fe!:i::;t;-iii>:.rr^:i!?;'' ■•;:.;:■.■ .': Hi'!' fvii'*!-,'' 1 > '' ■ I.' if '?l:i"^ ■■:■■■■ I ' '. i m^m^' THE CARE OF THE BABY A MANUAL FOR MOTHERS AND NURSES CONTAINING I'RACTICAL DIRECTIONS FOR THE MANAGEMENT OF INFANCY AND CHILDHOOD IN HEALTH AND IX DISKASK J V. CROZKR C.RIFFITH, M. D. Clinical ProfesiK>r of Diseases of Children in the Haspiul of the University of Penn- sylvania ; Physician to the Children"?. H<>spit.«l. to the Methodist Episcopal Hospiul, and to St. Agnes' Hospii.il. Philadelphia. Member o( the American Pediatric Society and of the Association of Anieiican Physicians SECOA'D EDITION, REVISED. PHILADELPHIA W. B. SAUNDERS 925 Walnut Street 189S. V A- 1121 1 Copyright, 1898, by W. B. SAUNDERS 2n0 COP^. I »V0 COPIES RECEIVED- 1898. ELECTROTYPED BY WESTCOTT t THOMSON, PHILADA. PRESS OF W. B. SAUNDERS. PHILADA. PREFACE TO THE SECOND EDITION. The very gratifying success which the first edition has met has made the author desirous of bringing the present one thoroughly up to the demands of the times. He has therefore submitted it to a complete revision, enlarging it considerably and adding several new illus- trations. He would again emphasize the statement made repeatedly throughout the volume, that the chapter on ''The Sick Baby" is not intended to supplant the physi- cian. This he considers impossible. It is designed especially for mothers in eineii'Liicv. where medical aid cannot be obtained. PREFACE The author has endeavored in the following pages to furnish a reliable guide for mothers anxious to infonn themselves with regard to the best way of caring for their children in sickness and in health. The first chapter of the book discusses the hygiene of pregnancy, the method of calculating the date of con- finement, and similar data. The characteristics of a healthy baby are considered in the second chapter, and the growth of its mind and body in the succeeding one. The chapters which follow relate to the methods of bath- ing, dressing, and feeding children of different 'ages, to the hours for sleeping, to physical and mental exercise and training, and to the proper qualities of the children's various nurses and rooms. A special effort has been made to emphasize details and to make them clear, complete, and thoroughly up to date. The chapter upon the baby's diseases has been written particularly for those mothers who, through various cir- cumstances, are unable to have a physician constantly within a moment's call. It contains a description of the symptoms by which we may know that disease is present; a consideration of the nursing of sick children; a concise resume of the commonest diseases of infancy 11 12 PREFACE. and childhood; and directions for the management of various accidents, including, among others, drowning and the swallowing of poisons. Such illustrations have been inserted as, it is thought, will make more plain the meaning of the text. To avoid repetition throughout the book, various recipes for food or medicine, as well as remarks on the employment of baths of various sorts in sickness, of poultices, disinfect- ants, massage, and the like, have been placed in the Appendix. Here also are tables showing the proper proportionate doses at different ages, the doses of many of the remedies most commonly given to children, the contents of the emergency medicine closet, etc. The numbered references scattered throughout the text of the book refer to corresponding paragraphs in the Ap- pendix. The author has endeavored to make his statements plain and easily tmderstood, yet scientifically accurate, in the hope that the volume may be of service not only to mothers and nurses, but also to medical students and to those practitioners whose opportunities for obser\ang children have been limited. With what his own ex- perience with children has led him to believe w^ould be most helpful, he has combined those teachings in other books of like nature which have seemed to him of most value; and he takes this opportunity to acknow- ledge his indebtedness to previous writers, not for- getting the contributors to the files of that excellent magazine for mothers, ' ' Babyhood. ' ' He would also PREFACE. 13 express his grateful thanks to his colleagues at the Uni- versity of Pennsylvania and at the Philadelphia Poly- clinic and School for Graduates in Medicine, Professors Hirst, Roberts, Randall, Van Harlingen, and Risley, who have revised for him, with many valuable sugges- tions, the pages bearing respectively upon the hygiene of pregnancy and of the nursing mother, surgical affec- tions, diseases of the ear, diseases of the skin, and dis- eases of the eye. CONTENTS. I PAGB I Introduction 17 CHAPTER I. Before the Baby Comes 19 CHAPTER II. The Baby 34 CHAPTER III. The Baby's Growth . 46 CHAPTER IV. The Baby's Toii^et 66 CHAPTER V. The Baby's Clothes S^ CHAPTER VI. Feeding the Baby 109 CHAPTER VII. Sleep ... 157 CHAPTER VIII. Exercise and Training, Physical, Mental, and Moral . 164 i5 1 6 CONTENTS, CHAPTER IX. The Baby's Nurses 182 CHAPTER X. The Baby's Rooms .198 CHAPTER XI. The Sick Baby 220 APPENDIX 353 THE CARE OF THE BABY. INTRODUCTION. It seems often to be taken for granted that the young mother will understand by a sort of intuition the care which her baby requires, as though it needed no more than a newborn animal of some lower order of life. The fact is that such a little animal, slight though its needs are when compared with those of a baby, has a parent which by instinct is far better able to care for it than is the human mother for her child. That she knows nothing is both the mother's safe- guard and her danger. Ready and anxious as she is to fit herself for her new duties, she is even by this anxiety rendered too ready to accept as gospel all that is told her about the care of her infant by those who assume to know, but who "darken counsel by words without knowledge." She thus becomes the prey of " old wives' fables" and of all sorts of gratuitous advice, the injuri- ousness of which is shown too late in the condition of the unfortunate child. A well-informed monthly nurse can be of great assist- ance to a new mother beginning the care of her baby. Unfortunately, not all nurses are of this class, and some are full of absurd and harmful practices and teach- ings, while even those who are intelligent and well trained often err greatly in many points. Of all this the mother is, of course, unable to judge, unless she herself 2 17 1 8 THE CARE OF THE BABY. knows what is right. The baby's grandmother is nat- urally rather rusty in matters relating to the care of chil- dren, although she may not be ready to admit it. Moreover, it is most true, in the words of the old song, that " Times have changed since then, And life is a different thing," and many methods which were considered entirely cor- rect years ago have since been greatly improved or even found to have been actually wrong. The mother there-, fore finds herself, after the departure of her nurse and physician, ignorant and without reliable resources upon which to draw. Such being the case, we may profitably consider, as briefly as possible with due regard to com- pleteness, some of the matters connected with babyhood from birth, and even before it, up to the time when childhood ceases. Baby is, indeed, a very indefinite term, often applied by mothers to children who have far outgrown their right to the name as strictly used. But "baby" the child still is to its mother, unless a second comer has. added dignity to the first-born's position, so "baby" it shall be to us in our present study of its wants ; for we must not forget that a child even of several years demands just as great care, although of a different sort, as it did when still in arms. From a strictly medical standpoint babyhood and childhood are very commonly divided into three jDeriods, concerning the exact limits of which physicians are not altogether agreed. Most conveniently we may speak of, first, mfancy^ which extends from birth to the age of tw^o years; second, early childhood^ from the age of two to that of six years; and, third, later childhood^ from the age of six years to that of puberty — that is, thirteen to BEFORE THE BABY COMES, 19 fifteen years. We shall repeatedly have occasion during our study of the subject to use these terms as thus defined. No observations made in the following pages concern- ing the baby when ill are intended to do away with the j physician any more than they are meant to make a ! mother entirely dependent upon him. Their object is ' only to help her understand what she can do without I medical advice, and how she shall do it; when she shall call a physician to her aid, and what she shall do before he comes. CHAPTER I. BEFORE THE BABY COMES. It is a fact which ought never to be forgotten that the proper care of the baby begins long before it is born, for to produce healthy offspring the parents must themselves be healthy. Although the manner of living always healthily is a subject far beyond the province of this volume, at least some attention must be given here to the way in which a woman should live after she has dis- covered that she is to be a mother. How she shall order her life should certainly be her first consideration, for, whether or not the coming of the baby is a welcome thought, her responsibility for the future welfare of the child that is to be remains the same. She has no right to act in any way that may injure another human life. Signs of Pregnancy. — Whether she is really preg- nant is naturally the first question, and one concerning which a woman does not ordinarily consult her physician. There are a large number of presumptive signs of preg- nancy, many of which she is capable of observing her- II 20 THE CARE OF THE BABY. self. It is proper to remark that none of these indicate anything further than the probable existence of preg- nancy. There are only a i^^ positive signs, and these can be detected by the physician alone. The most striking and valuable of the presumptive j signs is, of course, the cessation of the monthly periods; 1 yet even this is not entirely reliable, for various other • causes may account for it. It sometimes happens that ' menstruation is absent for several months in early mar- j ried life, and yet that conception has not taken place; \ while, on the other hand, the monthly periods occasion- ; ally come on regularly during a part or, rarely, all of j pregnancy, although in this case they are usually scanty ' and of short duration. Finally, a woman may conceive while still nursing and before menstruation has been re-established. As a rule, however, the cessation of j menstruation in a married woman previously regular "j indicates pregnancy. i Enlargement of the abdomen is another important ' sign, although usually not detected before the fourth j month of pregnancy. A valuable indication is enlarge- j nient of the breasts with tenderness of the nipples and a I decided widening and browning of the pink ring, or areola^ around them. Sometimes a small amount of a watery fluid is secreted later. The enlargement of the | breasts begins in some instances in the second month of ' pregnancy, and becomes quite noticeable in the fourth and fifth months. The alteration of the areola com- mences to be visible by the end of the second month. ' ' Morning sickness " is a symptom present in many women. It usually consists in the occurrence of nausea, and perhaps vomiting, in the early morning, but it some- times lasts all day. It appears generally in the second month, occurs every day or less frequently, and lasts only BEFORE THE BABY COMES. 21 through the third month ; but in bad cases it may con- tinue through the whole period, and become dangerous from the difficulty the patient experiences in retaining food. *' Quickening" is a sign of much value, but, like the others, only presumptive. By this term is meant the detection by the mother of the movements of the child within her. It was once thought that the child received life at this time, but this was, of course, erroneous. The child is just as much alive before quickening as after- ward, but its early movements are too feeble to be per- ceived until four or four and a half months after concep- tion. The movements at first give the sensation of a feeble fluttering, but soon become much more evident, and then feel like sudden, sharp strokes or kicks, and are often the cause of considerable or even great discomfort. There are a number of other less important presump- tive signs, such as variations in appetite, with abnormal hunger, or "longings," for unusual kinds of food. Again, the whole disposition may be changed completely for the time, and she who was formerly vivacious, cheerful, and good-natured may become dull and melan- cholic, full of the gloomiest forebodings, or excessively irritable. Sometimes, but, unfortunately, less frequently, just the reverse of this takes place, and the disposition is at the best during pregnancy. The exact time at which the baby may be expected is a matter of great importance, since so many preparations must be made for its arrival. Confinement occurs 272 to 275 days from the date of conception; but, as this date can rarely be determined exactly, it is customar}^ to reckon that pregnancy lasts 10 menstrual months of 28 days each — that is, 280 days — from the first day of the last menstrual period. This equals 40 weeks, or a little 22 THE CARE OF THE BABY. over 9 calendar months. A ready rule for determin- ing the date on which confinement may be expected is to count three months backward from the first day of the last menstruation and to add seven days to the date obtained. Thus, if the last period began on February 3, three months backward would bring it to November 3, and seven days added would make November lo the probable date. Since, however, the months are not of equal length, various tables have been constructed for a more accurate and convenient method of computing the date. The one upon the opposite page is a form very commonly in use. This method of reckoning is, of course, only approxi- mate even when the exact date is known on which it is sup- posed that conception occurred. It is therefore only safe to consider the calculated date of confinement as the middle of a period of two weeks, on any day of which labor may naturally take place. Where it is impossible ■ to reckon from the last menstrual period, it is custom- ary to count from the date of quickening. Four and a half months from this date, or five months in the case of a woman pregnant not for the first time, will give the " approximate date of confinement, although this is not " very accurate. Management of Pregnancy. — The prospective mother has, then, forty weeks during which she shall conduct herself in the way that will exert the most powerful influence for good upon the health of the coming little j. one. Bathing in tepid water may be enjoyed daily, but i very hot or very cold baths, sea-bathing, and foot-baths \ are dangerous. Moderate exercise in the open air is im- ^ portant, while the constant occupancy of close, heated rooms is distinctly harm^ful. All the pure air possible should be obtained. Walking is beneficial, as is driving \ BEFORE THE BABY COMES. 23 i •— 1 1 1 < V C 3 •-1 < *• P)^ fO M t^ m M t^ m m m^ M t^ m vO %^ 8>* ^^ vO m a^ VO m ^^ ^^ VO m VO m Os^ s^"^ g,^ S^^ On VO ON VO On VO OvvO On to ONVO g^- ^^ 00 m 00 M 00 N CI ^^ 00 -^ ^^ ^-^^ 00 VO 00 ■^ 00 Tt 00 r}- ^^ t^'^ N t^ M t>. M t^ m t^ m t^ m t^m t^ m t^m t^ m ^-^ -8?^ VO N N VO «VJ vO N VO N ^-^ VO N C4 VO M ^^ VON ^% u->0 r< m 10 M N VO M ^" VO M VO N tOM VOM to M ^" Tt OS ^S^ ^<^ ^m ^^ ^m ^- ^m ^m N m ^^ rooo ??^ mt-« ^^ ^S^ ^^ ^^ ^^ ^^ m On N 0\ S^ C^ M ?}^ N Ov N 00 ^^ M Ov ^^ N On WOO ^^ IH 00 M VO « VO M 10 ;j^ M 1^ ;;^ «oo ^"^ i-i 00 Ml t^ S?r S^ g^ 8^ 8^ S^ VO S^ i^ 8^ C< N S^ OsvO 2^^ 2^^ OvTj- M M ^^ 2^^ 2^^ 2^^ 2^^ 2^^ OvVO ONVO 00 \r\ 00 VO M N ^J? ^?? 00 N M N ^^ ^^ ^^ ^^ 00 to I-I N <2i? 00 ""t M N 1-4 N M N M N t^ M M N ^^ ^?? ^^ i-i M M M ir^ ^^ ^?? >o fO •1 N -0 M M CS VO M M N ^8 ^;? VO N ^?? ^^ ^^ ^^ ^S iTg t:?S VO Ov :i?s VOM I-I N 1??1 10 N M N VO N M M ^^ to M M M 2-;3 Tf On rh ON rJ-00 2-?3 ?8 ^?5 rt M M N 2-;j ?a ::8 :?S moo moo mi>. :?s m On :?8 ITS ::g :?S m 0\ « OS f< Ov N t>. N t^ N VO M 1^ N Ov N 00 M ON N ON N On N On MOO M 00 M 00 « VO « VO M VO M M «00 11 t^ M M = ^ M 00 M 00 wOO M t^ r^ i^ M M u^ VO ^ M M t^ VO 2Jr r^ t>. t^ VO ON^ 0\0 ONTh o\^ ovm Ov'O ONVO ONVO ONVO ONVO OvVO 0\ to 00 u^ 00 vn 00 fO 00 m M 00 N 00 ^ 00 Tj- 00 to M 00 to M 00 VO 00 "^ 00 Tf t^^ t^'*- t^ N t^ M *^« i>.m t-. 't M M *^2" jt>> m VO fO VO ro VO M VO « VO VO f^ VO N VO m VO m M VO r^ VO fO VO W tnrj ION loO xno M to ON »oN 10 M VO N VO N M VON VO N VOM "*»^ M Tj-Cv ^Ov -too Tj-M "*0 -t M rf w ^ M "^ « Ti-O M moo moo mt^ mo m o\ m m m mO moN N 0\ N Ox N t^ M »» N VO N On N 00 M Ov N ON N ON N On N 00 MOO MOO i-i vO M VO M VO M 00 M t^ M 00 MOO M 00 » 00 M t^ (0 h 5.2 Is! 8a, z< 24 THE CARE OF THE BABY. over smooth roads or riding in street cars; but horse- back riding, bicycling, dancing, driving over rough roads, lifting, straining of any kind, the use of the sewing-machine, and all other violent or long-continued forms of exercise ought sedulously to be avoided. Par- ticular care must be observed at the times at which the menstrual period would naturally occur if pregnancy did not exist. Sea-voyages are dangerous, on account of the liability to sea-sickness and the straining which accom- panies it. There is a very injurious custom among some women — that of refusing to go out of the house from the time when the alteration of figure becomes marked. Even were concealment of the figure impossible, health rather than appearance should be the first consideration. Amusement is, of course, necessary. There is no rea- son why pleasures should be abandoned, provided they are made entirely secondary to health. So, too, the fre- quenting of the theatre and of similar places of amuse- ment is often harmless, especially if it is found to exert no unduly exciting influence upon the emotions. In many women, however, the emotional nature is unusu- ally susceptible during pregnancy, and crowded places and exciting reading must be avoided. No amusements should be allowed to interfere with the obtaining of the large amount of sleep which is always required at this time. This brings us naturally to the consideration of the management of the mental condition. The unusually impressionable state characteristic of pregnancy renders a woman very prone to become the subject of great despon- dency. This she can relieve to a certain extent by the recollection that it is only a symptom shared by a great many others, and that there is no reason for the convic- tion that she will never survive the birth of her child. BEFORE THE BABY COMES. ±^ It is, of course, much easier to give this advice than to follow it. Consequently it is important that she avoid adding to her fears by listening to detailed accounts of the trials of other women under similar conditions, or by reading depressing novels or witnessing distressing sights. The experiencing of frights, the seeing of de- formed persons or animals, the hearing of bad news, and so on — maternal impressions^ as the doctors call them — are very commonly supposed to exert a powerful influence in producing some deformity or defect in the child; while the looking at beautiful objects, the listening to delight- ful music, and the reading of elevating books are also claimed to affect favorably the body or mind of the baby. As there is a possibility that such influences exist, every pregnant woman should avoid the one sort and cultivate the other. At the same time, there is certainly far more fable than truth in all this, and the action of such things is so infinitesimal and so uncommon that no woman need conclude that her child will surely be '^ marked " because she has been frightened or impressed in some way. The chances are hundreds of thousands to one that no such thing will happen. The various instances of maternal impression of which we so often hear are simply imagin- ary. On the other hand, there does exist the very cer- tain influence of inheritance. If a mother wishes her child to be healthy of body and beautiful of mind, she must previously have cultivated her own mind and body through years of training. The diet during pregnancy should be generous yet easily digestible. There is no reason why the usual diet should be altered at all, if it has been healthful and well assimilated, except that it is sometimes better to have the evening meal light. It is also wiser to eat meat only once a day, in order to throw less work upon the kidneys. 26 THE CARE OF THE BABY. There is no truth in the fancy that certain articles of food eaten can exert any special influence upon the development of the child. The dress is very important. The skin should be well protected against change of temperature by wearing woollen clothing both in summer and in winter. All garments must be loose enough not to interfere in the slightest with the progressive enlargement of the abdo- men and breasts. No woman with the slightest regard for the health of her child or for her own safety will resort to tight lacing in the endeavor to conceal her state as long as possible. From the very beginning of pregnancy she should abandon the corset altogether or use one especially adapted to prevent pressure, and should avoid circular garters and suspend the clothing from the shoulders as far as possible. There are now various dress-reform sys- tems on the market which answer the purpose very well, and which are certainly to be commended during preg- nancy, even though a woman cannot persuade herself to wear them always. High-heeled shoes ought not to be worn, as they put a strain on the back and the pelvis and may do serious damage. With the ex- hibition of proper taste and skill the dress can be so fashioned that no woman need have cause Fig. i.-Abdomi„al b^ *« "^egaM herself as unfit to appear in public. The abdomen may grow very large, especially in women who have previously borne children, and may demand some support. A binder will give relief, or, bet- ter still, one of the abdominal supporters which are especially made for this purpose (Fig. i). A week or two before confinement the abdomen usually seems to BEFORE THE BABY COMES. 2 7 grow a little smaller, the result of the settling of the womb lower into the pelvis. The care of the breasts must be commenced early, since upon this the ability to nurse the baby may largely depend. The entire removal of the pressure of the cloth- ing allows the breasts full opportunity to grow properly. They should, however, be covered warmly, and be well supported if their increasing size renders their weight uncomfortable. Particular attention must be given to the nipples, in order both to render them of a shape which the child can readily grasp and to make them secure later against the development of painful fissures. Sometimes there is a tendency to the formation on the nipples of a large amount of scaling skin. These scales must be washed away frequently if they show a disposi- tion to adhere. If, as the breast grows, the nipple is found not to stand out well, a nipple-protector of some sort may be worn constantly as an additional safeguard and aid to development. This should not be done except by medical advice. In cases of flat nipples it is frequently of advantage to endeavor every day to pull them very gently with the fingers out from the breast. Another excellent plan for accomplishing this end is the use of a breast-pump. The form shown in the illustration (Fig. 2) is one of the best, as some pumps are too powerful and are apt to do injur}^ Trac- tion by the fingers or by the pump should not be used in a way to do the slightest harm, ^ ^ Fig. 2. — Breast-pump. and no treatment of this sort should be begun until the last four weeks of pregnancy, lest a miscarriage be produced in women liable to it. With the beginning of the last month a hardening pro- 28 THE CARE OF THE BABY. cess for the nipples ought to be instituted, in order to prevent the formation of fissures later. A useful plan is that of applying, morning and night, a tannin solution (Appendix, 73) to the nipples with a piece of absorbent cotton. The question often arises whether there is any way of determining the sex of the coming child, or any course which the mother can pursue to influence it. The very fact that so many different methods are heard of is excel- lent proof that none of them are good for much. The truth is that there is absolutely no reliable means known to medical science for discovering in advance whether the child will be a boy or a girl, and not the slightest power of doing anything that will have an iota of influence in producing a child of the desired sex. Disorders of Pregnancy. — There are many discom- forts of pregnancy for which the sufferer herself may be able to do much. If simple means do not avail, she should not neglect to consult her physician, for there is surely no need of enduring any inconvenience that can be avoided. Constipation is exceedingly common at this time. The use of some laxative food, such as oatmeal por- ridge, green vegetables, figs, oranges, or stewed fruit, especially prunes, is often sufficiently effective. If not, mild drugs may be used without danger, as, for example, Seidlitz powders, or such mineral waters, in small doses before breakfast, as Hunyadi, Rubinat, Friedrichshall, and the like, or some gentle laxative pill prescribed by the attending physician. All strong purgatives and patent medicines are to be shunned. Enemata of tepid water may be used safely. Suppositories of glycerine or of gluten, or very small glycerine enemata are also of service. Irritability of the bladder is very common. It is relieved BEFORE THE BABY COMES. 29 to some extent by the recumbent position, which takes away the pressure of the heavy womb. If the urine is high-colored and causes smarting, a physician's advice should be had. Hemorrhoids, or piles, not infrequently develop in the later months of pregnancy. Ver)^ hot fomentations or sponging with very cold water, done fre- quently and followed by boric-acid-and-zinc ointment (Ap- pendix, 71) often affords great relief. Rest in the recum- bent position is also of value. If the bowels are kept reg- ular and all straining is avoided, hemorrhoids will not be so liable to form. Varicose veins or a painful swelling of the legs and lower parts of the body is often very annoy- ing as pregnancy advances. Rest lying down is one of the best means of relief, as is rubbing of the legs in an upward direction. It is often necessary to apply a soft flannel roller bandage from the toes nearly to the hips. This should be done before getting out of bed in the morning. If varicose veins grow at all large, a physician should be consulted, as there is danger of their bursting. Should the face swell, as well as the legs, it is probable that the kidneys are affected. As this is a dangerous compli- cation, no time should be lost in obtaining medical advice. Indeed, a specimen of the urine should be sent to the phy- sician from time to time during pregnancy, to make sure that no disorder of the kidneys is insidiously developing. A profuse flow of saliva sometimes occurs. It is occa- sionally relieved by a mouth-wash of tincture of myrrh in water. Toothache is not infrequent. If neuralgic only, it is often relieved by the use of a hot- water bag; but, unfortunately, it is not always of this nature. Decay of the teeth is very apt to occur during pregnancy, and it is best to consult a dentist occasionally, even though there be no toothache. No painful dental operation should be undergone if it possibly can be avoided. 30 THE CARE OF THE BABY. It sometimes happens that the hair falls out badly dur- ing pregnancy. This, like the toothache, may be only a temporary matter; but as it may be permanent, it is well to receive treatment for it. There is no reason whatever why a woman should suf- fer from morning sickness without at least making an effort to have it relieved. A plan frequently effectual is to take a cup of coffee, tea, broth, or hot milk early in the morning, without sitting up in bed, and then to rest or to sleep again for a short time before rising. If the vomiting persists during the day, food ought to be taken in very small amounts at frequent intervals. Of course, too, the food ought to be digestible and the bowels kept regular. Should the vomiting be severe and not be relieved in the way mentioned, medicines ordered by the physician will often control it. Heartburn and other evidences of indigestion, which are quite common in pregnancy, are often promptly re- lieved by soda-mint, and, if not, they should be prescribed for by the attending physician. Leucorrhoea is sometimes decidedly troublesome and even very irritating. Injections should not be used unless ordered by a physician, and then only with a very gentle stream from a fountain syringe (Fig. 3). The bag of the syringe must never be elevated more than a foot or two above the hips. Exter- nally, a solution of boric acid in water (Appendix, 75) may be used for bathing if there is any soreness, followed by the application of an ointment of oxide of zinc or of a pow^der of talc. Fig. x. — Fountain s^Tinge. _ . . ^ ^ ^. ^ ^ ^ Preparations for Confine- ment. — Finally, we must consider briefly some of the va- BEFORE THE BABY COMES. 31 rioiis preparations to be made for the confinement itself. The following list comprises the articles for the mother's use that should be provided in advance: Hand-towels. Ether, one-half pound. Brandy, two ounces. Vinegar, four ounces. Antiseptic tablets (corrosive sublimate), one bottle. A large, coarse new sponge. Braided silk, or a skein of bobbin (for tying the cord). A fountain syringe. A new soft-rubber catheter. One or two china basins. A porcelain bed-pan. Absorbent cotton, small package. Salicylated cotton, one-pound package. Carbolized gauze, one can. •New rubber cloth, one yard wide, two yards long. Nursery cloth, eight yards (for pads). Unbleached muslin, two yards (for binders). Carbolized vaseline, one-ounce bottle. Large oil-cloth or old rug (to protect the carpet). Large safety-pins. Fluid extract of ergot (bought one week before con- finement). Hot water in abundance (at time of confinement). The room which the prospective mother will occupy will ordinarily be her usual bed-room. It ought to be light, well ventilated, and large. It is a great conve- nience if there is an adjoining room for the monthly nurse, as this leaves to the mother the exclusive use of her own. The bed, when ready for the confinement, should be so situated that it is out of draughts and that its sides are not against the wall. The mattress should 32 THE CARE OE THE BABY. be of hair or other firm material, but certainly not of feathers; and extending entirely across it, at the level of the hips, there should be the strip of rubber cloth. Over this is spread the lower sheet of the bed, and finally, on the spot where the hips will lie, a protecting pad for the purpose of catching and absorbing the discharges. This pad should be a yard or more square. It is made of nursery cloth, and is pinned to the sheet with safety-pins. Under the bed is placed the oil-cloth or old rug. Many of these arrangements for sparing the bed and the floor are sometimes substituted by special rubber apparatus. The ' ' nursery cloth ' ' referred to consists of two layers of muslin with a layer of cotton quilted between them. It may be bought in the shops. It should be boiled for half an hour in a clothes-boiler, dried thoroughly, pinned up in a sheet, and put away out of the dust. The napkins which the mother will use should not be made until just before the confinement. She must, when making them, see that her hands are very clean, and she should put them away, when finished, in a clean place free from dust. It is far better, indeed, that the nurse make the napkins as needed. Each one is composed of an oblong wad of salicylated cotton enveloped in carbol- ized gauze folded in the usual form. All soiled napkins must be burnt at once. The abdominal bandages or "binders," of which there should be several, are composed of washed unbleached muslin half a yard wide and two or three feet long. If the nurse is in the house some time before the con- finement, as she should be, she will decide when to send for the physician, and thus relieve the patient of respon- sibility in the matter. If she has not yet come, the pro- spective mother will suspect that labor is about to begin from the occurrence of true pains. These are felt BEFORE THE BABY COMES. 33 either in the back or in front, last a quarter to half a minute, and come on rather regularly. The intervals between them at first last, perhaps, three-quarters of an hour, but gradually grow shorter, while the pains grow more severe and centre more and more in the back. There is often a slight discharge of blood (sometimes called a '' .show"), which is almost a positive proof that labor is about to commence. False pains^ as they are usually called, quite frequently occur at inter- vals during the two weeks before confinement. They are situated in the abdomen and have no element of regu- larity about them. The "bag of waters" is a sac containing a peculiar fluid in which the child floats. Its rupture is indicated by a continuous flowing or sudden gush of liquid. Should this happen, the physician must be sent for at once, even though there has been little or no pain. The rupture may take place, it is true, some days before the child is born, but much more frequently it does not occur until labor has really commenced, or even is nearly over. At the very beginning of the confinement the bowels ought to be emptied by an enema unless they have been moved just before. After labor is actually under way and the physician has arrived the patient has no further responsibility, and we need not consider the treatment that she requires or the various steps in the birth of the child. After its birth her physician will still attend to her needs and prescribe the form of diet best suited to her. When she is out of bed again and thrown on her own responsibility, her chief care for herself with regard to the baby must be to retain for it a suitable supply of milk. This can be dis- cussed more conveniently in the chapter which treats of Feeding the Baby. 34 THE CARE OF THE BABY CHAPTER II. THE BABY. The new-born baby is certainly not an object of beauty. Even its mother could hardly think it so, did she vsee it at the moment of its birth, before it has expe- rienced the improving influences of its first toilet — wet and more or less covered, as it is, with a peculiar whitish, waxy material. After it is washed and dressed its appear- ance even yet cannot be called altogether prepossessing. Still, despite its lack of beauty, its mother loves it and is naturally anxious to know whether it is ''all right." Many times afterward will she be fortunate if she can tell whether all is still right with it. As without a knowledge of how a baby of any age should look and act it is impos- sible to recognize illness developing, our first duty is to pass in review the characteristics of a healthy child — often called the features of health. A healthy and well-developed new-born infant should be plump and firm, with its bones well covered and with a soft and extremely delicate skin. This remarkable softness is due in great part to the presence everywhere of a coating of fine down, which is sometimes scarcely visible, sometimes quite abundant. The skin is of a decidedly reddish color, and only when the baby is suffering from some disease or when it is cold does it become mottled or bluish. Cold is the most frequent cause of this, for a baby has but feeble vitality as com- pared with an adult. The baby should weigh anywhere from 6^ to lo pounds, the average being 7^ pounds." Its length is about 19 inches, with a range, however, of from 16 to 22 inches. Any child which comes within these limits of THE BABY. 35 weight and length is to be called normal. Occasionally these figures are much exceeded, but not often. It must be remarked, too, that a child may be thin when born, and yet not be actually unhealthy. Before the child is a week old its lobster-red color often fades into a no more attractive, yellowish-red tint which makes it look almost as though it had an attack of jaun- dice. This is not jaundice, however, for the whites of the eyes show no trace of yellow. In this first week, also, the long down begins to fall out, and a more or less extensive shedding of the skin takes place, generally in the form of fine scales, but sometimes in shreds. This shedding always occurs, and may last a week or more, although with many babies it is almost imperceptible. By the time the baby is about two weeks old the yel- low tint has disappeared and the skin has taken on the real "baby" character which is so much admired, and which only needs to be seen to be appreciated. It is then of a clear, soft, pinkish-white tint, with the palms, soles, and cheeks of a deeper rose. A warm bath or rubbing the skin renders the whole body reddish. There are many other features about the body of a healthy baby with which we must acquaint ourselves, for, although they may seem rather uninteresting, they are matters of the greatest importance. The head is remarkably large as compared with the rest of the body, being, indeed, nearly as long from the crown to the chin as is the trunk. Immediately after birth, if this has been difficult or prolonged, the head is sometimes found squeezed into a shape which is start- ling, it is true, but which need cause no anxiety. (See Chapter XL, p. 277.) The contour of a baby's head as seen from above should be round or oval. At the back of the head and 36 THE CARE OF THE BABY. at a point just behind the forehead are two spots where there is no firm bone present, and only the skin and a thin membrane cover the brain, which can be seen to pulsate through them. These spots are called the anterior and posterior fontanelles (Fig. 4). The first, the one just back of the fore- head, is the larger of the two, and is the only one to the size of which the mother need give any attention. It is diamond- shaped, and should measure from one-half to one inch, or even two inches, in diameter Fig. 4.-Infant's skull: anterior soon after birth. It should fontaneiie above; posterior fonta- neither be mucli depressed uor nelle below. bulge much. The' new-born baby sometimes has a very considerable amount of hair on its head. The mother need feel no alarm at seeing this fall out to a great extent in a short time. Its nails, too, are well formed at birth, and grown fully out to the ends of the fingers. The tongue during the first week of life — and, indeed, up to the time when saliva becomes more abundant — is more or less covered with a whitish fur. This is no sign of digestive disturbance, but is probably the result of the greater dryness of the mouth present at this time of life. The chest of a baby is poorly developed as compared with the head, and its circumference is somewhat less. The shoulders and hips are narrow, and their girth is at first less than that of the head. On the other hand, the abdo7nen is large and prominent, the result chiefly of the extraordinarily large liver which a new-born Plate I. Baby a few weeks old, showing the natural curve of the legs with the bending in of the •oles. (From a photograph.) THE BABY. 17 child possesses. The arms are comparatively short, and the legs particularly so. The latter measure very little more than the length of the trunk. Every mother should remember that the baby at first has crooked legs, or rather what seem to be so, and that there is no cause for alarm on this account. It has the peculiar monkey-like power of turning its feet in in a way which brings the soles rather closely together. The accompanying illustration of a perfectly healthy and well- developed baby a few weeks old (PI. I.) shows the natural bowing of the legs. Of course there are such things as clubbing of the feet and bowing of the legs, but these are actual deformities of the joints and bones, not deceptive appearances merely. All these various peculiarities of shape which we have been considering change gradually with the growth of the child. We shall need to study them more fully in the next chapter. In addition to the features mentioned, it is necessary to know something of the expression of face and the position and gestures of a healthy child. The face of a very young baby when awake has an expression of wondering surprise. The look of intelligence which is there is only an apparent one. It is a pity, perhaps, to shatter a mother's fancy that her child notices what is going on, recognizes her, and expresses pleasure at her approach; still, the truth is that the baby at birth is about as intelligent as the sensitive plant, the leaves of which automatically close when touched. Like the plant with its leaves, the baby automatically closes its mouth and nurses without knowing that it does it. The color of the eyes is generally a very indefinite one — a sort of blue in all babies. However much they may be supposed at first to resemble the father's or the 38 THE CARE OF THE BABY. mother's, a change to a lighter or a darker hue is liable to occur at the age of seven or eight weeks. When a baby of any age is asleep its eyes are entirely shut and the expression is that of peaceful repose. The posittoft of its body, too, at this time is that of entire and graceful relaxation. The head is usually turned slightly to one side, and breathing goes on almost imperceptibly and without any movement of the nostrils. In the waking state the new-born baby is comparatively still, except for a .really remarkable disposition to grasp anything with which its hand conies in contact. In a very short time, however, it becomes when awake almost the em- bodiment of perpetual motion, the legs and arms being in nearly constant although purposeless action. The first act of the new-born child usually is to cry. No sound is so pleasing to the attending physician as a good, lusty cry from the little newcomer, for it shows that it has well entered on the use of the lungs which have hitherto been inactive, and that it has plenty of strength for all the functions of its new life. The mother likes to hear it too — better than she will later. There is good cause for the baby's crying at such a time, for the change from its previous existence to the contact with the chilling external air, and the comparatively rough handling which it receives, must constitute an ex- ceedingly disagreeable experience. The sound soon ceases, however, after the child is washed and dressed and put to rest. It may be taken as a positive rule that a baby does not cry without some reason. A cause exists, although it may be a trivial one, and the cry is the baby's only audible means of expressing its dissatisfaction with its state. The cry should be clear, and any alteration from the normal tone is a valuable indication that some diseased condition is present. What these alterations THE BABY. 39 are, and what they mean, we shall consider when we come to study the baby's illnesses. It is a curious fact, which may be mentioned here, that a young infant sheds no tears, no matter how hard it may cry. Finally, we must consider some matters connected with certain of the functions of life — namely, breathing, the action of the heart as shown by the pulse, the opera- tions of the bowels, the voiding of urine, and the condi- tion of the temperature. The respiration during sleep is quiet and comparatively regular. In the waking hours it exhibits a very great irregularity, which is present up to several years of age, although most marked in the first twelve months. The child often holds its breath a moment, yet, apparently, without any effort or any intention of doing so. A number of quick breaths may occur to- gether, or perhaps a number of slow ones. No weight whatever is to be attached to this peculiarity, for it is entirely characteristic of infancy and early childhood. The respiration in children up to the age of puberty is what is called abdominal ; and this applies to girls as well as to boys. The heaving movement is seen nearly entirely in the abdomen, the chest remaining compara- tively still. After girls reach the age of from thirteen to fifteen years the respiration is more from the chest, as it is in women. The rapidity of breathing in children varies with the age, as can be seen from the following table: Number of Respirations per Minute. At birth and for the first 2 or 3 weeks . . 30 to 50, average about 44. During the rest of the first year . . . . 25 to 35, average about 30. 1 to 2 years About 28. 2 to 4 years About 25. 4 to 15 years 20 to 25. Adult life 16 to 18. 40 THE CARE OF THE BABY. All these rates are from one-fifth to one-quarter less when the child is asleep, at least up to the age of four years, although after this the breathing is still slightly slower during sleep. The numbers given are average and approximate ones only, for the rate varies extraordinarily in young children. To estimate the frequency of the breathing we may watch the in-and-out movements of the abdomen, or perhaps put the hand lightly there and feel them. It is necessary to avoid the slightest excite- ment, since this increases the rapidity very greatly. During' sleep is an excellent time for making the obser- vation, allowing for the differences mentioned. "^^^^ pulse shares to a great extent the irregularity of the respiration, and the slightest excitement, such as cry- ing or even sucking, increases its rate so much that no conclusions can be drawn from any observations made under such conditions. The less the age the truer this statement is; and a mother consequently need feel no anxiety if her child of two or three years or less has a temporary pulse-rate of 20, 30, or even more beats per min- ute above the standard. Not only is the pulse influenced by excitement of any sort, but even when the baby is asleep or is perfectly quiet a decided irregularity can be perceived, which is perfectly natural and to be expected, although it would be abnormal, and perhaps dangerous, in an adult. The pulse may be felt at the wrist, or, when this does not succeed — as it often will not in the first weeks of life — in the neck or over the heart itself Another very good method is to watch the beating of the fontanelle. The table which follows shows the normal average pulse-rate at different ages. THE BABY. 4 1 Number of Pulse-beats per IMinute. At birth 130 to 150 First month 120 to 140 I to 6 months About 130 6 months to i year About 120 1 to 2 3'ears no to 120 2 to 4 3'ears no 6 3'ears 100 8 years 88 14 years 87 Adult life 72 This table ^^^ives the pulse-rates in children who are awake but perfectly quiet. The figures are even more approxi- mate than in the case of respiration, owing to the great tendency to irregularity referred to, and to the extreme difficulty experienced in finding the quiet state desired. For this reason the best time to count the pulse is when the child is asleep. We must remember, however, that sleep produces a decided lessening of the speed. In chil- dren under nine years of age the slowing is 16 or 20 beats per minute; from nine to twelve years it is about 8 beats; and from twelve to fifteen years, 2 beats. The rapidity of the pulse is slightly greater in girls than in boys of equal age, but the difference is not very material. The boivcls of a new-born baby are generally opened once or twice during the first day of life. The passages of the first two or three days consist of a peculiar thick and sticky, odorless, blackish or greenish-black sub- stance called )iicconium. This was produced in the bowel before the birth of the child. When the flow of mother's milk has been established the passages become canar3^- yellow in color, of the consistency of thick cream, have very little odor, frequently contain small masses of undi- gested milk if the baby is getting more nourishment than it can entirely assimilate, and number two to four in 42 THE CARE OF THE BABY. twenty-four hours. Gradually the frequency diminishes, so that from tSe age of six weeks or two months to that of two 3^ears there are usually only one to three move- ments daily, while the color is a trifle darker yellow, the consistency greater, and the odor rather more fecal. It is only after the age of two years, and when the diet has been considerably varied, that the passages become completely formed and of a distinctly fecal odor. There should never be any fetid odor from a natural and per- fectly healthy bowel-movement of a baby. Nevertheless, the number of movements of the bowels may vary considerably from the statements just made without indicating actual ill-health. There may be no more than one or two movements daily, even in early life, or they may number even five or six, and yet not constitute diarrhoea unless their character is also changed. The urine of a young healthy baby is generally almost like water in appearance, unirritating, has very little odor, and leaves no stain upon the diaper. Although it is generally passed within the first twenty-four hours, it not infrequently happens that the bladder is not emptied during the whole first day of life. This need not occa- sion any alarm, provided the baby is resting comfortably and is evidently in no distress. Just how often in twenty- four hours a baby usually passes water it is very difficult to state. Not only does it vary greatly with diiferent chil- dren, but with the day as well, depending upon the tem- perature of the air or upon the amount of nourishment taken. The average is probably six to ten times a day, but there may at times be an evacuation of urine every hour, or perhaps not for even ten hours, and yet the child be in perfect health. As age increases and control of the bladder is acquired the frequency diminishes to about six times a day or less. THE BABY. 43 The amount of urine evacuated varies with the ao^e, although not exactly in proportion to it. The following table shows approximately the amounts for different periods of life: Amount of Urink Passed Daily. Birth to 2 3'ears 8 to 12 ounces. 2 to 5 3'ears 15 to 25 5 to [o 3'ears 251035 10 to 15 years 35 to 40 " Adult life 52 Every mother should be acquainted with the normal tcmper-ature of a baby, in order that she may be able to appreciate the changes occurring in disease. There is no way of determining this except by the clinical thermom- eter, for it is impossible for her even to approximate it satisfactorily by simply placing her hand upon the skin. Even the fact that a baby's hands and feet are cold is not sufficient proof that it is not having high fever at the same time. A clinical thermometer should be in every household, and the mother should thoroughly understand its use and should employ it whenever the child seems at all ailing. The instrument commonly used is self-regis- tering; that is, the top of the column of mercury, which indicates the temperature attained, will remain at the 95 too us Fig. 5. — Clinical thermometer. highest point reached, even after the thermometer is removed from the child. The instrument is entirely of glass, without any outside casing, and the Fahrenheit scale is engraved upon the tube, dividing it into degrees and fifths of a degree (Fig. 5). The arrow on the tube merely points to what is considered nonnal — that is, 44 THE CARE OF THE BABY. 98f °. It may be disregarded altogether iu making the reading. The ordinary pattern is both stronger and less expensive than the more delicate "one-minute" ther- mometer. Very good instruments of the latter sort and of reasonable price can, however, be had, and these have the great advantage of requiring a shorter time to register, although they are somewhat more fragile. Many of the instruments have the stem so shaped that the front acts like a lens and magnifies the column of mercury, in order to make the reading more easy. This adds to the expense and is not at all necessar}'. The temperature may be taken in the arm-pit, mouth, or bowel. The first locality should ordinarily not be chosen for children, as the results obtained are often very misleading, owing to the difficulty experienced in bring- ing and keeping the surfaces of skin close together and thus excluding the air. The thermometer may be placed in the mouth of children of five or six years, who can be trusted not to bite upon it. To employ it the child should be seated or, still safer, made to lie down. The instrument should now be held firmly by its upper por- tion between the thumb and forefinger, and be swung or shaken forcibly until the column of mercury is made to descend in the tube far enough to bring its upper extrem- ity to 95° or thereabouts. The child now receiv^es the bulb under the tongue, and is told to close the lips upon it, but not to bite it. Very often the order will be under- stood better if the child is bidden to hold the instrument with one hand and to suck it "like a stick of candy" — that being an action with which every child seems famil- iar. The thermometer should be left in place at least four minutes, or, in the case of the more delicate instru- ments, two minutes. With younger children or those who, through sickness. THE BABY. 45 cannot be entrusted with the thermometer in the mouth, the temperature is more conveniently taken in the bowel. To do this the child is laid upon its back or side in the lap or on the bed and its thighs are flexed. The bulb, pre- viously oiled, is then gently inserted an inch or two by a screwing movement. The procedure is simple, painless, and free from danger. Although it is better to be sure that there are no fecal contents in the rectum, it is not necessary to remove them by injection, provided the ther- mometer be left in place somewhat longer — at least five minutes in all. If no feces are present, the time men- tioned for the mouth is sufficient. The thermometer should always be washed thoroughly with soap and cold water after use, disinfected with a boric-acid solution (Ap- pendix, 75), shaken down well, and placed in its case. The normal temperature of a baby fluctuates consider- ably during the first week of life, but then settles down to from 98° to 99° F., as in the adult. We must remem- ber, however, that children are liable to have their tem- perature elevated some fifths of a degree by slight causes, such as hard crying or struggling against the use of the instrument, or even by the taking of a large amount of nourishment, although these variations are not so apt to occur as in the case of the respiration and the pulse. There is, beside this, a regular variation during the twenty-four hours, which is present in adults also, but is less marked. The normal temperature rises slightly in the small hours of the morning, reaches its highest point early in the day, sinks again in the evening, and is at its lowest during the night. There may thus be a difference of one, two, or even three degrees between the readings at different times of the day. It is important to bear all this in mind, or we might become very unneces- sarily worried. We can feel assured that a temperature 46 THE CARE OF THE BABY. of 97.5° to 99° in the evening and 98° to 99.5° in the morning may be considered normal. It is only when a temperature of 100° is attained that we talk of fever. The signification of febrile temperatures in children we shall consider when we study the Sick Baby, in Chapter XI. Most of what has been said in this chapter relates to the baby while still very young. All the features de- scribed alter gradually with the increasing age of the child. The subject of the growth of the baby with the interesting changes which take place is so important that it must be considered in a chapter of its own, although a few of the progressive alterations, including those in pulse, respiration, temperature, urine, and bowel-move- ments, have been more conveniently discussed in this ' chapter. CHAPTER III. THE BABY'S GROWTH. Fortunately, the baby grows; for, charming as is its early helplessness, how much more delightful to watch the development of its beauty, strength, and in- telligence ! What mother will forget her happiness at the baby's first tooth, its first step, and its first word ! But all this progress comes only gradually; it is bit by bit that the child grows. By growth here is not meant increase in size and weight alone, important as these are. The baby's mind steadily grows, and the changes in it are even more remarkable than those of the body. The watching of this mental development is most interesting if we really appreciate just what the baby knows and just what it ought to know at different periods of life. THE BABY'S GROWTH. 47 Besides all this growth of what is already present to some extent, new acquisitions appear, such as the teeth, tears, saliva, and the ability to walk; and still other changes go on which are not actually visible, such as alterations in the digestive powers. When the baby is just born, and during the first few days of life, it is, as stated in the preceding chapter, very little more intelligent than a vegetable. Its soul and its intellect are there, but they are dormant, waiting to be awakened. It has also little control over its body, and all its movements are automatic or instinctive. Probably there is not a single expression of the face or motion of the arms or legs which represents a distinctly willed action. Supported in the arms, the child cannot hold its head upright, but lets it roll from side to side as though in danger of snapping it off. The child lies just as it is placed in bed, unable to change its position. A new-born baby probably cannot see except to dis- tinguish light from darkness, and will not wink when the finger is brought close to its eyes. It seems also unable to hear, and at first cannot smell, although taste is well developed. It is, in fact, not directly conscious of any- thing. When it nurses at the breast it does not know it is nursing, and when it cries it is ignorant of any sensa- tion that makes it cry. When it moves its arms and legs strongly during nursing, or when it throws its head back or lifts its hand in response to a forcible touch- ing of its nose, or when it takes hold of anything placed in its palm, it is not because it wishes to express eager- ness for anything to eat, or to move its head out of the way or to close its fingers, but simply because it cannot help it. It is not long, however, before an interesting change begins. There is seen a distinct increase in the power 48 THE CARE OF THE BABY. of control over the members. By the time the baby is three months old, or sometimes a little before this, it gradually begins to make efforts at grasping after objects, although totally unable to judge whether they are near or far away, and by six months it can make many well-directed movements and will play with toys. Before the age of two months the baby has evidently gained considerable power in lifting its head, and by that of three or four months it can hold it without support very well. It usually does not attempt to sit up until it is between three and four months old, and does not succeed in doing so until at least six months old. Even then it is not very steady, and is easily upset until the age of nine or ten months. At about six months the baby will sometimes make an effort to stand, if held upright on its feet in the mother's lap, and will try to put one foot in front of the other. At seven or eight months it begins to creep on its hands and knees, and by nine or ten months of age is often able to stand with support, and frequently to walk some steps by holding to the furniture or to some one's hand. By the age of one year strong children can walk a little without help. There is no absolute rule, however, for the time or for the exact order of learning to creep and to walk. Many children are very slow in walking, particularly if they have become expert and rapid crawlers, while some do not creep at all, but learn first to stand and then to walk. A mother should be in no hurry about the matter. Fifteen to eighteen months is really quite early enough for walk- ing, and some children do not learn until two years of age, and yet are perfectly healthy. Nevertheless, as great a delay as this latter cannot but lead to the suspicion that something is wrong with the child's development. THE BABY'S GROWTH. 49 It is a curious observation that when babies fall during their early efforts at walking they nearly always go back- ward into a sitting position. This is due to the fact that the muscles of the front of the leg have not yet become as strong as those of the back. Every child also naturally walks "pigeon-toed," and the learning to turn the toes out is always a slow matter. With the increasing power and control of motion there is a development of the senses also. By the age of six weeks or earlier the baby can fix its eyes upon objects near it, and will quickly shut them if something is moved rapidly toward them, and by the age of two months its vision is nearly perfect, although colors prob- ably cannot be distinguished at all until the age of a year, and the color-sense even after this increases slowly in many children. Hearing and the sense of smell de- velop rapidly, and within the first week the baby will be awakened by loud noises. It does not begin, however, to notice the character and the direction of .sounds until it is three months old. Musical tones arc sometimes recog- nized between the ages of one and two years, and a child of two or even less may distinctly prefer one tune to another, and perhaps know it by name. In other in- stances, however, the power to recognize a tune does not come until later childhood, and sometimes never. Things are made up to the baby later in life, for a child of ten years both sees and hears better than an adult. It would be interesting to know what a baby's sensa- tions are in its early months of life, but we can discover these only to a limited degree. It probably feels pretty comfortable, on the whole, and when uncom- fortable it cries. It experiences hunger and the inclina- tion to sleep. By the time it is a month old it often 50 THE CARE OF THE BABY. shows its pleasure by smiling, but it generally does not really laugli until five or six months of age, or even older. Smiles before the age of one month are usually not indicative of pleasure, but belong to the class of automatic and similar movements referred to. The child clearly begins to have more intelligence, and the pleasure that accompanies this, when it is three months old, and by this time shows distinct evidence of having a mind and of exercising some thought. By this age or a little later it learns to recognize its mother and to be pleased at her approach, and if hungry will cease crying when it sees her preparing to nurse it. It also enjoys bright objects, especially if they are moving before it. Between three and four months of age it begins to look about it more, to feel the pleasure of grasping after objects, and to show fear and wonder. When it is four or five months old it learns to recognize other friends and to smile and move its arms at them. When nine months old it will give its hand when requested, and will thoroughly enjoy a game of "peep-bo." By the completion of its first year it has learned to show distinctly, by expressions of face and by gestures, its likes and dislikes for the per- sons and acts of others. Between the age of one and two years the baby shows some idea of number. All sounds made early in life are impulsive only. Although the child at one or two months of age begins to use its voice in making peculiar cooing noises expres- sive of comfort and happiness, it does not, of course, ivill to utter these particular sounds rather than others. About the age of six months the baby commences to make different vowel sounds, especially that of ^ in. 21 " 22 " 23 " 24 25 25>^ 26 27 31 35 41 43 45 47 49 51 53 55 57 59 61 63 8 8^ 10^ 12X 13X 15 i6>( 17X 18^ 19^ 20>^ 21K 27 32 36 40 44 48 53 58 64 70 79 88 100 109 117 9 oz. 7>^ " io>^ " ^ 2 " ]] }• }• J I Gained i oz. a day; 7 I a week. (Gained ^ oz. a daj^; 5>^ ( oz. a week. Double original weight. f Gained ^ oz. a day; 4^ I oz. a week. . Gained yi inch a month. . Gainedaboutilb. amonth. . Treble original weight. . Gained 4 inches a jear. . Double original length. Gained 3 inches and 4 lbs. a 3'ear. f Gained 2 inches and 4 lbs. 1 a 3-ear. f Gained 2 inches and 5 lbs. 1 a 3'ear. f Gained 2 inches and 6 lbs. 1 a 3'ear. Gained 2 inches and about 9 lbs. a 3'ear. lyooking closely at the table, we notice several inter- esting facts. We see that the baby usually loses weight during the first week and often longer, but that by the end of two weeks it weighs distinctly more than at birth. THE BABY'S GROWTH. 53 The loss of weight is greater than the table shows, for by the age of one week the baby has regained most of the loss. To this rule there are many exceptions, since chil- dren sometimes grow steadil\' heavier from the beginning. During the last tliree weeks of the first month the baby gains about one ounce a day; in the second month about one ounce a day; and in the third and fourth months about five ounces a week; that is, about three-quarters of an ounce a day. By the time it is five montlis old it has doubled its original weight. In the fifth and sixth months it increases two-thirds of an ounce a day, and after this, from seven to twelve months, it gains at the rate of about one pound a month — that is, three and two- thirds ounces a week, or a trifle over half an ounce a day — except in the ninth, and again in the eleventh month, when the increase in weight often lessens somewliat. At the age of a year the baby has trebled its original weight. As to length, we are struck by the fact that from the age of two to that of four months the increase is one inch a month, and after this, up to one year, it is half an inch a month. After the first year we notice that, taking it all together, there is a gradual increase in the number of pounds and a decrease in the number of inches added yearly, four inches being gained in both the second and third years, three inches in the fourth and fifth years, and after this two inches a year. The gain in weight is four pounds yearly from the age of three to that of seven years, then five, then six, and then about nine pounds. It sometimes happens that at about the age of nine in girls and eleven in boys there is almost a cessation of growth for a short time. Later, at about twelve years, girls take on a par- ticularly rapid growth, and decidedly exceed boys of the 54 THE CARE OF THE BABY. same age in weight, although not in height. At fifteen or sixteen years the rapidity of growth in girls, both in weight and height, will be greatly diminished, while boys of this age will often begin to develop very rapidh', and will soon m.aterially exceed the other sex in both respects. These times for the retardation and accelera- tion of growth vary greatly, however, in different chil- dren. No fixed rule can be formulated. The weights and measurements in the table apply fairly well to children of both sexes, although it is a fact that boys at birth are apt to be somewhat larger and heavier than girls, and to continue so until the neighbor- hood of twelve years. In fact, all the figures in the table are, of course, only average ones, and a child may meas- ure or weigh somewhat less without there being any occasion for anxiety if it is perfectly healthy; while it may decidedly exceed the figures without being phenom- enal. This is especially true of children who have passed the age of three or four years. We all know how great the variations in size are in early and later child- hood. When, however, it is an infant which is materially behind in its height or weight, the mother should at least have her suspicion aroused that something is wrong. A useful and convenient plan of recording the weight during the first two years is upon a "Weight Chart," ^ such as the sample copy opposite. This is rather more accurate than the table. The figures at the top and bot- tom give the weeks and months of the age; those at the sides the pounds and ounces; each horizontal line representing four ounces. The line running diagonally across the chart represents the normal weight of an aver- age breast-fed baby. In using the chart the baby should be weighed weekly, a dot with ink made on or between 1 These charts in blocks of twenty-five ccm be obtained from the publisher of this book for 50 cents. THE BABY'S GROWTH. 55 the horizontal lines to correspond with the weight ob- tained, and these dots as made joined by an ink line. This weekly weighing of the baby is exceedingly im- portant in order to be sure that growth is going on prop- erly. But to obtain results at all accurate it is very im- portant that the baby be weighed without clothes, or, better still, that it be weighed when dressed, and that the weight of the clothes or of a similar suit be ascer- tained afterward and the amount deducted. It will not, of course, be necessary to weigh the clothes separately on every occasion if we are careful that they are always of the same sort. Systematic weighing is particu- larly important when some change in diet is being made, for we can determine in this , ,, ,, r , Fu;. 6. — 1 he " 1 avorite " baby scales. way whether tlie food is sufficiently nourishing in quality or great enough in quan- tity. Either accurate spring scales or steelyards serve to do the weighing. A very convenient form obtainable at many of the shops consists of strong spring scales with a basket firmly attached, as shown in the illustration (Fig. 6). In using the steelyard the child is pinned securely in a towel or opened diaper and this then hung on the hook. In weighing children of five years and older the clothes may be assumed roughly to be one-twelfth of the total weight of the-child when dressed. To measure the length, the baby may be held against the wall with its feet resting upon the floor, and the ,B 56 THE CARE OF THE BABY. height be marked above it. A much more convenient and correct method is to have a carpenter construct an apparatus like an enlarged foot-measure of the kind em- ployed by shoemakers. This is used when the child is lying on a firm bed, the end- p I piece being placed above its head and the sliding one moved along until the feet (both toes and heels) rest upon it. The apparatus shown in the illustration (Fig. 7) is forty-six inches long, and the upright pieces are eigllt inches in length and are lined with felt. As the baby grows, not only is there an increase in the total weight and height, but the relative value which the dimen- sions of the various parts of the body bear to each other also changes, since one part grows more rapidly than another. This is well shown by the accompanying illustra- tion, taken from an article by Dr. L. M. Yale^ (I^ig- 8). The six figures represent the ages of one, five, nine, thirteen, seven- teen, and twenty-two years; that is, they are separated by periods of four years each. Each figure is divided into four equal parts, marked by the crossing of the dotted lines. The lines are curved, simply because the child grows more and more slowh\ If its length kept increasing at the same rate all the time, it is obvious that the lines would be straight. If we look again at the dia- FiG. 7.— Appa- fe^^"^) we see that the head of the child of ratus for measur- one \'ear mcasurcs one-fourth of its total ing an infant s length. ^ Babyhood, vol. ii. p. 31 1. 11 THE BABY'S GROWTH. 57 length, while the trunk is not much more than this, and the legs do not measure more than one and one-half fourths (three-eighths). As the author says, the child 1 Fig. 8. 5 © 13 17 21 -Diagram showing pro|X)rtionate growth of diflerent parts of the body at various ages from l to 2I years. is "four heads high.^' In the adult of twenty-one years we see th^t the head is proportionately much smaller, measuring only two-thirteenths or less of the whole length, while the legs have grown much more rapidly, and now equal one-half of the total length. The trunk has not kept pace with the legs, for in the baby the middle of the body, as shown by the dotted line, is the navel, while in the adult it is decidedly lower. All this rapid growth of the legs is generally accomplished after the age of nine years, as the diagram shows. It is well known how rapidly boys and girls shoot up after this period, and how out of all proportion their appa- rently long legs seem. The legs are, in fact, really no longer than they ought to be, but we have grown so accustomed to the short legs of earlier years that the change does not seem natural. 58 THE CARE OF THE BABY. At the age of thirteen or fourteen years, the time of puberty, a decided change takes place in girls, the figure beginning to assume that of womanhood, and the men- strual discharge appearing; while at about the same time or a little later boys experience a change of voice. Besides the growth in height and weight, there is, of course, increase in girth as well. The matter of most importance here is the circumference of the head and that of the chest. We should know what these ought to be at different ages, for the proper increase of girth of chest is an indication of proper development, and varia- tions from the normal size of the head may indicate dis- ease. It is important, however, to remember that the heads of different babies vary much in shape and size within normal limits. The chest-measure should be taken just above the nipples, and that of the head at a little above the level of the eyebrows. The following table shows approximately the circumferences of the chest and of the head at different periods of life: Table Showing Circumferences of Head and Chest at Different Ages. HEAD. CHEST. Birth 1334 inches. 13 inches. 6 months 1634^ " 15^ " 1 year 18 " 17 " 2 years . . . , i8>^ " 1734' 3 " 19 " 19.^4^ " 6 " 1(^)4. " 2034^ 12 " 20 " 23;^^ Adult life 21;^ " 30 + It is interesting to observe from this table how much more rapidly the chest grows than the head. In this connection we must not forget the condition of the anterior fontanelle. This opening should become THE BABY'S CKoirTH. 59 steadily although slowly smaller by the growth of bone over it, and should be entirely closed in healthy children by the age of seventeen or eighteen months. Finally, we must consider some of the new acquisitions of the child in the line of development. Among these is the ability to shed tears, which has already been referred to. A new-born baby can cry and its eyes become moist, but it is generally not until the age of three or four months that tears actually run down its face. Another acquirement is tlie new head of hair which fol- lows the first one. At about the end of the first week the first hair often begins to fall out, and continues to do so for one or two weeks. A considerable amount of it also is worn away from the back of the head by friction upon the pillow. The new hair begins to grow in only ver>^ slowly, and is of the same soft, silky texture as the first, but lighter in color than it was, or than the hair will be in adult life. Indeed, throughout the child's life, leaving the first hair out of account, there is a tendency for the color to grow constantly darker. The speed with which the hair grows in is very variable. One may some- times see a child of five months with its head actually shaggy, but as a rule it is very thinly covered at this age and for mouths after it. Sometimes children are born with remarkablv shaggv heads of hair and do not suiTer this early loss of it. Then, too, the baby acquires increased powers of diges- tion not possessed before. Saliva is one of the secretions of value in the digestion of starch. In early life it is only sufficient in amount to keep the mouth moist, but at the age of three or four months it has increased so greatly that the baby begins to dribble and must have its clothing protected by a bib. ^lany people suppose that this dribbling is a sign of irritation produced by the cut- 60 THE CARE C^" THE BABY. ting of teeth, but, although it usually accompanies teething, it is really only the evidence of the acquisition by the child of the new secretion. Indeed, there is no excessive production of saliva at the time the teeth which are the hardest to cut — namely, the molars — come through the gums. There is certainly no intimate connection between healthy dentition and the flow of saliva. So, too, the secretion of the stomach, generally called the gastric juice, is very poorly developed in young babies, and the digestive strength of the juices of the pancreas and of the intestine is also very weak; but all these increase with advancing age. On the other hand, the movements of the stomach are remarkably active in babies, and we consequently often see regurgitation of food occurring daily. Finally, we have the acquisition which is the cause of the greatest excitement and pleasure to the family at first, and often of much worry later — the teeth. At the very outset we must bear in mind that teething is a normal process, and not a disease. We are making a woful mis- take if we attribute to teething disturbances of the baby which are caused by some real ailment. Many and many a mother has allowed a child to suffer, and even to die, because she has supposed that the evident distress was the result of an advancing tooth. It is one of the com- monest things in the world for a tooth to be cut without anyone knowing that anything is happening. It is never right for a mother to take it for granted that the teeth are the source of fretfulness, but a thorough search must be made for some more remote cause. Physicians sel- dom practise gum-lancing nowadays, as compared with the frequency of a few years ago. There is, however, such a thing as disordered dentition, but this can be better considered among the diseases of infancy. THE BABY'S GROWTH. 6l A baby at birth possesses smooth, firm gums, of a light- pink color, with quite uarrow and rather sharp and hard edges. After some months, as the teeth begin to ap- proach the surface, the edges of the gums grow broader on the anterior aspect and somewhat more prominent, but do not become red or inflamed in ordinary healthy teething. This condition may continue for a month or more before any teeth are cut. The teeth have a definite order of appearing; and yet this is subject to very great variation, and writers differ somewhat as to just what the normal order is. There are twenty milk teeth — tempo- rary or deciduous teeth, as they are also called — and b their eruption constitutes the first dentition. They consist, in each jaw, of two central incis- ors, two lateral incisors, two canines, two anterior molars, \,Nu^ ,. ' T, ' and two posterior molars. Their Fig. 9.— Di.igram showing ihe arrangement may be seen in the temporaiy teeth : a, central in- diagram (Fig. o). The CauiuC cisors; />, lateral nicisors; i\ ca- _ , . nines; r/, anterior molars ; e, ik)s. tCCtll of the UppCr jaW are COUl- terior molars. ,^^,^1^, ^,^|1^^ ^j^^ ^^^ ^^^^1^^ ^^^ those of the lower jaw the stomach teeth. The pcrma)icut teeth, or the teeth of the second dentition, number thirty-two. They begin to appear about the sixth year of life, and consist of four incisors, two canines, four bicuspids, and six molars in each jaw (Fig. lo). In this dentition the incisors and canines replace those of the first dentition, the bicuspids take the place of the temporary molars, and the perma- nent molars appear where there were no teeth at all before. The teeth are cut in distinct groups, with a pause be- tween the eruption of each group. This arrangement 62 THE CARE OF THE BABY. gives the child a rest from any irritation that may attend the process. The first group of the milk teeth to appear usually consists of the lower central incisors, which come through the gum at about the age of seven months, although Fig. io. — Diagram showing the permanent teeth: a, central incisors; b^ lateral incisors; c, canines; d, first bicuspids; e, second bicuspids; f, first molars; g, second molars; //, third molars. often earlier than this. Then occurs a pause of three to eight weeks, followed by the appearance of the second group, consisting of the four upper incisors, between the age of eight and ten months. The central upper incisors generally appear first, followed closely by the lateral upper incisors. A second pause now occurs, lasting from one to three weeks, followed b}' the eruption of the third group of teeth — namely, the four anterior molars and the two lower lateral incisors — which appear at the age of from tw^elve to fifteen months. The teeth of the third group are not all cut at once or in any invariable order, although the anterior molars in the upper jaw often come first, and are followed by the incisors and then by the molars of the low^er jaw. After the third group there comes a pause of two or three months, no more teeth ap- pearing until the age of eighteen months, at which time, THE BABY'S GROWTH. 6^ or between the ages of eighteen and twenty-four months, the fourth group, the canines, are cut. Finally, after another pause of two to four months, the fifth group, the posterior molars, appear, between the twentieth and thirtieth months of life. Thus it will be seen that a baby a year old should have at least six teeth, and pos- sibly twelve, if the third group is cut promptly, and that by the time it is two or two and one-half years of age all the temporary teeth should be through. The following tabular arrangement shows at a glance the order and time of the eruption of the temporary teeth: KuuPTioN OK Milk Tketh. First grou]) . . Two lower central incisors. . 7 nionlhs. Pause . . . . 3 to 8 weeks. Secoiul group . . 1^'oiir upper incisors i<» n> Pause . . . . I to 3 months. Third group . . Four aiUerior molars and two lower hiteral incisors ... 12 to 15 Pause . . . . 2 to 3 months. Fourth grouj) , . F'our canines 'S lo 24 Pause . . . . 2 to 4 months. Fifth group . . Four posterior molars . . . ju to 30 As has already been stated, a great deal of variation is seen both in the order and in the time of the cutting of the milk teeth, and the mother need not think it strange if the two lower central incisors are not the first to appear. So, too, a healthy baby may cut its first tooth at decidedly less than four months of age, or may even be born with some incisor teeth; or, on the other hand, may still be toothless at the age of eight or nine months. Instances of children born with teeth are uncommon. Such teeth generally soon fall out and are replaced at the proper age by the regular milk teeth. Sometimes, how- ever, they remain until supplanted by the teeth of the 64 THE CARE OF THE BABY. second dentition. It is at times necessary to remove these premature teeth, but the decision upon this point will naturally be left to the child's physician. Too great a delay in the beginning of dentition is a sign of ill-health, and a baby who has no teeth by the age of a year cannot be considered to be in a healthy state, however plump and well nourished it may bCc Just what ails it we shall consider in the chapter treat- ing of the Sick Baby. The milk teeth stay in position for several years. Then, as the permanent teeth push upward in the jaw beneath them, their roots become partially or entirely absorbed, and the teeth themselves loosen and fall out, or are pushed out by the advancing pennanent teeth, in much the same order as that in which they came in. Very often they do not fall out as soon as they should, and, as a result, the incoming second teeth are crowded out of position, and a very ugly displacement is finally produced, which is wholly the result of negligence on the part of the mother. A child should be taken to the dentist at regular intervals, whether or not the teeth are decayed, in order that no such disfigurement may arise; for it is much easier to prevent it than it is to correct it when once present. The narrowness of the jaw in a child is another reason why the permanent teeth, particularly the canines, are so often displaced forward and outw^ard, and this fact renders the advice of a dentist still more important. The earliest of the permanent set to appear are the first anterior molars, often called the "six-year-old teeth," which come in immediately adjoining and to the outside of the temporary second molars. The remaining per- manent teeth are cut in much the same order as the milk teeth. The order and the date of appearing are shown in the following table: THE BABY'S GROWTH. 