis, 20 tubercular, 306 Otitis media, 25, 255 Outdoor sleeping, clothing for, 310 treatment of tuberculosis, 309 Oxyuris vermicularis, 163 Pack, hot, 435 Pain, cry of, 30 Palpitation of heart, 176 Palsy, Bell's, 229 Pap,369 Papules, 257 Paquelin cautery, 472 Paralysis, 25 birth, 25 cerebral, 214 crossed, 213 definition of, 203 Erb's, 22, 214 facial, 22 Paralysis, infantile, 224 Landry's, 227 post-diphtheritic, 229, 326 Paraplegia, 203 Parasites, animal, 161 Paresthesia, 205 Parotitis, 344 Pasteurized milk, 363 Peculiarities of children's diseases, 11 Pediculosis capitis, 260 pubis, 260 Pemphigus neonatorum, 20 Pennsylvania quarantine laws, 32- 35 Peptonized milk, 367 Peptonizing mixture, 368 Percentage of cream, method for changing, 383 of mixtures, methods of deter- mining, 396 Percussion of heart, 174 Perforation, emergency treatment 426 in typhoid fever, 284, 289 Pericarditis, 20, 176 Pericardium, 171 Peritonitis, 20, 167 Pernicious anemia, 194 Pertussis, 341 Petit mal, 218 Peyer's patches, 284 Phagocytosis! 453 Pharyngitis, 124 atrophic, 126 chronic, 126 hypertrophic, 126 phlegmonous, 126 Phimosis, 25, 246 Photophobia, 248 Pia, 202 Pica, 114 Pigeon breast, 23 Piles, 164 Pink-eye, 252 Pitted teeth, 17 Pitting in small-pox, preventing 337 Plaster casts, 465 Plethora, 194 Pleurisy, 81 hemorrhagic, 89 INDEX 505 Pleurodynia, 89, 349 Pleuropneumonia, 106 Pneumohydrothorax, 90 Pneumonia, 20, 94 aspiration, 107 cerebral, 106 croupous, 24 cry of, 30 embolic septic, 108 hypostatic, 107 lobar, 101 serum treatment, 108 treatment of, 108 typhoid, 291 Pneumonic consolidation, 103 Pneumopericardium, 179 Pneumothorax, 90 artificial, in tuberculosis, 307 Poisons and their antidotes, 420 Poliomyelitis, acute anterior, 224 Polydactyly, 28 Polyuria, 233, 234 , Post-diphtheric paralysis, 229, 326 Pott's disease, 302 Poultices, 432 Premature babies, 42 Pressure symptoms, 211 Prognosis in diseases of children, 31 Proctitis, 164 Prolapse of rectum, 164 emergency treatment, 427 Promises to child, 52 Prone-pressure method of artificial respiration, 457 Proteids, 357 in artificial feeding, 379 Protein milk, 374 Pseudocrisis in pneumonia, 105 Pseudodiphtheria, 123 Pseudohypertrophy of muscles, 227 Psoas abscess, 304 Pulmonary insufficiency, 184 edema, 80 emphysema, 78 stenosis, 184 Pulmotor, 456 [, Pulse, 29, 175 dicrotic, 175 taking of, 45 venous, 175 water-hammer, 176 Purpura, 195 506 INDEX Purpura hemorrhagica, 195 Pustules, 258 Pyelitis, 243 Pylorospasm, 132 diet in, 133 gastro-enterostomy for, 134 lavage in, 134 operation in, 134 symptoms, 133 treatment, 133 weight-chart in, 134 Quarantine, regulations of, 32 Quinsy, 120 Rabies, 279 Rachitic rosary, 353 Rachitis, 352 Ranula, 114 Rashes, dates when they appear, 266^ Reaction, Wassermann, 46 Rectal irrigation, 50 Rectum, cold compresses to, 50 diseases of, 164 inflammation of, 164 prolapse of, 164 emergency treatment, 427 Reduplication of heart sounds, 184 Regurgitation, 182 after feeding, 51 aortic, 183 mitral, 183 Remittent malarial fever, 273 Renal calculus, 242 hyperemia, 236 Resolution, stage of, 103 Respiration, 29, 57 artificial, 454 Respiratory failure, 455 emergency treatment, 427 tract, diseases of, 23, 54 Rest, 408 Resuscitation, methods of, 454 Retropharyngeal abscess, 126 Rhagades, 275 Rheumatism, 26, 347 acute articular, 347 endocarditis after, 25 complicating, 27 Rheumatism, heart murmur in, 24 inflammatory, 347 muscular, 348 Rhinitis, 60 acute, 60 atrophic, 63 chronic, 61 hypertrophic, 63 Rice and oatmeal water, 365 flour gruel, 370 milk, 365 Rickets, 27, 49, 352 fetal, 216 Rickety children, eruption of teeth in, 15 Rogers' sphygmomanometer, 192 Rose cold, 78 Rotheln, 323 Round worms, 162 Rubella, 323 Rubeola, 320 Running ears, 25 Rusty sputum, 56 Salt bath, 439 solution, normal, 410 continuous injection, 451 Salvarsan, 278 Salvator, 456 Sarcoma of kidney, 244 Sardonic grin, 