65 Erui*tion of Permanent Teeth. Four first molars 6 years. Four central incisors . . . .7 " Four lateral incisors . . . . 8 " Four first bicuspids . . . 9 to 10 " Four second bicuspids . 10 to 11 " Four canines . 11 to 13 ** Four second molars 12 to 15 '* Four third molars 171025 The teeth of the lower jaw are cut somewhat belbre the corresponding ones of the upper jaw, the intervals bein<^, perhaps, as great as several niouflis. The time of the eruption of the pennanent teeth varies consider- ably within certain limits. The third molars are popu- larly termed the ''wisdom teeth.'* Their eruption is frequently delayed until considerably after the age of twenty-five years. The alterations in pulse and respiration and in the fre- (piency of the bowel-movements and of the passage of urine which take place with increasing age, as well as some of the minor changes of the first few weeks, have already been referred to at length in the preceding chap- ter. This was done as a matter of convenience merely, for the changes are connected closely with the baby's growth, and belong properly to the subject of the present chapter. Finally, let no mother conclude oflfhand that the statis- tics which have been given are incorrect because they do not accord with her experience in the case of her own children. They are average only, and are the result of much and careful study by different observers. Of course, some children are much ahead of the average, and others behind it, vet they are nevertheless neither remarkable nor unhealthy. 66 THE CARE OF THE BABY. CHAPTER IV. THE BABY'S TOILET. All this time, although we have been watching the baby grow, we have not seen it either bathed or dressed. In preparation for the first and for subsequent toilets it is customary, before the baby's birth, to get ready that most Fig. II.— Baby's basket. convenient article commonly known as the baby^s bas- ket. A large selection of baskets may be found in the shops, fitted in different ways to suit the varying fancies and means of mothers. In choosinof one it is to be remembered that too elaborate a basket is more orna- mental than useful. A serviceable form is a stand of THK BABY'S TOILET. (>7 wicker, the lower part of which consists of one or more shelves or of a closed basket where articles of clothing not immediately needed can be kept; while the upper portion, or baby's basket proper, consists of an oval or oblong, rather shallow receptacle which may or may not be provided with a lid (Fig. ii). It is important that the stand be low, as otherwise the articles contained can- Fin. 12. — Baby's bxsket, hani{>er forn not well be reached from the low chair used when mak- ing the child's toilet. The basket should possess several pockets around the inside, to hold the smaller articles. It should also have one or two pin-cushions fastened within it. The interior may be lined with silk or cam- bric, according to taste, and the basket draped with lace or Swiss muslin. A simpler and very popular kind of basket, more easily 68 THE CARE OF THE BABY. moved about, is one of the hamper form with a hinged lid. This is, of course, not provided with a stand. The lower part of the hamper contains clothing, while a tray above this holds the various articles for immediate use (Fig. 12). The baby's basket should contain the following articles: Salicylated cotton for dressing the cord. Plain absorbent cotton for washing the mouth and eyes. Blunt-pointed scissors. Safety-pins of assorted sizes. A soft baby's-hair-brush. A small, fine comb. Powder-box containing powder and puff. Soap in a metal or celluloid soap-box. A fine, soft sponge and a soft wash-rag. A jar of vaseline. An old soft blanket in which to receive the child after birth. A couple of soft towels. A woollen shawl or shoulder-blanket. A complete suit of clothes. The choice of the soap, powder, hair-brush, etc. will be considered presently, and the nature of the clothes will be discussed in the next chapter. The first washing of the baby is the business of the monthly nurse, and the mother has no share in it. Still, it is well for her to understand how it should be done, if only as a matter of interest. We must remember that the new-born baby is a very tender object, exceed- ingly susceptible to the influence of cold, and with a ver>^ delicate skin. Indeed, in the case of children weakly at birth the physician often forbids any washing whatever THE BABY'S TOILET. 69 until the vitality has increased. In giving a bath it is consequently necessary to guard most carefully against draughts. The doors and windows must be closed, and the child should be protected still further by placing a folding screen around the nurse's chair and the tub, and by doing the bathing before a fire unless the weather be very hot. The washing and dr>'ing should be done thoroughly, rapidly, and yet with the greatest gentleness. The nurse seats herself in her low chair beside the tub, with the baby's basket and the vessels of hot and cold water con- veniently at hand. She should protect herself with a rubber apron, over which is a second bath-apron of warmed soft flannel. A very convenient form which has been recommended consists of two long and broad pieces of flannel or other soft material sewed or, better, buttoned to the same waistband. The lower one of these may be used to hold the baby in, and the upper one to cover it after its daily bath and while it is being dried with the towels; or the upper one may hold the baby while being dried, after which it may Ije unbuttoned and cast aside, and the lower, dry apron may be used to hold the child while being dressed. At the first washing the old blan- ket contained in the baby's basket should be used to wrap the child in immediately after birth and until it has been oiled, soaped, and dip|:>ed. The new-born baby is more or less covered with a whitish, waxy substance which must be removed en- tirely, especially from all folds and hollows of the body, such as the armpits, hollows of the knees, groins, and ears, as otherwise irritation of the skin is apt to be set up. As the cleansing is not easily accomplished by ordinary washing, it is necessary first to rub the skin all over with olive oil or with purified white vaseline. This yo THE CARE OF THE BABY. is much better than lard unless the latter has been care- fully freed from salt by washing. The baby should now be laid on its back and be enveloped in the old blanket, and should then have its face carefully washed with warm water and a very soft sponge or wash-rag, but without soap. The eyes must receive particular atten- tion. The lids should be separated by the fingers and gently and thoroughly freed from all secretions by squeez- ing a little warm water between them and very geutly rubbing them with a little moistened absorbent cotton. This care is needed, because in the process of birth irri- tating substances often enter the eyes and set up a severe inflammation which may even terminate in loss of sight. Sometimes the physician in charge himself washes the eyes, or orders them to be washed with some antiseptic solution if he deems it necessary, but such solutions should never be used without his orders. The mouth must now be cleansed very carefully with a little absorbent cotton wrapped around the nurse's finger. Indeed, it is often necessary to wash the mouth instantly after birth if much mucus or other material has been forced into it. The bath may now be prepared, the water being at a temperature of ioo° F. as shown by the thermometer, not as guessed at b}^ the nurse. The whole body except the face, which has already been washed, is now rubbed with soap and water. The soap is best applied with a wash-rag, which adapts itself to the folds and creases rather better than a sponge does. The baby is then placed in its tub and entirely submerged except the head. It may be kept in the bath for a minute or two if it seems to enjoy it. While there its head and back are supported by the nurse's left arm and wrist, her hand grasping its left shoulder, and thus keeping it from THE BABY'S TOILET. 7 1 slipping down into the water. When the bath is over the child is lifted into the nnrse's flannel apron, covered well, and made to lie first on its back and then on its stomach while it \^ patted thoronghly dry with the softest towels. As a finishing tonch a little powder is dusted about the folds and hollows of the body and the baby is then ready to be dressed. Succeeding baths are much like this first one, with the exception of the oiling. Many physicians advise only a daily sponging until the cord has separated, and after this the tub-bathing. There are certain modifications in the bath, however, which depend upon the age of the child, and these, with some details regarding other mat- ters connected with the toilet, niHst be considered a little more particularly. The nature of the baby's bath-tub is of some import- ance. I*()r the first bath a ])aiiitt(l tin foot-tub, or even Fic. 13. — Folding bath-stand. a large basin, will answer, but it is well to be pro- vided in advance with a tub especially designed for a baby^s use. There are many varieties of these. A ser- viceable one for constant employment is of tin, porce- lain, or agate iron, oval in shape, and with a sloping back. Wooden and papier-mache tubs are difficult to keep clean. As leaning over such a tub while giving the bath is a very back-breaking procedure, it is desirable to 72 THE CARE OF THE BABY. place it upon a low stand, eighteen or more inches high, made for the purpose. Stands of this sort may be bought in the shops. They are either of permanent form or of such a nature that they can be folded up and put away when not in use (Fig. 13). Fig, 14. — Bath-tub on slats. A very convenient device has been described, intended to obviate stooping and to render the filling and empty- ing of the tub easier (Fig. 14). A couple of strong slats Fig. 15. — Home-made rubber bath-tub. several inches wide, with cleats on the under surface to prevent slipping, are placed across the ordinary station- ary bath-tub when needed. Upon these the baby's bath- tub rests, and may be filled by means of a rubber hose THE BABY'S TOILET. 73 screwed to the faucets. It is a good plan to attach the tub to tlie slats by straps when in use, in order to pre- vent the possibility of pushing it off. A still more convenient tub made of rubber can be bought. It is of a folding pattern, which does away entirely with the stand. It occupies very little space when not in use, and is especially serviceable to take to summer resorts or when visiting. It may even serve as the baby*s bed. An inexj^ensive home-made rubber tub is shown in the illustration (Fig. 15). The legs, each of which is thirty inches long, are pivoted upon the ends of the central bar. This and the four side- bars are each thirty-six inches in length. The latter are fastened firmly to the legs. The tub itself is made of a single piece of white rubber cloth thirty inches wide and one and a quarter yards long. There is a hem at each end, and through these hems broad tapes, each nineteen inches long, are passed and securely fastened to the ends of the side-bars. The sides of the rubber cloth are tacked to the top of ^^:^^^^^ /^'^^^^^^P^^^^^^^^^^^^ the side-bars. A .small (v^ j^ I j) plait at each corner gives ^^fc:;^.^^^ I -^^:^^^ the tub a better shape. ><:. ^_^ A little ingenuity can ^' ^.^,^^^. _ ^ ^^^ ^ easilv make the legs de- , ' - - - , Flc. iC— (.hinn M ., tachable from the central and side bars and from each other, and thus allow of packing the tub into very small space for travelling. An outfit for bathing is not complete without a rubber cloth or an oil-cloth to be laid beneath the tub to protect the floor, and the low chair with a broad seat upon which the nurse is to sit, and to which reference has already been made. One of the small china sponge-basins made 74 THE CARE OF THE BABY. especially for the baby's toilet is also very serviceable. It is divided into two compartments — one for cold and one for warm water (Fig. i6). After the child has reached the age of two or three years a second and somewhat larger tub may be bought. This is not an absolute necessity, as the ordinary station- ary bath-tub can be used instead. It is, however, a great convenience, and saves the uncomfortable leanjng over which is necessary with the latter. In this connection it is important to understand fully the value of early accustoming a baby to immersion in water. I have frequently seen the great fear of the tub bath, shown by children who had been accustomed to sponging only, interfere with the use of cool bathing in cases of fever and of exhaustion by summer heat, at times when it would have been of the greatest remedial value. Moreover, it is wellnigh impossible to attain by spong- ing alone, no matter how thoroughly done, the cleanli- ness which tub-bathing ensures. To prevent the fear of the bath developing, we should carefully avoid any sudden or rough plunging of the child into the water, and especially see that the head does not accidentally become submerged. Fear which has been acquired in any way may sometimes be overcome by cov- ering the tub with a blanket, placing the baby in this, and gradually lowering baby and blanket into the water; or the child may be put into the empty tub and allowed to play there until it is quite at home, and may then be accustomed to an amount of \vater which is increased a very little day by day. A wash-rag made of flannel or of diaper-cloth should be used for applying soap. A delightfully soft wash-rag is made of cotton stockinet. All the folds and hollows of the body must be soaped thoroughly, but no eftbrt should ever be made to force the fingers or anything else into the THE BABY'S TOILET. 75 ears, and no water should be allowed to remain there. Severe inflammation of the ears has often followed over- zealous attempts at cleansing. The scalp should be soaped daily during some months. After the age of six months, however, it is not advisable to do this quite so frequently, as it renders the hair dry and brittle. This does not mean that soaping of the head is to be neglected entirely. The application occasionally of a very little vaseline may be of l^enefit. As the infant grows into childhood the scalp should be washed with soap once or twice a week at least, and with water daily. Ivven the long hair of the girl need not prevent this. The importance of daily retracting the foreskin of boy babies, and of washing carefully beneath it, must not be forgotten (see Phimosis). For removing the soap-suds a sponge is better than a wash-rag, since it permits of the water being squeezed from it in a distinct stream. Only the finest sponges should be chosen, from which the minute flinty particles have been entirely removed in the process of prepara- tion. These little needle-like bodies are present in many of the cheaper sponges, and are very irritating to the skin even of an adult. The sponge and the wash-rag should be well washed out and be thoroughly dried in the air after each bath and before being used again. If this is done, there is no objection to their being kept in the rubber pockets with which the baby's basket is often furnished. In the choice of soap there is a wide range. It is important to select one which is entirely unirritating and free from an excess of alkali. Transparent glycerin soap and oatmeal soap are good, but there are few equal to the well-known Castile soap. As there are different varieties of this, some of which are not at all suitable, it is important to choose one of the finest imported brands, certainly made of olive oil and got from a dealer of well- 76 THE CARE OF THE BABY. known reliability. Still better are some of the imported German " super- fatted " soaps. One of these, called in Germany a Basis Seife^ is intended especially for use with children. It is unirritating, and contains an un- usual amount of oil. It can be procured through drug- gists, and is probably the best soap for infant use w^hich is to be had at the present time. The water used for the bath should be soft and clear when it is possible to obtain it so. Very hard water will make the skin rough and sore. It ma}^ be improved by boiling, which precipitates much of the lime, but it is better to substitute rain-water. Muddy water must be filtered. This may be done through one of the various filters made to screw upon the faucet. A very service- able plan is to tie a bag of flannel over the opening of the faucet and to let the water run very gently through it. A fresh bag should be used every day. The temperature of the water is very important. Our hands are so made that they accommodate them- selves readily to degrees of heat or cold. They are consequently poor guides in deter- mining the actual temperature of the bath. The bared elbow dipped into the w^ater is much more sensitive; but if we do not wish to have the baby sometimes parboiled and sometimes frozen, it is far better to use a bath thermometer (Fig. 17). This may be had at any good house-furnishing store or drug-store. The casing is made of wood, in order that the instrument shall not sink in the water. To test the temperature of the Fig. 17.— Bath bath the thermometer should be moved back ermomeer. ^^^^ forth iu the water for a few minutes, THE BABY'S TOILET. yj and tlie height of the iiiercury noticed while the bulb is still in it. The temperature of the first bath should be 100° F., and that of succeeding ones be lowered very gradually until, at the age of six months, the water is at 90^ to 95° I\ for winter or at 80° to 85*^ F. for summer. Actually cool baths should not be given before the age of four or five years, although by two years a cool sponging may im- mediately follow the warmer bath, provided the bracing effect is produced wliich may reasonably be expected. (For the temperature of hot, warm, and cool baths, etc., see Api)endix, 36.) Whatever the temperature of the bath, it is important that the head and the face be wet before the rest of the body. Enough water .should be used in bathing to cover the baby to the neck when supported in a .semi-reclining position. As it grows older and learns to sit upright the water need not reach above the armpits. The duration of the immersion should at first be one or two minutes, and later about five minutes. One bath .should be given every day, but in very hot weather, when the baby is evi- dently depressed by the heat, several cool baths daily are sometimes very beneficial. In such cases they are given, of course, for their cooling effect, not for cleansing purposes. Besides the regular daily bath, it is important to sponge the lower parts of the body after each bowel- movement, in order to ensure perfect cleanliness. Simple warm water is usually sufficient for this, and soap should not be employed. Most careful drying must follow. In the early mouths of life an evening sponging of the whole body is often practised. It is frequently of advantage, but is not an essential. When the child has reached the age of four years the bathing may consist of cool sponging every morning 78 THE CARE OF THE BABY. with water at a temperature of 75° to 80° F., the child perhaps standing in lukewarm water, but it is much better to continue the daily tub-bathing with water of 80° to 90° F. Prolonged soaking in hot water is to be condemned as excessively relaxing and as predisposing to catarrhal conditions. During later childhood the tem- perature of the bath may be reduced to 75° or 80° F. In this connection the importance of following experi- ence rather than theory cannot be too strongly insisted upon in regard to using cold water. If a child invariably shivers and continues cold after tepid or cold baths — that is, if a proper "reaction" does not take place — it will certainly be injured by continuing them. One must be quite sure, however, before abandoning them, that there is not somethinof wronor about the method rather than about the baths themselves. Brief immersion and brisk friction afterward are all that are required to make the baths healthful and tonic for the majority of children. The time for bathing a child is not so much a matter of importance as it is that the bath shall be given at the same hour every day, and not too soon after eating. At least an hour should elapse after taking food. It is also better not to allow the child to go out of doors imme- diately after bathing, especially in cold weather. During the first two or three years of life a morning hour — either before breakfast or at about nine or ten o'clock — is to be preferred unless an evening hour be chosen for the sake of relieving sleeplessness by means of the bath. Later the daily bath is best given when the child rises in the morning. A fuller consideration of baths of different tempera- tures and of different sorts, particularly as used in dis- ease, will be found in the Appendix (36-50). The choice of towels is of some importance. Especially for young babies they should be of the softest and most 1 THE BABY'S TOILET. 79 absorbent material. An old diaper constitutes one of the best of towels at this age, and later in life Turkish towel- ing, not new, is excellent. After the drying it is well to rub the baby briskly with the palm of the hand until its skin is slightly reddened, in order to establish a good circulation of the blood. Sometimes rubbing with warm alcohol or warm bathing whiskey or with a little olive oil is of distinct value for delicate children. Some difference of opinion exists regarding the advisa- bility of powdering the child after the bath. In theory, the drying should be so perfect that powder is not needed. In practice, however, it is difficult to obtain this perfect dryness, or to appreciate the failure until the production of chafing and fissures of the skin show^s that there has been a fault in this respect. It is therefore a useful plan, after using the towel as thoroughly as possible, to powder the folds of the skin, as around the neck, about the cars, in the armpits and groins, and behind the knees. The powder used should be of the simplest kind, such as finely-powdered starch or lycopodium, or, still better, talc. It is best to avoid the various scented powders on the market, since they may contain impurities. Some- times a little vaseline or cold cream may be applied with advantage instead of the powder. This is especially true if the creases in the skin appear to be somewhat too dry. We must consider briefly the subject of out-door bath- ing, and particularly of sea-baths. The action of salt water seems often to produce a peculiarly beneficial effect upon weakly children. Too much cannot be said against the exhibition of basest cruelty which may so often be seen — a father or mother carrying a screaming, terrified little one of tender age into the breakers. The exposure to the cold water and the action of the great fright can be nothing but very injurious. The only fit place for 8o THE CARE OF THE BABY. infants to take a salt bath is the tub. There is no harm, however, in dressing a child of three years of age, or even younger, in bathing-clothes, protecting it from the sun by a bathing-hat of suitable size, and allowing it, on a calm, warm day, to paddle in the ripples on the sand or to play in the pools of sun-warmed water left by the receding tide. In this way the child's confidence in the harmlessness of the water is established, and at the same time the good effects of sea-bathing are gained without fright.- The mother must never forget to watch carefully against chilling by too long a wetting or by exposure to strong winds in moist clothes. Older children who have acquired a love for surf- bath- ing or fresh-water bathing would apparently remain in the water for ever if permitted to do so. The mother must enforce a limitation of the bath to ten minutes at the longest if the water is cool, or twenty to twenty-five minutes if warm. Chattering of the teeth and blueness of the lips are indications that the bath should cease, no matter how short it may have been. The after-effects are a still better guide in the matter. Exhaustion or lassitude during the rest of the day renders necessary a reduction of the length of the baths or of their fre- quency. Not every child can bear a daily out-door bath. In the case of sea-bathing it is important to guard against blows of the breakers against the ears, since injury to the drums may result. There are certain other matters connected with the toilet which can best be considered in this connection. Prominent among these is the washing of the mouth and teeth. Babies are much disposed to various fonns of inflammation of the mouth. It is necessary, therefore, that a toilet of the mouth be perfonned systematically, and yet it is just as important that this be done with the THE BABY'S TOILET. 8 1 greatest care and gentleness, or there will be produced the very trouble which we are striving to prevent. Nurses often forget their own size and strength and roughly force a big finger into a delicate little mouth, thereby doing much more harm than good. To perform the toilet properly a little absorbent cotton should be wrapped around the little finger or around a smooth stick, taking care that the cotton project decidedly be- yond the end, and with this moistened in boiled luke- warm water and used gently the washing can be done very satisfactorily. It should be repeated three or four times a day, or, better still, after each feeding, of course using a fresh piece of cotton on each occasion. After the child begins to secrete saliva in abundance and to move the tongue freely it is unnecessary to wash the mouth so frequently. Mothers often think that it is a matter of no conse- quence if the milk teeth decay, since they will soon fall out in any case. This is far from the truth, for not only does their decay detract greatly from the child's good looks and become a fruitful source of toothache, but their imperfection or loss is a cause of indigestion from insuf- ficient mastication, and may even cause irregularity in the position of the permanent teeth. The washing of the mouth should be continued as the earliest teeth are cut, and the teeth themselves thoroughly rubbed with a moistened cloth morning and evening. After the majority of the milk teeth are through the gums, a small tooth-brush with soft bristles of badger- hair or specially softened pig-bristles is to be preferred. If any stains appear on the teeth, a little precipitated carbonate of lime in finely-powdered form may be used on the brush. If this does not prove successful in remov- ing the discoloration, a small pine stick, such as a match- 82 THE CARE OF THE BABY. stick, may be sharpened into a chisel-shaped edge, moist- ened, dipped in finely-powdered pumice-stone, and rubbed upon the spots until they are removed. Care must be taken to avoid injuring the gums while using the stick. The collection of tartar upon the teeth is the commonest cause of inflammation and receding of the gums, and nothing but diligent watchfulness will prevent it. As early as possible the child should be taught itself to use the tooth-brush and powder twice daily, and to draw waxed floss silk between the teeth or to use a quill tooth- pick — in private — after each meal. Should decay take place, it is all-important to have the trouble corrected by a dentist. Indeed, it is best in any case to let the baby pay its first visit to him not later than the age of two years, and after this regularly at intervals of six months. In this way the milk teeth may be prevented from decay- ing, and, in addition, will not be allowed to remain in place after they have commenced to interfere with the cutting of the second set. Besides the washing of the hair, of which we have already spoken, it is of course necessary to brush it, not only for appearance' sake, but also because frequent thorough brushing improves the scalp. The hair-brush for the baby's first use is made of camel's hair, in order not to irritate the scalp. As the child's hair increases in quantity and becomes less fine, a coarser brush must be procured, with bristles stiff" enough to remove all dan- druff" from the skin. Combs of any sort ought to be employed only to part the hair, and even for this purpose it is not advisable to use them in infancy, except wath the greatest care. The hair should be trimmed often. It is true that short hair is not so pretty, but it adds to the comfort of the child, and even little girls of three or four years or older may wear the hair short with decided ad- J THE BABY'S CLOTHES. 83 vantage in this respect. They will easily make up lost time when it is finally allowed to grow uninterruptedly. Certainly no boy should be made to wear long hair in curls after he puts on trousers, unless his mother wishes to subject him to the ridicule of his boy companions. Contrary to a commonly-accepted idea, the cutting of the hair has no effect in improving its growth. So, too, the clipping of the eyelashes does no good. They do not become longer as a result of this, but may grow coarse. The cutting of the finger-nails and toe-nails requires some attention. The finger-nails should be kept trimmed with scissors, yet not down to the quick nor too much at the corners. They may be kept clean with a soft nail- brush, and all the hang-nails be cut off close to the skin. The toe-nails should be cut straight across, and the cor- ners should never be rounded off. The following of this plan will aid in the prevention of ingrowing toe-nails. The completion of the baby's toilet — namely, dressing — can be more conveniently considered when studying the nature of the clothes, in the next chapter. CHAPTER V. THE BABY'S CLOTHES. In this chapter we must first consider the clothing required for a young infant; then that needed after short- ening of the clothes has taken place; and, finally, that to be used after baby-clothing is abandoned. The chief requirements of an infant's dress are looseness, softness, warmth, and simplicity. We usually avoid in this country the custom prevalent in some others — that of wrapping a child in swaddling-clothes in which it is actually rolled up like a small bundle. Yet even with us 84 THE CARE OF THE BABY. infants often are not dressed in a way to allow of the freedom of motion that is desirable. The binder is so tight that the ribs and abdomen are compressed and digestion is greatly interfered with, and sometimes even vomiting is produced, and the skirts are so long that the baby can move its legs only with difficulty. The clothing should be soft and light, in order that the delicate baby-skin be not irritated. Not only soft- ness in surface but softness in texture also is required; that is, the material ought to be porous and not too heavy, in order that evaporation of perspiration and the proper ventilation of the skin may take place. Simplic- ity is also important. This does not mean merely that the clothing be simply made, but that the whole arrange- ment be simple as well. If the garments are elaborate, not only is the expense of providing them very greatly and unnecessarily increased, but, more especially, the temptation arises of letting them be worn too long with- out washing. Still, if a mother desires to make the baby^s clothing of this nature, there is no real objection to it, although it may not be wise. The other kind of simplicity, however, is a positive requisite. Every un- necessary garment renders the exertion of being dressed and the burden of the clothes that much greater. To be rolled first on its stomach and then on its back an indef- inite number of times while one laver of clothinor after another is put upon it cannot but be very distressing to the baby. Finally, and the most important of all, the child's clothing must be warm. Children, particularly in in- fancy, are peculiarly unable to resist the depressing effects of cold, and everv care must be taken to ofuard against this. In prematurely-born infants life depends largely upon the maintenance of the body-heat We THE BABY'S CLOTHES. 8$ all know, or ought to know, that it is not the part which is exposed which necessarily feels the effect of exposure. A child may develop pneumonia or diarrhoea just as easily from chilling of the arms or legs as from direct exposure of the chest or abdomen. Consequently, the custom of dressing with thin sleeves or with short dresses and bare legs cannot be too strongly condemned. It is a practice which in cool weather is both dangerous and cruel. No parent would be willing to dress in that way, even did custom sanction it. Even in summer-time it is dangerous, especially in infancy. A child will be little, if any, warmer with a thin covering over the legs, and will un- doubtedly be very much safer. It is a great mistake to try to ''harden" a child by letting draughts blow on it and by covering it with insufficient clothing. Garments which are loose, and those made of material of loose texture, are warmer than others, on account of the air which they retain in their folds and interstices; for air, as is well known, is a very poor conductor of heat. There is no material which, in theory at least, answers all the requirements as well as wool. It is at once soft, loose-textured, light, and warm. With the excep- tion of the diapers, all the clothing which comes next to the skin of the child should, when possible, be made of wool. Its weight must, of course, vary with the season of the year, and its texture should always be of the ver>' softest. All-wool woven material or machine-knitted goods serve this purpose well. While all-wool garments next the skin are much to be preferred from a hygienic point of view, there are some grave objections to them. First among these is their great tendency to shrink, and consequently to become both harsh in texture and much too tight. The fact that so many ways of preventing this have been S6 TtiE CARE OF THE BABY. proposed indicates that none of them is entirely satis- factory. Now and then a laundress will be found who really understands the washing of woollens, but this is certainly the exception. An underwear has been devised to meet this emergency. It is composed of a cotton back with a fleece-wool lining, and does not shrink when washed. Still other devices consist in the employment of "merino" goods, made of a mixture of cotton and wool. These shrink badly if too much wool is present. The. other chief objection is that to some babies' skins, particularly in hot weather, all-wool clothing is very irritating. In such cases a garment of silk or of linen may be worn under the woollen one. The latter is apt to be chilling, and a better practice is to use merino goods of a sort which contains only a small portion of wool, or machine-knitted goods entirely of cotton. This soft porous cotton stockinet, made of different thicknesses for summer and winter, is very satisfactory. Having now considered some of the general principles which underlie the choice of materials used in the dress- ing of children, we may look more in detail into the character of the individual articles required. Most of them can be made at home, and paper patterns for them may be bought of the dealers. It is more convenient, however, although less economical, to buy the gannents ready made, and some of the clothes, such as all the close-fitting ones, are much better when not made at home. The larger establishments for children's and in- fants' clothing keep a line of varying sizes and weights. The binder, or abdominal band, is the term applied to the bandage which is commonly placed around the child's abdomen next to the skin. Many physicians are opposed to it utterly, and there is no question but that it is capable of doing great harm if improperly used. As THE BABY'S CLOTHES. ^J a means of support it is entirely unnecessary. The only object of the bandage is at first to keep the umbilical cord from being pulled upon by the clothes, and, later, to furnish a loose covering to the abdomen to prevent chill- ing. It can be done away with if the shirt is made to fasten to the diaper, but on the whole it is an advantage, provided only we remember that most important fact, that a binder must never bind. Nurses are much dis- posed to draw it very snug. This makes colic worse when the baby is troubled with gas, by not allowing the abdomen to distend; and there is danger, too, of produ- cing rupture in the same way, instead of preventing it, as it is sometimes sup}X)sed that a close binder will do. The best form of binder is the knitted circular one, on account of the greater elasticity which it possesses. This can be bought ready made, or can be knitted or crocheted at home. It should be circular, and be wide enough to extend from the hips well over the ribs — that is, about six inches (Fig. i8). It may be made with shoulder- straps if desired, or may be simply pinned to the shirt. There is usually a little tab in front to which the diaper may be pinned. If it is desired to make the binder of flannel, it should be of the width mentioned, and long enough to go somewhat more than ^^'^- i8.— Abdominal once around the body — that is, about twenty inches in length. The flannel should be of the softest kind, cut bias in order to increase its elasticity, and unhemmed. The knitted binder is, however, prefer- able, except, possibly, for the first week of life, or until the cord separates. The flannel binder is more easily ap- SS THE CARE OF THE BABY. plied at this time, and occasions less danger of pulling the cord, but with even ordinary care the other can be readily used from the first. Diapers or napkins should be made of soft, light, and absorbent material, and it is important to have them not too heating, especially in summer. Perhaps the best materials are linen and cotton diaper-cloths, either of which is about as good as the other, excepting that the linen is cooler. Canton flannel is not to be recommended, -as it is too little absorbent, and soon becomes harsh as a result of washing. The diapers for the early months of life should be a yard long and half a yard wide. By the time the child is three months old the width will often need to be increased to twenty inches and the length also to double this, and by about nine months further increase in size must often be made. The diaper, hemmed, is folded into a square, and this again into a triangle, mak- ing four thicknesses in all. A second diaper may be Fig. 19. — Diaper with diaper-square. folded into a square and be laid under the hips to prevent the moisture reaching the clothes; or it may be pinned around the waist in the usual triangular form, but with the point allowed to hang down behind. Instead of this THE BABY'S CLOTHES. 89 arrangement, which is rather heating and bulky, espe- cially in summer, it is often a good plan to use a small diaper folded two or more times to form a square of nine or eleven inches ("diaper-square") — just large enough to receive the urine and the passages from the bowels. This square is held in place by a thinner and larger linen diaper, which surrounds the hips in the usual way (Fig. 19). An excellent device is the Arnold knit diaper, which is not only very soft and absorbent, but also is shaped to fit the hips, and which must be much more comfortable to the baby than the ordinary form is. A rubber or other waterproof cover should never be applied outside the diaper. It is very heating and is liable to produce chafing and eczema. The diapers should always be changed just as soon as soiled, and should on no account be put on again until they have been washed, even though they have been only moistened with colorless urine. It is always dan- gerous simply to dr>' them and then to use them again. Nothing but pure soap, not too alkaline in character, should be employed in washing them, and soda ought to be avoided carefully, as otherwise a great deal of irritation of the skin may result. They should be passed through several rinsings of fresh water, to be sure that all soap has been removed. After washing they should be aired for a day before they are used, in order that they may become thoroughly dry. All ,. 1 , . 1 1 J Fig, 20. — Knitted sock. new diapers ought to be washed several times before the baby uses them, in order to ren- der them quite soft. Crocheted or knitted socks are an essential if the baby's 90 TME CARE OF THE BABY, skirts are made as short as is advisable, and even with the longest skirts they are to be recommended. They are made of silk thread or of soft yarn, reach fully half- way to the knee, and tie about the ankle with a narrow silk ribbon or a knitted cord (Fig. 20). All babies are clothed in much the same way as re- gards the garments already mentioned, but for the rest we have the choice of several forms of clothing. Of course, various minor modifications exist, but there appear to be three principal styles on which these are based. The first or oldest style consists of a shirt, a skirt fastened to a broad muslin band and called a "bar- row coat" or "pinning blanket," often a second petti- coat, and then an outside dress or slip. The second variety is like the first, except for the important differ- ence that the band of the petticoat is replaced by a loose waist with arm-holes; or the whole garment is made in "Princess" style — that is, without a distinct waist. In the third form, very often called the "Gertrude suit," the ordinary shirt is done away with, and, as originally described, the binder also, and the costume consists of three garments, all of the Princess pattern. The first style of dressing, not so often employed now as formerly, is decidedly objectionable. In this the pet- ticoat consists of a skirt of flannel reaching below the feet and attached to a muslin band which is deep enough to reach from the armpits to the hips. This band must of necessity be long enough to overlap considerably, to permit of pinning and to give room for growth. Such a garment as this breaks all the rules that we discussed as requisite for infants' clothing. It is cumbersome, it is more difficult to put on, and, above all, it is too tight. The closeness of application required to enable the band to support the weight of the skirt exerts far I THE BABY'S CLOTHES. 9t .(Si^^X^ Fig. 21.— Shirt. more pressure than the delicate ribs of the baby should receive. The second style of body-clothing is one which can be highly recommended. The shirt should be made of one of the materials already recommended for use next the skin. For winter it should be warm ; for summer, made of the same materials, but thinner, and for the hottest weather, very thin. In all seasons it should be long enough to reach below the hips, and should have sleeves extending to the wrists, and a high neck. It should be open the full length in front, and be fastened by small flat buttons (Fig. 21). It should be sufficiently loose not to compress the chest even after some shrinkage in wash- ing. A shirt with a chest-measure of fifteen inches is generally sufficient during the first three months of life. If it is too large, a smooth plait may be taken at each side. The shrinkage from washing can be avoided to a considerable extent by stretching the garment over a wooden form while drying. The best material for the petticoat is white flannel. The best form is one which is made throughout in Princess style and with arm-holes without sleeves. It should be open above at the back, and be made to fasten with one or two small flat buttons or with a narrow rib- bon to tie at the neck. In warm weather the petticoat may consist of a flannel skirt with a loose muslin waist. It is a great mistake to make infants' skirts too long, as it serves no good purpose, and impedes very greatly the freedom of their motions — that exercise of their legs 92 THE CARE OF THE BABY. which is SO to be desired. The petticoat should reach not more than six to ten inches below the feet. A length of twenty-five inches from the neck to the hem is quite sufficient. Some mothers prefer to have a second cam- bric petticoat over this, as it prevents the flannel showing through the dress, but this makes an extra, unnecessary garment and complicates the process of dressing. The slip or dress is of cambric or nainsook, loose, and of any style that suits the mother's fancy. It should fasten behind with buttons or a narrow ribbon, and should have sleeves coming to the wrists. Its length should equal or slightly exceed that of the petticoat. Of course, both the slip and the bottom of the petticoat may be trimmed according to taste. The third style of clothing, the Gertrude suit, 'consists, as stated, of three garments, and neither close-fitting shirt nor binder is used. The use of the binder, however, does not interfere with the plan of the suit. All these garments are cut in Princess style. As originally de- scribed, the inner one, which takes the place of the ordi- nary shirt and may be called the "Gertrude shirt," con- sisted of Canton flannel, reached from the neck to ten inches below the feet — that is, was twenty-five inches in all in length — had sleeves to the wrist, and all the seams on the outside. The middle garment, correspond- ing to the ordinary petticoat, was of flannel, had scalloped neck and arm-holes without sleeves, and was half an inch larger around and two to four inches longer. The third garment, the slip, was of the ordinary material, with high neck and long sleeves, and was slightly wider than the last and thirty or more inches in length. All were fastened behind with two or three small buttons. The chief ad- vantage of this style, apart from the looseness, is the very great convenience in dressing. The three are put together, one within the other, and sleeve within sleeve, THE BABY'S CLOTHES. 93 before they are put on, and then all are drawn on at one time as though they were but one. The material of the suit has since been modified in various ways. The inner garment is better made of something else than Canton flannel. One of the mate- rials already recommended for use next the skin is far superior. The second garment may be made of flannel for winter or of muslin for summer. The outer slip is of cambric or nainsook, as usual. There is no necessity of having the garments so long; twenty-eight inches is long enough for the slip, and somewhat less for the two other garments. This allows the child greater freedom of movement, yet without exposing it to danger of taking cold. If there is found to be a tendency for the air to enter at the back, owing to the fact that three garments open at the same position, the difficulty can be readily overcome by having the outer garment open in the centre of the back, the middle one somewhat to one side, and the inner one slightly toward the other side. The Gertrude suit is certainly an excellent one. It is superior to the second style described in the convenience attending dressing, but is perhaps inferior in that the under-garment does not adhere so closely to the body, and is therefore more apt to let the air reach the skin. This objection, however, is not of so much moment while the baby is still in long clothes. There are certain other suits advertised and used to some extent which are in all essentials made after the plan of the Gertrude suit device. If the mother desire it, she can have the baby^s clothes open in front instead of behind. This has the theoretical advantage that the child does not have to lie upon but- tons, tapes, or pins. Practically, it makes little differ- ence if the clothing is put on carefully and the child is not laid upon a hard surface. 94 THE CARE OF THE BABY. The length of garments in inches as given applies only to the first two or three months. They can, of course, be made with a hem sufficient to let out as the baby grows. So, too, the buttons can be shifted and the wrist-bands lengthened if the garments have been made large enough at the outset. It is better, however, not to have too many clothes at first, and to buy or make larger sizes as needed. The clothes for the night should be a complete change from those worn during the day. They consist of a binder, a diaper, a shirt either of the ordinary pattern or of the Gertrude style, according to preference, and an outer night-slip. This latter should be longer than the day-slip, and very roomy in order to allow of free move- ment of the legs. For winter-time it should be of flan- nel or Canton flannel and made to close with a draw- ing-string or with buttons at the bottom (Fig. 22). For hot summer weather it may be of muslin, and need not be fastened below. The baby requires no socks when in bed, but needs some night-socks to slip on when it has to be taken up. The necessity for fastening down the bed-covers if the baby is restless is referred to again in the chap- ter on Sleep. A certain number of garments are needed besides those mentioned. There is, in the first place, the old blanket in which the child shall be received immediately after birth, and which has been spoken of in describing the contents of the baby's bas- ket in Chapter IV. There should also be a warm shawl or shoulder-blanket, made of very soft flannel, which can be thrown about the baby and over its head w^hen it is carried from one room to another or w^hen it is taken Fig, 22, — Night- gown closed by a drawing - string at the bottom. THE BABY'S CLOTHES. 95 up at night. The shoulder-blanket should not be used except under these circumstances. A cap to be worn in the house is not needed unless the child shows a great disposition to take cold. A thin cambric cap is then sufficient, but even this should not be used except by the advice of the physician in charge. A knitted worsted sack is often useful if the room happens to be cooler than usual. A flannel or w^ash-flannel wrapper is also very ser- viceable in the mornings, before the baby receives its bath. The clothing for use out of doors varies, of course, with the season. In winter there is needed a long, very warm cloak of some woollen material such as cashmere; a warm thick hood covering the ears; a Shetland veil if the weather is windy or cold; and warm knitted mit- tens. In hot summer weather only a cap is required. This should be thin, of cambric or silk. We may pause here just a moment over the steps to be followed in the actual process of dressing a young infant, although this is something which seems to come almost intuitively to most mothers. After the new-born baby is bathed and dried it is laid upon its back in the nurse's lap, with the diaper in position under its hips. If a binder of flannel is used, it should at the same time be laid in place under the back. The stump of the umbil- ical cord is now dressed. The best method of doing this is to envelop it well in salicylated absorbent cotton, which can be procured at any first-class drug-store. It is then wrapped about with thread and laid against the abdomen upon the left side. The binder is then brought up from each side and pinned with safety-pins, or, if the circular knitted binder is used, is drawn up over the feet. It ought always to be so loose that the hand will slip easily between it and the skin. The diaper is now brought around and pinned, taking care that the hand can slip 96 THE CARE OF THE BABY. under it readily, as in the case of the binder. The socks are next put on, and then the shirt. The petticoat and dress are first adjusted to each other and are then slipped on together over the head. If the Gertrude suit is used, all three garments are slipped over the head at one time after having first been put together, sleeve within sleeve. At bed-time all clothing worn during the day is re- moved, a fresh binder and diaper are applied, and the night-clothes put on. If the Gertrude clothing is used, the under-garment and the night-gown are first fitted together and are then put on at the same time. Every day, at the time of the morning bath, the um- bilical cord must be carefully freed from the cotton, using great caution to avoid pulling it. After the bath it may be powdered with boric acid if there is any moisture or unpleasant odor about it, and a fresh dressing of cotton must be applied. By the fourth or fifth day the stump will have fallen off and the dressing of the cord will no longer be required. If the baby is sponged instead of being put in the tub during the first few days of life, there is no need to remove the original dressing from the cord, provided it seems dry and entirely without odor. There is scarcely anything about which there is so little uniformity of opinion as the number of changes of cloth- ing which should be provided in advance for the baby. This is not only because mothers V2X\ in the frequency with which they have laundr}^ work done, but also be- cause the number of garments which can be made to answer very well where economy is a matter of considera- tion may not seem at all suflficient to those anxious to have the baby very abundantly supplied. The following list of clothing — the layette, as it is com- monly called — may be considered one of average size: THE BABY'S CLOTHES 97 Long Clothes. Flannel binders 2 Knitted bands 4 Diapers 4 dozen or more. Shirts, close-fitting or Gertrude 6 Petticoats, flannel, or second Gertrude garment . . 4 Petticoats, cambric (if desired) 4 Slips 8 Socks 6 pairs. Night-gowns 6 Wrappers 3 Sacks, knitted 2 Cloak I Hood I Mittens i pair. Veil I Shoulder-blankets 2 There are certain other articles to be provided in ad- \ance, bnt they are more appropriately described else- where, when considering the baby's basket and the baby's bed. There is one, however, and a very service- able one, which may be mentioned here — namely, the lap-protector, although this is rather for the mother's use than for the baby's. A ver>' good pattern is shaped like a pillow-case, fastens at one end by buttons, and is made of corduroy, Turkish toweling, or some similar thick, washable material. It may be trimmed simply in any way desired. A doubled piece of rubber sheeting is made to slip inside of it. The rubber may be slipped out, and both it and the case washed when soiled. Instead of this, lap-protectors may be made of squares of nurser}' cloth, which can be thrown away when soiled. Still another useful article is a small soft pillow on which the baby can lie or be carried about during the early wrecks of life. When the baby has reached the age of six months, more or less, depending on the season of the year, the 7 98 THE CARE OF THE BABY. time for "shortening^' the clothes, or "short-coating," has come. The change should not be made in winter if it can be avoided. The number and material of the gar- ments remain nearly the same as before. The shortening may be accomplished by cutting down the skirts of the long clothes already in use, lengthening the sleeves, and letting out the waists if they have been made sufficiently large at first to allow of this. In the case of the Ger- trude suit, however, the shortened skirts, reaching, as they do, only to the ankles or a little higher, allow too free access of air to the trunk. It is therefore advisable to replace the inner loose garment by a close-fitting, long- sleeved, and high-necked shirt. The use of the binder is continued. Short clothes also necessitate a decided change in the covering of the feet and legs, which would otherwise be left too much exposed to the air. There is, of course, a great temptation for the admiring mother to leave the baby's plump little legs bare, but the practice is capable of doing great harm. There should be stock- ings long enough to reach to the diaper. They may be pinned to this, but a better way is to button them to broad elastic bands which can be buttoned or tied to tapes fastened to the inside of the upper part of the petticoat. Stockings of wool or of partly woollen goods, and of a thickness varying with the season of the year, are prob- ably to be preferred, but they frequently shrink so badly that raw silk or cotton stockings are often more practi- cally useful, especially in summer-time. The shrinking may be prevented to a considerable extent by stretching them over a wooden stocking-frame while drying. The toe should not be pointed, and the whole stocking-foot should not fit too closely, since the constant elastic pres- sure which it exerts may do harm. Indeed, the stock- ings ought to be rights and lefts, and narrowed off on the THE BABY'S CLOTHES. 99 outside of the foot, if such forms cau be bought or made. A great breadth of toe is ver}' desirable. Care must be obser\'ed that the interior is perfectly smooth and free from loose threads, knots, and wrinkles. The stockings should be white or of some color which is known not to contain any injurious substance capable of irritating the skin. In winter it is sometimes of advan- tage to furnish a child in short clothes with drawers also. These may be made of woollen or merino goods or of Can- ton flannel. It is convenient to make the legs separate, to button or pin to the upper part of the petticoat. They should fit rather closely and should reach to the shoe-tops (Fig. 23). Drawers of this pattern combined with the use of short stockings may entirely take the place of long stockings throughout the year, if it is so desired. In this case their weight varies, of course, with the season. Ex- cept that they are more easily changed when wet, they have no special advantage over long stockings, and the latter alone generally answer every pur- pose until the age when the dia- per is abandoned. When the baby becomes more active, and especially when it be- gins to creep or to stand, there is often a great deal of trouble with the diapers, which exhibit a tend- ency to fall off at the most inop- ^^'G. 23.— Drawers with sepa- portune moments, unless drawn ^^^^ ^^^^• much more tightly than is healthful. To obviate this difficulty the diapers may be pinned to the merino shirt, provided little squares of muslin be first sewed on the latter, to prevent the pins tearing holes; or the binder may be made with shoulder-straps and with a little lOO THE CARE OF THE BABY. tag in front to which the diaper can be attached. Dia- per-suspenders have been recommended to meet the dif- ficulty: they consist of a band of muslin about three inches wide, and long enough to go around the waist and to button in front. Two pieces of white silk elastic are attached to this, as shown in the illustration (Fig. 24), so as to cross over the shoulders. A little tag is sewed on one end of the band, and another at the middle, and to these the diaper is pinned after the suspenders have been ap- plied outside of the shirt. Very neat and light little waists can be bought or made, and to these both Fig. 24. — Diaper-suspenders. diapers and stockings may be fastened, in place of any of the plans mentioned. With the short dresses the baby may put on shoes, although it does not really need them until it begins to stand or to creep. In place of these we may at first use moccasins of chamois leather, kid, or felt. These are for sale in the shops, but they can be easily made at home. They form a very serviceable foot-covering, although there is difficulty in keeping them on unless they are well made and rather high on the ankle. The first real shoes should be of soft kid, with kid or thin leather soles, and of course without heels. Their shape is of great importance, since the softness of the tissues renders the deforming of the feet by improper shoes very easy. Not only should the shoe be somewhat longer than the foot and fully as wide, but it should be made to fit the foot, not the foot forced to fit the shoe. The toe should be wide and loose to permit the foot to spread, but the THE BABY'S CLOTHES. lOI instep and heel should fit closely or the foot will turn and rub. Flat laces are better than buttons, since they allow of a more perfect adaptation. The shoes ought always to be rights and lefts, for, although a baby's foot is fat Fig. 25. — Imprint of foot (from life, three-quarters natural size). Fig. 26. — Outline of sole of shoe to fit Fig. 25. and plump, it is in reality built on exactly the same lines as the adult foot — that is, the undeformed adult foot, The illustration (Fig. 25) is of the sole of the right foot of a child of thirteen months. It is a reproduction from life, reduced to three-quarters of the natural size, made by rubbing the sole with a little lampblack stirred in turpentine and sweet oil, and then pressing it against blotting-paper pinned on a board. The illustration seems unnatural and distorted at first sight, yet it shows how a foot actually presses upon the ground in walking, and proves the great importance of having the shoes rights and lefts even from the beginning. The out- I02 THE CARE OF THE BABY, line in the adjoining illustration (Fig. 26) represents the shape of the sole of a shoe which would fit this foot. For actual use it should, of course, be made slightly larger in order to keep the uppers from exercising undue pressure. Shoes of a proper pattern are difficult to obtain, since shoemakers find it easier to make them on the old model, according to which either one will fit equally well — or, rather, equally ill — on either foot. I\Ir. W. H. Steigerwalt, of Philadelphia, has for some years been making suitable shoes for the period of later childhood, and was furnishing very broad-toed shoes, but not rights and lefts, for use in infancy. At my suggestion he now provides shoes which are rights and lefts, and which con- form to the natural shape of the foot of the youngest age needing shoes at all. Sometimes a baby suffers greatly from cold feet shortly after it first begins to wear stockings and shoes. Fre- quent rubbing of the bare feet and the making of the shoes somewhat looser about the instep and ankle will overcome the trouble. After the baby is walking out of doors the thickness and stiffness of the sole must be increased, to protect the foot from being injured b}' irreg- ularities in the ground. Knitted sacks are still needed during the time short infant-clothing is worn, and wrappers serve the same purpose as before. The wrapper should be long and loose, and neither it nor the night-slip partakes in the general shortening. Even before the time of shortening, bibs may be needed to catch the greatly increased flow of saliva. These should be made of soft, absorbent cotton material, and be quilted. There is no objection to the placing of a somewhat smaller bib of rubber cloth under the cotton one. I^ater, larger bibs will be required for use when the child is eating. A very ser\'iceable article THE BABY'S CLOTHES. 103 when the baby begins to creep is a creeping apron. The drawers already described answer to a certain extent, but a much better device is the creeping apron shown in the ilhistration (Fig. 27). The lower portion consists of a wide, roomy, bag-like skirt, closed at the bottom and large enough to hold the skirts easily. This is fastened to a yoke above, which is provided with wide sleeves and wide arm-holes to permit of the arms easily slipping into them. At the lower end of the apron are two openings for the legs. These are gathered into bands fitted to the legs and are made to fasten below the knee. There should be a distance of fifteen inches be- tween the holes. The whole width of the skirt at the lower end should be twenty-seven or more inches. This device will effectually protect all the gannents and will check the action of draughts along the floor. Creeping aprons of this description can easily be made at home, but can- not, I think, be bought in the shops. If the mother finds the upper portion to be too warm, the yoke and sleeves may be dispensed with, and the bag-skirt be gathered into a band, from which shoulder-straps may pass over the shoulders and cross over the back. Of course this latter plan fails to prevent the sleeves of the baby's slip from becoming soiled. There is a form of creeping apron sometimes recom- mended and sold which should be avoided. It consists of a very wide pinafore gathered at the bottom of the skirt into a band, which fastens around the waist under Fig. 27. — Crccpmi; apruii. 104 ^-^^ CARE OF THE BABY. the clothes. This arrangement protects the clothing well, but leaves the legs more than usually exposed, since it holds the skirts away from them. For outdoor use a coat which is shorter than the long cloak of infancy is needed after the child has learned to walk. Warm knitted leggings which cover the whole lower half of the body up to the waist are serviceable in cold weather. Those made of Jersey are still better, as they are just as warm and much less bulky. The following list may serve as a guide to the number of garments needed at this time of life: Short Clothes. Knitted binders 4 Diapers 4 dozen. Shirts, close-fitting 6 Petticoats, flannel 4 Petticoats, cambric (if desired) 4 Dresses 8 to 12 Stockings 8 to 12 pairs. Shoes 2 pairs. Drawers (if desired) 8 to 12 pairs. Creeping aprons 2 Wrappers 3 Sacks 3 Bibs 12 Night-gowns 6 Cloak or coat i Hood or cap i Leggings i pair. Veil I Mittens i pair. The time for changing from the clothing of infancy to that of childhood depends not so much upon the age as upon the time when the baby learns to do without a diaper. Two years of age is a very late period for acquir- ing the proper control, and most children should be able THE BABY'S CLOTHES. I05 to have the change made by a year or earlier, at least during the day-time, if there has been careful training. After the change has been made it is still important to ensure thorough protection against cold, while at the same time the clothes are loose. The style of gannents and their number is a matter of minor consequence, and may be determined largely according to the fancy of the mother, although the binder should be worn until the age of two years. With the exception of the head and hands, no part of the body should be left exposed to the air, unless it be on the very hottest days of summer, and even then the child is little, if any, warmer, and is cer- tainly much safer, if fully covered with garments of very light weight and texture. The undershirt should be long-sleeved and high-necked, and of woollen or merino of a thickness depending on the season of the year. The drawers for winter use should be of the warmest material, such as Canton flannel or closely fitting woollen goods. The stockings should vary in thick- ness with the season, but should always be long. A loosely-fitting, high-necked, sleeveless waist, of warm material for winter and of muslin for summer, is conve- niently worn over the shirt. To this the stocking-sup- porters and drawers are attached, and in summer the white skirt as well. Circular garters ought never to be worn. In winter the child must wear, in addition, a flannel skirt attached to a waist of its own, to which the white skirt also may be buttoned. The child's outer dress may be of material, quality, and ornamentation in accord with the season and the pre- vailing styles. It is the custom to keep children in white dresses until the age of two or three years. If colors in light woollen material, or in cottons for summer, are preferred on account of the saving of laundry work, it is I06 THE CARE OF THE BABY. well to remember that certain colors for use in the sun- shine are much hotter than others. Black is twice as hot as white, and blue, even light blue, nearly as hot as black. Red stands about midway between black and white, with green hotter and yellow cooler than it. The long skirts reaching almost to the ground, which have been at times the fashion for small children, espe- cially girls, are not at all to be recommended. They are very much in the way, and oppose a great hinderance to the active movements which are so much to be desired. As the child grows older its style of dressing will, of course, vary according as it is a girl or a boy. The time and manner of showing the difference of sex by the dress is not a matter with which we can concern ourselves greatly in a book of this nature, and we must consider it only briefly. No change at all is made until the age of two years or older, depending upon the size of the child. At this time boys wear dresses made with box plaits from the neck, held in at the back by a belt which comes from the side seams, or, if preferred, goes entirely around the waist; while girls still wear the baby-dress, gathered in a yoke. At three or four years of age, depending on the size and shape of the child, the boy is put into trou- sers, either knickerbockers or the popular sailor costume. An important matter, with girls just as much as with boys, is that the same precautions to ensure looseness and warmth of the clothing shall be taken at this age as earlier in life. If corsets must finally be worn — as inex- orable Fashion still says they must — let the girl in her formative stage defer adopting them, or even corset- waists, just as long as possible. Her whole future well- being may depend upon this and similar early provisions for her health. There is nothing in all this which means that her clothes shall look uo^lv or ill-fittinor. THE BABY'S CLOTHES. 107 The night-dress of children who have ceased to wear baby clothes consists of a merino shirt, of thickness vary- ing with the season, and of night-drawers which are of Canton flannel in winter and nuislin in summer. The very frequent tendency which some children have to toss off the night-covering often renders it advisable to pro- vide the drawers with feet, so that the whole body except the head and hands is constantly covered (Fig. 28). A slit at the ankle allows the foot to be pushed through and the stocking to be put on in the morning without exposing the child. Not until well on in later childhood, at least in win- ter, should night-gowns be made for the girls, and night-shirts, or, still better, pajamas, for the boys. For out-of-door wear both sexes continue to wear caps until about the age of two years, when boys generally replace them by little hats. The use of a warm hood, or of some other form of head-covering which protects the ears, should certainly be adopted in winter. Warm wraps and coats are needed in winter, their na- ture depending upon the child's age and sex. The soles of the shoes are gradually increased in thickness as the child grows older, and at about the age of three or four years the part under the heel is made slightly thicker—/, e. has a ''spring." The spring is later made somewhat more pronounced, but it is only, as a rule, at about the age of ten or eleven years that actual heels are used. Sometimes boys' shoes Fig. 2S. — Night-drawers with closed feet. I08 THE CARE OF THE BABY. are given heels somewhat earlier, in order to make a dis- tinction from the shoes of girls. Leather leggings lined with flannel are very popular for children of three or four years and over. Rubber over-shoes should always be worn if the ground is at all damp. Rubber boots permit the child to play in the snow or on ver}^ wet ground. In later childhood mackintoshes serve to protect from rain. Before this time it is better that the child stay in the house in rainy weather. • We must never forget the possible danger of contracting cold after the use of waterproof clothing, from the fact that the body becomes damp from the retained perspiration. After the use of rubber boots the feet should be thoroughly dried and the stockings changed. The following list represents the clothes required for late infancy and early childhood up to the period when trousers are adopted by the boy. More drawers are needed at first than later, on account of the occasional lapses in the recently acquired control over the bladder. ClvOTHING FOR LATE INFANCY AND EARLIEST CHILDHOOD. Binders (up to two 5'ears of age) 4 Shirts 6 Drawers 6 to 12 Stockings 6 to 8 pairs. Shoes 2 pairs. Underwaists 4 Flannel skirts with waists attached 4 White skirts 4 Dresses 6 to 12 Night-drawers 4 Sacks 2 Cap or hat i Leggings i pair. Coat I Mittens or gloves i pair. Rubber shoes i pair. FEEDI.VG THE BABY. IO9 A few very brief comments are necessary regarding the clothing required during sickness. When the child is in bed it should be dressed in night-clothes identical with those usually worn. The garments should be changed night and morning, and be aired and warmed thoroughly before they are used again. There is seldom, if ever, any necessity of making a child go without changing its clothing for days or weeks for fear it will take cold. If the change is made properly, there is no risk. It is very important that the arms and chest be well covered with a sack of some sort when the child is awake. After it is well enough to be out of bed and to sit in a chair a flan- nel wrapper and knit or felt shoes are useful. Slippers are often dangerous, as they expose the feet to draughts. CHAPTER VI. FEEDING THE BABY. In this chapter we shall consider what is often one of the most difficult of all the questions of babyhood; the rock upon which manv and uianv a little l^ark has made shipwreck. There are but two ways to feed an infant — namely, either on human milk at the breast of the mother or of a wet-nurse, or upon an artificially prepared milk diet — and we have the two corresponding classes of the breast- fed and the bottle-fed baby. Happy are the little ones who belong to the first class, for there is no question whatever that the natural and proper food for infants is human milk. Statistics show beyond doubt that breast- fed babies as a class are larger and healthier than the bottle-fed ones, and that the mortality among them is far less. The most careful preparation cannot possibly no THE CARE OF THE BABY. make the milk of another animal chemically identical with that of a woman or similar in its eflfects on the child. It is undoubtedly true that the demands made upon the time of the nursing mother are most exacting, and that nursing is probably much the greatest inconvenience of motherhood. Still, the mother-love should certainly prompt the self-sacrifice. Let us, then, first consider breast-feeding. Many vary- ing directions are given regarding the time when the baby should be first put to the breast. We cannot do better in this respect than treat the child like any other little new-born animal which is not prevented by cast- iron rules from nursing as soon as it feels inclined. The natural instinct of a baby is to suck, and it should be allowed to do this as soon as the mother feels sufficiently rested to permit it, after both she and the child have been washed and dressed. This practice of early nursing is a good one, for the reason that it tends to ensure thorough contraction of the womb. It is true that there is ver)- little in the breast during the first two or three days. There is usually something, however — a thin, yellowish, sticky fluid looking like poorly-developed milk, and called colostriun. This is of a peculiar character, since, besides being of a nourishing nature, it has a somewhat purgative action upon the child's bowels, and it is advis- able that these be well opened early and the blackish contents (ineconiiiui) discharged. It is only by about the third day after confinement that the secretion of milk becomes well established. The early sucking by the child fulfils still other pur- poses besides those mentioned. It both stimulates the secretion of milk and draws out the nipples into better shape for the baby's future use. If the nipple is some- what depressed or poorly developed, it is much easier for FEEDIXG THE BABY. Ill the child to suck at it while the breast is still flaccid than after it has become full and tense with the con- tained milk. Many monthly nurses wish to feed the child during the first day or two of life with sweetened water, gruel, or other substances. This is usually totally unnecessary, and is often harmful. If the child really seems to be ravenously hungry, as shown by the avidity with which it grasps the nipple and the cries which it persistently utters, it may be given a very little cow's milk prepared according to the method to be considered later; but such a necessity rarely arises. Often a little moderately hot water will satisfy the child perfectly. During the first six weeks of life the child should be put to the breast regularly every two or two and a half hours during the day, and from this up to the time of weaning every three or four hours. It should be trained as far as possible to do without nursing at night — from ten in the evening to early in the morning. The tables given on pages 127 and 128 for guidance in the frequency of the feeding of bottle-babies apply equally to those nursed at the breast. Too much stress can- not be laid on the importance of regularity in nurs- ing. No fault is more common and more pernicious than that of suckling a child every time it cries, and simply for the sake of quieting it. The temptation to do this is great, it is true, but the final results are evil, for the baby's digestion is almost sure to suffer, and its dis- position to cry to become worse and worse. Moreover, a baby is to a wonderful degree a creature of routine, and when once it becomes a ''slave to bad habits" it will make everyone connected with it a slave to itself It should never be allowed to go to sleep at the breast with the nipple in its mouth, but should be kept awake until I 1 2 THE CARE OF THE BAB Y. it has finished or else be removed entirely. By the time of the next nursing it will be hungry enough to keep awake. It is a great mistake to suppose that every cry that stops temporarily during nursing denotes hunger. Often the child is thirsty, and a little water is really what it needs. This necessity of giving the baby water is very commonly forgotten. A nursing infant should have water offered to it several times a day. So, too, the stop- ping of a cry by nursing may occur because the entrance of the warm milk into the stomach temporarily relieves pain — only, of course, to increase the indigestion and to give worse colic presently. The mother also suffers from too frequent nursing, for not only is she then at the mercy of the child's habits, but she is extremely liable to develop cracked nipples as the result of the constant moistening. The baby while nursing ffom the left breast should be held on its right side with its head supported by the left arm of the mother. The mother should be propped slightly in bed with a pillow or should lie upon her side. After her convalescence she should lean a little forward while nurs- ing, so that the nipple points somewhat downward toward the child's mouth, and should slightly steady and elevate the breast with the first two fingers of the right hand to keep the weight from pressing upon its nose. If the child nurses too rapidly, the nipple should be withdrawn now and then to prevent its choking and to allow it to breathe. If the milk flows too freely of itself, it may be restrained by pressing the base of the nipple between the fingers and thumb; while if, on the other hand, it does not come quickly enough, and a delicate child seems unable to draw sufficient nourishment, the pressure of the hand upon the breast will aid in expelling it. In FEEDING THE BABY. II3 nursing from the right breast the position is of course reversed, and the child lies upon its left side. In rare instances, however, it will vomit if in this position while nursing, owing to the pressure of the liver upon the stomach. In such a case it may lie upon its right side with its legs tucked under the mother's right arm. If there is an abundance of milk, one breast is sufficient for one nursing, and the baby empties it after ten or fifteen minutes, is satisfied, falls asleep, and should at once be removed. The other breast should be reserved for the next nursing. The quantity of milk which a mother secretes during the first weeks of a baby's life is about one pint in twenty-four hours. Later the amount is increased as the needs of the child grow greater. Generally the mother at first has more milk than a baby can digest. A kind provision of nature prevents the over-feeding in which a strong baby indulges from doing it any harm, for the stomach simply rejects the over- supply, which comes up again just as it went down. It is not a true, forcible vomiting, such as occurs in older children, but is a simple regurgitation unattended by nausea, and need give the mother no immediate anxiety, provided the milk has no very sour odor and the health seems perfect. At the same time the trouble should be corrected by not allowing the baby to nurse quite so long or so often. In this connection we must consider the way in which a nursing mother ought to conduct her life, since upon this the health of the baby will depend. Her diet is a matter of much importance. What she shall eat during the time she is confined to bed will be carefully ordered by her physician. It is generally customary to alter the diet to some degree, either in quantity or in quality, since the confinement in bed may diminish somewhat the 114 THE CARE OF THE BABY. power of digestion. This is especially true of the first couple of days. After the mother is up and about she becomes her own mistress in this matter, and must determine for herself what is best for her. She should use every means to preserve her digestion in the very best condition by observing regularity in the time of meals, by eating slowly and masticating thoroughly, and by consuming only those things which are digestible and nutritious. There is a commonly prevailing notion that various substances must be avoided because they will give the baby colic by altering the milk. This is true only to a very limited extent, and generally only in so far as the mother's digestion is disturbed by what she has taken ; for it is certain that indigestion in the mother, by whatever means produced, is liable to be followed by indigestion in the child. It may sometimes happen, however, that raw fruit or acid substances eaten by the mother may, without affecting her digestion at all, in some way alter her milk and disagree with the baby; but this is rather the exception than the rule. It is also true that such articles of diet as onions, turnips, cauliflower, and cabbage, which have very distinct odors and tastes, are sometimes capable of imparting an unpleasant taste to the mother's milk, just as cow's milk may taste dis- agreeably of garlic. Most mothers, however, who have perfect digestion can eat nearly everything digestible without fear of affecting the baby. It is certainly true that there are drugs which, when taken by the mother, enter her milk, and it would some- times be possible for physicians to treat the child in this way. This is true of some of the purgative drugs and of certain others, but even in the case of medicines, as with foods, most mothers may be, to all intents, free FEEDING THE BABY. II5 from anxiety regarding the eflfect on. the baby of any- thing they may need to take. With regard to the use of stimulants, the nursing mother should follow her former habit of life if her health seems good. If she is delicate or weak she may find stimulants of service, but the advice of a physician had better be obtained in any case. Not infrequently there is an insufficient supply of milk, and the question arises whether the amount can be in- creased in any way. The drinking of large quantities of cow's milk, the use of various milk foods, soups, and perhaps of malted liquor in some form, may be of advan- tage. One of the thinner extracts of malt is often use- ful. It must be remembered, however, that increasing the secretion of milk does not necessarily increase its nourishing power, and that to take a large amount of liquid nourishment is sometimes only to play a decep- tion upon the baby. It may be merely following the example of the milkman who invokes the aid of the well-pump ; for, although the quantity secreted may be larger, the milk may be more watery and the actual amount of nourishment in twenty-four hours may be just the same as before. Still, much may often be done to alter the character of the milk, as we shall see presently. Equally important with proper diet is regular exercise and the enjoyment of fresh air, either on foot or in a car- riage. Late hours must be avoided, as must all sources of worry, anxiety, and nervous excitement. It is a not infrequent occurrence for the milk secreted shortly after a mother has experienced fright, violent anger, or other very powerful emotion to act as an intense poison to the baby. If a mother has been subjected to any such in- fluence, it is better to empty the breast with the pump Il6 THE CARE OF THE BABY. and to avoid nursing for a number of hours, substituting artificially prepared milk for the time being. ** The ability of the mother to nurse her child often depends upon the condition of her nipples. They should have been attended to during pregnancy, in the manner already described in Chapter I. In spite of all efforts, however, the birth of the child may find the nipples unfit for nursing. Their shape may be such that the baby can obtain no satisfactory hold, and in such a case an artificial nipple must be tried. There are many varieties of these, but those of the simplest con- struction should be chosen, as it is very necessary to keep them perfectly clean. One of the best consists of a glass base upon which is fitted a detachable rubber teat (Fig. 29). Such an apparatus may prove satis- ^'''' ^^7-^^^"^'^ factor>', and the effort to use it should always be made, but very frequently a badly-developed nipple will make it necessary to aban- don nursing. To keep the nipple in a good condition a mother should observe the req-ular times for nursing^ as alreadv referred to, and should invariably and immediately after nursing dry the nipples gently and thoroughly with a soft cloth, and then, for the first week or two, smear them with a little sweet oil. If the nipple becomes slightly raw or sore, it may after being dried have a special bismuth preparation applied and allowed to remain (Appendix, 74). It is important, too, to protect it carefully from any friction of the cloth- ing, possibly by the use of some form of nipple-shield, if the doctor sanctions it. Before nursinof a^ain the bis- FEEDING THE BABY. II7 miith application may be wiped away gently, but there is no need to do this very thoroughly, as it is not injuri- ous to the child if It is swallowed. The use of an arti- ficial nipple for a few days is to be recommended should the nipple be even only slightly sore. Should nursing become actually painful, a physician ought to be consulted immediately, for it is much easier to treat the fissures in the early stages than after they have become deep. If neglected, the pain of nursing may become simply unendurable. Sometimes the flow of milk is so great that even a strong baby cannot manage to take it all, and a constant hard distention of the breast, usually described as ''caked breast " or " milk cake, ' ' results. Unless this is promptly relieved there is great danger of an abscess forming. To prevent or relieve caking in such cases the breast requires long-continued and gentle but firm rubbing with warm sweet oil from the circumference toward the nipple, and the occasional application of the breast-pump (p. 27) to supplement the sucking by the child. The mother must on no account fail to consult her physician at once re- garding the diflficulty, and should not depend solely on the ministrations of the monthly nurse, as the matter is quite too serious for this. Eventually the baby must be weaned — that is, cease entirely to receive human milk, and be placed on a diet of another nature. The method of doing this and the age at which it shall be done vary somewhat with cir- cumstances. Some physicians advise that the baby begin to receive a small amount of artificial food when it reaches the age of five or six months, or even earlier than this, on the ground that its dependence upon mother's milk is thus rendered less absolute, and that it will not be subjected to the dangers which sudden wean- Il8 THE CARE OF THE BABY. ing entails should the milk of the mother rapidly ?Pi:y up. Although there is a degree of truth in this, yet it seems like guarding against a possible danger by incurring a very certain one — that of injuring the child's digestion; for experience shows that there are numberless instances of severe illness, and even of death, which have resulted from the early effort to replace mother's milk by cow's milk or other food, no matter how carefully prepared. Yet there is a mother's side to the question, for there is no doubt that the feeding of her baby month after month, from the breast alone renders her life very much confined and is a great drain upon her system, and in many instances her health, not only immediate but fu- ture, cannot endure it. In such cases, even when there is an abundance of breast-milk, the plan of giving one or possibly two bottles a day is to be thoughtfully considered. The substitution, however, should only be tried with the advice and under the supervision of the family physician. Certainly the safest course for the baby is that of feeding it solely from the breast until the age for weaning comes. So, too, if the baby ceases to grow at a proper rate, and it is proven that the breast-milk is insufficient in quantity or quality, the doctor may decide to combine artificial feeding with nursing. Ordinarily, weaning should take place at about the age of ten or eleven months. Longer nursing than this is generally too wearing upon the mother, and is also bad for the child, whose health is very likely to be impaired as a result of the breast-milk becoming thin and poor. Of course, the exact age to wean must depend on circum- stances. If the mother remains perfectly strong and the baby continues in the very best condition, it may be nursed until it is a year old, while the reverse of this may make early weaning necessary. Another very im- FEEDING THE BABY. I I9 portant matter is the season of the year. It is very bad policy to wean a child at the beginning of hot summer weather if it can be avoided in any way. It is certainly better to defer it until autumn, and to make up with artificial food any deficiency in the natural nourishment. Still another matter of some, though of less, importance is not to choose for weaning a period at which the baby is cutting a tooth. Weaning is best done somewhat gradually if pos- sible. At first but one bottle a day is given, the child being nursed at its other meals, but as time goes on the number of bottles given is gradually increased while the frequency of suckling is correspondingly diminished, until by the time about a month has elapsed the breast has been withdrawn entirely. This plan gives the child time to become accustomed to its new diet, which should consist of a milk-mixture as much like woman's milk as possible. The formula on page 135 may conveniently be followed. Sometimes it is necessary to wean rapidly. One of the chief causes of this is the refusal of the baby to take the bottle at all. Patience and persistence will generally overcome this, or it may be that the child will take food from a spoon or a cup. Should it still refuse, the only way open is to withdraw the breast entirely and at once until hunger forces it to eat. With sudden weaning, or sometimes even with the gradual process, the mother has much trouble from the distention of her breasts with milk, and must employ care lest an abscess result. She should take as little liquid of any kind as possible, whether water, tea, soup, milk, or whatever it may be. She should also take a gentle purgative, such as citrate of magnesia or a mineral water, keep the breasts sup- ported by a broad band going beneath them and over the 120 THE CARE OF THE BABY. shoulders, partially empty them occasionally with the breast-pump if the distention is painful, and prevent caking by diligently rubbing them with warm oil. Any other treatment, such as the application of ointments, had better be left to the family physician. Karly weaning may be rendered necessar}^ in differ- ent ways. If the mother is suffering from the drain of nursing or from great debility, consumption, or other exhausting ailment, or if she develop any severe acute disease, such as typhoid fever, pneumonia, or the like, nursing the child is quite out of the question. It is very commonly believed that the return of the menstrual period makes nursing improper. Although this occur- rence very often does render the milk unfit for the child, yet this is not an invariable rule, and the mother should do nothing precipitately in the matter. After the occur- rence of one monthly period there may be no reappear- ance of it for several months, and weaning would have been entirely unnecessary. Each case is a rule to itself, and onl}' the effect upon the mother and baby can settle the question, even if the periods have returned regularly. Should the mother become pregnant again, the child should be weaned, for it is too great a drain upon her to sustain both the one present and the one to come. Sometimes there is a great falling ofif in the quantity or qualit}' of the milk, which cannot be remedied in any way, or there may be an entire and even early cessation of the flow. Again, the breast-milk may be richer than the child can digest. Sometimes excessively painful fissures occurring in both breasts and refusing to heal, or the persistence of obstinately retracted nipples, may render nursing impossible, even with the aid of an arti- ficial nipple. Abscess of the breast prohibits nursing from the one that is affected. FEEDING THE BABY. 121 Before breast-feeding is abandoned on account of any defect in the amount or quality of the milk the mother should not fail to make sure that the trouble really exists, and that it cannot be remedied. The only accurate method of determining the character of the milk is, of course, to have a chemical analysis made of it. But even without this the mother may be able to form some idea of the nature of the difficulty. This is to be done partly by observation of the baby, partly by direct study of the milk with the aid of a creamometer and a specific gravity apparatus, such as are described and their employment explained on page 132. Those for use with human milk are usually made especially small, in order that less milk sliall be required. First, then, we must remember that if a baby is grow- ing at the proper rate, it is getting enough to eat. Any crying is probably due to some other cause than hunger, even although the child may not seem satisfied. If, however, it is not growing properly, and there is no diarrhcea, or vomiting, or other ailment to account for this, it is probable that the milk either is not rich enough, or that it is insufficient in amount. If the child tugs long and hungrily at the breast, and is unwilling to cease sucking after it should have finished, or if, perhaps, after a period of nursing, it drops the nipple with a dis- satisfied cry, it is ver}' likely that the milk is insufficient in quantity. This is particularly so if the breasts are flabby before nursing and seem to be quite empty after it. If, on the other hand, the milk is bluish and pale even though very abundant, and if the child seems tempo- rarily satisfied after nursing and the breasts are not emptied, it is probable that the richness of the milk is deficient. By looking at the analytical table on page 129 we see 122 THE CARE OF THE BABY. the ingredients of which milk consists. It is the fat and the albuminoids which are the ones especially liable to vary in quantity. The amount of sugar may be ignored at present, as it is less variable. Milk deficient in rich- ness may lack the proper proportion of either or both of these two ingredients. Which of them is at fault we can determine to some degree by direct study of the milk. In getting the milk for examination the baby should be allowed to nurse for a couple of minutes, the nipple should then be washed and dried carefully, and a por- tion (about one or two tablespoonfuls) should then be drawn by the breast-pump. The milk thus obtained represents about the middle of the nursing. Average human milk should separate in the cream- ometer about 7 per cent, of cream, which is equivalent to about 4 per cent, of fat. By determining the percentage of cream with this instrument and comparing it with the specific gravity we can, as we shall see presently, esti- mate the amount of albuminoids present, and decide whether the lack of richness is in fat or in albuminoids, or in both (see Table, page 123). But very often the necessity of weaning threatens on account of an excess of richness of the milk. An excess in the actual quantity of the milk may show itself by re- gurgitation (see pages 113 and 250) and often by the presence of large quantities of curds in the stools. This excess is generally easily controlled by removing the child from the breast before it has taken too much, or by compressing the nipple during the nursing in order to make the milk flow more slowly. Too great richness of the milk is not so easily managed. If there is too much fat present, there may be a tendency to vomit rancid- smelling material, or to suffer from diarrhoea. The test with the creamometer will show the actual amount of FEEDING THE BABY. 123 cream. By far the more frequent and troublesome fault, however, is an excess of the albuminoids. This usually shows itself by vomiting of curdy material, or, still oftener, by the constant presence of a large amount of white, curdy lumps in the stools. Except by the ex- amination of the milk, this condition can scarcely be dis- tinguished from the disordered stools dependent upon an excessive quantity of milk taken. Colic, too, is ver)' common, and all the symptoms of indigestion may finally grow so prominent that weaning may seem necessary. Again, by the use of the creamometer we may determine the amount of cream present, and then, by comparing this with the specific gravity we can judge whether the albuminoids are in excess. The following very useful table has been devised (Holt), by consulting which the mother may be aided in making, with a little practice, an approximate analysis of her breast-milk. The procedure is quite simple. If the specific gravity and the cream-percentage of any sample of breast-milk are obtained, and the two com- pared as found in the second and third columns of the table, the amount of albuminoids corresponding to these will be shown in the fourth column. At the same time it is certainly better, as a rule, to leave this analysis to some one experienced in such matters. Approximate Analysis of Breast-milk. Specific Gravity. ' 70° Fahr. I Cream, Twenty-four Hours. Average. Normal variations. Abnormal Albuminoids. 1031. 7 per cent. 1.5 per cent. 1028-1029. 8-12 per cent. 'Normal (rich milk). 1032-1033. 5-6 per cent. " (fair milk). Low (below 1028). j High (above 10 percent.).' " or slightly below " " " Normal (5-10 per cent ). Low (poor milk). " " " Low (below 5 per cent.), High (above 1033). High. " " " Normal. " " " Low. Very low (ver^' poor milk). I " high(very rich milk). High (rich milk). Normal, or nearly so. 124 THE CARE OF THE BABY. Supposing, now, that we have found some defect in the quantity or quality of the breast-milk. The ques- tion arising is whether something cannot be done to cor- rect this, instead of at once subjecting the baby to the trials of artificial feeding. Modification of the amount or kind of food taken, and of the method of living and the frequency of nursing, exerts a powerful influence upon the composition of the milk. Consequently much may often be accomplished by following certain rules, which are formulated in the following table (Rotch). Rules for Modifying Breast-milk. ^ . ^, ^ ^ , ^.^ ( Increase the liquids in the To increase the total quantity . { ,. „ , ^, ^ ^ 1 ^.^ ( Decrease the liquids in the To decrease the total quantity . j , . ^ r Shorten nursing-inter\^als ; de- To increase the total solids . . \ crease exercise ; decrease ••[ the Hquids in the diet. Lengthen nursing-intervals ; in- To decrease the total solids . . \ crease exercise ; increase the liquids in the diet. To increase the fat Increase the meat in the diet. To decrease the fat Decrease the meat in the diet. To increase the albuminoids . Decrease the exercise. Increase the exercise to the To decrease the albuminoids limit of fatio^ue Should the mother still find it necessary to abandon nursing, she does not necessarily have to wean the baby, since she may employ a wet-nurse. There is no question that the milk of a good wet-nurse is very greatly to be preferred to bottle-feeding. At the same time there are many and weighty objections to the employment of a wet-nurse. Not only is it ver>' difiicult to obtain one who even seems likely to be suitable, but the position of FEEDING THE BABY. 12$ the nurse at once makes her the tyrant of the household. She frequently proves to be altogether unreliable, will not take the care of herself which is necessary to the preser- vation of the quality of her milk, and at any moment may become dissatisfied and abandon her position, per- haps leaving the last state of the baby considerably worse than the first. Nevertheless, in the case of a deli- cate child or the failure of artificial food to agree, the employment of a wet-nurse often is the baby's only chance for life. The selection of a wet-nurse we can best discuss when considering the subject of The Baby's Nurses, in Chapter IX. This brings us to the consideration of the very compli- cated subject of artificial feedings often one of the most perplexing problems which can present itself to the com- bined study of mother and physician. In the effort to solve it too careful attention cannot be paid to the smallest and apparently most trifling details, for, although many a baby seems to have a totally insensitive stom- ach and will thrive on nearly anything, many another cannot keep in health unless the food suits it exactly. In endeavoring to feed a baby properly we must bear in mind three important factors, already referred to to some extent in discussing the means of modifying the breast- milk: (i) The quantity of the food; (2) The quality of the food; (3) The individual peculiarities of the child. (i) The Quantity of the Food. — One of the most fre- quent mistakes made in feeding a baby is that of giving it a much greater quantity of food than it can possibly assimilate, with the result that it either vomits it or passes it through the bowels in an indigested state. A new-born baby's stomach holds without distention only 126 THE CARE OF THE BABY. about one ounce (two tablespoonfuls) or less. The ac- companying illustration (Fig. 30) represents the actual size of the stomach at birth. It shows perhaps better than in any other way how small the infant stomach really is. How foolish, then, to feed a new-born child Fig. 30. — Stomach of infant at birth (natural size). from a full-sized nursing bottle, and to allow it to gorge itself with all it will take! Careful study of the size of the stomach at different ages in infancy, and of the quantity of milk drawn from the breast by a nursing baby, has led to pretty uniform conclusions among physi- cians regarding the amount of nourishment which may be suitably given to a child at dififerent periods of its life. The accompanying table, taken with slight modifi- cations from an excellent article by Dr. Rotch, shows the amount proper at each feeding, the number of feedings, and the total quantity required in twenty-four hours. As has been stated in a previous chapter, this and the following tables apply as well to children who are fed at the breast, and may be taken as a guide for the frequency of and hours for nursing them. FEEDING THE BABY. General Rules for Feeding. 127 Age. Intervals of feedings. Number of feedings in 24 hours. Average amount at each feeding. Average amount in 24 hours. ist week . . 2 hrs. 10 lOZ. lOOZ. 1-6 weeks . 2>^ hrs. 8 I>^-2 OZ. 12-16 OZ. 6-12 weeks, and possi- bly to 5th or 6th month V3hrs. 6 or 7 3-4 OZ. 18-24 OZ- 6 months . . 3 hrs. 6 60Z. 36 OZ. 10 months . 3>^-4 hrs. 5 80Z. 40 OZ. Thi.s table is intended to apply only to children of the normal lengths and weights corresponding to their ages, and is, like all rules, subject to exceptions. It is very important that the .size of a child be constantly borne in mind, since it is often more of a criterion than the age. It is manifestly absurd to expect a baby twice as large as another of the same age to be contented with the amount of food which .sati.sfies the smaller one. When, there- fore, a baby has largely fallen behind in gro\vth, we must often ignore its age to a great extent, and give to it an amount of nourishment not much in excess of that suit- able to the age to which its actual size and weight cor- respond. This age may be determined by consulting the table on page 52. On the other hand, some children take and digest much more food than others of equal age and equal size. In such cases it is safe to exceed the amount given in the table if we are quite sure the food is being digested. The following table gives in convenient form the hours for feeding a child under one year of age, whether on the bottle or at the breast. It is made to correspond, as far as possible, with the table just given, and is so arranged 128 THE CARE OF THE BABY. that feeding does not interfere with the hours for the morning and afternoon naps. Hours for Feeding. ist week. I week to 6 weeks. 6 weeks to 4 months. 4 to 8 months. 8 to 12 months. 7 A.M. 7 A.M. 7 A.M. 7 A.M. 7 A.M. 9 " II " 9-30 " 12 M. 10 " I P.M. 10 " I P.M. 10.30 " 2 P.M. I P.M. 3 " 5 " 7 " 9 " 12 " 2.30 P.M. 5 7.30 " 10 3 A.M. 4 " 7 *' 10 " 3 A.M. 4 " 7 " 10 " 6 " 10 " 4 A.M. This table, like the preceding, is of course intended only as a guide, not as a hard-and-fast rule. It is open to modification depending upon various factors. Some children with healthy appetites do not require or desire nursing so frequently. In some cases it is frequently necessary and advisable to waken the child at the ap- pointed hours for feeding. In other cases we may ad- vantageously make a different schedule if wakening often has to be done. Again, if a child wakens hungr\^ every night at a time different from that given in the table, it is better to feed it then than to allow it to rouse itself thoroughly by crying. In other cases the frequency of nursing cannot be diminished so early as the table gives for the different ages. (2) The Quality of the Food. — Regarding the char- acter of food to be given to a child — that is, its quality — it is evident that the more closely the food resembles mother's milk the more likely it is to agree with the child. It is a common custom to alter the composition of the artificially-prepared milk according to the increas- ing age of the child. To make this a routine procedure, FEEDING THE BABY. 129 in the case of healthy and flourishing babies, is unneces- sary and harmful. The mother's milk, if it keeps of good quality, does not vary very materially during the many months of suckling, and there is consequently no reason for any change in the composition of the artificial food if we can once get it to simulate human milk and to be well digested. Of course, if a child ceases to grow properly, an increase in the strength of the food may be needed. Ass's and mare's milk is considerably closer in composition to woman's milk than is that of other domestic animals. That of the goat is somewhat more like it than is that of the cow. It is rare, however, that either of the first two milks can be obtained, and they are apt to be expensive; and since all of them need in any case to be prepared in various ways before using, cow's milk becomes the only baby's food usually practi- cable. That it is, however, much unlike woman's milk in some particulars can be seen by consulting the fol- lowing table (Rotch), which gives approximate analyses of the two fluids. Woman's Milk. Cow's Milk. Reaction . Alkaline Reaction . Acid. Bacteria . None Bacteria . Present. Water . 87-88% Water . 86-87% Total soHds .... . 12-13% Total solids . . • 13-14% Fat .4% Fat .4% Albuminoids .... . 1% Albuminoids .... .4% Milk-sugar .7% Milk-sugar .4.5% Ash . 0.2% Ash . 0.7% Besides these characteristics, woman's milk has a specific gravity of about 1031, while cow's milk has that of about 1029. Cow's milk is, as the table shows, slightly acid in reaction in the condition in which it is served by the milkman. As drawn from the cow it ought to be 9 130 THE CARE OF THE BABY. alkaline, but very quickly becomes acid, owing to faults in the milking. When we consult the table we are struck by the fact that woman's milk has the same per- centage of fat as cow's milk, that it is almost twice as rich in sugar, and that it has only one-quarter as much of the ' ' albuminoids. ' ' By this last term are desig- nated those portions of the milk upon which the produc- tion of new tissue in the baby largely depends. Among these is the casein of the milk — namely, the part which forms the curd. This casein is particularly abundant in cow's milk, and it is this ingredient especially which renders the pure milk of the cow unfit for the baby. Now, if we dilute cow's milk with water sufficiently to render the percentage of albuminoids identical with that of human milk, we shall meantime lower the amount of sugar and of fat, and the milk will be very imperfect in these particulars. The only method by which to overcome the difficulty is to make up the de- ficiency after dilution by adding more cream and sugar. Besides this, we must add to the mixture a small quantity of an alkali, such as bicarbonate of soda, or lime-water, in order to take away the slight acidity. Another characteristic of cow's milk is the fact that the curd which forms in it is much tougher and firmer than that which is seen in woman's milk. This may be due to some chemical peculiarity of the casein, but it seems more likely to be dependent chiefly upon the greater amount of it present, since a sufficient dilution renders the curd identical in appearance with that of human milk. Undoubtedly there do exist distinct differ- ences of some sort between the albuminoids of woman's milk and of cow's milk. It has been claimed, too, that boiling causes the form- ation of a tougher curd, and it is certain that it does alter FEEDING THE BABY. I3I the milk in some way which may render it rather more difficult to digest. Although there are numbers of infant's foods on the market, as a rule by far the safest and most accurate sub- stitute for mother's milk can be prepared at home. To make the mixture properly it is of primary importance that the several ingredients themselves be of proper quality. The cow's milk should be unskimmed and should be pro- cured from a reliable dealer whose cows are healthy and carefully kept, and are not fed upon swill or other refuse material. It is of no advantage to have the milk from a single cow; it is, in fact, of distinct disadvantage, for the great difference which exists between the milk of differ- ent cows makes it impossible to prepare a proper imita- tion of mother's milk according to any fixed rules unless we should have the individual cow's milk analyzed in order to determine in just what way the mixture should be made. Besides this, the milk of any cow is subject to variations from time to time, depending upon the nature of the food given it, the health of the animal, and other factors. It is therefore preferable to use mixed herd milk — not solely Aldemey, which is too rich — since this gives a much more uniform basis for the food. Every possible precaution should be taken to ensure absolute cleanliness of the udder, the milk pail, and the hands during milking, and the milk should then be cooled rapidly and at once scaled in jars. We can judge to a large extent of the quality of the milk by its appear- ance. It should be of a yellowish- white color, without any bluish tinge. To determine still more accurately its quality an instrument called a lactometer is employed, although the simplest apparatus is the urinometer, used by physicians for testing urine. This latter apparatus, which may be procured through any druggist, consists 32 THE CARE OF THE BABY. I of a small glass cylindrical tube and a specific-gravity glass, as shown in the illustration (Fig. 31). The tube should be partially filled with milk of the ^P=^ usual room-temperature (70° F.) and the glass be floated in it. The specific gravity of the milk — that is, its density as compared with water — may then be read off on the scale on the stem of the apparatus. The average density of cow's milk is 1029, water being called li ; 1000. The apparatus is only of limited value, for milk which is very poor may give F1G.31.— Urin- j-es^its similar to that which is fig ^2- ometer. • i * n i ^ very rich. All that we can say Creamometer. here is that if the specific gravity is less than 1028 or more than 1035, the milk is suspicious. Of course, even a normal specific gravity, taken by itself, is not proof that the milk is good. So, too, there is no accurate instrument for household use which shows the richness of the milk in cream. An inexpensive apparatus called a crcaviometer or cream gauge is sold in the instrument-shops and is often recom- mended. It consists of a cylindrical tube, all or the upper part of which is graduated. The milk is allowed to stand in this, carefully corked, for twenty-four hours, at about 70° Fahr., until the cream rises, and the thick- ness of the layer of the latter is then read off on the scale (Fig. 32). Theoretically, the cream in the apparatus should measure ^ or y^ of the total height of the column. The trouble with the creamometer, however, is that some milk, even though rich, parts with the cream ver\- slowly and imperfectly, while some poor milk allows nearlv all PEEDIKG THE BABY. 1^3 of it to go to the surface. The results with the appa- ratus are consequently very misleading, for the poor milk may seem to have more cream than the rich. I know, in fact, of no way for the mother to determine the amount of cream except roughly by the color and richness in ap- pearance of the milk. Where the milk seems even sus- picious the milkman should be changed. In cities it is easy to have an analysis of the milk made by a chemist. The use of the creamometer for testing human milk is rather more satisfactory. It has already been described on page 122. There is one test which we can always apply — namely, that for acidity. A strip of blue litmus-paper dipped part way into the milk will turn faintly red if it is acid, as it nearly always is when delivered by the milkman. The milk should be put in the tube of the urinometer, and the paper examined through the glass while still in the milk. If, after the mixture with soda-solution or lime- water and the sterilizing, presently to be described, we again find that blue litmus-paper turns red, we know that the milk is becoming sour and is unfit for use. Milk is often artificially colored to give it a rich creamy appearance. The substance oftenest used for this purpose is annatto. It may be detected by mixing a pinch of baking-soda with a couple of tablespoonfuls of the milk, inserting one-half of a strip of filter-paper in the fluid, and allowing it to remain over night. Annatto will give a distinct orange tint to the immersed paper. The choice of the cream which is to be added in mak- ing the baby's food is of importance, since it varies greatly in richness. To be accurate a chemical analysis is needed. For practical purposes it is chiefly important to consider how the cream is obtained — whether by skim- ming or by a centrifugal machine such as is used in the 134 '^HE CARE 02^ THE BABY.- large dairies. The thinner centrifugal cream, about as thin as a machine makes it, is to be preferred. It con- tains 20 per cent, of fat, while the average cream obtained by skimming possesses only about 16 per cent, of fat. It is better to obtain the centrifugal cream when possible, as its richness is more uniform, and, besides this, it is not so apt to have undergone changes as a result of the long standing to which ordinary cream is subjected. When skimmed cream must be used, instructions should be given to the. dairyman that the milk stand always the same number of hours, and at the same temperature, before skimming, and that it always be skimmed by the same person. The amount of cream used in preparing the bottle will depend entirely upon its percentage of fat, since the richer it is the less, of course, will be required. Very often the quantity can be determined solely by experience in feeding the child. As in the case of milk, it is better that the cream come from a herd rather than from one cow. Although ordinary sugar (cane-sugar) may be used to sweeten the baby's food, it is better to employ milk-sugar, since this is the variety naturally present in milk. Cane- sugar answers just as well for sweetening, but it is prob- able that the milk-sugar serves some other purpose than this merely. Should it be desired for any reason to use cane-sugar, it is important to remember that it has several times the sweetening power of milk-sugar, and must therefore be used in a considerably smaller amount. Some physicians recommend that a pinch of salt be added to the mixture in order to make up for the amount naturally in the milk before the dilution. The addition certainly does no harm, although it is not an essential. We are now ready to examine the methods of mixing our ingredients in order to produce the correct artificial FEEDING THE BABY. 1 35 human milk. Various mixtures have been described, but many of them are only poor imitations. A very good one is that proposed by Dr. A. V. IMeigs (Appendix, i). Artificial human milk prepared according to this formula approaches very closely to the character of natural milk. It is, however, much more alkaline than necessary, and the taste of the lime-water is evident. Moreover, the sugar-water used in it must be made fresh every day or two, as it will spoil. The use of lime-water (Appendix, 22) in milk mixtures decidedly complicates the process of sterilizing at a high temperature, as we shall see presently. As the sole value of the lime is to render the preparation alkaline, bicar- bonate of soda (baking-soda) should be used where steril- ization is to be employed, since it answers this purpose just as well and is just as healthful for the baby. The following mixture is easy to prepare: Formula for Milk Mixture. Milk I oz. ; Cream, centrifugal (20 per cent, fat) . . lYz oz.; or Cream, skimmed {16 per cent, fat) ... 2 oz. ; Lime-water or soda-solution K oz. ; Milk-sugar i measure; Water, enough to make 8 oz. The amount of cream varies with its richness, as indicated in the formula. The soda-solution is of the strength of i grain of bicarbonate of soda in a half ounce of water. It will keep indefinitely. A half dozen or more packages, each containing i drachm of soda, may be obtained from a druggist at small cost. One of these dissolved in a quart of water forms a solution of the proper strength, one tablespoonful of it equalling in alkalinity one table- 136 THE CARE OP THE BABY. Spoonful of lime-water. It should be kept in a bottle, well corked. To save expense the milk-sugar should be bought sev- eral pounds at a time, and from a wholesale druggist. The required amount may be measured out as needed. A Philadelphia drug firm (A. Blair & Co.) has made at my suggestion a small tin measure (Fig. 33) somewhat different in shape from the one devised by Dr. Rotch, and holding 3f drachms of milk-sugar — the quantity required for eight ounces of the milk mixture. The measure should be filled by scooping up the sugar out of its box and pressing it gently against the box's side with a force which is as nearly as possible the same on all occasions. Of course, in this and in other formulae given we may =^^ ^^^' 33- — Sugar-measure. dissolve the measure of sugar in the water, thus making a sugar-water. This is sometimes convenient when we wish to make somewhat more or less than the eight ounces of 'milk mixture. It is often a difficult matter to procure a satisfactory cream. We may then, in place of the formula recom- mended, use one in which "/<:?/- ?^/ ///&," as it is called, is employed. This is obtained as follows: Have made a syphon — a U-shaped tube — from a piece of glass tubing, letting the short arm be about eight inches long and the long arm about twice this. Procure in the morn- ing one quart of milk, place it in a cylindrical glass jar, such as a preserve-jar, screw its lid on tightly, place on ice, and allow it to stand for six hours. At the end of this time remove the jar carefully without shaking, fill PEED INC THE BABY. I37 the syphou with boiled water, insert the short arm gently down to the bottom of the jar, and syphon off all but six ounces of the milk. This remaining top-milk is really a thin cream, and we may use it in the following formula, which makes a mixture a trifle weaker than that in the formula just given. Top-milk Mixture. Top-milk 2 oz.; Lime-water or soda-solution '2 oz. ; Milk-sugar i measure; Water, enough to make S oz. The jar, lid, syphon, and bottles should be washed or, preferably, boiled, daily before using. A line may be filed on the jar, showing the level at which six ounces still remain in it. This is a convenience in syphoning. We must remember that by no means every baby can start upon a milk mixture as strong as the ones just given, although these represent the strength of human milk. If they disagree, they must be abandoned at once, and some other mixture of different proportions tried. Of recent years physicians have been accustoming them- selves more and more to the calculation of various for- mulae to suit individual cases, basing these upon accurate estimated percentages of fat, albuminoids, and sugar, rather than upon a mere guessing at the number of tea- spoons or tablespoons or ounces of milk and cream which may seem to be needed. But to do this is certainly beyond the power of any mother untrained in such matters. It is to be strongly urged, therefore, that in every case where a certain milk mixture disagrees with a child the proper calculation of another formula be re- ferred at once to the family physician. Having determined the proper ingredients and tlieit 138 THE CARE OF THE BABV. amounts, the next thing to do is to put them together in the proper manner. The subject of sterilization is an im- portant one in this connection. Mother's milk as drawn from the breast has been found to be entirely or nearly free from those microscopic germs of decomposition which are the cause of souring. Cow's milk as it comes from the udder should be equally free, but through lack of cleanli- ness in milking, or even by exposure to the air during the delay which must necessarily occur before it reaches the baby, it becomes infected with quite enough of the germs to produce the poisonous changes which have killed so many infants. The fact that milk appears per- fectly sweet is no criterion, for if the germs are already in it the harmful changes may take place even after the baby has had its meal. As it is generally impossible to procure cow's milk sufficiently free from the germs, the only method is to sterilize the milk — that is, to kill the germs. There are various means which may be employed for accomplishing this end, all of them depending upon the fact that a temperature equalling that of boiling water, or even less, if applied sufficiently long, will prevent sour- ing, and will also kill any germs of such diseases as t>'- phoid fever, diphtheria, and the like which may chance to be present. The milk mixture may be boiled in a vessel immediately before using, or it may be placed in bottles and those surrounded by boiling water, or steamed in a farina kettle for three-quarters of an hour. The objec- tions to actually boiling the milk are that it gives it an unpleasant taste, and probably affects its chemical char- acter in a such a way that it becomes less digestible than before. It is also very troublesome, because it must be done at each feeding. The other methods are crude and not very satisfactory'. It is far better, therefore, to pro- cure at once a special apparatus for sterilizing, since its FEEDING THE BABY. 1 39 initial cost is small and it will save a world of trouble in the end. It should be almost as much of a necessity in the household as are the baby's clothes. The great principle of all sterilizing is, first, the killing of germs present in the milk, and, second, the prevent- ing of other germs from entering into it later. If both these ends are fully met, the milk will keep sweet for months or even years. Such perfect preparation is, how- ever, seldom attained and is not necessary. There are two classes of apparatus used to accomplish the destruction of the germs: one, known as a sterilizer, which sterilizes the milk at a boiling temperature (212° F.); the other, called a Pasteurizer, which is really a modified sterilizer, killing the germs at a much lower temperature. Of recent years the latter has become much the more popular. Of the sterilizer, various forms have been devised, but one of the best is that known as Arnold's. This apparatus is provided with eight bottles, each holding a little over seven ounces, and marked on the glass. with a graduated scale of ounces, by means of which the amount of nourishment poured into them can readily be measured (Fig. 34). The method, then, in detail for preparing the baby^s food, including the use of the sterilizer, is as follows: As soon as the milk and cream come in the morning, the mixture for the entire day should be prepared according to one of the formulae on pages 135 and 137. As large a quantity should be made as the table on page 127 or the experience with the individual child shows will be re- quired for the twenty-four hours. The bottles, previously thoroughly cleaned, should each be filled with as much of the mixture as is required for each feeding. They must next have their mouths carefully dried and stopped with plugs of raw cotton (not absorbent). They are then 140 THE CARE OF THE BABV. placed in the rack in the sterilizing chamber and the lid and hood are applied. The pan of the sterilizer is now filled two-thirds full with water, and the whole is placed Fig. 34. — Arnold sterilizer. on the hot stove for an hour. About twenty^ minutes of this time will be occupied in heating the milk up to the high temperature required, and the remainder in keeping FEEDING THE BABY. I4I it at that point and thus sterilizing it. Raw cotton is used as a plug because experience shows that the minute germs cannot pass through it. It is best, however, that it shall not come into contact with the milk. When it is desired to carry the bottles about to any extent after sterilizing, it is better to use a rubber cork instead of the cotton. In this case the bottles, with the corks very loosely in place, are put in the sterilizer for about twenty minutes until the liquid and the air con- tained is thoroughly heated. The corks are then pushed firmly into place and the sterilizing is continued. The bottles thus corked may lie afterward in any position. Sterilized milk prepared in this way should keep per- fectly sweet without being placed on ice. As an addi- tional safeguard, however, it is better to keep the bottles in a cool place, although this is not needed if the process has been properly carried out. We must never forget that the cotton plug must not be removed, even for a moment, from the time it is first put in place until the time for feeding the baby comes. Food prepared as described above will keep perfectly well for twenty-four hours at least, but in the hottest weather it is an additional safeguard to re-heat in the evening the bottles which are to be used during the night and early morning. When milk is to be prepared for use while travel- ling, a more thorough sterilization is necessary in order to avoid the possibility of any germs being left alive. To accomplish this the bottles of milk should be subjected to sterilization upon one day, again upon the second, and then again upon the third. The disadvantage of using lime-water in preparing the milk mixture becomes evident in sterilizing. Not only does the lime combine in some way with the sugar and 142 THE CARE OF THE BABY. produce a brownish color, but it is largely precipitated by boiling, and the lime-water is thus destroyed. We can, of course, obviate this by adding the lime-water to each bottle just before feeding the baby, but it becomes rather a complicated matter to calculate just what quantity of it is required with the gradually increasing amounts of nourishment which the baby demands. The use of soda- solution instead of lime-water allows us to complete the mixture at the outset. As already stated, it seems certain that the boiling of milk, or even the sterilizing of it in the manner de- scribed, lessens its digestibil- ity to a cousiderable extent. On this account Pasteuriza- tion is much to be preferred, and is, indeed, the method now approved by most physi- cians. The process, as we have seen, is only a modified sterilizing. It was devised Fia^T^TlFV^an's Pasteurizer. by the celebrated French chemist Pasteur, and first employed in the manufacture of wine. As applied to milk it consists in heating the bottles containing the milk mixture to a temperature of 155° or 167° F. instead of to 212°, as in ordinary sterilizing, and in then remov- ing them to the refrigerator just as soon as they will stand the cold. It has been found that this process destroys the germs sufficiently for practical purposes, and that it does not alter the digestibility of the milk or affect its taste. Of the devices for Pasteurizing, that most to be rec- ommended is the Freeman Pasteurizer (Fig. 35). This consists of a metal pail into which fits a rack holding FEEDING THE BABY. 1 43 the bottles, much as in the sterilizer. The pail is partly filled with water, heated to boiling on the stove, and then removed. The rack with bottles, prepared as for steriliz- ing, is then placed in it, the lid applied, and the whole allowed to stand on a table for forty-five minutes. The exact quantity of water required has been accurately calculated by the inventor. The scientific principle involved is that while this amount of water cools, the milk in the bottles grows warm, until both soon reach the desired temperature. After the forty-five minutes have elapsed water from a spigot is turned into the pail in order to cool the bottles rapidly, and these are then kept upon ice. This keeping on ice is important, as Pasteurized milk requires rather more care to preserve it than sterilized milk does. The use of the apparatus is very simple, its cost is small, and one should certainly be procured whenever a child has to be fed artificially. It is perfectly possible to Pasteurize in other ways, but the process is troublesome, for to obtain satisfactory re- sults the temperature must be exact. We may, for in- stance, use the Arnold sterilizer, leaving the hood off" and setting the lid ajar, and continuing the heating for forty- five minutes. But to be sure that we are obtaining the correct temperature it is necessary to have a special ther- mometer in one of the bottles and to watch this con- stantly. So, too, it has been proposed to place the bottles of milk in a dishpan or large saucepan of water, preferably with an inverted tin pieplate with holes punched in it laid inside as a false bottom, and to heat fliis until the thermometer in the water reaches 170° F. The pan should then be removed from the stove, covered with an old blanket, and allowed to stand forty-five minutes. But here, too, the troublesome use of a ther- mometer is required, and after the pan is removed from 144 I'HE CARE OF THE BABY. the stove we do not know at all what temperature the milk actually maintains. The results cannot be accu- rate. Indeed, Pasteurization, though so simple and secure with a Pasteurizer, is not a safe and easy process with any makeshift, and all such should be avoided. It is much better to sterilize outright than to do imperfect Pasteur- ization. A few words must be said about the articles required for feeding the baby with the artificially prepared food, and the method of doing this. It is usually unnecessary to have any special nursing-bottle, for the ordinary bottle used in the Pasteurizer answers for nursing as well. When the time for giving nourishment conies this bottle containing the prepared milk should have the cotton plug removed and be fitted with a rubber nipple, and then be set in a cup of water, which should be heated until the contents of the bottle are at a temperature not exceeding 95° to 100°. Since the baby is apt to wake hungry and impatient in the night, it is well to be able to heat its milk quickly. A small, narrow, cylindrical tin vessel, tall enough to hold the bottle and to cover it with water to the neck onh', about three inches in diameter, and with a perforated false bottom, answers the purpose admirably. Such a vessel, placed on an alcohol pocket stove, or similar heat- ing apparatus, will take but a very short time to bring the milk to the proper temperature, whereas a receptacle holding a large quantity of water will take much longer. Any tinsmith can make a vessel of this sort, or it may be purchased from the agencies of the Walker-Gordon IMilk Laboratory in many of our cities. ]\Iany mothers en- deavor to heat the baby's food by putting the bottle con- taining it directly into hot water. This is a bad plan, as FEEDING THE BABY. 1 45 it is enough to crack the glass. Heating gradually in the way described takes very little longer. In giving the bottle the child should be laid upon the lap, or should be held in the arms much as in the posi- tion for nursing from the left breast. The bottle should be held in the hand and its position be so changed from time to time that its neck is always full of milk. The baby requires ten or more minutes to finish its meal. If the rubber collapses, or if the milk does not flow freely, the edge of the nipple should occasionally be lifted from the neck of the bottle for a moment and a little air allowed to enter. It is well in any case to withdraw the nipple from the child's mouth now and then to permit of a moment's rest or to allow air to enter the bottle. When the child has emptied its bottle it must be deprived of it immediately. If the bottle has not been emptied completely, the remaining contents must be thrown out at once. To let the baby continue to suck after the bottle is empty is a very bad practice. If the baby is allowed to suck at any nipple for the sake of quieting it at other times than when fed, it should be one of the holeless ones, attached to an ivory disk — a " Com- forter," as it is called; but the advisability of permitting this is very questionable. Bottles employed for feeding should be made very smooth inside, without angles and depressions which col- lect milk and render cleaning difhcult. Immediately after nursing the bottles should be rinsed well and then submerged in a strong solution of washing-soda and water. They should stand in this until evening, when they may be rinsed thoroughlv in pure water, and have the interior scrubbed with a bristle brush. It is a good plan to boil them also. They may then be placed, in- verted, in the sterilizer or elsewhere to drain and dry. 10 146 THE CARE OF THE BABY. The rubber nipples, of which there should be at least two, are preferably of conical shape (Fig. 36). Those of black rubber are rather better than those / 1 of white, on account of their greater soft- I 1 ness. Most white rubber, too, is said to I 1 contain lead. Those nipples should be I 11 chosen which have the least odor and j 1| taste; as babies sometimes object to this. J ll The openings in the end should be large ^>^^..-*^ enough to allow the milk to pass freely Fig. 36.-Rubber ^|^g^ sucked, but should not permit it to nipp e. ^^^ ^^^ i's,s\.. When the bottle is inverted the milk should drop easily from it. If the holes are not of sufficient size, they may be enlarged with a hot pin or needle. As the nipple gets older it collapses too easily and the holes become too large, and a new nipple must be used. There are nipples made with rubber ribs upon the inside, the object being to add to the stiflfness and prevent collapsing. Others come without holes, in order that the mother may make them herself of the size she desires. At once after nursing the nipples should be scrubbed thoroughly without, and then, by inverting, within, with a soft bristle brush, and after this be kept submerged in water until needed. Just before using they should be dipped for a moment in hot water. The nip- ple connected with the bottle by a long rubber or glass tube should not be used under any circuifistances. It is utterly impossible to keep such a tube clean, and the device cannot be sufficiently condemned. Silver nip- ples have also been employed to do away with the trouble caused by collapsing; but they are very hard upon the baby's mouth. When there is unusual trouble experienced with the collapsing of the nipples, some special method of allow- FEEDING THE BABY. 147 ing the air ingress to the bottle is necessary. There is a ventilated nipple on the market which answers the pur- pose very well. In it a very small rubber tube connected with the outside passes from the side of the nipple into the bottle. This nipple is more difficult to keep clean than the ordinary form, and, unless unusual precautions are taken, some form of ventilated bottle is preferable. One of these bottles has a small hole, the size of a pin, perforated through its neck close to the nipple. A nar- row elastic band, or the edge of the nipple itself, covers this, and may be lifted off to admit air when necessar>'. Another form of ventilated bottle has an air- valve in the bottom. As a rule, however, no special method of allow- ing air to enter is needed if the instructions already given are followed. In case special nursing-bottles of any kind are desired, there should be at least two of them, in order that one may have ample time to soak. (3) The Individual Peculiarities of the Child. — We have to consider finally the third factor in infant feeding — namely, the element of idiosyncrasy, which renders the nourishment of babies not the simple matter it might otherwise be. With all our care the cow's-milk prepara- tion cannot be made exactly identical with woman's milk. We may arrange to have, for instance, exactly the same amount of albuminoids in each, but these albuminoids in themselves differ somewhat in chemical character. Conse- quently, the milk prepared in the best manner possible may not agree. We must then try to find by pure experi- ment what food will suit the baby best. It is here that the individuality of the child conies in, for, of course, what answers for one may not do at all for another. In such cases we may try certain of the proprietary infant' s- foods on the market, or we may make special mixtures, increasing or oftener decreasing the quantity of some one 148 7UIE CARE OF THE BALY. or more of the ingredients of the cow's-milk mixture; or we may predigest the food or modify it in some other way until we discover something which suits the baby's digestion. I cannot too strongly urge that no mother make these trials on her own responsibility. The matter is too serious for any unskilful experiments, and often is exceedingly difficult even for the most experienced physician. Regarding the numerous patented foods it need only be said that some of them are harmful and none of them are necessary or desirable for a child with a healthy diges- tion. All are made from cow's milk, just as the mixture recommended is. Although many of them claim to be "a perfect substitute for mother's milk," none of them are this, and many contain starch in considerable quantities. Others, although utilizing starch, have transformed it into dextrin or grape-sugar in the process of manu- facture. This procedure certainly presents no advantage over, and is in some respects inferior to, the direct addi- tion of milk-sugar to the milk in the manner recom- mended. The very best of the patent foods are only tolerably successful efforts to simulate mother's milk, and this is no more than we can do ourselves by fol- lowing the formulae given. A mother who wishes to feel sure that her baby is getting nourishment upon the composition of which she can fairly well depend will prepare her own mixture. When, however, there exists some individual pecu- liarity which renders it advisable that the child be tried with one of the foods upon the market, the physician in charge, and not the mother or the nurse, should have the selection. He will probably choose one which is free from starch. The mother can very readily and simply, in the following way, satisfy a laudable curiosit}- regard- FEEDING THE BABY. 1 49 ing the presence of starch in any of the foods on the market: Dissolve a portion in hot water, add a few drops of tincture of iodine to a tablespoon ful of water, mix a little of this with the dissolved food, and if starch is present a blue color will result. There is one form of prepared food on the market which is scarcely ever admissible — namely, co)idejised 7)iilk. When it is diluted sufficiently to make the albu- minoids digestible it contains far too little fat; and in many cases it is diluted so much that the proportion of albuminoids also is much less than it should be. I have seen so many babies starving on condensed milk that I now rarely give it. It is true that some babies grow fat and are seemingly healthy, but the health is often only ap- parent, and rickets is very liable to result. If food is necessary during the first few days of life, before the se- cretion of the breast is established, condensed milk may be employed; but even then it offers no special advantage over the feeding with diluted cow's milk (see page 135). The only other time when condensed milk may be advan- tageously used is upon railway journeys and the like, but even then it is better to use milk which has been spe- cially sterilized, as recommended upon page 141. Con- densed milk could, of course, be strengthened by the addition of cream before using, and thus made a service- able food, but this method presents no advantage over that of preparing the food entirely at home in the manner already described. In place of the commercial foods there are several home-mixed milk preparations which experience has shown to be of value in some cases of delicate digestion. One of these is the gelatin food which was recommended by Dr. J. F. Meigs (Appendix, 12). The gelatin and the arrowroot in this mixture seem to prevent the formation 150 THE CARE OF THE BABY. of SO heavy a curd. Another useful preparation in some cases is one into which whey and cream enter (Appendix, 14). Still another is the mixture of i part of cream and 5 or 6 parts of water or barley-water. These cream mix- tures are often of great service where a child cannot take milk at all. The formula known as " Biedert's cream mixture," proposed by the celebrated German physician of that name, and intended for babies under three months of age, is one of this sort. There are still other prepara- tions, such as albumen-water (Appendix, 3), veal tea (Appendix, 16), etc., which contain neither milk nor cream. Their use, however, is limited entirely to children who are actually ill rather than to those with delicate di- gestion merely or with some idiosyncrasy regarding food. In some instances peptonizing the food is of great service. The method of doing this will be described later (Appendix, 23-35). ^^ must bear in mind that the administration of a predigested food during a long period takes away, to some extent, the power of the stomach to do its own digestion. The admixture of thickening substances containing starch for the purpose of "breaking the curd " is not to be recommended as a routine practice. In some in- stances, however, it is certainly of benefit. (See Oat- meal-water, Arrowroot-water, and Flour-ball; Appendix, 5. 6, 17). In this connection we may consider more at length tlie very important subject already referred to — that of the administration of food containing starch. An infant in the first four months of life possesses only slight power of digesting starch. The pancreatic juice and the saliva, the function of which it is to digest starch, are little devel- oped at this period, and even after the age of four months the power increases but slowly. It is a very frequent cus- FEEDING THE BABY. I5I torn with mothers to give children a crust of bread to bite upon. Indeed, a baby is lucky if it gets off without any further maternal experimentation than this, for it is during the first eighteen months of life that so many innocents are slaughtered by "just a taste " of table food, given on the ground that because they wanted it, it was right for them to have it. It is best not to allow even a crust before the child is eight or nine months old, by which time a thriving baby may take starch in small quantities without disadvantage in the winter, although it does not need it. The better course, however, is to allow no starch, nor, in fact, anything but milk, until the age of one year. In hot weather no change whatever should be made in the diet until autumn, even though the child be more than a year old. Of course, these remarks apply only to thriving chil- dren. It sometimes happens in the last months of the first year, or even earlier, that the diet must be supple- mented in various ways, as by certain meat foods, such as the yellow of ^%%^ beef-juice and various peptonized- beef preparations, and sometimes even by starch in con- siderable quantity; but a healthy baby does not need these things, and should not receive them except by medical advice. So, too, it is often necessary during the latter part of the first year, if the baby is not growing at the proper rate, to increase the amount of milk in the mixture to, perhaps, one-quarter, one-half, or even a larger fraction of the total volume; but this should not be done unless it is actually and undoubtedly required. We have so far considered only the manner of feeding a baby before the time of weaning. After it has been fully weaned its nourishment may be gradually increased in strength. This applies equally well to a bottle-fed baby who has reached the usual age for weaning. By about t^2 THE CARE OF THE BABY. the age of twelve months a child may be fed upon undi- luted milk and may begin to take other articles of diet in addition, such as beef-juice, eggs, and starchy food in moderate quantity. These will be given from a spoon, but the milk may be given from a bottle as long as the child is inclined to take it in this way. As a guide for the feeding of a child of from twelve to eighteen months the following diet list may be of service. The numbered menus indicate the choice that the mother may have, alternating them so that the child will not tire of any: Diet from One Year to Eighteen Months. Breakfast (6 to 7 a. m.). — (i) A glass of milk with stale bread broken in it. (2) Oatmeal, arrowroot, wheaten grits, hom- iny grits, etc., made into a porridge with milk and well cooked for two hours at least. (3) A soft-boiled or poached ^%% with bread broken in it, and a glass of milk. Second Meal (10 a. m.). — A glass of milk. Dinner (1.30 to 2 p. m.) — (i) Bread moistened with dish-gra\'>^ (no fat), beef-tea, or beef-juice (Appendix, 22) ; a glass of milk. (2) Rice or grits moistened in the same wa^' ; a glass of milk. (3) A soft-boiled ^%% and stale bread thinly buttered ; a glass of milk. Rice, sago, or tapioca pudding, or junket, in small quantities as dessert with any of these diets. Fourth Meal (5 p. m.). — A glass of milk or some bread and milk. Fifth Meal (9 to 10 p. m.). — A glass of milk. It is, of course, understood that the baby does not sud- denly plunge into any such diet at twelve months, but that the list and the variety are only very gradually in- creased, and that milk remains the principal article of diet. The last meal should be given only if the child wakens. If it rouses some hours before the time for the first morning meal, and remains awake, it should be FEEDIXG THE BABY. T53 given a cup of milk to stay the stomach until breakfast. It is no longer necessary at this age to sterilize the milk in cool weather, if care is taken to keep it carefully. In hot weather it is safer to sterilize it still. After the age of eighteen months up to that of two years the diet is only very little more extended. The following list will be a guide: Diet from Eighteen Months to Two Years. Breakfast (7 A. m.). — (1) A glass ofniilk with a slice of bread and butter or a soda, Graham, oatmeal, or similar unsweetened biscuit. (2) A soft-boiled ^%% with bread and butter and a glass of milk. (3) Porridge as described in the previous list. Second Meal (10 A. m.). — (i) Bread broken in milk. (2) Bread and butter or a soda or other biscuit with a glass of milk. Dinner (2 p.m.). — (r) Boiled rice or a baked potato mashed and moistened with dish-gravy or beef-juice; a glass of milk. (2) Mutton or chicken broth with barley or rice in it, or "beef food;" some bread and butter, and some sago or rice pudding made with milk. (3) A small portion of minced white meat of chicken, turkej', or fish, or minced rare roast-beef, beefsteak, lamb, or mutton ; bread and butter ; a glass of milk. Fourth Meal (5 p.m.).— (i) Bread and milk. (2) Bread and butter and a glass of milk. It is probable that no fifth meal will be needed, but if it is it should consist only of milk. The term ''beef food " is used here in the very general sense of some of the commercial ready-made beef preparations. Among the best are those in which the beef is already peptonized. There are a number of excellent foods on the market, but the family physician had better be consulted regard- ing them. It is important to know that not every child can digest potato easily, and that this variety of starchy food must be tried with caution. Further, that many children have great difficulty in digesting any form of 154 THE CARE OF THE BABY. starch. In such cases the diet should be chiefly of ani- mal food during the first two years of life. After the child has cut sixteen or twenty teeth — say, by the age of two years — we may still further increase the diet by allowing it to eat solid meat food. For dinner it may have tender chicken, fish, mutton, or beef cut small but without actual mincing. Fresh or stewed fruits in small quantity are also good, among these being included raspberries, strawberries, grapes freed from the seeds, peaches, juice of oranges, and stewed apples. Bananas should not be given. The diet then may be as follows : Diet from Two to Three Years. Breakfast (7 to 8 a. m.). — (i) A small portion of beef-steak, with oatmeal, hominy grits, wheaten grits, corn meal, or other cereal porridge with plenty of milk. (2) A soft- boiled Q%%, bread and butter, and a glass of milk. Second Meal (11 a. m.). — (i) A glass of milk with bread and butter or with a soda or other biscuit. (2) Bread and milk. (3) Chicken or mutton broth. Dinner (2 p.m.). — Roasted fowl, mutton, or beef cut fine; mashed baked potato with butter or dish-grav\' on it ; bread and butter. As dessert, tapioca, sago, or rice pud- ding, junket, or some of the fruits mentioned. Supper (6 p. m.). — (i) Bread and butter. (2) Milk with soda or similar biscuit or with bread and butter. It is very necessar}^ to bear in mind two facts regard- ing these tables: first, that they are only a guide, not an absolute rule, both as to the time of meals and as to the nature of the food; and, second, that they rather represent the extreme of what a child can take than in- dicate what every child ought to have. Although motliers are very prone to worry because their children are not getting "strong enough food," there is less danger of this happening than of the food being too I FEEDING THE BABY. 155 strong. Many a baby does wonderfully well with milk alone long after others are taking a diet somewhat like the list given for the age of eighteen months to two years. In such a case it is folly to alter the diet hastily. The weight and the general condition of the baby are far better guides than the number of months old which it hap- pens to be or the number of teeth cut. It is always very important, as previously pointed out, to make no changes during the hot weather when it is possible to avoid doing so. On the least disturbance of the digestion, too, the diet should be cut down to milk for a day or two. From the age of about two and a half years onward the child can sit at the table in its high chair with the family, or at a small table close to the mother. If it never receives articles of diet not suited to it, it will soon learn not to ask for them. At the age of three years the child may have its diet considerably increased in variety, since it has now acquired powers of digestion much more like those of the adult. Some of the green vegetables are of advantage. It is very important at this age to prevent a child from helping itself to all sorts of edible articles both at the table and, especially, between meals. If it is really hungry there is no objection to its having some simple thing between meals, not sufficient in amount to lessen the appetite at the regular meal-time. It is impossible to give any series of distinct diet lists for the age of three years and onward, inasmuch as the child now eats from the family table and of the food provided for all. Care must be taken that it receives no indigesti- ble, highly-seasoned, or made-over dishes, and that it masticates slowly and thoroughly. The chief meal (dinner) ought always to be in the middle of the day, and the supper always light, as of bread and milk or cereals and milk, in order that sleep may be sound. Milk should 156 THE CARE OF THE BABY. still constitute a large part of the diet, and meat more than once a day is often a disadvantage. The following lists may serve as a guide to the kinds of food suitable to a child of three years and later, and those which must be used with care or be avoided. Of course, as the child passes this age the list of permissible articles gradually increases until, by the time of puberty or earlier, the diet is practically that of adults. Foods Permitted. Meats. — Broiled beef-steak, lamb chops, and chicken ; stewed liver ; roasted or boiled beef, mutton, lamb, chicken, and turkey ; broiled or boiled fish ; raw or stewed 03-sters. Eggs. — Soft-boiled, poached, scrambled, omelette. Cereals. — Light and not too fresh wheaten and Graham bread, toast, zwieback ; plain unsweetened biscuit, as oatmeal, Graham, soda, water, etc. ; hominj- grits, wheaten grits, corn meal, barley-, rice, oatmeal, maccaroni, etc. Soups. — Plain soup and broth of nearly any kind. Vegetables. — White potatoes, boiled onions, spinach, peas, asparagus, except the hard parts, string and other beans, salsify, lettuce, stewed celery, 3'oung beets, arrowroot, tapioca, sago, etc. Fruits. — Nearly all if stewed and sweetened ; of raw fruits, peaches are one of the best ; pears, well-ripened and fresh raspberries, vStra wherries, blackberries, grapes without the skin and seeds. Desserts. — Light puddings, as rice pudding without raisins, bread pudding, etc., plain custards, wine jelh-, ice-cream. Food to be Taken with Considerable Caution. Kidne}-, muffins, hot rolls, sweet potatoes, baked beans, squash, turnips, parsnips, carrots, egg-plant, stewed tomatoes, green corn, cherries, plums, apples, huckleberries, gooseberries, currants. Foods to be Avoided. Fried food of an \' kind; griddle-cakes; pork; highly-seasoned food; pastry; all heavy, dough}', or ver}- sweet puddings, unripe. SLEEP. 157 sour, or wilted fruit; bananas, pineapples, cucumbers, raw celery, raw tomatoes, cabbage, cauliflower, nuts, candies, preserved fruits, tea, coffee, alcoholic beverages. The feeding of a child when sick is such an important matter, and one so very difficult, that it must be left nearly entirely to the judgment of the physician. The remarks already made upon the feeding of children with delicate stomachs or with idiosyncrasies regarding food apply in this connection also. The further brief consideration which we can give to the general principles underlying the stibject will be found in Chapter XI., in the section upon the Management of Sick Children. In the Appendix will be found some recipes for various forms of food useful in sickness and health, including food-preparations for use in the bottle. CHAPTER VII SLEEP. Avery young baby is asleep nearly all the time except when nursing or having its toilet made. Its total amount of sleep should be about eighteen or nineteen hours every day. As it grows older it sleeps less and less, and at the age of two months it will often lie awake quietly for an hour or so at a time. By the time it is a year old it requires fifteen or sixteen hours of sleep everyday; at two to three years, twelve or thirteen hours; at four to five years, ten or eleven hours; and at twelve to thirteen years, nine or ten hours. A baby who is sleepless and fretful at night generally has something the matter with it or else has been badly trained. It is important from the very first to accustom a child to sleep at definite hours, else the parents' lives are in danger of becoming a burden to them. To walk the floor night after night 158 THE CARE OF THE BABY. or to be obliged to sit up with a healthy child and sing it to sleep is a form of martyrdom which is entirely un- called for. Provided one is sure that the baby is not sick, it should be put to bed and not be taken up again to induce it to sleep, and the mother should avoid sitting in the room unless she wishes to be obliged to sit there every evening. If the little one never knows any other way than this of being put to sleep, there will usually be no difficulty in the matter after it has once learned its les- son; but to begin the training and not persistently to continue it is a fatal yielding of which the child will be sure to take advantage when a second battle begins. Except for the first few days of life, during which, as is generally thought best, it should lie on its right side as much as possible, the position which a healthy child assumes while sleeping is a matter of not the slightest consequence. If it wants to lie on its stomach, there is no possible good objection to be raised against it. There is sometimes a great deal of needless anxiety among mothers with regard to this matter. It is only in a rickety child that a deformity w^ould be liable to occur from the habit — as would equally well result from the constant as- sumption of any other position. We must remember the necessity of changing the position now and then of ever>^ child too young or too feeble to turn itself easily and often. Before the age of three or four months the baby is put to bed at 5.30 or 6 p. m., and should rouse but once or twice during the night. After this age it should go to bed at 6 or 7 in the evening after nursing, be fed at 10 or II p. M., but be trained to sleep without further nurs- ing until 6 or 7 in the morning. It will then need feed- ing again, after which it can again sleep if it desires. Through the day it may at first sleep as much as it feels inclined, but it is sometimes a good plan, by the time it SLEEP. 1 59 is a month old, to encourage its keeping awake for about an hour before its bed-time, in order that it may have a better night's rest. By the time the baby is six months old it will probably begin to limit its sleep by day to a nap in the morning of from one and a half to two hours. The time of the morning nap will depend largely upon the hours of nurs- ing. The child should be undressed for it and be regu- larly put to bed. Sometimes at this age a short after- noon nap is needed, but this should not last longer than until 4 P. M., lest the night's rest be interfered with, and it should not be allowed unless the child cannot do with- out it. At one year of age and on to the age of two years the same arrangement of the sleeping hours holds good, except that an afternoon nap is not desirable. The morning sleep will then be of two hours' duration, begin- ning at II or 12. If the fifth meal at lo p. M. is not required, the child can sleep uninterruptedly throughout the whole night. At two years of age the morning sleep is shortened to one-half or one hour. From this time up to the age of four or five the morning sleep is still taken if the child seems to need it, but is not to be insisted upon. Children of four years or older should continue to go to bed at 8 o'clock or earlier, and the hour should gradually be changed to 9 o'clock by the age of ten or twelve years. A certain degree of latitude is to be allowed to all that has been said. For instance, if a child persistently wakens very early in the morning and does not go to sleep again, it is better to make the bedtime somewhat later. So, too, a child must be allowed to wake of its own accord in the morning, even though the regular hour be passed. This is certainly true up to the age of four or five years, and even after this it must be remem- l60 THE CARE OF THE BABY. bered that children need a great deal of sleep. If rising at a certain hour in the morning is necessary, and the child seems tired, the hour for retiring must be made a little earlier. In no case must the amount of sleep desired be curtailed. A child of any age should not be allowed to lie in bed after thoroughly awake. It is important to preserve great regularity in the hours of sleeping. Few things upset a child more than a failure to do this. There should be no romping games or excite- ment of any nature for at least an hour before going to bed at night, or the child will be apt to sleep badly. We must next determine what is best for the baby to sleep in. It should never sleep in the bed with its mother. Not only is there a possible danger of her over- laying it — a danger which is real and not imaginary, since statistics show that it occurs very frequently, and history records it even as long ago as the time of King Solomon — but there is a constant temptation to nurse it too often. The baby, on its part, acquires the bad habit of nursing only partially, sleeping a short time, rousing, and nursing again. Moreover, it is very liable to get the covers over its head and to obtain much less fresh air than it should. The first bed generally used for the baby is the bas- sinet, and sleep should begin in this from the first day of life. The bassinet consists of a wicker basket with high sides and with or without a hood over one end. It should stand high, so as to avoid draughts on the floor. It should not be too large to be easily portable, in order that it may be readily moved from one room to another if desired. It may conveniently be lined with some colored or white material and covered outside with Swiss muslin; but these and any further decorations may be as varied and as elaborate as the mother pleases. It SLEEP. i6t is, however, better to have them simple and inexpen- sive, to permit of changing them when dusty or soiled. The illustration shows one of the ordinary forms of bas- sinet furnished in the shops (Fig. 37). A large oval clothes-basket would answer as a substitute. Fig. 37. — Bassinet. The bassinet is superior to the crib for the early months of life, because it gives the child more support at the sides and keeps it warmer if well tucked in. Cur- tains may be fitted to it, and are of service if there is any danger of draughts, but as they cut off the fresh air and catch the dust it is better to do without them; place the bassinet in a sheltered situation, and protect 11 1 62 THE CARE OF THE BABY. it, if necessary, from draughts and light by a portable screen. A cradle may be used instead of the bassinet. The form with projecting rockers is a constant invitation to everybody to trip over them, and the swinging form is also not to be recommended unless it is never swung. Although the rocking probably does no harm, it is against all the principles of training which we have been considering to make it a necessity in putting the child to sleep. If the child has never been rocked, it can never miss it. When the baby is eight or nine months old it should be transferred to a crib, in which it should sleep until five years of age. The crib should have sides which let down on hinges or on slides, and which should be high enough to prevent falling out, for it is astonishing over what high sides a small child can climb. The hinged side takes up much more room in opening, and the sliding variety is consequently more convenient if it is so made that the child cannot by any means let it down upon its arms or legs. The old-fashioned trundle-bed is faulty, as it brings the child too near the draughts on the floor. The crib is, as a rule, better without curtains. It should be provided with a woven-wire mattress, and this should be as high from the floor as in an ordinary bed. The remaining contents and the manner of making up the bed are the same as for the bassinet, and the one de- scription answers for both. There should be, namely, a soft, thin hair mattress, which is decidedly better for strong children than one of feathers is, as the latter is much too warm. Over this is laid a rubber cloth, and the whole is covered by a doubled sheet. Sometimes a quilted bed- cover may be put over the rubber, to increase the softness and warmth. This is a very good plan in winter. It is SLEEP. 163 also sometimes well to place a small pad, like the lap- protector described in Chapter V., directly under the baby, over the sheet. There should be a small, soft, thin feather pillow covered with a fine linen pillow-slip. In summer a pillow of curled hair is cooler. The cov- erings of the baby in bed consist of a sheet, as many soft blankets as the season requires, and a light spread. In cold weather an eiderdown quilt is very useful. All the coverings should be light in weight, yet warm. The sheet should be of muslin rather than of linen, as there is a coldness about the latter which it is very difficult to overcome. The pillow-cases, however, are better made of linen. We must constantly bear in mind the very great im- portance of properly airing the bed after it has been slept in, and of warming it before it is used again. Every morning the windows of the room should be opened and the bed-covers be stripped off, and, with the mattress, exposed to the air and sun for at least two hours. Before the child is put to bed in the evening the covers should be well pulled down and allowed to stay so for half an hour or more. In cold weather the sheets should be taken off and warmed. Indeed, it is a good plan to warm them at all seasons except in the height of summer. If this is done, there is no necessity for a child to sleep between blankets, unless, possibly, in earliest infancy. It is difficult to keep blankets fresh and sweet if used in this way. If the sheets become soiled, they must be changed at once, no matter how often the soiling occurs. It is important to keep the rubber cloth well cleaned and aired. The great disposition evinced by most children to wriggle themselves outside of the bed-clothes renders something to prevent this desirable. There are many • 164 THE CARE OF THE BABY. bed-clothes fasteners described, but as simple a form as any consists of two short pieces of elastic, each of which is attached to the covers by a clamp and is fastened to the side of the bed or crib by pieces of ribbon. This plan is rather better than that of pinning the covers to the pillows with large safety pins, since the elastic allows of a certain degree of turning and moving about. Where the child shall sleep at night is a matter de- pending largely upon circumstances. The best plan, theoretically, is that which places the baby, after the first few weeks, with its nurse in the night nursery. If the child is nourished at the breast, it can be brought to the mother's room at the proper hours and then be taken back. This relieves the mother of care during the night. If it is bottle-fed, the nurse gives it its nourishment. Many a mother, however, is naturally, and with good reason, unwilling to entrust so much responsibility to any employed person, while in other cases the means of the parents or the rooms of the house do not permit of such an arrangement, and the baby has to sleep in the mother's room. After the age of a year, however, it should certainly have a separate room at night if pos- sible. The morning and afternoon naps are to be taken in the room used for sleeping in at night. CHAPTER VIII. EXERCISE AND TRAINING, PHYSICAL. MENTAL, AND MORAL. The training of the baby, physically, mentally, and morally, is so large a subject that we can consider only its most salient points. !3 INFANT'S WBiaHT CHART. EXERCISE AND TRAINING. 