278 Scabies, 260 Scales, 258 Scarlatina, 314 miliaris, 316 Scarlet fever, 314 anginoid, 316 kidneys after, 26 malignant, 317 Schafer method of artificial respira- tion, 457 Sciatica, 228 Scissors gait, 224 Sclerema, 23 Sclerosis, 224 Scoliosis, 354 Scorbutus, 351 Screw-driver teeth, 17 Scurvy, 27, 351 Seat-worms, 163 Seborrhea, 258 INDEX 507 Serum, Flexner's, 269 treatment of pneumonia, 108 Shock, emergency treatment, 427 Shower bath, 441 Sight, development of, 14 Silvester's method of artificial res- piration, 456 Singultus, 132 Siphoning milk, apparatus for, 382 method for, 382 Sitting hot-air bath, 439 Sitz bath, 439 Six fingers, 24 Skiagraphy, 469 Skimmed milk, 381 Skin, diseases of, 25, 257 masks for, 468 Sleep, disorders of, 223 in childhood, 41 in infancy, 41 in newborn babe, 40 Small-pox, 334 black, 336 malignant, 336 Smell, development of, 14 Solutions, percentage, rules for, 477 Spasmodic croup, 65 Spasms, nodding, 25 Spasmus gyrans, 222 Speech, disorders of, 222 Sphygmomanometer, 192 Spice poultice, 433 Spinal cord, anatomy of, 200 diseases of, 223 nerves, 202 Spine, observation of, 49 Spirochaeta pallida, 277 Spitting of blood, treatment, 426 Spleen, diseases of, 166 removal of, 167 Splint, Hamilton, 461 Splints, 463 Sponge bath, 428, 442 Spotted fever, 267 Sputum, 56 collecting, for examination, 313 disposal of, 312 in tuberculosis, 313 Starch bath, 441 poultice, 433 Stenosis, aortic, 183 mitral, 182 Stenosis of lacrimal duct, 250 pulmonary, 184 tricuspid, 183 Sterilization of bottles, 50 of thermometer, 52 Sterilized milk, 364 Stomach, capacity of, 129 dilatation of, 138 diseases of, 129 nursing in, 139 inflammation of, 135 malformations of, 134 washing, 448 Stomach-tube, feeding by, 450 Stomatitits, 116 aphthous, 116 gangrenous, 117 parasitic, 117 mercurial, 118 ulcerative, 117 Stools, disinfection of, in typhoid fever, 294 Strabismus, 25, 250 Strait jacket, 467 Strangulation of intestine, 160 Strawberry tongue, 112, 315 Stricture of esophagus, 129 Stridor, congenital, 22 Stridulous breathing, 66 Strumous children, eruption of teeth in, 15 Stuttering, 222 St. Vitus' dance, 25, 220 Stye, 250 Subsultus tendinum, 100 Sugar in urine, 236 Sulphur bath, 441 Summer diarrhea, 145 Sunstroke, treatment, 427 Sympathetic nerves, 202 Symptomatology of children's dis- eases, 28 Syncope, 205 Synechia, 250 Syphilis, 275 hereditary, 26 cry of, 30 Wassermann reaction in, 46 Syphilitic laryngitis, 65 Syringing, 442 ear, 443 eye, 442 508 in Syringing, mouth, 446 nose, 444 Syringomyelia, 227 Systole, 182 Systolic sound, 174 Tache cerebrale, 269 Tachycardia, 175 Taenia saginata, 161 solium, 161 Talipes valgus, 28 varus, 28 Talking, 15 Tape-worms, 161 Tar bath, 442 Teeth, 15 eruption of, 15 in strumous or rickety children, 15 Hutchinson's, 16 laminated, 17 milk, average age of eruption of, 15 permanent, average age of erup- tion of, 15 pitted, 17 screw-driver, 17 Temper, cry of, t,o Temperature, 28 changing Centigrade to Fahren- heit, 478 methods of reduction, 428 sudden rise of, 51 taking, of, 43, 44, 50 Tenesmus, 142 Tepid bath, 442 Testicle, undescended, 246 Test-meals, 139 Tetanic convulsions, 203 Tetanus, 20, 278 Tetany, 25, 221 Therapeutic limit, 411 Therapeutics, 410 Thermometer, sterilization of, 52 Throat, examination of, 51 foreign bodies in, 425 Thrombosis, 215 Thrush, 117 Tibia, bowing of, 28 Tinea circinata, 260 tonsurans, 260 Tongue in digestive diseases, 112 Tongue, inflammation of, 115 strawberry, 112 Tongue-tie, 115 Tonsillectomy, 122 Tonsillitis, 119 Tonsils, hypertrophy of, 120 Top-milk mixtures, 386 Tormina, 142 Torticollis, 222, 349 Touch, development of, 14 Tracheotomy, 333 Tremors, 204 Tricuspid stenosis, 183 Trismus, 278 Trousseau's sign, 221 Tubercular adenitis, 26, 307 arthritis, 306 dactylitis, 307 laryngitis, 65 meningitis, 25, 208 osteomyelitis, 306 Tuberculosis, 26, 296 acute miliary, 301 care