1 65 For the first two weeks of life the baby takes very little physical exercise, but after this it begins to kick and to move its arms about in a way which ensures plenty of it, if only its clothes are of such a nature that the move- ments are not impeded. At the age of two weeks the child may be systematically carried about in the arms two or three times a day, as a means of furnishing additional change of position. We must bear in mind that its spine is still very weak, and that it must be supported in a proper manner. The baby should be placed on its back upon a pillow on the nurse's arm, and after it is a month old it may be carried in the same way, but with- out the pillow. When three or four months old, and up to the age of six or eight months, it may be seated up- right upon the arm, with the hand of the other side sup- porting its head and back carefully, although as the age advances this support is not always necessary. As the back bends very easily in any direction in infancy, we must guard against any permanent cur^'ature developing by seeing that the child is carried sometimes on one arm and sometimes on the other. Closely connected with the exercising of the baby is its exposure to the outdoor air. Although this is often of much benefit, it is a mistake to be in too great a hurry with the process of "hardening," so called, since this frequently only succeeds in making the child ill, just as pampering makes it delicate. No absolute rule can be given for the date at which the baby shall be taken out for the first time. If at the age of two weeks it is well and is properly protected, the nurse when walking with it may carry it into another room of a somewhat cooler temperature. This will give quite suflScient change of air. By the time it is a month old, or even before this, it may be taken into the open air in summer-time, and 1 66 THE CARE OF THE BABY. kept there for ten or twenty minutes on the first visit, and longer on subsequent ones. In midwinter it is better to delay longer, and not to make the first excursion out of doors until the age of two or possibly three months. There is no doubt that it is sometimes still wiser to wait until spring if the baby has been born in the winter season, but this must be determined largely by circum- stances and for each individual case. An autumn baby ought, if possible, to go out before winter sets in, and then to continue to do this on all good da3's. Damp, windy, or very cold days are always to be avoided during the early months of life, and even after this period exposure to them is of questionable advantage, for we have always to balance the good that may come from the outing against the harm that may result from the unfavorable weather. It is a mistaken idea that every child must be in the open air every day, no matter what the nature of the weather may be. Even on the best days it is important to avoid chilling and to keep a close watch over the condition of the hands and feet. The least chilliness of these is a warning to go in. One plan which can be safely adopted with autumn or winter babies is that of opening the windows in one of the rooms of the house, wrapping the baby thoroughly, and walking wnth it in this room for half an hour or so, just as though it were out of doors. The windows should at first be shut down before the baby is taken into the room, but later they may be left open if the weather is not too cold. Of course, draughts must be avoided. The first going out should be in the nurse's arms, since the heat of her body keeps the child warm, and the sup- port of her arm and hand renders it much more comfort- able. After the age of three or four months, depending on the season, it may be taken out in a perambulator. EXERCISE AND TRAINING. 1 6/ The choice of the perambulator and the manner in which it shall be used are matters of much importance. The perambulator should be well balanced, so that there is no danger of it "tipping over backward, and should especially have easy springs, in order to save the baby as far as possible from the results of careless wheel- ing. It should be provided with an adjustable seat for use when the child begins to sit up. It should also have a detachable overhanging sun-shade or adjustable hood for use in the sun. It is necessary, too, to see that this is always taken with the carriage and is always used when needed, for nothing is more common than to find a care- less nurse wheeling a baby with the sun full in its face. The color of the shade, or rather of its lining, is a very important matter too often overlooked. One which is white or of some bright color, such as red or yellow, m.ay seriously injure the eyes, for it reflects into them the glare from the ground. At least the lining ought to be of some dark color, such as green or brown. The car- riage should be provided with a soft warm bed and with warm covers and a pillow. A knitted or crocheted afghan is a serviceable article. For use in summer, mattresses and pillows of hair are much cooler than those of feathers. As the baby grows more active there is very great dan- ger of its falling out of its carriage. To prevent this accident most perambulators are provided with a straight strap in front of the child. This is often very unsatisfac- tory, since it does not keep the child either from climbing over, if active, or from being thrown out in case of acci- dent. Some really serviceable preventive of this very real danger of falling is required, and a very good form is that shown in the illustration. This consists of a strap which goes entirely around the waist and is attached by smaller straps to the sides of the carriage (Fig. 38). 1 6^ THE CARE OF THE BABY. A child that has reached the age of six months will no longer be content to lie flat in its carriage. It is then necessary to see that it is well supported with extra pillows at the back and sides. For children of this age, or for older ones who can sit easily without support, the adjusta- ble seat should be placed in _ „ ^ , , the coach. Fig. 38.— Strap for coach. ^ , _ - From the age of three months onward it is an excellent plan to place the baby at times upon a blanket or mattress in some place in the room which is free from draughts, and so to- arrange its clothing that it is allowed to make freely all the motions of which it is capable. This gives it a good chance to learn to stand or to creep as soon as it reaches the age for it. A clothes-basket or large box padded with soft material makes a good place for this early exercise. Whether or not the child shall creep upon the floor depends on circumstances. In win- ter the lowest layer of air is very apt to be cool, and in severe weather the use of the floor is almost out of the question, even though the nursery has comparatively few draughts. So, too, if a child has a cold, it had better be kept off* the floor until well again. The creeping apron described elsewhere is very serviceable for keeping the air from the child. To prevent a creeping child from reaching unsuitable parts of the room it is a good plan to place it within a small portable pen. The portions of the fence are separable, so that the whole can be put away in small compass when not in use. Pens of this kind can be bought or can easily be made (Fig. 39). Efforts at walking give the baby abundance of a new EXERCISE AND TRAINING. 169 kind of exercise, and we must take particular heed that it is not overdone. Too much cannot be said in favor of Fig. 39. — Creeping pen. letting the baby take its own time in making the new acquisition. No appliances to aid walking should be used, and the child should not be urged at all. The advisabil- ity of using baby-jumpers is very questionable. If there seems to be a tendency for the legs or ankles to bend, walking must be discouraged entirely, for it is much easier to prevent the deformity than to correct it. At this period of life the child should still be kept in the peram- bulator during the daily airing, but later, when it has learned to walk pretty well, it may have ten or fifteen minutes' additional outdoor exercise on its feet. Gradu- ally the duration of the outdoor walk may be increased, but the perambulator must still be used for most of the time until the child is two and a half or three years old. A half mile at the most is quite sufficient, and often more than enough, for a walk at this age. Sometimes children who have outgrown the perambu- lator will ride with pleasure in a "play" express- wagon or, in winter, on a sled. The little two-wheeled carts for children, made in various designs, and known by various names, such as "jaunting car," "mail cart," 170 THE CARE OF THE BABY. ''chair car," and the like (Fig. 40), have become very popular in the last few years, and are most serviceable. Certainly some vehicle ought to be ready at hand at this Fig. 40. — Mail-cart. period of life. We are too prone to forget how short the legs of little children are, and how easily their strength is exhausted. There is one form of compulsory exercise which should be carefully avoided. I refer to the trotting on the knee which is so common with many nurses. When one compares the diminutive size of the baby, lying on its back or stomach in the nurse's lap, with the vigor of the trotting to which it is subjected, there can be no surprise awakened if vomiting and other disturbances of digestion are produced. Even should these not occur, the habit is a bad one, since the baby may gradually become accus- tomed even to this hard usage, and learn to depend on it for being put to sleep, just as it will depend on singing or rocking when used for this purpose. In this connection we may leave for a moment the exercise of the body-muscles in general to consider the training of certain others — namely, those which control the emptying of the bladder and the bowels. After it is EXERCISE AND TRAINING. I7I three months old the baby becomes conscious of these acts, and often at this early age, or sometimes before it, its education may be begun. It is most liable to empty its bladder soon after a meal, and to open its bowels with some regularity as to time. If the mother will place a receptacle under it while it is lying in her lap a little while before either evacuation is expected, the child will very gradually learn to recognize the purpose of the pro- cedure. Perhaps the event may be aided by the mother or nurse systematically making some sound at the time, which the child will learn to associate with it. As the baby grows old enough to sit up, even though partially supported, it may be placed in the nursery chair at the proper time, and always with the greatest regularity as to the hour. Patience and perseverance will accomplish the desired teaching at last. It scarcely need be remarked that punishment for delinquencies in this line is totally out of the question at any age. Of course, children dif- fer in the rapidity with which they learn this control. Many have accomplished it by the age of a year; most should have done so by eighteen months of age; all ought to have learned it by the end of the second year at latest, and some may be trusted during the day when six months old, or even considerably less than this. The control is always decidedly less during the night. With increasing age children become able to take with- out fatigue an amount of exisrcise which is really aston- ishing. Still, there is the necessity of guarding constantly against an excess of it in the excitement of play, as well as of seeing that every portion of the body shares in it. Rolling hoop can be begun'by quite young children, and the use of a rocking-horse is valuable for exercise in the nursery. A velocipede which cannot be upset will be of service as soon as a child is old enough to use it. For 1/2 THE CARE OF THE BABY. older children dancing is a very desirable indoor exercise if done in moderation and with proper precautions against taking cold. The objections so often urged against skipping rope are in no way valid unless the exercise is indulged in to great excess. After the age of puberty, however, it may be harmful to delicate girls. Skating, especially on ice, is excellent, under proper precautions, for both boys and girls. There is, of course, the risk of falls, but no active sports are unattended by some ele- ment of danger. The art of swimming should be acquired by every child, not only for the exercise which it gives, but also for the safety which it may some time ensure. The use of the bicycle is to be commended, provided the guiding apparatus be of such a height and so placed that the child cannot stoop over in the position so gener- ally assumed by bicyclists, and provided that this form of exercise be not employed too exclusively; for although the lower extremities are well used, the upper ones are not sufficiently so, and the position of the anns tends to contract the chest. Tennis and other outdoor games may be indulged in freely. Nothing can be better for chil- dren than riding, first on a donkey or pony, and later on a horse — the girls, of course, riding astride, just as the boys do. Indeed, none of these outdoor sports are intended for boys alone, and girls should be encouraged to take part in all of them. Many a woman has to thank her romping, outdoor girl-life for the robust health which she afterwards enjoys. Let the girl be a hoyden just as long as she pleases — the longer the better. Sedentar}^ indoor amusements should, in fact, be discouraged. It is much easier to tone her down and " make a lady " of her after a while than it is to tone her up if she has no good constitution on which to build. A girl grows into a " tiling of beauty " only if of sound health. EXERCISE AND TRAINING. 1 73 A city-bred child, however, has little opportunity of taking the necessary amount of exercise of any kind, unless a park or an open square be somewhere in the vicinity. It is consequently of the greatest benefit to take growing children to the country, mountains, or sea- side for as much as possible of the warmer season of the year. Places which are merely fashionable resorts are not suitable unless the children are in no way trammelled by the restrictions from which their elders suffer. Even though plenty of exercise can be had in summer, the inclemency of the weather in winter often presents a great obstacle to obtaining it at that season. Besides this, the confinement of school-life in winter often tells upon the health of the child. It is now that the well- regulated gymnasium fills a place taken by nothing else. It would be a wonderful aid to the formation of sound health did every child attend one systematically. It is much better to spend a half hour or fifteen minutes there every day than it is to exercise for a longer period only two or three times a week. Where no gymnasium is available much can be done at home. One of the best methods for delevoping the arms and chest consists in swinging on a low swing or hanging for a few moments by the arms from a horizontal bar, repeating this fre- quently during the day. Swedish movements are of great value, and massage is also of service, although less efficient. The calisthenic exercises now used at many schools are to be recommended highly. It is especially useful in the case of young children to have such exer- cise accompanied by music, as it makes it of greater interest. The various sports w^hich have been referred to of course come under the head of Amusements also, and exercise the mind as well as the body. Childhood is 174 THE CARE OF THE BABY, often called "the play- time of life." The chief occupa- tion of the child is to play, and everything else must be made subservient to this. The training of the mind can be combined with it, but should always hold a secondary place, for there is little use of a sound mind, and little chance of getting it, unless the body, too, be sound. Still, while the child is playing it is learning, and the acquiring of knowledge commences often before we have any idea of it. As we cannot hinder the learning, we must early begin to superintend it, and to guide the baby in its amusements, as well as in other things, in a line which will instruct both its mind and its moral sense. We can in the limits of this chapter merely touch on some of the matters connected with the mental and inoral training. Early in life the baby needs ver}' little diver- sion. Indeed, up to the age of five or six months it does not require playthings, although at this age it will be amused by a rattle or a rubber doll. Later it needs more toys to be used in the house on rainy days, and others which it can play with out of doors. A heap of clean sea sand will furnish a child of two or three years an un- ending source of amusement. It should not be forgotten that it is not only a foolish extravagance to load a child of any age with expensive and fragile toys, but that it is distinctly prejudicial also. Always looking for something new, the child soon becomes discontented with the things it has, no matter how fresh and good they may be. Lack of valuation, too, breeds lack of care of the playthings. Simplicity in desires will better be attained by having only a few toys, although certain others may be kept in reserve and be given only on special occasions or as a special favor or reward which has been well earned. Habits of neat- ness can be taught in the use of playthings, and even EXERCISE AND TRAINING. 1/5 when small a child can learn the lesson of "a place for everything." Toys may be chosen which instruct. Picture-books, Noah's arks and animals, the kinder- garten toys, and, a little later, lettered blocks, are of this class. With the latter many a child has learned its letters almost without efifort or special instruction. There is really no hurry about teaching a child to talk. Of course, the more attention there is given to the matter, the sooner will most babies learn. The only thing which should be carefully borne in mind is the great folly of ever using ''baby-talk." It is no more comprehensible to the child and no easier for the mother. Gibberish talked to the baby means that it will learn only gibberish. Then at an age when it becomes a mor- tification to the parents the child of three or four years may still be talking a nearly unintelligible jargon. The constant questioning on the part of children is often very trying, but should never be rudely repressed. Bear with it patiently, even encourage it; answer truth- fully all you can, and remember how very much there is which the child is so anxious to learn all about. Of course there are times when the questions are out of place and must be gently checked. So, too, with the noise of children: although it is often disagreeable and needs to be stopped, we must never forget that to make a noise is nat- ural, and not to make it is a thing which has to be learned. It is important to remember that in the instruction of children example is far more valuable than precept. Children are wonderful imitators, and their words and actions will be copied largely from those with whom they are most intimately thrown. If a child is never told a falsehood by its parents or its nurse, and is taught to look upon it with horror, there will be little danger of its becoming untruthful. The punishing of a child for a 176 THE CARE OF THE BABY. fault after it has told the truth about it is simply encour- aging it to lie on the next occasion. We must not, in this connection, overlook the fact that the excessively vivid im- agination of a child sometimes leads it to view its fancies as realities. Thus it will tell all manner of false stories of what it or others have done or said, and will often actually believe it all. This is only a sort of roman- cing, and must be sharply distinguished from deliberate lying, with which it has not the slightest connection. The habit of implicit, unquestioning obedience cannot be taught too early. It is of far too frequent occurrence for a mother to tell her child that if it will obey some command she will buy it a toy or reward it in some other way. There can be no greater folly than this, for the little one needs no great power of reasoning to under- stand that the act of obedience is thus made a favor done by it to its parent. To obey because the command is given and because the child loves its parents should be the only reason. This does not mean that a parent may be tyrannical, exacting, or unreasonable. Remember that the child ma}' be right and you wrong. One should never use threats or employ punishments unless they are really necessary. Punishment should be carefully selected, never given in anger, but in sorrow, and never of a nature that may frighten the child or injure its health in any way. The boxing of the ears may do serious harm, and imprisonment in dark closets and similar punishments are equally dangerous. When a child has been threatened with a punishment, and has, in spite of this, committed the forbidden act, it should not fail to pay the penalty, else it will soon learn to despise its parents' commands. Of course, exceptions arise where justice must be tempered with mercy, but these are to be exceptions only. If parents would less frequently tell EXERCISE AND TRAINING. 1/7 their children '■'' don' t^''' but give them something to ^^, there would be fewer lapses from obedience. I have said so much in this connection about the import- ance of obedience because its value is especially great in sickness. Many a time a physician is rendered helpless to a great extent because a poorly-trained child refuses to take medicine prescribed for it, except after losing a pitched battle over it and doing its nervous system injury by the struggle. A freedom from selfishness is a quality which cannot be taught too early. A child should learn to think and to do for others, and not for itself This is a difficult lesson to learn, for we are all selfish by nature. It should also learn to have a fitting respect for and to act with gentleness and kindness to all created things, whether animate or inanimate. A child should never be told to "hit the bad floor" against which it has struck its head. This is nothing else than teaching revenge, to say noth- ing of the foolishness of it. As the child grows older one of the best means of incul- cating a love for and a sympathy with objects in nature is to allow it to have a growing plant or a pet of some kind of which it shall have the care. This teaches thoughtful- ness as well as serves as an amusement. Of course, we cannot expect the child to have the whole responsibility of the care of the pet, for this is asking too much of its perseverance and enthusiasm. The parents should assist, but must not take the whole care upon them. In this way the pet does not become a burden or a source of ill- advised reproaches. I must strongly advise against the common habit of making the baby the centre of an admiring circle of vis- itors. The baby should see just enough of company to teach it to be free from a dread of strangers. As a rule, 12 178 THE CARE OF THE BABY. however, it should not be brought into the parlor. The custom not only bores the visitors, too polite to say so, but it excites the baby far too much. A little later this course results in the development of a forward child who is always "showing oflf" or interrupting the conversa- tion of its elders. Children's parties, too, are far too exciting for babies, and even in early and later childhood they should be of rare occurrence and simple in their arrangements, and are best held in the very early evening or late afternoon. Much harm, sometimes irreparable, is often done by allowing a child to grow up almost entirely in the society of domestics. If parents want children to learn pleasing and polite manners, the use of good English, and refined modes of eating, they must associate their children with themselves; and if they themselves do not possess these qualities, they should cultivate them as thoroughly and rapidly as possible. In the effort to teach the child in these respects they may profitably let it appear at the general table as soon as it reaches the age of two and a half or three years, or at the most four years, unless company is present. It is a valuable safeguard against a child pushing its chair over if it is fastened in some way to the table. Very early we should begin to teach a child not to have unreasoning fear; and one of the best means of accomplishing this is never to let it be frightened. Such toys as the jack-in-the-box and those which make a sud- den loud noise should not be given to very young chil- dren, as they may be the cause of great fright. A child should be taught to have no fear of such things as mice, worms, and other innocent animals. It should look upon the dark as equally harmless with the light. Too great caution cannot be used in the choice of EXERCISE AND TRAINING. 1 79 stories told or read to little children, since they sometimes gather from what seems to be least harmful the occasion of a timidity not easily recovered from. Ghost-stories are, of course, entirely out of the question. They have often been the cause of untold mental suffering and of a fear which a lifetime has not overcome. Even stories which excite the imagination too vividly are to be avoided, although they may be entirely free from ele- ments causing alarm. Up to the age of nine or ten years boys and girls are disposed to play together unless some too officious person has made the boys dislike the girls' games, and the girls feel that the boys are rough and ''horrid." No hinder- ance should be opposed to this joining in play, since it induces the girls to lead an active life. The mother should never forget, however, that it is important to ex- ercise careful although unobserved supervision over the morals of the children, whether the sexes play together or separately, since even those who appear perfectly in- nocent are by no means always so; nor is it invariably some one else's children who are at fault. Experience shows that almost no age is too young to need the sub- jection to this watchfulness. Finally, we must consider briefly the management of the school-life of children. With the comparatively recent improvements in schooling, children may be sent to a kindergarten by the age of three or four years. The key-note of the kindergarten is the acquiring of know- ledge by play. At the same time the child is amused and learns a certain degree of discipline and order. Many of the games are accompanied by little songs and move- ments of the body, which are always designed to impart knowlege of some sort. Thus the child sings of the flight of birds, and imitates the flying by the motion of l8o THE CARE OF THE BABY. the arms. It learns also of the harmony of colors by weaving colored papers, and gains manual dexterity at the same time. A knowledge of number and of form comes from playing with blocks. A grain of corn may be the text for a story about growth, and the child learns a song regarding this. These instances illustrate briefly the methods of the kindergarten. Whenever a good school of the kind is available, it should be utilized, and when it is not, the mother should herself devote some time daily to instruct- ing her child on the lines indicated. There are now many excellent manuals on kindergarten instruction which give details of the method of teaching. But with some children even the simple instruction of the kinder- garten may give too much mental work; for the learning of songs and rhymes is, of course, a decided mental effort. There is really no need to teach a child to read before the age of six years. Precocity is not a thing to be desired. Indeed, in delicate children it is to be dis- couraged strongly. It is not the slightest indication of talent or genius. Many children teach themselves their letters, as has already been mentioned; many go further, and learn to read with very little assistance if they have once been given the start; while still other children find study always a burden. If we have succeeded in getting the power of observation and attention well cultivated by the kindergarten object-lesson methods, reading will usually come readily enough. By the time the child is six or seven years old it may be given some regular lessons and do some actual study, but not at the expense of health, and the hours should be very short. Three or four hours daily are quite enough up to the age of ten years. Throughout the EXERCISE AND TRAINING. l8l early school-life there should be no studies to prepare at home, for the confinement of the school-hours is all that, and often more than, the health can stand. The great fault of the age as regards the mental training of children is that of over-pressure. We expect the children, with their brains still in a formative state, to do far more mental work than most of their elders do. The dano^er of over-study is particularly true in the case of girls, who are more disposed than boys toward a quiet, sedentary life; but both sexes must be most carefully guarded against too much brain-work. Eyes are often irreparably injured by school studies, not only as the result of in- sufficient or badly-placed light, but in consequence simply of too constant use. IMany cases of nearsighted- ness are the result of the improper use of the eyes early in life, or of e\'es which need correcting by glasses. Spinal curvature often results from faulty methods of sitting at school (see p. 218). It is very important in the "one-session " school that there be a recess of sufficient length to allow the child to obtain something more to eat than doughnuts and sweets. Indeed, attendance upon the best school in the world is not worth a hastily-swallowed breakfast and a hurried, indigestible lunch. In this respect, as in all others, schooling must always be secondary to the care of the health. The value of the use of gymnastic exercises has already been referred to earlier in this chapter. Where it is possible to do so a school should be selected which provides these for the children, since they not only prac- tise the muscles, but also make an excellent break in the tedium of the school-day and return the children re- freshed to their studies. The subject of the sending of older children to board- ing-school is too many-sided for consideration here. Over 1 82 THE CARE OF THE BABY. against the advantage of the increased independence and self-reliance attained must be set the lack of parental and home influences and the danger of acquiring bad habits of all sorts. From a strictly medical standpoint we have chiefly to assure ourselves, in selecting a boarding-school, that the children do not pass either sleeping or waking hours in crowded and ill-ventilated rooms, that they are well fed, and that they receive abundant opportunity for exercise and sleep. The danger of contracting contagious diseases in either day-schools or boarding-schools must never be forgotten. Unfortunately, it is one from which there is no absolute safeguard, especially since many parents are utterly reck- less of the risk to other children which arises from send- ing back too soon their own children who have been ill. The periods of quarantine for the different diseases, which will be found in Chapter XL, should invariably be followed. Any boarding-school in which there is an extended outbreak of diphtheria, scarlet fever, or other dangerous infectious disease ought to be closed unless there are exceptional facilities for isolation and treat- ment. Any other matters connected with school-life can better be treated of when we consider the School-room in a later chapter. CHAPTER IX. THE BABY'S NURSES. During the period of life in which the baby needs especial care it may come under the attention of four sorts of nurses: (i) the monthly nurse; (2) the wet-nurse; (3) the child's nurse or nurse-maid; and (4) the trained THE BABY'S NURSES. 1 83 nurse in case of sickness. We must briefly consider these, and the qualities to be desired in each. I. The Monthly Nurse. Although the monthly nurse is really the nurse for the mother, yet it is upon her that the care of the baby depends during the earliest period of its life. She it is who washes and dresses the child during the time the mother is confined to bed, and who watches its condition and reports this to the attending physician. The choice of the monthly nurse is a matter of the greatest importance for both the mother and the baby. The physician in charge of the confinement may wish to recommend some one on whom he can depend, and in this case the entire responsibility rests upon him. If, however, the selection is left to the mother, she should choose one not so much because she knows her name as the nurse of Mrs. So-and-so as because she has, if possi- ble, some knowledge of her real ability. Many monthly nurses, and particularly the older ones or those who have not had careful school-training — and sometimes, un- fortunately, even those who have and who might be expected to know better — are filled with all sorts of wrong ideas about the care of the new-born child. Not only so, but they consider their "experience" so great that they become obstinate and self-willed, and incapable of receiving advice or even of obeying orders. They will follow their own plans with the baby, on the ground that its care is their business, and not the doctor's. Every physician has seen instances of great damage done in this way. A truly well-trained nurse has not only been taught the proper care of the mother and infant, but has learned also that she is to modify her methods promptly and silently according to the directions of the physician 1 84 THE CARE OF THE BABY. in charge. In such a nurse the mother may put the greatest confidence. The nurse should be engaged some months in advance, and all pecuniary arrangements made in detail. It is a good plan to have her in the house a week or so before the confinement is expected, or, if this is not possible, then within easy reach, so that she may be sent for with the very first signs of beginning labor. She ordinarily stays for a month or more after the birth of the child, but so long a time is not always necessary. It is the custom for the nurse to sleep in the room of the mother, or, still better, in the adjoining room. In the latter, too, she can take her meals if it is desirable. She is to take full charge of the baby, determining the hours for feeding, and preparing its food should the mother be unable to nurse it herself. She is not ordinarily ex- pected to do any washing of the baby's clothes, except, perhaps, the diapers, nor to wash her own garments. She should be able to prepare special articles of sick-diet for the mother, in case there is need for her to do so. 2. The Wet-nurse. The second variety of nurse with which we sometimes have to do is the wet-nurse. The advantages and disad- vantages connected with the employment of a nurse of this kind have already been spoken of when considering the Feeding of the Baby in Chapter VI. When it is found desirable to nourish a baby in this way the choice of the wet-nurse is a matter of great importance. For- tunately, this also can often be left entirely to the phy- sician in charge. It is absolutely necessary that the wet-nurse be in good health, strong, and not too fat. A most careful examination on the part of the physician is required, since nearly any form of ill-health impairs the quality of the milk, and there are some diseases, i THE BABY'S NURSES. 1 85 such as syphilis, which can be transmitted directly from the nurse to the child at the breast. An examination of the nurse's baby is also a guide to the health of its mother and to the nutrient value of her milk. The nurse should preferably be from twenty to thirty years of age. It is better that her own and her foster baby be of approximately the same age. It is well if her own child is several weeks old, in order that a tendency to the early drying up of the milk need not be feared. Her breasts should be firm and conical in shape if it is her first child, or only very slightly pendulous if she has had several children. They should contain plenty of milk, as shown by the ability to press some from them after the child has done nursing. They should, however, become distinctly more flabby when emptied. If they do not, their size may depend simply upon their being covered by a large amount of fat. The nipple should project well and be free from cracks. The moral character of the wet-nurse cannot be disre- garded. She should be amiable, temperate, and with a lively sense of the responsibility of her position. If otherwise, the health of the child is sure to suffer. If she gives way to violent anger, her milk may become for the time actually poisonous, and produce colic, diarrhoea, convulsions, or even more serious results. If intemper- ate, she may while intoxicated allow the child to suffer injury; and if she is irresponsible in any other way, she may surreptitiously feed the child with cow's milk if her own diminishes, give it an opiate if it does not sleep, neglect the care of its body in some manner, or abandon it without warning. A married woman is to be preferred, but the difficulties connected with obtaining a good wet-nurse are so great, and married wet-nurses often so scarce, that it is folly to l86 THE CARE OF THE BABY. refuse to engage an unmarried one if she is qualified in other respects. Because she has made one so false a step does not prove her wholly bad. We must remember that we are not seeking examples of morality or instituting rewards for virtue or punishments for crime, but are simply trying to obtain a suitable manufacturer of human milk for a child who will suffer without it. This remark applies, however, only as regards the first illegitimate child. A woman who has had more than one child ille- gitimately will probably be depraved in other respects and be unfit to be trusted. It is only through the danger of neglect, however, that the moral vices of a wet-nurse affect her foster child. There is no more probability of a baby imbibing the character of the nurse through the milk which she gives, much as we hear this talked about, than there is danger of a child learning to "moo" because it is fed on cow's milk. It is necessary to regulate carefully the wet-nurse's diet, and her method of living in general, according to the principles which have been determined in a previous chapter to be of service to the health of the nursing mother (pp. 113-117). The nurse must have plenty of exercise in the open air, sleep in a well-ventilated room, and be provided with an abundance of digestible, nutri- tious food. At the same time we must remember that a w^oman taken from the lower walks of life and given un- restrained opportunity to indulge freely in food to which she has not been accustomed is ver}' apt to eat too much and to exercise too little. Indigestion follows as a natural result, and the health of the nurse suffers and her milk diminishes or even disappears. The use of stimulants by the wet-nurse is seldom necessar}'. A woman whose health demands them is not in a fit con- dition to fill the place. THE BABY'S NURSES. 1 8/ Finally, the wet-nurse must be made to adhere to the rules for nursing laid down in a previous chapter (Chap- ter VI.). But however well qualified the nurse may seem, a wise mother will not hand over the care of the baby entirely to her, but will exercise a careful supervision over everything that goes on, particularly at night. 3. The Nurse-maid. The third form of nurse, and the one whose qualifica- tions deserve especial attention, is the ordinary child's nurse. Scarcely anything is more diflficult than the obtaining of a thoroughly good child's nurse, scarcely anything more important to the child, and yet scarcely anything more carelessly done. Many a mother en- gages a woman of whom she knows practically nothing, and transfers to her, blindly and completely, the care of the baby. To say that this is all wrong is easy; to ob- viate it is difiicult Mothers often state with great reason that one can- not expect all the virtues for three or four dollars a week, and with this fatalistic salve to their consciences let the matter rest; but the ill results of this indifference are not, however, so easily escaped, and will sooner or later show themselves in some way. A mother should first consider carefully what qualities are to be desired in a nurse-maid, and then exert her efforts to discover one who possesses them. Finally, after she has obtained the ''invaluable girl" it is most important of all never to trust her. Even could the nurse's good intentions be relied upon, her knowledge and judgment are liable to be deficient, however honest she may be in her efforts to do her best. By this it is not meant that the mother dare appear openly distrustful, since such a course would discourage the best nurse, but 1 88 THE CARE OF THE BABY. rather that she must, as a matter of course, give a con- stant supervision, and make it understood that she her- self is the chief, and not the second, in the care of the baby. It is her duty to her child to be secretly a spy upon the nurse, disagreeable as the situation is. The entire confidence which mothers often repose in their nurse-maids is a matter of wonder to others, and sometimes of indignation. Instances are too common in which a stranger, moved to pity by seeing a baby wofully neglected or abused, has with pure disinterestedness reported the case to the mother, only to be met with the haughty answer, ^' I have every confidence in my nurse." Nurses are constantly seen in parks and other public places absorbed in reading, or chatting unconcernedly with each other or with some of their male friends, while the babies lie crying in their carriages, perhaps exposed to the full rays of a hot sun or unprotected from a cold wind. Many a time we may see an old woman support- ing a crying child on her knee and joggling it roughly up and down to the sound of some crooning ditty until one would think that its poor little head must ache, and its teeth, if it has any, must be loose in its jaws. The bad effects of such treatment have already been referred to in the preceding chapter. How often, too, are babies taken by nurses on their shopping expeditions, or even to the houses of their friends, where they are perhaps ex- posed to some dangerous contagious disease! Seeing, then, how important the choosing of the nurse- maid is, we must review some of the qualifications which she should possess. This applies not only to her physical qualities but to her mental and moral characteristics as well, since the child is liable to have its mind and dispo- sition moulded largely by its nurse, and it is mani- festly impossible for it to attain the qualities so much THE BABY'S NURSES. 1 89 to be desired if its constant pattern is the reverse of them all. In the first place, the nurse must be in good health. The existence of any disease, and especially of consump- tion or other form of tuberculosis, should be an absolute disqualification. The employment of a nurse with syphilis must also be carefully guarded against. Such conditions as offensive nasal catarrh, bad breath, pro- fuse odorous perspiration, and the like, although not actually dangerous to the child, render the presence of the nurse very unpleasant. There is some question regarding the best age for a nurse to be. In general the age of thirty to forty-five years is to be preferred. Half-grown girls are seldom fit to have the charge of a child entrusted to them; young women are very liable to give too much attention to en- joying themselves with their friends; while old women, although sometimes invaluable, are as a class prone to be self-opinionated and forgetful. Of course there are nu- merous exceptions to this statement. The nurse should be strong. If delicately and slightly built, the carrying of the baby for hours at a time will be beyond her strength. If, on the other hand, she is very stout, she will be able to do little more than support her own weight when walking. Besides, the mass of her flesh is very heating to a baby held in her arms or lap in hot weather. The comeliness of the nurse is a matter of comparative indifference. Children are apt to think that all those whom they love are beautiful. If only the nurse loves her charge and has features not actually repelling, more is not needed. Even babies in arms perceive the loving and trust-inspiring expression and are contented. This sincere love of little children is one of the o:reat 190 THE CARE OF THE BABY. requisites of a good nurse. She should have chosen her work, not because it offered as good a way as any of gaining a livelihood, but because she prefers it to any- thing else. If the love be present, other good qualities will not be entirely wauling. A devoted nurse will not, for instance, easily lose her patience or become angry with the child, even though it is really annoying. Two other qualities which are very important are in- telligence and docility. The nurse should have sufficient intelligence to be able to understand, remember, and carry out any instructions given her, and should be docile enough to be glad to do this, no matter how much pre- vious experience she has had. Experience is, of course, of the greatest value, yet experience without docility is especially to be shunned. A nurse of this character is as hard to mould as a stone, and can be taught abso- lutely nothing. Better far an intelligent though inex- perienced woman who is willing to learn. Truthfulness and conscientiousness on the part of the nurse are greatly to be desired, but, unfortunately, far too rare. How is it possible for a child to be taught by its parents the sin of lying and the importance of obedi- ence if it constantly hears its nurse teiiing falsehoods and sees things done which have been posit' xor- bidden? Then, too, the baby may be saved mu^ii suffer- ing if the nurse has the courage to admit when she does not know, and to report promptly any alteration in the child's health or any accident which may have befallen it, even though this may have been the result of her own carelessness. A cheerful and lively disposition is very important, particularly when the baby reaches the age when talking commences. It sometimes happens that a child's mental faculties develop ver)^ slowly if it is much with a nurse THE BABY'S NURSES. I9I who is very quiet and makes no effort to teach it, but that they at once take on a rapid growth when one of different disposition is substituted. The possession by the nurse of good manners and gentleness of disposition, and of a control of good lan- guage, is of great advantage when it can be obtained. Children will thus learn instinctively to be polite and kind. A rough, boisterous, ill-mannered child is the natural outcome of association with a coarse-natured, loud-voiced nurse. Yet mothers often seem to overlook this very obvious fact. Finally, the nurse must be cleanly in her person and dress, temperate, methodical, and neat. A woman who does not keep herself clean cannot be expected to care properly for the cleanliness of her charge or to see that the nursery is kept free from dirt. So, too, if she has not habits of neatness, method, and order there will be a constant state of confusion in the nursery, nothing will ever be in its place, the baby's clothing will always be out of repair, and, especially if there are several children, her work will always be behindhand. The difhculty attending the procuring of nurses who are in any sense qualified for their position and who can be at alMrusted is very great, inasmuch as nurse-maids frequently come from the ignorant and untrustworthy classes. To obviate this difficulty the plan of having a jiursery governess is sometimes followed with advan- tage, especially where there are several children in the family. The occupant of such a position should be ex- perienced in the care of children, intelligent, well-edu- cated and refined, and capable of teaching the rudiments of an education to children who have not yet been sent to school. In some cases she may have under her super- vision an ordinary nurse-maid, and it should be her 192 THE CARE OF THE BABY. Special duty to see that the children receive proper care from the maid. Such a woman expects and should receive greater remuneration than an ordinary nurse- maid, and can hardly be asked to take her meals with the domestics. Her position in the household is, indeed, an anomalous and often inconvenient one for all concerned. The excellent plan of having training schools for nurse-maids was devised some years ago, and has been put into successful ])ractice in several of our cities. A further carrying out of the scheme in other places is much to be desired, for it would help largely to do away with the present very perplexing nurse problem. Having dealt with the nurse's qualities, we have still to consider, first, the nurse's duties to the child, and, second, the mother's duties to the nurse. The nurse is generally expected to take as complete charge of the child as the mother chooses. She washes and dresses it, prepares its food if it is on the bottle, and takes it out for its airing, either in her arms or in the perambulator as the mother wishes. She sleeps in the room with it and attends to it at night, or, if the baby sleeps in the mother's room, arises when called and gives it any attention that may be required. She reports promptly the slighest evidence of illness. As the baby grows she endeavors to train it mentally and morally, enforcing obedience, politeness, neatness, and the like, on the lines already indicated. Possibh^ the repairing of the child's garments is assigned to her. There are certain things which the nurse should be distinctly instructed that she shall not do, and some of these ^'dont's" the mother may profitably take to her- self as well. She should never be impatient or cross with the little one. She should never omit to say "please" and "thank you" if she asks a favor of the THE BABY'S NURSES. 1 93 child, else the use of the words on its part cannot be expected. She should never use harsh commands or rough language of any kind. She should endeavor to exact implicit obedience on the part of the child, but she should also never show anger or take the punishment into her own hands, except such harmless, not corporal forms as the mother distinctly permits — for example, the taking away of a doll, the making to sit in a corner, etc., but never the shutting in a dark closet. She must never give any object to a child old enough to talk simply because it cries for it, but must insist upon being asked politely for it. She should teach a child to have no fear of harmless objects by herself never showing fear. She should never frighten the child in the slightest degree. A nurse who tells a child a ghost-story or who makes it fear the dark is little short of a criminal, and deserves to be punished as such. On behalf of all physicians, since their labors with children are not easy at the best, I do strongly urge that neither mother nor nurse ever hold up the doctor as a bogy who will give some bad medicine or take the child away if it does not obey some command which has been given. Such a course destroys the child's trust in and fondness for the physician, and renders his examination and treatment of it when sick far more difficult. The nurse should never administer a particle of medi- cine unless told to do so by the mother, and never give food solely for the purpose of quieting a child if crying. She should never use baby-talk to a child learning to talk, as this retards its acquiring of distinct speech. Finally, she must never allow the baby to lie or sit in the hot sun or in a windy or damp place, and she should not take it into a shop or a private house without the mother's consent. 13 194 THE CARE OF THE BABY. What, now, are the mother's duties to the nurse? Chief of all is that of paying her well if she is worth it — and she should not be employed if she is not. The baby is far too precious to allow of hesitation in this mat- ter. The mother should avoid imposing duties upon her which do not belong to her, for if she is a faithful nurse she will have enough to do to attend to her own affairs. She should see that the nurse has full opportunities to do her shopping and to see her friends unattended by the baby, since this removes the temptation of taking it with her. While openly assuming the entire guidance of the baby's life, and secretly watching that her directions are properly carried out, the mother must show^ no sign of distrust, and must endeavor to enlist the interest and win the affection of the nurse. Finally, she must act with the nurse, and not against her, in the management of the children, always upholding the nurse's authority before them, even though she after- ward explain to her in private that she differs with her, and wishes in the future that some other line of action be pursued. A word with regard to French and German nurses. If it is a difficult matter to find a thoroughly good nurse among the large number of English-speaking nurses, how much more among the much smaller number of French and German ones who present themseh'es! If a mother desires to employ one of foreign race, she should first of all see that she has the qualities of a child's nurse. That the child learn a foreign language is far less im- portant than that it be well cared for in body and mind. Moreover, there is a very strong temptation, hard to resist, to insist upon the child spending almost all its time with the nurse, in order that it may have the greatest opportunity to acquire her language. Xo THE BABY'S NUJ^SES. I95 mother who loves her little one can afford to run the risk which this entails. 4. The Trained Nurse. The nurse trained especially for the care of the sick is the last one of the baby's caretakers to whom we must turn our attention. In cases of slight illness, or even in more serious disease, the mother with the help of the nurse-maid may be able to carry out the directions of the physician without outside help. Often, however, this is almost impracticable. A sick child demands the constant attention of some one, and it is frequently an utter im- possibility for a mother to attend properly to the patient and to look after her other duties. Moreover, of all things, experience is to be desired in the care of sick- ness, and a young mother has usually had no chance to acquire it. Fortunately, in many of the larger cities a skilful trained nurse can now be readily obtained. Such a nurse is more than a luxury. She brings with her the great- est comfort to the inexperienced mother and increased chances of recovery to the child. Unless the expense absolutely forbids, every child who is or who is likely to become seriously ill should promptly be provided with a trained nurse. A good nurse is just as important as a good doctor — yes, even more so, for the skill of a doctor cannot avail unless his directions are carefully carried out. The mother's anxiety and her disposition to yield to the child's wishes greatly interfere with her judgment and her ability to nurse properly. The employment of a nurse, however, does not mean that all authority is to be taken from the mother. The child is hers; her duty to it remains the same, and she is still mistress in the house. The nurse is her employee, 196 THE CARE OF THE BABY. and will obey her directions if she gives them. At the same time, the nurse is directly answerable to the phy- sician, and dare not, if she is faithful, disobey his orders. As she has been engaged to assume the responsibility of the nursing and to exercise her trained skill in the care of the child, the mother will be chary of interfering, unless she sees to a certainty that things are not going well and that the nurse is not as competent as she ought to be; and even then she had better talk the matter over with the physician first. The special qualifications of a trained nurse are beyond the province of this volume, and can be referred to but briefly. The nurse should have been thoroughly taught in a training school connected with a good hospital, and she should have had special experience in the nurs- ing of sick children. Many a nurse is excellent with adults, but does not possess the peculiar knack of caring for a sick child. An old woman who has merely gathered together a lot of useless or harmful theories and practices may have had a deal of "experience," but it may only have confirmed her in her fatal mistakes. Such a woman is to be avoided carefully, as she is no more a trained nurse than an "herb doctor" is a physician. This by no means implies that all elderly women without hospital training are worthless, for many of them are excellent. Still, a hospital nurse is usually to be preferred. A trained nurse should be young and strong, docile, alert, self-possessed, and gentle of hand, step, and voice. She should be neat in appearance and very clean. She will wear wash-dresses, slippers, and a nurse's cap, all of which are not intended as a mark of her office only, but have their distinct purposes of cleanliness and quiet as well. Her experience should have taught her to observe care- fully the different evidences of disease, which we shall THE BABY'S NURSES. 1 97 study in a later chapter, and to understand to a consider- able extent what they indicate. If she has been well trained and is capable, she will at once take charge of the ordering of the sick-room and the diet of the patient, and will inspire a feeling of relief in the mind of the anxious mother — and of the doctor, too — such as no words can express. She will see that the child's food is pre- pared properly, and it is her duty even to go into the kitchen and to prepare it herself if it cannot be managed otherwise. Of course this cannot be done in cases of contagious disease, since she must then not go through the house to any extent. In diseases of this nature the nurse cannot associate with others of the household. She must sleep and eat in the sick-room or in an adjoining room connected with it, and she should pass through the house only on her way out for her daily walk, stopping to talk with no one and entering no other room. In preparing to go out she should wash her hands thoroughly with carbolized water (Appendix, 92) and change her slippers for walking-shoes and her wash-dress for her street-ofown. After the disease is over she will take the proper steps for disinfecting the room. These will be described in Chapter X. If a mother is herself nursing a child with an infectious disease, she must separate herself absolutely from her other children, and follow in all respects the rules given for the conduct of the trained nurse. As with the nurse-maid, there is a duty of the mother to the trained nurse. The nurse is not made of iron, as seems often supposed, and if she is to accomplish the best results for the child she must have regular times for sleep and outdoor exercise. Worn out by watching, she may easily overlook her duties, administer the wrong medicine, or make some other serious blunder. In their 198 THE CARE OF THE BABY. interest in their patients nurses frequently forget this fact. The mother must see that the nurse takes sufficient sleep and fresh air, that she is well fed, and that her garments are laundered for her. In very severe and prolonged cases two nurses are needed, or the mother must arrange that she or some one else take turns with the nurse. CHAPTER X. THE BABY'S ROOMS. However much we may desire to select rooms for the baby according to some definite fixed rule, such an arrangement is manifestly impossible unless we build a house to suit the baby, and then occupy it uninterrupt- edly. Frequently not what is best, but what is possible, is the plan which must be adopted. This applies par- ticularly to those occupying hotels or boarding-houses, but even to householders to a considerable degree. The advice given in this chapter is intended to be followed as closely as circumstances will permit. The baby's first room is, of course, that of the mother. Here it was born, and here it will probably remain until it is several weeks old at least. Later, two rooms should be provided for its occupancy — the one for its waking hours, and the other to sleep in at night and when taking its morning and afternoon naps. These rooms must be selected with the greatest care, as they are the most im- portant in the house. As the child grows older the selec- tion of other rooms is to be considered — namely, the sick- room and the school-room. The principles which govern the choice of any of these rooms apply equally well in THE BABY'S ROOMS. 1 99 cases in which necessity compels the children to share their apartments with other members of the family. I. The Day Nursery. The position of the day nursery is a matter of much moment. As the family can rarely undertake to provide one nursery for summer and another for winter, the selec- tion of the room must be made with reference to its suitability in winter-time, since in warm weather the child will be nearly the entire day out of doors, or very possibly with the family at a summer resort. It is neces- sary, therefore, to choose for the day nursery the brightest, airiest room in the house. Sunlight in the room is of inestimable value. The exposure should preferably be south. If this cannot be had, a room with a window looking east is rather better than a westward outlook, on account of the presence of the morning sun. A corner room with large windows opening south and west is the ideal one. Indeed, there should always be more than one window if it can be had. In the warm season the heat of the sun can be modified by the use of blinds or awnings. There may be difficulties connected with the heating, or some other conditions which render a certain room undesirable, although the exposure is all that can be wished. Naturally all the various circumstances must be taken into consideration. The nursery should not be upon a level with the ground, as it is apt to be too damp. The third story is the best, provided it is not directly under the roof. More light, air, and dryness can usually be obtained at this elevation, while the noise in the house is less liable to disturb the nursery, or that in the nursery to annoy the rest of the house. The room should have as much air- space as possible. There ought to be from 500 to 1000 200 THE CARE OF THE BABY. cubic feet for each individual occupying it. The num- ber of cubic feet is easily calculated by multiplying the length of the room by its breadth, and the result by the height. Estimating looo feet as the supply required for each person, a room lo feet high, 15 feet wide, and 20 feet long would accommodate two children and the nurse. This does not, of course, mean to the exclusion of proper ventilation, and as the number of inmates is often greater than this, and the room no larger, or even smaller, ventilation must be still more carefully at- tended to. The ventilation and heating of the room is often a difficult problem. Proper ventilation consists in provid- ing a constant and abundant supply of fresh air, yet without draughts. A house built to accomplish success- fully both heating and ventilating will supply fresh w^arm air and will remove through ventilators the air already used without the necessity of opening a window. Few houses, however, are constructed in this way. In a dwell- ing as ordinarily built, without this system, an open fire- place will furnish a method of removing air that is unex- celled, except that it is prone to create draughts upon the floor, which must be particularly guarded against. Where there is no fire-place a ventilator connected with a chimney may be put in the upper part of the wall and the foul air removed in this way. Furnace heating through flues and a register supplies fresh warmed air from without. If fresh air must be admitted from a window, it is very important to have it done in a way to avoid draughts. This may be accomplished by the use of an ordinary ventilating-board. This consists of a board 4 to 6 inches high, m^de to fit accurately below the lower sash, which \z closed upon it. In this way air i-s admitted between the upper and lower sashes. In THE BABY'S ROOMS. 20] place of fitting under the lower sash the board may be lo or 12 inches high and may be placed against the inside of the window-frame. If the lower sash is now raised 2 or 3 inches, air enters below and is directed upward between the sash and the board, at the same time that it also enters the room between the sashes, thus producing two currents. An improvement upon this arrangement is the apparatus shown in the illustration Fig. 41. — Window ventilator: view from inside the room. (Fig. 41). The pipes, of which the bent portion is upon the inside of the room, serve to direct the cold air upward and thus to prevent draughts. By a damper in each the amount of air entering can be regulated at pleasure. The board itself is of two pieces which slide upon each other, thus allowing the apparatus to be fitted under the sash in a window of any breadth. This ventilator can be obtained of any large hardware or house-furnishing store. Another apparatus sometimes used is the revolv- ing-wheel ventilator, which may be set in one of the upper window-panes, and is made to rotate by the pas- sage of the air through it. A wooden frame covered with cheese-cloth or thin muslin, and made to fit in the window like a fly screen, admits air freely but checks draughts, and is sometimes useful. Besides this constant ventilation "the room must be aired thoroughly with wide-open windows once or twice 202 THE CARE OF THE BABY. a day, at a time when the child is absent, and then be well warmed before it is used again. For heating the nursery probably nothing as yet takes the place of a good hot-air furnace, since this is both easily controlled by opening or closing the register, is more efficient in cold weather, and aids ventilation by supplying fresh warm air from without. The air, it is true, is often too dry, particularly when the ordinary furnace supplied with drums and hot-air chamber is used. It is also liable at times to carry coal-gas with it. Air coming in flues from over hot-water pipes is prob- ably preferable. The dryness may be modified to a cer- tain extent by placing vessels containing water imme- diately in front of the register. An apparatus for this purpose, consisting of a perforated metal case containing a porous pottery vessel of water, and made to hang in front of a wall register, has been placed on the market. It is a good plan to have the registers rather high in the wall, as this puts them where they cannot be touched by the children, and tends also to prevent draughts. Heating by steam radiators is very effectual, but more difficult to control; moreover, it fails to aid sufficiently in ventilating. Gas stoves should never be employed unless they are supplied with smoke-pipes connected wath the chimney or passing through a hole in the window or wall, as otherwise they fill the air with the products of combus- tion. The open fire-place is the ideal form of heating in moderately cool weather, although wasteful of fuel. In severe weather, however, it heats too unevenly, making one portion of the room very hot and leaving the rest cold. The ordinary air-tight coal stove is very service- able for heating, but is of little use for ventilation. Cer- tain stoves of special manufacture supply ventilation as well as heat. It is very important that stoves, fireplaces, THE BABY'S ROOMS. 203 hot registers, radiators, and all lights in use be so guard- ed that there can be no possibility of the baby burning itself. A couple of thermometers should be placed in different parts of the nursery, away from the windows or the heating apparatus, and one of them should certainly be near the floor, since the air is often so much cooler there, and a child's whole body is so much closer to the floor than an adult's is. The temperature ought to be kept as uniform as possible, 70° F. being the extreme of heat allowed, and 66° to 68° being a much better temperature. In this connection must be mentioned the fact that in cold weather there is always a draught of air from a win- dow, even when closed. Weather-stripping will prevent some of this, but the greater part of it is due to the chill- ing of the air by the cold glass. This is remedied to a considerable extent by the use of double sash, but, as it is not entirely hindered, it is better in very cold weather not to allow the child to play near a window, and per- haps not upon the floor at all. The furnishing of the nursery should be of such a nature that cleanliness can be strictly enforced, partic- ularly if the room is to be used at any time as a sick- room. The floor should be well made, with the boards closely joined and smooth, all the cracks and holes stopped with putty, and the whole painted or, still better, finished with varnish or oil in the natural wood ; or if the floor is old and poor it may be covered with oil-cloth. Carpeting of some sort is an essential, but it had better not be tacked to the floor. If made in the form of one or more rugs, both they and the floor can be cleaned more easily. The walls of the room are best painted a bright, cheer- ful tint, and the ceiling likewise. If paint cannot be used, 204 THE CARE OF THE BABY. a wall-paper may be chosen which can be washed. Paper of this nature, coated with a sort of varnish, can readily be obtained. It will bear sponging with plain water, but soap may injure it. The wall-paper ought not to con- tain colors made with arsenic, and any old paper ought to be removed previous to repapering. Some large open shelves against the wall are a very great convenience. Bright-colored, cheap pictures may adorn the room. More expensive ones are to be tabooed, since circum- stances may arise, such as the occurrence of some con- tagious disease, which may render it advisable to destroy them. An important matter is the fitting of all windows with firm bars to prevent the children from falling out. There should also be a swinging or sliding gate in the doorway to keep the baby from reaching the stairway. The latch to the gate must, of course, be out of reach, on the side away from the nursery. The furniture of the nursery should be strong, light, plain, and easily cleaned. Upholstered pieces are not desirable. Both large and small chairs, with and without rockers, are needed, and a low table at which the chil- dren can play and, if desired, take their meals. None of these articles should have sharp corners, and the rock- ing-chairs are better if of the swinging style without visible rockers. "There is also needed a ''nurser}' chair" — a little wicker or wooden chair with a hole in the seat and a place for the proper vessel below. This chair should never be used for any other than the one purpose. A tall light screen is a very serviceable article for the cut- ting off of lights and draughts. Much of what has been said sounds as though the nur- sery were to be a bare and ugly room, but this is far from being the case. There is a large range for the exhibition THE BABY'S ROOMS. 205 of taste in furnishing. The carpet may be as pretty as one wishes, although it had better be inexpensive. Painted walls can always be made to look well if the tints are good. In addition, the room may be provided with a canary bird, the pictures referred to, a globe of gold-fish, some growing plants, and similar objects. Such a nursery, when occupied by a child happy with its toys, cannot but present as pretty a sight as one could desire. It may be said here that growing and flowering plants, with possibly the exception of those producing a heavy odor, are never injurious in the nursery, either by day or by night, and are perhaps even beneficial. The nursery should be kept scrupulously clean. Be- sides the daily dusting, the rugs should be taken up once a week, and the floor, as well as the furniture and wood- work in general, washed with a damp cloth. The wiping off" of the walls from time to time must not be forgotten. No food or empty dishes or nursing-bottles should be allowed to stand about, and soiled diapers or receptacles containing urine or evacuations from the bowels must be promptly removed. Closets should be inspected fre- quently, lest something unpleasant have been put away in them. In fact, every precaution must be taken to keep the air sweet and clean. The effort to preserve the air pure suggests the question regarding the stationary wash-stand. There is a great prejudice among many against them. A well-trapped stationary wash-stand fitted with the best modern traps, and with additional careful trapping of the main drain- pipe of the house before it passes to the sewer, is probably entirely devoid of danger if flushed often and if inspected by a good plumber at frequent intervals. Nevertheless, since severe sickness mav result from draining^ which is not so perfect, it is sometimes thought better to have no 206 THE CARE OF THE BABY. plumbing at all in either the day or the night nursery. A wash-stand of doubtful plumbing may either be plugged with putty or, still better, cut off from the sewer. Any wash-stand may be made perfectly safe by having it empty through a special pipe not connected with the sewer in any way. It may, for instance, discharge into the rain-water pipe from the roof, provided this does not join the sewer, as so many of them do. The latter arrange- ment would be far worse than the ordinary one. Wash-stands should be kept perfectly clean, and never used as slop-sinks. They should be washed frequently with a strong soda-solution, ammonia, or a solution of copperas or carbolic acid (Appendix, 92). This will deodorize the pipe on the room side, but does no good whatever as a disinfectant if the plumbing is imperfect. 2. The Night Nursery. In the numerous cases in which a family cannot arrange to set aside a room especially for the night nursery, the children must sleep either in the day nursery or in the mother's room. Indeed, where there is but one child a nieht nurserv is hardlv needed, but where there are several children in the house, attended by a nurse, it is a very great convenience. The night nurser}' should be used whenever the children sleep, whether by night or by day. The qualifications necessary for it are to a consid- erable extent those desirable for the day nursery. Since it is so strongly advisable that a mother keep some w^atch over her children at night, the night nursery ought to be somewhere near the mother's room — indeed, connected with it if possible. Ventilation must be provided for at night in the manner already described for the manage- ment of the day nursery. The sleeping-room should also be thoroughly aired after each occasion on which it THE BABY'S ROOMS. 207 is used, and then warmed again to remove all traces of dampness. The temperature at night should be 60° to 65° F. It is not Lest to throw the windows widely open and to allow the children to sleep in a cold room. Such a procedure is exceedingly likely to bring on catarrhal troubles. The furnishing of the sleeping-room is similar to that already described for the day nursery, as regards the floors, walls, carpet, and the simplicity of furniture. There should be in it several chairs, a bed for the nurse, and one for each of the children. The beds must be carefully placed to be out of all draughts. The use of folding screens is often a great aid to this end. The bath-tub and other articles for the toilet may be kept either here or in the day nursery, according as it is found most convenient to make the children's toilet in the one or the other place. This applies also to the chest of drawers which contains the clothing. Should the night nursery be used for the morning toilet of the chil- dren, the temperature should be elevated to 68° or 70° F. before it is performed. In the lighting of the night nursery it is to be remem- bered that the burning of any ordinary light con- sumes a great deal of oxygen in the room, besides filling the air with harmful substances. One ordinary gas-burner uses per hour as much pure air as several adult persons. Nevertheless, artificial light of some sort is a necessity in the mornings and late afternoons of win- ter. Gaslight is probably the least objectionable kind or- dinarily to be had, but if the gas furnished is of bad qual- ity the products of its combustion will be more than usu- ally harmful. In such a case oil lamps or candles should be used — as, of course, they must be where there is no gas in the house. Ordinarily, oil is not to be preferred, 2o8 THE CARE OF THE BABY. because it is much more dangerous from the chance of the lamps exploding or of being upset by children. When it is possible to do so, it is a good plan to have the lights placed immediately beneath a pipe which is con- nected with the chimney. This will carry off the prod- ucts of combustion, although it does not, of course, pre- vent the consumption of oxygen. Nothing equals elec- tric lighting for a nursery, since it is not only less hot, but consumes no air at all and is destitute of danger to the children. It is better that children be accustomed to sleep with- out light in the room. Should it be found necessary to have a light all night long on account of the frequent rousings of the baby, a night-lamp of some form is the best. Different forms of this may be obtained at the drug-stores. They are so constructed that they will con- FlG. 42. — Pyramid night-light. tinue to burn faintly during the entire night, and they consume a minimum of the oxygen of the air. A good form is the "Pyramid night-light" (Fig. 42). It is pro- vided with a small glass chimney, which has the advantage THE BABY'S ROOMS. 209 of protecting the flame from currents of air and making it steadier. The light is furnished by a small candle, about an inch and a half in height and breadth, which is sur- rounded by a thin layer of plaster of Paris to ensure entire safety. A dark metal shade with an opening on one side only may be fitted over the night-light to keep the rays from falling upon the sleeping child. When a house is provided with an electric current an electric lamp of special device, giving but one candle power, can be used as a night-light, or the ordinary electric lamp may be partially covered by a dark screen. 3. The Sick-room. Ordinarily, either the day or the night nursery must serve as the sick-room as well, the choice between them depending upon circumstances. Where, however, one of several small children in a family is taken seriously ill, quiet and careful nursing are required, or, perhaps, isolation on account of the disease being of a contagious nature. It is then almost a necessity to choose some chamber to serve as a special sick-room for the time being. The following description is of a sick-room suit- able to meet the requirements of contagious diseases in particular: The room should be large and airy, with plenty of sun- light, unless the condition of the child's eyes or of its nervous system renders light objectionable. All the old ideas about the ' ' darkened room ' ' as appropriate to sick- ness are things of the past among intelligent people. Even when the eyes are inflamed a great degree of dark- ening is not needed if a screen will serve to give suffi- cient protection. The room should be at the top of the house, if possible, and on an entirely different floor from that containing rooms occupied by other members of the 14 2IO THE CARE OF THE BABY. family, particularly children. All unnecessary articles of furniture should be removed, and pictures, curtains, and carpetings put away if they have any value. Chests of drawers and closets in the room should be emptied of their contents. If it is desirable to keep the apartment from looking bare, some cheap curtains may be placed at the windows, and one or two old small rugs or pieces of carpet be laid upon the floor. These may be destroyed when the illness is over. Great care must be taken to preserve strict cleanliness. The floor and furniture should be wiped off" with a damp cloth at frequent inter- vals, but no sweeping can be permitted. No empty dishes with remnants of food, and no ofiensive articles, must be allowed to remain. It is difficult, and sometimes impossible, to prevent the disease from spreading through the house. Certain pre- cautions regarding the room are necessary, but to be of value they must be of a radical nature. Vessels contain- ing so-called ''disinfectant" substances standing about the room are absolutely useless, and simply serve to make a bad smell. If the house permits of having another room, large or small, opening into the sick-room, the task is much lighter. A sheet constantly moistened with a disinfectant solution (Appendix, 92, 94) should be hung at the outer doorway of this anteroom, and the door be kept closed. The windows of the anteroom may be kept open most of the time if the weather permits, and in this room all plates, forks, spoons, nursing-bottles, etc. that have been used may first be washed in ordinary water and then placed in a disinfectant solution for a time (Appendix, 92). There should be in this room a wash-tub filled with this solution, in which all linen used about the patient or the bed can soak for some hours. After this it may be wrung out and placed in a bucket, THE BABY'S ROOMS. 211 and can then be carried to the laundry without danger to the household. Immersion in boilino^ water kills all germs. Warming of milk or the preparation of any- liquid articles of diet may be done in the anteroom, and anything brought from the kitchen or elsewhere in the house may be received by the nurse at the door of this room and then taken to the sick-room. When the illness is over the sick-room and anteroom must be thoroughly disinfected. The floors must be washed with carbolic acid or corrosive sublimate (Appendix, 92, 96, 97), and the walls and ceilings, if painted, be treated in the same manner. Paper on the walls, if it cannot be washed, should be removed and new paper applied. The furniture and bedsteads may also be washed with the disinfectant solution — avoiding, however, the use of corrosive sublimate upon metal. The disinfectant solu- tions are very poisonous if swallowed, and must be used with care. If the mattresses and pillows are well reno- vated by steam and re-covered, they are entirely safe, but if they are small and old and can well be spared it is best to destroy them. In some of the larger cities the health authorities will undertake the thorough disinfec- tion of articles of this kind. As a final additional pre- caution in disinfecting the room, it has been the custom to burn sulphur in it, although it is still disputed how effectual this is. The health authorities will attend to this also if desired, but the nurse or mother can do it just as well. Sulphur fumigators come already pre- pared for the purpose, and with printed directions. They may be had of the leading druggists. In place of these the broken roll sulphur may be placed in a tin vessel, slightly moif.tened with alcohol, and ignited. Three pounds of sulphur are required for every thou- sand feet of air-space in the room. The windows of the 212 THE CARE OF THE BABY. room should be closed tightly, and all the cracks about them and the doors, as well as the key-hole, stopped with cotton or paper. The pan of sulphur is then floated or supported in a tub of water to prevent setting fire to the floor, the sulphur is ignited, and the door closed. If the sulphur fumigators are employed, the box should be placed in a dish half filled with earth. After at least six hours the door may be opened, the sashes raised, and the room well aired. If it is not possible to have the mat- tress and pillows steamed, they should be left in the room during the fumigation, first partially opening them so that the fumes of the sulphur may penetrate them better. A much better plan is the disinfection of the room with formalin, which is volatilized over a special forma- lin lamp, for sale by druggists. Formalin has been found to be far superior to sulphur as a germ-destroyer. The requirements of the sick-room are, of course, modified somewhat if the disease is not contagious. There is no need of an anteroom or of moistened sheets and the like. It is still useful to have the room well out of the way if the disease is one which demands quiet, and it is just as well, too, to have no unnecessary furni- ture in it. The practice of covering tables and shelving with all the bottles and boxes of medicine which have been in use since the illness began renders the room very imsightly and adds greatly to the evidence of sickness, besides opening up the possibility of giving the wrong medicine. Medicines no longer wanted should be re- moved entirely, and those still in use should be concealed in a convenient place. The ventilation and heating of any sick-room are mat- ters of the greatest difficulty. While fresh air is even more important than during health, yet in many diseases THE BABY'S ROOMS. 213 the child is peculiarly susceptible to draughts and to changes of temperature. Very often the same method of window ventilation can be employed in the sick-room as recommended for use in the nursery, provided the bed be carefully protected against draughts. Sometimes additional ventilation may be secured by covering the patient entirely with the bed-clothes and opening the windows wide for three or four minutes. This plan, however, makes a decided alteration of the temperature of the room, and is dangerous in many diseases. It should not be done except by the advice of the physician. In some cases, as in measles, scarlet fever, or any disease of the lungs or bronchial tubes, it often seems impossible to open the windows in the slightest degree without danger of giving the child cold. Where there is an open fire-place or a good ventilator in the room the difficulty is largely solved, as either of these will serve to provide sufficient ventilation, the pure air entering by the cracks of the windows and doors; but even with this method we must be on the lookout for draughts, so susceptible to them do children with these diseases become. The existence of currents of air can be sought for by going about the room with a lighted candle or a burning match and testing the cracks of doors, windows, closets, wash- boards, etc. It is not that we wish to stop all entrance of air from these places, since that would interfere with the foul air going out. It is only necessary that we place the bed so that it is not exposed to the air-currents. In the absence of a fire-place, in these susceptible cases, ventilation must be procured from an adjoining room where the air is kept fresh and warm. As a means of rapidly deodorizing a room the burning of aromatic pastilles, to be procured in the drug-stores, is very serviceable. Burning coffee has much the same 214 THE CARE OF THE BABY. effect. Of course, nothing of this sort in any way takes the place of ventilation. In some diseases, particularly those of the throat or the lungs, it may be desirable to have the air kept constantly moist. This may be accomplished by boiling water in a flat, shallow pan over an alcohol flame. If it is desired to bring the moisture still closer to the child, water may be boiled in a kettle, and a tube connected with the spout may be brought close to the face, taking care, how- ever, that it is far enough removed to avoid too great heat. We do not desire to give the child steam, but water vapor. An apparatus for this purpose, known as the croup kettle (Fig. 43), may be purchased from the Fig. 43. — Croup kettle. Fig. 44.— Steam atomizer. instrument-maker or druggist. A ver}' satisfactor}' appa- ratus for producing moisture in the room is the steam atomizer, for sale by druggists and instrument-makers (Fig. 44). The bringing of the vapor close to the patient 1 THE BABY'S ROOMS. 215 is still further aided by draping a couple of sheets over the bed to form a ''croup tcnt^'' so that they fall down well about it, and are open at one side only, like a tent door (Fig. 45). Broom-handles fastened upright, one at Fig. 45. — Croup tent. each corner of the crib, and connected by cord at their tops, form a framework of the proper height to support the tent. Where it is desired to make the vapor aromatic with such substances as turpentine, oil of pine, oil of eucahptus, and the like, the best way is to pour these into the shallow pan of boiling water or the croup kettle referred to, being careful to avoid the flame. (See Ap- pendix, 98.) The temperature of the sick-room should be very uni- form, and should be about that of the day nursery. When the air is being kept constantly moist the tempera- ture should be slightly higher. In the sick-room or in the day nursery or night nursery 2l6 THE CARE OF THE BABY. there should be a medicine-chest or wall-closet. Here should be placed such remedies and appliances as a mother is justified in using herself. A list of articles which should be constantly kept in the medicine-closet, ready for use in cases of emergency, will be found in Appendix, iii. No dangerous medicine should be placed in this closet, except under special precautions. Bottles containing laudanum or paregoric, belladonna and other poison, or any fluids to be used externally should never be placed here unless of such a nature that they may be recognized readily even in the dark. If this precaution is not followed, some dreadful accident may happen. A ''poison-guard" may be had in the drug-stores. A. I&CSO^ ^^ consists of a little wooden ^/ ffevV'^ ^^^^ ^^^^^ ^ chain attached (Fig. 46). It is to be fastened to the neck of the bottle, and serves to call attention to the fact that the contents are dan- gerous, or only to be used ex- ternally. There is a still better device, consisting of a bottle moulded with points projecting after the fashion of cut-glass (Fig. 47). The dangerous nature of the contents is perceived the moment the hand touches it. All the household medicines and the articles for use in emergencies should invariably be kept in the closet, and nothing else should be placed there. In this way there will be no confusion when a mother wants anything in a hurry. Do not keep all the half-used medicines remain- ing from what the doctor has ordered at various times. A Fig. 46.— Bottle with poison-guard. Fig. 47.— Poi son-bottle. THE BABY'S ROOMS. Z\J few of them might be of service in the future, but the majority were good only for the occasion when ordered, and the closet will soon be filled to overflowing with them. Do not forget to keep the closet locked, and the key in a safe but accessible place. I have known of a little child, with a fondness for *' playing doctor," seriously drugging the bab>' of the family as a result of the neglect of this precaution. A ver>' serviceable article for use in the sick-room or nursery is a small nursery refrigerator, which serves to keep ice or milk or other foods during the night. As ordinarily made this consists of a small metal vessel, eighteen inches or two feet long, with the lid, bottom, and sides of two layers — the outer one of tin and the inner of zinc — with a narrow space for air between them. A simple method of preventing ice from melting is to put it into a tin or wooden pail, around and rising above which is a hood of several layers of newspaper. The paper is gathered together and tied above the ice. Some arrangement for the heating of food at night is serviceable during illness. There are various appliances made to fit over a gas-jet or on the chimney of an oil-lamp, and upon wliich a cup or other vessel may be heated. In place of these a small alcohol pocket-stove can be pro- cured. A vessel for warming the food has been described on page 144. 4. The School-room. Unfortunately, the furnishing and the regulating of the school-room are generally beyond our control. We can- not here consider at length the method of constructing a school-building to furnish the proper light, heat, and ventilation so greatly to be desired. It is certain that colds, near-sightedness, backache, headache, and various 2l8 THE CARE OF THE BABY. nervous derangements may be expected as the result of a defect in the hygiene of the school-room, even though no mental overwork be indulged in. If the nursery with two or three inmates should be well ventilated, how much more important is the ventilation where a large number of children are collected in one room! Parents should refuse to send their children to a school, however desirable in other respects, if it is plainly apparent that there are going to be constant draughts on the one hand or great lack of proper air-space on the other. In rural districts, or even in the city, parents who em- ploy a nursery governess may prefer their children to be taught at home. In such case the day nursery will often be the room chosen, and its fitting qualities require no further comment. In other instances several families may combine in the employment of a governess, and will desire to select in one of the dwellings a room which will be suitable for the purpose. On this account a few remarks will not be out of place upon some of the re- quirements of the ideal school-room, as well as upon some of the dangers of an unsuitable room. They may, indeed, be useful even to those whose children regularly attend school, for the subject is one with which we all should be somewhat familiar. One of the most im- portant considerations in this connection is the danger of the production of spinal deformity. A lateral curv- ature of the spine is likely to develop, especially in girls with weak muscles, as the result of sitting in school with- out proper support to the back, or of improper position assumed while writing or while standing at recitation. To avoid this deformity it is important that the child stand squarely upon both feet when reciting, and espe- cially that the desk and chair be of a proper kind. Many of these are very harmful, and produce a habit of stoop- THE BABY'S ROOM. 219 ing that may never be recovered from. The chair should allow the child's feet to rest upon the floor, and should have a back which thoroughly supports the lozver por- tion of the spine. This latter feature is of the greatest importance, but is very frequently wanting. The upper part of the chair-back should slope slightly backward to support the remainder of the spine when the child is at rest. In some excellent chairs the chair-back does not extend as high as the shoulders, since no need of support is felt if the hollow of the spine and the part below it are properly sustained. The low-backed chair is the only form that gives support when the child is writing, since it allows of the chair being kept close to the desk with- out the elbows hitting anything behind them. The desk-lid is often too high, and as a result the right elbow is too much elevated. This produces a twist of the spine, which after a while becomes permanent as a lateral curvature. (Compare illustration on page 280). The edge of the desk-lid nearest to the child should reach only just as high as the elbows, and should over- lap the edge of the seat. The child should face the desk squarely, with both arms resting upon it. A desk which is too high and is not properly placed not only tends to produce deformity of the spine, but also brings the book on it too close to the eyes and produces near-sightedness as a result. Other affections of the eyes, followed by headache and other symptoms, result from the use of the eyes in an insufficient light or from facing too bright a light. The windows should be at the back of the room and upon one side, preferably the left, since this does away with trying cross-lights. Of course, the same pre- caution regarding the proper arrangement of lights must be looked after when the child is reading at home. As to the actual size of the school-room required, it is 220 THE CARE OF THE BABY. calculated that there should be 300 cubic feet of air-space for every scholar. For a class of forty scholars this will require a room 28 by 32 by 13 >^ feet (Lincoln). To make this amount of air-space sufficient to keep the room in a proper condition it is necessary that the air be completely changed six times in an hour. Manifestly an ordinar}^ school-room with closed windows and no efficient system of ventilation does not accomplish this. No wonder the poor children grow sleepy and find study hard work! CHAPTER XI. THE SICK BABY. This chapter, necessarily a somewhat long one, must not be viewed as an effi)rt to render a mother capable of "doctoring " her own children. Such an attempt would be a hopeless one, inasmuch as with the treatment of a sick baby the experienced physician often has his hands far more than full. It is intended only to impart such knowledge as will enable a mother to know whether the child is ill, what is probably the nature of its ailment, whether she shall send for a physician, what she shall do before he comes, and how she shall carry out his direc- tions afterward. The actual treatment of disease, except of the simplest kind, cannot be considered. It is far wiser for the mother to meddle very little with the baby's illnesses. We may conveniently divide our subject into — I. The Features of Disease; II. The Management of Sick Children; III. The Disorders of Childhood. THE SICK BABY. 221 I. The Features of Disease. We have already considered, in Chapter II., the cha- racteristics of a healthy baby, often called ' ' the features of healthy Bearing these in mind, we can now deal with some of the ' ^features of disease.^ ' ' in order that we may see what can be learned by close observation of a sick child. 't\\^ position assumed in sickness is a matter of impor- tance. A child feverish or in pain is usually very restless even when asleep. When awake it desires constantly to be taken up, put down again, or carried about. Some- times, however, at the beginning of an acute disease it lies heavy and stupid for a long time. In prolonged ill- nesses and in severe acute disorders the great exhaustion is shown by the child lying upon its back, with its face turned toward the ceiling, in a condition of complete apathy. It may lie like a log, scarcely breathing for days before death takes place. Perfect immobility may also be seen in children who are entirely unconscious although not exhausted. A constant tossing off of the covers at night occurs early in rickets. A baby shows a desire to be propped up with pillows or to sit erect or to be carried in the mother's arms with its head over her shoulder whenever breathing is much interfered with, as in diphtheria of the larynx and in affections of the heart and lungs. The constant assumption of one position or the keeping of one part of the body still may indicate paralysis. When, however, a cry attends a forcible change of position, it shows that the child was still be- cause movement caused pain. Sleeping with the mouth open and the head thrown back often attends chronic en- largement of the tonsils in young children, although it may be seen in other affections which make breathing difl&cult. In inflammation of the brain the head is often 222 THE CARE OF THE BABY. drawn far back and held stiffly so. Sometimes, too, in this disease the child lies upon one side with the back arched, the knees drawn up, and the arms crossing over the chest. A constant burying of the face in the pillow or in the mother's lap occurs in severe inflammation of the eyes. The gestures are often indicative of disease. Babies often place the hands near the seat of pain: thus in slight inflammation of the mouth, such as may accompany painful teething, they tend to put the hand in the mouth; in earache to place it to the ear; and in headache to raise it to the head. In headache or in affections of the brain they sometimes pluck at the hair or the ears, although they may often do this when there is no such trouble. Picking at the nose or at the opening of the bowel is seen in irritation of the intestine from worms or from other cause. The motion of the hands is often, how- ever, deceptive. For instance, a child with pain in its chest may sometimes refer it to the abdomen and place its hand there. In approaching convulsions the thumbs are often drawn tightly into the palms of the hands and the toes are stiffly bent or straightened. Ver}' young babies, however, are apt to do this, although healthy. The alternate doubling up and straightening of the body, with squirming movements, making of fists, kicking, and crying, is an indication of colic. This is especially true if the symptoms come on suddenly and disappear as suddenly, perhaps attended by the expulsion of gas from the bowel. The color of the skin is often altered in disease. It is yellow in jaundice, and is bluish, especially over the face, in congenital heart disease. There is a purplish tint around the eyes and mouth, with a prominence of the veins of the face, in weakly children or in those with i THE SICK BABY. 223 disordered digestion. A pale circle around the mouth accompanies nausea. The skin frequently acquires an earthy hue in chronic diarrhoea, and is pale in any con- dition in which the blood is impoverished, as in Bright' s disease, rickets, consumption, or any exhausted state. Flushing of the face accompanies fever, but besides this there is often seen a flushing without fever in older children the subjects of chronic disorders of digestion. Sudden flushing or paling is sometimes seen in disease of the brain. The expressio7i of the face varies with the disease. Young, healthy babies have little expression of any kind except that of wondering surprise. In whooping- cough and measles the face is swollen and somewhat flushed, giving the child a heavy, stupid expression. There is also swelling of the face, especially about the eyes, in Bright' s disease. Repeated momentary crossing of the eyes often indicates approaching convulsions. A wrinkling of the forehead often denotes pain. In very severe acute diarrhoea it is astonishing with what rapidity the face will become sunken and shrivelled, and so covered with deep lines that the baby is almost unrec- ognizable. The same thing occurs more slowly in the condition commonly known as marasjmis. Often the face has an expression of distress in the beginning of any serious disease. If the edges of the nostrils move in and out with breathing, we may suspect some difficulty of respiration such as attends pneumonia. The baby sleeps with its eyes half open in exhausted conditions or when suffering pain. Chewing movements during sleep result from disordered digestion, and a smile in very young infants often has the same cause. The head ^y\\\\AX.'s, certain noteworthy features. Excess- ive perspiration when sleeping is an early symptom of 224 '^^^ CARE OF THE BABY. rickets. Botli in this disease and in hydrocephalus (water on the brain) the face seems small and the head large, but in the former the head is square and flat on top, while in the latter it is of a somewhat globular shape. (Compare illustrations, Plate III.). The fontanelle is prominent and throbs forcibly in inflammation of the brain, is too large in rickets and hydrocephalus, bulges in the latter affection, and is sunken in debilitated states. The disfigurements of the head immediately following birth will be described later in this chapter (p. 277). The chest exhibits a heaving movement with a drawing in of the spaces between the ribs in any disease in which breathing is difficult. A chicken-breasted chest is seen in Pott's disease of the spine, and to some extent in bad cases of enlargement of the tonsils; a "violin-shaped" chest in rickets; a bulging of one side in pleurisy with fluid; and a long, narrow chest, with a general flattening of the upper part, in older children predisposed to con- sumption. The abdomejt is swollen and hard in colic. It is also much distended with gas in rickets, and is constantly so in chronic indigestion in later childhood. It is usually much sunken in inflammation of the brain or in severe exhausting diarrhoea. It may be distended with liquid in some cases of dropsy. The study of the ay furnishes one of the most valuable means of learning what ails a baby. An unremitting cry is usually due to hunger, or sometimes to thirst, but scarcely any cry is so unappeasable as that of earache. We must remember that not every cry that ceases when the baby is nursed is caused by hunger. Some- times the cry of colic will be temporarily helped in this wa}'. Sometimes a persistent Qxy is due to pain of another nature — such, for instance, as that caused by the THE SICK BABY. 225 pricking of a pin. It may also be produced by the in- tense, constant itching of eczema. A paroxysmal cry, very severe for a time and then ceasing absolutely, is probably due to colic, particularly if accompanied by the distention of the abdomen and the movements of the body already referred to. If the baby cries every time it is picked up, it is probable that the pressure upon the chest while lifting it gives pain. This may be the result of rickets or of pleurisy. Crying when any one part is touched suggests, of course, that there is something wrong there. A sleepy child has a fretful cry, often with rubbing of the eyes and other evi- dences of its sensations. A freqnent, peevish, whining cry is heard in children with general poor health or discomfort. A single shrill scream uttered now and then is often heard in inflammation of the brain. In any disease in which there is difficulty in getting enough air into the lungs the cry is very short and the child cries but little, because it cannot hold its breath long enough for it. A nasal cry occurs with cold in the head. A short cry immediately after coughing indicates that the cough hurts the chest. Crying when the bowels are moved shows that there is pain at that time. A loud, violent cry coming on suddenly is very often an exhibition of temper. A child of two to six years, waking at night with violent screaming, is probably suffering from night-terrors. In conditions of very great weakness and exhaustion the baby moans feebly, or it may twist its face into the posi- tion for crying, but emit no sound at all. This latter is also true in some cases of inflammation of the larynx, while in other cases the cry is hoarse or croupy. Crying when anything goes into the mouth makes one suspect some trouble there. If it occurs with swallowing, it is probable that the throat is inflamed. 15 226 THE CARE OF THE BAB\. With the act of crying there ought always to be tears in children over three or four months of age. If there are none, it is an indication that the disease is serious, and their reappearance is then a good sign. The character of the cough is also instructive. A long- continued, loud, nearly painless cough, at first tight and later loose, is heard in bronchitis. A short, tight, sup- pressed cough, which is followed by a grimace and, per- haps, by a cry, indicates some inflammation about the chest, often pneumonia. There is a brazen, barking, **croupy '' cough in spasmodic croup. In inflammation of the larynx, including true croup, the cough is hoarse or even almost noiseless. The cough of whooping-cough is so peculiar that it must be described separately. Then there are certain coughs which are purely nervous or dependent upon remote affections. Thus the so-called "stomach cough" is caused by some irritation of the stomach or bowels. It is not nearly so frequent as mothers suppose. Irritation about the nose or the canal of the ears sometimes induces a cough in a similar way. Enlarged tonsils or elongated palate may also produce a cough. The breathing of a young child, particularly if under one year of age and awake, is always slightly irregular. If it becomes very decidedly so, we suspect disease, particularly of the brain. A combination of long pauses, lasting half a minute or a minute, with breathing which is at first very faint, gradually becomes more and more deep, and then slowly dies away entirely, goes by the name of " Cheyne-Stokes respiration" and is found in affections of the brain. It is one of the worst of symp- toms except in infancy, and even then it is alarming. The rate of respiration is increased in fever in propor- tion to the height of the temperature (see page 229). It THE SICK BABY. 227 is increased also by pain, in rickets, and especially in some affections of the Inngs. Sixty respirations a minute is not at all excessive for a child of two years with pneumonia, and the speed is frequently decidedly greater than this. Breathing is often very slow in disease of the brain, particularly tubercular meningitis. Poisoning by opiates produces the same effect. Frequent deep sighing or yawning occurs in brain affections, in faintness, or in great exhaustion, and may be a very unfavorable symptom. Breathing entirely through the mouth shows that the nose is completely blocked, while snuffling breathing is the result of a partial catarrhal obstruction. A gurgling in the throat not accompanied by cough may indicate that there is mucus in the back part of it, the result of a slight inflammation. "Labored" breathing, in which the chest is pulled up by each breath while the muscles of the neck become tense, the pit of the stomach and the spaces between the ribs sink in, and the edges of the nostrils move in and out, is seen in conditions where the natural ease of respiration is greatly interfered with, as in pneumonia, diphtheria of the larynx, asthma, and the like. Long-drawn, noisy inspirations and expirations are heard in obstruction of the larynx, as from laryngeal diphtheria or spasmodic croup. The rate of the pulse is subject to such variations in infants that its examination is of less value than it would otherwise be. In early childhood its ob- servation is of more value, although even then decep- tive. Unusual irregularity is an important symptom in affections of the brain and of the heart. Fever is accom- panied by an increase in the pulse-rate, the degree of which depends, as a rule, upon the height of the tem- perature (see p. 229). Slowing of the pulse is a very 228 THE CARE OF THE BABY. important symptom, seen particularly in affections of the brain, and sometimes in Bright' s disease and jaundice. The temperature and the method of determining it have already been referred to in Chapter II. It is of all things important to remember that in infancy and childhood fever is easily produced and runs high from slight causes. Al- though a very decided elevation should render a mother anxious to discover the cause, there is no reason why it should at once throw her into a paroxysm of fright. Even slight cold or the presence of constipation or slight dis- turbance of digestion may in babies sometimes produce a temperature of 103° or more. We do not speak of fever unless the temperature reaches 100°. A temperature of 102° or 103° constitutes moderate fever, while that of 104° or 105° is high fever, and above 105° very high. A tem- perature of 107° is very dangerous, and is usually not recovered from. The danger from fever depends not only upon its height, but upon its duration also. A temper- ature of 105° may be easily borne for a short time, but it becomes alarmiug if much prolonged. There is a notable tendency to variation of the tem- perature of fever during the day, but, contrary to the condition in health, the elevation at night is nearly always greater than in the morning. We do not need to be discouraged, therefore, should a child whose tempera- ture had diminished considerably in the morning have it become much higher by the evening. On the other hand, should a morning fever be only as high as that of the evening before, we may conclude that the tendency to elevation is really greater. A sudden fall of temperature is usually a favorable sign, but this is not always so, for unless it is accompanied by an improvement in the other symptoms, it may indicate that death is imminent. The various febrile diseases have each their characteristic THE SICK BABY, 229 course with regard to the height, duration, and variation of temperature, but the subject is too difficult to be dis- cussed in a book of this sort. With elevation of temperature from any cause there is a corresponding increase of the rate of both pulse and respiration. About eight or ten beats of the pulse and about two or three respirations may be added for each degree of temperature above normal. This ratio is equiv- alent to about one additional respiration for each three or four beats of the pulse. There are certain diseases, as pneumonia, scarlet fever, typhoid fever, and some others, where this normal ratio is not preserved. The rates, as given, hold good, especially for adult life. It is probable that in children the rate of increase of pulse and respira- tion for each degree of temperature is somewhat greater. Instead of elevation we sometimes find depression of temperature below normal. A temperature of 97° or less in the rectum is always alarming in children, and one of 95° rarely occurs unless the child is dying. Exhaustion from any cause, as from profuse diarrhoea, obstinate continued vomiting, or hemorrhage, is liable to produce a depression of temperature, and some de- gree of reduction is always present in babies suffering from insufficient nourishment, anaemia, or chronic dis- eases of the heart and lungs. So, too, after attacks of the various febrile diseases the temperature is liable to be below normal for some days. The /ojigjie of newly-born infants is generally whitish, and continues to be so until the saliva becomes plentiful. After this we usually find it coated in disturbances of the stomach and bowels and in nearly any disorder accom- panied by fever, although not, as a rule, so thickly as in adults. Yet we cannot lay so much stress on the coating of the tongue in the early years of life as in later years, 230 THE CARE OF THE BABY. for children with perfect digestion often exhibit coated tongues, while those with severe intestinal catarrh may often have tongues of perfectly natural appearance. In scarlet fever the tongue becomes bright red after a few days, and in measles and whooping-cough it is often slightly bluish. In the latter affection an ulcer' may sometimes be found directly under the tongue, where the thin membrane binds it to the floor of the mouth. In thrush the tongue is covered with white patches like curdled milk. A pale, flabby tongue, marked by the teeth at its edges, indicates debility or impaired diges- tion. In prolonged or very high fever the tongue grows dry, and in some diseases of the stomach or bowels it may look like raw beef Grinding of the teeth is a frequent symptom in infants in whom dentition has commenced. It generally indi- cates an irritated nervous system. Most often this depends upon some disturbance of digestion; less often upon the presence of worms. The symptom is present during or preceding a convulsion, and may occur, too, in disease of the brain. In some babies it appears to be only a nervous habit. The manner of nursing or swallowing frequently affords important information. A baby whose nose is much obstructed or who has pneumonia can nurse for but a moment, and then has to let the nipple go in order to breathe more satisfactorily. If it gives a few sucks and then drops the nipple with a cry, we must suspect that the mouth is sore and that nursing is painful. If it swallows with a gurgling noise, often stops to cough, and does as little nursing as possible, we suspect that the throat may be sore. The ceasing to nurse at all, in the case of a very sick baby, is an evidence of great weakness or increasing stupor, and is a most unfavorable symptom. THE SICK BABY. 23 1 Urine that is high-colored and stains the diaper, or that shows a thick reddish cloud after standing, may accompany fever or indigestion. Sometimes the urine under these conditions is milky when first passed. In some babies a diet containing beef-juice or other highly nitrogenous food will produce this reddish cloud, or even actual, red, sand-like particles. A decidedly yellow stain on the diaper occurs when there is jaundice. The amount of urine passed is scanty in fever, and especially so in acute Bright' s disease. In the latter disease the urine is often of a smoky or even a muddy appearance. The pos- sibility of the occurrence of this symptom after scarlet fever must always be kept in mind, in order that a phy- sician may be summoned very quickly, since it is a serious matter. The boivcl-movements characteristic of health have already been described. Apart from the various altera- tions in appearance seen in diarrhoea and constipation, and presently to be referred to, we find that the passages are often putty-colored in disorders of the liver, frequently tarry in appearance in bleeding within the bowel, and liable to be black after taking bismuth, charcoal, or iron. Infants who are receiving more milk than they can digest constantly have whitish lumps in their stools, or even entirely formed but almost white passages. The presence of a certain amount of greenish coloration of the passages is not infrequent. This is, of course, an evidence of indigestion. II. The Management of Sick Children. Where a trained nurse used to the ways of children can be had, the nursing of a sick child will generally go on without trouble. Still, no mother ought to be without knowledge on the subject^ and the majority need it badly, 232 THE CARE OF THE BABY. in case they must themselves fill the nurse's place. The following remarks, although descriptive of the duties of a nurse, are intended especially for the mother nursing her own sick children. One of the nurse's chief cares should be, of course, to observe the child closely in the search for evidences of disease. Another, and often a very difficult one, is the administration of medicine and food. If the child has been well trained in habits of obedience, it will take what is given to it without much objection. If it is not so trained, the nurse must exercise the greatest firmness and insist upon being obeyed, or, failing in this, must use whatever means of persuasion will most easily attain the desired end. Very often the promise of a chocolate or other sweet, some pennies, or a simple toy will serve to overcome the obstinacy. This, of course, is rank bri- bery, and against all rules for moral training. Sickness, however, is hardly the time to inculcate principles which should have been taught long before, and the taking of food and medicine is so important that the end fully jus- tifies the means. Should a child still prove obstinate, it is better to lose little time in argument or pleading which must be repeated several times a day. The nurse will do better if she promptly takes the child up, wraps a shawl closely about its body and arms to prevent interference, holds its nose carefully, and then, when it opens its mouth to breathe, inserts the spoon as far as possible, empties it gently, and withdraws it slowly. If the spoon is not withdrawn, the child has difficulty in swallowing. This seems like harsh treatment; still, if it is done without excitement or anger, and as a matter of course, the child soon looks upon it as inevitable, and will often take its medicine quietly, without making a frequent repetition of the procedure necessary. In young babies the pressure THE SICK BABY. 233 of the chin backward and downward with the finger will often serve to open the mouth. Often an infant who spits out the greater part of a teaspoonful of medicine will take it very well if given a little at a time. Sometimes a child continues to fight so hard that the exhaustion following seems to overbalance all the good that can ensue. Let the physician be informed promptly of the state of the case, and let him have the responsi- bility of determining what course it is best to pursue. In all giving of medicine there must be the strictest ad- herence to truth, and no child must ever be told that a disagreeable dose "tastes good." If this course is not followed the one dose is all that it will ever take. It will feel, too, that it has been imposed upon, and will distrust the nurse. In the case of children who lie stupid or semi- delirious in bed, and to whom the administration of food or medicine in the ordinary way is difiBcult or impossible, much can sometimes be accomplished by the use of the medicine-dropper. If this be inserted beside the teeth and emptied, the contents will usually be swallowed. The dropper should not be placed between the teeth, on account of the danger of its being bitten. Many liquid medicines will be of a disagreeable taste, no matter how great care the physician may take in pre- scribing or the druggist in preparing. The bad taste may be avoided to some extent by letting the child take a sip of milk or water, a mint drop, or a suck at an orange immediately before and after swallowing. Castor oil may be floated on soda-water, ice-water, whiskey and water, or lemon-juice. In this way it often tastes very little. It is also nearly tasteless if stirred in hot milk, but the child must not be deceived as to the nature of the drink, or it may turn against plain milk. Cod-liver oil is not disagreeable to most children, many of them 234 THE CARE OF THE BABY. even learning to like it. All unmixed oils given from a spoon should be warmed in it to make them less thick. After taking any acid medicine it is a good plan for the child to rinse its mouth with a solution of baking-soda in water. This will prevent the teeth being set on edge or injured. Small and comparatively tasteless powders can best be placed directly upon the tongue and a sip of water then given to wash them down. Sometimes they may be mixed with a little sugar and taken in the same way. If larger, they can be stirred up thoroughly in a little jam or scraped apple, provided there is no disease of digestion which makes this inadvisable. Another good plan is to put a small quantity of sugar in a tea- spoon, empty the powder upon this in an even layer, and fill up the spoon with sugar. The whole is then moist- ened with water and swallowed. Tasteless powders may frequently be given in bread and milk or milk toast with- out the child perceiving them in the slightest. Very young children cannot take pills. Later they learn easily, particularly if the pills be placed within a little jelly or preserved fruit. It is sometimes a good plan to let the child practise with home-made bread pills until it learns how to swallow them easily. In giving liquid medicines it is important that all doses be meas- ured accurately. Teaspoons vary greatly in size, and, besides, we cannot determine just when they are exactly full. The little glasses marked with "teaspoon" and "tablespoon," to be had at any drug-store, are much to be preferred. As even these are not accurate, the best plan is to procure a four-ounce graduate, such as is used by druggists, marked with drachms and ounces (Fig. 68, p. 386). In the Appendix (108-110) will be found a table of equivalents showing the relative value of tablespoon- fuls and teaspoonfuls, ounces and drachms, and so on, a THE SICK BABY. 235 table of dosage for different ages, and a dose-list of some of the medicines most frequently given to children. The proper doses of the various remedies which may be re- ferred to under the different diseases will be found in this last table. It must not be forgotten that the drops of all alcoholic fluids are much smaller than those of water (Appendix, 108). Feeding a sick child is even more important than giving medicine, and often just as difficult. Where there is great loss of appetite it is important to remember that the child will sometimes drink all of a small glass of milk when it will take much less, or none, of a more formidable-looking larger one. A pinch of salt in boiled milk helps to take away its disagreeable taste — but it should be only a pinch. Under many conditions a little sugar may be added. Sometimes a sick child can be persuaded to drink milk or to take other food if the nurse will take some also. Sometimes milk may be given in place of water when the child asks for a drink. Vari- ous other expedients dependent upon the individual case will suggest themselves to an intelligent, wide-awake nurse. Three good rules are to be borne in mind in this connec- tion: First, never make any experiment with new articles of food in the case of children suffering from diseases of the stomach or bowels or in typhoid fever; second, at the outset of any illness give little or no nourishment; third, if vomiting occurs whenever food is given in the course of any affection, stop all feeding until the doctor can be consulted. A number of prepared foods often useful in sickness will be found in the Appendix (Dietary). An absurd and still too widespread idea is that a sick person must receive a limited amount of water. As a rule, and particularly in fevers, all the water that a child 236 THE CARE OF THE BABY. asks for may be given it, provided this does not take the place of nourishment. Often the promise of water as a reward will induce the taking of some food. Where for any reason the amount of water must be restricted, it will be found that a child will often be content with a small glass provided it is allowed to drain it, while it would have clamored for more if permitted to empty a large glass only partially. Quiet in the room is very greatly to be desired, and is often wofully neglected. Babies cannot, and children of three or four years do not, ask for it, since they do not realize that their headaches and nervousness are the re- sults of noise. Visits by friends should be forbidden. A sick child should be encouraged to lie in its bed as much as possible, although there are some exceptions to this. Thus, for instance, when a little patient has some disease attended by difficulty in breathing, it is usually much more comfortable if allowed to sit in its crib, or even if carried in the nurse's arms with its head over her shoulder. A weak, exhausted child, or one with fluid in the chest, should never be raised rapidly to a sitting position in the bed; indeed, all movement is to be avoided as far as possible, as it is exhausting or danger- ous. A nurse about to move a child with an injured limb should always support the member well and keep it on the side away from her. A child with hip7Joint dis- ease or with disease of the vSpine should be lifted hori- zontally, in order to keep the weight of the body from pressing on the sensitive part. The position of the sick child in bed is of great importance in pneumonia or in any disease attended by exhaustion. It should be changed frequently from the back to one side or the other, to prevent the blood from settling in any one part of the lung and to hinder, too, the formation of bed-sores. THE SICK BABY. 237 Many people seem to have an irresistible desire to cover children very warmly in bed, no matter how much fever they may have or how hot the weather may be. This is, of course, all wrong. The covers should be light in such conditions, and a child sufficiently old should be asked whether it is too warm. A feverish baby should never be held long on the lap in hot weather. On the other hand, whenever a child is taken up, though only for a moment, it should have a wrap thrown about it. We often forget, too, that when well enough to be propped in bed its arms and chest are more lightly clothed than when it is completely dressed. It is folly to put a child to bed for a bronchitis and not to guard it, by having it wear a light sack, against the danger of taking cold. There should be a bed-dress for the night and another for the day (see page 109). Cleanliness of the body is very necessary in sickness. As a rule, the child should be sponged all over once or twice a day with soap and water or sometimes with water and alcohol, either cool or wann according to circum- stances. In cases of diarrhoea careful local washing should follow each evacuation of the bowels. Starch- water (Appendix, 43) is preferable to ordinary water for this purpose, and the application of a dusting powder completes the drying. The warm tub-bath can be used in many diseases. In the eruptive fevers, however, neither this nor sponging should be employed without medical advice, since some physicians are much opposed to them in diseases accompanied by a rash. It is much better at the beginning of any illness to obtain explicit directions regarding bathing. The bed for the sick child should be comfortable and clean. The sheets should be changed often, and the fresh ones always warmed before they are used. In cases of 238 THE CARE OF THE BABY. prolonged illness it is a good plan, although not often practised, to have two beds, one for the day and one for the night. This gives an opportunity for airing the beds, and the change is distinctly restful to the patient. A draw-sheet or pad of some sort is of service where there is any tendency to soiling of the bed. After an offensive movement from the bowels fresh air is needed in the room as soon as possible. As the throw- ing open of the windows is often impracticable, an aro- matic pastille or some coffee may be burned. This pro- cedure of course does not purify the air in the slightest, but it does serve to conceal to some extent the disagree- able odor until ventilation can remove it entirely. The method of nursing infectious diseases and of disin- fecting the room has already been described when treat- ing of the Trained Nurse and of the Sick-room in Chapters IX. and X. Various methods for the external treatment of a sick child are often ordered by the physician. Baths are used for this purpose as well as for cleanliness. The baths may be general or local, hot or cold, applied in the form of sponge-baths, tub-baths, wet packs, and other methods, and medicated in various ways. Further details of these procedures and of their value in disease will be found under the heading of Baths in the Appendix (36-50). Physicians often order dry heat or moist heat to be used locally. The former is applied in the shape of hot bottles, bags of hot water, sand, or salt, hot bricks, or a hot stove-lid. It is useful where the circulation is poor and the temperature of the body is lower than it should be. The hot articles should be wrapped carefully in flannel to prevent burning the skin. This is especially important when the child is unconscious and cannot THE SICK BABY. 239 complain, since serious burns have often been produced by carelessness in this respect. Moist heat is of value to relieve pain and inflammation. It may be used in the form of fomentations or of poultices of dififerent kinds (Appendix, 50-62). The former are lighter, but the latter retain their heat longer. Cold is applied locally, in the form either of cold com- presses (Appendix, 50) or of ice-bags, in order to subdue inflammation or pain. Ice-bags are made of thin rubber, and are of different sizes and forms. The thinner the rubber the more easily does the bag adapt itself to the shape of the part and the more successfully keep it cool. Many of the ice-bags sold in the shops are entirely too thick and are practically useless. A pig's bladder filled with ice forms an excellent substitute for the rubber bag. The bag should be not more than half filled with small fragments of ice. If it is too full, it is impossible to apply it accurately. Since the moisture of the surround- ing air condenses on the bag, dry towels must be so placed that the drip will not wet the child. A piece of thin cloth must sometimes be placed between the ice- bag and the skin to prevent the latter from being frozen, but ordinarily this is not needed, and checks the action of the cold too greatly. The nurse will often be required to make other appli- cations, such as mustard plasters, turpentine stupes, spice plasters, and the like (Appendix, 63-66). She will some- times need, too, to administer enemata for constipation or for inflammation of the bowel and diarrhoea, or per- haps even to give nourishment in this way. A hard- rubber syringe holding four to six ounces and fitted with a piston which moves very easily is well suited for ordinary use. Another form useful for small injections, 240 THE CARE OF THE BABY. called the Infant's syringe," consists of a soft-rubber bulb with a hard-rubber nozzle (Fig. 48). Fig. 48. — Infant's syringe. In using a syringe the fluid should be drawn into it, the nozzle then well greased with vaseline and inserted, and the contents expelled very slowly. For giving large injections, as in inflammation of the bowel and constipa- tion, the ordinary elastic bulb syringe (Fig. 49) or, much better, a fountain syringe (Fig. 3, p. 30) is sometimes to be preferred. A long rubber tube with a funnel at one Fig. 49. — Elastic bulb syringe, end and a hard-rubber nozzle at the other makes an excellent extemporaneous fountain syringe. As it is sometimes difiicult to get a child to retain an injection, I THE SICK BABY. 24 1 it is a good plan to wrap a narrow roller bandage firmly around the nozzle (Fig. 50). The pressure of the band- age against the opening of the bowel helps to prevent the fluid from being ejected. Large injections should be given very slowly, with the child upon its back or its left side. It is often necessary for the nurse to make applications to the throat. This is best done with a large, straight camel' s-hair brush firmly fastened to a straight, stout Fig. '-^o. li.ad-rubber syringe with roller bandage on the nozzle. stick. The bent brushes or those mounted on wire handles are not nearly so easily controlled. Physicians often use cotton wrapped on a metal applicator. If the child is well trained and of sufficient age, it is simply necessary to depress the tongue with a spoon while mak- ing the application. In younger children the procedure is often one of a good deal of difficulty, and two persons are required to accomplish it satisfactorily. The helper holds the child facing a bright light, and wrapped in a shawl which keeps its arms and hands close to its sides. The nurse now takes her position opposite it, with a tea- spoon in the left hand and a brush already prepared in the other. Watching her opportunity, she carefully in- serts the handle of the spoon between the teeth and gradually works it inward. As it reaches the back of the tongue the child gags and at the same time invol- untarily opens its mouth widely. This is the moment for the rapid yet thorough painting of the throat. 16 242 THE CARE OF THE BABY. Spraying of the throat is done with an atomizer (Fig. 51). When employing this apparatus it is im- FiG. 51. — Bulb atomizer. portant to see that the tongue is well depressed, as otherwise most of the solution lights upon it instead of where needed. The method of observing pulse, temperature, and res- piration has alread}^ Deen considered in Chapter II. A few words only can be devoted here to the diet to be followed in sickness. As has already been intimated it may be accepted as an axiom that every child suddenly taken ill is better, for some time at least, without food. This is particularly true of infants attacked by severe acute vomiting and diarrhoea. There is absolutely noth- ing to be gained by putting into a baby's stomach food which will simply serve to keep up the irritation present there or in the intestines. Certainly all milk should be stopped for twenty-four hours, and the baby be fed on barley-water (Appendix, 2) or albumen-water (Appendix, 3). A loss of appetite with a coated tongue occurring in a child of any age is not always a sign that a tonic or digestant is needed. It is often but a prayer on the part of the stomach to be given a period of rest. Should a feverish condition last some days, the diet THE SICK BAB V. 243 should continue to be of the lightest. It is often one of the most difficult things imaginable to find out what kind of food will best agree with infants suffering from chronic indigestion or chronic diarrhoea. A sincere pity for the little patients compels me to urge most strongly that the mother make no experiments in such a case. Immeasurable harm to numberless babies has followed just such experimentation. The experienced physician, with his best endeavors, often finds the discovery of the proper food a herculean task. The various recipes for different articles of diet that will be found in the Appendix are intended, not to constitute a list from which the mother shall select at her own discretion, but to be a guide in the preparation of the food which the child's physician may direct. A well-trained nurse keeps a careful daily record of everything which has taken place relative to the child. Thus a portion of such a record would perhaps read as follows : June 23, 1894. 8a.m. Temperature, 102.6°; pulse, 140; respiration, 35. Took 6 ounces of milk and 2 ounces of lime-water. Cough medicine and pill given. A half teaspoon ful of whiskey. 10 A. M. Bowels opened, natural in appearance. 11 A. M. Took only 3 ounces of milk and i ounce of lime-water. Medicine and whiskey given. Temperature, 103°. 12.30 p. M. Very restless and nervous. Temperature, 105°. Has coughed a great deal. Sponged with cool water. 1 p. M. Temperature, 101.2°. Quiet; looks better. 2 p. M. Has slept for an hour. Temperature, 102° ; pulse, 132 ; respiration, 34. Cough medicine and pill given. Half teaspoonful of whiskey and 4 ounces of beef tea. Such a record as this is of the greatest assistance to the doctor, and tells him of the progress of the case better than any answers to questions could possibly do. 244 THE CARE OF THE BABY. A still better and more quickly-read arrangement, kept on paper of a suitable size, would be as follows : 3 i 1 Medicines. Food. Stimulants. Remarks. 6,23 94. 8 a.m. 102.6 140 35 I teaspoonful cough mix- ture and I pill. 60Z. milk and 2 oz. lime- water. Yz teaspoon- ful whis- key. 10 Bowels opened ; nat- ural in appear- ance. II 103 I teaspoonful cough mix- ture. 3 oz. milk and I oz. lime- water. Yi teaspoon- ful whis- key. 12.30 P.M. 105 Very restless and nervous. Coughed a great deal. Sponged with cool water. I 101.2 Quiet ; looks better. 2 102 132 34 I teaspoonful 4 oz. beef tea. cough mix- ture and I pill. % teaspoon- ful whis- key. Has slept for an hour. As a rule, nurses keep the record of the pulse, tem- perature, and respiration on a special chart provided for the purpose. There are various charts of this sort, of different patterns, to be had from medical publishers. The author ventures to recommend the "Graphic Clin- ical Chart" designed by himself. III. The Disorders of Childhood. Under this heading may be considered briefly a few of the commoner diseases, habits, and accidents of children, with such treatment as the mother is justified in using. They are classified to some extent as a matter of conve- nience, but the divisions are not sharply defined, and some disorders which have been placed in one class might with equal propriety have been considered in some THE SICK BABY. 245 other. Lack of space has made the descriptions necessa- rily concise. (l) DISEASES OF THE DIGESTIVE APPARATUS. Hare-lip. — A complete cleft through one or both sides of the upper lip, exposing the teeth and even extending into the nose. It sometimes interferes with sucking, and requires a specially-prepared rubber nipple, or makes feeding from a spoon necessary. It should be operated upon in the early weeks of life. The success of the opera- tion is often very remarkable. Cleft Palate. — A fissure through the palate, forming one cavity of the mouth and nose. It is very often com- bined with hare-lip. It not only greatly interferes with talking later in life, but in infancy renders nursing im- possible by taking away the power of suction. In such a case the child must be fed with the mother's milk from a spoon or from a feeding-cup with a spout to it, to which a rather long nipple with large openings is attached. The milk thus flows into the mouth by gravity, without the need of sucking. A special apparatus has been de- vised, consisting of an ordinary nipple to the upper sur- face of which is attached a flap of thin rubber, made to act as a false palate and to close the unnatural opening during nursing. Operation is better deferred until the child is two or more years old. Tongue-tie. — In this condition the little membrane on the under surface of the tongue is too tight or is attached too far forward and holds the tongue down. It is much more uncommon than is ordinarily supposed. If the child can suck well and can protrude its tongue at all, 246 THE CARE OF THE BABY. there is no tongue-tie of any account. The operation for the affection is simple and painless. Inflammation of the Mouth. — ^catarrhal inflamma- tion may occur during fever, or from indigestion or lack of cleanliness, or sometimes during dentition. The mouth is hot and tender, and nursing is painful, the nipple being dropped with a cry. The lining of the gums, cheeks, and palate is much reddened, and is either dryer than natural or very moist from a profuse secretion of saliva. In aphthous inflammation little shallow ulcers (aphthcE) form over the tongue, palate, and inside lining of the lips and cheeks. The treatment for either of these conditions consists in the administration of a mild purgative, such as castor oil or magnesia, and the frequent application of a mouth- wash (Appendix, 79). There is a much more extensive and serious ulcerous inflammation, and another still worse, the gangrenous form, which must at once be referred to a physician; as, indeed, the simpler forms must be if they do not heal immediately. Thrush. — A disease of the mouth far commonest in bottle-fed or sickly children in the early weeks of life. Small whitish patches, sometimes crowded thickly to- gether, form over the lining of the mouth, and especially on the tongue. They greatly resemble curdled milk, but differ in that they can be removed only by the use of con- siderable force. A lack of perfect cleanliness about the mouth and the bottles and rubber nipples, and the use of bottles with long rubber tubes, are active factors in producing the disease. It is very commonly associated THE SICK BAB V. 247 with some disturbance of digestion, and it is distinctly contagious. The symptoms are an indisposition to nurse on account of the pain produced, often combined with colic, and some diarrhoea and vomiting. Treatment consists in the greatest cleanliness in every- thing about the food. The patches must be rubbed away as gently as possible every two or three hours with the finger covered with a soft moist cloth, and the mouth then sprayed with a solution of boric acid (Appendix, 75); or a small portion of borax and glycerin (x\ppendix, 79) may be applied with a camel's-hair brush. As the disease is sometimes fatal in delicate children, the advice of a physician should be obtained. Disordered Dentition. — It has already been stated that the cutting of the teeth is not, as a rule, responsible for any of the ailments so commonly attributed to the pro- cess, and that redness of and irritation of the gums are not necessary parts of it. It is, however, true that some babies are peculiarly susceptible to even slight disturb- ances in the mouth, and that we occasionally find attend- ing the eruption of the teeth various symptoms which can be accounted for in no other way. At times a certain amount of catarrhal inflammation of the gums is present, shown by increased heat with some redness and by a dis- position to bite vigorously upon anything placed in the mouth. Slight diarrhoea, loss of appetite, feverishness, bron- chitis, some eruption of the skin, and, especially, great restlessness, irritability, or other nervous symptoms, may appear shortly before a tooth is cut, and disappear with astonishing rapidity as soon as it is through the gum. Remarkable improvement will sometimes follow within a few hours the lancing of the gum over an approaching ^48 THE CARE 01^ THE BABY. tooth. Nevertheless, it is only rarely that lancing is really necessary. The important point is that disordered dentition is the exception and not the rule, and that the mother must never assume that it is teething which makes her baby ill, or try to treat this symptom or let it go as a matter of no consequence. If the baby enjoys biting at a soft-rubber ring or hav- ing its gums gently rubbed with the finger, there is no objection to this; but no attempt should ever be made to " rub the tooth through " with the finger-nail or a thim- ble or other hard substance, as this is often the cause of inflammation of the gums. Dentition may be much delayed, or the teeth may come in irregularly or decay very rapidly. Early decay of the teeth or the completion of the first year without a tooth makes the existence of rickets seem very probable. It occasionally happens that certain of the first or second teeth are never cut. Gum-boil. — This consists of an abscess at the root of a diseased tooth, lasting several days and then usually bursting. Painting the gum with tincture of iodine or applying one of the little toothache plasters to be bought in the drug-stores may prevent the abscess from forming. Holding warm water in the mouth or the application of a warm-water bag to the cheek relieves the pain. Lan- cing the abscess is the quickest cure. Sore Throat. — Infants with sore throat avoid much nursing and swallow with a gulp and a cry. Older chil- dren will frequently complain of the throat, but in many cases they make no complaint even though it is much inflamed. Fever is generally present, and the speech often is a little thick. The throat may be red without THE SICK BABY. M9 swelling of the tonsils, or the tonsils also may be red and swollen, and perhaps may exhibit one or more white points. It is needless at once to become greatly alarmed over these latter. They are common and usually mean nothing, but as they sometimes indicate beginning diph- theria, the child should be isolated at once and a phy- sician be sent for. (See Diphtheria.) A child with sore throat should be confined to bed, given a laxative, and allowed to suck pieces of ice fre- quently and to use an astringent gargle (Appendix, 8i). If there is much fever, a simple fever mixture (Appen- dix, 103) may be administered until the physician arrives. He may find it best to give other remedies or to order the throat to be painted internally. The danger of per- manent deafness following repeated attacks of sore throat must never be forgotten. Chronic Enlargement of the Tonsils. — A common affection in children, beginning in early infancy. The tonsils are pale without sign of inflammation, and some- times are so large that they almost touch. Associated with this enlargement is usually an overgrowth of certain tissue resembling the tonsils, situated out of sight high up in the throat at the back of the nose, and it is this overgrowth that causes the chief hinderance to breath- ing. In some cases the child constantly breathes with its mouth open, and often snores badly at night. Its speech is thick, affections of the ears are frequent, and the voice has a heavy, stopped-up sound, much like that of a person with a bad cold in the head. Treatment is important, for the constant difficulty in getting sufficient air is apt to produce impairment of development and of the general health, and even to make the child chicken- breasted. Permanent deafness may also result. 250 THE CARE OF THE BABY. Chronic Indigestion. — A condition marked by capri- ciousness of or great loss of appetite, coated and often *' worm-eaten " tongue, flushing of the face with or with- out fever, pain and swelling of the abdomen, restlessness at night, slight headache, and often constipation alter- nating with slight diarrhoea. Mucus is very apt to appear in the passages, whether these are loose or hard. The disease is frequently seen in later childhood, and is a very obstinate one. In the line of treatment diet is of prime importance. All fats and sweets must be avoided, and the amount of starchy food be reduced very much. Milk, lean meats, poultry, eggs, and green vegetables constitute the principal articles of diet. Medicines are usually required. Vomiting. — The fact that an over-fed baby will regur- gitate the excess of milk which it has taken has already been alluded to (p. 113). There is a difference between regurgitation and true vomiting. The latter is accom- panied by coldness and moisture of the skin, indicating nausea. The vomitino^ mav be a sino^le effort and mav bring relief, or it may be repeated again and again until the patient's state is alarming. It does not always in- dicate a disordered stomach, for it frequently ushers in some acute disease, such as pneumonia or scarlet fever, and it is repeated and very obstinate in inflammation of the brain. The importance is manifest of having a phy- sician determine the cause in serious cases. The chief treatment consists in the immediate and absolute stopping of all nourishment. No food should be given for six or more hours, and after that onh^ small amounts of barley- water or albumen- water (Appendix, 2, 3). Complete rest is essential, and trotting on the knee, raising suddenly, or other quick movements must be avoided. A spice plaster »v« Plate II. size.) Roundworm. (Drawn from life ; one-half natural size.) 2. Thread-worms. (Natural 3. Small portions from different parts in the length of a tape-worm. (Drawn from life ; natural size.) THE SICK BABY. 25 I or mustard plaster (Appendix, 64, 65) may be placed over the position of the stomach, just below the ribs in front, slightly to the left side. Soda-mint (Appendix, 100) may be given, or to older children soda-mint and tincture of ginger. The swallowing of pieces of ice (not allowing them to dissolve in the mouth) is often useful. After the attack is over a laxative, such as magnesia, may be administered, for the purpose of carrying out of the intestines any irritating substances which may have entered them. Diarrhoeal Diseases. — These are oftenest caused by improper food, by taking cold, or by exposure to the sun or to heat. They are exceedingly common in bottle- fed babies in summer-time, as a result of changes pro- duced in the milk by the high temperature. The num- ber of passages varies from four or six up to thirty, forty, or more in twenty-four hours. Their character, too, is changed from the normal. They may be greenish, yel- lowish-green, whitish from the presence of undigested milk, clay-colored from absence of bile, black, brown, or colorless; semi-liquid or very watery; odorless or ex- cessively offensive; small in size or so large that we wonder how a child's bowel could have held so much. Mucus and blood may be present. In simple diarrhoea^ which is very common in summer, the passages exhibit some one of the colors mentioned, there is little if any fever, and vomiting may or may not occur. In cholera infanttnn the passages are very numerous, are entirely watery and colorless, and there is constant, exhausting vomiting and high fever, followed at last by great coldness. It is a comparatively rare disease. In inflammation of the intestine (inflammatory diar- rhoea), on the other hand, the movements are usually 252 THE CARE OF THE BABY. small, liquid, exhibit color of some sort, and contain mucus. Moderate fever is present, and vomiting is not a prominent symptom. Many of the cases of severe summer diarrhoea are of this nature. In dysentery — which is only another name for a severe form of inflammatory diarrhoea — the passages are small and very frequent, are composed largely of mucus, often contain a considerable amount of blood, and are accom- panied by much straining. • An infant ' ' falls away ' ' with astonishing rapidity in severe diarrhceal disorders, and in twenty-four to forty- eight hours may become shrivelled, wrinkled, and cold. The disease is, as a rule, not so rapid or so serious after infancy is past, but even then it is very weakening; con- sequently no case should ever be allowed to run on with- out treatment. A mother, if she cannot conveniently do otherwise, may treat slight attacks herself for not longer than twenty-four hours, but after this must delay no longer in calling in a physician. She should be careful to save the passages to show to him. The first essential of treatment is to stop all food, since it only adds fuel to the fire. A baby if hungry may have a little barley-water (Appendix, 2). If very hot it may be bathed with cool water, or if cold may have a mustard bath. Absolute rest in bed is very desirable. In the beginning of the attack a dose of castor oil may be given to empty the bowel of anything irritating it. Af- ter this I or 2 teaspoonfuls of a chalk-and-bismuth mix- ture (Appendix, 102) may be given every couple of hours. Bismuth colors the passages black, and no alarm need be felt at the presence of this color. The mother should never give paregoric, laudanum, or other preparation of opium to a child suffering from diarrhoea or any other disease. It is an invaluable but a danorerous medicine. THE SICK BABY. 253 Some healthy-looking but over-fed babies, instead of regurgitating, constantly void undigested milk in the stools and have too frequent passages. The amount of food should be reduced or its character altered. Insuf- ficient clothing is a cause of repeated attacks of diar- rhoea. A careful covering of the abdomen, arms, and legs with close-fitting garments of a nature suitable to the season is the best prevention. Constipation, — A very frequent disease in children, and especially in infants. Those fed on the bottle are most disposed to it. The passages may be too infrequent or too hard, and generally are both. In treating the affection the cause of the difficulty should be sought and removed, and laxative drugs be kept as a last resource. As an increase of the fat in the food is often needed, a larger proportion of cream can be added to the bottle, or, in the case of breast-fed babies, be fed from a spoon. A teaspoonful or less of olive oil given once a day, or of drug-store '* syrup" two or three times a day, is harmless and often effectual. The employment of oatmeal-water (Appendix, 5) instead of plain water in preparing the bottle, or of brown sugar or a syrupy malt extract for sweetening it, may have the desired laxative effect. When this does not answer, a small quantity of the oat- meal itself or of other starchy food may be added instead of oatmeal-water, but this should be done only by a phy- sician's advice. In children over one year of age a little stewed fruit or a baked apple may be tried carefully. Strained stewed-prune juice is often excellent. The juice of an orange is frequently very serviceable, and a little may sometimes be given with advantage even to a younger baby. In still older children the diet should contain plenty of fluid and of foods that are somewhat laxative. 254 THE CARE OF THE BABY. The very early cultivation of a habit of regularity helps to prevent constipation. At a certain fixed hour, best after one of the principal meals, generally breakfast, the baby as soon as old enough may be supported on its nursery chair and kept there for five minutes at least, but never permitted to strain. A daily cool bath fol- lowed by brisk friction is of decided benefit. Daily mas- sage of the abdomen is an excellent remedy, practised just before the hour at which an evacuation is desired. The palm of the hand should be applied with gentle pressure just above the right groin, and be carried in a horseshoe-shaped curve up to the edge of the ribs, across to the left side, and down toward the left groin, thus fol- lowing the course of the large intestine and propelling its contents toward the opening. The hand should be warm, a little sweet oil or vaseline should be used, and the massage should last about ten minutes. The treatment detailed is intended for habitual consti- pation. For the immediate unloading of the bowel one of the simplest and least harmful methods is the giving of one or more enemata of warm water containing salt in the proportion of a teaspoonful to a pint. Soapy water may be used instead if something stronger is needed. The amount to be injected varies with the age. For young babies one or two ounces is sufiicient, and for those of two years two or three times this amount. Either the hard-rubber syringe or the infant's syringe may be used (pp. 240, 241). A useful injection consists of half a tea- spoonful of glycerin with an equal quantity of water, or, if this does not answer, of glycerin in full strength. This is best given from a small hard-rubber syringe hold- ing not more than half an ounce. The opening in the nozzle should be larger than ordinar>^, as the glycerin does not flow readily. If the mass in the bowel is large THE SICK BABY. 255 and very hard, an injection of warm sweet oil, retained some hours if possible, is better than anything else. It should be followed by an enema of soapy water. In some cases it is necessary to insert the finger or a small spoon- handle into the bowel and break up the masses carefully. Glycerin suppositories (glycerin and soap) of a size for children are often excellent for emptying the bowel. Gluten suppositories are also serviceable in many in- stances. A more economical plan is to employ little home-made suppositories of Castile soap, or, in place of these, a soap stick, which also can be made at home, and which has the advantage of lasting for repeated usings. It consists of a smooth, conical stick of firm Castile soap two or more inches long, half an inch thick at the base, and tapering toward the other end to the thinness of about one-quarter of an inch (Fig. 52). It should be greased with vaseline before using it, in- serted part way into the bowel, and held there until a tendency to an evacuation shows itself. If none of the methods described are effectual, laxative drugs must be employed. Their use, however, ought to be deferred as long as possible, and is much better left to a physician. Probably the best and least harmful of drugs is cascara in some form. There is made a cascara cordial which has a pleasant taste and is very effectual. Another very useful preparation is the syrup of senna, which is easily taken by children, as its taste is agree- able. Ivittle sugar-coated pills each containing -^ grain or less of aloin are sometimes of service, one being given daily to a child of two years. A small quantity of manna, about 5 grains, can be given to a baby of six Fig. 52. — Soap stick. 