of soiled bed linen in, 312 cleanliness in, 310 disinfection of excreta in, 312 lung immobilization in, 307 nursing in, 308 of bones, 302 of bronchial lymph-glands, 302 of intestines, 155 of joints, 302 of kidney, 243 outdoor treatment, 309 treatment of, 307 Tuberculous bronchopneumonia, 299 Tumors, cerebral, 215 Turpentine stupe, 431 Tympanites in typhoid fever, 289 . Typhoid fever, 26, 282 pneumonia, 291 spine, 290 state in bronchopneumonia, 100 ulcer, 284 vaccination against, 291 walking, 282 Typhus fever, 279 symptoms, 280 Ulcer, gastric, 137 of frenum, 115 INDEX 509 Ulcer, typhoid, 284 Ulcerative stomatitis, 117 Uncinaria duodenalis, 163 Undescended testicle, 246 Urea, 115 Uremia, 237 Urethritis, 247 Urinary tract, diseases of, 231 Urine, 233 collecting of, 234 examination of, 235 method of collecting, 45 retention of, treatment, 428 suppression of, treatment, 427 Urotropin, 227 Urticaria, 260 Uvulitis, 126 Vaccination, 338 against typhoid, 291 Vaccines, 415, 453 Vaccinia, 338 Vaginal douching, 453 injections, 453 Vaginitis, 247 Vapor bath, 436 Varicella, 337 Variola, 334 Varioloid, 336 Ventilation,'409 Vesical calculus, 246 spasm, 246 Vesicles, 258 Vincent's angina, 123 Vinegar and mercury bath, 442 Volvulus, 160 Vomiting, 131 cyclic, 132 habit, 132 of blood, treatment, 426 persistent, treatment, 428 Vomitus, disinfection of, in per- tussis, 52 Von Jaksch's disease, 194 Walking, 14 typhoid, 286 Wassermann reaction, 46, 277 Water, drinking of, 48 in food, 359 Water-hammer pulse, 176 Weakness, cry of, 30 Weaning, 377 Webbed fingers, 28 Weight, 11 chart, 13 Griffith's, 12 in pylorospasm, 134 table, 14 Weights and measures, 474 Wet cups, 432 Whey, 366 and milk, 366 and white of egg, 366 milk, and white of egg, 366 Whooping-cough, 341 Widal reaction, 290 Wine measure, table of, 474 whey, 367 Woman's milk and cows' milk, difference between, 362 Worms, intestinal, 161 round,162 seat-, 163 tape-, 161 Wounds, dressing of, 471 emergency treatment, 428 Wry-neck, 222 Yellow tubercle, 300 Young's rule for dosage, 411 Youth, general hygiene in, 41 period of, 11 Books for Nurses PUBLISHED BY W. B. SAUNDERS COMPANY West Washington Square Philadelphia London: 9, Henrietta Street, Covent Garden Sanders' Nursing anew work Miss Sanders' new book is undoubtedly the most complete and most practical work on nursing ever published. Every thing about every subject with which the nurse should be familiar is detailed in a clean cut, definite way. There is no other nursing book so full of good, practical informa- tion—information you need. Modern Methods in Nursing. By Georgiana J. SANDERS, formerly Superintendent of Nurses at Massachusetts Gen- eral Hospital. i2mo of 881 pages, with 227 illustrations. Cloth, $2.50 net. Dunton's Occupation Therapy JUST ISSUED Dr. Dutiton gives those forms likely to be of most service to the nurse in private practice. 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It tells the nurse how to do those things she is called upon to do in her first year in the training school—the actual ward work. First-Year Nursing. By Minnie Goodnow, R. N.t formerly Super- intendent of the Women's Hospital, Denver. 121110 of 354 pages, illustrated. Cloth, $1.50 net. Aikens' Hospital Management This is just the work for hospital superintendents, training- school principals, physicians, and all who are actively inter- ested in hospital administration. The Medical Record says: "Tells in concise form exactly what a hospital should do and how it should be run, from the scrubwoman up to its financing." Hospital Management. Arranged and edited by Charlotte A, Aikens, formerly Director of Sibley Memorial Hospital, Washing- ton, D. C. 12010 of 488 pages, illustrated. Cloth, $3.00 net JUST READY NEW (3d) EDITION Aikens' Primary Studies Trahied Nurse and Hospital Review says: "It is safe to say that any pupil who has mastered even the major portion of this work would be one of the best prepared first year pupils who ever stood for examination." Primary Studies for Nurses, By Charlotte A. Aikens, formerly Director of Sibley Memorial Hospital, Washington, D. C. i2mo of 471 pages, illustrated. Cloth, $1.75 net Aikens' Training-School Methods and the Head Nurse This work not only tells how to teach, but also what should be taught the nurse and how much. The Medical Record says° " This book is original, breezy and healthy." Hospital Training-School Methods and the Head Nurse. By Char- lotte A. Aikens, formerly Director of Sibley Memorial Hospital, Washington, D. C. 12010 of 267 pages. Cloth, $1.50 net Aikens' Clinical Studies NEW (2d) EDITION This work for second and third year students is written on the same lines as the author's successful work for primary stu- dents. Dietetic and Hygienic Gazette says there " is a large amount of practical information in this book." Clinical Studies for Nurses. By Charlotte A. Aikens, formerly Director of Sibley Memorial Hospital, Washington, D. C. 121110 of 56g pages, illustrated Cloth, $2.00 net 3 Bolduan and Grund's Bacteriology The authors have laid particular emphasis on the immediate application of bacteriology to the art of nursing. It is an applied bacteriology in the truest sense. A study of all the ordinary modes of transmission of infection are included. Applied Bacteriology for Nurses. By Charles F. Bolduan, M.D., Assistant to the General Medical Officer, and Marie Grund, M.D., Bacteriologist, Research Laboratory, Department of Health, City of New York. 12110 of 166 pages, illustrated. Cloth, $1.25 net. 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Cloth, $1.50 net JUST ISSUED NEW (3d) EDITION Paul's Fever Nursing In the first part you get chapters on fever in general, hygiene, diet, methods for reducing the fever, complications. In the second part each infection is taken up in detail. In the third part you get antitoxins and vaccines, bacteria, warnings of the full dose of drugs, poison antidotes, enemata, etc. Nursing in the Acute Infectious Fevers. By George P. Paul, M. D. i2moof 275 pages, illustrated. Cloth, $1.00 net 6 McCombs, Diseases of Children for Nurses NEW (2d) EDITION Dr. McCombs' experience in lecturing to nurses has enabled him to emphasize/wtf those points that nurses most need to know. National Hospital Record says: "We have needed a good book on children's diseases and this volume admirably fills the want." The nurse's side has been written by head nurses, very valuable being the work of Miss Jennie Manly. Diseases of Children for Nurses. By Robert S. McCombs, M. 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Flexible leather, gold edges, $1.00 net; with patent thumb index, $1.25 net. Lewis' Anatomy and Physiology ed™on Nurses Joarnal of Pacific Coast says "it is not in any sense rudimentary, but comprehensive in its treatment of the sub- jects." The low price makes this book particularly attractive. Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., Lec- turer on Anatomy and Physiology for Nurses, Lewis Hospital, Bay City, Mich. 121110 of 126 pages, 150 illustrations. Cloth, $1.75 net Bohm & Painter's Massage The methods described are those employed in Hoffa's Clinic —methods that give results. Every step is illustrated, showing you the exact direction of the strokings. The pictures are large. You get the technic used in Professor Hoffa's Clinic. Octavo of 91 pages, with 97 illustrations. By Max Bohm, M. D., Berlin, Germany. Edited by Charles F. Painter, M. D., Professor or Orthopedic Surgery, Tufts College Medical School, Boston. Cloth, $1.75 net SECOND EDITION Grafstrom's Mechano-therapy Dr. Grafstrom gives you here the Swedish system of mechan- otherapy. You are given the effects of certain movements, gymnastic postures, medical gymnastics, general massage