256 THE CARE OF THE BABY. months once a day or oftener, dissolved in the milk, as its taste is sweet, or 10 grains of phosphate of soda may be used in a similar manner. Magnesia or spiced syrup of rhubarb answers very well, but only for occasional use. Colic. — Severe pain in the abdomen, usually due to distention by gas. It is one of the commonest ailments of infancy, and frequently appears in those perfectly well in other respects. It may occur either only occasionally or many times every day. The symptoms consist of sudden and violent crying — which may continue until the child is bluish in the face and often exhausted and cold — a swollen and hard abdomen, and doubling up and straightening of the legs, arms, and trunk. These symp- toms last a variable time and then suddenly cease, per- haps preceded by the passage of wind by the mouth or bowel. Chilling of the skin and indigestion are the commonest causes, the latter usually depending on too frequent or too abundant feeding. To prevent repeated attacks the stomach should be allowed to rest by dimin- ishing the amount of nourishment and increasing the length of time between feedings. If the baby is bottle- fed, it may be necessary to change the character of the food in some way, but this should be the duty of the physician. The child must be warmly clothed, since any chilling of the surface may cause pain, no matter how good the digestion may be. The feet and legs especially should be kept warm by thick loose stockings and by daily friction with a mixture of i part of turpentine and 3 parts of sweet oil. An abdominal binder may be worn if one is not already in use. During an attack the baby must never be fed. The warm milk, it is true, often stops the crying for the mo- ment, but it is sure to increase the indigestion and to THE SICK BABY. 257 bring the pain back as bad as, or worse than, ever. Rubbing the abdomen for several minutes, or the mere change of the child's position, as by lifting it over the shoulder, will sometimes cause the gas to escape and the colic to cease. A spice plaster (Appendix, 64) is often very useful. Sometimes an injection of two or more ounces of warm water will relieve the attack. Generally, some medicine given internally is necessary. Pepper- mint-water or cinnamon-water, diluted and sweetened and given after each nursing, may keep the pain from coming on; while during an attack one of the simplest and most effectual remedies is soda-mint (Appendix, 100) mixed with an equal quantity of hot water and given every half hour or hour for a time. If the baby seems exhausted and cold as a result of the pain, it should be given a few^ drops of brandy in a teaspoonful of hot sweetened water and be placed at once in a hot bath, and after that should be kept very warm and have a mustard plaster (Appendix, 65) applied over the abdo- men. The doctor should be summoned at once. Con- stantly-recurring colic, not relieved or prevented by the means described, is beyond the ability of the mother to treat. Congenital Closure of the Bowel. — Complete ob- struction, oftenest not far within the opening of the bowel, or the entire absence of any opening. Failure on the part of the baby to empty its bowels for one or two days after birth renders one suspicious of the presence of this condition. Unless some operation is performed, death is inevitable in the course of a few days. Prolapse of the Bowel. — A protrusion of more or less of the bowel through the external opening. It is usually 17 258 THE CARE OF THE BABY. the result of diarrhoea or of the straining of constipation, and generally occurs in debilitated children. In the mildest and fortunately the most frequent cases only the lining of the bowel is pushed out for about half an inch, forming a dark, purplish-red, puckered ring out- side of the opening. This can be easily pushed back, or it goes back of itself after a little time. The protru- sion may take place every time the bowels are opened with the slightest straining effort. In the more serious cases a protrusion of five or six or more inches of intes- tine may take place at any movement of the bowels, or even when the child is walking or standing. The pro- lapsed bowel gives at first discomfort, and soon actual pain if not replaced. After the protrusion has occurred a few times it is apt to happen repeatedly. The first treatment is to replace the prolapse. The child should be laid upon its back or stomach and the protruding bowel be gently pushed back with the fingers, previously well greased with vaseline. To prevent the recurrence the passages must be kept soft and all strain- ing be avoided. • Cold bathing of the parts is useful. While the bowels are being moved some support must be given by pressing the buttocks together or by placing the child upon its back and receiving the passages in a diaper. A board with a small hole in it three or four inches in diameter, placed over the chamber, gives great support and tends to prevent prolapse. In cases which do not readily yield to this treatment astringent injec- tions or suppositories will be prescribed by the physician in charge. Very bad cases need operation. Rupture; Hernia. — A protrusion of a portion of the bowel through some weak spot in the muscles of the abdominal walls, forming under the skin a soft, round THE SICK BABY. 259 swelling which grows larger when the child cries, often disappears when it lies down, and can easily be pushed back into the abdomen. It is a common affec- tion in infants, may even be present at birth, and is most often seen at the navel, and next in the groin. Hernia is always dangerous if neglected, and should be treated at once. The physician in charge will probably pre- scribe a truss, which must be worn the entire time. If for any reason the truss is taken off for a moment, the bowel must be kept in by the hand. Recovery nearly always follows if treatment is begun early. Should a baby with rupture begin to cry persistently, to suffer from constipation and obstinate vomiting, and to appear very ill, a physician must be called immediately, for it is possible that the bowel has been constricted at the open- ing through the tissues and has become inflamed, and the condition is then very serious. Worms. — There are three principal species of worms which may be found in children: (i) the thread-worm; (2) the round worm ; (3) the tape- worm. The first and second varieties are much the commonest. Worms produce only indefinite symptoms or none at all. They may, it is true, cause itching at the opening of the bowel, picking at the nose, variable appetite and other evidences of disordered digestion, restlessness at night, grinding the teeth, and perhaps even convulsions, but many other disturbances of the digestive canal can produce these symptoms equally well. (i) Thread-worms or seat-worms strongly resemble little pieces of white cotton thread from }{ to j4 inch long (PL 11. , Fig. 2). They occupy the lower part of the bowel, and coat the passages in great numbers. This species is the one particularly liable to cause severe itch- 26o THE CARE OF THE BABY. ing of the opening of the bowel at night. Treatment consists in great cleanliness and the injection every other night for a week or two of as much of an infusion of quassia (Appendix, 88) as the child can hold comfortably. If this does not answer, medical advice will be needed. (2) Round worms are reddish- white in color and resem- ble common earth-worms in shape, but are thicker and from four to twelve inches long (PI. II., Fig. i). They inhabit the small intestine, but often wander into the large intestine and are evacuated, and sometimes even enter the stomach and are vomited. They are present in the bowels in great numbers. Although evidences of indigestion may be present, the only characteristic symp- tom is the discovery of the worm in the passages. No "worm medicines" should ever be given except by the family doctor, for they are not safe in the hands of others. (3) Tape-worm is occasionally seen in children. Often not even the ordinary evidences of digestive disturbance are produced by it, and the only way of recognizing that there is a worm is the discovery of portions of it in the passages (PI. II. , Fig. 3). The parasite is composed of a great number of segments joined together, making a total length of perhaps many feet. The segments are smaller and smaller as they approach the "neck" and the "head." The neck is no thicker than a thread, and the head is only about as large as an ordinary pin-head. The treatment of the disease is beyond the skill of the mother. It is essential to remove the head in order to prevent a new worm from forming. To be sure that this has been accomplished the passages should be received in a vessel of water and then be shaken d.bout gently and without pulling the worm until the feces are entirely separated. The water may then be poured oflf carefully THE SICK BABY. 26 1 and fresh added until quite clear, when the worm may be examined. The worm should never be pulled upon while it is being passed, lest the head be broken oflf in the bowel. Jaundice. — A very common affection in the first week of life, characterized by yellowness of the skin, the whites of the eyes, and the lining of the mouth, and by highly-colored urine which stains the diapers yellow. It is commonly unattended by other symptoms, and dis- appears in a week or ten days. Rarely it is an evidence of some serious or fatal disease. Very young babies are liable to acquire a yellowish tint of the skin which is not jaundice, since the whites of the eyes are not affected. Older children may develop jaundice associated with symptoms of indigestion. Treatment for infants is often not needed, while older children may have a light diet, as of beef tea or milk foods, and be given magnesia or some laxative mineral water. It is much better, how- ever, to call in the family physician. (2) DISEASES OF THE ORGANS OF RESPIRATION. Cold in the Head ; Coryza. — A disorder to which children are particularly liable on account of the greater sensitiveness of their skin. To avoid it draughts must be carefully shunned, particularly upon the nearly-bald head of a baby, clothing must be sufficiently warm, and the general health must be made robust by an outdoor life and the avoidance of over-heated and ill-ventilated rooms. The symptoms consist in watering eyes, sneez- ing, running nose, and a nasal tone of the voice. The disease is troublesome in infancy, for the obstruction to the breathing renders nursing difficult. One of the great dangers dependent on coryza is inflammation of the ears, 262 THE CARE OF THE BABY. or, in case colds are of frequent occurrence, permanent deafness. Treatment consists in giving the child a warm bath in a warm room, drying it carefully and rapidly, and keep- ing it in a temperature which is very equable and rather higher than usual. It is better, indeed, to put the child to bed. The diet should be lighter than usual. A laxa- tive, preferably castor oil, should be given, and a fever mixture (Appendix, 103) if needed. It is often useful to apply vaseline within the nose with a camel' s-hair pencil, and also to rub it upon the bridge. Spasmodic Croup. — This disease, although very alarm- ing, is fortunately not often dangerous. It is generally the result of exposure to cold, but is sometimes due to indi- gestion or to irritation of the throat. Some children are very liable to suifer from repeated attacks, while others never do, however severely they may take cold. Often there is an evident family predisposition. The symptoms may or may not begin with hoarseness during the day, and toward night the peculiar sharp, barking, metallic, ' ' croupy ' ' cough. After the child has been asleep for a few hours it awakes suddenly, sits upright and grasps at any- thing it can reach, and is scarcely able to get its breath. The croupy cough is now loud and ver}' characteristic, the inspiration of air noisy, the voice only a hoarse whisper, and the face bluish and perspiring. The worst of the condition lasts only a few minutes, but a tendency to croupy cough and oppressed breathing may persist for perhaps half an hour or longer, after which the child drops asleep, and usually rests quietly for the remainder of the night. Another attack is very apt to occur upon each of several succeeding nights. The disease is commonest in the third year of life, and THE SICK BABY. 263 then steadily decreases in frequency. It is seen only occasionally after the age of six years. Treatment is primarily preventive. Croupy children should be guarded with especial care against exposure to wind and damp. On the slightest sign of croupiness in the afternoon the mother should administer some medi- cine prescribed by the physician; or, in case she has no such preparation, she can use that given in the Appendix (104). This is not one of the strongest, but is one which she can safely give without medical advice. In the treatment of the attack a warm mustard bath and an emetic (Appendix, 106) should be given. Moist- ening the air with the steam atomizer or the croup kettle (p. 214) is of great service. There is absolutely no value in amber necklaces and such other relics of barbaric superstition, except the sedative action upon the mind of the mother. Instances of apparent cure by them are merely coincidences. Membranous Croup. — See Diphtheria. Bronchitis. — An inflammation of the bronchial tubes accompanied by cough. It is a very common affection in children, and results from taking cold. It is usually pre- ceded by a cold in the head. Any hoarseness present is due to laryngitis. The cough is frequent, at first dry and tight, but later becoming loose and rattling as the inflammation diminishes. Often some wheezing or rat- tling can be heard with respiration. The child does not seem very sick unless the bronchitis is unusually severe; has but slight fever, and breathes but little, if any, more rapidly than natural. It may raise a good deal of mucus, but, before the age of six or seven years, nearly always swallows it instead of spitting it out. The only treatment 264 T^HE CARE OF THE BABY. the mother may venture on is the general method advised for cold in the head, combined with a thorough rubbing of the chest, both in front and behind, twice a day with oil of amber, diluted with equal parts of sweet oil if the patient is less than a year old. A physician should be called in at once, as in infancy and early childhood the disease may easily pass into pneumonia. Pneumonia. — The terms congestion of the lungs^ pneu- monia^ capillary broitchitis^ and inflamjnation of the lungs are to all intents and purposes identical in meaning. The disease may come on suddenly, perhaps even with a convulsion and without previous warning, or it may de- velop from a bronchitis already present. There are high fever, flushed cheeks, a frequent, painful, and very short cough, and rapid catching breathing, with a moving in and out of the edges of the nose, and, in bad cases, of the pit of the stomach, the spaces between the ribs, and the muscles of the neck. The child is restless and toss- ing, or, if very sick, sometimes lies quiet with its cheeks and lips pale and bluish and its breathing very rapid and shallow. The disease is always serious, and requires the com- bined skill and attention of the physician, nurse, and mother. In addition to what was said in the general re- marks on disease and on nursing earlier in this chapter, it may be stated here, first, that the labored breathing shows the need of plenty of fresh air, although without draughts; second, that the child may be allowed to assume any position it pleases, and that a change of position may give great relief; third, that in any case where blueness, pallor, and failure of the powers are coming on rapidly, a hot bath may be administered while the doctor is being sent for, and may save the baby's life (see p. 366). THE SICK BABY. 265 (3) DISEASES OF THE BRAIN AND NERVOUS SYSTEM AND OF THE SPECIAL SENSES. Convulsions, Spasms. — One of the most common and dangerous diseases of infancy and early childhood, demanding knowledge, presence of mind, and decision on the part of the mother. Among the various causes are the onset of some severe illness — such as pneumonia or scarlet fever, — indigestion, constipation, intestinal worms, high fever from whatever source, disordered dentition, diseases of the brain, very hot weather, fright, severe pain, rickets, whooping-cough, etc. The frequency of convulsions is much the greatest in infancy, and rapidly diminishes after the first year. In the mildest attacks, often called "inward spasms," there may be only a tendency to squint and to bend the thumbs into the palms, with slight twitching of the mouth or eyelids, and perhaps of the head or limbs. These symptoms may pass away in a moment or may usher in a genuine attack. In a typically severe convulsion the child often makes a choking sound, ceases to breathe for a moment, and becomes unconscious, stiff, and somewhat arched back- ward. The eyes are staring, rolling, or squinted, the hands clenched, and the mouth firmly shut. In a few seconds the face becomes bluish from lack of air in the lungs, and then the "working" begins. In this stage the breathing is irregular and noisy; the arms, legs, and trunk are jerked about in all directions, but principally with an alternate bending and straightening movement; the eyes are rolled; there is frothing at the mouth, and the teeth, if there are any, are ground together and may bite the tongue. In a few moments the movements grow less violent and then cease, and the child begins to cry 266 THE CARE OF THE BABY. or goes into a heavy sleep with its body rather stifFer than usual. Sometimes before consciousness is entirely regained another spasm occurs, and so the child may go on from fit to fit until it dies. The whole attack lasts from one or two minutes to hours. Treatment must be very prompt. The child should at once have a bath of ioo° F. which should cover it to its neck, while cold cloths, frequently renewed, are kept on its head. It must be left in the water for ten minutes, and then be wrapped in a blanket without dry- ing. Since the attack may be due to irritating food in the stomach, the child should be made to vomit by giv- ing it a teaspoonful of syrup of ipecacuanha or other emetic (Appendix, io6) just as soon as it can be made to swallow. If the fit still continues and the doctor has not come, the bowel should be washed out with a large injec- tion of warm water, and this be followed by one suitable to quiet the nervous system (Appendix, 87), the latter injection being held in by pressure of the thumb over the opening of the bowel. Fortunately, the hot bath and the emetic answer every purpose in most cases, and relieve the attack in a few minutes. In very severe cases which have resisted other treat- ment and where no physician can be obtained, the child may be made to inhale a small quantity of ether poured upon a towel and held close to the nose. This should be kept up only until relaxation of the body and cessation of the convulsive movements occur. It must be borne in mind that ether in unskilled hands is dangerous. It should be used only as a last resort, and because not to use it is the greater evil. The conviclsions of epilepsy are identical in appearance with the ordinary spasms described. They may begin in early infancy, and in such cases can be distinguished THE SICK BAB V. 26/ only by the persistent recurrence of the fits as the child grows older. No special treatment is needed during the epileptic convulsion, other than placing the child in a comfortable position, guarding it from injuring itself and loosening the clothing about the neck. No effort should be made to straighten the arms, bend out the thumbs, hold down the legs, and the like. Night-terrors. — In this disease a child of from two to six years or older, apparently in perfect health, starts suddenly from sleep, screaming and cold with fright, stands in bed or even runs through the room, does not seem thoroughly conscious, fails to recognize its mother, and cannot be pacified. Night-terrors differ from an ordinary nightmare in the confusion and fright which persist after waking, and in the child's inability to tell afterward what frightened it. As a rule, the attacks, of which there is usually but one in the course of the night, come on after one or two hours' sleep, and last but a few minutes. They may occur every night or only at irregular intervals, and in rare cases they take place even while the child is awake during the day. The principal causes are some disturbance of digestion and the exist- ence of a highly sensitive nervous system. Treatment consists in careful diet if there is indigestion, the avoid- ance of excitement, a healthy outdoor life, and especially the giving of a very light evening meal. If this does not cure and the attacks are frequent, medical advice should be obtained, as l)ad cases may possibly run into epilepsy. Sleeplessness; Insomnia. — This arises from a great many difi'erent sources, and the treatment, of course, varies accordingly. Among the causes may be men- 268 THE CARE OF THE BABY. tioned colic or pain of any other nature; constipation; indigestion; too much sleep during the day; too early going to bed; too exciting play just before bedtime; hunger resulting from too long an interval between nurs- ing and putting to rCvSt; too hearty a supper in the case of older children; not enough fresh air during the day; imperfect ventilation and over-heating of the bed-room; hot bed-covering at night; cold feet; a bright light in the room, and the sound of voices penetrating into it. The remedies for these causes are self-evident. A baby nursed too frequently during the day may show the force of habit by desiring to be fed often during the night, although not actually hungry. When a baby begins to fret as though sleepy, and yet will not sleep, it is fair to presume that it has been over-fatigued. It is ' ' too tired to sleep." Prevention is the only cure for this. In many cases, especially in nervous subjects, there seems to be no cause whatever for insomnia except an individ- ual peculiarity, and the child may lie in bed entirely comfortable, yet equally wakeful. In such cases it is often a good plan to give the daily bath at bedtime, mak- ing it slightly warmer than usual, in order to obtain its sedative action, and simply to sponge in the morning. Sometimes putting the child to bed at a rather later hour is of service. There is a large selection among drugs useful in sleep- lessness, and some of them are decidedly harmful under certain conditions. The one to be chosen requires very careful consideration, and the mother should never give any of them except by medical advice. Headache. — Pain in the head is of frequent occurrence in children, and even in babies. Older children com- plain directly of it, but in infants it can be recognized THE SICK BABY. 269 only by a wrinkling of the brows, persistent crying, a rolling of the head from side to side, or the moving of the hand toward the painful region. The causes of head- ache are very numerous, and often difficult to ascertain. Among the most common of them are forms of brain disease, and especially meningitis, fever from any cause, neuralgia, indigestion and constipation, fatigue, im- poverishment of the blood, strain of the eyes at school, excessive mental work, general debility, and disease of the heart or kidneys. To distinguish which is the acting cause, and then to determine what treatment is required, is usually beyond a mother's power. Rest, the preven- tion of noises, bathing the head with cold water or bay rum, a mustard plaster at the back of the neck, a mus- tard foot-bath, restricted diet, and the administration of a laxative may be tried without danger. St. Vitus's Dance; Chorea. — A nervous disorder chiefly seen in children, characterized by irregular jerk- ing movements of the arms and legs, often with grimaces and sometimes with decided loss of power. The attack frequently begins with what appears to be awkwardness, the child dropping its food at the table, and having a tendency to walk awkwardly or trip over things. The disease may become so severe that the child is unable to feed or dress itself, or even to walk. The affection often can be traced to a fright or to over- work at school or other nervous strain. It also appears to be especially liable to develop in rheumatic children. Its great danger is that it may be followed by heart dis- ease. The child should be taken from school, and all sources of excitement removed. Sometimes confinement to bed is necessary. In all cases medical treatment is required. 2/0 THE CARE OF THE BABY. Paralysis ; Palsy. — A widespread or limited, more or less complete loss of power. There are various causes and forms of the disease. Sometimes the pressure occur- ring naturally during a tedious confinement, or less often that occasioned by the use of instruments, injures the brain, and both affects the mind and produces a birth- palsy as well. Generally the arm and leg of only one side are affected, yet both sides are not infrequently in- volved. This form of birth-palsy may improve con- siderably or may become worse with advancing years. Sometimes a paralysis of one side of the face or of one arm occurs during birth from direct pressure of instru- ments upon a nerve, the brain having nothing to do with it. This variety will nearly always recover in a few days or weeks. There is 2^ paralysis following diphtheria which attacks especially the muscles of the throat and eyes, causing food to enter the back of the nose and producing squint. Occasionally it affects the whole body. Recovery is usually complete. Paralysis of a somewhat similar nature, due to inflam- mation of the nerves not the result of diphtheria, is occasionally seen. A paralysis due to disease of the spinal cord is frequent in children. The commonest form begins suddenly with fever, restlessness, sometimes convulsions, more or less delirium, and other vague symptoms. No diagnosis is possible until in a day or so paralysis of one or more extremities develops. Sometimes the onset is even more sudden, and a child, well on going to bed, is found para- lyzed in the morning. Considerable improvement takes place, though slowly, but more or less loss of power and wasting of the limbs will probably remain through life. THE SICK BABY. 2/1 Another form of spiual paralysis is that occurring in curvature of the spine. (See Pott'' s Disease^ p. 281.) The greatest perseverance in carrying out the treat- ment is necessary in all forms of paralysis. The affected parts are frequently cold, and need to be dressed very warmly. After the acute stage is over thorough rubbing and kneading must be kept up day after day for months in the effort to maintain and to increase the strength of the muscles. The physician in charge may advise elec- tricity for the same purpose. The child should in most cases be made to use the paralyzed parts as much as pos- sible. The use of crutches and other apparatus must not be begun unless absolutely unavoidable, as this is the most certain way to render them indispensable throughout life. If the doctor finds that the child really cannot learn to walk again, he will probably advise some sort of brace which, with the help of a cane, will give the needed support and render crutches superfluous. Hydrocephalus; Water on the Brain. — This is an enlargement of the head resulting from a great accu- mulation of fluid within the skull. The head and the fontanelles grow constantly larger, the latter bulge, and the bones become thin. The shape is somewhat glob- ular, so that the face seems small and the head very large, the forehead overhanging the face, and the sides of the head extending beyond the ears. In mild cases the mind is not affected, but in severer ones the child is feeble-minded and has little control over its body. (PI. III., Fig. I.) Feeble-mindedness; Idiocy. — Idiocy — which differs from feeble-mindedness only in degree — is a condition 2/2 THE CARE OF THE BABY. which is often born with the child, although it may develop in infancy or childhood as the result of some disease or from injury to the brain. A congenitally weak-minded baby does not notice as soon as it should. It will perhaps not follow a bright light with its eyes, nor turn its head toward the source of a noise, long after a normal child does both of these acts. As it grows older it is very slow in learning to hold up its head, to sit up, or to hold objects in its hands. Even by two years of age it may make no attempt to walk or to utter any distinctly-articulated sound. Its face has a vacant expression and it slobbers a great deal. At three or four years of age it may have learned a few words or may still be unable to speak or to understand at all. This description is of a well-marked case. There are all grades of the condition, however, down to what may be called simply backwardness^ in which the child's powers are slow in developing, but finally expand to a very satisfactory degree if carefully trained. The mother must be able to recognize the mental defect as early as possible, with the intent that she may lose no time in beginning the training. The success at best is slow, and efforts must be unremitting and be uninfluenced by dis- couragement. Sometimes it is better to place the child in^an institution where its education can be superintended by those accustomed to this work. Deaf-mutism. — This resembles idiocy so closely for the first few months of life that its recognition is dif- ficult or impossible. A deaf-mute takes no notice of sound because it cannot hear it, while a feeble-minded baby hears, but has not the sense to notice it. By the age of six months we should be able to decide between the two conditions. A deaf baby shows by this time THE SICK BABY. 273 none of the bodily feebleness or lack of development of the idiot. It has an intelligent expression, and will play with toys and smile at its mother, yet will take no notice of such a sound as that of a bell rung behind it. Very loud noises may make an impression upon it, either be- cause it is not totally deaf or, more often, because it feels such vibrations as come, for instance, from the slamming of a door. The child's ears should at once be examined by an aurist, in order that something may be done, if possible, before it is too late. If found incurable, it should when older be trained to talk and understand by lip-reading, in which so much success has been attained in recent years, and which is so superior to the awkward deaf-and-dumb alphabet. There are institutions which are devoted solely to this instruction, and children often learn articulate language so well that they talk audibly and understand almost as if they could hear. Congenital Blindness. — This cannot at first be dis- tinguished from idiocy, which, indeed, not infrequently accompanies it. Only time can show the difference. A feeble-minded child will eventually learn to fix its eyes upon objects unless it is an absolute idiot, in which case its mental deficiency will show itself in other ways as well. Inflammation of the Eyes. — This affection may occur at any age. The most dangerous form {ophthalmia of the new-born^ ophthalmia neonatorimi) is that which develops a few days — usually about three — after birth, and which may cause blindness in spite of the most careful treatment. To prevent this the eyes should be carefully washed after birth, in the manner described in Chapter IV. Should the inflammation begin, the lids 18 274 THE CARE OF THE BABY. stick together after sleep, and pus may be found at the corners and on the inner surface of the lower lid. The lids soon swell greatly, and their lining and that of the eye itself is very red and secretes an abundant thick dis- charge. As this is very infectious, the nurse must care- fully keep any of it from getting into her own eyes or those of the mother or of other children, while at the same time the baby's other eye, if sound, must be guarded by an antiseptic bandage. A physician must be summoned without a moment's delay, since thorough and early treatment of a cleansing and disinfecting nature is essential. The nurse must see that the eye is kept scrupulously clean by very frequent washing, and that the lotion ordered really gets inside the lids. To accom- plish this the baby should be held on the lap, with the head inclined backward and toward the diseased side. The lids must then be gently separated and the lotion dropped in from an "eye-dropper." This consists of an ordinary medicine-dropper, but with the point smooth and rounded or bulbous to prevent accident. Absorbent cotton wet with the lotion may be used in- stead of the dropper. The lower lid is drawn down slightly and some of the fluid is squeezed upon it. The solution should enter at the corner next the nose. The inclination of the head carries it through toward the cheek, thus keeping it away from the sound eye. The sticking of the lids may be prevented by rubbing their edges with a little vaseline. Any cotton or cloths used for washing the eye should be burned, and the nurse should disinfect her hands after each treatment of the child, and before she touches her own eyes (Appendix, 96, 97). Older children may suffer from various forms of inflam- mation. In some of the severer cases minute blisters or ulcers develop upon the front of the eyes, and children THE SICK BABY. 275 cannot be persuaded to open them at all on account of the great pain which light produces. As it is difficult to distinguish between the serious and the trifling inflam- mations, a physician should be consulted promptly. Pre- vious to his visit the eyes may be bathed frequently with cold water and a little soothing eye-wash dropped into them often (Appendix, 80). No poultice or bandage, or any of the numerous eye-washes sold in the shops, should ever be used without a physician's advice. Sometimes the edges of the lids become chronically red and inflamed, and the growth of the eyelashes affected. This occurs usually in children whose health has been impaired. Styes. — Small inflamed swellings on the edges of the lid, especially in older children, which form in a few days and then subside, or soften and discharge, or, finally, persist in the form of little tumors. Some children are very liable to have styes repeatedly, while others never do. Often the general health is at fault, and demands tonics; while in many cases, particularly in school-chil- dren, there is some defect of vision which needs exam- ination by an ophthalmologist. This is especially the case in children who constantly develop styes. For the relief of a stye already present the frequent applica- tion of small, very hot fomentations is the best method of treatment. Squint; Strabismus. — Strabismus may be either con- vergent, producing a condition of ' ' cross-eye, ' ' or di- vergent, so that one eye turns outward. Either one or both eyes may be affected. Of course, the mother can do nothing; but there is one thing she must not do, namely, neglect it. Not only does strabismus detract greatly 2^6 THE CARE OF THE BABY. from a child's good looks, but it will finally produce great impairment of the sight of the aflfected eye. Treat- ment ought to begin very early in order to be of value. In infancy and early childhood the dropping of certain solutions into the eye may gradually correct the defect. In other cases the use of spectacles may be needed, or the performing of an operation which is not at all dangerous. Inflammation of the Ears ; Earache ; Running Ears. — Earache is, of course, only a symptom of different forms of inflammation of the ear which may or may not go on to the formation of pus. The child may develop pain suddenly in the night, although it was well or had only a slight cold in the throat or nose when it went to bed. The chief symptom in infants is loud, persistent crying, not relieved by anything, and sometimes made worse by pressure just in front of or just behind the affected ear. Occasionally a baby will raise its hand to the seat of pain. Older children can easily locate the pain, although they sometimes refer it to the teeth. There is usually fever and some degree of deafness. The pain may subside after a few hours, or may con- tinue with intermissions even for days. If pus is pro- duced, it will finally perforate the drum-membrane and be discharged, probably with relief of pain. If insuffi- ciently cleansed, the ear often has a very offensive odor. No medicine of any kind should be dropped into the ear, and no poultice or other wet application placed over it. A hot-water bag or bottle held to the ear will often remove the pain in a little while. Relief may be ob- tained by repeatedly syringing the ear with water as hot as can be borne, or the child may be laid on the sound side and the water be poured into the affected ear, which should then be covered with hot dry flannel. The pro- THE SICK BABY. 2'/y cedure must be repeated frequently. The child should be kept quiet and warm, and the temperature of the room should not be less than 70° F. The diet should be light. A laxative and a fever mixture (Appendix, 103) aid in re- lieving the inflammation. If the pain persists or if pus is discharged from the ear, it is best to consult a physi- cian, since, apart from the chances of permanent deaf- ness, there is always danger that inflamma- tion may extend to the brain. In cases of dis- charge from the ear the mother may very gently syringe the canal with warm water as often as is necessary to keep it clean, but should put no plug of cotton into it unless the child is going into the open air. The best syringe for her to use is a small bulbous one, Fic.ls^Ear- called the *' Ear and ulcer syringe," which is syringe. made of soft rubber throughout (Fig. 53). (4) DISEASES OF THE BONES, MUSCLES, SKIN, ETC. Deformities of tiie Head. — An alteration in the shape of the head may occur as a result of prolonged pressure received during birth. The deformity is due partly to the displacement of the bones and partly to swelling of the scalp (PI. III. , Fig. 2). Attention is called to it here because it is often the source of great though entirely needless anxiety on the part of the mother. If it is let alone it will be all right in a few days. On no account should any attempt be made to squeeze it into shape. A distorted and marked head is sometimes the unavoidable result of delivery by instruments. Here, too, the traces of deformity will usually disappear in a short time. In rare instances a large lump on the head, the size of an egg^ is caused by an accumulation of blood under the skin, or in other very unusual cases by a portion of the 278 THE CARE OF THE BABY. brain protruding through an unnatural opening in the skull and elevating the skin over it. Such a deformity as the latter does not, of course, disappear. In hydro- cephalus and in rickets there is a deformity of the head characteristic of each respectively — in the one globular and in the other square (see PI. III., Figs, i and 3). These deformities are better considered in connection with other symptoms of the two diseases. Protruding Ears. — Mothers are often exercised greatly over a too great prominence of the baby's ears. Probably little alteration in the shape can be accomplished in most instances, and it is better not to meddle with them. A cap or a network bandage may be worn during sleep, to keep the ears from being bent by the pillow, and to press them inward somewhat. A slight operation may be performed in bad cases to bring the ears closer to the head. Deformed Hands and Feet. — Children are sometimes born with sitpermnnerary digits on the hands or feet, or with webbing between the fingers or toes similar to that seen in a duck's foot. Any operation required should be done early. Club-foot is a distorted shape of the foot, in which, most commonly, the front part of the foot is turned in- ward and the heel is raised. Sometimes there occur con- tractions of the foot into other forms. The condition may be present at birth or may be acquired. Treatment should begin immediately and be persevered with. The application of a splint or of some apparatus and the fre- quent manipulation of the foot will effect a cure in many cases. In others there must be an operation as well. Ingrowing toe-iiail is a condition in which the edge 3 t? n ^^ •HI 3XV1J THE SICK BAB K 279 of the nail, usually of the great toe, is pushed into the flesh, which rises above it. It will not develop if the shoes have been made of proper size and shape and the toe-nails have been cut according to the directions already given. Should the deformity be already present, a small quantity of cotton should be packed under the corner of the nail, in order to raise it above the flesh. The nail must be cut square or, still better, concave across, with a notch in the centre (Fig. 54), and should also be scraped thin down the middle with the edge of a knife. The corners should never be rounded off. If the disease has advanced too far for this plan of treatment, the advice of a physician must be had. Fig. 54.— Hip-joint Disease. — A tubercular inflam- Method of cutting mation of the hip-joint, the results of which an ingrowing toe- are so serious that every mother should be on the alert to recognize its insidious onset. One of the earliest symptoms is pain, in some cases situated in the hip itself, but very often felt only in the knee. The child is prone to start suddenly from sleep, suffering from pain. Very soon some degree of lameness comes on, lasting at first for a few days at a time. The child often tries to rest the affected hip by standing on the sound leg. Parents often make a fatal mistake at this period by at- tributing the symptoms to the existence of ''growing pains" and of weakness of the knees. A physician should be called in without delay, for the recovery is tedious at the very best. In many cases abscesses form, and even life is lost. Curvature of the Spine. — There are three forms of this affection, very different in* nature and cause, which 28o THE CARE OF THE BABY. may be mentioned here. In the first, called lateral curvature^ the spine makes an S-shaped curve, as shown by the illustration (Fig. 55). Rickets is the commonest cause in young children, while a faulty position in sitting at school, or the carrying of some weight (as a baby-brother Fig. 55. — Lateral curvature of the spine. or baby-sister) always upon the one arm, produces it in older children. It is much commoner in girls than in boys. Mothers should not fail to examine their children for the defect at intervals. The disease consists in weak- ness of the articulations and muscles rather than of the bones. The treatment must be directed by a physician. Such gymnastic exercises and the assumption of such positions are required as will mechanically correct the deformity. THE SICK BABY. 281 The second variety of curvature, called caries of the spine ^ Pot f s disease^ or angular curvature.^ is due to tu- bercular softening and destruction of the bones of the spine, and is of so grave import that its earliest symp- toms should be reported to the physician. It is rare before the age of two years. A fall or blow seems sometimes to Fig. 56, — Slight degree of curvature of the spine, from a case of Pott's disease. start the process, but the majority of cases are in no way due to injury. One of the earliest symptoms is a pecu- liar stiff, tottering walk with a tendency to fall forward. The child moves the back rigidly and as a whole in order to avoid any jarring. It will not bend the back to pick up anything from the floor, but does it by bending the knees. If the trouble is higher in the spine, the shoulders are sometimes carried ' ' shrugged up ' ' and the neck stiff. Where the disease is low in the spine the child 282 THE CARE OF THE BABY. sometimes has a disposition to walk leaning forward, with the hands at times upon the thighs. Pain felt at the seat of trouble is usually present. Early in the disease pain is very often felt in the abdomen, and resembles a stomach-ache caused by indigestion. Sooner or later there develops a slight prominence of the spine which only a skilled eye may detect. Eventually the promi- nence becomes quite visible (Fig. 56), and it may even result in great deformity. The third form, the rickety posterior curvature^ occurs in severe cases of rickets in infancy (Fig. 57). It is due to the same articular and mus- cular weakness which produces lateral curvature, but it consists of a very long rounded curve extending posteriorly and oc- cupying nearly the whole length of the back, while in Pott's dis- ease the curve is at first more angular, short, and small. Ulceration of the Navel. — Instead of drying up properly the navel cord sometimes be- comes soft and ill-smelling and leaves a large ulcer after falling off. In some cases a pea-sized red protuberance can be detected within the navel, and from this comes a little discharge which irritates the surrounding skin. Frequent thorough dusting with a powder consisting of boric acid and oxide of zinc (Appendix, 90) will often effect a cure promptly. If not, the family physician may have to cauterize the ulcer, or perhaps cut off the protuberance. Fig. 57 -Rickety curvature of the spine. THE SICK BAB V. 283 Bleeding from the Navel. — Severe hemorrhage from the cord occasionally takes place some hours after birth ; or later, after the cord has fallen off, hemorrhage may occur from the navel itself. In the former case the cord should promptly be tied again between the body and the point from which the blood seems to come; in the latter the bleeding point must be firmly compressed between the finger and thumb until a physician can be obtained. Birth-marks ; Mother's-marks. — Under this heading are included both n<^m^ as physicians call them, and moles. A itcsvus consists of a red or purple patch on the skin, sometimes on a level with it, sometimes elevated above it. Although usually small, it is occasionally ex- tensive, and in some instances it is disposed to grow, and may then prove dangerous. A mole is a dark pigmented area in the skin, either flat or elevated, smooth or covered with hair. It is generally small, but sometimes is of sufficient size to cause great disfigurement. Contrary to the popular belief, birth-marks are in no way dependent, in the vast majority of cases, upon im- pressions made upon the mind of the mother before the child was born (compare page 25). Treatment can be prescribed only by a physician. Cauterization or some more serious operation may be needed, and some birth- marks cannot be removed at all. Warts. — These disfiguring growths are most common in children. They are apt to develop rapidly, and often to disappear quite as quickly without treatment. There is no good evidence that charms have any curative value whatever, and most of the applications recommended are equally useless. The warts are best let alone or cauter- ized by a physician. 284 THE CARE OF THE BABY. Red Gum ; Strophulus. — Titles formerly applied to a red, pimply eruption from which babies often suffer during the first wee^s of life. The rash is generally either eczema or prickly heat. Prickly Heat; Miliaria. — A very common affection in infants, consisting of an eruption of numerous minute red elevations (papules), or of pinhead-sized, inflamed blisters (vesicles), or of both together (see page 296). These are closely crowded, particularly where there is much perspiration, as about the neck and over the trunk. The disease begins very suddenly and is attended by more or less burning and tingling, but seldom by the very in- tense itching of eczema. The latter affection, moreover, usually develops more slowly and its vesicles show a greater tendency to run together. Prickly heat is seen chiefly in hot weather, and especially in children who are too warmly clothed and who perspire profusely as a result of this. Treatment consequently consists chiefly in avoiding or removing the cause. The clothing must be made as cool as the child can wear with entire safety. It is particularly in children disposed to prickly heat that woollen underclothing must sometimes be replaced in summer by cotton material (see p. 86). The irritated skin may be dusted with a camphor-and-zinc powder (Appendix, 89) and the child given a laxative alkaline mixture (Appendix, loi) or a dose of magnesia and a light diet. Sometimes the itching is- relieved by a solu- tion of a teaspoonful of baking-soda in a pint of water dabbed on and allowed to dry. If recovery does not follow in a very few days, a physician's advice should be obtained. Eczema. — A troublesome disease, particularly common THE SICK BABY, 285 in infants, lasting days, months, or occasionally even years, and limited to a large or a small area, or, in rare instances, covering the entire body. The special tend- ency to sufifer from it disappears in most cases by the end of the first year, although it is frequent at all periods of life. Among the principal causes are inherited tendency, debilitated constitution, imperfect hygiene, im- proper diet (particularly in infants the early use of starchy food), digestive disturbances, the eruption of a tooth, irritating soap, the contact of soiled diapers, any other local irritation, etc. Often no cause can be dis- covered. The commonest situations are about the head, the crotch, the groins, and the folds of the joints in gen- eral. In the most frequent form the skin becomes bright red and covered ^yith minute, pinhead-sized vesicles. These soon rupture, leaving the surface swollen, red, and moistened with a watery discharge which may thicken and form crusts with raw flesh beneath. In another form the skin is dry, red, thickened, and somewhat scaly, and perhaps cracks easily. In still another com- mon variety numerous small pustules develop; while in another the eruption is chiefly composed of papules (see p. 296). The attack is attended by itching which is often so intense that the child is nearly frantic. This is generally worse at night, and may prevent sleeping. Owing to the disposition of the rash to spread, every case should early be put under a physician's care. The treatment open to the mother is to remove the cause if it can be found. Besides this she may give a laxative at the outset, reduce the quantity and the strength of the food, hinder scratching by putting the hands into mittens or even by fastening them to the sides, prevent any friction of the skin from rough clothing, cease to employ soap, use no more water on the diseased part than is 286 THE CARE OF THE BABY. absolutely necessary, and employ a lotion of starch and boric acid instead of plain water for cleansing (Appen- dix, 78). The skin, if red and weeping, may be dusted frequently with a drying powder (Appendix, 91). Sur- faces which touch each other must be separated by placing between them a thin layer of absorbent cotton or patent lint well filled with the powder. Soaking in sweet oil may be employed to remove any crusts. Hives; Nettle-rash; Urticaria. — Few or numerous distinct raised blotches, pinkish or whitish in color, and of a size which, although having a considerable range, averages that of the finger-nail. They often resemble closely the elevations produced by the stings of insects. A crop of hives comes out with great suddeness, lasts a few hours or a day, and is then, perhaps, succeeded by another, the whole attack persisting for two or three days or sometimes becoming chronic. The burning and ting- ling are often intense. The commonest cause is some disturbance of digestion. Sometimes one certain article of diet will, without affecting the digestion, always pro- duce nettle-rash in one child, and another article will have the same ej0fect in another child. Among the foods most apt to act in this way are fish, shell-fish, straw- berries, pineapples, mushrooms, and sausages. Some- times the presence on the skin of a single insect, as a hairy caterpillar or a flea, may bring out a large crop of hives. Contact with the stinging-nettle or with the jelly- fish may produce the rash. The treatment usually effi- cacious for mild cases consists in giving a dose of mag- nesia followed by a laxative alkaline mixture (Appendix, loi) and reducing the diet temporarily. The skin may be powdered frequently with camphor-and-zinc powder (Appendix, 89), or the spots dabbed with absorbent cotton i THE SICK BAB Y. 287 wet with equal parts of vinegar and water or with a special cooling lotion (Appendix, 84). In cases which tend to be chronic or to recur frequently the great aim must be to search for and remove the cause. Starch-and- soda baths (Appendix, 44) often do great good, but the disease ought to be treated by a physician if it lasts more than a few days, as it is sometimes most difficult to cure. Chafing; Cracks; Roughness of the Skin; Chap- ping. — Chafing may occur wherever two moist surfaces of skin are constantly touching each other. It is common in the folds of the neck in fat babies, in the armpits, and about the buttocks, thighs, and groins. In the latter localities it is liable to be produced by a too infrequent changing of diapers, particularly if there is a sour diar- rhoea. When the attack is severe the skin is bright red, tender, moist, and looks almost raw. In children dis- posed to it the disease may be prevented by ensuring great cleanliness and by the use of starch-water for wash- ing, followed by a thorough drying and dusting with a talc powder. When there is diarrhoea, the free applica- tion of vaseline helps to keep the skin from becoming moist. To cure chafing already present the methods mentioned must be followed, and, in addition, pieces of lint previously dusted with an astringent powder (Ap- pendix, 91) should be placed in the folds between the affected surfaces. Cracks are generally produced in the same way as chafing, and are in reality of the same nature. Those in the folds of the neck are sometimes very difficult to heal. The frequent application of a hot wet sponge followed by careful drying may be of benefit. A general rough^iess of the skin is generally best treated by thorough rubbing with olive oil or vaseline after bathing. 288 THE CARE OF THE BABY. Chapping of the hands and face usually results from exposure to cold. It is best prevented by protecting with veil and gloves. The treatment is much the same as for roughness of the skin. Stomach-rash ; Tooth-rash. — Terms often used by mothers to designate many sorts of rashes seen in infants. They are more properly applied to an erup- tion of erythema^ that is, of a diffuse redness or of dis- tinct, pea-sized, scarcely elevated spots which appear very suddenly, last a few hours or days, and produce no irritation. This often develops in infants suffering from some digestive disturbance. Treatment is generally not required, other than that for the indigestion. Boils and other Pustular Eruptions. — In a strictly medical sense, a boil, or furuncle^ consists of an elevated, rounded or conical, dusky-red, painful, and very tender swelling which contains pus. When it bursts it is found to have a distinct ' ' core ' * of dead tissue. Furuncles may be single, but are very apt to occur several at a time and in successive crops. Impairment of the gen- eral health or, in babies especially, chronic digestive dis- turbance causes them in many cases, but some children have a peculiar predisposition to them, although ap- parently well in other respects. The disease, however, is never a sign of robust health, as has sometimes been supposed. There are various other pustular eruptions which are popularly known as ' ' boils, ' ' but which are named otherwise by physicians. Some of these are the result of most unfavorable hygienic conditions; others are evi- dences of eczema; others occur entirely independently of any affection of the general health or digesticn ; others Plate IV. Girl with measles, showing the characteristic grouping of the eruption and the peculiar heavy and swollen appearance of the face. (From a photograph.) THE SICK BABY. 289 constitute a peculiar acute contagious disease; and still others are the result of syphilis. The only treatment of pustular eruptions which is justifiable without the advice of a physician is the protecting of the affected parts or the smearing them with a little ichthyol. Poultices must never be applied unless ordered. When used, they should be mixed with a boric-acid solution (Appendix, 75) in- stead of with plain water, or, still better, the dressing should be the antiseptic poultice described later (Appen- dix, 62). Tonic treatment and change of air are needed in many cases. Fever-blisters. — Small groups of minute, closely- crowded blisters (vesicles, see p. 296) which contain a clear watery fluid, and which, if not ruptured, dry into a crust. In many children slight fever, such as accom- panies a cold or indigestion, will invariably produce them. They are generally situated on the lips or the edges of the nose, although in bad cases they may spread over the face or below the chin. The spots should be smeared twice a day with ichthyol or with a zinc-and- bismuth ointment (Appendix, 68). Dandruff; Milk-crust. — Young babies often show a tendency to an excessive production of oily scales upon the head. Unless carefully watched, these will accumu- late in large yellowish patches commonly called the milk-crust. Some mothers have a mistaken notion that this should be carefully let alone. Great cleanliness will prevent any such accumulation, and rubbing the head daily with a boric-acid ointment (Appendix, 70) will often check the excess of oily secretion. A patch already formed should be removed by soaking it with warm olive oil and then washing it with Castile soap and warm 19 290 THE CARE OF THE BABY. water. A fine-tooth comb should never be used on it. When the patch is found to have a raw, weeping surface beneath it, it is not simply milk-crust, but is eczema, and should be treated accordingly. In older children there is often a production of dryer scales, or dandruffs which are without the very oily cha- racter, and which consequently fly about when the hair is brushed. The scalp should be washed frequently with water and one of the German salicylic-acid or sulphur superfatted soaps. If dandruff persists, a physician must be consulted, since falling of the hair may follow. Ringworm. — A common and very contagious affection, due to a microscopic, mould-like, fungous growth. On the face and body it occurs much most frequently in child- hood, and on the scalp it is found only at this time of life. In the former situation it consists of a single dull-red, more or less circular spot, which gradually enlarges into a patch with a red, somewhat scaly border and a paler, more natural centre. This ring-like shape gives the name to the disease. On the scalp, which is by far the commonest situation, the patches are numerous, circular, and little, if at all, red. The hair comes out, leaving the spots more or less bald, and often covered with fine scales and with short, brittle stumps of broken hairs which can be pulled out easily. This latter is a characteristic symptom. Ringworm of the scalp is so difficult to cure and so tedious at the best that no mother should dream of un- dertaking its treatment. Her province is to follow direc- tions carefully and to see that other children, her own as well as those of other people, do not catch it. The affected child must on no account be sent to school, and all its toilet articles must be kept strictly for its own use. Some sort of skull-cap may be worn to prevent the germs Plate V. Child with well-developed rickets suffering also from chicken-pox, showing the contracted ■chest, swollen abdomen, and enlarged wrists of the first disease, and the characteristic rash •of the second. (From a photograph.) THE SICK BABY. 29 1 from getting about. The sooner a physician sees the case the greater the chance of getting it under control. Ringworm of the body is much more easily cured. An ointment such as that given in the Appendix (69) may be rubbed into the spot twice a day for a week or longer; but here, too, a wise mother will not undertake the care of the case herself. Itch ; Scabies. — An intensely itching and very con- tagious affection of the skin, due to the presence of a minute insect which burrows under the surface. The disease may attack any age from infancy up. Although commonest among the poor and dirty, it may by contact with them be contracted by the cleanest child. Exam- ination shows scattered, small pimples, which may oc- cupy any part of the body, but which are usually first found on the sides of the fingers. The toes, armpits, buttocks, and the central parts of the body are also favorite seats. Sometimes a few irregularly shaped ridges, one to ten lines long, show themselves here and there and make the diagnosis certain. They are the bur- rows in which the female insect lays her eggs. Often, however, the itching is so intense, and the skin so irri- tated and torn by the scratching which this incites, that the original characteristic appearance is destroyed and the diagnosis may be difiBcult. If several children of one family, and perhaps the parents as well, are suffering from an itching eruption, it is pretty certain that the disease is the itch. Treatment is almost beyond the power of the mother, for the applications necessary some- times produce decided irritation which must be checked. As contagion takes place by the clothing and the bed- linen, particular attention must be given to their disin- fection. 292 THE CARE OF THE BABY. Lice; Pediculi. — Although these little insects are by right the inhabitants of the unwashed, any child, no matter how clean, may be infected by them through some accidental contact with another. When once in posses- sion, they are not killed by the simple washing of the head with soap and water. The first symptom is a very decided itching of the scalp. The scratching which this causes, and the irritation by the animals themselves, set up an inflammation, and produce pustules and matting of the hair if the case is severe. Eczema situated at the back of the head is in most cases the result of the pres- ence of lice. Careful inspection shows the minute oval eggs (7iits) attached by one end to the hairs. The careful use of a fine-tooth comb will probably remove some of the animals themselves. Many different applications are equally serviceable, but some of them are quite irritating. One of the safest and most popular is the ointment of stavesacre (larkspur-seeds), which should be rubbed upon the scalp several days in succession. Kerosene is also a good application, but must not be applied near a flame of any sort. The hair meanwhile should be washed re- peatedly with vinegar in order to destroy the nits. With proper care long hair need not be cut. There is one species of lice — body-lice — which infests the clothing only. The remedy consists in entire de- struction or baking of the infested garments and the placing of the child in a disinfectant bath (Appendix, 95)- (5) INFECTIOUS DISEASES. Of the numerous infectious diseases, we may consider typhoid fever, small-pox, chicken-pox, vaccination, scarlet fever, measles, German measles, diphtheria, mumps, and whooping-cough. They are called infectious because due to microscopic germs which are capable of being transmitted from per- THE SICK BAB V. 293 sons with the disease or from other sources and of infect- ing the system of others. Some diseases are contagious as well as infectious. Malaria is an instance of one which is infectious because due to a microscopic germ, but which is not contagious because it cannot be con- tracted from another person. All the diseases enumer- ated above are both contagious and infectious. The infection may be by direct contact, or the germs may in some cases be carried by another person or by water, food, clothing, books, letters, etc. The germs of some of the diseases have a great tenacity of life. A case of con- tagious disease is always the result of some other case from which the contagion comes, even though we are not able to trace the connection. All of the diseases mentioned, with the possible exception of whooping- cough, are accompanied by more or less fever. Some of them are called eruptive fevers^ because there is a cha- racteristic eruption or rash upon the skin. Treatment is entirely the province of a physician. There is absolutely no way known to avoid contracting them except by keeping away from the contagion. The carrying of disinfectants about the body, such as bags of camphor or carbolized substances, is entirely useless. The recogni- tion of the existence of one of the infectious diseases is beyond the mother's skill in many instances, while in others it is comparatively easy. The table which fol- lows gives in convenient form information regarding these diseases, which will be of value to a mother de- sirous of understanding something of their nature. Physicians use certain terms as applied to infectious diseases, which may conveniently be described in this connection. The day of the disease — as the " first day '^ or the "third day" — is in accord with the ordinary method of dividing time, and does not indicate the num- 294 THE CARE OF THE BABY, TABLE OF INFEC Disease. Incubation lasts— Date of Characteristic Symptom from beginning of Invasion. Characteristic Symptom. Typhoid fever. About 14 days. 7th or 8th day. Rose-red, slightly elevated spots. Scarlet fever. I to 7 days. 1st or 2d day. Intense, bright -red blush over body. Measles. 12 to 14 days. 4th day. Dusky or purplish - red, slightly elevated spots, scattered and in characteristic groupings. German measles. 7 to 21 days. 1st day. Pale, rose-red spots or uniform blush; no characteristic group- ings. Chicken-pox. 13 to 17 days. 1st day. Pea-sized, scattered vesicles. Varioloid (Variola). 10 to 14 days. 3d day (may be 1st or 2d). Red, elevated papules ; then ves- icles; then often pustules. Vaccinia (Vaccina- tion). I to 2 days. 1st day (3d after vacci- nation). A red papule, becoming a vesicle and then a pustule ; surrounded by a broad red area. Erysipelas. 3 to 7 days. 1st or 2d day. Bright-red blush ; puffy skin ; often blisters. Diphtheria. 2 to 12 days. 1st or 2d day. White membrane on tonsils and other parts of throat. Whooping- cough. 2 to 7 days. 7th to 14th day. A prolonged paroxysm of cough- ing followed by a crowing in- spiration (whoop). Mumps. 7 to 21 days. 1st day. Swelling in front, below, and be- hind the ear and below the jaw. ber of times twenty-four hours have elapsed since the symptoms first appeared. Thus, if the onset of symp- toms occurred, for instance, at 10 p. m. on Tuesday the 14th, the "second day of the disease" does not begin with 10 P. M. on the 15th, but is counted from midnight of the 14th — the time when Wednesday the 15th begins, although this is only two hours after the onset. The THE SICK BABY. TIOUS DISEASES. 295 Other Principal Symptoms. Whole Duration of Disease from Onset. Quarantine lasts from Onset — Apathy ; diarrhoea ; nose - bleed ; headache. 2 to 4 weeks. While disease lasts. Sore throat; often vomiting with onset. 7 to 9 days or more (not including des- quamation). 6 weeks at least. Cold in head; running eyes; cough J hoarseness. 7 to 8 days. 3 weeks. Slight sore throat; slight running of eyes and nose. 3 to 4 days. 3 weeks. None ; or slight fever. A week or less. 3 to 4 weeks. Headache; backache; vomiting. About 14 days. 4 to 8 weeks. Often feverishness and malaise. About 3 weeks. None. Fever; pain. 4 to 6 days, or several weeks if it spreads. Averages 2 weeks. Debility; fever. 10 to 14 days. 3 to 4 weeks. Vomiting; spitting of blood. 6 to 8 weeks 6 to 8 weeks, (while whoop lasts). Pain when chewing. A week or less. 3 to 4 weeks. stage of incubation denotes the period which elapses between exposure to contagion and the appearance of the first symptoms. The stage of invasion is the time fol- lowing incubation, in which there are distinct evidences of illness, although the characteristic symptom (such as the eruption in measles or the whoop in whooping- cough) has not appeared. Symptoms seen during this 296 THE CARE OF THE BABY. period are called prodromal or initial. The first day of invasion marks the onset of the disease, and from this day the duration of the disease is dated. Next comes the stage of characteristic symptoms called the eruptive stage in the case of eruptive fevers. Sometimes the invasion lasts less than a day, as, for instance, in chicken- pox, and the characteristic symptoms then appear on the first day of the disease; that is, there is no evident stage of invasion. Desqiiamatio^t is the shedding of the skin which follows in some of the fevers. The duration of the contagiousness, throughout which the child should be kept from mingling with others, is sometimes called the period of quaranthie or of isolation. Certain other terms are used in speaking of some of the eruptive fevers and of certain skin diseases. A vesicle is a little elevated blister, the size of a split pea or smaller, filled with a clear, watery fluid. A macitle is a small red spot not elevated above the skin. A papule is a red, pimple-like elevation. A pustule is shaped like a papule or a vesicle, but contains pus. The following is a much abbreviated review of the infectious diseases, supplementary to the table and con- taining chiefly facts not mentioned there. Typhoid Fever. — As frequent in children as in adults, but less severe; less common under three years of age, and occurring oftenest in autumn. It is but slightly con- tagious, for it is transmitted only by the germs from the bowel-movements contaminating the drinking-water or the food of others. As a rule, one attack protects from subsequent ones. Symptoms of invasion begin very insidiously with debility, loss of appetite, fever, and often diarrhoea and nose-bleed. Sometimes, especially in children, the onset is much more sudden. The fever THE SICK BABY. 297 gradually increases for a week, then stays high (103° to 104°) for a week or two, but with a very characteristic difference between the morning and evening temper- atures, and then gradually diminishes. Very frequently children scarcely feel sick at all, and the disease in them may stop much short of the usual three weeks. Diar- rhoea is not very common in children. The characteris- tic rose spots are usually only few and are not always present. They are found solely or chiefly on the trunk, and especially on the abdomen, come in successive crops, and continue to appear until the middle of the third week or for a shorter time. They are slightly elevated, oval, rose-red, and about one-sixth of an inch long, and disappear momentarily when pressed upon. Inflamma- tion in the bowel is always present, and ulcers are liable to form; and if the thin, paper-like wall of one of these ulcers perforates, death almost certainly follows in a few hours. We can easily see, then, the tremendous import- ance of very soft food, especially milk, and of absolute rest in bed and the use of a bed-pan, no matter how slightly sick the child may seem. Since the germs are contained in the passages only, these should be covered as soon as passed, and be disinfected promptly (Appendix, 93). The bed-linen and bed-clothes also ought to be disinfected. Scarlet Fever; Scarlatina; Scarlet Rash. — The dif- ferent names mean exactly the same. The disease is one of the commonest affections of children, occurs at any time of year, is rare under the age of one year and espe- cially under that of six months, and is very contagious, yet less so than measles. The germs are transmitted by the breath and the skin, and can be carried in the cloth- ing from the sick to the well. Their vitality is remark- 298 THE CARE OF THE BABY. able, for, attached to some garment, they may live even a year. A second attack is of great rarity, for in nearly every supposed instance of it the child really had some unrecognized rash on one of the occasions. The disease may be so mild that it is overlooked, or so severe that the child dies in a few hours. The lightest case is capable of giving the most severe form to other children. In a case of average severity the first symptoms are vomiting, fever, rapid pulse, and sore throat. The rash appears within twenty-four hours, and often first about the neck, but rapidly spreads over the whole body except the face. It consists of minute red points, not at all elevated, and so closely crowded that the skin appears a uniform bright red. As a rule, the eruption is widespread when the child is first examined. The color increases in intensity for two or three days, begins to fade in three or four days after the onset, and lasts in all about a week. At about the end of the first or second week the skin begins to peel in large or small shreds, and this characteristic desquama- tion continues several weeks. During the height of the disease fever persists, the throat is sore, swollen, bright red, and often seriously inflamed, and the tonsils may be covered with white patches resembling diphtheritic mem- brane. The tongue loses its coating and becomes bright red with the minute natural prominences unusually large ("strawberry tongue"). The rapidity of the pulse is greater than the elevation of the temperature would lead one to expect. The fever disappears in seven to nine days, and the acute stage is over. In bad cases with severe throat-symptoms fever may last much longer than this, while in the mildest cases the rash may disappear in twenty-four hours and there may have been but the slight- est fever. The disease is always alarming, because the cases which begin mildly may eventually become severe, THE SICK BABY. 299 or be followed by inflammation of the ears, pneumonia, abscesses of the glands in the neck, or Bright' s disease. The last-mentioned disease may come on even after the child has been convalescent from the fever for two or three weeks. It must be guarded against with especial care. In the way of treatment, the slightest possible chance of taking cold must be avoided. The child should be con- fined to bed, and the windows must not be opened in the slightest, or any bathing or sponging employed, until the doctor in charge is asked what he wishes done in the matter. Very often he will have the child oiled all over as an additional safeguard against cold and to keep the desquamating and very infectious skin from getting about the room. Further preventive measures against spreading consist in isolating the child the moment the mother suspects that it may have scarlet fever, in carry- ing out careful disinfection during the attack, and in de- ferring the removal of quarantine until she is quite sure that the danger is over. The caution about bathing is given not because it expresses the writer's views on its danger, but because some physicians are greatly opposed to all bathing in this disease. It does not apply to the first hot bath, useful at the beginning of nearly any acute disease in children. Measles; Rubeola; Morbilli. — Probably the most fre- quent and most contagious of the eruptive fevers; occur- ring oftenest in the cold season, and rarely in babies less than one year, or, especially, six months, old. It appears to be contagious even during the period of in- cubation. It is caught generally from the breath, for, although the infection can cling to objects about the patient and be carried by a third person, this occurrence 300 THE CARE OF THE BABY. is certainly very rare. The germ has little vitality as compared with that of scarlet fever. Second attacks of measles, although more frequent than is the case with scarlet fever, are still very unusual. In nearly all the re- ported instances so often heard of the children had measles upon one occasion and German measles or some skin afifec- tion upon the other. Measles is usually regarded as a dis- ease of little consequence; but this is an error. In children not previously in good health it may prove fatal, gener- ally by inducing pneumonia, tuberculosis, or some other complication. The attack begins with all the symptoms of a very bad cold, such as feverishness, sneezing, run- ning of the nose and eyes, heavy, stupid expression of the face, hoarseness, and cough. The child is so often stupid and sleepy that the expression ' ' sleeping for the measles ' ' has become a common one. Frequently the onset is much milder, and the child is out of doors, ver}^ slightly sick. The rash begins upon the fourth day of the dis- ease, in the form of purplish-red, slightly elevated, flat- tened papules about the size of a split pea. These ap- pear first upon the face, but spread over the entire body in about twenty-four hours. Many of them remain dis- tinct, while others unite by their edges and form irregu- lar blotches and lines many of which are crescent-shaped. This grouping is very characteristic of the disease. Plate IV. is from a photograph of a child with measles, and shows very well both the nature of the eruption and the heavy, somewhat swollen face and thickened lips. All the symptoms mentioned persist or grow worse, and there may also be diarrhoea. By the sixth or seventh day of the disease the fever has ceased, and by the seventh or eighth day the rash has disappeared. There is often a faint mottling and a fine desquamation of branny scales lasting a week after the rash has disap- THE SICK BABY. 3OI peared. There is no peeling as in scarlatina. At the beginning of the attack a hot bath may be given, but other treatment will be directed by the physician. It is best to keep the child in bed about ten days, to avoid the danger of taking cold. Bright light should be excluded, since the eyes are inflamed. German Measles; Rubella; Rbtheln. — The term "French measles" is only an incorrect name for this disease. "Roseola" is another term very loosely used, and applied to other affections as well. German measles is just as distinct from ordinary measles as scarlet fever is. That a child has suffered from one of the three dis- eases protects it in no way from the other two. It is less common than these, oftenest seen in the winter-time, very contagious, rarely occurs twice in one person, and seldom attacks children under one year old. The contagion is transmitted as in measles. The disease is quite variable, in some cases resembling measles, and in others scarlet fever, so closely that even the attending physician cannot make a positive diagnosis. There are seldom any pro- dromal symptoms, or they are only those of a very slight cold, and are followed by the rash within twenty-four hours. This comes out first on the face as pale-rose, very slightly elevated spots, of the size of a pin-head up to that of a split pea, which do not run together into distinct small blotches as in measles, although they do very often fuse into large areas of an almost uniform redness looking much like the rash of scarlet fever. The eruption spreads rapidly downward over the body, like a wave in that it fades rapidly also, and may have nearly disappeared from the face by the time it is fully out on the feet. It is gone from every part by the third or fourth day. The symp- toms during the presence of the rash are very moderate 302 THE CARE OF THE BABY. fever with slight running of the eyes and nose and slight sore throat. Desquamation of a few branny scales often follows the rash. Care must be taken to guard against cold, as bronchitis or pneumonia may develop. Chicken-pox ; Varicella. — A very common and con- tagious disease, rarely occurring twice in one person, and not so often attacking those under six months of age — although this last is less true of it than of measles and scarlet fever. It resembles the mildest varioloid very closely, but is an entirely distinct disease. Contagion is transmitted by the breath or scabs, and very exceptionally it is possible for a third person to carry it from the sick to the well. The disease is generally very mild. Prodro- mal symptoms are absent. The discovery of the charac- teristic rash is usually the first symptom, although some- times there is slight fever and malaise for a few hours before. The eruption consists at first of rose-colored spots which usually appear first on the neck and trunk, and which change in a few hours into prominent vesicles, from a few to hundreds in number, one-quarter of an inch or less in diameter, filled with a clear watery fluid, and sometimes surrounded by a slight red halo. The vesicles come out in crops, the older ones rapidly drying up and forming scabs. There may be mild fever during the presence of the eruption. The attack lasts a week or less, although all the scabs may not be gone for some time longer. Plate V., from a photograph, shows the vesicles dotted over the trunk in a case of chicken-pox with a moderate development of the rash. The child should be confined to the house, away from other children, or to bed if there is an extensive eruption. Other treatment is not often required. Care should be taken that the spots are not picked at or torn, as this THE SICK BABY. 303 increases the danger of leaving scars. When the vesicles on the face are unusually large some attention must be given to prevent scarring. They may be punctured with a needle and then touched carefully with a solution of equal parts of pure carbolic acid and glycerin. This so- lution must not be allowed to spread over the face. It is poisonous if swallowed. The advice of a physician had better be asked about its use. Small-pox ; Varioloid. — Varioloid, or modified small- pox., is in reality a mild form of small-pox, modified by occurring in one who has been partially protected by vaccination. Small-pox in any form is, fortunately, becoming comparatively rare. The difference between the symptoms of the modified and grave forms are those of degree only. Either form may be caught from a per- son suffering with the other. The disease is very con- tagious, and the contagious principle, which arises chiefly from the skin, permeates the air about the patient, and has, besides, a remarkable tenacity of life, since it may stick to clothing for months or years. As a rule, one attack protects against a second, but instances of two or more attacks are quite numerous. It occurs oftenest in the cold season. It is less frequent during the first year of life, although it may sometimes attack children even before birth. The symptoms of the invasion consist, if well marked, of more or less headache, pain in the back, high fever, drowsiness, vomiting, and sometimes convulsions. A red flush over the skin may be present. Sometimes, however, the initial symptoms are so mild that they are unnoticed. The eruption appears on the third day of the disease, or sometimes, in varioloid, on the first or second day. It first consists of spots which feel like shot under the skin, appear on any part of the 304 THE CARE OF THE BABY. body, grow more prominent by the time they are a day old, and on the next day — the fifth of the disease — be- come projecting, red, conical papules with a little clear, watery fluid at the apex. Very quickly the whole papule now becomes filled with clear fluid (vesicle). This is very unlike chicken-pox, in which there is never any shot-like sensation and in which the spots are full of fluid almost from the beginning. The vesicles of typical small-pox now go on to produce pus (pustules), but in varioloid many of the papules never form vesicles, while most of the vesicles which do form begin to dry up and produce crusts by the eighth or ninth day of the disease, without going through the pustular stage. Some of the vesicles, however, do pustulate, and are not only longer in producing the scabs, but also leave marks afterward. The scabs begin to fall by about the fourteenth day. The fever and the other initial symptoms usually disappear when the rash comes out, but return in typical small-pox when the eruption becomes pustular. Contagion certainly lasts until every trace of scabbing has disappeared and thorough disinfection has been made, but the contagious power is so strong that it is best to quarantine the pa- tient for eight weeks. Isolation and disinfection should be prompt and perfect, and everybody in the house should be re-vaccinated at once. The treatment must be left entirely to a physician. Vaccinia; Cow-pox; Vaccination. — Vaccinia prob- ably is small-pox occurring in cattle, but so modified by this fact that when introduced by "vaccination" into the human body it produces only a single sore, although it protects the whole system from a general attack. The fact that small-pox made such frightful ravages before vaccination was practised, yet is comparatively uncom- THE SICK BAB V. 305 mon now^ is positive proof of the value and the great importance of vaccination for ever}^ child. The sup- posed dangers of transmitting other diseases by vaccina- ting with human lymph are largely imaginary, and with the calf (bovine) lymph they no longer exist. The danger of erysipelas or of blood-poisoning setting in is little if any greater from vaccination than from a scratch or sore of any other nature. The best time to vaccinate is at about the age of two or three months, provided the child has no skin eruption and is in good health in other respects. Girl babies should certainly not be vaccinated on any part of the arm where the scar will show in later years. The thigh or the leg is a very desirable place. After vaccination nothing is seen until the second or third day, when a red papule appears, which grows larger, and which by the fifth or sixth day after vaccina- tion has become a vesicle filled with a watery fluid. This increases in size until the eighth day, when it is nearly as large as a ten-cent piece. By the tenth day the vesicle has become a pustule, with its contents yellowish and cloudy, and with a broad red ring two to three inches in diameter surrounding it. By the eleventh or twelfth day the redness lessens and the fluid begins to dry; by the fourteenth day the scab is pretty well formed; and by the end of three weeks or thereabouts this falls off" — if, indeed, the child has not rubbed it off" before — and leaves a scar which finally becomes white and pitted. Generally there is some fever by the third or fourth day after vacci- nation. This persists, perhaps with restlessness and irrita- bility, until the eighth or tenth day. Sometimes a child seems quite sick. After the vesicle begins to form it should be guarded against injury by covering it with a pad of salicylated absorbent cotton fastened on loosely with a roller bandage or adhesive plaster. This is better 20 306 THE CARE OF THE BABY. than most of the vaccination shields in the market, since these are difficult to keep in place. Often the doctor pre- fers to apply the cotton immediately after vaccination, in order to guard against any possible, although remote, danger of blood-poisoning. If the vaccination does not *'take," it must be repeated until it does. It is only very rarely that the effort will not at last succeed. Most children who have been successfully vaccinated will never develop small-pox, but in others the protection ceases to a certain degree after a number of years, and they may contract varioloid. Absolute protection may be counted as lasting about seven years. A child should therefore be re- vaccinated at the age of seven years, and again at that of fourteen years. When small-pox is prev- alent every one in the house should be vaccinated who h^s not had it done successfully within a few years. Erysipelas. — This disease may attack any age, is com- monest in early spring, and is contagious to a limited extent only. It develops usually about a wound, even though it be a very small one; consequently in early infancy it is generally seen about the navel. When not about a wound, it occurs oftenest on the face. The con- tagious principle probably emanates from the skin, and may adhere to furniture or to clothing, and be carried by another person from the sick to the well. One attack does not protect in the slightest from others. The dis- ease begins with fever, languor or restlessness, delirium or stupor, and pain in the part involved. These symp- toms are often preceded by a convulsion or, in older children, a chill. The eruption appears in a few hours. The skin of some part of the body becomes shiny and as evenly bright red as though red ink had been spilled on it. The color disappears upon pressure, but returns THE SICK BABY. 307 rapidly. Sometimes small blisters form. The tissues beneath the surface become much swollen. The inflam- mation, pain, and fever continue for two or three days, and after four or five days the attack is over, at least in the original area. Unfortunately, the eruption tends to spread in different directions, and the disease may thus last indefinitely. Desquamation in small or large scales occurs. Erysipelas is usually very fatal in children one or two weeks old, and severe at all times in infancy. A child sick with it should be separated, especially from any one who has even a slight abrasion of the skin. A new-born baby with the disease must be at once removed from its mother for the sake of the latter, for erysipelas in a woman after confinement is very dangerous. Quarantine should certainly last as long as there is any scaling. Probably two weeks from the onset of the disease would be an average figure for cases in which the eruption had not spread from the original spot. Diphtheria. — A very common, contagious, and danger- ous disease, attacking any age, although rare in early infancy, and most frequent in damp and cold weather. The contagious principle is contained in the breath, and still more in the saliva and in the membrane from the throat or nose. It may stick to clothing or other objects, retain its poisonous properties for months, and be carried from the sick to the well. The inhalation of sewer-gas has often been supposed to cause the disease. While this is not certainly true, it is possible that the constant breathing of this gas or the living under any other un- favorable hygienic conditions makes the disease much more likely to occur. One attack in no way protects from subsequent ones. The disease begins with fever- 308 THE CARE OF THE BABY. ishness, loss of appetite, debility, heaviness, and sore throat. Examination of the throat at this stage may show the tonsils swollen and, perhaps, exhibiting a few dotted white points as in ordinary tonsillitis, but nothing characteristic. In a few hours or by the next day there has developed, except in the mildest cases, a white opaque membrane covering one or both tonsils and ex- tending to other parts of the throat. The child con- tinues feeble and feverish; the membrane spreads; the glands below the jaw on each side are generally swollen; and there is apt to be a running from the nose, due to the extension of the disease to it. In average cases which recover the patches begin to disappear after a week, and are entirely gone after ten to fourteen days. The symptoms meanwhile have slowly ceased, except the very decided and characteristic weakness, which per- sists for a long time. In unfavorable cases the membrane continues to form and the child finally dies of exhaustion. The membrane very often spreads to the larynx and produces laryngeal diphtheria — that is, membranoics croup. This very dangerous condition is apt to come on between the third and sixth days of the disease. Sometimes, however, the membrane attacks the larynx first or solely. Nearly every case of membranous croup is in reality laryn- geal diphtheria. Although there are occasional instances in which the membrane in the larynx is not diphthe- ritic, the diagnosis of such an occurrence cannot ordina- rily be made with certainty. The first symptom of mem- branous croup is hoarseness, which is soon followed by rapid and noisy breathing and the peculiar croupy cough. Unlike spasmodic croup, the obstruction to breathing is persistent. The child sits up in bed laboring for breath, looks pale and bluish, and will die painfully of suflfoca- tion in a few hours or days if relief cannot be had. THE SICK BABY. 309 The danger of paralysis following diphtheria has already been alluded to (p. 270). It is most apt to come on during convalescence, between the third and fifth weeks. With regard to the treatment of diphtheria, any child who shows even a small whitish spot in the throat should be isolated promptly and be visited by the family physician. It may be nothing of consequence, but it may be the beginning of diphtheria, and isolation may keep the disease from spreading to others. Should the physician order applications to the throat, his instruc- tions must be carried out implicitly, no matter how cruel they seem. Whoever paints the throat must take par- ticular care that none of the membrane is coughed into his or her nose, eyes, or mouth. The remarkable reduction of strength which attends and follows the disease must never be forgotten. Death from sudden heart failure has not unfrequently occurred after all symptoms had disappeared. Consequently, no child suffering from or convalescent from diphtheria should be allowed to get out of bed, or even to sit up of itself, until the physi- cian in charge permits; and if it must be taken up, it should be lifted very slowly and carefully. All the pre- cautions for isolation and disinfection must be followed exactly. All cloths used for the reception of membrane or of saliva should be burned at once. If there is any difficulty in breathing caused by diphtheria of the larynx, the air of the room may be moistened, as well as disin- fected, by a disinfectant vapor (Appendix, 98). Quaran- tine should continue for at least a week after all trace of membrane and redness has left the throat and the run- ning from the nose has stopped; or, still better, until the physician can find no more germs in the throat or nose. In cases of laryngeal diphtheria parents should not hesi- 310 THE CARE OF THE BABY. tate to give permission for any operation which the physi- cian in charge may advise. Prompt consent may mean the saving of life, and certainly often gives temporary relief at the least. Whooping-cough ; Pertussis. — A ver}^ frequent and exceedingly contagious disease of children; oftenest seen under the age of five years, but less so under six months, and equally common at all seasons of the year. It is more serious than is ordinarily supposed, and a great number of children die from its effects, usually as the result of some complication, especially pneumonia, tuberculosis, convulsions, or catarrh of the bowels. The contagious principle seems to reside in the expectoration and the breath, and probably is active during the whole attack, but usually requires close contact to communicate it. The carrying of the contagion by a third person is certainly very unusual. A second attack occurs with even greater rarity than is the case in measles and scarlatina. The disease may be severe, or so light that the child is hardly incommoded by it. The younger the child the more dangerous is the disease likely to be. The attack begins with slight cold in the head and a troublesome cough which is worse at night and not relieved by the ordinary treatment for bronchitis. In a very few days the cough occurs in longer paroxysms, during which the child is red in the face and seems hardly able to get its breath, and after which it may vomit. After this stage of invasion^ which averages two weeks, but which may last for only a few days, the whooping or paroxysmal j/^^^ begins. The paroxysms, or "kinks" as they are often called, are now longer and more intense. The child gives a long series of rapidly-repeated short coughs with- out drawing breath, and continues this until it is nearly THE SICK BABY, 3II blue. At last it makes a long-drawn inspiration with a peculiar loud crowing sound — the well-known whoop. Very often the whole process is repeated immediately, and perhaps again and again. The paroxysms are frequently so severe that they are followed by vomiting, and the child may lose flesh and strength from its inability to retain food. A large amount of stringy mucus flows from the mouth after the attacks, and may be accom- panied by blood. The paroxysms are most frequent at night. In a mild case there are only five or six in twenty-four hours, but in a severe one there are forty or fifty or more. In the mildest cases it sometimes happens that no whooping occurs at any time; still, the peculiar paroxysmal character of the cough often makes the nature of the disease plain. The intensity of the attack remains the same for about three weeks in cases of average severity, and then the stage of decline begins. The paroxysms become less fre- quent and the cough much looser, and little by little the whooping disappears, until it ceases by six or eight weeks from the first onset of cough, and only a bronchitis is left, which lasts an indefinite time. When the attack occurs in the autumn the bronchitis is very obstinate, and may continue with occasional whooping throughout the winter. Just how long the disease is contagious is uncertain. We are safe in saying that it averages six or eight weeks from the beginning of the attack. It probably grows less contagious as time passes. If the whoop has once distinctly stopped and there has been a period of some days without it, we may call the disease over, even although the whooping should begin again later. The second whooping is a sort of habit left by the disease, and children have been known to do it even a year after the 312 THE CARE OF THE BABY. attack was over. It cannot properly be considered a part of the infectious disease. Treatment should be ordered by a physician in every case, not only on account of the discomfort which attends the attack, but also because of the danger of complications. Although the disease can only occasion- ally be cut short, it can usually be relieved very de- cidedly. If one plan of treatment does not answer, another probably will. The child should have an abun- dance of fresh air, be warmly clad, and not be exposed to draughts. Sleeping in a room which has been well aired and not occupied all day will often prevent many paroxysms at night. During the paroxysm the child's head should be supported by the hand. In very bad cases, in which the child becomes almost or quite uncon- scious and ceases to breathe, it should be slapped in the face with a cold wet towel. Fortunately, these cases are not very common. Later in the disease a change of air will sometimes do wonders. Mumps. — A painful but not dangerous inflammation of the salivary glands, which are situated in front of, below, and behind the ears and below the jaw. It is commonest in the cold season, and seldom attacks very young infants. It is distinctly contagious, even during incubation, prob- ably by inhaling the breath, since close contact is required. One attack usually protects from subsequent ones. The disease begins with dulness, more or less fever, and pain and stiffness about the jaws, usually on one side. A swelling, situated below and slightly behind the ear, rapidly develops, and becomes ver}^ marked within forty- eight hours. There is much tenderness on pressure, chewing is often impossible, talking and swallowing are difficult, and sometimes the mouth can scarcely THE SICK BABY. 313 be opened. After a day or two the other side of. the face generally becomes affected in the same way. The whole attack lasts about a week. Treatment consists in rest in bed and the administration of a laxative and a fever mix- ture (Appendix, 103). Food should be soft. A wad of cotton covered on the outside with oil silk may be fast- ened over the inflamed region. Hot fomentations or poultices may be applied if the pain is very great. Quite rarely the disease becomes dangerous from complications. (6) MISCELLANEOUS DISORDERS AND HABITS. Premature Birth. — A child may be born in the seventh or eighth month of pregnancy, or even earlier, long be- fore it is quite ready to live outside of the mother's body, and when it weighs not more, perhaps, than two and a Fig. 58. — Couveuse. half or three pounds. We need not necessarily despair of the life of a baby, however unpromising it seems at first. Children born at six and a half months have grown up strong at last, although it is not often they sur- 314 '^^HE CARE OF THE BABY, vive if born before the seventb month. The great need of such a baby is heat, and the maternity hospitals employ an apparatus, called a couveuse^ brooder^ or incubator^ espe- cially devised to supply it (Fig. 58). For family use a couveuse maybe bought at the instrument-makers, or hired from some of them. This is perhaps better, as the apparatus is costly. But with an increased degree of attention it may be done without entirely fairly well. If a premature baby is bathed at all immediatel}^ after birth, the temperature of the water should be 102° F., and the greatest care should be taken while drying to see that the child is not chilled. It should be made very warm by swaddling it in raw cot- ton, head and all, leaving only the face exposed, wrapping it about with a blanket, and tying it around with a roller bandage. Hot bottles should be placed on each side of it as it lies thus wrapped up in the bed, and fresh ones be substituted frequently. A very convenient method is to place the child in a baby's bath-tub half full of raw cotton in which numerous hot bottles have been concealed. The child's only clothing consists of a diaper and a shirt. The room should be kept warm, and especially so when this human bundle is unwrapped for its bath. After bathing it should be rubbed with sweet oil and be rolled up again in fresh cotton. Often it is better to omit all bathing, and simply to rub with the oil. Nourishment must be given every hour in small quantities. If the child is too weak to suck, as is usually the case, it should be fed from a spoon or a medicine-dropper. Sometimes it is necessar}^ to nourish it through a long elastic tube passed through the mouth into the stomach. Rickets. — A disease characterized by impairment of the general health, but especially by imperfect develop- ment of the bones. It is commonest between the ages of THE SICK BABY. 315 six months and three years. Among the causes are in- sufficient clothing, damp or ill-ventilated dwellings, a lack of outdoor air, and inherited weakness of constitu- tion; but the chief cause is some defect in the character of the food. Babies fed on healthy breast-milk are not liable to develop rickets, but we must be sure that the milk is actually healthy. Thus, for instance, too long deferring of weaning may cause the disease by rendering the milk of insufficient strength. Babies fed on con- densed milk are exceedingly prone to develop it, however well the food has seemed to agree. Children are very likely to become rickety who have constantly suffered from disturbances of the stomach and bowels, the result of food which contains too much of the casein of milk, or in which there is starch or anything else indigestible. The first symptoms in well-marked cases are free per- spiration about the head while the child is asleep, restless- ness, tossing off of the bed-clothes, distention of the abdo- men with gas, and sometimes a disposition to cry when picked up, the last being due to tenderness about the ribs. These early symptoms are very important, inas- much as prompt treatment may arrest the disease before it advances further. A little later there will be decided enlargement of the joints, especially of the wrists and of • the junctions of the ribs with the cartilages in front. The latter produces a row of little prominences running from above downward outside the nipple on each side of the chest. This is often called the "rickety rosary," from its resemblance to a string of large beads. It can be felt, and in severe cases seen as well. The head is enlarged and square, with a projecting forehead and flat sides and top (PL III., Fig. 3). The fontanelle remains open, and by the age of a year may be even larger than at birth. The teeth are late in appearing, and there may 3l6 THE CARE OF THE BABY. be none at the age of one year. They often decay very early. The muscles are weak and the bones soft, and as a result deformities develop. Bow-legs or knock-knees often develop, and the chest acquires in its trans- verse circumference a peculiar violin-shape with the smaller end in front, a groove on each side running longitudinally from top to bottom, and a decided promi- nence of the breast-bone. With this is combined very often a marked enlargement of the abdomen. Lateral curvature of the spine in young children is usually due to rickets. The long posterior curvature has already been alluded to (p. 282). The accompanying illustration (PL V.) shows the enlarged abdomen and wrists, and to some extent the narrowing of the chest. Children with rickets are often fat, and we should there- fore have no false sense of security because there has been no loss of weight. They are also peculiarly liable to suffer from colds in the chest, convulsions, and catarrh of the bowels. The principal treatment of rickets is preventive. Plenty of the best nourishment, a life largely in the open air and sunlight, daily immersion in the bath, and prompt attention to any disturbance of the stomach and bowels will usually avoid any danger. If symptoms appear, there is something hygienically wrong, which must be searched out. The food must be made even more nutritious, yet digestible. Raw-beef juice is often useful. A change of air, especially to the sea-shore, may do much toward the recovering of the lost health. Cod-liver oil and daily salt baths (Appendix, 45) are the best remedies. All attempts of the child to stand should be discouraged, as bending of the legs is liable to follow. It is hardly neces- sary to say that the treatment of a disease as serious as this must be guided by a physician. THE SICK BABY. 31/ Scrofula. — The term scrofula is an antiquated one which is mentioned here merely to condemn it. There is no such disease as scrofula. Most of the different ail- ments once called by this name are in reality only mani- festations of tuberculosis in different parts of the body. It is a mistake to call the delicate, flabby children with enlarged glands and sore eyes ' ' scrofulous. ' ' Some of them are tubercular, some syphilitic, and some owe their ailments to other causes. The term, if used at all, should be applied only to children who have a tendency, per- haps inherited, to develop tubercular affections; but even this use is questionable, and, owing to the confusion which exists about the proper employment of the word, it is better to abandon it altogether. Rheumatism. — This disease may show itself as a severe acute inflammation of many of the joints of the body, with high fever and extreme pain on the slightest movement; as a slighter and more chronic inflammation of only one or a few joints, which become more or less red, tender, and swollen; as a stiffness and soreness of some of the muscles; or, finally, in some other more unusual way, as in the heart or the nervous system. It is much more fre- quent in children than is commonly supposed. The fact that an infant cries out when some part is moved, or that it is unwilling to use an arm or a leg as freely as ordi- narily, should render one suspicious that rheumatism is present. The mildest form of articular rheumatism may be followed by St. Vitus' dance or by heart disease. The latter is more liable to follow rheumatism in children than in adults. It is, indeed, at times the first and the only symptom of the rheumatic state, and there may be no articular or muscular pain at all. In older children the pains in the joints, which are often called "growing pains ' ' or are attributed to sprains, and looked upon as 3l8 THE CARE OF THE BABY. matters of no consequence, may really be due to rheuma- tism or to hip-joint disease. The diagnosis is so import- ant that medical advice is recommended in all doubtful cases, and certainly in those which are clearly rheumatic. A child with even a slight attack of joint rheumatism is better kept at rest in bed, in order to ward oflf a rheu- matic inflammation of the heart by throwing as little work on that organ as possible. The food should be light and easily digestible, and meat should be avoided to a great extent or entirely. All exposure to chill must be prevented, and the inflamed parts should be wrapped in cotton-wool or flannel. Enlarged Glands. — The glands in the neck or else- where may enlarge, and can then be felt as larger or smaller movable and somewhat tender lumps below^ the skin. If the inflammation in them is intense, they grow larger still, become red and soft and filled with pus, and finally burst. When they show a tendenc}^ to persist, to increase in size and number, and, it may be, slowly to suppurate one after another, the suspicion arises that tu- berculosis is the cause. The suddenly-developing inflam- mations are generally due to an acute irritation some- where. For instance, enlargement of the glands below the jaw is often the result of inflammation in the mouth, and occurs in diphtheria and scarlatina because the mouth and throat are affected. Enlarged glands at the back of the neck follow irritation of the scalp by eczema or other cause; those below and behind the ear result from irrita- tion of the ears or swelling of the tonsils, or frequently accompany measles and German measles; those in the armpit may be the result of some sore upon the hand, chest, or arm; and those in the groin may follow^ a similar condition of the low^er extremity. Usually the sw^ellings THE SICK BAB V. 3 1 9 disappear very soon after the cause is removed. The dis- appearance may be aided by rubbing them gently twice a day with soap liniment. Sometimes, however, the swell- ing is very obstinate, or may go on rapidly to form an ab- scess. As a rule, only one gland is involved in such cases. In any case where the swelling does not disap- pear promptly a physician should be consulted, as the trouble may be of a serious nature. Marasmus. — This term, so commonly used, does not indicate any distinct disease, but rather a progressive wasting or *' fading away" of the body. The child be- comes excessively thin, is pale and often sallow, its face is wrinkled, and its flesh hangs on its bones. Among the causes are tuberculosis, syphilis, chronic vomiting, per- sistent although slight diarrhoea, and food which is in- adequate in quality or quantity. In nearly every case a physician can discover the cause, and often can remedy it. Inflammation of the Breasts. — In both boy and girl babies a day or two old the breasts are very apt to swell, to become tender, and to secrete a milk-like fluid. If they are let alone or are rubbed gently with warm oil or vaseline, the trouble disappears in one or two weeks. If the swelling is very decided and the breasts are red, wet dressings will be of service, but the physician in attend- ance must take charge in such cases. Some ignorant nurses have the habit of squeezing the breasts of new- born children in order to empty them w^ell or, in the case of girl babies, to favor a good development later in life. Such a procedure is unnecessary and harmful in the ex- treme, and may even produce an abscess. Hiccough. — Although seldom of any serious impor- 320 THE CARE OF THE BABY. tance, this may be very annoying. It consists of a spas- modic contraction of the diaphragm. It is usually dependent upon some disturbance of digestion, but may be due to many other causes. In babies it may often be relieved by a rapid change of position, patting the back, or by giving a little hot water, perhaps with soda mint (Appendix, loo). In the case of older children the drinking of a glass of water, the holding the breath as long as possible, or causing the child to laugh is often effective. Fever. — Fever is, of course, only a symptom of a large number of affections. As it often develops sud- denly and without other symptoms, a mother should know some simple plan of treatment which may do good and cannot work harm, and which she may employ before the physician arrives. First of all, the clinical thermom- eter should always be used (see p. 43) to determine whether or not there really is fever. A moist skin and cool hands are not always a sign of the absence of fever, any more than hot head or hands are a positive sign of its presence. A feverish child has usually little appetite or power of digestion, and food should be withheld or be of the lightest kind. Milk is the best thing under most circumstances, or some such article as milk-toast, junket, arrowroot, or light broth. If food is vomited, the child should have no nourishment at all. A good laxative, such as a full dose of magnesia or castor oil, is always admissible, and a fever mixture (Appendix, 103) may be given. Confinement to bed is desirable. Other children should be kept away, both for the sake of quiet and to avoid danger of contagion should an infec- tious disease be beginning. A warm mustard bath (Ap- pendix, 38, 42) is often given to "bring out the rash" THE SICK BABY. 321 if it is an eruptive fever starting. If fever persists and no perspiration has occurred four or %m^ hours after the bath, the extra wrappings may be removed and the coverings made as light as is comfortable to the patient. The abnormal heat of the skin makes the thickness of covering required less than in health. The child may have water to drink, cool but not iced, freely in any reasonable quantity. Mothers err greatly in refusing to give a thirsty child water. Bathing of the head with bay rum is always permissible if it does not produce chilliness. A cold wet cloth may be laid on the head if headache is severe. Dropsy. — An accumulation of fluid in any part of the body. The condition may be limited to one part, or may be general and affect the whole surface of the body. The most frequent causes are disease of the heart and Bright's disease. In the last stages of chronic debilitat- ing diseases, such as consumption, dropsy of the feet and hands shows that the end is approaching. Peritonitis and disease of the liver produce dropsy of the abdomen. Treatment can be conducted only by a physician. Cold Hands and Feet. — This condition is usually a sign of imperfect circulation, itself depending upon in- digestion, general poor health, insufficient clothing, lack of exercise, and similar causes. It not infrequently develops shortly after the baby begins to wear stockings and shoes, before it has became accustomed to them. The stockings should be warm and loose, and the shoes large. The warmth of the clothing of the whole body ought to be increased, and all other possible causes re- moved. Sponging the hands and feet with cold water and following this by brisk friction is often a valuable 21 322 777^ CARE OF THE BABY. plan, or they may be rubbed daily with turpentine, per- haps mixed with an equal part of sweet oil. As children cannot sleep well if the hands and feet are cold at night, a hot-water bottle or bag must be placed in the bed if other plans do not suffice. Retention of Urine. — No urine may be passed for twenty-four or even more hours after birth, and yet nothing serious be amiss. If a warm bath or a poultice over the bladder does not relieve the difficulty, the advice of a physician ought to be asked promptly, as there may be some physical obstruction. Sometimes the pain which passing water causes induces a child to retain the urine as long as possible. Sometimes, too, after a severe attack of colic a child is unable to pass water for perhaps twelve hours, and suffers considerable pain as a result, as shown by the straining cry and the frequent doubling of the legs upon the abdomen. A bath or a poultice will probably produce a passage of urine. There is apt to be but little urine passed at the beginning of fever or during severe diarrhoea. Such a condition is a matter of no consequence, so far, at least, as the urinary symptoms are concerned. In acute Bright' s disease the urine is often smoky or muddy (brownish, not reddish) in appearance and very scanty. This condition is a very serious one. It is more apt to develop during or after scarlet fever. A hot poultice should be applied over the kidneys — that is, just below the last ribs on each side of the spine — and a doctor must be summoned at once. Bed-wetting; Incontinence of Urine. — The habit of wetting the bed at night or the clothes by day is a dis- ease^ and not a bad habit merely, and it is an unwar- rantable cruelty to punish a child for it. There are cases THE SICK BABY. 323 in which threats or punishment may avail, but these are so rare that they may be ignored for all practical pur- poses. The causes are various, and the advice of a physician is always required, for the matter is sometimes serious and is always annoying. The only treatment open to the mother is to see that the child has a light supper, is made to pass its water just before going to bed, drinks no fluids for some hours before bedtime, is taken up frequently during the night to empty its bladder, sleeps on the side and not on the back, and is not too warmly covered. To prevent sleeping on the back an empty spool may be tied at the middle of the spine by a tape going around the waist. Pain in Passing Urine. — It may happen that a baby in apparently perfect health often suddenly begins to cry bitterly without any discoverable cause, continues this for a short time, and then ceases. There are no other s}inptoms, but further study shows that the crying occurs only when the urine is passed. The natural con- clusion is that the passage is painful, and an examina- tion of the parts should be made. If nothing can be found, it is probable that the urine is unusually irri- tating. In such cases an examination of the diaper may show a reddish or yellowish deposit which, when dry, can be rubbed between the fingers, and which feels like the very finest gravel — as, indeed, it is. Piiimosis. — This term denotes the existence of a long and very narrow fore-skin in boy babies, which cannot be retracted so as to expose completely the parts beneath. It always demands examination by a physician, since the retention of the cheesy secretion beneath it is liable to make trouble if the condition is neglected. Sometimes 324 THE CARE OF THE BABY. circumcision is required, but oftener less radical treat- ment is sufficient. Leucorrhoea. — A leucorrhcea which maybe quite pro- fuse is not at all of infrequent occurrence in little girls even in infancy. The knowledge of this fact may save a great deal of unnecessary anxiety. The disease some- times comes from direct injur>^ received, for instance, from a fall on a sharp object, or in other ways, but much oftener is the evidence of debility. It is occasionally produced by thread-worms which have found their way into the passage from the bowel. Treatment consists in great cleanliness, washing with and injecting of a solu- tion of boric acid (Appendix, 75), and, in case there is a great deal of external irritation, the application of a boric- acid-and-zinc ointment (Appendix, 71) upon a piece of lint folded and laid between the irritated surfaces. In any obstinate case — and the disease is very apt to prove so — a physician must be consulted. The Blue Baby ; Congenital Cyanosis. — It some- times happens that a new-born baby has a bluish tinge, showing that the blood does not circulate properly or get enough oxygen. This is not infrequent in the first days of life, and is then a matter of no consequence if the child is otherwise well. Should, however, the color per- sist, the heart is probably diseased. In mild cases the blue tinge appears only when the baby cries, but if the disease is severe the color is constant and death will probably take place in a few days or months. In those who live to older childhood, or even to grow up, there is apt to be shortness of breath, palpitation, and a tend- ency to the bluish tinge either constantly present or com- ing on with exertion or with any slight cold in the chest. THE SICK BABY. 325 Snoring ; Mouth-breathing. — These symptoms may be due to overgrown tonsillar tissue, as already mentioned, or to obstruction to breathing through the nose from some other cause. An examination of the throat and nose should be made by a physician in every case, since it is important to remedy the difficulty as soon as possi- ble. Children who have long been mouth-breathers from nasal obstruction often acquire a characteristic expres- sion of face and an impairment of bodily and mental development (Chap. XL, p. 249). Snoring in infancy is not often merely a habit; but should examination show clearly that it is so, the infant's mouth may be gently closed whenever it is found open during sleep. A band- age may be placed under the chin and over the top of the head, and this will serve the purpose even better. Thumb-sucl^ pint of boil- ing water. Sometimes used in place of barley-water. 12. Dr. J. F. Meigs' Gelatin Food. — Gelatin-water is prepared as in the last formula. As soon as the gela- tin is dissolved, and while the water is still boiling, add I teaspoonful of arrowroot which has been previously rubbed up into a paste with a little cold water. Milk 356 THE CARE OF THE BABY. and cream are added at the same time in varying pro- portions. The late Dr. J. F. Meigs found this to agree with many sick children when other foods failed. 13. Whey. — To J^ pint of warm milk add i teaspoon- ful of essence of pepsin or liquid pepsin, or 2 teaspoon- fuls of liquid rennet. After it stiffens, beat up the curd with a fork. Strain off the whey. Useful for delicate stomachs which cannot bear milk. 14. Cream-and-Whey Mixture. — Cream, Whey, Warm water, 2 ounces; Milk-sugar, i teaspoonful. 15. Wine Whey. — While boiling ^ pint of milk add 2 ounces of sherry wine. Strain. 16. Veal Tea. — Cut fine i pound of veal as free from fat as possible; put into i^ pints of cold water; keep hot without boiling for three or four hours; strain; let cool; skim off the fat. Sometimes ordered in cases of weak digestion in in- fants. 17. FIour-Ball. — Tie i pound of flour tightly in a bag and boil for ten hours. After it is cold take it out of the cloth and dry it for ten hours. Then peel off the outside coat of dough. The hard ball which remains should be grated when needed and mixed with milk in var}'ing pro- portions: I or 2 teaspoonfuls to 8 ounces of diluted milk is generally sufficient. Useful in some cases of delicate stomach. DIETARY. 357 1 8. Beef Tea. — To i pound of lean beef, minced and free from fat, skin, and tendon, add i pint of water. Stir and let stand in an earthen vessel for an hour; then heat well, but without boiling, for another hour; strain and let cool. When about to use, remove all the fat with a piece of soft paper, warm, and season with salt. 19. Beef Tea Rapidly Made. — Place i pound of scraped lean beef in ^ pint of boiling water in an enamelled saucepan; cover; keep gently warm for ten minutes; strain into a teacup, and place the cup in ice- water. When cold, skim off all fat, pour into a warmed cup, warm gently, season, and use. Beef teas made by this and the preceding recipe are more palatable than some of the ready-made beef-extract preparations, but have little nutritive value as compared with the peptonized beef foods on the market. 20. Scraped Raw Meat. — Take a thick piece of raw tenderloin steak as free from tendon and fat as possible, scrape, grate or mince it very fine, and then pound it in a mortar until it is reduced to a pulp. Now rub it through a fine sieve; flavor with salt or sugar, and roll it into little balls. For younger children rub it up with a little water until it is of the consistence of thick cream, and feed it from a spoon. This is ver}^ nourishing in some of the wasting dis- eases. A child of a year or less should begin with not more than three teaspoonfuls during the course of a day. There is the possibility of tape-worm being acquired by the use of raw meat. To prevent this the steak may be cooked slightly first and then the brown outside layer cut away. 358 THE CARE OF THE BABY. 21. Beef-Juice. — Season and very slightly broil a piece of steak free from fat; then cut it into small pieces and express the juice with a lemon- squeezer or, much better, with one of the meat-presses to be bought at the druggist's (Fig. 65). The juice can be warmed only slightly after it is obtained, or it may be given ice-cold. 22. Lime - Water. — Place a piece of unslaked lime the size of an ^^^ in i gallon of water in an earthen vessel. Stir and let set- tle ; pour off the first water and add fresh. Keep covered to ex- clude the dust. Use from the top. Add water and stir from time to time. Fig. 65. — Meat-press. 23. Peptonized Food. — The failure of the power of digestion renders predigestion (peptonizing) of the food necessary in some cases. Pepsin, the secretion of the stomach, may be utilized for this purpose, but for several reasons the secretion of the pancreas, often combined with bicarbonate of soda, is generally employed. Although there are various equally good pancreatic preparations on the market, such, for instance, as those of Parke, Davis & Co., and Armour & Co., yet for sake of convenience, and because it is very well known, the pancreatic extract of Fairchild Bros, and Foster is the one mentioned in the following recipes. Besides being sold in bulk, it is conveniently furnished in the form of "peptonizing tubes," each glass tube containing 5 grains of extract of pancreas and 15 grains of bicarbonate of soda. As the DIETARY. 359 tubes are rather expensive, one can just as readily have a number of powders put up at a drug-store, each contain- ing the proper amount of pancreatic extract and soda. In the peptonizing of any food it is important to re- member that warmth is necessary for the action of the digestant, while cold checks it, and too great a heat de- stroys it altogether. The food undergoing peptonizing should be kept at a temperature of about 115° F. — that is, never so hot that the finger cannot be kept in it with- out discomfort. The peptonizing must not be allowed to become quite complete, or the bitter taste of peptones will be produced. This does not injure the food in the least, but makes the child unwilling to take it. The food should be tasted frequently during the process, and on the development of the slightest bitterness the tempera- ture should be quickly raised to the boiling-point or the food be put quickly on ice. The temperature of boiling is sufficient to destroy the digestant to a large extent, and consequently to interfere with further peptonizing. The chilling by ice arrests the action of the pancreatin, but only while the milk is kept cold. 24. Peptonized Milk. — Add to 4 tablespoonfuls of cool water half of the contents of a peptonizing tube; stir until dissolved; add to 3^ pint of cool milk, and put the vessel containing this into water of a temperature of 115° F. ; let it remain there for ten minutes, or for a shorter time if the slightest bitter taste develops. Then put at once on ice or, better, heat quickly to boiling. 25. Sterilized Peptonized Milk-mixture. — Prepare the infant's milk-mixture according to the formula on page 135 or page 137. Then add the peptonizing powder in the proportion of one tube to each 8 ounces of com- 360 THE CARE OF THE BABY. billed milk and cream. For instance, if the formula on page 135 is employed, and 16 per cent, cream used, we have in 8 ounces 2^ ounces of milk and cream. This will require about one-third of the contents of a pepton- izing tube. If 20 per cent, cream is used, or the top- milk formula followed, as on page 137, about one quarter of a tube will be enough. After adding the powder shake thoroughly, and peptonize as just described, finishing the process by raising the temperature quickly to that of boiling. Now place the proper amount of the food in each bottle, put the bottles in the sterilizer, and sterilize for half an hour. This will be long enough, on account of the previous scalding. Instead of this plan, we may mix the milk and cream, add one peptonizing tube to each 8 ounces, and pep- tonize. Then mix with milk-sugar and water according to the formula. The proper amount of food may now be placed in each bottle and sterilized. In either method neither soda solution nor lime water is needed, as the milk is already made alkaline by the peptonizing powder. 26. Pasteurized Peptonized Milk Mixture. — Since the temperature employed in pasteurizing is not suffi- ciently high to arrest the action of the peptonizing pow- der, the only feasible method is to prepare the bottles of pasteurized milk as described on page 142, and to keep them until needed. Then, as each bottle is about to be used it should have added one-third or one-quarter of the contents of a peptonizing tube, according to the mixture employed (see Appendix, 25), be shaken thoroughly, stood in water of 110° to 115° F. for about ten minutes, cooled down slightly to the proper temperature for feeding, and given to the baby at once, before the peptonizing has a DIETARY. 361 chance to advance too far. A little trial will show the length of time required in order to stop the process short of developing a bitter taste. 27. Peptogenic Milk Powder. — This preparation fur- nishes a very convenient method of preparing a predi- gested milk-mixture which approximates the character of human milk, although, according to recent analyses, rather too rich in casein. It consists of a mixture of extract of pancreas, soda and other alkalies, and milk- sugar, and is so arranged that it may be measured out and mixed with the proper amount of water, milk, and cream according to printed directions. It is not so accu- rate a method as the use of peptonizing tubes, and is altogether a cruder process, while it does not present any decided advantage. 28. Peptonized Beef Tea. — Mix 8 ounces of finely- minced beef, free from fat, with i pint of water. Sim- mer from one to two hours with frequent stirring. Cool down to 110° or 115° F. — that is, a temperature not hot enough to give discomfort to the finger held in it — and empty into it one peptonizing tube. Stir until dissolved. Keep at the same temperature for an hour or two with occasional stirring, avoiding any bitter taste. Then boil for a moment, strain, and season. 29. Peptonized Oysters. — Boil for a few minutes in a saucepan half a dozen large oysters with their juice and ^ pint of water. Remove the oysters, mince and mash them to a pulp, and put this into a glass jar with the broth. Add 15 grains of bicarbonate of soda and 15 grains of extract of pancreas, and keep at 115° F. for one and a half hours or less, avoiding any decidedly 362 THE CARE OF THE BABY. bitter taste. Then put into a saucepan, add J^ pint of milk, and heat to boiling. Season. 30. Peptonized Gruel. — Gruel may be made in the ordinary way; as, for example: Arrowroot, fine oatmeal, wheat flour, sago, or other farina- ceous substance, i heaping teaspoon- ful or more; Cold water, J^ pint. Mix thoroughly and boil well for a few minutes with con- stant stirring until quite thick. Then stir in i pint of cold milk and strain into a jar. Empty in one pepton- izing tube. Keep warm (115° F.) for twenty minutes, or less than this if the faintest trace of bitterness develops. Then quickly raise it to boiling to stop further action. 31. Peptonized Milk Toast. — Milk toast in which there is plenty of milk may be peptonized by making it into a pulp and then stirring in the contents of a pep- tonizing tube, and proceeding in the same way as for peptonizing gruel. 32. Peptonized Milk Punch. — Fill a tumbler one-third full of crushed ice. Put in it as much stimulant as suits the age of the child (pp. 386, 389); fill up with pepton- ized milk ; sweeten according to taste, and grate a little nutmeg over the top. 33. Nutrient Enemata. — For the giving of nutrient enemata one of the syringes already figured and de- DIETARY. 363 scribed can be employed (pp. 240, 241). As the bowel has only feeble powers of absorption, it is better to have the food already in a predigested state. To ensure its being absorbed and retained it is better to have the food already in a predigested state and to give only ver}' small amounts at one time: ;4 to i teaspoon ful is enough at one year of age; i teaspoonful to i tablespoonful from one to four years; and from i to 8 tablespoonfuls up to twelve years. Any of the reliable peptonized meat preparations on the market may be employed in concen- tration much greater than is directed for use by the mouth. Such articles as defibrinated blood and other blood preparations, although not predigested, are readily absorbed and are of great value. Predigested nutrient enemata may be made at home by the use of pepsin or, especially, pancreatic prepara- tions. Milk peptonized in the way already described can be given, or the warmed milk may be mixed with the peptonizing agent and injected at once. 34. Peptonized Beef Enema. — A peptonized beef enema may be made as follows: Add I tablespoonful of minced lean raw beef to 4 table- spoonfuls of water. Heat to boiling. Rub through a colander. When only warm, add the contents of a pep- tonizing tube and inject at once. 35. Peptonized Egg Enema. — This is a useful nu- trient enema made by adding the contents of a peptoniz- ing tube to the white of one ^%% previously dissolved in three times its volume of water. 364 THE CARE OF THE BABY. II. Remedies for Local Use. I. Baths. 36. Baths in Sickness. — In a medical sense a ** bath '* is the application of water in nearly any way, either to the entire surface of the body or to part of it. Although there are many other varieties, we may limit our con- sideration to the following: [a) Whole baths, including — 1. Sponge bath; 2. Tub bath; 3. Shower bath ; 4. Sheet bath; 5. Vapor bath ; 6. Medicated bath (mustard, starch, soda, salt, sulphur, bran, disinfecting). (U) Partial baths, including — 7. Foot bath; 8. Wet compresses, including fomentations. From another point of view baths may be distinguished according to the temperature of the water. A convenient classification is the following: 1. Cold bath, temperature of 40° to 70° F. 2. Cool '' 3. Tepid ^' 4. Warm '' 5. Hot '' These definitions of temperature are used in the descrip- tions which follow. 37. Sponge Bathi or Ablution. — This is the simple, general washing of the body with wash-rag or sponge. u 70° '' 80° u (( 80° '' 90° (( u 9c° " 100° u ( ( 100° '' 110° u REMEDIES FOR LOCAL USE. 365 It may be used as a medicinal agent as well as for clean- liness. In sickness even more than ordinary care is needed to prevent taking cold. The sick child should be undressed completely, unless too weak, and put between blankets. The sponging must be performed rapidly and under the covers, doing one part at a time and drying it before going to another. Follow the order: hands, arms, face and head, neck, chest in front, back, abdomen, lower extremities. The child should be rolled from one side to the other if too weak to be lifted. The sponge or wash-rag need not be wet enough to be sloppy. Tepid spo)igi)ig or cool spoNgifig is an excellent means of reducing fever. Cold sponging is still more so, but must not be given except by a physician's order. The sponging may last ten or fifteen minutes and be repeated every couple of hours or oftener as needed. The addition of alcohol or bay rum adds to the cooling effect. When the fever is threateningly high and cold sponging is to be used, the child should not be covered at all; a rubber sheet is placed beneath the blanket, and the sponge may be large and saturated with water. On account of the fear which some physicians have of the use of water in eruptive fevers, no sponging at all should be used in such cases until the doctor has been consulted. Sponging with bathing-whiskey or with a mixture of equal parts of alcohol and water containing all the alum that will dissolve in it is useful where there is much perspiration or when the skin seems tender and liable to become sore (Appendix, 83). Alum will not dissolve at all in alco- hol alone. 38. Tub Bath. — The use of the tub for washing has already been described. The warm tub bath is of service 366 THE CARE OF THE BABY. in disease, but must be given with the greatest precau- tions against subsequent chilling. It is often ordered for the purpose of bringing out and keeping out the eruption of measles or scarlet fever in severe cases in which the gravity of the symptoms seems to depend on the failure of the rash to develop properly. It may well be given at the onset of any acute disease. It is also useful for pro- ducing perspiration and in this way checking a cold, allaying nervous excitement and thus producing sleep, reducing moderate fever, and stopping an attack of con- vulsions or of spasmodic croup. To get the full effect the child should be taken from the bath after ten or more minutes' immersion, placed quickly between warm blank- ets without being dried, and covered well in bed. When the bath is used to produce sleep, the child may be dried and the blanket dispensed with. Cases of eruptive fevers should not be given warm baths — except the initial one — unless medical advice be first obtained. The cold or cool tub bath should be used for medical purposes only if the physician orders it. It is not often given to young children unless there is high fever which cold sponging fails to reduce. In later childhood it is probably the best method known at the present time for treating typhoid fever. In order to avoid fright it is often best to put the child in a warm bath and then gradually cool the water until the proper temperature is reached. This is called the graduated bath. The hot tub bath is a very powerful stimulant, rarely to be used without the physician's order. Sometimes a baby which seems to be rapidly failing in strength or growing cold, or becoming greatly oppressed in breath- ing from some disease of the lungs, will revive in a wonderful manner if plunged into a bath of ichd° or iio° F., kept there one to three minutes, taken out, and REMEDIES FOR LOCAL USE. 367 wrapped in blankets without drying. Of course, gentle- ness and absence of sudden movement are absolutely es- sential in such threatening states. It must also be said that the hot bath sometimes appears to make the child worse. In such a case it must be discontinued at once. 39. Shower Bath. — The cool shower bath is to be used only in later childhood as an excellent nervous and muscular stimulant. The cold shower bath should never be used unless a ph}sician orders it. 40. Sheet Bath, or Wet Pack. — This may be either hot or cold. To give a cold pack^ a rubber cloth should be put over the bed and a sheet be wrung out in cold water and laid upon it. The child is now stripped, placed upon and enveloped in the sheet with the exception of the head, and then wrapped outside of all with a blanket. The feet may be left out if it is desired, in order that a hot- water bag may be put to them should this seem advis- able. The cold pack is often useful to quiet very great nervousness and to produce sleep. The child may be left in it for an hour or so if it goes to sleep; or, if it does not, may be taken out in fifteen minutes and wrapped in a warm, dry blanket. The pack is also em- ployed for reducing moderate fever, but in order to be of any service it must be renewed every five or ten minutes ten or twelve consecutive times if the temperature is high; the whole process lasting about an hour. Where fever is extremely high a pack with ice-water is some- times employed. The child is stripped and covered with cloths dipped in the ice-water, not forgetting to place them on the head. The cloths must be redipped every two or three minutes, and the rectal temperature must be taken very frequently to guard against too great a fall. 368 THE CARE OF THE BABY. A hot pack^ or blanket bath^ is given by wrapping the child in blankets wrung out in hot water, and covering with several dry blankets. The pack may be renewed in half an hour. It produces perspiration in the same way as the warm bath with subsequent blanket wrappings. 41. Vapor Bath. — This is used to relieve the dropsy of Bright' s disease by producing profuse perspiration. The bed is well covered with blankets which reach nearly or quite to the floor, but which are kept oflf the child by half barrel-hoops or by a chair in the bed or in some other way. A stream of vapor from a kettle or pan of boiling water is conducted by a tin pipe beneath the cover, taking care that it does not come in too hot a state against the body. Other methods of producing vapor consist in placing a vessel of slaking lime, or a bucket of water with hot bricks dropped into it, under the bed in such a way that the vapor can rise at the sides and reach the child under the covers. The hot-air bath is used for the same purpose as the vapor bath, of which it is a modification. The hot air from an alcohol lamp is conducted under the covers by a tin pipe. With either of these baths great care must be observed that the bed clothing does not become ig- nited by the flame of the lamp. 42. Mustard Bath. — Mustard is added to the warm tub bath in the proportion of >^ or i ounce (i to 2 mod- erately heaping tablespoonfuls) to i gallon of water. This is superior to the simple warm bath for bringing out the rash in eruptive fevers, and is a powerful stimulant when the child is rapidly failing from any cause. It is especially useful in infancy and early child- hood. REMEDIES FOR LOCAL USE. 369 43. Starch Bath ; Starch -Water. — The starch bath should be made of the strength of >i a cupful of boiled starch to every 4 gallons of water. If the starch has jellied, it may be broken up with the hand or pressed through a coarse wet cloth. The bath is very useful for hives and some other irritating skin affections. Starch-water for washing the skin or for use in ene- mata may be made in the same way. For the latter pur- pose it may be a little thicker, so that it leaves a slightly sticky sensation on the fingers. 44. Soda Bath. — This consists of i tablespoonful of washing soda to every 4 gallons of water. It is used for the same purpose as the starch bath, with which it is very commonly combined by dissolving the soda in the starch-water. 45. Salt Bath. — This may be made by dissolving ordi- nary salt, rock salt, or prepared sea-salt in water in the strength of 4 ounces (4 heaping tablespoonfuls) to i gal- lon. Given tepid or cool and followed by brisk rubbing, it is a valuable tonic, especially for rickety children. 46. Sulphur Bath. — This is made by dissolving 20 grains of sulphide of potash in each gallon of water. It cannot be given in a metal tub. It is of service in chronic rheumatism and in some affections of the skin. 47. Bran Bath. — Enough bran may be put in the water to make it milky. As this would choke the pipes of sta- tionary bath-tubs, the bath can be made by putting a pound or more of bran into a thin muslin bag and boil- ing this for a quarter of an hour. The water may then be added to the bath until it is milky. Bran baths are used in certain diseases of the skin. 24 370 THE CARE OF THE BABY. 48. Disinfecting Bath. — (See Appendix, 95.) 49. Foot Batii. — A partial bath of this sort is gener- ally given in the form of the hot mustard foot-bath, in the proportion of i ounce of mustard (2 moderately heaping tablespoonfuls) to i gallon of water. It is an excellent measure when a child has taken cold. Great care must be observed, however, to have the room warm, the bed- clothes also warm, and to ensure protection of the rest of the body, including the thighs, when the feet and legs are in the water. A useful plan is to have the tub in the bed, under the covers, while the child lies in bed well covered up. It is often best to put the child between blankets afterward, as in the case of the warm tub bath. 50. Wet Compress. — This form of partial bath con- sists of a cloth wet with water and kept applied to some part of the body. An ordinary zuarm compress is made by folding a piece of soft cloth or of patent lint into two or three thicknesses, dipping it into tepid water, laying it on the part, covering it with a piece of oil silk or par- affin paper a little larger than the cloth, and gently band- aging it on. It is useful in reducing inflammation, as in cases of sore throat. A cold compress consists of a thin cloth, like a hand- kerchief, folded into two or three layers, dipped in cold water or, perhaps, in ice-water, wrung out, and laid on the affected part. Alcohol with twice its volume of ice- water is serviceable for this purpose. The compress is not covered with oil silk, and it must be changed every few minutes, since it rapidly becomes warm. Instead of this method, it may be kept cold by allowing ice-water to drop on it from a vessel higher than the patient. A strip of soft cotton cloth or a skein of darning cotton or a lamp-wick, with one end in the vessel and the other on REMEDIES FOR LOCAL USE. 37 1 the compress, will supply enough fresh water. A rubber cloth should be placed under the compress in such a way that the child does not become wet. The cold compress is of service in inflammation, sprains, and the like. A hot compress^ or fomentation^ is made of a piece of flannel folded three or four times into the form of a pad. This is placed in an open towel, dipped into boiling water, wrung out thoroughly by twisting the towel, re- moved from it, tested by the nurse against her cheeks to ascertain that it is not too hot, applied to the part, and covered quickly with oil silk and a folded dry towel, with or without a bandage. The fomentation should be re- newed in half an hour if we wish to keep up decided heat. It is often very useful in relieving pain. A poul- tice is to be preferred, except that it is heavier. 2. Poultices and Plasters. 51. Poultices. — The poultice is intended to furnish a dressing which will retain its heat longer than a fomen- tation. It should be half an inch or less in thickness. The thicker it is the longer it stays warm, but of course the greater its weight. Placed on the chest, it must be thin or its weight will do harm. A poultice should always be tested against the cheek of the nurse before it is applied to the child, and should always be put on grad- ually. Of the various forms, those made of flaxseed, slippery elm, mush, bread, bran, hops, starch, mustard, and charcoal may be referred to. I 52. Flaxseed Poultice. — One of the best known and i most serviceable kinds. Heat a sufficient quantity of I water in a tin or china dish nearly or quite to boiling. I Add flaxseed meal slowly, stirring constantly and vigor- ' ously with a spoon until it is of the consistence of hot mush, too thick to flow. Spread this with a case-knife 1^2, THE CARE OF THE BABY. Upon a piece of cotton or linen cloth; fold the edges over slightly, and cover it with an old pocket-handker- chief or piece of thin muslin, cheese-cloth, or netting. Test to see that it is not too hot; apply, cover with oil silk or paraffin paper, and bandage on. Renew every few hours. The addition of a little oil will keep it soft longer. Everything must be in readiness before the poultice is mixed, or it will grow cold. 53. Slippery-Elm Poultice. — Prepared from ground slippery-elm bark in the same way as the flaxseed poul- tice. 54. Mush Poultice. — This is made of com-meal mush. It has no advantage over the flaxseed poultice. 55. Bread-and-Milk Poultice. — A popular and easily- prepared poultice. Stale bread-crumb is stirred into hot milk until the proper consistency is attained. It should be kept hot a few minutes to ensure the bread being well softened, then spread and applied. Water may be used instead of milk. 56. Bran Poultice. — When a flaxseed poultice would be too heavy, as in some cases of pain and tenderness in the abdomen, a bran poultice may be used. A flannel bag is partly filled with bran, thoroughly wet with boil- ing water, wrung out in a towel, and applied. 57. Hop Poultice. — Prepared and used exactly as is the bran poultice, over which it has no particular advan- tage except that it is still lighter. 58. Starch Poultice. — Thick boiled starch is spread REMEDIES FOR LOCAL USE. 373 warm on a cloth and applied directly to the skin without any covering between. It is used to lessen irritation in some affections of the skin. 59. Mustard Poultice. — The same as a mustard plaster (Appendix, 65). 60. Charcoal Poultice. — This is made from flax- seed meal mixed with an equal quantity of powdered charcoal. More dry charcoal is sprinkled over it after it is spread. It was formerly often used as a dressing for foul-smelling sores and wounds. 61. Jacket Poultice. — Sometimes a useful application in pneumonia. A piece of thin muslin or linen is used, long enough to go entirely around the chest, and wide enough when doubled to extend from the lowest ribs to the collar bones. The cloth is opened, the hot mass of the poultice spread on one half, the other half folded over it, and the poultice applied as hot as the child can bear it. Oil silk or paraffin paper covers it externally. The poul- tice should be renewed ever}' few hours, and the new one must always be ready to put on before the old one is taken off It should be drawn up close under the armpits and toward the collar bones and fastened over the shoulders and at one side with pieces of broad tape. The open edge of the poultice should be above, in order to prevent the contents falling out. A jacket poultice of bran may be made by construct- ing a jacket of muslin with a lining of the same sewed to it everywhere except at a single small opening through which the bran can be pushed. The poultice must be quilted to hold the bran in place, soaked in boiling water, pressed out, and applied when of the right temperature. The same poultice can be used again and again. 374 THE CARE OF THE BABY. 62. Antiseptic Poultice. — For use on open wounds, surgeons favor some form of antiseptic poultice, and ob- ject to flaxseed and other varieties already described. One of the best poultices consists of several layers of cheese-cloth or clean soft linen wrung out in a hot anti- septic fluid (Appendix, 75), laid on the wound, covered with paraffin paper, and bound on with a roller bandage. 63. Turpentine Stupe. — A piece of flannel is wrung out in hot water, as in preparing a fomentation, and then sprinkled evenly with turpentine, about half a teaspoon- ful being used for each square foot of flannel. It is then applied, covered with oil silk and a dry towel, and left on half an hour to an hour, more or less, depending on the degree of irritation it produces. 64. Spice Plaster. — This 'is a very serviceable applica- tion for infants with severe colic. To prepare it take i part each of ground ginger, cloves, cinnamon, and all- spice, with or without y^ part of cayenne pepper, according as the plaster is to be strong or weak. Put the dry and well-mixed powder into a flannel bag, spread it evenly, and quilt the bag to prevent the spices from get- ting into lumps. Before applying, wet it with hot alcohol or hot whiskey. The same spice-bag may be used repeat- edly until it begins to lose its strength too greatly. 65. Mustard Plaster. — Strictly speaking, this is a poultice, since, as used for children, the mustard is added to flour or flaxseed meal, and the whole moistened and heated: i part of mustard should be mixed with 3 or 4, or, in the case of infants, 5, parts of flour or flaxseed meal. Boiling water is added and the mixture stirred until it is of the proper softness. It is then spread on a REMEDIES FOR LOCAL USE. 375 cloth and applied directly to the skin. If it burns too much, a layer of linen or some other thin material can be placed between. It should be kept on until the skin is well reddened, but not long enough to blister. 66. Pepper Plaster; Nutmeg Plaster. — These old- fashioned but excellent preparations are of service in mild bronchitis or sore throat. Lard or, still better, mutton suet is spread evenly on a cloth and black pepper or powdered nutmeg dusted rather thickly over it. Red pepper may be used instead, but in smaller amount. The plaster may be worn for days over the chest or around the throat. Another plaster is made by mixing a very little cayenne pepper in a thin paste of flour and water and applying on a thin cloth. 67. Cotton Jacket. — This is sometimes ordered by physicians in cases of pneumonia. A muslin waist should be made, reaching high in front and behind, and tying or pinning over the shoulders and down one side under the arm. To the inside of this a thick layer of cotton batting is loosely attached. If it. is desired to retain the perspiration and keep the skin moist, a layer of oil silk is sewed outside of the muslin, or the cotton may be sewed directly to the oil silk, cut in the shape of a waist. 68. 3. Ointments. Bismuth-and-Zinc Ointment. Subnitrate of bismuth. 30 grains; Oxide of zinc, 30 '' Lanolin, ^ ounce; Vaseline, % " 37^ THE CARE OF THE BABY. 69. Ointment for Ringworm. Sulphur, J^ drachm; Tar ointment, i " Benzoated lard, i ounce. To be well rubbed in two or three times a day. 70. Boric-Acid Ointment. Boric acid, i drachm; Vaseline, ^ ounce; Lanolin, J^ '* 71- Boric-Acid-and-Zinc Ointment. Boric acid, ^ drachm; Oxide of zinc, >^ *' Lanolin, J^ ounce; Vaseline, i^ *' 4. Solutions and Mixtures. 72. Carbolized Oil. Pure carbolic acid (Calvert's No. i), y^ drachm; Finest olive oil, 2 fluidounces. This should be marked *' Poison!" 73. Tannic-Acid-and-Glycerin Nipple Lotion. Glycerite of tannic acid, i fluidounce; Water, i To be painted upon the nipple and allowed to remain. 74. Bismuth Nipple Lotion. Subnitrate of bismuth, i ounce; Castor oil, i fluidounce. To be used as the preceding. REMEDIES FOR LOCAL USE- 377 75. Boric-Acid Lotion. Boric acid, J^ ounce; Water, i pint. To be used as an antiseptic wash in dressing wounds. 76. Carbolic-Acid Lotion. Pure carbolic acid (Calvert's No. i), ^ drachm; Water, 6 fluidounces. To be used as the preceding. To be marked " Poison!'* 77. Corrosive-Sublimate Antiseptic Lotion. Corrosive sublimate, ij^ grains; Tartaric acid, 6]/^ '' Distilled water, 8 fluidounces. To be used and marked as the preceding. Injurious to metal. A more convenient method of preparing it is to dis- solve in 3 pints of water one of the sublimate tablets which are for sale by druggists. Either method makes a solution of the strength of i of sublimate in 3000 of water. 78. Starch-and-Boric-Acid Lotion. — Starch is to be dissolved in the boric-acid solution (No. 75) in the same way as when preparing ordinary starch-water (No. 43). 79. Borax-and-Glycerin Lotion. Borax, 20 grains; Tincture of myrrh, J^ fluidrachm; Glycerin, i " Water, enough to make i fluidounce. Apply frequently to the inside of the mouth for inflam- mation or thrush. 378 THE CARE OF THE BABY. 80. Eye Lotion. Boric acid, 20 grains; Camphor-water, 2 fluidounces. 81. Astringent Gargle. Tannic acid, i heaping teaspoonful; Water, i tumblerful. Dissolve and use as a gargle. 82. Tannic-Acid Solution for Nose-bleed. Tannic acid, 2 drachms; Glycerin, i fluidrachm; Water, 2 fluidounces. To be injected or snuflfed into the nose in obstinate cases of nose-bleed. 83. Alum Lotion. Alum, 6 drachms; Water, 8 fluidounces; Alcohol, 8 '' To be used as a wash in excessive perspiration or if bed- sores are threatening. 84. Cooling Lotion. Pure carbolic acid (Calvert's No. i), 40 grains; Ether, 2 fluidrachms; Alcohol, 6 fluidounces. To be dabbed on the parts and let dry. To be marked "Poison!" 85. Lotion for Freckles. No. 1. Compound tincture of benzoin, i fluidrachm; Glycerin, yi fluidrachm; Rose-water, 3 fluidounces. REMEDIES FOR LOCAL USE. 379 86. Lotion for Freckles. No. 2. Borax, i drachm; Dilute acetic acid, yi fluidounce; Rose-water, }^ fluidounce. 87. Injection for Convulsions. Bromide of potash, 10 grains; Hydrate of chloral, 3 " Milk of asafoetida, 2 fluidounces. One or two tablespoon fuls as an injection for an infant. To be repeated in half an hour if needed. 88. Injection for Seat-worms. Quassia-chips, i ounce (i small teacupful); Water, i pint. Let soak for two or three hours. Inject slowly as much as the child will contain. 5. Powders. 89. Compound Camphor Powder. Camphor, i drachm; Oxide of zinc, % ounce; Starch, >^ ounce. Make into a very fine powder. 90. Boric-Acid-and-Zinc Powder. Boric acid, >^ ounce; Oxide of zinc, j4 ounce. Make into a very fine powder. 91. Bismuth-and-Zinc Powder. Subnitrate of bismuth, >^ ounce; Oxide of zinc, >^ ounce. Make into a very fine powder. 380 the care of the baby. 6. Disinfectants. 92. Carbolic Acid. Carbolic acid (Calvert's No. 4), 6j^ ounces; Glycerin, 4 fluidounces; Water, i gallon. This forms a 5 per cent, solution suitable for disinfecting dishes, clothing, thermometers, metal work, and the hands of the nurse. Clothes should be soaked in it for several hours, then wrung out, carried away in a covered bucket, and boiled thoroughly. It may be used also to wet the sheet hung at the door. 93. Chloride of Lime. Chloride of lime, 4 ounces; Water (soft), i gallon. A pint or a quart of this is to be thoroughly mixed with the passages from the bowels of typhoid-fever cases, covered, and allowed to stand for three hours before emptying. The solution may also be used to mix with any infectious expectorated or vomited matter. 94. Chlorinated Soda. Solution of chlorinated soda, 6 fluidounces; Water, enough to make i quart. Useful for disinfecting the hands, eating utensils (except silver), etc., but not so suitable for clothing as No. 92. It may be used to wet the sheet in front of the door. 95. Disinfectant Bath. — The solution No. 92 diluted with twice its volume of water, or No. 94 diluted with four times its volume, may be used for a final disinfecting REMEDIES FOR LOCAL USE. 38 1 bath in which a child may be placed after an attack of scarlet fever or other contagious disease. 96. Corrosive-Sublimate Solution. Corrosive sublimate, 2 ounces; Tartaric acid, 24 " Carminate of soda, 8 grains; Water, i quart. This is the formula of the Paris disinfecting service; 4 ounces mixed with i gallon of water makes a solution of the strength of i part of the sublimate in 500 of water. The blue carminate of soda is added to give a slight color, so that the poisonous nature of the solution may be easily recognized. The solution is suitable for disinfecting floors, wood-work, leather, rubber, etc. It must not be used upon metal. Clothing may be disinfected by im- mersing it for two hours in a mixture of ]/> ounce of the stock solution and i gallon of water. There is some dan- ger, however, of its becoming stained by the carminate of soda. The sheet in front of the door of the room may be moistened with a mixture of 2 ounces of the stock solu- tion and I gallon of water. 97. Corrosive-Sublimate Solution, No. 2. — One of the sublimate tablets referred to in No. yj^ dissolved in i pint of water, makes a solution of the strength of i part in 1000. This is by far the most convenient method of preparing the sublimate solution for disinfecting purposes. 98. Disinfectant Vapor. Pure carbolic acid, i ounce; Oil of eucalyptus, i fluidounce; Turpentine, 8 fluidounces. Two tablespoonfuls may be poured on a quart of water in 382 THE CARE OF THE BABY. a shallow pan, and this kept constantly simmering in the room of a diphtheritic patient, for the purpose of moist- ening and disinfecting the air. Fresh solution must be added from time to time. The flame must be kept well away from the liquid. 99. Dry Disinfectants. — Dry copperas (sulphate of iron) or chloride of lime may be placed in large amounts in water-closets, water-pipes, cesspools, and the like, for the purpose of disinfecting them. III. Remedies for Internal Administration. 100. Soda-Mint. Bicarbonate of soda, yi drachm; Aromatic spirits of ammonia, )^ fluidrachm; Spearmint-water or peppermint- water, enough to make 2 fluidounces. A teaspoonful in hot water at one year of age. loi. Laxative Alkaline Mixture. Bicarbonate of soda, ^ drachm; Spiced syrup of rhubarb, 4 fluidrachms; Syrup of senna, 4 " Syrup of orange, i fluidounce. A teaspoonful, more or less, three times a day at one year of age, depending upon the intensity of its action. 102. Chalk-and-Bismuth Mixture. Subnitrate of bismuth, i^ drachms; Chalk mixture, 2 fluidounces. A teaspoonful every three hours or oftener at one year of age. A younger child requires a dose not much smaller than this. REMEDIES FOR INTERNAL ADMINISTRATION 383 103. Fever Mixture. Sweet spirits of nitre, i^ fluidrachms; Citrate of potash, 30 grains; Syrup of lemon, 4 fluidrachms; Water, enough to make 2 fluidounces. A teaspoonful every three hours at one year of age. 104. Croup Mixture. Syrup of ipecacuanha, 2]/^ fluidrachms; Bromide of potash, ^ drachm; Hive syrup i fluidrachm; Cinnamon- water, 1234 fluidrachms. A teaspoonful every hour or two for three or four doses at two years of age. 105. Jeaunel's General Antidote for Poisoning. {a) Calcined magnesia, 2 ounces; Animal charcoal, i ounce; Water, 20 fluidounces. (I)) Monsel's solution of iron, 2 fluidounces. When needed, the two solutions should be mixed to- gether, shaken hard, and given two tablespoonfuls at a time, repeated very frequently. 106. Emetics. A teaspoonful or more of syrup of ipecacuanha, repeated in fifteen minutes. A glass of warm water with as much common salt as it will dissolve. A half teaspoonful of alum stirred up in syrup or in molasses. 384 THE CARE OF THE BABY. A teaspoonful of mustard in a large quantity of warm water, if other emetics fail. IV. Miscellaneous. 107. Massage. — This is a procedure which no one is capable of carrying out as it should be done unless trained well and long in both its theory and its practice. Still, where a skilled masseuse cannot be obtained, the mother or nurse can perhaps do something, and it is certainly worth the trial; but it should be attempted only imder the advice and direction of the physician, who can at least give some idea as to what he desires and the method of procedure, even though he be no adept himself. Massage often does more good in cases of paralysis than any other plan of treatment. Children suffering from general debility or from chronic catarrhal condi- tions of the stomach and bowels are often aided greatly by it. Constipation and colic in babies are frequently much relieved by rubbing and kneading the abdomen, provided this is done in the proper way (p. 254). There are, indeed, many conditions in which massage finds a useful sphere. There are various technical terms used to designate the diSerent manipulations. Prominent among these are effleurage (stroking), friction (rubbing),/^/r?>j^^^ (knead- ing), and tapotement (tapping). The method of perform- ing each of these and the conditions in which they are specially useful is far too large a subject for consideration in a book of this nature, even were it profitable to speak further of a matter for which actual demonstration is the only satisfactory^ explanation. 108. Table of Approximate Equivalent Measures. — The following table shows the relative vahie of drops, teaspoonfuls, fluidrachms, fluidounces, etc. : \ MISCELLANEOUS. 385 1 minim (T1\,j) =1 drop water, or 2 drops tinctures, spirits, or wines. 30 minims = \ fluidrachm (fl^ss) = i coffeespoonful. 60 " =1 " (fl3J) = i teaspoonful. 2 fluidrachms =2 teaspoonfub = i dessertspoonfiil. 4 " =\ fluidounce (fl5ss)=4 ** = i tablespoonful. 8 " =1 " (ti^j} = 2 tablespoonfuls. 2 fluidounces =4 '* =1 wineglassful. 8 « =\ pint (Oss) . . . = I tumblerful. 16 " =1 « (Oj). 32 " =2 pints =1 quart. 8 pints . . =4 quarts = I gallon (Cj). For measuring minims we ought to have one of the small minim glasses sold by druggists (Fig. 66). Very commonly medicines are given by drops instead of minims. In such a case we must never forget that the drop is of a very variable size, depending upon both the nature of the liquid and the nature of the ar- ticle from which the drop falls. To be exact we should purchase an ac- curate medicine-dropper (Fig. 67), and have the druggist test it, no mat- ter how reliable it is claimed to be. An accurate dropper will give 60 drops of water to the fluidrachm; that is, i drop equals i minim. Alcoholic solu- tions, however, such as most of the tinctures and spirits, and whiskey and other stimulants, drop about 120 drops to the fluidrachm; that is, 2 drops equal i minim. Consequently, if the Fig. 66.— Minim glass physician orders a drop of laudanum, (natural size). and the mother uses the minim glass, she must measure 25 386 THE CARE OF THE BABY. out only half a minim. This difference which sometimes exists between the drop and the minim is a matter of the Fig. 6'] . — Medicine-dropper. very greatest importance. For measuring larger doses teaspoons and tablespoons are very unsatisfactory, since they vary so much in size. The ordinary measuring glasses, although much better, are also in- accurate. It is much wiser to purchase a four-ounce glass graduate from the druggist (Fig. 68). Fig. 68. — Four- ounce glass grad uate. 109. Table of Proportionate Dosage at Different Ages. — The size of a dose varies, first, with the age of the child; second, with its size; third, with the nature of the disease; fourth, with the individual medi- cine. There can, indeed, be no absolute rule, and there are numerous exceptions, for children bear some drugs in proportionately much larger doses than adults do, while certain others they can take in only the minutest quantities. As a rule, the actual age is not so much the basis of calculation as that age to which the length and weight of the child correspond. The following table forms a general guide for the different periods of life: Adult I 18 3'ears | or i 12 " h 8 to 10 5-ears f 6 years \ MISCELLANEOUS. 387 4 years \ 3 " \ 2 " \ I year ^ 9 months tV == t dose of i year. 6 " ^ = \ " I " Birth to 3 months tu = i '* i " no. Dose List for Children One Year Old. — Accord- ing to the previous table (No. 109), the dose at 2 years is approximately one and a half times, at 3 years twice, at 6 years three times, at 8 to 10 years four times the amounts given below, while the doses at less than i year may likewise be determined by consulting the same table. As has been frequently stated elsewhere in this book, no mother should attempt to prescribe for her child. This list is given solely for nurses and for the sake of that general information which never comes amiss, and which may prove useful in cases of great emergency where a physician cannot be found. It is especially to be remem- bered that opium is the drug to which children are par- ticularly susceptible. Remember, too, the difference between drops and minims. (See page 385.) AcetaniUd (antifebrin) gr. i to J. Aconite, tincture n\^ i to }. Ammonia, aromatic spirits of tt\^ 2 to 4. Antimony, wine of tt\^ 2 to 4. Antipyrin gr. 1 to ^. Asafcetida, milk of i*^\\.o\. Belladonna, tincture rr\^ ^ to 2. Bismuth, subnitrate gr. i to 6. Brandy (see Stimulants). Bromide of potash or soda gr. ^ to 4. Calomel gr. ^ to ^ (^ in one single dose). Cascara cordial tt\^ 4 to 30. Cascara sagrada, fluid extract tt\^ i to 4. Castor oil f3 ^ to i. 388 THE CARE OF THE BABY. Catechu, tincture tt\^ 5. Cinnamon-water f3 j to i. Chalk mixture f3 i to i. Chloral gr. ^ to 3. Chlorate of potash gr. i. Citrate of magnesia (see Magnesia). Citrate of potash gr. i to 2. Cod-liver oil f3 i to i. Digitalis, tincture TT\,^toi. Dover's powder gr. \ to \. Epsom salt gr. 3 to 10. Fowler's solution of arsenic tt\^ ^ to i. Gin (see Stimulants). Ginger, tincture tt^ i to 4. Hive syrup (see Squills, comp. syrup of). Hoffmann's anod3ne tt\^ i to 5. Hydrochloric acid, dilute tt\^ i to 2. Iodide of potash gr. ^ to i. Ipecacuanha, syrup or wine tt\^ i to 5. Iron, citrate gr. Ho i. Iron, reduced gr. ^ to ^. Iron, syrup of iodide n\^ i to 3. Iron, tincture of chloride tt\^ 2 to 2. Kino, tincture ^ 5- Laudanum. [A tincture] n^ J to |. Liquorice powder gr. 2 to 4. Magnesia gr. 5 to 20. Magnesia, citrate (liquid) f3 i to 2. Malt extract tt\^ 10 to 15. Manna gr. 5 to 10. Morphine gr. tto to ^^j. Nitre, sweet spirits of n^ 2 to 6. Nux vomica, tincture . . tt\^ 1 to i. Olive oil iZ\^o\. Paregoric. [A tincture] tt\^ 3 to 10. Peppermint-water fo * to i. Pepsin gr. i to I. Phenacetin gr. i to ^. Quinine gr. ^o i. Rhubarb, syrup of fo ¥ to ^. MISCELLANEOUS. ' 389 Salicylate of soda gr. ^ to i. Senna gr. i to 4. Senna, syrup n^ 10 to 15. Soda, bicarbonate . gr. i to 2. Squills, comp. syrup n\, i to 2. Squills, syrup n\^ i to 5. Stimulants : Brandy rr^ 5 to 30. Gin rn, 5 to 15. Port wine n\^ 5 to 30. Sherry n\^ 5 to 30. Whiskey n\^ 5 to 30. Sulphuric acid, dilute tt\^ ] to 4. Tannic acid gr. ^ to i. Whiskey (see Stimulants). Wine (see Stimulants). III. Medicine Closet. — The contents of the medicine closet, to which reference was made in Chapter X., p. 216, should be somewhat according to the following list. This contains, among other things, articles useful for accidents, including poisoning. The list may be curtailed in some respects, but suffers consequently in completeness. Those liquids marked with an * are for external use or are dan- gerous. They should be in poison-bottles. List of Articles for Medicine Closet. Glass graduate marked with fluidrachms and fluid- ounces; minim glass; accurate dropper; hard-rubber syringe holding four or six ounces; small druggist's hand scales for weighing medicines; camel's -hair brushes; small straight dressing- forceps; a pair of scis- sors; absorbent cotton; several one-inch and two-inch roller bandages, one to three yards long; patent lint; old linen; a spool of rubber adhesive plaster; court plaster; paraffin paper or oil silk; * alcohol; whiskey; olive oil; 390 THE CARE OF THE BABY. * ammonia water; * turpentine; glycerin; * distilled fluid extract of hamamelis (witch-hazel) for bruises; *soap liniment for sprains; * tincture of iodine; * solution of boric acid for washing cuts (No. 75); flaxseed meal; mustard; magnesia; vaseline; castor oil; zinc ointment; soda-mint; baking soda; sweet spirits of nitre; aromatic spirits of ammonia; bromide of potash in 20-grain pow- ders, to be divided according to the age; * tincture of digitalis; syrup of ipecacuanha; tannic acid for use in poisoning; Epsom salt for poisoning; vinegar for poison- ing; sulphate of copper in 3-grain powders, for poisoning by matches; Jeanne? s antidote for poisoning. INDEX, Abdomen, conditions of, in disease, 224 enlargement of, in colic, 256 in pregnancy, 20 in rickets, 315, 316 massage of, 254, 384 of child, size at birth, 36 Abdominal band. See Binder. belt for pregnancy, 26 Accidents, 329 Air, fresh. In pregnancy, 22 moistening of, 202, 214, 309 out-door exposure to, 165, 166 Albumin-water, 354 Alum solution, 365, 378 Amusements, 1 71-174 in pregnancy, 24 Antiseptic lotions, 377, 380, 381 Appetite, loss of, 235, 250, 320 Applications, external, 238, 242, 364 Apron, bath-, 69 creeping, 103, 168 Arms, short, at birth, 37 Arrowroot-water, 354 Atomizer, bulb, 242 steam, 214, 263 Baby, characteristics of, in health, 34 -jumper, 169 method of carrying, 165, 236, 335 sensations of, 49 -talk, 167 use of the term, 18 Baby's basket, 66 Backwardness, 272 Bag of waters, 33 Bandage. See Binder. roller-, method of applying, 330 Barley and egg, 354 -water, 353 Barrel-hoojis to keep covers off, 368 Barrow coat, 90 Basin, sponge-, 73 Bassinet, 160 Bath apron, 69 blanket, 368 bran, 369 daily, 71 disinfectant, 370, 380 duration of, 70, 77, 80, 366 fear of, 74 first, 68 foot, 370 for a prematurely-born child, 314 graduated, 366 hot-air, 368 hour for, 78 method of giving, 69 mustard, 368 powder after, 79 salt, 369 sheet, 367 shower, 367 soap for, 75 soda, 369 sponge, 364 starch, 369 sulphur, 369 temperature of, 70, 76, 78, 364 thermometer, 76 towels for, 78 tub, 70, 365 vapor, 368 water for, 76, 77 Bathing. See also Bath. during pregnancy, 22 for sleeplessness, 78, 268, 366, 367 importance of tub-, 74 room for, 207 Baths in disease, 238, 364 out-door, 79 Bath-tub, 71, 72, 74 stand for, 71, 72 Bed, airing of, 163 -clothes-fasteners, 164 confinement to, during sickness, 236 391 392 INDEX. Bed- covers, 162, 163, 237 for confinement, 31 for infant, 160 furnishing of, 162 in sickness, 237 -room shoes, 109 trundle-, 162 warming of, 163 -wetting, 322 Beef-juice, 358 effect on urine, 231 Beef-tea, 357 peptonized, 361 Bibs, 102 Bicycle, 172 Biedert's cream mixture, 150 Binder for child, 86, 97, 104, 105 for mother, 31, 32 Birth-marks, 25, 283 -palsy, 270 premature, 313 Bismuth-andzinc ointment, 375 powder, 379 Bismuth nipple lotion, 376 Bites of animals, t^^-^, 334 Bladder, irritability of, in pregnancy, 23 Blanket, pinning, 90 shoulder, 94 to receive baby at birth, 68, 69, 94 Bleeding, arrest of, 330, 331 from navel, 283 from nose, 344 Blindness, congenital, 273 from inflammation of the eyes, 273 Blue baby, 324 Body, feebleness of, in idiocy, 273 -movements in early life, 47, 48 Boils, 248, 288 Bones, broken or displaced, 335 Boots, rubber, 108 Borax-and-glycerin lotion, 377 Boric-acid-and-zinc ointment, 376 powder, 379 Boric-acid lotion, 377 ointment, 376 Bottle-feeding. See Feeding, artificial. Bottle, feeding-. See N'lirsing bottle. for poisons, 216 -tip. See Alpple. Bowel, closure of, 257 inflammation of, 251 itching of, 222, 259 Bowel-movements. See Passages. prolapse of, 257 Bowels, teaching control over, 51, 171 Bow-legs, 37, 169, 316 Brain, concussion of, 328 disease of, 222-226, 250, 269-272, 278 water on the. See Hydrocephalus. Breast, abscess of, 117, 120, 319 caked, 117 feeding at. See Feeding. -pump, 27 Breasts, care of, 27, 116 distention of, 117, 119, 319 enlargement of, in pregnancy, 20 inflammation of, in infants, 319 Breath, holding the, 317 Breathing. See Respiration. Bright's disease, 223, 231, 322, 368 Bronchitis, 263, 264, 375 Brooder, 314 Bruises, 334 Brush for head, 82 for throat, 24I tooth-, 81 ' Burning child, 337 , Burns, 336, i^^Z \ Cap, 95, 104, 107, 108 I Carbolic-acid antiseptic lotion, 377 ! disinfectant solution, 380 Carbolized oil, 376 Carriage, 167, 168 "express-wagon," 169 prevention of falling from, 167 Carrying the child in sickness, 236, 335 method of, 165 Cart, 170 Cereals, 152, 155 Chafing, 287 Chair, nursing-, 171, 204, 254 -car, 170 Chairs for nursery, 204, 207 for school-room, 219 Chalk-and-bismuth mixture, 382 Chapping, 288 Character, training of, 174, 179, 190 Chest in disease, 224 in health, 36, 58 Chicken-breasted, 224, 249 -pox, 302, 304 Chilblains, 339 INDEX. 393 Childbirth. See Confinement. Childhood, disorders of, 220, 244 early and later, definition of, 18 Child's nurse. See Ntirse-tnaid. Chloride-of-lime solution, 380 Chlorinated-soda solution, 380 Choking, 343 Cholera infantum, 251 Chorea, 269 Cleft palate, 245 Cloak, 95, 104 Clothes-basket for early exercise, 168 Clothing. See also Petticoat, Shirt, etc. after shortening, 98, 104 difference in heat depending on color, 106 different styles of, for infants, 90 disinfection of, 210 during pregnancy, 26 during sickness, 109 for different sexes, 106, 107 fornight, 94, 107 for out-doors, 95, 104, 107 general remarks on, "^i in couveuse, 314 of childhood, 104, 108 of infancy, 86, 104 undergarments, material for, 85 Club-foot, 37, 278 Coat, 104, 107 rubber, 108 Cold, application of, 239 effect of, on child, 34, 84, 339 in the head, 261 Colds treated by bath, 366, 368, 370 Colic, 112, 222, 225, 256, 384 Color of skin, 34, 35, 222 Colors, absorption of heal by, 106 Colostrum, no Comb, 82, 292 Comforter, 145 Compound camphor powder, 379 Compresses, wet, 370 Confinement, "bag of waters," 33 bed for, 31 binder, 32 calculating date of, 21-23 napkins, 32 l)ains of, 32 preparations for, 30 room for, 31 " show," II Constipation, 253, 256 Constipation in pregnancy, 28 Consumption, 223, 224 Contentment, 174 Convulsions, 222, 223, 265, 366 Cooling lotion, 378 Cord, navel. See A'avel cord. Corrosive-sublimate antiseptic lotion, 377 disinfectant solution, 381 Corsets, 106 Corj'za, 261 Cotton underwear, 86 Cough, signification of, 226 Couveuse, 314 Cow-pox, 304 I Cracks in skin, 287 Cradle, 162 Cream, 122, .i^, 132, 133, 135 -and-barley water, 150 -and-whey mixture, 356 mixture, Biedert's, 150 Creamometer, 122, 123, 132 Creeping, 48, 168 apron, 103, 163 pen for early exercise, 168 Crib, 161, 162 Croup kettle, 214,263 membranous, 263 mixture, 383 spasmodic, 262 tent, 215 Cr)', signification of, 38, 1 1 2, 224, 323 Curd, " breaking of," 150 I Curvature of spine. See Spine. Cuts and tears, 329 Cyanosis, congenital, 324 Dancing, 172 Dandruff, 289 Day of the disease, 293 Deafness, 252, 262, 272, 277 Dentition. See also Teeth and Teeth- ing. delayed, 64 disordered, 60, 247 Despondency in pregnancy, 24 Desquamation, 296 Diaper-cover, rubber, 89 -squares, 89 -suspenders, 100 Diapers, baby, 88 leaving off of, 104 Diarrhoea, 223, 224, 237, 251 394 INDEX. Diet. See also Food^xi^ Feeding, after three years, 155 after weaning, 151 from eighteen months to two years, 153 from one year to eighteen months, 152 from two to three years, 154 influence on breast-milk, 114, 115, 124 in pregnancy, 25 necessity of caution in changing, 117, 147, 152^ 154, 235, 243 of nursing mother, 113, 124 Dietary, 243, 353 Diphtheria, 270, 307 Diseases, contagious, 182, 197, 209- 212, 293 due to unhygienic school-room and schooling, 181, 217 features of, 221 infectious, 182, 197, 292, 294 of bones, muscles, skin, etc., 277 of brain and nervous system and of the special senses, 265 of digestive apparatus, 245 of organs of respiration, 261 record of, 243, 244 Disinfectant vapor, 309, 381 Disinfectants, 380 Disinfection about body, uselessness of, 293 in contagious diseases, 210 of wash-stand, 206 Dislocations, 335 Disorders of childhood, 244 of pregnancy, 28 Disposition, alteration in pregnancy, 21 Dog-bites, 333 Donkey, 172 Dose of common remedies for chil- dren one year old, 234, 387 size of, at different ages, 386 Drachm, fluid, 385 Draughts, 68, 168, 200, 201, 203, 213, 218 Drawers, 99, 104, 105, 108 night-, 107, 108 Dress for childhood, 105 or slip for infancy, 92 Dressing, method of, 95 the cord, 95, 96 Drops, 385 Dropsy in children, 224, 321, 368 in pregnancy, 29 Drowning, 347 Drying, 71, 78 Dysentery, 252 Earache, 276 Ears, foreign bodies in the, 342 inflammation of, 261, 276 injury by bath, 75, 80 protruding, 278 washing of, 75 Eczema, 225, 284, 290, 292, 346 Emergencies, 329 Emetics, 383 Enemata for convulsions, 379 for thread-worms, 379 nutrient, 362 syringes for, 339, 240 Epilepsy, 266, 267 Eruptions, pustular, 288 Erj'sipelas, 305, 306 Erythema, 288 ' Exercise, calisthenic, 173 clothes-basket or pen for, 168 express- wagon or mail-cart for, 169 for nursing mother, 1 15 gymnastic, 173, 1 81 infant's earliest, 165 in pregnancy, 22 large amount borne by child, 171 length of out-door walk, 169 trotting on knee, 170 Expectoration, age when begun, 263 Express-wagon, 169 Eye, acid in the, 341 dropper, 274 foreign bodies in the, 340 lime in the, 341 lotion, 378 wounds of the, 342 Eyelashes, effect of cutting, %-^ Eyes, color of, 37 crossing of, 223, 265, 270, 275 first washing of, 70 half-open, 223 inflammation of, 222, 273 injuiy of, by study, I Si, 219, 269 purplish tint about, 223 Face, expression of, in disease, 223 in health, 37 Fainting, 347 I INDEX. 