treatment, massage for the various conditions. The illustra- tions are full-page line drawings. Mechanotherapy (Massage and Medical Gymnastics). By Axel V. Grafstrom, B. Sc, M. D., Attending Physician Gustavus Adolphus Orphanage, Jamestown, New York. i6mo of 200 pages. Cloth, $1.25. net Friedenwald and Ruhrah's Dietetics for INUrSeS NEW (3d) EDITION This work has been prepared to meet the needs of the nurse, both in training school and after graduation. American Jour- nal of Nursi/ig says it "is exactly the book for which nurses and others have long and vainly sought." Dietetics for Nurses. By Julius Friedenwald, M. D., Professor of Diseases of the Stomach, and John Ruhrah, M.D., Professor of Diseases of Children, College of Physicians and Surgeons, Baltimore. i2mo volume of 431 pages. Cloth, $1.50 net FOURTH EDITION Friedenwald & Ruhrah on Diet This work is a fuller treatment of the subject of diet, pre- sented along the same lines as the smaller work. Everything concerning diets, their preparation and use, coloric values, rectal feeding, etc., is here given in the light of the most re- cent researches. Diet in Health and Disease. By Julius Friedenwald, M.D., and John Ruhrah, M.D. Octavo volume of 857 pages. Cloth, $4.00 net Pyle's Personal Hygiene new^St?^ Dr. Pyle's work discusses the care of the teeth, skin, com- plexion and hair, bathing, clothing, mouth breathing, catch- ing cold; singing, care of the eyes, school hygiene, body posture, ventilation, heating, water supply, house-cleaning, home gymnastics, first-aid measures, etc. A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. 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D., University of Pennsylvania. 12110 of 247 pages. Cloth, $1.50 net JUST OUT NEW (6th) EDITION Griffith's Care of the Baby Here is a book that tells in simple, straightforward language exactly how to care for the baby in health and disease; how to keep it well and strong; and should it fall sick, how to carry out the physician's instructions and nurse it back to health again. The Care of the' Baby. By J. P. Crozer Griffith, M.D., Univers- ity of Pennsylvania. i2mo of 458 pages, illustrated. Cloth, $1.50 net Hoxie & Laptad's Medicine for Nurses Medicine for Nurses and Housemothers. By George Howard Hoxie, M. D., University of Kansas; and Peari, L. LapTad. 12mo of 351 pages, illustrated. Cloth, $1.50 net. New (2d) Edition. This book gives you information that will help you to carry out the directions of the physician and care for the sick in emergencies. It teaches you how to recognize any signs and changes that may occur be- tween visits of the physician, and, if necessary, to meet conditions until the physician's arrival. Boyd's State Registration for Nurses State Registration for Nurses. By Louie Croft Boyd, R. N., Graduate Colorado Training School for Nurses. Octovo of 149 pages. Cloth, $1.25 net. New (2d) Edition. Morrow's Immediate Care of Injured Immediate Care of the Injured. By Albert S. Mor- row, M. D., New York City Home for Aged and In- firm. Octavo of 354 pages, with 242 illustrations. Cloth, $2.50 net. New (2d) Edition. deNancrede's Anatomy NEw <7,h) edition Essentials of Anatomy. By Charles B. G. deNan- crede, M. D., University of Michigan. 12mo of 400 pages, 180 illustrations. Cloth, $1.00 net. Morris' Materia Medica NEw (7.h> edition Essentials of Materia Medica, Therapeutics, and Pre- scription Writing. By Henry Morris, M. D. Re- vised by W. A. Bastedo, M. D., Columbia University, New York. 12mo of 300 pages, illustrated. Cloth, $1.00 net. Register's Fever Nursing A Text Book on Practical Fever Nursing. By Edward C. Register, M. D., North Carolina Medical College. Octavo of 350 pages, illustrated. Cloth, $2.50 net. ■I / wn 2 3 ms f mm kxXHHhJbc WY 159 M129d 1916 H 54530510R E ■8bb8K( >'ffl8BB& IC(?WWM I'M ^1 NLM DSEflflDGT 7 1 NATIONAL LIBRARY OF MEDICINE NLM052880097