395 Falling backward, 49 Falsehoods, 175, 190 Fearlessness, 178, 193 Features of disease, 221 of health, 34-46, 221 Feeble-mindedness, 271 Feeding. See also Nursing, Diet, and Food. artificial, 125 at the breast, no action on womb, no disadvantages to mother, 1 18 length of time for, wt, method of, 112 bottle-. See Feeding, artificial. -bottle. See Nursing bottle. by wet-nurse, 124 frequency of, ni, 127, 152, 153, 154 from the bottle, 145 discontinuance of, 152 length of time for, 145 position of baby, 145 from cup or spoon, 1 19 general rules for, 127 hours for, 127, 128, 152-155 in cleft palate, 245 in first day or two of life, in in sickness, 157, 235, 242, 353 prematurely-born children, 314 Feet, cold, 43, 102, 256, 321 deformity of, 278 turned in at birth, 37 Fever, 46, 228, 319 baths for, 365-368 -blisters, 289 giving of water in, 235, 321 -mixture, 383 relation to pulse and respiration, 229 Fevers, eruptive, 293 Fire, child a-, 337 -place, 200, 202, 213 Fish-hooks, wounds by, 332 Fits. See Convulsions. Flaxseed tea, 355 Floor, draughts on, 168, 200, 203 playing on, 168, 203 Flour-ball, 356 Flowers in nursery, 205 Fomentations, 371 Fontanelles in disease, 224, 271, 315 in health, 36, 58 Food. See also Diet, Feeding, and Milk. Food, abstinence from, in acute dis- ease, 235, 242, 250, 252, 256 cereal, 156 character of, for baby, 109, 128 gelatin, 149, 355 heating of, 145, 217 increase of fat in, 253 peptonized, 150, 153, 358, 363 prepared beef-, 153, 357, 363 quantity required, 125 relation to size and weight, 127 Food, starchy. See Starch. table-, injuriousness of, 15 1 to suit individual child, 147 warming of, 144 Foods, patented infants', 131, 148 permitted after three years, 156 to be avoided, 156 to be taken cautiously, 156 Foot, clubbed, 278 reproduction of imprint, 102 Forehead, wrinkling of, 223 Foreign bodies in the ear, 342 in the eye, 340 in the nose, 344 swallowing of, 343 Foreskin, narrow, 323 washing of, 75 Forwardness, 178 Fractures, 335 Freckles, 338, 378, 379 Freezing, 339 French measles, 301 Frights during pregnancy, 25 Frost-bite, 339 Fumigation, method of, 2n Furuncle, 288 Games and sports, 1 71-174 Gargle, 378 Gastric juice, 60 Gate to nursery, 204 Gelatin solution, 355 Gentleness, 177 German measles, 301 enlarged glands in, 318 Gertrude suit, 90, 92, 93, 96 Gestures in disease, 222 Glands, abscess of, 299, 329 enlarged, 318 Governess, 191, 218 Gown, night-, 94, 97, 107 Graduate, glass, 234, 286 396 INDEX. Gravel, 231 Grinding of teeth, 230, 259, 265 Growth, general remarks on, 46 Gruel, peptonized, 362 Gum-arabic water, 355 Gum-boil, 248 Gums, See also Mouth. lancing of, 60, 247 rubbing tooth through, 248 Gymnasium, 173 Habits, 313 Hair-brush, 82 Hair, care of, 75, 82 change of color of, 59 new growth of, 59 on body, 34 on head, falling out of, 30, 36, 59 pulling at, 213 Hand, movement to seat of pain, 222 Hands, cold, 256, 320, 321 deformity of, 267 hot, relation to fever, 320 " Hardening," 85, 165 Hare-lip, 245 Hat, 107, 108 Head, deformity of, at birth, 35, 277 fontanelles. See Fontanelles. holding erect, 48, 272 in disease, 221, 223 perspiration of, 223, 315 size and shape, 35, 58, 224, 271, 277, 315 Headache, 268 Health, features of, 34, 221 Hearing at birth, 47 increase in power of, 49 in idiocy, 272 Heart disease, 317 Heat, application of, 238 Heating, methods of, 202, 212 Height. See Length. Hemorrhage. See Bleeding. Hemorrhoids in pregnancy, 29 Hernia, 258 Hiccough, 319 Hip-joint disease, 279 Hips at birth, 36 Hives, 286 Hoarseness, 226, 262, 263, 300, 308 Hood, 95, 107 Hoop, rolling of, 171 Horse, 172 Hydrocephalus, 224, 271, 278 Ice, method of keeping, 217 Ice-bags, 239 Idiocy, 271 Imitation, power of, 175 Incubation, stage of, 295 Incubator, 314 Indigestion, chronic, 223, 250 in pregnancy, 30 Infancy, definition of, 18 Initial symptoms, 296 Injections, See Enemata. Inquisitiveness, 175 Insonmia, 267, 366, 367 Intellect. See Mind. Intelligence. See also Mind. at birth, 37, 47 growth of, 47, 50 Invasion, stage of, 295 Isolation, 296 Itch, 291 Jacket, cotton, 375 Jaundice, 35, 222, 261 Jaunting car, 169 Jaw, V-shaped, 326 Jeaunel's general antidote for poison- ing, 350, l^l, 390 Joints, dislocation of, 335 enlargement of, 315, 317 Kindergarten, 179 Knock knees, 316 Labor. See Confinement. Lactometer, 131 Lameness, 279 Lap-protector, 97 Laryngitis, 225, 263 Laughing, 50 Laxative alkaline mixture, 382 Layette, 96 Leggings, 104, 108 Legs, bending of, 37, 169, 316 crooked, at birth, 37 short, at birth, 37 Length at birth, 34, 53 " increase in, 52-57 measure for determining, 56 Leucoixhoea in childhood, 324 in pregnancy, 30 INDEX. 397 Lice, 292 Lighting, methods of, 207, 219 Lime-water, 358 disadvantages of, 135, 142 Lisping, 327 Lists. See Tables and Lists. Liver at birth, 36 " Longings," 2i Lotions, 376-379 Lungs, congestion of, 264 inflammation of, 264 Lying, 175. 196 Macule, 295 Mail-cart, 169 Management of pregnancy, 22 of sick children, 231 Marasmus, 223, 319 " Markings " on children, 25, 283 Massage, 173, 254, 384 Masturbation, 329 Maternal impressions, 25, 2S3 Mattress, material and protection of, 31, 162 renovating, 2II, 212 Meals, number and hours, 127, L28, 152, 156 Measles, 223, 299 French, 301 German, 301 glands in, 318 Measure for determining length, 56 for milk-sugar, 136 Measures, table of eiiuivalent, 3S5 Measuring of medicines, 234, 3S5 Meconium, 41, no Medicine closet, 216, 389 -dropper, 38$ -glasses, 234, 3S6 method of giving, 232-235 Medicines, care of, 212, 216, 349 size of dose of, 234, 385, 386 Meigs' gelatin food, 149, 355 milk mixture, 135, 353 Membranous croup, 263, 308 Menstruation, absent in pregnancy, 20 influence on breast- milk, 120 Merino underwear, 86 Miliaria, 284 Milk. See also Feeding and Food. acidity, test for, 133 albuminoids of, 122, 123, 124, 129, 130 Milk, Alderney, 131 amounts at different ages, 127 ass's, 129 boiled, 130, 138, 142, 225 breast-, 1 10 analysis of, 129 approximate analysis of, 123 best nourishment for child, 109 influence of diet on, 114, 115, 124 of drugs on, 114 of emotions on, 115 of menstruation on, 120 of pregnancy on, 120 insufficient supply of, 115, 120 modification of,' 124 quantity secreted, 113 time flow begins, lio -cake, 117 casein of, 130 condensed, 149 cow's, analysis of, 129 artificially-colored, test for, 133 care of, 131 characteristics of, 1 29-1 31 mixed herd preferable, 174 cream of. See Cream. -crust, 279 fat in, 122, 124, 129, 130, 134 goat's, 129 mare's, 129 mixture. Author's formula for, 135 increasing strength of, 12S, 151 Meigs', 135, 353 mixtures, to substitute mother's milk, general remarks on, 131, 144 Pasteurized, 142, 360 peptonized, 359-361 poisonous, 115, 138 punch, peptonized, 362 regurgitation of, 1 13, 250 salt added to, 134, 235 sterilized, 138, 361 digestibility of, 142 for travelling, 141 preservation of, 141 -sugar, 134, 136 measure for, 136 teeth. See Teeth. toast, peptonized, 362 top, 137 wet-nurse, no influence on traits of child, 186 Mind. See also Intelligence. 398 INDEX. Mind, effect of pregnancy on, 24 over-use of, 180, 181 training of, 174, 178, 179, 181, 190 Minim glass, 385 Minims, 385 Miscellaneous disorders and habits, 313 Mittens, 95, 97, 104 Moccasins, icx) Mole, 283 Monthly nurse. See Nurse. periods. See Menstruation. Moral character, training of, 174-179, 190 Morals, supervision over, 179 Morbilli, 299 Mosquito-bites, 333 Mother, disadvantages of nursing to, 118 ignorance of, 17 Mother, nursing-, diet of, 113, 1 15, 124 exercise and fresh air for, 1 1 5 use of stimulants by, 115 Mother's marks, 283 Mouth, appearance in teething, 61 -breathing, 221, 249, 325 hand in, 222 inflammation of, 246, 247 washing of, 70, 80, 234 Movement, pain on, 221 Movements of body at birth, 47 increase in power of, 47 in disease, 222 in health, 37 of bowels. See Passages. Mumps, 312 NiEVUS, 283 Nails, biting the, 326 care of, 83 condition at birth, 36 toe-, ingrowing, 278 Napkins for baby. See Diapers. for confinement, 32 Nature, love of objects in, 177 Nausea, 223, 256 Navel, bleeding from, 283 cord, dressing of, 95, 96 falling off of, 96 ulcer of, 282 Neatness, 174, 191, 196 Needle, wound by, 332 Nettle-rash, 286 Night-clothes, 94, 97, 104, 107, 108 Night-terrors, 267 Nightmare, 267 Nipple, artificial, 116 for cleft palate, 245 -protector, 27 rubber, care of, 146 collapsing of, 146 -shield, 116 ventilated, 147 with tube, objection to, 146 Nipples, care of, during nursing, 116 during pregnancy, 27 fissures of, 27, 1 1 2, 1 16, 1 17 hardening of, 27 retracted, 27, no, 116 Noise natural to child, 175 j Nose, foreign bodies in the, 344 I picking at, 222 I Nose-bleed, 344, 378 Nostrils, moving of, 223 Number, idea of, 50 Nurse, child's. See Nwse-maid. "experienced," 183, 190, 196 monthly, choice of, 183 duties of, 184 incompetence of, 17 trained, dress of, 196, 197 duties of, 232 privileges of, 197 qualifications of, 196 record kept by, 243, 244 wet-, hygiene of, 186 milk without influence on traits of child, 186 objections to, 124 qualifications of, 184 supervision over, 187 Nurse-maid, age of, 189 " don'ts " for, 192 duties of mother to, 194 to the child, 192 French, 194 German, 194 qualifications of, 1 88-1 92 supervision over, 187, 194 untxustworthiness of, 188 upholding authority of, 194 -maids, training-school for, 192 Nursery, attractiveness of, 204 ceiling, floor, and walls, 203 chair, 171, 204, 254 cleanliness of, 205 cloth, 31 INDEX. 199 Nursery, day, 199 flowering plants in, 205 furnishing of, 203, 204, 207 gate to, 204 governess, 191 heating of, 202 lighting of, 207 night, 206 pictures in, 204 position in house, 199, 206 refrigerator, 217 size of, 200 temperature of, 203, 207 ventilation of, 200-202, 206 wash-stand in, 205 windows to, 199, 20i, 203, 204 Nursing. _ See also Feeding. bottle, 144 smoothness of, 145 sucking at, when empty, 145 ventilated, 147 washing of, 145 with long tube, 146, 246 influence of pregnancy on, 120 manner of, by sick child, 230 of contagious disease, 197, 209-212 Oatmeal-water, 354 Obedience, 176, 177, 232 Ointments, 375 Onset of disease, 296 Ophthalmia, 273 Ounce, fluid-, 385 Oysters, peptonized, 361 Pack, wet, 367 Pain, growing, 279, 317 in knee and hip, 279 on movement, 221, 225, 315, 317 on passing urine, 322, 323 result of chilling, 256 Pains during confinement, 32 Pajamas, 107 Palate, cleft, 245 Palsy, 270 Pancreatic juice, 150 Papule, 296 Paralysis, 270 at birth, 270 diphtheritic 270, 309 position in, 221, 222 spinal, 270 Parties, children's, 178 Passages, habit of regularity, 171, 254 meconium, 41, no mucus in, 250-252 number and color in disease, 251- 258 in health, 41, 42, 65 sponging after, 77 straining at, 252, 254, 258 Pasteurizing, 139, 142-144 Pediculi, 292 Pen, creeping, 168 Peptogenic milk powder, 361 Peptonized beef enema, 363 foods, 358 tea, 361 egg enema, 363 food, 150, 358 gruel, 362 milk, 359-361 punch, 362 toast, 362 oysters, 361 Perambulator. See Carriage. Perspiration of head, 223, 224, 315 sponging for, 365 Pertussis, 310 Pets, 177 Petticoat, 90 Gertrude, 90, 92 Phimosis, 323, 329 Pigeon-toed, 49 Piles in pregnancy, 29 Pillow, 163 on which to carry child, 97 Pillows, renovating, 211, 212 Pills, method of giving, 234 Pint, 385 Plaster, mustard, 374 nutmeg, 375 pepper, 375 spice, 374 Play, 48, 174 Pleasure, sensations and expression of, 50 Pleurisy, 224, 225 Pneumonia, 264 Poison-bottle, 216 elder, 346 -guard, 216 ivy, 345 oak, 345, 346 sumach, 345 Poisons and antidotes, 350, 383, 390 400 INDEX. Poisons, swallowing of, 349 Pony, 172 Position during sleep, 158 in disease, 221, 236 in health, 38 necessity of changing, 158 when nursing, 112 from bottle, 145 Pott's disease of spine, 224, 281 Poultice, antiseptic, 374 bran, 372, 373 bread-and-milk, 372 charcoal, 373 flaxseed, 371 hop, 372 jacket, 373 mush, 372 mustard, 373 slippery-elm, 372 starch, 372 Poultices and plasters, 371 Powder after bath, 71, 79 Powders, 379 method of giving, 234 Precocity, 180 Pregnancy, amusements in, 24 bathing during, 22 care of breasts during, 27 clothing during, 26 diet in, 25 disorders of, 28 duration of, 21, 23 exercise in, 22 importance of careful life during, 19 influence on nursing, 120 management of, 22 maternal impressions, 25 mental condition in, 24 signs of, 19 Prickly heat, 284 Princess pattern, 90, 91, 92 Prodromal symptoms, 296 Puberty, 18, 58, 172 Pulse during sleep, 41 in disease, 227 in health, 40, 65 method of observing, 40, 41 relation to temperature and respira- tion, 229 Punishments, 176, 193 Pustule, 296 Quarantine, 182, 296 Quart, 385 Quickening, 21 "Rash, bringing out the," 320, 366 nettle, 285 of eruptive fevers, 293 stomach, 288 tooth, 288 Raw meat, scraped, 357 Read, learning to, 175, 180 Record, daily, of the disease, 243, 244 Red gum, 284 Refrigerator, nursery, 217 Registers, 202 Regurgitation, 113, 250 Remedies for internal administration, 382 for local use, 364 Respiration, artificial, 347 Cheyne-Stokes, 226 during sleep, 38, 39 in disease, 221, 223, 224, 226 in heahh, 38-40, 65 method of observing, 40 relation to temperature and pulse, 229 through the mouth, 221, 249, 325 Restlessness, 221 Rheumatism, 317, 369 Rice-water, 355 Rickets, 221, 223, 224, 278, 280, 282, 314 Ringworm, 290, 376 Rocking-horse, 171 Room for confinement, 31 for school. See School-room. for sickness. See Sick-room. for sleeping, 164 Rooms for child, different sorts of, 1 98 Rope, skipping, 172 Roseola, 301 Rotheln, 301 Rubber cloth for bed, 31, 32, 162, 163 diaper-cover, 89 garments, 108 Rubella, 301 Rubeola, 299 Rupture, 258 Sack, 95, 97, 102, 104, 108, 237 Saint Vitus' dance, 269, 317 Saliva, 59, 150, 246 profuse flow in pregnancy, 29 INDEX. 40 T Scabies, 291 Scalds, 336 Scales for weighing child, 55 Scarlatina, 297 Scarlet fever, 231, 297 rash, 297 School, boarding, 181 diseases developed at, 181, 182, 217, 218 gymnastic exercises at, 173 kindergarten, 179 -life, hours for study, 180 recess at, 181 -room, 217 desks and chairs for, 218, 219 lighting of, 2 [9 size requiretl, 219 ventilation of, 220 Scrofula, 317 Sea-baths, 79 -voyages in pregnancy, 24 Seeing, See Sight. Self-abuse, 329 Selfishness, freedom from, 177 Sensations, subjective, of baby, 49 Servants, association of child with, 178 Sex, determining before birth, 28 Sexes, difference in clothing for, 106, ' 107 sports same for each, 172, 179 supervision of morals of, 179 Sheets, 31, 32, 162, 163 Shirt, 91, 96, 104, 105, 107, 108 Gertrude, 92, 96 Shoe, outline of sole, 102 Shoes, bed-room, 109 heels to, 107 moccasins, 100 rights and lefts, loi rubber, 108 soles to, 102, 107 Shoulders at birth, 36 " shrugged up," 281 " Show " in confinement, 33 Sick children, bathing of, 237, 238, 364 feedmg of, 157, 235, 242, 353 management of, 221, 231 Sickness, abstinence from food during, 235, 242, 250, 252, 256 bathing in, 237, 238, 364 bed in, 236-238 clothing during, 109 26 Sickness, feeding in, 157, 235, 242, 353 morning, 20, 30 Sick-room, 209 anteroom to, 210, 212 deodorizing of, 213, 238 disinfection of, 210 for contagious diseases, 209 furnishing of, 210, 216, 217 heating of, 212 lighting of, 209 moistening air of, 214 neatness in, 212 position of, 209 (juiet in, 236 temperature of, 215 ventilation of, 212 Sight at birth, 47 defective, 273, 275, 276 increase of power of, 49 in idiocy, 272 Sitting erect, 48 in idiocy, 272 Skating, 172 Skin, chapping, chafing, and cracking of, 287 color of, 34, 35, 222 irritated by clothing, 86, 284 moist, relation to fever, 320 necessity of keeping covered, 84, 85, 105 roughness of, 287 scraped, 332 shedding of, 35, 296 Skirts, 105 advantage of shortness, 91, 106 Sleep at breast not to be allowed, iii between blankets, 163 during the day, 157, 159 effect on pulse, 41 on respiration, 40 hours for, 157-160 in disease, 221, 222, 223 method of putting to, 158 position during, ■}^^, 158 room for, 164, 206 starting in, 279 Sleeplessness, 267, 366, 367 Slip, 92 Slipjiers not advisable, 109 Small-pox, 303 Smell, increase in sense of, 49 sense of, at birth, 47 Smiling, 50, 223 402 INDEX. Snake-bites, 334 Snoring, 249, 325 Soap, method of applying, 70 stick, 255 varieties of, 75 Socks, 89, 97 Soda-mint, 382 -solution for milk mixture, 135, 142 " Soothing drinks," 350 Sounds, utterance of, 50 Spasm. See Convulsions. Specific gravity glass, 121, 132 Speech. See also Talk. defective, 327 Spinal cord, paralysis fpom disease of, 270 Spine, curv^ature of, 165, 181, 279 angular, 281 lateral, 218, 280 rickety posterior, 282 Pott's disease of, 224, 281 Splinters, 332 Sponge, 70, 75 Sponging, 71, 77, 237, 364 Spoonfuls of different sorts, 234, 385 Sports and games, 171, 174 out-door, intended for both sexes, 172, 179 Sprains, 334 Stammering, 327 Standing, 48, 218 Starch-and-boric-acid lotion, 377 Starch in the food, 148 age for allowing, 151 difficulty of digesting, 150, 250, 315 test for, 149 -water, 369 Sterilizer, 138, 139 Sterilizing, 139 effect on digestibility of milk, 142 method in detail, 139 modified, 142 Stimulants for child, dose of, 389 use of, by mother, 1 14 Stings by insects, 333 Stockings, 98, 104, 105, 108 Stomach cough, 226 rash, 288 secretion and movements of, 60 size of, at birth, 126 Stories suitable for children, 179, 193 Strabismus, 275 Strophulus, 284 Study. See also Mind. hours for, 180 injuring eyes by, 181, 219, 269 Stupe, turpentine, 374 Stuttering, 327 Styes, 275 Sucking at empty bottle, 146 the thumb, 325 Suffocation, 347 Sugar, cane-, 134 -measure, 138 milk-, 134, 136 Suit, Gertrude, 90, 92, 93, 96, 98 Summer resorts, 173 Sunburn, 338 Supernumerary digits, 278 Suppositories, 255 Suspenders for diapers, 100 for holding stockings, 98, 105 Swallowing, manner of, in disease, 230 of foreign bodies, 343 of poisons, 349 Swamp dogwood, 346 Swedish movements, 173 Swimming, 172 Syringe, ear, 277, 342 fountain, 30, 240 infant's, 240, 254 rubber, 241, 254 Table, sitting at, 155, 178 Tables and Lists : Amounts of urine passed daily, 43 Analysis of breast milk, 129 Approximate analysis of breast milk, 123 Approximate equivalent measures, 385 Articles for baby's basket, 68 for confinement, 31 for medicine closet, 389 Calculating date of confinement, 23 Circumference of head and chest at different ages, 58 Clothes for earliest childhood, 108 Comparative analysis of woman's and cow's milk, 129 Diet from eighteen months to two years, 153 from one year to eighteen months, 152 INDEX. 403 Tables and Lists : Diet from two to three years, 154 Doses of medicine for children one year old, 387 Eruption of milk teeth, 63 of permanent teeth, 65 Foods permitted, 156 to be avoided, 156 to be taken cautiously, 1 56 Formula for milk mixture, 135, 137 General rules for feeding, 127 Growth in length and weight, 52 Hours for feeding, 128 Infants' weight chart, 54 Infectious diseases, 294, 295 Long clothes, 97 Number of pulse-beats per minute, 41 of respirations per minute, 39 Poisons and antidotes, 350 Proportionate doses at different ages, 386 Record of course of disease, 243, 244 Rules for modifying breast milk, 124 Short clothes, 104 Time of eruption of milk teeth, 63 of permanent teeth, 65 Top milk mixture, 137 Tales suitable for children, 163, 193 Talk. See also Speech. "baby," objection to, 175, 193 Talk, learning to, 175, 190 Talking in idiocy, 272 Tannic- acid-and-glycerin nipple lotion, 376 Tannic-acid solution for nose-bleed, 378 Tanning of the skin, 338 Taste at birth, 48 Tears, 38, 59, 226 Tears and cuts, 329 Teeth, cleaning of, 81 decay of, in pregnancy, 29 deciduous. See Teeth, milk. grinding of, 230, 259, 265 milk, 61 decay of, 64, 81, 248, 316 falling out of, 64 necessity for removing, 64, 72 time and order of eruption, 62 Teeth, permanent, 61 time and order of eruption, 64 present at birth, 63 prominent, 326 temporary. See Teeth, milk. Teething. See also Dentition. process of, 61 relation to flow of saliva, 59 Temperature chart, 244 in disease, 228 method of taking, 43 normal, 43, 45 of bath, 70, 77, 78, 364 testing of, 76 of nursery, 203, 207 of sick-room, 215 relation to pulse and respiration, 229 sensation of skin to hand misleading, 43 Tennis, 172 Thermometer, bath, 76 clinical, 43, 44, 320 nursery, 203 Thirst, 112, 225, 235, 236, 321 Throat, applications to, 241 sore, 248, 370 Thrush, 246 Thumb-sucking, 325 Toast-water, 354 Tongue at birth, 36 in disease, 229 strawberry, 298 -tie, 245 " worm-eaten, 250 Tonsils, acute inflammation of, 249 chronic enlargement of, 221, 224, 249 Toothache in pregnancy, 29 Tooth rash, 288 rubbing through the gums, 248 Tourniquet, 331 Towels for bathing, 78 Toys, 174 poisonous, 349 Trained nurse. See Nurse. Training-school for nurse-maids, 192 Travelling, food for, 141, 149 Trotting on knee, 170 Tub, 71, 72, 74 Tumblerful, 385 Typhoid fever, 294 cold bath in, 366 404 INDEX. Underclothes. See Clothing. Urine, amounts passed daily at differ- ent ages, 43 frequent passage of, in pregnancy, 29 in Bright's disease, 231, 322 incontinence of, 322 in disease, 231 in health, 42, 65 learning control over, 51, 104, 171 pain on passing, 322, 323 retention of, 42, 322 Urinometer, 131 Urticaria, 286 Vaccination, 304 Varicella, 302, 304 Variola, 294 Varioloid, 302, 303 Veal tea, 356 Veil, 95, 96, 104 Veins, prominence of, 222 varicose, in pregnancy, 29 Velocipede, 171 VeHtilating board, 200 Ventilation, 163, 200-202, 206, 212, 220 Ventilator, wheel, 201 window, 201 Vesicle, 296 Virginia creeper, 345 Vision. See Sight. Vomiting, 235, 242, 250 Waist for supporting clothing, 100, 105 Walk, learning to, 48, 169 stiff, 281 Walking, discouraging of, 316 in idiocy, 272 pigeon-toed, 49 Warmth, necessity of, 84, 1 05, 314 Warts, 283 Wash-rag, 70, 74, 75 -stand in nursery, 205 Water, necessity of giving, 112, 225, 235, 236, 321 on the brain. See Hydrocephalus. Waxy substance on skin at birth, 69 W^eaning, 117, 151 age for, 1 1 8 early, reasons for, 1 20 method of, 117, 119 season of year for, 119 W^eather-stripping, 203 Webbing of fingers or toes, 278 Weight at birth, 34, 52 charts for recording, 54 increase in, 51-54 method of obtaining, 54 Wet-nurse. See Xtirse. Wetting the bed, 322 Whey, 356 -and- cream mixture, 150 Whooping-cough, 223, 230, 310 Window bars, 204 Wine whey, 356 Wineglassful, 385 Woollen underwear, 85 Wonns, round, 260 seat-, 259, 379 tape-, 260, 357 thread-, 259, 379 Wounds, contused, 334 mcised, 329 lacerated, 331 of the eye, 342 lX)isoned, m punctured, 332 Wrapper, 95, 97, 102, 104, 109 STANDARD Medical and Surgical Works PUBLISHED BY W. B. SAUNDERS, 925 Walnut Street, PhiladelpMa, Pa. PAGE ♦American Text-Book of Applied Thera- peutics 4 ♦American Text- Book of Dis. of Children . 9 *An American J'ext- Book of Diseases of the Eye, Ear, Nose, and I'hroat 31 *An American Text-Book of Genito-Uri- nary and Skin Diseases 31 ♦American Text- Book of Gynecology . , . 8 ♦American Text-Book of Obstetrics ... 5 ♦American Text-Book of Physiology ... 3 ♦American Text-Book of Practice .... 6 ♦American Text-Book of Surgery ... 7 Anders' Theory and Practice of Medicine . 31 Ashton's Obstetrics 28 Atlas of Skin Diseases 12 Ball's Bacteriology 28 Bastin's Laboratory Exercises in Botany . 22 Beck's Surgical Asepsis 26 Boisliniere's Obstetric Accidents, Emer- gencies, and Operations 23 Brockway's Physics 28 Burr's Nervous Diseases 26 Butler's Materia Medica and Therapeutics 29 Cerna's Notes on the Newer Remedies . . 18 Chapman's Medic.ii Jurisprudence . . . . 26 Church and Peterson's Nervous and Men- tal Diseases 31 Ciarkson's Histology 14 Colien and Eshner's Diagnosis 28 Corwin's Diagnosis of the Thorax .... 29 Cragin's Gynaecology 28 Crookshanic's Text-Book of Bacteriology . 13 DaCosta's Manual of Surgery 26 De Schweinitz's Diseases of the Eye ... 15 Dorland's Obstetrics 26 Frothingham's Bacteriological Guide ... 16 Garrigues' Diseases of Women 20 Gleason's Diseases of the Ear 28 ♦Gould and Pyle's Anomalies and Curi- osities of Medicine 30 Griffin's Materia Medica and Therapeutics 26 Griffith's Care of the Baby 24 Gross's Autobiography 10 Hampton's Nursing 23 Hare's Physiology 28 Hart's Diet in Sickness and in Health . . 22 Haynes' Manual of Anatomy 26 Heisler's Embryology 31 Hirst's Obstetrics 31 Hyde's Syphilis and Venereal Diseases . . 26 Jackson and Gleason's Diseases of the Eye, Nose, and Throat 28 Tewett's Outlines of Obstetrics 21 ICeating's Pronouncing Dictionary .... 10 Keating's Life Insurance 23 Keen's Operation Blanks 22 Kyle's Diseases of Nose and Throat ... 26 Laine's Temperature Charts 18 PAGE .26 Lockwood's Practice of Medicine Long's Syllabus of Gynecology 20 Macdonald's Surgical Diagnosis and Treat- ment 31 McFarland's Pathogenic B;tcteria .... 16 Matlory and Wright's Pathological 'J'ech- nique 31 Martin's Surgery 28 Martin's Minor Surgery, Bandaging, and Venereal Diseases 28 Meigs' Feeding in Early Infancy 16 Moore's Orthopedic Surgery 31 Morris' Materia Medica and Therapeutics 28 Morris' Practice of Medicine 28 Morten's Nurses' Dictionary 24 Nancredc's Anatomy and Dissection ... 17 Nancrede's Anatomy 28 Norris' Syllabus of Obstetrical Lectures . 21 Penrose's Gynecology 31 Powell's Diseases of Children 28 Pye's Elementary Bandaging and Surgical Dressing 29 Raymond's Physiology 26 Rowland's Clinical Skiagraphy 14 Saundby's Renal and Urinary Diseases . . 29 •Saunders' American Vear-Book of Medi- cine and Surgery 32 Saunders' Pocket Medical Formulary . . 19 Saunders' Pocket Medical Lexicon .... 32 Saunders' New Aid Series of Manuals . 25, 26 Saunders' Series of Question Conipends 27, 28 Sayrc's Practice of Pharmacy 28 Semplc's Pathology and Morbid Anatomy 28 Scmple's Legal Medicine, Toxicology, and Hygiene 28 Senn's Geniio-Urinary Tuberculosis ... 31 Senn's Tumors 11 Senn's Syllabus of Lectures on Surgery . .21 Shaw's Nervous Diseases and Insanity . . 28 Starr's Diet- Lists for Children 24 Stelwagon's Diseases of the Skin 28 Stengel's Manual of Pathology 26 Stevens' Materia Medica and Therapeutics 18 ' Stevens' Practice of Medicine 17 • Stewart's Manual of Physiology 21 Stewart and Lawrance's Medical Elec- tricity 28 Stoney's Practical Points in Nursing ... 13 Sutton and Giles' Diseases of Women . . 26 Thomas's Diet-List and Sick-Room Dietary24 1 hornton's Dose-Book and Manual of Pre- scription-Writing 26 Van Valzah and Nisbet's Diseases of the Stomach 31 Vierordt and Stuart's Medical Diagtiosis . 12 Warren's Surgical Pathology n WolflTs Chemistry 28 Wolffs Examination of Urine 28 The works indicated thus (*) are sold by subscription (not by booksellers), usually through travelling solicitors, but they can be obtained direct from the office of publication (charges of shipment prepaid) by remitting tlie quoted prices. Full descriptive circulars of such works will be sent to any address upon application. All the other books advertised in this catalogue are commonly for sale by booksellers in all parts of the United States ; but any book will be sent by the publisher to any address (post-paid) on receipt of the price herein given. I GENERAL INFORMATION, One Price. One price absolutely without deviation. No discounts allowed, regardless of the number of books purchased at one time. Prices on all works have been fixed extremely low, with the view to selling them strictly net and for cash. Orders. An order accompanied by remittance will receive prompt attention, books being sent to any address in the United States, by mail or express, all charges prepaid. We prefer to send books by express when possible, and if sent C. O. D, we pay all charges for returning the money. Small orders of three dollars or less must invariably be accompanied by remit- tance. How to Send There are four ways by which money can be sent at our Money by risk, namely: a post-office money order, an express money Mail. order, a bank-check (draft), and in a registered letter. Money sent in any other way is at the sender's risk. Silver should not be sent through the mail. Shipments. Subscription Books. Latest Editions. Bindings. Descriptive Circulars. All books, being packed in patent metal-edged boxes, neces- sarily reach our patrons by mail or express in excellent condi- tion. Books in our catalogue marked " For sale by subscription only " may be secured by ordering them through any of our authorized travelling salesmen, or direct from the Philadelphia office ; they are not for sale by booksellers. All other books in our catalogue can be prociured of any bookseller at the advertised prices, or directly from us. We handle only our own publications, and cannot supply second-hand books nor the publications of other houses. In every instance the latest revised edition is sent. In ordering, be careful to state the style of binding desired — Cloth, Sheep, or Half-Morocco. . A complete descriptive circular, giving table of contents, etc. of any book sold by subscription only, will be sent free on application. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by William H. Howell, Ph. D., M. D., Professor of Physiology in the Johns Hopkins University, Baltimore, Md. One handsome octavo volume of 1052 pages, fully illustrated. Prices : Cloth, ^6.00 net; Sheep or Half- Morocco, ^7.00 net. This vi^ork is the most notable attempt yet made in America to combine in one volume the entire subject of Human Physiology by well-known teachers who have given especial study to that part of the subject upon which they write. The completed work represents the present status of the science of Physiology, particularly from the standpoint of the student of medicine and of the medical practitioner. The collaboration of several teachers in the preparation of an elementary text- book of physiology is unusual, the almost invariable rule heretofore having been for a single author to write the entire book. One of the advantages to be derived from this collaboration method is that the more limited literature necessary for consultation by each author has enabled him to base his elementary account upon a comprehensive knowledge of the subject assigned to him ; another, and perhaps the most important, advantage is that the student gains the point of view of a number of teachers. In a measure he reaps the same benefit as would be obtained by following courses of instruction under different teachers. The different standpoints assumed, and the differences in emphasis laid upon the various lines of procedure, chemical, physical, and anatomical, should give the student a better insight into the methods of the science as it exists to-day. The work will also be found useful to many medical practitioners who may wish to keep in touch with the development of modern physiology. The main divisions of the subject-matter are as follows : General Physiology of Muscle and Nerve — Secretion — Chemistry of Digestion and Nutrition — Movements of the Alimentary Canal, Bladder, and Ureter— Blood and Lymph — Circulation — Respiration — Animal Heat — Central Nervous System — Special Senses — Special Muscular Mechanisms — Reproduction — Chemistry of the Animal Body. CONTRIBUTORS : HENRY P. BOWDITCH, M. D., Professor of Physiology, Harvard Medi- cal School. JOHN G. CURTIS, M. D., Professor of Physiology, Columbia Uni- versity, N. Y. (College of Physicians and Surgeons). HENRY H. DONALDSON, Ph. D., Head-Professor of Neurology, Univer- sity of Chicago. W. H. HOWELL, Ph.D., M. D., Professor of Physiology, Johns Hopkins University. FREDERIC S. LEE, Ph. D., Adjunct Professor of Physiology, Colum- bia University, N. Y. (College of Physicians and Surgeons). WARREN P. LOMBARD, M.D., Professor of Physiology, Michigan. University of GRAHAM LUSK, Ph.D., Professor of Physiology, Yale Medical School. W. T. PORTER, M.D., Assistant Professor of Physiology, Har- vard Medical School. EDWARD T. REICHERT, M.D., Professor of Physiology, University of Pennsylvania. HENRY SEW ALL, Ph.D., M.D., Professor of Physiology, Medical Deparfr ment. University of Denver. W. B. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- TICS. For the Use of Practitioners and Students. Edited by James C. Wilson, M. D., Professor of the Practice of Medicine and of Clinical Medicine in the Jefferson Medical College. One handsome octavo volume of 1326 pages. Illustrated. Prices: Cloth, ^7.00 net; Sheep or Half- Morocco, ;^8.oo net. The arrangement of this volume has been based, so far as possible, upon modern pathologic doctrines, beginning with the intoxications, and following with infections, diseases due to internal parasites, diseases of undetermined origin, and finally the disorders of the several bodily systems— digestive, re- spiratory, circulatory, renal, nervous, and cutaneous. It was thought proper to include also a consideration of the disorders of pregnancy. The list of contributors comprises the names of many who have acquired dis- tinction as practitioners and teachers of practice, of clinical medicine, and of the specialties. CONTRIBUTORS : Dr. I. E. Atkinson, Baltimore, Md. Sanger Brown, Chicago, III. John B. Chapin, Philadelphia, Pa. William C. Dabney, Charlottesville, Va. John Chalmers DaCosta, Philada,, Pa. I. N. Danforth, Chicago, 111. John L. Dawson, Jr., Charleston, S. C. F. X. Dercum, Philadelphia, Pa. George Dock, Ann Arbor, Mich. Robert T. Edes, Jamaica Plain, Mass. Augustus A. Eshner, Philadelphia, Pa. J. T. Eskridge, Denver, Ccl. F. Forchheimer, Cincinnati, O. Carl Frese, Philadelphia, Pa. Edwin E. Graham, Philadelphia, Pa. John Guiteras, Philadelphia, Pa. Frederick P. Henry, Philadelphia, Pa. Guy Hinsdale, Philadelphia, Pa. Orville Horwitz, Philadelphia, Pa. W. W. Johnston, Washington, D. C. Ernest Laplace, Philadelphia, Pa. A. Laveran, Paris, France. Dr. James Hendrie Lloyd, Philadelphia, Pa. John Noland Mackenzie, Baltimore, Md. J. W. McLaughlin, Austin, Texas. A. Lawrence Mason, Boston, Mass. Charles K. Mills, Philadelphia, Pa. John K. Mitchell. Philadelphia, Pa. W. P. Northrup, New York City. William Osier, Baltimore, Md. Frederick A. Packard, Philadelphia, Pa. Theophilus Parvin, Philadelphia, Pa. Beaven Rake, London, Engla.nd. E. O. Shakespeare, Philadelphia, Pa. Wharton Sinkler, Philadelphia, Pa. Louis Starr, Philadelphia, Pa. Henry W. Stelwagon, Philadelphia, Pa. James Stewart, Montreal, Canada. Charles G. Stockton, Buflfalo, N. Y. James Tyson, Philadelphia, Pa. Victor C. Vaughan, Ann Arbor, Mich. James T. Whittaker, Cincinnati, O. J. C. Wilson, Philadelphia, Pa. The articles, with two exceptions, are the contributions of American writers. Written from the standpoint of the practitioner, the aim of the work is to facili- tate the application of knowledge to the prevention, the cure, and the allevia- tion of disease. The endeavor throughout has been to conform to the title of the book — Applied Therapeutics — to indicate the course of treatment to be pursued at the bedside, rather than to name a list of drugs that have been used at one time or another. While the scientific superiority and the practical desirability of the metric system of weights and measures is admitted, it has not been deemed best to discard entirely the older system of figures, so that both sets Lave been given where occasion demanded. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by Richard C. Norrts, M. D. ; Art Editor, Robert L, Dickinson, M. D. One handsome octavo volume of over looo pages, with nearly 900 colored and half-tone illustrations. Prices: Cloth, ^7.00; Sheep or Half-Morocco, $8.00. The advent of each successive volume of the series of the American Text- books has been signalized by the most flattering comment from both the Press and the Profession. The high consideration received by these text-books, and their attainment to an authoritative position in current medical literature, have been matters of deep international interest, which finds its fullest expression in the demand for these publications from all parts of the civilized world. In the preparation of the "American Text-Book of Obstetrics" the editor has called to his aid proficient collaborators whose professional prominence entitles them to recognition, and whose disquisitions exemplify Practical Obstetrics. While these writers were each assigned special themes for dis- cussion, the correlation of the subject-matter is, nevertheless, such as ensures logical connection in treatment, the deductions of which thoroughly represent the latest advances in the science, and which elucidate the best modern methods of procedure. The more conspicuous feature of the treatise is its wealth of illustrative matter. The production of the illustrations had been in progress for several years, under the personal supervision of Robert L. Dickinson, M. D., to whose artistic judgment and professional experience is due the most sumptuously illustrated work of the period. By means of the photographic art, combined with the skill of the artist and draughtsman, conventional illustration is super- seded by rational methods of delineation. Furthermore, the volume is a revelation as to the possibilities that may be reached in mechanical execution, through the unsparing hand of its publisher. CONTRIBUTORS Dr. James C. Cameron. Edward P. Davis. Robert L. Dickinson. Charles Warrington Earle. James H. Etheridge. Henry J. Garrigiies. Barton Cooke Hirst. Charles Jewett. Dr. Howard A. Kelly. Richard C. Norris. Chauncey D. Palmer. Theophilus Parvin. George A. Piersol. Edward Reynolds. Henry Schwarz. "At first glance we are overwhelmed by the magnitude of this work in several respects, viz. : First, by the size of the volume, then by the array of eminent teachers in this depart- ment who have taken part in its production, then by the profuseness and character of the illustrations, and last, but not least, the conciseness and clearness with which the text is ren- dered. This is an entirely new composition, embodying the highest knowledge of the art as it stands to-day by authors who occupy the front rank in their specialty, and there are many of them. We cannot turn over these pages without being struck by the superb illustrations which adorn so many of them. We are confident that this most practical work will find instant appreciation by practitioners as well as students." — New York Medical Times. Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical work that 1 have ever seen. I congratulate you and thank you for this superb work, which alone is sufficient to place you first in the ranks of medical publishers. With profound respect I am sincerely yours, Alex. J. C. Skenb. W. B. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK ON THE THEORY AND PRACTICE OF MEDICINE. By American Teachers. Edited by William Pepper, M. D., LL.D., Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. Complete in two handsome royal-octavo volumes of about looo pages each, with illustrations to elucidate the text wherever necessary. Price per Volume : Cloth, $5.00 net; Sheep or Half-Morocco, ^6.00 net. VOIiUME I. CONTAINS: Hygiene. — Fevers (Ephemeral, Simple Con- tinued, Typhus, Typhoid, Epidemic Cerebro- spinal Meningitis, and Relapsing). — Scarla- tina, Measles, Rotheln, Variola, Varioloid, Vaccinia, Varicella, Mumps, Whooping-cough, Anthrax, Hydrophobia, Trichinosis, Actino- mycosis, Glanders, and Tetanus. — Tubercu- losis, Scrofula, Syphilis, Diphtheria, Erysipe- las, Malaria, Cholera, and Yellow Fever. — Nervous, Muscular, and Mental Diseases etc. VOIiUME II. CONTAINS: Urine (Chemistry and Microscopy). — Kid- ney and Lungs. — Air-passages (Larynx and Bronchi) and Pleura. — Pharynx, (Esophagus, Stomach and Intestines (including Intestinal Parasites), Heart, Aorta, Arteries and Veins. — Peritoneum, Liver, and Pancreas. — Diathet- ic Diseases (Rheumatism, Rheumatoid Ar- thritis, Gout, Lithsemia, and Diabetes.)— Blood and Spleen. — Inflammation, Embolism, Thrombosis, Fever, and Bacteriology. The articles ai-e not written as though addressed to students in lectures, but are exhaustive descriptions of diseases, with the newest facts as regards Causa- tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large number of approved formulae. The recent advances made in the study of the bacterial origin of various diseases are fully described, as well as the bearing of the knowledge so gained upon prevention and cure. The subjects of Bacteriology as a whole and of Immunity are fully considered in a separate section. Methods of diagnosis are given the most minute and careful attention, thus enabling the reader to learn the very latest methods of investigation without consulting works specially devoted to the subject. CONTRIBUTORS ; Dr. J. S. Billings, Philadelphia. Francis Delafield, New York. Reginald H. Fitz, Boston. James W. Holland, Philadelphia. Henry M. Lyman, Chicago. William Osier, Baltimore. Dr. William Pepper, Philadelphia. W. Gilman Thompson, New York. W. H. Welch, Baltimore. James T. Whittaker, Cincinnati. James C. Wilson, Philadelphia. Horatio C. Wood, Philadelphia. " We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second and last volume leads us to modify that verdict and to say that the completed work is, in our opinion, the best of its kind it has ever been our fortune to see. It is complete, thorough, accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well bound. It is a model of what the modern text-book should be."— A>w York Medical yournal. " A library upon modern medical art. The work must promote the wider diffusion of sound knowledge." — Afnerican ^Lancet. " A trusty counsellor for the practitioner or senior student, on which he may implicitly rtVf."— Edinburgh Medical journal. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription, AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- liam W. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. Forming one handsome royal-octavo volume of 1250 pages (10x7 inches), with 500 wood-cuts in text, and 37 colored and half-tone plates, many of them engraved from original photographs and drawings furnished by the authors. Prices : Cloth, ^7.00 net; Sheep or Half- Morocco, j^S.oo net. SECOND EDITION, REVISED AND ENLARGED, With a Section devoted to '* The Use of the Rbntgen Rays in Surgery." The want of a text-book which could be used by the practitioner and at the same time be recommended to the medical student has been deeply felt, espe- cially by teachers of surgery; hence, when it was suggested to a number of these that it would be well to unite in preparing a text-book of this description, great unanimity of opinion was found to exist, and the gentlemen below named gladly consented to join in its production. While there is no distinctive Amer- ican Surgery, yet America has contributed very largely to the progress of modern surgery, and among the foremost of those who have aided in developing this art and science will be found the authors of the present volume. All of tbem are teachers of surgery in leading medical schools and hospitals in the United States and Canada. Especial prominence has been given to Surgical Bacteriology, a feature which is believed to be unique in a surgical text-book in the English language. Asep- sis and Antisepsis have received particular attention. The text is brought well up to date in such important branches as cerebral, spinal, intestinal, and pelvic surgery, the most important and newest operations in these departments being described and illustrated. The text of the entire book has been submitted to all the authors for their mutual criticism and revision — an idea in book-making that is entirely new and original. The book as a whole, therefore, expresses on all the important sur- gical topics of the day the consensus of opinion of the eminent surgeons who have joined in its preparation. One of the most attractive features of the book is its illustrations. Very many of them are original and faithful reproductions of photographs taken directly from patients or from specimens. CONTRIBUTORS ; Dr. Charles H. Burnett, Philadelphia. Phineas S. Conner, Cincinnati. Frederic S. Dennis, New York. William W. Keen, Philadelphia. Charles B. Nancrede, Ann Arbor, Mich. Roswell Park, Buffalo, N. Y. Lewis S. Pilcher, New York. Dr. Nicholas Senn, Chicago, Francis J. Shepherd, Montreal, Canada. Lewis A. Stimson, New York. William Thomson, Philadelphia, J. Collins Warren, Boston. J. William White, Philadelphia, " If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look verjl carefully to their laurels if they are to preserve a position in the van of surgical practice."— London Lancet, tV. S. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND SURGICAL, for the use of Students and Practitioners. Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume, with 360 illustrations in text and 37 colored and half-tone plates. Prices: Cloth, ^6.00 net; Sheep or Half -Morocco, ^7.00 net. In this volume all anatomical descriptions, excepting those essential to a clear understanding of the text, have been omitted, the illustrations being largely de- pended upon to elucidate the anatomy of the parts. This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for physicians and students. A clear line of treatment has been laid down in every case, and although no attempt has been made to dis- cuss mooted points, still the most important of these have been noted and ex- plained. The operations recommended are fully illustrated, so that the reader, having a picture of the procedure described in the text under his eye, cannot fail to grasp the idea. All extraneous matter and discussions have been carefully excluded, the attempt being made to allow no unnecessary details to cumber the text. The subject-matter is brought up to date at every point, and the work is as nearly as possible the combined opinions of the ten specialists who hgure as the authors. The work is well illustrated throughout with wood-cuts, half-tone and colored plates, mostly selected from the authors' private collections. CONTRIBUTORS : Dr. Henry T. Byford. John M. Baldy. Edwin Cragin. J. H. Etheridge. William Goodell. Dr. Howard A. Kelly. Fiorian Krug. E. E. Montgomery. William R. Pryor. George M. Tuttle. " The most notable contribution to gynecological literature since 1887 and the most complete exponent of gynecology which we have. No subject seems to have been neglected, .... and the gynecologist and surgeon, and the general practitioner who has any desire to practise diseases of women, will find it of practical value. In the matter of illustrations and plates the book surpasses anything we have seen." — Boston Medical and Surgical yournal. " A valuable addition to the literature of Gynecology. The writers are progressive, aggressive, and earnest in their convictions."— A/^^zm/ News, Philadelphia. " A thoroughly modern text-book, and gives reliable and well-tempered advice and \n- %XxViCX\ovi.."— Edinburgh Medical Journal. " The harmony of its conclusions and the homogeneity of its style give it an individuality which suggests a single rather than a m\i\xvp\&2i\x\hox%\v\'^''— Annals of Surgery. " It must command attention and respect as a worthy representation of our advanced clinical tGnching."— A tnerican Journal of Medical Sciences. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- DREN. By American Teachers. Edited by Louis Starr, M. D., assisted by Thompson S. Westcott, M. D. In one handsome royal-8va volume of 1190 pages, profusely illustrated with wood-cuts, half-tone and colored plates. Net Prices : Cloth, $7.00 ; Sheep or Half-Morocco, 38.00. The plan of this work embraces a series of original articles written by some sixty well-known psediatrists, representing collectively the teachings of the most prominent medical schools and colleges of America. The work is intended to be a PRACTICAL book, suitable for constant and handy reference by the practi- tioner and the advanced student. One decided innovation is the large number of authors, nearly every article being contributed by a specialist in the linj on which he writes. This, while entailing considerable labor upon the editors, has resulted in the publication of a work thoroughly new and abreast of the times. 5 Especial attention has been given to the latest accepted teachings upon the etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- dren, with the introduction of many special formulae and therapeutic procedures. Special chapters embrace at unusual length the Diseases of the Eye, Ear, Nose and Throat, and the Skin ; while the introductory chapters cover fully the important subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of Food. Tracheotomy, Intubation, Circumcision, and such minor surgical pro- cedures coming within the province of the medical practitioner are carefully considered. CONTRIBUTORS : Dr. S. S. Adams, Washington. John Ashhiirst, Jr., Philadelphia. A. D. Blackader, Montreal, Canada. Dillon Brown. New York. Edward M. Buckingham, Boston. Charles W. Burr, Philadelphia. W. E. Casselberry, Chicago. Henry Dwight Chapin, New York. W. S. Christopher, Chicago. Archibald Church, Chicago. Floyd M. Crandall, New York. . Andrew F. Currier, New York. Roland G. Curtin, Philadelphia J. M. DaCosta, Philadelphia. 1. N. Danforth, Chicago. Edward P. Davis, Philadelphia, John B. Deaver, Philadelphia. G. E. de Schweinitz, Philadelphia. John Doming, New York. Charles Warrington Earle, Chicago. Wm. A. Edwards, San Diego, Cal. F. Forchheimer, Cincinnati. J. Henry Fruitnight, New York. Landon Carter Gray, New York. J. P. Crozer Griffith. Philadelphia. W. A. Hardaway. St. Louis. M. P Hatfield, Chicago. Barton Cooke Hirst, Philadelphia. H. Illoway, Cincinnati. Henry Jackson, Boston. Charles G. Jennings, Detroit. Henry Koplik, New York. Dr. Thomas S. Latimer, Baltimore. Albert R. Leeds, Hoboken, N. J. J. Hendrie Lloyd, Philadelphia. George Roe Lockwood, New York. Henry M. Lyman, Chicago. Francis T. Miles, Baltimore. Charles K. Mills, Philadelphia. John H. Musser, Philadelphia. Thomas R. Neilson, Philadelphia. W. P. Northrup, New York. William Osier, Baltimore. Frederick A. Packard, Philadelphia. William Pepper, Philadelphia. Frederick Peterson, New York. W. T. Plant, Syracuse, New York. William M. Powell, Atlantic City. B. Alexander Randall, Philadelphia. Edward O. Shakespeare, Philadelphia F. C. Shattuck, Boston. J. Lewis Smith, New York. Louis Starr, Philadelphia. M. Allen Starr, New York. J. Madison Taylor, Philadelphia. Charles W. Townsend, Boston. James Tyson, Philadelphia. W. S. Thayer, Baltimore. Victor C. Vaughan, Ann Arbor, Mich Thompson S. Westcott, Philadelphia. Henry R. Wharton, Philadelphia. J. William Whhe, Philadelphia. C. Wilson, Philadelphia, 10 W. B. SAUNDERS' A NEW PRONOUNCING DICTIONARY OF MEDICINE, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M. D., LL.D,, Fellow of the College of Physicians of Phila- delphia ; Vice-President of the American Paediatric Society ; Ex-President of the Association of Life Insurance Medical Directors ; Editor " Cyclo- paedia of the Diseases of Children," etc. ; and Henry Hamilton, author of " A New Translation of Virgil's ^Eneid into English Rhyme ;" co- author of " Saunders' Medical Lexicon," etc, ; with the Collaboration of J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. With an Appendix containing important Tables of Bacilli, Micrococci, Leucomaines, Ptomaines, Drugs and Materials used in Antiseptic Sur- gery, Poisons and their Antidotes, Weights and Measures, Thermometric Scales, New Official and Unofficial Drugs, etc. One very attractive volume of over 800 pages. Second Revised Edition, Prices: Cloth, ^5.00 net ; Sheep ^or Half-Morocco, ^6.00 net ; with Denison's Patent Ready- Refer- ence Index ; without patent index, Cloth, $4.00 net ; Sheep or Half- Morocco, ^5.00 net. PROF£SSIO?rAI. OPIXIOXS. " I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it to my classes." Henry M. Lyman, M. D., Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." C. A. LiNDSLEY, M. D., Professor of Theory and Practice of Medicine, Medical Dept. Yale University: Secretary Connecticut State Board of Health, New Haven, Conn, AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- fessor of Surgery in the Jefferson Medical College of Philadelphia, with Reminiscences of His Times and Contemporaries. Edited by his sons, Samuel W. Gross, M. D., LL.D,, late Professor of Principles of Surgery and of Clinical Surgery in the Jefferson Medical College, and A, Haller Gross, A. M,, of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price per Volume, $2.50 net This autobiography, which was continued by the late eminent surgeon until within three months of his death, contains a full and accurate history of his early struggles, trials, and subsequent successes, told in a singularly interesting and charming manner, and embraces short and graphic pen-portraits of many of the most distinguished men — surgeons, physicians, divines, lawyers, states- men, scientists, etc. — with whom he was brought in contact in America and in Europe ; the whole forming a retrospect of more than three-quarters of a century. 1 CATALOGUE OF MEDICAL WORKS. II SURGICAL PATHOLOGY AND THERAPEUTICS. By John Collins Warren, M. D., LL.D., Professor of Surgery, Medical Depart- ment Harvard University ; Surgeon to the Massachusetts General Hospital, etc. A handsome octavo volume of 832 pages, with 136 relief and litho- graphic illustrations, 33 of vi^hich are printed in colors, and all of which were drawn by William J. Kaula from original specimens. Prices : Cloth, $6,00 net; Half- Morocco, ^7.00 net. " The volume is for the bedside, the amphitheatre, and the ward. It deals with things not as we see them through the microscope alone, but as the prac- titioner sees their effect in his patients ; not only as they appear in and affect culture-media, but also as they influence the human body ; and, following up the demonstrations of the nature of diseases, the author points out their logical treatment." i^New York Medical yournal). " It is the handsomest specimen of book-making * -5^ -3^ that has ever been issued from the American medical press " {American Journal of the Medical Sciences, Philadelphia). Without Exception, the Illustrations are the Best ever Seen in a "Work of this Kind. "A most striking and very excellent feature of this book is its illustrations. Without ex- ception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. * * * Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section. " — Annals of Surgery, Philadelphia. PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 engravings, including full-page colored plates. Prices: Cloth, ;^6.oo netj Half-Morocco, ;^7.oo net. Books specially devoted to this subject are few, and in our text-books and systems of surgery this part of surgical pathology is usually condensed to a de- gree incompatible with its scientific and clinical importance. The author spent many years in collecting the material for this work, and has taken great pains to present it in a manner that should prove useful as a text-book for the student, a work of reference for the busy practitioner, and a reliable, safe guide for the surgeon. The more difficult operations are fully described and illustrated. More than one hundred of the illustrations are original, while the remainder were selected from books and medical journals not readily accessible. " The most exhaustive of any recent book in English on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed, .... and the author has given a notable and lasting contribution to ^wx^try ." —yournal of American Medical Asso- ciation, Chicago. 12 W. B. SAUNDERS' MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of Medicine at the University of Heidelberg. Translated, with additions, from the Second Enlarged German Edition, with the author's permission, by Francis H. Stuart, A. M., M. D. Third and Revised Edition. In one handsome royal-octavo volume of 700 pages, 178 fine wood-cuts in text, many of which are in colors. Prices : Cloth, ^4.00 net ; Sheep or Half-Morocco, $5.00 net. In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the bedside. It is distinctly a clin- ical work by a master teacher, characterized by thoroughness, fulness, and accu- racy. It is a mine of information upon the points that are so often passed over without explanation. Especial attention has been given to the germ-theory as a factor in the origin of disease. This valuable work is now published in German, English, Russian, and Italian. The issue of a third American edition within two years indicates the favor with which it has been received by the profession. THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- LITIC AFFECTIONS. (American Edition.) Translation from the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- sician to, and Physician to the department for Diseases of the Skin at, the Middlesex Hospital, London. Photo-lithochromes from the famous models of dermatological and syphilitic cases in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood -cuts and letter-press. In 12 Parts, at ^3.00 per Part. Parts i to 8 now ready. "The plates are beautifully executed."— Jonathan Hutchinson, M. D. (London Hospital). "The plates in this Atlas are remarkably accurate and artistic reproductions o^ typical examples of skin disease. The work will be of great value to the practitioner and student." — William Anderson, M. D. (St. Thomas Hospital). " If the succeeding parts of this Atlas are to be similar to Part i, now before us, we have no hesitation in cordially recommending it to the favorable notice of our readers as one of the finest dermatological atlases with which we are acquainted." — Glasgow Medical jfournal , Aug., 1895. " Of all the atlases of skin diseases which have been published in recent years, the present one promises to be of greatest interest and value, especiallj' from the standpoint of the general practitioner." — American Medico-Surgical Bulletin, Feb. 22, 1896. " The introduction of explanatory' wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit." — Neiv York Medical Journal, Feb. 15, 1896. " An interesting feature of the Atlas is the descriptive text, \^hich is written for each picture by the physician who treated the case or at whose instigation the models have been made. We predict for this truly beautiful work a large circulation in all parts of the medical world where the names St. Louis and Baretta have preceded it." — Medical Record, N. Y., Feb. i, 1896. CATALOGUE OF MEDICAL WORKS. 1 3 PRACTICAL POINTS IN NURSING. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass. ; Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated with 73 engravings in the text, and 9 colored and half-tone plates. Cloth. Price, ^1.75 net. SECOND EDITION, THOROUGHLY REVISED. In this volume the author explains, in popular language and in the shortest possible form, the entire range oi private nursing as distinguished from hospital nursing, and the nurse is instructed how best to meet the various emergencies of medical and surgical cases when distant from medical or surgical aid or when thrown on her own resources. An especially valuable feature of the work w^ill be found in the directions to the nurse how to if?iprovise everything ordinarily needed in the sick-room, where the embarrassment of the nurse, owing to the want of proper appliances, is fre- quently extreme. The work has been logically divided into the following sections : I. The Nurse : her responsibilities, qualifications, equipment, etc. II, The Sick-Room : its selection, preparation, and management. III. The Patient : duties of the nurse in medical, surgical, obstetric, and gyne- cologic cases. IV. Nursing in Accidents and Emergencies. V, Nursing in Special Medical Cases. VI. Nursing of the New-born and Sick Children. VII. Physiology and Descriptive Anatomy, The Appendix contains much information in compact form that will be found of great value to the nurse, including Rules for Feeding the Sick ; Recipes for Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for Computing the Date of Labor; List of Abbreviations ; Dose-List; and a full and complete Glossary of Medical Terms and Nursing Treatment, "This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise and how to prepare everything ordinarily needed in the illness of her -p^Uftnt." —American Journal of Obstetrics and Diseases of Women and Children, Aug., 1896. A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and Prevention of Infective Diseases and an account of Yeasts and Moulds, Hsematozoa, and Psorosperms, By Edgar M. Crookshank, M. B., Pro- fessor of Comparative Pathology and Bacteriology, King's College, London. A handsome octavo volume of 700 pages, with 273 engravings in the text, and 22 original and colored plates. Price, ^6,50 net. This book, though nominally a Fourth Edition of Professor Crookshank's " Manual of Bacteriology," is practically a new work, the old one having been reconstructed, greatly enlarged, revised throughout, and largely rewritten, forming a text-book for the Bacteriological Laboratory, for Medical Ofhcers of Health, and for Veterinary Inspectors. 14 fV. B. SAUNDERS' A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- TICAL. For the Use of Students. By Arthur Clarkson, M. B., C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in the Yorkshire College, Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 beautifully colored original illustrations. Price, strongly bound in Cloth, ^6.00 net. The purpose of the writer in this work has been to furnish the student of His- tology, in one volume, with both the descriptive and the practical part of the science. The first two chapters are devoted to the consideration of the general methods of Histology ; subsequently, in each chapter, the structure of the tissue or organ is first systematically described, the student is then taken tutorially over the specimens illustrating it, and, finally, an appendix affords a short note, of the methods of preparation. "We would most cordially recommend it to all students of histology." — Dublin Medical Journal. "It is pleasant to give unqualified praise to the colored illustrations ; . . . the standard is high, and many of them are not only extremely beautiful, but very clear and demonstra- tive. . . . The plan of the book is excellent." — Liverpool Medical jfournal. ARCHIVES OF CLINICAL SKIAGRAPHY. By Sydney Rowland, B. A., Camb. A series of collotype illustrations, with descriptive text, illustrating the applications of the New Photography to Medicine and Sur- gery. Price, per Part, ^i.oo. Parts I. to V. now ready. The object of this publication is to put on record in permanent fonn some of the most striking applications of the new photography to the needs of Medicine and Surgery. The progress of this new art has been so rapid that, although Prof. Rontgen's discovery is only a thing of yesterday, it has already taken its place among the approved and accepted aids to diagnosis. WATER AND WATER SUPPLIES. By John C. Thresh, D. Sc, M. B., D. P. H., Lecturer on Public Health, King's College, London; Editor of the "Journal of State Medicine," etc. i2mo, 438 pages, illus- trated. Handsomely bound in Cloth, with gold side and back stamps. Price, ^2.25 net. This work will furnish any one interested in public health the information requisite for forming an opinion as to whether any supply or proposed supply is sufficiently wholesome and abundant, and whether the cost can be considered reasonable. The work does not pretend to be a treatise on Engineering, yet it contains sufficient detail to enable any one who has studied it to consider intelligently any scheme which may be submitted for supplying a community with water. CATALOGUE OF MEDICAL WORKS. 1 5 DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- tice. By G. E. DE ScHWEiNiTZ, M. D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. A handsome royal- octavo volume of 679 pages, with 256 fine illustrations, many of which are original, and 2 chromo-lithographic plates. Prices : Cloth, ^^4.00 net ; Sheep or Half-Morocco, $5.00 net. The object of this work is to present to the student, and to the practitioner who is beginning work in the fields of ophthalmology, a plain description of the optical defects and diseases of the eye. To this end special attention has been paid to the clinical side of the question ; and the method of examination, the symptomatology leading to a diagnosis, and the treatment of the various ocular defects have been brought into prominence. SECOND EDITION, REVISED AND GREATLY ENLARGED. The entire book has been thoroughly revised. In addition to this general revision, special paragraphs on the following new matter have been introduced : Filamentous Keratitis, Blood-staining of the Cornea, Essential Phthisis Bulbi, Foreign Bodies in the Lens, Circinate Retinitis, Symmetrical Changes at the Macula Lutea in Infancy, Hyaline Bodies in the Papilla, Monocular Diplopia, Subconjunctival Injections of Germicides, Infiltration-Anaesthesia, and Steriliza- tion of Collyria. Brief mention of Ophthalmia Nodosa, Electric Ophthalmia, and Angioid Streaks in the Retina also finds place. An Appendix has been added, containing a full description of the method of determining the corneal astigmatism with the ophthalmometer of Javal and Schiotz, and the rotations of the eyes with the tropometer of Stevens, The chapter on Operations has been enlarged and rewritten. " A clearly written, comprehensive manual. . . . One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical scx^nce."— British Medical Journal. " The work is characterized by a lucidity of expression which leaves the reader in no doubt as to the meaning of the language employed. . . . We know of no work in which these diseases are dealt with more satisfactorily, and indications for treatment more clearly given, and in harmony with the practice of the most advanced ophthalmologists." — Mari- time Medical News. " It is hardly too much to say that for the student and practitioner beginning the study of Ophthalmology, it is the best single volume at present published." — Medical News. " The latest and one of the best books on Ophthalmology. The book is thoroughly up to date, and is certainly a work which not only commends itself to the student, but is a ready reference for the busy practitioner." — International Medical Review. PROFESSIONAL. OPINIOJfS. "A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." William Pepper, M. D. Provost and Professor of Theory and Practice of Medicine and Clinical Medicine in the University of Pennsylvania. *' ConUins in concise and reliable form the accepted views of Ophthalmic Science." William Thomson, M. D., Professor of Ophthalmology, fefferson Medical College, Philadelphia, Pa. 1 6 IV. B. SAUNDERS' TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- cially written for Students of Medicine. By Joseph McFarland, M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgical College of Philadelphia, etc. 359 pages, finely illustrated. Price, Cloth, ^552.50 net. The book presents a concise account of the technical procedures necessary in the study of Bacteriology. It describes the life-history of pathogenic bacteria, and the pathological lesions following invasion. The work is intended to be a text-book for the medical student and for the practitioner who has had no recent laboratory training in this department of medi- cal science. The instructions given as to needed apparatus, cultures, stainings, microscopic examinations, etc., are ample for the student's needs, and will afford to the physician much information that will interest and profit him relative to a subject which modern science shows to go far in explaining the etiology of many diseased conditions. The illustrations have been gathered from standard sources, and comprise the best and most complete aggregation extant. " It is excellently adapted for the medical students and practitioners for whom it is avowedly written. . . . The descriptions given are accurate and readable, and the book should prove useful to those for whom it is written. — London Lancet, Aug. 29, 1896. " The author has succeded admirably in presenting the essential details of bacteriological technics, together with a judiciously chosen summary of our present knowledge of pathogenic bacteria. . . . The work, we think, should have a wide circulation among English-speaking students of medicine." — N. Y. Medical Joicrnal , April 4, 1896. " The book will be found of considerable use by medical men who have not had a special bacteriological training, and who desire to understand this important branch of medical science." — Edinburgh Medical Journal, July, 1896. LABORATORY GUIDE FOR THE BACTERIOLOGIST. By Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- nary Science, Sheffield Scientific School, Yale University. Illustrated. Price, Cloth, 75 cents. The technical methods involved in bacteria-culture, methods of staining, and microscopical study are fully described and arranged as simply and concisely as possible. The book is especially intended for use in laborator}' work " It is a convenient and useful little work, and will more than repay the ouday necessary for its purchase in the saving of time which would otherwise be consumed in looking up the various points of technique so clearly and concisely laid down in its pages." — American Med.- Surg. Bulletin. FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. Bound in limp cloth, flush edges. Price, 25 cents net. Synopsis : Analyses of Milk — Importance of the Subject of Feeding in Early Infancy — Proportion of Casein and Sugar in Human Milk — Time to Begin Arti- ficial Feeding of Infants — Amount of Food to be Administered at Each Feed- ing — Intervals between Feedings — Increase in Amount of Food at Different Periods of Infant Development — Unsuitableness of Condensed Milk as a Sub- stitute for Mother's Milk — Objections to Sterilization or "Pasteurization" of Milk — Advances made in the Method of Artificial Feeding of Infants. CATALOGUE OF MEDICAL W.ORKS. ly ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- CAL DISSECTION, containing " Hints on Dissection " By Charles B, Nancrede, M. D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy ; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition. lost 8vo, over 500 pages, with handsome full-page lithographic plates in colors, and over 200 illustrations. Price : Extra Cloth or Oilcloth for the dissection-room, ;^2.oo net. Neither pains nor expense has been spared to make this vi'ork the most ex- haustive yet concise Student's Manual of Anatomy and Dissection ever pub- lished, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been specially drawn and engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole being based on the eleventh edition of Gray's Anatomy, "The plates are of more than ordinary excellence, and are of especial value to students in their work in the dissecting-room."— y-ngolo- gist to St. Agnes' Hospital, Philadelphia ; Instructor in Clinical Microscopy and Assistant Demonstrator of Patholog}' in Jefferson Medical College. %* There will be published in the same series, at sh^rt intervals, carefully prepared works on various subjects, by prominent specialists. SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form. THE LATEST, MOST COMPLETE, and BEST ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature Students and Practitioners in every City of the United States and Canada. THE REASON WHY. They are the advance guard of ** Student's Helps " — that do help; they are the leaders in their special line, we// and authoritative/y written by ab/e men^ who, as teachers in the /arge co//eges, know exact/y what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- come Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty- four subjects, has been kept thoroughly revised and enlarged when necessaiy, many of them being in their fourth and fifth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- ket, none of them approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence : 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Size of type and quality of paper and binding. V- Any of these Compends will toe mailed on receipt of price (see over for List). SAUNDERS' QUESTION-COMPEND SERIES. Price, Cloth, $1.00 per copy, except when otherwise noted. 1. ESSENTIALS OF PHYSIOLOGY. 4th edition. Illustrated. Re- vised and enlarged by H. A. Hare, M. D (Price, $1.00 net.) 2. ESSENTIALS OF SURGERY. 6th edition, with an Appendix on Antiseptic Surgery. 90 illustrations. By Edward Martin, M. D. 3. ESSENTIALS OF ANATOMY. 5th edition, with an Appendix. 180 illustrations. By Charles B. Nancrede, M, D. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 4th edition, revised, with an Appendix. By Law rence Wolff, M. D. 5. ESSENTIALS OF OBSTETRICS. 4th edition, revised and en- larged. 75 illustrations. By W. Easterly Ashton, M. D. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 7th thousand. 46 illustrations. By C. E. Armand Semple, M. D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION-WRITING. 4th edition. By Henry Morris, M. D. 8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D. An Appendix on Urine Examination, Illustrated. By Lawrence Wolff, M. D. 3d edition, enlarged by some 300 Es- sential Formulae, selected from eminent authorities, by Wm. M. Powell, M. D. (Double number, price $2.00.) 10. ESSENTIALS OF GYNiECOLOGY. 4th edition, revised. With 62 illustrations. By Edwin B. Cragin, M. D. 11. ESSENTIALS OF DISEASES OF THE SKIN. 3d edition, re- vised and enlarged. 71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M. D. (Price, ^i.oo net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. 2d edition, revised and enlarged. 78 illustrations. By Edward Martin, M. D. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 130 illustrations. By C. E. Armand Semple, M. D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 illustrations. 2d edition, revised. By Edward Jackson, M. D., and E. Baldwin Gleason, M. D. 15. ESSENTIALS OF DISEASES OF CHILDREN. Second edi tion. By William H. Powell, M. D. 16. ESSENTIALS OF EXAMINATION OF URINE. " Colored " Vogel Scale," and numerous illustrations. By Lawrence Wolff, M. D. (Price, 75 cents.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis-Cohen, M. D., and A. A. Eshner, M. D. 55 illustrations, some in colors. (Price, $1 .50 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By L. E. Sayre. 2d edition, revised. 20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustra- tions. By M. V. Ball, M. D. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations. 3d edition, revised. By John C. Shaw, M. D. 22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised. By Fred J. Brockway, M. D. (Price, Si.oo net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By David D. Stewart, M. D., and Edward S. Lawrance, M. D. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Glea^ SON, M. D. 114 illustrations. Second edition, revised and enlarged. RECENT PUBLICATIONS PENROSE'S DISEASES OF WOMEN A Text=Book of Diseases of Women. By Charles B. Penrose, M.D., Ph.D., Professor of Gynecology in the University of Pennsylvania ; Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. "I shall value very highly the copy of Penrose's "Diseases of Women " received. I have already recommended it to my class as the best book."— Howard A. Kelly, Professor of Gynecology ami Obstetrics, JoJuis Hopkins University, Baltimore, Md. SENN'S GENITO=URINARY TUBERCULOSIS Tuberculosis of the Genito-Urinary Organs, Male and Female. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. SUTTON AND GILES* DISEASES OF WOMEN Diseases of Women. By J. Bi.and SurroN, F.R.C.S., Assistant Surgeon to Middle- sex Hospital, and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B.Sc. Lond., F R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, handsomely illustrated. Cloth, ^2.50 net. BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR= MACOLOGY A Text-Book of Materia Medica, Therapeutics, and Pharmacology. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's Medical School, etc. Octavo, 858 pages, illustrated. Cloth, ^.00 net ; Sheep, J5.00 net. SAUNDBY'S RENAL AND URINARY DISEASES Lectures on Renal and Urinary Diseases. By Robert Saundbv. M.D. Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirur- gical Society ; Physician to the General Hosi)ital ; Consulting Physician to the Eye Hospital and to the Hospital for Diseases of Women ; Professor of Medicine in Mason College, Birmingham, etc. Octavo volume of 434 pages, with numerous illustrations and 4 colored plates. Cloth, $2.50 net. PYE'S BANDAGING Elementary Bandaging and Surgical Dressing, with Directions Concerning the Immediate Treatment of Cases of Emergency. For the Use of Dressers and Nurses. By Walier Pve, F.R.C.S., Late Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 illustrations. Cloth, flexible covers. Price, 75 cents neU MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE I Pathological Technique. By Frank B. Mallorv, A.M., M.D., Assistant Professor I of Pathology, Harvard University Medical School ; and James H. Wright, A.M., 1 M.D., Instructor in Pathology, Harvard University Medical School. Octavo volume I of 396 pages, handsomely illustrated. Cloth, $2.50 net. i " I have been looking forward to the publication of this book, and I am glad to say I that I find it to be a most useful laboratory and post-mortem guide, full of practical infor- I mation, and well up to date."— William H. ^Nkvcu, Professor of Pathology, Johns \ Hopkins University, Baltimore, Md. \ ANDERS' PRACTICE OF MEDICINE ! A Text=Book of the Practice of Medicine. By James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico- Chirurgical College, Philadelphia. In one handsome octavo volume of 1287 pages, fully illustrated. Cloth, fc.50 net ; Sheep or Half Morocco, 16,50 net. 29 JUST ISSUED. SOLD BY SUBSCRIPTION. ANOMALIES AND CURIOSITIES OF MEDICINE. BY GEORGE M. GOULD, M. D., and WALTER L. PYLE, M. D. Several years of exhaustive research have been spent by the authors in the great medical libraries of the United States and Europe in collecting the material for this work, iledical literature of all ages and all languages has been carefully searched, as a glance at the Bibliographic Index will show. Ths facts, which will be of extreme value to the author and lecturer, have been arranged and annotated, and full reference footnotes given, indicating whence they have been obtained. In view of the persistent and dominant interest in the anomalous and curious, a thorough and systematic collection of this kind (the first of which the authors have knowledge) must have its own peculiar sphere of usefulness. As a complete and authoritative Book of Reference it will be of value not only to members of the medical profession, but to all persons interested in general scientific, sociologic, and medico-legal topics ; in fact, the general inter- est of the subject and the dearth of any complete work upon it make this volume one of the most important literary innovations of the day. An especially valuable feature of th€ book consists of the Indexing. Besides a complete and comprehensive General Index, containing numerous cross-references to the subjects discussed, and the names of the authors of the more important reports, there is a convenient Bibliographic Index and a Table of Contents. The plan has been adopted of printing the topical headings in bold= face type, the reader being thereby enabled to tell at a glance the subject- matter of any particular paragraph or page. Illustrations have been freely employed throughout the work, there being 165 relief cuts and 130 half-tones in the text, and 12 colored and half-tone full- page plates — a total of over 320 separate figures. The careful rendering of the text and references, the wealth of illustrations, the mechanical skill represented in the typography, the printing, and the bind- ing, combine to make this book one of the most attractive medical publications ever issued. Handsome Imperial Octavo Volume of 968 Pages. PRICES: Cloth, $6.00 net; Half Morocco, $7.00 net. 30 JUST ISSUED AN AMERICAN TEXT=BOOK OF GENITO=URINARY AND SKIN DISEASES Edited by L. Bolton Bangs, M.D., Late Professor of Genito-Urinary and Venereal Diseases, New York Post-Graduate Medical School and Hospital; and William A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri Medical College. Octavo volume of over 1200 pages, with 300 illustrations in the text, and 20 full-page colored plates. Prices : Cloth, $7.00 net ; Sheep or Half Morocco, |8.oo net. MOORE'S ORTHOPEDIC SURGERY A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Ortho- pedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. 8vo, 356 pages, handsomely illustrated. Cloth, $2.50 net. MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. Edin., L.R.C.S. Edin., Professor of the Practice of Surgery and of Clinical Surgery in Hamline Uni- versity; Visiting Surgeon to St. Barnabas' Hospital, Minneapolis, etc. Octavo volume of 800 pages, handsomely illustrated. Cloth, $5.00 net ; Half Morocco, $6.co net. CHAPIN ON INSANITY A Compendium of Insanity. By John B. Chapin, M.D., LL.D., Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physician-Superintendent of the Willard State Hospital, New York, etc. i2mo., 234 pages, illustrated. Cloth, $1.25 net. KEEN ON THE SURGERY OF TYPHOID FEVER The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Surgery and of Clinical Surgery, Jeffer- son Medical College, Philada. Octavo volume of 400 pages. Cloth, $3.00 net. VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH Diseases of the Stomach. By William W. van Valzah, M.D., Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic ; and J. Douglas Nisbet, M.D., Adjunct Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. Cloth, $3.50 net. IN PREPARATION AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jefferson Medical College; and B. Alexander Randall, M.D., Professor of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia Polyclinic. CHURCH AND PETERSON»S NERVOUS AND MENTAL DISEASES Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental Diseases and Medical Jurisprudence, Northwestern University Medical School, Chicago; and Frederick Peterson, M.D. , Clinical Professor of Mental Diseases, Woman's Medical College, New York, etc. KYLE ON THE NOSE AND THROAT Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Clinical Professor of Laryngology and Rhinology, Jelferson Medical College, Philadelphia; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital, etc. STENGEL'S PATHOLOGY A Manual of Pathology. By Alfred Stengel, M.D., Physician to the Philadel- phia Hospital; Professor of Clinical Medicine in the Woman's Medical College; Physician to the Children's Hospital, etc. HIRST'S OBSTETRICS A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of Ob stetrics, University of Pennsylvania. HEISLER'S EMBRYOLOGY A Text=Book of Embryology. By John C. Heisler, M.D., Professor of Anatomy, Medico-Chirurgical College, Philadelphia. NOW HEADY, VOLUMES FOn 1896,1897,1898. AMERICAN YEAR-BOOK OF MEDICINE and SURGERY, Edited by GEORGE M. GOULD, A.M., M. D. Assisted by Eminent American Speoialiots and Teachers. ^ Notwithstanding the rapid multiplication of medical and surgical works, C still these publications fail to meet fully the requirements of the general physician^ ^ ^ inasmuch as he feels the need of something more than mere text -books of well- "^^ g known principles of medical science. Mr. Saunders has long been impressed ^ ^ with this fact, which is confirmed by the unanimity of expression from the pro- ^ S fession at large, as indicated by advices from his large corps of canvassers. ^ fe This deficiency would best be met by current journalistic literature, but most ^ "o^ practitioners have scant access to this almost unlimited source of information, «. S and the busy practiser has but little time to search out in periodicals the many c^ § interesting cases whose study would doubtless be of inestimable value in his ;: © practice. Therefore, a work which places before the physician in convenient h^ ^ form an epitomization of this literature by persons competent to pronounce upon 5 § The Value of a Discovery or of a Method of Treatment X «» cannot but command his highest appreciation. It is this critical and judicial ^ .^ function that will be assumed by the Editorial staff of the " American Year- f^ Book of Medicine and Surgery." ^ g It is the special purpose of the Editor, whose experience peculiarly qualifies «. § him for the preparation of this work, not only to review the contributions to ^j American journals, but also the methods and discoveries reported in the leading § ti medical journals of Europe, thus enlarging the survey and making the work ^ » characteristically international. These reviews will not simply be a series of § undigested abstracts indiscriminately run together, nor will they be retrospective » ^ of " news " one or two years old, but the treatment presented will be synthetic '^ and dogmatic, and will include only what is new. Moreover, through expert ^ condensation by experienced writers these discussions will be Comprised in a Single Volume of about 1200 Pages. The work will be replete with original and selected illustrations skilfully reproduced, for the most part in Mr. Saunders' own studios established for the purpose, thus ensuring accuracy in delineation, affording efficient aids to a right comprehension of the text, and adding to the attractiveness of the volume. Prices : Cloth, $6.50 net; Half Morocco, I7.50 net. W. B. SAUNDERS, Publisher, ^^ 925 Walnut Street, Philadelphia. e %^ ^^ .^^' --Xv^. '^ -^^^f,^ "^%7-: " < ^- * ' ^ * ' a\ s- /■ 0' %A^ /, -'. 0^ ^^^ -t^ : "■■■■■■ ^''^••.■::,'.;.■'.,.;t!il'l ' ::- .;vll' list! !iit ' •■' '^'( '^O ■'■' ii''Jf'iM ■ ■ ■ w"-^ 'h'^^^^ \ ' o!-(!;M •'•^Mt;;i;;;^ -mm .' '■r> '''.■■/:'!',ii.iii'K(:lu"tUUiiiii Mm\^ , ,'.r;?}:'^t;;;';ii'{U; { { il«»U'J!